December 2016 Dhaka, Bangladesh - SPFMSPspfmsp.org/wp-content/uploads/2017/01/2017-01-10... · Field visits identified a number of additional issues. During January-August 2016, in

December 2016

Dhaka, Bangladesh

Report on the Diagnostic Study of Demand Side Financing –

Maternal Health Voucher Scheme of Bangladesh (DSF – MHVS)

M. Mahmud Khan, PhD

Professor, Department of Health Services Policy and Management,

University of South Carolina,

Columbia, SC, USA.

&

Dr. Md. Abdur Rahman Khan

Former Director General, Directorate General of Health Services,

MOHFW, Government of Bangladesh.

December 2016

Report on the Diagnostic Study of Demand Side Financing – Maternal Voucher Scheme of Bangladesh (DSF-MHVS)

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Executive Summary

The purpose of this report is to present the results of a diagnostic study of Demand-side financing of Maternal Health

Voucher Scheme (DSF-MHVS). The study has examined how the programme is being currently implemented and what

specific policy changes and reforms may help improve Value for Money (VfM) in DSF-MHVS. The focus has been to better

understand the problems and concerns of DSF-MHVS from the perspectives of managers, policy makers, implementers,

health care providers and the beneficiaries.

This study followed a “mixed method” approach by combining results of literature review, quantitative data analyses and

qualitative research methods. Data collected by the programme were obtained for the quantitative analyses and

additional information was collected through a survey of WHO Quality Managers (QMs) in charge of implementing the

programme in all 53 DSF upazilas of the country. The qualitative aspect of the research is based on discussions and

interviews with policy planners, decision-makers, development partners, programme managers, programme

implementers, health care providers and the beneficiaries.

The principal objectives of DSF-MHVS are to increase demand and utilization of maternal health services, to improve

access to and utilization of safe delivery, to encourage institutional delivery and to improve equity in the utilization of

maternal health services. In 2015-16, the scheme enrolled more than 107 thousand beneficiaries in 53 upazilas.

The DSF-MHVS provides poor mothers with vouchers that can be used to obtain three antenatal care (ANC), safe delivery,

postnatal care and assisted delivery or caesarean section delivery, if needed. The scheme provides transportation costs

(up to five trips) and cash incentives for safe deliveries (either in a facility or at home) to mothers for first and eligible

second deliveries (mothers adopting family planning after first delivery). Literature review indicates that the programme

has been successful in increasing utilization of maternal health services by pregnant women participating in DSF-MHVS

compared to the utilization by non-participants.

The financial resources of the programme flow through the Ministry of Health and Family Welfare (MOHFW). The fund is

released to a MHVS account operated by Line Director (LD) of Maternal, Neonatal, Child and Adolescent Health (MNCAH),

MOHFW. From this account funds are transferred in instalments to MHVS upazila account and then to seed fund account

for paying private and public sector providers for services delivered to MHVS beneficiaries.

Literature review identified a number of issues and concerns related to the implementation and functioning of DSF-MHVS:

administrative and management concerns (e.g., some of the MHVS implementers at the upazila and union levels were

not aware of policies and procedures of the programme), financial issues (e.g., Significant delays in the payment of

incentives to beneficiaries), target group identification issues (e.g., eligibility criteria for enrolment in the programme not

followed properly), quality and comprehensiveness of health care services delivered (e.g., half of MHVS health facilities

were not Comprehensive Emergency Obstetric Care (CEmOC) facilities), lack of knowledge of beneficiaries on MHVS, out-

of-pocket (OOP) expenses (e.g., beneficiaries paid for some of the covered services) and provider payment and its impact

on provider behaviour (e.g., over-utilization of caesarean section delivery).

Discussions with policy makers, representatives of development partners and field level implementers identified similar

concerns and issues. Most were of opinion that DSF-MHVS has improved access to maternal health services and the

programme should be strengthened and scaled-up. Delay in flow of funds creates significant obstacles in running DSF-

MHVS and some suggested creating advance payment account or imprest fund for timely payment of cash incentives,

travel allowances, etc. to beneficiaries. It was suggested that the programme should allow a number of options for


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disbursing money to beneficiaries including online banking, e-cash transfer, use of postal money order, etc. The

discussions also mentioned the need for reorganization of DSF committees, involvement of independent third party for

monitoring quantity and quality of services delivered and disbursement of funds, change in the criteria for identifying the

poor, etc.

Field visits identified a number of additional issues. During January-August 2016, in Daudkandi upazila, the number of

ANC services used at Upazila Health Complex (UHC) by DSF-MHVS participants was 458 compared to 3115 for non-

participants. 13% of all ANC services at the UHC were offered to voucher holders and they accounted for 19.5% of all

normal deliveries. About 71% of all C-section deliveries at the UHC were conducted on voucher holders. Among the

mothers delivering in UHC, C-section rate was 40.8% for voucher holders and 6.3% among non-DSF participants,

indicating possible overutilization of C-section delivery under DSF.

Discussions with the owner of a private hospital in Daudkandi upazila indicate that the market prices for different

maternal health services were significantly higher than the unit prices set by the DSF-MHVS. Although the private facility

manager/owner mentioned that they accept DSF-MHVS reimbursement as full payment for services, some beneficiaries

reported paying extra for services they have received. Some DSF-MHVS mothers also mentioned buying drugs and

supplies at both private and public health care facilities. Some beneficiaries of DSF-MHVS expressed concerns about high

level of C-section delivery.

The field trips found that the DSF committees were not active in the two areas visited. Some pregnant women were

recruited into the programme very late in their pregnancies implying weak programme implementation practices as well

as lack of community awareness about the programme.

Important concerns identified by the QMs were: problems with system of distributing money through bank accounts;

non-availability of clinical personnel in health facilities; delayed payments to beneficiaries; lack of communication among

village, union and UHC program personnel; lack of interest of Upazila Health and Family Planning Officers in the

programme and lack of accountability within the programme. The QMs also suggested some reforms to address the

concerns. Most frequently mentioned suggestions were: ensure regular flow of funds for timely reimbursement to

beneficiaries, consider disbursing money through Bikash, postal or other e-cash system, DSF should ensure availability

of right mix of health care providers, monitoring and supervision of the programme should be strengthened, improve

understanding of mothers about the program, criteria for defining poverty should be revised.

Given the utilization of maternal health services in the programme areas, total budget needs become Tk.126.4 million for

paying for the services provided by health care personnel. The most important item within provider payment was the cost

of caesarean section delivery, which represents about 57% of total health service expenses. The budget needs for 2015-

16 to pay the beneficiaries was about Tk. 146.7 million. Institutional delivery related incentives represent about 63% of

total payments. The administrative cost at the facility level, which includes incentive payments for UHFPO and RMO at

the UHC and salary payment for one office staff per UHC, is estimated at Tk. 5.6 million. Therefore, total service-related

expenses in 2015-16 should be Tk. 278.7 million.

According to the budget and expenditure reports, average annual budget of the programme over the last five years was

about Tk. 12.674 million per upazila or Tk. 671.72 million per year for the programme in 53 upazilas. The expense on the

average is relatively high due to higher enrolment in the programme prior to 2014-15. Excluding the expenses related to

payment for services and incentive payments for beneficiaries, the remaining expenses were Tk.13.21 lac or Tk.1.321

million per upazila. A number of MOHFW personnel are involved with the programme and additional personnel are


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appointed by the World Health Organization (WHO). Since the programme requires the presence of these administrative

and operational personnel, the value of their time should be included in the programme cost.

Unit costs associated with the programme are reported below including the personnel cost not in programme budget.

Provider payments for the services delivered: Tk. 1,181 per voucher distributed

Paying beneficiaries for travel and incentives: Tk. 1,371 per voucher distributed

Paying UHFPO and RMO for delivery cases: Tk. 100 per institutional delivery

Office staff wage payment (upazila level): Tk. 18,720 per upazila per year

Expenses on meetings, printing, supplies, copying: Tk. 1.321 million/upazila

Expenses related to advertisement/publicity: Tk. 0.10 million/upazila

Additional personnel cost, management/implementation: Tk. 0.45 million/upazila

Only 15 upazilas in the programme belong to the poorest 20% of upazilas of Bangladesh while another 11 belonged to

second poorest quintile. The selection of upazilas was not based on geographic poverty rates. If the upper poverty line of

2010 is used for identifying the poor pregnant women in 53 upazilas under DSF, the programme should have distributed

91,558 vouchers (assuming that poverty rate among first and second order pregnancy cases is 10% higher than upazila

poverty rate) in 2015-16 but the programme actually distributed 107,000 vouchers, 17% higher than the number of poor

women in the upazilas.

Some suggestions are listed below by specific areas of concern.

Flow of fund related issues:

1. It is important to identify the causes of delay in the flow of funds. The time lag between the adoption of budget and

release of funds to MOHFW needs to be reduced to less than 30 days. Time needed for flow of funds from MOHFW to

upazila level should be reduced as well.

2. Ministry of Finance may consider creating an imprest account to be administered by the management of DSF-MHVS.

The management entity can potentially be a financial entity or a third party administrator.

3. The programme should allow beneficiaries to choose from a number of alternative ways of receiving payments. The

mechanisms for paying may range from bank accounts including online banking and micro-credit accounts, postal

money orders or e-cash or mobile transfer of funds.

4. The requirements for opening bank accounts should be simplified.

Programme management related issues:

5. The committees formed for planning and administering different aspects of DSF-MHVS should be carefully reviewed.

The number of committees may be reduced.

6. The presence QMs appears critical for proper implementation and management of programme activities at village,

union and upazila levels. Programme should appoint administrative personnel at upazila level who will be in charge of

local level programme activities including data management, verification of eligibility, keeping contacts with village and

union level stakeholders and beneficiaries.

7. The programme needs an independent monitoring entity to verify quantities of services delivered as well as the quality.

The monitoring system should also collect information on out-of-pocket expenses of beneficiaries.


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8. Programme should adopt a systematic social mobilization strategy to improve programme related knowledge of all

stakeholders including programme managers and implementers, DSF-MHVS beneficiaries and health care providers. It is

also important to develop a “user-friendly” booklet to make mothers aware of pregnancy related health issue, safe

delivery practices, care of newborn and importance of breastfeeding.

Incentive payment related issues:

9. The price schedule used by the programme should be carefully evaluated to ensure that the prices are consistent with

the social objective of improving maternal and neonatal health and improving access to health care services by poor

pregnant women in rural Bangladesh.

10. Incentive payments to public sector health care providers for services delivered to DSF-MHVS beneficiaries represent

a conflict of interest situation. Solution to this problem should be identified.

Targeting the beneficiaries:

11. Indicators for selection of poor households should be revised. Income-based poverty indicators are difficult to verify

and the programme should devise easy to monitor poverty indicators for identifying the target population.

12. Since the maternal mortality ratio was found to be highest for the middle wealth quintile in Bangladesh (by Maternal

Mortality survey), changing the eligibility criteria to allow inclusion of poorest 50% may be considered if targeting the

programme towards the poor is desired. Costs and benefits of universal coverage should also be evaluated.

13. Targeting efficiency of DSF-MHVS is not known. The programme should carry out a community level survey to estimate

how efficient the programme is in reaching the poor.

14. For inclusion of new upazilas, the programme should consider “geographic targeting”, i.e., selecting the poorest

upazilas of the country for expansion of DSF-MHVS.

Specific Suggestions

Expand the programme by using geographic targeting, i.e., targeting high poverty rate upazilas. In high poverty rate

areas, universal coverage can be adopted.

Delay in flow of funds should be addressed immediately. Imprest account may be created for ensuring timely

payment to beneficiaries as well as to health care providers.

The programme should allow beneficiaries a number of options for receiving incentive payments, such as, direct

deposit into bank accounts, e-cash, mobile banking, postal money order, etc.

Price schedule used by DSF-MHVS should be carefully reviewed to understand and correct how the unit prices affect

patient and provider behaviour.

Purchaser and provider of health care services should not be the same entity and at the upazila level, roles played

by UHC should be redefined.

The benefit package needs updating. The benefit package should include all services required for safe delivery

including ultrasound for complicated pregnancies, tests for blood sugar and blood grouping. User payments for

covered services should be prohibited.

Informational booklet on pregnancy, progression of pregnancy, food and nutritional needs, danger signs of

pregnancy, pregnancy complications, safe delivery practices, care of newborn, etc. should be developed and

distributed to all pregnant women in the area.


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Diagnostic studies of similar programmes should be carried out to identify potential economies of scope, i.e.,

whether the value-for-money in each of the programmes can be improved by integrating it with other similar

programmes. The benefits and costs of integrating DSF-MHVS with similar social protection programmes should

be examined.

The programme should develop a comprehensive integrated Management Information System (HMIS) for DSF-

MHVS, which can be integrated with UHC HMIS.

Household survey in DSF-MHVS area should be carried out to understand targeting efficiency. The survey should

also obtain information on possible over-reporting of service utilization. Facility-based survey should also be

organized to measure quality and quantity of maternal health services produced in public and private health care

facilities.

This report was discussed in a meeting in the MOHFW. Major stakeholders of the scheme participated in the meeting.

There was a general consensus in the meeting on the findings and suggestions made in this report. Realistic reform

plan should be prepared for implementation of the recommendations put forward in the report. The GOB and

SPFMSP project should take necessary initiatives in this direction.


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Contents Executive Summary ................................................................................................................................................................................................ i

Abbreviations ................................................................................................................................................................................................... vii

I. Background to DSF-MHVS................................................................................................................................................................... 1

II. Objectives of the diagnostic study ................................................................................................................................................... 2

III. Methodology of the study ................................................................................................................................................................... 2

IV. The Demand Side Financing Programme: Maternal Health Voucher Scheme ............................................................. 3

a. DSF-MHVS Objectives and its Development ............................................................................................................................ 3

b. Identifying the poor: the official criteria and distribution of vouchers............................................................................. 3

c. Management of the voucher scheme......................................................................................................................................... 4

d. Flow of funds and fund transfer mechanism ........................................................................................................................... 4

e. Benefit Package and Payment Rates for Voucher Holders and Health Care Providers .............................................. 6

V. Results of the Diagnostic Study ......................................................................................................................................................... 7

a. Issues and Concerns identified by other studies .................................................................................................................... 7

b. Opinion of policy-makers and key informants ........................................................................................................................ 9

c. Field visits: Opinions from the field ........................................................................................................................................... 10

d. Survey of WHO Quality Managers (QMs) .................................................................................................................................. 11

e. Analysis of Programme Data ....................................................................................................................................................... 12

f. Targeting Efficiency of MHVS ...................................................................................................................................................... 18

VI. Policy Suggestions ......................................................................................................................................................................... 20

a. Issues related to flow of funds .................................................................................................................................................... 20

b. Administration and management related issues ................................................................................................................. 22

c. Paying the providers ...................................................................................................................................................................... 22

d. Targeting poor mothers ............................................................................................................................................................... 24

e. Knowledge and communication related issues in the programme ............................................................................... 25

f. Data needs for improving effectiveness and efficiency of DSF ......................................................................................... 25

g. Comparison with other similar social protection programmes ....................................................................................... 26

VII. Concluding Remarks ............................................................................................................................................................................... 27

References .............................................................................................................................................................................................................. 30

Annex A: DSF Upazilas with their 2010 Poverty Head-Count Ratio ....................................................................................................... 31

Annex B: Questionnaire used to survey the Quality Managers of DSF ................................................................................................. 35

Annex C: Budget and Expenditures of DSF MHVS ...................................................................................................................................... 37

Annex D: List of Poorest 50 upazilas of Bangladesh .................................................................................................................................. 41

Annex E: List of Individuals met during the field visits and in Dhaka, Bangladesh .......................................................................... 43

Annex F: Comparative Summary Statements for DSF-MHVS ................................................................................................................. 45

Annex G: Minutes of the meeting on report presentation and discussion ......................................................................................... 50


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Abbreviations

ANC Ante Natal Care

CEmOC Comprehensive Emergency Obstetric Care

CSBA Community based Skilled Birth Attendants

DHS Demographic Health Survey

DSF Demand Side Financing

EmOC Emergency Obstetric Care

GOB Government of Bangladesh

FWA Family Welfare Assistant

FWV Family Welfare Visitor

HA Health Assistant

HMIS Health Management Information System

IMR Infant Mortality Rate

MHVS Maternal Health Voucher Scheme

MMR Maternal Mortality Ratio

MNCAH Maternal, Neonatal, Child and Adolescent Health

MOF Ministry of Finance

MOHFW Ministry of Health and Family Welfare

OOP Out Of Pocket

PNC Post Natal Care

QM Quality Manager

SPFMSP Strengthening Public Financial Management for Social Protection

UHC Upazila Health Complex

UHFPO Upazila Health and Family Planning Officer

UNO Upazila Nirbahi Officer (Upazila officer in charge)

VfM Value for Money

WHO World Health Organization


1

This report is a diagnostic study of one specific social protection program, the Demand Side Financing of maternal and

neonatal health, the Maternal Health Voucher Scheme (DSF-MHVS). The diagnostic study has examined the process of

programme implementation in practice and identified some specific policy changes and reforms that may help improve

value for money (VfM) in DSF-MHVS. The study was carried out during September - December 2016. The focus of the study

has been to better understand the problems and concerns of DSF-MHVS from the perspectives of managers, policy

makers, implementers, health care providers and the beneficiaries.

I. Background to DSF-MHVS

Maternal, Neonatal and child health care are priority health care services for Bangladesh and the five year plans of the

country have consistently emphasized the importance of improving maternal and child health. Although Bangladesh has

seen significant improvements in health outcomes, further progress in maternal and child health can be achieved through

improved access to quality health care services to all, especially to the disadvantaged population groups.

