Program Evaluation Improving Access to Delivery Care and Reducing the Equity Gap Through Voucher Program in Bangladesh: Evidence From Difference-in-Differences Analysis Kaji Tamanna Keya 1 , Benjamin Bellows 2 , Ubaidur Rob 3 , and Charlotte Warren 1 Abstract To test a statistically significant change in delivery by medically trained providers following introduction of a demand-side financing voucher, a population-based quasi-experimental study was undertaken, with 3,300 mothers in 2010 and 3,334 mothers at follow-up in 2012 in government-implemented voucher program and control areas. Results found that voucher program was significantly associated with increased public health facility use (difference-in-differences (DID) 13.9) and significantly increased delivery complication man- agement care (DID 13.2) at facility although a null effect was found in facility-based delivery increase. A subset analysis of the five well- functioning facilities showed that facility deliveries increased DID 5.3 percentage points. Quintile-based analysis of all facilities showed that facility delivery increased more than threefold in lower quintile households comparing to twofold in control sites. The program needs better targeting to the beneficiaries, ensuring available gynecologist–anesthetist pair and midwives, effective monitoring, and timely fund reimbursements to facilities. Keywords equity, access, delivery care, voucher, Bangladesh, difference-in-differences Background Underutilized and low-quality maternity services at health facilities are common in low- and middle-income countries (LMIC) and over the past decade, policymakers have been revising policies to address the persistent challenge by adopt- ing demand-side financing (DSF), such as vouchers and con- ditional cash transfers that encourage consumers to seek care from qualified service providers. 1–7 In voucher initiatives, the beneficiaries, usually disadvantaged and underserved popula- tions, are given a subsidy to seek care from skilled healthcare providers. Available evidence indicates that vouchers can improve service utilization and quality among target popula- tions. 1,4,8–12 The strategy can reduce consumer out-of-pocket costs of healthcare and increases demand for services. In Bangladesh, the government implemented a DSF program, enrolling mostly public facilities progressively across subdis- tricts or upazilas. The previous studies conducted in voucher areas showed that voucher was associated with increase in facility-based deliveries. 13–15 Although there is evidence indicating that voucher programs can increase the use of sub- sidized health services, there is a lack of evidence regarding the impact of the voucher on reducing inequitable utilization trends between rich and poor. 4,10,16–19 Primary maternal health services continue to favor weal- thier households in LMIC. 20–22 In Bangladesh, 90% of deliv- eries in the lowest quintile occur at home, whereas only 40% of deliveries in the highest quintile occur at home. 23 In Bangladesh, public facilities are underutilized due to low-quality services, the out-of-pocket burden of medicines and surgical procedures, and transportation cost 24,25 with the result in an estimated annual 7,000 maternal deaths. 26 To increase safe delivery among poor rural women, the gov- ernment of Bangladesh introduced a DSF scheme known as Maternal Health Voucher Scheme in 2006. 15,27,28 The program promotes maternal health services including institu- tionalized delivery and home-based delivery assisted by med- ically trained providers (MTP) to the poor and disadvantaged population in selected subdistricts (upazilas). The MTP cadre International Quarterly of Community Health Education 2018, Vol. 38(2) 137–145 ! The Author(s) 2018 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0272684X17749568 journals.sagepub.com/home/qch 1 Population Council, Washington, DC, USA 2 Population Council, Lusaka, Zambia 3 Population Council, Dhaka, Bangladesh Corresponding Author: Kaji Tamanna Keya, Population Council, 4301 Connecticut Avenue, Washington, DC 20008, USA. Email: kkeya@brandeis.edu