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Conditional Cash Transfers for Improving
Uptake of Health Interventions
in Low- and Middle-Income Countries
A Systematic Review
Context Cash transfers conditional on certain behaviors, intended to provide access
to social services, have been introduced in several developing countries. The effec- tiveness of these strategies in different contexts has not previously been the subject ofa systematic review.
INTHEPAST10YEARS,SOMELATIN ObjectiveToassesstheeffectivenessofconditionalmonetarytransfersinimprov-
ing access to and use of health services, as well as improving health outcomes, in low- Data Sources Relevant publications were identified via electronic medical and so-
cial 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 Econom- ics 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 CentralRegister of Controlled Trials, the Database of Abstracts of Reviews of Effectiveness, and the Effective Practice and Organization of Care Group (EPOC) Register. Refer- ence lists of relevant papers and “gray” literature resources were also searched.
Study Selection To be included, a paper had to meet study design criteria (ran-
domized 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 re- trieved for assessment and 10 were included in this review.
Data Extraction Methodological details and outcomes were extracted by 2 review-
ers 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 Conclusions Further research is needed to clarify the cost effectiveness of condi-
tional 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.
America. There is discussion of simi-lar programs in sub-Saharan Africa, Author Affiliations: London School of Hygiene & Tropi-
Corresponding Author: Mylene Lagarde, MSc, Re-
search Fellow, London School of Hygiene & TropicalMedicine, Health Policy Unit, Keppel Street, London, WCE1 7HT, England (mylene.lagarde@lshtm.ac.uk).
1900 JAMA, October 24/31, 2007—Vol 298, No. 16 (Reprinted)
2007 American Medical Association. All rights reserved.
CONDITIONAL CASH TRANSFERS FOR IMPROVING UPTAKE OF HEALTH INTERVENTIONS both: cash transfer, conditional cash transfer, monetary incentive, social protection, safety nets, health services, health, and demand. No limitation To identify “gray” literature studies, tings, statistical pooling of results was articles for full-text assessment. Ten ar- ies that evaluated the effect of directly ticles that describe data and results from 6 studies (TABLE 1) were included in
Asignacio´n Familial14 had access to 2 Description of Interventions
trolled trials, controlled before and af- Finally, in Brazil the program Bolsa A f r i c a , m o s t i n c l u d e d s t u d i e s A l i m e n t a c¸ a˜ o 1 5 w a s t a r g e t e d t o analyses, and multi cross-sectional stud- America. In Mexico, the seminal Pro- g r e s a p r o g r a m ( l a t e r c a l l e d Opportunidades)7-11 aimed to improve w o r k s h o p s f o r t h e w o m e n a n d stracts of retrieved publications and se- d e s c r i b e d a p i l o t p r o g r a m i n Red de Proteccio´n Social12 pilot pro- Methodological Limitations
tion, setting, and outcome measures.
of Included Studies
2007 American Medical Association. All rights reserved.
(Reprinted) JAMA, October 24/31, 2007—Vol 298, No. 16 1901
CONDITIONAL CASH TRANSFERS FOR IMPROVING UPTAKE OF HEALTH INTERVENTIONS Table 1. Description of Interventions
Setting and
Methodological
Study Design
Participants
Transfer Size, US $
Other Benefits
Requirements
Limitations
1999, and 2000caused bias towardoverrepresentation oflow-income households(while the broaderhousehold survey onlyled to a 5% attrition rate);clustering effects notcontrolled for in someanalyses; lack of datareliability for use of healthservices (facility registrarsdidn’t discriminatebetween users who werein the conditional cashtransfer clusters andother users); lack ofdata reliability forimmunizations (problemsof data recording likelyleading to overestimatesof positive results) patients redraw when azero was originallyselected) designatedbeneficiarymunicipalities(selected onsocioeconomiccriteria) biased; control groupwas also more likely toreceive anotherconditional cash transferbased on educationconditionalities only(Bolsa Escola) 1902 JAMA, October 24/31, 2007—Vol 298, No. 16 (Reprinted)
2007 American Medical Association. All rights reserved.
CONDITIONAL CASH TRANSFERS FOR IMPROVING UPTAKE OF HEALTH INTERVENTIONS flawed implementation or design.8,9,12,20 Care-Seeking Behavior
services (TABLE 2).
