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Vouchers as demand side financing instruments for health care: A review of the Bangladesh maternal voucher scheme

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  • Schmidt, Jean-Olivier
  • Ensor, Tim
  • Hossain, Atia
  • Khan, Salam

Abstract

Objectives Demand side financing (DSF) mechanisms transfer purchasing power to specified groups for defined goods and services in order to increase access to specified services. This is an important innovation in health care systems where access remains poor despite substantial subsidies towards the supply side. In Bangladesh, a maternal health DSF pilot in 33 sub-districts was launched in 2007. We report the results of a rapid review of this scheme undertaken during 2008 after 1 year of its setup.Methods Quantitative data collected by DSF committees, facilities and national information systems were assessed alongside qualitative data, i.e. key informant interviews and focus group discussions with beneficiaries and health service providers on the operation of the scheme in 6 sub-districts.Results The scheme provides vouchers to women distributed by health workers that entitle mainly poor women to receive skilled care at home or a facility and also provide payments for transport and food. After initial setbacks voucher distribution rose quickly. The data also suggest that the rise in facility based delivery appeared to be more rapid in DSF than in other non-DSF areas, although the methods do not allow for a strict causal attribution as there might be co-founding effects. Fears that the financial incentives for surgical delivery would lead to an over emphasis on Caesarean section appear to be unfounded although the trends need further monitoring. DSF provides substantial additional funding to facilities but remains complex to administer, requiring a parallel administrative mechanism putting additional work burden on the health workers. There is little evidence that the mechanism encourages competition due to the limited provision of health care services.Conclusions The main question outstanding is whether the achievements of the DSF scheme could be achieved more efficiently by adapting the regular government funding rather than creating an entirely new mechanism. Also, improving the quality of health care services cannot be expected by the DSF mechanism alone within an environment lacking the pre-requirements for competition. Quality assurance mechanisms need to be put in place. A large-scale impact evaluation is currently underway.

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  • Schmidt, Jean-Olivier & Ensor, Tim & Hossain, Atia & Khan, Salam, 2010. "Vouchers as demand side financing instruments for health care: A review of the Bangladesh maternal voucher scheme," Health Policy, Elsevier, vol. 96(2), pages 98-107, July.
    • Handle: RePEc:eee:hepoli:v:96:y:2010:i:2:p:98-107
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    2. Sayedur Rahman & Aziz Ahmed Choudhury & Rasheda Khanam & Syed Mamun Ibne Moin & Salahuddin Ahmed & Nazma Begum & Nurun Naher Shoma & Md Abdul Quaiyum & Abdullah H Baqui & for the Projahnmo Study Group, 2017. "Effect of a package of integrated demand- and supply-side interventions on facility delivery rates in rural Bangladesh: Implications for large-scale programs," PLOS ONE, Public Library of Science, vol. 12(10), pages 1-13, October.
    3. Witvorapong, Nopphol & Foshanji, Abo Ismael, 2016. "The impact of a conditional cash transfer program on the utilization of non-targeted services: Evidence from Afghanistan," Social Science & Medicine, Elsevier, vol. 152(C), pages 87-95.
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    5. Hiroyuki Egami & Tomoya Matsumoto, 2020. "Mobile Money Use and Healthcare Utilization: Evidence from Rural Uganda," Sustainability, MDPI, vol. 12(9), pages 1-34, May.
    6. Seohyun Lee & Abdul-jabiru Adam, 2021. "Designing a Logic Model for Mobile Maternal Health e-Voucher Programs in Low- and Middle-Income Countries: An Interpretive Review," IJERPH, MDPI, vol. 19(1), pages 1-37, December.
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    8. Nguyen, Ha & Knowles, James, 2010. "Demand for voluntary health insurance in developing countries: The case of Vietnam's school-age children and adolescent student health insurance program," Social Science & Medicine, Elsevier, vol. 71(12), pages 2074-2082, December.
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    11. Grépin, Karen A. & Habyarimana, James & Jack, William, 2019. "Cash on delivery: Results of a randomized experiment to promote maternal health care in Kenya," Journal of Health Economics, Elsevier, vol. 65(C), pages 15-30.

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