Maternal health commodity landscaping exercise: A snapshot of the Bangladesh program

Despite consistent efforts of the government and national stakeholders, every year in Bangladesh over 5,000 mothers and thousands of children die. Most of these deaths would be preventable with increased access to quality services including existing medicines and other health commodities. The United Nation’s Commission on Life-Saving Commodities for Women and Children suggests that an important cause of these deaths is lack of access and appropriate use of 13 life-saving commodities. This document describes an effort by the Population Council to assess the country’s policies, guidelines, and availability for these 13 life-saving commodities as well as engaging with key stakeholders to implement the UN Commission’s recommendations in conjunction with this assessment’s findings. This assessment validated the availability of the 13 commodities in three districts at district, subdistrict, and community levels, and within drug stores, in 15 government facilities and 27 private drug stores. Key stakeholders were consulted. A national workshop stimulated discussion, identified national priorities and information gaps, and identified areas requiring policy review. This stakeholder engagement helped identify opportunities for organizations’ contributions to implementing the recommendations

Innovative financing through pay-for-performance for providers to improve quality of care in Bangladesh: Transforming research into action

To improve access to and use of facility-based obstetric and newborn care, the Government of Bangladesh is implementing two innovative performance-based financing programs, namely demand-side financing (DSF) and pay-for-performance (P4P). With the purpose of identifying the lessons learned, limitations of the P4P and DSF models, and scopes for cross learning, a two-day workshop was organized in Dhaka. This workshop report, prepared by the Population Council, resulted in several recommendations to modify DSF and P4P schemes. In Bangladesh, the need for continuing performance-based financing programs to meet MDGs and other health indicators is beyond argument, but it is urgently required to decide in what capacity the performance-based financing program should continue. The government needs to prepare itself to continue performance-based incentive programs in pursuance of achieving the MDGs of reducing maternal and neonatal mortality

Innovative financing through pay-for-performance for providers to improve quality of care in Bangladesh: Transforming research into action

To improve access to, and use of, facility-based obstetric and newborn care services in rural areas, the Government of Bangladesh is implementing two innovative performance-based financing programs: demand-side financing (DSF) and pay-for-performance (P4P). Both programs have contributed to the increase in institutional deliveries, yet not enough women receive the recommended care during pregnancy and delivery. DSF and P4P are implemented in parallel and have their own merits and limitations. As described in this brief, a two-day workshop was organized in 2011 in Dhaka to identify the lessons learned and limitations of P4P and DSF models and scopes for cross-learning. Both DSF and P4P were found to have the same goal but differ in approaches and outcomes. The main difference is that P4P implements a “quality of care”-based incentive mechanism for maternal, newborn, and child health (MNCH) care, which has the potential to improve monitoring of health-service delivery in rural areas of Bangladesh. The workshop resulted in several recommendations for modifying DSF and P4P schemes

A P4P model for increased utilization of maternal, newborn and child health services in Bangladesh

In Bangladesh, maternal health programs are not yet reaching the desired level of facility-based obstetric care service. Most deliveries are conducted by untrained persons at home, demonstrating inequity in access to recommended maternal health care services and underutilization of existing obstetric and newborn care services. Suboptimal performance by providers is a key barrier to improving availability and quality of maternal, newborn, and child health (MNCH) services. To increase use of facility-based services, an operations research study of “pay-for-performance” (P4P) incentives for providers and subsidization of consumer costs was initiated in 2010. The study, part of the Government of Bangladesh–United Nations MNCH and maternal and newborn health projects, has been included as a human resource innovation project under the operational plan of the Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare, Government of Bangladesh. The Population Council provided technical assistance in implementing the study, with collaboration from James P. Grant School of Public Health of BRAC University. This policy brief describes the implementation of the P4P operations research study and its consequent implications for policymakers

Reducing unsafe menstrual regulation through medication in Bangladesh

The Population Council and Marie Stopes Bangladesh, in collaboration with the Directorate General of Family Planning and with funding from the World Health Organization, tested the feasibility of introducing menstrual regulation with medication (MRM) in Bangladesh and assessed the acceptability of providing MRM using the combination drug regimen mifepristone and misoprostol in urban and rural public health facilities. As reported in this policy brief, the study demonstrates that it is feasible and safe to introduce MRM in rural and urban public health facilities. Given the choice, almost two-thirds of women preferred MRM to manual vacuum aspiration and women receiving MRM reported being satisfied or very satisfied with their quality of care. The report recommends that the Ministry of Health and Family Welfare and its partners work together to train providers and to procure the medical commodities to introduce MRM as an option for menstrual regulation in health facilities nationwide

Workshop report: Introducing pay-for-performance (P4P) approach and increase utilization of maternal, newborn, and child health services in Bangladesh

