Experiences of conditional and unconditional cash transfers intended for improving health outcomes and health service use: a qualitative evidence synthesis (2024)

Monitoring Editor: Cochrane Effective Practice and Organisation of Care Group, Clara A Yoshino, Kristi Sidney-Annerstedt, Tom Wingfield, Beatrice Kirubi, Kerri Viney, Delia Boccia, and Salla Atkins

Experiences and perceptions of cash transfers for health

What is the aim of this synthesis?

The aim of this Cochrane qualitative evidence synthesis was to explore how people receiving health‐related conditional or unconditional cash transfers experienced them. We analysed 41 qualitative studies to answer this question.

Key messages

People appreciate cash transfers and see them as necessary for their basic needs. However, cash transfers can influence people’s relationships in positive and negative ways. Not all people want to receive cash and some recipients do not perceive that cash alone will be enough to change their health behaviour.

What was studied in this synthesis?

Conditional and unconditional cash transfer programmes are found across the world. A conditional cash transfer is money (cash) that is given to people if they behave in a certain way. For example, parents could receive cash if they take their children to a health centre. An unconditional cash transfer is money that is given without any conditions or rules about its use. In some settings, people receive cash transfers through government programmes. In other settings, cash transfers are mainly given through non‐governmental organisations or research projects. Many of these programmes aim to improve people’s health, but research measuring the effect of these programmes on health shows mixed results. We, therefore, wanted to explore how people experienced these programmes.

What are the main findings?

We included 127 studies in the review and sampled 41 of these studies for our analysis. Thirty‐two further studies were found after the updated search on 5 July 2022 and are awaiting classification. The sampled studies were from 24 different countries, across all World Health Organization regions. These studies primarily explored the views and experiences of cash transfer recipients with different health conditions, such as infectious diseases, disabilities and long‐term illnesses, sexual and reproductive health, and maternal and child health. We had mainly moderate‐to‐high confidence in our findings. We found that people receiving the cash transfers saw them as necessary. They described the cash as helpful in the short term, and sometimes in the long term. However, people often felt that the amount given was too little to meet their needs. They also felt that the cash alone was not enough to change their behaviour and that they also needed other types of support, such as social or psychological support or training and opportunities for employment. People described how the cash empowered them and made them more independent, especially women and people with disabilities. In some settings, people experienced pressure from family or programme staff on how to use cash. People described how the cash had improved their relationships with their families and the community. However, in communities where some received the cash and others did not, this could also cause tension, suspicion and conflict. Some people also described being stigmatised for receiving cash transfers. While people often experienced barriers to accessing cash, some refused or were hesitant to receive the cash. Some recipients found cash transfer programmes more acceptable when they agreed with programme goals and processes.

How up‐to‐date is this synthesis?

We searched for studies published before 5 June 2020. The search was rerun in July 2022 and an additional 32 studies are awaiting classification.

Summary of findings 1

Description of the topic

In this review, we included both conditional and unconditional cash transfers as well as cash‐plus interventions that could include either a conditional or unconditional cash transfer. We defined unconditional cash transfers (UCT) as non‐contributory monetary payments to individuals by governmental, international or non‐governmental organisations to help them meet minimum consumption needs (Garcia 2012). We defined conditional cash transfers (CCT) as similar non‐contributory monetary payments to individuals subject to the condition that they comply with specific requirements, e.g.payment dependent on children attending school or attendance for health care (Shibuya 2008). 'Non‐contributory' in this instance refers to cash payments, which are not a form of insurance and do not require a partial payment or deposit by an individual to receive them now or in the future. We defined cash‐plus interventions as interventions in which cash is provided in combination with an additional form of intervention, for example, education (Roelen 2017) or health services.

We included cash transfers targeted for improving health or health behaviours or that were assessed for health outcomes. While we recognise the larger effects that cash transfer programmes can have on the Sustainable Development Goals, economies at large and general well‐being, our review was limited to examining the impact of cash transfers on the health and well‐being of individuals.

