Conditional cash transfer schemes in Nigeria: potential gains for maternal and child health service uptake in a national pilot programme

Abstract

Background: This paper describes use of a Conditional Cash Transfer (CCT) programme to encourage use of critical MNCH services among rural women in Nigeria.

Methods: The CCT programme was first implemented as a pilot in 37 primary health care facilities (PHCs), in nine Nigerian states. The programme entitles women using these facilities up to N5,000 (approximately US$30) if they attend antenatal care (ANC), skilled delivery, and postnatal care. There are 88 other PHCs from these nine states included in this study, which implemented a standard package of supply upgrades without the CCT. Data on monthly service uptake throughout the continuum of care was collected at 124 facilities during quarterly monitoring visits. An interrupted time series using segmented linear regression was applied to estimate separately the effects of the CCT programme and supply package on service uptake.

Results: From April 2013-March 2014, 20,133 women enrolled in the CCT. Sixty-four percent of beneficiaries returned at least once after registration, and 80% of women delivering with skilled attendance returned after delivery. The CCT intervention is associated with a statistically significant increase in the monthly number of women attending four or more ANC visits (increase of 15.12 visits per 100,000 catchment population, p < 0.01; 95% confidence interval 7.38 to 22.85), despite a negative level effect immediately after the intervention began (-45.53/100,000 catchment population; p < 0.05; 95% CI -82.71 to -8.36). A statistically significant increase was also observed in the monthly number of women receiving two or more Tetanus toxoid doses during pregnancy (21.65/100,000 catchment population; p < 0.01; 95% CI 9.23 to 34.08). Changes for other outcomes with the CCT intervention (number of women attending first ANC visit; number of deliveries with skilled attendance; number of neonates receiving OPV at birth) were not found to be statistically significant.

Conclusions: The results show that the CCT intervention is capable of significant effects on service uptake, although results for several outcomes of interest were inconclusive. Key lessons learnt from the pilot phase of implementation include a need to track beneficiary retention throughout the continuum of care as closely as possible, and avert loss to follow-up.

Figure 1

States selected for CCT Pilot Programme. List of the states selected for the Conditional Cash Transfer (CCT) Pilot Programme, shown on the right of the diagram. The figure shows how these states were selected: first by determining that three states should be represented from each of three tiers of performance in a previous evaluation of the Midwives Service Scheme (MSS) in 2012. For each tier, three states were selected from two of Nigeria’s six geopolitical zones. Abbreviations: FCT, Federal Capital Territory.

Figure 2

Cumulative total enrollment of CCT beneficiaries, as at 31.03.2014. Shows the number of women enrolled in the Conditional Cash Transfer (CCT) Pilot Programme since operations began in April 2013. The total beneficiary count at the end of each quarter and as at 31^st March 2014 are shown. The trend for the Federal Capital Territory (FCT) is shown as a subset of the overall cumulative total, as during the second quarter of 2013 this was the only state implementing the pilot.

Figure 3

Percentage of CCT beneficiaries observed returning after enrolment, by state, as at 31.03.14. Shows the percentage of Conditional Cash Transfer (CCT) beneficiaries who were recorded by project staff as returning to the primary healthcare (PHC) facility they enrolled at. Returning is defined as fulfilling any of co-responsibilities 2–4 in Table 1. The denominator (number of beneficiaries in sample) is shown below each state. Abbreviations: ANC, Antenatal care.

Figure 4

Percentage of deliveries which were followed by post natal care, by state, as at 31.03.14. Shows the percentage of Conditional Cash Transfer (CCT) beneficiaries who were recorded by project staff as returning to the primary healthcare (PHC) facility after delivery. Returning is defined as fulfilling co-responsibility 4 in Table 1: either by attending for zero-dose neonatal immunization, or for a post-natal visit for the mother, or both. The denominator (number of deliveries in sample) is shown below each state.

Figure 5

Time series plot of monthly service uptake for key services, in states piloting CCT programme. Trends in service use at 31 clusters in nine states piloting the SURE-P Conditional Cash Transfer (CCT), shown as monthly totals standardised per 100,000 catchment population from 2012–2014. The trends are shown separately for the nine clusters implementing the CCT and 22 comparison clusters. A) Total attendance for first antenatal care visit; B) Total number of pregnant women attending four or more ANC visits; C) Total number of women receiving two or more doses Tetanus toxoid during pregnancy. D) Total number of women delivering with skilled attendance; E) Total number of newborns provided with zero-dose OPV. Abbreviations: ANC, Antenatal care; OPV, Oral polio vaccine.