Prepared Under HNPSP of the Ministry of Health and Family Welfare COSTING OF MATERNAL HEALTH SERVICES IN BANGLADESH

Transcription

1 Prepared Under HNPSP of the Ministry of Health and Family Welfare COSTING OF MATERNAL HEALTH SERVICES IN BANGLADESH February 2010

2 Recommended Citation: Chankova, Slavea, Sushil R. Howlader, Syed A. Hamid. Subrata Routh, Tasnuva Sultana, Hong Wang. February Costing of Maternal Health Services in Bangladesh. Bethesda, MD: Review, Analysis and Assessment of Issues Related to Health Care Financing and Health Economics in Bangladesh, Abt Associates Inc. Contract/Project No.: / Submitted to: Helga Piechulek and Atia Hossain GTZ-Bangladesh House 10/A, Road 90, Gulshan-2 Dhaka 1212, Bangladesh Abt Associates Inc Montgomery Avenue, Suite 800 North Bethesda, Maryland Tel: Fax: In collaboration with: RTM International 581, Shewrapara, Begum Rokeya Sharoni, Mirpur Dhaka 1216, Bangladesh

3 COSTING OF MATERNAL HEALTH SERVICES IN BANGLADESH DISCLAIMER The authors views expressed in this publication do not necessarily reflect the views of the Deutsche Gesellschaft für Tech Zusammenarbeit (GTZ) GmbH

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5 CONTENTS Contents... iii Acronyms... vii Acknowledgments... ix Executive Summary... xi Introduction Provider Costs for Maternal Health Services Methodology Results Discussion Consumer Costs of Maternal Health Services Methodology Results Discussion Normative Costs of Key Maternal Health Services Methodology Results Discussion Total Costs of Key Maternal Health Services for Achieving MDG Methodology Results DIscussion Policy Recommendations...47 Annex A: Assumptions and Parameters in MDG5 Costing Model Annex B: Participant List Technical Workshop Annex C: Participant List, Small Group Consultation Annex D: Average Time Spent by Providers in Public Health Facilities for Maternal Health Patients Bibliography iii

6 LIST OF TABLES Table 1: Selected health facilities...8 Table 2: Maternal health service provided in sample of facilities...10 Table 3: Provider cost of package of 4 ANC visits, public facilities...16 Table 4: Provider cost of normal delivery, public facilities...16 Table 5: Provider cost of postpartum care, public facilities...16 Table 6: Provider cost of c-section, public facilities...17 Table 7: Provider cost of abortion complications, public facilities...17 Table 8: Provider cost of postpartum hemorrhage, public facilities...17 Table 9: Provider cost of eclampsia, public facilities...18 Table 10: Fee for package of 4 ANC visits, private for-profit and NGO facilities...18 Table 11: Fee for normal delivery, private for-profit and NGO facilities...18 Table 12: Fee for postpartum care, private for-profit and NGO facilities...19 Table 13: Fee for c-section, private for-profit and NGO facilities...19 Table 14: Fee for treatment of abortion complications, private for-profit and NGO facilities...19 Table 15: Fee for treatment of postpartum hemorrhage, private forprofit and NGO facilities...20 Table 16: Fee for treatment of eclampsia, private for-profit facilities...20 Table 17: Medical consumer cost of key maternal health services, by type of facility...27 Table 18: Non-medical consumer cost of ANC and PPC (per visit)...28 Table 19: Non-medical consumer cost of delivery and complications treatment*...29 Table 20: Household expenditures for home delivery and postpartum care by medically trained provider...29 Table 21: Normative unit cost of package of 4 ANC visits, public facilities...36 Table 22: Normative unit cost of normal delivery, public facilities...36 Table 23: Normative unit cost of postpartum care, public facilities...36 Table 24: Normative unit cost of c-section, public facilities...37 Table 25: Normative unit cost of abortion complications, public facilities...37 Table 26: Normative unit cost of postpartum hemorrhage, public facilities...37 Table 27: Normative unit cost of eclampsia, public facilities...38 Table 28: Baseline and targets for maternal health services coverage,* Table 29: Baseline and targets for maternal health services as percent of births, Table 30: Distribution of target number of patient-visits for maternal health services by type of provider, Table 31: Provider unit costs for maternal health services...44 iv

7 Table 32: Projected costs of providing maternal health services at target coverage, (million taka)...45 Table 33: Distribution of projected costs of maternal health services by type of provider, Table 34: Non-medical consumer unit costs for obtaining maternal health services (in taka)...46 Table 35: Projected non-medical consumer cost for obtaining maternal health services, (million taka)...46 Table D1. Minutes spent by individual providers per patient for one outpatient visit/inpatient day...56 Table D2. Average number of inpatient days for maternal health services...57 v

