THE CONDITIONAL CASH TRANSFER INITIATIVE OF THE MDG OFFICE The Concept Paper Introduction

Conditional cash transfer (CCT) programs aim to reduce poverty by making welfare programs conditional upon the receivers' actions. The government only transfers the money to persons who meet certain criteria. These criteria may include enrolling children into public schools, getting regular check-ups at the doctor's office, receiving vaccinations, or the like. CCTs are unique in seeking to help the current generation in poverty, as well as breaking the cycle of poverty for the next through the development of human capital. Although conditional cash transfers (CCTs) are traditionally evaluated in relation to child schooling and nutrition outcomes, there is growing interest in specifically examining maternal and reproductive health impacts. Large-scale government conditional cash transfer (CCT) programs have become a mainstay in social protection and poverty reduction strategies throughout Central and South America and are increasingly being implemented in Sub-Saharan Africa and the Middle East (Fiszbein et al. 2009; Handa and Davis 2006; Lagarde, Haines, and Palmer 2007). In 2010/2011, an operations research project on Cash Transfers (CT) for Safe Motherhood (SM) led by Interact Worldwide and supported by ODI was set-up with the aim being to provide cash transfers to vulnerable women to increase their access to, and use of, maternal health services. The rationale was that such services, i.e. antenatal care, skilled delivery at birth and postnatal care, reduce maternal and neonatal mortality and morbidity (Jones et al., 2011).

OUR CONCEPT: The primary objective of the Conditional Cash Transfer therefore is to provide incentives for the very poor pregnant women of the population within designated Local Governments to have facility based deliveries or deliveries under the supervision of a skilled birth attendant. The rationale therefore is to increase the demand for health and/or nutritional services. It is however

assumed within this model that on getting to the facility all the skills and amenities required are available to ensure a safe pregnancy period and consequent delivery. And with this, there will be a significant reduction in Maternal Mortality among this group and ultimately in the State. It is noteworthy at this point that the Conditional Cash Transfer focuses on the pregnant poor woman and her access to a skilled birth attendant at the point of delivery and not necessarily on the facility. It is therefore assumed that the State and the Local Government will ensure that all complimentary services required to make the intervention a success is provided. It is the understanding of this project team, and from data gathered from across the continent where this intervention has been implemented, that this conditional transfer of an incentive to the poorest pregnant women in the community can be in cash- as it obtains in many parts- or in kind. We have however opted for the option of providing conditional incentives in cash and in kind so as to ensure the sustainability of the project and more importantly for the avoidance of the creation of a secondary market as a result of a purely in-kind transfer. THE OBJECTIVES OF OGUN STATE PRE-NATAL CCT PROGRAMME - gbomoro 1. To reduce the maternal and infant mortality and morbidity of the poorest of the poor in the selected communities and ultimately across the state 2. To reduce the incidence of LBW(Low Birth Weight) and ELBW (Extreme Low Birth Weight) in babies born to the selected population as a result of poverty 3. To increase the acceptance of Family planning technology by these population and hence deterrent of a possible population explosion

COMPONENT OF gbomoro
Successful implementation of CCTs always requires that all essential components of the programme are well captured and clearly articulated. Generally, CCTs share a common basic structure of three components i. a cash transfer,

ii. iii.

a targeting mechanism, and conditionality.

By targeting the transfers to poor pregnant women, the program will alleviate maternal and infant mortality and morbidity in Ogun State.

PROGRAM COMPONENT Table 1 provides a summary of the major components of OGSG Pre-natal CCT Programme

Table 1:

COMPONENT OFgbomoro PROGRAMME COMPONENT Geographic LGAs that are recognized as having high population of poor communities Community Selection based on baseline survey INITIATIVES Geographic To be implemented in the 3 senatorial districts of Ogun state 2 Local Government Areas per Senatorial district Community Sensitisation campaign on CCT Use existing Ward Development Committees (WDC) TORs for WDC

Eligibility: Geographic, community, and specific targeting Eligibility assessment -

Specific - Use categorical indicators to select recipients

Specific Eligibility Assessment Questions (EAQ) o Score of 5 or more points acceptable as vulnerable and eligible for inclusion

