Public Health and Policy, London School of Hygiene and Tropical Medicine, UK.
Health, Nutrition and Population Unit, The World Bank, Washington DC, USA.
Soc Sci Med. 2014 Jan;100:72-83. doi: 10.1016/j.socscimed.2013.10.030. Epub 2013 Nov 4.
Demand-side financial incentive (DSF) is an emerging strategy to improve health seeking behavior and health status in many low- and middle-income countries. This narrative synthesis assessed the demand- and supply-side effects of DSF. Forty one electronic data bases were searched to screen relevant experimental and quasi-experimental study designs. Out of the 64 selected papers, 28 were eligible for this review and they described 19 DSF initiatives across Asia, Africa and Latin America. There were three categories of initiatives, namely long-run multi-sectoral programs or LMPs (governmental); long-run health-exclusive programs (governmental); and short-run health-exclusive initiatives (both governmental and non-governmental). Irrespective of the nature of incentives and initiatives, all DSF programs could achieve their expected behavioral outcomes on healthcare seeking and utilization substantially. However, there existed a few negative and perverse outcomes on health seeking behavior and DSF's impact on continuous health seeking choices (e.g. bed net use and routine adult health check-ups) was mixed. Their effects on maternal health status, diarrhea, malaria and out-of-pocket expenditure were under-explored; while chronic non-communicable diseases were not directly covered by any DSF programs. DSF could reduce HIV prevalence and child deaths, and enhance nutritional and growth status of children. The direction and magnitude of their effects on health status was elastic to the evaluation design employed. On health system benefits, despite prioritizing on vulnerable groups, DSF's substantial effect on the poorest of the poor was mixed compared to that on the relatively richer groups. Though DSF initiatives intended to improve service delivery status, many could not optimally do so, especially to meet the additionally generated demand for care. Causal pathways of DSF's effects should be explored in-depth for mid-course corrections and cross-country learning on their design, implementation and evaluation. More policy-specific analyses on LMPs are needed to assess how 'multi-sectoral' approaches can be cost-effective and sustainable in the long run compared to 'health exclusive' incentives.
需求方财政激励（DSF）是一种新兴策略，旨在改善许多中低收入国家的卫生服务利用和健康状况。本叙述性综述评估了 DSF 的需求方和供给方效应。检索了 41 个电子数据库以筛选相关的实验和准实验设计研究。在 64 篇入选论文中，有 28 篇符合本综述要求，它们描述了亚洲、非洲和拉丁美洲的 19 项 DSF 举措。这些举措分为三类，即长期多部门计划或 LMP（政府）、长期仅限卫生的计划（政府）以及短期仅限卫生的举措（政府和非政府）。无论激励措施和举措的性质如何，所有 DSF 方案都能在很大程度上实现预期的医疗保健利用行为结果。然而，在寻求卫生服务方面存在一些负面和反常的结果，DSF 对持续寻求卫生服务选择（例如使用蚊帐和常规成人健康检查）的影响好坏参半。其对孕产妇健康状况、腹泻、疟疾和自付支出的影响尚未得到充分探讨；而慢性非传染性疾病则未被任何 DSF 方案直接涵盖。DSF 可降低艾滋病毒流行率和儿童死亡率，并改善儿童的营养和生长状况。评价设计的差异导致其对健康状况的影响方向和程度存在差异。就卫生系统效益而言，尽管优先考虑弱势群体，但与相对较富裕群体相比，DSF 对最贫困人群的显著影响好坏参半。虽然 DSF 举措旨在改善服务提供状况，但许多举措无法最佳地实现这一目标，尤其是无法满足额外产生的医疗需求。应深入探讨 DSF 影响的因果途径，以便在设计、实施和评价方面进行中期调整和跨国学习。需要进行更多针对 LMP 的政策具体分析，以评估“多部门”方法与“仅限卫生”激励措施相比在长期内如何具有成本效益和可持续性。
