Demand Side Factors Effect on EOC Program on Maternal Health and Pregnancy

Abstract

A cross sectional comparative study was conducted among the pregnant women from both the DSF voucher holder and non voucher holder group in Bogura Upazilla, under Bogura District to assess the impact on financial subsidy on women’s health, pregnancy outcome etc. Sample size was 200, 100 women with DSF facilities and 100 with no DSF facilities. Data were collected using a structured and open ended questionnaire and samples were chosen purposively. Among the respondents of both the voucher holders and non – voucher holders more than four fifths were house wives, followed by house maid (13% & 10%). The mean family size of voucher holders was 5.78 ± 1.71 ranging from 3 – 16. The mean monthly income of the respondent’s family was 2121.67± 1123.12 Tk. a month. Non – voucher holder women’s family was better in regards to education, income, health seeking behavior etc. There was significant association between voucher holding and occurrence of delivery at public hospital instead of home delivery (p < 0.05). Those women with voucher or DSF facilities were 12.5 times more likely to go to public hospital for delivery than those without voucher (OR = 12.5 at 95% CI: 6.431 – 24.298). Voucher holder women were much more likely to take regular ANC than the non -voucher holder (OR = 76.221 at 95% CI: 10.845 – 535.682). Voucher-holder women were 23 times more likely to take regular iron, vitamins than the non-voucher holder women (OR = 23.1 at 95% CI: 8.820 – 60.283). Voucher holder  women were 13 times more likely to take regular physical check up like pulse, BP etc than the non-voucher holder women (OR = 13.3 at 95% CI: 6.49 – 27.197). Voucher holder women were 3 times more likely to take additional nutritious food than the non- voucher holder women (OR = 3.1 at 95% CI: 2.101 – 4.519). Voucher holder women were 0.115 (8.7) times less likely to conduct delivery by unskilled birth attendant than the non-voucher holder women (OR = 0.115 at 95% CI: 0.069 – .192). Voucher holder women were 0.358 (2.8) times less likely to develop complication before delivery than the non-voucher holder (OR = 0.358 at 95% CI: 0.225 – .569). Voucher holder women were 15.3 times more likely to have satisfactory knowledge on complication of pregnancy than the non-voucher holder women (OR = 15.251 at 95% CI: 7.644 – 30.430). All the above mentioned relationship between voucher holding and individual issues regarding check up or complications or else was statistically significant (p < 0.05). From this study major recommendations can be to enhance voucher scheme of DSF gradually to all Upazilla, family counseling, extensive advocacy, communication, social mobilization (ACS) activities etc.

Introduction

In the last few there has been an increasing awareness that many of the core public health innovations in the health sector have failed to achieve expected objectives. There is a wealth of evidence that suggests that the poor and vulnerable often benefit less from public health spending than wealthier income groups. The primacy of funding and provision of primary health care services is well accepted by enlightened policy makers and health professionals. Yet evidence of the impact on outcomes from supply side interventions, such as spending on rural clinics, remains inconclusive. Weaknesses on the supply side has led to some interest in consumer led demand-side financing as a way to improve the targeting of specific groups and also as an instrument for promoting provider efficiency. Consumer led demand -side financing mechanisms have been defined as a “transfer of purchasing power to specified groups for defined goods and services”. They often utilize vouchers where a consumer is given a written entitlement which can be exchanged for a specified service, up to a predetermined amount at accredited facilities. In other cases consumers do not receive written entitlement but are told to claim a given service from a provider which then claims directly from the financing agency. Some schemes that is voucher-like, such as HMO access in the US, have deliberately steered away from using the term voucher because of adverse connotations with other welfare schemes.

Vouchers and other demand -side financing methods have been used in the US, Europe, a few South American and some other low and middle income countries for a wide range of socially desirable services including health, education, public housing and essential food. Although vouchers have received much recent attention in the public finance literature, they are not a new device. Steuerle et al. mentions that returning war veterans were offered education vouchers in the US from 1944 while vouchers for food date back to the 196os. Consumer led demand-side financing can be used in a number of different ways to further public policy objectives. These objectives include:

 As a means of targeting low income or other vulnerable people, as in the case of vouchers for the disabled to pay for transport and higher education vouchers for the poor.

 As a means to change behavior of voucher holder, as in the case of vouchers for women that are breast-feeding or to encourage people to come off drugs.

Demand side financing places purchasing power into the hands of consumers to spend on specific services. This is in contrast to providing a direct input based subsidy to providers to deliver a service. Vouchers are often the vehicle for transferring the purchasing power defined as “a subsidy that grants limited purchasing power to an individual to choose among a restricted set of goods and services”. Bradford and Shaviro have suggested that demand-side financing or voucher schemes have the following four characteristics (Bradford, 1999):

1. Grant to consumers based on personal or household characteristics – these grants are provided in order to enable re-distribution of resources towards those with greater need and/or lower ability to finance these needs.

2. Intermediate choice – users are not confined to one facility but can shop around between facilities for a specified good. Yet the choice is not totally free otherwise the finance method would become indistinguishable from cash -grant. Users must spend the resources on a specified good at specified outlets.

3. Supplier competition – so that providers are encouraged to compete for the finance provided to the consumer.

4. Declining marginal rate of reimbursement (MRR) – so that the value of the voucher is limited and payment beyond a certain limit is made in full by the consumer (or some other third-party payer). Bradford and Shaviro refer to this as the principle of 100%-0% MRR.¹

To these criteria we might also add the perhaps self-evident requirement that payment by consumers will be for a service rather than for inputs. Consumers, unlike ministries of education or health, are not primarily interested in ensuring employment of staff or purchasing drugs but in obtaining a specific end-service resulting from the mix of these inputs. It is clear that while vouchers satisfy each of these characteristics so also do some other forms of finance. A budget given to a public (or private) hospital to pay for staff and non – staff inputs does not meet these criteria since the grant is not personal and no choice is permitted. On the other hand an intermediate public purchaser (for example a district health authority or social insurance fund) that permits patients to obtain care from a range of accredited public and private facilities and then pays for the service (up to an agreed level) based on quantity of service provided also satisfies some of these conditions. As in many areas of public policy there are plenty of grey areas. Some schemes might not fully be described as demand -side financing (based on the above criteria) but nor are they fully supply side input-based mechanisms.

Why use demand side financing?

There is increasing awareness that supply subsidies for health and education services often fail to benefit those that are most vulnerable in a community. This recognition has led to a growing interest in and experimentation with, consumer led demand side financing systems. These can be defined as placing purchasing power in to the hands of consumers to spend on specific services at accredited facilities. A common modality is to use a voucher or other evidence of entitlement to a specific level of services. Vouchers have been used in a number of countries across a range of social services. This type of consumer-led demand side financing can be contrasted both with traditional supply subsidies and also third -party purchasing of services common in systems with developed social insurance systems. Most experimentation has been in the education sector but there are also examples in health, housing and essential nutrition. The international evidence suggests that vouchers have been successful in raising the consumption of key services amongst key groups. Impacts include increase in enrolment and reduced drop -out rates for vouchers for schooling and increased clinic utilization and compliance with treatment regimes for health programs. Evidence also suggests that vouchers can be used to target vulnerable groups.

Reducing maternal and child mortality is an important goal of the Millennium declaration and a major concern for policy makers in developing countries. One of the important barriers to reducing maternal mortality is the low utilization of maternal health services provided by the public health system through it supplies side mechanisms. Demand side financing is increasingly being proposed as one of the options to increase access to reproductive and child health services and is generating great interest in a number of developing countries. Demand side financing not only promotes equity through improved access and better targeting of subsidies, but also provides incentives for efficiency and provider choice by involving the private sector.

This study tries to examine the impact on pregnancy out come and women’s health during pregnancy period and health seeking behavior of the women’s who are receiving financial subsidy and regular check up due to demand side financing program and those who are not getting these services in a selected Upazilla where DSF program is operating.

Background

Bangladesh is one of the developing countries of the world. The country is beset with problems of poverty, population explosion, ignorance, illiteracy & diseases. The country is beset with problems of poverty, population explosion, ignorance, illiterate & diseases. The mortality rates are high, infant mortality rates are high, infant mortality is about 71 per 1000 live birth, maternal mortality 4.4 per 1000 live birth, crude death rate is 8.4 per 1000 population and expectation of life at birth is about 58.7 years.³ These statistics are far higher than those of developed countries and also to other developing countries in this region. In most developing countries due to limited health facilities, lack of quick transportation & other cultural and economic reasons, deliveries occur at home and are conducted by Traditional Birth Attendants (TBA). TBAs, whether trained or untrained, provide antenatal care to the pregnant woman, attend deliveries at home and provide post natal care. This is the picture of most of the developing countries^.4 But simple antenatal can save millions of lives of pregnant women by early detection at risk and complication associated with pregnancy. Antenatal care is care of the women during pregnancy with aim to promote, protect and maintain the health of the mothers during pregnancy and assure safe delivery with healthy baby.