Maternal Mortality Ratio (MMR) of Bangladesh declined from 3.29 per 1000 live births in 2000 to 2.15 in 2011 (BBS,

September 2016). It further reduced to about 1.43 per 1000 live births by 2014. Under-five mortality also declined rapidly

from 94 per 1000 live births in 2000 to 46 in 2014. Improvements in health status happened in all socioeconomic groups

but disparity in health outcomes has remained relatively high. For example, MMR among the lowest wealth quintile

population was about 90% higher than the highest quintile (NIPORT, December 2012) but interestingly maternal mortality

survey found that the MMR was not the highest among the poorest group. The MMR was reported to be the highest among

the middle wealth quintile, implying that further improvements in MMR will require more broad-based intervention rather

than targeting the poorest.

According to the Demographic and Health Survey (DHS) of Bangladesh, 64% of women who gave birth in three years

preceding the survey received antenatal care (ANC) from trained personnel and 31% had four or more ANC visits. 95% of

highest wealth quintile mothers received ANC from trained personnel while it was only 36% for the lowest quintile.

Percent of women receiving ANC from public sector was 41% among the lowest wealth quintile and 24% for the highest

quintile while the percentages receiving ANC from private providers were 33% and 71% for lowest and highest wealth

quintile respectively. Therefore, public sector health care facilities are the predominant source of maternal health care

services for poor households in Bangladesh.

About 62% of all births in Bangladesh took place at home in 2014, 13% in public sector health care facilities and 22% in

private facilities. Percent of all births happening in health care facilities was only 14.5% among the lowest wealth quintile

and 70% among highest quintile. Deliveries done through caesarean sections increased rapidly over the years, from 4%

in 2004 to 23% in 2014. Rapid increase in the caesarean section rates is a concern even though it was very low in 2004.

More than 60% of women did not receive any postnatal care in the preceding three years prior to the DHS survey in 2014.

Those who received postnatal care (PNC), only 31.5% received the care from trained medical personnel. PNC utilization

gap between lowest to highest wealth quintile was quite large as well. Among the lowest wealth quintile, PNC utilization

rate was 13% and for the highest quintile it was 63% (NIPORT, Bangladesh Demographic and Health Survey 2014, March

2016). Therefore, utilization of ANC, safe delivery and PNC can be improved significantly in Bangladesh, especially for the

poorer sections of the population.

In Bangladesh, out-of-pocket (OOP) payment for obtaining formal or informal health care services represents a large part

of total health care expenditure. In 2012, OOP payments by households accounted for 63% of total health expenditure

(HEU, 2012). One study reported that about 64% of pregnancies sought at least some maternal health services from public

or private facilities and almost all incurred OOP expenses. The average OOP expense (using weighted average of public


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and private facility users) was about $108 per institutional delivery. Even for users of public sector health facilities, OOP

was found to be about $46 (Rahman, Rob, Noor, & Bellows, 2013). Another study reported that for normal deliveries

average OOP was about $29 and deliveries with complications incurred an average OOP expense of $261 (Hoque, Powell-

Jackson, Dasgupta, Chowdury, & Koblinsky, 2012). High burden of OOP expenses is likely to affect adversely utilization of

maternal and child health services. Policies to lower OOP should improve utilization of maternal health services.

The DSF- MHVS was designed to increase the utilization of maternal health services in Bangladesh in order to improve

maternal and neonatal health outcomes. The scheme encouraged utilization of quality maternal health services

delivered by trained clinical personnel.

II. Objectives of the diagnostic study

This diagnostic study intended to identify and document major concerns and issues with the MHVS. Potential sources of

inefficiencies of the scheme were also explored. More specifically, the objectives of the study are:

1. To review and understand different characteristic features of the scheme including its objectives, program design,

eligibility criteria, etc.

2. To review different types of processes adopted for implementation of the scheme including targeting of

beneficiaries; timely and quality services being offered to the beneficiaries and issues and challenges currently being

faced by the service providers as well as beneficiaries.

3. To provide recommendations to improve value for money for the programme.

4. To analyse possible benefits and costs of expanding the scheme from its current level of operations and to discuss

possible economies of scale.

5. To provide information on administrative and other costs of the programme to enable future estimation of potential

cost savings through economies of scope, i.e., combining DSF-MHVS with other similar programs.

6. To derive cost parameters for use in future studies to estimate budget impacts of reformed plans and/or to develop

integrated approach of providing social safety net services and interventions at national and sub-national levels.

III. Methodology of the study

To achieve the objectives of the study, a number of methodological approaches were adopted. The method adopted

may be termed as a mixed-method approach where multiple research strategies are followed. Both qualitative and

quantitative research methods were used to help diagnose the programme concerns without conducting a full evaluation

of the programme. One of the main objectives of the study is to identify specific approaches for improving value for money

(VfM) and the focus has been to collect information on potential sources of inefficiencies through key informant

interviews, qualitative surveys and analysis of administrative data. Specific methodological steps are listed below.

a. Literature review: issues and concerns identified by previous studies on DSF-MHVS. Are the evidences consistent

enough to come up with actionable changes or reforms? Both published and unpublished studies were reviewed.

b. Key informant interviews: discussions with policy makers at national and sub-national levels as well as personnel

involved in the implementation of the program at the field level.

c. Field visits: two field visits were organized. The field visits included one high-performing DSF-MHVS area and one

relatively low performance area.

d. Discussions with World Health Organization (WHO) DSF-MHVS Quality Managers (QMs): to identify problems, issues

and concerns from the point of view of implementers at the field level (QMs are involved with various operational

aspects of the programme).


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e. Survey of WHO QMs: a structured questionnaire was used to collect information from all QMs appointed to manage

DSF-MHVS at the upazila level.

f. Quantitative analysis of programme data: DSF-MHVS related data were obtained for the years 2011 to 2016.

IV. The Demand Side Financing Programme: Maternal Health Voucher Scheme

a. DSF-MHVS Objectives and its Development

The DSF-MHVS is a demand side financing strategy to achieve a number of objectives related to improvements in

maternal and neonatal health in Bangladesh. The specific objectives of the programme are: (i) to increase demand and

utilization of maternal health services, (ii) to improve access and utilization of safe delivery, (iii) to encourage institutional

delivery and (iv) to improve equity in the utilization of maternal health services. During the year 2015-16, the scheme

enrolled more than 107 thousand beneficiaries which represented about 3% of all pregnancies of Bangladesh (assuming

crude birth rate of 20 per 1000 population and July 1 2016 population as 165.5 million). Therefore, the programme

currently covers only a small proportion of all births happening in the country.

According to the official procedures of the programme, the DSF-MHVS intends to provide poor mothers with a booklet

containing a number of vouchers which the pregnant women can use to obtain three ANCs, safe delivery and PNC free of

charge. The vouchers also cover assisted delivery and caesarean section delivery, if needed. To reduce the cost of

accessing maternal health services, the scheme provides transportation cost and cash incentives to mothers for safe

delivery (either in a facility or at home but with assistance from skilled personnel). The programme started in phases in

2006 and currently it is in operation in 53 upazilas (sub-districts) located in 41 districts of Bangladesh. The scheme

provides direct subsidies to the target group to enable them to obtain specific services from designated public and private

health care facilities. Although it is a demand side financing programme, the current design is actually a mixture of

conditional cash transfer for utilization of maternal health services (the demand side) as well as cash incentives for public

sector service providers (the supply side).

b. Identifying the poor: the official criteria and distribution of vouchers

According to the official manual of the program, three criteria are used to identify poor households. (i) Monthly income of

Tk. 3,100 or less, (ii) Amount of land owned by the household is less than 0.15 acre, (iii) Household does not own any

income earning assets like livestock, poultry, fish farm, orchard, rickshaw and rickshaw van, etc. Official system of

determining eligibility in DSF-MHVS is shown by a schematic diagram in Figure 1. Although it is not clear how exactly these

criteria are supposed to be implemented, it appears that the programme implementers interpret the criteria as

simultaneous satisfaction of all three conditions. Using a fixed level of money income for identifying the poor is

problematic for a number of reasons. Size of the household, price inflation over the years, etc. affect the poverty line but

the programme did not change the poverty income level for a number of years. It should be noted that if price index is

used to correct for upper poverty line of Bangladesh, poverty line in 2016 should be about Tk. 6,700 per month per family

of three implying that the programme defined poverty income is much lower than the poverty line for Bangladesh.

There are additional conditions which must be satisfied for enrolling beneficiaries in the programme. The beneficiary

must be a resident of the upazila and the pregnancy must be either first or second order pregnancy. In case of second

pregnancy, use of family planning methods prior to the pregnancy has been listed as an additional requirement. In

practice, the programme uses an informal approach of identifying the beneficiaries. Field level Family Welfare Assistant

(FWA) or Health Assistant (HA) or Skilled Birth Attendant (SBA) enrols eligible pregnant women using the poverty criteria

by completing a registration card. Union DSF committee approves the registration by counter-signing the card and sends

it to the upazila for voucher allocation and distribution. At the upazila level, the QMs verify the eligibility of few randomly


4

selected registered women. Once verified, the voucher book is issued and the woman can get the book either from the

upazila health centre (UHC) or from FWA, HA or SBA at the community level.

Figure 1: Official Method of Identifying the MHVS beneficiaries

c. Management of the voucher scheme

The programme is managed and implemented through a number of committees and sub-committees. At the national

level, there is a National DSF Steering Committee, National DSF Programme Implementation Committee and a DSF

Technical sub-committee. At the district level, District Designation Body for the selection of private hospitals/clinics

chaired by the Civil Surgeon (CG) manages selection and accreditation of health care providers for participation in the

scheme. Two committees are created at the upazila level, the Upazila DSF Committee and the Upazila Seed Fund

Committee, both chaired by the Upazila Nirbahi Officer (UNO: the Upazila Officer in Charge). Each of the unions within

the upazila has a Union DSF Committee chaired by the Union Parishad (Union Council) Chair. Membership of these

committees with their responsibilities can be found in a recent report (Farzana, March 2014).

d. Flow of funds and fund transfer mechanism

The DSF-MHVS is implemented by the Ministry of Health and Family Welfare (MOHFW) using pool fund which includes

GOB development budget money and contributions by development partners.

The flow of funds for DSF-MHVS from the Ministry of Finance to the lowest level can be summarized as follows. The pool

fund budget is transferred to an account titled ‘Maternal Health Voucher Scheme’ (MHVS) operated by Line Director (LD)

Pregnant woman (resident of the upazila)

Woman from poor household Woman not poor

First pregnancy Second pregnancy Third or higher order

pregnancy

Used family planning prior to

the pregnancy Did not use family

planning methods

Beneficiary of MHVS

Criteria for defining “poor”

Household income: < Tk 3100/ month

Functionally landless (<0.15 acre of land)

Does not have any other productive asset


5

of Maternal, Neonatal, Child and Adolescent Health (MNCAH). DSF administrators reported that the release of funds from

the Ministry of Finance (MOF) to the MOHFW takes some time, usually about two months, after the acceptance of the

budget. The release of funds from the MOHFW to the MHVS account requires development of detailed plan for the

programme. Once the plan has been finalized and approved by the MOHFW and the World Bank, money is transferred to

the MHVS account of the LD. From this account, funds are transferred in instalments to MHVS Upazila account at the

upazila branch of Sonali Bank. The Upazila Health & Family Planning Officer (UHFPO), on behalf of the Upazila DSF

committee, operates the account. The seed fund account is also created at the upazila level with an initial one-time

payment of Tk. 65,000. This fund is supposed to be used to buy medical and surgical requisites or other instruments and

supplies needed for the provision of maternal health services. From the upazila MHVS account the payments for private

and public sector providers (for services provided to MHVS mothers) are transferred to the seed fund account. Private

providers are paid based on a pre-defined payment schedule for the services delivered. Public sector health care

providers also receive incentive payments but the payment received by public providers per unit of service is half of the

price indicated for the service in the payment schedule. Since public sector providers are full-time government

employees, the payments they receive for delivering maternal health services are designed to encourage provision of

quality maternal health services to voucher holders. The remaining half of unit prices goes to the public sector facility to

help improve availability and delivery of maternal health services, including drugs and supplies.

Figure 2: Flow of Funds from Centre to Health Care Providers and Voucher Holders


6

e. Benefit Package and Payment Rates for Voucher Holders and Health Care Providers

The voucher book allows the beneficiaries to receive a number of benefits. The benefit package consists of three ANC

visits, one PNC visit, safe delivery including caesarean delivery and services needed to deal with pregnancy and delivery

related complications. The voucher holders are supposed to get these services without any out-of-pocket expenses. To

encourage poor pregnant women to obtain services from health facilities, the programme pays a fixed amount of money

for travel expenses per trip to obtain the services included in the benefit package. Therefore, the beneficiaries can receive

travel expenses for maximum of five trips (three ANC, one PNC and one trip for delivery). In addition, mothers also get

incentive payments for safe delivery, although the incentive amount to be paid depends on whether the safe delivery

happened in the home of the beneficiary or in a health facility. This part of MHVS payment schedule can be considered

the demand side financing component. The benefits MHVS participants are supposed to receive are listed in table 1.

Table 1: Benefit Package for Voucher Holders

Services and benefits Payments expected from beneficiaries for service

Incentive payments to beneficiary

Three ANC visits None None*

Laboratory tests: blood and urine None None*

Safe delivery in facility (includes normal

deliveries, vacuum or forceps deliveries and

C-section deliveries)

Diagnostic and lab tests not

mentioned as part of benefit package

were probably charged to

beneficiaries

Tk. 2,000

Safe delivery at home None Tk. 500

Delivery complications None None*

Referral to upper-level facilities None None*

One PNC visit None None*

Travel expenses (travels related to ANC and

PNC visits, safe delivery in facility)

Actual travel expenses paid out-of-

pocket†

Tk. 100 per trip, maximum of

5 trips

* This refers to incentive payments related to utilization of services, not travel or other expenses associated with the

receipt of services, which are listed separately

† Beneficiaries pay travel expenses out-of-pocket for seeking care from facilities. They are supposed to receive Tk. 100

per trip from the programme irrespective of actual travel costs incurred.

The voucher holders can obtain services from approved public sector and private sector health facilities if private

providers are approved for service delivery in the upazila. Since the beneficiaries are supposed to get the services free of

charge, the programme needed a mechanism of paying the private health care providers when they provide services to

voucher holders. Paying the providers requires prospectively defining unit prices for each of the covered services in the

DSF-MHVS. In order to encourage provision of service by private health facilities, the prices must be appropriate for the

services to be offered. It is not clear how the programme came up with the unit prices or costs and how appropriate the

prices are. Public sector health facilities are funded by the GOB and they are expected to provide all necessary maternal

and child health services free of charge irrespective of participation in voucher programme. Therefore, unlike the private

sector, public sector providers do not require additional payment for the services they provide. The programme, in order

to incentivise public sector health care providers to participate in the programme and to offer quality maternal health

services to the disadvantaged population groups, a payment schedule was developed for public sector service providers

as well. Public health facilities also receive additional incentive payments to participate in the MHVS. Table 2 shows the

unit prices set by the programme for paying public and private sector providers and the amount paid out to health care

workers who actually provided the services to DSF-MHVS beneficiaries. For private sector, the money to be paid to actual

health care providers is not mandated and so the private sector can negotiate the fee to be paid to providers for each

type of the services covered under the programme.


7

Table 2: Unit Prices in Taka for Public and Private Sector Facilities

Services Public facility/Providers Private facility/Providers

Unit price Providers get Unit price Provider share

Registration of participant 20.00 20.00 -- --

ANC visit 50.00 25.00 50.00 No set rule

Urine test (two allowed) 35.00 17.50 35.00

Blood test (two allowed) 35.00 17.50 35.00

Normal delivery 300.00 150.00 300.00

Medicine (total) 100.00 0.00

Vacuum/forceps delivery 1,000.00 500.00 1,000.00

C-section delivery 6,000.00 3,000.00 6,000.00

Eclampsia management 1,000.00 0.00 1,000.00

PNC visit 50.00 25.00 50.00

Referral of a case 0.00 0.00

Administrative expenses

Payment for UHFPO Tk.50/delivery -- -- --

Payment for RMO Tk.50/delivery -- -- --

Payment for office staff Tk.60/ day -- -- --

As shown in table 2, payments for each health care provider are clearly defined for the public sector health workers but it

is not defined for the private sector. Private sector facilities receive the total unit price per service type and then the

facilities decide how to apportion the money to different health care providers and support staff. In public sector health

facilities, providers receive Tk.17.50 per laboratory test and the money is paid to the health care worker conducting the

test. The payment for ANC goes to ANC visit providers (either FWV, CSBA, doctor or nurse). For home based normal

delivery, the health care provider gets Tk.75 while the total money allotted for normal institutional delivery (Tk.150) is

divided among the health workers involved (Tk.60 for the doctor, Tk.40 for nurse, Tk. 25 for wardboy or female helper).

For conducting the C-section in a public sector health facility, the surgeon conducting the C-section gets Tk. 1,100 and

the anaesthetist gets Tk.600. Tk.500 goes to operation assistant, Tk.250 each to two senior nurses, Tk.100 each to two

ward-boys or female helpers and Tk.100 for the cleaner. Delivery complication related payments are Tk.300 for doctor,

Tk.100 for nurse, Tk.50 for wardboy or female helper and Tk.50 for cleaner.