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9 ACRONYMS ANC BBS BDHS CC CSBA DGFP DGHS DH DSF EmOC FGD FWA FWV GTZ GoB HA HEU HNPSP IRB KII MCH MCWC MDG MIS MO MOHFW MMR NGO PHC Antenatal Care Bangladesh Bureau of Statistics Bangladesh Demographic and Health Survey Community clinic Community Skilled Birth Attendant Directorate General Family Planning Directorate General of Health Services District Hospital Demand-Side Financing (Pilot maternal health voucher scheme) Emergency Obstetric Care Focus Group Discussion Family Welfare Assistant Family Welfare Visitor Gesellschaft für Technische Zusammenarbeit Government of Bangladesh Health Assistant Health Economics Unit, MOHFW Health Nutrition and Population Sector Program Institutional Review Board Key Informant Interview Maternal and child health Maternal and Child Welfare Center Millennium Development Goal Management Information System Medical Officer Ministry of Health and Family Welfare Maternal Mortality Ratio Non-Government Organization Primary Health Care vii

10 PPC PRS RMO RPIP RTM UHC UHFPO UHFWC UN UNDP USD WHO Postpartum care Poverty Reduction Strategy Residential Medical Officer Revised Program Implementation Plan Research, Training and Management International Upazila Health Complex Upazila Health and Family Planning Officer Union Health and Family Welfare Centre United Nations United Nations Development Program United States Dollar World Health Organization viii

11 ACKNOWLEDGMENTS This report is the product of the collaborative efforts of many individuals who contributed to the design, analysis, and completion of the study. This is the final report for Study B (Costing of Maternal Health Services in Bangladesh) of the project Review, Analysis and Assessment of Issues Related to Health Care Financing and Health Economics in Bangladesh, funded by the Deutsche Gesellschaft für Technische Zusammenarbeit GmbH (GTZ) and prepared under HNPSP of the MOHFW. We are very grateful for the support and guidance provided by the Health Economics Unit (HEU) of the Government of Bangladesh s Ministry of Health and Family Welfare (MOHFW), as well as the Directorate General of Health Services (DGHS) and Directorate General of Family Planning Services (DGFP). We gratefully acknowledge the role played by Dr. Shamim Ara Begum, ex-joint Chief (Joint Secretary) and ex-line Director, HEU in expediting the process of the study. We also gratefully acknowledge Dr. Md. Anwar Hossain Munshi, Joint Chief (Joint Secretary) and Line Director, HEU in facilitating dissemination of the study and hosting the dissemination workshop in February We also want to thank Dr. Abdul Mannan and Mr. Balijur Rahman for their support. Mr. Md. Rafiqul Islam Khan Deputy Secretary, HEU, was continuously supportive and extended necessary cooperation and guidance. Stakeholders and expert participants in the June 2009 inception workshop, the November 2009 technical consultation workshop, and the November 2009 small group expert consultation meeting all shared essential insights that informed our data analyses, which we deeply appreciate. We are grateful for the technical support provided by Nancy Sloan, Shafiqul Alam Siddiqui, and Sandhya Sundaram; data and information provided by Tahmina Begum, Tania Dmytraczenko, and Tim Ensor; technical reviews by Drs. Mursaleena Islam and Laurel Hatt and data analysis by Ha Nguyen and Obiko Magvanjav of Abt Associates; and, the support provided by Dr. Ahmed Al-Kabir, Jamil Chowdhury, Dipika Paul, and Rezwana Chowdhury of RTM International. We also want to thank the data collection, data entry, and data analysis teams for their hard work. We acknowledge the contribution of all the public, private and NGO facilities, who provided their support and data for the project, including facility managers, health providers and staff, who gave us some of their very valuable time. We also want to thank all the women and maternal health care seekers who provided valuable time and data. Finally, we thank Dr. Helga Piechulek, Jean-Olivier Schmidt, and Atia Hossain of GTZ for their support and assistance. Without all this support at various levels, it would have been impossible to accomplish the task. ix

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13 EXECUTIVE SUMMARY Bangladesh has made substantial progress in health and population services, particularly in reducing fertility and child mortality, and in increasing the coverage of health and family planning services (WHO 2005). Over the past decade, there have been substantial reductions in child and infant mortality and improvement in life expectancy, but maternal mortality remains high (WHO 2009). There are 322 maternal deaths per 100,000 live births (NIPORT et al., 2003), and maternal deaths are a key contributor to the high neonatal mortality of 37 per 1,000 births (BDHS 2007). Improving maternal health service provision requires adequate resource allocation and strategies to address both the supply side and demand side barriers for maternal health services. Effective planning and budgeting of health services requires comprehensive information on the costs of service provision, particularly the unit costs incurred by providers per patient visit/treatment episode. Addressing the demand side barriers to accessing maternal health services requires information on the consumer costs for obtaining these services. A full costing of the maternal health services, including both provider and consumer costs, can help improve the design and budget allocation for safe motherhood programs, as well as any comparable national maternal health financing plan. In addition, such information can help estimate the required financial resources to achieve the targets related to MDG 5. However, in Bangladesh, there are no comprehensive data on unit costs of key maternal health services. In early 2009, the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) commissioned a study of the costs of maternal health services in the public, private, and NGO sectors in Bangladesh. This study was conducted by Abt Associates Inc., a US-based international research and technical assistance organization, and the Bangladesh-based team of Research, Training and Management International (RTM). The purpose of this activity was to provide valuable information to the MOHFW and its Health Economics Unit (HEU) to support the planning and budgeting for maternal health services. STUDY OBJECTIVES The specific objectives of the study are: To estimate the current unit costs of providing key maternal health services including: ANC, normal (vaginal) delivery, postpartum care, c-section, care for post abortion complications, postpartum haemorrhage and eclampsia at the facility level by public, private and NGO providers at various levels (primary, secondary and tertiary). To estimate current total consumer costs of receiving the same set of maternal health services at the facility level. To estimate the provider and consumer costs of home-based delivery (including essential newborn care) by a skilled provider. xi

