Effects of unconditional and conditional cash transfers on child health and development in Zimbabwe: a cluster-randomised trial

Laura Robertson, Phyllis Mushati, Jeffrey W Eaton, Lovemore Dumba, Gideon Mavise, Jeremiah Makoni, Christina Schumacher, Tom Crea, Roeland Monasch, Lorraine Sherr, Geoffrey P Garnett, Constance Nyamukapa, Simon Gregson, Laura Robertson, Phyllis Mushati, Jeffrey W Eaton, Lovemore Dumba, Gideon Mavise, Jeremiah Makoni, Christina Schumacher, Tom Crea, Roeland Monasch, Lorraine Sherr, Geoffrey P Garnett, Constance Nyamukapa, Simon Gregson

Abstract

Background: Cash-transfer programmes can improve the wellbeing of vulnerable children, but few studies have rigorously assessed their effectiveness in sub-Saharan Africa. We investigated the effects of unconditional cash transfers (UCTs) and conditional cash transfers (CCTs) on birth registration, vaccination uptake, and school attendance in children in Zimbabwe.

Methods: We did a matched, cluster-randomised controlled trial in ten sites in Manicaland, Zimbabwe. We divided each study site into three clusters. After a baseline survey between July, and September, 2009, clusters in each site were randomly assigned to UCT, CCT, or control, by drawing of lots from a hat. Eligible households contained children younger than 18 years and satisfied at least one other criteria: head of household was younger than 18 years; household cared for at least one orphan younger than 18 years, a disabled person, or an individual who was chronically ill; or household was in poorest wealth quintile. Between January, 2010, and January, 2011, households in UCT clusters collected payments every 2 months. Households in CCT clusters could receive the same amount but were monitored for compliance with several conditions related to child wellbeing. Eligible households in all clusters, including control clusters, had access to parenting skills classes and received maize seed and fertiliser in December, 2009, and August, 2010. Households and individuals delivering the intervention were not masked, but data analysts were. The primary endpoints were proportion of children younger than 5 years with a birth certificate, proportion younger than 5 years with up-to-date vaccinations, and proportion aged 6-12 years attending school at least 80% of the time. This trial is registered with ClinicalTrials.gov, number NCT00966849.

Findings: 1199 eligible households were allocated to the control group, 1525 to the UCT group, and 1319 to the CCT group. Compared with control clusters, the proportion of children aged 0-4 years with birth certificates had increased by 1·5% (95% CI -7·1 to 10·1) in the UCT group and by 16·4% (7·8-25·0) in the CCT group by the end of the intervention period. The proportions of children aged 0-4 years with complete vaccination records was 3·1% (-3·8 to 9·9) greater in the UCT group and 1·8% (-5·0 to 8·7) greater in the CCT group than in the control group. The proportions of children aged 6-12 years who attended school at least 80% of the time was 7·2% (0·8-13·7) higher in the UCT group and 7·6% (1·2-14·1) in the CCT group than in the control group.

Interpretation: Our results support strategies to integrate cash transfers into social welfare programming in sub-Saharan Africa, but further evidence is needed for the comparative effectiveness of UCT and CCT programmes in this region.

Funding: Wellcome Trust, the World Bank through the Partnership for Child Development, and the Programme of Support for the Zimbabwe National Action Plan for Orphans and Vulnerable Children.

Copyright © 2013 Elsevier Ltd. All rights reserved.

Figures

Figure 1
Figure 1
Trial profile showing participating households *Interviewed by research assistants from the Biomedical Research and Training Institute (Harare, Zimbabwe).
Figure 2
Figure 2
Trial profile showing children aged 0–4 years in participating households
Figure 3
Figure 3
Trial profile showing children aged 6–12 years in participating households
Figure 4
Figure 4
Trial profile showing children aged 13–17 years in participating households
Figure 5
Figure 5
Effects of UCT and CCT programmes on the primary and additional endpoints Comparison of proportion of (A) children aged 0–4 years with a birth certificate, (B) children aged 0–4 years with complete vaccination records, (C) children aged 6–12 years who attended school at least 80% of the time in the previous month, and (D) children aged 13–17 years who attended school at least 80% of the time in the previous month. UCT=unconditional cash transfer. CCT=conditional cash transfer.

