Impact of Maternal and Child Health Private Expenditure on Poverty and Inequity in Bangladesh: Out-of-Pocket Payments by Patients at Ministry of Health and Family Welfare Facilities in Bangladesh and the Impact of the Maternal Voucher Scheme on Costs and Access of Mothers and Children - Technical Report B

The Government of Bangladesh has made it a priority to expand access by the poor to maternal, neonatal, and child health (MNCH) services. Central to its strategy is the provision of healthcare services at free or nearly free prices through Ministry of Health and Family Welfare (MOHFW) facilities. However, poor families make less use of MOHFW services than the non-poor, and many patients are reported to incur significant costs at MOHFW facilities. The Patient Exit Survey (PES) 2011 carried out exit interviews of over 5,000 inpatients and outpatients at a representative sample of MOHFW facilities in order to find out why patients incur out-of-pocket expenses at MOHFW facilities, to quantify their size, and to assess the impact of demand-side financing (DSF) pilot schemes on patient out-of-pocket costs and utilization of MNCH services. Almost all outpatients and inpatients report out-of pocket expenses associated with their healthcare visits. These fall into four categories: (i) travel costs to reach the healthcare institution, (ii) official fees charged by MOHFW facilities, (iii) informal or unofficial fees paid to persons inside the facility to obtain services or other benefits, and (iv) the costs of purchasing medicines recommended by the medical staff that which are not available at the health facility. The major out-of-pocket expense reported is purchasing medicines and supplies that are recommended by medical staff but are not available at the facility. About 50% of outpatients and over 90% of inpatients rreport such costs, which average Tk301 per outpatient and Tk980 per inpatient. Travel costs to the facility average Tk27 for outpatients and Tk131 for inpatients, however, travel costs for expectant mothers are much higher and average Tk220. About 50% of outpatients and 75% of inpatients report having to pay official fees, with inpatient women who had delivered, reporting higher-than-average fees. The incidence of informal payments is much lower than anticipated, with most outpatients reporting no such expenses. There have been large increases since 2006 in facility childbirths at facilities enrolled in the DSF schemes, with the greatest impact seen in those enrolled in the universal DSF schemes. However, findings show that the DSF actual out-of-pocket costs incurred at the time of treatment are no lower at DSF enrolled facilities, and that equity of utilization does not seem to have been improved.