Immunization Coverage
showing unclear effects (TABLE 3).
tant attrition bias of the follow-up sur- the health facilities by 2.09 visits per day in the areas where it was offered decline in coverage in the control zones, facilities twice as frequently as nonben- with poor nutrition in treatment groups.
cility data, the Honduras program is said vey for this substudy10,11 limited the pos- sibilities to control for some of the bi- were immunized against tuberculosis.
2007 American Medical Association. All rights reserved.
(Reprinted) JAMA, October 24/31, 2007—Vol 298, No. 16 1903
CONDITIONAL CASH TRANSFERS FOR IMPROVING UPTAKE OF HEALTH INTERVENTIONS Table 2. Impact on Care-Seeking Behavior
Initial Rate
Final Rate
(Intervention (Intervention
Source and Outcomes
Treatment Effectb
Mexico (Progresa)
Gertler,7 2000
Daily consultations per public clinic in program No. of visits to a public clinic in the 4 weeks preceding the survey—children aged 0-2 yd No. of visits to a public clinic in the 4 weeks preceding the survey—children aged 3-5 yd there was no noticeable effect on the im- No. of visits to a public clinic in the 4 weeks No. of visits to a public clinic in the 4 weeks preceding the survey—adults aged 18-50 yd No. of visits to all facilities in the 4 weeks preceding the survey—children aged 0-2 yd been caused by an indirect contamina-tion effect in that efforts to deliver vac- No. of visits to all facilities in the 4 weeks preceding the survey—children aged 3-5 yd No. of visits to all facilities in the 4 weeks No. of visits to all facilities in the 4 weeks preceding the survey—adults aged 18-50 yd Anthropometric Outcomes
Nicaragua (Red de Protección Social)
Maluccio and Flores,12 2004
Children aged 0-3 y taken to a health center Ն1 Children aged 0-3 y taken to health control and Children aged 0-3 y taken to health control and smaller mean effects (see TABLE 4).
weighed in the past 6 mo—extremely poor Thornton,13 2006
Individuals who went to a voluntary counseling
and testing center to learn their results, % for newborns in urban areas of the treat- Honduras (Programa de Asignación Familial)
ment localities, which is likely to be at- Morris et al,14 2004
Women attending a 10-d postpartum physical helped increase the height-for-age z Children taken to a health center Ն1 in the past Colombia (Familias en Acción)
Attanasio et al,16,17 2005
Children aged Ͻ24 mo with current schedule of
Children aged 24-48 mo with current schedule nutritional status of children older than Children aged Ͼ48 mo with current schedule of Abbreviation: CI, confidence interval.
a Empty cells denote that the outcome was not previously measured (as opposed to not presented by the author) and is b For the Mexican program, shows net variations in the number of visits/consultations; for all other programs, shows net variations in percentage points (taking into account comparison vs control groups).
d Computed with surveys carried out after the beginning of the intervention only.
f Maluccio and Flores classified households into 3 groups (extreme poor, poor, nonpoor) based on their annual total house- hold expenditures measured in 2000, using 2001 national poverty lines developed by the World Bank.
Mean attendance of people without incentives was 0.39; treatment effect is estimated with a model controlling for the impact of distance to the voluntary counseling and testing center.
