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Review |

Conditional Cash Transfers for Improving Uptake of Health Interventions in Low- and Middle-Income Countries:  A Systematic Review FREE

Mylene Lagarde, MSc; Andy Haines, MD; Natasha Palmer, PhD
[+] Author Affiliations

Author Affiliations: London School of Hygiene & Tropical Medicine, London, England.

More Author Information
JAMA. 2007;298(16):1900-1910. doi:10.1001/jama.298.16.1900.
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Published online

Context Cash transfers conditional on certain behaviors, intended to provide access to social services, have been introduced in several developing countries. The effectiveness of these strategies in different contexts has not previously been the subject of a systematic review.

Objective To assess the effectiveness of conditional monetary transfers in improving access to and use of health services, as well as improving health outcomes, in low- and middle-income countries.

Data Sources Relevant publications were identified via electronic medical and social science databases from inception to April 2006 (PubMED, EMBASE, POPLINE, CAB Direct, Healthcare Management Information Consortium, WHOLIS (World Health Organization Library Database), African Healthline, International Bibliography of the Social Sciences (IBSS), Eldis, British Library for Development Studies (BLDS), ID21, Journal Storage (Jstor), Inter-Science, ScienceDirect, Internet Documents in Economics Access Service (Research Papers in Economics) (IDEAS[Repec]), Latin American and Caribbean Health Sciences Literature (LILACS), MEDCARIB, Virtual Library in Health (ADOLEC), Pan American Health Organization (PAHO), FRANCIS, The Cochrane Central Register of Controlled Trials, the Database of Abstracts of Reviews of Effectiveness, and the Effective Practice and Organization of Care Group (EPOC) Register. Reference lists of relevant papers and “gray” literature resources were also searched.

Study Selection To be included, a paper had to meet study design criteria (randomized controlled trial, interrupted time series analysis, and controlled before and after study) and include a measure of at least 1 of the following outcomes: health care utilization, health expenditure, or health outcomes. Twenty-eight papers were retrieved for assessment and 10 were included in this review.

Data Extraction Methodological details and outcomes were extracted by 2 reviewers who independently assessed the quality of the papers.

Results Overall, the evidence suggests that conditional cash transfer programs are effective in increasing the use of preventive services and sometimes improving health status.

Conclusions Further research is needed to clarify the cost effectiveness of conditional cash transfer programs and better understand which components play a critical role. The potential success and desirability of such programs in low-income settings, with more limited health system capacity, also deserves more investigation.

In the past 10 years, some Latin American countries have introduced programs that provide monetary transfers to households on the condition that they comply with a set of behavioral requirements. These requirements are typically linked to attendance for preventive interventions at primary health care facilities and educational enrollment for children.

These programs are justified by social equity concerns, especially when they target disadvantaged groups. As low-income individuals usually face the greatest barriers to access, such conditional cash transfer mechanisms can also help redistribute resources to reduce health inequities. They can potentially increase the use of health services by low-income individuals by providing funds to help overcome some financial barriers to access, including costs related to seeking health care or sending children to school.

Interest in conditional cash transfer programs has increased, and these programs are spreading beyond Latin America. There is discussion of similar programs in sub-Saharan Africa, and there are pilot programs aimed at improving uptake of maternal health services in Bangladesh and Nepal.1,2 Until now, although a number of overviews have been carried out,3,4 there has been no systematic review critically assessing existing evidence on this subject.

A number of relevant databases (available from author on request) were searched using the following key terms, their combinations, or both: cash transfer, conditional cash transfer, monetary incentive, social protection, safety nets, health services, health, and demand. No limitation regarding publishing date was used. To identify “gray” literature studies, we systematically reviewed the bibliographies of all relevant publications, searched the System for Information on Gray Literature in Europe database (SIGLE), and explored online resources extensively (available from author on request).

The scope of the review was restricted to interventions in low- and middle-income countries as defined by the World Bank. We identified all studies that evaluated the effect of directly transferring money to households conditional on some requirements, at least 1 of which had to be related to health-seeking behavior. Studies on in-kind or unconditional cash transfers were excluded.