V. Results of the Diagnostic Study

a. Issues and Concerns identified by other studies

A number of studies were reviewed to understand various issues and concerns identified by these reports. Most of the

studies concluded that the DSF-MHVS has significantly improved access to maternal health services for the voucher

holders and utilization of ANC, safe delivery and PNC have increased in the DSF areas and among voucher holders

(Rannan-Eliya, Technical Report B, 2012; Farzana, March 2014; Halim, March 2014; Anwar, Blaakman, & Akhter, September

2013; Hatt, et al., February 2010; Ahmed & Khan, 2011; Noor, Talukder, & Rob, 2013). Equity in maternal health service

utilization also improved in the DSF areas compared to similar non-DSF areas although one study did not find any effect

on equity (Rannan-Eliya, Technical Report B, 2012). This specific study, however, tried to derive equity implications

through patient surveys carried out in health care facilities, which is not the recommended approach of evaluating equity

implications of a programme. The programme has also improved utilization of Upazila Health Centres (UHCs) in DSF

areas implying that public sector health care delivery system can be strengthened through the voucher scheme (Noor &


8

Rob, Does Maternal Health Voucher Scheme Have an Impact on Out-of-pocket Expenditure and Utilization of Delivery

Care Services in Rural Bangladesh?, 2013).

The studies reviewed identified a number of issues and concerns related to the implementation and functioning of the

DSF. These issues are summarized in the paragraphs below.

(i) Administrative and management issues: MHVS implementers at the upazila and union levels sometimes did

not know the details of the programme implementation and the benefit package of voucher holders.

Consistent policies were not followed in all geographic areas in the identification of poor pregnant women.

One study reports that at the initial stage of MHVS implementation, some upazilas misunderstood the

enrolment criteria and enrolled individuals who should not have been in the programme (Ahmed & Khan,

2011). Lack of communication between the programme management at the centre and local level

implementers was considered a significant concern. Some studies also mentioned that union level DSF

committees were not functional in some areas. The orientation trainings organized at the local level were not

very effective (Koehlmoos, et al., September 2008).

(ii) Financial issues: Significant delay in the payment of the incentives to beneficiaries is a major concern. This

problem was identified by almost all studies evaluating the DSF programme (Hatt, et al., February 2010; Ahmed

& Khan, 2011). More recent studies also report delay in fund disbursement as an important threat to the

programme (Anwar, Blaakman, & Akhter, September 2013). The delay probably varies from year to year but the

usual delay appears to be in between three to six months (Anwar, Blaakman, & Akhter, September 2013). One

study reported that the funds for the programme are released only twice a year and in one year the first

instalment was not even transferred to the Ministry of Health before December (Farzana, March 2014;

Koehlmoos, et al., September 2008). Delay in the flow of funds happen at all levels, adversely affecting the

efficient functioning of programme activities. Sending the unspent money back to the central treasury at the

end of fiscal year creates further delays in fund disbursement to beneficiaries (Sabur, December 2015).

(iii) Target group identification: The MHVS defines the eligibility criteria for enrolment in the programme but

eligibility criteria are not often followed (Hatt, et al., February 2010). In some cases, vouchers were distributed

to individuals who were not eligible (Koehlmoos, et al., September 2008). All pregnant women are supposed

to be identified and brought into the programme during the first trimester. One study reported that pregnant

women were enrolled in the programme as late as eight to nine months of pregnancy. The requirement that

the pregnancy should be either first or second for the women was not adopted in some cases (Koehlmoos, et

al., September 2008). The poverty income defined by the programme is also considered unrealistic, given the

improvements in economic status of population in Bangladesh and the overall price inflation over the years

(Anwar, Blaakman, & Akhter, September 2013). Although the studies indicated the possibility of mistargeting,

none reported on the degree of mistargeting in the programme.

(iv) Quality of health care services in DSF areas: One study has examined technical and clinical quality for DSF and

non-DSF area health facilities. Although the sample size is quite small, the study provided some idea about

relative quality of facilities using quality monitoring checklist (Anwar, Blaakman, & Akhter, September 2013).

Quality of care index was found to be higher in DSF facilities than in non-DSF facilities. Only 50% of facilities in

DSF area were found to be Comprehensive Emergency Obstetric Care (CEmOC) facilities. Lack of specialist

doctors, obstetrics and anaesthesiologists, was found to be an important concern (Koehlmoos, et al.,

September 2008; Anwar, Blaakman, & Akhter, September 2013). Not using partograph on a routine basis has


9

also been reported as a significant problem in both DSF and non-DSF health facilities, especially because

caesarean section deliveries are increasing rapidly over the years.

(v) Knowledge of voucher holders about the benefit package and about DSF-MHVS in general: One study indicates

that the DSF program is weak in terms of community mobilization and providing relevant information to

pregnant women and to future potential beneficiaries. Even the voucher holders did not know all the services

that are entitled to under the programme (Anwar, Blaakman, & Akhter, September 2013).

(vi) Out-of-pocket (OOP) expenses of voucher holders: Noor et al. used a difference in difference approach to

estimate the effect of DSF-MHVS on out-of-pocket expenses for accessing maternal health services. They found

that in the DSF intervention areas, average OOP cost for normal delivery declined by 16% while it declined by

37% for caesarean delivery compared to the expenses in control areas. Survey of facility users did not find

lower out-of-pocket expenses in DSF upazila health centres (Rannan-Eliya, Technical Report B, 2012). The

studies, however, implies that the services were not obtained free-of-charge by voucher holders.

(vii) Provider payment and supplier induced demand issues: One concern raised by a number of studies is the

possibility of over-utilization of caesarean section delivery due to high level of incentives given to the surgeon

compared to what the doctor gets for a normal delivery. In the public sector, doctor receives only Tk. 60 per

normal delivery and Tk. 1,100 for C-section delivery. The C-section delivery incentive amount is more than 18

times of the normal delivery incentive at the facility level. The information reported by the studies indicate

much higher rate of C-section delivery in DSF areas compared to other comparable areas (Anwar, Blaakman,

& Akhter, September 2013; Farzana, March 2014; Noor & Rob, Does Maternal Health Voucher Scheme Have an

Impact on Out-of-pocket Expenditure and Utilization of Delivery Care Services in Rural Bangladesh?, 2013).

b. Opinion of policy-makers and key informants

The team discussed with a number of policy makers, representatives of development partners and field level

implementers to identify potential issues and concerns. At all levels, the key informants were of the opinion that DSF-

MHVS has improved access to maternal health service by pregnant women, especially for poor women in the DSF areas.

Most believe that the programme should be strengthened and scaled-up to improve maternal health status in

Bangladesh. The discussions with different stakeholders identified following issues or concerns.

Budgetary process and Annual Development Program (ADP) allocation is time consuming. The time lag between

start of fiscal year and actual budgetary allocation to MOHFW could be about 3-6 months. This delay creates

significant obstacles in running the DSF-MHVS.

Since the DSF fund comes from the development budget, after the beginning of the financial year MOHFW releases

quarterly allotment in favour of LD. LD then send advance drawing request to MOHFW, which then is sent to MOF for

approval. The approval then comes back to LD. The LD submits bill to Accountant General (AG) office for drawing

the fund. Thereafter, fund is disbursed to UHFPO’s MHVS account. This process may take few additional months.

Advance is required for payment of cash incentive, travel allowance, etc. The programme should develop a

mechanism to get advance on a timely basis for continuing the essential operations of the programme.

Paying mothers through bank accounts appears to be not working as planned. In most areas, bank managers are

not interested to open accounts for the poor women as it is perceived to be one-time banking only with significant

administrative costs involved. The requirement of getting a cell phone number for the beneficiaries in order to

transfer money to the bank account has also become an issue.

Incentive money is not paid on a timely basis to beneficiaries. They often have to travel a number of times to the

upazila to get their money. This creates dissatisfaction among the DSF-MHVS enrolees.


10

The programme should consider a number of options for disbursing money to beneficiaries including online

banking, e-cash transfer system, use of postal money order, etc. This will allow disbursement from the centre

without the need for going through the upazila account.

There are too many DSF committees. The number of committees can be reduced and the number of DSF meetings

can also be reduced by combining DSF discussions with other meeting agenda items at union and upazila levels.

Third party should be involved for ensuring quality of services delivered, improved management and transparency

of the programme and reimbursing health care providers for the services delivered. Involvement of the third party

will create internal checks and balances within the system.

The administrative cost of the programme is high and there appears to be significant mismanagement within the

system.

Human resource availability should be ensured before the programme encourages mothers to come to facilities for

the delivery of babies. More than half of the DSF facilities are not ready to provide CEmOC services.

Criteria used for identifying the poor are not appropriate. These should be revised to reflect the current poverty

situation and poverty level income.

Identifying the poor and targeting the poor pregnant women is not working. The question is whether the programme

will be more efficient if it is converted into a universal coverage programme.

c. Field visits: Opinions from the field

The first field visit took place in Daudkandi upazila, Comilla. The team visited the Upazila Health Complex (UHC), the

private hospital contracted by DSF in the area and a village (Village: Shobibad, Union: Baro Para) in the upazila. At the

UHC, the team members met with the Upazila Health and Family Planning Officer (UHFPO), Resident Medical Officer

(RMO), gynaecological consultants and the anaesthetics. The purpose of the discussions was to better understand the

services delivered and issues/concerns with delivery of maternal health services from the UHC and from other lower level

health facilities.

During the field visit, data were collected on service delivery from the UHC. During January 2016 to August 2016, number

of ANCs used at UHC was 458 for voucher holders and 3,115 for non-DSF cases. Therefore, 13% of all ANC services

provided at UHC were given to the DSF voucher holders. During this eight month period, DSF voucher holders accounted

for 19.5% of all normal deliveries at the UHC (122 deliveries out of 627). From January-August 2016, total number of C-

sections done at the UHC was 118 and out of this 84 cases were DSF voucher holders (71% of all caesarean sections done).

Among the mothers delivering in UHC, C-section rate was 40.8% for DSF voucher holders and 6.3% among non-DSF

pregnant women. Large difference in C-section rates between DSF and non-DSF mothers indicate possible effect of

monetary incentives on clinical decision-making. This comparison may be biased due to a number of other possible

reasons: (i) non-DSF women with complicated pregnancies and/or requiring caesarean sections may prefer to use private

health care facilities, (ii) DSF voucher holders with complicated pregnancies are encouraged to use UHC by health care

providers.

Interview with the owner of the private hospital in the area indicates that the private sector usually charges about Tk.

9,000 to 12,000 for a C-section delivery and Tk. 3,000 to 4,000 for a normal delivery in this rural community. The prices they

receive under DSF-MHVS for the services delivered are lower than the “market prices” for private patients. According to

the private facility manager/owner, they do not charge anything extra for the services delivered and they accept the DSF

payments as the total payment for the services. Some beneficiaries, however, mentioned that the private hospital charged


11

extra money. Some mothers also mentioned that they had to buy some drugs and supplies while receiving services from

UHC and private health care providers.

It was clear from the discussions with the beneficiaries in project areas visited that mothers and their family members

were concerned about the pressure doctors exert on pregnant women to undergo caesarean delivery. All the beneficiaries

the team met in the villages received the incentive and travel money together in one instalment in Daudkandi only few

weeks prior to the field visit in early October. They also complained that the bank managers do not want to see them in

the bank because the children make “noises or cry” annoying the manager and the clients of the bank. If housing

condition and ownership of assets are considered, none of the participants (including a newly enrolled woman

interviewed) appear to be from poor households (almost all lived in houses with tin-roof, cement floor and tin walls,

houses had electricity and connected to gas supply line.).

In the second field trip to Sarishabari upazila of Jamalpur district, the team discussed MHVS with the Civil Surgeon (CS)

at the district level. The CS was not involved with the day to day operational and management aspects of the programme.

No report goes through the CS despite him being the district health authority and chairperson of the DSF technical

committee. District committee did not meet at all in the previous one year. The CS suggested that the upazila DSF

committee should be chaired by the UHFPO rather than the UNO. Upazila and union level DSF committees were also

found to be not functional and have met only few times during 2015 in both the areas.

The team members talked to four pregnant women in Sharishabari who have come to the UHC for obtaining ANC. All four

were in their 3rd trimester of pregnancy, although that was their first visit as DSF-MHVS mother. Recruiting pregnant

women at this late stage implies problems with programme implementation as well as lack of awareness of pregnant

women about the programme. Four recent beneficiaries were interviewed in a village and none of these beneficiaries

received their travel money or incentive payments at the time of the field trip. These DSF beneficiaries were also not poor

if housing and amenities available are considered. Therefore, the enrolment criteria may not have been followed in

registering the women in DSF-MHVS. The programme participants in this area reported that they had to buy drugs and

supplies themselves for caesarean section and pregnancy complications.

d. Survey of WHO Quality Managers (QMs)

This study took advantage of the presence of WHO QMs in Dhaka for their annual training session to carry out a quick

survey. A structured questionnaire was used to collect information on specific areas of concerns and issues (see Annex B

for the questionnaire).

The QMs were asked to list three most important current concerns of the DSF-MHVS programme and the concerns listed

are shown in Table 3. About 65% of the QMs thought that the new system of distributing money through bank accounts

was not working. Mothers had to travel to bank a number of times, had to fill a long form to open an account, banks often

were not interested in opening the account and costs associated with cashing cheques were high (due to the cost

associated with getting the cheque book, etc.). Non-availability of clinical personnel in health facilities has been

mentioned by 50% of survey participants. 46% mentioned flow of funds as one of the major concerns and about 20 to

25% mentioned other issues and problems.

Table 3: Three most important issues and concerns as identified by the WHO QMs

Money disbursement through bank accounts have become problematic

Skilled personnel not available at health facilities

Problems and concerns with regular/timely flow of funds for the program


12

Lack of communication among village, union and UHC program personnel

UHFPO not interested, lack of accountability

Gynaecology and anaesthesiology pair not available

Other important results are: 85% mentioned that independent verification of poverty status of voucher recipients are

carried out by the QMs on a regular basis, on the average 74% of poor pregnant women receive vouchers, 77% of

participants are poor, 100% of health care providers and almost 100% of beneficiaries eventually receive the incentive

money, average delay in getting funds is about eight months, 60% of the areas do not provide new-born incentive funds

anymore and those who provide incentive funds, none provides it on a timely basis. Regarding the incentive payments,

the survey participants mentioned that there was no difference in time-lag between government and private providers or

between relatively better-off or poor beneficiaries.

Most frequently mentioned reforms or changes were:

Regular flow of funds should be ensured, delay in disbursing funds is a significant concern

Transferring money through banks is not working. The programme should consider disbursing money to

beneficiaries through Bikash, postal or other e-cash system

Women should get their travel reimbursement at exit from the facility. They should also get their incentive payments

at exit after delivery and within few days in case of home delivery

DSF should ensure availability of right mix of health care providers

Monitoring and supervision should be strengthened. In some areas, the UHFPO does not show any interest in the

programme

Improve understanding of mothers about the program to help in the recruitment of eligible women as well as

making women aware of the benefits of MHVS

Poverty criteria as defined are difficult to implement and verify

e. Analysis of Programme Data

This section presents results of the analysis of administrative or programme data. There are two different data sets that

were obtained. One data set reports the monthly utilization of different types of services by DSF-MHVS beneficiaries and

the second data set presents budget and cost numbers since 2011.

(i) Maternal health utilization pattern

Figure 3 shows the number of vouchers distributed in different years since 2011 and the number of safe deliveries

conducted among the MHVS beneficiaries. The number of voucher books distributed as well as the number of safe

deliveries conducted among DSF mothers have declined in recent years. The decline in DSF-MHVS participation should

not be interpreted as decline in the demand for DSF programme.

The principal reason for the decline in the number of DSF voucher holders in 2015-16 is the way the target numbers are

calculated for the upazilas. In 2014-15, target number of pregnant women was calculated by assuming a Crude Birth Rate

(CBR) of 2.6 per 100 population and then 50% of pregnancies were considered eligible. From June 2016, CBR was changed

to 2.2 and it was assumed that 40% of pregnancies will be eligible. This adjustment reduced actual target number by 10%

but the voucher distribution declined by 27%. With full implementation of this target calculation over a full year, target

number is expected to decline by 32% compared to 2015-16.

The change in the target calculation may have created uncertainty at the field level producing much sharper decline in

voucher distribution than the rate of decline of target numbers. Even the new CBR used by the programme to calculate


13

the target numbers is higher than the average CBR of the country in 2016. In addition, the programme assumed that 40%

of pregnancies as eligible for DSF-MHVS, which is likely to be higher than the proportion of pregnant women poor in these

53 upazilas. This assumption further inflates the number of women eligible for participation in DSF-MHVS. Therefore, the

target calculation, even after the recent corrections, overestimates the target population and communicating these target

numbers to programme implementers at the upazila level may encourage enrolment of non-eligible women in an effort

to move closer to the target numbers.

Figure 3: Target numbers, voucher books distributed and number of safe deliveries among DSF participants by year

Figure 4 shows the utilization of maternal health services by the voucher holders. Due to lower enrolment in the

programme in 2015-16, utilization of various services, in absolute terms, also declined in the year compared to the

previous years. Vouchers distributed as a percent of target were around 72 to 79% for all years excepting 2015-16 when it

declined to 59%. Proportion of voucher holders selecting safe delivery methods varied from 74% in 2015-16 to 86% in

2012-13.

155289 152401158545

145900

107021129929 130509 129194

116370

79015

206153201756 201756 201756

182458

60000

80000

100000

120000

140000

160000

180000

200000

220000

2011-12 2012-13 2013-14 2014-15 2015-16

Voucher distributed No. of safe deliveries Target No.


