Demand-side financing measures to increase maternal health service utilisation and improve health outcomes: a systematic review of evidence from low- and middle-income countries

Background In many countries financing for health services has traditionally been disbursed directly from governmental and non-governmental funding agencies to providers of services: the ‘supply-side’ of healthcare markets. Demand-side financing offers a supplementary model in which some funds are instead channelled through, or to, prospective users. In this review we considered evidence on five forms of demand-side financing that have been used to promote maternal health in developing countries: unconditional cash transfers conditional cash transfers short-term cash payments to offset the cost of accessing maternal health services vouchers for maternal health services vouchers for ‘merit’ goods that promote maternal health. Objectives The overall review objective was to assess the effects of demand-side financing interventions on maternal health service utilisation and on maternal health outcomes in low- and middle-income countries. Broader effects on perinatal and infant health, the situation of underprivileged women and the health care system were also assessed. Inclusion criteria Types of participants This review considered poor, rural or socially excluded women of all ages who were either pregnant or within 42 days of the conclusion of pregnancy, the limit for postnatal care as defined by the World Health Organization. The review also considered the providers of services. Types of intervention(s)/phenomena of interest The intervention of interest was any programme that incorporated demand-side financing as a mechanism to increase the consumption of goods and services that could impact on maternal health outcomes. This included the direct consumption of maternal health care goods and services as well as related ‘merit goods’ such as improved nutrition. We included systems in which potential users of maternal health services are financially empowered to make restricted decisions on buying maternal health-related goods or services — sometimes known as consumer-led demand-side financing. We also included programmes that provided unconditional cash benefits to pregnant women (for example in the form of maternity allowances), or to families with children under five years of age where there was evidence concerning maternal health outcomes. Types of studies We aimed to include quantitative studies (experimental, observational and descriptive), qualitative studies (including designs based on phenomenology, grounded theory, ethnography, action research and feminist research), and economic studies (cost-effectiveness, cost-utility and costs studies). Search strategy The Joanna Briggs Institute methodology for mixed-method systematic reviews was adopted. A three-step systematic search strategy was used to: 1) identify key terms, 2) search bibliographic databases and 3) retrieve additional publications from reference lists and sources of grey literature. Data Collection Data were extracted from papers included in the review using the standardised data extraction tools for quantitative, qualitative and economic data from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information. Data Synthesis The quantitative and economic findings are presented in narrative form. Qualitative research findings were pooled using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. This involved the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings), and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories were then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice or policy. Conclusions Seventy-two studies were included in the review. Drawing on work from several continents, many of the included studies were reports and evaluations for relevant government or funding agencies and represented important lesson-learning about implementation issues. However, fewer than half were published in peer reviewed journals and few were of high research quality. For three modes of demand-side financing (conditional cash transfers, payments to offset costs of access to maternal healthcare, and vouchers for maternity services) we found evidence relevant to review questions on the utilisation of maternal health services, barriers to the provision of demand-side financing and supply-side preconditions to implementing demand-side financing schemes. There was insufficient evidence to provide comprehensive answers for review questions on the effect of demand-side financing interventions on maternal, perinatal and infant health outcomes and on the social and financial situation of underprivileged women. There was also insufficient evidence on the cost-effectiveness of demand-side financing interventions and preconditions for sustainability and scale-up of demand-side financing schemes. Implications for practice Salient recommendations for policymakers regarding demand-side financing for maternal health derived from the current evidence are: Streamlined policy goals focused on increasing utilisation of services are most effective Careful design of incentives for skilled practitioners is required Demand-side financing mechanisms cannot on their own improve quality of services; supply-side measures are required to complement these Simple and transparent processes for administering and disbursing benefits are more likely to be successful in improving uptake of services Careful planning for initial and scaled up demand-side financing is essential to success, including input from women's organisations and other user representatives Demand-side financing can be an effective targeting mechanism but only if it does not require substantially new systems for identifying beneficiaries Policy should recognise that even well designed demand-side financing schemes may fail to function as intended unless other barriers to access are addressed. Implications for research There is a pressing need for large, robust studies on the short- and longer-term impact of demand-side financing on maternal and infant mortality and morbidity, which should also reflect ‘good practice’ indicators such as the uptake and duration of exclusive breastfeeding and compliance with infant immunisation programmes. It is also important that the impact on outcomes of subsequent pregnancies is evaluated. Moderate and large-sized demand-side financing programmes that have recently or will soon be scaled up, such as those in Kenya, Uganda and Bangladesh, represent the most obvious sites for such evaluations, and lessons may be learnt from Mexico's PROGRESA/ Oportunidades about how to establish a well-embedded monitoring and rigorous evaluation structure. Other important areas that require further study include: The effects of unconditional cash transfers and vouchers for food on maternal health and other outcomes; The quality of services that are provided to beneficiaries of demand-side financing schemes, the maternity care experience for the user, and how these can be optimised; The specific effects of demand-side financing schemes for poor, rural and socially excluded women; Mechanisms to involve women's organisations and other user representatives in design and implementation and monitoring of demand-side financing schemes; Any effect of demand-side financing interventions on competition in markets for the provision of health services; The cost-effectiveness of demand-side financing interventions, comparing with similar investment in supply-side financing mechanisms; The optimal and most practical administration systems for demand-side financing programmes at different stages of scale up, to avoid duplication and undue expense while maintaining efficiency and transparency; Wider effects of adoption of demand-side financing interventions on quality of life for women, household poverty, social organisation of maternity care, and notions of state obligation and women's entitlement.