Paying for reproductive health services in Bangladesh: intersections between cost, quality and culture.

Abstract

In 1997 a consortium of non-governmental organizations (NGOs) in Bangladesh began to implement health sector reform measures intended to expand access to and improve the quality of family planning and other basic health services. The new service delivery model entails higher costs for clients and requires that they take greater initiative. Clients have to travel further to get certain services, and they have to pay more for them than they did under the previous door-to-door family planning model. This paper is based on findings from a qualitative study looking at client and community reactions to the programme changes. It examines a number of barriers to access and constraints to cost recovery, including gender, class and ideas about entitlements, the role of government and obligations among people. The NGOs want to maximize cost recovery while making the basic services they offer accessible to most people. The findings suggest that this requires more than the establishment of an appropriate pricing structure. Attitudes related to charging and paying for services must also change, along with the institutional policies and practices that support them.

Full text

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Introduction
The public provision of health and family planning services to
the poor at no charge (or for a nominal cost) is common in
low-income countries. Policy-makers, providers and clients
alike tend to agree that the quality of these highly subsidized
services is inadequate. And because free services and health
commodities are often under-funded, and therefore insuffici-
ent to meet demand, they are vulnerable to informal gate-
keepers who collect unofficial charges (Saha and Bartlema
1998: 160).
Policy-makers often view cost recovery as a necessary com-
ponent in improving the quality and financial sustainability
of services. The client should have greater rights and
ability to demand higher quality if he or she is ‘the payer’ or
‘partial payer’, at least in theory. Even the poor may benefit
from a system in which they are required to pay more if
the system becomes more predictable and transparent, and
their decisions about service utilization are based on better
information.
Various studies suggest that willingness to pay is contingent
on the perceived quality of the services and may be enhanced
by introducing quality improvements (Litvack and Bodart
1993; Yazbeck 1995; Alderman and Lavy 1996; Hotchkiss et
al. 1998; Hardee and Smith 2000). However, in many
societies, the idea that the poor are entitled to free services is
common, and introducing charges for services or commodi-
ties (like contraceptives or medications) that were previously
free or available for a token payment is no simple matter. In
cases where utilization of basic services declined following
the introduction or augmentation of fees, it is often not clear
from the literature to what extent these declines were due to
clients’ inability to pay as opposed to their unwillingness to
pay based on their perceptions of service quality (Hotchkiss
1998). If it is true that, in many settings, improving service
quality prevents a drop in utilization when prices are raised,
then it becomes essential to understand what constitutes
quality from client perspectives.
In 1997 the Bangladesh Government issued a new Health and
Population Sector Strategy. The Strategy calls for various
reforms, including greater integration of family planning with
health, a focus on users of services rather than demographic
targets, improved quality of care and a wider range of repro-
ductive health services, with increased attention to maternal
and adolescent health care, provided as part of an ‘essential
services package’ (ESP). A consortium of non-governmental
organizations (NGOs) supported by the US Agency for Inter-
national Development (USAID) has moved ahead of the
government in implementing the ESP approach. The NGOs
have discontinued or cut back door-to-door contraceptive
distribution in favour of offering a wider range of services
through clinics and satellite clinics, with village depots for
re-supplying contraceptives in rural areas. The NGOs have
also invested in technical and management training, insti-
tuted standards and protocols, and made physical improve-
ments to the clinics. Users are being charged modest fees for
these services, many of which used to be provided free of
charge or at lower cost, and some of which (mainly contra-
ceptives) used to be delivered to their homes. The higher
quality and greater range of services available from the
NGOs are intended to attract clients and increase the health
impact of services. But for this to happen, the intended users
must be willing and able to take more initiative and to bear
HEALTH POLICY AND PLANNING; 17(3): 273–280© Oxford University Press 2002
Paying for reproductive health services in Bangladesh:
intersections between cost, quality and culture
SIDNEY RUTH SCHULER,1LISA M BATES2AND MD. KHAIRUL ISLAM3
1JSI Research and Training Institute, Arlington, VA, USA, 2Harvard University School of Public Health, Boston, MA,
USA and 3PLAN International, Dhaka, Bangladesh
In 1997 a consortium of non-governmental organizations (NGOs) in Bangladesh began to implement health
sector reform measures intended to expand access to and improve the quality of family planning and other
basic health services. The new service delivery model entails higher costs for clients and requires that they
take greater initiative. Clients have to travel further to get certain services, and they have to pay more for
them than they did under the previous door-to-door family planning model. This paper is based on findings
from a qualitative study looking at client and community reactions to the programme changes. It examines
a number of barriers to access and constraints to cost recovery, including gender, class and ideas about
entitlements, the role of government and obligations among people. The NGOs want to maximize cost
recovery while making the basic services they offer accessible to most people. The findings suggest that this
requires more than the establishment of an appropriate pricing structure. Attitudes related to charging and
paying for services must also change, along with the institutional policies and practices that support them.
