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Do conditional cash transfers improve the uptake of health interventions in low- and middle-income countries?

Over the past few years, several Latin American countries have introduced programmes that provide monetary transfers to households on the condition that they comply with certain health behaviours. The rationale is that the transfers can potentially increase the use of health services by low-income individuals by providing funds to help overcome some financial barriers to access.

Key messages

Six studies of conditional cash transfer programmes carried out in low and middle- income countries found an increase in the use of health services and mixed effects on immunisation coverage and health status.
The capacity of each health system to deal with the increased demand should be considered, particularly in low-income countries where the capacity of health systems may not be sufficient.
The cost-effectiveness of conditional cash transfer programmes, compared with supply-side strategies and other policy options, has not been evaluated.

Who is this summary for?

People making decisions concerning the use of conditional cash transfers to improve the uptake of health interventions.

This summary includes:

Key findings from research based on a systematic review
Considerations about the relevance of this research for low income countries

Not included:

Recommendations
Additional evidence not included in the systematic review
Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low and middle- income countries: a systematic review. JAMA 2007; 298:1900-10.

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

In the past decade, some Latin American and African countries have introduced pro- grammes that provide monetary transfers to targeted households on the condition that they comply with a set of behavioural requirements. These requirements are typically linked to attendance at primary care centres for preventive interventions and to educational enrolment for children.

The rationale is that the transfers can potentially increase the use of health services by low-income individuals by providing funds to help overcome some financial barriers to access, such as the costs associated with seeking health care or sending children to school.

Interest in conditional cash transfers has increased and such programmes are being implemented in a number of countries within and beyond Latin America.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.

About the systematic review underlying this summary

/	What the review authors searched for	What the review authors found
Review Objectives: 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
Interventions	Programmes in which money was transferred directly to households conditional on some requirements, at least one of which had to be related to health-seeking behaviour.	Five large-scale conditional cash transfer programmes in Latin America targeted at disadvantaged households, and one pilot program in Africa (Malawi) targeted at individuals tested for HIV.
Participants	Users and non-users of health services in low- and middle-income countries.	Disadvantaged households in low-income areas of selected Latin American countries, and individuals who underwent HIV testing in rural areas in Malawi.
Settings	Low- and middle-income countries as defined by the World Bank.	Low- and middle-income countries: five in Latin American (Mex- ico, Nicaragua, Honduras, Brazil and Colombia) and one in Africa (Malawi).
Outcomes	Healthcare utilisation or access to health care, household health expenditure, health or anthropom- etric outcomes	Care-seeking behaviour (five studies); immunisation coverage (four studies); anthropometric outcomes (four studies); and health status (three studies)
Date of most recent search: April 2006
Limitations: This is a good quality systematic review with only minor limitation

Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low and middle- income countries: a systematic review. JAMA 2007; 298:1900-10.

About the certainty of the  evidence (GRADE)

High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.

Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.

Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.

Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

Ten articles that reported the results from six studies (four randomised trials, one quasi- randomised evaluation, and one controlled before-after study) were included. Five out of six studies evaluated large-scale conditional cash transfer programmes in Latin America (Mexico, Nicaragua, Colombia, Honduras and Brazil), targeted at disadvantaged households in low-income areas in order to increase school and preventive health examinations attendance. The other study was of a pilot programme in Malawi that tested whether financial incentives would increase the collection of HIV test results.

The mean monetary transfer per household ranged between US $17 and 50 for Latin American studies and was US $1 per individual in the Malawi study. In the case of Mexico, Nicaragua and Brazil households received additional nutrition supplements for children.

Overall, the evidence suggests that conditional cash transfer programmes can be effective in increasing the use of preventive services and can sometimes improve immunisation coverage and health status.

Outcomes	Impact	No of Participants (studies)	Quality of the evidence (GRADE)
Care-seeking behaviour	All the studies reported an increase in the use of health services in the group with cash transfers (27% increase in individuals returning for volun- tary HIV counselling, 2.1 more visits per day to health facilities, 11-20% more children taken to the health centre in the past month, 23-33% more children < 4 yrs attending preventive healthcare visits)	5,832,619 (5 studies)**
Immunisation coverage	The effects were unclear (increased vaccination rates in children for measles and tuberculosis but only in specific groups or temporarily, and without change in one study)	5,832,619 (4 studies)
Health status	Mixed effects on objectively measured health outcomes (anaemia) and posi- tive effects on mothers’ reports of children’s health outcomes (22-25% de- crease in the probability of children <3 yrs being reported ill in the past month)	5,421,619 (3 studies)
RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see explanations)