1904 JAMA, October 24/31, 2007—Vol 298, No. 16 (Reprinted)
2007 American Medical Association. All rights reserved.
CONDITIONAL CASH TRANSFERS FOR IMPROVING UPTAKE OF HEALTH INTERVENTIONS mothers (see “Comment” section).
improvement of the height-for-age z Health Status
score by 0.17) and the proportion of Nicaragua, Colombia) included in the Table 3. Impact on Immunization Coverage
Initial Rate
Final Rate
Outcomes
(Intervention Areas)
(Intervention Areas)
Treatment Effecta
Mexico (Progresa)
Nicaragua (Red de Protección Social)
Honduras (Programa de Asignación Familial)
Colombia (Familias en Acción)
Abbreviations: CI, confidence interval; DPT, diphtheria, tetanus toxoids, pertussis (antigens unspecified)/pentavalent.
a Shows net variations in percentage points or probability (taking into account comparison vs control groups).
2007 American Medical Association. All rights reserved.
(Reprinted) JAMA, October 24/31, 2007—Vol 298, No. 16 1905
CONDITIONAL CASH TRANSFERS FOR IMPROVING UPTAKE OF HEALTH INTERVENTIONS ers’ reports of health outcomes of their children (TABLE 5).
versely, Rivera at al11 show that after 1 rate of anemia than the control group.
Table 4. Impact on Anthropometric and Nutritional Outcomes
Initial Rate
Final Rate
Outcomes
(Intervention Areas)a (Intervention Areas)a Treatment Effectb
Mexico (Progresa)
Height (cm) of children aged 12-36 mo (in September 1999) Likelihood of children aged 12-36 mo (in September 1999) Height (cm) of children aged 4-12 mo (at baseline, Height (cm) of children aged 12-36 mo (at baseline, Height (cm) of children aged 24-36 mo (at baseline, Height (cm) of children aged 36-48 mo (at baseline, Growth (cm) of children aged Ͻ6 months (at baseline) from poorest households (after 2 y of program participationvs 1 y in the control group)f Growth (cm) of children aged 6-12 mo (at baseline) from poorest households (after 2 y of program participationvs 1 y in the control group)f Nicaragua (Red de Protección Social)
Maluccio and Flores,12 Height-for-age z score for children aged Children aged Ͻ5 y who are underweight, % Brazil (Bolsa Alimentação)
Height-for-age z score for children aged Ͻ24 mo Height-for-age z score for children aged 24-48 mo Height-for-age z score for children aged 4-7 y Mean height-for-age z score for children aged Weight-for-age z score for children aged Ͻ24 mo Weight-for-age z score for children aged 24-48 mo Weight-for-age z score for children aged 4-7 y Mean weight-for-age z score for children aged Colombia (Familias en Acción)
Height-for-age z score of children aged Ͻ24 mo Height-for-age z score of children aged 24-48 mo Height-for-age z score of children aged Ͼ48 mo Probability of chronic malnourishment for children aged Probability of chronic malnourishment for children aged Probability of chronic malnourishment for children aged a Empty cells denote that the outcome was not previously measured (as opposed to not presented by the author) and is not applicable.
b Shows net variations in percentage points or net variations in scores (taking into account comparison with control groups).
d An estimate of 0.75 means that children benefiting from the treatment were 25% less likely than controls to be affected.
f Rivera et al classified households into 2 income-based groups: below the 50th percentile or at and above the 50th percentile.
