Bangladesh has made impressive progress in reducing child mortality but rates
of maternal mortality have not reduced appreciably over the past decade. The
current estimate of maternal mortality ratio for Bangladesh is in the range
of 300-400 per 100,000 live births (NIPORT, 2002). The major causes of maternal
deaths include postpartum haemorrhage, eclampsia, complications due to unsafe
abortion, obstructed labour, postpartum sepsis etc. with hemorrhage and eclampsia
accounting for 55% of the maternal deaths. Many of these deaths are preventable
with timely detection and intervention by medically trained birth attendants.
Utilization of safe delivery services from medically trained providers is abysmally
low in the country. According to BDHS 2004 (NIPORT, 2002), 46.8% of the pregnant
women had at least one antenatal check-up (ANC) for the most recent birth; 18%
of women had a post-natal check-up (PNC) within 42 days of delivery. With 90%
of the deliveries taking place at home only 13% of home deliveries were assisted
by skilled birth attendants. Although 25% of pregnancies during the past 5 years
had complication during delivery only 29% of them sought care from a medically
trained provider. The utilization of safe delivery services has been most inequitable
among all the healthcare services – for example, use of skill birth attendant
for delivery among the women from the lowest asset quintiles is a third of those
from the highest quintile (NIPORT, 2002). The scenario is similar for PNC, facility
based delivery and use of cesarean sections. Specially designed programs on
safe delivery services in the country had limited success in reducing the inequities
in their utilization (Anwar et. al. 2008). Thus, increasing overall utilization
of the safe delivery services in the country is a challenge in general and among
the poor in particular.
Chakaria Community Health Project of ICDDR,B facilitated a process where village-based
indigenous self-help organizations took initiative to improve health of the
villagers through health promotional activities and establishment of village
health posts. As a part of the activities 13 women from the villages were trained
as community paramedics who were later trained as skilled birth attendants.
They carried out their activities through home visits and from the village health
posts under the supervision of two project physicians. A brief description of
the service package is provided later in this paper. Details of the approaches
along with lessons learned have been presented elsewhere (Bhuiya / Ribaux /
Eppler 2001). The women selected from the community through a competitive process
were trained as community paramedics and midwives (Skilled birth Attendants
or SBAs) from Ganasystha Kendra, a national health NGO. The course was residential
and lasted three months. The SBAs were trained on the job by project physicians
continuously from 1999. They were trained to provide ANC, PNC, carry out basic
lab tests, and to provide assistance during delivery (home delivery for normal
cases and referral services in case of emergency). The services were provided
for a nominal fee as decided by the village health post committees. The poor
households, certified by the village health post committee, received free services.
The SBAs received salary from the project. An evaluation of the 10 year project
activities during 2005 showed that the utilization of the SBAs had increased
since 1999 but the level of utilization by the poor remained low compared to
the better off. An enquiry of the reasons for low utilization rate by the poor
revealed that the direct and indirect cost of services is a major barrier to
the utilization of safe motherhood services from poor households. The situation
required a search for a new strategy to enhance utilization of the services
among the poor.
An innovative approach to reaching the poor
In January 2006, a new relationship was established with the 11 SBAs still
working with the project to address the persistent inequity in the use of safe
motherhood services. Under the new relationship the SBAs were no longer salaried
staff but were paid for providing safe motherhood service to the women from
the lowest two asset quintiles (indicating their status of poverty). There were
several steps to the process as described below.
At first voucher eligible women were identified. Each SBA had an assigned catchment
area of approximately 2000 households. During their quarterly visits in the
catchment area they identified pregnancy as reported by the women. Some pregnant
women were also listed when they came for checkups at the village health posts
(static community managed health facility). For all the pregnant women, the
SBAs collected necessary information to identify and locate them. The SBAs submit
the list to the project officers every month. The project statistician carries
out principal component analysis to obtain weights for each of the assets which
in turn were used to calculate asset scores for all the households. The households
are then distributed in five equal categories based on their asset scores and
a list of households belonging to the lowest two asset quintiles is prepared.
These asset based procedures are quite commonly used now-a-days in studying
socioeconomic inequities in health and health care utilization (Filmer / Prichett
2001).
Second, the list of eligible women was verified and voucher distributed. Project
officers visit the listed households to verify the list supplied by the SBAs
and to deliver the vouchers to the pregnant women within a week of receiving
the list. The women are advised to avail safe motherhood services from the SBA
responsible for the area in exchange of the vouchers.
Third, Safe delivery service was provided. ANC service is provided by the SBAs
six days a week at the village health posts. PNC is a domiciliary service. An
ICDDR,B physician also attends the village health posts one day in a week. Some
times SBAs also provide ANC and PNC services from their own home-based chambers.
SBAs assist delivery at the women’s home and in case of complications during
ANC, PNC or delivery, refer the client to Government secondary or tertiary healthcare
facility, NGO hospitals and private clinic. For each of the services provided
to the poor women, SBAs collect vouchers. At the end of each month they submit
the vouchers to the project office for reimbursement.
Fourth, the claims were verified for reimbursement. The project officers visit
all the women for whom the SBAs claim reimbursement for the services they provided.
