Demand-side Financing Research Articles

교육바우처 정책 사상의 원류와 그 원리에 대한 소고

This study explores the ideological foundation of education vouchers, focusing on educational support programs for commoners during the French Revolution and the educational philosophies of Thomas Paine and John Stuart Mill. Thomas Paine emphasized the expansion of educational choice through government support and assistance for the poor, while John Stuart Mill advocated for educational improvement through free choice and competition. Their philosophies have become core ideas in the modern school choice movement and were institutionalized in the education voucher policy by Milton Friedman. This study analyzes the outcomes of education vouchers from the perspective of public choice theory and examines models such as the Tiebout hypothesis, Demand Side Financing, and Home and Community-Based Services (HCBS). Additionally, it explores the relationship between Hirschman's Exit-Voice-Loyalty model and the principle of voucher choice. In conclusion, this paper emphasizes how these concepts are related to choice and competition in public services. Furthermore, it highlights that the principles inherent in education vouchers serve as an important ideological foundation for democracy and economic development.

Transforming Lives Through Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (ABPMJAY): A Review

Background: The Pradhan Mantri Jan Arogya Yojana (PMJAY) program was created in line with the global goal of Universal Health Coverage (UHC), and aims to ensure everyone has access to quality healthcare services without suffering financial difficulties. In India, over 60% of healthcare spending is still borne by households, and a significant portion of the population lacks any form of health protection coverage. Discussion: The High-Level Expert Group (HLEG) recommended a shift from supply-side healthcare financing to demand-side financing, leading to the introduction of government-sponsored health insurance schemes. To achieve Universal Health Coverage (UHC), the Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched following the recommendations of the National Health Policy 2017. The PMJAY program is the world's largest publicly sponsored social health insurance program, delivering comprehensive healthcare services covering primary, secondary, and tertiary care levels. The scheme covers approximately 12 crore households, including more than 50 crore beneficiaries, offering healthcare coverage of up to Rs. 5 lakh per family annually. PMJAY operates nationwide in India, covering all states and union territories except for a few.. Conclusion: To move forward, PMJAY can play a transformative role in the healthcare landscape, integrate with primary healthcare, contribute to economic development, and expand its scope to include more healthcare services.

Implementation strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning, a mixed-methods systematic review

BackgroundDemand generation aims to increase clients’ desire to use family planning. The aim of this work was to systematically summarize strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning.MethodsWe searched electronic bibliographic databases from inception to October 2022. We included quantitative, qualitative, and mixed methods reports on demand generation strategies in family planning, regardless of country, language, publication status, or methodological limitations. We assessed abstracts, titles and full-text papers according to the inclusion criteria, extracted data, and assessed methodological quality of included reports. We used the convergent integrated approach and a deductive thematic synthesis to summarize demand generation themes and subthemes. We used the health system building blocks to synthesize the factors affecting implementation (barriers and facilitators). We used GRADE-CERQual to assess our confidence in the findings.ResultsForty-six studies (published 1990–2022) were included: forty-one quantitative, one qualitative, and four mixed methods). Three were from one high-income country, and forty three from LMIC settings. Half of reports were judged to be of unclear risk of bias. There were unique yet interrelated strategies of scaling-up demand generation for family planning. Interpersonal communication strategies increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain. Mass media exposure increases knowledge and positive attitudes and may increase the intention to use modern contraceptive methods. Demand-side financing approaches probably increase awareness of contraceptives and the use of modern contraceptive methods among poor clients. Multifaceted Demand generation approaches probably improve adoption, coverage and sustainability of modern methods use. Factors that influence the success of implementing these strategies include users knowledge about family planning methods, the availability of modern methods, and the accessibility to services.ConclusionsDemand generation strategies may function independently or supplement each other. The myriad of techniques of the different demand generation strategies, the complexities of family planning services, and human interactions defy simplistic conclusions on how a specific strategy or a bundle of strategies may succeed in increasing and sustaining family planning utilization.Trial RegistrationSystematic review registration: Center for Open Science, osf.io/286j5

The Flipped Break-Even: Re-Balancing Demand- and Supply-Side Financing of Health Centers in Cambodia.

