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Hyunsoo Chung

Christiana Chinyere Ekezie, Kathleen Lamont, Sohinee Bhattacharya

Objective: Conduct a systematic review to assess the impact of poverty elimination on maternal and child health through cash transfer programs in sub-Saharan Africa.
Methods: We searched Medline, Embase, Cochrane library, CINAHL, PsychInfo, Pubmed, Scopus and African Journals for randomized controlled trials (RCTs) assessing cash transfer interventions for improving maternal and/or child health in Sub-Saharan Africa We also searched organizational websites, reference lists of included studies, relevant reviews and Google Scholar for grey literature using search terms such as “conditional/ unconditional cash transfer program”, “maternal health”, “child health”, “Sub-Saharan Africa” as MeSH headings or synonym search combining with AND or OR Boolean operators as appropriate. Searches were not limited to a particular language or time period. Two reviewers independently screened all potentially relevant records against inclusion criteria, extracted data and assessed methodological quality of included studies using critical appraisal skills programme scoring.
Findings: Seven studies were found to meet the inclusion criteria agreed a priori and were included in the review. Findings from one study showed increased probability of delaying pregnancy in adolescents and reduced risky sexual behaviour, with another study reporting increased utilization of antenatal care and increased skilled attendance at delivery. In terms of child health benefits, there was reduced probability of chronic illnesses in children from households who benefited from cash transfers, however, there was no  effect seen on the proportion of children vaccinated when compared to the controls. Other positive effects seen include increased acceptance of Prevention of Mother to Child Transmission (PMTCT) services, and increased birth registrations and school attendance for school age children.
Conclusion: This review suggests that cash transfers have a positive impact on maternal and child health in sub-Saharan Africa, however, the evidence is limited and this topic will benefit from more in-depth trials conducted in the region.

Introduction

Poverty is a phenomenon that affects all regions of the world. It manifests in different forms, some of which include lack of income and productive resources, hunger and malnutrition, ill-health, limited or lack of access to education and other basic services, increased morbidity and mortality from illness.1 It has far-reaching effects not only at the individual level but also on the development of nations, prompting world leaders to include eradication of poverty as a Millennium Development Goal. However, statistics show that about 896 million people still live at or below 1.90 USD per week, with 42.6% of these people living in sub-Saharan Africa.2

Impoverished societies tend to have worse health outcomes. This often leads to a vicious cycle where one perpetuates the other.3 One possible link between the two conditions is through nutrition and employment, since malnutrition associated with poverty leads to ill health, which in turn leads to unemployment and loss of earnings, sustaining the cycle of poverty. Other factors such as living conditions, access to water and sanitation, education, access to healthcare and social exclusion, also contribute to the perpetuation of this cycle. A good measure of the health of a nation are maternal and child health indices such as maternal and infant mortality and accessibility of maternal healthcare, which includes antenatal visits and skilled attendance at delivery. According to the World Health Organization, a delivery should be attended by a skilled birth attendant (SBA) who is trained to proficiency in the skills needed to manage normal pregnancies, childbirth and the immediate postnatal period, as well as in the identification, management and referral of complications in women and newborns.4 The proportion of deliveries assisted by SBAs has been used as an indicator for maternal mortality reduction. This indicator shows a wide gap between the rich and the poor, both when comparing between countries and when comparing between different populations within the same country.4

Many countries and international organizations have tried to create poverty alleviation programs and interventions for the improvement of health outcomes for poor populations.5,6,7 Such programs include cash transfer programs, which began in Latin America and the Caribbean (LAC) and have since been extended to other low- and middle-income countries (LMICs). The cash transfer programs are demand-driven, anti-poverty measures that transfer monetary resources to targeted households. Transfers are usually sized to close the gap between average consumption in the lowest income quintile and the extreme poverty line. Some cash transfers are given conditional upon household investment in their children’s health, education and nutrition—in these cases, spending is monitored and transfers are withheld until conditions are satisfied—while some transfers are unconditional and the beneficiaries are not expected to fulfill any preset conditions.8 The type of cash transfer employed—conditional or unconditional—is determined by the program organizers and whether they aim to assess the effects of poverty alleviation on particular aspects of social service utilization. An example is the Janani Suraksha Yojana in India, which specifically assesses maternal and newborn health.9

Although the program has been successful in other regions of the world, and some African countries have even implemented the same strategies, little has been studied about its impact in sub-Saharan Africa, especially in the area of maternal and child health outcomes. Reviews of financial incentives have found the strategies to be effective in improving utilization of healthcare in the broader context of LMICs but the quality of the evidence utilized was poor with minimal inclusion of randomized controlled trials.10, 11 This systematic review therefore aims to assess the impact of cash transfer programs on maternal and child health in sub-Saharan Africa using evidence from randomized controlled trials.

