Health and Nutrition Vouchers for Marginalized Urban Extreme Poor in Bangladesh

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Executive Summary

This study examines the experimental use of vouchers in Bangladesh by 3 different agencies, funded by the EU, to address health gaps for the urban extreme poor by providing essential health and nutrition service delivery through public-private partnerships.

In the last 20 years, Bangladesh has been going through a process of urbanization. A recent estimate by the World Bank (2019) suggests that around 28.6 million people, equivalent to 55% of the total urban population, currently live in slums. Around two thirds of urban population growth are due to rural to urban migration and one-third due to natural population increase. Most of these rural migrants lack the resources to meet their basic needs including housing and health care.

The urban poor face many complex health needs, including a high prevalence of non-communicable diseases, with insufficient access to health care, and high out of pocket payments – 74% of current health expenditure. High user fees and distance to travel are further barriers to accessing services and are a major reason why people postpone or forego healthcare despite increased health needs. The voucher model aimed at reducing the financial barriers to accessing health services for the urban poor and supporting vulnerable populations in accessing health care without suffering financial hardships.

Funded by the EU – the project was designed as three pilots implemented by three different entities: Concern Worldwide in partnership with SAJIDA Foundation; Dhaka Ahsania Mission (DAM), in partnership with Christian Aid; and Resource Integration Centre (RIC).

Vouchers, a form of results-based financing (RBF) have been used in many sectors, including health, in low, middle-, and high-income countries. More specifically, health vouchers work as both a financing mechanism to provide subsidized health care to a targeted population and as a programmatic tool to reduce barriers to access and increase use of critical health services. Research has demonstrated that vouchers can effectively increase utilization, enhance equity, and improve quality and availability of care.

Through vouchers, the household can receive a clearly defined health service package at pre-selected health facilities free of charge or at a reduced fee. The subsidy goes directly to the client in the form of a voucher (whether paper or through an electronic token) – that the client can then redeem this at a health provider.

Partnering with the government, and the local municipalities, the implementing partners developed a service package for which the vouchers can be used at the designated public and private hospitals. The service package included treatment for general illness, maternal health, and emergency services. The value of the vouchers were not uniform across the implementing partners either with the type of services or the costs. The reason for this is because the target populations for the implementing partners were different.

Hospitals were identified and contracted to participate in the scheme, based on a set standard criteria to ensure quality of care. Households were identified using poverty and vulnerability targeting criteria. The majority of households targeted made use of the voucher indicating that their access to formal health care improved considerably, as well as changed health seeking behavior. The COVID-19 pandemic led to some disruption in access during the life of the pilots.

While this is a development project, conducted in line with government efforts to improve the healthcare of the residents of slums in Bangladesh , the design could be applicable to humanitarian contexts in which similar financial barriers obstruct access to health services. The response analysis for a humanitarian context, however, may look different, particularly in refugee contexts with challenges around safe access to services.

Finally following an evaluation on of the three pilots, a common model is expected to be used for scaling up within Bangladesh.