In Bangladesh currently 23,000 women die every year due to cause related to pregnancy and child birth, maternal nutritional status, practices during pregnancy and delivery and availability of obstetric care are factors that not only affect the survival of both mother and child, but they also influence subsequent growth and development of the new born. In Bangladesh, the risk of maternal mortality is 150 times greater than in developed countries. The maternal mortality is around 3.2 per thousand live births. It is estimated that a quarter of all pregnancies are high risk.

The provision of special care for women during pregnancy through the public health services was a relatively late development in modern obstetrics. Not until the late 1930s did the United Kingdom of Great Britain and Northern Ireland authorities decide that all women should be offered regular check-ups during pregnancy as an integral part of maternity care, some 30 years after the introduction of formalized labor and delivery care. This development was stimulated by the realization that whereas maternal mortality due to puerperal sepsis, hemorrhage and obstructed labor had declined substantially during the early years of the 20th century, this was not the case for deaths associated with Eclampsia. If these Eclampsia-related deaths were to be averted, it was supposed, interventions would be needed earlier during the pregnancy, to measure blood pressure, identify women at risk of eclamptic convulsions, and take measures to reduce blood pressure whenever possible. During the second half of the 20th century, international awareness grew of the dimensions of the tragedy of maternal mortality; national governments collaborated with technical assistance and donor agencies to ensure that pregnant women in developing countries also had access to maternity care. However, providing access for all pregnant women to care during the short period of labor and delivery is logistically and operationally a much more complex endeavor than making services available during the much longer – and less unpredictable – antenatal period. As a result, many programs focused attention on providing antenatal care rather than delivery care. Unfortunately, antenatal care interventions alone do not address the main causes of maternal deaths that result from complications arising during labor, delivery and the immediate postpartum period. Major causes of maternal and perinatal mortality rate are related to pregnancy complications. A large proportion of the maternal and perinatal deaths is preventable by proper antenatal and delivery care. But, studies conducted by various authors show that attendance to delivery by trained personnel is critically low at 6.9%^.

Every minute, a woman dies in pregnancy or childbirth, this adds up to more than 10 million over a generation. Almost all of these women—99 per cent—live and die in developing countries. A high maternal death rate is an indicator of an inadequate health care system, including those that offer poor and only limited access to health services. It also indicates that a woman’s fundamental rights to life and health are being violated. Yet the vast majority of maternal deaths could be prevented. In industrialized countries, deaths owing to pregnancy and childbirth are rare. The maternal death rate in East Asia and Latin America has also decreased—by as much as 50 per cent in some countries. But in Africa and South Asia, complications during pregnancy and childbirth remain the most frequent cause of death for women. In some countries the number is increasing. And when women suffer and die, children suffer and die also. We know what it takes to save women’s lives: universal access to contraception to avoid unintended pregnancies, access to skilled care during delivery, and rapid access to quality emergency obstetric care when required.Every year, 536,000 women die from pregnancy related causes. This adds up to more than 10 million women over a generation. Every year, more than 1 million children are left motherless and vulnerable because of maternal death. Children who have lost their mothers are up to 10 times more likely to die prematurely than those who haven’t. The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about 1 in 7 in Niger and about 1 in 48,000 in Ireland. 10-15 million women a year suffer severe or long lasting illnesses or disabilities caused by complications during pregnancy or childbirth. This range from obstetric fistula to infertility and depression. The main reasons for maternal deaths are hemorrhage, infections, and unsafe abortions, high blood pressure leading to seizures and obstructed labor.

At the 1994 International Conference on Population and Development (ICPD), the participating countries agreed to reduce maternal mortality to 75 per cent below 1990 levels by 2015. The agreement was re-affirmed in 2000, when the international community also agreed on this target for the Millennium Development Goal 5. Progress is measured by tracking the maternal mortality ratios in each country, as well as the proportion of births assisted by skilled attendant. The additional target for MDG5 is “universal access to Reproductive Health” by the year 2015. Collectively, The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), ICPD Program of Action, Beijing Platform for Action and the MDGs constitute the commitments behind multilateral, bilateral and local efforts to reduce maternal mortality.

Two of the most important issue regarding women’s health during pregnancy are safe delivery and ANC. Safe delivery refers to a parturition process where there is no threat to mother and baby and there is least chance of complication after delivery. Both the antenatal care and safe delivery practice are important to reduced maternal and infant mortality and morbidity. But the safe motherhood practice is very poor in most of the developing countries like Bangladesh. Antenatal care coverage is an important indicator of health service utilization in a country. The primary objective of antenatal care is to achieve at the end of pregnancy a healthy mother and a healthy baby. During this care abnormality that may arise in pregnancy are detected and pregnant women are immunized against tetanus. With better ANC, maternal morbidity and mortality and also infant morbidity and mortality and also infant morbidity and mortality can be reduced. Ideally this care should begin in the early part of pregnancy and should be continued up to delivery through a series of visits for routine physical and other examinations. Antenatal care is the completed supervision of the pregnant woman to     maintain, protect and promote the health of mother and fetus as well as newborn. World congress launched the ‘safe motherhood program’ in 1988 in FIGO conference held in Rio (Brazil) and directed consultant national societies to orient the major part of their activity for safe motherhood initiatives². A safe motherhood initiative is a global effort to reduce maternal mortality and morbidity. This aims to ensure improvement in the quality and safety of lives of women through adoption of health and non-health strategies^.

To meet the Millennium Development Goals and the needs of the women and infants in Bangladesh, the Government of Bangladesh developed and implemented a demand-side finance scheme with the aim of increasing access to and coverage of maternal health services among poor women. The Directorate General of Health Services of the Ministry of Health and Family Welfare under the Health, Nutrition and Population Program embarked on piloting the Demand Side Financing Scheme in 33 administrative areas between 2005 and 2007, increasing to 60 by early 2008. ICDDR,B was given the task of performing a rapid assessment in 2008. The use of the voucher scheme was initially piloted in 21 areas, out of which 9 were universal, meaning all pregnant women were able to participate, and 12 were means tested; meaning only poor pregnant women were able to participate. The rapid assessment attempted to capture knowledge, attitudes and practices around the various implementation strategies and delays surrounding the scheme. Various levels of designated service providers of all Upazilla were entitled to financial incentives, established at the national level. The service providers include skilled birth attendant (SBA) with six months training on safe delivery, FWV, Senior Staff Nurse, any MBBS qualified doctors, surgeons and Anaestheticians. Due to scarcity of data on the progress of the Demand Side Financing scheme and the urgent need for an assessment, only six Upazilla were selected for inclusion. The assessment instruments included questionnaires for structured interviews with the beneficiaries, formats, guidelines for focus group discussion and in-depth interview.

To provide a 360˚ assessment, research participants included beneficiaries, multiple layers of service providers, union and Upazilla level officials, and key leaders within the communities. The overall objective of the rapid assessment was to measure progress in terms of registration of pregnant women and voucher distribution, utilization of services using maternal health voucher, identify barriers to disbursement of Demand Side Financing money to beneficiaries and service providers and collect recommendation on possible solutions to overcome those barriers.

The basic idea behind demand side financing in health is that subsidizing demand among the poor for specific health services of known cost-effectiveness, whilst allowing a competitive market for its provision, may be more beneficial than using the same resources to subsidies supply [Sandiford et al 2004]. By introducing market mechanism, this approach alters the incentives for health providers, resulting in increased efficiency, improved service quality and responsiveness thereby providing value for money service. For example, the quantity of funding received by the provider depends upon the outputs produced. In addition, by being able to better target government subsidies to the very poor, it contributes to promoting equity. Demand side financing schemes enable governments to purchase outputs rather than inputs and offer choice of providers to beneficiaries. Choice creates incentives to lower prices and/or raise quality. The key-defining feature of a demand side subsidy is a direct link between the intended beneficiary, the subsidy and the desired output, be that access, utilization or even some form of health outcome.

Justification of the study

Majority of women especially in rural areas are careless about the utility of safe delivery, this carelessness contribute to high maternal mortality rate (MMR) and infant mortality rate (IMR). The main barrier for implementation of safe delivery for each and every woman in the country is due to lack of knowledge and poverty. The important decisions in family or a household are taken by male member(s) of the family. Husband’s of couple play and important role in decision making process in most of the cases. Women’s health issues have attained higher international visibility and renewed political commitment in recent decades. While targeted policies and programs have enabled women to lead healthier lives, significant gender-based health disparities remain in many countries. In some low- and middle-income countries, up to half of hospital budgets allocated to obstetrics and gynecology are spent treating complications of unsafe abortion. In most developing countries, women lack the basic information and social support needed to make informed decisions regarding their sexual health and safer delivery .

