Using Demand-Side Incentives in Chiapas to Improve Maternal and Neonatal Health

Session: Demand-Side Financing

Presenter: Ignez Tristao, Inter-American Development Bank
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Background: The poorest women in hard-to-reach areas in Chiapas, Mexico have substantial difficulties accessing quality maternal and neonatal health care services. Studies in the region have shown that transportation is one of the main barriers to access services due to its cost. Providing pregnant women transportation vouchers (TTV) to deliver in a safe environment could increase the demand for health services and save many lives.

Methodology: The TTV is being implemented by the state Health Ministry, taking advantage of their existing health delivery platforms, create demand for institutional births, combined with service delivery interventions financed by the Salud Mesoamerica-2015 Initiative. A randomized controlled trial of TTV was implemented as a proof-of-concept in 23 participating primary care regions serving hard-to-reach women. The trial involved three arms, where two different delivery mechanisms where tested for TTVs; voucher was either given directly to the pregnant women during prenatal care, or to a midwife for each pregnant woman under their care along with a small monetary incentive for every institutional birth. The third arm served as a control.

Results: After a year of implementation both treatment arms have shown promising evidence of a sizable effect on institutional deliveries; TTV for pregnant women showed a 25 percentage point (PP) increase, while TTV for midwives showed a 15 PP increase, even when at most half of eligible women received a voucher. Qualitative evidence has revealed the most salient barriers to maternal health care are: lack of access and availability of transportation, language, perceived low quality of obstetric care at facility level and cultural practices.

Conclusion: TTVs may provide a cost-effective intervention to scale-up institutional services for women in hard-to-reach areas, especially where cost of transportation is a key barrier. Results will contribute to technical and fiscal policy-decisions in Chiapas.

The Equity Impact of Targeting the Poorest in Performance Based Financing: A Qualitative Study

Session: Demand-Side Financing

Presenter: F.W.G.M. van de Looij, Cordaid
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Performance-based Financing (PBF) is a promising approach to improve maternal, new-born and child health services in developing countries, but there are concerns that it may inadequately address inequalities in access to care. Incentives for reaching the poor may prove beneficial, but evidence remains limited.  We evaluated a system of targeting the poorest of society (“indigents”) in a PBF program in Cameroon, examining (under)coverage, leakage, and positive and negative (side) effects as experienced by the community. We conducted a documentation review, 59 key informant interviews, and 33 focus group discussions with community members (poor and vulnerable people – registered as indigents and those not registered as such).  We found that the criteria used to target indigents were consistent with local definitions of poverty and vulnerability. Leakage was not a concern. Nevertheless, the targeting system only reached a tiny proportion (≤1%) of the catchment population, and other poor and vulnerable people were missed. Low initial objectives and implementation problems –including a focus on easily identifiable groups (elderly, orphans), lack of clarity about the criteria, lack of transport for identification, and insufficient motivation of community health workers– are likely to explain the low coverage.  Registered indigents experienced improvements in access, quality and promptness of care. Improvements in economic status and less financial worries were also reported. However, problems including lack of transport and insufficient knowledge about the targeting benefits, remain barriers for health care use. The main negative effects of the system as experienced by indigents were negative reactions (e.g. jealousy) of community members.  In conclusion, a system of targeting the poorest of society in PBF programs may help reduce inequalities in health care use, but design and implementation problems can lead to substantial under-coverage. Furthermore, remaining barriers to health care use (e.g. transport) and negative reactions towards indigents due to their status deserve attention.

Is Cashless Delivery Boon or Bane? An Analysis of RMNCH Services in Odisha, India

Session: Demand-Side Financing

Presenter: Meena Som, UNICEF
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Background: In the recent years, Government of India under the umbrella of National Health Mission (NHM) has introduced a number of schemes like JSY (Janani Surakshya Yojana) and JSSK (Janani Sishu Surakshya Karyakram) to improve maternal and child survival and promote cashless institutional delivery. Government of Odisha has also introduced MAMATA the direct cash benefit scheme. Despite constant efforts by the government for improving maternal health care services, families are still spending significant amount for delivery services at the facilities. This paper assesses the level of Out-of Pocket Expenditure (OOPE) incurred during delivery and the extent to which JSY, JSSK and MAMTA, incentives could share the financial burden.