1906 JAMA, October 24/31, 2007—Vol 298, No. 16 (Reprinted)
2007 American Medical Association. All rights reserved.
CONDITIONAL CASH TRANSFERS FOR IMPROVING UPTAKE OF HEALTH INTERVENTIONS Table 5. Impact on Health Outcomes
Initial Rate
Final Rate
Outcomes
(Intervention Areas)a (Intervention Areas)a Treatment Effectb
Mexico (Progresa)
Children whose mother reported that they were ill in the Children whose mother reported that they were ill in the Likelihood of children aged Ͻ3 y at baseline to be Likelihood of children aged Ͻ3 y at baseline to be reported ill (impact after 2 mo of program)d Likelihood of children aged Ͻ3 y at baseline to be reported ill (impact after 8 mo of program)d Likelihood of children aged Ͻ3 y at baseline to be reported ill (impact after 14 mo of program)d Likelihood of children aged Ͻ3 y at baseline to be reported ill (impact after 20 mo of program)d Likelihood of children born during duration of Progresa to Mean hemoglobin value (g/dL) of children aged Ͻ12 mo (at baseline), after 1 y of program participation vs noexposure in the control group Prevalence of anemia (%) for children aged Ͻ12 mo (at baseline), after 1 y of program participation vs noexposure in the control group Prevalence of anemia (%) for children aged Ͻ12 mo (at baseline), after 2 y of program participation vs 1 y inthe control group Colombia (Familias en Acción)
Probability of diarrhea being reported for children in rural Probability of diarrhea being reported for children in rural Probability of diarrhea being reported for children in rural Probability of diarrhea being reported for children in urban Probability of diarrhea being reported for children in urban Probability of diarrhea being reported for children in urban Probability of respiratory disease symptoms being reported Probability of respiratory disease symptoms being reported for children in rural areas aged 24-48 mo Probability of respiratory disease symptoms being reported Probability of respiratory disease symptoms being reported, for children in urban areas, aged Ͻ24 mo Probability of respiratory disease symptoms being reported for children in urban areas aged 24-48 mo Probability of respiratory disease symptoms being reported Nicaragua (Red de Protección Social)
a Empty cells denote that the outcome was not previously measured (as opposed to not presented by the author) and is not applicable.
b Shows net percentage point or probability variations (taking into account the comparison with control groups).
d An estimate of 0.75 means that children benefiting from the treatment were 25% less likely than controls to be affected.
2007 American Medical Association. All rights reserved.
(Reprinted) JAMA, October 24/31, 2007—Vol 298, No. 16 1907
CONDITIONAL CASH TRANSFERS FOR IMPROVING UPTAKE OF HEALTH INTERVENTIONS Table 6. Financial Sustainability of the Programs
Average Cost
per Family
Mean Transfer
Transfer Budget as
Total Budget,
Household
Beneficiary,
per Household,
a Proportion of the
Beneficiaries
Total Budget
Dates are based on Handa and Davis with additional computations by the authors.24 analyses of the data from 1 study (theMexico program) demonstrates the ex- tors7-11 of the same data, giving rise to analyses and results, and not citing each ers’ reports of the health of their chil- transfer in different settings and to as- to settings such as sub-Saharan Africa.
TABLE 6 demonstrates that under
cal limitations found in existing studies nificant.24 From this point of view, there 1908 JAMA, October 24/31, 2007—Vol 298, No. 16 (Reprinted)
2007 American Medical Association. All rights reserved.
CONDITIONAL CASH TRANSFERS FOR IMPROVING UPTAKE OF HEALTH INTERVENTIONS ever, the success of these strategies de- the eligibility criteria are relaxed or dis- tant to consider the availability of these ing the cost-effectiveness of theses pro- Author Contributions: Ms Lagarde had full access to
critical as well.25 In such settings, it is verse effects can also occur. In the stud- all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the dataanalysis.
Study concept and design: Lagarde, Haines, Palmer.
fore the introduction of conditional cash Acquisition of data: Lagarde.
Analysis and interpretation of data: Lagarde, Haines.
Drafting of the manuscript: Lagarde.
Critical revision of the manuscript for important in- gible for a subsidy. Morris et al15 suggest tellectual content: Lagarde, Haines, Palmer.
Obtained funding: Haines, Palmer.
Administrative, technical, or material support: Lagarde, Haines.
Study supervision: Palmer.
Financial Disclosures: None reported.
a misinterpretation of eligibility rules.
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, manage- ment, analysis, and interpretation of the data; or thepreparation, review, or approval of the manuscript.
individuals, regardless of their possible Additional Contribution: We also thank Andy Ox-
man, MD from the Cochrane EPOC Group for his use-ful comments on the protocol of this review. Dr Ox- man did not receive compensation for his contribution REFERENCES
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2007 American Medical Association. All rights reserved.

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