Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania.
Management Sciences for Health, New York, USA.
Soc Sci Med. 2019 Mar;225:17-25. doi: 10.1016/j.socscimed.2019.02.005. Epub 2019 Feb 10.
Demand side financing strategies have been a popular means of increasing coverage and availability of effective maternal and child health services in low and middle income countries (LMIC). However, most research to date has focused on the effects of demand side financing on the use and costs of care with less attention being paid to how they work to achieve outcomes. This study used a mixed methods evaluation to determine the effect of a targeted health insurance scheme on access to affordable quality maternal and child care, and assess implementation fidelity and how this affected programme outcomes. Programme effects on service access, affordability and quality were evaluated using difference in difference regression analysis, with outcomes being measured through facility, patient and household surveys and observations of care before the intervention started and eighteen months later. A simultaneous process evaluation was designed as a case study of the implementation experience. A total of 90 in-depth interviews (IDIs) and five focus group discussions were conducted during three rounds of data collection among respondents from management, facility and community. The scheme achieved high coverage among the target population and reduced the amount paid for antenatal and delivery care; however, there was no effect on service coverage and limited effects on quality of care. The lack of programme effects was partly due to the late timing of first antenatal care visits and registration for the scheme together with limited understanding of entitlements among beneficiaries and providers. Better communication of programme benefits is needed to enhance effects together with integration of such schemes within existing purchasing mechanisms and in financially decentralised health systems.
需求方融资策略一直是提高中低收入国家（LMIC）有效母婴卫生服务覆盖率和可及性的一种流行手段。然而，迄今为止大多数研究都集中在需求方融资对护理使用和成本的影响上，而对其实现结果的方式关注较少。本研究采用混合方法评估，以确定有针对性的医疗保险计划对获得负担得起的优质母婴保健的影响，并评估实施保真度以及这如何影响方案结果。使用差异中的差异回归分析评估了方案对服务可及性、可负担性和质量的影响，通过在干预前和十八个月后对设施、患者和家庭调查以及护理观察来衡量结果。同时进行了一项实施情况评估，作为实施经验的案例研究。在三轮数据收集期间，对来自管理层、医疗机构和社区的受访者进行了总共 90 次深入访谈（IDIs）和 5 次焦点小组讨论。该计划在目标人群中实现了高覆盖率，并降低了产前和分娩护理的费用；然而，对服务覆盖范围没有影响，对护理质量的影响有限。方案效果不佳部分归因于首次产前护理就诊和计划注册的时间较晚，以及受益人对权利的理解有限。需要更好地宣传方案效益，以提高效果，同时将此类计划纳入现有的购买机制和财政分散的卫生系统中。
