Financial incentives and maternal health: where do we go from here?

Health financing strategies that incorporate financial incentives are being applied in many low- and middle-income countries, and improving maternal and neonatal health is often a central goal. As yet, there have been few reviews of such programmes and their impact on maternal health. The US Government Evidence Summit on Enhancing Provision and use of Maternal Health Services through Financial Incentives was convened on 24-25 April 2012 to address this gap. This article, the final in a series assessing the effects of financial incentives--performance-based incentives (PBIs), insurance, user fee exemption programmes, conditional cash transfers, and vouchers--summarizes the evidence and discusses issues of context, programme design and implementation, cost-effectiveness, and sustainability. We suggest key areas to consider when designing and implementing financial incentive programmes for enhancing maternal health and highlight gaps in evidence that could benefit from additional research. Although the methodological rigor of studies varies, the evidence, overall, suggests that financial incentives can enhance demand for and improve the supply of maternal health services. Definitive evidence demonstrating a link between incentives and improved health outcomes is lacking; however, the evidence suggests that financial incentives can increase the quantity and quality of maternal health services and address health systems and financial barriers that prevent women from accessing and providers from delivering quality, lifesaving maternal healthcare.

A taxonomy and results from a comprehensive review of 28 maternal health voucher programmes.

It is increasingly clear that Millennium Development Goal 4 and 5 will not be achieved in many low- and middle-income countries with the weakest gains among the poor. Recognizing that there are large inequalities in reproductive health outcomes, the post-2015 agenda on universal health coverage will likely generate strategies that target resources where maternal and newborn deaths are the highest. In 2012, the United States Agency for International Development convened an Evidence Summit to review the knowledge and gaps on the utilization of financial incentives to enhance the quality and uptake of maternal healthcare. The goal was to provide donors and governments of the low- and middle-income countries with evidence-informed recommendations on practice, policy, and strategies regarding the use of financial incentives, including vouchers, to enhance the demand and supply of maternal health services. The findings in this paper are intended to guide governments interested in maternal health voucher programmes with recommendations for sustainable implementation and impact. The Evidence Summit undertook a systematic review of five financing strategies. This paper presents the methods and findings for vouchers, building on a taxonomy to catalogue knowledge about voucher programme design and functionality. More than 120 characteristics under five major categories were identified: programme principles (objectives and financing); governance and management; benefits package and beneficiary targeting; providers (contracting and service pricing); and implementation arrangements (marketing, claims processing, and monitoring and evaluation). Among the 28 identified maternal health voucher programmes, common characteristics included: a stated objective to increase the use of services among the means-tested poor; contracted-out programme management; contracting either exclusively private facilities or a mix of public and private providers; prioritizing community-based distribution of vouchers; and tracking individual claims for performance purposes. Maternal voucher programmes differed on whether contracted providers were given training on clinical or administrative issues; whether some form of service verification was undertaken at facility or community-level; and the relative size of programme management costs in the overall programme budget. Evidence suggests voucher programmes can serve populations with national-level impact. Reaching scale depends on whether the voucher programme can: (i) keep management costs low, (ii) induce a large demand-side response among the bottom two quintiles, and (iii) achieve a quality of care that translates a greater number of facility-based deliveries into a reduction in maternal morbidity and mortality.

Systematic Review: the use of vouchers for reproductive health services in developing countries: systematic review.

OBJECTIVES: To identify where vouchers have been used for reproductive health (RH) services, to what extent RH voucher programmes have been evaluated, and whether the programmes have been effective. METHODS: A systematic search of the peer review and grey literature was conducted to identify RH voucher programmes and evaluation findings. Experts were consulted to verify RH voucher programme information and identify further programmes and studies not found in the literature search. Studies were examined for outcomes regarding targeting, costs, knowledge, utilization, quality, and population health impact. Included studies used cross-sectional, before-and-after and quasi-experimental designs. RESULTS: Thirteen RH voucher programmes fitting established criteria were identified. RH voucher programmes were located in Bangladesh, Cambodia, China, Kenya (2), Korea, India, Indonesia, Nicaragua (3), Taiwan, and Uganda. Among RH voucher programmes, 7 were quantitatively evaluated in 15 studies. All evaluations reported some positive findings, indicating that RH voucher programmes increased utilization of RH services, improved quality of care, and improved population health outcomes. CONCLUSIONS: The potential for RH voucher programmes appears positive; however, more research is needed to examine programme effectiveness using strong study designs. In particular, it is important to see stronger evidence on cost-effectiveness and population health impacts, where the findings can best direct governments and external funders.