14 To estimate the normative costs of maternal health services based on treatment standards for quality service provision. To project total costs of maternal health services required for achieving the MDG/Poverty Reduction Strategy (PRS) targets, based on these costs 1. PROVIDER COST OF MATERNAL HEALTH SERVICES OVERVIEW OF PROVIDER UNIT COST ESTIMATION APPROACH The approach used to estimate provider costs in public facilities was based on the Mother Baby Package Costing Model developed by WHO (WHO 1999), modified to reflect the context in Bangladesh and the purpose of this study. Provider unit costs were estimated per patient-visit for each maternal health condition. The costing model used the ingredients approach for each particular service, which adds the cost of labor, drugs and supplies, equipment, and other facility costs incurred by a provider for treating each patient. Data was collected from a sample of health facilities at all levels of care (primary, secondary, and tertiary). This approach was not replicated in private and NGO facilities because, based on prior experience of the study team, these providers are typically not willing to share detailed information on their service provision costs. Therefore, data was collected on the private/ngo providers fees/charges to consumers for each maternal health service. STUDY SAMPLE First, out of the 64 districts in Bangladesh, two districts were chosen for the survey: Patuakhali and Sirajgonj. These districts were selected to cover different parts of the country. One district was selected from northern Bangladesh (Rajshahi Division) and one from southern part (Dhaka, Khulna, Barisal, Chillagong and Sylhet divisions). It was expected that data from the two different parts of the country would provide a more representative (spatial) scenario of the country. The selected districts included areas where the Demand Side Financing (DSF) pilot maternal health voucher scheme was being implemented. A total of 18 healthcare facilities were selected across the two districts, including 10 public, 4 private for-profit and 4 NGO facilities. In addition, one public sector tertiary facility was selected (not located in the study districts). DATA COLLECTION METHODS In public facilities, data collection for the study had two main components: Provider survey: Data on all provider costs, except staff time spent for maternal health clients, was collected through a provider (health facility) questionnaire. Time motion observation: Data on provider time spent for maternal health clients was obtained through time motion observation of clients. In private for-profit and in NGO facilities, all data was collected using a provider questionnaire capturing the fees/charges for maternal health services. xii

15 Information on provider costs of home-based delivery by CSBA was collected through a survey of CSBAs. The CSBA survey was conducted with providers in 40 villages where the second round of the household survey for Study A was conducted. RESULTS PROVIDER UNIT COSTS FOR FACILITY-BASED CARE ANC: In the public sector, the total cost of a package of four ANC visits varies across type of facility, from 112 Taka in community clinics to 673 Taka in district hospitals. Drugs, supplies, and diagnostic tests account for the largest share of provider unit costs for ANC in each type of facility, except at the tertiary level where labor costs represent the largest share of costs. Total provider costs at the tertiary level are lower than at secondary and some primary level facilities because the tertiary hospital charges patients for all tests, whereas some test in district hospitals and all tests in UHCs are free for patients. The fee charged for a package of four ANC visits is Taka in NGO facilities, where pregnant women receive only consultation, and is much more expensive in private for-profit facilities (2,000 2,010 Taka) where the package of care also includes drugs and tests. Normal delivery: The unit cost of normal delivery in a public health facility ranges from 150 Taka at the primary level to 499 Taka at the tertiary level. Labor costs vary considerably across facilities, reflecting different types of providers attending to normal delivery patients in each type of facility. Drugs, supplies and tests constitute between 26% and 70% of costs, whereas the share of labor costs is in the range of 23-69%. Provider unit cost of home based delivery by a CSBA is estimated at 267 Taka. Charges for normal delivery are in NGO facilities are in the range of Taka, while in private forprofit facilities fees are in the range of 2,500 to 3,750 Taka. Postpartum care: The unit cost of postpartum care provided in public facilities increases from 36 Taka at community clinics to 251 Taka at district hospitals. As with ANC, drugs, supplies, and tests account for the largest share of costs, 45% to 77%. At the tertiary level, patients pay for nearly all drugs and supplies, and all tests; this translates into a relatively low provider cost for this component. The fees charged for postpartum care visit by private for-profit facilities are 300 Taka and are much higher than the fees of NGO providers (20-30 Taka). One of the reasons for this difference is that NGO facilities provide post-natal care for patients who do not have complications, whereas private for-profit facilities tend to treat more women who experience complications in the postpartum period. Accordingly, the fees cited by NGO providers include only consultation, whereas the fees of for-profit providers also include drug, supplies, and diagnostic tests for postpartum care. C-section: In the public sector, the unit cost of c-section is lowest at the MCWC (306 Taka) and highest at the medical college hospital where the unit cost is 1,510 Taka. Labor costs are the main component of total costs in primary and secondary level facilities. Costs of drugs, supplies, and tests as well as costs of labor are substantially higher at the tertiary level, than at lower-level facilities, reflecting the more specialized care available at the tertiary level. The fees charged by the NGO facility (5,500 Taka) for c-section are about half of the fees for this service paid by patients in private for-profit facilities (10,000 to 13,500 Taka depending on level of facility). Abortion complications: In the public sector, the unit cost of treatment of abortion complications varies considerably by type of facility, from 235 Taka at MCWC to 1,306 Taka at the medical college hospital. Labor costs are the main component of total costs in most facilities, reflecting the fact that patients with abortion complications are hospitalized for several days. Costs of drugs, supplies, and tests are substantially higher at the tertiary level, than at lower-level facilities. While patients in NGO facilities are charged about 2,000 Taka for treatment of post-abortion complications, the fees charged by private for-profit facilities for these services are multiple times higher (4,000 to more than 6,000 Taka). xiii