We included studies with the following study designs: randomized controlled trials, controlled before and after studies, interrupted time-series analyses, and multi cross-sectional studies using matching techniques. To be included, a study had to include a measure of at least 1 of the following outcomes: health care utilization or access to health care, household health expenditure, or health or anthropometric outcomes.

Two of the authors (M.L. and A.H.) independently sifted the titles and abstracts of retrieved publications and selected potentially relevant articles. In case of disagreement, full-text articles were retrieved and examined. All articles that were judged to meet criteria for this study were then independently reviewed (M.L. and A.H.). A data collection form was used to collect information on study design, intervention, setting, and outcome measures.

The quality of the selected studies was assessed independently by the 2 authors using criteria adapted from those of the Cochrane collaboration5 and tailored to the features of the studies. Given the potentially spurious results that could arise from ignoring clustering effects,6 attention was paid to assessing whether clustering effects were accounted for in the analyses. Discrepancies in quality ratings were resolved by discussion between the authors.

Given the heterogeneity of interventions, outcome measurements, and settings, statistical pooling of results was not attempted and a narrative synthesis was undertaken.

The review of titles and abstracts of more than 24 000 references from the main search led to the retrieval of 28 articles for full-text assessment. Ten articles that describe data and results from 6 studies (Table 1) were included in the final review. Of these 6 studies, 4 were randomized trials,7,1214 1 was a quasi-randomized evaluation,15 and 1 was a controlled before and after study.16

Table Graphic Jump LocationTable 1. Description of Interventions
Description of Interventions

With the exception of 1 study in Africa, most included studies described large-scale conditional cash transfer programs in Latin America. In Mexico, the seminal Progresa program (later called Opportunidades)711 aimed to improve health and education outcomes of low-income children. Households, selected on socioeconomic criteria, were given cash provided that children regularly attended both school and appointments for preventive health care. Participating children aged 4 to 23 months were also given food supplements. In Nicaragua, the Red de Protección Social12 pilot program was designed in a similar manner to the program in Mexico. Disadvantaged households in low-income areas received a cash transfer provided they brought their children who were younger than aged 5 years to preventive health examinations (where they received antiparasitic drugs, vitamins, iron supplements, and vaccinations) and attended health education workshops. An additional cash transfer was contingent on enrollment and regular attendance at primary school. The program Familias en Acción16 in Colombia was also similar. Targeting the poorest households in disadvantaged municipalities, it provided monetary transfers to mothers on the condition that their children who were younger than aged 7 years attended preventive health examinations, and another transfer if their children aged 7 to 17 years attended school regularly. Mothers were also encouraged to attend health education courses. In Honduras, any household in municipalities with high prevalence of malnutrition and benefiting from the Programa de Asignación Familial14 had access to 2 types of monetary incentives: one conditional on school attendance of children aged 6 to 12 years, and the other conditional on undergoing monthly preventive health examinations for children and prenatal care attendance for pregnant women. Finally, in Brazil the program Bolsa Alimentação15 was targeted to improve child and maternal health among low income populations. Mothers received capped transfers based on the number of beneficiaries (either children younger than aged 7 years or pregnant or lactating woman) in the household. Transfers were conditional on attendance at preventive health check ups and nutrition workshops for the women and adherence to vaccination schedules for children. The 1 study from Africa described a pilot program in Malawi13 that tested whether financial incentives would increase the collection of human immunodeficiency virus test results.

Methodological Limitations of Included Studies

Lack of reliability of data was a problem for some studies. For instance, results entirely based on self-reported outcomes may have been unreliable, in particular when respondents believed that their answers could jeopardize enrollment in a program. The authors of the Honduras study acknowledged this as a possible limitation.14 They found discrepancies between health cards and reports by mothers on their use of child growth-monitoring services, explained by self-report. Barham8 also noted that some lack of specificity of survey instruments may have led the researchers to overestimate the effects of the program in Mexico on immunization.

