August, 2008 - SUPPORT Summary of a systematic review | print this article |

Do conditional cash transfers improve the uptake of health interventions in low- and middle-income countries?

Over the past few years, several Latin American countries have introduced programmes that provide monetary transfers to households on the condition that they comply with certain health behaviours. The rationale is that the transfers can potentially increase the use of health services by low-income individuals by providing funds to help overcome some financial barriers to access.

Key messages

  • Six studies of conditional cash transfer programmes carried out in low and middle- income countries found an increase in the use of health services and mixed effects on immunisation coverage and health status.
  • The capacity of each health system to deal with the increased demand should be considered, particularly in low-income countries where the capacity of health systems may not be sufficient.
  • The cost-effectiveness of conditional cash transfer programmes, compared with supply-side strategies and other policy options, has not been evaluated.


In the past decade, some Latin American and African countries have introduced pro- grammes that provide monetary transfers to targeted households on the condition that they comply with a set of behavioural requirements. These requirements are typically linked to attendance at primary care centres for preventive interventions and to educational enrolment for children.

The rationale is that the transfers can potentially increase the use of health services by low-income individuals by providing funds to help overcome some financial barriers to access, such as the costs associated with seeking health care or sending children to school.

Interest in conditional cash transfers has increased and such programmes are being implemented in a number of countries within and beyond Latin America.

About the systematic review underlying this summary

Review Objectives: To assess the effectiveness of conditional monetary transfers in improving access to and use of health services, as well as improving health outcomes, in low- and middle-income countries
/What the review authors searched forWhat the review authors found
Interventions Programmes in which money was transferred directly to households conditional on some requirements, at least one of which had to be related to health-seeking behaviour.
Five large-scale conditional cash transfer programmes in Latin America targeted at disadvantaged households, and one pilot program in Africa (Malawi) targeted at individuals tested for HIV.
Participants Users and non-users of health services in low- and middle-income countries.
Disadvantaged households in low-income areas of selected Latin American countries, and individuals who underwent HIV testing in rural areas in Malawi.
Settings Low- and middle-income countries as defined by the World Bank.
Low- and middle-income countries: five in Latin American (Mex- ico, Nicaragua, Honduras, Brazil and Colombia) and one in Africa (Malawi).
Outcomes Healthcare utilisation or access to health care, household health expenditure, health or anthropom- etric outcomes
Care-seeking behaviour (five studies); immunisation coverage (four studies); anthropometric outcomes (four studies); and health status (three studies)
Date of most recent search: April 2006
Limitations: This is a good quality systematic review with only minor limitation

Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low and middle- income countries: a systematic review. JAMA 2007; 298:1900-10.

Summary of findings

Ten articles that reported the results from six studies (four randomised trials, one quasi- randomised evaluation, and one controlled before-after study) were included. Five out of six studies evaluated large-scale conditional cash transfer programmes in Latin America (Mexico, Nicaragua, Colombia, Honduras and Brazil), targeted at disadvantaged households in low-income areas in order to increase school and preventive health examinations attendance. The other study was of a pilot programme in Malawi that tested whether financial incentives would increase the collection of HIV test results.

The mean monetary transfer per household ranged between US $17 and 50 for Latin American studies and was US $1 per individual in the Malawi study. In the case of Mexico, Nicaragua and Brazil households received additional nutrition supplements for children.

  • Overall, the evidence suggests that conditional cash transfer programmes can be effective in increasing the use of preventive services and can sometimes improve immunisation coverage and health status.
Outcomes Impact No of Participants
Quality of the evidence
Care-seeking behaviour
All the studies reported an increase in the use of health services in the group with cash transfers (27% increase in individuals returning for volun- tary HIV counselling, 2.1 more visits per day to health facilities, 11-20% more children taken to the health centre in the past month, 23-33% more children < 4 yrs attending preventive healthcare visits)

(5 studies)**

Immunisation coverage
The effects were unclear (increased vaccination rates in children for measles and tuberculosis but only in specific groups or temporarily, and without change in one study)

(4 studies)

Health status Mixed effects on objectively measured health outcomes (anaemia) and posi- tive effects on mothers’ reports of children’s health outcomes (22-25% de- crease in the probability of children <3 yrs being reported ill in the past month)

(3 studies)

RR: Risk ratio     GRADE: GRADE Working Group grades of evidence (see explanations)

Relevance of the review for low-income countries



  • All of the studies were undertaken in low- and middle- income countries, predominantly in Latin America.
  • Components of the evaluated programmes other than the cash transfers may have impacted on the results. For instance, health status and anthropometric measures could have been influenced by nutritional supplements provided to children in these studies; better diet resulting from the increased available revenue of households; or the benefits of mothers attending health education meetings.