16 Postpartum hemorrhage: The unit cost of treatment of postpartum hemorrhage in the public sector is in the range of Taka. As with the other obstetric complications, labor costs are the main component of total costs. Costs of drugs, supplies, and tests are relatively low because patients pay nearly the full cost of this component. While patients in NGO facilities are charged about 2,000 Taka for treatment of postpartum hemorrhage, the fees charged by private for-profit facilities for these services are multiple times higher (4,000 to more than 6,000 Taka). Eclampsia: Treatment of eclampsia, which requires a lengthy hospital stay, varies from 521 Taka to 1,142 Taka in public health facilities. Similarly to the other obstetric complications, the unit cost of treatment of eclampsia is driven by labor costs, and patients pay for most of the drugs and supplies used for treatment. Treatment of eclampsia is the most-expensive service in private for-profit facilities, among the services included in the study, costing as much as 15,000 Taka. The NGO facilities in the survey did not provide treatment for eclampsia (patients were referred to the district hospital). DISCUSSION In the public sector, provider unit costs for each service vary considerably by type of facility. This variation is mostly driven by differences in the types of drugs and supplies which are provided for free in each type of facility. Comparison of current unit costs across types of services shows that public provider costs are highest for obstetric complications (c-section, abortion complications, eclampsia) where unit costs at the tertiary level are as high as 1,300-1,500 Taka. For outpatient services, such as ANC and PPC, drugs, supplies, and tests account for the largest share of total costs across most public facilities. By contrast, labor costs typically constitute the largest share of provider costs for inpatient services, particularly for complications which require longer hospital stays. The fees charged by NGO facilities are higher than public provider costs for delivery and obstetric complications at the same level, whereas the fees for ANC and postpartum care are lower (due to the fact that NGO facilities only provide consultation for these services). Public for-profit providers charge fees that are substantially higher than NGO fees for all services. 2. CONSUMER COSTS OF MATERNAL HEALTH SERVICES This part of the report presents the methods, data, and results on consumer unit costs for the key maternal health services that are the focus of the study, including costs of both home-based and facilitybased care. Consumer unit cost is defined as the total cost incurred by a consumer (patient) per treatment episode for a given condition, except for ANC where we present unit cost for a package of four ANC visits. OVERVIEW OF CONSUMER UNIT COST ESTIMATION APPROACH AND DATA COLLECTION METHODS For facility-based care, data was collected from a sample of 190 maternity patients exiting the health facilities included in the provider cost study. For home-based care, data was collected from a sample of 429 women who had delivered at home with a skilled birth attendant within the six months prior to the survey. In addition, some data from the provider survey was used for the calculation of consumer unit costs. In public facilities, data collection for the study had two main components: xiv

17 Patient exit survey: Data on consumer costs associated with health facility visit (except for costs of drugs and supplies) were collected through exit client interviews. Provider survey: Data on the consumer costs of medicines and supplies were collected from the provider survey (described in Part 1) based on prescriptions and market prices. In private for-profit and in NGO facilities, data was collected through: Patient exit survey: Data on consumer costs associated with health facility visit (except for fees/charges by the health facility) were collected through exit client interview. Provider survey: Data on the fees/charges to consumers for all services (including drugs and supplies) received at the health facility was collected from the provider survey. Data on consumer costs of home delivery with a skilled birth attendant was collected as part of Study A using: Household survey that collected information on the expenditures incurred for home-based delivery. RESULTS MEDICAL CONSUMER UNIT COSTS OF MATERNAL HEALTH SERVICES Overall, consumer costs (or out-of-pocket expenditures) for each service in public facilities increase with the level of care. Consumer medical expenditures for treatment of obstetric complications (csection, abortion complications, postpartum hemorrhage) are higher in the NGO than in the public sector, but similar for normal delivery (at comparable facility level). For all services, treatment is most expensive for consumers in the private-for profit sector. ANC: Consumer medical expenditures for ANC (for a package of four visits, including drugs, supplies, and diagnostic/laboratory tests) in public facilities is estimated at 104 Taka at the primary level, but increase to 595 Taka at secondary and 937 Taka at tertiary facility levels, where a greater range of lab tests are provided and almost always paid for out-of-pocket. NGO facilities do not provide lab tests and consumers seeking care there are charged less, Taka. In private for-profit facilities, patients are charged a total of about 2,000 Taka for a comprehensive package that includes consultations, tests, and drugs. Normal delivery: Expenditures for normal delivery in public facilities vary from 917 Taka at the tertiary level to about 750 Taka at lower facility levels. Normal delivery costs Taka in an NGO facility, and 2,500-3,750 Taka in a private for-profit facility. Expenditures by households for home delivery assisted by a skilled provider were 421 Taka on average. Postpartum care: Women receiving postpartum care pay most in public tertiary facility (660 Taka), and expenditures decrease considerably at lower levels of care, to 57 Taka at the primary level. NGO facilities charge only Taka for a postpartum check-up (providing only consultation), whereas private for-profit facilities charge 300 Taka. Expenditures by households for home-based postpartum care received from a medically trained provider were 113 Taka on average. xv

