Improving Access to Delivery Care and Reducing the Equity Gap Through Voucher Program in Bangladesh: Evidence From Difference-in-Differences Analysis

Keya, Kaji Tamanna; Bellows, Benjamin; Rob, Ubaidur; Warren, Charlotte E.

doi:10.1177/0272684x17749568

Cited by 7 publications

(4 citation statements)

References 32 publications

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“…Our analyses support 2 main conclusions. First, the introduction of the MHVS was positively associated with selected maternal health services, particularly the probability of delivering in a health facility, which is consistent with the literature on the impact of voucher schemes in LMICs [33], including Bangladesh [20,23,24,27,28]. Second, despite having a longer period of follow-up than most extant evaluations [31,33], we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality.…”

Section: Discussionsupporting

confidence: 87%

“…However, this research cannot inform inference regarding the causal effect of the MHVS. The only quasi-experimental evaluation, a differences-in-differences analysis that compared changes in outcomes for 11 upazilas before and after they were added to the program in 2010 to corresponding changes from 11 matched control upazilas, suggests that the program increased use of public facilities, but did not influence the proportion of women receiving maternal health services unless the treated group was restricted to 5 high-performing upazilas [ 28 , 29 ].…”

Section: Introductionmentioning

confidence: 99%

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Health care services use, stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh: A difference-in-differences analysis of Bangladesh Demographic and Health Survey data, 2000 to 2016

et al. 2022

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Background Starting in 2006 to 2007, the Government of Bangladesh implemented the Maternal Health Voucher Scheme (MHVS). This program provides pregnant women with vouchers that can be exchanged for health services from eligible public and private sector providers. In this study, we examined whether access to the MHVS was associated with maternal health services utilization, stillbirth, and neonatal and infant mortality. Methods and findings We used information on pregnancies and live births between 2000 to 2016 reported by women 15 to 49 years of age surveyed as part of the Bangladesh Demographic and Health Surveys. Our analytic sample included 23,275 pregnancies lasting at least 7 months for analyses of stillbirth and between 15,125 and 21,668 live births for analyses of health services use, neonatal, and infant mortality. With respect to live births occurring prior to the introduction of the MHVS, 31.3%, 14.1%, and 18.0% of women, respectively, reported receiving at least 3 antenatal care visits, delivering in a health institution, and having a skilled birth attendant at delivery. Rates of neonatal and infant mortality during this period were 40 and 63 per 1,000 live births, respectively, and there were 32 stillbirths per 1,000 pregnancies lasting at least 7 months. We applied a difference-in-differences design to estimate the effect of providing subdistrict-level access to the MHVS program, with inverse probability of treatment weights to address selection into the program. The introduction of the MHVS program was associated with a lagged improvement in the probability of delivering in a health facility, one of the primary targets of the program, although associations with other health services were less evident. After 6 years of access to the MHVS, the probabilities of reporting at least 3 antenatal care visits, delivering in a health facility, and having a skilled birth attendant present increased by 3.0 [95% confidence interval (95% CI) = −4.8, 10.7], 6.5 (95% CI = −0.6, 13.6), and 5.8 (95% CI = −1.8, 13.3) percentage points, respectively. We did not observe evidence consistent with the program improving health outcomes, with probabilities of stillbirth, neonatal mortality, and infant mortality decreasing by 0.7 (95% CI = −1.3, 2.6), 0.8 (95% CI = −1.7, 3.4), and 1.3 (95% CI = −2.5, 5.1) percentage points, respectively, after 6 years of access to the MHVS. The sample size was insufficient to detect smaller associations with adequate precision. Additionally, we cannot rule out the possibility of measurement error, although it was likely nondifferential by treatment group, or unmeasured confounding by concomitant interventions that were implemented differentially in treated and control areas. Conclusions In this study, we found that the introduction of the MHVS was positively associated with the probability of delivering in a health facility, but despite a longer period of follow-up than most extant evaluations, we did not observe attendant reductions in stillbirth, neonatal mortality, or infant mortality. Further work and engagement with stakeholders is needed to assess if the MHVS has affected the quality of care and health inequalities and whether the design and eligibility of the program should be modified to improve maternal and neonatal health outcomes.