Key words: health care reform, user fees, NGOs, reproductive health, gender, culture, ability to pay, willingness to pay, cost
recovery, Bangladesh

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the added costs – the direct charges for services and com-
modities, as well as the monetary, psychological and (for
some) social costs of accessing them.
Research conducted prior to the programme change had
provided some evidence that it would be possible to institute
modest increases in fees for contraceptives and maternal and
child health (MCH) services without undermining utilization
(Quayyum et al. 1997a, b; Levin et al. 1999; Routh et al. 2000).
Based on this evidence, the NGOs set initial prices which
were to be adjusted later, if necessary, based on experience
and on findings from additional studies that were underway.
The NGOs work in areas allocated to them by the Bangladesh
government; thus they have instituted user charges (albeit not
consistently) for services that are available for free at clinics
and satellite clinics in other jurisdictions, in some cases
nearby. The NGOs’ ability to attract clients may depend to a
large extent on their ability to provide higher quality services
than those the public sector provides.
This paper presents community and client perspectives
regarding service quality and user charges for basic family
health services in urban and rural areas of Bangladesh. It
discusses factors influencing both ability and willingness to
pay for services, such as poverty and gender inequality, but
also ideas about the role of government, and the influence of
past and present policies. The findings come from a multi-
method, qualitative study assessing the effects of the new
NGO service delivery strategies on patterns of utilization,
client-provider relations, client satisfaction, and household-
level decision-making about family planning and other repro-
ductive health services.
Data sources
The sites were two urban and three rural areas where the
transition from home to clinic-based services was underway,
and one area where household delivery of contraceptives was
still in effect under the government’s management. The NGO
sites were selected in collaboration with USAID and the
NGO consortium, and were considered average in terms of
performance. Within the five NGO sites, data collection was
focused in two to three sub-areas, one within a 1-mile radius
of the clinic, and one to two between 2–4 miles away, where
satellite clinics were regularly held. Both users and non-users
of the NGO services were asked about their experiences and
perceptions of the range of service providers available,
including but not limited to the NGOs implementing the new
service delivery model.
The data were collected by five female and two male field
researchers who were experienced and well trained in quali-
tative methods. Teams of two to four researchers made
multiple visits of 2–3 weeks to each site between January 1998
and July 2000. Respondents were asked about their experi-
ences prior to policy changes as well as recent experiences.
Both open- and closed-ended questions were used. Criteria
for assessing quality of services were ascertained from spon-
taneous comments about their experiences with various types
of providers and decision-making regarding the use of various
health services. Direct questions about specific dimensions of
quality were also asked of recent clients (e.g. general ambi-
ence and cleanliness of the facility, the range of services
provided, privacy, technical competence of staff, content and
tone of communication with clients).
This paper is based on approximately 500 transcripts from
in-depth, semi-structured interviews, 30 of which were group
discussions. In addition, researchers’ unstructured ethno-
graphic field notes were collected and analyzed. Respondents
were identified through both convenience and purposive
sampling, using the ‘snowball’ method, key informants and
service records. Although random procedures were not used,
efforts were made to ensure representation of key population
subgroups, including individuals who had never used the
NGO services. The researchers used an ethnographic data-
base program in thematic coding.