14

Figure 4: Utilization of ANC, PNC and Delivery Services by MHVS mothers

Figure 5 shows the C-section rates by DSF upazilas. The rates were calculated using number of safe deliveries as the

denominator (number of C-section deliveries as percent of total safe deliveries among voucher holders). The C-section

rates in 2015-16 varied from zero percent to more than 45%. In 12 upazilas under DSF-MHVS, the C-section rates were

more than 25%. It should be noted that a significant proportion of voucher holders drop out from the programme and

details on these pregnant women are not available in the administrative data set (as they did not utilize DSF-MHVS

benefits).

Figure 5: C-section delivery rates for DSF beneficiaries by Upazila (percent of DSF safe deliveries in the area)

ANC1 ANC2 ANC3 Safe delivery PNC

2011-12 138658 127430 114013 129929 124564

2012-13 136592 124564 112731 130509 125974

2013-14 141363 133561 119011 129194 125103

2014-15 135613 125660 110021 116370 111353

2015-16 97311 86590 72434 79015 75174

0

20000

40000

60000

80000

100000

120000

140000

160000

2011-12 2012-13 2013-14 2014-15 2015-16

0

5

10

15

20

25

30

35

40

45

50

C-s

ecti

on

rate

%


15

The upazilas where the C-section rates were very high, higher than 25% of DSF-MHVS participants in 2015-16, are listed in

Table 4. The table also reports whether the upazilas had gynaecology and anaesthetist pair in the UHC for all the 12

months in the year and whether there is at least one private facility contracted by DSF in the area. It is interesting to note

that not all upazilas with high C-section rates had the pair present for the whole year. In fact, in some of the upazilas, the

health care provider pair were absent for all 12 months. For example, in Fakirhat, the gynaecologist was present for 10

months but the anaesthetist was not present at all implying absence of the pair for the whole year. Despite this, the upazila

shows the second highest rate of C-section deliveries. In Ulipur, neither the gynaecologist nor the anaesthetist was

present although it is possible that the pair was present in the private sector provider contracted by DSF-MHVS in the

area.

Table 4: List of upazilas with high rate of C-section delivery rates (>25%), presence of gynaecology-anaesthetist pair and

involvement of private sector, 2015-16

Upazila Pair present all 12

months?

Private sector

contracted?

C-section rate (% of safe

deliveries)

Sreemangal Yes No 27.7

Kalia Yes No 27.9

Shyamnagar Yes No 28.1

Chatkhil No Yes 28.3

Khetlal Yes No 28.3

Ukhia No Yes 28.9

Ulipur No Yes 31.5

Chawgacha Yes No 33.0

Atrai No No 34.6

Raipur Yes No 35.4

Fakirhat No No 37.7

Mirsharai YES Yes 45.6

(ii) Expenditures on maternal health services and incentives for beneficiaries

Using the utilization of various services and unit prices of services, it is possible to calculate the total money needed for

paying for the health care services used by the voucher holders. The costs are estimated only for one year – the fiscal year

2015-16. The costs include the payments for health care providers as well as the incentive payments offered to

programme beneficiaries. The estimates reflect the cost the programme would have incurred for incentive payments and

reimbursements for services if all the payments were made according to price/incentive schedule of the programme. The

cost estimates presented here may overestimate the actual expenses slightly due to non-availability of few relevant

information. For example, utilization data do not report source of ANC and PNC services. If the ANC and PNC services are

obtained from the FWA at the community level, pregnant women are not entitled for travel cost. In this estimation, we

have assumed that all ANC and PNC services were obtained from health facilities.

Another service category not reported in the data set is the number of facility based delivery numbers. Only for recent few

months, the number of deliveries is reported by place of delivery. The proportion of all deliveries happening in health

facilities for the months March to August 2016 was used to estimate the total facility births for the whole year 2015-16. For

all the 53 upazilas taken together, 41.35% births happened at home, 53.95% births happened in public health care

facilities and the remaining 4.7% happened in private facilities.


16

Table 5 reports the budget needed to pay the health care providers and the beneficiaries for all the maternal health

services provided to voucher holders. The unit prices mentioned in table 2 were used to calculate the total budget needed

to pay for the services, travel expenses and incentive payments. Given the utilization of maternal health services, total

budget needs become Tk.124.1 million for paying for the services provided by the health care personnel. The most

important cost item in provider payments is the cost of caesarean section delivery, which represents about 59% of total

health service expenses. The second-most important expenditure category is the payment for normal deliveries. Cost of

service provision can be reduced significantly if the caesarean section rate can be reduced.

The budget needs for 2015-16 to pay the beneficiaries their incentive payments were about Tk. 149.1 million. Institutional

delivery related incentives represent about 62% of total payments to voucher holders and additional 11% was paid for

safe home deliveries. The administrative cost at the facility level, which includes incentive payments for UHFPO and RMO

at the UHC and salary payment for one office staff per UHC, is estimated at Tk. 5.6 million. Therefore, total service-related

expenses amount to Tk. 278.7 million.

Table 5: Estimation of budget needs to pay for maternal health services in 53 DSF upazilas of Bangladesh for the year 2015-

16

Total number of vouchers distributed in the year 107,021

Number of safe deliveries conducted in the year 78,905

Expenses for paying providers In taka Expenses for paying beneficiaries In taka

Registration 2140420 Travel reimbursement, ANC/PNC 33200000

ANC 1 expenses 4865550 Travel reimbursement, delivery 4627778

ANC 2 expenses 4329500 Institutional delivery incentive 92600000

ANC 3 expenses 3621700 Home delivery incentive 16300000

Blood test 1 1664040 Referral related travel cost 2323500

Blood test 2 1232595

Urine test 1 1666735

Urine test 2 1234415

Normal Delivery 26700000

C-section delivery 72600000

Vacuum or forceps delivery 203000

D&C 10000

Eclampsia case related 42000

PNC expenses 3758700

Payment for UHFPO/ RMO 4627778

Office staff 992160

Total service related cost to be paid to providers

124,068,655

Administrative cost for facility managers

5,619,938

Total cost: facility related 129,688,593 Total cost: Beneficiary payments 149,051,278

Total cost needed to pay health care providers and beneficiaries of the programme 278,739,871

If the voucher books are distributed evenly over the year and if all pregnant women are enrolled in the programme within

the first trimester (say at three months of gestation), number of deliveries conducted in a year should be approximately

equal to the total number of vouchers distributed. Therefore, to find the cost parameters of the programme for calculating


17

total cost under different scenarios, we can use the number of vouchers distributed as the denominator for service-related

expenses. For incentive payments to UHFPO and RMO, the relevant denominator should be the number of institutional

deliveries. Administrative expenses should use the number of upazilas in the programme as the denominator. Number of

vouchers distributed will depend on gross fertility rate, poverty rate and the percent of total births that is first order and

second order births. Therefore, the cost parameters of DSF-MHVS for delivering maternal health services in 2015-16

should be as follows:

Provider payments for the services delivered: Tk. 1,181 per voucher distributed

Paying beneficiaries for travel and incentives: Tk. 1,371 per voucher distributed

Paying UHFPO and RMO for delivery cases: Tk. 100 per institutional delivery

Office staff wage payment: Tk. 18,720 per upazila per year

(iii) Programme Budget and Expenditure as reported by MHVS

Paying for the health care services are not the only expenses the programme incurs in running the activities of DSF-MHVS.

To estimate other expenses, we can examine the budget and expenditure numbers reported by the programme over the

last few years. Annex C reproduces the budget and expenditure numbers for the years 2011-2016 and the average

expenses per year over these five years after adjusting the budget and expenditure numbers for inflation using the

Consumer Price Index of Bangladesh (BBS, September 2016). According to the budget and expenditure levels reported,

average annual budget of the programme was about Tk. 12.674 million per upazila or Tk. 671.72 million per year for the

programme in 53 upazilas. Excluding the expenses related to payment for services and incentive payments for

beneficiaries, the remaining expenses becomes Tk.13.21 lac or Tk.1.321 million per upazila. These additional expenses

include postages, printing and publications, stationaries and office supplies, publicity and advertisement, training,

orientation meetings, transportation costs for project personnel, medical supplies, copying, committee meetings,

computers and other expenses. It is interesting that over the last few years there were virtually no expenditures on office

supplies, publicity and advertisement. Field level implementation personnel as well as potential beneficiaries should be

made aware about the various aspects of the programme including the benefit package provided by the programme to

the beneficiaries. To improve knowledge of participants about the programme, it is important to use some resources on

advertisement, behaviour change communications, trainings, etc. Based on the average budget numbers, it is assumed

that publicity and training of providers should cost about Tk. 0.10 lac per year for the programme.

(iv) Other expenses not in the budget

One additional cost component not included in the budget or expenditure numbers of the programme is related to

overall management and implementation of MHVS. A number of Ministry of Health personnel are involved with the

programme and additional personnel are appointed by the World Health Organization (WHO). Since the programme

requires the presence of these administrative and operational personnel, the programme should consider the value of

their time as important cost items. In the field visits, it was clear that the MHVS will not work effectively if the WHO QMs

are not there at the upazila level. The cost calculations are shown below:

Time allocated by MOHFW personnel: 10% each for three personnel (Line Director, Deputy Director and programme

manager, assistant director and deputy programme manager, finance and administration) plus 100% time of deputy

programme manager, DSF.

Value of time MOHFW personnel, per month = 0.1(Tk.71,500+65,500+54,500)+ (54,500) = Tk. 73,650


18

Value of time of WHO appointed personnel to DSF = 1,17,000+ 2*(89,000) + 27* (60,000) = 1,915,000

Annual administrative and implementation cost out-of-budget of MHVS

= (Tk. 73,650+Tk.1,915,000)*12 month = Tk. 23,863,800

Annual administrative and implementation cost per upazila = Tk. 450,260

Parameters for other cost items and personnel cost for management and implementation of the programme are listed

below.

Expenses on meetings, printing, supplies, copying, etc.: Tk. 1.321 million/upazila

Expenses related to advertisement/publicity: Tk. 0.10 million/upazila

Additional personnel cost for management/ implementation: Tk. 0.45 million/upazila

f. Targeting Efficiency of MHVS

(i) Measuring targeting efficiency

Two measures of targeting efficiency can be used to understand how efficiently the programme identifies the target

population for inclusion in the programme activities. Assume that the population (pregnant woman) in an area is N. There

are two mutually exclusive groups of pregnant women: poor Np and non-poor Nnp. The number of individuals enrolled in

MHVS is B and the enrolees are either from poor households, Bp, or from non-poor households Bnp. Using these notations,

we can define the targeting efficiency measures as:

Proportion of poor women in the programme T1 = 𝐵𝑝

𝐵=

𝐵𝑝

𝐵𝑝+𝐵𝑛𝑝

Proportion of poor enrolled in the programme T2 = 𝐵𝑝

𝑁𝑝=

𝐵𝑝

𝐵𝑝+𝐵𝑛𝑝×

𝐵𝑝+𝐵𝑛𝑝

𝑁𝑝+𝑁𝑛𝑝÷

𝑁𝑝

𝑁𝑝+𝑁𝑛𝑝

The first measure shows what fraction of programme participants are poor and the second measure shows what fraction

of poor people are actually enrolled in the programme. The second measure is affected by proportion of poor women in

the programme (T1), size of the program (proportion of population enrolled) and the proportion of population poor. From

national data we can approximately derive proportion of pregnant women poor in the upazila and the proportion of

population enrolled in the programme but there is no information on the proportion of pregnant women poor among all

women enrolled. The field visits conducted by the team members indicate that the proportion of enrolees of the

programme poor is quite low. Without a community level random sample, it is not possible to derive how efficient the

programme is in terms of targeting efficiency. It is unlikely that the programme will be more efficient than other social

protection programmes of the country. A report found that T1 measure is probably less than 0.5 for social protection

programmes that target the poor in the community (World Bank, 2013).

The subjective opinion of the QMs is that about 74% of poor pregnant women are actually enrolled in the programme

and 77% of all enrolled women are poor. Since QMs are in charge of verifying and cross-checking the eligibility criteria, it

is likely that they would tend to overstate the proportion of poor enrolled. Given the target setting mechanism, if all target

women are actually enrolled, it should represent 40% of pregnancies in the area. Since the actual enrolment is about 60%

of target, percent of pregnant women enrolled would be about 24%. If T1 is 0.77 and T2 is 0.74, poverty rate among

pregnant women in these 53 upazilas would be about 24%. Given the poverty rates in the upazilas, 38% of enrolled

women should be poor implying that less than 50% of poor pregnant women were enrolled in the programme if 77% of

enrolled were poor.


19

(ii) Efficiency of geographic targeting

Since targeting the poor women is an important objective of the programme, it is important to choose upazilas with

relatively high poverty head-count ratio (proportion of population below the poverty line). Upazila level headcount ratio

of poverty was used to indicate how efficient the programme was in targeting the poor areas of the country. Figure 6

shows the distribution of DSF upazilas by poverty status. Note that the programme selected 15 upazilas from the poorest

20% of upazilas in Bangladesh another 11 from the second poorest quintile. 15 upazilas were selected from the least poor

40% of upazilas of the country. Clearly, the selection of the upazilas was not based on geographic poverty ratio. Not

choosing the poorest upazilas does not necessarily imply that the programme fails to reach the poor; how effectively it

can reach the poor depends on the targeting efficiency in each of the areas. Annex A lists the MHVS upazilas by their head-

count ratio of poverty.


20

Figure 6: Distribution of MHVS upazilas by poverty quintile of all upazilas in Bangladesh (using 2010 upazila level poverty

rate estimates)

(iii) Enrolment if upper poverty line is used for targeting

If the upper poverty line of 2010 is used for identifying the poor pregnant women, total number of vouchers that the

programme should have distributed in 2015-16 would have been 91,558 (assuming that poverty rate among first and

second order pregnancy cases is 10% higher than upazila poverty rate) but the programme distributed about 107,000

vouchers. Therefore, the programme distributed 17% more vouchers than the number of poor women in the 53 upazilas.

The estimates are reported in Annex A, table A2. For each upazila in the DSF programme, we started with the male and

female population in 2001 and 2011. Using the inter-censul population growth rate, male and female population for 2016

was projected. Using the age distribution of women in Bangladesh, we assumed that in all the upazilas 65.39% of women

are in the age group 15 to 49 years. The district level gross fertility rates were used to calculate total number of births

expected in 2016, number of pregnant women poor was derived using upazila level poverty rate (plus 10%). The DHS data

implies that about 63% of all births in 2014 in Bangladesh were first or second birth order (assuming equal number of

second and third order births). Using this ratio, number of pregnant women eligible for participation in DSF programme

was calculated.

The table indicates that the number of vouchers distributed in some areas were much higher than the expected number

of poor pregnant women. In Daulatpur, number of vouchers distributed was higher than what is expected based on

fertility and poverty rates. In fact, the number of vouchers distributed was higher than the expected number of poor

eligible women in 31 upazilas out of 53 upazilas. Since the small area poverty estimation may have some errors, this is

not a definitive calculation but indicates the possibility of significant mistargeting in the DSF-MHVS programme.

VI. Policy Suggestions

a. Issues related to flow of funds One of the most important concerns raised by all the stakeholders during discussions and exchange of ideas was the

issue of long delay in the flow of funds from the GOB to MOHFW and then to other lower level entities involved with the

management and implementation of the programme. At the beneficiary level, the delay in payment of incentives was

around eight to 10 months. Late payment of incentives and transportation expenses go against the very purpose of

15

1112

9

6

13.9

10.111.0

8.3

5.5

0

2

4

6

8

10

12

14

16

Highest poverty rateupazilas (lowest

quintile)

Second highestpoverty upazilas

Third quintile Fouth quintile Lowest poverty rateupazilas (highest

quintile)

No of DSF upazilas DSF upazilas as % of total in the category


21

demand side financing which intends to improve demand for specific maternal health services by lowering the cost of

accessing care. Paying the incentives after eight to 10 months will be viewed by the beneficiaries as income

supplementation rather than price reduction and so the effect on utilization will be lower than the effect due to “price

effects”.

(i) Flow of funds from national to upazila level

Inter-ministerial communications are needed to find a mechanism for improving flow of funds from the Ministry of

Finance to the Ministry of Health. Prior studies mentioned a delay of about three to six months at this level alone.

Suggestion 1: Ministry of Finance should allocate budgeted money for the programme to the Ministry of Health immediately

after the adoption of the annual budget. The causes of long delay in allocating the funds should be identified and corrected.

The objective should be to lower the time lag between budget adoption and payment to MOHFW to less than 30 days.

The process of requesting advance for the funding of the programme is cumbersome and should be simplified.

Suggestion 2: The MOHFW should request allocation of imprest. Special permission will be required as the draw of advance

for DSF-MHVS will be much higher than usual imprest.

(ii) Mode of paying the providers and the beneficiaries

Our field visits as well as various studies reviewed identified delay in paying the beneficiaries as a critical concern. Paying

the providers, although delayed, has not been mentioned as an important issue. The programme should devise ways to

ensure timely payments to beneficiaries. A number of prior studies have discussed possible ways of improving the

situation. Payment through bank accounts was adopted recently to reduce the time lag in paying the beneficiaries.

Discussions during the field visits indicate that the payment through bank accounts is not working as expected. A

significant proportion of women became frustrated and gave-up on the idea of opening a bank account. For paying the

beneficiaries, it is important to provide wide range of options. The payments could be through bank accounts (traditional

accounts, online banking accounts and any other bank accounts the beneficiaries may already have, including the

accounts with NGO micro-credit entities), through postal money orders or through e-cash or mobile payment systems.

