A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol Cash for Women’s Empowerment? A Mixed-Methods Evaluation of the Government of Zambia’s Child Grant Program The Short-Term Impacts of a Schooling Conditional Cash Transfer Program on the Sexual Behavior of Young Women Impact of the Kenya Cash Transfer for Orphans and Vulnerable Children on early pregnancy and marriage of adolescent girls. Effects of cash transfers on Children’s health and social protection in Sub-Saharan Africa: differences in outcomes based on orphan status and household assets Effects of unconditional and conditional cash transfers on child health and development in Zimbabwe: a cluster-randomised trial Unconditional government social cash transfer in Africa does not increase fertility The impact of cash transfers on social determinants of health and health inequalities in Sub-Saharan Africa: a systematic review protocol Eradicating diseases: The effect of conditional cash transfers on vaccination coverage in rural Nicaragua.
Background The use of financial incentives and penalties to encourage uptake of healthy behaviors is increasingly seen as a viable intervention in developed countries . Previous review s of the effectiveness of financial incentives and penalties for encouraging the uptake of healthy behaviors have focused on individual behaviors making it difficult to draw overall conclusions about the effectiveness of such interventions . This systematic review will explore the effectiveness of financial incentives and penalties for encouraging a wide range of behaviors , including : smoking cessation , increased physical activity , healthier dietary intake , sensible patterns of alcohol consumption , safe sun , safe sex , and primary preventive clinical behaviors . Methods Systematic methods will be used to search existing literature and screen studies for inclusion . All studies that meet the following inclusion criteria will be included in the review : participants were 18 years old or older and living in high-income countries ; interventions included cash or cash-like incentives to promote the uptake of healthy behaviors , or cash or cash-like penalties to discourage unhealthy behaviors ; the comparator was usual care or no intervention ; study design was r and omized controlled trial , cluster r and omized controlled trial , controlled before and after study , or interrupted time series analysis . Two review ers will independently screen the publications to ensure they meet the inclusion criteria . Quality will be assessed by two research ers , working independently , using the Cochrane risk of bias tool . Meta- analysis will be conducted , if appropriate . Any studies identified as at ‘ high risk of bias ’ will be excluded from meta- analysis . Discussion This systematic review will provide policy-relevant recommendations for the use of financial incentives and penalties as a method of encouraging uptake of healthy behaviors Summary . — The empowerment of women , broadly defined , is an often-cited objective and benefit of social cash transfer programs in developing countries . Despite the promise and potential of cash transfers to empower women , the evidence supporting this outcome is mixed . In addition , there is little evidence from programs at scale in sub-Saharan Africa . We conducted a mixed- methods evaluation of the Government of Zambia ’s Child Grant Program , a poverty-targeted , unconditional transfer given to mothers or primary caregivers of young children aged zero to five . The quantitative component was a four-year longitudinal clustered-r and omized control trial in three rural districts , and the qualitative component was a one-time data collection involving in-depth interviews with women and their partners stratified on marital status and program participation . Our study found that women in beneficiary households were making more sole or joint decisions ( across five out of nine domains ) ; however , impacts translated into relatively modest increases in the number of decision domains a woman is involved in , on average by 0.34 ( or a 6 % increase over a baseline mean of 5.3 ) . Qualitatively , we found that changes in intrahousehold relationships were limited by entrenched gender norms , which indicate men as heads of household and primary decision makers . However , women ’s narratives showed the transfer increased financial empowerment as they were able to retain control over transfers for household investment and savings for emergencies . We highlight method ological challenges in using intrahousehold decision making as the primary indicator to measure empowerment . Results show potential for unconditional cash transfer programs to improve the financial and intrahousehold status of female beneficiaries , however it is likely additional design components are need for transformational change Recent evidence suggests that conditional cash transfer programs for schooling are effective in raising school enrollment and attendance . However , there is also reason to believe that such programs can affect other outcomes , such as the sexual behavior of their young beneficiaries .  Zomba Cash Transfer Program is a r and omized , ongoing conditional cash transfer intervention targeting young women in Malawi that provides incentives ( in the form of school fees and cash transfers ) to current schoolgirls and recent dropouts to stay in or return to school . An average offer of US$ 10/month conditional on satisfactory school attendance – plus direct payment of secondary school fees – led to significant declines in early marriage , teenage pregnancy , and self-reported sexual activity among program beneficiaries after just one year of program implementation . For program beneficiaries who were out of school at baseline , the probability of getting married and becoming pregnant declined by more than 40 percent and 30 percent , respectively . In addition , the incidence of the onset of sexual activity was 38 percent lower among all program beneficiaries than the control group . Overall , these results suggest that conditional cash transfer programs not only serve as useful tools for improving school attendance , but may also reduce sexual activity , teen pregnancy , and early marriage There is promising evidence that poverty-targeted cash