Quality and willingness to pay
In Bangladesh the poor are known to spend money on various
sources of health care, including traditional practitioners,
pharmacies and non-accredited village doctors. Even in
government facilities where services are officially available
for free, charges are often collected informally (Government
of Bangladesh 1999; Killingsworth 1999).1Thus, one might
assume that most poor people would be willing and able to
pay a modest charge for basic services in NGO clinics if they
perceive the services to be of adequate quality.
Our study findings generally confirmed that people are
prepared to travel further and pay more for higher quality
services and that NGOs are effectively addressing key aspects
of quality that clients value. Paramount among these is the
interpersonal dimension of quality – treating clients kindly,
tactfully and with respect, whether poor or comparatively
better off (Bates et al. 2000; Schuler et al. 2000). The primacy
of client–provider communication in client assessments of
quality has been documented in many other studies world-
wide (Gallen and Lettenmaier 1987; Raymundo and Cruz
1993; Haddad and Fournier 1995; Murphy 2000).
But, not surprisingly, respondents in our study were not
always willing to pay for a particular service, nor equally
disposed to pay for all types of services, and this fact may have
wider implications than the designers of the new strategy
anticipated. Our findings suggest that poor people’s willing-
ness to pay for health and family planning services is best
understood in the context of their health-seeking strategies
and the cost–benefit calculations that they commonly employ.
Gender inequality is one factor influencing these strategies
and calculations. Another is the government’s past and
present policies, in response to which people have formed
certain ideas about the government’s agenda and its roles and
responsibilities, particularly towards the poor. Notions about
obligations among people, and the importance of looking out
for one’s own, influence health-seeking strategies and willing-
ness to pay insofar as people are unwilling to pay when they
feel it is not right to charge them. These topics are explored
below.
274 Sidney Ruth Schuler et al.

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Health-seeking strategies of the poor
Reliance on free and low cost services
Interview findings suggest that poor families tend to make
significant expenditures for health only in the context of
health problems seen as life-threatening or problems that
interfere with the family’s ability to generate income. “Many
people need to go to the hospital but don’t. They sit and wait
for their diseases to get worse,” said a middle-aged mother of
six in one of the rural sites.
When they do seek health services, many people reported
sacrificing considerable time and effort to get them for free
or at the lowest possible cost. Some had travelled long
distances, often on foot, undergone long waits in crowded
government facilities and gone to a variety of different places
(including but not limited to government facilities) for
different health needs in order to get services and commodi-
ties at the lowest cost. The findings also show that many of
the poorest have long been dependent on the government for
reproductive and other health services. Low-income respon-
dents described many limitations of the government health
system, but also made it clear that they were grateful to get
free or nominally priced health care even if obtaining it was
difficult or unpleasant.
Unwillingness to spend on women’s health care
Social restrictions on women’s mobility appear to have
relaxed considerably. In all six study areas, it had become
quite common for women to go to clinics for family planning
and other preventive and minor curative care, for themselves
and their children. (The data suggest that women’s increased
ability to go to health facilities is a consequence of economic
opportunities that have drawn women into the public sphere
as well as widespread acceptance of family planning and
other preventive health measures – two trends amply docu-
mented throughout the country.) But families are often
unwilling to spend much on preventive care and treatment
for women. Because of gender inequality and women’s
exclusion from many types of wage employment, the thresh-
old for defining a health crisis tends to be high for women.
“They tell their wives to disregard it since it is already there
and the family’s work is still getting done,” said one rural
woman resignedly.
A man told the researchers that he used to get angry when his
wife went out of the house by herself. He no longer cared
about that, he explained, but he did not want to have to spend
what little money he had on his wife, and that is why he didn’t
like her going to doctors. Another man, an agricultural wage
labourer without any education, said defensively: “I can’t
manage to provide food properly so how will I manage
medical treatment for my wife? She has a father and a brother
– let them take care of it!”
