Demand Side Financing and Healthcare Seeking of Pregnant Women

Demand-side financing (DSF) scheme is popularly known as the maternal health voucher program, which is launched in many developing countries of the world including Bangladesh as an intervention of developing overall health status. Maternal mortality ratio is a strong indicator of health profile of any country and pregnant women are prone to fall vulnerable situation. This review was aimed to find gap/missing of existing literature in order to make foundation of new research on healthcare seeking of pregnant women along with financing coverage. After repeated critical review of number original articles, some gaps have been found. Almost every article they focused on outcome and mildly highlighted input variables but did not consider all possible variables and missed to show interlink between those variables.

Payment mechanism for institutional births in Nepal

Background Since the Millennium Development Goal era, there have been several efforts to increase institutional births using demand side financing. Since 2005, Government of Nepal has implemented Maternity Incentive Scheme (MIS) to reduce out of pocket expenditure (OOPE) for institutional birth. We aim to assess OOPE among women who had institutional births and coverage of MIS in Nepal. Method We conducted a prospective cohort study in 12 hospitals of Nepal for a period of 18 months. All women who were admitted in the hospital for delivery and consented were enrolled into the study. Research nurses conducted pre-discharge interviews with women on costs paid for medical services and non-medical services. We analysed the out of pocket expenditure by mode of delivery, duration of stay and hospitals. We also analysed the coverage of maternal incentive scheme in these hospitals. Results Among the women (n-21,697) reporting OOPE, the average expenditure per birth was 41.5 USD with 36 % attributing to transportation cost. The median OOPE was highest in Bheri hospital (60.3 USD) in comparison with other hospitals. The OOPE increased by 1.5 USD (1.2, 1.8) with each additional day stay in the hospital. There was a difference in the OOPE by mode of delivery, duration of hospital-stay and hospital of birth. The median OOPE was high among the caesarean birth with 43.3 USD in comparison with vaginal birth, 32.6 USD. The median OOPE was 44.7 USD, if the women stayed for 7 days and 33.5 USD if the women stayed for 24 h. The OOPE increased by 1.5 USD with each additional day of hospital stay after 24 h. The coverage of maternal incentive was 96.5 % among the women enrolled in the study. Conclusions Families still make out of pocket expenditure for institutional birth with a large proportion attributed to hospital care. OOPE for institutional births varied by duration of stay and mode of birth. Given the near universal coverage of incentive scheme, there is a need to review the amount of re-imbursement done to women based on duration of stay and mode of birth.

The Effect of A Demand Side Financing Program on the Continuum of Maternal and Child Health Care in India

Background The Indian Government launched a demand-side financing program, ‘Janani Suraksha Yojana’ (JSY) in 2005 with the aim of reducing maternal and neonatal mortality through increased access to institutional delivery care service. This paper analyses the effects of the JSY on the uptake of maternal and child health (MNCH) care services intending to understand the overall impact of the program on the continuum of care. Methods Using the 2013-14 round of the District-level Household Survey (DLHS) surveyed in high performing states, the average treatment effect on the treated (ATT) was estimated by using the Propensity Score Matching (PSM). Results are reported regarding both ATTs and deviations from the theoretical continuum of care line, which represents 100% uptake, i.e., all women availing all the MNCH services. Results Overall, JSY effects on MNCH components ranged between 0.7% and 12%. As expected, the highest impact of the JSY was on institutional delivery (ATT: 0.12; 95% CI: 0.104-0.131) and the lowest for breastfeeding more than six months (ATT: 0.007; 95% CI: -0.014-0.027). Deviation from the complete continuum of care line ranged from 2.3% to 80.9%. The highest deviation was for three or more Tetanus Toxoid (100%-19.1%=80.9%) injections and the lowest for Polio given at any time (100%-97.7%=2.3%). Conclusions The program had high effects on those MNCH care services, the uptakes of which were already high without the program (low deviations from the continuum of care line), and the program had low effects on those MNCH care services, which had low uptakes in the absence of the program (high deviations from the continuum of care line). The program should also incentivize the utilization of those MNCH care services, which have low uptakes in the absence of the program.

