Populations in Low- and Middle-Income Countries (LMIC) continue to face daunting challenges. Mothers and children are the most affected by these challenges, which include a double burden of communicable and non-communicable diseases, higher infant and maternal mortality, malnutrition, etc. These challenges have been exacerbated, by the novel COVID-19 pandemic, which has dismantled the prevailing social safety nets (Busch-Hallen, Walters, Rowe, Chowdhury, & Arabi, 2020; Cash & Patel, 2020; Teachout & Zipfel, 2020). The future remains ambiguous, with vaccine access as the fault line along which economic recovery may split (IMF, 2021).
Although the full impact of the COVID-19 on maternal health and child survival remains unknown, recent studies have predicted devastating impacts. For instance, if routine healthcare is disrupted (e.g., 9.8% to 51.9% reduced coverage) and access to food is decreased (e.g., 10% increased prevalence of wasting), the resulting consequences will be devasting. Such disruptions could translate to 253,500 additional child deaths and 12,200 additional maternal deaths (Busch-Hallen et al., 2020; Headey et al., 2020; Roberton et al., 2020). These initial estimates do not account for other important aspects, such as disrupted breastfeeding practices, the duration of the pandemic, and subsequent lockdowns, and subsequent mental health issues. Hence, the need for evidence-based policies to navigate the time post-COVID-19; especially in the area of Maternal and Child Health (MCH), which should be central to any recovery strategy (Jacob et al., 2020; Modi & Hanson, 2021).
Cash Transfer (CT) programs are one of the public health interventions that policymakers and funders can rely on to improve MCH outcomes in LMICs. These programs were initially launched in Latin America (i.e., Brazil and Mexico) in the mid-90s to provide education and health to historically “excluded” populations, before being adopted in other LMICs (Turley, 2020).
CT programs represent a “set of public and private policies or programs aimed at preventing, reducing and eliminating economic and social vulnerability to poverty and deprivation” (UNICEF-ESARO, 2015, p. 1). They are often implemented as a direct transfer payment of money to eligible persons and can be either conditional or unconditional. Unconditional Cash Transfer (UCT) programs provide cash to all eligible and registered beneficiaries; whereas Conditional Cash Transfer (CCT) programs require an eligible person to take a specified course of action, also known as co-responsibilities or conditionalities, to receive a benefit (Das, Do, & Özler, 2005; Garcia, Moore, & Moore, 2012). Generally, co-responsibilities include actions such as attending required medical check-ups, completing required immunizations, school attendance, adults’ attendance of education seminar covering topics such as health, family planning, nutrition, adherence to immunization, registering child birth, exclusive breastfeeding, etc. (Chakrabarti, Pan, & Singh, 2021; Garcia et al., 2012).
These programs have been widely implemented in Latin America, in Africa, and South Asia. For instance, Bolsa Familia introduced in Brazil in 2003 after merging three existing conditional and unconditional cash transfer programs, is one of the largest CCT programs in the world (Bauer, Paula, & Evans-Lacko, 2021; Neves et al., 2020). It covered over 14 million eligible households that met the eligibility criteria: households with children less than 17 years of age and/or pregnant women making less than R$120 (USD $68) per capita monthly. In addition to this overall payment, the Bolsa Familia program also sent monthly transfer to extremely poor families (i.e., those earning less than R$64 or USD $34), regardless of their composition (Soares, Ribas, & Osório, 2010).
CT programs are also common among Asian countries. For instance, in 2011 the state of Odisha in India, initiated a statewide CCT program named Mamata to improve MCH outcomes and promote health-seeking behaviors (Chakrabarti et al., 2021). Other similar programs in South Asia include the Aama (Mothers’) program in Nepal, Janani Suraksha Yojana (Safe Motherhood Scheme) and the Chiranjeevi Yojana (Scheme for Long Life) in India; the Maternal Health Voucher Scheme in Bangladesh and the Sehat (Health) Voucher Scheme in Pakistan (Jehan et al., 2012).