Men’s reluctance to spend money on their wives’ health care
extends to family planning as well. Compared to research
from a number of years ago (Schuler et al. 1996), our findings
suggest that men’s appreciation of the importance of fertility
control for their family’s welfare has increased. Yet they
remain reluctant to pay much for it. One urban woman, who
switched from oral contraceptives to contraceptive injections
because of side effects, was warned by her husband: “you
never know what type of problems may arise”, but he did
not forbid her from using the method. When she then had
menstrual problems, her husband became very angry and
scolded her repeatedly, despite her own efforts to improve
her condition by resuming pills. He refused to take her to a
doctor, saying, “you have taken the injection, so you suffer”.
Family planning continues to be considered a women’s
concern, probably in part due to the targeting of women
throughout the government’s fertility reduction programmes.
Those interviewed often said that women were expected to
bear their pain, especially in families living on very low
incomes, and that they sometimes chose to do so rather than
squander the family’s resources (as they saw it). Because they
could not justify, to themselves or their families, the antici-
pated expenses of dealing with contraceptive side effects,
women worried by their symptoms often discontinued using
contraception or switched methods.
Power and personal relationships
Poor respondents often relied on personal relationships to
get access to health services or to get better services for a
lower price. And the existence of a personal relationship
often influenced the choice of provider as well as expec-
tations about payment. That one is likely to receive poor
treatment in health facilities without the intervention of a
personal friend, relative or other advocate connected with
the facility is a theme that recurred repeatedly in interviews
about health care decision-making and utilization, and many
women reported seeking these types of advocates.2Indeed,
many aspects of life in Bangladesh are shaped by
patron–client relationships, and a poor person’s ability to
get access to resources typically requires a link with someone
more influential (see Hassan 1999). A recent study on
unofficial payments in government health facilities found
that the collection of such fees was ‘open to local restraint
exerted through personal connections and patient/family
reputation’ (Killingsworth 1999: 158).3“Only the wealthy
can get good health care” was a frequent lament among
participants in our study, both in individual and group inter-
views. Respondents said that service providers would not
dare to “misbehave” (by overcharging) those who were
economically influential, and that the better off and more
educated “know how to talk” with the service providers. The
comparatively wealthy were also more likely to be personally
acquainted with doctors or to have a kinship tie to them. A
rural woman complained:
“We [poor people] have to buy medicine but they [the
rich] get two saline instead of one. If a rich woman comes
they will take plenty of time to examine her, but I will not
get any special favours. Probably they [the rich] are able
to do something if they do not get good treatment. They
will protest, saying that if the government hospital takes
money [bribes] we will not go there for treatment . . . .
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Then they [the doctors] take care of them properly. But if
we ask for medicine they say they have run out, and we
should go out and buy it.”
When faced with a health crisis the poor often appealed to
better-off patrons in the community to help them arrange or
pay for care. For example, a boy in one of the research
villages had severe pain in his ear. His father took him to a
district hospital, where they felt they were being ignored.
After waiting a long time they left the health centre and
called upon the son of a wealthy merchant who was a local
political leader. The young man obliged by going with them
to the hospital. According to the boy’s father, the man spoke
forcefully to the doctor, instructing him to give the child
proper care. The father was satisfied with the treatment they
then received.
Institutionalizing kindness and equity
Our overall sense from interviews is that people generally do
not expect kindness or respect from health service providers.
Clients generally saw compassion towards the poor as an
individual character trait, one that is highly valued but
unrelated to job responsibilities. Some clients in the NGO
clinics, by contrast, commented that the staff’s kind behav-
iour towards them was intended to attract them – that the
staff have to be nice in order to build up a clientele and avoid
clinic closure and the loss of their jobs. This attitude may
signal an emerging ‘consumer awareness’ that, in the long
run, could contribute to better quality of care by forcing
providers to compete for clients amongst an increasing
number of health care options available to rural and urban
residents.
Indeed, we were surprised to find that most users of NGO
clinics said the staff treated everyone well, regardless of social
status. For example,
“I am on familiar terms with all of the staff because I have
been there so many times, but I don’t think they do extra
favours for me just because I am familiar. They treat me
as they treat others. Whoever comes first is seen first. They
see me according to my serial number. It doesn’t matter if
someone is rich or poor, known or unknown to them.”
