interventions

Figure 6.1 Typology and theory of change of included financial incentive interventions

Financial incentive interventions

Supply side Demand side

PBF

Provider income Voucher

Provider income User fees CCT

User income

RMCH service coverage

Source: Reproduced from Neelsen et al. 2021.

Note: CCT = conditional cash transfer; PBF = performance-based financing; RMCH = reproductive, maternal, and child health.

financially reward enrollees for complying with maternal and child health (MCH) service use conditions.

Performance pay, included in PBF programs, is thus essentially a supplyside intervention that increases health providers’ income when more and higher quality–targeted services are provided to patients, but it does not directly affect the user fees paid by households or their income. CCTs act on the demand side by increasing the household’s income when they use targeted services, but they do not directly increase providers’ incomes. Vouchers play a role on both the supply and demand sides: when a voucher is redeemed for specific services, the fee paid by patients is reduced and the income received by providers increases.

A growing evaluative literature has explored the effectiveness of financial incentive interventions on health service coverage in low- and middleincome countries (LMICs), and an increasing number of reviews are available that synthesize this growing evidence base. For the emerging literature on PBF, the most recent comprehensive review (Diaconu et al. 2020), for

which literature searches were conducted in 2018, finds the evidence on RMCH service coverage to be inconsistent and of low overall certainty. The literature on demand-side financial incentive schemes, including CCT programs and maternal voucher schemes, is older and more extensive, and some of those studies have already been the subject of systematic reviews (see, for example, Gaarder, Glassman, and Todd 2010; Bellows et al. 2016; Bassani et al. 2013; Glassman et al. 2013; Gopalan et al. 2014). The latest reviews of voucher and CCT programs—for which literature searches date back five years or longer—find more consistent positive impacts, particularly on family planning (vouchers) and maternity care, whereas effects on childhood vaccination are inconclusive (de Souza Cruz, Azevedo de Moura, and Soares Neto 2017; Hunter et al. 2017; Taaffe, Longosz, and Wilson 2017).

Except for a small number of CCT program reviews (Gaarder, Glassman, and Todd 2010; Bassani et al. 2013; Glassman et al. 2013; Oyo-Ita et al. 2016) and one review of voucher impacts on family planning (Belaid et al. 2016), the available reviews are narrative in nature. Due to this absence of quantitative syntheses, the average magnitude and heterogeneity of effect sizes of financial incentive interventions, which form important parameters for policy decisions, remain unknown to date. This section summarizes the findings of a recent systematic review and meta-analysis that attempts to close this knowledge gap as follows (Neelsen et al. 2021). First, conducting a meta-analysis across PBF, voucher, and CCT schemes can determine whether financial incentives, on average, improve access to RMCH service utilization. Next, the meta-analysis allows estimation of the mean effects of PBF, voucher, and CCT interventions for increasing RMCH service utilization. Finally, the analysis investigates selected contextual and program features of financial incentive programs for RMCH service utilization impacts.

Previous systematic reviews of financial incentives for RMCH have typically cited dissimilarities across interventions as a reason not to conduct quantitative syntheses of program impacts. However, if outcomes and interventions are similar enough, meta-analysis is indicated as soon as two studies are available (Valentine, Pigott, and Rothstein 2010; Higgins and Green 2011; Ryan and Cochrane Consumers and Communication Review Group 2016). As discussed in this chapter, although the outcome variable definitions are very similar across the studies in this review, differences in intervention designs and contexts can be substantial even within the three intervention types.