18 C-section: Consumer costs for c-section are substantially higher in private for-profit facilities, than in NGO or public sector facilities. A c-section in a private for-profit clinic costs as much as 13,500 Taka, compared to 5,500 Taka in an NGO facility, and 827-2,271 Taka in a public facility. Abortion complications: Similarly, treatment of abortion complications is most expensive in private for-profit facilities, where patients are charged 4,000-6,250 Taka for treatment. In NGO facilities, the consumer medical cost of c-section is 2,020 Taka, whereas in public facilities the costs range from 1,043 to about 3,000 Taka. Eclampsia and postpartum hemorrhage: Treatment of eclampsia and postpartum hemorrhage are also most expensive in the private sector where patients are charged from 4,000 to 15,000 Taka. In the public sector, treatment of eclampsia or postpartum hemorrhage can cost from 489 to 2,112 Taka. RESULTS NON-MEDICAL CONSUMER UNIT COSTS OF MATERNAL HEALTH SERVICES Data from the patient exit survey, collected from patients in public, private, and NGO facilities shows that non-medical out-of-pocket expenditures incurred by patients for outpatient maternal services (ANC and PPC) is from 32 to 68 Taka per visit to the facility. For patients at the primary and secondary level facilities, these expenditures were all on transportation to and from the facility. At the primary level, on average about half of expenditures were for the patient s transportation, and the remaining were costs for companion and other non-medical expenses. For inpatient maternal services, total non-medical expenditures are in the range of 1,654 to 2,059 Taka. The cost of patient s travel to and from the facility increases by level of care. Travel and food costs for the patient constitute at least half of total non-medical expenditures at each level of care. DISCUSSION As in the case of provider costs, consumer unit costs (out-of-pocket expenditures) also vary considerably by level of public facility, for each type of service. While consumer expenditures for ANC and PPC visits are relatively low in lower-level public and NGO facilities (e.g Taka per visit at the primary level), expenditures for obstetric complications can be as high as 3,000 Taka in the public sector, 5,500 Taka in the NGO sector, and 15,000 Taka in private for-profit facilities. In public facilities, the possible reasons for the increase in consumer expenditures as the level of facility increases are that higher level facilities provide a much larger and improved package of each service than do lower level facilities, and secondly, the amount of subsidy given to the patient is much higher in the lower level facility. In private for profit facilities, medical consumer expenditures are several-fold higher than in public facilities for all maternal services, as clients of the private facilities do not get any subsidy; and these facilities earn a profit margin. For the NGO secondary facilities, the consumer unit costs for such services as c-section, abortion complications and postpartum hemorrhage are substantially higher than that in the secondary level public facilities of the same level, suggesting subsidy levels at NGOs to be lower than in the public sector for these services. For other services, such as ANC, normal delivery, and PPC, the unit consumer medical costs are lower in the NGO facilities compared to the public facilities, suggesting that the NGO xvi

19 facilities are providing higher subsidy to the patients of these services. Medical unit costs for consumers at NGO facilities are lower than in private-for-profit facilities. While non-medical consumer expenditures are very low in all facilities for ANC and PPC, they are considerably high for delivery and complications treatment in all levels of facilities. Travel costs and costs for companions drive non-medical consumer costs for these services. 3. NORMATIVE COSTS OF KEY MATERNAL HEALTH SERVICES Normative unit cost is defined as the total cost incurred by a provider (health facility) per patient per treatment episode for a given condition, if treatment is provided according to quality standards. OVERVIEW OF NORMATIVE COST ESTIMATION APPROACH AND DATA COLLECTION METHODS The approach used to estimate normative costs was based on the Mother Baby Package Costing Model developed by WHO (WHO 1999), modified to reflect the context in Bangladesh and the purpose of this study. The normative cost estimation approach used data collected from the provider survey of 11 public health facilities (described in detail in Part 1 of this report) and two consultative meetings with public health and practicing senior medical experts in Bangladesh. RESULTS ANC: The normative cost of ANC (package of four visits) increases from 858 Taka at the primary level to 1,092 Taka at the tertiary level. At each level of care, drugs, supplies, and tests account for the largest share of costs (more than 80%), followed by labor costs which range from 12% to 16% of total cost Normal delivery: The normative cost of normal (vaginal) delivery at a public health facility increases from 423 Taka at the primary level to 1,280 Taka at the tertiary level. Drugs, supplies, and tests account for the largest share of total costs in facilities (67-88%), followed by labor costs. For home-based delivery by a CSBA, the normative provider cost is estimated at 287 Taka, with labor costs accounting for most of the cost. Postpartum care: The normative cost of postpartum care also increases considerably between the primary level of care (247 Taka) and the tertiary level (685 Taka). Drugs, supplies, and tests account for the largest share of total costs (84-89%). C-section: The normative cost of c-section increases by level of care, from 1,781 Taka in primary level facilities to 3,284 Taka at the tertiary level. Drugs, supplies, and tests account for about 80% of costs, while labor costs account for most of the remaining costs. Abortion complications: The normative cost of treating abortion complications ranges from 2,124 to 3,169 Taka, with drugs, supplies, and tests constituting the largest share of costs. Postpartum hemorrhage: The normative cost of postpartum hemorrhage (treated only in secondary and tertiary facilities in our sample) is 712 Taka at the secondary level but substantially higher, 1,991 xvii

