Demand-side financing for maternal and newborn health: what do we know about factors that affect implementation of cash transfers and voucher programmes?

Women and their families can face multiple barriers to accessing maternity care services, and financial barriers are a well-documented concern [1, 2]. In many countries there are demands for out-of-pocket formal fees and informal payments for care services or supplies such as medicines, sutures, gloves and diagnostic tests [3, 4]. There are the practical and financial difficulties of travel to health centres and the opportunity costs of being away from home or from work, or from dependents. For poor families, any such costs can cause severe financial hardship [5], and may result in delays or avoidance of care-seeking that increase health risks for mothers and newborns and further escalate costs. One approach to ameliorate these effects is the use of ‘demand-side’ financing (DSF) interventions that are designed to promote health by providing cash or vouchers to users to offset some of the financial costs of using or getting to maternity care services, or to increase household income and incentivise ‘healthy behaviours’.

Within this overarching definition there are five types of DSF that have been used in the health sector and there are important differences in their intended mechanism of action [6, 7]. Conditional cash transfers, which have been widely used in Latin America, aim to increase utilisation of maternity care services by making regular payments to households linked to ‘conditionalities’ including attendance at community meetings and uptake of government health services. These are primarily focused on child health and development but some schemes include maternity care uptake. Unconditional cash transfers are similar regular payments but, in the absence of specific conditionalities for service utilisation, have the more general aim of alleviating the effect of poverty on a woman’s health during pregnancy. Short-term cash payments to offset costs are typically retrospective payments made at government health facilities to those who attend for care. Vouchers for maternity care services aim to reduce the cost of maternity care services and vouchers for ‘merit’ goods aim to reduce the cost of merit goods (such as food or insecticide-treated nets) that promote maternal health. Vouchers may be distributed by community-based workers or at health facilities, and voucher schemes may be designed to incorporate services in the private sector as well as government facilities.

There have been seven systematic reviews of evidence on the impact of DSF mechanisms on maternal health during the period 2007–2012 [7‐13]. Two of the reviews examined the impact of cash transfers [9, 11], three the impact of vouchers [8, 12, 13], and two the role of multiple types of DSF [7, 10]. The systematic reviews reported on a rapidly growing body of evidence that DSF can lead to a short-term increase in uptake of maternity care services, but could offer little evidence on longer-term effects on service uptake or maternal and neonatal morbidity and mortality. A recently published systematic review has confirmed these findings [14].

This article has been commissioned by the World Health Organization’s Department of Maternal, Newborn, Child and Adolescent Health as part of a series of articles on health promotion interventions. The series aims to document factors that affect programme implementation in order to support policy-makers and decisions on how best to improve access to skilled care during pregnancy, childbirth and after birth. This article focuses on factors that have been found to affect implementation of DSF programmes in maternal and newborn health and has three components: a review of stakeholder perspectives and experiences of DSF interventions; information on the barriers and facilitators to implementation of the interventions, and a discussion on how these relate to the improvements in care-seeking outcomes reported elsewhere and what this means for programmatic initiatives [14].

This article is a secondary analysis of studies identified in a systematic review that was conducted in 2012 [6, 7] and repeated in 2015 [14]. The systematic review used the Joanna Briggs Institute approach, which incorporates both quantitative and qualitative data into reviews and has been used to review evidence on a range of policy and healthcare systems topics [15]. The population of interest in the review was economically poor women who were pregnant or within 42 days of end of pregnancy, in the context of low- and middle-income (both lower- and upper-middle) countries as defined by the World Bank at the time the study was published. The intervention of interest was DSF as a mechanism to increase consumption of goods and services intended to impact positively on maternal and newborn health. Outcomes of interest in the systematic review related to the effectiveness of DSF programmes to promote uptake of maternity care services and maternal and newborn health, and wider impact on quality of care. In addition to questions of effectiveness, the 2012 review also analysed qualitative research relating to barriers and facilitators for effective and sustainable programme implementation.

The systematic searches for the review used 30 terms in 19 medical, health and social policy databases and seven databases of unpublished research, and aimed to retrieve quantitative and qualitative studies that were published between January 1990 and June 2015. Retrieved studies were examined using Joanna Briggs Institute tools for critical appraisal of quantitative and qualitative research that include questions on study methods and the presentation of findings [15]. The review team assigned an overall quality rating to individual studies using a three-point rating system (low-, medium- or high-quality), similar to that used to assess study bias in the Effective Public Health Practice Project (EPHPP) quality assessment tool. The rating assigned to each study was based on assessments of study methods and reporting using critical appraisal tools produced by the Joanna Briggs Institute. The assessments are described in detail in a linked systematic review [14].