It is well known that supply subsidies for health services often fail to benefit the most vulnerable women, children and the poor. Therefore, Demand Side Financing (DSF) mechanisms are intended to reduce the demand side barriers. In Bangladesh, about 92% of births are still delivered at home and skill birth attendants attend only 13.0 percent of births. About 69.0 percent of the poor households do not have access to any ANC compared to 22.0 percent of the richest quintile. It was hypothesized that various demand side factors contribute in reducing access of the poor to maternal healthcare.¹² In Bangladesh from 2005 Demand Side Financing is being operated at selected Upazilla level and it’s apparently yielding good result. Poor ill educated rural women are eager to get financial and health care benefit offered by this program. But after three years of adoption of this program in this country study to evaluate its performance scientifically has rarely been attempted. This study would give a comparison between health seeking behavior, pregnancy out come, over all health status between who are receiving services and benefit of DSF and who don’t in a selected Upazilla. So the study findings would be able to highlight the effectiveness of the program as well as its over all impact on maternal and child health, the most critical problem of our national health.

Research Question:

What is the effect of EOC program (financial subsidy of DSF) on maternal health and pregnancy outcome in Bogura Upazilla, Bogura?

Research Objective:

General objective:            

To compare the health seeking behavior of women between DSF voucher holder women and non voucher holder women, pregnancy outcome and assess the effect of financial subsidy delivered from EOC program or Demand Side Financing (DSF) on maternal health and pregnancy outcome.

Specific Objectives:

• To compare health seeking behavior of women (both the voucher holder and non voucher holder) during pregnancy period.
• To compare the pregnancy outcome of both the voucher holder and non voucher holder women of that Upazilla.
• To compare socio-demographic status of both the voucher holder and non voucher holder women enrolled for the study purpose.
• To assess the effect of financial subsidy on maternal health and pregnancy outcome.

Key variables:

Dependent variables:

Effect of financial subsidy on maternal health and pregnancy outcome in Bogura Upazilla, Bogura.

Independent variables:

Socio-demographic variables:

• Age
• Religion
• Respondents education
• Husbands education
• Respondents occupation
• Husbands occupation
• Monthly family income
• No. of family members

Information regarding pregnancy:

• No. of pregnancy experienced
• No. of alive offspring
• No. of abortion (if any)

Information regarding healthcare seeking and pregnancy outcome:

• Birth attendant
• Complication before onset of delivery
• Complication after delivery
• Nutritional status of the new born babies
• Knowledge regarding danger signs of pregnancy
• ANC seeking
• Intake of vitamins or iron regularly
• Level of cooperation from respondents family
• Habit of nutritional food intake by the respondents
• Fate of delivery

Information regarding opinion on necessity of DSF:

• Respondents opinion on effectiveness of DSF voucher
• Respondents opinion on adequacy of DSF voucher

Operational definition:

Effect of EOC: In this study effect refers to  the difference in health care seeking (ANC, regular check up), food intake, birth attendant, delivery place, health status of mother and new born child between pregnant women who are getting financial and service facilities from DSF (Demand Side Financing) and those women who are not covered with these facilities.

Financial subsidy of DSF: These encompass two types’ subsidies. Firstly subsidy for the voucher holder pregnant women i.e. if they take one ANC visit they would receive 100 Tk., for safer delivery 2000 Tk. (NVD), for 1 PNC, transport cost towards hospital 100 Tk. each and gift box for new born worth 500 Tk. Secondly in case of complication additional cost like for forceps delivery, vacuum extraction or D & C 1000 Tk, CS 6000 Tk, medicine cost 100 tk, transport cost for getting the pregnant women to better health centre 500 Tk.

Pregnancy outcome: In terms of new born baby’s status (still birth, alive), health status of new born (in term of Low birth weight, under weight or over weight), and maternal health status (healthy after birth, complication, deteriorated health with out complication).

Health seeking of women: In this study health seeking behavior refers to ANC and other regular check up by the pregnant women under study.

Voucher holder: The women covered with financial and service facility by DSF (Demand Side Financing) program.

Assessment of impact of financial subsidy: The impact of financial subsidy would be assessed through the difference in health care seeking (ANC, regular check up), food intake, birth attendant, delivery place, health status of mother and new born child between pregnant women who are getting financial and service facilities from DSF (Demand Side Financing) and those women who are not covered with these facilities.

LITERATURE REVIEW 

There is increasing awareness that supply subsidies for health and education services often fail to benefit those that are most vulnerable in a community. This recognition has led to a growing interest in and experimentation with, consumer-led demand side financing systems (CL-DSF). These mechanisms place purchasing power in the hands of consumers to spend on specific services at accredited facilities. International evidence in education and health sectors suggest a limited success of CL-DSF in raising the consumption of key services amongst priority groups. There is also some evidence that vouchers can be used to improve targeting of vulnerable groups. There is very little positive evidence on the effect of CL-DSF on service quality as a consequence of greater competition. Location of services relative to population means that areas with more provider choice, particularly in the private sector, tend to be dominated by higher and middle-income households. Extending CL-DSF in low-income countries requires the development of capacity in administering these financing schemes and also accrediting providers. Schemes could focus primarily on fixed packages of key services aimed at easily identifiable groups. Piloting and robust evaluation is required to fill the evidence gap on the impact of these mechanisms. Extending demand financing to less predictable services, such as hospital coverage for the population, is likely to require the development of a voucher scheme to purchase insurance. This suggests an already developed insurance market and is unlikely to be appropriate in most low-income countries for some time.

A study was conducted in Bangladesh; the purpose of the study was to look at the feasibility of DSF scheme among the rural poor mothers by collecting information on demand side factors of maternal healthcare and also to assess the purchasing capacity and communities’ behavior towards introducing DSF scheme. The study covered all types of districts – plain, riverine, hilly and tribal. Primary data were collected from the pregnant mothers and mothers in the post natal period. Key informants interviews (KIIs) were conducted with the community and religious leaders, and public representatives. Population representatives sample (PRS) were collected from 6 areas including 450 pregnant and women in the neonatal period. The rate of utilization of ANC was 32.2 percent, PNC was 14.3 percent, and deliveries assisted by medically competent persons were 10.5 percent. The average cost of ANC was Tk.68.75 (US$1), PNC Tk.41.25 (US$0.60) and delivery Tk.650 (About US$10.0). Majority of the families met up the cost of delivery from savings (29.5 percent), followed by personal loan (4.5 percent) and selling of household goods or assets like cows, goats, trees or ornaments (50.0 percent). Findings suggest that introducing prepaid voucher scheme would increase utilization of maternal healthcare, empower people to make choices among different providers, increase quality of care or supply of goods make providers responsive to users and provide financial protection in the event of major illness. Considering the economical status of the households with the pregnant mothers some prepaid voucher scheme may be introduced. The proposed voucher in tentative and could be introduced in a sliding scale. Targeting the poor and choosing beneficiaries need to be a careful exercise for a developing country like Bangladesh.

In the absence of government intervention, the benefits of health services accrue disproportionately to the well-off and this to an extent that is usually politically unacceptable in democratic countries.  Therefore governments, and in developing countries the donors that support them, usually subsidize health services for the poor.  Since identifying and targeting the poor is often difficult, many countries opted to establish publicly owned and operated networks of health services with free services for all at the point of delivery.  Though this strategy has worked well for some countries, and acceptably for many others, over the years serious shortcomings in it have become evident. One the one hand, technological and economic advancements have led populations to demand services that even wealthy governments cannot afford to pay for. On the other hand, the inefficiency of publicly operated health services, and their poor responsiveness to patient expectations, has brought into question the appropriateness of public-sector run health services.  However, those advocating private provision of services have struggled to find transparent and efficient ways to contract the private sector to target public resources to the poor.  One of the options worthy of consideration, and one that has been successfully applied in other sectors, is the use of vouchers. Vouchers and coupons are essentially a way of providing funds for the purchase of a specified range of goods and services. ‘Tied cash’ is one expression that has been used to describe them. Their ability to restrict consumption to ‘socially desirable’ goods and services offers donors and lending agencies an attractive mechanism by which they can invest in developing countries in a manner that subsidizes demand without introducing the market distortions that many supply-side subsidies do.  In other words it enables them to purchase outputs rather than inputs at the same time as offering beneficiaries a choice of provider.  This element of choice sets voucher schemes aside from other output-based aid (such as supply-side subsidies to providers operating under performance-based contracts) and creates incentives to lower prices and/or raise quality, particularly quality as perceived by the voucher bearer.  It is perhaps surprising then, that there have not been more attempts to structure development assistance around voucher schemes.

Health care can be funded in a number of ways ranging from direct user charges (out of pocket) payments to indirect methods that pool across time (prepayment) and across different risk and wealth groups (insurance and general taxation). All these methods can be used to finance maternal health services. When assessing the impact of financing mechanisms it is important to be aware of the different ways they effect service delivery patterns and utilization. Specifically most systems have both equity and efficiency aspects that combine to impact on health service utilization and health status. In general indirect methods that help families to pool the costs of maternal health services are preferable to direct methods of payment. It is also clear, however, that user charges may sometimes help to mitigate deficiencies in systems of pooled funding. Available literature suggests that financing mechanisms for maternal health services could be improved by systems that increase transparency help to mitigate demand-side costs of services and provide funding for that promotes transparent charging for services. While the limited experience of demand-side mechanisms for improving access to maternal health services more evaluation is required.

