BACKGROUND: Universal Health Coverage is widely endorsed as the pivotal goal in global health, however substantial barriers to accessing health services for children in low and middle-income countries (LMIC) exist. Failure to access healthcare is an important contributor to child mortality in these settings. Barriers to access have been widely studied, however effective interventions to overcome barriers and increase access to services for children are less well documented.
METHODS: We conducted a systematic review of effectiveness of interventions aimed at increasing access to health services for children aged 5 years and below in LMIC. Four databases (EMBASE, Global Health, MEDLINE, and PSYCINFO) were searched in January 2016. Studies were included if they evaluated interventions that aimed to increase: health care utilisation; immunisation uptake; and compliance with medication or referral. Randomised controlled trials and non-randomised controlled study designs were included in the review. A narrative approach was used to synthesise results.
RESULTS: Fifty seven studies were included in the review. Approximately half of studies (49%) were conducted in sub-Saharan Africa. Most studies were randomised controlled trials (n = 44; 77%) with the remaining studies employing non-randomised designs. Very few studies were judged as high quality. Studies evaluated a diverse range of interventions and various outcomes. Supply side interventions included: delivery of services at or closer to home and service level improvements (eg. integration of services). Demand side interventions included: educational programmes, text messages, and financial or other incentives. Interventions that delivered services at or closer to home and text messages were in general associated with a significant improvement in relevant outcomes. A consistent pattern was not noted for the remaining studies.
CONCLUSIONS: This review fills a gap in the literature by providing evidence of the range and effectiveness of interventions that can be used to increase access for children aged ≤5 years in LMIC. It highlights some intervention areas that seem to show encouraging trends including text message reminders and delivery of services at or close to home. However, given the methodological limitations found in existing studies, the results of this review must be interpreted with caution.
SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD420160334200.
OBJECTIVE: To assess the evidence of the impact of user fees on maternal health service utilization and related health outcomes in low- and middle-income countries, as well as their impact on inequalities in these outcomes.
METHODS: Studies were identified by modifying a search strategy from a related systematic review. Primary studies of any design were included if they reported the effect of fee changes on maternal health service utilization, related health outcomes and inequalities in these outcomes. For each study, data were systematically extracted and a quality assessment conducted. Due to the heterogeneity of study methods, results were examined narratively.
FINDINGS: Twenty studies were included. Designs and analytic approaches comprised: two interrupted time series, eight repeated cross-sectional, nine before-and-after without comparison groups and one before-and-after in three groups. Overall, the quality of studies was poor. Few studies addressed potential sources of bias, such as secular trends over time, and even basic tests of statistical significance were often not reported. Consistency in the direction of effects provided some evidence of an increase in facility delivery in particular after fees were removed, as well as possible increases in the number of managed delivery complications. There was little evidence of the effect on health outcomes or inequality in accessing care and, where available, the direction of effect varied.
CONCLUSION: Despite the global momentum to abolish user fees for maternal and child health services, robust evidence quantifying impact remains scant. Improved methods for evaluating and reporting on these interventions are recommended, including better descriptions of the interventions and context, looking at a range of outcome measures, and adopting robust analytical methods that allow for adjustment of underlying and seasonal trends, reporting immediate as well as longer-term (e.g. at 6 months and 1 year) effects and using comparison groups where possible.