(urban woman)
“They treat you based on your illness. If you have a
serious problem they may give you four sets of pills, and
if it is minor, only two. It is not a question of rich or poor
– rich and poor alike must buy a ticket, and it costs only
15 taka!” (rural mother of three)
Policies, norms and expectations
Government’s role as health care provider
Many of those interviewed conveyed a sense of resignation,
saying that the poor generally lacked access to health care,
but that little could be done to alter this. Others expressed
feelings of indignation at the injustice of this situation,
protesting that the government was failing to fulfill its
responsibility to the poor. This sense of entitlement was
sometimes extended to NGO services as well, perhaps
because reproductive health services provided by NGOs tend
to be so similar to those provided by the government that
many clients did not know the difference. (The NGOs’
adoption of the same green umbrella logo that the govern-
ment uses to show that the ESP is available has probably
contributed to this confusion.) An urban woman who worked
as a vendor complained about the NGO service charges:
“They used to provide treatment according to government
policy [i.e. free of charge], but now they say ‘give me ten taka
and I will examine you.’”
The NGOs in this study are providing family planning and
basic health services (the ESP) in geographic areas where the
government has assigned them to work. In many of these
areas, people are now obliged to pay for contraceptives and
other essential services they previously received for free or at
a lower cost. This was a less significant problem for women in
the urban sites, where a variety of government, NGO and
private sources of health care are available in relatively close
proximity. In rural areas the transportation and time costs are
more likely to limit the feasibility of going to a government
facility to get free services, and some felt it was arbitrary and
unfair that they should have to pay for what the government
provided for free in neighbouring jurisdictions. One rural
woman complained, “Where my mother lives they provide lots
of medicine [without charge], but here [in the NGO clinic] they
provide nothing, not even two tablets . . .”
In some cases rural people who had travelled to government
facilities were turned away and told to use the NGO services
in their own administrative area. The government health staff
may have been doing this to support the NGOs and their new
programme, or to comply with the government’s system for
tracking contraceptive distribution. In any case, the study
respondents thought it was unfair, and they resented the way
they were treated by government health staff. One woman,
who had walked a long way to get free contraceptives, com-
mented, “The apas [‘sisters’ – in this case health staff] seemed
very angry with me. They asked me angrily, where do I live,
why have I come, etc., etc. It wasn’t only me. A woman came
from another village and they were asking her why she had left
her village and come there. In the end they did not give that
woman her injection. I felt really bad for her . . . . Doctors
should not act that way. They should be cool tempered. They
are not giving us their own things, they are giving things
allocated by the government, and they are getting their salary
from the government.”
Psychological impact of fertility reduction policies
In addition to free contraceptives and related services, the
Ministry of Health and Family Planning has, for years,
provided payments to people who adopt long-acting contra-
ceptive methods (sterilization, IUDs and more recently
Norplant) to compensate them for travel costs and forgone
wages, which may make contraceptive use prohibitive for the
very poor. Clients have come to expect compensation for
using clinical methods even though they do so on their own
volition and for their own benefit, making it difficult for the
276Sidney Ruth Schuler et al.

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NGOs to charge clients, particularly for long-acting methods.
Believing the government wants them to use contraceptives,
some people feel that they should not have to pay for them or
for treating side effects (Schuler et al. 2001). As a rural
woman with five children commented: “When I need medi-
cines for my menstruation which stopped because of taking the
injection, they want money. Aren’t they supposed to give medi-
cines free? It was caused by the injection!”
Another woman having problems with contraceptive injec-
tions complained: “It was the same when I used to take pills
(oral contraceptives). Then too the apas would say that they
would give medicine for the physical weakness, but only if I
paid for it. I say that if we have to give money, we should take
it from [a private] doctor.” In other words, why pay money to
those whose job it is to get women to accept family planning?
