The cash incentive scheme
The first phase of the study, the Afya Credit Incentive for Improved Maternal and Child Health, was carried out in Siaya County, Kenya, an area with current rates of 695 maternal deaths per 100,000 births, and 125 infant deaths per 1000 live births. These mortality rates are far above the national average and Millennium Development Goals targets, and largely stem from under-use of maternal and child healthcare services.
The pilot study, carried out in collaboration with the Safe Water and AIDS Project and supported by the County Government, provided cash payments for 200 women in Siaya to cover direct and indirect costs that hinder visits to health facilities, such as service fees and transport, food that women purchase for themselves or their accompanying children while waiting to be attended, clothing suitable for the social nature of visits to ante-natal classes, and the opportunity costs of taking time away from income generating activities.
One recent study showed that in sub-Saharan Africa, although 71% of pregnant women attended formal antenatal care visit at least once, only 44% came for the recommended four visits, and 44% deliver in health facilities. However, in the pilot study, more than 80% of the women made it to the fourth antenatal visit, and over 90% delivered in health facilities, far above the figures in the literature.
For the first time health workers achieved and exceeded service demand targets set to them by the Ministry of Health and the County health management teams.
With funding from the Gates Foundation, SEI and its partners will scale up the study from 200 women to 3,600 women, thus covering all pregnant women and their infants across 18 health facilities in Siaya District over a 24-month period.
Caroline Ochieng, SEI Research Fellow and project leader said, “At a minimum, the project will have a significant direct impact on the health of 7200 individuals who are the mother-child pairs we will enroll.”
Building on lessons learned
The success of the pilot study not only demonstrated that the payments were highly effective in ensuring continuity of health visits from pregnancy to post-natal period, but also that the cash transfer approach can effect positive behaviour change. The scheme also showed the acceptability of this type of incentive in the region, and has laid scientific and policy groundwork for testing and scaling up personal financial incentives as a means to tackle hard-to-change behaviours that significantly impact on maternal and child health in Kenya.
The second phase will provide an opportunity for testing the feasibility of the scheme at a much larger scale. While the first phase entailed manual recording of health visits, the second phase will partner with businesses in Kenya’s well-developed ICT and mobile banking sectors to design and implement an electronic system for logging the health visits and transferring cash to recipients.
A model scheme for other governments and development organizations
The project staff hopes that the scheme will serve as model for further uptake by governments all over Africa and major donors across the continent.
“Since 2009, the Government of Kenya has been implementing the Cash Transfer for Orphans and Vulnerable Children (CT-OVC) programme”, noted Ochieng. “At the end of the project we hope that we can convince them to extend this type of programme to also cover pregnant women using this type of intervention.”