Encouraging maternal health service utilization: an evaluation of the Bangladesh voucher program

With the ultimate goal of reducing maternal and neonatal mortality, many countries have recently adopted innovative financing mechanisms to encourage the use of professional maternal health services. The current study evaluates one such initiative - a pilot voucher program in Bangladesh. The program provides poor women with cash incentives and free access to antenatal, delivery, and postnatal care, as well as cash incentives for providers to offer these services. We conducted a household survey of 2208 women who delivered in the 6 months before the survey (conducted in 2009) in 16 intervention and 16 matched comparison sub-districts. Probit and linear regressions are used to analyze the effects of residing in voucher sub-districts on the use of professional maternal health services and associated out-of-pocket expenditures. Using information on birth history, we conducted sensitivity analyses employing difference-in-differences methods, comparing women's reported births before and after the program's initiation in the intervention and comparison sub-districts. We found that the program significantly increased the use of antenatal, delivery, and postnatal care with qualified providers. Compared to women in matched comparison sub-districts, women in intervention areas had a 46.4 percentage point higher probability of using a qualified provider and 13.6 percentage point higher probability of institutional delivery. They also paid approximately Taka 640 (US$ 9.43) less for maternal health services, equivalent to 64% of the sample's average monthly household expenditure per capita. No significant effect of vouchers was found on the rate of Cesarean section. Our findings therefore support voucher program expansion targeting the economically disadvantaged to improve the use of priority health services. The Bangladesh voucher program is a useful example for other developing countries interested in improving maternal health service utilization.