A study was conducted in Nicaragua. The objective of this study was to evaluate a competitive voucher program intended to make sexual and reproductive health care (SRHC) accessible to adolescents from disadvantaged areas of Managua. A quasi-experimental intervention study was performed in which 28,711 vouchers that gave free access to SRHC in 20 health centers were distributed to adolescents. To evaluate the impact, community sampling took place in markets, neighborhoods, and outside schools where self-administered questionnaires were distributed. The study comprised a random sample of 3,009 female adolescents, ages 12 to 20 years old, 904 voucher receivers and 2,105 non receivers. Their use of SRHC, and knowledge and use of contraceptives and condoms were measured. Voucher receivers had a significantly higher use of SRHC compared with non receivers, 34% versus 19% (adjusted odds ratio, 3.1; 95% confidence interval, 2.5–3.8). The highest influence was seen among respondents at schools, where use was 24% relative to 6% in non receivers (adjusted odds ratio, 5.9; 95% confidence interval, 3.7–9.5). Voucher receivers answered significantly more questions correctly that were related to knowledge of contraceptives and sexually transmitted infections than non receivers. At schools, sexually active voucher receivers had a significantly higher use of modern contraceptives than non receivers, 48% versus 33% (adjusted odds ratio, 2.3; 95% confidence interval, 1.2–4.4); and in neighborhoods, condom use during last sexual contact was significantly greater among voucher receivers than non receivers (adjusted odds ratio, 2.5; 95% confidence interval, 1.4–4.5). The voucher program succeeded in increasing access to SRHC for poor and underserved girls. The needs of adolescents were met with a relatively simple intervention through existing health facilities. Many adolescents appeared willing to protect themselves against the risks of sexual intercourse. This suggests that access to SRHC can play an important role in changing youth behavior and increase the use of contraceptives and condoms.

In an assessment of a maternal health voucher program in Gujarat, India, Bhat et al. find the program appropriately targets the poor and results in significant savings for the indigent. The Chiranjeevi scheme provides vouchers to expectant below-poverty line mothers to reimburse them for the out-of-pocket costs associated with delivery, ante-natal care, transportation, and accompaniment at a private provider. The assessment found that mothers enrolled in the scheme paid less than one-fifth as much as mothers not enrolled in the scheme, had a marked increase in ante-natal services, and were significantly more likely to birth in an institution. Assessment of the program also confirmed appropriate targeting of the poor. Deficits of the program included a low rate of post-natal care, and a failure to make delivery cost-free for mothers. Bhat et al. note that purchasing maternal health care packages in bulk from private obstetricians allowed for a significant economy of scale compared to market rates.

In an analysis of delivery location for slum-dwelling pregnant women in Nairobi, Kenya, Bazant et al. find mothers give birth in private facilities at almost twice the rate of public facilities. Of women surveyed, 42% gave birth in private clinics and 3% in private mission hospitals, whereas 20% birthed in government hospitals, and 1% at government health centers. Over a third of those surveyed gave birth at home without assistance of a train professional. Distance to the site of care proved an important determinant to location of care; 72% of women who attended private clinics had an estimated travel time of less than 30 minutes, whereas the majority of women attending government hospitals traveled more than an hour to reach the facilities. Assistance during delivery was more likely to be provided by a nurse or midwife in the private sector, whereas doctors delivered a higher percentage of children in the public sector (55.3%) as compared to the private sector (47.5%). The median cost for uncomplicated deliveries at government hospitals was over 60% higher than the median cost for an uncomplicated delivery in the private sector. Predictors of birth in a private facility included: lower maternal and partner education, larger household size, a lack of prior complicated pregnancy, and private use of pre-natal care during pregnancy. Bazant et al conclude that given the “heavy reliance of women on private facilities for childbirth” public-private partnerships are needed for increased support and oversight. The authors additionally suggest social franchising “may enable the leveraging of human resources and standardization of maternal health-care provision.”

Kozhimannil et al. conduct a population-level comparative analysis of a national health insurance program, PhilHealth, and a social franchise, Well Family Midwife Clinics, in the Philippines to determine whether the program affected prenatal care visits and institutional deliveries in pregnant women. Although both programs were associated with a statistically significant increase in prenatal care, only PhilHealth, the national insurance scheme, was associated with meeting the targeted standard of four pre-natal visits for expecting mothers. The authors determine that neither intervention significantly affected the probability of giving birth in an institutional setting. Kozhimannil et al. additionally find the national health insurance scheme more effectively reached more vulnerable poor and rural demographics than Well Family. The authors note the variable effectiveness between the programs may be due to Well Family’s smaller scale not being able reach enough individuals to have a “detectable change in the achievement of care standards on a population level.” Kozhimannil et al. also suggest that neither program was effective in increasing institutional deliveries because of a failure to change the calcified cultural tradition of home birth, or provide transportation for expecting mothers.

Ngo et al. analyze the development of a government-run social franchise of rural reproductive health clinics in Vietnam. In the 1990s in Vietnam user fees were imposed in government health centers and private practices were legalized. Following this, the public perceived commune health stations as providing lower quality care, having worse outcomes, and providing less availability of essential supplies than their private counterparts. With the technical assistance of Marie Stopes International, the two provincial government health departments in central Vietnam developed a fractional social franchise for reproductive health and family planning services for community health stations. A preliminary evaluation of the program revealed increased quality and client satisfaction, a willingness of clients to pay for additional services, and a shift from private clinics to the government franchise for RH and FP services.

Onwujeke et al. examine differences in enrollment and utilization in two community-based insurance (CBHI) schemes in Nigeria. The authors find that enrollment was associated with enrollee perception of financial risk protection and quality treatment, and the primary reasons for non-enrollment were inability to pay premiums, concurrent enrollment in a government scheme, and distance from an enrolled facility. The authors argue that although overall enrollment in both programs was low, enrollment was equitable among different socioeconomic groups. This was due to the flexible payment schemes, which allowed the premium to be paid in installments. The authors note that differential enrollment in the two programs can be attributed to: insufficient community involvement, a lack of trust in the programs, and the voluntary nature of the enrollment. The authors argue that both CBHI schemes are not sustainable because of small risk pools and dependency on subsidies, and they recommend the creation of exemptions for in-need groups.

Polonsky et al. examine whether community health insurance (CHI) schemes equitably provide care in rural Armenia. The CHI schemes, established by Oxfam and coordinated by local NGOs, attempt to address rural Armenian equity and access problems caused by large out-of-pocket costs and informal payments for the state-funded health system. From a survey of villages with and without CHI schemes, the authors conclude that healthcare utilization is higher in villages with CHI plans, particularly among the poorest quintile, women, and the elderly. Additionally, in villages with an established CHI scheme, both members participating in the scheme and non-members had higher rates of utilization compared to non-CHI villages, possibly related to improvement in the quality of care. Yet Polonsky et al note that the overall participation rate in CHI schemes was low, possibly due to issues of affordability, dissatisfaction with the package of care offered, and free-riding of non-members to emergency services. The authors conclude the increased equity present in rural Armenia can be attributed to a “sustained and significant external subsidy,” close supervision by funders and implementing NGOs, local ownership, and premium exemptions for the poorest residents.

A newly published study in PLoS reports on a randomized control trial of free health care in rural Ghana to determine the degree to which out-of-pocket payments, rather than quality of service, cultural factors, availability of services, or distance to services, affect health-seeking behavior and associated health outcomes. In the trial, 1227 Ghanaian youth were provided free access to primary and secondary care and free drugs while the control group received no financial assistance. The intervention group demonstrated a marked decrease in the use of informal health care, such as traditional healers or home remedies, compared to the control group. Free health care further had a “modest but significant” impact on health care use – children were taken to primary health care facilities more frequently in the intervention group (2.8 episodes per person year) than in the control group (2.5 episodes per person year). The researchers found no significant difference between the groups in number of episodes of fever, deaths, or prevalence of anemia or malaria. These results, showing a lack of effect between free healthcare and health outcomes, call into question the idea that fees provide a significant barrier to health access, suggesting a greater role for other factors such as distance to health care facility and lack of knowledge about when to use health care services in producing outcomes.

De Costa et al interview key policy stakeholders in the Madhya Pradesh, India, to unpack causes of inadequate coordination between public and private health services. According to their analysis, a “mutual lack of confidence” undermined collaboration between the public and private groups. Public sector stakeholders perceived the private sector as being motivated solely by economic interests, “poorly responsive to partnership initiatives, and focused on self-interest,” while the private sector stakeholders viewed the public sector as “non-supportive, corrupt, and making unrealistic partnership demands.” The authors argue that an important factor contributing to mistrust derives from higher private sector salaries. They suggest, modestly, that collaboration between the public and private sectors could be assisted by altering the predominantly out-of-pocket payment system for health that predominates in India.

