Health Policy and Planning – October 2014

Health Policy and Planning
Volume 29 Issue 7 October 2014

Acceptability of conditions in a community-led cash transfer programme for orphaned and vulnerable children in Zimbabwe
Morten Skovdal1,2, Laura Robertson3, Phyllis Mushati4, Lovemore Dumba5, Lorraine Sherr6,
Constance Nyamukapa3,4 and Simon Gregson3,4
Author Affiliations
1Institute of Social Psychology, London School of Economics and Political Science, Houghton Street, WC2A 2AE, London, UK, 2Save the Children, 1 St John’s Lane, EC1M 4AR, London, UK, 3Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, Praed Street, W2 1NY, London, UK, 4Biomedical Research and Training Institute, No. 10 Seagrave Road, Avondale, Harare, Zimbabwe, 5Catholic Relief Services, 95 Park Lane, Harare, Zimbabwe and 6Department of Infection and Population Health, Royal Free Hospital, Rowland Hill Street, NW3 2PF, University College London, London, UK
Accepted July 8, 2013.
Evidence suggests that a regular and reliable transfer of cash to households with orphaned and vulnerable children has a strong and positive effect on child outcomes. However, conditional cash transfers are considered by some as particularly intrusive and the question on whether or not to apply conditions to cash transfers is an issue of controversy. Contributing to policy debates on the appropriateness of conditions, this article sets out to investigate the overall buy-in of conditions by different stakeholders and to identify pathways that contribute to an acceptability of conditions.
The article draws on data from a cluster-randomized trial of a community-led cash transfer programme in Manicaland, eastern Zimbabwe. An endpoint survey distributed to 5167 households assessed community members’ acceptance of conditions and 35 in-depth interviews and 3 focus groups with a total of 58 adults and 4 youth examined local perceptions of conditions. The study found a significant and widespread acceptance of conditions primarily because they were seen as fair and a proxy for good parenting or guardianship. In a socio-economic context where child grants are not considered a citizen entitlement, community members and cash transfer recipients valued the conditions associated with these grants. The community members interpreted the fulfilment of the conditions as a proxy for achievement and merit, enabling them to participate rather than sit back as passive recipients of aid.
Although conditions have a paternalistic undertone and engender the sceptics’ view of conditions being pernicious and even abominable, it is important to recognize that community members, when given the opportunity to participate in programme design and implementation, can take advantage of conditions and appropriate them in a way that helps them manage change and overcome the social divisiveness or conflict that otherwise may arise when some people are identified to benefit and others not.

Health and access to care for undocumented migrants living in the European Union: a scoping review
Aniek Woodward1,2,*, Natasha Howard1 and Ivan Wolffers3
Author Affiliations
1Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, Tavistock Place, London, WC1H 9SH, UK, 2King’s International Development Institute and King’s Centre for Global Health, King’s College London, London, WC2R 2LS, UK and 3Vrije Universiteit Medical Centre, Amsterdam, 1007 MB, the Netherlands
Accepted July 11, 2013.
Literature on health and access to care of undocumented migrants in the European Union (EU) is limited and heterogeneous in focus and quality. Authors conducted a scoping review to identify the extent, nature and distribution of existing primary research (1990–2012), thus clarifying what is known, key gaps, and potential next steps.
Authors used Arksey and O’Malley’s six-stage scoping framework, with Levac, Colquhoun and O’Brien’s revisions, to review identified sources. Findings were summarized thematically: (i) physical, mental and social health issues, (ii) access and barriers to care, (iii) vulnerable groups and (iv) policy and rights.
Fifty-four sources were included of 598 identified, with 93% (50/54) published during 2005–2012. EU member states from Eastern Europe were under-represented, particularly in single-country studies. Most study designs (52%) were qualitative. Sampling descriptions were generally poor, and sampling purposeful, with only four studies using any randomization. Demographic descriptions were far from uniform and only two studies focused on undocumented children and youth. Most (80%) included findings on health-care access, with obstacles reported at primary, secondary and tertiary levels. Major access barriers included fear, lack of awareness of rights, socioeconomics. Mental disorders appeared widespread, while obstetric needs and injuries were key reasons for seeking care. Pregnant women, children and detainees appeared most vulnerable. While EU policy supports health-care access for undocumented migrants, practices remain haphazard, with studies reporting differing interpretation and implementation of rights at regional, institutional and individual levels.
This scoping review is an initial attempt to describe available primary evidence on health and access to care for undocumented migrants in the European Union. It underlines the need for more and better-quality research, increased co-operation between gatekeepers, providers, researchers and policy makers, and reduced ambiguities in health-care rights and obligations for undocumented migrants.

Does the distribution of healthcare utilization match needs in Africa?
Igna Bonfrer1,*, Ellen van de Poel1, Michael Grimm2,3 and Eddy Van Doorslaer1,4
Author Affiliations
1Institute of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3000 DR Rotterdam, The Netherlands, 2Department of Economics, University of Passau, Innstrasse 29, 94032, Passau, Germany, 3International Institute of Social Studies, Erasmus University Rotterdam, Kortenaerkade 12, 2518 AX, The Hague, The Netherlands and 4Erasmus School of Economics, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3000 DR Rotterdam, The Netherlands
Accepted September 9, 2013.
An equitable distribution of healthcare use, distributed according to people’s needs instead of ability to pay, is an important goal featuring on many health policy agendas worldwide. However, relatively little is known about the extent to which this principle is violated across socio-economic groups in Sub-Saharan Africa (SSA). We examine cross-country comparative micro-data from 18 SSA countries and find that considerable inequalities in healthcare use exist and vary across countries. For almost all countries studied, healthcare utilization is considerably higher among the rich. When decomposing these inequalities we find that wealth is the single most important driver. In 12 of the 18 countries wealth is responsible for more than half of total inequality in the use of care, and in 8 countries wealth even explains more of the inequality than need, education, employment, marital status and urbanicity together. For the richer countries, notably Mauritius, Namibia, South Africa and Swaziland, the contribution of wealth is typically less important. As the bulk of inequality is not related to need for care and poor people use less care because they do not have the ability to pay, healthcare utilization in these countries is to a large extent unfairly distributed. The weak average relationship between need for and use of health care and the potential reporting heterogeneity in self-reported health across socio-economic groups imply that our findings are likely to even underestimate actual inequities in health care. At a macro level, we find that a better match of needs and use is realized in those countries with better governance and more physicians. Given the absence of social health insurance in most of these countries, policies that aim to reduce inequities in access to and use of health care must include an enhanced capacity of the poor to generate income.