Monetary incentives in primary health care and effects on use and coverage of preventive health care interventions in rural Honduras: cluster randomised trial
Scaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of demand. In Latin America, some governments have been trying to increase demand for health interventions by making direct payments to poor households contingent on them...
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| Published in: | The Lancet (British edition) Vol. 364; no. 9450; pp. 2030 - 2037 |
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| Main Authors: | , , , |
| Format: | Journal Article |
| Language: | English |
| Published: |
London
Elsevier Ltd
04.12.2004
Lancet Elsevier Limited |
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| ISSN: | 0140-6736, 1474-547X, 1474-547X |
| Online Access: | Get full text |
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| Abstract | Scaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of demand. In Latin America, some governments have been trying to increase demand for health interventions by making direct payments to poor households contingent on them keeping up-to-date with preventive health services. We undertook a public health programme effectiveness trial in Honduras to assess this approach, contrasting it with a direct transfer of resources to local health teams.
70 municipalities were selected because they had the country's highest prevalence of malnutrition. They were allocated at random to four groups: money to households; resources to local health teams combined with a community-based nutrition intervention; both packages; and neither. Evaluation surveys of about 5600 households were undertaken at baseline and roughly 2 years later. Pregnant women and mothers of children younger than 3 years old were asked about use of health services (primary outcome) and coverage of interventions such as immunisation and growth monitoring (secondary outcome). Reports were supplemented with data from children's health cards and government service utilisation data. Analysis was by mixed effects regression, accounting for the municipality-level randomisation.
The household-level intervention had a large impact (15–20 percentage points; p<0·01) on the reported coverage of antenatal care and well-child check-ups. Childhood immunisation series could thus be started more opportunely, and the coverage of growth monitoring was markedly increased (15–21 percentage points; p<0·01. Measles and tetanus toxoid immunisation were not affected. The transfer of resources to local health teams could not be implemented properly because of legal complications.
Conditional payments to households increase the use and coverage of preventive health care interventions. |
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| AbstractList | Scaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of demand. In Latin America, some governments have been trying to increase demand for health interventions by making direct payments to poor households contingent on them keeping up-to-date with preventive health services. We undertook a public health programme effectiveness trial in Honduras to assess this approach, contrasting it with a direct transfer of resources to local health teams.BACKGROUNDScaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of demand. In Latin America, some governments have been trying to increase demand for health interventions by making direct payments to poor households contingent on them keeping up-to-date with preventive health services. We undertook a public health programme effectiveness trial in Honduras to assess this approach, contrasting it with a direct transfer of resources to local health teams.70 municipalities were selected because they had the country's highest prevalence of malnutrition. They were allocated at random to four groups: money to households; resources to local health teams combined with a community-based nutrition intervention; both packages; and neither. Evaluation surveys of about 5600 households were undertaken at baseline and roughly 2 years later. Pregnant women and mothers of children younger than 3 years old were asked about use of health services (primary outcome) and coverage of interventions such as immunisation and growth monitoring (secondary outcome). Reports were supplemented with data from children's health cards and government service utilisation data. Analysis was by mixed effects regression, accounting for the municipality-level randomisation.METHODS70 municipalities were selected because they had the country's highest prevalence of malnutrition. They were allocated at random to four groups: money to households; resources to local health teams combined with a community-based nutrition intervention; both packages; and neither. Evaluation surveys