Abstract
BackgroundCash transfers and vouchers are forms of ‘demand-side financing’ that have been widely used to promote maternal and newborn health in low- and middle-income countries during the last 15 years.MethodsThis systematic review consolidates evidence from seven published systematic reviews on the effects of different types of cash transfers and vouchers on the use and quality of maternity care services, and updates the systematic searches to June 2015 using the Joanna Briggs Institute approach for systematic reviewing. The review protocol for this update was registered with PROSPERO (CRD42015020637).ResultsData from 51 studies (15 more than previous reviews) and 22 cash transfer and voucher programmes suggest that approaches tied to service use (either via payment conditionalities or vouchers for selected services) can increase use of antenatal care, use of a skilled attendant at birth and in the case of vouchers, postnatal care too. The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care, and for vouchers for maternity care services and birth with a skilled birth attendant. However, effects appear to be shaped by a complex set of social and healthcare system barriers and facilitators. Studies have typically focused on an initial programme period, usually two or three years after initiation, and many lack a counterfactual comparison with supply-side investment. There are few studies to indicate that programmes have led to improvements in quality of maternity care or maternal and newborn health outcomes.ConclusionFuture research should use multiple intervention arms to compare cost-effectiveness with similar investment in public services, and should look beyond short- to medium-term service utilisation by examining programme costs, longer-term effects on service utilisation and health outcomes, and the equity of those effects.
Highlights
Prospective users of health services in many countries face financial costs for transport and treatment and opportunity costs of receiving care, and such costs are well-documented barriers for the uptake of maternity care services [1,2,3]
The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care, and for vouchers for maternity care services and birth with a skilled birth attendant
There are few studies to indicate that programmes have led to improvements in quality of maternity care or maternal and newborn health outcomes
Summary
Prospective users of health services in many countries face financial costs for transport and treatment and opportunity costs of receiving care, and such costs are well-documented barriers for the uptake of maternity care services [1,2,3]. To date there have been seven published systematic reviews of evidence on the impact of aspects of demand-side financing on maternal health (Table 1). These concluded that demandside financing increases uptake of maternity care services shorter-term but evidence of population level uptake over longer periods of time was limited. Few studies collated data for more than two to three years, and conclusions could not be drawn about longer-term effects, and evidence did not enable impacts to be assessed on maternal and newborn health, quality of care, or cost-effectiveness. Murray et al 2014 [4] noted that most studies included in their review were unable to assess impacts on health outcomes due to small sample sizes. Cash transfers and vouchers are forms of ‘demand-side financing’ that have been widely used to promote maternal and newborn health in low- and middle-income countries during the last 15 years
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