Can the active engagement of primary stakeholders in service provision contribute to improving the quality of health care? If so, what role should government and development agencies play in this process? This document by DFID’s Health Systems Resource Centre explores the different uses of the ‘demand side’ concept, the challenges that demand side approaches pose to service delivery in the health sector of low income and transitional countries and the implications of these differences for policy actors, particularly international agencies.
The public sector has been affected by a crisis in funding and governance. Health provision has become increasingly pluralistic, with many providers competing in an unregulated market and an increasing failure of management and regulation to ensure the provision of high quality, accessible health services for poor populations. As a consequence, ‘demand side’ (DS) approaches to service provision are high on the pro-poor agenda, despite lack of clarity over their meaning and policy implications. The term ‘demand side’ refers broadly to the behaviour and inputs of the recipients or intended recipients of service provision, encompassing individuals, households and communities. Implementing demand side approaches generally raises two main concerns. One is understanding health seeking behaviours and patterns of utilisation with a view to either changing them, or catering better to them. The other is finding ways of harnessing the demand side in pressing for change and improving the responsiveness of the “supply side” while balancing the pressure for change with the capacity of the supply side to respond.
Six DS approaches are identified: changing user behaviour to improve health outcomes; rights-based approaches; improving accountability through DS; participatory approaches; multi-sectoral/multiple stakeholder approaches; and DS financing. There is consensus on the need to improve service delivery for the poor. Yet the various meanings associated with the term ‘demand side’ manifest ideological differences in the ways it should be addressed. Other findings are:
- DS approaches bring a wide range of actors into the policy process.
- Governments and donors need to engage more actively with direct users, as well as with organisations which represent or advocate for user interests.
- DS approaches pose major challenges to aid agencies and raise questions about the way they work, whom they work with and how they relate to the different aid instruments.
In a context where DS approaches are starting to shape the policy process, donors need to:
- Analyse institutional and micro/macro political issues to understand the new context in which service delivery takes place.
- Understand the politics of engaging both with government and bureaucracies and with civil society and communities.
- Acknowledge the resource and institutional limitations faced by the supply side.
- Catalogue and share experiences to promote learning within the health sector and across sectors.
- Assess the long-term impact of DS side approaches on institutional arrangements and service delivery. Special attention has to be given to the role of the public sector.
- Negotiate a greater role for DS engagement within present aid approaches such as budget support.