This verification is made before the payment is made to check whether the services
were really provided. Once verified, payment is made during the first week of
the month for the claims made during the preceding month. The payment is made
through bank transfer to SBAs bank account.
Did the vouchers enhance service utilization by the poor?
Data on the utilization of the services of the SBAs came from the Chakaria
Health and Demographic Surveillance System (HDSS) maintained by ICDDR,B. HDSS
is a sample based quarterly data collection system covering nearly 7,000 households.
During the visit information on source of ANC, PNC, and delivery assistance
are collected for women who are pregnant and who delivered during the three
months preceding the visit. The catchment area of the SBAs was the intervention
area. The utilization of services provided by the SBAs was calculated for pre
and post of voucher time periods. Information about voucher utilization was
collected from the project office.
When we segregated the utilization of safe motherhood services by providers
it was easy to see that the project SBAs have made important contribution to
the rise of the use of ANC, PNC and delivery services among the mothers from
poor households.
Although there is a rise in the use of safe motherhood services we were interested
to see whether women who were given vouchers actually use them. From the program
data we found that the vouchers for assistance during delivery and PNC within
24 hours of delivery were the least used and the vouchers for ANCs were the
most used. However, it is important to note that for each of the services there
were still many women who did not use the vouchers.
Qualitative interviews with mothers who received vouchers but did not use them
showed that there is a lack of knowledge about the benefits of using the SBAs.
Mothers and other decision makers often did not feel any need to consult the
SBAs, felt confident about using the existing TBAs and sometimes even expressed
fear that availing the services of the SBAs can lead to cesarean section. In
addition, mothers also mentioned accessibility of the SBAs, distance and cost
as important factors for non-participation.
In any program involving cash incentives for the service providers it is important
to find out how many of the claims made by the providers are genuine. We compared
the number of claims made by the SBA with the actual disbursement of the claims
and found that almost 20% of the claims were invalidated after verification.
The highest proportion of invalid claims was for delivery assistance (more expensive
service) while the lowest proportion of invalid claims was made for tear-repair.
What did we learn from this experience?
The experience of performance based payment scheme described in this article
has implications for future DSF schemes. Before discussing the implications
however, some unique features of the present scheme need to be elaborated. In
this scheme former ICDDR,B staff were the designated service providers. This
decision simplified the program process in several ways.
First, as ICDDR,B trained these SBAs – we knew their skill levels. In reality
if a program wishes to serve maximum number of mothers they need to engage service
providers from both public and private sector. Some kind of accreditation mechanisms
will have to be defined and put in place for choosing providers who have the
skills to provide adequate services.
Second, in the present scheme, the salary of the SBAs were converted to vouchers
and left in the hands of the women from poor households. If the SBAs have to
earn money from the project they had to serve the poor. Thus, it was not a voluntary
incentive mechanism to top up salary rather it was the only way to guarantee
a fixed income in this remote rural area. In real life a program will need to
decide whether the private sector providers and public sectors will be paid
equally. In many public sector setups the providers are salaried staff and providing
safe delivery services is part of their job description. In such a situation
one will need to decide whether the public sector providers will receive additional
payment in exchange of the vouchers for services they are supposed to provide
as a salaried staff. If they are to be paid what is the amount of payment? The
mechanism of such payment can be a major challenge for bureaucracies that involve
various ministries.
Third, monitoring of the claims made by the providers for their genuineness
is an important challenge. Under the present scheme, the monitoring was done
by project staff that had no incentive to collect information that supported
the SBAs. In reality, if the verification of the claims were done through a
member of the scheme, appropriate checks and balances need to be institutionalized
to reduce/avoid misuse. Another option would be to involve local government
in monitoring of the activities.
Fourth, identifying the program beneficiaries is another challenge. The scheme
described had the opportunity to access data from HDSS which will not be available
in other places. However, it may be possible to involve the local government
authorities in identifying poor.
In conclusion we can say that performance based payment has the potential to
increase service utilization among the poor. However, there are many practical
issues that need to be sorted out and mechanisms for tackling them need to be
thought through to maximize the benefit for the poor.
*Mohammed Iqbal is a medical doctor who works at ICDDR,B as Public Health
Physician. He is involved with several research initiatives looking at the impact
of training village doctors on reduction of harmful practices and reaching the
poor with safe delivery services through community based skilled birth attendants.
Contact: miqbal@icddrb.org
*Sabrina Rasheed is a nutritionist who works at ICDDR,B as Assistant Scientist.
She is involved with research projects that look the impact of health interventions
on the lives of rural and urban populations.
*Abbas Bhuiya is a Social Scientist working in ICDDR,B. He heads the Social
and Behavioural Sciences Unit and the Poverty and Health Programme and works
in several projects linked to equity, poverty, and health and community empowerment.
Acknowledgement: This research activity was funded by Department
for International Development, UK (DFID), grant number 2007-047 and by Government
of Bangladesh through IHP-HNPRP. ICDDR,B acknowledges with gratitude the commitment
of DFID and Government of Bangladesh to the Centre's research efforts. The authors
would also like to gratefully acknowledge the contributions of the participating
Skilled Birth Attendants, the women in the community, and the staff of the Chakaria
project.
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