Data were extracted from included studies using standardised tools developed by the Joanna Briggs Institute, and the findings presented in this article have been analysed thematically using a comprehensive framework for factors affecting implementation of health promotion interventions, adapted from the SURE (Supporting the Use of Research Evidence) framework for preparing policy briefs [16]. The analytical framework, which is described in detail in a paper by Smith et al. in this series, includes five ‘levels’ of factors that affect policy implementation (main stakeholders in communities, healthcare providers, other stakeholders, health service delivery factors and social and political factors) and provides a list of types of barrier and enabler for each level. One of the authors, BMH, read through all included studies and extracted data relating to each level of the framework, then both authors examined the extracted data and re-organised them into themes based on the list of types of barrier and enabler.

This analysis has highlighted a series of well-documented challenges for the implementation of DSF schemes in maternal and newborn health. These include issues of programme scope (in terms of programme eligibility, size and timing of payments and voucher entitlements), wider problems in healthcare systems (including inadequate infrastructure and human resources, lack of medicines and problems with corruption) and the population’s awareness and perceptions of programmes and health services. A recent systematic review concluded that despite evaluations spanning 15 years of implementation, DSF programmes have yet to demonstrate positive impact of programmes on quality of care or maternal and newborn health outcomes [14]. That finding may reflect insufficient attention during programme design and implementation to improving the quality of care being provided and to conditions of access to comprehensive emergency care [113]. Research highlighted in our analysis indicates that the implementation of DSF programmes may reinforce existing healthcare system problems including poor quality of care, demands for informal fees and the systematic exclusion of vulnerable groups. Vouchers for maternity care services are often proposed as a means to improve quality of care however experiences indicate private providers may find reimbursement rates to be unattractive and engage in practices such as providing differential quality of care or ‘skimming’ programme users who require minimal intervention. Taken together, these findings suggest a need for greater attention to issues of implementation in DSF programmes and to the context in which they are to be introduced. They indicate serious concerns for the use of DSF as a stand-alone interventions in maternal and newborn health in low- and middle-income countries, and raise questions regarding which (if any) maternal and newborn healthcare services are suited to modalities of DSF.

Where DSF programmes have improved care-seeking, the programmes have tended to include (or be accompanied by) additional investment in health facilities or staff, while those without such investment have struggled (see Tables 2 and 3). Other important factors that have enabled DSF programmes to improve care-seeking have included appropriate payment size and timing for short-term cash payments and cash transfer programmes, and an adequate package of entitlements (including transport costs) in voucher schemes. When well-supported and -supervised, community-based workers, leaders and women’s groups have been important facilitators for programmes as they have raised awareness of programme details and helped to counter negative perceptions of programmes.

The longest-running DSF programmes included in this review have been cash transfer schemes that were introduced by national or state governments as part of wider social welfare programmes. Programmes since the launch of the Millennium Development Goals have tended to focus more narrowly on specific maternal health services with the aim to improve their coverage on indicators such as skilled attendants at birth or facility births. Most evaluations have shown quantitative improvements in coverage rates [14]. However, many have relied on funding from donors, and some were implemented for only short pilot periods. Studies have highlighted the high start-up costs of DSF programmes [24, 78], and those running in parallel to welfare systems are likely to have continued high overhead costs. Policy-makers need to consider whether DSF programmes that involve cash payments or vouchers are likely to be an optimal use of resources, or whether increased supply-side investment would be equally effective.

After quite widespread implementation and considerable policy enthusiasm in some quarters, evaluations have shed light on the importance of a number of detailed design and implementation issues as outlined above. The synthesis of findings reveals a complex picture of experiences DSF programmes in maternal and newborn health. While they indicate that cash payments and vouchers can be successful in improving service utilisation rates at least in the short term in an array of contexts, there are frequent concerns about inclusion criteria or distribution mechanisms that effectively exclude migrants, young and multiparous women, about staff charging informal fees once at the facilities, and about the struggle to maintain quality of care under greater demand. Unsurprisingly, the programmes that have successfully promoted uptake of specific maternity care services using cash or voucher incentives, such as Nepal’s Safe Delivery Incentive Programme and Bangladesh’s Maternal Health Voucher Scheme, are those which were carefully designed with adequate scope (in terms of programme eligibility, payment size and timing, or services and goods to which they provide entitlement) to properly address maternal and newborn health aims, were well-supported in communities and/or which operated within effective healthcare systems.

Research is still needed in a number of areas and the opportunity to update our original systematic review has reminded us of the narrow range of issues and indicators included in many evaluations of DSF programmes. Review papers on this topic are at risk of tunnel vision as a result. It is our considered view that after almost 15 years of evaluating DSF schemes there are some questions about the DSF approach which are important but rarely posed. For example, we found no evaluations that attempted to gauge the experience of coercion when birth in a health facility becomes a conditionality for women to receive state welfare payments. There is comparatively little evidence on the implementation of unconditional cash transfers as part of maternal and neonatal health programmes, despite growing interest in these within the international development community. Similarly, comparative research on alternative forms of financing, such as health equity funds, would provide useful insights. Furthermore, research on policy processes and the reasons for introducing DSF schemes rather than efforts to remove user fees or improve supply-side quality of care could also help to generate understanding of the role of these initiatives, how they become sustainable and where they fit (or do not fit) with plans to achieve equitable universal health coverage.