Do essential service packages benefit the poor? Preliminary evidence from Bangladesh.

In 1998 Bangladesh began a sector wide approach (SWAp) to the extension of health care to vulnerable groups in the country. The central feature of this approach is the funding of an essential service package (ESP) emphasizing maternal care, certain communicable diseases and child health. This study examines the way in which public sector expenditures are distributed by comparing the actual beneficiaries of spending with the target groups identified by the sector strategy. It finds that while the ESP is helping to target resources at priority services, considerable barriers to access by vulnerable groups persist. The study suggests a number of issues that need to be addressed to improve the performance of the programme. First, improved targeting requires greater emphasis on the process of access to key services. Secondly, improving the efficiency of service provision at primary level is a key element to increasing access, since individual primary providers are often not ready to provide the standard of care required by the ESP approach to services. Finally, the system of financial control and management needs to be modified in order to make allocations more responsive to the priorities determined by the SWAp. Given the widespread adoption of the ESP approach to health care, the paper also suggests a wider research agenda that examines its impact in other countries and evaluates this worldwide experiment in health service prioritization.