of about 5600 households were undertaken at baseline and roughly 2 years later. Pregnant women and mothers of children younger than 3 years old were asked about use of health services (primary outcome) and coverage of interventions such as immunisation and growth monitoring (secondary outcome). Reports were supplemented with data from children's health cards and government service utilisation data. Analysis was by mixed effects regression, accounting for the municipality-level randomisation.The household-level intervention had a large impact (15-20 percentage points; p<0.01) on the reported coverage of antenatal care and well-child check-ups. Childhood immunisation series could thus be started more opportunely, and the coverage of growth monitoring was markedly increased (15-21 percentage points; p<0.01. Measles and tetanus toxoid immunisation were not affected. The transfer of resources to local health teams could not be implemented properly because of legal complications.FINDINGSThe household-level intervention had a large impact (15-20 percentage points; p<0.01) on the reported coverage of antenatal care and well-child check-ups. Childhood immunisation series could thus be started more opportunely, and the coverage of growth monitoring was markedly increased (15-21 percentage points; p<0.01. Measles and tetanus toxoid immunisation were not affected. The transfer of resources to local health teams could not be implemented properly because of legal complications.Conditional payments to households increase the use and coverage of preventive health care interventions.INTERPRETATIONConditional payments to households increase the use and coverage of preventive health care interventions. Scaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of demand. In Latin America, some governments have been trying to increase demand for health interventions by making direct payments to poor households contingent on them keeping up-to-date with preventive health services. We undertook a public health programme effectiveness trial in Honduras to assess this approach, contrasting it with a direct transfer of resources to local health teams. 70 municipalities were selected because they had the country's highest prevalence of malnutrition. They were allocated at random to four groups: money to households; resources to local health teams combined with a community-based nutrition intervention; both packages; and neither. Evaluation surveys of about 5600 households were undertaken at baseline and roughly 2 years later. Pregnant women and mothers of children younger than 3 years old were asked about use of health services (primary outcome) and coverage of interventions such as immunisation and growth monitoring (secondary outcome). Reports were supplemented with data from children's health cards and government service utilisation data. Analysis was by mixed effects regression, accounting for the municipality-level randomisation. The household-level intervention had a large impact (15–20 percentage points; p<0·01) on the reported coverage of antenatal care and well-child check-ups. Childhood immunisation series could thus be started more opportunely, and the coverage of growth monitoring was markedly increased (15–21 percentage points; p<0·01. Measles and tetanus toxoid immunisation were not affected. The transfer of resources to local health teams could not be implemented properly because of legal complications. Conditional payments to households increase the use and coverage of preventive health care interventions. Scaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of demand. In Latin America, some governments have been trying to increase demand for health interventions by making direct payments to poor households contingent on them keeping up-to-date with preventive health services. We undertook a public health programme effectiveness trial in Honduras to assess this approach, contrasting it with a direct transfer of resources to local health teams. 70 municipalities were selected because they had the country's highest prevalence of malnutrition. They were allocated at random to four groups: money to households; resources to local health teams combined with a community-based nutrition intervention; both packages; and neither. Evaluation surveys of about 5600 households were undertaken at baseline and roughly 2 years later. Pregnant women and mothers of children younger than 3 years old were asked about use of health services (primary outcome) and coverage of interventions such as immunisation and growth monitoring (secondary outcome). Reports were supplemented with data from children's health cards and government service utilisation data. Analysis was by mixed effects regression, accounting for the municipality-level randomisation. The household-level intervention had a large impact (15-20 percentage points; p<0.01) on the reported coverage of antenatal care and well-child check-ups. Childhood immunisation series could thus be started more opportunely, and the coverage of growth monitoring was markedly increased (15-21 percentage points; p<0.01. Measles and tetanus toxoid immunisation were not affected. The transfer of resources to local health teams could not be implemented properly because of legal complications. Conditional payments to households increase the use and coverage of preventive health care interventions. Scaling-up of effective preventive interventions in child and maternal health is constrained in many developing countries by lack of demand. In Latin America, some governments have been trying to increase demand for health interventions by making direct payments to poor households contingent on them keeping up-to-date with preventive health services. We undertook a public health programme effectiveness trial in Honduras to assess this approach, contrasting it with a direct transfer of resources to local health teams. 70 municipalities were selected because they had the country's highest prevalence of malnutrition. They were allocated at random to four groups: money to households; resources to local health teams combined with a community-based nutrition intervention; both packages; and neither. Evaluation surveys of about 5600 households were undertaken at baseline and roughly 2 years later. Pregnant women and mothers of children younger than 3 years old were asked about use of health services (primary outcome) and coverage of interventions such as immunisation and growth monitoring (secondary outcome). Reports were supplemented with data from children's health cards and government service utilisation data. Analysis was by mixed effects regression, accounting for the municipality-level randomisation. The household-level intervention had a large impact (15-20 percentage points; p<0.01) on the reported coverage of antenatal care and well-child check-ups. Childhood immunisation series could thus be started more opportunely, and the coverage of growth monitoring was markedly increased (15-21 percentage points; p<0.01. Measles and tetanus toxoid immunisation were not affected. The transfer of resources to local health teams could not be implemented properly because of legal complications. Conditional payments to households increase the use and coverage of preventive health care interventions. |
| Author | Morris, Saul S Flores, Rafael Medina, Juan Manuel Olinto, Pedro |
| Author_xml | – sequence: 1 givenname: Saul S surname: Morris fullname: Morris, Saul S email: s-morris@dfid.gov.uk organization: Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, UK – sequence: 2 givenname: Rafael surname: Flores fullname: Flores, Rafael organization: Rollins School of Public Health, Emory University, Atlanta GE, USA – sequence: 3 givenname: Pedro surname: Olinto fullname: Olinto, Pedro organization: Food Consumption and Nutrition Division, International Food Policy Research Institute, Washington DC, USA – sequence: 4 givenname: Juan Manuel surname: Medina fullname: Medina, Juan Manuel organization: Food Consumption and Nutrition Division, International Food Policy Research Institute, Washington DC, USA |
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| Cites_doi | 10.2105/AJPH.94.3.400 10.1016/S0140-6736(03)13870-6 10.1016/S0140-6736(03)15180-X 10.1016/S0140-6736(03)13811-1 |
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| References | Hanson, Ranson, Oliveira-Cruz, Mills (bib4) 2001 Victora, Habicht, Bryce (bib15) 2004; 94 Gertler, Boyce (bib6) Morris, Olinto, Flores, Nilson, Figueiro (bib14) 2004; 134 Jones, Steketee, Black, Bhutta, Morris, the Bellagio Child Survival Study Group (bib2) 2003; 362 Van Roekel, Plowman, Griffiths, Vivas de Alvarado, Matute, Calder-n (bib11) 2002 Tsu (bib3) 2004; 363 Inter-American Development Bank Research Department (bib5) 2003; 1 Murray (bib12) 1998 Instituto Nacional de Estad'stica (bib8) 2001 Bryce, el Arifeen, Pariyo, Lanata, Gwatkin, Habicht, the Multi-Country Evaluation of IMCI Study Group (bib1) 2003; 362 Government of Honduras (bib9) 1997 Murray, Wolfinger (bib13) 1994 Maluccio, Caldés, Castillo-Macy, Flores, Neidecker-Gonzales (bib7) 2000 Brown, Franco, Rafeh, Hatzell (bib10) 1998 Instituto Nacional de Estad'stica (10.1016/S0140-6736(04)17515-6_bib8) Maluccio (10.1016/S0140-6736(04)17515-6_bib7) 2000 Bryce (10.1016/S0140-6736(04)17515-6_bib1) 2003; 362 Jones (10.1016/S0140-6736(04)17515-6_bib2) 2003; 362 Murray (10.1016/S0140-6736(04)17515-6_bib12) 1998 Gertler (10.1016/S0140-6736(04)17515-6_bib6) Murray (10.1016/S0140-6736(04)17515-6_bib13) 1994 Tsu (10.1016/S0140-6736(04)17515-6_bib3) 2004; 363 Van Roekel (10.1016/S0140-6736(04)17515-6_bib11) 2002 Government of Honduras (10.1016/S0140-6736(04)17515-6_bib9) 1997 Morris (10.1016/S0140-6736(04)17515-6_bib14) 2004; 134 Victora (10.1016/S0140-6736(04)17515-6_bib15) 2004; 94 Brown (10.1016/S0140-6736(04)17515-6_bib10) 1998 Hanson (10.1016/S0140-6736(04)17515-6_bib4) 2001 Inter-American Development Bank Research Department (10.1016/S0140-6736(04)17515-6_bib5) 2003; 1 15582042 - Lancet. 2004 Dec 4-10;364(9450):1996-7 |