Demand Side: Recipients selection Use the eligibility criteria Enrollment screening Information about the process for appeal and settlement of grievances

Benefits Cash & in-kind transfers

Cash transfer In-kind transfer Pre-natal heath care Free delivery Post-natal health care

Cash transfer of N for each pre-natal health clinic attendance Mama kits Purpose-specific handsets For continuous contact with Medicare agents all through period of participation in the programme

Supply Side: Selection Services provided

Facility selection criteria o PHC in LGA & Community Health education every month Child growth and monitoring Free medication Family Planning workshops

Weekly/monthly Provision of antiparasite medicine Vitamins & iron supplements Vaccinations Recipients receive incentive of cash for each attendance Mama-kits will be provided on delivery of baby

Conditionality Attend a minimum of 4 antenatal clinic (depending on the gestational age) Recipients must have institutional delivery (or at least attended to by a skilled birth

attendant) Attend at least one postnatal appointment 6 weeks after birth

Nutritional items and few items of clothing for the baby

Method of Disbursement Monitoring & Evaluation

Zenith Bank Eazymoney

Demand Side

Supply Side

Disbursement

Rigorous evaluations Indicators o Numbers of functional ward development committees o Number of meetings held by the WDC Number of recipients registered and referred to health facility o Number of recipients attending ANC at the facility o Number of MamaKits distributed to recipients o Number of recipients delivering at the health facility o Number of recipients accepting family planning commodities o Number of recipients accessing infant welfare clinic with their baby o Number of recipients given SP and LLIN Number of recipients accessing their visits/nutritional

Family planning precautions are put in place o Child spacing Distribution of purposespecific handsets to recipients Cost effectiveness Distribution of program impact

incentives Regular audit of payment schedules and actual payments made

PERFORMANCE INDICATORS

KEY STRATEGIC INITIATIVES

Number of newborn with birth weights greater or equal to 2.5kg. Number of women accessing family planning services Number of women attending ANC services in selected facilities Number of infants immunized at 6 weeks of delivery Post-partum Vitamin A coverage Number of infants with appropriate weight at 6 weeks Engagement of traditional/mission/community birth attendants in the selected community Involvement of community-based organizations in the selected localities Referrals of complicated cases to secondary facilities Enhanced developmental relations between health workers and the recipients

Targeting Methods and Mechanism

Methods: this refers to the set of rules, criteria, and other elements of programme design that define beneficiary eligibility Mechanism: refers to the larger elements of program design, including the very important question of the choice of intermediary agents and organizational design.

RECIPIENT SELECTION/ METHOD OF IMPLEMENTATION: In the implementation process of the CCT, it is imperative all the essential components are well captured and clearly articulated to guarantee a wholistic approach and overall success of the project. TARGET SELECTION: A three-tier target selection process will be conducted so as to take into consideration all factors that might contribute to an equitable selection process. These are; a. Geographical selection b. Community-based targeting selection c. Specific target selection as a derivative of (b) to avoid errors of inclusion and exclusion Geographical Selection: Ogun State has 3 senatorial districts and 20 Local Government Areas. To ensure equity and political representation, this CCT project is to be implemented in the three senatorial districts with 2LGAs per senatorial district. These are also LGAs that are recognized as having a high population of poor communities. Community-based targeting: Upon selection of the Local Government Areas, the communities are then selected based on the report of the prior-to conducted baseline survey in which the poorest communities with the largest populations in these LGAs will have been selected. Following this selection of communities and in order to provide basic understanding of the Conditional Cash Transfer at the community level, a sensitization campaign on CCT will be conducted with the various interest groups in the community. Participants at the community sensitization will include pregnant women (0-9months), representatives of organizations and associations in the community.

