Effective preventive treatments are not reaching the mothers and children who need them. One reason for this is lack of demand for these services. In parts of Latin America, families are being paid to be healthy and seek regular check-ups.

Results from Mexico and Nicaragua, where direct payments are made to poor families on condition that they keep up with preventive health measures, show a significant improvement in the coverage of services. But would the improvement be similar, or greater, if the money was invested in improving basic services?  In 2000 the government of Honduras implemented a health programme that included a randomised trial to test this question.

The programme included activities designed to increase demand for preventive health care for pregnant women, new mothers and children under three years old. The study measured the rates of use of health care facilities, along with the proportion of women and children covered by immunisation and growth monitoring services.

Two sets of interventions were designed: one included direct payments for regular attendance at health checks (the household level package); the other was aimed at strengthening health services (the service level package). The programme was implemented and evaluated in 70 mountainous, rural municipalities with a total population of 660,000 people and the highest prevalence of malnutrition in the country.

Significant findings include:

• In 2001, 79 percent eligible of households received their payment vouchers, whereas only 17 percent of payments were made to community health teams.
• Based on mothers’ reports, groups receiving the payment vouchers showed an 18 to 20 percent increase in uptake of antenatal care and routine child check-ups. No increase in uptake occurred with the service-level package, and neither package affected attendance levels for the ten day check-up.
• The household level package was associated with increased coverage of growth monitoring, while there was no significant increase in this measure associated with the service level package.
• The household level package showed increases in coverage of some but not all vaccines.
• Government statistics showed a marked increase in service use in municipalities assigned to the service-level package, but this was not specific to the age-groups targeted by the programme. There was increased use of services for pre-school children, but not for antenatal care, in municipalities assigned to the household-level package.
• An unexpected side-effect saw the proportion of women reporting a pregnancy during the previous 12 months decrease markedly in the groups that did not receive the vouchers. The decrease was far smaller in groups that received the vouchers.

The incentives tested produced a large increase in the coverage of some preventive health care services. Lessons for policy are:

• Conditional direct payments to poor households in disadvantaged areas can increase the use of preventive health care services.
• The increased attendance for child check-ups allowed child immunisation and growth monitoring to take place more regularly.
• Transferring resources to hard to reach primary health care services proved difficult both legally and logistically. Direct payments to households were more effective.
• To ensure that increased uptake is translated into improved health, high quality preventive health services must be provided. Incentives should be targeted to encourage families to improve child and maternal health.

Source(s):
‘Monetary incentives in primary health care and effects on use and coverage of preventive care interventions in rural Honduras: cluster randomised trial', The Lancet 364: 2030-2037, by S. Morris et al, 2004 Full document.

Funded by: Government of Honduras

id21 Research Highlight: 20 October 2005

Further Information:
Saul S. Morris
EMAD
Department for International Development
1 Palace Street
London SW1 5HE
UK

Tel: +44 (0) 20 70231013
Fax: +44 (0) 20 70230356
Contact the contributor: ifpriprafdc@hotmail.com

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