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Is demand-side financing equity enhancing? Lessons from a maternal health voucher scheme in Bangladesh


  • Ahmed, Shakil
  • Khan, M. Mahmud


Demand-side financing (DSF) is used in the less-developed countries of the world to improve access to healthcare and to encourage market supply. Under DSF, households receive vouchers that can be used to pay for healthcare services. This study evaluated the effects of a universal DSF on maternal healthcare service utilization in Bangladesh. A household survey was conducted in and around the voucher scheme area one year after the initiation of the project. Women who gave birth within a year prior to the survey were interviewed. The utilization rates of maternal health services were found to be higher for all socioeconomic groups in the project area than in the comparison areas. Voucher recipients in the project area were 3.6Â times more likely to be assisted by skilled health personnel during delivery, 2.5Â times more likely to deliver the baby in a health facility, 2.8Â times more likely to receive postnatal care (PNC), 2.0Â times more likely to get antenatal care (ANC) services and 1.5Â times more likely to seek treatment for obstetric complications than pregnant women not in the program. The degree of socioeconomic inequality in maternal health service utilization was also lower in the project area than in the comparison area. The use of vouchers evidenced much stronger demand-increasing effects on the poor. Poor voucher recipients were 4.3Â times more likely to deliver in a health facility and two times more likely to use skilled health personnel at delivery than the non-poor recipients. Contrary to the inverse equity hypothesis, the voucher scheme reduced inequality even in the short run. Despite these improvements, socioeconomic disparity in the use of maternal health services has remained pro-rich, implying that demand-side financing alone will be insufficient to achieve the Millennium Development Goal for maternal health. A comprehensive system-wide approach, including supply-side strengthening, will be needed to adequately address maternal health concerns in poor developing countries.

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  • Ahmed, Shakil & Khan, M. Mahmud, 2011. "Is demand-side financing equity enhancing? Lessons from a maternal health voucher scheme in Bangladesh," Social Science & Medicine, Elsevier, vol. 72(10), pages 1704-1710, May.
  • Handle: RePEc:eee:socmed:v:72:y:2011:i:10:p:1704-1710

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    References listed on IDEAS

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    1. Mohammad Rifat Haider & Mohammad Masudur Rahman & Md Moinuddin & Ahmed Ehsanur Rahman & Shakil Ahmed & M Mahmud Khan, 2017. "Impact of maternal and neonatal health initiatives on inequity in maternal health care utilization in Bangladesh," PLOS ONE, Public Library of Science, vol. 12(7), pages 1-15, July.
    2. Kuwawenaruwa, August & Ramsey, Kate & Binyaruka, Peter & Baraka, Jitihada & Manzi, Fatuma & Borghi, Josephine, 2019. "Implementation and effectiveness of free health insurance for the poor pregnant women in Tanzania: A mixed methods evaluation," Social Science & Medicine, Elsevier, vol. 225(C), pages 17-25.
    3. Zafer Çalışkan & Dilek Kılıç & Selcen Öztürk & Emre Atılgan, 2015. "Equity in maternal health care service utilization: a systematic review for developing countries," International Journal of Public Health, Springer;Swiss School of Public Health (SSPH+), vol. 60(7), pages 815-825, November.
    4. Pulok, Mohammad Habibullah & Sabah, Md Nasim-Us Sabah & Uddin, Jalal & Enemark, Ulrika, 2015. "Progress in utilization of antenatal and delivery care services in Bangladesh: Where does the equity gap lie?," MPRA Paper 63496, University Library of Munich, Germany.
    5. 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.
    6. Chatterjee, Somdeep & Poddar, Prashant, 2019. "Maternal Health, Children Education and Women Empowerment: Quasi-Experimental Evidence from India," GLO Discussion Paper Series 332, Global Labor Organization (GLO).
    7. Sanni Yaya & Ghose Bishwajit & Michael Ekholuenetale & Vaibhav Shah, 2017. "Awareness and utilization of community clinic services among women in rural areas in Bangladesh: A cross-sectional study," PLOS ONE, Public Library of Science, vol. 12(10), pages 1-10, October.
    8. Ahmed Shoukry Rashad & Mesbah Fathy Sharaf, 2016. "Socio-Economic Inequalities in Maternity Care Under Political Instability: Evidence from Egypt, Jordan and Yemen," Working Papers 1011, Economic Research Forum, revised Jun 2016.
    9. Joshua Amo-Adjei & Kofi Aduo-Adjei & Christiana Opoku-Nyamah & Chimaroake Izugbara, 2018. "Analysis of socioeconomic differences in the quality of antenatal services in low and middle-income countries (LMICs)," PLOS ONE, Public Library of Science, vol. 13(2), pages 1-12, February.
    10. Kamiya, Yusuke & Yoshimura, Yukie & Islam, Mohammad Tajul, 2013. "An impact evaluation of the Safe Motherhood Promotion Project in Bangladesh: Evidence from Japanese aid-funded technical cooperation," Social Science & Medicine, Elsevier, vol. 83(C), pages 34-41.
    11. Coffey, Diane, 2014. "Costs and consequences of a cash transfer for hospital births in a rural district of Uttar Pradesh, India," Social Science & Medicine, Elsevier, vol. 114(C), pages 89-96.
    12. Kim, Chang-O & Joung, Won Oh, 2014. "Effect of the Crisis Assistance Program on poverty transition for seriously ill people in South Korea: A quasi-experimental study," Social Science & Medicine, Elsevier, vol. 101(C), pages 28-35.
    13. Randive, Bharat & San Sebastian, Miguel & De Costa, Ayesha & Lindholm, Lars, 2014. "Inequalities in institutional delivery uptake and maternal mortality reduction in the context of cash incentive program, Janani Suraksha Yojana: Results from nine states in India," Social Science & Medicine, Elsevier, vol. 123(C), pages 1-6.
    14. Asian Development Bank (ADB), 2012. "Impact of Maternal and Child Health Private Expenditure on Poverty and Inequity in Bangladesh: Out-of-Pocket Payments by Patients at Ministry of Health and Family Welfare Facilities in Bangladesh and ," ADB Reports RPT135432-3, Asian Development Bank (ADB), revised 02 Sep 2013.
    15. Mats Målqvist & Beibei Yuan & Nadja Trygg & Katarina Selling & Sarah Thomsen, 2013. "Targeted Interventions for Improved Equity in Maternal and Child Health in Low- and Middle-Income Settings: A Systematic Review and Meta-Analysis," PLOS ONE, Public Library of Science, vol. 8(6), pages 1-10, June.
    16. Annear, Peter Leslie & Ahmed, Shakil & Ros, Chhun Eang & Ir, Por, 2013. "Strengthening institutional and organizational capacity for social health protection of the informal sector in lesser-developed countries: A study of policy barriers and opportunities in Cambodia," Social Science & Medicine, Elsevier, vol. 96(C), pages 223-231.
    17. Rahman, Mohammad Mahbubur & Pallikadavath, Saseendran, 2018. "How much do conditional cash transfers increase the utilization of maternal and child health care services? New evidence from Janani Suraksha Yojana in India," Economics & Human Biology, Elsevier, vol. 31(C), pages 164-183.


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