In a recent study, WHO and Health Action International researchers report that common essential prescription drugs remain unavailable and unaffordable to the majority of people in thirty-six middle and low-income countries but that availability was consistently higher in the private sector than public sector.  The authors ascribe this to “inadequate funding, lack of incentives for maintaining stocks, inefficient distribution systems, or leakage of medicines for private resale” in the public sector as well as the common public sector practice of marking up drug prices to cross-subsidize other components of the health system.  Cameron et al also contend that generics were more available than costlier originator brands in the private sector in survey countries. The authors believe that drug availability could be increased by “improving procurement efficiency” through national pooled purchasing, procuring drugs by generic name, and making medicines available in the private sector at subsidized prices.  The authors also contend that affordability could be increased by regulating mark-ups, increasing the use of generic medicines through “ensuring the quality of generic products, encouraging price competition,” and increasing the confidence of health professionals in the quality of generic medicines.

This survey of women’s health-seeking behaviors in rural northern Pakistan highlights the success of the private non-profit Aga Khan Health Services (AKHSP) in promoting access to services by facilitating culturally appropriate treatment. Survey participants noted the presence of female staff, positive staff attitudes, and high quality services and medicines at AKHSP. Surveyed women visited AKHSP more frequently than other health services despite increased costs and inconvenient access, stating that the presence of female staff was their main reason for visiting AKHSP over government-run services. To increase women’s use of health services, Shaikh et al recommend social marketing with community health workers and mass-level health education campaigns to inform and empower women, as well as increased communication and coordination between the private and public health services.

Nguyen et al argue that changes in Vietnam’s health care system have paralleled the country’s transition to a market economy: since 1989, the Vietnamese government has transformed the country’s health system by introducing user fees and health insurance and by deregulating pharmaceuticals. These changes aimed to increase quality but have also led to increased out-of-pocket costs leaving many individuals unable to afford care. Nguyen et al surveyed households in rural Northern Vietnam to determine factors influencing health care provider choice. Rural Vietnamese households overwhelmingly used private providers (60%), followed by self-treatment (23%), then public providers (10%). People with higher education levels and larger families were more likely to seek routine treatment from private providers, while the poorest were more likely to use self-treatment for routine conditions. All rural individuals tended to use public health systems for the most costly treatments. Nguyen et al argue that recent changes in the Vietnamese health care system have given more affluent individuals increased access to private health care, while the increased availability of medicines has led poorer individuals to self-treat rather than pay low quality public providers. The authors bring new information to this issue, highlighting that private providers are often considered better and cheaper than the nominally free government services.

A comparative case study of four Central American countries’ experience with limited contracting between public purchasing agencies and external health care providers using an analytical framework based on equity and efficiency. Contracting between non-governmental primary care providers and public purchasing agencies has occurred recently in several Latin America countries as a way to increase efficiency, quality, sustainability and accessibility. Macq et. al. identify that the performance of contracted parties are influenced by three factors: 1) “core descriptive elements of the contractual relation” (including the selection process, definition of benefits packages, management of resources, and quality management), 2) external factors (such as health related technical issues, as well as economic, political, social, and financial beliefs of the contracting agency), and 3) the relationship between the contracting agency and key stakeholders in the larger health system. Upon review of the contracting experiences, the authors conclude that the complexity of contracting requires making clear technical and value-based choices during the nascent stages and adopting flexible behaviors to cope with unexpected planning development and to manage contracting external providers.

Coverage of cost-effective maternal health services remains poor due to insufficient supply and inadequate demand for these services among the poorest groups. Households pay too great a share of the costs of maternal health services, or do not seek care because they cannot afford the costs. Available evidence creates a strong case for removal of user fees and provision of universal coverage for pregnant women, particularly for delivery care. To be successful, governments must also replenish the income lost through the abolition of user fees. Where insurance schemes exist, maternal health care needs to be included in the benefits package, and careful design is needed to ensure uptake by the poorest people. Voucher schemes should be tested in low-income settings, and their costs and relative cost-effectiveness assessed. Further research is needed on methods to target financial assistance for transport and time costs. Current investment in maternal health is insufficient to meet the fifth Millennium Development Goal (MDG), and much greater resources are needed to scale up coverage of maternal health services and create demand. Existing global estimates are too crude to be of use for domestic planning, since resource requirements will vary; budgets need first to be developed at country-level. Donors need to increase financial contributions for maternal health in low-income countries to help fill the resource gap. Resource tracking at country and donor levels will help hold countries and donors to account for their commitments to achieving the maternal health MDG.

The Bangladesh Association of Voluntary Sterilization (BAVS) implemented a home-based SBA program between 1992 and 1997 in all rural unions of Chandpur Sadar Upazila about 60 km south and south-east of Dhaka, the capital of Bangladesh. Local community women with 5–10 years of schooling were trained for 6 months in midwifery, including hands-on birthing experience, to do safe home-deliveries and provide antenatal and postnatal care services in their respective communities. The Nongovernmental Organization (NGO) Service Delivery Project (NSDP), in collaboration with its partner NGOs, initiated a home-based SBA program in 10 different rural and periurban areas of the country with its existing nurses or midwives (nurses are trained for 4 years and family-welfare visitors for 18 months) in May 2005. During inception, all selected nurses or midwives received 1 week refresher training on evidence-based maternal and newborn health-care techniques. In February to May 2006, the International Centre for Diarrhea Disease, Bangladesh (ICDDR, B) evaluated these two home-based SBA programs for their functionality, use and sustainability. As part of the evaluation, cross-sectional community surveys were done in both BAVS and NSDP home-based SBA areas among women who had given birth in the previous 12 months (excluding abortions or miscarriages). We present findings from the cross-sectional surveys.

For field-data collection, self-weighted cluster sampling was used. Selection of clusters was with equal probability and a take-all strategy was followed at the second stage. A list of primary sampling units was generated after reviewing the population distribution of mouzas (a revenue village with a jurisdiction list number) in each study area (BAVS and NSDP). To reduce the workload, mouzas with populations of more than 2000 people were divided into segments with each segment consisting of about 1000 people. Each segment was considered a primary sampling unit. In each study area, an exhaustive list of primary sampling units was generated with the help of local NGO managers. Sixty primary sampling units were then selected randomly from both NSDP and BAVS areas. For sample-size calculation, we used 9.4% as the prevalence of skilled attendance in rural and peri urban areas, and 2% as precision, and a design effect of 1.2 for two stages in the sample selection technique. Twelve trained interviewers collected data by use of a structured questionnaire. The questionnaire gathered information on background, use of antenatal care, use of SBA, use of postnatal care, perceived quality of care and cost of services. Field supervisors and study investigators closely supervised field activities; 5% of cases were re-interviewed to ensure a high degree of quality of data. In total, 2164 women were interviewed, which was slightly higher than the estimated minimum sample size of 2000. The non-response rate was 0%. Wealth was measured in terms of asset quintiles with the pooled household-level data following principal components and factor analysis methods. Other variables used to measure inequity were distance to nearest government hospital (5 km or less or more than 5 km), area of residence (urban or rural), and educational status of both women and their husbands (none, 1–4 years, 5–9 years, and ≥ 10 years of schooling), and religion (Muslim or Hindu and other). Antenatal care was measured in number of visits to any provider whether formal or informal. Outcome measures focused on whether an SBA (doctor, nurse or midwife, excluding trained or untrained traditional birth attendant) was present at delivery, whether caesarean section was used, or whether any postnatal care was received. Home-based attendants with 6 months or 18 months midwifery training in the BAVS study and the NSDP study, respectively, were considered SBAs in this study. To look for determinants of using these services, multivariate logistic regression models were used to calculate crude and adjusted odds ratios. In multi logistic regression models, the independent variables included asset quintile, education of the woman and her husband, distance to nearest government hospital, religion, number of antenatal care visits, and reported complication status during pregnancy or delivery. Area of residence was excluded from the multivariate model due to the high degree of colinearity with distance to government hospital. The age and parity of women were used as control variables.

Most respondents were Muslims (94.5%) and housewives (95.2%). Average household size was 6.3 people, and monthly household expenditure about US$ 90. More than 80% of households had sanitary latrines, but only 33% had televisions, 26.8% had mobile phones, and 61% had electricity. At least 1 year of schooling had been completed by 80.2% of respondents, while the rate was 72.6% among their husbands. The average distance between home and the nearest government hospital was 6.2 km. Of the respondents, 15% were less than 20 years old while 4.2% were more than 35 years old. About 35% were in their first pregnancy and 10% of women had had five or more pregnancies. In our study areas, 35% of deliveries were attended by SBAs: 22.8% at health facilities and 12.4% at home. Of the 22.8% facility-deliveries, 12.9% took place at private facilities, 9.1% in government facilities, while only 0.8% were in NGO facilities. About two-thirds of all deliveries took place at home with unskilled birth attendants. Caesarean sections were performed on 10.8% of the study population, while 93% and 28% had at least one antenatal and postnatal care visit respectively. Of all caesarean deliveries, 73% took place at private facilities, 3% in NGO facilities, and the remaining 24% were in government facilities. For those who received antenatal care, the mean number of visits was 4.38, and 50% had four or more visits. Mean gestational age was 16.9 weeks and 30.2 weeks for the first and last antenatal-care visits respectively. Among those who received antenatal care, 32% had their last visit at government facilities, 16% at NGO clinics, 24.5% at private facilities, and the remaining 27.5% were at home. By type of service providers, 32.5% received their last antenatal-care visit from qualified physicians, 36% from NGO paramedics (including home-based SBAs), 25.4% from government paramedics, and 6.1% from informal providers (including TBAs and village doctors). Of those who received postnatal care, their mean number of visits was 1.8. Only 5.5% of mothers received postnatal care within 48 h and 14% within 1 week after giving birth. There were substantial inequities in the use of SBAs by asset quintile, education, area of residence, and distance to hospital. Use of skilled attendance was 15.6% among mothers from the poorest quintile households and 63.3% for mothers from the richest quintile households. Similarly the skilled attendance rate was 18.2% and 74.3% among mothers with no education and with higher education (≥ 10 years schooling) respectively. Use of SBAs was higher among those living in urban areas than among those in rural areas (42.8% versus 32%). Distance to the nearest government hospital had a negative influence on delivery by an SBA (41% of women living within 5 km of a government hospital gave birth with an SBA compared with 28% of women living more than 5 km from a facility). Use of skilled attendance was higher among other religious groups (mostly Hindus) than among Muslims (61.3% versus 33.6% respectively).

