Effectiveness of conditional cash transfers (Afya credits incentive) to retain women in the continuum of care during pregnancy, birth and the postnatal period in Kenya: a cluster-randomised trial

ObjectivesGiven high maternal and child mortality rates, we assessed the impact of conditional cash transfers (CCTs) to retain women in the continuum of care (antenatal care (ANC), delivery at facility, postnatal care (PNC) and child immunisation).DesignWe conducted an unblinded 1:1 cluster-randomised controlled trial.Setting48 health facilities in Siaya County, Kenya were randomised. The trial ran from May 2017 to December 2019.Participants2922 women were recruited to the control and 2522 to the intervention arm.InterventionsAn electronic system recorded attendance and triggered payments to the participant’s mobile for the intervention arm (US$4.5), and phone credit for the control arm (US$0.5). Eligibility criteria were resident in the catchment area and access to a mobile phone.Primary outcomesPrimary outcomes were any ANC, delivery, any PNC between 4 and 12 months after delivery, childhood immunisation and referral attendance to other facilities for ANC or PNC. Given problems with the electronic system, primary outcomes were obtained from maternal clinic books if participants brought them to data extraction meetings (1257 (50%) of intervention and 1053 (36%) control arm participants). Attendance at referrals to other facilities is not reported because of limited data.ResultsWe found a significantly higher proportion of appointments attended for ANC (67% vs 60%, adjusted OR (aOR) 1.90; 95% CI 1.36 to 2.66) and child immunisation (88% vs 85%; aOR 1.74; 95% CI 1.10 to 2.77) in intervention than control arm. No intervention effect was seen considering delivery at the facility (90% vs 92%; aOR 0.58; 95% CI 0.25 to 1.33) and any PNC attendance (82% vs 81%; aOR 1.25; 95% CI 0.74 to 2.10) separately. The pooled OR across all attendance types was 1.64 (1.28 to 2.10).ConclusionsDemand-side financing incentives, such as CCTs, can improve attendance for appointments. However, attention needs to be paid to the technology, the barriers that remain for delivery at facility and PNC visits and encouraging women to attend ANC visits within the recommended WHO timeframe.Trial registrationNCT03021070.

Revisiting the food security system in India in the pandemic era: the case of a Southern Indian state

PurposeThe objective of this paper was twofold-revisiting the in-kind public distribution system (PDS) – India's flagship food security intervention and seeking beneficiary perspectives on its efficacy. The feasibility of cash transfers as an alternative mechanism is also examined, especially in the context of the COVID-19 pandemic.Design/methodology/approachPrimary and secondary data from the southern Indian state of Tamil Nadu were used. In-depth interviews with beneficiaries using phenomenology were conducted to evaluate their perception and willingness to shift to a cash-based PDS in the pre and post-pandemic periods. Secondary district-level data were also used to ascertain institutional preparedness for this shift.FindingsIn-depth interviews of 105 beneficiaries revealed valuable insights, which seem to have significantly changed post-pandemic. Beneficiaries in the post-pandemic period seem much more inclined toward cash transfers, though a combination of cash plus in-kind benefits seems to be strongly preferred. Secondary results pointed out to the lack of institutional preparedness in financial inclusion. The research suggested that while the existing PDS needs to be overhauled, policymakers should look at a model of cash plus in-kind transfers as a probable alternative to pure cash transfers.Originality/valueThere is a dearth of in-depth state-specific studies on beneficiary perception of PDS, and this is important since the economic and sociocultural milieu in each region is unique. Being the only state with universal food security, its experience could yield important insights for other states or even middle or low-income countries similar to India.