Journal Article

Effect of a maternal health voucher scheme on out-of-pocket expenditure and use of delivery care services in rural Bangladesh: A prospective controlled study

Background
Most births in rural Bangladesh are done at home because of barriers to access to facility-based services. To address this issue, the Bangladeshi Government piloted a demand-side financing scheme (the maternal health voucher programme) at subdistrict public health facilities in rural areas. We assessed the effect of this intervention on use of delivery care services and out-of-pocket expenses.

Methods
We did a non-randomised, controlled study. We selected 22 subdistricts in Bangladesh with a probability proportional to their size: 11 intervention subdistricts took part in the demand-side financing programme and 11 control subdistricts did not. We selected 150 women from each subdistrict. From each subdistrict, three of nine unions and three villages from each union were selected through probability proportional to size and from each selected village we drew the required numbers of respondents through simple random sampling. We included women aged 18–49 years who had given birth in the previous 12 months. A baseline survey was done in 2010, and a follow-up survey was done in 2012, recording socioeconomic and demographic characteristics as well as service use and cost of services, collected with a structured questionnaire.

Findings
3300 women were surveyed (1650 in each group). Use of delivery services was 8% (126/1650) in 2010 versus 16% (263/1663) in 2012 in the intervention subdistricts and 8% (129/1650) versus 11% (178/1671) in control areas. Delivery at a public health facility in the intervention areas increased significantly compared with the control areas (p<0·0001) and the intervention contributed to some of the change (difference in differences 5·1%). Average out-of-pocket cost in intervention areas fell for both normal births (from US$40 to $22) and caesarean births (from $115 to $80). In control areas, average out-of-pocket cost decreased slightly for normal births (from $33 to $29), but increased for caesarean births (from $118 to $125).

Interpretation
To sustain the trend of use, the maternal health voucher programme needs to continue to provide financial assistance to women who cannot afford to seek delivery care in health facilities.