Laurel E. Hatt, MPH, PhD Abt Associates U.S. Government Evidence Summit: Enhancing Provision and Use of Maternal Health Services through Financial Incentives

Claudia Morrissey (Chair) Save the Children Laurel Hatt (Co-Chair) Abt Associates Inc. Karen Cavanaugh U.S. Agency for International Development Marion Koso-Thomas National Institute of Child Health and Human Development Saifuddin Ahmed Johns Hopkins University Bloomberg School of Public Health Ben Bellows Population Council Ana Langer Harvard School of Public Health Bert Peterson University of North Carolina at Chapel Hill Gillings School of Global Public Health Craig Lissner World Health Organization Hendree Jones RTI International Isabella Danel Centers for Disease Control Jeff Sine RTI International Jessica Celentano Harvard School of Public Health John Townsend Population Council Karen Fogg U.S. Agency for International Development Nahed Matta U.S. Agency for International Development Ratha Loganathan U.S. Agency for International Development Robert Balster U.S. Agency for International Development Sonali KordeU.S. Agency for International Development Supriya Madhavan Johns Hopkins University Bloomberg School of Public Health Ubaidur Rob Population Council, Bangladesh

 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

 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

 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

 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

 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?

 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)

 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

 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

 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

 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

 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.

 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

 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.

 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.

 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?)

 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

 Thank you!

 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