Relevance of the review for low-income countries

Findings	Interpretation*
APPLICABILITY
All of the studies were undertaken in low- and middle- income countries, predominantly in Latin America. Components of the evaluated programmes other than the cash transfers may have impacted on the results. For instance, health status and anthropometric measures could have been influenced by nutritional supplements provided to children in these studies; better diet resulting from the increased available revenue of households; or the benefits of mothers attending health education meetings.	Most of the evidence is likely to be applicable in Latin American health systems, although differences in health systems that could impact on the effects of conditional cash transfers still need to be considered. In particular, the capacity of health systems to deal with increased demand needs to be considered. In resource-poor settings where public spending on healthcare is low and access to effective interventions limited, expanding the capacity of health services would be necessary for cash transfers to result in improved use of health services. It is difficult to disentangle the relative importance of different components of the programmes that included more than cash transfers. The effects of non-cash components could be especially relevant in some LMICs.
EQUITY
In Nicaragua, increases in household expenditures were the greatest for the poorest group as was the uptake of preventive services for infants. On the other hand, nutritional benefits in Mexico were greater for children whose mother had more than five years of schooling, which could suggest that these programmes do not achieve perfectly their ambition of “levelling the playing field”.	Children from disadvantaged environments, at household and community levels, seem to gain greater benefits from the programmes than those from more advantaged environments. However, it may be more difficult and costly for people living in rural and other underserved areas to have access to the specific health services targeted by cash transfers. Therefore, if an adjustment is not incorporated into the transfers, those recipients would benefit less than those with better access to health services.
ECONOMIC CONSIDERATIONS
Conditional cash transfer programmes may require significant flows of money.	It is not possible, especially for resource-poor settings, to establish which policy options would be the most efficient in improving access to and use of health services for targeted populations. For example, the removal of users fees for using health facilities is an alternative policy option to improve access and utilisation in some contexts.
MONITORING & EVALUATION
The cost-effectiveness of conditional cash transfer programmes compared with supply-side interventions (for example, improving the quantity and quality of healthcare services) has not been evaluated. Cash transfers may be either too high or too low to induce the conditional action, resulting in inefficiency.	The cost-effectiveness of conditional cash transfer programmes should be evaluated in low-income settings with more limited health system capacity prior to wide spread implementation in those settings. Attention should be paid to evaluating which components play a critical role (cash versus non-cash transfers); the size of the transfers; and the financial sustainability of such programmes.
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income countries. For additional details about how these judgements were made see:

Additional information

Related literature

Lagaarde M, Palmer N. Evidence from systematic reviews to inform decision making regarding financing mechanisms that improve access to health services for poor people. A policy brief prepared for the International Dialogue on Evidence-Informed Action to Achieve Health Goals in Developing Countries (IDEAHealth). Geneva: Alliance for Health Policy and Systems Research, 2006.

Oxman AD, Fretheim A. An overview of research on the effects of results-based financing. Oslo: Norwegian Knowledge Centre for the Health Services, 2008. In press.

Eichler R. Can ”Pay for Performance” Increase Utilization by the Poor and Improve the Quality of Health Services? Discussion paper for the first meeting of the Working Group on Performance-Based Incentives. Washington DC: Center for Global Development, 2006;

Handa S, Davis B. The experience of conditional cash transfers in Latin America and the Caribbean. Dev Policy Rev 2006; 24:513-536.

Ensor T, Cooper S. Overcoming Barriers to Health Service Access and Influencing the Demand Side Through Purchasing. Washington, DC: World Bank; 2004.

de Janvry A, Sadoulet E. Making conditional cash transfer programs more efficient: designing for maximum effect of the conditionality. World Bank Econ Rev 2006; 20:1-29.

This summary was prepared by

Tomás Pantoja, Universidad Catolica de Chile, Santiago, Chile

Conflict of interest

None declared. For details, see:

Acknowledgements

This summary has been peer reviewed by: Mylene Lagarde, UK; Atle Fretheim, Norway; Qingyue Meng, China; Suzanne Kiwanuka, Uganda.

This summary should be cited as

Pantoja T. Do conditional cash transfers improve the uptake of health interventions in low and middle- income countries? A SUPPORT Summary of a systematic review. August 2008. www.support- collaboration.org/summaries.htm

About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

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