NRDF - National Research & Development Foundation, Peshawar


Reducing Maternal And Neonatal Fatalities among Flood Affectees in District Charsadda through a Voucher Scheme

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District Charsadda, Khyber Pakhtunkhwa


  • Avert imminent crises of maternal and newborn health in district Charsadda amongst the poorest of the poor
  • Implement an already proven strategy for demand-side financing of maternal health services for saving lives of mothers and newborns
  • Broaden the scope of the project to community, family and men in particular for changing behaviors vis-à-vis women’s rights to health services
  • Table the case in concerned policy circles for demand-side financing of health services along with supply-side subsidies; and
  • Provide evidence for an effective entry-point for empowering women

Project Period:

June 2010 to July 2012



The 2010 flooding has brought destruction and misery to the people of Pakistan at an unprecedented scale. Khyber Pakhtunkhwa, which was already economically poor as compared to other provinces and struggling to grapple with the issue of terrorism, faced the first onslaught of flooding. By the time the heaviest flooding had moved southward, a big part of the province was affected while the district of Charsadda was among the worst hit. According to government figures, one-third of the population of Charsadda was directly affected by flooding. Now, after a year, the flood affected population of Charsadda has returned to their respective areas and trying to rebuild their shattered lives. Food and shelter, in other words surviving through each passing day, are their ultimate concerns. Health in general and maternal health in particular which were already neglected are now given least importance. If expecting mothers are not supported for their antenatal, delivery and postpartum needs, it could have serious bearings on an already meager status of maternal and neonatal health in the district.

The mortality and morbidity rate during pregnancy and child birth are very high in Pakistan as compared to the rest of the world. The maternal mortality ratio in the country is approximately 340 deaths per 100,000 live births in urban areas, and as high as 700 deaths per 100,000 live births in rural areas (Jalil, 2004). Neonatal health has only recently been identified as a public health priority in Pakistan. Some five million children are born in Pakistan each year, and approximately 225,000 die before they reach one month old (Jalil, 2004; Bhutta & Rehman, 1997).

The major reasons for the phenomena included poverty, lack of female doctors and absence of fully equipped health facilities particularly in rural areas of the country. The social norms also forbid pregnant ladies to go for regular check up to male doctors. They very often receive a negative response from their husbands and in laws to seek medical services during pregnancies on one or the other pre-text. The community and religious leaders are believed to play a key role in shaping up these behaviors. In addition, the married women, their families and the traditional birth attendants hardly realize the importance of preparing and planning for a delivery or for any potential health emergencies during birth. Furthermore, very few of them are aware of the complications of deliveries including fever, prematurity, respiratory problems and cord infection. The level of awareness of peri-natal and post-partum problems, unsafe deliveries, new born care, family planning services and frequent and high risk pregnancies, sexually transmitted diseases and psychological traumas are also very nominal and often confused by the traditional birth attendants. The public health sector is providing the bulk of health and preventive service in the country including to the poor communities in the rural setting of Charsadda.

However, these facilities are underutilized due to the absence of qualified female staff, modern equipments, medicines, ambulance service and lack of clean drinking water and privacy for female visitors. As a result, the general public is increasingly inclined to seek health services from the private sector which beside others also involved exorbitant costs. A vast number of people living under the poverty line (45 %) cannot afford these inflated costs and at the same time face difficulties to cover long distances to avail health facilities in the government run set ups particularly in the aftermath of last year floods which has further compromised their options to do so. The reason is that a large number (1 RHC, 4 CDs, 9 BHU’s and 1 MCH center) of health facilities received phenomenal damages in the 22 hard hit union councils of the district which has a very negative impact on the health of local population. It is pertinent to note that the district have 1 each DHQ and THQ hospital, 3 RHC’s, 45 BHU’s, 7 CDs and 1 MCH center to provide health services to the entire population of the district particularly to the under privileged communities. Most of these facilities are ill equipped and under staffed. Thus the deteriorated conditions of these facilities and alarming status of mother and child health in Charsadda district necessitate an urgent need for action to save the mother and child lives in the district.

An innovative and effective way to avert the imminent crises of maternal and newborn health in district Charsadda is through demand-side financing mechanisms or a voucher scheme. Vouchers transfer purchasing power to specified groups for defined goods and services in order to increase access to specified services. This is an important innovation in health care systems where access remains poor despite substantial subsidies towards the supply side. Vouchers are targeted at identified underserved groups (such as the marginalized), for specific services (such as reproductive health and family planning). While some countries have run voucher programs for education or for food supplementation for the poor for many years, the U.S. Food Stamp Program is one example. More recently, it has become an effective mechanism of targeting essential health services to specific population groups, such as pregnant women. The interest in voucher schemes for demand-side financing of health services in developing countries is more recent, with programs taking place over the past decade or less in Bangladesh, China, Kenya, Nicaragua and Uganda, among others. The scheme in Bangladesh showed that incentives provided through the voucher system motivated public providers to offer a higher level of services and beneficiaries also expressed their overall satisfaction.

The provision of health care in the public sector is largely financed through supply side subsidies. Low-priced or officially free public health care is intended to ensure the entire population’s access to care. However, even in Pakistan there is evidence that people, including poor, seek better-quality health care in the private sector and pay out of pocket. Due to difficulty in reaching certain population groups, the low quality of some public health care, informal payments, and other reasons, supply-side interventions often under serve the poor. Evidence now shows that in many developing countries, even where public care is officially available free of charge; the poor seek better quality health care in the private sector on payment basis. Voucher programs, if well designed and well administered, can help achieve a broad range of common reproductive health and family planning policy goals, such as improving equity, efficiency, quality, access, and choice in health care services.