JMIR Publications

ABSTRACT

Background:

Mobile money-based cash transfer interventions are becoming increasingly utilised, especially in humanitarian settings. The South of Madagascar constituted a humanitarian emergency in 2021/2022 when the second wave of the COVID-19 pandemic and a severe famine affected the fragile region simultaneously.

Objective:

This mixed-methods study aims to analyse the impact and factors influencing the success of a mobile-money-based conditional cash transfer intervention for healthcare utilisation at four primary and eleven secondary facilities in Madagascar.

Methods:

We drew on quantitative data from facility registers, detailing patient numbers per month, divided by categories (maternity care, surgical care, paediatric care, outpatient care, and inpatient care). We conducted an interrupted time series analysis, using the end of the intervention in July 2022 as the cut-off point. For qualitative data, we drew on data from 63 in-depth interviews conducted with healthcare providers, NGO staff, policymakers beneficiaries, and non-beneficiaries of the intervention, interpreted using reflexive thematic analysis.

Results:

The interrupted time series analysis showed a significant, negative impact of the end of the intervention on healthcare utilisation. The changes were most pronounced for surgical and paediatric care. The key factors that influenced the success of the implementation were grouped across three levels. At the community level, outreach conducted for the project was a decisive factor. At participating facilities, staff motivation, bonus payments paid by the NGO, pre-existing activities of the same implementing NGO, and the digital literacy of facility staff influenced the intervention. Lastly, on the side of the implementing NGO, the NGO staff present at each facility and the speed and ease of the intervention’s administrative processes emerged as decisive factors.

Conclusions:

The conditional cash transfer intervention was successful in increasing healthcare utilisation in Southern Madagascar in a humanitarian setting. Future, similar interventions should proactively consider the key factors identified.