Review question
In some low- and middle-income countries (LMICs), governments and other organisations sometimes give money to poor or vulnerable people (for example, older people or orphans), without requiring them to do anything in particular to receive the money ('unconditional cash transfers'). In other programmes, people can only receive this money if they engage in required behaviours, such as using health services or sending their children to school ('conditional cash transfers'). This review aimed to find out whether receiving unconditional cash transfers would improve people's use of health services and their actual health, compared with not receiving an unconditional cash transfer, receiving a smaller unconditional amount or receiving a conditional cash transfer. It also aimed to assess the effects of unconditional cash transfers on daily living conditions that determine health and healthcare spending, such as attending school, owning livestock, having a job or being extremely poor.
Background
Unconditional cash transfers are a type of social protection intervention that addresses income. It is unknown whether unconditional cash transfers are more, less or equally effective as conditional transfers. We reviewed the evidence on the effect of unconditional cash transfers on health service use and health outcomes among children and adults in LMICs.
What did we find?
We included experimental and selected non-experimental studies of unconditional cash transfers in people of all ages in LMICs. We included studies that compared people who received an unconditional cash transfer with those who did not receive a transfer. We looked for studies that examined health services use and health outcomes.
We found 34 studies (25 experimental and 9 non-experimental ones) with 1,140,385 participants (45,538 children and 1,094,847 adults) and 50,095 households in Africa, the Americas and South-East Asia. Governments or experimental researchers organised the unconditional cash transfer programmes. Most studies were funded by national governments or international organisations, or both.
Key results
We use the following terms to indicate our level of confidence in the evidence we found:
- 'probably' for evidence about which we are moderately confident;
- 'may' for evidence about which we have little confidence; and
- 'uncertain' for evidence about which we are not confident.
An unconditional cash transfer:
- may not have changed the likelihood of people having used any health service in the previous 1 to 12 months;
- probably led to a clinically meaningful, very large reduction in people's risk of having had any illness in the previous 2 weeks to 3 months;
- may have increased the likelihood of people having had secure access to food over the previous month;
- may have increased the average number of different food groups that people in the household consumed over the previous week;
- probably led to an important, moderate increase in the likelihood of children attending school;
- may have reduced people's risk of living in extreme poverty;
- may have increased the amount of money people spent on health care.
Despite several studies providing relevant evidence, the effects of unconditional cash transfers on the likelihood of children being stunted (having reduced growth and development) and on people's depression levels remain uncertain. No study estimated the effects of unconditional cash transfers on dying.
We are uncertain whether unconditional cash transfers impacted livestock ownership, participation in child labour, adult employment and parenting quality. The effects of unconditional transfers on differences in health were very uncertain. We did not identify any harms arising from unconditional cash transfers.
Three experimental studies reported evidence on the impact of an unconditional transfer compared with a conditional transfer 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. However, only one study provided evidence for each of these outcomes, and it was very uncertain for all three.
In general, where we had little or no confidence in the evidence, this was because people in the studies likely knew what 'treatment' they were getting (that is, a cash transfer or no cash transfer), and it was also likely that the researchers collecting information also knew which groups of people were recipients and which were not. Additionally, our confidence in the evidence was limited because in half of the studies, researchers were unable to collect follow-up information from a considerable percentage of participants.
Conclusions
This body of evidence suggests that unconditional cash transfers may not impact health services use among children and adults in low- and middle-income countries. Unconditional cash transfers probably or may improve:
- some health outcomes (such as the likelihood of having had any illness, the likelihood of having secure access to food, and diversity in one's diet);
- two social determinants of health (namely, the likelihood of attending school and living in extreme poverty);
- healthcare expenditure.
The evidence on the health effects of unconditional cash transfers compared with those of conditional transfers is uncertain.
How up to date is the evidence?
Current to September 2021.
This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), two social determinants of health (i.e. the likelihoods of attending school and being extremely poor), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.
Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age, or HIV infection) are a social protection intervention addressing a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided only if recipients follow prescribed behaviours, e.g. use a health service or attend school) is unknown.
To assess the effects of UCTs on health services use and health outcomes in children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure, and to compare the effects of UCTs versus CCTs.
For this update, we searched 15 electronic academic databases, including CENTRAL, MEDLINE and EconLit, in September 2021. We also searched four electronic grey literature databases, websites of key organisations and reference lists of previous systematic reviews, key journals and included study records.
We included both parallel-group and cluster-randomised controlled trials (C-RCTs), quasi-RCTs, cohort studies, controlled before-and-after studies (CBAs), and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (≥ 18 years) in LMICs. Comparison groups received either no UCT, a smaller UCT or a CCT. Our primary outcomes were any health services use or health outcome.
Two review authors independently screened potentially relevant records for inclusion, extracted data and assessed the risk of bias. We obtained missing data from study authors if feasible. For C-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method using a random-effects model. Where meta-analysis was impossible, we synthesised results using vote counting based on effect direction. We assessed the certainty of the evidence using GRADE.
We included 34 studies (25 studies of 20 C-RCTs, six CBAs, and three cohort studies) involving 1,140,385 participants (45,538 children, 1,094,847 adults) and 50,095 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative syntheses. These analysed 29 independent data sets. The 24 UCTs identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 81.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT; three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection or performance bias, or both). Most studies were funded by national governments or international organisations, or both.
Throughout the review, we use the words 'probably' to indicate moderate-certainty evidence, 'may/maybe' for low-certainty evidence, and 'uncertain' for very low-certainty evidence.
Health services use
We assumed greater use of any health services to be beneficial. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09; I2 = 2%; 5 C-RCTs, 4972 participants; low-certainty evidence).
Health outcomes
At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (RR 0.79, 95% CI 0.67 to 0.92; I2 = 53%; 6 C-RCTs, 9367 participants; moderate-certainty evidence). UCTs may have increased the likelihood of having been food secure over the previous month, at 13 to 36 months into the intervention (RR 1.25, 95% CI 1.09 to 1.45; I2 = 85%; 5 C-RCTs, 2687 participants; low-certainty evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01; I2 = 79%; 4 C-RCTs, 9347 participants; low-certainty evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. We found no study on the effect of UCTs on mortality risk.
Social determinants of health
UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.04 to 1.09; I2 = 0%; 8 C-RCTs, 7136 participants; moderate-certainty evidence). UCTs may have reduced the likelihood of households being extremely poor, at 12 to 36 months into the intervention (RR 0.92, 95% CI 0.87 to 0.97; I2 = 63%; 6 C-RCTs, 3805 participants; low-certainty evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, participation in labour, and parenting quality.
Healthcare expenditure
Evidence from eight cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 36 months into the intervention (low-certainty evidence).
Equity, harms and comparison with CCTs
The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services or had any illness, or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three.