Some studies had problems with the quality of their randomization. Behrman and Todd18 show that the program in Mexico experienced a breakdown of randomization within the clusters, although randomization of the clusters was successful. In addition, leakage (within and between clusters) and selective distribution of the limited nutritional supplements to older children deemed by health workers to have poor nutritional status further weakened the study design.10

In the experiment on learning human immunodeficiency virus status in Malawi,13 the randomization of the value of vouchers (valued between 0 and US $3) was not successful and the final distribution of cash vouchers was skewed toward higher values.

Several biases were detected in the nutritional subsample of the study in Mexico.10,19 In addition to an important attrition bias of the follow-up survey, there were significant differences in the characteristics of control and treatment children, causing bias toward overrepresentation of children with poor nutrition in treatment groups. Finally, the absence of a baseline survey for this substudy10,11 limited the possibilities to control for some of the biases mentioned.

In the nonrandomized study, the lack of comparability between control and intervention sites may have led to spurious conclusions.20 However, all studies used rigorous statistical methods to address the specificities of some study designs (clustering effects) or to control for potential biases stemming from flawed implementation or design.8,9,12,20 All studies but 1 used intention-to-treat estimators.10 The analysis performed by Behrman10 may have overestimated the effects of the program in controlling for leakage and implementation problems in the delivery of the nutrition complements (Papilla).

Due to the variety of methods used to analyze the effects of the interventions and the different ways each paper reported results, synthesis and sometimes even comparisons between publications on the same program were difficult.

Care-Seeking Behavior

Five studies reported that conditional cash transfers increased use of health services (Table 2).

Table Graphic Jump LocationTable 2. Impact on Care-Seeking Behavior

The Malawi8 pilot project to increase uptake of human immunodeficiency virus results found that participants were very responsive to any monetary incentive. The introduction of an incentive increased the percentage of individuals collecting human immunodeficiency virus test results by a mean of 27% (after controlling for distance). There was also a positive linear effect with the level of incentive (each extra dollar increased the collection of human immunodeficiency virus results by a mean of 9%).

Based on facility-level data, Gertler7 found that the Mexico project scheme increased the mean number of visits to the health facilities by 2.09 visits per day in the areas where it was offered—beneficiary families visited the health facilities twice as frequently as nonbeneficiary families. Based on similar facility data, the Honduras program is said to have significantly increased use of health services by 23% for infants younger than aged 1 year and 42% for preschool children aged 1 to 5 years.15 Morris et al15 report that the program in Honduras also increased the mean percentage of individuals receiving prenatal care by 19 percentage points, routine pediatric examinations by 20 percentage points, and growth-monitoring visits for children by 16 percentage points. However, they found no effect on the percentage of women who received a 10-day follow-up visit after delivery.

Findings from the Nicaraguan program show a mean increase of 19 percentage points after 1 year and 11 percentage points after 2 years on the proportion of infants (aged 0-3 years) taken to health centers in the past 6 months.12 This effect was only significant for disadvantaged children, who benefited from most of the increase (24 percentage points). Children from families with greater income levels did not improve their use significantly. Finally, according to household survey data, the Colombian program16,17 led to an increase in children's preventive health care visits by 23 percentage points for children younger than aged 2 years and 33 percentage points for children aged 2 to 4 years. There was no significant increase for older children.

Immunization Coverage

Four studies detail the impact of conditional cash transfer programs on immunization coverage, with the results showing unclear effects (Table 3).

Table Graphic Jump LocationTable 3. Impact on Immunization Coverage

Barham8 shows that immunization against measles increased by a mean of 3 percentage points 6 months after the beginning of the program in Mexico and that tuberculosis vaccination was 5 percentage points greater for children aged 12 to 23 months at baseline. However, the latter increase was due to a sudden decline in coverage in the control zones, and this increase disappeared 6 months later, once the control areas returned to their initial levels. In Mexico, immunization rates were already very high before the program began, even in areas covered by the program, where 88% of children younger than 12 months and 97% of children aged 12 to 23 months were immunized against tuberculosis.

