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Not just money: what mothers value in conditional cash transfer programs in India

Countries
India
Sources
BMJ
Publication date
Origin
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Krishna D Rao, Shivani Kachwaha, Avril Kaplan, David Bishai

Abstract

Introduction Conditional cash transfers (CCTs) have become an important policy tool for increasing demand for key maternal and child health services in low/middle-income countries. Yet, these programs have had variable success in increasing service use. Understanding beneficiary preferences for design features of CCTs can increase program effectiveness.

Methods We conducted a Discrete choice experiment in two districts of Uttar Pradesh, India in 2018 with 405 mothers with young children (<3 years). Respondents were asked to choose between hypothetical CCT programme profiles described in terms of five attribute levels (cash, antenatal care visits, growth-monitoring and immunisation visits, visit duration and health benefit received) and responses were analysed using mixed logit regression.

Results Mothers most valued the cash transfer amount, followed by the health benefit received from services. Mothers did not have a strong preference for conditionalities related to the number of health centre visits or for time spent seeking care; however, service delivery points were in close proximity to households. Mothers were willing to accept lower cash rewards for better perceived health benefits—they were willing to accept 2854 Indian rupees ($41) less for a programme that produced good health, which is about half the amount currently offered by India’s Maternal Benefits Program. Mothers who had low utilisation of health services, and those from poor households, valued the cash transfer and the health benefit significantly more than others.

Conclusion Both cash transfers and the perceived health benefit from services are highly valued, particularly by infrequent service users. In CCTs, this highlights the importance of communicating value of services to beneficiaries by informing about health benefits of services and providing quality care. Conditionalities requiring frequent health centre visits or time taken for seeking care may not have large negative effects on CCT participation in contexts of good service coverage.

Introduction

Conditional cash transfer (CCT) programmes have become an important policy tool to increase demand for maternal and child health services. In its original conception, like in Mexico’s Prospera (formerly Progresa and Oportunidades) or Brazil’s Bolsa Familia, CCTs served as broad-based social safety nets that provided income support to poor households. To receive cash transfers beneficiaries are required to fulfil conditionalities related to use of maternal and child health services, among others. More recently in South Asia, a new type of targeted CCT programme emerged that offered cash rewards to incentivise households to use specific health services, rather than serve as a social safety net. For example, India’s Janani Surakshna Yogna (JSY) programme offers cash rewards to mothers for delivering at a health facility. In either case, CCT programmes can increase demand for health services through the income effect of additional disposable income that enables households to purchase health services or pay for transport, as well as through the conditionalities related to maternal and child health services.1

CCTs typically include a range of maternal and child health service conditionalities, such as requiring pregnant and lactating women to attend educational workshops, have prenatal and postnatal health visits, deliver in a health facility, keep mothers and child vaccinations up-to-date, have children regularly attend growth-monitoring sessions and health check-ups.2 3 Evidence from broad-based CCT programmes on service uptake has been mixed, and comparisons complicated, due to variation in CCT programme conditionalities across countries, and outcome indicators measured in evaluations. Reviews report that CCTs have had variable effects across countries.2–4 For example, in Honduras there was a 19% increase in pregnant women having at least five antenatal care (ANC) visits, but only 8% in Mexico, and no effect in El Salvador, Nepal and Guatemala, or Chile.2 3 5 There were no significant increases in pregnant women getting tetanus toxoid vaccination in Honduras and Mexico. Facility deliveries increased by 15% in Nicaragua, and births attended by skilled personnel increased by 11% in Mexico and El Salvador, but not in Guatemala and Uruguay.3 There seems to be no effect on postpartum visits in Honduras and El Salvador.3 CCTs in Colombia, Honduras and Mexico have had significant effects on increasing child immunisation. And in Chile, Colombia and Jamaica, there was an increase in children going for regular check-ups, but not so in Honduras. Among the targeted CCT programmes, India’s JSY has been found to increase institutional deliveries at public facilities by 49%, though a similar programme in Nepal increased institutional deliveries by only 4%.3 Moreover, in the JSY programme, even in the presence of cash rewards for institutional deliveries, a significant number of women deliver at home, and programme participation varies considerably subnationally.6 7

