August, 2016 - SUPPORT Summary of a systematic review | print this article |

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 or families by providing funds to help overcome some financial barriers to access.

 

Key messages

  • Conditional cash transfer programmes in low and middle-income countries probably lead to 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.

Background

In the past decade, some Latin American and African countries have introduced programmes 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 healthcare 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.



About the systematic review underlying this summary

Review objectives: To assess the effectiveness of conditional monetary transfers in improving access to and use of health services and health outcomes in low- and middle-income countries
Type of What the review authors searched for What the review authors found
Study designs & 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.
Four randomised trials, one quasi-randomised evaluation, and one controlled before-after study were found.
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 (Mexico, Nicaragua, Honduras, Brazil and Colombia) and one in Africa (Malawi).
Outcomes Healthcare utilisation or access to healthcare, household health expenditure, health or anthropometric outcomes.
Care-seeking behaviour (five studies); immunisation coverage (four studies); anthropometric outcomes (four studies); and health status (three studies).
Date of most recent search: January 2011.
Limitations: This is a well-conducted systematic review with only minor limitations.

Lagarde M, Haines A, Palmer N. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane Database of Systematic Reviews 2009, Issue 4.

Summary of findings

Six studies were included. Five 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.

  • Conditional cash transfer programmes probably are effective in increasing the use of preventive services and can sometimes improve immunisation coverage and health status. The certainty of this evidence is moderate.

Conditional cash transfers

People:  Users and non-users of health services

Settings:  Low- and middle-income countries

Intervention: Conditional cash transfers to improve access to and use of health services and health outcomes

Comparison: No intervention

Outcomes Impact Certainty 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 voluntary 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).

Moderate

Immunisation coverage

The effects were mixed (increased vaccination rates in children for measles and tuberculosis but only in specific groups or temporarily, and without change in one study).

Moderate

Health status

Mixed effects on objectively measured health outcomes (anaemia) and positive effects on mothers’ reports of children’s health outcomes (22-25% decrease in the probability of children <3 yrs being reported ill in the past months).

Moderate

GRADE: GRADE Working Group grades of evidence (see above and last page)

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 low-income countries.
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 fully achieve 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 user 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 (e.g. cash versus non-cash transfers and 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-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods

Additional information

Related literature

 

Oxman AD, Fretheim A. Can paying for results help to achieve the Millennium Development Goals? Overview of the effectiveness of results-based financing. Journal of Evidence-Based Medicine 2009; 2:70-83.

 

Oxman AD, Fretheim A. Can paying for results help to achieve the Millennium Development Goals? A critical review of selected evaluations of results-based financing. Journal of Evidence-Based Medicine 2009; 2:184–95.

 

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: www.supportsummaries.org/coi

Acknowledgements

This summary has been peer reviewed by: Mylene Lagarde, Atle Fretheim, Qingyue Meng, Suzanne Kiwanuka, and Hanna Bergman.

This review should be cited as

Lagarde M, Haines A, Palmer N. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane Database of Systematic Reviews 2009, Issue 4.

The 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 2016. www.supportsummaries.org

Keywords

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, conditional cash transfer, conditional monetary transfer, results-based financing.



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