The evaluation of the Honduras program15 showed a mean increase of 6.9 percentage points in the coverage of the first dose of diphtheria, tetanus toxoids, pertussis (antigens unspecified) pentavalent vaccine among children younger than 3 years, but no effect on measles vaccination or on tetanus immunization among pregnant women. The program in Colombia increased the probability that parents had complied with the diphtheria, tetanus toxoids, pertussis (antigens unspecified) pentavalent vaccination schedule for their children at age 24 months, although there was no noticeable effect on the immunization rates of older children.16,17

Finally, the program in Nicaragua12 failed to demonstrate improved vaccination coverage, although this may have been caused by an indirect contamination effect in that efforts to deliver vaccines in program areas also had positive effects on vaccine availability in control zones.

Anthropometric Outcomes

Programs that monitored their impact on anthropometric measures commonly showed positive outcomes, but these are limited to some beneficiary subgroups only, which may hide smaller mean effects (see Table 4).

Table Graphic Jump LocationTable 4. Impact on Anthropometric and Nutritional Outcomes

The Colombian experiment records an improvement in the nutritional status of newborns and infants.16 There was a mean weight increase of 0.58 kg for newborns in urban areas of the treatment localities, which is likely to be attributable to improved nutrition of mothers during pregnancy. Attanasio et al16 also showed that the program helped increase the height-for-age z score of infants younger than 2 years (by 0.161), which translated into a diminution of the probability of being malnourished. However the experiment failed to show any impact on the nutritional status of children older than 24 months, or on the weight of newborns in rural areas.

Three analyses of the program in Mexico estimated911 various effects on heights of participants, using different statistical models, different populations, and different survey waves. Using data from 1998 and 2000, focusing on children younger than 12 months at baseline, Rivera et al11 concluded that beneficial effects were maximal for poorest children aged younger than 6 months. They found that an exposure of 2 years to the program, compared with a 1-year exposure at a later age (when aged 12-18 months), resulted in a mean incremental growth of 1.1 cm. Using 1999 data matched with 1997 socioeconomic data to control for covariates, Gertler9 estimated that children aged 12 to 36 months after 1 year of exposure to the Mexico program (in September 1999) were 0.96 cm taller than children from control areas. However, it did not affect their probability of being stunted. Finally, trying to compensate for several biases, Behrman and Hoddinot10 found similar results and showed that children aged between 12 and 36 months gained approximately 1 cm—one-sixth of the mean annual growth experienced in the absence of the program—after 1 year of exposure to the program. The authors further showed that this effect was principally captured by the oldest group—children aged 24 to 36 months at baseline—who experienced a height increase of 1.22 cm. This could be explained by the fact that nutritional supplements were given to children older than 2 years only when they were underweight,11 thereby maximizing the potential effect of these supplements.

The analysis of the Nicaraguan program12 showed that it had reduced the magnitude of stunting (net mean improvement of the height-for-age z score by 0.17) and the proportion of underweight children aged 0 to 5 years (a net impact of 6 percentage points after 2 years). On the other hand it did not have an impact on the proportion of wasted children aged 0 to 5 years, probably due to the very low level of wasting at baseline, which limits the statistical power to detect small changes.

However, the evaluation of the Brazilian program15 shows no effect on height-for-age measures and even a negative impact on weight-for-age for children younger than 7 years. These unexpected findings may have come from a misunderstanding of the eligibility criteria for the program by participating mothers (see “Comment” section).

Health Status

Other health outcomes were reported from 3 of the 7 programs (Mexico, Nicaragua, Colombia) included in the review. They showed mixed effects on objectively measured health outcomes and positive effects on mothers' reports of health outcomes of their children (Table 5).

The impact on anemia was assessed by 2 of the programs. The program in Nicaragua showed no impact on anemia prevalence among infants.12 Conversely, Rivera at al11 show that after 1 year of benefits from the program in Mexico, children in the intervention group had a significant higher level of hemoglobin, and therefore a lower rate of anemia than the control group. Furthermore, these differences disappeared once the control group had been exposed to the program for 1 year. Using different sets of data than Rivera et al,11 data from Gertler9 show that children in the Mexico program aged 12 to 36 months between October and December 1999 were 25% less likely to be anemic than those in the control sites. The accuracy of these results is challenged by leakage and nonrandomization in the allocation of the nutrition supplements,19 which may have contributed to underestimating the true effects of this program.10