How the intervention might work

There is evidence that cash transfers can improve adherence to treatment, health‐seeking behaviour (Chaturvedi 2015), vaccination rates (Carvalho 2014), and health outcomes including TB treatment completion and cure (Torrens 2015). UHC will contribute towards eliminating the direct costs of medical care (UHC 2030 International Health Partnership 2017), but more than that is needed to cover non‐medical direct costs (e.g. food and transport) and indirect costs such as income loss due to illness, disability and healthcare use (Lönnroth 2014). Without such supplements to household income, long‐term diseases requiring frequent clinic attendance can push low‐income patients into further poverty (Munro 2007).

Non‐attendance at clinic appointments occurs for many reasons, for example, not being able to afford time off work or lack of affordable transportation to the clinic. On the other hand, individuals may lack the incentive to attend clinic appointments or preventive care, such as antenatal visits or vaccination appointments. In this sense, UCT and CCT intervention types have different pathways to achieve outcomes.

This review aims to contribute to the literature on cash transfers by examining the pathways and conceptualisation of how the interventions work. Important to consider here is how the programme conceptualisation may affect recipients' experience. For conditional cash transfers, the pathway to impact could be conceptualised, for example, using the 'nudge' theory (Thaler 2009), which posits that individuals sometimes make bad choices, and should be 'nudged' towards better ones. The approach has been adopted in many settings as a public health approach, and has been evaluated in, for example, diabetes care (Möllenkamp 2019), and curbing obesity through healthy eating (Arno 2016). The experience of a recipient of such a programme may be completely different from that of a recipient of a programme that is defined using an egalitarian, supportive approach. Differences in such attitudes may be across conditional and unconditional cash transfer programmes, but also, for example, between different programmes within the category of CCT programmes.

Conditional, unconditional and cash‐plus strategies have different pathways to impact. Conditional transfers have a potentially stronger impact on health and health behaviour, as receiving the transfer can be tied to these outcomes. The pathway of unconditional transfers could be seen as less direct, and more complex in the way that they affect health behaviours, potentially through availing funding to cover direct or indirect costs of treatment, or through reducing household stress. Cash‐plus strategies, in turn, include cash as an intervention component, whereas the other component can be, for example, education (Pettifor 2019), with various impacts on health behaviours. This study aims to examine both the intended and unintended effects of these interventions and how recipients — both at a household and an individual level — experience and perceive the intervention, including whether it is acceptable to them, and what unintended outcomes may emerge.

The logic model presented inFigure 1presents how the interventions — conditional, unconditional and cash‐plus — could result in different short‐ and long‐term outcomes. We also show below how the broader sociodemographic, policy context and healthcare system, as well as community support, gender relations and inequalities, function in the background of these interventions. The broader societal impact of the interventions is, however, beyond the remit of this review: our focus is on the short‐ and long‐term impact as reported by individuals who receive the cash transfer. The model shows that all three interventions can produce an increase in (and more predictable) income. Conditional transfers can also result in a change in the desired health behaviour. The outcomes can be numerous, from improved mental well‐being and reduced stress, and long‐term outcomes that include improved health and reduced risk of poverty‐related diseases. There are likely, however, several unintended consequences that we could not capture in the logic model.

Why is it important to do this review and how will this review supplement what is already known in this area?

To date, no review has examined health‐related cash transfer programme designs, delivery and outcomes from a recipient perspective, including their perceptions and experiences of the cash transfers or the unintended consequences that these interventions may have. While cash transfers may be beneficial for health outcomes, there are several important issues to investigate and discuss before designing (Krubiner 2017) and implementing such programmes on a larger scale. Another important issue is that the experiences of persons or patients receiving conditional or unconditional cash transfers are not frequently discussed. The latter is linked to ongoing discussions concerning to whom this cash should be provided — a particular household member, or to men, or women (Yoong 2012) — and what effects and uses the cash might have when provided to different recipients. To investigate these process‐related issues and understand recipient perspectives, qualitative evidence is needed (Lewin 2015). Qualitative research can help to investigate the pathways from cash transfers to health, and to identify context‐appropriate interventions.

