Download - 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
o Number of recipients
delivering at thehealth facility
o Number of recipients
accepting familyplanningcommodities
o Number of recipients
accessing infantwelfare clinic withtheir baby
o Number of recipients
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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