The impact of 2 programs on mothers' reports of the health of their children was also examined. In Colombia, a reduction in the probability of reported diarrhea symptoms for children aged younger than 48 months living in rural areas was reported. Again, older groups did not appear to have benefited.16 The program did not appear to have an effect on the probability of experiencing respiratory symptoms. Gertler’s9 analysis of data from the Mexico program7 concludes that the intervention led to a decrease in the reported prevalence of childhood illness in the past month by 4.7 percentage points for children younger than 3 years at baseline, and by 3.2 percentage points for children between the ages of 3 and 5 years. In another analysis in which the sample used is restricted to households eligible to the Mexico program, Gertler9 shows that the program led to a 22% decrease in the probability of children younger than 3 years of age being reported as having been ill in the past month. Exploring the impact of the program in relation with how long children had benefited from it, the study further illustrated that in less than 1 year, beneficiary children (who were aged < 3 years at baseline) were 25% less likely to be reported as having been ill, and this percentage rose to 40% after 20 months of exposure to the program. An analysis of data on newborns suggested that the Mexico program had a positive prenatal care effect because children born to mothers in this program were 25% less likely than those born in nonbeneficiary households to be reported as having been ill in the previous 4 weeks.

This review of evidence from 6 conditional cash transfer programs reveals a reasonably consistent picture of the effects of such programs on health-related behaviors and, to some extent, outcomes. These types of demand-side strategies seem successful in increasing use of health services and improving nutritional and anthropometric outcomes and preventive behaviors. However, their overall effect on health status remains less clear. This highlights the importance of a focus on the supply of adequate and effective health services for demand-side programs such as these to have a more reliable effect on health outcomes.

Further research is needed to investigate the impact of conditional cash transfer in different settings and to assess the pathways by which any effects are achieved. The methodological limitations found in existing studies emphasize the need for carefully designed evaluations. In particular, baseline data collection is needed to assess whether randomization has been effective and, where necessary, to adjust for differences in intervention and control groups. Cluster trials are the most appropriate design in many cases, but care needs to be taken to ensure that biases do not occur due to assignment of conditional cash transfers within the intervention clusters. Overlapping analyses of the data from 1 study (the Mexico program) demonstrates the extent to which large-scale evaluations in this area are still relatively uncoordinated. We found independent analysis by a number of different investigators711 of the same data, giving rise to different articles reporting different analyses and results, and not citing each other. Subgroup analyses were frequent, particularly with regards to different age groups. Other commentators have pointed out how unplanned subgroup analyses of trials can lead to spurious conclusions.21 Analyses of multiple outcomes was also common, which can lead to difficulties of interpretation.22

There is also a difficulty in disentangling the relative importance of different components of the programs, as underlined by Gertler.9 For instance, health status and anthropometric measures are likely to be influenced by nutritional supplements provided to children,7,12 better diet resulting from the increased available revenue of households,23 or the benefits of mothers attending health education meetings. None of the included studies could investigate which barriers to access the programs had been particularly successful to help overcome (eg, financial, cultural, etc).

There are several further questions, not addressed by the studies in this review, but which are highly relevant to current discussions of the desirability of conditional cash transfer programs to settings such as sub-Saharan Africa.

Table 6 demonstrates that under conditional cash transfer programs, the flows of money required may be significant.24 From this point of view, there are several key gaps in knowledge for future program design.

Table Graphic Jump LocationTable 6. Financial Sustainability of the Programs

First, the cost-effectiveness of conditional cash transfer programs compared with classic supply-side interventions (eg, improving quantity and quality of infrastructure and services) has not been examined, as most conditional cash transfer programs have so far been implemented in settings with relatively adequate (health) infrastructures. Therefore, monetary transfers (and compulsory education workshops) were probably the most relevant strategies to address demand-side barriers (eg, financial or cultural ones). But in more resource-poor settings where public spending on health is low and access to effective interventions very limited, supply-side obstacles such as geographical inaccessibility or poor quality of services are critical as well.25 In such settings, it is likely that expanding health system capacity may be a preliminary step before the introduction of conditional cash transfer programs.