Supply-side healthcare financing still dominates healthcare financing in many countries where the government provides line-item budgets for health facilities irrespective of the quantity or quality of services rendered. There is a risk that this approach will reduce the efficiency of services and the value of money for patients. This paper analyzes the situation of public health centers in Cambodia to determine the relevance of supply- and demand-side financing as well as lump sum and performance-based financing. Based on a sample of the provinces of Kampong Thom and Kampot in the year 2019, we determined the income and expenditure of each facility and computed the unit cost with comprehensive step-down costing. Furthermore, the National Quality Enhancement Monitoring Tool (NQEMT) provided us with a quality score for each facility. Finally, we calculated the efficiency as the quotient of quality and cost per service unit as well as correlations between the variables. The results show that the largest share of income was received from supply-side financing, i.e., the government supports the health centers with line-item budgets irrespective of the number of patients and the quality of care. This paper demonstrates that the efficiency of public health centers increases if the relevance of performance-based financing increases. Thus, the authors recommend increasing performance-based financing in Cambodia to improve value-based healthcare. There are several alternatives available to re-balance demand- and supply-side financing, and all of them must be thoroughly analyzed before they are implemented.

Impact of India's publicly financed health insurance scheme on public sector district hospitals: a health financing perspective

Districts hospitals in India play a pivotal role in delivering health care services in the public sector and are empanelled under India's national health insurance scheme i.e. Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PMJAY). In this paper, we evaluate the extent to which the PMJAY impacts the district hospitals from a financing perspective. We used cost data from India's nationally representative costing study-'Costing of Health Services in India' (CHSI) to determine the incremental cost of treating PMJAY patients, after adjusting for resources that are paid through supply-side government financing route. Second, we used data on number and claim value paid to public district and sub-district hospitals during 2019, to determine the additional revenue generated through PMJAY. The annual net financial gain per district hospital was estimated as the difference between payments under PMJAY, and the incremental cost of delivering the services. At current levels of utilisation, the district hospitals in India gain a net annual financial benefit of $ 26.1 (₹1839.3) million, which can potentially increase up to $ 41.8 (₹ 2942.9) million with an increase in the share of patient volume. For an average district hospital, we estimate net annual financial gain of $ 169,607 (₹ 11.9 million), increasing up to $ 271,372 (₹ 19.1 million) per hospital with increased utilisation. Demand-side financing mechanisms can be used to strengthen the public sector. Increasing utilisation of district hospitals, by either gatekeeping or improving availability of services will enhance financial gains for district hospitals and strengthen public sector. Department of Health Research, Ministry of Health & Family Welfare, Government of India.

Reducing the constraints to school access and progress: assessing the effects of a scholarship program in rural Malawi

PurposeThe study aims to provide insight on the potential effectiveness of demand-side financing for catalyzing improved educational outcomes in Malawi; and, given the extent of cost-related constraints to school contexts in other low-income countries, the results have relevance for education policy decisions more broadly.Design/methodology/approachThis study utilizes a non-equivalent groups research design to compare the educational experiences and outcomes of two student groups – those who did and those who did not receive a needs-based scholarship to attend secondary school and college in the Dowa, Kasungu, and Lilongwe Districts of Malawi. The authors assess impacts across a range of short and medium-term outcomes, including: school attendance, withdrawal, attainment, graduation, employment status, employment quality, and post-schooling income.FindingsThe scholarship substantially reduces the household cost of participation in school, and reduces the distance travelled to school. As a result, scholarship recipients attain between 1 and 1.5 years of additional schooling and graduate at higher rates. In terms of post-schooling outcomes, recipients are in higher wage-earning occupations after leaving school. Overall, results suggest that scholarships are an effective demand-side strategy for improving educational attainment, progression, and potentially longer-term labor market outcomes.Originality/valueThe study adds new evidence on policy approaches for expanding access to educational opportunities and increasing labor market outcomes in a context (Malawi specifically and sub-Saharan Africa more broadly) where evidence on such demand-side interventions is still growing.