Equation of health care with pharmaceuticals
“I have paid the doctor just to talk to her about my illness
. . . . They don’t give you medicine here. They don’t give
medicine anywhere anymore, not even at the government
hospital! All of the medicines are being sold outside [i.e.
government supplies are sold illegally]. Nobody shows
any compassion for the poor. I did not ask her for medi-
cine because I had heard before that they did not provide
[free] medicine . . . . It is senseless to write prescriptions
for poor people like us. If we can’t buy the medicine then
what good is a prescription?!”
This woman’s outburst contains two important themes that
emerged in all of the sites. One is poor people’s sense of
entitlement to some level of health care and the frustration
and resentment that result when they feel they are not receiv-
ing it. This frustration is illustrated in some of the remarks
presented earlier, to the effect that providers are corrupt and
prejudiced against the poor. The woman quoted here did not
even ask for assistance in getting medications because she
assumed her requests would be denied. Second is the tend-
ency to equate healthcare with medication. Ironically, the
same woman also praised the doctor’s treatment of her,
showing that she valued the quality of her interpersonal
exchange with health facility personnel. Yet, this aspect was
overshadowed by the fact that the providers recommended a
treatment that was beyond her reach.
In interviews about health care utilization and decision-
making, respondents from the poorest economic groups often
said they preferred to go to government facilities because free
medicine was available there. As a pregnant woman from the
rural areas put it, “We are poor people. We will go wherever
we can get medicine for the least amount of money.” Many
people spoke of health clinics as if they were government-
subsidized pharmacies where the diagnosis as well as the
treatment is provided ‘over the counter’. For problems seen
as relatively minor, including most reproductive health issues
and common illnesses, what made one facility superior to
another (from the client point of view) was whether drugs
were available, and whether they could be obtained for free
or at a nominal cost. The following quote from a field
researcher suggests that both staff behaviour and clients’
priorities are to blame for the equation of healthcare with the
dispensing of medications:
“Although there was a stool next to the paramedic for
clients, no one felt it necessary to sit there. All the women
were talking about their problems and the paramedic was
giving out medicine accordingly. I saw [the client I was
interviewing] standing beside the paramedic and telling
her something. Without looking at the client, the para-
medic gave her some tablets wrapped in paper and said
something to her . . . . Within a minute [the client]
emerged from the room smiling, and came over to talk
with me . . . . Sometimes she had to return from the clinic
without medicine, and often they gave very few pills but
today she got more so she was happy, she told me. ‘The
medicine of this clinic is very effective. We get good results
from taking it. But there is a problem here. The [staff] do
not come regularly and they do not provide the medicine
properly’ she explained, ‘We hear that they sell the good
medicines. They used to provide a whole packet of medi-
cine for children’s fever and cough but now they divide it
among five people.’ She explained the irregular attendance
of the staff by saying, ‘If they come they have to provide
medicine, and if they came every day their supply would
run short.’”
This comment also shows the common perception that
getting drugs and vitamins from government facilities
depends on the whim of clinic staff, which women saw as
symptomatic of corruption and discrimination against them
as poor people. We did not find the same level of acrimony in
connection with access to medicines in the NGO clinics, but
medicine was, nonetheless, a frequent concern. One 25-year-
old woman with primary level education believed that the
medications she received from the NGO clinic were ineffec-
tive because her symptoms had not resolved. She assumed
she was being taken advantage of because she was poor:
“There are [accredited] doctors in the [NGO] clinic but they
do not give us the good medicine; they give to some, otherwise
they would get caught, but only to those who are acquainted
with them. But we can never say anything.” Because women
have become used to leaving government facilities empty-
handed, it may not occur to them to ask that fees for
medication be waived at NGO clinics.
Obligations among people
In contrast to the oft-stated view among the study respon-
dents that the poor typically face discrimination in health
facilities, there was also evidence of a general expectation
that one would not (or should not) be exploited or badly
treated when there was a personal relationship involved.
Cultural norms dictate that people should help their own
when they can. As a result, in a context of widespread
poverty, charging for services and commodities that used to
be free or less expensive may be interpreted as exploitative.
This line of thinking may explain why the local women who
ran contraceptive supply depots in the NGO areas initially
found it difficult to collect relatively nominal charges from
their clients, as well as why some clients were not just
Paying for reproductive health services 277