MAIN FINDINGS: Headline Findings: a summary statement Financial incentives can lead to increased uptake and coverage of a number of health interventions and practices for children under the age of five, but the evidence base is limited and generally of low quality. Evidence Base The authors include 25 studies in this review, of which 13 took place in Latin America and the Caribbean, eight in Sub-Saharan Africa and four in South Asia. Of the studies, 48 percent assess cash-transfer programmes (41 percent conditional cash-transfer programmes and 7 percent unconditional cash-transfer programmes), 22 percent assess the effects of removing user fees and 25 percent assess microcredit programmes. In terms of child health coverage indicators, 12 studies look at vaccination coverage, 19 studies look at health-care use, four studies look at the management of diarrhoeal diseases, four studies look at other preventive health and three studies look at breastfeeding practices. Implications for policy and practice Breastfeeding practices: Financial incentives can have a positive impact on some breastfeeding practices. Evidence from two studies in Bolivia and Ghana shows that microcredit programmes conditional on participation of mothers in health and nutrition education lead to a 22 percent increase in new-born babies receiving colostrum, on average (mean risk difference [MD] = 0.22; 95 percent confidence interval [CI]: 0.08, 0.35). However, two studies of conditional and unconditional microcredit interventions in Honduras and Ecuador found no significant effects on prevalence of breastfeeding. The overall size and quality of the evidence base is low.Vaccination coverage: Evidence from conditional cash-transfer and conditional microcredit programmes shows no impact on vaccination coverage, specifically BCG, DPT-1, DPT-3, measles or polio. Evidence from four conditional cash-transfer programmes suggests that these programmes may increase coverage of full age-appropriate vaccination, but the average effect is not statistically significant (MD = 0.05; CI: −0.01, 0.10). The available evidence base is only of moderate to low quality. Use of preventative health care: Evidence from five conditional cash-transfer programmes shows a 14 percent increase, on average, in the use of preventive health care by children under the age of five (MD = 0.14; CI: −0.00, 0.29), though the average effect is not statistically significant. The authors also note that the effects vary across studies and the evidence is of variable quality. Removal of user fees lead to a 33 percent increase in the prevalence of health-care use, on average (MD = 0.33; CI: 0.24, 0.43), and a 99 percent increase in the frequency of health-care use, on average (MD = 0.99; CI: 0.71, 1.27)—but, again, the quality of evidence is low.Management of child diarrhoea: The evidence for the impact of financial-incentive programmes on management of childhood diarrhoea is poor, with only single studies looking at the impact of either unconditional or conditional microcredit on use of oral rehydration or care-seeking during diarrhoea. Two studies of conditional microcredit interventions suggest no effect of the intervention on the practice of continuing child feeding during diarrhoea. Other preventative health care: Evidence from two conditional cash-transfer programmes finds a 16 percent increase in the average coverage of Vitamin A supplements, but the results are not statistically significant (MD = 0.16; CI: −0.01, 0.34). Implications for further research The review team calls for future systematic reviews to assess the impact of financial incentives on child morbidity and mortality. They also state that future primary research should try to isolate the effects of the financial and non-financial components of programmes. BACKGROUND: Financial incentives that provide direct or indirect monetary incentives to households, such as voucher schemes or cash-transfer programmes, are commonly used to help overcome poverty and improve health of populations in low- and middle-income countries. One channel by which they are expected to do this is through the removal of financial barriers to health care. This is expected to improve access, uptake and coverage of health services such as immunisation, treatment of diarrhoea and preventative health interventions. Previous reviews have looked at the impact of different types of financial incentives on health outcomes. However, this is the first review to comprehensively review the effectiveness of financial-incentive programmes in low- and middle-income countries targeted at the coverage and uptake of health services and behaviours of children under the age of five. RESEARCH OBJECTIVES: The authors aimed to investigate the effects of six different types of financial-incentive programmes—unconditional cash transfers, conditional cash transfers, unconditional microcredit, conditional microcredit, unconditional voucher, conditional voucher and user-fee removal—on uptake and coverage of health interventions for children under the age of five. METHODOLOGY: The authors included randomised controlled trials, cluster-randomised controlled trials and observational studies that assessed the effect of financial incentives on indicators of health-care coverage for children under the age of five. Eligible studies reported the effect of financial incentives on the following types of health-coverage outcomes: breastfeeding, vaccination, health-care use, diarrhoeal diseases and other preventive health interventions. The authors used the Child Health Evaluation Reference Group (CHERG) systematic review guidelines and searched for studies published in either peer-reviewed journals or institutional/commissioned reports covering the period up to 1 September 2012. They searched in the databases PubMed, EMBASE and AMED and used Google Scholar and the Microfinance Gateway library to complement this search. They assessed the quality of the included studies and used meta-analysis to synthesise effect sizes.
BACKGROUND: Delays in receiving effective care during labor and at birth may be fatal for the mother and fetus, contributing to 2 million annual intrapartum stillbirths and intrapartum-related neonatal deaths each year.
OBJECTIVE: We present a systematic review of strategies to link families and facilities, including community mobilization, financial incentives, emergency referral and transport systems, prenatal risk screening, and maternity waiting homes.
RESULTS: There is moderate quality evidence that community mobilization with high levels of community engagement can increase institutional births and significantly reduce perinatal and early neonatal mortality. Meta-analysis showed a doubling of skilled birth attendance and a 36% reduction in early neonatal mortality. However, no data are available on intrapartum-specific outcomes. Evidence is limited, but promising, that financial incentive schemes and community referral/transport systems may increase rates of skilled birth attendance and emergency obstetric care utilization; however, impact on mortality is unknown. Current evidence for maternity waiting homes and risk screening is low quality.