Economic evaluation of a conditional cash transfer to retain women in the continuum of care during pregnancy, birth and the postnatal period in Kenya.

There is limited evidence on the cost and cost-effectiveness of cash transfer programmes to improve maternal and child health in Kenya and other sub-Saharan African countries. This article presents the economic evaluation results of the Afya trial, assessing the costs, cost-effectiveness and equity impact of a demand-side financing intervention that promotes utilisation of maternal health services in rural Kenya. The cost of implementing the Afya intervention was estimated from a provider perspective. Cost data were collected prospectively from all implementing and non-implementing partners, and from health service providers. Cost-efficiency was analysed using cost-transfer ratios and cost per mother enrolled into the intervention. Cost-effectiveness was assessed as cost per additional eligible antenatal care visit as a result of the intervention, when compared with standard care. The equity impact of the intervention was also assessed using a multidimensional poverty index (MPI). Programme cost per mother enrolled was International (INT)$313 of which INT$ 92 consisted of direct transfer payments, suggesting a cost transfer ratio of 2.4. Direct healthcare utilisation costs reflected a small proportion of total provider costs, amounting to INT$ 21,756. The total provider cost of the Afya intervention was INT$808,942. The provider cost per additional eligible ANC visit was INT$1,035. This is substantially higher than estimated annual health expenditure per capita at the county level of $INT61. MPI estimates suggest around 27.4% of participant households were multidimensionally poor. MPI quintiles did not significantly modify the intervention effect, suggesting the impact of the intervention did not differ by socioeconomic status. Based on the available evidence, it is not possible to conclude whether the Afya intervention was cost-effective. A simple comparison with current health expenditure in Siaya county suggests that the intervention as implemented is likely to be unaffordable. Consideration needs to be given to strengthening the supply-side of the cash transfer intervention before replication or uptake at scale.

Demand Side Financing and Healthcare Seeking of Pregnant Women

Demand-side financing (DSF) scheme is popularly known as the maternal health voucher program, which is launched in many developing countries of the world including Bangladesh as an intervention of developing overall health status. Maternal mortality ratio is a strong indicator of health profile of any country and pregnant women are prone to fall vulnerable situation. This review was aimed to find gap/missing of existing literature in order to make foundation of new research on healthcare seeking of pregnant women along with financing coverage. After repeated critical review of number original articles, some gaps have been found. Almost every article they focused on outcome and mildly highlighted input variables but did not consider all possible variables and missed to show interlink between those variables.

Payment mechanism for institutional births in Nepal

BackgroundSince the Millennium Development Goal era, there have been several efforts to increase institutional births using demand side financing. Since 2005, Government of Nepal has implemented Maternity Incentive Scheme (MIS) to reduce out of pocket expenditure (OOPE) for institutional birth. We aim to assess OOPE among women who had institutional births and coverage of MIS in Nepal.MethodWe conducted a prospective cohort study in 12 hospitals of Nepal for a period of 18 months. All women who were admitted in the hospital for delivery and consented were enrolled into the study. Research nurses conducted pre-discharge interviews with women on costs paid for medical services and non-medical services. We analysed the out of pocket expenditure by mode of delivery, duration of stay and hospitals. We also analysed the coverage of maternal incentive scheme in these hospitals.ResultsAmong the women (n-21,697) reporting OOPE, the average expenditure per birth was 41.5 USD with 36 % attributing to transportation cost. The median OOPE was highest in Bheri hospital (60.3 USD) in comparison with other hospitals. The OOPE increased by 1.5 USD (1.2, 1.8) with each additional day stay in the hospital. There was a difference in the OOPE by mode of delivery, duration of hospital-stay and hospital of birth. The median OOPE was high among the caesarean birth with 43.3 USD in comparison with vaginal birth, 32.6 USD. The median OOPE was 44.7 USD, if the women stayed for 7 days and 33.5 USD if the women stayed for 24 h. The OOPE increased by 1.5 USD with each additional day of hospital stay after 24 h. The coverage of maternal incentive was 96.5 % among the women enrolled in the study.ConclusionsFamilies still make out of pocket expenditure for institutional birth with a large proportion attributed to hospital care. OOPE for institutional births varied by duration of stay and mode of birth. Given the near universal coverage of incentive scheme, there is a need to review the amount of re-imbursement done to women based on duration of stay and mode of birth.