Methodology:  The study was carried out in among 1194 women, who delivered children in the last 2 years. Descriptive statistics and a two part model are used to address above objectives. The two-part model is an analytical model in which the first step is modelling the probability of a household incurring expenditure on delivery using the logit model. In the second step, Ordinary Least Squares (OLS) regression was carried out for those who had incurred any expenditure on delivery.

Results:  The mean expenditure on normal and C-section delivery are Rs 1822/- (USD 30) and Rs. 8350/- (USD 139) respectively. Results also suggest that there is a significant difference in the level of expenditure by selected socio-economic characteristics. Though the mission of JSY and JSSK is to make delivery cashless, about 75% respondents under C-section delivery reported that, they were asked money during delivery.

Conclusion:  It is vital to promote the free and cashless delivery schemes like JSSK more effectively. Orientation to the frontline workers about the new schemes and improving awareness can make the mission possible.

Improving Maternal Health Outcomes in Uganda: Cost-Effectiveness of Reproductive Health Vouchers and Community-Based Health Insurance

Session: Demand-Side Financing

Presenter: Uzaib Saya, Management Sciences for Health
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Financial barriers to health such as the introduction of user fees at the point of care result in decreased utilization of curative services of as much as 55%.  This USAID-supported study examined the cost-effectiveness of two financing strategies in Uganda that remove barriers in health care-seeking for women of reproductive age (WRA) through the use of economic subsidies.  Data on utilization and costs for reproductive health vouchers (RHVs) and community-based health insurance (CBHI) programs were collected via field observations from site visits in Western Uganda, desk reviews, and structured interviews with key informants. Costs of CBHI were gathered from costs of normal delivery, and enrollment in CBHI. Costs of deliveries reimbursed through RHVs were obtained from secondary data of the schemes managed by Marie Stopes Uganda. The impact of both strategies was calculated through the equivalent increase in facility-based deliveries that would lead to disability-adjusted life years (DALYs) averted.  The costs of facility deliveries ranged from USD $17.62-$18.79.  Almost 1356 DALYs were averted due to the increased number of health facility births from voucher use.   The incremental cost-effectiveness ratio (ICER) for the voucher program was USD $302/DALY averted.  The costs of subsidizing CBHI for one year for a pregnant woman was USD $59.26 including the costs of the package and delivery. CBHI coverage of maternity and malaria services corresponded to 19.9 DALYs gained. The ICER for the CBHI program was USD $298/DALY averted.   Both vouchers and CBHI schemes are highly cost-effective since they are less than Uganda’s per capita GNP of USD $510 per capita.  Policymakers can look to improve upon the goals of an equitable health system by employing voucher schemes that ensure adequate targeting of WRA, and through CBHI schemes that focus on household enrollment using a sliding-scale premium structure and further goals of universal health coverage (UHC).

Impacts of Conditional Cash Transfers and Free Provision of Maternal Health: Nepal’s Safe Delivery Incentive Program

Session: Demand-Side Financing

Presenter: Elina Pradhan, Harvard T.H. Chan School of Public Health

In improving maternal health outcomes and utilization of maternal health services, different programs have been implemented to address the demand-side as well as the supply-side of maternal health care. In this study, we examine the differential impact of two programs–a conditional cash transfer (CCT) program and a program combining CCT and user-fee exemption for skilled birth attendance in Nepal. Employing a difference-in-difference model, we find that although skilled birth attendance increases significantly during the intervention period, the increases in skilled birth attendance in the combined intervention group was not significantly higher than in the CCT-only program. The added incentive of the user-fee exemption did not significantly increase skilled birth attendance. However, conditional on areas with adequate road networks, the combined intervention led to higher skilled birth attendance compared to the CCT-only program.

