1. Objectives

To evaluate the effectiveness of conditional cash transfers (CCT) on improving health outcomes and access to healthcare, with emphasis on poorer populations in low- and middle-income countries

2. How studies were identified

The following databases were searched in May 2009:

• CENTRAL (The Cochrane Library 2009)
• PubMED
• EMBASE
• Popline
• African Healthline
• IBSS (International Bibliography in Social Sciences)
• The Database of Abstracts of Reviews of Effectiveness and the Effective Practice and Organisation of Care Group Register
• BLDS
• ID21
• ELDIS
• The Antwerp Institute of Tropical Medicine database
• JSTOR
• Inter-Science
• Science Direct
• IDEAS (Repec)
• LILACS
• CAB-Direct (Global Health)
• Healthcare Management Information Consortium
• World Health Organization Library Information System
• MEDCARIB
• ADOLEC
• FRANCIS
• BDSP
• USAID database

Websites, working papers, and reference lists were also searched and the authors directly contacted researchers in the field

3. Criteria for including studies in the review

3.1 Study type

Randomized controlled trials, cluster-randomized controlled trials, and controlled before and after studies. Interrupted time-series analyses were eligible provided that the time point when the intervention took place was clearly defined and there were ≥3 data points before and after the intervention

3.2 Study participants

Populations in low- and middle-income countries who would potentially access healthcare services

(No limitation was placed on type of healthcare provider, level of healthcare delivery, or type of health service)

3.3 Interventions

Direct monetary transfers made to households, conditioned on a particular behaviour or action (e.g., visit to a healthcare facility for a check-up)

3.4 Primary outcomes

Changes in the use of healthcare services

• Any objective measure relating to the consumption of health services, such as:
• Immunization coverage
• Number of healthcare facility visits
• Rates of hospitalization

Changes in health outcomes

• Morbidity
• Mortality

Secondary outcomes included healthcare expenditures made by the patient and/or their family and changes in equity of access

4. Main results

4.1 Included studies

Six intervention trials were included in this review

• Four studies were cluster-randomized trials and two trials were controlled before-and-after studies
• Interventions were targeted at individuals, households or communities, and all involved monetary transfers, although some also provided free access to health services and nutritional supplements
• Cash transfers were conditional on school attendance, utilization of healthcare/education/nutrition services, attendance at a preventive health education workshop, up-to-date immunization, and returning for HIV test results
• Outcomes included healthcare service uptake, immunization rates, anthropometric or nutritional outcomes, morbidity, preventive and prenatal healthcare service attendance, and the proportion of individuals returning for their HIV test results

4.2 Study settings

• Brazil, Colombia, Honduras, Malawi, Mexico, and Nicaragua
• Most studies selected households or individuals on the basis of poverty, and five of the six studies were conducted in middle-income countries in Latin America

4.3 Study settings

How the data were analysed
Before-and-after comparisons were made for all outcomes with available data. Data were not pooled for statistical analysis due to heterogeneity in the interventions and outcomes reported. All reported effect estimates were extracted directly from the original studies and were not re-analyzed, and only data accounting for baseline differences in the outcomes of interest was extracted. All cluster-randomized trials reported cluster-adjusted results.

Results
Uptake of health services
Returning for HIV test results
Compared to the control group receiving no CCT, the proportion of those who collected their HIV test results increased by 27 percentage points among the group receiving US$1 to US$3 per collection.

Healthcare facility use
In areas where CCTs were offered, the number of daily outpatient visits to healthcare facilities increased by 2.09 in one cluster-randomized trial in Mexico. In another trial in Honduras, the use of healthcare services for pre-school children increased significantly in comparison to control areas while the uptake of antenatal care and postnatal check-ups did not. In the Nicaraguan trial, the proportion of infants taken to health centres in the past six months increased by 19.5 percentage points with CCT implementation, although this fell to 11 percentage points the following year.

Impact on health outcomes
In rural Colombia, CCTs reduced the proportion of reported diarrhoea among children aged less than 48 months, although no change was reported for older children. Respiratory symptoms among children did not differ following CCT implementation. A CCT programme in Mexico reported a 22% decrease in the likelihood of children less than three years of age having been ill in the last month, with the greatest improvements observed among those remaining in the programme the longest.

Impact on immunisation coverage
TB immunization rates for children aged 12 to 23 months increased by five percentage points relative to control areas six months after initiation of the CCT programme in the Mexican trial. However, this was likely due to a decrease in TB vaccination coverage in the control areas. In the same trial, measles immunization rates in children aged 12 to 23 months increased by three percentage points relative to controls, and by six percentage points in areas known to have low vaccination coverage. The uptake of the first dose of DPT/pentavalent vaccine increased by 6.9% in Honduras with CCT, and in Colombia an increase in compliance with the DPT schedule for infants of 8.9 percentage points was also observed. Tetanus vaccination for pregnant women and measles vaccination for children did not increase in Honduras, and no vaccination coverage improvements were found in Nicaragua, although this may be due to increased coverage in control areas.

Impact on anthropometric or nutritional outcomes
Newborn weight increased by 0.58 kg in urban CCT areas in Colombia, and CCTs significantly decreased the probability of chronic malnourishment among children less than 24 months of age. No improvements were found among newborns in rural CCT areas, or for children over two years of age. In Nicaragua, height-for-age Z-scores for children aged less than five were significantly improved, and the proportion of children under five who were underweight was reduced by six percentage points. CCTs had no effect on the prevalence of anaemia or on mean haemoglobin among infants aged six to 59 months of age in Nicaragua. In Brazil, the mean height-for-age Z-score among children under seven was reduced with CCTs relative to the control group. Growth in height increased by 1.1 cm among infants less than six months of age from the poorest households in the Mexican trial, although infants aged six to 12 months showed no improvement with CCTs. The height of children aged between 12 and 36 months statistically significantly improved among the CCT group relative to controls by approximately 1 cm, depending on the method of analysis. After one year, the mean haemoglobin of children in CCT households in the Mexican trial increased by 0.37 g/dL relative to the control group, although the prevalence of anaemia increased by 10.6 percentage points. The prevalence of anaemia decreased relative to controls after two years of the CCT programme, although this did not reach statistical significance.

5. Additional author observations*

Most trials were conducted in middle-income countries in Latin America, limiting the generalizability of the findings to other populations. The included studies were judged to be at moderate to high risk of bias for overall methodological quality. Methodological problems included contamination bias in the Mexican trial whereby nutritional supplements were sometimes given to children in control areas, and attrition bias in the same trial whereby children remaining in the study were more likely to have a poor nutritional status. These biases may have under- and over-estimated the effect of the CCT programme, respectively. The unintended consequence of a reduction in height-for-age Z-scores among children under seven in the Brazilian trial may have been due to a misunderstanding among the mothers who potentially believed that child malnourishment was required for CCT programme eligibility.

Current evidence suggests that CCT programmes increase the uptake of preventive healthcare services when these services are already free. However, CCT programmes had varying effectiveness on the improvement of vaccination coverage and on child anthropometric and nutritional status, and their effect on the use of services that are not free remains unknown.

The cost-effectiveness of CCT programmes urgently requires investigation. Other public health interventions, such as the provision of more healthcare facilities, may prove to be a better allocation of sparse healthcare funding in resource-constrained areas. Furthermore, investigating how CCTs operate to increase the uptake of free healthcare services and improve health and nutritional outcomes is warranted. Finally, analysing the effect of CCT among groups with varying levels of socio-economic position may reveal thresholds at which positive effects are observed.