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
Bert Peterson
Craig Lissner
Harvard School of Public Health
University of North Carolina at Chapel Hill Gillings School of Global Public
Health
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 Korde
U.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
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Four types of demand-side incentives were reviewed:
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Vouchers for services
Vouchers for products (ITNs)
Price subsidies
User fee exemptions for services
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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
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17 articles reviewed
◦ Included articles covering 5 country experiences (Bangladesh,
Cambodia, Kenya, Pakistan, and Uganda)
◦ 4 multi-country reviews
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Wide variation in services covered, outreach methods,
targeted populations, prices charged, concurrent
supply-side investments
◦ Complicates ability to isolate driver of effects
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The evidence indicates that voucher programs are
associated with greater use of maternal health services
◦ Increases in the use of ANC, skilled birth attendance, facilitybased delivery, and PNC
◦ Reduced disparities in service utilization by income
◦ Mixed effects on provider choice, competition
◦ No evidence of distortion of C-section provision
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No solid evidence of effects on maternal health
outcomes
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Limitations of evidence reviewed:
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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?
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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
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9 articles reviewed
◦ Tanzania (7 studies)
◦ Ghana (2 studies)
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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
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Limitations of the evidence reviewed
◦ Generally weak study designs; no comparison groups (prepost or cross-sectional only)
◦ Contamination from other programs
◦ Concerns about cost-effectiveness, sustainability
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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.
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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
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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.
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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
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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
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22 studies reviewed
◦ 18 articles covering 12 country experiences; 4 multi-country
reviews
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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).
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Effects on quality of services was either negative,
neutral, or not measured.
Effects on maternal and neonatal health outcomes
have not been conclusively demonstrated.
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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
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Grade of the evidence is generally weak.
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Maternal health voucher programs associated with increases
in ANC, skilled attendance, facility deliveries, and PNC.
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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.
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Evidence from one strong study suggests it is more costeffective to provide ITNs for free than sell at subsidized price.
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Little or no conclusive evidence on the effects of these
incentives on MNH outcomes.
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Supply-side effects of fee exemptions can be negative
(reduced quality of services, provider motivation); critical to
address to ensure desired maternal health outcomes.
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Long-term effects are generally unknown. Initial effects may
not persist.
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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.
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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
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Where user fees eliminated, carefully design a system for
replacing lost fee revenue
 Protect quality of care and provider motivation
 Prevent informal payments
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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?)
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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
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Stakeholders urgently need high-grade evidence in
this rapidly changing and promising policy arena

Thank you!
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How (and how effectively) providers are reimbursed
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Geographic access to health services
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Availability of alternative providers
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Quality of service or product being incentivized
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How much the policy actually lowers patient costs
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How well the policy is communicated to providers and
patients; social marketing and behavior change campaigns
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Cultural preferences and awareness; extent to which
item/service is “valued” or its importance for health is
understood