Efforts to Promote Equitable Financing Mechanisms in Support Of Maternal Health Programs by Removing Financial Barriers, Especially Direct Payments in Kano, Northern Nigeria

Session: Demand-Side Financing

Presenter: Yusuf Mohammed, College of Health Sciences, Bayero University
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Background: There is now broad consensus that health user fees ‘punish the poor and prevent people from accessing life-saving treatment. According to WHO, user fees are ‘the most inequitable method for financing health-care services. In recent years, governments of several low-income countries have taken decisive action by removing fully or partially user fees in the health sector. The analysis shows that African leaders are willing to take strong action to remove financial barriers met by vulnerable groups, especially pregnant women and children. Free “Maternal Health Care” has received particular attention from governments. In Kano State, it was estimated that the state maternal mortality ratio (MMR) was 1600 deaths/1000, 000 live births, three times the national (Nigerian) average and up to 56% of women reported that getting money for treatment was a serious problem in accessing health care.

Methodology: Introduction of free maternal and child health services in 2011 that includes antenatal care with drugs, government hospitals delivery and other post-delivery care and management. Available records were obtained from 3 pilots’ hospitals selected during the fee exemption phase (2011-2013), and during an equivalent duration of time prior to the fee exemption phase (2008-2010).

Results: In the 3 hospitals combined 2535 deliveries took place, 831 (32.8%) before fee exemption while 1,704 (67.2%) took place within the same period after fee exemption and intervention of free Maternal and Child Health, MCH policy implementation.

Conclusions: This study found that there was a significant increase in the likelihood of delivering in a health facility after the implementation of the fee exemption policy. The Kano State free MCH with fee exemption policy particularly assisted some groups of the population who were likely to have the biggest financial barriers in delivering in health facilities, this may have resulted in reduced maternal mortality and morbidity.


Improving Maternal and Newborn Health through Participatory Learning and Action Facilitated through Accredited Social Health Activists in Eastern India: A Cluster Randomized Controlled Trial

Session: Women’s Groups Working Together to Save Newborn Lives and Improve Maternal and Child Health and Nutrition

Presenter: Shibanand Rath, Ekjut
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Background: A quarter of the world’s neonatal deaths and 17% of maternal deaths occur in India. Few community-based interventions to improve maternal and newborn health have been tested through the community health workers supported by India’s National Rural Health Mission (NRHM).

Methods: We did a cluster-randomized controlled trial of a community intervention to improve maternal and newborn heath in 30 geographic clusters in five rural districts of Jharkhand and Odisha, eastern India, covering a population of 156,518. Government approved Accredited Social Health Activists (ASHAs) supported women’s group through a participatory learning and action cycle. The groups discussed and prioritized maternal and newborn health problems, prioritized and implemented feasible strategies to address them, then evaluated their progress. The trial’s primary outcome was neonatal mortality. Secondary outcomes included preventive and care-seeking practices. Fifteen clusters were allocated to the intervention group and another fifteen to control. In each cluster, around 10 ASHAs performed their government-mandated activities and facilitated women’s group meetings. In control areas, ASHAs only performed their usual activities. Study participants were women (15-49) who gave birth between 1st September 2009 and 31st December 2012 in the 30 clusters. We identified births, stillbirths, and neonatal deaths, and interviewed mothers six weeks after delivery.

Results: Analysis of 7219 births over two years showed a 31% reduction of neonatal mortality in intervention areas compared to control areas (Odds Ratio: 0.69, 95% CI: 0.53-0.89). The decline was greater (46%) when adjusted for baseline differences in mortality (aOdds Ratio: 0.54, 95% CI: 0.37-0.81). There were increases in the proportion of infants wrapped and placed on their mother’s skin within one hour of birth, and non-significant improvements in birth preparedness and health facility births.

