Unconditional cash transfers for reducing poverty: effect on health services use and health outcomes in low- and middle-income countries
Some programmes provide cash transfers or grants for reducing poverty and vulnerabilities without imposing any obligations on the recipients (‘unconditional cash transfers’, or UCTs) in low- and middle-income countries (LMICs). Other times, people can only receive these cash transfers if they engage in required behaviours, such as using health services or sending their children to school (‘conditional cash transfers’, or CCTs). This review aimed to find out whether receiving UCTs would improve people’s use of health services and their health outcomes, compared with not receiving a UCT, receiving a smaller UCT amount or receiving a CCT. It also aimed to assess the effects of UCTs on daily living conditions that determine health and healthcare spending.
UCTs are a type of social protection intervention that addresses income. It is unknown whether UCTs are more, less or equally as effective as CCTs. We reviewed the evidence on the effect of UCTs on health service use and health outcomes among children and adults in LMICs.
The evidence is current to May 2017. We included experimental and selected non-experimental studies of UCTs in people of all ages in LMICs. We included studies that compared participants who received a UCT with those who received no UCT. We looked for studies that examined health services use and health outcomes.
We found 21 studies (16 experimental and 5 non-experimental ones) with 1,092,877 participants (36,068 children and 1,056,809 adults) and 31,865 households in Africa, the Americas and South-East Asia. The UCTs were government programmes or research experiments. Most studies were funded by national governments and/or international organisations.
We use the words ‘probably’ to indicate moderate-quality evidence, ‘may/maybe’ for low-quality evidence, and ‘uncertain’ for very low-quality evidence. A UCT may not impact the likelihood of having used any health service in the previous 1 to 12 months. UCTs probably led to a clinically meaningful, very large reduction in the risk of having had any illness in the previous two weeks to three months. They may increase the likelihood of having had secure access to food over the previous month. They may also increase the average number of different food groups consumed in the household over the previous week. Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of stunting and on depression levels remain uncertain. No study estimated effects on dying. UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school. The evidence was uncertain for whether UCTs impacted livestock ownership, extreme poverty, participation in child labour, adult employment and parenting quality. UCTs may increase the amount of money spent on health care. The effects of UCTs on differences in health were very uncertain. We did not identify any harms from UCTs. Three experimental studies reported evidence on the impact of a UCT compared with a CCT on the likelihood of having used any health services, the likelihood of having had any illness or the average number of food groups consumed in the household, but evidence was limited to one study per outcome and was very uncertain for all three.
Quality of the evidence
Of the seven prioritised primary outcomes, the body of evidence for one outcome was of moderate quality, for three outcomes of low quality, for two outcomes of very low quality, and for one outcome, there was no evidence at all.
This body of evidence suggests that unconditional cash transfer (UCTs) may not impact health services use among children and adults in LMICs. UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having secure access to food, and diversity in one’s diet), one social determinant of health (i.e. the likelihood of attending school), and healthcare expenditure. The evidence on the health effects of UCTs compared with those of CCTs is uncertain.