Economic Development and Health

Can cash transfers improve access to maternal- and child- healthcare?

Conditional Cash Transfers (CCTs) are programmes which give direct payments (in any form) to an eligible person. CCTs are used in many Low- and Middle-Income Countries to reduce present and prevent future poverty through investment in human capital. Given the importance of the prenatal period and of the first days after birth for child development (Attanasio, 2015, Almond et al, 2018), many CCTs are conditioned on meeting the objectives of antenatal care (ANC) and postnatal care (PNC).

In economics, providing financial incentives (“cash”) is described as a demand-side policy. In the field of health, incentives are given to individuals with low demand for healthcare due to lack of information, lack of resources or cultural beliefs. The objective of these financial incentives is to increase their demand for healthcare. However, in the case of ANC and PNC, increasing the demand may increase pressure on already constrained health systems, which can have a negative impact on maternal and child health services and associated maternal and infant outcomes.

Researchers from the Institute for Global Health and the Department of Economics at UCL have studied the effects of CCT programmes targeting ANC and PNC on important outcomes such as healthcare utilisation, perinatal mortality and postnatal appointment attendance.

Can cash transfers increase antenatal and postnatal care and child immunisation? The Afya trial in Kenya.

In Kenya, many pregnant women are faced with huge barriers in accessing ANC and PNC. In 2014 only 57% of women attended the minimum 4 health centre visits recommended by the World Health Organisation. Moreover, 62% of infants did not receive postnatal check-ups during the first week after birth.

The Afya trial, implemented between May 2017 and December 2019 in Siaya county, Kenya, involved making a payment of US$4.5 to pregnant women at each clinic visit using a mobile phone service. The objective of this trial was to assess the effectiveness of a single payment to pregnant women to support retention from antenatal to postnatal care, measured at one year postpartum. Prof Jolene Skordis, Dr Neha Batura and Mr Tom Palmer, from the UCL Institute from Global Health, along with colleagues from the Stockholm Environment Institute in Sweden and from the Safe Water and AIDS Project in Kenya, performed the economic evaluation of the Afya trial.

The programme was founded to increase ANC attendance and child immunisation. For those that received the CCT, the likelihood of attending ANC appointments and having children vaccinated was 90% and 74% higher, respectively, than for those who did not receive the incentive. However, there was no impact on whether a mother-to-be gave birth at a formal health facility or on PNC attendance.

What are the spillover effects of increasing healthcare seeking via CCTs?

As shown in the Kenyan case, CCTs can be an effective tool for increasing ANC and child immunisation. However, are there potential negative externalities of these demand-side policies? Prof Marcos Vera-Hernandez of the Economics Department and Alison Andrew, PhD candidate at the Economics Department and researcher at the Institute for Fiscal Studies, investigate whether incentivising the demand without any supply-side policy could lead to

negative externalities due to congestion in the health care system resulting in lower quality services for all.

To do so, they study the effects of India’s Janani Suraksha Yojana (JSY), a large CCT programme that encourages women to give birth in a formal health facility. JSY pays around 28 times the average rural daily wage for casual labour as financial incentives. The programme has played an important role in the decline of home births in India, which fell from 80% in 2005 to 40% in 2011. This programme encourages people to seek health care (demand-side), while it does not provide additional funding to the healthcare centres to cope with the increased demand (supply-side)

The authors study the impact of the JSY focusing on the pre-existing system capacity. They found that the JSY programme led to an average increase of 7.86 percentage points in the probability of a health facility delivery. The increase in deliveries was higher in areas with already constrained health care capacities. In these areas, deliveries in healthcare facilities increased by almost 150% (from 1.92 per facility per day to 4.80). However, the risk of perinatal mortality increased by 0.90 percentage points during the study period. This finding suggests that focusing solely on the demand side and increasing deliveries in health centres may not necessarily improve children’s health, due to lack of capacity. This result is supported by the finding that JSY had no impact on perinatal mortality in areas with above-median capacity. Finally, an alarming finding is that the probability of children receiving any check-ups between two and ten days fell. This is a likely consequence of constrained resources; if more resources are given to health centre births, less can be given to other services such as check-up services. The authors suggest that to meet increased demand, facilities had to discharge women earlier and/or reduce check-ups for new-born children.

Conclusion

The results of these two studies by UCL economists showed that demand-side policies, such as cash transfers, can have negative consequences for maternal and child health if they are not complemented by supply-side policies. In Kenya, the CCTs increased ANC clinic attendance and child immunisation appointments, but there was no impact on facility delivery or PNC visits. In the Indian case, the programme increased facility delivery. However, in areas with more constrained health facilities, the programme increased the risk of perinatal mortality.

To ensure access to an equitable and universal health system, health authorities must pay attention to the design of effective programmes to ensure that women are retained in the continuum of care, even after their child has been born. Moreover, health authorities must ensure that health centres can manage increases in demand to avoid the potential negative effects of service congestion.

References: Vanhuyse, F., Stirrup, O., Odhiambo, A., Palmer, T., Dickin, S., Skordis, J., ... & Copas, A. (2022). Effectiveness of conditional cash transfers (Afya credits incentive) to retain women in the continuum of care during pregnancy, birth and the postnatal period in Kenya: a cluster-randomised trial. BMJ open, 12(1), e055921.          Andrew, A., Vera-Hernandez, M. (2022). Incentivizing Demand for Supply-Constrained Care: Institutional Birth in India. Forthcoming at the Review of Economics and Statistics Almond, D., Currie, J., & Duque, V. (2018).         Childhood circumstances and adult outcomes: Act II. Journal of Economic Literature, 56(4), 1360-1446.         Attanasio, O. P. (2015). The determinants of human capital formation during the early years of life: Theory, measurement, and policies. Journal of the European Economic Association, 13(6), 949-997.

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