While it is reasonable to expect that people are generally happy to receive cash, whether in return for attending a clinic or in general, implementing these programmes in new settings needs information about which forms of cash transfers are seen as most convenient; which barriers and facilitators to receiving cash transfers exist in different settings; and whether they are acceptable in comparison to other approaches of health improvement, including in‐kind transfers, such as nutritional supplements or food parcels (Grobler 2011).

Existing Cochrane Reviews focusing on conditional and unconditional cash transfers give indications that cash transfers are a promising way of both supporting patients and incentivising them to attend health services (Lagarde 2009;Pega 2022) or to engage in health behaviours. Concurrently, cash transfers are increasingly used in developmental or emergency aid and humanitarian settings with reported positive health outcomes and service use (Van Daalen 2022). As a social protection measure, cash transfers are included in country policies and key international policies, such as the United Nations' Sustainable Development Goals (UN 2015) and the WHO's End TB Strategy (Uplekar 2015).

Some studies have explored the perceptions of cash transfer recipients in specific contexts: for example, in Nigeria, a conditional cash transfer programme increased facility attendance and uptake of maternal and child health services by reducing the costs of transport to access the service for pregnant women (Ezenwaka 2021a). In South Africa, experiences of the government child grant have been assessed (Zembe‐Mkabile 2015), as have experiences of conditional cash transfers to improve safe sexual practices among sex workers (Cooper 2017) and to incentivise adherence to HIV treatment and care (Czaicki 2017). In a high‐income country, there is also evidence that cash transfers are acceptable to incentivise recipients to do chlamydia screening (Parker 2015).Through a qualitative approach, the current review contributes to this body of literature with global evidence on the perspectives and experiences of cash transfer recipients and proposes areas to address when developing cash transfer policies intended for better health outcomes and health service uptake.

In summary, consolidated evidence concerning how these interventions are perceived by recipients is needed, as is a description of the possible unintended outcomes described by the recipients. This review seeks to understand cash transfer recipients’ experiences and perceptions of these interventions, including acceptability, feasibility, and unintended consequences.

Criteria for considering studies for this review

Search methods for identification of studies

Selection of studies

We collated the records identified from databases, removed duplicates and uploaded them into Covidence. Four review authors (SA, KSA, KV and TW) then independently assessed the titles and abstracts of each record to identify relevant studies. We retrieved the full texts of all abstracts identified as potentially relevant and two independent review authors assessed each full‐text article for inclusion according to the criteria below. For both the title/abstract and full‐text screening, review authors resolved disagreements through discussion or, when required, by seeking a third review author’s opinion. For articles not identified through databases, two authors screened titles and abstracts and conducted full‐text assessment independently.

Our inclusion criteria were:

• primary studies;

• studies using mixed methods with qualitative data or qualitative studies;

• studies that report on experiences of cash transfer interventions provided by governmental, non‐governmental or international agencies, or private for‐profit agencies.

We included studies where the recipients could be:

• adult patients (male or female, over 18 years of age) of healthcare services (primary, secondary or tertiary); or

• the general adult population for the purpose of increasing, initiating or maintaining preventive or curative health behaviours (e.g. vaccinations, treatment adherence, or testing or screening for disease); or

• adults where the cash transfer is intended to benefit their children;

• studies reporting on the perspective of parents receiving the cash transfer for their child, or adult patients receiving the cash transfer in low‐, middle‐ and high‐income countries;

• studies focusing on any mental or physical health condition and any social protection or other cash transfer mechanism.

We included studies where participants were currently receiving a cash transfer or had recently (within six months) received a cash transfer.

We excluded papers that focused on in‐kind transfers only, systematic reviews or literature reviews, quantitative studies, studies on cash transfers not examined for health outcomes (e.g. those focusing explicitly on poverty relief only), pay for performance for health workers, loan and savings groups, microfinance initiatives, and health insurance. We also excluded papers that did not include actual recipients or carers of recipients, but rather discussed potential interventions.

We retrieved the full text of papers that we considered relevant for independent assessment. Two review authors (from a combination of SA, KSA, KV, BK and TW) assessed the articles based on the review’s inclusion criteria. Where there were disagreements, we discussed these with a third author’s help.

