1. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 1 Maternal Mortality in Kenya and Bangladesh A comparative overview & some analysis Jean-Olivier Schmidt

2. Compare - what? Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 2 MMR in Kenya and Bangladesh

3. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 3 MMR in Kenya and Bangladesh

4. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 4 MMR in Kenya and Bangladesh

5. Are we comparing apples and pears........de gustibus non est disputandum MDGs: we, ie the World Community, have universally recognized and accepted MDGs that make it binding for the countries to achieve these. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 5 MMR in Kenya and Bangladesh

6. Compare – why? Amartya Sen: What can Africa and India learn from each other (1987)? There are indeed a great many lessons to be learnt by India and Africa from the experiences of each other. Kuhn (2011): Routes to low Mortality in poor countries revisited. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 6 MMR in Kenya and Bangladesh

7. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 7 MMR in Kenya and Bangladesh 1990 Bangladesh: 574 Kenya: 600 2015 Bangladesh: 143 Kenya: 147 20002010 Kenya: 418 Bangladesh: 320 Kenya: 488 Bangladesh: 192

8. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 8 MMR in Kenya and Bangladesh OUTCOME Kenya 418 Bangladesh: 390 OUTCOME Kenya 488 Bangladesh: 192 10 years

9. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 9 MMR in Kenya and Bangladesh 10 years OUTCOME Kenya 418 Bangladesh: 390 OUTCOME Kenya 488 Bangladesh: 192

10. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 10 MMR in Kenya and Bangladesh OUTCOME Kenya 488 Bangladesh: 192 Financial Inputs Kenya: 27 US$ Bangladesh: 15 US$ Kenya: OOP/THE 36% Bangladesh: OOP/THE 67% Kenya: GDP/capita: PPP: 1711 US$ Bangladesh: GDP/capita: PPP: 1600 US$ Outputs by the Health System K:Institutional delivery/SBA: 43/44% BD: Institutional delivery/SBA: 20/24% BD Adult lit. rate: 55% K Adult lit. rate: 87% Inequity: K: 1 to 5 BD: 1 to 10

11. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 11 MMR in Kenya and Bangladesh Maternal deaths are the most common cause of death (about 1/4) among women 20 34 years, and is also an important cause of death for women aged 35 39 years Source: BMMS 2010

12. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 12 MMR in Kenya and Bangladesh Maternal deaths are the most common cause of death (about 1/4) among women 20 34 years, and is also an important cause of death for women aged 35 39 years Source: BMMS 2010

13. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 13 MMR in Kenya and Bangladesh Hemorrhage and eclampsia, despite impressive declines, still cause more than half of maternal deaths Reasons for fall are several: Medical Socio economic Demographic Source: BMMS 2010

14. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 14 MMR in Kenya and Bangladesh Medical Causes of decline in MMR since 2001 in Bangladesh Reduction in Eclampsia (30% of total decline) Reduction in Haemorrhage (25%) Reduction Abortion related (10%) Reduction of cases of Obstructed labour (3%), among others These cases require facility based treatment and medically trained birth attendants and staff. Source: BMMS 2010

15. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 15 MMR in Kenya and Bangladesh Source: BMMS 2010

16. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 16 MMR in Kenya and Bangladesh Source: BMMS 2010

17. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 17 MMR in Kenya and Bangladesh Source: BMMS 2010

18. What accounts for the increased use of services? Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 18 MMR in Kenya and Bangladesh Improved Access to Health Services: Numbers of facilities with maternal health services has increased Improved road transport (roads, bridges, bus services) Mobile phones available nationally, and at low cost Income at national and household levels have improved, including among poor households

19. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 19 MMR in Kenya and Bangladesh

20. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 20 MMR in Kenya and Bangladesh Demographic patterns explains a big part of the variance between Bangladesh and Kenya. But fertility does not explain all. Socio-economic factors are rather in favour of Kenya, therefore it seems attention should be turned to the medical factors. How are the standards of institutional delivery effectively met? Qualification of personnel, equipment of facilities? Geographic distance? Non proximal factors? Homogeneity, social consensus, imagined communities (cf Kuhn 2011)

21. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 21 MMR in Kenya and Bangladesh Caveat: Are definitions and methodologies misleading? BMMS: all deaths that occurred during pregnancy and two months after pregnancy, even if the death is due to non-maternal causes." KDHS

22. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 22 MMR in Kenya and Bangladesh Further initiatives in Bangladesh to work on Maternal Health Pilot on demand side financing Costing of health services

23. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 23 MMR in Kenya and Bangladesh Evaluate demand-side DSF program impacts on: - Use of skilled providers at delivery, C-section, ANC, and PNC Out-of-pocket expenditures on MH services Evaluate supply-side DSF program impacts on: - Provider skills and knowledge - Facility quality Objectives of the evaluation

24. Pregnant women get all maternal health services for free Pregnant women get Tk 2000 cash incentive and gift box (value of Tk 500) for delivering with a qualified provider, and Tk 500 total transport stipend for 3 ANC visits, delivery, and PNC –Qualified providers for delivery are CSBAs and doctors Providers/field workers get cash incentives for registering women and providing MH services (ANC, delivery, PNC, complications) Control Districts (Upazilas) Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 24 MMR in Kenya and Bangladesh DSF Programme Overview

25. Large, significant demand-side impacts Multi-variate: The likelihood of delivery with skilled provider increased by 42 percentage points in universal DSF upazila (vs. control) and by 50 percentage point in means-tested DSF upazila (vs. control) Out-of-pocket expenditures for ANC, delivery care, and PNC significantly lower in DSF (Tk 1,442) compared to control (Tk 2,191) Less supply side-impact Some evidence of quality differences but mostly non-significant Much larger patient volume in DSF facilities, compared to control Seed fund utilized to procure drugs and supplies in some cases Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 25 MMR in Kenya and Bangladesh Main findings

26. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 26 MMR in Kenya and Bangladesh Comparing cost of DSF program to Benefits: US $ 161-165: Incremental cost per additional delivery with a skilled provider due to DSF program (includes overhead cost and ANC cost) US $ 67-76: Average cost per voucher distributed/receipt Government and development partners will need to compare this cost estimate with other MH programs and opportunity cost in Bangladesh

27. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 27 MMR in Kenya and Bangladesh Costing of Maternal Health Services and MDG5: Empirical (unit cost approach) and normative costing Total price tag for key maternal health services at coverage levels consistent with achieving the MDG 5 is 1,704 million USD. About 70% of this amount will be needed to provide the target level and quality of ANC services. The costs of normal delivery are 9% of the total resource requirement, and the costs of treating the leading obstetric emergency complications account for 20%. This is a five-fold increase for the annual budget for Maternal health services

28. Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 28 MMR in Kenya and Bangladesh Thanks for your attention! Donnobad! Asante Sana!