Laurel E. Hatt, MPH, PhD Abt Associates

1. Effects of Demand-Side Incentives on Use of Maternal Health ServicesSecond Global Symposium on Health Systems ResearchBeijing, October 31, 2012 Laurel E. Hatt, MPH, PhD Abt Associates U.S. Government Evidence Summit: Enhancing Provision and Use of Maternal Health Services through Financial Incentives

2. ERT 3 Members

3. Framing • We reviewed 55 papers on demand-side financial incentives (other than CCTs) that aim to increase uptake of maternal and neonatal health services • Four types of demand-side incentives were reviewed: • Vouchers for services • Vouchers for products (ITNs) • Price subsidies • User fee exemptions for services

4. Evidence Review Findings

5. 1. Vouchers for MNH services • Description of the incentive: • Provide access to defined service or service package (e.g. ANC, skilled delivery care, EmOC, PNC, transport) • Sold at discount or distributed free • Can be targeted to specific population groups • Distribution of vouchers as educational intervention • Redeemable at accredited (public or private) facilities, which are contracted by voucher management agency • May stimulate competition among providers

6. 1. Vouchers for MNH services • 17 articles reviewed • Included articles covering 5 country experiences (Bangladesh, Cambodia, Kenya, Pakistan, and Uganda) • 4 multi-country reviews • Wide variation in services covered, outreach methods, targeted populations, prices charged, concurrent supply-side investments • Complicates ability to isolate driver of effects

7. 1. Vouchers for MNH services • The evidence indicates that voucher programs are associated with greater use of maternal health services • Increases in the use of ANC, skilled birth attendance, facility-based delivery, and PNC • Reduced disparities in service utilization by income • Mixed effects on provider choice, competition • No evidence of distortion of C-section provision • No solid evidence of effects on maternal health outcomes

8. 1. Vouchers for MNH services • Limitations of evidence reviewed: • Short duration of program implementation; pilots • Differences between intervention and comparison groups • Weaknesses in statistical analysis • Effects on supply-side quality not robustly measured • Lack of information on relative cost-effectiveness of vouchers (vs. other possible approaches) • Sustainability?

10. 2. Vouchers for Insecticide-Treated Nets (ITNs) • Description of the incentive: • Vouchers for ITNs given or sold to pregnant women, often during antenatal care visit • Aim to increase uptake of ITNs by pregnant women and children under five • Posited to be promote sustainable distribution through public and private channels • 9 articles reviewed • Tanzania (7 studies) • Ghana (2 studies)

11. 2. Vouchers for ITNs • Vouchers can modestly increase ITN use, but low rates of reaching pregnant women with vouchers • Low rates of voucher redemption • Lower rates of voucher receipt, use among poorest women • Voucher programs have not achieved >60% coverage • Limitations of the evidence reviewed • Generally weak study designs; no comparison groups (pre-post or cross-sectional only) • Contamination from other programs • Concerns about cost-effectiveness, sustainability

12. 3. Price subsidies • Description of the incentive: • Price subsidies were defined as provision of free or reduced price products or transportation, and sale of products on a sliding scale. • 4 studies reviewed • Free and subsidized food for pregnant women in Brazil (2) • Subsidized transportation for obstetric emergencies in India • Subsidized and free distribution of ITNs to pregnant women in Kenya

13. 3. Price subsidies • Providing free ITNs increases uptake with no decrease in use and without wastage. Increases in price substantially reduce uptake. • Distributing free bed nets is potentially more cost-effective than providing subsidized nets for sale. • Few conclusions can be drawn from studies on food subsidies or subsidized emergency transport. • Limitations: • Few studies; 1 strong (RCT), 3 weak • Vastly different interventions • Effect of free distribution on private retail sector not measured

15. 4. User fee exemptions • Description of the incentive: • Reduction or waiver of out-of-pocket fees charged to health service users at the point of service. • Exemptions for specific MH services, for all pregnant women, for indigent groups, or for primary health care overall • 22 studies reviewed • 18 articles covering 12 country experiences; 4 multi-country reviews

16. 4. User fee exemptions • Some evidence that user fee exemptions for MH services are associated with short-term: • Increases in facility delivery rates (weak evidence) • Increases in C-section rates (modest evidence). • Increased utilization of facility-based malaria care by pregnant women (modest evidence). • Effects on quality of services was either negative, neutral, or not measured. • Effects on maternal and neonatal health outcomes have not been conclusively demonstrated.

17. 4. User fee exemptions • Limitations of the evidence reviewed • Few studies with control or comparison groups • Mainly pre-post, cross-sectional, or qualitative studies; 1 quasi-experimental • Short duration since policy implementation – little information about long-term effects • Concerns about sustainability of funding

18. Conclusions • Grade of the evidence is generally weak. • Maternal health voucher programs associated with increases in ANC, skilled attendance, facility deliveries, and PNC. • Weak evidence that user fee removal may result in increased facility delivery rates, C-sections, and malaria care-seeking among pregnant women, at least in the short term. • Evidence from one strong study suggests it is more cost-effective to provide ITNs for free than sell at subsidized price.

19. Conclusions • Little or no conclusive evidence on the effects of these incentives on MNH outcomes. • Supply-side effects of fee exemptions can be negative (reduced quality of services, provider motivation); critical to address to ensure desired maternal health outcomes. • Long-term effects are generally unknown. Initial effects may not persist. • Removing financial barriers to MH services will not reduce maternal mortality if the quality of facility-based care is very poor or if transportation barriers persist.

20. Recommendations • Plan and execute “demand-side” initiatives in the context of likely supply-side responses • Link policies with broader improvement in the health system, addressing quality of care, transport costs, and other barriers • Where user fees eliminated, carefully design a system for replacing lost fee revenue • Protect quality of care and provider motivation • Prevent informal payments • Continue testing and refining voucher programs for MH; shown to have short-term, rapid effects • Design and field more robust evaluation research • Health outcomes, quality, equity, cost-effectiveness • Longer time horizons (sustainability?)

21. Take Home Messages • Generally poor quality of the evidence limited our ability to make strong recommendations regarding instituting demand-side financing mechanisms for maternal health care services and products • Stakeholders urgently need high-grade evidence in this rapidly changing and promising policy arena

22. Thank you!

23. Effect modifiers • How (and how effectively) providers are reimbursed • Geographic access to health services • Availability of alternative providers • Quality of service or product being incentivized • How much the policy actually lowers patient costs • How well the policy is communicated to providers and patients; social marketing and behavior change campaigns • Cultural preferences and awareness; extent to which item/service is “valued” or its importance for health is understood