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Promoting institutional obstetrics and newborn care in Bangladesh by subsidising out of pocket costs.

Author(s) Mst. Farhana Akter1, Ubaidur Rob2, Ismat Ara Hena3.
Affiliation(s) 1Poverty, Gender and Youth, Population Council, Dhaka, Bangladesh, 2Reproductive Health, Population Council, Dhaka, Bangladesh, 3Reproductive Health, Population Council, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Women and Children
Summary Maternal and child health programs are yet to achieve the  impact on the obstetric and newborn care services utilization from institutions in Bangladesh. This paper explains whether subsidizing out of pocket costs for women promotes the utilization of institutional obstetrics and newborn care or not. Coupons were provided to poor pregnant women and mothers of newborn babies to cover transportation, medical costs and incidental costs for receiving institutional services. A rigorous process of community assessment and use of poverty tool was employed to select eligible women. Three-fourths of the poor pregnant women were identified as eligible for coupon distribution from 20,833 pregnant women.
Background Maternal and neonatal health programs are yet to achieve the desired impact on the utilization of obstetric and newborn care services from public-sector health facilities in Bangladesh. Home delivery and untrained providers during delivery largely contribute to the underutilization of the existing obstetric and newborn care services provided at facilities. Demand-side barrier costs remains a key challenge to the utilisation of skilled maternal newborn and child health (MNCH) care. The cultural and social belief system, social stigma associated with pregnancy and birth, distance of the facility, lack of information on sources of care, lack of awareness on the value of maternal health services, and high access costs (e.g. direct and indirect costs) are considered important demand-side barriers (Ensor 2004). Cost concerns hinder the seeking of professional maternity care and emergency obstetric care, and contribute to maternal death (Koeing 2007; Rob et al. 2006). Poor families face resource constraints and other disincentives to make use of health facilities. High transportation costs due to distance to health facilities and other out-of-pocket costs contribute to limited access to health care by those who need it most (Glassman, Todd, and Gaarder 2007; Khan 2005).
Objectives The Population Council implemented Pay-for-Performance (P4P) for providers and subsidised out of pocket costs for clients to improve MNCH services by addressing supply and demand-side barriers in Bangladesh with funding from UNICEF. This paper explores whether the subsidisation of out of pocket cost of clients promotes the utilisation of obstetrics and newborn health services. Financial assistance in the form of coupons were provided to poor pregnant women to cover transportation, medical and incidental cost for receiving services from facilities.
Methodology A rigorous process consisting of community assessment and use of the poverty tool was employed to select eligible women from the six upazilas of two northern districts of Bangladesh. Information about coupon utilization was collected from the pregnant mother’s identification list, distribution list, and the service statistics. During the service provision period, a quick survey was conducted among the coupon recipients to know the challenges and opportunities of coupon utilization at the health facilities, which would contribute to service utilisation at the facilities. Coupons were distributed during the period January 2011 to June 2011 among the pregnant women who were supposed to deliver by November 2011. The coupon distribution process was used the government field level workers, supervisors and NGO workers to make them aware of the project as well as develop ownership. Two quarters into the implementation, coupon counselling was conducted by the NGO field workers in all coupon project areas. The main objectives were to identify the causes of not using the coupon by the pregnant mothers.To collect detail information about coupon utilisation, service statistics were collected monthly from the service facilities. Process documentation was done from the in-depth interviews that used coupons as well as those that didn't. This paper will describe the experiences of coupon distribution, utilisation and services utilisation as a whole (coupon and non-coupon) from the health facilities of 2 northern district of Bangladesh.
Three-fourths of the poor pregnant women were identified as eligible for coupon distribution among the identified 20,833 pregnant women in the intervention areas, and of them, 92 percent received coupons. Coupon cards cover transportation, medical and incidental costs for antenatal care, delivery care, post natal care, pregnancy complications, neonatal complications and under five children complications.Coupon card distribution started in January 2011 in one district and in March 2011 in another district. Coupons were distributed using NGO workers in the case of the unavailability of government workers. Due to poor utilization rates of coupon beneficiaries, 284 field workers were oriented and engaged for coupon promotion and validation of the coupon distribution activities in September 2011.
Results About 88 percent coupon card holders in a district and 72 percent coupon card holders in another district reported that those eligible to receive the coupons did so. The remainder either damaged or lost the cards or did not receive the cards from the fieldworkers. Among the two districts, 40 percent of coupon recipients used their coupons in Gaibandha district and in Kurigram district 60 percent of coupon recipient used their coupons to receive services from the public-sector health facilities. The coupon clients responded well in terms of receiving the antenatal care services but were reluctant to have deliveries at the facilities and use coupon for newborn care. Coupons were mostly utilised for receiving antenatal care services (79 percent) followed by institutional delivery (17 percent), postnatal care (16 percent) and pregnancy complications care (13 percent) (Table 1). Findings suggest that about one in ten users used coupons for receiving neonatal and under five complication related services from the selected public-sector health facilities, with a significant variation across the areas. The majority of the coupon users used their coupon for antenatal care followed by PNC and delivery care with no variation across the areas. Process documentation suggests that due to the unavailability of fieldworkers, coupon distribution was not performed appropriately as the project used the government field-workers. Similarly the field-workers who were active in distributing the coupons were not interested in counselling the client to use coupons. The most cited reasons for non-use of coupon is inadequate knowledge about the coupon (41 percent) followed by not perceiving the need to receive services from the health facilities (22 percent), long distance and poor transportation facility (9 percent) and delay in receiving the coupon (8 percent).The challenges of transportation remained a reality in some places in spite of offering transportation costs through the coupon. Travelling to the facilities involving multiple vehicles including rickshaw, auto-rickshaw, boat, and bus from the remote char unions are cumbersome; and the transportation cost offered was not adequate for round-trip transportation cost to the facilities.There are several low performing areas located very far from health facilities. There were no usual transportation systems available in those areas. The majority of those people depend on walking and boat and it needs 4 to 7 hours to reach health facilities.
Conclusion • Intensive advocacy at the community levels and increasing the quality of antennal care may encourage women to plan delivery at the facilities.• Awareness raising activities are essential in generating demand for services and to encourage use of coupon cards at the facilities.• Including roundtrip transportation and additional cost of other arrangements (like, vehicle, ambulance, etc.) for the client for reaching the health facilities may increase the use of coupons and health facilities.

• Rigorous involvement of fieldworkers ,especially government fieldworkers in the coupon mechanism, may increase the coupon utilization.

• The poorest areas with greater geographical drawback will benefit from a combination of a demand plus supply side P4P approach in Bangladesh.

• Government should introduce subsidising out of pocket costs across the country, especially in underprivileged and disadvantaged areas.

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