Evaluation of maternal & child health policies, programmes and services

Introduction. Maternal health care suffers from sub-optimal performance, client extortion and low quality of care in Bangladesh. Supply side barriers with a synergistic effect on demand side constraints make services inaccessible for poor women living in rural, remote areas.
Theoretical focus. Inspired by Pay-for-performance (P4P) that ties performance with financial incentives, the government implemented two P4P models- Strategy-I incentivized both providers and clients, and Strategy-II only the providers.
Methods. With a quasi-experimental design, interviews with 2,124 exit clients and 473 providers were conducted; monthly service statistics, quarterly quality assurance visit measurements, and auditor’s validation reports were collected for evaluation.
Findings. Institutional deliveries and quality of care score were increased significantly. Overall client satisfaction was highest in strategy-I for providing free medicines and not requiring extra payment. Cost per service unit was US$8. Although overall client satisfaction increased, staff behavior was not improved. Targets could not be set for complications services. Facilities not having minimal staff tend to fail.
Conclusions. The study tested a team based incentive mechanism. Design adjustments are to be made to make providers accountable for their behaviors.

In recent years, the role of the state in provision of public services is being reexamined around the world with many experiment in alternative service delivery structures. India is at the forefront of some of these innovative programs which include one of world’s largest conditional cash transfer programs – payment to women and community health workers for hospital delivery as well as health insurance program for the poor where government pays the premiums for use of government as well private health facilities. These investments should improve maternal health outcomes including use of prenatal care, hospital delivery and postnatal care.
However, these programs are set up in a context where public service delivery systems remain indifferent to patient welfare, private health systems are poorly monitored and gender norms and intra-household inequalities constrain women’s ability to seek health care. Thus, careful evaluation of these programs and their impact is necessary to understand their effectiveness and ability to reach the poorest.
Using unique nationally representative longitudinal survey of over 40,000 households conducted before and after , this paper examines the impact of India’s Janani Suraksha Yojana (JSY), a conditional cash transfer program for hospital delivery, for improving access to maternal care.

Using linked data from the 2009 COMPASS health facility and household surveys, this paper examines the association of the quality of maternal health services with their use in the past five years in five states of Nigeria. The results of multilevel logistic regression models revealed a strong positive association between the availability of essential delivery care equipment and supplies and the odds of initiating antenatal care in the first trimester of pregnancy. The odds of institutional delivery were significantly higher in Local Government Areas (LGAs) that scored higher on management practices that were supportive of quality maternal health services than in LGAs that scored lower, after controlling for other factors. More comprehensive provider training on maternal health had a significant negative association with skilled attendance at birth and institutional delivery. The findings suggest that efforts to increase the utilization of maternal health services should improve health facility management practices, ensure the availability of essential equipment and supplies, and conduct further research to better understand how provider training may influence service use.

In Cambodia, recent figures have shown impressive declines in the maternal mortality rate alongside commensurate increases in maternal healthcare use over the last decade (DHS 2010). In this paper, we examine the determinants of this rise in service use in Cambodia, particularly focusing on the role of social health protection schemes such as health equity funds in driving this change. Using baseline survey data from the evaluation of the Reproductive Health (RH) vouchers program being conducted by Population Council (N=2201), we use a binary response multilevel random effects model to examine both individual-level and community-level influences on facility-based deliveries and antenatal care use among women in three provinces in Cambodia. Preliminary results suggest that social health protection schemes as well as community-level influences are significant in determining the use of maternal healthcare services. Implications for policy development and healthcare financing programs including the targeted RH voucher program are discussed.