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 Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites.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.
Highlights
Demand-side financing, where funds for specific services are channelled through, or to, prospective users, is employed in health and education sectors in many low- and middle-income countries
‘Demand-side’ financing (DSF) approaches have been seen as means to ameliorate this situation, and have been employed in many different contexts in lowand middle-income countries in attempts to help overcome barriers to access to maternity care
DSF mechanisms have often taken the form either of vouchers that can be exchanged for subsidised goods or specific services [6,7,8], or of short-term cash incentives or reimbursements that are linked to service use [9,10]
Summary
Demand-side financing, where funds for specific services are channelled through, or to, prospective users, is employed in health and education sectors in many low- and middle-income countries. DSF mechanisms have often taken the form either of vouchers that can be exchanged for subsidised goods or specific services [6,7,8], or of short-term cash incentives or reimbursements that are linked to service use [9,10]. Some cash transfers, provided as maternity benefits or allowances, do not impose conditions of uptake of specific goods or services but are assumed to facilitate poor women’s access to them by reducing financial barriers [14]
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