transfer programs can have positive impacts on  adolescent transitions to adulthood in re source poor setting s , however existing research is typically from small scale programs in diverse geographic and cultural setting s. We provide estimates of the impact of a national unconditional cash transfer program , the Kenya Cash Transfer for Orphans and Vulnerable Children  , on pregnancy and early marriage among females aged 12 to 24 , four years after program initiation . The evaluation was design ed as a clustered r and omized controlled trial and ran from 2007 to 2011 , capitalizing on the existence of a control group , which was delayed entry to the program due to budget constraints . Findings indicate that , among 1549 females included in the study , while the program reduced the likelihood of pregnancy by five percentage points , there was no significant impact on likelihood of early marriage . Program impacts on pregnancy appear to work through increasing the enrollment of young women in school , financial stability of the household and delayed age at first sex . The Kenyan program is similar in design to most other major national cash transfer programs in Eastern and Southern Africa , suggesting a degree of generalizability of the results reported here . Although the objective of the program is primarily poverty alleviation , it appears to have an important impact on facilitating the successful transition of adolescent girls into adulthood Background Unconditional and conditional cash transfer programmes ( UCT and CCT ) show potential to improve the well-being of orphans and other children made vulnerable by HIV/AIDS ( OVC ) . We address the gap in current underst and ing about the extent to which household-based cash transfers differentially impact individual children ’s outcomes , according to risk or protective factors such as orphan status and household assets . Methods Data were obtained from a cluster-r and omised controlled trial in eastern Zimbabwe , with r and om assignment to three study arms – UCT , CCT or control . The sample included 5,331 children ages 6 - 17 from 1,697 households . Generalized linear mixed models were specified to predict OVC health vulnerability ( child chronic illness and disability ) and social protection ( birth registration and 90 % school attendance ) . Models included child-level risk factors ( age , orphan status ) ; household risk factors ( adults with chronic illnesses and disabilities , greater household size ) ; and household protective factors ( including asset-holding ) . Interactions were systematic ally tested . Results Orphan status was associated with decreased likelihood for birth registration , and paternal orphans and children for whom both parents ’ survival status was unknown were less likely to attend school . In the UCT arm , paternal orphans fared better in likelihood of birth registration compared with non-paternal orphans . Effects of study arms on outcomes were not moderated by any other risk or protective factors . High household asset-holding was associated with decreased likelihood of child ’s chronic illness and increased birth registration and school attendance , but household assets did not moderate the effects of cash transfers on risk or protective factors . Conclusion Orphaned children are at higher risk for poor social protection outcomes even when cared for in family-based setting s. UCT and CCT each produced direct effects on children ’s social protection which are not moderated by other child- and household-level risk factors , but orphans are less likely to attend school or obtain birth registration . The effects of UCT and CCT are not moderated by asset-holding , but greater household assets predict greater social protection outcomes . Intervention efforts need to focus on ameliorating the additional risk burden carried by orphaned children . These efforts might include caregiver education , and additional incentives based on efforts made specifically for orphaned children Summary Background Cash-transfer programmes can improve the wellbeing of vulnerable children , but few studies have rigorously assessed their effectiveness in sub-Saharan Africa . We investigated the effects of unconditional cash transfers ( UCTs ) and conditional cash transfers ( CCTs ) on birth registration , vaccination uptake , and school attendance in children in Zimbabwe . Methods We did a matched , cluster-r and omised controlled trial in ten sites in Manical and , Zimbabwe . We divided each study site into three clusters . After a baseline survey between July , and September , 2009 , clusters in each site were r and omly assigned to UCT , CCT , or control , by drawing of lots from a hat . Eligible households contained children younger than 18 years and satisfied at least one other criteria : head of household was younger than 18 years ; household cared for at least one orphan younger than 18 years , a disabled person , or an individual who was chronically ill ; or household was in poorest wealth quintile . Between January , 2010 , and January , 2011 , households in UCT clusters collected payments every 2 months . Households in CCT clusters could receive the same amount but were monitored for compliance with several conditions related to child wellbeing . Eligible households in all clusters , including control clusters , had access to parenting skills classes and received maize seed and fertiliser in December , 2009 , and August , 2010 . Households and individuals delivering the intervention were not masked , but data analysts were . The primary endpoints were proportion of children younger than 5 years with a birth certificate , proportion younger than 5 years with up-to- date vaccinations , and proportion aged 6–12 years attending school at least 80 % of the time . This trial is registered with Clinical Trials.gov , number NCT00966849 . Findings 1199 eligible households were allocated to the control group , 1525 to the UCT group , and 1319 to the CCT group . Compared with control clusters , the proportion of children aged 0–4 years with birth certificates had increased by 1·5 % ( 95 % CI −7·1 to 10·1 ) in the UCT group and by 16·4 % ( 7·8–25·0 ) in the CCT group by the end of the intervention period . The proportions of children aged 0–4 years with complete vaccination records