Impacts of Demand Side financing Instruments on the Continuum of Care for Maternal and Child Health in India and Bangladesh

Having one of the highest global rates of premature deaths and poor health among pregnant women and their newborn, India and Bangladesh remain as key nations to reduce global rates of unfavourable health outcomes among women and children. Key to reducing these rates is to encourage improved coverage of health care services. Among the number of strategies used by policy-makers in both these countries - drawing on international experiences - are interventions that aim to influence women and children - particularly those from poorer households or other socially vulnerable communities - to use key health services by providing them with direct or indirect financial incentives. In this project, we aim to investigate to what extent these incentives, either involving directly paying cash amounts or providing free services in private health facilities, are successful in improving some of the most important indicators related to improved health care services directed at pregnant women and young children. In addition, we will study the barriers impeding improved access to health services, including factors such as availability of and accessibility to health facilities; we will also consider quality of care in the health services as a potentially strong determinant of whether people choose to use the health services that are offered. The results will help us to determine how these different barriers can be reduced so that the optimum potential of these financial incentives could be attained in these two countries. Ultimately, the data gathered will allow us to identify what likely modifications in the design of these financial incentive are required, in conjunction with supportive, positive improvements in quality of care, in order to attain improved health goals for women and children.

The project builds on the collective, multidisciplinary expertise of experienced researchers brought together by a rich collaboration of Universities and research Institutes from the UK, India and Bangladesh. The research we propose involves extensive use of available household survey data and fresh data collected through primary surveys in three Indian states (Bihar, Gujarat and Karnataka) and two divisions in Bangladesh. The surveys will cover the three most important schemes regarding financial incentives in the two countries - the Janani Suraksha Yojana (Maternity Security Scheme) and Chiranjeevi (or the Long-Life Scheme) schemes in India and the Maternal Health Voucher Scheme (MHVS) in Bangladesh. Key decision-makers in the Health Ministries in both the countries have shown a great interest in the proposed project, and intend to use the evidence generated to strengthen or review the existing interventions. By using robust, scientific approaches combined with micro-level insights from the target population, the project results will be of crucial influence in the decision-making toolkit for the health policy-makers in both India and Bangladesh.

This research project aims to generate robust empirical evidence leading to the design of a new model financing mechanism that can effectively incentivise behaviours that improve health outcomes for women and children. Using India and Bangladesh as the research setting, we examine the interplay of factors related to demand for health services, socioeconomic attributes, quality of services being offered and the overarching health system characteristics that operates in a dynamic framework to determine how major demand-side financing (DSF) instruments are successful in influencing desired outcomes. We extend the research scope by aligning the objectives with recent global priorities in improving maternal and child health, which places emphasis on a wider continuum of Reproductive, Maternal, Neonatal and Child Health outcomes, as measured through key health service coverage indicators. The research approach involves extensive use of available household survey data and fresh data collected through primary surveys in three Indian states and two divisions in Bangladesh. Among them, the surveys will cover the three most important schemes regarding financial incentives in the two countries - the Janani Suraksha Yojana (Maternity Security Scheme) and Chiranjeevi (or the Long-Life Scheme) schemes in India and the Maternal Health Voucher Scheme (MHVS) in Bangladesh. Several innovative tools such as a comprehensive module to assess quality of care combining both clinical and users' perspectives, facility surveys, retrospective collection of event histories through surveying a cohort of women that automatically controls for variations in programme implementation over a staggered period enriches the empirical methods and strengthens the potential adaptability of the results.

The potential beneficiaries of this research are (1) Central and State/Provincial Governments in India and Bangladesh (2) International donor organisations (3) the public (4) the Academic community

1. Central and State/Divisional/local Governments:
Ministry of Health and Family Welfare, Government of India
Ministry of Health and Family Welfare, Government of Bangladesh
Ministry of Ministry of Finance, Government of Bangladesh
Ministry of planning of Finance, Government of Bangladesh
State/divisional Health and Family Welfare Department
Local governments in both India and Bangladesh
National (rural) health mission, Government of India
Department of Health Research, Government of India

This research will benefit national governments as demand side financing (DSF) interventions are mainly supported by national programmes. This research will help national and state/provincial governments to choose best DSF for effective coverage of maternal and child health services. This will not only save resources but also improve maternal and child health of the poor.

2. International donor/partner organisations
DFID, UNFPA, UNICEF, WHO, World Bank, Wellcome Trust, Bill & Melinda Gates Foundation
Many national health programmes, including maternal and child health programmes, in low and middle income countries are supported by international donor organisations. This research will help international partner/donor organisations in two ways: (1) to support further research in this area in other low and middle income settings- supporting research (2) to support DSF instruments that provide best maternal and child health service uptake.

3. The Public and civil society organisations
Women and children, the poor and tax payers
The public, particularly women and children will derive direct benefits from this research. This research will help governments and non-government providers to achieve better coverage of services for women and children in rural areas, particularly the poor. The long term impact of this study on population health in poor settings is significant for addressing poverty and vulnerability in the longer term.

4. National and international academic community
National and international researchers
Health financing researchers
Maternal and child health researchers

This research will generate new evidence about the impact of various forms of DSF interventions on maternal and child health. This can influence academics to undertake research on similar topic areas in other settings. As data from this study will be available for academic use, we anticipate researchers using this data for further research.