Financial Incentives and Maternal Health: Where Do We Go from Here?

By Morgan, Lindsay; Stanton, Mary Ellen et al. | Journal of Health Population and Nutrition, December 2013 | Go to article overview

Financial Incentives and Maternal Health: Where Do We Go from Here?


Morgan, Lindsay, Stanton, Mary Ellen, Higgs, Elizabeth S., Balster, Robert L., Bellows, Ben W., Brandes, Neal, Comfort, Alison B., Eichler, Rena, Glassman, Amanda, Hatt, Laurel E., Conlon, Claudia M., Koblinsky, Marge, Journal of Health Population and Nutrition


INTRODUCTION

All over the world, prospects for women and their babies are improving. Between 1990 and 2010, maternal deaths declined by nearly 50% worldwide (http://www.who.int/mediacentre/factsheets/ fs348/en/). The use of effective maternal health interventions, such as uterotonics to prevent excess bleeding and magnesium sulphate to treat severe pre-eclampsia and eclampsia, is increasing. Option B+ for prevention and treatment of HIV/ AIDS in pregnant women is being initiated (Under Option B+, all pregnant women living with HIV are offered lifelong ART, irrespective of their CD4 count). Intermittent Preventive Treatment (IPT) in pregnancy and long-lasting insecticide-treated bednets are proving effective in reducing the risk of malaria infection among pregnant women, with benefits to both mothers and their children. Yet, despite significant political and financial commitments and technological advances, underutilization of services and poor quality provision persist. As a result, about 287,000 women continue to die each year from complications relating to pregnancy and childbirth-about one in every two minutes (1). The vast majority of these women live in poor countries and the vast majority of these deaths are preventable.

The importance of (dis)incentives

Transforming effective interventions into improved health outcomes requires tackling the disincentives patients and providers face in taking actions that lead to better health. Better health requires that individuals demand and are able to access services, that providers are motivated to deliver quality care (and have the inputs needed to do so), and that managers at all levels are encouraged to address systemic barriers to achieving health goals. The choices that both patients and providers make are influenced by incentives in the health systems that enable or constrain them and drive their behaviour.

Many disincentives exist that may prevent a woman and her family from seeking and reaching care due to inadequate knowledge, low levels of perceived need, social norms and taboos, transportation costs, opportunity costs of time-offfrom work, and the logistical costs associated with childcare. Furthermore, user fees at the point of service may lead households to prioritize urgent curative care services and neglect preventive care (2,3).

On the supply side, lack of supervision and support, inadequate numbers of providers, along with low, fixed salaries that do not vary based on performance, may not spur health providers to creatively solve problems and can lead to low productivity, absenteeism, clinical care of poor quality, lack of innovation, and even disrespectful care. Reimbursement for expenses can encourage providers to devote time and energy to tracking and justifying inputs rather than to expanding coverage, promoting preventive services, or solving systemic problems, even when they have the intrinsic motivation to do so.

Financial incentives

Health financing strategies that incorporate financial incentives aim to address these issues by providing a direct link between money spent and results generated. On the supply side, performance-based incentives (PBIs) aim to spur providers to focus on improvements in the quantity and quality of services by paying incentives only when such results have been delivered and verified. Demand-side programmes also incentivize results-the utilization of services. Incentives, thus, aim to minimize financial barriers to seeking and accessing services while also holding providers accountable for results.

Although the use of financial incentives for maternal health is growing, clarity on the state of the evidence supporting the effectiveness and sustainability of these interventions has been lacking. Yet, governments and donors need evidence to guide policy and practice. With this in mind, the US Government Evidence Summit was held on 24-25 April 2014 to review the evidence on financial incentives and provide recommendations for policy, practice, and research (Detailed results of the evidence review process are provided in other articles in this Supplement of the Journal). …

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