In Bangladesh, improving skilled birth attendance at delivery and access to facility-based obstetric and newborn care are vital to improving maternal and neonatal health. The health system in Bangladesh faces a critical challenge on the supply side: unavailability of quality services at public health facilities, due to inadequately motivated providers, vacant positions, and provider absenteeism. As well, salaries of public-sector providers do not depend on quality of work or quantity of services provided. Paying an incentive to facilities based on a performance benchmark has the potential of increasing the quantity and quality of maternal, neonatal, and child health (MNCH) care. The Population Council proposes a pilot study that will test two innovative service delivery models to provide financial incentives to facilities to enhance performance, and subsidized coupons to poor clients to increase access and utilization of MNCH services. As part of the proposed pay-for-performance (P4P) project, policy workshops were organized to develop an implementable P4P Guideline and Coupon Guidelines. Findings from these workshops are detailed in this report

A pay-for-performance innovation integrating the quantity and quality of care in maternal, newborn and child health services in Bangladesh

The Population Council explored the possibilities of introducing a Pay-for-Performance (P4P) scheme in Bangladesh to improve maternal, newborn and child healthcare (MNCH) services. Based on the consultation and with guidance from the Government of Bangladesh, the Population Council and UNICEF provided technical assistance to the Directorate General of Health Services (DGHS) to test two P4P strategies for MNCH service providers to improve service volume and quality of care, and for poor clients to receive services subsidized through vouchers or coupons. The first strategy is a combination of pay-for-performance for providers and subsidized coupons for poor pregnant women, newborns, and under-five children, while the second strategy employs only the pay-for-performance incentives for the providers. Both strategies performed well relative to the comparison site, however strategy II with incentives for providers alone can be introduced at the low-performing but poorer regions; while the poorest areas with greater geographical draw back will benefit from a combination of a demand plus supply side P4P approach. The report acknowledges that monetary incentives alone are NOT enough to improve the MNCH services and that long-term solutions require putting a stronger system in place

Introducing medical MR in Bangladesh: MRM final report

The Population Council Bangladesh, in collaboration with the Directorate General of Family Planning and Marie Stopes Bangladesh, with funding from the World Health Organization and the DFID-supported STEP UP project, conducted an 18-month operations research study from January 2012 to June 2013. This operations research tested the feasibility of introducing menstrual regulation with medication (MRM) in Bangladesh and assessed accessibility of the combination regimen of mifepristone and misoprostol in urban and rural health facilities. Based on this study’s results, the feasibility of introducing MRM services in Bangladesh is clear, and women receiving MRM were satisfied with their overall quality of care. It is imperative that this service be incorporated into the national family planning program for the safety, health, and well-being of Bangladeshi women. The report details some considerations before introducing MRM services nationwide

Incentivizing providers to improve maternal, newborn and child health services in Bangladesh: Pay-for-performance model refinement and advocacy (P4P MRA) final report

An operations research project by the Directorate General of Health Services (DGHS) of the Ministry of Health and Family Welfare, Government of Bangladesh tested the feasibility of a pay-for-performance (P4P) approach, which offered financial incentives to reward service providers for meeting and exceeding specified performance targets for maternal, newborn, and child health services. In response to the encouraging findings, the DGHS implemented a follow-up project, with technical assistance from Population Council and UNICEF, to utilize the experiences and findings of the P4P OR project. Despite it short duration, implementation of the revised P4P scheme induced improvements in service volume and quality of care. These projects contributed toward increasing institutional delivery, requiring less incentive cost compared to that of the DSF program, and enhancing client satisfaction by reducing out-of-pocket expenses. Despite the brief implementation period, contribution of P4P interventions in rapidly raising the level of institutional deliveries creates optimism toward meeting the MDG of reducing maternal and infant mortality

Facility assessment report: Introducing pay-for-performance (P4P) approach to increase utilization of maternal, newborn, and child health services in Bangladesh

Under the leadership of the Directorate General of Health Services, the Population Council in collaboration with James P. Grant School of Public Health, BRAC University and with support from UNICEF is testing an innovative service delivery model to provide financial incentives to institutions to enhance their performance on maternal, newborn, and child health (MNCH) services in three districts of Bangladesh as part of GOB-UNICEF’s ongoing MNCH/MNH projects. A comparative analysis on the availability and condition of physical and human assets across 16 health facilities will inform what is needed in a facility in terms of inputs and processes. This report presents the key findings of the rapid assessment of 16 government health facilities conducted in the preparatory phase of the P4P project. A comprehensive assessment will be followed before incentive-related intervention activities can be initiated. This facilities assessment report indicates that no facilities are in perfect condition to provide quality MNCH services because all are burdened with problems related to human resource, physical infrastructure, equipment, logistics and supplies, and medicine. Before initiating the performance-based incentives, the lack in physical and human assets must be addressed