20 Taka, at the tertiary level. This difference is explained by the higher cost of drugs, supplies, and tests at the tertiary level, and the fact that they constitute the largest share of costs, 82-90%. Eclampsia: The normative cost of eclampsia (treated only in secondary and tertiary facilities in our sample) is 1,036 Taka at the tertiary level and about 1,700 Taka at the secondary level. DISCUSSION The public sector normative costs for all services are considerably higher than the corresponding current provider unit cost estimates in public facilities. This difference reflects primarily the considerable share of drugs, medical supplies, and diagnostic tests that are currently paid for out-of-pocket by patients in the public sector. In addition, the difference between current and normative public sector unit costs reflects an adjustment of the current list and amounts of drugs/supplies used for treatment in some facilities to reflect best practices and expert-prescribed norms for usage of these drugs/supplies. One notable finding is that for each service normative public sector costs are considerably lower than the fees charged by private sector providers. This difference reflects the profit margin of private facilities, but may also reflect the higher drug/supplies costs of private providers (who are less likely to be able to benefit from the lower large-scale procurement - prices available to the public sector), and may possibly reflect differences in the quality of services (e.g. better inpatient infrastructure for patients in private clinics, compared to public facilities). 4. TOTAL COSTS OF KEY MATERNAL HEALTH SERVICES FOR ACHIEVING MDG 5 This part of the report presents the methods, data, and results from a model used to project the total costs of achieving coverage of key maternal health services associated with attaining MDG 5 and related Poverty Reduction Strategy (PRS) targets in The maternal health services included in the costing model are: ANC, delivery with a skilled birth attendant, PPC, c-section, and treatment of postabortion complications, eclampsia, and postpartum hemorrhage. OVERVIEW OF COST ESTIMATION APPROACH AND DATA COLLECTION METHODS The model design uses the service unit cost approach, which calculates the total cost of each maternal health service by multiplying the unit cost by the number of target service units (patient visits or treatment episodes). This design is similar to the modeling methods used by other costing models aiming to estimate total costs of service provision towards given targets (WHO 2005/Johns et. al 2007, Jahan 2009). The baseline values and targets for each of the maternal health services included in the MDG model were determined through a multi-stage process: (1) extensive review of national maternal health strategy documents, published maternal health studies, and available survey and statistical data; (2) a technical consultation workshop in Dhaka with public and private sector stakeholders; and, (3) an expert consultation meeting of senior medical professionals. The parameters and assumptions used to estimate specific service provision units (number of patients) based on these targets were determined from relevant literature on maternal health complications and services utilization. xviii

21 RESULTS The total price tag for providing the set of key maternal health services at coverage levels consistent with achieving the MDG 5 is 116,565 million Taka (1,704 million USD). About 70% of this amount will be needed to provide the target level and quality of ANC services. The costs of normal delivery are 9% of the total resource requirement, and the costs of treating the leading obstetric emergency complications account for 20%. The private sector would have the largest share of total costs (65%), followed by the public sector (33%) and the NGO sector (2%). The high fees charged by private facilities (proxy for their costs) and the large proportion of patients who receive facility-based maternal care in private for-profit facilities explain the considerable share of total resources for the private for-profit sector. For each maternal service, except for PPC, the largest share of required resources remains for the private sector. The higher normative costs of PPC in the public sector largely explain its share of total resources required for this service. The total cost to consumers to access the set of key maternal health services at coverage levels consistent with achieving the MDG 5 is 20,822 million Taka (304 million USD). About 84% of this amount would be spent on receiving inpatient and emergency maternal care for delivery and complications, and the remaining 16% on accessing ANC and postpartum care services. DISCUSSION AND POLICY RECOMMENDATIONS In order to achieve the MDG targets for all maternal services, the amount of resource use has to increase from 8,157 million Taka in 2010 to 36,449 million Taka in 2015 a nearly five-fold increase. The grand total resource needs for all MDG years (until 2015) is 116,565 million Taka a large amount indeed. To provide ANC at the targeted level will require the highest proportion (70%) of resources, followed by that for C-section care. Similarly to many other developing countries, Bangladesh is facing a need to expand priority health services with resource constraints. Therefore, in addition to increasing resources, existing resources have to be used more effectively and efficiently. Based on the results of this study, a number of policy strategies can be considered by policymakers: The first recommended policy strategy is service decentralization. The results of this study indicate that about two-thirds of ANC services that are delivered in public health facilities are delivered by secondary and tertiary healthcare facilities. These services could be delivered at the primary care center/facility more efficiently if the quality of care can be ensured at the primary care level. The implementation of this policy could also free up the scarce resources at the secondary and tertiary care levels for more complicated health problems. The second recommended strategy is system integration, to support a service decentralization policy. This means that appropriate referral systems need to be built among primary, secondary, and tertiary levels of facilities, with clear defined responsibilities for service delivery at each level. This integrated delivery system will provide backup for primary health service delivery and allow for complicated cases to be referred promptly to a higher level facility if a more complex treatment is necessary. The third policy strategy that needs to be considered is public-private partnership. As this study pointed out, about 40% of maternal patient-visits (treatment episodes) would be in private xix

