Universally, these indicators, and especially maternal and infant morbidity and mortality, are poorest among low-income populations. Stagnating indicators for several reproductive and child health conditions in many countries of Africa and Asia are a major concern for national governments and development partners striving to achieve the Millennium Development Goals (MDGs).

If the voucher scheme in Bangladesh is found effective, it may help other countries to adopt this approach for improving utilization of maternity care services for reducing maternal mortality. We expect a significant increase in the utilization of maternal health care services by the accredited health facilities in the experimental areas compared to the control areas as a direct result of the interventions. This is a quasi-experimental study which will investigate the impact of the voucher approach on improving maternal health behaviors and status and reducing inequities at the population level. A population-based survey will also be carried out in two types of locations: areas where vouchers are distributed and similar locations where vouchers are not distributed. In-depth interviews with key stakeholders will be conducted to gain a deeper understanding about the program.

Facility inventories, client exit interviews and service provider interviews will be used to collect comparable data across each facility for assessing readiness and quality of care. In Bangladesh, the activities will be conducted in 11 accredited health facilities where Demand Side Financing program is being implemented and compared with populations drawn from areas served by similar non-accredited facilities. Population Council-Nairobi, funded by the Bill and Melinda Gates Foundation, intends to address the lack of evidence around the pros and cons of 'voucher and accreditation' approaches to improving the reproductive health of low income women in five developing countries. At this point in time, however, there is a paucity of evidence describing how the various voucher programs function in different settings, for various reproductive health services. Initial findings from the few assessments of reproductive health voucher-and-accreditation programs suggest that, if implemented well, these programs have great potential for achieving the policy objectives of increasing access and use, reducing inequities and enhancing program efficiency and service quality. Broadly termed 'Demand-Side Financing' or 'Output-Based Aid', includes a range of interventions that channel government or donor subsidies to the service user rather than the service provider. Cost of delivering reproductive health services to low-income populations will always require total or partial subsidization by the government and/or development partners.

Atlasti coupon