Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 1 Maternal Mortality in Kenya and Bangladesh...

Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 1

Maternal Mortality inKenya and Bangladesh

A comparative overview & some analysis

Jean-Olivier Schmidt

Compare - what?


MMR in Kenya and BangladeshMMR in Kenya and Bangladesh





Are we comparing apples and pears....

....”de gustibus non est disputandum”

MDGs: we, ie the World Community, have universally

recognized and accepted MDGs that make it binding for the

countries to achieve these.



Compare – why?• Amartya Sen: What can Africa and India learn from each

other (1987)? “There are indeed a great many lessons to be learnt by India and Africa from the experiences of each other.”

• Kuhn (2011): Routes to low Mortality in poor countries revisited.





1990

Bangladesh: 574

Kenya: 600

2015

Bangladesh: 143

Kenya: 147

2000 2010

Kenya: 418

Bangladesh: 320

Kenya: 488

Bangladesh: 192



OUTCOME

Kenya 418

Bangladesh: 390

OUTCOME

Kenya 488

Bangladesh: 192

10 years



10 yearsOUTCOME

Kenya 418

Bangladesh: 390

OUTCOME

Kenya 488

Bangladesh: 192



OUTCOME

Kenya 488

Bangladesh: 192

Financial Inputs

Kenya: 27 US$

Bangladesh: 15 US$

Kenya: OOP/THE

36%

Bangladesh: OOP/THE

67%

Kenya: GDP/capita: PPP: 1711 US$ Bangladesh: GDP/capita:

PPP: 1600 US$

Outputs by the Health System

K:Institutional delivery/SBA:

43/44%

BD: Institutional delivery/SBA:

20/24%

BD Adult lit. rate: 55%K Adult lit. rate: 87%

Inequity:K: 1 to 5

BD: 1 to 10



Maternal deaths are the most common cause of death(about 1/4) among women 20‐34 years, and is also animportant cause of death for women aged 35‐39 years

Source: BMMS 2010



Maternal deaths are the most common cause of death(about 1/4) among women 20‐34 years, and is also animportant cause of death for women aged 35‐39 years

Source: BMMS 2010



Hemorrhage and eclampsia, despite impressive declines, still cause more than half of maternal deaths

Reasons for fall are several:MedicalSocio‐economicDemographic

Source: BMMS 2010



Medical Causes of decline in MMR since 2001 in Bangladesh

• Reduction in Eclampsia (30% of total decline)•Reduction in Haemorrhage (25%)• Reduction Abortion related (10%)• Reduction of cases of Obstructed labour (3%), among others

These cases require facility based treatment and medically trained birth attendants and staff.

Source: BMMS 2010



Source: BMMS 2010



Source: BMMS 2010



Source: BMMS 2010

What accounts for the increased use of

services?



Improved Access to Health Services:

Numbers of facilities with maternal health services has increasedImproved road transport (roads, bridges, bus services)Mobile phones available nationally, and at low cost Income at national and household levels haveimproved, including among poor households





Demographic patterns explains a big part of the variance between Bangladesh and Kenya. But fertility does not explain all. Socio-economic factors are rather in favour of Kenya, therefore it seems attention should be turned to the medical factors.

How are the standards of institutional delivery effectively met? Qualification of personnel, equipment of facilities?

Geographic distance?

Non proximal factors? Homogeneity, social consensus, “imagined communities” (cf Kuhn 2011)



Caveat: Are definitions and methodologies misleading? BMMS:

“all deaths that occurred during pregnancy and two months after pregnancy, even if the death is due to non-maternal causes."

KDHS



Further initiatives in Bangladesh to work on Maternal Health

Pilot on demand side financing

Costing of health services



Evaluate “demand-side” DSF program impacts on:- Use of skilled providers at delivery, C-section, ANC, and PNCOut-of-pocket expenditures on MH services

Evaluate “supply-side” DSF program impacts on:- Provider skills and knowledge- Facility quality

Objectives of the evaluation

• Pregnant women get all maternal health services for free• Pregnant women get Tk 2000 cash incentive and gift box (value of

Tk 500) for delivering with a qualified provider, and Tk 500 total transport stipend for 3 ANC visits, delivery, and PNC– Qualified providers for delivery are CSBAs and doctors

• Providers/field workers get cash incentives for registering women and providing MH services (ANC, delivery, PNC, complications)

• Control Districts (Upazilas)



DSF Programme Overview

• Large, significant demand-side impacts

Multi-variate: The likelihood of delivery with skilled provider increased by 42 percentage points in universal DSF upazila (vs. control) and by 50 percentage point in means-tested DSF upazila (vs. control)

Out-of-pocket expenditures for ANC, delivery care, and PNC significantly lower in DSF (Tk 1,442) compared to control (Tk 2,191)

• Less supply side-impact Some evidence of quality differences but mostly non-significant Much larger patient volume in DSF facilities, compared to control “Seed fund” utilized to procure drugs and supplies in some cases



Main findings



Comparing cost of DSF program to Benefits:

US $ 161-165: Incremental cost per additional delivery with a skilled provider due to DSF program (includes overhead cost and ANC cost)

US $ 67-76: Average cost per voucher distributed/receipt

Government and development partners will need to compare this cost estimate with other MH programs and opportunity cost in Bangladesh



Costing of Maternal Health Services and MDG5:

Empirical (unit cost approach) and normative costing

Total “price tag” for key maternal health services at coverage levels consistent with achieving the MDG 5 is 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%.

This is a five-fold increase for the annual budget for Maternal health services



Thanks for your attention!

Donnobad! Asante Sana!

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Brown Bag Lunch GIZ Health Programme 31.03.2011. Slide 1 Maternal Mortality in Kenya and Bangladesh...

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