Methods

We followed the PRISMA guidelines for conducting systematic reviews ,which include a checklist for evaluating and reporting RCTs.12

Data sources and Searches

We systematically searched the bibliographic databases: Medline, Embase and PsycINFO through Ovid (1946 to May 28th 2016), the Cochrane library through Wiley Interscience, Cumulative Index to Nursing and Allied Health Literature (CINAHL) through EBSCO host, PubMed through the National Center for Biotechnology Information), Scopus through Elsevier and African Journals online. The search used Boolean operators to combine MeSH terms and text words and synonyms for “cash transfer”, “maternal health”, “child health” and “sub-Saharan Africa.” The search strategy developed was first used to conduct a search in Medline between March and May 2016, and was then adapted for searching the other databases (Appendix 1). Other sources such as World Bank reports, WHO reports, Institute for Fiscal studies, United Nations reports, United Nations International Children’s Fund (UNICEF), Department for International Development (DfID) UK, United Nations Development Programme (UNDP) and the United States Agency for International Development (USAID) were also searched. In addition, we screened the reference lists of all of the included studies and also relevant reviews. Google Scholar was used to identify grey literature and unpublished studies. No restrictions were placed on language or date of publication.

Study selection

The scope of the study was limited to countries in sub-Saharan Africa. Other inclusion criteria include RCTs that evaluate both the impact of increased income/cash to households through cash transfers (conditional or unconditional) as well as report their effects on maternal or child health. Studies with outcomes such as increased access to hospital services, improved nutrition, family planning, school enrollment, vaccination programs and anthropometric measurements were included. RCTs assessing the effects of cash transfer on men the elderly, or those reporting sexual or mental health outcomes were excluded, as well as those conducted in other low-and-middle income countries outside the sub-Saharan Africa region. Two reviewers independently assessed study titles and abstracts and those that satisfied the inclusion criteria were obtained for full-text appraisal for eligibility for inclusion in the review. Disagreements between reviewers were resolved through discussion or referred to a third reviewer for arbitration.

Data extraction and quality assessment

Two independent reviewers extracted the following information from each eligible study: name of first author, the year that the study was conducted, study location, description of the participants, type of cash transfer and conditional requirements where applicable and the results and effect size when reported. Quality of the included studies was assessed using the Critical Appraisal Skills Programme (CASP) tool designed for evaluating RCTs. This tool uses a set of 11 questions to assess the study validity, the randomization procedure, the reporting of results and the relevance of the findings and a study with a score of ≥ 8 is considered a good quality study (maximum score of 11).

Results

Our searches yielded a total of 1,978 citations. After removing duplicates, screening titles, and abstracts, 14 citations (11 studies, two theses and one conference presentation) were considered potentially eligible for inclusion and selected for further appraisal. Of these, seven did not meet the inclusion criteria and were therefore excluded – three of these were duplicate papers of the same study and four were not RCTs. Seven RCTs met the inclusion criteria and were included in the review. Figure 1 presents the flow diagram of study selection process. All studies scored ≥8 on the CASP scoring system.

Table 1 displays the characteristics of and the findings from the included studies.

Study setting

All studies were conducted in sub-Saharan Africa, with an emphasis in the southern regions, as per inclusion criteria. Two trials were conducted in Zimbabwe.13, 14 One experiment each took place in Zambia, Kenya, Uganda, Malawi and the Democratic Republic of Congo, respectively.15, 16, 17, 18, 19

Study design

All of the studies used a cluster randomized control design where eligible villages or lowest units of administration were the unit of randomization. Two studies conducted three-arm randomized controlled trials – unconditional cash transfer, conditional cash transfer and control.13, 14 In one study, the control arm consisted of delayed entry into the cash transfer programs.16

