Pay-for-Performance and other mechanisms to achieve universal health care

This paper examined out-of-pocket expenses incurred by women for availing maternal health care services at public and private health facilities. This article used data from a baseline household survey evaluating the impact of demand side financing vouchers on utilization and service delivery for maternal health care. The survey was conducted in 2010 among 3300 women who gave birth within previous 12 months from starting date of data collection. Information on costs incurred to receive antenatal, delivery and postnatal care services were collected. Findings reveal that the majority of women reported paying out-of-pocket expenses for availing maternal health care services both at public and private facilities. On average, women paid US$3.6 out-of-pocket expenses for receiving antenatal care at public health facilities and US$12.4 at private health facilities. Similarly, women paid one and half times more for normal (US$42.3) and cesarean deliveries (US$136.2) at private health facilities compared to public health facilities. On the other hand, costs for postnatal care did not vary significantly between public and private health facilities. Utilization of maternal care services can be improved if out-of-pocket expenses can be minimized.

Maternal and child health programs are yet to achieve desired impact on the obstetric and newborn care services utilization from public-sector health facilities in Bangladesh. Home delivery and untrained providers largely contribute to the underutilization of the existing obstetric and newborn care services provided at facilities. Demand-side barriers particularly cost remains a key challenge to utilize MNCH care from facilities. This paper explore whether subsidized consumer cost increases utilization of obstetrics and newborn health service from facilities. Financial assistance in the form of coupon was provided to poor pregnant women to cover transportation and medical cost for receiving services from facilities. A rigorous process consisting of community assessment and use of poverty tool was employed to select eligible women. Three-fourths of the poor pregnant women were identified as eligible for coupon distribution from 20,833 pregnant women from 2 districts. Seventy nine percent coupons were utilized for receiving the ANC services followed by institutional delivery, PNC, and pregnancy complications care. The most cited reason for non-use of coupon is inadequate knowledge about the coupon and transportation cost. Round trip transportation costs and intensive advocacy at the community will increase the coupon use.

This paper examines the community-level effect of the maternal health voucher program on out-of-pocket spending on delivery services at private health facilities in Uganda. Household-level data were collected before (in 2008) and two years after the program started (in 2010-2011) among women aged 15-49 years who had a birth in the 12 months preceding the survey. A total of 1,569 women were interviewed in 2008 with 327 most recent births occurring at a private health facility; the corresponding figures for 2010-2011 were 666 women with 196 most recent births occurring at a private health facility. The effect of the program is determined by difference-in-differences estimation through simple comparison of changes in proportions as well as the estimation of a multilevel random-intercept logit model. The results show that there was a significantly greater decline in the proportion of women that paid for delivery services and in the likelihood of paying for the services at private facilities in exposed than in non-exposed villages. The findings indicate that the maternal health voucher program significantly contributed to reductions in the likelihood of paying out-of-pocket for delivery services at private health facilities in the regions where it is implemented.