CONCLUSIONS: Empowering communities is an important strategy to reduce the large burden of intrapartum complications. Innovations are needed to bring the poor closer to obstetric care, such as financial incentives and cell phone technology. New questions need to be asked of "old" strategies such as risk screening and maternity waiting homes. The effect of all of these strategies on maternal and perinatal mortality, particularly intrapartum-related outcomes, requires further evaluation.
OBJECTIVE: To assess the effects of user charges on the uptake of health services in low- and middle-income countries.
METHODS: A systematic search of 25 social science, economics and health literature databases and other sources was performed to identify and appraise studies on the effects of introducing, removing, increasing or reducing user charges on the uptake of various health services in low- and middle-income countries. Only experimental or quasi-experimental study designs were considered: cluster randomized controlled trials (C-RCT), controlled " before and after" (CBA) studies and interrupted time series (ITS) studies. Papers were assessed in which the effect of the intervention was measured in terms of changes in service utilization (including equity outcomes), household expenditure or health outcomes.
FINDINGS: Sixteen studies were included: five CBA, two C-RCT and nine ITS. Only studies reporting effects on health service utilization, sometimes across socioeconomic groups, were identified. Removing or reducing user fees was found to increase the utilization of curative services and perhaps preventive services as well, but may have negatively impacted service quality. Introducing or increasing fees reduced the utilization of some curative services, although quality improvements may have helped maintain utilization in some cases. When fees were either introduced or removed, the impact was immediate and abrupt. Studies did not adequately show whether such an increase or reduction in utilization was sustained over the longer term. In addition, most of the studies were given low-quality ratings based on criteria adapted from those of the Cochrane Collaboration's Effective Practice and Organisation of Care group.
CONCLUSIONS: There is a need for more high-quality research examining the effects of changes in user fees for health services in low- and middle-income countries.
In this article we outline research since 1995 on the impact of various financing strategies on access to health services or health outcomes in low income countries. The limited evidence available suggests, in general, that user fees deterred utilisation. Prepayment or insurance schemes offered potential for improving access, but are very limited in scope. Conditional cash payments showed promise for improving uptake of interventions, but could also create a perverse incentive. The largely African origin of the reports of user fees, and the evidence from Latin America on conditional cash transfers, demonstrate the importance of the context in which studies are done. There is a need for improved quality of research in this area. Larger scale, upfront funding for evaluation of health financing initiatives is necessary to ensure an evidence base that corresponds to the importance of this issue for achieving development goals.
Universal Health Coverage is widely endorsed as the pivotal goal in global health, however substantial barriers to accessing health services for children in low and middle-income countries (LMIC) exist. Failure to access healthcare is an important contributor to child mortality in these settings. Barriers to access have been widely studied, however effective interventions to overcome barriers and increase access to services for children are less well documented.
METHODS:
We conducted a systematic review of effectiveness of interventions aimed at increasing access to health services for children aged 5 years and below in LMIC. Four databases (EMBASE, Global Health, MEDLINE, and PSYCINFO) were searched in January 2016. Studies were included if they evaluated interventions that aimed to increase: health care utilisation; immunisation uptake; and compliance with medication or referral. Randomised controlled trials and non-randomised controlled study designs were included in the review. A narrative approach was used to synthesise results.
RESULTS:
Fifty seven studies were included in the review. Approximately half of studies (49%) were conducted in sub-Saharan Africa. Most studies were randomised controlled trials (n = 44; 77%) with the remaining studies employing non-randomised designs. Very few studies were judged as high quality. Studies evaluated a diverse range of interventions and various outcomes. Supply side interventions included: delivery of services at or closer to home and service level improvements (eg. integration of services). Demand side interventions included: educational programmes, text messages, and financial or other incentives. Interventions that delivered services at or closer to home and text messages were in general associated with a significant improvement in relevant outcomes. A consistent pattern was not noted for the remaining studies.
CONCLUSIONS:
This review fills a gap in the literature by providing evidence of the range and effectiveness of interventions that can be used to increase access for children aged ≤5 years in LMIC. It highlights some intervention areas that seem to show encouraging trends including text message reminders and delivery of services at or close to home. However, given the methodological limitations found in existing studies, the results of this review must be interpreted with caution.