Various modalities for paying the beneficiaries have been discussed in a report by Sabur (Sabur, December 2015). The

programme may allow the beneficiaries to choose from a list of alternative mechanisms of paying. With bank accounts,

women have to travel to the local bank a number of times just to open an account and then a number of times to

withdraw the funds. The requirement of providing a cell-phone number for the reimbursement of funds to beneficiaries

may also be problematic. According to DHS 2014, about 60% of poorest quintile households do not own cell phones.

Paying the beneficiaries through mobile cash transfer will cost about 2% of funds disbursed, although GOB may negotiate

a lower rate with the service providers due to the volume of the total funds to be transferred. The administrative cost of

transferring funds should be paid by the programme and should not be subtracted from the funds to be received by the

beneficiaries.

Suggestion 3: Allow beneficiaries to choose from a number of alternative ways of receiving the incentive funds and transport

cost. The alternatives could be (i) regular bank accounts, (ii) online banking, (iii) micro-credit accounts, (iv) postal money

order, (v) e-cash or mobile transfer of funds. The payments to beneficiaries can be done directly from MHVS account at the

centre.

Suggestion 4: The system of opening bank accounts should be simplified. The application for opening an account is too long.

Using traditional banking for paying DSF beneficiaries three to four times in a year may not be the most cost-effective


22

mechanism, from the perspective of the bank management and the beneficiaries (especially for those who currently do not

hold any bank accounts).

b. Administration and management related issues

The DSF-MHVS has defined a number of DSF committees for proper functioning of the programme. It was observed that

many of the committees are not functional. For example, at the district level, the committee has little or no involvement

with the day to day activities of the programme. At the union level, DSF committees met infrequently and many Union

Parishad members were not aware of the activities of DSF-MHVS.

Suggestion 5: Different DSF committees may be streamlined for improved efficiency and the need for multiple committees in

running the DSF-MHVS may be reviewed. Reduction in the number of committees associated with DSF-MHVS should reduce

expenditures on orientation meetings, travel costs, etc.

Limited involvement of government officials with DSF-MHVS implies lack of ownership of the programme by the

government. At upazila level, WHO QMs have become critical in proper functioning of the programme. The DSF QMs are

the only ones at the upazila level keeping liaison with upazila, union and field level health staff and beneficiaries.

Suggestion 6: For proper functioning of the programme, arrangements should be made to ensure the presence of one full-

time personnel per upazila. This administrative person will be in charge of all programme activities including verification of

eligibility, keeping contacts with stakeholders and beneficiaries, coordinating data collection with upazila level Health

Information System personnel, etc.

c. Paying the providers

Since the services are supposed to be offered free-of-charge to the beneficiaries, the service providers, especially the

private health care providers, need to be paid for the services they provide. Table 6 shows the official DSF-MHVS prices

and the market price of the services in one of the rural upazila visited by the study team. If the mid-values of the private

market prices are used for comparative purposes, the ratios of market to DSF-MHVS prices were 8.0 for ANC and PNC, 2.6

for lab tests, 11.7 for normal delivery, 5.0 for vacuum or forceps delivery and 1.75 for C-section delivery. Given these price

ratios, private sector will have relatively high incentives to conduct C-section deliveries and laboratory tests. The gap that

exists between the market price and the DSF-MHVS price also encourages imposing additional user fees on DSF

beneficiaries.

Table 6: Comparison of DSF-MHVS unit prices and the market prices of the services in one rural upazila (data collected from

Daudkandi upazila, Comilla)

Services DSF-MHVS price Private market price in Daudkandi upazila

ANC visit 50 300-500

Urine test 35 80-100

Blood test 35 80-100

Normal delivery 300 3,000-4,000

Vacuum/forceps delivery 1,000 5,000

C-section delivery 6,000 9,000-12,000

Eclampsia management 1,000 Price information not available

PNC visit 50 300-500


23

The payment rates should be carefully evaluated to ensure that the prices are consistent with the social objective of

improving maternal and neonatal health as well as improving access to maternal health services by poor pregnant

women in rural Bangladesh.

Suggestion 7: The price list for DSF-MHVS services should be carefully evaluated. The gap between market price and DSF-

MHVS price encourages imposition of user fees by health care providers. Systematic independent monitoring of user-fees is

needed to ensure that beneficiaries are not charged extra for essential maternal health services.

Suggestion 8: The MHVS benefit package does not include some required diagnostic and laboratory tests (blood grouping,

blood sugar, and ultrasound under specific situations). The programme may consider including these tests in the package.

The DSF prices of these tests should be set at levels to allow recovery of cost but the DSF-MHVS price should be similar to the

market to DSF price ratios of already included tests.

One important issue often raised in key informant interviews was related to payments made to public sector facilities and

public health care providers for delivering DSF services. The reimbursement to public sector facilities, unlike the

reimbursement to private facilities, represents “incentive payments” rather than reimbursing the cost of the services.

Public sector health facilities and health care providers are already paid by the government and, therefore, the question

was whether the public sector service providers or institutions should get paid for the services which they are supposed

to provide anyway. Since the UHC is also the purchaser of services, it creates conflict of interest situation (restricting use

of private sector facilities, over-reporting the services delivered).

Suggestion 9: To resolve the conflict of interest situation of public sector health care providers (UHC), two alternative

approaches can be adopted; (i) Making UHC as the service provider only (payment of incentives can continue) without being

in charge of purchasing or (ii) No incentive payments to public sector facilities and providers but UHC remains the purchaser

of private services. If the incentive payments to public health care providers are continued, the programme should evaluate

the possible implications of lowering the incentive payments.

Suggestion 10: The programme should develop a system of monitoring actual delivery of maternal health services by

designated health care providers. Possibility of misreporting quantities of services provided is high because of associated

incentive payments. The monitoring system should also monitor the quality of services delivered by both the public and

private sector health care providers.

The MHVS prices for different services are also creating incentive and disincentive effects on health care providers. The

market price ratio of caesarean and normal delivery is about 4.0. The MHVS pays Tk. 400 for a normal delivery (including

drug cost of Tk.100) and Tk. 6,000 for a caesarean section, implying a ratio of 15.0, much higher than the ratio of these two

services in the market. Such a big shift in price ratios encourages health care providers to perform caesarean section

delivery at a higher rate than necessary. If the money paid to the doctor in public sector health facility is considered, the

ratio of these two modes of delivery becomes even more lop-sided. The physician making the decision gets Tk.60 for a

normal delivery and Tk. 1,100 for a caesarean section delivery (ratio of 18.0).

Suggestions 11: Rationalize the difference in payments for C-section and normal deliveries in the programme. The prices for

modes of deliveries may be set at a fixed level to reduce incentives for conducting C-section deliveries. If public sector

incentives are continued, the programme should carefully evaluate the prices to use. A good starting point would be to pay

about Tk. 600 per delivery, irrespective of mode of delivery. For private sector as well, the price per delivery should be similar.

The equalization of C-section and normal delivery prices may create some unintended consequences. One possibility is

that the UHC would have incentives to refer pregnant women at upper level facilities for conducting C-sections.


24

Suggestion 12: Community level health workers should receive trainings on early detection of potential beneficiaries. The

payment for registration of a beneficiary should not be offered if the community health workers identify the beneficiary after

the second trimester of pregnancy.

d. Targeting poor mothers

None of the studies conducted on DSF-MHVS estimated the targeting efficiency. It is not known how effective the

programme is in reaching the poor mothers. There are indirect indications that the targeting is not working well. In the

field surveys, the team observed significant issues with identifying the poor. In fact, almost all beneficiaries interviewed

during the field visits appeared to be from middle income group or better. Given the performance of other social

protection programmes in Bangladesh, it is unlikely that the MHVS will have better targeting efficiency than other similar

interventions.

To improve the targeting efficiency, one approach could be to implement “geographic targeting”, i.e., selecting relatively

poor upazilas for the implementation of the programme. In Bangladesh, if poorest 50 upazilas are selected by the head-

count ratio of poverty, the upazilas will be very different from the upazilas now in the programme. The list of upazilas with

the highest poverty rates is shown in Annex D. Note that only eight of the current DSF upazilas are in this list. Once the

upazilas are selected on the basis of poverty rate, the programme can consider implementing a universal voucher scheme

without trying to identify who is poor and who is not. If the universal program is implemented in poor upazilas and using

first or second pregnancies as eligible, targeting efficiency rate will be about 60% (60% of those who are in the program

will be poor) with 100% of the poor covered by the programme. This level of targeting efficiency will be higher than the

targeting efficiency of most of the social protection programmes in Bangladesh intending to reach the poor. In fact, if

geographic targeting is used, more than 16% of poor pregnant women can be reached by implementing the programme

in 50 poorest upazilas. Total cost of the program will increase as the number of pregnant women targeted will become

about 170,000. If the programme intends to reduce the cost, it can consider enrolling only the first pregnancies in MHVS

rather than enrolling the first and second pregnancies.

Total expenses would be Tk. 550 million with Tk. 116.3 million as overhead expenses if the programme adopts universal

targeting in poorest upazilas of Bangladesh. The overhead expenses in relative terms will decline to 21% from current

level of 27%. Therefore, implementing the programme in poor areas will have significantly higher value for money

compared to current situation. If only the first child is targeted, annual cost of the programme will be Tk. 342 million with

30% as administrative cost.

Suggestion 13: The MHVS should consider targeting poorest upazilas of the country. Universal coverage of first and second

pregnancies in poor upazilas will improve targeting efficiency to about 60%. The cost of the programme will increase by

about 57% but the cost will remain same as the current cost if only the first pregnancies are targeted.

The DSF-MHVS has not changed the criteria used to identify the poor for a number of years. Household income of Tk.

3100 per month appears too low, given the poverty line of the country and price changes over the last few years. If we use

upper poverty line and correcting the poverty line using CPI, the poverty line for 2016-17 should be about Tk. 6700 per

month for a family of three. In practice, however, the programme does not use the poverty criteria strictly in identifying

the beneficiaries.

Suggestion 14: If the programme wants to continue with targeting individuals based on poverty of the household, targeting

criteria should be revised to incorporate easily observable but specific and sensitive indicators like construction material

used for housing, ownership of TV, etc. Targeting criteria that include income, land ownership should be avoided.


25

Suggestion 15: The programme should evaluate the possible implications of defining eligibility criteria to include poorest

50% of pregnant women rather than targeting poorest 15 to 20% of the population. Since the MMR is the highest in

Bangladesh for the middle wealth category, enrolling poorest 50% should help improve maternal health outcomes

significantly. In a universal targeting, if the programme allows use of public sector health facilities only, richer groups may

not be interested in participating in the programme, effectively making the programme targeted towards the poorer

sections of the population.

The formula used by the programme to calculate the target number of beneficiaries per upazila overestimates the target

numbers, which probably encourage field level implementers to enrol non-eligible pregnant women.

Suggestion 16: If within upazila targeting is used, DSF-MHVS may continue estimating target number of beneficiaries for each

of the upazilas for programmatic reasons but the programme should not share the target numbers with the upazilas. The

target number per upazila is likely to be biased and may lead to mistargeting.

e. Knowledge and communication related issues in the programme

From discussions with the policy planners at the centre and field level implementers, it is clear that communications

within the programme among personnel at different levels were quite poor. A significant proportion of QMs thought that

incentive money provided to mothers for adopting safe delivery has been discontinued although that was not the case.

The QMs are the principal contacts between the programme and the beneficiaries and therefore, wrong information

trickles down from the QMs to all potential beneficiaries. This will have negative consequence on the programme.

Suggestion 17: The programme should try to reduce the communication gap between programme management and field

level implementers. A system of regular two-way communications will allow project managers to better understand the

issues and concerns experienced at the field level as well as field level implementers to become fully aware of the policies

and procedures being reformed or changed.

Late identification of beneficiaries is related to two types of communication and knowledge failures. If the programme is

well publicized at the community level, eligible pregnant women are more likely to contact FWA and HA to report their

pregnancies. The second failure is related to the effectiveness of the FWAs and HAs in identifying new pregnancy cases.

Field level communication between the FWAs, HAs and the potential beneficiaries needs strengthening. One way to do

this will be to adopt social mobilization strategy for making the community members aware of the programme activities

and benefits.

Suggestion 18: MHVS should adopt social mobilization strategies to improve knowledge of potential beneficiaries in the

communities as well as to help improve effectiveness of community level health workers in identifying eligible

beneficiaries.

f. Data needs for improving effectiveness and efficiency of DSF

During the field visit, it was observed that the programme level data were collected by the WHO QMs and then transmitted

to the coordinators of the programme. The information is also sent to programme and deputy directors of DSF-MHVS.

Major concern is that the data collection has not been integrated with the regular Health Management Information

System (HMIS). The UHC HMIS reports data on services delivered by UHC to DSF-MHVS mothers. The programme needs

a system of collecting information on services received by DSF-MHVS beneficiaries at all levels, including services

delivered at home of the beneficiaries. All pieces of information can be integrated with the HMIS in order to improve timely

flow of information from the field level to the centre.


26

Suggestion 19: The programme should develop a comprehensive Management Information System (MIS) for DSF-MHVS,

which can be integrated with UHC HMIS. Integration with HMIS will help reduce the time-lag between service delivery and

flow of funds to the upazila level. It will also improve the effectiveness of HMIS and help strengthen management of the

programme and evidence-based decision making.

There are no data on targeting efficiency of DSF-MHVS, i.e., it is not known what percent of poor pregnant women are

actually enrolled in the programme and what percent of beneficiaries are poor. Community level household survey can

be used to estimate targeting efficiency. Interviews conducted at exit from heath facilities will not be able to provide

information on targeting efficiency.

The quantities of maternal health services delivered to DSF-MHVS beneficiaries are also not verified by external entities.

Service utilization are reported by the DSF upazilas and since the UHCs are both purchasers and providers of services,

possibility of over-reporting utilization (reporting higher quantities of services delivered) and upcoming (e.g., reporting a

normal delivery as C-section delivery) exist. No study has examined the degree of over-reporting and upcoming, if any.

Suggestion 20: The programme should conduct surveys and/or patient chart reviews to estimate the degree of mistargeting

as well as possible over-reporting or up-coding of service delivery.

g. Comparison with other similar social protection programmes

This study focused on one social protection programme, the DSF-MHVS. The GOB has implemented many social

protection programmes by targeting different segments of the population but some of the programmes are likely to have

considerable overlapping even though they are administratively independent, implying inefficient use of administrative

and management resources. For example, Maternal Allowance (MA) Programme for the poor with annual budget of Tk.

1,584 million should have considerable overlapping with DSF-MHVS in terms of beneficiaries covered. Low-income

Lactating Mother Allowance (LMA) programme targets low-income women in urban areas and so will not have

overlapping with DSF-MHVS (which is implemented in rural areas) but it is important to consider the benefits of expanding

the programme in rural areas to provide assistance to disadvantaged women from early stage of pregnancies to weaning

period of the baby up to two years of age. The programme costs of MA and potential overlap of the programme with DSF-

MHVS should be evaluated to identify the potentials for improving VfM of both the programmes. Therefore, the GOB

should conduct similar diagnostic studies on similar social protection programmes to identify potential economies of

scope.

Suggestion 21: Conduct diagnostic studies on other social protection programmes that target pregnant women and

lactating mothers.


27

VII. Concluding Remarks

This report presents the results of a diagnostic study of Demand Side Financing of Maternal Health Voucher Scheme.

Diagnostic study is not a full evaluation of a programme but an attempt to “diagnose” its problems and concerns through

qualitative and quantitative approaches. This study has adopted a mixed method of analysis by combining key informant

interviews with quantitative analysis of administrative data. Qualitative research approach included interviews with policy

makers, development partners, implementing agencies, health care providers and programme beneficiaries. A structured

questionnaire was used to collect information from the WHO Quality Managers on specific problems and concerns they

face at upazila level or below. Two sets of quantitative data were made available from the programme, one related to

budget allocation/expenditure by year since 2011 and the other one on utilization of maternal health services by DSF-

MHVS beneficiaries by month for the years 2011 to 2016.

Budget and expenditure data for 2015-16 fiscal year indicates that total budget of the programme was Taka 492.2 million

but total expenditure was Taka 312.4 million. A number of reasons may explain the divergence between budget allocation

for the year and the actual expenditure. For example, delayed payments to health care providers and beneficiaries may

explain a part of this divergence. However, given that only 63.5% of budget allocation was actually spent, it possibly

indicates significant divergence between planned activities and activities actually performed by the programme. The

reform plan of DSF-MHVS should carefully look into the reasons for the difference between budgetary outlays and actual

expenditure with a view to design a mechanism for improved and efficient utilisation of funds.

The long delay in the flow of funds from the national level accounts to upazila MHVS accounts was identified as a systemic

issue that affects efficiency and effectiveness of the programme. Although the problem has been cited by all studies on

MHVS since 2009, no systematic attempts were made to address this concern. The MOHFW in collaboration with the

Ministry of Finance should take initiatives for improving the timelines for release and flow of funds. It is also suggested

that the programme considers creating an imprest fund to help smooth-out the delay in the approval of programme

plans and release of funds.

The administrative data on service utilization report the quantities of various services utilized by DSF-MHVS beneficiaries.