| References_xml | – year: 1997 ident: bib9 publication-title: VII Censo Nacional de Talla en Escolares de Primer Grado 1997 – volume: 363 start-page: 75 year: 2004 end-page: 76 ident: bib3 article-title: New and underused technologies to reduce maternal mortality publication-title: Lancet – year: 1998 ident: bib12 publication-title: Design and analysis of group-randomized trials – start-page: 140 year: 1994 end-page: 154 ident: bib13 article-title: Analysis issues in the evaluation of community trials: progress towards solutions in SAS/STAT MIXED publication-title: J Comm Psychol – volume: 134 year: 2004 ident: bib14 article-title: Conditional cash transfers are associated with a small reduction in the rate of weight gain of pre-school children in north-east Brazil publication-title: Nutrition – year: 1998 ident: bib10 publication-title: Quality assurance of health care in developing countries – volume: 1 start-page: 1 year: 2003 end-page: 4 ident: bib5 article-title: A new generation of social programs publication-title: Ideas for development in the Americas – year: 2001 ident: bib4 article-title: Constraints to scaling up health interventions: a conceptual framework and empirical analysis publication-title: CMH working paper series WG5 paper no. 14 – year: 2002 ident: bib11 publication-title: BASICS II midterm evaluation of the AIN program in Honduras 2000 – year: 2000 ident: bib7 article-title: Final report: Nicaragua social protection network/red de protecci—n social de Nicaragua publication-title: Pilot phase evaluation system: impact evaluation – volume: 94 start-page: 400 year: 2004 end-page: 405 ident: bib15 article-title: Evidence-based public health: moving beyond randomized trials publication-title: AJPH – year: 2001 ident: bib8 article-title: Publicaci-n censo – volume: 362 start-page: 159 year: 2003 end-page: 164 ident: bib1 article-title: Reducing child mortality: can public health deliver? publication-title: Lancet – ident: bib6 article-title: An experiment in incentive-based welfare: the impact of PROGRESA on health in Mexico – volume: 362 start-page: 65 year: 2003 end-page: 71 ident: bib2 article-title: How many child deaths can we prevent this year? publication-title: Lancet – volume: 94 start-page: 400 year: 2004 ident: 10.1016/S0140-6736(04)17515-6_bib15 article-title: Evidence-based public health: moving beyond randomized trials publication-title: AJPH doi: 10.2105/AJPH.94.3.400 – year: 1998 ident: 10.1016/S0140-6736(04)17515-6_bib12 – year: 1998 ident: 10.1016/S0140-6736(04)17515-6_bib10 – year: 2000 ident: 10.1016/S0140-6736(04)17515-6_bib7 article-title: Final report: Nicaragua social protection network/red de protecci—n social de Nicaragua – year: 1997 ident: 10.1016/S0140-6736(04)17515-6_bib9 – volume: 1 start-page: 1 year: 2003 ident: 10.1016/S0140-6736(04)17515-6_bib5 article-title: A new generation of social programs publication-title: Ideas for development in the Americas – volume: 362 start-page: 159 year: 2003 ident: 10.1016/S0140-6736(04)17515-6_bib1 article-title: Reducing child mortality: can public health deliver? publication-title: Lancet doi: 10.1016/S0140-6736(03)13870-6 – start-page: 140 year: 1994 ident: 10.1016/S0140-6736(04)17515-6_bib13 article-title: Analysis issues in the evaluation of community trials: progress towards solutions in SAS/STAT MIXED publication-title: J Comm Psychol – volume: 363 start-page: 75 year: 2004 ident: 10.1016/S0140-6736(04)17515-6_bib3 article-title: New and underused technologies to reduce maternal mortality publication-title: Lancet doi: 10.1016/S0140-6736(03)15180-X – ident: 10.1016/S0140-6736(04)17515-6_bib8 – volume: 362 start-page: 65 year: 2003 ident: 10.1016/S0140-6736(04)17515-6_bib2 article-title: How many child deaths can we prevent this year? publication-title: Lancet doi: 10.1016/S0140-6736(03)13811-1 – year: 2001 ident: 10.1016/S0140-6736(04)17515-6_bib4 article-title: Constraints to scaling up health interventions: a conceptual framework and empirical analysis – year: 2002 ident: 10.1016/S0140-6736(04)17515-6_bib11 – ident: 10.1016/S0140-6736(04)17515-6_bib6 – volume: 134 year: 2004 ident: 10.1016/S0140-6736(04)17515-6_bib14 article-title: Conditional cash transfers are associated with a small reduction in the rate of weight gain of pre-school children in north-east Brazil publication-title: Nutrition – reference: 15582042 - Lancet. 2004 Dec 4-10;364(9450):1996-7 |
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