Antenatal care visits increased use of SBAs at birth: only 7.6% of those with no antenatal care visit used SBAs, while nearly 50% of mothers with four or more visits did so. Skilled attendance at birth was 48% among mothers who reported at least one complication during pregnancy or the delivery period compared with 23% among those who did not. Among women from the poorest quintile households, 3.3% had caesarean sections, whereas 28.4% of mothers from the richest quintile did so. Similarly, use of caesarean section was significantly higher among mothers with higher education, from urban areas, those who lived within 5 km of government hospitals, and who were not Muslim. In the bivariate analysis, the uptake of caesarean section was also significantly higher among those who reported complications and received more antenatal care visits. Use of postnatal care services varied by asset quintiles, education of parents, and number of antenatal care visits, but not by distance to health facility or religion. The uptake of postnatal care services was greater in rural areas (30.1%) than in urban areas (23.2%). In multilogistic regressions, all seven independent variables were significant predictors for use of SBAs. The best predictor for use of SBAs was the education level of the woman, followed by (strength of association) reported complication status, wealth quintile, number of antenatal care visits, distance to nearest government facility, education of the husband and religion. The significant predictors for use of caesarean section deliveries were (by order of strength of association): education of woman, reported complications during pregnancy and delivery, asset quintile, religion, education of husband and distance to nearest government hospital. The influence of the number of antenatal care visits upon delivery by caesarean sections was attenuated and lost its significant association when effects of all covariates were controlled statistically.

Multilogistic regression shows that significant predictors for use of postnatal care services were asset quintile, reported complication status of mothers, and number of antenatal care visits, but not distance, religion, or education of the women or her husband. Inequality was highest for delivery by caesarean section (rich: poor ratio = 7.52; concentration index = 0.48; Fig. 1) and lowest for use of any antenatal care services (rich: poor ratio = 1.13; concentration index = 0.03). For delivery by SBA and use of postnatal care services, the rich: poor ratio and concentration index were 4.06 and 0.28, and 1.74 and 0.11, respectively (Fig. 1). Skilled delivery care services from the private sector were used less by poor people than services from government and NGO facilities, or home-based skilled providers. Services from unskilled providers were used most by poor people.

A study was conducted at Karnataka, India. The study rationale was for all pregnant women, the most significant demand side barrier in Karnataka as in the rest of India was the cost of maternal services especially cost of institutional delivery services. Demand side financing has been recently discussed as a complimentary financing mechanism to address some of these issues. 1. To study the feasibility of use of vouchers among pregnant women to overcome cost barriers. 2. To design and estimate the cost of a competitive voucher model. In depth interviews, focus group discussions with health care providers, pregnant women, and HIV counselors were used as main tools for collecting data on barriers to maternal health care, costs for various services and on feasibility of use of vouchers. Based on inputs from various stakeholders a voucher scheme model was designed to cover issues in operation, management, and monitoring aspects of the scheme. Costs of such an option for a sub-district were also estimated using unit costs and estimates of pregnancies, complications, and HIV prevalence. Our study reiterated that access to maternal health care was very much affected by costs of care. Vouchers as an option for reducing the cost barrier were acceptable to both providers (private and public) and users. Voucher as a small information booklet with a unique identification number that allows for record keeping with vital medical information prerecorded and readily available during emergencies would be most useful. To prevent fraud and misuse and given the low level of health care utilization cross socio-economic groups, we recommend that the vouchers be provided universally rather than be targeted to below poverty line families. The cost of such a scheme for two years for a population of one million, under universal coverage, would be $4.31 million (covering unit costs of $46 for normal delivery; $195 for c-sections; $339 for HIV positive mothers). One-way sensitivity analysis showed that the total estimated cost of pilot program changed by 7% to 11% for up to 100% change in baseline input parameters. Vouchers appear to be an acceptable and feasible option for improving maternal health care in Karnataka. From a user perspective, the primary advantage of a voucher was the reduced dependency on loans to pay for emergency services. Women also reported that having a voucher in hand would empower them to demand care. Thus the possible returns from the introduction of a voucher scheme in terms of improved health and reduced impoverishment for households would thus outweigh the potential risks in terms of escalation of program costs.

A study was conducted in Bangladesh to explore use-inequity in maternal health-care services in home-based skilled-birth-attendant (SBA) program areas in Bangladesh. Data from a community survey, conducted from February to May 2006, were analyzed to examine inequities in use of SBAs, caesarean sections for deliveries and postnatal care services according to key socioeconomic factors. Of 2164 deliveries, 35% had an SBA, 22.8% were in health facilities and 10.8% were by caesarean section. Rates of uptake of antenatal and postnatal care were 93% and 28%, respectively. There were substantial use-inequities in maternal health by asset quintiles, distance, and area of residence, and education of both the woman and her husband. However, not all inequities were the same. After adjusting for other determinants, the differences in the use of maternal health-care services for poor and rich people remained substantial [adjusted odds ratio (OR) 2.51 (95% confidence interval, CI: 1.68–3.76) for skilled attendance; OR 2.58 (95% CI: 1.28–5.19) for use of caesarean sections and OR 1.53 (95% CI: 1.05–2.25) for use of postnatal care services]. Complications during pregnancy influenced use of SBAs, caesarean-section delivery and postnatal care services. The number of antenatal care visits was a significant predictor for use of SBAs and postnatal care, but not for caesarean sections. Use of maternity care services was higher in the study areas than national averages, but a tremendous use-inequity persists. Interventions to overcome financial barriers are recommended to address inequity in maternal health. A greater focus is needed on the implementation and evaluation of maternal-health interventions for poor people.

A study was conducted in Nicaragua. This study evaluates the impact and sustainability of a competitive voucher program on the quality of SRH care for poor and underserved female adolescents and the usefulness of the simulated patient (SP) method for such evaluation. 28,711 vouchers were distributed to adolescents in disadvantaged areas of Managua that gave free-of-charge access to SRH care in 4 public, 10 non-governmental and 5 private clinics. Providers received training and guidelines, treatment protocols, and financial incentives for each adolescent attended. All clinics were visited by female adolescent SPs requesting contraception. SPs were sent one week before, during (with voucher) and one month after the intervention. After each consultation they were interviewed with a standardized questionnaire. Twenty-one criteria were scored and grouped into four categories. Clinics’ scores were compared using non-parametric statistical methods (paired design: before-during and before-after). Also the influence of doctors’ characteristics was tested using non-parametric statistical methods. Some aspects of service quality improved during the voucher program. Before the program started 8 of the 16 SPs returned ’empty handed’, although all were eligible contraceptive users. During the program 16/17 left with a contraceptive method (p = 0.01). Furthermore, more SPs were involved in the contraceptive method choice (13/17 vs.5/16, p = 0.02). Shared decision-making on contraceptive method as well as condom promotion had significantly increased after the program ended. Female doctors had best scores before- during and after the intervention. The improvements were more pronounced among male doctors and doctors older than 40, though these improvements did not sustain after the program ended. This study illustrates provider-related obstacles adolescents often face when requesting contraception. The care provided during the voucher program improved for some important outcomes. The improvements were more pronounced among providers with the weakest initial performance. Shared decision-making and condom promotion were improvements that sustained after the program ended. The SP method is suitable and relatively easy to apply in monitoring clinics’ performance, yielding important and relevant information. Objective assessment of change through the SP method is much more complex and expensive.

Study Design

It was a cross sectional comparative study conducted among the pregnant women from both the DSF voucher holder and non voucher holder group in Bogura Upazilla, Bogura District to assess the impact on financial subsidy on women’s health, pregnancy outcome etc.

Study place

The study was carried out by Bogura Upazilla, Bogura.

Study Period

The study was conducted from April 2010 to August 2010.

Study population

All the pregnant women of selected Upazilla both voucher holder and non voucher holder, who delivered their end product of gestation within last two months both at hospital and community level.

