Implementation of the Afya conditional cash transfer intervention to retain women in the continuum of care: a mixed-methods process evaluation

The Afya CCT intervention aimed to retain women in the continuum of maternal healthcare, including antenatal care (ANC), delivery at facility and postnatal care (PNC) in Siaya County, Kenya. The cash transfers were delivered using an electronic card-reader system at health facilities. It was evaluated in a trial that randomized 48 health facilities to intervention or control, and which found modest increases in attendance for ANC and immunization appointments, but little effect on delivery at facility and PNC visits.

The authors conducted a mixed-methods process evaluation, using the Afya electronic portal with recorded visits and payments, and report on use of the electronic card reader system from each healthcare facility to assess fidelity. Focus group interviews with participants (N=5) and one-on-one interviews with participants (N=10) and healthcare staff (N=15) were conducted to assess the acceptability of the intervention. Data analyses were conducted using descriptive statistics and qualitative content analysis, as appropriate.

Delivery of the Afya CCT intervention was negatively affected by problems with the electronic card reader system and a decrease in adherence to its use over the intervention period by healthcare staff, resulting in low implementation fidelity. Acceptability of cash transfers in the form of mobile transfers was high for participants. Initially, the intervention was acceptable to healthcare staff, especially with respect to improvements in attaining facility targets for ante-natal care visits. However, acceptability was negatively affected by significant delays linked to the card reader system.

The findings highlight operational challenges in delivering the Afya CCT intervention using the Afya electronic card reader system, and the need for greater technology readiness before further scale-up.