References

    1. Shibuya K. Conditional cash transfer: a magic bullet for health? Lancet. 2008;371:789–791.
    1. Adato M, Bassett L. Social protection to support orphans and vulnerable children and families: the potential of cash transfers to protect education, health and nutrition. AIDS Care. 2009;21:60–75.
    1. Fiszbein A, Schady N. Conditional cash transfers: reducing present and future poverty. World Bank; Washington, DC: 2009.
    1. Nyamukapa C, Gregson S. Extended family's and women's roles in safeguarding orphans' education in AIDS-afflicted rural Zimbabwe. Social Sci Med. 2005;60:2155–2167.
    1. de Brauw A, Hoddinott J. Must conditional cash transfer programs be conditioned to be effective? The impact of conditioning transfers on school enrollment in Mexico. International Food Policy Research Institute; Washington, DC: 2007.
    1. Ranganathan M, Lagarde M. Promoting healthy behaviours and improving health outcomes in low and middle income countries: a review of the impact of conditional cash transfer programmes. Prev Med. 2012;55(suppl):S95–105.
    1. Behrman JR, Parker SW, Todd PE. Schooling impacts of conditional cash transfers on young children: evidence from Mexico. Econ Dev Cult Change. 2009;57:439–477.
    1. Baird SJ, Garfein RS, McIntosh CT, Özler B. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet. 2012;379:1320–1329.
    1. Adato M, Bassett L. What is the potential of cash transfers to strengthen families affected by HIV and AIDS? A review of the evidence on impacts and key policy debates. Joint Learning Initiative on Children and AIDS, International Food Policy Research Institute; Washington, DC: 2008.
    1. Gregson S, Garnett GP, Nyamukapa C. HIV decline associated with behavior change in eastern Zimbabwe. Science. 2006;311:664–666.
    1. Gregson S, Nyamukapa C, Schumacher C, et al. Evidence for a contribution of the community response to HIV decline in eastern Zimbabwe? AIDS Care (in press).
    1. Lopman B, Lewis J, Nyamukapa C, Mushati P, Chandiwana S, Gregson S. HIV incidence and poverty in Manicaland, Zimbabwe: is HIV becoming a disease of the poor? AIDS. 2007;21(suppl 7):S57–S66.
    1. Hargreaves JR, Morison LA, Gear JS. “Hearing the voices of the poor”: assigning poverty lines on the basis of local perceptions of poverty. A quantitative analysis of qualitative data from participatory wealth ranking in rural South Africa. World Dev. 2007;35:212–229.
    1. Donner A, Klar N. Design and analysis of cluster randomisation trials in health research. Hodder Arnold Publication; London: 2000.
    1. UNICEF . Survey on orphans and other vulnerable children in rural and high density Zimbabwe 2004/2005. UNICEF Zimbabwe; Harare: 2005.
    1. Hayes RJ, Bennett S. Simple sample size calculation for cluster-randomized trials. Int J Epidemiol. 1999;28:319–326.
    1. Kane RL, Johnson PE, Town RJ, Butler M. A structured review of the effect of economic incentives on consumers' preventive behavior. Am J Prev Med. 2004;27:327–352.
    1. Marteau TM, Ashcroft RE, Oliver A. Using financial incentives to achieve healthy behaviour. BMJ. 2009;338:b1415.
    1. Barham T, Maluccio JA. Eradicating diseases: the effect of conditional cash transfers on vaccination coverage in rural Nicaragua. J Health Econ. 2009;28:611–621.
    1. Baird S, McIntosh C, Ozler B. Cash or condition? Evidence from a cash transfer experiment. World Bank; Washington, DC: 2012.
    1. World Bank . World Development Report 2013: jobs. World Bank; Washington DC: 2012.
    1. Case A, Hosegood V, Lund F. The reach and impact of child support grants: evidence from KwaZulu-Natal. Dev South Afr. 2005;22:467–482.
    1. Samson M, Lee U, Ndlebe A. Final report: the social and economic impact of South Africa's social security system (research paper 37) Economic Policy Research Institute; Cape Town: 2004.
    1. Ministry of Community Development and Social Services, German Technical Cooperation in Zambia Final evaluation report: Kalomo social cash transfer scheme. 2007. (accessed Feb 8, 2013).
    1. Miller C, Tsoka M, Reichert K. Impact evaluation report: external evaluation of the Mchinji social cash transfer pilot (draft) Center for International Health and Development, Boston University; Boston, MA: 2008.
    1. Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review. JAMA. 2007;298:1900–1910.
    1. Attanasio O, Mesnard A. The impact of a conditional cash transfer programme on consumption in Colombia. Institute of Fiscal Studies; London: 2005.
    1. Morris SS, Flores R, Olinto P, Medina JM. Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: cluster randomised trial. Lancet. 2004;364:2030–2037.
    1. Barham T. The impact of the Mexican conditional cash transfer on immunization rates. Department of Agriculture and Resource Economics; Berkeley, CA: 2005.

Source: PubMed

Szponzorok és közreműködők

Egészségi állapot

Kábítószer-beavatkozások

3
Iratkozz fel