Types of cash transfer

The included studies evaluated interventions that raised household income through regular payments to the identified households. The income came in the form of cash transfers: Some experiments evaluated an unconditional cash transfer while others evaluated a conditional cash transfer program.15, 19 Only two other cash transfer programs consisted of mixed conditional and unconditional transfers, with one arm each of conditional and unconditional transfers.13, 14 The remaining three studies evaluated social cash transfers, in which unconditional cash transfers were made to vulnerable households or groups of individuals.16, 17, 18,20 The conditional transfers were based on fulfilling certain conditions such as food provision in the home, regular health check-ups for the household and school enrollment for the children. In contrast, the unconditional transfers had no conditions which had to be met, but the recipients had to be identified by the community and check in regularly with the distributors. One of the transfers was targeted specifically at households with orphaned or vulnerable children, where the children had lost one or both parents or were separated from them.14

The value of cash transfer varied between 18 and 21 USD monthly and were dependent on the number of children or eligible women in the household.

Effects of cash transfer on Maternal health

Three of the seven included studies assessed maternal health outcomes. One study found that an unconditional cash transfer program in Kenya resulted in a 5% reduction in early pregnancy and an increase in the healthy transition of vulnerable girls into adulthood, with reduced incidence of risky sexual behaviour in the intervention group compared to the control group.13 A different study reported increased antenatal clinic attendance in households receiving 0.40 USD per visit compared to controls although the study noted no difference in the odds of delivering in a health facility between the women in the intervention group and the control group.17 However, results from a national, randomized social cash transfer program in Zambia show increased skilled attendance at birth, meaning that more women in the intervention group utilized hospital services during delivery.15

Effects of Cash Transfer on Child health

Two studies reported improved child health outcomes such as decreased likelihood of chronic or childhood illnesses.13, 18 One of the studies also reported higher odds of children utilizing health services and decreased odds of illnesses that prevented normal activities.18 Non-health benefits of cash transfer programs included increased birth registration and increased school attendance for children of school age, although these benefits may further translate into health benefits in the longer term (with the children being better educated on how to live healthy lives, and the government using the statistics from the birth registrations to plan for health services).13, 14 This study did not, however, note any difference in the proportion of children who were vaccinated in both the intervention and the control groups.14 The one study conducted in the Democratic Republic of the Congo reported increased attendance at clinics and increased acceptance of PMTCT in intervention groups compared to controls.19

Discussion

Principal findings 

We conducted a systematic review of randomized controlled trials evaluating the effect of cash transfer programs on maternal and child health in sub-Saharan Africa. The primary studies reported a variety of health and non-health related outcomes. There was an increase in the probability of delaying pregnancy noted in adolescents, which reduced the likelihood of early pregnancy, as well as an increase in the utilization of antenatal care, with an associated increase in skilled birth attendance following delivery. This is in keeping with the findings of a review that assessed different countries from Asia and Latin America and reported an increase in antenatal visits, skilled birth attendance at delivery, delivery at health facilities and tetanus vaccination for the mothers.9 A different article, not specifically targeted toward vulnerable populations, reviewed the effects of conditional cash transfers for improving uptake of health interventions in LMIC, and concluded that overall cash transfers are effective in increasing usage of preventive health services such as vaccination and sometimes effective in improving general health, although the effect was small or unclear.21 These findings suggest that increasing income through cash transfers to poor households subsequently increases health-care seeking behaviour and reduces home deliveries and the attendant risks associated with unskilled birth attendance.22 Increased income may also have served as an aid to overcome the barrier effects created by user fees charged by health facilities which the poor cannot afford; hence, with more resources for the household, women have more incentive to seek health care.3

In terms of child health benefits, the review reported lower odds of illnesses that prevented normal activities and an overall reduction in childhood and chronic illnesses. Other positive effects include increased acceptance of the PMTCT services, increased birth registrations for newborns and for children less than 18 years who had not been previously registered and increased school attendance for children of school age. Although we did not find any review that assessed the impact of cash transfer on these particular aspects of child health, the review by Bassani et al (2013) assessed the impact of financial incentives on child health including breastfeeding practices, use of healthcare facilities (when ill and for regular medical check-ups) and vaccination. They found that there was low quality evidence of the impact of cash transfers on health care use by children especially for children under five years. They also found no effect of financial incentive on age-appropriate immunization coverage which supports our finding in this review that the cash transfers had no impact on vaccination.11 Leroy et al (2009) in their own study assessed impact of cash transfer on child nutrition and its impact on child health and they found an increase in their anthropometric measurements following cash transfers to their households.23 These findings show that cash transfers may have a positive impact on child health but the documented evidence is not enough to prove it.