Using the quantities of services utilized, expenditure on incentive payments and payments for health services can be

derived. For 2015-16, the estimated expenditures on services and incentives was Taka 272.6 million. Programme

expenditure data indicate that total payment on services and incentives in the year was Taka 275.3 million, similar to the

estimated expenses based on service utilization information. Expenditure on services and incentives to total expenditure

was 0.87 if the administrative data on budget and expenditures are used. This implies that the overhead cost of the

programme was about 13% in 2015-16. If all personnel costs involved with administration, management and

implementation of the programme are included (salary of government officials as well as WHO based personnel assigned

to DSF), the ratio becomes 0.73 implying that the overhead cost becomes 27%. Therefore, the overhead cost of the

programme is quite reasonable, assuming that the service delivery data actually represents the quantities of services

delivered.

A comparison of unit prices of various services set by DSF-MHVS and the market prices of the services in one rural upazila

of Bangladesh (used for comparative purposes only) indicate that the market prices are significantly higher than the

official unit prices. Despite these differences, the providers did not complain about the relatively low prices reimbursed

by the programme. The gaps between prices set by the programme and the market prices in rural upazilas create the

opportunity for charging extra user fees to beneficiaries by both the public and private sector health care providers.


28

Therefore, the programme needs to adopt regular monitoring of out-of-pocket expenses incurred by DSF enrolees when

receiving maternal health services.

Another concern is the wide variability of market price to DSF-MHVS price ratios for different service-types. The price for

C-section shows the lowest ratio of market price to programme adopted unit price but the ratio for normal delivery was

much higher implying that the programme creates significantly higher monetary incentives to conduct C-section

deliveries. The payments to public sector health care providers are also biased in favour of C-section delivery. There are

some indications that the programme enrolees experience much higher rates of C-section delivery compared to other

women not in the programme. The payments for C-section and normal deliveries should be rationalised to discourage

over-utilization of C-section deliveries. If not addressed, the concerns related to unnecessary C-sections conducted by

health care providers may actually discourage utilization of health facilities by DSF-MHVS beneficiaries, which may have

other negative consequences on maternal health outcomes. Therefore, this is an important issue needing immediate

attention. It is proposed that the reimbursements for normal and C-section deliveries be made equal to lower the rate of

unnecessary C-sections.

The DSF-MHVS has identified specific maternal health services required for improving health outcomes of mothers and

neonates. Since the services are listed explicitly by the programme, it is important to come up with a comprehensive list.

For example, blood groupings and blood sugar tests are not listed as part of ANC. These tests as well as ultrasound for

complicated pregnancies should be included in the list of services covered by the programme. This does not necessarily

imply that the programme should set unit prices for each of these services. It is possible to define all-inclusive package

price with penalty for not providing the required laboratory and diagnostic tests.

It is proposed that the selection of upazilas for scaling up DSF–MHVS be based on small area poverty mapping and

poorest upazilas should be selected for inclusion. Even though some of the current DSF-MHVS upazilas do not belong to

poorest or second poorest quintiles of upazilas of the country, the programme may continue in these upazilas. If the

programme selects 50 poorest upazilas of the country for scaling-up, even a universal targeting will improve targeting

efficiency of reaching poor pregnant women to 60%.

For the success of DSF-MHVS, it is extremely important to ensure timely payment to beneficiaries so that the payments

would be viewed as incentive payments for services utilized rather than an income supplementation. Different modes of

paying beneficiaries have been discussed in this report and it is suggested that the beneficiaries be offered a number of

alternative options for receiving payments. The options offered may include deposit to bank accounts, e-cash, mobile

banking, postal money order, etc. The choice of options will also encourage competition among the monetary service

providers.

The purpose, roles and involvement of public and private sectors at the upazila level should be clearly defined so that

policy reforms can be guided by taking into account their specific roles and functions. In the current system, public

provider at the upazila level acts as the service provider as well as purchaser of services. This creates conflict of interest

situations. Potential consequences of conflict of interest environment should be identified and addressed in the reform

plan. Since the possibility of misreporting service utilization is there, it is important to verify the reported deliveries

happening at UHCs, private facilities, union level facilities and in community clinics. The degree of misreporting can

possibly be reduced by lowering the gap between incentive payments to mothers for safe delivery at home and at health

facility. Facility based delivery incentive payments may be reduced to Tk. 1000 while the home delivery incentive can be

increased from the current level of Tk. 500.


29

Reported budget and expenditure indicate that the programme spent virtually no resources on publicity and

advertisements since 2011. It is proposed that the programme adopt a comprehensive social mobilization strategy

including distribution of ‘user-friendly’ informational booklet on pregnancy, safe pregnancy practices, pregnancy

complications, nutrition, danger signs, care of newborn, importance of breast feeding, etc. Social mobilization is an

integrating process where stakeholders are provided with information, tools and skills to become active participants.

SOCMOB calls for the involvement of all relevant sectors of society for a common development objective (Hetzel, 2004).

The overall reforms for DSF-MHVS should also take into consideration the macro-picture, and closely look at how

coordination with similar programmes such as the Lactating Mothers Allowance and Maternity Allowance may help

improve efficiency and effectiveness of the programmes.

The draft report of the study was discussed in a meeting in the MOHFW on December 15, 2016. Major stakeholders of the

scheme in the Government along with the representatives of concerned Development Partners participated in the

meeting. There was a general consensus in the meeting on the findings and suggestions made in this report. The next

step should be to prepare a realistic reform plan for implementation of the recommendations put forward in the report.

The GOB and SPFMSP project should take necessary initiatives in this direction. The approved minutes of the meeting

can be found in Annex G of the report.


30

References

Ahmed, S., & Khan, M. (2011). A maternal health voucher scheme: what have we learned from the demand-side

financing scheme in Bangladesh? Health Policy and Planning, 25–32.

Anwar, I., Blaakman, A., & Akhter, S. (September 2013). Program Evaluation for Demand Side Financing Maternal Health

Voucher Scheme in Bangladesh: Final Report. Dhaka.

BBS, B. B. (September 2016). Statistical Yearbook Bangladesh 2015. Dhaka: Ministry of Planning, Government of

Bangladesh.

Farzana, S. (March 2014). Demand Side Financing (DSF) - Maternal Health Voucher Scheme in Bangladesh. Bangladesh:

Government of Bangladesh and World Health Organization.

Halim, M. A. (March 2014). An Analysis of Facility based Exit Interview with the Maternal Voucher Recipients under Demand

Side Financing Initiative in Bangladesh. Dhaka.

Hatt, L., Nguyen, H., Sloan, N., Miner, S., Magvanjav, O., Sharma, A., . . . Wang, H. (February 2010). Economic Evaluation of

Demand-Side Financing (DSF) for Maternal Health in Bangladesh. Bethesda: Abt Associates Inc.

Hetzel, B. (2004). Towards global elimination of brain damage due to iodine deficiency, Section IV by Jack Ling. Oxford

University Press.

HEU, H. E. (2012). Summary: Bangladesh National Health Accounts 1997-2012. Dhaka: Govt of Bangladesh.

Hoque, M., Powell-Jackson, T., Dasgupta, S., Chowdury, M., & Koblinsky, M. (2012). Costs of Maternal Health-related

Complications in Bangladesh. Journal of Health, Population and Nutrition, 30(2), 205-212.

Koehlmoos, T., Ashraf, A., Kabir, H., Islam, Z., Gazi, R., Saha, N., & Khyang, J. (September 2008). Rapid Assessment of

Demand-side Financing Experiences in Bangladesh. Dhaka: ICDDR,B.

NIPORT, N. I. (December 2012). Bangladesh Maternal Mortality and Health Care Survey 2010. Bangladesh: Govt of

Bangladesh, USAID, AusAID and UNFPA.

NIPORT, N. I. (March 2016). Bangladesh Demographic and Health Survey 2014. Dhaka: NIPORT, USAID and Mitra

Associates.

Noor, F., & Rob, U. (2013). Does Maternal Health Voucher Scheme Have an Impact on Out-of-pocket Expenditure and

Utilization of Delivery Care Services in Rural Bangladesh? Dhaka: Population Council.

Noor, F., Talukder, N., & Rob, U. (2013). 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. Lancet, (p. 20).

Rahman, M., Rob, U., Noor, F., & Bellows, B. (2013). Out-of-pocket expenses for maternity care in rural Bangladesh: A

public-private comparison. International Quarterly of Community Health Education, Volume 33(2), 143-157.

Rannan-Eliya, R. G. (Technical Report B, 2012). Impact of maternal and child health private expenditure on poverty and

inequity: Out-of-pocket payments by patients at Ministry of Health and Family Welfare facilities in Bangladesh,

and the impact of the Maternal Voucher Scheme on costs and access of mot. Mandaluyong City.

Sabur, M. A. (December 2015). Cash Transfer Modality for Demand Side Financing (DSF). Dhaka: Ministry of Health and

Family Welfare, Government of Bangladesh.

World Bank, W. (2013). Poverty Assessment: Assessing a Decade of Progress in Reducing Poverty, 2000-2010. Dhaka:

Bangladesh Development Series Paper No. 31.


31

Annex A: DSF Upazilas with their 2010 Poverty Head-Count Ratio

Table A1: Listing of DSF Upazilas ranked by percent of poor in the upazila and National Ranking of the DSF Upazilas using

Poverty Rates in all Upazilas

Poverty rank of DSF upazilas among all upazilas in Bangladesh

Serial # District Upazila

code

Upazila % extreme

poor

%

poor

Rank

1 KURIGRAM 4994 ULIPUR 46.2 65.3 4

2 JAMALPUR 3915 DEWANGANJ 41.6 58.5 13

3 RANGPUR 8527 GANGACHARA 39.0 58.3 14

4 JAMALPUR 3958 MADARGANJ 38.2 55.5 26

5 BARISAL 610 BANARI PARA 38.1 52.2 38

6 PIROJPUR 7976 NAZIRPUR 36.6 51.5 41

7 MYMENSINGH 6124 HALUAGHAT 30.6 50.3 49

8 SATKHIRA 8786 SHYAMNAGAR 33.8 50.2 50

9 CHANDPUR 1379 MATLAB UTTAR 28.6 49.9 53

10 SATKHIRA 8704 ASSASUNI 32.0 48.4 63

11 SHARIATPUR 8665 NARIA 30.5 48.1 65

12 DINAJPUR 2760 KHANSAMA 25.8 46.5 77

13 SIRAJGANJ 8827 CHAUHALI 28.1 45.5 87

14 GAIBANDHA 3230 GOBINDAGANJ 29.0 45.4 88

15 JAMALPUR 3985 SARISHABARI 27.6 44.7 97

16 JESSORE 4111 CHAUGACHHA 20.7 42.8 114

17 GOPALGANJ 3591 TUNGIPARA 26.1 42.6 116

18 KHULNA 4764 PAIKGACHHA 23.3 42.4 120

19 SIRAJGANJ 8867 SHAHJADPUR 25.1 41.8 129

20 MADARIPUR 5487 SHIB CHAR 20.2 38.8 156

21 COMILLA 1936 DAUDKANDI 21.0 38.5 158

22 COX'S BAZAR 2290 TEKNAF 19.7 38.2 163

23 COX'S BAZAR 2294 UKHIA 20.1 37.8 167

24 COMILLA 1994 TITAS 19.4 37.7 169

25 COMILLA 1975 MEGHNA 19.0 37.3 173

26 BAGERHAT 134 FAKIRHAT 19.2 36.4 186

27 COX'S BAZAR 2266 RAMU 17.8 34.3 219

28 PANCHAGARH 7734 DEBIGANJ 16.6 34.2 222

29 FARIDPUR 2910 BHANGA 17.0 33.5 230

30 THAKURGAON 9451 HARIPUR 13.1 29.7 283

31 NARSINGDI 6864 ROYPURA 16.2 29.4 285

32 MAULVIBAZAR 5883 SREEMANGAL 24.7 29.3 287

Poverty rank of DSF upazilas among all upazilas in Bangladesh

SN District Upazila

code

Upazila % extreme

poor

%

poor

Rank

33 SUNAMGANJ 9086 SULLA 22.9 28.3 299


32

34 BHOLA 925 CHAR FASSON 14.9 28.2 300

35 HABIGANJ 3611 BANIACHONG 22.2 27.6 310

36 BRAHMANBARIA 1204 BANCHHARAMPUR 13.2 27.3 313

37 TANGAIL 9366 MIRZAPUR 16.0 26.7 323

38 THAKURGAON 9408 BALIADANGI 11.3 26.5 325

39 JOYPURHAT 3861 KHETLAL 11.7 26.1 330

40 KISHORGONJ 4892 TARAIL 14.7 26.1 332

41 NAWABGANJ 7088 SHIBGANJ 12.2 26.0 339

42 TANGAIL 9385 SAKHIPUR 15.5 26.0 341

43 MAULVIBAZAR 5814 BARLEKHA 20.8 25.7 346

44 NARAIL 6528 KALIA 9.7 23.3 380

45 SUNAMGANJ 9047 JAGANNATHPUR 15.8 21.0 406

46 PATUAKHALI 7866 KALA PARA 9.7 20.3 410

47 MANIKGANJ 5628 HARIRAMPUR 8.3 18.1 431

48 LAKSHMIPUR 5158 ROYPUR 8.7 16.7 444

49 MEHERPUR 5747 GANGNI 5.2 15.8 452

50 NAOGAON 6403 Atrai 5.0 13.5 475

51 CHITTAGONG 1553 MIRSHARAI 4.6 13.4 476

52 NOAKHALI 7510 CHATKHIL 1.5 4.8 520

53 KUSHTIA 5039 DAULATPUR 1.0 4.0 524


33

Table A2: Calculating the target pregnancy cases by upazila using upazila level poverty rate

Name of

Upazila

Predicted 2016

population

(1000)

Gross

fert.

rate

(1000

women

15-49)

Estimat

e of

number

of births

First or

secon

d

births

Poor

pregnan

t

women

of total

pregnan

t

Poor

women

with 1 or

2nd

pregnanc

y

Vouchers

distribute

d in 2015-

16

Voucher

s as

% of

eligible

women Male Femal

e

ASSASUNI 138.2 141.4 53 4902 3088 2372 1644 1208 73%

ATRAI 98.1 101.8 58 3862 2433 521 361 1953 540%

BALIADANGI 105.0 103.9 76 5162 3252 1368 948 1830 193%

BANARI PARA 71.1 75.0 74 3629 2286 1894 1313 1539 117%

BANCHHARAMPU

R

139.5 169.4 88 9750 6143 2662 1845 643 35%

BANIACHONG 178.8 192.0 78 9790 6168 2702 1873 513 27%

BARLEKHA 127.7 142.4 61 5681 3579 1460 1012 778 77%

BHANGA 129.2 144.6 72 6810 4290 2281 1581 1649 104%

CHAR FASSON 236.9 243.4 91 14486 9126 4085 2831 385 14%

CHATKHIL 87.9 108.0 99 6992 4405 336 233 1846 794%

CHAUGACHHA 119.7 122.1 61 4871 3069 2085 1445 1826 126%

CHAUHALI 79.5 83.2 80 4351 2741 1980 1372 484 35%

DAUDKANDI 146.1 162.7 67 7128 4491 2744 1902 2084 110%

DAULATPUR 228.0 235.8 71 10947 6897 438 303 4664 1537%

DEBIGANJ 123.2 124.3 75 6094 3839 2084 1444 2500 173%

DEWANGANJ 133.5 142.0 84 7802 4915 4564 3163 3651 115%

FAKIRHAT 69.0 69.6 60 2729 1719 993 688 700 102%

GANGACHARA 157.5 161.0 110 11584 7298 6753 4680 2703 58%

GANGNI 153.3 162.1 69 7315 4608 1156 801 3579 447%

GOBINDAGANJ 268.8 277.3 63 11422 7196 5186 3594 6282 175%

HALUAGHAT 146.1 154.5 93 9398 5921 4727 3276 2704 83%

HARIPUR 78.4 80.8 76 4018 2531 1193 827 1264 153%

HARIRAMPUR 58.2 68.6 71 3187 2008 577 400 986 247%

JAGANNATHPUR 137.6 142.0 65 6034 3802 1267 878 499 57%

KALA PARA 130.5 127.8 56 4681 2949 950 659 2968 451%

KALIA 111.1 115.2 98 7384 4652 1721 1192 577 48%

KHANSAMA 92.5 91.7 64 3838 2418 1785 1237 2099 170%

KHETLAL 51.7 52.6 49 1684 1061 440 305 1182 388%

MADARGANJ 135.9 143.7 84 7891 4971 4379 3035 2386 79%

MATLAB UTTAR 144.1 160.9 78 8206 5170 4095 2838 2015 71%

MEGHNA 60.5 59.9 67 2623 1652 978 678 558 82%

MIRSHARAI 189.0 224.7 60 8817 5555 1182 819 2174 266%

MIRZAPUR 200.2 231.1 78 11785 7425 3147 2181 2368 109%

NARIA 109.5 126.2 74 6107 3847 2937 2036 1425 70%


34

NAZIRPUR 89.5 92.5 71 4296 2707 2213 1533 1597 104%

PAIKGACHHA 122.0 125.5 57 4679 2948 1984 1375 2174 158%

RAMU 153.8 152.4 81 8073 5086 2769 1919 2508 131%

ROYPUR 139.0 157.4 64 6588 4150 1100 762 1135 149%

Name of

Upazila

Predicted 2016

population

(1000)

Gross

fert.

rate

(1000

women

15-49)

