Evaluation of Bangladesh's Maternal Health Voucher Program

Maternal mortality in Bangladesh remains high, and skilled providers attend only 18% of births. To improve access to maternal health services, Bangladesh began piloting a safe motherhood voucher program in 2006. Vouchers are distributed to pregnant women for free antenatal, delivery, and postpartum care; transportation and cash stipends are also provided. Health facilities and providers receive an incentive payment for each voucher patient treated. The purpose of this study was to evaluate the impact of the voucher program on maternal health care utilization, expenditures, and facility quality.

We conducted a household survey in 16 intervention and 16 matched control subdistricts. 2,208 recently delivered women were interviewed about birth history, sociodemographic characteristics, voucher receipt, and maternal care utilization and expenditures. Probit and linear regressions were used to analyze voucher program effects on skilled birth attendance, C-sections, and maternal health expenditures. Qualitative data were also collected.

Approximately 70% of women in pilot areas had received vouchers. Deliveries with qualified providers were 42 to 50 percentage points higher in intervention subdistricts (p<0.001) than in matched control districts, while delivery expenditures were significantly lower. There was no significant difference in C-section rates. Beneficiaries and providers reported long delays in receiving incentive payments. Stillbirth and neonatal mortality rates were lower in voucher facilities, but measures of facility quality were only marginally better in voucher facilities.

Bangladesh's voucher program has greatly increased access to safe motherhood services and reduced out-of-pocket expenditures in pilot areas. Quality and human resources limitations continue to present challenges for scale-up.