Are user fees in health care always evil? Evidence from family planning, maternal, and child health services

The effect of introducing or increasing user fees for health services in low- and middle-income countries is controversial. While user fees are advocated as an effective means of generating revenue and enabling health service quality improvement, they constitute a financial barrier to access health services for the poorer. This paper contributes to the literature on the demand-side financing in health by providing evidence on the medium-term effects of introducing user fees on the utilisation of family planning, antenatal care, and delivery care services, women’s access to health care, and child health status in a middle-income country setting. Using a difference-in-differences identification strategy to establish causality, we find that the introduction of user fees in Egypt had no negative effect on the utilisation of family planning and delivery care services. Further, fees did not hinder women’s access to care and did not harm child health outcomes. Positive effects were even observed with respect to the utilisation of antenatal care services. Our findings are compatible with the hypothesis that the potential decrease in demand due to the user fee imposition might have been offset by an increased willingness to pay for a quality of health care that could be, at least partly, perceived as higher.

Financing the Small and Medium Enterprises in Post COVID- 19 Nigerian Economies: Issues and Perspectives

The purpose of this paper is to explore the financing needs of Small and Medium Enterprises in the Post COVID-19 Nigeria Economy. The present state of the Economy was reviewed to determine how the pandemic has affected both the economy and the SMEs.Also a study to determine financing gaps of the SMEs in Nigeria using the simple descriptive means and standard deviations was carried out. The study is based on a sample of 150 small business owners across different sectors (Trade, Services, ICT, Education, and Hospitability) in Port Harcourt Rivers State. The results show that SMEs have financing gaps that are demand related. Consistent with previous studies, the results show that risk aversion, desire to maintain control and reputational effects are key factors explaining the demand-side financing gaps of SMEs in Nigeria. An outlook of the post COVID-19 era projects a weak economy that would struggle to recover. This paper concludes that SMEs that are already faced with demand related financing gaps and aggravated by low sales and supply chain shocks caused by the pandemic should be more strategic in pursuing their financing needs in the wake of post COVID-19 dwindling economy. To strengthen and enhance the capabilities of SMEs, recommendations are made to both the SMEs and the Monetary Authorities.

Decision time: Cost estimations and policy implications to advance Universal Health Coverage in Cambodia

Cambodia aims to expand social health protection to move toward Universal Health Coverage. We developed a modeling tool to facilitate the simple, interactive estimation of cost and coverage for three policy alternatives, enabling decision-makers to simultaneously adjust for scenario options currently under consideration. Assuming the adoption of all scenario options, the projected cost of expanding social health protection to all is US$42 million, to vulnerable individuals is US$32.1 million, and to uncovered 1st–3rd wealth quintile people is US$30.4 million. These policy alternatives are projected to increase population coverage to 100%, 89.1%, and 92.5% by 2025, respectively. The results have multiple policy implications. First, given the similar costs and coverage estimates for the targeted approaches, and other considerations, expansion to the 1st–3rd wealth quintiles is recommended. Second, the model quantifies the potential impacts for policy changes relating to each scenario option. The inclusion of dependents under the contributory schemes significantly shifts costs; reversing the policy of non-payment for priority public health services increases public health facility revenue; and, alignment of reimbursement rates leverages demand-side financing which can increase value for money. Finally, the cost estimates provide a basis for economic planning. Revenue raising options include increasing the contribution ceiling for the private employees’ scheme and the progressive adoption of strategic purchasing.