22 sector facilities, accounting for nearly two-thirds of the required financial resources for maternal health services consistent with MDG5. This share of total financial resources would be paid outof pocket by consumers directly to providers. It is uncertain whether (and to what extent), the Government of Bangladesh is ready to reduce consumers out-of-pocket expenditures and become a purchaser of private-sector services on behalf of consumers. If the government considers purchasing private sector maternal health services, one option is to purchase these services at existing private sector prices which are about two to three times higher than service unit costs in the public sector. Another option would be for the government to negotiate reduced prices from private sector providers, consistent with the large volume of services purchased from them. If the government chooses to purchase maternal health services from the private sector, a performance based payment mechanism for such purchases should be considered. This fourth policy strategy, a performance based payment mechanism for private sector services, would be essential for the development of a public-private partnership for maternal health services provision. With this performance based payment policy strategy, the government would be better positioned to control the cost of services while improving/maintaining the quality of services. xx

23 INTRODUCTION BACKGROUND Bangladesh is one of the least developed countries in Asia, with more than half of the population living on less than a dollar a day and a literacy rate of 53 percent (UNDP 2009). It is one of the world s most densely populated countries, with a population of 145 million and an area of 148,000 km 2 (Bangladesh Bureau of Statistics 2009). The country is affected by recurring flooding and cyclones that exacerbate the health and economic situation of its population. Bangladesh has made substantial progress in health and population services, particularly in reducing fertility and child mortality, and in increasing the coverage of health and family planning services (WHO 2005). Over the past decade, there have been substantial reductions in child and infant mortality and improvement in life expectancy, but maternal mortality remains high (WHO 2009). There are 322 maternal deaths per 100,000 live births (NIPORT et al., 2003), 1 and maternal deaths are a key contributor to the high neonatal mortality of 37 per 1,000 births (BDHS 2007). About 75% of babies born to mothers who die during childbirth also die in the first week of their lives (WHO 2005). The major causes of maternal deaths in Bangladesh include: postpartum hemorrhage, eclampsia, complications of unsafe abortion, obstructed labour, postpartum sepsis and violence and injuries (MOHWF 2004). Access to and use of skilled birth care and emergency obstetric care are main factors contributing to maternal mortality. Only 18% of deliveries in Bangladesh occur with a medically trained provider, and 85% of deliveries are at home (BDHS 2007). Per capita health expenditures in Bangladesh are approximately US$12, of which 64% are borne by households as out-of-pocket spending (HEU/MOH, 2003). Health services are provided by the public sector, not-for-profit non-governmental organizations (NGOs) and the for-profit private sector. Public health services are free or subsidized, but widespread shortages of drugs in pubic facilities mean that households seeking care in the public sector often have to pay for treatment. Services in many public health facilities fall short of required quality standards (Tulane University and ACPR, 2009). The second Health, Nutrition and Population Sector Programme (HNPSP), implemented from 2005 until 2010, aims to improve access to quality affordable health care for the entire population. A key goal for the health sector in Bangladesh is to achieve the United Nations Millennium Development Goal 5 (MDG 5) to reduce the maternal mortality ratio (MMR) by three quarters between 1990 and 2015 (GOB 2005). The most recent Revised Program Implementation Plan (RPIP) of the HNPSP outlines the broad activities, targets, strategies, priority issues and consolidated cost estimates for improving maternal health. One of the key objectives in the RPIP is to increase coverage of care by skilled providers during pregnancy, childbirth, and postpartum period (MOHFW/GOB, 2008). Improving maternal health service provision requires adequate resource allocation and strategies to address both the supply side and demand side barriers for maternal health services. On the supply side, 1 The Bangladesh Bureau of Statistics estimates MMR at 351 for 2007 from the Sample Vital Registration System (BBS, 2008). 1 Costing of Maternal Health Services in Bangladesh 1