Demand side financing scheme for maternal and child health of Tamil Nadu: evaluation of benefit received status and awareness level among third trimester pregnant mothers, seeking care at Madurai Medical College Hospital, 2019

Background: Dr. Muthulakshmi Reddy Maternity Benefit Scheme (MRMBS) of Tamil Nadu Government is demand side financing scheme to poor pregnant mothers to compensate wage loss and for nutritional support. Scheme was revised during 2018. Primary objectives were to estimate proportion of benefit received status and median awareness level among third trimester pregnant mothers regarding MRMBS scheme. Secondary objective was to determine association between above two.Methods: We conducted cross sectional study among third trimester pregnant mothers who sought care at Madurai Medical College Hospital; adopted consecutive sampling; sample size 96. We collected data with semi structured questionnaire; calculated proportions with confidence intervals, median, interquartile range and performed bivariate analysis; observed privacy and confidentiality; obtained informed written consent from participants.Results: Enrollment percentage was 97% (91 to 99%). Proportion of mothers who received any benefit, any installment and any nutrition kit were 82% (72 to 89%), 39% (29 to 49%) and 76% (66 to 85%) respectively. Proportion who received appropriate benefit, appropriate instalment(s) and two nutrition kits were 3% (0.7 to 9%), 22% (14 to 31%) and 3% (0.7 to 9%) respectively. Regarding awareness score, lowest, highest, median and interquartile range were 5, 23, 14 and 11 to 17 respectively. Odds ratio for awareness score above median (exposure) and any benefit received status (outcome) was 4.2 (1.2to19.2).Conclusions: Enrollment was satisfactory. Overall any benefit received status had been achieved by at least one nutrition kit supply. Second instalment and kit issue needed improvement. Huge scope existed for improvement of awareness among beneficiaries.

Financing From Demand-Side in Education

The belief in the importance of education on economic and social development has resulted in the education expenses being largely covered by the public budget. Countries' approaches to financing education services may vary depending on the tendency to see the education as mixed, complete or private goods and the policies they follow in this direction. In order to fully meet the demands for education, it is of great importance that the available financial resources are spent on the basis of effectively and accountability, as well as the ratio of the financial resources allocated for education. The failure in education is largely attributed to the lack of funding. However, this failure is largely ignored because of the poor use of existing financing, as well as the inadequacy of funding resources. It is an important issue to observe the measures of equality and equity in the distribution of resources related to education and of efficiency and accountability in their spending. Demand-side financing approach in education includes the issues of the freedom of school choice as part of initiating inter-school competitions, giving the ‘Education Cheque’ or the ‘Education Voucher’ to student parents and their submitting this cheque or voucher to the board of the school where school stakeholders are also included and where they send their children, within the framework of a protocol, instead of spending the determined money considering the free market conditions or transferring it directly via the education center or district units to the school account for each student studying at each school level. The purpose of this study is to create awareness among education stakeholders and researchers such as decision-makers, managers and teachers regarding the education in by examining the approaches of ‘Demand-Side Financing’ which is based on parents/ customers' initiative in the use of financial resources allocated from the general budget for education. Key words: Demand-side financing, education financing, financing

Determinants of Household’s Healthcare Payment in Nepal: Evidence from Living Standard Survey III Data

Healthcare financing has always remained an important development issue for Government of Nepal to ensure equity and availability of basic health care services for all but the largest portion of health financing is met by out of pocket payment (OOP), a private financing source of households. So this study aims to assess the situation of private healthcare financing and analyze the factors associated with it. A cross sectional descriptive cum analytical study was designed based on living standard survey data of CBS (2012), Nepal. It is a rich and country wide representative data comprising 5988 households. The study applied logistic regression to analyze the determinants of out of pocket payment. The major findings of the study shows a particular household’s mean healthcare cost was NRs. 1119 for acute illness and cost of medicine occupied the major portion of the cost. The mean OOP healthcare cost is higher for urban residents, mountain dwellers, and households belonging to province 3 and people belonging to highest wealth quintiles. The odds of household facing OOP payment increases for male headed households, larger households and households belonging to province number 2. Conversely, odds of household facing OOP decreases for households residing in urban and province number4. The study concludes that out of pocket payment is an important source of private healthcare financing source. So there is a need to effectively implement the demand side financing programs and health insurance scheme to protect households from financial burden.

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

To test a statistically significant change in delivery by medically trained providers following introduction of a demand-side financing voucher, a population-based quasi-experimental study was undertaken, with 3,300 mothers in 2010 and 3,334 mothers at follow-up in 2012 in government-implemented voucher program and control areas. Results found that voucher program was significantly associated with increased public health facility use (difference-in-differences (DID) 13.9) and significantly increased delivery complication management care (DID 13.2) at facility although a null effect was found in facility-based delivery increase. A subset analysis of the five well-functioning facilities showed that facility deliveries increased DID 5.3 percentage points. Quintile-based analysis of all facilities showed that facility delivery increased more than threefold in lower quintile households comparing to twofold in control sites. The program needs better targeting to the beneficiaries, ensuring available gynecologist–anesthetist pair and midwives, effective monitoring, and timely fund reimbursements to facilities.