STIMULATING DEMAND: AN ASSESSMENT OF THE CONDITIONAL CASH TRANSFER PROJECT IN AFGHANISTAN
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Date
2016-03-29
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Johns Hopkins University
Abstract
Statement of Problem: Despite significant progress over the last decade in expanding access to basic health services in Afghanistan, utilization of maternal and child health services remains low. First introduced in Latin America and now expanding to countries in Africa and Asia, conditional cash transfer (CCT) programs, which provide monetary incentives to households meeting certain behavioral requirements, show promising results. While evidence in favor of CCT for low-income and middle-income countries is growing, little is known about the effects of CCT in post-conflict settings where resources are stretched, service provision is limited, systems are fragile, and security is tenuous.
In Afghanistan, the Ministry of Public Health (MoPH), in collaboration with the Global Alliance for Vaccines and Immunization (GAVI), launched a conditional cash transfer project from 2009 to 2011 to increase utilization of institutional delivery and DPT3 vaccination. The program included four intervention arms: in the household arm, women received 300 AFNs for delivering at a health facility and 150 AFNs for bringing her child into the clinic for DPT3 vaccination. In the community health workers (CHW) arm, CHWs received 150 AFNs per completed referral for DPT3 and institutional delivery. In the combined arm, both households and CHWs received incentives for delivery and DPT3 vaccination. Finally, in the control arm, no incentives were provided.
The objectives of this mixed methods, post-test only study are (1) to assess the association of the three incentive schemes on institutional delivery and DPT3 vaccination in Afghanistan, and (2) to understand implementation factors that may affect program outcomes.
Methods: Concurrent mixed-methods approach was used to assess program outcomes and to gain a better understanding of the implementation factors. Data sources include cross-sectional household survey, in-depth interviews, document reviews, and health facility assessments. To assess the association of the cash incentive schemes on service utilization, I used a mixed-effects logistic regression model with inverse probability weighting to account for differentials in sample characteristics due to non-random selection of study arms through quasi-experimental design. To better understand contextual and implementation factors, I conducted content analysis. Findings were integrated in the analysis phase and formed the basis for program recommendations to policy makers.
Key Findings: Quantitative analysis provided mixed findings. Positive associations between cash incentive and program outcomes (DTP3 vaccination and institutional delivery) were observed in the household arm where families received cash after they had utilized the services. However, cash payments to CHWs for DPT3 and institutional delivery referrals appear to have no effect on service utilization. Finally, in the combined arm where both CHWs and households receive cash, I observed a negative association in the combined arm for institutional delivery, and a positive association for DPT3 vaccination.
Substantial variation in program outcome at the village level were noted, suggesting that unobserved health systems and contextual factors are likely to influence program outcome. This finding is supported by qualitative data. As a result of the limited technical capacity of the organization contracted to implement the CCT project, health facility staff used a variety of strategies to manage delays in cash replenishment and to ensure communities knew about the program and understood the benefits. Despite challenges, most interviewed stakeholders were positive about the program, indicating that CCT may be an acceptable demand-side intervention in Afghanistan.
Conclusions: Findings suggest design, implementation, and evaluation of CCT program in low-resource settings require careful consideration. Program design needs to be informed by a sound feasibility study, and the implementation process should be closely monitored. Further studies are needed to provide the Ministry with more robust evidence on the efficacy and effectiveness of CCT interventions to increase service utilization in Afghanistan.
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Keywords
Conditional Cash Transfer, Afghanistan