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

BackgroundDemand-side financing (DSF) interventions, including cash transfers and vouchers, have been introduced to promote maternal and newborn health in a range of low- and middle-income countries. These interventions vary in design but have typically been used to increase health service utilisation by offsetting some financial costs for users, or increasing household income and incentivising 'healthy behaviours'. This article documents experiences and implementation factors associated with use of DSF in maternal and newborn health.MethodsA secondary analysis (using an adapted Supporting the Use of Research Evidence framework - SURE) was performed on studies that had previously been identified in a systematic review of evidence on DSF interventions in maternal and newborn health.ResultsThe article draws on findings from 49 quantitative and 49 qualitative studies. The studies give insights on difficulties with exclusion of migrants, young and multiparous women, with demands for informal fees at facilities, and with challenges maintaining quality of care under increasing demand. Schemes experienced difficulties if communities faced long distances to reach participating facilities and poor access to transport, and where there was inadequate health infrastructure and human resources, shortages of medicines and problems with corruption. Studies that documented improved care-seeking indicated the importance of adequate programme scope (in terms of programme eligibility, size and timing of payments and voucher entitlements) to address the issue of concern, concurrent investments in supply-side capacity to sustain and/or improve quality of care, and awareness generation using community-based workers, leaders and women's groups. ConclusionsEvaluations spanning more than 15 years of implementation of DSF programmes reveal a complex picture of experiences that reflect the importance of financial and other social, geographical and health systems factors as barriers to accessing care. Careful design of DSF programmes as part of broader maternal and newborn health initiatives would need to take into account these barriers, the behaviours of staff and the quality of care in health facilities. Research is still needed on the policy context for DSF schemes in order to understand how they become sustainable and where they fit, or do not fit, with plans to achieve equitable universal health coverage

Bolsa Família: um survey sobre os efeitos do programa de transferência de renda condicionada do Brasil

Revisam-se pesquisas sobre efeitos do Programa Bolsa Família. Há quatro evidências frequentes. A primeira é que o programa tem focalização relativamente boa, mas que pode ainda ser melhorada. A segunda é o efeito positivo sobre a aquisição (consumo) de alimentos – sem conclusões sobre a qualidade da dieta. A terceira diz respeito ao estimulo às crianças a participarem da escola (matrícula, frequência e progressão), embora pouco se saiba sobre os efeitos na aprendizagem. A ausência de efeitos sobre a fecundidade das mulheres caracteriza a quarta conclusão robusta que se pode tirar da literatura, ainda que mais estudos devam ser realizados. Em outras dimensões, as evidências não formam consenso sobre direção dos efeitos.This paper surveys the literature about the effects of Bolsa Familia Program. We found four main results. The first is that the program is relatively well targeted, but it can still be improved.The second is the positive effect on the acquisition (consumption) of food, but there is no conclusions about the quality of the diet. The third is that the program encourages children to attend school (enrollment, attendance and progression). However, little is known about the effects on learning. The absence of effects on the fecundity of the women characterizes the fourth conclusion that can be drawn from the literature, although more studies must be carried out on this topic. In other dimensions, the evidence does not form consensus on the direction of effects

High-quality health systems in the Sustainable Development Goals era: time for a revolution

Although health outcomes have improved in low-income and middle-income countries (LMICs) in the past several decades, a new reality is at hand. Changing health needs, growing public expectations, and ambitious new health goals are raising the bar for health systems to produce better health outcomes and greater social value. But staying on current trajectory will not suffice to meet these demands. What is needed are high-quality health systems that optimise health care in each given context by consistently delivering care that improves or maintains health, by being valued and trusted by all people, and by responding to changing population needs. Quality should not be the purview of the elite or an aspiration for some distant future; it should be the DNA of all health systems. Furthermore, the human right to health is meaningless without good quality care because health systems cannot improve health without it. We propose that health systems be judged primarily on their impacts, including better health and its equitable distribution; on the confidence of people in their health system; and on their economic benefit, and processes of care, consisting of competent care and positive user experience. The foundations of high-quality health systems include the population and their health needs and expectations, governance of the health sector and partnerships across sectors, platforms for care delivery, workforce numbers and skills, and tools and resources, from medicines to data. In addition to strong foundations, health systems need to develop the capacity to measure and use data to learn. High-quality health systems should be informed by four values: they are for people, and they are equitable, resilient, and efficient.</p