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In a recent conversation, Anrudh Jain from the Population Council and I discussed the differences between supply side interventions (such as training midwives) and demand side interventions (such as vouchers) for maternal health and how both are needed if we are to end preventable maternal mortality. Cash transfers and vouchers are excellent ways to create demand for health care services; however, if health care systems are broken or understaffed, then the increased demand will outstrip the supply and outcomes will not be improved.
Numerous papers and reports have documented broken health systems that are unable to absorb increases in uptake:
- A recent paper from Muralidharan et al. (PDF) “call[s] attention to the glaring scale of the problem of absent providers in public health clinics in India.” The authors found absenteeism for health workers in India to be between 22.3% and 56.3% of days depending on the state, with a country average of 39.3%.
- Pascaline Dupas from UCLA discusses (PDF) evidence on health seeking behavior, but find that “the competence of doctors in low-income countries is low, [and] the quality of care patients receive is even lower than would be expected given their doctor’s competence, especially among the poor.
- In Sierra Leone, where the government instituted free health care for pregnant women, lactating mothers and children under five, demand for health care has skyrocketed, but the system appears unable to meet that demand. According to an IPS News report, “Infants are crammed two or three to a bed, sometimes more,” and a report on the program found “the number of health staff has been increased since the launch…[but] is still insufficient to match the service delivery demand.”
In these cases, increasing demand for services may not have any impact on outcomes due to a lack of capacity for the health system to incorporate the increased demand.
Maternal health is often described as health system failure. Even though cash transfers can be effective at generating demand, in order to address maternal health disparities, the supply of services must also be considered.