We initially ran the searches in June 2020 and reran them in July 2022, when we found further 32 studies, which are now classified as awaiting classification. We will incorporate these studies in a future review update.

Language translation

We assessed titles that were available in English. Where the titles were translations of other languages, we sourced the abstract and asked colleagues for help in assessing their inclusion. The full text of studies that were in other languages than English was assessed by colleagues using a grid of assessment criteria. The languages included Spanish, Portuguese, Chinese and Russian.Only one study in Spanish that met the criteria for inclusion was identified during the update of the search. The full text in Spanish was assessed by four reviewers, two authors (CAY and TW) and two native Spanish‐speaking colleagues.

Sampling of studies

Qualitative evidence synthesis aims for variation in concepts rather than an exhaustive sample, and large amounts of study data can impair the quality of the analysis. We used a multistep framework for sampling from the list of 127 studies eligible for inclusion. The steps included:

• start with maximum variation sampling using WHO regions: inclusion of all studies from under‐represented regions with the least articles e.g. Eastern Mediterranean Region (EMR), South‐East Asia Region (SEAR) and Western Pacific Region (WPR);

• review of studies by type of health condition involved (preventive interventions, infectious diseases, non‐communicable diseases/chronic illnesses, reproductive and maternal health and child health): inclusion of all studies from conditions under‐represented, e.g. mental health;

• review of studies by the richness of data, as defined byAmes 2019, through a combination of intensity sampling and criterion selection (type of study, amount of data, journal, coherence with objective).

We first used a maximum variation sampling strategy (Ames 2019) to allow a global perspective and understanding of the cash transfer experience. The sampling frame took into consideration the intervention country and its corresponding WHO region (WHO 2022), the health conditions for which the social protection was targeted, the type of cash transfer, and the sample population for the study.

We then employed criterion sampling and classified the study articles by the level of data richness using theAmes 2019data richness score, and the degree to which the study focused on health.

First, studies that had a marginal focus on health were removed from the sampling frame (n = 16). Next, we classified the data richness based on a scale of 1 to 5, where 5 was the highest score (Ames 2019). We then selected and included for sampling all studies with a data richness score of 3 and above (n = 112) as per the Ames method (Ames 2019). These studies were then sorted by country and health condition. For the countries that were heavily represented in the final count, a selection for sampling was done to ensure that no health condition was over‐represented in the sampled articles. For example, out of eight studies with social protection interventions for non‐communicable diseases (NCDs) in the UK, we selected four studies. We then checked to ensure that under‐represented health conditions such as mental health (n = 1) were among the sampled studies. The final list of studies sampled for analysis consisted of 41 papers.

Data extraction

We extracted data using a specially developed form that extracted information about the characteristics of included studies, including first author, date of publication, country and WHO region of the study, the context of the study, participant group, research methods used, the intervention studied and the health outcome linked to the study, as well as the sociopolitical context related to the intervention, if described in the article. We also extracted key results, themes and participant quotations that illustrated the themes from the articles.

We used Dedoose, a qualitative data analysis package, to extract the main concepts and ideas from the included articles, using the categorisation of first, second and third‐order constructs (Atkins 2008). We listed these and checked for duplications.

We then categorised each paper according to the type of transfer (UCT, CCT, cash‐plus) and looked at the relation of these concepts within each category. We started with the paper that scored higher on the richness scale that was considered to have a thick description.

Assessing the methodological limitations of included studies

We assessed the quality of individual studies using the CASP quality criteria (Critical Appraisal Skills Programme 2018). Three review authors (SA, KSA and BK) independently assessed each study using the CASP form. Where there was a disagreement, a third review author was involved in the discussion. Three domains were included in the quality assessment: validity of the results, author reflexivity and ethical considerations. We excluded the CASP section seeking to establish the value of the research locally as we do not have the capacity to evaluate this domain for the various study contexts. The results of the quality assessment are shown in the Methodological Limitations.