Demand side financing scheme for maternal and child health of Tamil Nadu: evaluation of benefit received status and awareness level among third trimester pregnant mothers, seeking care at Madurai Medical College Hospital, 2019

Background: Dr. Muthulakshmi Reddy Maternity Benefit Scheme (MRMBS) of Tamil Nadu Government is demand side financing scheme to poor pregnant mothers to compensate wage loss and for nutritional support. Scheme was revised during 2018. Primary objectives were to estimate proportion of benefit received status and median awareness level among third trimester pregnant mothers regarding MRMBS scheme. Secondary objective was to determine association between above two.Methods: We conducted cross sectional study among third trimester pregnant mothers who sought care at Madurai Medical College Hospital; adopted consecutive sampling; sample size 96. We collected data with semi structured questionnaire; calculated proportions with confidence intervals, median, interquartile range and performed bivariate analysis; observed privacy and confidentiality; obtained informed written consent from participants.Results: Enrollment percentage was 97% (91 to 99%). Proportion of mothers who received any benefit, any installment and any nutrition kit were 82% (72 to 89%), 39% (29 to 49%) and 76% (66 to 85%) respectively. Proportion who received appropriate benefit, appropriate instalment(s) and two nutrition kits were 3% (0.7 to 9%), 22% (14 to 31%) and 3% (0.7 to 9%) respectively. Regarding awareness score, lowest, highest, median and interquartile range were 5, 23, 14 and 11 to 17 respectively. Odds ratio for awareness score above median (exposure) and any benefit received status (outcome) was 4.2 (1.2to19.2).Conclusions: Enrollment was satisfactory. Overall any benefit received status had been achieved by at least one nutrition kit supply. Second instalment and kit issue needed improvement. Huge scope existed for improvement of awareness among beneficiaries.

Indirect Cost of Institutional Delivery under Safe Motherhood Program in Pokhara Metropolitan

Introduction: Cost analysis can be an important element and it help to sort out important economic issues. The economic constraint is one of the factors that hinder service utilization among rural women attending urban health although there is Maternal Incentive Scheme, households often have to pay a too large share of the indirect costs of maternity services, or do not seek care because of it.
 Methods: Cross sectional study design which is community based with quantitative method were used for this study to assess the indirect cost of institutional delivery under safe motherhood program in Pokhara Metropolitan from Jan 2019 to June 2019. Study population were the mothers who delivered at health facilities having safe motherhood program within the 6 months preceding the survey. Probability Proportional to size sampling method was adopted with face to face interview among the care takers of mothers. Reliability and validity was maintained by applying different strategies carefully developing tools, pretesting, double entry and validation. Data entry, management and analysis was done with Epi Data and SPSS (20 version) Software.
 Results: In this study majority more than half (54.4%) of the mothers were between 25-34 years. Majority of the participants were male and nearly half of the respondents were belonged to Janajatis (51.5%). More than one fourth (29.6%) of the mothers were from the highest quintile. Median expenditure for indirect cost was NRs 4900 which ranges from NRs 500 to NRs 47000.
 Conclusions: From the study we can conclude that existing Aama Surakshya Program can save only a few expenditure of mothers there should need to review this demand side financing scheme and also need to address the main barriers for service utilization i.e. indirect cost of institutional delivery.

Demand-side financing in the form of baby packages in Northern Mozambique: Results from an observational study.