Second, the size of the transfers needed in different settings requires more attention, due to 2 sources of inefficiency of conditional cash transfer programs as identified by de Janvry and Sadoulet.26 On the one hand, such programs can yield very high costs per marginal visit/change induced, because money is given to all targeted individuals, regardless of their possible previous compliance with the conditionality of the programs. Consequently, the positive outcomes of conditional cash transfer programs should be weighted against their cost-effectiveness, in particular when both monetary incentives and initial uptake of services in the target population are already high.

On the other hand, the existence of possible threshold effects of incentives levels may lead to inefficiency because the cash transfers will either be too high or too low to induce the conditional action. Only 1 study tried to monitor the relative effects of different sizes of cash transfers,13 but the amounts concerned might have been too small to capture any potential threshold effect.

These issues will be a particular priority if conditional cash transfer programs are expanded into areas where the eligibility criteria are relaxed or discontinued as means testing may be more difficult and costly in low-income settings because of the absence of reliable information systems such as the ones used in Latin American programs. If the entire population becomes eligible for payment, evaluating the cost-effectiveness of theses programs will become critical.

Expanding conditional cash transfer programs also raises issues of ethics and broader effectiveness, once unintentional effects are taken into account. Conditional monetary transfer programs create strong incentives to change behavior, but unanticipated perverse effects can also occur. In the studies included in this review, Stecklov et al27 found that the Honduran program may have resulted in an increase in fertility of 2 to 4 percentage points, because pregnant women only were eligible for a subsidy. Morris et al15 suggest that the unexpected small negative impact of the Brazil program on children's weight gain may be explained by a misinterpretation of eligibility rules. Beneficiaries may have mistakenly thought that having at least 1 malnourished child was necessary for continued membership of the program. It is clear that programs with such potentially strong effects must be designed with care, and it is important to develop measures of welfare that are broad enough to record intended and unintended effects. Due consideration must also be given to the ethical implications of a policy tool that can change the behavior of low-income or vulnerable groups. In particular, the ethics of some programs using monetary incentives to promote irreversible contraceptive methods have been criticized.2830

The review suggests that conditional cash transfer programs constitute an effective approach to scaling-up access and use of preventive services in specific contexts when perverse incentives are avoided. However, the success of these strategies depends on the existence of effective primary health services and local infrastructures. In the case of the more complex Latin American programs, it is also dependent on effective systems for identifying and making payments to low-income families. It is important to consider the availability of these requirements in many of the other low-income settings in which conditional cash transfer might be considered. Further rigorous evaluations of future programs in low-income settings are needed, taking into account the lessons learned from the studies identified so far, and avoiding as far as possible the methodological pitfalls outlined.

Corresponding Author: Mylene Lagarde, MSc, Research Fellow, London School of Hygiene & Tropical Medicine, Health Policy Unit, Keppel Street, London, WCE1 7HT, England (mylene.lagarde@lshtm.ac.uk).

Author Contributions: Ms Lagarde had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Lagarde, Haines, Palmer.

Acquisition of data: Lagarde.

Analysis and interpretation of data: Lagarde, Haines.

Drafting of the manuscript: Lagarde.

Critical revision of the manuscript for important intellectual content: Lagarde, Haines, Palmer.

Obtained funding: Haines, Palmer.

Administrative, technical, or material support: Lagarde, Haines.

Study supervision: Palmer.

Financial Disclosures: None reported.

Funding/Support: We gratefully acknowledge the Bill and Melinda Gates Foundation for funding this work.

Role of the Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.

Additional Contribution: We also thank Andy Oxman, MD from the Cochrane EPOC Group for his useful comments on the protocol of this review. Dr Oxman did not receive compensation for his contribution to this article.

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Figures

Tables

Table Graphic Jump LocationTable 1. Description of Interventions
Table Graphic Jump LocationTable 2. Impact on Care-Seeking Behavior
Table Graphic Jump LocationTable 3. Impact on Immunization Coverage
Table Graphic Jump LocationTable 4. Impact on Anthropometric and Nutritional Outcomes
Table Graphic Jump LocationTable 6. Financial Sustainability of the Programs

References

Government of Nepal.  Maternity Incentive Scheme Guidelines. Kathmandu: Family Health Division, Government of Nepal; 2005
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