  • Most of the evidence is likely to be applicable in Latin American health systems, although differences in health systems that could impact on the effects of conditional cash transfers still need to be considered. In particular, the capacity of health systems to deal with increased demand needs to be considered. In resource-poor settings where public spending on healthcare is low and access to effective interventions limited, expanding the capacity of health services would be necessary for cash transfers to result in improved use of health services.
  • It is difficult to disentangle the relative importance of different components of the programmes that included more than cash transfers. The effects of non-cash components could be especially relevant in some LMICs.
  • In Nicaragua, increases in household expenditures were the greatest for the poorest group as was the uptake of preventive services for infants. On the other hand, nutritional benefits in Mexico were greater for children whose mother had more than five years of schooling, which could suggest that these programmes do not achieve perfectly their ambition of “levelling the playing field”.
  • Children from disadvantaged environments, at household and community levels, seem to gain greater benefits from the programmes than those from more advantaged environments. However, it may be more difficult and costly for people living in rural and other underserved areas to have access to the specific health services targeted by cash transfers. Therefore, if an adjustment is not incorporated into the transfers, those recipients would benefit less than those with better access to health services.
  • Conditional cash transfer programmes may require significant flows of money.
  • It is not possible, especially for resource-poor settings, to establish which policy options would be the most efficient in improving access to and use of health services for targeted populations. For example, the removal of users fees for using health facilities is an alternative policy option to improve access and utilisation in some contexts.


  • The cost-effectiveness of conditional cash transfer programmes compared with supply-side interventions (for example, improving the quantity and quality of healthcare services) has not been evaluated.
  • Cash transfers may be either too high or too low to induce the conditional action, resulting in inefficiency.


  • The cost-effectiveness of conditional cash transfer programmes should be evaluated in low-income settings with more limited health system capacity prior to wide spread implementation in those settings. Attention should be paid to evaluating which components play a critical role (cash versus non-cash transfers); the size of the transfers; and the financial sustainability of such programmes.
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income countries. For additional details about how these judgements were made see:

Additional information

Related literature

Lagaarde M, Palmer N. Evidence from systematic reviews to inform decision making regarding financing mechanisms that improve access to health services for poor people. A policy brief prepared for the International Dialogue on Evidence-Informed Action to Achieve Health Goals in Developing Countries (IDEAHealth). Geneva: Alliance for Health Policy and Systems Research, 2006.

Oxman AD, Fretheim A. An overview of research on the effects of results-based financing. Oslo: Norwegian Knowledge Centre for the Health Services, 2008. In press.

Eichler R. Can ”Pay for Performance” Increase Utilization by the Poor and Improve the Quality of Health Services? Discussion paper for the first meeting of the Working Group on Performance-Based Incentives. Washington DC: Center for Global Development, 2006;

Handa S, Davis B. The experience of conditional cash transfers in Latin America and the Caribbean. Dev Policy Rev 2006; 24:513-536.

Ensor T, Cooper S. Overcoming Barriers to Health Service Access and Influencing the Demand Side Through Purchasing. Washington, DC: World Bank; 2004.

de Janvry A, Sadoulet E. Making conditional cash transfer programs more efficient: designing for maximum effect of the conditionality. World Bank Econ Rev 2006; 20:1-29.


This summary was prepared by

Tomás Pantoja, Universidad Catolica de Chile, Santiago, Chile


Conflict of interest

None declared. For details, see:



This summary has been peer reviewed by: Mylene Lagarde, UK; Atle Fretheim, Norway; Qingyue Meng, China; Suzanne Kiwanuka, Uganda.


This summary should be cited as

Pantoja T. Do conditional cash transfers improve the uptake of health interventions in low and middle- income countries? A SUPPORT Summary of a systematic review. August 2008.