was 3·1 % ( −3·8 to 9·9 ) greater in the UCT group and 1·8 % ( −5·0 to 8·7 ) greater in the CCT group than in the control group . The proportions of children aged 6–12 years who attended school at least 80 % of the time was 7·2 % ( 0·8–13·7 ) higher in the UCT group and 7·6 % ( 1·2–14·1 ) in the CCT group than in the control group . Interpretation Our results support strategies to integrate cash transfers into social welfare programming in sub-Saharan Africa , but further evidence is needed for the comparative effectiveness of UCT and CCT programmes in this region . Funding Wellcome Trust , the World Bank through the Partnership for Child Development , and the Programme of Support for the Zimbabwe National Action Plan for Orphans and Vulnerable Children Among policymakers , a common perception surrounding the effects of cash transfer programmes , particularly unconditional programmes targeted to families with children , is that they induce increased fertility . We evaluate the Zambian Child Grant Programme  , a government unconditional cash transfer targeted to families with a child under the age of 5 and examine impacts on fertility and household composition . The evaluation was a cluster r and omized control trial , with data collected over 4 years from 2010 to 2014 . Our results indicate that there are no programme impacts on overall fertility . Our results contribute to a small evidence base demonstrating that there are no unintended incentives related to fertility due to cash transfers Background There is increasing pressure to address the social determinants of health ( SDoH ) and health inequities through the implementation of culturally acceptable interventions particularly in Sub-Saharan Africa ( SSA ) where health outcomes are generally poor . Available evaluation research on cash transfers ( CTs ) suggests that the programs may influence the wider determinants of health in SSA ; yet , there has been no attempt to synthesize the evidence regarding their contribution to tackling the SDoH and health inequalities . To date , nearly all the review s on CTs ' impact on health have predominantly featured evidence from Latin America with limited transferability to the social , cultural , and political environments in SSA . Therefore , the aim of this study is to undertake a systematic review to assess the role of CTs in tackling the wider determinants of health and health inequalities in SSA . Methods / design A systematic review of published and unpublished literature on CTs ’ impact on health and health determinants covering the period 2000–2016 will be undertaken . Studies will be considered for inclusion if they present quantitative or qualitative data , including all relevant study design s. The SDoH conceptual framework will be used to guide the data extraction process . EPPI Review er software will be used for data management and analysis . Studies included in the review will be analyzed by narrative synthesis and /or meta- analysis as appropriate for the nature of the data retrieved . Discussion This review will provide empirical evidence on the impact of CTs on SDoH to inform CT policy , implementation , and research in SSA . The protocol follows the Preferred Reporting Items for Systematic Review and Meta- Analysis Protocol s ( PRISMA -P ) . Systematic review registration This protocol has been registered with the PROSPERO international prospect i ve register of systematic review s , reference CRD42015025015 Despite significant global efforts to improve vaccination coverage against major childhood diseases , vaccination rates are below 90 % . To eradicate diseases such as measles , however , vaccination rates close to 95 % are needed . We use a r and omized experiment to investigate the effect of a dem and incentive , a conditional cash transfer program , in improving  vaccination coverage in rural Nicaragua . Double-difference estimates show the program led to large increases in vaccination coverage , and these result ed in vaccination levels greater than 95 % for some vaccines . Effects were especially large for children who are typically harder to reach with traditional supply-side interventions
The quality of evidence on the effect of financial incentives on breastfeeding practice s was low but seems to indicate a potential positive impact on receiving colostrum , early initiation of breastfeeding , exclusive breastfeeding and mean duration of exclusive breastfeeding .
There is no effect of financial incentives on immunization coverage although there was moderate quality evidence of conditional cash transfers leading to a small but non-significant increase in coverage of age-appropriate immunization .
Conclusions Financial incentives may have potential to promote increased coverage of several important child health interventions , but the quality of evidence available is low .
The more pronounced effects seem to be achieved by programs that directly removed user fees for access to health services .
Some indication of effect were also observed for programs that conditioned financial incentives on participation in health education and attendance to health care visits .
This finding suggest that the measured effect may be less a consequence of the financial incentive and more due to conditionalities addressing important informational barriers
Background Financial incentives are widely used strategies to alleviate poverty , foster development , and improve health .
Cash transfer programs , microcredit , user fee removal policies and voucher schemes that provide direct or indirect monetary incentives to households have been used for decades in Latin America , Sub-Saharan Africa , and more recently in Southeast Asia .
Until now , no systematic review of the impact of financial incentives on coverage and uptake of health interventions targeting children under 5 years of age has been conducted .
The objective of this review is to provide estimates on the effect of six types of financial incentive programs : ( i ) Unconditional cash transfers ( CT ) , ( ii ) Conditional cash transfers ( CCT ) , ( iii ) Microcredit ( MC ) , ( iv ) Conditional Microcredit ( CMC ) , ( v ) Voucher schemes ( VS ) and ( vi ) User fee removal ( UFR ) on the uptake and coverage of health interventions targeting children under the age of five years .