Strengths and limitations

Strengths of this review include a focused question with strict inclusion and exclusion criteria agreed a priori, a comprehensive search strategy with no language or date restrictions applied to multiple bibliographic databases and a systematic approach. We deliberately included only randomized controlled trials, as this type of study design provides the highest quality of evidence. We also intended to focus on maternal and child health outcomes, but there was a dearth of primary studies assessing measurable outcomes in this area. Both clinical and statistical heterogeneity were evident in all the included studies, especially in terms of the outcomes assessed. This precluded pooling of studies in a meta-analysis. Furthermore, we cannot rule out publication bias, although this is less likely in a systematic review of randomized controlled trials.

Although there were recorded successes of the cash transfer program as a way of increasing the income in the households receiving the payments, most of the studies were conducted in the eastern and southern regions of Africa and not from other regions of sub-Saharan Africa. Also, because most were large-scale programs, the evaluation and proper analysis of the outcomes were not all recorded, making the assessment and generalizability of the results to other parts of the sub-Saharan African region difficult.

Implications for policy and practice

This review found a positive impact of cash transfer programs on sexual health behavior with a reduction in risky sexual activities. As a result of the raised income, women have more financial control and are able to make better decisions. This has great implication for the fight against HIV/AIDS, which also has a high incidence rate in the sub-Saharan African region and strongly affects the morbidity and mortality rates of maternal and child health in the region. In this way, cash transfer programs may address the causal pathways linking poverty to HIV/AIDS and also reduce the number of the vulnerable children mostly orphaned by the death of their parents due to HIV/AIDS.24

The review also showed an increase in birth registration of the children, which implies an increase in health facility utilization at delivery by mothers since birth registrations were far more likely if the birth took place in a health facility. This will contribute to vital statistics that are not very well-recorded in most parts of sub-Saharan Africa—such accurate data will assist in planning and policymaking. There was also no evidence of increased uptake of vaccination as reported by Robertson et al.,14 which is of great concern especially in such a region where vaccines are available for childhood preventable diseases. However, reduced childhood and chronic illnesses were noted from these households,18 which will lead to the improved well-being of the children, fewer absences due to illness and a reduction in child mortality.

The enrollment of children in school was a requirement for the conditional cash transfer programs.13,14 The implication is that more school-age children will have access to education. This especially has a great impact on female children, as this reduces the rate of early marriages (through increased knowledge and exposure which helps with making better decisions), age of first sexual experience and early pregnancies with the attendant increase in morbidity and mortality for under-aged pregnant women.16

It should also be noted that there are no reports on the supply-side of the health provision to assess the quality of services delivered at the health facilities. This highlights the importance of a focus on the supply-side of adequate and effective health services for demand-side programs to have a more reliable effect on health outcome.18

There are also limited reports on the cost-effectiveness of the cash transfer programs and their sustainability in sub-Saharan Africa, as most of them are currently international donor-driven with little inputs from the benefiting governments. Therefore, more research in this area is crucial to produce more evidence which can influence policy makers to invest more funds in such programs.

As most of the cash transfer programs are not designed primarily for the objective of affecting maternal health, (most are targeted at the household with vulnerable children), there is no measurable program impact on a range of maternal health indicators.13 This therefore calls for more research to assess more maternal health care indicators.

It is also important to study the impact of the cash transfer programs in different settings and countries of the sub-Saharan region to assess the influence of culture and geographical location on the success of these programs. Emphasis should be put on the need for carefully designed evaluation of programs to ensure correct interpretation of effects starting with baseline collection of data prior to cash payments to help with progress monitoring.

Conclusion

This review has shown visible but limited evidence that cash transfer programs have an effect on maternal and child health by increasing the income and resources available in the household and subsequently increasing health-seeking behaviour and improving the standard of living for beneficiaries. Nevertheless, more evidence is still emerging and will further in-depth research in this area, especially in the sub-Saharan African region, will help to provide more quantifiable information that can be used to influence policy making in the region.

Figures

Table 1: Description of included studies

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Table 2: Quality assessment of included studies using the Critical Appraisal Skills Programme (CASP) Randomised Controlled Trials Checklist

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Figure 1. Flow Diagram of study selection

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References

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Acknowledgements

The authors would like to thank Mrs Melanie Bickerton of the Medical School Library, University of Aberdeen for her help with developing the search strategies.