Elsevier

Social Science & Medicine

Volume 100, January 2014, Pages 72-83
Social Science & Medicine

Review
Health sector demand-side financial incentives in low- and middle-income countries: A systematic review on demand- and supply-side effects

https://doi.org/10.1016/j.socscimed.2013.10.030Get rights and content

Highlights

  • This review investigated the existing evidence on DSF's demand- and supply-side effects in LMICs.

  • It assessed various types of DSF initiatives and incentives in both public and private sectors.

  • Many studies evaluated causality between an incentive and its respective behavioral outcomes than final health outcomes.

  • Mixed-methods evaluation designs would be relevant to explore DSF's wider effects.

  • DSF's causal pathways of effects and contextual factors would be decisive for its scale up and sustainability.

Abstract

Demand-side financial incentive (DSF) is an emerging strategy to improve health seeking behavior and health status in many low- and middle-income countries. This narrative synthesis assessed the demand- and supply-side effects of DSF. Forty one electronic data bases were searched to screen relevant experimental and quasi-experimental study designs. Out of the 64 selected papers, 28 were eligible for this review and they described 19 DSF initiatives across Asia, Africa and Latin America. There were three categories of initiatives, namely long-run multi-sectoral programs or LMPs (governmental); long-run health-exclusive programs (governmental); and short-run health-exclusive initiatives (both governmental and non-governmental). Irrespective of the nature of incentives and initiatives, all DSF programs could achieve their expected behavioral outcomes on healthcare seeking and utilization substantially. However, there existed a few negative and perverse outcomes on health seeking behavior and DSF's impact on continuous health seeking choices (e.g. bed net use and routine adult health check-ups) was mixed. Their effects on maternal health status, diarrhea, malaria and out-of-pocket expenditure were under-explored; while chronic non-communicable diseases were not directly covered by any DSF programs. DSF could reduce HIV prevalence and child deaths, and enhance nutritional and growth status of children. The direction and magnitude of their effects on health status was elastic to the evaluation design employed. On health system benefits, despite prioritizing on vulnerable groups, DSF's substantial effect on the poorest of the poor was mixed compared to that on the relatively richer groups. Though DSF initiatives intended to improve service delivery status, many could not optimally do so, especially to meet the additionally generated demand for care. Causal pathways of DSF's effects should be explored in-depth for mid-course corrections and cross-country learning on their design, implementation and evaluation. More policy-specific analyses on LMPs are needed to assess how ‘multi-sectoral’ approaches can be cost-effective and sustainable in the long run compared to ‘health exclusive’ incentives.

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.

References (47)

  • R. Atun et al.

    A systematic review of the evidence on integration of targeted health interventions into health systems

    Health Policy and Planning

    (2010)
  • S.J. Baird et al.

    Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial

    Lancet

    (2012)
  • S.L. Barber

    Mexico's conditional cash transfer programme increases cesarean section rates among the rural poor

    European Journal of Public Health

    (2009)
  • S.L. Barber et al.

    Empowering women to obtain high quality care: evidence from an evaluation of Mexico's conditional cash transfer programme

    Health Policy and Planning

    (2008)
  • J.R. Behrman et al.

    The impact of the PROGRESA/Oportunidades conditional cash transfer program on health and related outcomes for the aging in Mexico

    (2011)
  • C. Eldridge et al.

    Performance-based payment: some reflections on the discourse, evidence and unanswered questions

    Health Policy and Planning

    (2009)
  • T. Ensor

    Consumer-oriented demand side financing in health and education and its relevance for low and middle income countries

    International Journal of Health Planning and Management

    (2004)
  • I. Forde et al.

    Cash transfer schemes and the health sector: making the case for greater involvement

    Bulletin of the World Health Organization

    (2012)
  • F. Frethtim

    An overview of research on the effects o results-based financing

    (2008)
  • P. Gertler et al.

    Final report: the impact of progressa on health

    (2001)
  • E. Galasso

    Alleviating extreme poverty in Chile: the short term effects of Chile Solidario

    Estudios de Economomia

    (2011)
  • S.S. Gopalan et al.

    Addressing maternal healthcare through demand side financial incentives: experience of Janani Suraksha Yojana Program in India

    BMC Health Services Research

    (2012)
  • I. Gupta et al.

    Demand side financing in health how far can it address the issue of low utilization in developing countries?

    (2010)
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