Several factors explain the variable success of CCT programmes on increasing demand for health services. For one, the cash reward offered may be lower than the minimum reward acceptable to beneficiaries to fulfil conditionalities. Other factors, such as proximity to service delivery points, the influence of community and household members, trust in government programmes, cultural practices and behaviour of health workers are also critical factors that affect programme participation.1 8 9 In particular, as Handa et al point out, increased income or conditionalities will have limited effects on demand for services because of limited supply and poor quality of services.1 Studies on India’s JSY programme report that cash incentives are an important reason why women choose to deliver in a health facility.10 However, many women choose to deliver at home due to6 perceptions of quality of care offered at health facilities (particularly for complicated deliveries), and their inability to secure transportation or companions to visit a health facility.10 The role of quality perceptions in the choice of which facility women give birth has also been highlighted in studies on facility bypassing.11

In this paper we aim to examine beneficiary preferences for attributes (ie, cash amount and conditionalities) of a targeted CCT programme focused on maternal and child health services in India. Understanding beneficiary (ie, mothers) preferences for programme design features can better align the CCT programme design with user preferences, thereby making the programme more acceptable, as well as potentially improving performance. A second objective is to examine preferences for CCT programme features among mothers who are less likely to use maternal and child health services. This is a key population whose preferences CCT programmes aim to change; as such examining their preferences will inform strategies to increase their programme participation. This study uses a discrete choice experiment (DCE), a stated-preference method and part of the conjoint analysis family, to understand user preferences for design features for a CCT program.12

The study is set in the state of Uttar Pradesh (UP) in north India, with population over 200 million and poor maternal and child health indicators. In 2015, UP had the highest infant mortality rate (64 deaths per 1000 live births) in the country, and around 65% of children 12–23 months of age received three doses of diphtheria, pertussis and tetanus vaccine.13 Further, only 26% of women received at least four antenatal check-ups, and 13% consuming iron–folic acid supplements for 100 days or more during pregnancy.13 In this context, CCT programmes can have a significant impact on uptake of maternal and child health services.

CCT programs focused on maternal and child in India

In India, CCTs are rapidly becoming important in national strategies to improve maternal and child health. State-level CCT programmes that focus on increasing demand for health services among mothers and young children have existed for several decades, though national programmes appeared more recently.14 The first national CCT programme, JSY, was launched in 2005 and provided poor women a cash incentive for delivering in a health facility. The JSY has been credited with increasing institutional deliveries and reducing perinatal and neonatal deaths, though these successes have been tempered with concerns about poor-quality services women receive when they give birth at government facilities.6

CCT programmes focused on maternal and child health are expected to undergo significant expansion in India. In 2017, the national Pradhan Mantri Matritva Vandana Yojana or the Maternity Benefit Program (MBP) was introduced with the objective of increasing healthcare use during pregnancy and early childhood.15 The MBP provides a cash transfer of 5000 Indian rupees ($71) to eligible pregnant women for their first live birth in three instalments, tied to conditionalities of pregnancy registration, at least one ANC visit, birth registration and child vaccination.16 To fulfil the MBP conditionalities, mothers need to visit the local nutrition centres (Anganwadi Center or AWC) on Village Health and Nutrition Days (VHND) held monthly. The effect the MBP has on maternal and child health and nutrition outcomes is unknown due to early stages of implementation. A recent study on a similar state-level CCT programme from Odisha state showed positive effects on use of ANC services, iron–folic acid supplementation and household food security.14 Extending CCT programmes to child nutrition is also under discussion in India and has been mooted in the government’s National Nutrition Strategy.17 18