Estimat

e of

number

of births

First or

secon

d

births

Poor

pregnan

t

women

of total

pregnan

t

Poor

women

with 1 or

2nd

pregnanc

y

Vouchers

distribute

d in 2015-

16

Voucher

s as

% of

eligible

women Male Femal

e

ROYPURA 273.7 308.7 93 18774 11828 5520 3825 2781 73%

SAKHIPUR 137.3 161.0 78 8214 5175 2136 1480 2910 197%

SARISHABARI

UPAZILA

159.0 172.3 84 9467 5964 4232 2932 1916 65%

SHAHJADPUR 302.9 309.0 80 16165 10184 6757 4683 3236 69%

SHIB CHAR 153.1 163.5 87 9303 5861 3609 2501 1671 67%

SHIBGANJ 313.0 324.7 78 16561 10433 4306 2984 7232 242%

SHYAMNAGAR 149.6 171.3 53 5938 3741 2981 2066 3506 170%

SREEMANGAL 167.7 172.6 61 6883 4336 2017 1398 2082 149%

SULLA 59.1 59.9 65 2545 1603 720 499 334 67%

TARAIL 79.0 84.2 102 5614 3537 1465 1016 1772 174%

TEKNAF 149.7 153.0 81 8105 5106 3096 2146 1700 79%

TITAS 94.0 105.8 67 4637 2921 1748 1211 321 26%

TUNGIPARA 50.5 51.6 76 2563 1615 1092 757 1284 170%

UKHIA 119.5 120.7 81 6393 4028 2417 1675 1248 75%

ULIPUR 197.3 217.2 53 7527 4742 4915 3406 3592 105%


35

Annex B: Questionnaire used to survey the Quality Managers of DSF

Demand Side Financing: Maternal Voucher Scheme

Opinion survey on the operational aspects of the program

1. The upazilas in which you are working now: (i) ______________, (ii) ____________

2. List three most important problems faced by the DSF scheme in these two areas?

(i) __________________________________

(ii) __________________________________

(iii) __________________________________

3. Suggest what can be done to solve or lower the problems you have identified

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_________________________________________________________________

4. How does the program identify poor pregnant women in the area? Describe.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_________________________________________________________________

5. Who identifies the pregnant women for participation in the program? ____________________________

_______________________________________________________________________________________________

___________________________________________________________________________

6. Is there any independent verification whether the pregnant woman is poor or not? (Yes/No) _________

7. What percent of poor pregnant women do you think are actually in the program? ___________________

8. What percent of pregnant women in the program are actually poor? _____________________________

9. Propose alternative ways of identifying poor pregnant women for participation in the program?

_____________________________________________________________________________________

_______________________________________________________________________________________________

___________________________________________________________________________

10. Do you think all the health care providers get their money eventually for the services they provide to DSF women

(even if delayed)? (Yes/No) ________________________

11. If Q10 is no, what percent of providers ultimately get their money or incentives for the services they provide to DSF

beneficiaries? ___________________

12. What is the “average” time gap (in months) between service provision and actual receipt of money by health care

providers? ___________________

13. What percent of health care providers, in your opinion, get their money within three months of service provision to

DSF mothers? _________________________

14. Is the payment made to government sector health care providers take less time than payment to private sector

providers (if private providers exist)? ______________

15. What percent of health care providers, in your opinion, do not receive their payments within six months after the

service provision? ___________________________________


36

16. Do you think all the beneficiaries ultimately get their transportation related money for the services they have sought

for health care providers? ________________________

17. What is the “average” time gap, in months, between receiving of the service and actual receipt of transport money by

the beneficiaries? ___________________________

18. What percent of beneficiaries, in your opinion, get their transport related expenses within three months of service

utilization? _________________________

19. Does the transportation expense payment made to relatively better-off beneficiaries take lower time than payment

made to poor beneficiaries? ________________________

20. What percent of women, in your opinion, do not receive their payments within six months after the service

provision? _____________________________________

21. Do women get their new-born incentive money on time? ______________________

22. What is the average time gap between delivery of the baby and receipt of the new-born incentive package the

mothers? _____________________________________

23. Can you suggest ways to reduce the time gap between service provision and receipt of the money?

_______________________________________________________________________________________________

___________________________________________________________________________

24. What are the possible consequences for the program not receiving the money on a timely basis?

_______________________________________________________________________________________________

___________________________________________________________________________

25. Do the DSF women spend additional money for receiving maternal health services from government health care

facilities (not including transport expenses or food expenses)? __________________________

26. Do the DSF women spend additional money for receiving maternal health services from private health care facilities

(not including transport expenses or food expenses)? _______________________________

27. Do you think the DSF program is good for poor pregnant women? (Yes/No) ______________________

28. Do you think the DSF program creates trust problems between health care providers and the beneficiaries? Why and

how? _____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

29. Any other important issues you would like to mention? ______________________________________

_______________________________________________________________________________________________

___________________________________________________________________________

30. Any other comments and suggestions? __________________________________________________

_______________________________________________________________________________________________

___________________________________________________________________________


37

Annex C: Budget and Expenditures of DSF MHVS

Name of the Programme: DSF Year: July 2011-June 2013, In Lac Taka (100,000)

SL # Economic code

Heads 2011-2012 2012-2013

Allocation Expenditure Allocation Expenditure

GoB Dev. RPA (through GoB)




1 4801 Transport Expenses (for pregnant women) - 700.00 - 600.00 - 600.00 - 525.00

2 4815 Postage - 2.00 - - - - - -

3 4827 Printing and publications 40.00 - 4.99 - 44.00 - 43.95 -

4 4828 Stationaries, seals & stamps 5.00 - - - 0.25 - - -

5 4833 Publicity and advertisement - 8.00 - - - - - -

6 4840 Training (for service provider) - 150.00 - 150.00 - 165.00 - 165.00

7 4842 Orientation - 400.00 - 400.00 - 350.00 - 350.00

8 4846 Transportation cost 4.00 - - - - - - -

9 4854 Procure usable goods 2.00 5.00 0.47 - 0.25 - - -

10 4868 Treatment and surgical goods supply - 18.00 - - - 18.11 - 13.61

11 4869 Voucher fund (treatment) - 1,700.00 - 1,646.30 - 1,650.00 - 1,535.58

12 4883 Honorarium (cash incentives for mothers) - 3,385.15 - 2,680.23 - 1,920.50 - 1,920.50

13 4886 Survey 18.00 -

14 4887 Copy - 8.00 - 8.00 - 13.18 - 13.18

15 4895 Committee meetings - 4.00 - 4.00 - 4.40 - 4.40

16 4899 Other expenditure - 283.00 - 283.00 - 270.00 - 270.00

17 6815 Computer and spare parts - 20.00 - - - 25.48 - 25.47

18 6821 Furniture - 14.20 - - - 24.50 - 24.50

Total 51.00 6,715.35 5.46 5,771.53 44.50 5,041.17 43.95 4,847.24

CPI 170.19 181.73

4801: Transport Expenses (to beneficiaries); Total 5 visits (3 ANC, one delivery and 1 PNC visit-100 taka for each visit) and taka 500 for referral.

4840: Training and Orientation of service provider: All doctors, nurses and other staffs of health and family planning department working at UHC, all field staff of both health and FP department (30 in each batch)

4842: Advocacy and Orientation: Upazila DSF committee members, Union DSF committee members (30 in each batch)

4869: Voucher Fund: All service providers Incentives and all medicines and all MSR.

Name of the Programme: DSF


38

Year: July 2013-June 2015, In Lac Taka (100,000)

SL # Economic code

Heads 2013-2014 2014-2015



GoB Dev.

RPA (through GoB)

GoB Dev.

RPA (through GoB)

GoB Dev.

RPA (through

GoB)


2 4815 Postage - - - - - - - -


4 4828 Stationaries, seals & stamps - - - - - - - -

5 4833 Publicity and advertisement 0.40 - 0.26 - - - - -


7 4842 Orientation - 484.00 - 248.59 - 361.90 - 231.83

8 4846 Transportation cost - - - - - - - -

9 4854 Procure usable goods - - - - - - - -

10 4868 Treatment and surgical goods supply - - - - - - - -


12 4883 Honorarium (cash incentives for mothers) - 2,500.00 - 2,497.01 - 2,400.00 - 582.67

13 4886 Survey

14 4887 Copy - 14.52 - 14.37 - 17.91 - -


16 4899 Other expenditure - 600.00 - - - - - -

17 6815 Computer and spare parts - - - - - 2.00 - -

18 6821 Furniture - - - - 2.50 - - -

Total 51.00 6,715.35 50.21 6,534.86 35.33 5,095.64 52.50 5,815.67

CPI 195.08 207.58






39

Name of the Programme: DSF

Year: July 2015-June 2016, In Lac Taka (100,000)

SL # Economic code

Heads 2015-2016 Average per year 2011-16 in 2015-16 prices



GoB Dev.

RPA (through GoB)

GoB Dev.

RPA (through GoB)

GoB Dev.

RPA (through

GoB)


2 4815 Postage - - - - - 0.52 - -


4 4828 Stationaries, seals & stamps - - - - 1.36 - - -

5 4833 Publicity and advertisement - - - - 0.09 2.08 0.06 -


7 4842 Orientation - 235.00 - 213.93 - 422.53 - 337.32

8 4846 Transportation cost - - - - 1.04 - - -

9 4854 Procure usable goods - - - - 0.58 1.30 0.12 -

10 4868 Treatment and surgical goods supply - - - - - 9.07 - 3.31


12 4883 Honorarium (cash incentives for mothers) - 2,000.00 - 1,186.48 - 2,822.42 - 2,089.30

13 4886 Survey - 4.67 - -

14 4887 Copy - - - - - 12.38 - 8.53


16 4899 Other expenditure - - - - - 274.96 - 139.09

17 6815 Computer and spare parts - 2.00 - - - 12.21 - 6.19

18 6821 Furniture - - - - 0.53 9.64 - 5.96

Total 51.00 6,715.35 55.00 4,867.22 40.79 3,083.31 57.60 6,659.48

CPI 220.88






40

Expenses per upazila under DSF based on historical budget and expense numbers (in Lac Taka, 2015-16 prices)

SL # Economic code Heads

Average budget per upazila

Average Expenditure per

upazila

1 4801 Transport Expenses (for pregnant women) 13.46 8.82

2 4815 Postage 0.01 0.00

3 4827 Printing and publications 1.02 0.67

4 4828 Stationaries, seals & stamps 0.03 0.00

5 4833 Publicity and advertisement 0.04 0.00

6 4840 Training (for service provider) 3.67 3.05

7 4842 Orientation 7.97 6.36

8 4846 Transportation cost 0.02 0.00

9 4854 Procure usable goods 0.04 0.00

10 4868 Treatment and surgical goods supply 0.17 0.06

11 4869 Voucher fund (treatment) 41.03 34.60

12 4883 Honorarium (cash incentives for mothers) 53.25 39.42

13 4886 Survey 0.09 0.00

14 4887 Copy 0.23 0.16

15 4895 Committee meetings 0.09 0.05

16 4899 Other expenditure 5.19 2.62

17 6815 Computer and spare parts 0.23 0.12

18 6821 Furniture 0.19 0.11

Total 126.74 96.05


41

Annex D: List of Poorest 50 upazilas of Bangladesh zl-code

zila-name upz-code upazila-name % Extreme Poor (lower

poverty line)

% Poor (Upper poverty line)

Rank DSF Upazila?

49 KURIGRAM 4908 CHAR RAJIBPUR 48.7 68.8 1

49 KURIGRAM 4918 PHULBARI 48.8 68.5 2

49 KURIGRAM 4977 RAJARHAT 48.6 67.7 3

49 KURIGRAM 4994 ULIPUR 46.2 65.3 4 Yes

49 KURIGRAM 4906 BHURUNGAMARI 44.7 65.1 5

49 KURIGRAM 4961 NAGESHWARI 45.4 65 6

6 BARISAL 662 MHENDIGANJ 50 64.4 7

6 BARISAL 636 HIZLA 49.5 62.3 8

13 CHANDPUR 1347 HAIM CHAR 41 61.3 9

49 KURIGRAM 4909 CHILMARI 42.1 61.1 10

61 MYMENSINGH 6172 NANDAIL 41.8 60.7 11

61 MYMENSINGH 6181 PHULPUR 39.2 58.8 12

39 JAMALPUR 3915 DEWANGANJ 41.6 58.5 13 Yes

85 RANGPUR 8527 GANGACHARA 39 58.3 14 Yes

86 SHARIATPUR 8636 GOSAIRHAT 40.7 58.3 15

61 MYMENSINGH 6116 DHOBAURA 38.4 58.2 17

6 BARISAL 669 MULADI 44.1 58.2 16

32 GAIBANDHA 3221 FULCHHARI 39.8 58.1 18

49 KURIGRAM 4952 KURIGRAM SADAR 40.5 58 19

49 KURIGRAM 4979 RAUMARI 36 57 20

86 SHARIATPUR 8614 BHEDARGANJ 38.3 56.3 22

13 CHANDPUR 1358 KACHUA 35 56.3 21

61 MYMENSINGH 6131 ISHWARGANJ 35.8 56 23

89 SHERPUR 8988 SHERPUR SADAR 35.6 55.8 24

6 BARISAL 632 GAURNADI 39.9 55.5 25

39 JAMALPUR 3958 MADARGANJ 38.2 55.5 26 Yes

6 BARISAL 607 BAKERGANJ 42.2 55.4 27


42

39 JAMALPUR 3929 ISLAMPUR 38.2 55 28

86 SHARIATPUR 8694 ZANJIRA 34.9 54 29

13 CHANDPUR 1349 HAJIGANJ 32.5 53.7 30

13 CHANDPUR 1376 MATLAB DAKSHIN 32.4 53.7 31

3 BANDARBAN 395 THANCHI 31.7 53 32

32 GAIBANDHA 3288 SAGHATA 34.1 52.8 33

61 MYMENSINGH 6120 FULBARIA 32.8 52.6 34

91 SYLHET 9141 GOWAINGHAT 46.5 52.6 35

85 RANGPUR 8592 TARAGANJ 32.4 52.4 36

61 MYMENSINGH 6152 MYMENSINGH SADAR 39.3 52.3 37

6 BARISAL 610 BANARI PARA 38.1 52.2 38 Yes

79 PIROJPUR 7947 KAWKHALI 39.6 52.2 39

6 BARISAL 694 WAZIRPUR 37.8 52.1 40

79 PIROJPUR 7976 NAZIRPUR 36.6 51.5 41 Yes

6 BARISAL 602 AGAILJHARA 38.2 51.1 42

32 GAIBANDHA 3282 SADULLAPUR 31.1 51 43

55 MAGURA 5566 MOHAMMADPUR 30.6 50.8 44

61 MYMENSINGH 6123 GAURIPUR 30.5 50.6 45

82 RAJBARI 8229 GOALANDA 31.8 50.5 47

13 CHANDPUR 1395 SHAHRASTI 29.5 50.5 46

39 JAMALPUR 3907 BAKSHIGANJ 34.3 50.4 48

61 MYMENSINGH 6124 HALUAGHAT 30.6 50.3 49 Yes

87 SATKHIRA 8786 SHYAMNAGAR 33.8 50.2 50 Yes


43

Annex E: List of Individuals met during the field visits and in Dhaka, Bangladesh Persons/Organisations Consulted and discussed on DSF Programme:

Government of Bangladesh in Dhaka

Mr. Md. Moslem Chowdhury-Additional Secretary, Ministry of finance and NPD, SPFMSP Project

Mr. Monzurul Alam Bhuiyan-Joint Secretary, MOF and ED, SPFMSP Project

Mr. Ataur Rahman-Deputy Secretary, DD, SPFMSP Project

Mr. M M Reza-Advisor, P.M.M.U, Ministry of Health and Family Welfare.

Dr. Mohiuddin Osmani-Joint Chief Planning, MOH & FW

Mr. Ibrahim Khalil-Senior Assistant Chief.