The sensitization will be facilitated by the health educator from the Local Government Area, the ward focal person and a technical representative from the State CCT committee Highlights of the sensitization meeting will include: Definition of CCT Reasons for CCT Who should benefit from CCT? The selection criteria for recipients of CCT What they will benefit from CCT What to expect from the facility if qualified for CCT Registration modalities for qualified candidates

The existing structure at the community level is such that there are Ward Development committees. These communities will be given TORs as it applies to the CCT such that there is community ownership of the program. These committees play a critical role in the selction of the poorest of the poor in their communities and the TORs are given to avoid errors of inclusion or exclusion. These TORs are to be strictly adhered to and adherence to which will be closely monitored by the State MDG committee. The terms of reference of the committee are: Selection of recipients (Poor pregnant women) in the community Presentation of selected recipients for biometric registration Refer selected and registered recipients to the health facility Liaise with the bank vendors and the recipients to confirm the payment of stipends Provide or distribute information package s for the recipients and potential recipients at all times.

Hold meeting with health facility officials to review the weakness and areas of adjustment of the scheme.

The committee will also play a role in conflict resolution on the scheme The committees will also serve as a watch-dog to prevent affluent pregnant women in the community from encroaching to the programme.

In the event that there are no existing WDCs in the selected communities, new committees will be inaugurated to serve this function. Community based targeting is expected to generate better information, better enforcement, and more positive spillovers. Efforts are geared towards mitigating against the possibility of this methodology to create costly rent-seeking activities. Emphasis on the need for transparency and integrity in the recipient selection process will be communicated to the community committees to ensure the enrolment of the true poorest of the poor in this populations and not a biased selection of family and friends or based on political party affiliations. Specific recipient selection: This is a derivative of the community selection process i.e. the recipients selected by the communities undergo further screening for eligibility using categorical indicators/ a scorecard. ELIGIBILITY ASSESSMENT QUESTIONS: Does the woman live in a single room, or house with earth/dirt/straw floor or mud/straw/corrugated sheet roofing? Does she have no more than 0.5 ha plot of land? Does she have less than two livestock (cows or goats)? Is she illiterate or with education only up to primary school? Is she often or occasionally having fewer than three meals a day? Is she or anyone in her household suffering from chronic or regular illness? Does she have disabled children/husband/household member living with her? Is she widowed/single/separated/divorced? Does the household have over four dependents? (five or more) Does each household member have at least two complete sets of

Yes = 1, No = 0 Yes = 1, No = 0 Yes = 1, No = 0 Yes = 1, No = 0 Yes = 1, No = 0 Yes = 1, No = 0 Yes = 1, No = 0 Yes = 1, No = 0 Yes = 1 No = 0 Yes = 1 No = 0

clothing?
If the total score for a pregnant woman was five or over, she would be considered eligible to participate, particularly vulnerable or ultra poor.

This final screening is done at the weekly recipient enrolment meeting done at the community level before the pregnant woman can access the facility. At this enrolment the recipient is again educated on the conditions for fully benefitting from the CCT and the various entitlements with every prescheduled visit to the facility as well as the patient flow matrix upon arrival at the facility. It will also be made clear to her that the bulk of the entitlement will be received at the post-natal visit. Recipients will in addition be well-informed on the right or the process if appeal. In which case appeal processes will be made quick in all instances. The Conditionalities: The eligibility criteria to access this incentive will be dependent on a number of factors being satisfied by the recipient which will be assessed at different milestones in the ante-natal and post natal period. These conditionalities include: a. Woman must attend four antenatal visits from the fourth month/second trimester/ mandatory number of visits to delivery depending on gestational age at enrolment: at each visit each recipient will be given a predetermined amount of money in cash. b. They have an institutional delivery, or are at least attended to by a skilled birth attendant: At point of delivery Mama-kits will be provided for free to these women as well as post delivery package with nutritional items and a few items of clothing for the baby. c. They attend at least one postnatal appointment six weeks after birth: This is a critical part of the incentive provision as it ensure all necessary family planning precautions are put in place for child spacing as multiple deliveries without adequate spacing also puts the mothers at risk. FACILITY ACCESS/SUPPLY-SIDE INCENTIVES The facility selection process in each LGA and community will have been done based on the following; 1. Located in or relatively close to a highly populated rural area

2. A facility that has an existing institutional arrangement such as an ongoing Midwives Service Scheme operating 3. Recently refurbished by the State/ LGA The two major areas that require policy focus at the facility level are; a. Service delivery b. Incentives for service providers. Service delivery: In the area of service delivery it is essential to ensure ease of navigation of recipients and that the service providers are well-trained in the various areas that compliment service delivery. The flow of services are as follows; Ante-natal care The recipients upon arrival at the health facility will undergo the following 1. Validation at entry to the facility by health workers (Nurse/Midwife). 2. Registration on each visit (ANC, Delivery and Post natal care) to the health facility.