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Section: Discussionsupporting

confidence: 87%

Section: Introductionmentioning

confidence: 99%

Health care services use, stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh: A difference-in-differences analysis of Bangladesh Demographic and Health Survey data, 2000 to 2016

et al. 2022

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“…Even the effectiveness of health services innovations (viz., targeted service delivery, demand-side nancing, and contracting out facilities) in improving equity in low and lower-middle-income countries was found to be contingent on the government's capacity to enforce accountability mechanisms and provide adequate program inputs ( nancing and workforce) [69,70]. Demand-side nancing schemes, in particular, were found to improve equitable skilled delivery care when facilities had higher service readiness [71,72].…”

Section: Discussionmentioning

confidence: 99%

Socioeconomic equity in maternal health services use in Bangladesh: The role of service readiness in health facilities during the period 2001–2016

Ahsan,

Angeles,

Curtis

et al. 2024

Preprint

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Background Equity in health services use is related to utilizing equal treatment for equal health needs, irrespective of socioeconomic status. Inequity in maternal health services use in low- and middle-income countries has become a central public health policy and research issue in recent years to achieve universal health coverage by 2030. For Bangladesh, we examined if the socioeconomic equity for selected maternal health services use (viz., antenatal care from a medically trained provider, facility delivery, and management of complications) improved more in districts with high facility readiness than in the rest of the country during 2001‒2016. Methods We used data from three rounds of the Bangladesh Maternal Mortality and Health Care Survey and corresponding rounds of the Bangladesh Health Facility Survey to estimate the differential effect of facility readiness on equity in maternal health services use during 2001‒2016. We applied an adaptation of the Difference-in-Differences (DID) model based on linear probability models on a pooled dataset of 2001, 2010, and 2016 household surveys linked to corresponding health facility surveys. Results Bangladesh has made impressive improvements in the overall use of maternal health services, but the increase was not uniform for all the population groups. Though there have been modest improvements in equity for ANC and treatment for complications, inequity for facility delivery increased noticeably between 2001 and 2016. The nonpoor-poor gap in the high facility readiness districts increased faster than in the low readiness districts during 2001‒2016, resulting in a more inequitable distribution of facility delivery services (p < 0.05). We also found that ANC became more equitable between 2001 and 2016 among women living < 1 hour from a private facility (p < 0.05). Conclusions This is the first systematic investigation of the role of facility readiness on maternal health equity in Bangladesh using nationally representative data. This study found persistent socioeconomic inequities in the use of all three key maternal health services, and for facility delivery, socioeconomic inequity worsened over time. The empirical evidence and policy measures presented here provide a way forward for policymakers to provide equitable care for safe delivery services in Bangladesh.

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“…Very few of the previous studies use modern study designs that would enable them to draw conclusions about the causal effect of voucher programmes. One exception is Keya et al [13], who follow a difference-indifference approach to evaluate a voucher programme aimed at delivering care in Bangladesh. The results show a significant increase in public health facility use and an increase in delivery complication management care.…”

Section: Previous Researchmentioning

confidence: 99%

The impact of a reproductive health voucher in Uganda using a quasi-experimental matching design

Andersson,

Kawuki,

Månsson

et al. 2024

Reprod Health

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This study assesses the impact of a voucher project that targeted vulnerable and poor pregnant women in Uganda. Highly subsidised vouchers gave access to a package of safe delivery services consisting of four antenatal visits, safe delivery, one postnatal visit, the treatment and management of selected pregnancy-related medical conditions and complications, and emergency transport. Vouchers were sold during the project’s operational period from 2016 to 2019. This study covers 8 out of 25 project-benefiting districts in Uganda and a total of 1,881 pregnancies, including both beneficiary and non-beneficiary mothers. Using a matching design, the results show a positive effect on the survival of new-born babies. The difference in the survival rate between the control group and the treatment group is 5.4% points, indicating that the voucher project reduced infant mortality by more than 65 per cent.

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Improving Access to Delivery Care and Reducing the Equity Gap Through Voucher Program in Bangladesh: Evidence From Difference-in-Differences Analysis

Cited by 7 publications

References 32 publications

Health care services use, stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh: A difference-in-differences analysis of Bangladesh Demographic and Health Survey data, 2000 to 2016

Health care services use, stillbirth, and neonatal and infant survival following implementation of the Maternal Health Voucher Scheme in Bangladesh: A difference-in-differences analysis of Bangladesh Demographic and Health Survey data, 2000 to 2016

Socioeconomic equity in maternal health services use in Bangladesh: The role of service readiness in health facilities during the period 2001–2016

The impact of a reproductive health voucher in Uganda using a quasi-experimental matching design

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