1. DEMAND SIDE FINANCING MATERNAL HEALTH VOUCHER SCHEME in Bangladesh 1

2. Maternal health in Bangladesh  Context  149.8m total population (Rural 73%)  545 Sub-districts  31.5% Population below poverty line  71% deliveries take place at home  29% Institutional delivery  32% Skilled attended delivery  194 MMR (BMMS 2010)  2.15 TFR (BBS 2009)  Demand-side barriers to access  Poverty  Illiteracy  Geographical accessibility  Lack of information about health services  High direct and indirect costs especially transportation  Intra-household expenditure preferences  Socio-cultural norms 2

3. DSF program overview: incentives for both demand and supply side  Aims to rapidly increase utilization of maternal health (MH) services via:  Vouchers for free antenatal (ANC), delivery, emergency referral, and postnatal care (PNC), and laboratory tests.  Cash transfers Tk. 2000 [$25] and gift bags if women deliver with skilled birth attendant at home or in facility, and transport stipend Tk. 500 [$ 6.25]. Emergency referral transport is also available.  Cash incentives for providers/field workers for registering women and providing MH services  “Seed fund” for facilities 3

4. Project Beneficiaries: the poor and vulnerable women  In general, pregnant women are eligible to receive free voucher under the scheme if they fulfil the following criteria:  First and second pregnancy  Resident in the respective Upazila  Are functionally landless i.e. owning less than 0.15 acre of land.  Have extremely low or irregular income - households earning less than Taka 2500 [US$ 31.25] per month (proposed to be increased to 3100 [US$38.75])  Lack of productive assets.

5. Empowered voucher holders: Have a choice of service provider Home based delivery Facility delivery SBA Upazila Health Complex/Distr ict Hosp/MCWC Union Sub- Center Comm. Clinic NGO/Pri vate Clinic Family Welfare Center Client in labor 5

6. Governance structures

7. 7 Financial Year In million 2011-2012BDT 706.00US$ 8.83 2012-2013BDT 778.00US$ 9.73 2013-2014BDT 856.95US$ 10.71 2014-2015 & 2015-2016BDT 1985.14US$ 24.81 Total earmarked allocation for DSF (2011-16) BDT 4326.04US$ 54.08 (0.7%) Total Health Sector Budget (2011-16) BDT 569935.40US$ 7.7 billion Expanded DSF is sustainable at <1% of health sector budget Budget in HPNSDP 2011-16 earmarked for DSF

8. Evaluations on DSF Maternal Health Voucher Scheme  In 2008, a rapid assessment of DSF with support of GTZ and MOHFW found maternal health service utilization had increased substantially in pilot sub districts. Report advocated scale up.  In 2010, USA-based Abt Associates with GTZ and MOHFW support assessed economic evaluation of expanded program. Study found that DSF had a strong positive effect on the use of maternal health services in expanded program.  In 2011, Population Council began a quasi-experimental evaluation of DSF. Baseline in 2011 was collected utilization and cost data from 11 DSF and 11 non-DSF sub districts. End line survey completed May 2013. Results pending.  In 2013, an In-depth study is done. Results disseminated.

9. Effectiveness 9

10. ANC1 (%) of DSF vs National (BDHS) Source: DSF project office 10

11. ANC in DSF Upazila vs Control Upazila Source: Economic evaluation, 2010 11

12. Safe delivery (%) of DSF vs National (BDHS) Source: DSF project office 12

13. Percentages of deliveries with a skilled provider Source: Economic evaluation, 2010 13

14. C-section (%) of DSF vs National (BDHS) Source: DSF project office 14

15. PNC (%) of DSF vs National (BDHS) Source: DSF project office 15

16. Equity 16

17. Project Beneficiaries  In general, pregnant women are eligible to receive free voucher under the scheme if they fulfil the following criteria:  First and second pregnancy  Resident in the respective Upazila  Are functionally landless i.e. owning less than 0.15 acre of land.  Have extremely low or irregular income - households earning less than Taka 2500 [US$ 31.25] per month (proposed to be increased to 3100 [US$38.75])  Lack of productive assets.

18. Where does the DSF support ($48) go for a normal delivery?

19. Where does the DSF support ($145) go for complicated cases (except vacuum)?

20. Things to ponder  Is DSF effective?  Is DSF able to address equity?  Does it contribute in achieving MDG target of MMR?  Should we recommend for scaling up? 20

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