Impact Evaluation of the Demand-Side Financing Program for Maternal Health in Bangladesh

1. Impact Evaluation of the Demand-Side Financing Program for Maternal Health in Bangladesh Laurel Hatt, Ha Nguyen, Nancy Sloan, Sara Miner, Obiko Magvanjav, Asha Sharma, Jamil Chowdhury, Rezwana Chowdhury, Dipika Paul, Mursaleena Islam, and Hong Wang

2. Bangladesh context • High maternal mortality ratio (MMR): 320 maternal deaths per 100,000 live births • 85% of deliveries at home, few with medical provider • Millennium Development Goal 5: Cut MMR to 143 by 2015

3. Bangladesh pilot DSF program • Aims to rapidly increase utilization of maternal health (MH) services via: • Vouchers for free antenatal (ANC), delivery, emergency, and postnatal care (PNC), and for transportation • Cash transfers (Tk. 2000 [$30]) and gift bags if women deliver with skilled birth attendant at home or in facility • Cash incentives for providers/field workers for registering women and providing MH services; “seed fund” for facilities • Eligibility: local residents only; pregnant for 1st or 2nd time; used family planning prior to 2nd pregnancy; means testing in some areas • Started in 2007 in 21 subdistricts; now in 45

4. Evaluate DSF program impacts on: Use of skilled providers at delivery, C-section, ANC, and PNC Out-of-pocket expenditures on maternal health services Provider skills, knowledge; facility quality Assess operations of the DSF program Evaluation objectives ANC visit by voucher recipient

5. Methods • Lack of useable baseline data • 21 DSF subdistricts matched with 21 control subdistricts • Data sources: • Household survey (N=2,208) of women who delivered in prior six months • 10 focus group discussions with women • 16 facility assessments • 51 provider interviews • 90 key informant interviews at subdistrict and central levels • Administrative reports • Descriptive and multivariate analyses

6. Findings New mothers line up to receive cash stipends and gift boxes

7. % receiving ANC significantly higher in voucher areas

8. % delivering with a skilled provider significantly higher in voucher areas

9. More home deliveries attended by qualified birth attendants

10. % with PNC visit significantly higher in voucher areas

11. OOP expenditure significantly lower in voucher areas

12. Multivariate analyses confirm impact • Cross-sectional regression: • Compared to living in a control subdistrict, residence in a DSF subdistrict increased the likelihood of delivery with skilled provider by 42 to 50 percentage points • Using “pre”- and “post”-DSF birth history data from recently delivered women: • Difference-in-differences and fixed effects analyses also confirmed program impacts

13. Conclusions: Strong DSF impacts • Women in DSF areas were significantly more likely to have at least 3 ANC visits (55%) than women in the control areas (34%). • The DSF program is significantly associated with higher rates of delivery with qualified providers -- more than twice as high in DSF (64%) as in control subdistricts (27%). • No significant differences in C-section rates (10% vs. 9%) • Women in DSF areas spent significantly less on pregnancy & delivery care than women in control areas

14. Challenges remain … • Big upsurge in patient volumes is overwhelming • Shortages of human resources, supplies and medicines • Limited targeting • Leakage to higher-parity women (~11% of recipients) • Little income targeting in means-tested areas • Delays in funds disbursements are a serious problem • Impact of incentives (to providers and consumers) diminished if not connected with desired behaviors • Cost and sustainability concerns

15. GTZ funded the original study, which was implemented by Abt Associates Inc. (USA) and its partner RTM International (Bangladesh) Special thanks to the Bangladesh Ministry of Health and Family Welfare, Health Economics Unit, WHO and DSF program office for their support http://www.abtassociates.com/HSRsymposium Acknowledgements