3. The recipient is then allowed to see an health worker for vital signs check ups a. Blood pressure b. Temperature c. Weight d. Height e. Immunization f. Pulse rate 4. She then proceeds to have the normal ante natal health education talk on nutrition, hygiene, malaria prevention, danger signs, pregnancy, signs of on-set of labor, family planning, exclusive breastfeeding etc)

5. During ante natal clinic, food demonstration session on preparation of locally made foods 6. She will then go to have her physical examination. This includes examination for a. Anaemia b. Oedema c. Fetal heart beat d. Breast e. Funda height f. Position of the foetus g. Presentation of the foetus h. Prescription of necessary drugs 7. She books for her next appointment and given a clearance for payment with the agents of the bank. 8. She is referred to payment point by the attending midwife / nurse 9. She then gets paid by the agent of the bank and dropped a copy of her next appointment date with the agent. 10. Her next booking could be for delivery at the facility Delivery: Validation at entry to the facility by health workers (Nurse/Midwife) Registration on each visit (ANC, Delivery and Post natal care) to the health facility Mama kits will be given to her after registration at point of delivery After delivery, the bank vendor will be notified by the health worker for payment She will be given the date for her post-natal clinic appointment

Post Natal care Validation at entry to the facility by health workers (Nurse/Midwife) Registration on each visit (ANC, Delivery and Post natal care) to the health facility The recipient and her baby are then allowed to see a health worker for: a. Blood pressure b. Temperature c. Weight d. Height e. Immunization f. Pulse rate She then proceeds to have the normal ante natal health education talks on nutrition, hygiene, malaria prevention, family planning, Exclusive breastfeeding etc) She will then go to have her physical examination. This includes examination for a. Anaemia b. Oedema c. Vaginal discharge d. Breast lumps e. Any abnormalities in the baby f. Any nutritional deficiencies in the baby g. Prescription of necessary drugs h. Administer Vitamin A She will then be referred to family planning unit for family planning. If she receives, she will be given a clearance which she will present to bank vendor for final payment, if not she will be given another appointment to the family planning unit.

Payments certified by the health worker with family planning in-situ and evidence of immunization of the baby should be cleared by the health worker that completed the programme and the mobile phone will be collected. Monitoring and Evaluation The Conditional Cash Transfer for maternal health will be monitored at three levels; at the Demand Supply Disbursement levels Demand level monitoring indicators

Numbers of functional ward development committees Number of meetings held by the ward development committees Number of recipients registered and referred to the health facility

Supply level monitoring indicators

.Number of recipients attending ANC at the facility. Number of mama kits distributed to recipients. Number of recipients delivering at the health facility. Number of recipients accepting family planning commodities. Number of recipients accessing infant welfare clinic with their baby. Number of recipients given SP and LLIN. Disbursement level monitoring

Number of recipients accessing their visits/nutritional stipends Overall programme indicators (performance indicators) Number of newborn with birth weights greater or equal to 2.5kg Number of women accessing family planning services

Number of women attending ANC services in selected facilities. Number of infants immunized at 6 weeks of delivery Post partum vitamin A coverage Number of infants with appropriate weight at 6 weeks

Collection of Data M & E data will be collected from three sources; The community, The health facility The bank M & E data collection tools will be designed and applied from the three sources while the analysis of data collected will be done collected manually using the designed tool. There will be monthly rendition of data collected at the three sources while there will be quarterly review of the data collected from the State programme office. KEY STRATEGIC INITIATIVES Engagement of traditional/mission/community birth attendants in the selected community Involvement of community-based organizations in the selected communities Enhance interpersonal communication between health workers and recipients Referrals of complicated cases to a secondary facility a. Who is eligible? This will be determined by the attending midwife based on laid down guidelines and standard operating procedures for management of obstetrics emergency b. Mode of referral: Arrangement will be made with the Ward development committees on prompt transportation of eligible recipients to the accredited referral/secondary facility.