The sum of its parts:

Simple, innovative cash transfer scheme for pregnant women saves lives in Kandahar Province

By Sayed Maroof Hamdard
UNICEF Afghanistan/2017/Hamdard

11 December 2017

Kandahar, Afghanistan, 11 December 2017 – Baby Ezatullah was delivered two months ago at a health centre in Kandahar Province’s Daman district. He’s come back today for his vaccinations while his mum, Bibi, receives a post-natal check-up. He’s the fourth child of parents Lalai and Bibi, but the first to be born under appropriate medical supervision. Like many Afghan babies, his siblings were born at home, putting both mother and child at great – and unnecessary – risk. Bibi nearly lost her life delivering her third child, who is also lucky to have survived the home birth. 

When Bibi was pregnant with Ezatulluh, Lalai met a community health worker in the family’s village who informed him of an interesting programme: if Lalai’s wife chose to deliver at the health centre with a skilled birth attendant, not only would the family benefit from professional health care, but they would also receive 1,000 afghanis (US$14.37).

Lalai took the opportunity, allowing his family to benefit from the conditional cash transfer (CCT) programme being run in Dand and Daman districts of Kandahar Province. The first time this type of demand-side financing programme has been implemented in Afghanistan, CCT incentives have encouraged families like Lalai and Bibi’s to choose hospitals for deliveries. Nine health centres in these districts provide 1,000 afghanis (US$14.37) to a mother who gives birth at health facilities, covering the cost of transport, which is often prohibitively high to Afghan families.

UNICEF Afghanistan/2017/Hamdard
Sharifa three-month-old receives a medical check-up at the in Zakeer Sharif Comprehensive Heal Center Dand District of Kandahar Province.

Despite significant progress over the last decade in delivering a basic package of health services (BPHS) in Afghanistan, utilization of maternal and child health services at the health facility remains low, especially in rural areas. Many families continue to deliver their children at home, usually without a trained health worker in attendance. CCT efforts aim to change this and are contributing to real progress in improving institutional delivery and saving lives of mothers and newborns. 

“Child birth was very tough and risky for us,” Lalai said. “I almost lost my wife and third child during delivery. Thanks to community health workers for their guidance and encouragement for hospital deliveries, now I understand the importance of skilled birth attendance.” Lalai used the money they received at the health centre for dietary supplements for his wife. “Now my wife and child are in very good condition, and we are very happy.”

Evidence from this experience in southern Afghanistan indicates an opportunity to increase the utilization of health services by addressing gaps in the demand for services, access to transportation and use of community health workers. Based on this information, the Ministry of Public Health and UNICEF determined an innovative approach to address low service utilization by implementing a CCT project in three target provinces. By providing a small cash sum, this project incentivizes women to give birth at health facilities and community health workers to encourage pregnant women to do so. The overall goal of this initiative is to increase demand for deliveries at health institutions and thereby improve maternal and neonatal health outcomes during the intrapartum period, which occurs between labour and delivery and poses the most danger to pregnant women.

This approach has been used in other countries successfully and led families to seek more health care.

“During pregnancy, I had my husband’s full support,” Bibi said. “When your husband supports you, the family members will support you, too. Otherwise, it can be difficult to give birth in a health centre. The incentive motivated me to inform other women to attend institutional delivery as well.”

UNICEF Afghanistan/2017/Hamdard
Conditional cash transfer (CCT) program expanded hospitalized delivery and immunization services in Dand and Daman districts of Kandahar.

In Dand and Daman districts, the number of deliveries at health facilities is increasing, according to Marhaba, a midwife in Madesar health centre. “Now, a lot of pregnant women are going to health facilities because they are encouraged by the CCT programme,” she said.  

Sharifa was born three months ago, in Dand district’s Zakeer Sharif health centre. Her family also received 1,000 afghanis from the programme. Her father, Wali Mohammad, said, “Our family members are very happy because the delivery of my daughter was safe and doctors were very supportive, and we received 1,000 afghanis as well. This amount can convince other poor families to allow their women to come to health centre for child birth. Due to the support from the doctors and midwives and the safe delivery, now my wife and mother are encouraging pregnant women across the village to deliver at hospitals.”

The mother of Sharifa said, “Today we are here to vaccinate my daughter and visit the doctor for my post-natal care. I am happy from the support of doctors during and after the delivery and the incentive is helping me to motivate pregnant woman from poor families to come to health centre for child birth.”

Compared to 2016, the CCT programme has expanded hospitalized delivery and immunization services in Dand and Daman districts of Kandahar Province. Over the first 10 months of 2017, a total of 1,457 women received 1,000 afghanis after benefiting from skilled birth attendance in health facilities.