In Africa, major CT programs such as the Productive Safety Net Program’s Direct Support (PSNP-DS) in Ethiopia and the Hunger Safety Net Program (HSNP) in Nigeria were designed to address food insecurity. Leveraging on the success of these programs, African governments and external donors, mainly the World Bank, expanded CT programs to address other challenges, including access to healthcare. Still, many CT programs are geared toward relief or development goals (Garcia et al., 2012). Examples include the Zambia’s Child Grant Program (CGP) (Handa et al, 2016), the Subsidiary Reinvestment and Empowerment Program (SURE-P) in Nigeria (Okoli et al., 2014), the Manicaland program in Zimbabwe (Robertson et al., 2013), the “Santé Nutritionnelle à Assise Communautaire dans la région de Kayes” (SNACK–CAN) in Mali (Adubra et al., 2019), and many others (Onwuchekwa et al., 2021).
Rationale for the study
Findings about the effectiveness of these programs to improve MCH outcomes, beyond service utilization, remain inconclusive (Onwuchekwa et al., 2021; Singh et al., 2021). Most evaluations of these programs tend to focus on the utilization of healthcare services by the beneficiaries and other social determinants of health, thereby overlooking specific health outcomes related to mortality, individuals’ capacity to function, or the subjective sense of well-being (Parrish, 2010). The only synthesis we found examined mental health outcomes among young people under 25 years of age (Zimmerman et al., 2021). As suggested by Parrish (2010, p. 1), “positive health outcomes for people include being alive; functioning well mentally, physically and socially, and having a sense of well-being”. On this account, it could be argued that service utilization is one underlying pathway through which CT programs affect health outcomes. However, no research synthesis has been done on these outcomes as the end points among women of childbearing age and children under 18 years of age. Several factors may be contributing to this gap. Many of the aforementioned studies are lacking a coherent operationalization of the concepts of maternal and child health outcomes, beyond service utilization metrics (Hunter et al., 2017; Owusu-Addo et al., 2018b; Singh et al., 2021), which creates larger heterogeneity across studies (Owusu-Addo & Cross, 2014).
In this time of competing priorities across the world, allocation of scarce resources needs to rely on evidence-based science. Both governments, and external funders navigate resource constraints as they allocate funding. Lack of evidence on a given programmatic effort, could undermine not only funding allocation, but also any progress achieved. Hence, it is crucial to fill any gaps in the existing literature with respect to the effectiveness of CT programs and their impact on MCH outcomes, to keep these programs running, and to advocate in favor of scaling to other geographies and demographics.
Finally, some of the major barriers to the successful implementation of these programs include the lack of transparency, an endemic corruption, and lack of valid data (Wright et al., 2018). These limitations and issues represent opportunities for new areas of investigation.
Scope of synthesis
This research synthesis focuses on the relationship between CT programs and MCH outcomes, other than service utilization. It covers studies that evaluated the effect/impact of CT programs on MCH outcomes in Sub-Saharan African countries for the period between 2000 – 2021. The focus on these countries stems from the fact that they are facing similar socioeconomic and political situations, and often share the same social norms, which are associated with populations’ health behaviors (Cotterill et al., 2019; Gai Tobe et al., 2019; Harith & Mahmud, 2020; Zhang et al., 2020). The nature and scope of CT programs in Sub-Saharan African countries differ from that of other LMICs. For instance, by contrast to Latin American countries whose CT programs are solidarity-based nationwide social policies enacted by their respective Governments, CT programs in Sub-Saharan African countries are often not an expression of deliberate policy program, with clear commitment by the national or local Governments. Instead, CT programs in those countries are driven by international agencies and donors who support small-scale pilot projects (Scarlato & d'Agostino, 2016). Therefore, CT programs in this region need further evidence to continue to attract funds both from local governments, and from international donors. The chosen period reflects the time when these programs became available within the region (Owusu-Addo & Cross, 2014).
This synthesis addressed the lack of evidence on the effectiveness of CT programs to positively impact MCH outcomes, beyond service utilization-based metrics. Outcome indicators defined in this review were based on mortality, subjective health state, experiential, and psychological state, and on the ability to function. Protective behaviors that promote health were also considered.
- To what extent CT programs can improve MCH outcomes (functional, subjective sense of well-being, experiential state, and death) in Sub-Saharan African countries?
- What are the potential pathways through which CT programs influence MCH outcomes?