Dataset Information

Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review.

ABSTRACT:

Background

Demand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system.

Methods

The protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis.

Results

Thirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems.

Conclusions

Demand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.

SUBMITTER: Murray SF

PROVIDER: S-EPMC3897964 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:ObjectivePrior studies have reported inequitable global access to essential medicines for cardiovascular disease (CVD) prevention, especially statins. Here we examine recent trends and disparities in statin utilisation at the income group, regional and country levels.DesignEcological study. Pharmaceutical sales data were used to examine statin utilisation in high-income counties (HICs) and low/middle-income countries (LMICs) from 2015 to 2020. Population estimates were obtained from the Global Burden of Disease. Fixed-effects panel regression analysis was used to examine associations between statin utilisation and country-level factors.SettingGlobal, including 41 HICs and 50 LMICs.ParticipantsPopulation older than 40 years of age.Primary and secondary outcome measuresStatin utilisation was measured using defined daily doses (DDDs) per 1000 population ≥40 years per day (TPD).ResultsGlobally, statin utilisation increased 24.7% from 54.7 DDDs/TPD in 2015 to 68.3 DDDs/TPD in 2020. However, regional and income group disparities persisted during this period. In 2020, statin utilisation was more than six times higher in HICs than LMICs (192.4 vs 28.4 DDDs/TPD, p<0.01). Substantial disparities were also observed between LMICs, ranging from 3.1 DDDs/TPD in West African nations to 225.0 DDDs/TPD in Lebanon in 2020. While statin utilisation increased in most LMICs between 2015 and 2020, several experienced declines in utilisation, most notably Venezuela (-85.1%, from 92.3 to 14.0 DDDs/TPD). In LMICs, every $100 increase in per capita health spending was associated with a 17% increase in statin utilisation, while every 10% increase in out-of-pocket health spending was associated with a 11% decline (both p<0.05).ConclusionsDespite global increases in statin utilisation, there are substantial regional and country-level disparities between HICs and LMICs. To address global CVD disparities, policymakers should promote increased and equitable access to statins in LMICs.

Project description:BackgroundHealth systems are often fragmented in low- and middle-income countries (LMICs). This can increase inefficiencies and restrict progress towards universal health coverage. The objective of the systematic review described in this protocol will be to evaluate and synthesize the evidence concerning the impacts of health systems financing fragmentation in LMICs.MethodsLiterature searches will be conducted in multiple electronic databases, from their inception onwards, including MEDLINE, EMBASE, LILACS, CINAHL, Scopus, ScienceDirect, Scielo, Cochrane Library, EconLit, and JSTOR. Gray literature will be also targeted through searching OpenSIGLE, Google Scholar, and institutional websites (e.g., HMIC, The World Bank, WHO, PAHO, OECD). The search strings will include keywords related to LMICs, health system financing fragmentation, and health system goals. Experimental, quasi-experimental, and observational studies conducted in LMICs and examining health financing fragmentation across any relevant metric (e.g., the presence of different health funders/insurers, risk pooling mechanisms, eligibility categories, benefits packages, premiums) will be included. Studies will be eligible if they compare financing fragmentation in alternative settings or at least two-time points. The primary outcomes will be health system-related goals such as health outcomes (e.g., mortality, morbidity, patient-reported outcome measures) and indicators of access, services utilization, equity, and financial risk protection. Additional outcomes will include intermediate health system objectives (e.g., indicators of efficiency and quality). Two reviewers will independently screen all citations, abstract data, and full-text articles. Potential conflicts will be resolved through discussion and, when necessary, resolved by a third reviewer. The methodological quality (or risk of bias) of selected studies will be appraised using established checklists. Data extraction categories will include the studies' objective and design, the fragmentation measurement and domains, and health outcomes linked to the fragmentation. A narrative synthesis will be used to describe the results and characteristics of all included studies and to explore relationships and findings both within and between the studies.DiscussionEvidence on the impacts of health system fragmentation in LMICs is key for identifying evidence gaps and priority areas for intervention. This knowledge will be valuable to health system policymakers aiming to strengthen health systems in LMICs.Systematic review registrationPROSPERO CRD42020201467.