BackgroundThe Maternal Mortality Ratio in Mozambique has stagnated at 405 deaths per 100,000 live births with virtually no progress over the last 15 years. Low Institutional Birth Rates (IBRs) levelling around 50% in many rural areas constitute one of the contributing reasons. Demand-side financing has successfully increased usage of maternal health services in other countries, but little information exists on in-kind incentives in rural Africa. The objective was to test the impact on Institutional Birth Rates of giving a USD 5.50 baby package incentive to every woman who came to give birth in a health centre in a rural, poor district of Cabo Delgado, Mozambique.Methods and findingsThe intervention was implemented in one district in 2010 with the remaining 15 districts serving as controls. The total population in the 16 districts in 2006 was just under 1.5 million people. IBRs were observed from 2006 to 2013 (53 months before and 55 months after the intervention began). The non-intervention districts showed a slight increase, from a mean IBR of 0.39 (SD = 0.10) in 2006 to 0.67 (SD = 0.13) in 2014. The intervention district had a dramatic increase in IBRs within six months of the start of the intervention in 2010, which was sustained until the end of the study. Adjusting for the background increase and for confounders, including health facilities and health personnel per district, and taking clustering in districts into account, the estimated rate ratio of institutional births in the intervention district was 1.80 (95% CI 1.72, 1.89 p<0.001).ConclusionWomen were almost twice as likely to have an institutional birth following the introduction of the baby package.

PIH50 EFFECT OF INTRODUCTION OF MATERNAL HEALTH VOUCHERS ON QUALITY OF MATERNAL HEALTH CARE SERVICES IN RURAL BANGLADESH: A QUASI-EXPERIMENTAL SURVEY

The Demand Side Financing - Maternal Health Voucher Scheme (DSF-MHVS) was launched in 2006 in Bangladesh with the aim to improve maternal health and to increase safe delivery in institutional settings. Although the MHVS has improved utilization of maternal health services, nothing is known about the effect of the program on the quality of delivery care. This study measures the quality of maternal health services before and after the implementation of the program. Data were collected from 22 regional health facilities in 2010 and 2012. Half of these facilities was control facilities score-matched with facilities in voucher program areas. A difference-in-difference (DID) analysis was conducted to measure the quality indicators (on a scale of 0-100) such as quality of comprehensive maternity functions (based on 12 indicators), quality of labor-room preparedness (average of 10 indicators), quality of labor-room equipment (average of 8 indicators) and quality of operation-theater equipment (average of 9 indicators). Satisfaction of clients and delivery volume were also measured in both control and intervention areas Findings suggest that none of the quality scores improved significantly after 18 months of voucher implementation. However, number of facilities providing more than 500 deliveries per year became doubled in voucher areas. Findings suggest that aggregated quality scores did not significantly improve after voucher introduction meaning voucher had no imapct in quality improvement of delivery care. The volume of 500 delivery increased in voucher areas since the program was targeted to increase the institutional delivery.

Financing From Demand-Side in Education

The belief in the importance of education on economic and social development has resulted in the education expenses being largely covered by the public budget. Countries' approaches to financing education services may vary depending on the tendency to see the education as mixed, complete or private goods and the policies they follow in this direction. In order to fully meet the demands for education, it is of great importance that the available financial resources are spent on the basis of effectively and accountability, as well as the ratio of the financial resources allocated for education. The failure in education is largely attributed to the lack of funding. However, this failure is largely ignored because of the poor use of existing financing, as well as the inadequacy of funding resources. It is an important issue to observe the measures of equality and equity in the distribution of resources related to education and of efficiency and accountability in their spending. Demand-side financing approach in education includes the issues of the freedom of school choice as part of initiating inter-school competitions, giving the 'Education Cheque' or the 'Education Voucher' to student parents and their submitting this cheque or voucher to the board of the school where school stakeholders are also included and where they send their children, within the framework of a protocol, instead of spending the determined money considering the free market conditions or transferring it directly via the education center or district units to the school account for each student studying at each school level. The purpose of this study is to create awareness among education stakeholders and researchers such as decision-makers, managers and teachers regarding the education in by examining the approaches of 'Demand-Side Financing' which is based on parents/ customers' initiative in the use of financial resources allocated from the general budget for education. Key words: Demand-side financing, education financing, financing

