“I didn’t go to the health center because it took a long time, and on top of that they treated me badly,” recounted a Quechua woman in the town of Oruro, Bolivia. “We have our own customs for childbirth”.
She is not alone in those views. According to a recent national survey, the main reason why women avoid prenatal care is distrust of health personnel (26 percent). Other reasons include the distance they must travel to reach the health facility (21 percent), lack of time because they are busy with children or work (12 percent), and opposition from their spouse or family (6 percent).
In 2009, the Bolivian government initiated a conditional cash transfer program, known as the Juana Azurduy Voucher Program, designed exclusively to encourage the use of preventive health services by pregnant women for themselves and their children aged under two.
The program uses conditional cash transfers (CCTs), delivered through a voucher, which have proven effective in increasing the demand for health services.
However, as with many countries, the program’s weak spot is access to and quality of health services, which affects the program’s potential impact in terms of development.
Experience has shown that ultimate improvement in maternal, neonatal, and child health can be achieved only if incentives to increase demand, are accompanied by policies and investments that bolster the supply of these services.
The Inter-American Development Bank (IDB) played an important role in supporting the operational implementation and improvement of the Juana Azurduy Voucher Program investing $5.1 million between 2010 and 2013. Investments were also made in primary care supply services, infrastructure, equipment, and the training of health personnel.
The IDB program repaired and equipped 29 centers and health clinics in selected rural areas, including birthing rooms adapted to the local culture and a solar-powered hot water supply. Eight maternity houses were built, which allow pregnant women to stay near the health center in the days leading up to birth.
To improve the responsiveness of health personnel and quality of care, six departmental classroom training centers were created, equipped with modern technology for practical teaching. An online platform was created to train personnel through online courses. Some 1,516 people have trained at a primary care level.
IDB’s support to the Juana Azurduy Vouchers program funded cash transfers to 69,258 women and children, and supplied identity documents or birth certificates for 3,861 women and children—a requirement to register for a voucher. Today, 33 percent of pregnant women and 50 percent of children under age two are enrolled in the program, although many of those eligible have yet to enroll.
DID THE PROGRAM WORK?
To evaluate the impact of the voucher scheme on demand for health services two methodologies were used.
The first was a discontinuous regression based on the child’s age. The second was a model of fixed effects at the sibling level.
The findings show that pregnant women receiving the vouchers visit a health center at an earlier stage in their pregnancy than those who do not, which promotes proper nutrition for the mother and fetus.
Women who do not participate in the voucher program wait on average until the 13.6 week of pregnancy to have their first prenatal check-up, while those using the voucher visit the health center at week 11.3.
The probability of completing four prenatal visits increased from 74 percent to 84 percent. In rural areas, 60 percent of women allow their delivery to be attended by trained health personnel; this average increased to 63 percent for women participating in the voucher program.
Due to the increase in prenatal visits, children in urban areas have had higher birth-weight. In turn, the likelihood of being born with a low birth-weight decreased from 10 percent to 2 percent.
The estimated rate of stillbirths among women enrolled in the voucher program decreased by 11 percent, indicating a possible reduction of child mortality during birth.
Evaluators were unable to detect positive results in other final indicators, which indicate that the quality of services, and the correct application of protocols by health personnel, remains a challenge for the sector in Bolivia.
The voucher program has a long way to go to increase its coverage of pregnant women and children under age two; and to improve the technical elements of the final payments, the composition of transfers, and the operational design of the payment system.
However, the voucher program has achieved the objective of a conditional cash transfer: it has increased the use of health services! Furthermore, the country is making valuable public policy decisions based on evidence, allowing for a thorough evaluation of the program’s effects. The impact assessment can be used to enhance the voucher system, which is already improving the lives and health of hard-to-reach women and young children.30
This story is part of our impact evaluations included in the document: Development Effectiveness Overview, a publication that that highlights the lessons and experiences of IDB projects and evaluations.