ReviewHealth sector demand-side financial incentives in low- and middle-income countries: A systematic review on demand- and supply-side effects
Introduction
In recent times, many countries have adopted demand-side financing (DSF) as a complimentary strategy for supply-side financing (SSF) on certain publicly provided goods (Ensor 2004). Under DSF, public budget to purchase these goods such as healthcare and nutrition goes directly to consumers instead of providers (Gupta, Joe, & Rudra, 2010). Consumers are typically entitled to purchase services from either public or private providers with the money from the government. DSF introduced three key changes in the public financing approach (Standing, 2004). First, it envisages that the government should provide purchasing power to consumers than directly engaging in service provision. Secondly, it entitles the government with a supervisory role on service provision and purchase to ensure fairness and efficiency. Thirdly, it tunes public financing as ‘output- based’ instead of ‘input-based’ so that adequate consumer and provider accountability could be achieved.
DSF is a widely growing differential healthcare delivery approach to address unmet health needs (Gopalan and Varatharajan, 2012, Savedoff, 2010). The underlying objective of DSF is to improve population health, and individual and social capabilities by addressing the population exposure on various risks such as social determinants of health (e.g. poverty, gender). The scope of DSF is more pronounced for under-served populations and regions. This prioritization is to augment the possibility of achieving many far-fledged health goals in a stipulated time-frame (Forde, Rasanathan, & Krech, 2012). There are two classifications for health sector DSF measures (Gopalan & Varatharajan, 2012). The first category is the consumer-led incentive to improve health related behaviors and health care utilization. These are mainly provided through cash transfers, vouchers and flat-rate subsidies. They usually pose conditionality on certain behaviors and are targeted on specific health goals (e.g. reducing maternal deaths). Since consumer-incentives are known for altering behavior changes, they are more deployed for merit goods with known externalities (e.g. vaccination) and essential primary healthcare services. The second type of DSF is health insurance (HI) or financial risk-protection measure. HI is usually not conditional on specific consumer health behaviors (except a few for maternal and chronic disease care) and is meant largely for secondary and tertiary care services.
Section snippets
Aims
This review uses systematic methods to investigate the demand- and supply-side effects of consumer-led (or the first category of DSF) financial incentives. This review is pertinent as the existing synthesized evidence does not cover all types of consumer-incentives, by confining their focus on conditional cash transfers only. They have also mostly explored DSF initiatives which are part of the multi-sectoral social protection measures in Latin America. Unlike the Latin American model, vertical
Methods
This systematic review was designed and reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (Moher, Liberati, Tetzlaff, & Altman, 2009) and a pre-designed review protocol.
Description of studies
Out of the 28 studies, 15 were of experimental and 13 were of quasi-experimental designs (Table 1). They assessed 19 DSF initiatives across 16 countries from Asia (n = 6), Africa (n = 5) and Latin America (n = 8). All studies provided quantitative outcomes predominantly. However, there was one study (Ahmad et al. 2007) which largely provided qualitative findings as it applied a mixed-methods approach. All studies covered more than one behavioral or health outcomes. Only one study (Stecklov,
Evaluation methods and DSF's effects
The nature of evaluation design was related to the direction and magnitude of the particular effects of each DSF initiative. As DSF was an output-based strategy, evaluation questions explored primarily how an incentive resulted into its intended outcome. Conditionality in DSF was always tied to an activity than improving health status. Hence, evaluation questions largely assessed behavioral outcomes than final health outcomes. However, a few experimental studies had explored the health status
Differential effects among various initiatives, incentives and design features
As the outcomes were heterogeneous among studies, we could not statistically explore if any differential performance occurred among various types of incentives and initiatives. Otherwise, irrespective of the nature of initiatives and incentives, all studies reported that DSF could improve behavioral outcomes. However, their impact on consumer behavior which requires continuous adherence (e.g. bed net use and adult checkups) was mixed and varied between countries, irrespective of the type of
Summary of findings
We conducted an extensive search and assessed several papers and reports on demand-side financial incentives. We found that DSF initiatives, irrespective of the nature of incentive, initiative and duration were effective on improving consumer behavioral outcomes. The effect on continuous client behavior choices were mixed and varied across countries. Existing evidence is confined to consumer behavioral and a few health outcomes, and the deeper effects (e.g. cost-effectiveness and final health
Policy implications
DSF appears to be a reliable healthcare delivery strategy to improve preventive, promotive and certain curative healthcare aspects (Soares, Osório, Soares, Medeiros, & Zepeda, 2007; WHO 2010). However, DSF initiatives need some amendments in their design, objectives and implementation strategies to enable them to address primary healthcare comprehensively. One major structural change could be in their objective and design. They need to rationally cover primary healthcare issues and go beyond
Acknowledgments
We would like to thank the authors of the papers we have reviewed for the prompt response to our queries. We are also indebted to the anonymous reviewers and the Editorial Board for their valuable comments.
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