Inclusion criteria:

• Voucher holder women who delivered their end product of gestation within last two months both at hospital.
• Non – voucher holder women who delivered their end product of gestation within last two months both at hospital and community level (mostly community level).

Exclusion criteria:

• Married women who didn’t delivered their end product of gestation within last two months both at hospital and community level.

Sample size

The sample size was purposively selected at 200, 100 women with voucher & 100 with out voucher.

Sampling technique 

Purposive sampling technique was followed.

Data Collection tools 

For smooth conduction of the study, a structured and open ended questionnaire was developed consisting of five parts. The first part of the interview schedule was on socio-demo graphic status related questions, second part on respondents obstetric history, third part on their health care seeking during pregnancy, fourth part on pregnancy outcome and last part on their over all opinion on DSF voucher scheme.

Data Collection procedure 

After explaining the purpose of the study data was collected through face to face interview using a Bengali structured questionnaire.

Conduction of the study, quality control and monitoring  

The investigator herself was collect the data from the selected Upazilla. The collected data was checked and verified by the investigator at the end of work every day. Any inaccuracy and inconsistency was corrected in the next working day. However, cross checking of the collected data was made randomly.

Data processing and data analysis

The data entry was started immediately after the completion of data collection. The collected data was checked, verified and then entered into the computer. Only fully completed datasheet was entered into the computer for final analysis. The analysis was carried out with the help of SPSS (Statistical package for social science) Windows software program.

Ethical issues

For smooth condition of the study, the respondents were informed about the purpose of the study. There was no loss of working hours of the respondents; about 20 minutes time was required for each interview.  Before the interview, the respondents were briefed about the objectives of the study and their voluntary participation was sought. Before interviewing, a written informed consent were obtained from the respondents and they were assured that the collected data would be kept confidential.

Results

In this study 100 women who received DSF (Demand Side Financing) facilities and 100 women who didn’t avail those facilities were compared. The two groups were homogenous regarding age, socio-economic status etc.

Table 1 Distribution of the respondents by age (n = 200)

Non voucher holder women were relatively younger than the voucher holder women. Majority of women of both group were below the age of 30 years. The mean age of voucher holders was 27.23 ± 5.71 with a range of 15 – 36 years, while mean age of non – voucher holders was 26.89 ± 5.98 with a range of 14 – 37 years.

Table  Distribution of the respondents by religion (n = 200)

Among the both voucher holders and non – voucher holder groups Muslim were majority , followed by Hindu (15%) of voucher holder and 13% of non – voucher holders.

Table  Educational status of the respondents (n = 200)

Non voucher women were relatively less educated than the voucher holder women. 34% of the voucher holders had primary level of education against 24% of non voucher holders. On the other hand, majority of the SSC and above level education were seen among voucher holders. But most of the respondent women were below primary level of education

Table  Educational status of the respondent’s husbands (n = 200)

Over all educational status of voucher holders husbands was better than that of non – voucher holders. 38% of the voucher holder’s husbands had primary level of education against 35% of non voucher holders. Majority of the SSC and above level education were seen among voucher holder’s husbands.

Table  Occupation of the respondents (n = 200)

Among the respondents of both the voucher holders and non – voucher holders more than four fifths were house wives, followed by house maid (13% & 10%). Few students were noted as well.

Table  Occupation of the respondent’s husbands (n = 200)

Above half of the respondent’s husbands both voucher holder and non – voucher holder groups were farmers, followed by day labor (15% & 12%). Among the remaining small business (10% & 13%) were notable.

Table  Distribution of the respondents by monthly family income (n = 200)

The mean monthly family income of the voucher holders family was 1989.78 ± 1071.34 with a range of 500 – 5500 Tk. The mean monthly family income of the non – voucher holders family was 2253.69 ± 1175.47 with a range of 800 – 7,500 Tk. 52% of voucher holders and 48% of non – voucher holders family was earning between 2001-3000 Tk. a month, followed by 1001-2000 Tk. (28% & 24%). Over all the economic status of non – voucher holders was better than that of voucher holders.

Table  Distribution of the respondents by family size (n = 200)

The mean family size of voucher holders was 5.78 ± 1.71 ranging from 3 – 16. The mean family size of non – voucher holders was 4.99 ± 1.99 ranging from 2 – 15. The largest group was of 5-6 family members (54% of voucher holders & 57% of non voucher holders), followed by ≥7 members group (33% of voucher holders & 27% of non voucher holders).

Table  Distribution of the respondents by number of pregnancy (n = 200)

46% of voucher holder women and 51% of non voucher holder women experienced twice pregnancy before. 25% of voucher holder women and 22% of non voucher holder women experienced thrice pregnancy before. 24% of voucher holder women and 20% of non voucher holder women experienced pregnancy for four times before.

Table  Distribution of the respondents by number of alive children (n = 200

44% of voucher holder women and 52% of non voucher holder women had two alive offspring. 26% of voucher holder women and 20% of non voucher holder women had three alive children. 25% of voucher holder women and 18% of non voucher holder women had four alive children.

Table  Distribution of the respondents by their previous experience of abortion

(n = 200)

8% of voucher holder women and 11% of non voucher holder women experienced abortion previously.

Table  Distribution of the respondents by their frequency of abortion (n = 19)

Out of 19 respondents with previous experience of abortion 16 had abortion for once only.

Table  Relationship between voucher holding status and ANC seeking (n = 200)

Voucher holder women were much more likely to take regular ANC than the non voucher holder women (OR = 76.221 at 95% CI: 10.845 – 535.682). The relationship between voucher holding and regular ANC check up was statistically significant (p < 0.05).

Table  Relationship between voucher holding status and regular iron, vitamin intake by respondents (n = 200)

Voucher holder women were 23 times more likely to take regular iron, vitamins than the non voucher holder women (OR = 23.1 at 95% CI: 8.820 – 60.283). The relationship between voucher holding and regular intake of iron tablet or vitamins was statistically significant (p < 0.05).

Table Relationship between voucher holding status and regular physical check up by the respondents (n = 200)

Voucher holder women were 13 times more likely to take regular physical check up like pulse, BP etc than the non voucher holder women (OR = 13.3 at 95% CI: 6.49 – 27.197). The relationship between voucher holding and regular physical check up was statistically significant (p < 0.05).

Table  Relationship between voucher holding status and adequate nutritious food intake (n = 200)

Voucher holder women were 3 times more likely to take additional nutritious food than the non voucher holder women (OR = 3.1 at 95% CI: 2.101 – 4.519). The relationship between voucher holding and additional nutritious food intake was statistically significant (p < 0.05).

Table Relationship between voucher holding status and birth attendant (n = 200)

Voucher holder women were 0.115 (8.7) times less likely to conduct delivery by unskilled birth attendant than the non voucher holder women (OR = 0.115 at 95% CI: 0.069 – .192). The relationship between voucher holding and conduction of delivery by skilled birth attendant was statistically significant (p < 0.05).

Table  Relationship between voucher holding status and complication before delivery (n = 200)

Voucher holder women were 0.358 (2.8) times less likely to develop complication before delivery than the non voucher holder women (OR = .358 at 95% CI: 0.225 – .569). The relationship between voucher holding and development of complication before delivery was statistically significant (p < 0.05).

Table  Relationship between voucher holding status and respondents knowledge on complication of pregnancy (n = 200)

Voucher holder women were 15.3 times more likely to have satisfactory knowledge on complication of pregnancy than the non voucher holder women (OR = 15.251 at 95% CI: 7.644 – 30.430). The relationship between voucher holding and level of knowledge on pregnancy related complication was statistically significant (p < 0.05).

*** There was 7 danger sign in questionnaire. Out of those 7 if any respondent could identify at least 4 sign was judged to possess satisfactory level of knowledge in this regard.

Table  Relationship between voucher holding status and nutritional status of newborn babies (n = 200)

Voucher holder women’s babies were 3.1 times more likely to be of normal weight than the non voucher holder women (OR = 3.058 at 95% CI: 1.714 – 5.457). The relationship between voucher holding and weight of newborn baby was statistically significant (p < 0.05).  

