Cash transfers and the social determinants of health: a conceptual framework

This article proposes a conceptual framework for understanding the linkages between cash transfers (CTs) and the social determinants of health (SDoH). It provides insights into how CTs can influence various SDoH and emphasizes the importance of health promoter involvement in CT programs. This framework is useful for policy makers, program managers, and researchers working to improve health equity through social protection interventions.

Key Insights

Overview of CTs

Cash transfers (CTs) are defined as direct, regular, and predictable non-contributory payments aimed at increasing income and improving household capacity to absorb financial shocks (Arnold et al., 2011). They can be conditional (CCTs) or unconditional (UCTs), with CCTs requiring beneficiary households to adopt specific positive behaviors (Fiszbein and Schady, 2009) and UCTs providing cash without conditions (Baird et al., 2013).

Limited Recognition of the Concept of SDoH

Analyses of documents and interviews revealed a limited recognition of the SDoH concept. Out of 79 reports reviewed, the term “social determinants” was mentioned in only one report (Owusu-Addo, 2016).

Impact on Structural Determinants of Health

CTs can impact structural determinants of health such as financial poverty, education, productive capacity, employment, child labor, civic participation, and women’s empowerment (Owusu-Addo et al., 2018).

Impact on Intermediate Determinants of Health

CTs can positively affect material circumstances (e.g., food security, housing), psychosocial circumstances (e.g., relief from debt, self-esteem), and sexual health behavior.

The Architecture of CTs

CTs as a national policy constitute a social protection action shaped by national social protection policy frameworks and other structural mechanisms including the international development policy agenda and the socio-economic and political economy of a particular country.

Household and Local Level Contexts

Household level factors such as household size and composition, intra-household dynamics, and livelihood strategies used by the household can serve as enabling or inhibiting factors in relation to CTs’ impact (Handa et al., 2014a; Akresh et al., 2016).

Getting the SDoH onto the CT policy agenda

The evidence indicates there is limited recognition, knowledge and application of the SDoH concept in CT policy making, implementation and evaluation.

Key Statistics & Data

• Globally, as of 2014, there were 130 UCTs, with marked growth in SSA where the number increased from 21 in 2010 to 40 in 2014 (World Bank, 2015).
• CTs were found to have reduced poverty headcount, poverty gap and poverty severity by 6, 7 and 9 percentage points, respectively, in Malawi (Malawi SCTP Evaluation Team, 2015).
• In Zambia, a child grant program reduced poverty headcount, poverty gap and poverty severity by 10, 10 and 8 percentage points (AIR, 2015b).
• The 2016 SDGs report estimates that in SSA, the births of 54% of children under five have not been recorded (UN, 2016).

Methodology

The development of the framework followed two stages: evidence review and stakeholder involvement. The evidence review entailed a systematic literature search to identify published and unpublished impact evaluation studies of CT programs in SSA covering the period 2000–16. Thematic framework approach was used for data analysis.

Implications and Conclusions

The framework provides a visual tool for conceptualizing how CTs can be used to address the SDoH and health equity. As CTs are largely developed and implemented by government sectors other than health, health promoters can use the framework to put on the agenda of politicians and CT policy makers the need to assign more substantive role to the health sector, and for inter-sectoral action on SDoH through CTs.