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

Lead Research Organisation: University of Portsmouth
Department Name: Sch of Health Sciences and Social Work

Abstract

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.

Technical Summary

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.

Planned Impact

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.
 
Description First Advisory Committee Meeting
Geographic Reach Asia 
Policy Influence Type Participation in a advisory committee
 
Description Inter-governmental partnership
Geographic Reach Multiple continents/international 
Policy Influence Type Participation in a national consultation
Impact A policy declaration document was created at the meeting
 
Description Food fortification project 
Organisation University of Kinshasa
PI Contribution University of Kinshasa (UNIKIN) DR Congo.
Collaborator Contribution Participated in the disucssions and contributed to the proposal development.
Impact This collaboration resuted in a full grant application to MRC.
Start Year 2017
 
Description Hanoi Medical University 
Organisation Hanoi Medical University
PI Contribution We had one workshop with the Hanoi team. We are working on a collaborative research grant application to MRC..
Collaborator Contribution They are providing faculty time to write grant applications and research papers
Impact We hope to submit the grant application in April 2019.
Start Year 2018
 
Description Mahidol 
Organisation Mahidol University
Country Thailand 
Sector Academic/University 
PI Contribution In participating grant application that was submitted to the NIHR Global Health Unit
Collaborator Contribution Expert advice and local partnership
Impact - Joint grant application, multidisciplinary
Start Year 2017
 
Description Partners in Population and Development 
Organisation Population and Development Centre
Country France 
Sector Charity/Non Profit 
PI Contribution I have presented a paper at the 13th inter-ministerial meeting of the Partners in Population and Development (PPD) in Dakar during 28-29 November, 2016.
Collaborator Contribution Partners from Bangladesh are part of this collaboration. They are part of the research grant application that involved PPD partner countries which include Bangladesh.
Impact As a result of this collaboration the University of Portsmouth signed a memorandum of co-operation with the Partners in Population and Development. This means the the University of Portsmouth has access to the 26 countries that are part of the PPD partner countries from the global South.
Start Year 2016
 
Description University of Gajah Mada, Indonesia 
Organisation Gadjah Mada University
Country Indonesia 
Sector Academic/University 
PI Contribution We jointly applied 3 grant applications to the UK Research Councils. In the process our collaborating team gained experience of writing high quality grant applications.
Collaborator Contribution They provided us with local knowledge that was necessary for the grant application. They also provided us with skills and knowledge on various substantive issues that helped us to write grant applications more effectively.
Impact The outputs were mainly grant applications.
Start Year 2016
 
Description 9th European Congress on Tropical Medicine and International Health, Basel, Switzerland 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The title of the presentation was: Financing healthcare through micro health insurance in Bangladesh.
Year(s) Of Engagement Activity 2015
 
Description Discussion with superintendent, kurigram sadar hospital regarding MHVS, Bangladesh 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact The kurigram hospital runs MHVS and we discussed about their experience with MHVS.
Year(s) Of Engagement Activity 2017
 
Description Dissemination seminar on health financing projects 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Dr. Shehrin presented findings from one of her projects on health financing. Had informal discussion about Maternal Health Voucher Scheme (MHVS) with policy makers from the ministry of health and family welfare, Government of Bangladesh.
Year(s) Of Engagement Activity 2018
 
Description Dissemination seminar on the studies on service coverage and quality aspects of Universal Health Coverage 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact The seminar was attended by policy makers from the ministry of health and family welfare, academia, and other stakeholders. Dr. Shehrin engaged in informal discussion with the stakeholders regarding the MRC study on demand side financing in Bangladesh
Year(s) Of Engagement Activity 2018
 
Description Engagement with policy makers at Partners in Population and Development, Dakar 2017 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Both ministers and academic community from 26 partner countries from the global south participated.
Year(s) Of Engagement Activity 2016
 
Description International workshop at Malang, Indonesia 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact International workshop on identifying priority areas for population and health research in the South East Asia Region
Year(s) Of Engagement Activity 2017
URL http://globalhealth.port.ac.uk/
 
Description Meeting with DPM, MHVS 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact Informed preliminary findings of the MRC study. Discussed potential for initiating an urban voucher scheme with support from EU. Requested assistance in getting letter of support from Deputy General Health Services (DGHS).
Year(s) Of Engagement Activity 2017
 
Description Meeting with Director, MHVS, Government of Bangladesh 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact Informed preliminary findings of the MRC study. Discussed potential for initiating an urban voucher scheme with support from EU. Requested for a letter of support from DGHS
Year(s) Of Engagement Activity 2017
 
Description Meeting with the Executive Director of the Partners in Population and Development, Dhaka, Bangladesh 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact This was a meeting to discuss the project progress and how the Partners in Population and Development (an inter-governmental organisation) can we used to engage with heads of states of countries from the South.
Year(s) Of Engagement Activity 2016
 
Description Population Association of America, Chicago 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Dr Pallikadavath will be presenting (oral) a paper "The effect of demand side financing programme on the continuum of maternal and child health care in India, at the Population Association of America annual conference in Chicago during April 27-29 at Chicago, USA>
Year(s) Of Engagement Activity 2017
URL http://www.populationassociation.org/
 
Description Prince Mahidol Award Conference 2016, Bangkok, Thailand 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Research for Achieving Universal Health Coverage: An Account of ICDDR,B Strategies
Year(s) Of Engagement Activity 2016
 
Description Project annual visit to Chakaria by government representatives 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Stakeholders from the Ministry of Health and Family Welfare, Ministry of Planning, Ministry of Public Administration joined a trip to explore activities of a government funded health financing project ongoing in Chakaria, a field site of icddr,b in Cox's Bazar district. Dr. Shehrin attended the trip and engaged in various discussion regarding work on health financing as well as on demand side financing scheme of the government
Year(s) Of Engagement Activity 2017
 
Description Second meeting of the Advisory Committee 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Other audiences
Results and Impact Shared highlights from preliminary findings from the first round survey. The chair of the committee, the secretary of health , Ministry of Health and Family Welfare sought suggestions for improving services of MHVS. The Bangladesh team provided a few specific suggestions which were supported by the committee.
Year(s) Of Engagement Activity 2017
 
Description Writing workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Writing workshop was held in Bangladesh with members of MRC study team from icddr,b, University of Portsmouth and Malawi College of Medicine
Year(s) Of Engagement Activity 2017