Prepared Under HNPSP of the Ministry of Health and Family Welfare ECONOMIC EVALUATION OF DEMAND-SIDE FINANCING (DSF) PROGRAM FOR MATERNAL HEALTH IN BANGLADESH February 2010 Recommended Citation: Hatt, Laurel, Ha Nguyen, Nancy Sloan, Sara Miner, Obiko Magvanjav, Asha Sharma, Jamil Chowdhury, Rezwana Chowdhury, Dipika Paul, Mursaleena Islam, and Hong Wang. February 2010. Economic Evaluation of Demand-Side Financing (DSF) for Maternal Health in Bangladesh. Bethesda, MD: Review, Analysis and Assessment of Issues Related to Health Care Financing and Health Economics in Bangladesh, Abt Associates Inc. Contract/Project No.: 81107242 / 03-2255.2-001-00 Submitted to: Helga Piechulek and Atia Hossain GTZ-Bangladesh House 10/A, Road 90, Gulshan-2 Dhaka 1212, Bangladesh Abt Associates Inc. 4550 Montgomery Avenue, Suite 800 North Bethesda, Maryland 20814 Tel: 301.347.5000. Fax: 301.913.9061 www.abtassociates.com In collaboration with: RTM International 581, Shewrapara, Begum Rokeya Sharoni, Mirpur Dhaka 1216, Bangladesh 2 Economic Evaluation of DSF Voucher Program in Bangladesh ECONOMIC EVALUATION OF DEMAND- SIDE FINANCING (DSF) FOR MATERNAL HEALTH IN BANGLADESH DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH. CONTENTS Acronyms.................................................................................... xiii Acknowledgments....................................................................... xv Executive Summary.................................................................. xvii 1. Introduction....................................................................... 1 1.1 Objectives of the evaluation............................................................. 1 1.2 Organization of the report ............................................................... 2 2. Background and literature review................................... 3 2.1 Maternal health in Bangladesh.......................................................... 3 2.2 International and local experiences with Demand-Side Financing (DSF) programs ................................................................ 4 2.3 The DSF maternal health voucher program in Bangladesh......... 7 2.3.1 Pilot DSF program areas...................................................... 7 2.3.2 Funding and management structure................................... 7 2.3.3 Eligibility criteria.................................................................... 8 2.3.4 Beneficiary identification process ....................................... 8 2.3.5 Voucher distribution............................................................. 9 2.3.6 Participating health care providers..................................... 9 2.3.7 Voucher benefits to consumers.......................................... 9 2.3.8 Provider reimbursement and incentives.......................... 10 2.3.9 Distribution of cash and in-kind incentives to consumers and providers.............................................................................. 11 2.4 Summary of findings from 2005 baseline report ......................... 12 3. Methods............................................................................ 15 3.1 Overview of data collection methods........................................... 15 3.2 Instrument preparation and pre-testing ....................................... 15 3.3 Selection of upazilas for the evaluation......................................... 16 3.4 Selection of respondents................................................................. 19 3.5 Field data collection procedures.................................................... 20 3.5.1 Hiring and training data collectors ................................... 20 3.5.2 Informed consent procedures........................................... 20 3.5.3 Qualitative data collection................................................. 20 3.5.4 Phase 1 household survey data collection....................... 20 3.5.5 Phase 2 household survey data collection....................... 21 3.5.6 Administrative data collection .......................................... 21 iii 3.5.7 Summary of completed data collection ........................... 21 3.6 Transcription, translation and data entry..................................... 23 3.7 Household survey processing......................................................... 23 3.7.1 Sampling weights ................................................................. 23 3.7.2 Comparison of phase 1 and phase 2 household survey data............................................................................................... 24 3.8 Analysis .............................................................................................. 25 3.8.1 Variable construction ......................................................... 25 3.8.2 Analytic approach................................................................ 25 3.9 Limitations ......................................................................................... 26 4. Findings Part 1: Voucher Operations............................ 29 4.1 Voucher program design................................................................. 29 4.1.1 Targeting and identification of the poor.......................... 29 4.1.2 Incentives for consumers and providers ......................... 30 4.1.3 Involvement of NGO and Private Sector Facilities........ 30 4.2 Implementation and logistics .......................................................... 31 4.2.1 Informing consumers about the DSF program............... 31 4.2.2 Identifying eligible beneficiaries......................................... 34 4.2.3 Voucher distribution........................................................... 39 4.2.4 Payment of cash and in-kind benefits to consumers ..... 44 4.2.5 Service provision under the voucher program .............. 48 4.2.6 Monitoring and evaluation systems .................................. 51 4.3 Financial management and accounting .......................................... 53 4.3.1 Financial management......................................................... 53 4.3.2 Financial sustainability of scheme...................................... 55 4.4 Institutional arrangements and governance ................................. 56 4.4.1 DSF program organizational structures and systems.... 56 4.4.2 Responsiveness to stakeholders and consumers ........... 57 4.5 Summary of key findings.................................................................. 58 5. Findings Part 2: Effect of the DSF program on the demand side................................................................................. 61 5.1 Household survey sample description .......................................... 61 5.2 Bi-variate analyses ............................................................................ 65 5.2.1 Antenatal care...................................................................... 65 5.2.2 Delivery care........................................................................ 67 5.2.3 Postnatal care ...................................................................... 70 5.2.4 Subanalysis: ANC, delivery care, and PNC among voucher recipients ..................................................................... 71 5.2.5 Subanalysis: Pre-post comparison of previous births .... 73 5.2.6 Out-of-pocket (OOP) expenditures................................ 74 iv Economic Evaluation of DSF Voucher Program in Bangladesh 5.2.7 Subanalysis: Differential Impacts of the DSF program according to poverty status ..................................................... 76 5.2.8 Beneficiary use of cash incentive ...................................... 81 5.3 Multivariate analyses ........................................................................ 82 5.4 Qualitative findings........................................................................... 87 5.4.1 Beneficiary opinions about the voucher program.......... 87 5.4.2 Key informant opinions about the voucher program.... 88 5.4.3 Provider perceptions of DSF program impacts on beneficiaries ................................................................................ 89 5.4.4 Perceived effect on use of other programs and services 89 5.5 Program cost and cost-effectiveness analyses ............................. 90 5.5.1 total program cost in 16 upazilas ..................................... 90 5.5.2 Average cost per voucher distributed............................. 91 5.5.3 cost-Effectiveness analysis.................................................. 91 5.6 Summary of key findings.................................................................. 93 6. Findings Part 3: Effect of the DSF program on the supply side.................................................................................... 97 6.1 Results from Facility Quality Assessment..................................... 97 6.1.1 Sample description.............................................................. 97 6.1.2 MCH/FP Services Provided in The Year Prior to Assessment ................................................................................. 98 6.1.3 Staffing.................................................................................100 6.1.4 Registers, Educational Materials and Sessions ..............102 6.1.5 Referral Capacity...............................................................102 6.1.6 Infrastructure.....................................................................103