DISCUSSION

It was a Cross sectional comparative study conducted among the pregnant women from both the DSF voucher holder and non voucher holder group in Bogura Upazilla,Kaptai,Bogura District to assess the impact on financial subsidy on women’s health, pregnancy outcome etc. In this study 100 women who received DSF (Demand Side Financing) facilities and 100 women who didn’t avail those facilities were compared. The two groups were same regarding age, socio-economic status etc. Data were collected using a structure and open ended questionnaire and samples were chosen purposively. Among the voucher holders most of them were either <25 (43%) or 25 – 29 (45%) age group. Among the non – voucher holders 48% were <25 age groups while 41% were 25 – 29 years age group. The mean age of voucher holders was 27.23 ± 5.71 with a range of 15 – 36 years, while mean age of non – voucher holders was 26.89 ± 5.98 with a range of 14 – 37 years. Among the both voucher holders and non – voucher holder groups Muslim were majority , followed by Hindu (15%) of voucher holder and 13% of non – voucher holders. Over all educational status of voucher holders was better than that of non – voucher holders. 34% of the voucher holders had primary level of education against 24% of non voucher holders. Majority of the SSC and above level education were seen among voucher holders. Over all educational status of voucher holders husbands was better than that of non – voucher holders. 38% of the voucher holder’s husbands had primary level of education against 35% of non voucher holders. Majority of the SSC and above level education were seen among voucher holder’s husbands. Among the respondents of both the voucher holders and non – voucher holders more than four fifths were house wives, followed by house maid (13% & 10%). Few students were noted as well. Above half of the respondent’s husbands both voucher holder and non – voucher holder groups were farmers, followed by day labor (15% & 12%). Among the remaining small business (10% & 13%) were notable. The mean monthly family income of the voucher holders family was 1989.78 ± 1071.34 with a range of 500 – 5500 Tk. The mean monthly family income of the non – voucher holders family was 2253.69 ± 1175.47 with a range of 800 – 7,500 Tk. 52% of voucher holders and 48% of non – voucher holders family was earning between 2001-3000 Tk. a month, followed by 1001-2000 Tk. (28% & 24%). Over all the economic status of non – voucher holders was better than that of voucher holders. The mean family size of voucher holders was 5.78 ± 1.71 ranging from 3 – 16. The mean family size of non – voucher holders was 4.99 ± 1.99 ranging from 2 – 15. The largest group was of 5-6 family members (54% of voucher holders & 57% of non voucher holders), followed by ≥7 members group (33% of voucher holders & 27% of non voucher holders).

46% of voucher holder women and 51% of non voucher holder women experienced twice pregnancy before. 25% of voucher holder women and 22% of non voucher holder women experienced thrice pregnancy before. 24% of voucher holder women and 20% of non voucher holder women experienced pregnancy for four times before. 44% of voucher holder women and 52% of non voucher holder women had two alive offspring. 26% of voucher holder women and 20% of non voucher holder women had three alive children. 25% of voucher holder women and 18% of non voucher holder women had four alive children. 8% of voucher holder women and 11% of non voucher holder women experienced abortion previously. Out of 19 respondents with previous experience of abortion 16 had abortion for once only.

There was significant association between voucher holding and occurrence of delivery at public hospital instead of home delivery (p < 0.05). Those women with voucher or receiving DSF facilities were 12.5 times more likely to go to public hospital for delivery than those with out voucher (OR = 12.5 at 95% CI: 6.431 – 24.298). Voucher holder women were much more likely to take regular ANC than the non voucher holder women (OR = 76.221 at 95% CI: 10.845 – 535.682). The relationship between voucher holding and regular ANC check up was statistically significant (p < 0.05). Voucher holder women were 23 times more likely to take regular iron, vitamins than the non voucher holder women (OR = 23.1 at 95% CI: 8.820 – 60.283). The relationship between voucher holding and regular intake of iron tablet or vitamins was statistically significant (p < 0.05). Voucher holder women were 13 times more likely to take regular physical check up like pulse, BP etc than the non voucher holder women (OR = 13.3 at 95% CI: 6.49 – 27.197). The relationship between voucher holding and regular physical check up was statistically significant (p < 0.05). Voucher holder women were 3 times more likely to take additional nutritious food than the non voucher holder women (OR = 3.1 at 95% CI: 2.101 – 4.519). The relationship between voucher holding and additional nutritious food intake was statistically significant (p < 0.05).

A study was conducted in Bangladesh; the purpose of the study was to look at the feasibility of DSF scheme among the rural poor mothers by collecting information on demand side factors of maternal healthcare and also to assess the purchasing capacity and communities’ behavior towards introducing DSF scheme. The rate of utilization of ANC was 32.2 percent, PNC was 14.3 percent, and deliveries assisted by medically competent persons were 10.5 percent. Findings suggest that introducing prepaid voucher scheme would increase utilization of maternal healthcare, empower people to make choices among different providers, increase quality of care or supply of goods make providers responsive to users and provide financial protection in the event of major illness. A study was conducted in Nicaragua. The objective of this study was to evaluate a competitive voucher program intended to make sexual and reproductive health care (SRHC) accessible to adolescents from disadvantaged areas of Managua. Voucher receivers had a significantly higher use of SRHC compared with non receivers, 34% versus 19% (adjusted odds ratio, 3.1; 95% confidence interval, 2.5–3.8). This survey of women’s health-seeking behaviors in rural northern Pakistan highlights the success of the private non-profit Aga Khan Health Services (AKHSP) in promoting access to services by facilitating culturally appropriate treatment. Survey participants noted the presence of female staff, positive staff attitudes, and high quality services and medicines at AKHSP. Surveyed women visited AKHSP more frequently than other health services despite increased costs and inconvenient access, stating that the presence of female staff was their main reason for visiting AKHSP over government-run services. Onwujeke et al. examine differences in enrollment and utilization in two community-based insurance (CBHI) schemes in Nigeria. The authors find that enrollment was associated with enrollee perception of financial risk protection and quality treatment, and the primary reasons for non-enrollment were inability to pay premiums, concurrent enrollment in a government scheme, and distance from an enrolled facility.

In this study voucher holder women were 0.115 (8.7) times less likely to conduct delivery by unskilled birth attendant than the non voucher holder women (OR = 0.115 at 95% CI: 0.069 – .192). The relationship between voucher holding and conduction of delivery by skilled birth attendant was statistically significant (p < 0.05). Voucher holder women were 0.358 (2.8) times less likely to develop complication before delivery than the non voucher holder women (OR = .358 at 95% CI: 0.225 – .569). The relationship between voucher holding and development of complication before delivery was statistically significant (p < 0.05). Voucher holder women were 15.3 times more likely to have satisfactory knowledge on complication of pregnancy than the non voucher holder women (OR = 15.251 at 95% CI: 7.644 – 30.430). The relationship between voucher holding and level of knowledge on pregnancy related complication was statistically significant (p < 0.05). (There was 7 danger sign in questionnaire. Out of those 7 if any respondent could identify at least 4 sign was judged to possess satisfactory level of knowledge in this regard). Voucher holder women’s babies were 3.1 times more likely to be of normal weight than the non voucher holder women (OR = 3.058 at 95% CI: 1.714 – 5.457). The relationship between voucher holding and weight of newborn baby was statistically significant (p < 0.05).

A study was conducted in Bangladesh to explore use-inequity in maternal health-care services in home-based skilled-birth-attendant (SBA) program areas in Bangladesh. After adjusting for other determinants, the differences in the use of maternal health-care services for poor and rich people remained substantial [adjusted odds ratio (OR) 2.51 (95% confidence interval, CI: 1.68–3.76) for skilled attendance; OR 2.58 (95% CI: 1.28–5.19) for use of caesarean sections and OR 1.53 (95% CI: 1.05–2.25) for use of postnatal care services]. In a recent study, WHO and Health Action International researchers report that common essential prescription drugs remain unavailable and unaffordable to the majority of people in thirty-six middle and low-income countries but that availability was consistently higher in the private sector than public sector.  The authors ascribe this to “inadequate funding, lack of incentives for maintaining stocks, inefficient distribution systems, or leakage of medicines for private resale” in the public sector as well as the common public sector practice of marking up drug prices to cross-subsidize other components of the health system.

Conclusion

It was a Cross sectional comparative study conducted among the pregnant women from both the DSF voucher holder and non voucher holder group in Bogura Upazilla,Kaptai,Bogura District to assess the impact on financial subsidy on women’s health, pregnancy outcome etc.

Most of them had poor level of education (below primary level), young (less than 30 years of age), Muslim, house wives. Non – voucher holder women’s family was better in regards to education, income, health seeking behavior etc.

The study findings suggest that voucher distribution and financial assistance can encourage women to seek more ANC care, hospital delivery, more regular check up during pregnancy. Financial subsidy and regular seeking of treatment and healthcare can lead to better nutritional status and better pregnancy outcome with less complication of pregnancy. Over all status of delivered babies (i.e. birth weight, neonatal infection) was better of voucher holder women than non voucher holder women. Voucher holder women were more likely to have satisfactory knowledge on complication of pregnancy than the non voucher holder women. All the above mentioned relationship between voucher holding and individual issues regarding check up or complications or else was statistically significant (p < 0.05). The study findings strongly suggest that financial subsidy is very helpful for better treatment seeking, pregnancy outcome etc.

Recommendation

This study finding reveals that pregnancy outcome, health seeking behavior is better among DSF voucher holder women than non voucher holder women, although voucher holder women’s families are less educated and poorer that the non – voucher holder women.

From the study the above mentioned recommendation can be drawn –

1. ACS (Advocacy, communication and social mobilization) program at Upazilla Health Complex, rural Govt. and NGO level to improve health seeking behavior of all regarding care of pregnancy and safe delivery.
2. Expansion of DSF to almost all Upazilla.
3. Family counseling for ensuring more utilization of available reproductive and maternal health services.
4. Adoption of voucher scheme as a component of NGOs program on reproductive and maternal health at rural level.