Social protection programmes can aim to improve health directly, for example by conditioning programmes on attendance at health services, or indirectly, for example through supplemented income and therefore consumption (Barrientos & Niño-Zarazúa, 2011).
Key social protection interventions that have health impacts are cash transfers and social health insurance. More evidence is available on cash transfers, particularly from conditional cash transfers (CCTs) in Latin America (and in particular Mexico’s PROGRESA/Oportunidades programme) (Bastagli et al., 2016: 131). CCTs are often conditioned on health investments (e.g. incentivising attendance for health education, measurements of height and weight, immunisations, and nutritional supplementation). Emerging evidence is also found from ‘cash plus’ programmes that provide linkages to health services.
There is strong evidence on the positive impacts of cash transfers (and some on health insurance programmes) on access to and use of health services, particularly in relation to children’s and maternal health. There is also evidence that cash transfers can be effective in tackling structural determinants of health outcomes such as financial poverty and intermediate determinants such as dietary diversity and sexual behaviours. Less evidence is available of impacts on health outcomes (in particular for objectively measured outcomes).
Access to and use of health services
Several reviews report strong evidence on the positive impacts of cash transfers on access to and use of health services.
A 2017 systematic review identified 51 studies of 22 cash transfer and voucher programmes and found ‘that approaches tied to service use (either via payment conditionalities or vouchers for selected services) can increase use of antenatal care, use of a skilled attendant at birth, and in the case of vouchers, postnatal care too. The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care, and for vouchers for maternity care services and birth with a skilled birth attendant’ (Hunter et al., 2017: 1). The CCT review by Glassman et al. (2012: abstract) finds that ‘conditional cash transfers have increased antenatal visits, skilled attendance at birth, delivery at a health facility, and tetanus toxoid vaccination for mothers, and reduced the incidence of low birth weight’.
A 2016 rigorous review found that, on the whole, cash transfers – both conditional and unconditional – have increased use of health facilities (Bastagli et al., 2016: 8). Of 15 studies reporting on the use of health facilities, nine reported ‘statistically significant increases, ranging from an additional 0.28 preventative visits in Jamaica’s PATH programme to an extra 2.3 general health visits in Tanzania’s Social Action Fund’ (ibid.: 128).
Looking at cash plus programmes, free enrolment in health insurance for beneficiaries of the LEAP cash transfer programme in Ghana improved use of health services and reduced out-of-pocket health expenditures (Handa et al., 2014). Meanwhile qualitative evidence from Owusu-Addo et al.’s (2018: 691) review of cash transfers in sub-Saharan Africa indicated that ‘while cash transfers play a critical role in removing the financial barriers associated with utilising health services, the money is not enough to meet all expenses associated with medical care’.
For health insurance, a 2013 systematic review finds ‘relatively consistent evidence that health insurance is positively correlated with the use of maternal health services’ (Comfort et al., 2013: 81). A 2012 systematic review reports ‘strong evidence that [community-based health insurance] improves resource mobilization for health and that both CBHI and SHI [social health insurance] improve health service utilization and provide financial protection for members in terms of reducing their out-of-pocket expenditure’ (Spaan et al., 2012: 689). However, Acharya et al. (2012: 8) found that while there was some evidence that health insurance schemes targeted at poorer households increased health-care utilisation in terms of outpatient visits and hospitalisation, there was weak evidence to show that health insurance reduced out-of-pocket health expenses, in particular for the poorest.
Health outcomes – for example, morbidity, mortality
Systematic reviews highlight that there are few studies that look at the impact of cash transfers or health insurance on maternal and newborn health, and changes in health status (Hunter et al., 2017; Glassman et al., 2012: 690; Comfort et al., 2013; Acharya et al., 2012).
A review of cash transfers in sub-Saharan Africa found moderate evidence that cash transfers impact on health and quality of life outcomes (Owusu-Addo et al., 2018: 675). Of nine programmes focused on child health outcomes, seven reported significant effects (ibid.: 689). Based largely on mothers’ reports of health outcomes of their children, ‘reduction in illness rates ranged from 4.9 [percentage points] in Zambia… to 17.02 [percentage points] in Lesotho…’ (ibid.: 690). In addition, three studies reported impacts on HIV and sexually transmitted infections (STIs): two had positive impacts on reducing prevalence or risk, and one found no significant difference between beneficiaries and non-beneficiaries (ibid.). The review also reports that ‘mental health indicators (happiness, hope, psychological distress and depression) were measured in six programs of which four programs showed significant improvements’ (ibid.). The review identified that the size of the transfer and irregularity of transfer payment may hinder cash transfer effectiveness, and called for the provision of supplementary services and behaviour change interventions to optimise the impact of cash transfers on health and nutrition outcomes (ibid.: 676). Having the supply capacity to meet health service demand is also critical (Barrientos & Niño-Zarazúa, 2011).