Conclusion: Women’s group meetings facilitated by ASHAs reduced neonatal mortality. Scaling up this strategy may be feasible in rural underserved areas of India.

Improving the Health of Pregnant Women and Children in Ntcheu District, Malawi

Session: Women’s Groups Working Together to Save Newborn Lives and Improve Maternal and Child Health and Nutrition

Presenter: Mikey Rosato, Women and Children First UK
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Background: Maternal mortality rates in Malawi remain high at 510 per 100,000 live births and 675 per 100,000 in the central region. Our project aimed to improve maternal and child health and reduce mortality by mobilising and empowering communities through participatory learning and action in women’s groups, male involvement, IEC activities and engaging village chiefs; and by training and mentoring healthcare staff. The project was implemented between 2010 and 2015 by the Ministry of Health Malawi’s Perinatal Care Project supported by Women and Children First (UK). Beneficiaries were 22,645 women of reproductive age in 144 villages and 244 health workers.

Methodology: A 400-household survey in 20 villages was selected randomly from a sampling frame of 118. A health facility (HF) assessment of the availability and quality of care used an existing tool and we led 20 key informant interviews and focus group discussions with 113 men and women. Purposive and snowball sampling identified men and women from 10% of the beneficiary villages for KIIs and FGDs. Data analysis used SPSS version 22; SAS JMP Genomics software 7.0, 2013; and transcripts and field notes were analysed through NVIVO 10. Primary research information was triangulated with the MICS 2014, DHS, 2010 HMIS, project surveys, reports and monitoring data.

Results: Demand for services and women’s satisfaction with care increased but quality of care in HFs was often compromised, mainly due to external factors. Key achievements: Intervention Baseline (2010) Endline (2014) Malawi Antenatal care, first trimester 9% 19% 12.4% (DHS, 2010) Institutional delivery 78% 94% 88.9%, (MICS, 2014) Skilled birth attendance 51% 93% 87.4% (MICS, 2014) Postnatal attendance within 7 days 49% 93% 81.3% within 2 days, (MICS, 2014)

Conclusion: Outreach activities and community mobilization contributed to the observed increases in accessing care with strong impact on skilled birth attendance and postnatal care.

The Equity Impact of Community Women’s Groups to Reduce Neonatal Mortality: A Meta-Analysis of Four Cluster Randomized Trials

Session: Women’s Groups Working Together to Save Newborn Lives and Improve Maternal and Child Health and Nutrition

Presenter: Kishwar Azad, Diabetic Association of Bangladesh Perinatal Care Project
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Background: Socio-economic health inequalities are substantial in most countries. Little is known about what works to remedy this. Trials in Asia and Africa have shown a strong impact of community women’s groups on neonatal mortality (NMR) when coverage is high, but their equity impact remains unknown. We describe and explain the equity impact of this intervention across socio-economic strata.

Methods: We conducted a secondary analysis of four randomised trials in Nepal, India, Bangladesh, and Malawi. We estimated intervention effects on NMR and health behaviours for lower and higher socio-economic strata using logistic regression analysis. Differences in effect between socio-economic strata were tested. A meta-analysis was done for all trials combined.

Results: The analysis included 69,119 live births and 2,505 neonatal deaths. The intervention strongly reduced NMR in lower (55-64% reduction depending on the measure of socio-economic position used) and higher (36-45%) socio-economic strata. The intervention was pro-poor and did not show evidence of ‘elite-capture’: among the most marginalized populations NMR in intervention areas was 64% lower than control areas, compared with 36% lower among the less marginalized in the last trial year. The intervention strongly improved home care practices, with no systematic differences in effect between socio-economic strata.

Conclusion: Community women’s groups improve the survival of all newborns, especially among disadvantaged groups but also among the better-off. Groups may reverse the inverse-care law and contribute to an equitable reduction in neonatal mortality across socio-economic strata.