Dr. Saidur Rahman-Director, PHC and LD, MNCAH, DGHS

Dr. Pabitra Kumar Sikder-Deputy Director and Programme Manager

Dr. A K M Rafiqul Hyder-DPM, DSF

World Health Organization

Dr. Edwin C. Salvador, Medical Officer, Public Health Administration

Dr. Murad Sultan, NPO, Health System

Dr. Md. Mohsin, Consultant DSF, WHO

Dr. Deen Mohammad, National Coordinator, WHO DSF Cell

Two Zonal Coordinators

26 Upazilla Quality Managers

Maxwell Stamps LLC, Dhaka, Bangladesh

Mr. Duncan King, Project Director, SPFMSP project

Mr. Dan Wartonick, Ex Team Leader, SPFMSP Project

Mr. Siddiqur Rahman Choudhury, Acting Team Leader, SPFMSP Project

Dr. Kavim V Bhatnagar-Social Protection Economist, SPFMSP Project

Mr. Mozammel Haque-Social Protection Specialist, SPFMSP Project

Ms. Treena Watson-Coordinator, SPFMSP Project

Ms. Emily Wylde-over Video Conference

DFID, Dhaka

Dr. Sahlina Ahmed, Health and Population Advisor, DFID

Ms. Farhana Mostafa, Programme Manager, DFID

World Bank, Dhaka

Dr. Bushra Bente Alam, Health Advisor,

Dr. Shakil Ahmed, Senior Health Economist

Dr. Asib Nasim, Consultant (Health)

Dr. Tahmina Begum, Consultant Economist

UNFPA

Dr. Syed Abu Jafar Md Musa, Advisor, UNFPA

Field visit meetings

Daudkandi Upazilla, Comilla

Mr. Md. Al-Amin, UNO, Daudkandi

Dr. Shah Alam Molla, UH&FPO, Daudkandi


44

Dr. Habibur Rahman, RMO, UHC, Daudkandi

Upazila Family Planning Officer and five doctors of UHC

Mr. Imran Hossain, WHO, Quality Manager

Mr. Kamal Uddin, Owner and Chief Executive Officer, Kamal Hospital, Gouripur

Mr. Abul Hashem Sarkar, Chairman, Gouripur Union Parishad

And other members of the union parishad

Jamalpur District Hospital and Sharishabari Upazila, Jamalpur

Jamalpur District Hospital

Dr. Md. Abdullah Al-Amin, Superintendent and Assistant Director, Jamalpur District Hospital

Dr. Md. Moshayer-ul-Islam, Civil Surgeon, Jamalpur

Prof. M A Wakil, Principal, Jamalpur Medical College

Dr. Tarun Kumar Dhar, Senior Consultant, Obs. & Gynae

Dr. Md. Nurul Islam Talukdar, Senior Consultant, Anesthesia

Dr. Md. Sirajul Islam, RMO of the General Hospital, Jamalpur

Dr. Md. Ferdous Hasan, RMO, Jamalpur General Hospital

Dr. Fakhria Alam, Junior Consultant, OBGYN, Jamalpur General Hospital

Sharishabari Upazila

Dr. Md. Fazlul Haque, UHFPO

Dr. Mumtaz Uddin Ahmed, RMO

Dr. Brishti Ghosh, Medical Officer (MO)

Dr. Mazreha Naeem Mishi, MO

Dr. Md. Shahedur Rahman, MO

Dr. M. Samia Islam, Dental Surgeon

Mr. Bulbul Hossain; QM,WHO

Mr. Shahabuddin, Health Inspector (in charge)


45

Annex F: Comparative Summary Statements for DSF-MHVS

Specific areas/

dimensions

Existing provision Issues and challenges Proposed revisions Rationale

Flow of funds

and issues

related to fund

release and

disbursement

Funds of the programme flow

through multiple channels

within Health and Finance

Ministries.

Delays in flow of funds range

from 3 to 12 months. The

average delay in disbursing

service providers and

beneficiaries is about six to

eight months, creating

significant obstacles in smooth

functioning of DSF–MHVS.

Budget allocative processes should

be optimised; time lag between the

adoption of budget and release of

funds to MOHFW and then to the

upazila level needs to be reduced

to less than 30 days.

The time lags in the release of

funds from Ministry of Finance to

Ministry of Health can be reduced;

adoption of improved information

system can reduce time lag of flow

of funds from MOHFW to upazila

level MHVS account.

No provision for stop gap fund

and / or contingency fund to

meet day-to-day requirements

of the programme.

First tranche of quarterly fund is

usually released only during the

second quarter creating a huge

backlog of payment to service

providers as well as to

beneficiaries.

Establish an imprest account so

that beneficiaries can be paid

immediately after receiving the

services.

The imprest account can smooth

out the irregular flow of money.

The imprest account money is

considered an advance to be

adjusted with expenditures after

the submission of incentive and

service related payment vouchers.

Unit prices to health care

providers and the incentive

payments to beneficiaries are

paid through bank accounts.

Paying the beneficiaries through

bank accounts is not working

properly. Opening the bank

account has not been easy for

some beneficiaries. Getting the

money through the bank

accounts also involves

additional expenses for

beneficiaries.

Beneficiaries be offered a number

of options for reimbursing the

incentive money or travel expenses.

The options may include (a) bank

account, (b) mobile banking, (c) e-

cash payment, (d) postal money

order, etc.

Offering alternative options for

receiving incentive funds will

improve satisfaction of

beneficiaries with the programme.

It will also reduce cost of getting

the incentive money from the

perspective of beneficiaries. This

will reduce the possibility of fund

leakage.

Specific areas/

dimensions


Price and

incentive

schedule used by

the programme

for paying

Unit prices are set by the

programme to pay for different

maternal health services.

Price and incentive schedule

used by the programme may

encourage providers to charge

user fees to beneficiaries and to

a) Ratios of upazila level market

prices to prices set by programme

should be similar across services.

The ratios now vary widely.

The ratios of market to

programme prices affect incentive

structure of health care providers.

Incentive payments to

beneficiaries for home and


46

providers for

various maternal

health services

overuse certain type of maternal

health services

b) The gap in incentive payments to

beneficiaries for institutional and

home deliveries should be reduced.

institutional deliveries should be

rationalized to discourage

misreporting of institutional

deliveries.

For public sector health

facilities, physicians deciding

between normal and C-section

delivery receive Tk. 60 per

normal delivery but Tk. 1,100 for

C-section delivery. Private sector

facilities get Tk. 300 for normal

delivery and Tk. 6,000 for C-

section delivery.

The difference in payments

between C-section and normal

deliveries is very high

encouraging delivery of babies

through unnecessary C-

sections. C-section rate is

significantly higher for DSF

beneficiaries than non-DSF

mothers.

The payments for C-section and

normal deliveries should be

reexamined to ensure that

unnecessary C-sections are

discouraged. The payment for C-

section delivery and normal

delivery may be equalized.

Equal or quite similar level of

payments for both normal and C-

section deliveries will lower the

likelihood of performing C-

sections that are not medically

indicated.

Not all necessary maternal

health services are listed in the

list of benefits of the

programme. The programme

benefits include tests for blood

hemoglobin and urine test for

albumin. No other laboratory

and diagnostic tests are listed.

Health care providers often

recommend tests for blood

groupings and blood sugar. For

some mothers, ultrasound is

also recommended. Since these

tests are not mentioned in the

programme benefit package,

DSF enrollees are often asked to

pay for these services out of

pocket.

Blood groupings, blood sugar test

and ultrasound for complicated

pregnancies can be listed under the

benefit package.

Inclusion of these tests in the

benefit package will lower the out-

of-pocket expenses of DSF-MHVS

beneficiaries.

Specific areas/

dimensions


Administrative

and

management

related issues

Six MHVS implementation

committees, three at national

level, one at district level, one at

upazila level and one at union

level.

Not all committees are active

and many did not meet in a

year. Union level committees

often not functional.

Different DSF committees may be

streamlined for improved efficiency

and the need for multiple

committees in running DSF-MHVS

may be reviewed.

Streamlining the DSF committees

will improve efficiency of the

programme. Reduction in the

number of committees should

reduce expenditures on

orientation meetings, travel costs,

etc.


47

There is no personnel at the

upazila level who is in charge of

the DSF-MHVS. The WHO Quality

Managers (QMs) were appointed

on an adhoc basis.

Presence of WHO QMs appears

essential for proper functioning

of DSF-MHVS activities at

upazila level and below. With

the departure of the temporary

QMs, the programme will have

difficulty in implementing its

activities.

One full-time staff should be

appointed per upazila. This

administrative person will be in

charge of all programme activities

including verification of eligibility,

keeping contacts with stakeholders

and beneficiaries, coordinating

data collection using UHC Health

Information System.

The programme needs a

coordinator at the upazila level

who will liaison with all the

stakeholders at upazila, union and

community levels. A full time staff

is also needed to ensure that the

DSF related information is

collected and reported through

the regular HMIS of UHC.

Upazila Health and Family

Planning Officer (UHFPO) is in

charge of DSF accounts at the

upazila level. Upazila Health

Complex is also a provider of

DSF services in addition to

paying for services provided by

private health care facilities.

Since the UHC is also the

purchaser of services, it creates

conflict of interest situation

(restricting use of private sector

facilities, over-reporting the

services delivered).

Two alternative approaches can be

adopted; (i) Making UHC the service

provider (payment of incentives

can continue) without being in

charge of purchasing or (ii) No

incentive payments to public sector

facilities and providers but UHC

remains the purchaser of services

from private providers.

To resolve the potential conflict of

interest situation, health care

delivery function should be

separated from purchasing

function of health facilities.

Currently, there is no

independent verification of

quantities and types of services

provided.

Quantities of services delivered

are possibly over-reported as

the UHC is both payer and

provider

Monitor quantity and quality of

maternal health services delivered

by public and private providers.

Possibility of misreporting

quantities of services provided is

high because of associated

incentive payments.

Specific areas/

dimensions


Identification of

the beneficiaries

of the

programme

Criteria for selection of voucher

holder are (a) monthly income

of 3100 or less, (b) Land owned

less then 0.15 acre, (c) does not

have any other income source

or productive assets.

The criteria used for identifying

the potential beneficiaries are

out-of-date. The specific criteria

are not easy to observe or verify

leading to selection of non-

eligible women.

Needs to be revisited considering

the present socio economic

condition. Easily observable

housing and asset ownership

characteristics should be used to

identify the poor households.

Use of easily observable and

verifiable characteristics will

simplify identification of target

population. Targeting efficiency

can be improved if asset based or

housing based characteristics are

used.

Target numbers of women are

estimated for each upazila using

Upazilas vary widely in terms of

poverty rate as well as CBR.

Target number of eligible women

should be calculated for the

Budget needed for the

programme depends on the


48

crude birth rate (CBR) of

Bangladesh and assuming 40%

of pregnancies as eligible.

Arbitrary use of 40% as eligible

biases the target calculations.

programme using more realistic

assumptions on poverty rate and

CBR. Upazila specific estimates of

target should be avoided.

estimate of target number of

eligible women. Using appropriate

parameters in the estimation

process is important to find the

budget requirements.

The programme is now in

operation in 53 upazilas of the

country. The upazilas were not

selected on the basis of poverty

rate.

Since the upazilas were not

selected based on poverty rate,

a significant number of upazilas

in the programme do not show

high rates of poverty. This

increases the possibility of

mistargeting.

The programme should scale up its

activities using upazila level poverty

level. In the poor upazilas, the

programme may adopt universal

coverage rather than targeting poor

households only.

In poor upazilas, if all pregnant

women are targeted, percent of

poor pregnant women in the

programme will be about 60%.

Geographic targeting will have

high targeting efficiency.

Officially the DSF-MHVS uses

poverty criteria to identify the

poor pregnant women for

enrollment in the programme.

The official criteria are rarely

used in practice and many of

the enrolled women appear not

poor.

The enrollment criteria may be

revised to allow enrollment of

poorest 50% women.

Maternal Mortality Ratio (MMR) is

not the highest for poorest

quintile. The MMR are high for all

three poorest quintile and the

middle wealth quintile showed

the highest mean MMR. Therefore,

not targeting narrowly the poorest

quintile may not be a major

concern.

Specific areas/

dimensions


Advocacy,

communication

and social

mobilization

Little or no formal

communications between

central level policy makers and

the upazila level programme

managers and implementers

Lack of communication

between the centre and field

level often creates confusions in

the implementation of the

programme. In some cases,

programme implementers are

not fully aware of the policies

and procedures.

Organize regular contacts between

programme management and field

level implementers. Regular

communications will allow

managers to better understand

issues/concerns at the field level

and field level become aware of

policy changes.

Regular two-way communications

will reduce the knowledge gap

among various levels of the

programme.

Little or no social mobilization

and awareness initiatives

Programme management and

field level service providers/

implementers lack knowledge

Social mobilization activities

should be organized on a regular

basis to improve knowledge of all

Lack of knowledge about the

programme makes it difficult for

health workers to recruit eligible


49

implemented by the

programme

about the programme and

programme benefits

stakeholders including the

community members about DSF-

MHVS and it benefits

women. Better understanding of

programme benefits will improve

service utilization.

Data needs and

future research

needs

There is no data on targeting

efficiency of the programme

Information on targeting

efficiency is not known.

Programme should conduct

household surveys to estimate

targeting efficiency, if universal

targeting is not used

Without more information on

targeting efficiency, it is difficult to

design policies for better

targeting.

Reliability and validity of

reported service utilization

information is not known

Providers are paid on the basis

of service utilization. Incentives

exist to over-report utilization.

Up-coding of services may also

happen.

Patient chart reviews to estimate

the degree of mistargeting as well

as possible over-reporting or up-

coding of service delivery.

Services delivered may be

misreported in some cases. To

reduce mis-reporting, regular

monitoring of service utilization is

needed.

Management information

system of the programme is not

comprehensive. The

information is collected by

Quality Managers (QMs) at the

upazila level and then

transmitted to the project.

The information system is

adhoc and upazila HMIS does

not collect all relevant

information on DSF-MHVS.

DSF-MHVS should develop an

integrated and comprehensive MIS

and the system should be

compatible with HMIS so that all

information can eventually be

integrated with regular HMIS.

Regular MIS will allow flow of

information on a regular basis

lowering the time-gap between

service utilization and incentive

payments. It should also

strengthen regular HMIS.


50

Annex G: Minutes of the meeting on report presentation and discussion

Government of the People's Republic of Bangladesh

Ministry of Health and Family Welfare

Planning Wing, Health-6 Bangladesh Secretariat, Dhaka

MoHFW/AC(H-6) /DSF/2016/ Date: 04.01.2017

Subject: Minutes of the Meeting held on "Dissemination and Finalizing the Draft Report on Diagnostic of Demand Side Financing— Maternal Health Voucher Scheme.

A meeting was held on 14 December 2016 on "Dissemination and Finalizing the Draft Report on Diagnostic of

Demand Side Financing— Maternal Health Voucher Scheme "in the Conference Room of Planning wing of the

ministry of Health and welfare (MOHFW). Dr. A E Md. Muhiuddin Osmani, Joint Chief (Planning), MoHFW

presided over the meeting. The list of the participants is appended as Annex-A.

2. Discussion:

2.1. The Chairperson welcomed all to the meeting. After a brief introduction of all, the Chair then

invited to make a Presentation on the DSF -MH VS programme for the MOHFW.

2.2. The team of consultants headed by Prof. Mahmud Khan made the key presentation. He

mentioned that the presentation is based on the draft report of the diagnostic study on DSF-

MHVS and findings of the study The suggestions and comments of the participants of this

meeting would be addressed in the final report. He also informed that the study was mostly

based on literature review.

2.3. The presentation was followed by discussions including questions, suggestions, comments and

feedback to be incorporated into the report. Main suggestions, comments and questions that

were discussed are as follows:

a) Distinction between the Market Price of Services by Private Sector and that of DSF

Voucher should be clearly stated comparing the two at the rural / appropriate level

b) Selection of Upazila for implementing / rolling out of DSF — MHVS should be based on

Poverty Mapping and 50 most Poor Upazillas should be considered on priority basis. It

was also discussed that the scheme could be universalised in those Upazilas. Argument

put forward was based on an improvement in targeting efficiency level of the scheme that

could be improved up to 60%.

c) The inordinate delay in the fund flow from The MOHFW to Upazila of the programme was

extensively discussed and was identified as a systemic issue. It was discussed that

(SPFMSP) project of the Finance Division has a mandate to improve upon the PFM


51

structures of social protection schemes and should take the initiative of improving the

efficiency and timelines for release and flow of funds of the DSF-MHVS programme.

d) It was suggested that the Programme should also consider creating an imprest fund to

contribute towards timely payments before the first quarter advance is released The

SPFMSP suggested that this could be looked up further in the design of the reform plan.

e) The issue of beneficiaries being paid by cheque was also discussed and it was suggested

that the proposed reforms should also look Into easier methods to provide payment to

beneficiaries.

f) The role and involvement of the private sector in service delivery should be clearly stated

and concerns, if any, should be identified in the reform plan,

g) The proposed reform plan should also look into the reasons behind the difference

between the budgetary outlays and the actual expenditure incurred in the programme

with a view to design an improved and efficient utilisation of funds.

h) The issue of differential rates for normal delivery and C-section was discussed and it was

suggested by the consultants that the same should be rationalised and equated for an

improved incentive structure.

i) It was suggested that 'user-friendly' guidelines in the form of a booklet should be

developed by the MOHFW as part of the awareness campaign towards enhanced

utilisation of health services amongst the potential beneficiaries.

j) The overall reforms for DSF-MHVS should also take into consideration the macro-picture,

and closely look at how coordination with similar programmes such as the Lactating

Mothers Allowance and Maternity Allowance may be improved.

k) A comparative statement showing the existing system along with the proposed system

and reasons thereof should be provided as an annexure to the report.

3. Recommendations:

3.1. The meeting unanimously adopted the following recommendations of the report discussed in

the meeting.

Institutional arrangements and procedure for fund flow needs to be revisited to reduce the

existing long time lag in payment to the beneficiaries as well as to the service providers. Possibility

for establishing an imprest fund might be explored to reduce the delays in pavment, il. Reforming

the existing payment system to the beneficiaries to include multiple payment options such as mobile

banking, micro financial services, mobile payments etc might be considered; iii. For implementation

of the programme, the poorest 50 upazilas should be selected first The possibility of

universalization of the scheme in those 50 upazilas and the cost associated with It Should also be

explored, iv. The rates provided for different services by the scheme should be reviewed/

rationalized to reduce the gap between the market price and also to avoid any distortion such as

preference for unnecessary C — section and diagnostic tests.

v, Establish a mechanism for coordination amongst DSF—MHVS and similar programmes such as

the Lactating Mothers Allowance and Maternity


52

Allowance.

vi. A more 'user-friendly' guideline in the form of a booklet to be developed by the MOHFW as part

of the awareness campaign towards enhanced utilisation of health services amongst the

potential beneficiaries,

4. As there was no other issue to discuss the meeting was concluded with a vote of thanks from the Chair.

(Dr. A. E. Md. Muhiuddin Osmani)

Joint Chief

Ministry of Health and Family Welfare

Documents

December 2016 Dhaka, Bangladesh - SPFMSPspfmsp.org/wp-content/uploads/2017/01/2017-01-10... · Field visits identified a number of additional issues. During January-August 2016, in