BANGLADESH: Demand-Side Financing Bolsters Maternal Health

Plans to expand demand-side financing (DSF) through vouchers could further improve the maternal health of thousands of women in Bangladesh, experts and government officials say.

“The results are very encouraging so far and we could see more,” Shaila Sharmin Zaman, senior assistant chief of planning in the Ministry of Health and Family Welfare (MOHFW), told IRIN. “We are in the process of analyzing the data and in two months we will know the impact of DSF in reducing maternal deaths.”

Under the programme, poor pregnant women receive vouchers that entitle them to free maternal health services, transport subsidies, and a cash incentive for giving birth with the assistance of a qualified maternal healthcare provider (public, non-governmental or private).

The Bangladesh DSF voucher scheme was developed by the MOHFW with support from the World Health Organization. It aims to reduce the financial barriers faced by poor women in accessing maternal healthcare, and increase the demand for institutional services in childbirth.

In line with the Millennium Development Goals, Bangladesh hopes to reduce its current maternal mortality ratio (MMR) of 194 per 100,000 live births to 143 by 2015. The rate has declined from 322 in 2001.

Community health workers identify eligible beneficiaries according to a number of criteria, including economic status, whether this is the first or second pregnancy, in which district the woman resides, and the lack of land or other productive assets.

The project was launched in 2004 but became functional in 2007 and has now been implemented in 37 sub-districts (upazilas). To date, more than 500,000 women have benefited.

“In July 2011 the third phase began, covering 53 upazilas, and we plan to expand the scheme to 152 of the country's 481 upazilas by the end of 2015,” Zaman said.

A 2010 government survey of maternal mortality and healthcare reported better care-seeking practices, and that the use of higher level health facilities for delivery had resulted in a 40 percent reduction in maternal deaths in the last 10 years.

The first evaluation study of the scheme, carried out with technical advice from the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) in 2010, reported that deliveries assisted by skilled personnel reached 64 percent in the DSF areas, compared to a national average of 29 percent, according to the Bangladesh 2011 Demographic and Health survey.

“The voucher scheme stimulated poor women to seek essential service delivery because they did not need money,” said Muhammad Abdul Hannan Khan, a senior technical advisor at GIZ, noting that the voucher scheme increased the demand for antenatal, delivery and postnatal care by poor women who were unaware of their rights.

But concerns have been raised about possible corruption in the distribution of vouchers, and allegations that the relatives of influential people were being favoured. “There is a risk of corruption. We try to computerize the system, and track down the beneficiaries and raise awareness to the people, but the risk is still there,” Khan conceded.

“The voucher scheme cannot improve the quality of health facilities or change people's behaviour,” said Tapash Roy, a maternal health programme manager at the Bangladesh Rehabilitation Assistance Committee (BRAC), which also runs a maternal health voucher scheme in rural areas and urban slums.

“We target marginalized people that are not easy to locate, and the voucher had a significant impact on reducing maternal mortality rates,” he said.

Although more women are using the services, awareness has not improved much, perhaps indicating that they are doing so because of the financial incentive and other benefits offered by the vouchers.

There is also a restriction that limits participating mothers to just two pregnancies, effectively blocking access to extremely poor women who tend to have more than two children, health experts noted.

The incentive payments may also generate new problems and conflicts between health workers and administrative staff, who are not paid extra money for enrolling the beneficiaries.

Experts concluded that further in-depth study should be undertaken before scaling up the programme to a wider geographic reach.