Determinants of Household’s Healthcare Payment in Nepal: Evidence from Living Standard Survey III Data

Healthcare financing has always remained an important development issue for Government of Nepal to ensure equity and availability of basic health care services for all but the largest portion of health financing is met by out of pocket payment (OOP), a private financing source of households. So this study aims to assess the situation of private healthcare financing and analyze the factors associated with it. A cross sectional descriptive cum analytical study was designed based on living standard survey data of CBS (2012), Nepal. It is a rich and country wide representative data comprising 5988 households. The study applied logistic regression to analyze the determinants of out of pocket payment. The major findings of the study shows a particular household’s mean healthcare cost was NRs. 1119 for acute illness and cost of medicine occupied the major portion of the cost. The mean OOP healthcare cost is higher for urban residents, mountain dwellers, and households belonging to province 3 and people belonging to highest wealth quintiles. The odds of household facing OOP payment increases for male headed households, larger households and households belonging to province number 2. Conversely, odds of household facing OOP decreases for households residing in urban and province number4. The study concludes that out of pocket payment is an important source of private healthcare financing source. So there is a need to effectively implement the demand side financing programs and health insurance scheme to protect households from financial burden.

Implementation and effectiveness of free health insurance for the poor pregnant women in Tanzania: A mixed methods evaluation

Demand side financing strategies have been a popular means of increasing coverage and availability of effective maternal and child health services in low and middle income countries (LMIC). However, most research to date has focused on the effects of demand side financing on the use and costs of care with less attention being paid to how they work to achieve outcomes. This study used a mixed methods evaluation to determine the effect of a targeted health insurance scheme on access to affordable quality maternal and child care, and assess implementation fidelity and how this affected programme outcomes.Programme effects on service access, affordability and quality were evaluated using difference in difference regression analysis, with outcomes being measured through facility, patient and household surveys and observations of care before the intervention started and eighteen months later. A simultaneous process evaluation was designed as a case study of the implementation experience. A total of 90 in-depth interviews (IDIs) and five focus group discussions were conducted during three rounds of data collection among respondents from management, facility and community. The scheme achieved high coverage among the target population and reduced the amount paid for antenatal and delivery care; however, there was no effect on service coverage and limited effects on quality of care. The lack of programme effects was partly due to the late timing of first antenatal care visits and registration for the scheme together with limited understanding of entitlements among beneficiaries and providers.Better communication of programme benefits is needed to enhance effects together with integration of such schemes within existing purchasing mechanisms and in financially decentralised health systems.

Partnering with Private Providers to Promote Long-Acting Contraceptives in Urban Bangladesh: A Mixed-Methods Feasibility Study.

Bangladesh's pluralistic health system has diversified opportunities for clients to obtain family planning, but public-private partnerships could improve access to services, particularly in urban areas. Sixteen providers, clients and program managers were interviewed to assess perspectives on a family planning orientation and demand-side financing referral program tested in Mirpur, Bangladesh. The 15-month program, conducted in 2015-2016, was designed to encourage private providers to identify non-family planning clients with unmet contraceptive needs, promote choice of a broader contraceptive mix and refer clients to one of three public or nonprofit clinics for provision of their preferred method. Use of the system was assessed by tracking referral slips. Most stakeholders reported that it was acceptable and feasible to discuss fertility intentions with clients presenting for non-family planning matters. Providers were able to alleviate clients' misconceptions and fears concerning long-acting contraceptive methods, but were unable to address patriarchal and religious barriers. The majority of referrals were done by private providers who had a pre-existing relationship with one of the family planning clinics and referred clients to that clinic; overall, documented referrals accounted for 13% of provision of reversible and permanent methods at that clinic during the study period. Providing private practitioners with appropriate training on contraceptives and referral could improve Bangladeshi women's access to long-acting and other contraceptive methods in urban areas, and may be useful for other types of health workers. Further study of suitable referral systems is warranted.