cct gbomoro - concept paper draft

7/27/2019 CCT GBOMORO - Concept Paper Draft

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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 childschooling 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


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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 OFgbomoro

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,


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ii. a targeting mechanism, and

iii. conditionality.

By targeting the transfers to poor pregnant women, the program will alleviatematernal 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

PROGRAMMECOMPONENT

INITIATIVES

Eligibility:

- Geographic,community, andspecific targeting

- Eligibilityassessment

Geographic Geographic

LGAs that are

recognized ashaving highpopulation of poorcommunities

To be implemented in

the 3 senatorialdistricts of Ogun state

2 Local Government

Areas per Senatorialdistrict

Community Community

- Selection based on

baseline survey Sensitisation campaign

on CCT

Use existing Ward

DevelopmentCommittees (WDC)

TORs for WDC

Specific Specific

- Use categoricalindicators to selectrecipients

Eligibility Assessment

Questions (EAQ)o Score of 5 or

more pointsacceptable asvulnerableand eligiblefor inclusion


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Demand Side:

- Recipients selection

- Benefits

Cash & in-kind

transfers

Use the eligibility

criteria

Enrollment screening

Information about theprocess for appeal andsettlement ofgrievances

Cash transfer

In-kind transfer

Pre-natal heath care

Free delivery

Post-natal health care

Cash transfer of N for

each pre-natal healthclinic attendance

Mama kits

Purpose-specific

handsets

For continuouscontact with

Medicare agents allthrough period ofparticipation in theprogramme

Supply Side:

- Selection

Services provided

Facility selection

criteriao 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

Conditionality Attend a minimum of4 antenatal clinic(depending on thegestational age)

Recipients must have

institutional delivery(or at least attendedto by a skilled birth

Recipients receiveincentive of cash foreach attendance

Mama-kits will be

provided on delivery ofbaby


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attendant)

Attend at least one

postnatal appointment6 weeks after birth

Nutritional items and

few items of clothingfor the baby

Family planning

precautions are put inplace

o Child spacing

Method ofDisbursement

Zenith Bank

Eazymoney Distribution of purpose-

specific handsets torecipients

Monitoring &

Evaluation

Demand Side

Supply Side

Disbursement

Rigorous evaluations

Indicators

o Numbers of

functional warddevelopment

committeeso Number of meetings

held by the WDC

Number of

recipientsregistered andreferred to healthfacility

o Number of recipients

attending ANC at thefacility

o Number of Mama-

Kits distributed torecipients


delivering at thehealth facility


accepting familyplanningcommodities


accessing infantwelfare clinic withtheir baby


given SP and LLIN

Number of recipientsaccessing theirvisits/nutritional

Cost effectiveness

Distribution of program

impact


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incentiveso Regular audit of

payment schedulesand actual paymentsmade

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

weeksKEY STRATEGIC

INITIATIVES

Engagement of traditional/mission/community birth

attendants in the selected community

Involvement of community-based organizations inthe selected localities

Referrals of complicated cases to secondary

facilities

Enhanced developmental relations between health

workers and the recipients

Targeting Methods and Mechanism


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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 theConditional 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.


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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 orexclusion. 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.


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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?

Yes = 1, No = 0

Does she have no more than 0.5 ha plot of land? Yes = 1, No = 0

Does she have less than two livestock (cows or goats)? Yes = 1, No = 0

Is she illiterate or with education only up to primary school? Yes = 1, No = 0

Is she often or occasionally having fewer than three meals a day? Yes = 1, No = 0

Is she or anyone in her household suffering from chronic or regularillness?

Yes = 1, No = 0

Does she have disabled children/husband/household member living

with her?

Yes = 1, No = 0

Is she widowed/single/separated/divorced? Yes = 1, No = 0

Does the household have over four dependents? (five or more) Yes = 1 No = 0

Does each household member have at least two complete sets of Yes = 1 No = 0


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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


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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)


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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


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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.


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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


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- 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.


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cct gbomoro - concept paper draft

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