We have shown that UCT and CCT significantly increased the proportion of children with good school attendance in Manicaland, Zimbabwe. CCT, but not UCT, significantly increased the proportion with a birth certificate. However, neither programme significantly increased the proportion with a complete vaccination record. Our conditions were soft—ie, households received support to meet conditions before their transfers were reduced. In view of the 6-month initial grace period, it is unlikely that many households received reduced transfers when they did not meet conditions. Therefore, identification of the specific component of the CCT programme that produced the reported effects is difficult. Interpretation is further complicated by the potential for respondents in the UCT and CCT groups to have been affected by the evaluation process: community awareness about the aims of the project could have affected actual or reported behaviours (eg, emphasis on school attendance as an outcome of the assessment by programme implementers could have encouraged caregivers to send their children to school).
Several factors could explain why CCT, but not UCT, had a large effect on birth registration. First, the proportion of children in the region with a birth certificate at baseline was less than 50%, which was probably related to bureaucratic barriers and poor awareness about birth registration. Second, DOMCCP helped many households in the CCT group to obtain birth certificates. Third, birth registration is a one-time event; it does not have to be maintained. Reviews17,18
suggest that economic incentives most effectively affect behaviours in the short term.
Neither UCT nor CCT significantly increased the proportion of children with up-to-date vaccinations. A previous systematic review6
showed that CCT positively affected vaccination coverage when conditions included attendance at preventive health-care services.19
In Manicaland, vaccinations are often delivered via mobile outreach, and cash transfers might not affect access to these services. Furthermore, measles and BCG vaccination coverage was high at baseline (>94%; appendix
), restricting the potential for the interventions to increase uptake.
In Malawi, both UCT and CCT improved school attendance in adolescent girls, although CCT produced the largest effect.20
In our study, the effect of CCT on school attendance was only slightly larger than was the effect of UCT. In the 1980s, Zimbabwe expanded education services; adult literacy and school enrolment remain high compared with other sub-Saharan African countries.21
Therefore, conditions might not be necessary to raise awareness about the benefits of education, which leaves poverty as the principal barrier to school attendance. However, the larger effect in the CCT group suggests that conditions—either through support or provision of a direct incentive—could also help to increase school attendance.
Strengths of our study were its cluster-randomised design, large sample size, low numbers of households that refused to participate, and high follow-up. Our clusters represent four different area types, which improves generalisability to similar rural areas in southern and eastern Africa. However, we did the study shortly after a period of economic crisis in Zimbabwe, which could limit this generalisability. We probably missed some vulnerable children—eg, those living in institutions. However, most vulnerable children in Zimbabwe are cared for in households, usually within the extended family.4
We did record evidence of contamination between groups: almost a third of UCT households reported having to comply with conditions. UCT households could have been inadvertently exposed to awareness campaigns about conditions, which were done in the study areas. DOMCCP representatives work throughout our study clusters; UCT households that reported having to comply with conditions could have also accessed support from these workers. Our finding that households that reported having to comply with conditions had higher proportions of children with birth certificates and good school attendance than did households that did not have to meet conditions could have meant that the intention-to-treat analysis overestimated the effect of the UCT. Furthermore, two control villages were accidentally enrolled into the UCT programme, which might have meant we underestimated the effects of the cash transfers in our intention-to-treat analysis.
Our study was limited by the short intervention period. Whether the effects of the programmes would change with time is unclear. The follow-up survey was done 2 months after interventions had finished, so fear of penalties should not have biased responses from CCT households, although the effects of the programmes could have attenuated by the time of the survey.
Overall, our results support strategies to integrate cash transfers into social welfare programming for orphans and vulnerable children that are presently implemented in several sub-Saharan Africa countries (panel
). Further work is needed to assess whether the increased costs associated with monitoring compliance with conditions is compensated by greater improvements in child-welfare outcomes.
Panel. Research in context
Two systematic reviews2,6
of unconditional cash transfer (UCT) and conditional cash transfer (CCT) programmes fromed the basis of our review. We supplemented the information from the systematic reviews with a search of PubMed for reports published in English with the search terms “cash*” and “transfer*”. We used no date restrictions. Few rigorous assessments of UCT programmes have been reported. Adato and Bassett2
did a review of cash transfers in the context of HIV epidemics, which included ten UCT programmes. All studies that reported quantitative evaluation data were included in the review. Adato and Bassett2
reported positive effects of UCT interventions on a range of outcomes in several countries in sub-Saharan Africa, including increased school enrolment and attendance in children in South Africa,22,23
Many rigorous assessments of CCT programmes have been done, largely in Latin America. A systematic review6,26
of the effects of CCT interventions on health outcomes identified eight studies from Latin America that conditioned transfers on health behaviours. In most studies, the transfers were also conditioned on school enrolment or attendance, or both. The interventions targeted poor households and communities. Four19,27–29
of six studies that investigated the effects of CCT programmes on child-related health-seeking behaviours showed significant positive effects. All four studies (from Colombia,27
) that investigated the effects of CCT on immunisation coverage reported positive effects, although these results were sometimes limited to specific age groups and vaccine types and, in Mexico, the positive effects attenuated with time.6
Studies not included in the systematic review have also showed positive effects of CCT programmes on school attendance in Latin America.2,7
Few studies have compared the effects of UCT and CCT programmes in the same setting. Baird and colleagues8
analysed data from a trial of UCT and CCT in Malawi and reported no significant differences between UCT and CCT groups, although cash transfers significantly reduced infections with HIV and herpes simplex virus 2 in adolescent girls. In a secondary analysis,20
they showed that the CCT programme, which was conditional on regular school attendance, had a significantly greater positive effect on school enrolment and performance than did the UCT programme, but that teenage pregnancy and marriage were significantly more frequent in adolescent girls in the CCT group than in those in the UCT group.
Our results support strategies to integrate cash transfers into social welfare programming in sub-Saharan Africa. Further evidence is needed for the comparative cost-effectiveness of UCT and CCT programmes in low-income settings with high HIV prevalence in sub-Saharan Africa.