24 ongoing strategies in Bangladesh include upgrading of public sector health facilities to expand provision basic and emergency obstetric care services, and scaling up the training of community skilled birth attendants (CSBA). The Ministry of Health and Family Welfare (MOHFW) is currently implementing a demand side financing (DSF) pilot based on a maternal health services voucher scheme in 33 subdistricts. The vouchers cover care from designated providers for three antenatal check-ups, delivery (normal or complicated, including c-section), and one postpartum check-up, as well as a cash allowance for transport cost, food and a gift box for the mother. The success of the DSF scheme underpins plans for its expansion to additional areas of the country. Effective planning and budgeting of health services requires comprehensive information on the costs of service provision, particularly the unit costs incurred by providers per patient visit/treatment episode. Addressing the demand side barriers to accessing maternal health services requires information on the consumer costs for obtaining these services. A full costing of the maternal health services covered by the DSF pilot, including both provider and consumer costs, can help improve the design and budget allocation of the DSF, as well as any comparable national maternal health financing plan. In addition, such information can help estimate the required financial resources to achieve the targets related to MDG 5. However, in Bangladesh, there are no comprehensive data on unit costs of key maternal health services such as antenatal care (ANC), normal/vaginal delivery, c-section, postpartum care (PPC) and interventions for managing complications such as eclampsia, postpartum haemorrhage and post abortion complications. In early 2009, the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) commissioned a study of the costs of maternal health services in the public, private, and NGO sectors in Bangladesh. The study was conducted by Abt Associates Inc., a US-based international research and technical assistance organization, and the Bangladesh-based Research, Training and Management International (RTM). The purpose of this activity was to provide valuable information to the MOHFW and its Health Economics Unit (HEU) to support the planning and budgeting for maternal health services. A stakeholder workshop was conducted in Dhaka in June 2009 to share the methodology, objectives, and other technical aspects of the study. Technical experts and other stakeholders participated in the workshop. This participatory process was designed to ensure quality and relevance of the study, and to encourage buy-in and consensus building regarding all technical aspects of the study. STUDY OBJECTIVES The overall objective of this study is to provide information on the full economic costs of maternal health service delivery and to project the total costs of achieving coverage of health services associated with MDG5. The specific objectives of the study are: To estimate the current unit costs of providing key maternal health services including: ANC, normal (vaginal) delivery, postpartum care 2, c-section, care for post abortion complications, postpartum haemorrhage and eclampsia at the facility level by public, private and NGO providers at various levels (primary, secondary and tertiary) 2 Postpartum care is sometimes referred to as post-natal care for the mother. Generally, the term post-natal care refers to services for the baby. 2 Costing of Maternal Health Services in Bangladesh

25 To estimate current total consumer costs of receiving the same set of maternal health services at the facility level. To estimate the provider and consumer costs of home-based delivery (including essential newborn care) by a skilled provider. To estimate the normative costs of maternal health services based on treatment standards for quality service provision. To project total costs of maternal health services required for achieving the MDG/Poverty Reduction Strategy (PRS) targets, based on these costs This report is organized as follows: the remaining sections of the Introduction provide and overview of maternal health services provision in Bangladesh, and a review of existing costing studies for maternal health services; Part 1 presents the provider unit cost results; Part 2 presents the results on costs to consumers; Part 3 compares the actual (current) and normative costs of maternal health service provision; and Part 4 presents the costs of maternal health service provision for achieving the MDG/PRS targets. MATERNAL HEALTH SERVICES IN BANGLADESH Bangladesh is divided into 6 divisions, which are further divided into 64 districts, 508 sub-districts (known as upazilas in rural areas and thanas in metropolitan areas), 4,484 unions (counties) and villages. The population in an upazila ranges from 200,000 to 450,000. Maternal health services in Bangladesh are provided through both facility and community-based approaches, by the public, private for-profit, and NGO sectors. Facility-based services in the public sector are provided at three levels: (1) primary health care facilities at the upazila and lower level; (2) secondary level facilities including district hospitals and other health facilities located in the district/division headquarters; and (3) tertiary level facilities including specialized and teaching health institutions, most of which are in the capital and other large cities. Primary level public facilities include Upazila Health Complexes (UHC), Union Health and Family Welfare Centers (UHFWC), and community clinics (CC). Secondary level public facilities include district hospitals (DH), and Maternal and Child Welfare Centers (MCWC). Private for-profit and NGO hospitals and clinics operate at all level of care. In the public sector, basic emergency obstetric care (EOC) services are available in most health facilities, while comprehensive EOC is available in a few UHCs, most DHs and district-level MCWCs, all medical college hospitals, and one post-graduate institute (Mridha et. al 2009). However, according to a recent health facility survey that categorized providers based on the availability of required drugs and supplies, comprehensive emergency obstetric care services at the public sector primary and secondary level can be effectively provided by only 19% of DHs, 5% of UHCs, and 2% of MCWCs (Tulane University SPHTM and ACPR 2009). Overall, the survey found that only 2% of facilities in Bangladesh could be considered having obstetric first aid components, although 75% of them provide delivery care. Shortage of health care personnel, especially in the rural and lower level health facilities, is another problem for health services provision by the public health sector. This is additionally exacerbated by high rates of health workers absenteeism. Costing of Maternal Health Services in Bangladesh 3