Understanding the ‘demand side’ in service delivery: Definitions, frameworks and tools from the health sector

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Demand side approaches are currently high on the pro-poor agenda. This paper examines the different understandings of ‘demand side’ in various literatures, in operational and policy perspectives and in international agencies. It maps out the different ways in which demand side issues have been defined in the health sector context in low and middle-income countries, together with various frameworks and tools that have been employed in developing demand side initiatives.

The term ‘demand side’ appears with increasing frequency in health planning and policy literature. The main drivers behind this interest are located in the economic and institutional crises and transformations of national health sectors in the last decade, including increasing marketisation and provider pluralism, the collapse (in some settings) of public sector services, and governance and regulatory failures. This has gone alongside the limited success of supply side health sector reforms in improving health service delivery.

This has led to two main demand side 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 to find ways of harnessing the demand side in pressing for change and improving the responsiveness of the supply side.

The most recent World Development Report (2004) on improving service delivery to poor people particularly captures the emerging demand side language of empowerment, voice and accountability. However, this emerging language is not necessarily being used in the same way by different actors and stakeholders. Although an emerging consensus in international health policy debates is detected, there is clear ideological water on the demand side between some of the human rights/social justice language of empowerment, and some of the consumer voice/choice language of empowerment.

Six main approaches to understanding and working on the demand side are reviewed in terms of the themes, actors and tools that they are associated with, and the key challenges which they present for the health sector. These approaches are: changing user behaviour to improve health outcomes; rights-based approaches; improving accountability through the demand side; participatory approaches; multi-sectoral/multiple stakeholder approaches; and demand side financing.

The paper concludes by drawing out some general implications of demand side approaches for development agency thinking and practice. It also highlights areas where there is scope for cross-sectoral learning. It argues that demand side approaches pose major challenges not only to governments but also to the way agencies work and how aid instruments are deployed. One of the principle challenges is the need to come to terms with the changing institutional landscape and configurations of actors that make it up. These include not just the users but organisations and coalitions that represent or advocate for user interests or that cut across the demand–supply divide. Agencies may find themselves in a more active engagement with these. This raises issues about the modes by which agencies work and the actors with which they work. It suggests the need for a potentially different and even more challenging politics of aid.