Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review

Abstract

BackgroundDemand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system.MethodsThe protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis.ResultsThirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems.ConclusionsDemand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.

Do Participatory Learning and Action Women’s Groups Alone or Combined with Cash or Food Transfers Expand Women’s Agency in Rural Nepal?

“…Unconditional or conditional cash and food transfers have also become a popular policy tool for achieving a diverse range of outcomes including social protection (Holmes & Uphadya, 2009) and improvements in health, education and nutrition indicators (Adato & Hoddinott, 2010;Murray, Hunter, Bisht, Ensor, & Bick, 2014). Policies of cash and food transfer programmes usually target female beneficiaries because theoretical and empirical literature suggests that women are more likely to use resources on family and child wellbeing than men (Yoong, Rabinovich, & Diepeveen, 2012) and because such transfers may strengthen women's bargaining power (Yoong et al, 2012).…”

Better Obstetrics in Rural Nigeria study: evaluating the Nigerian Midwives Service Scheme

“…In the longer-term, we recommend that demand-side incentives be incorporated into the scheme. However, this comes with its own caveats: first, it is clear that cash incentives are not a magic bullet (Murray et al 2014); second, while there is evidence that these incentives help to stimulate demand, there is very little evidence that increased use of services translates to mortality reduction (Godlonton & Okeke 2015;Mazumdar et al 2011;Okeke & Chari 2015).…”

“…A significant amount of effort has been devoted to eliminating demand-side barriers, with a growing number of countries implementing programs that provide financial incentives to use maternal and child health services (Murray et al 2014). The Janani Suraksha Yojana in India, the Safe Delivery Incentives Program in Nepal, and the Maternal Health Voucher Scheme in Bangladesh are examples of such programs.…”

Exploring public private partnerships in health and education: a critique

“…For example, within the health sector, systematic reviews of one type of PPP program, health voucher schemes that seek to promote better access to health care services, question their long term impact, particularly in relation to overall health systems. (Nachtnebel et al, 2015;Murray et al, 2014). Similar points have been made in relation to research on education voucher schemes in Chile (Verger et al, 2016) ), but there is little connected commentary on these cross sectoral effects Scholars have argued that questions of equity are not sufficiently addressed through PPP health projects and the issue of accessibility and quality of care remains an on-going challenge (Jehan et al, 2012;Kanya et al, 2014) and similar points are made in relation to a form of education PPPs, where overseas development assistance is spent on low cost private schools, where provision is uneven and many of the poorest children are not reached (Heyneman and Stern, 2014;Härmä, 2016).…”