An older review of CCTs by Lagarde et al. (2009: 3), covering 10 papers reporting results from six studies, found three studies reported on higher order health outcomes. Findings were: ‘Mixed effects on objectively measured health outcomes (anaemia) and positive effects on mothers’ reports of children’s health outcomes (22–25% decrease in the probability of children <3 years old being reported ill in the last month’ (ibid.). Lagarde et al. (2009: 2) highlight that while in some cases programmes have noted improvements in health outcomes, ‘it is unclear to which components these positive effects should be attributed’.
A systematic review of the evidence on the effects of health insurance in low- and middle-income countries found few studies focused on the quality of maternal health services or maternal and neonatal health outcomes (Comfort et al., 2013: 81). The evidence available on the quality and health outcomes was found to be ‘inconclusive, given the differences in measurement, contradictory findings, and statistical limitations’ (ibid.).
Structural and intermediate determinants of health outcomes
A 2018 systematic review of cash transfers in sub-Saharan Africa looked at 24 cash transfers comprising 11 unconditional, eight conditional and five combined unconditional and conditional cash transfers (Owusu-Addo et al., 2018: 675). The review found ‘cash transfers can be effective in tackling structural determinants of health such as financial poverty, education, household resilience, child labour, social capital and social cohesion, civic participation, and birth registration’ (ibid.). The review further found ‘cash transfers modify intermediate determinants such as dietary diversity, child deprivation, sexual risk behaviours, teen pregnancy and early marriage’ (ibid.). Cash transfer effectiveness is influenced by ‘intervention design features, macro-economic stability, household dynamics and community acceptance of programs’ (ibid.)
Owusu-Addo, E., Renzaho, A. M., & Smith, B. J. (2018). The impact of cash transfers on social determinants of health and health inequalities in sub-Saharan Africa: A systematic review. Health Policy and Planning, 33(5), 675–696.
A systematic review of the literature on cash transfers’ impact on health and quality of life outcomes, and structural and intermediate determinants of health in sub-Saharan Africa covering the period 2000–2016 identified evidence from 53 studies covering 24 cash transfers. The review found that CTs can be effective in tackling structural and intermediate determinants of health, with moderate evidence on their impact on health and nutritional outcomes.
Bastagli, F., Hagen-Zanker, J., Harman, L., Barca, V., Sturge, G., & Schmidt, T. (2016). Cash transfers: What does the evidence say? A rigorous review of programme impact and of the role of design and implementation features. London: ODI.
See summary in Poverty, inequality and vulnerability – Key texts.
Hunter, B. M., Harrison, S., Portela, A., & Bick, D. (2017). The effects of cash transfers and vouchers on the use and quality of maternity care services: A systematic review. PLoS ONE 12(3): e0173068.
Consolidating and updating evidence from seven published systematic reviews on the effects of different types of cash transfers and vouchers on the use and quality of maternity care services, the authors conclude that ‘effects appear to be shaped by a complex set of social and healthcare system barriers and facilitators. Studies have typically focused on an initial programme period, usually two or three years after initiation, and many lack a counterfactual comparison with supply-side investment’ (p. 1).
Comfort, A. B., Peterson, L. A., & Hatt, L. E. (2013). Effect of health insurance on the use and provision of maternal health services and maternal and neonatal health outcomes: A systematic review. Journal of Health, Population and Nutrition, 31(4 Suppl. 2), S81–S105.
Glassman, A., Duran, D., Fleisher, L., Singer, D., Sturke, R., Angeles, G., … & Saldana, K. (2013). Impact of conditional cash transfers on maternal and newborn health. Journal of Health, Population and Nutrition, 31(4 Suppl. 2), S48–S66.
Spaan, E., Mathijssen, J., Tromp, N., McBain, F., Have, A. T., & Baltussen, R. (2012). The impact of health insurance in Africa and Asia: A systematic review. Bulletin of the World Health Organization, 90, 685–692.
Barrientos, A., & Niño-Zarazúa, M. (2011). Social transfers and chronic poverty: Objectives, design, reach and impact. Manchester: Chronic Poverty Research Centre.
Lagarde, M., Haines, A., & Palmer, N. (2009). The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane Database of Systematic Reviews 2009, 4(CD008137).
Conference/seminar/webinar: Social protection for health: What are the health policy and systems research priorities? (2018). World Health Organization. (1h:21)