Data management, analysis and synthesis

We used a cloud‐based server with specifically developed forms on Microsoft Excel for managing the data from different sources. For the searches of academic databases, we imported search findings into Covidence and removed duplicates. The Covidence database and the cloud server were accessible to all review authors. Included papers, searches of grey literature, citation searches, and reference searches were kept on the cloud‐based server.

Initially, we extracted the meaning units from the papers, following first and second‐order constructs (second‐order constructs being what the author interprets the participants are saying) (Atkins 2008). We coded these using an inductive coding framework and through a thematic analysis approach. We then extracted these codes from the Dedoose system into Excel, and CAY, SA, and KSA, as the author team, discussed the structure of the coding framework, reorganising and renaming it. Using the Dedoose system, we then coded articles using this coding framework, adapting the framework as we went on to consider emerging issues. Two authors then verified the coding process and added data that should have been included.

We categorised each paper according to the type of cash transfer programme described (UCT, CCT or cash‐plus). We then conducted the process of comparison by using an information‐rich index paper, identified during the data extraction phase. We started from the richest paper, in our assessment of data richness as per the Ames method, and proceeded to translate each study into the previous one. We proceeded from paper to paper and compared themes across each other. During this process, we examined the studies in terms of their focus and content to determine whether we could conduct a reciprocal and/or refutational translation.

For the synthesis of the data, we did a reciprocal translation (Noblit 1988), linking similar findings between the studies according to each theme. We compared findings across different interventions, settings, and health conditions to detect response patterns. We paid attention to the patterns emerging in terms of the country setting, sex, sociopolitical setting, and programmatic setting, as well as the impact of other contextual factors, particularly poverty rates in the setting, and how they might affect analysis findings.We noted carefully where there were contradictory results and conducted a refutational translation analysis. We looked at the context, the design of each study, and how they impacted the differences in the findings. The incongruencies and disparities were described within the themes.

We then transformed the thematic description into review findings. We conducted a constant comparison of review findings, descriptive text and the original articles throughout the analysis process. We examined this to determine whether a line of argument synthesis, as described by Noblit and Hare, was possible (Noblit 1988). A flowchart illustrating the stages of the analytic process is shown inFigure 2.

Assessing our confidence in the review findings

The review authors (CAY, SA and KSA) used the Confidence in the Evidence from Reviews of Qualitative Research (GRADE‐CERQual 2022) approach to assess our confidence in each finding (Lewin 2018), using the iSoQ (Interactive Summary of Qualitative Findings 2022) Beta programme for the assessment. GRADE‐CERQual assesses confidence in the evidence, based on the following four key components.

1. Methodological limitations of included studies: the extent to which there are concerns about the design or conduct of the primary studies that contributed evidence to an individual review finding.

2. Coherence of the review finding: an assessment of how clear and cogent the fit is between the data from the primary studies and a review finding that synthesises those data. By cogent, we mean all supported or compelling.

3. Adequacy of the data contributing to a review finding: an overall determination of the degree of richness and quantity of data supporting a review finding.

4. Relevance of the included studies to the review question: the extent to which the body of evidence from the primary studies supporting a review finding applies to the context (perspective or population, phenomenon of interest, setting) specified in the review question.

After assessing each of the four components, the three review authors (CAY, KSA, SA) made a judgement about the overall confidence in the evidence supporting the review finding. The team judged confidence as high, moderate, low or very low. The final assessment was based on a consensus among the review authors. All findings started as high confidence and were graded down if there were important concerns regarding any of the GRADE‐CERQual components.

Summary of qualitative findings table and evidence profile

Summaries of the findings and our assessments of confidence in these findings are presented in theTable 1. Detailed descriptions of our confidence assessment are presented inTable 2.

Integrating our findings with Cochrane Intervention Reviews

We identified reviews related to this qualitative evidence synthesis by Lagarde and colleagues (Lagarde 2009) on conditional cash transfers and Pega and colleagues (Pega 2022) on unconditional cash transfers. Our initial plan was to juxtapose findings from our review with theirs in a matrix following the method used by others (Harden 2018). As we completed the process with the studies included in the Lagarde review, we understood that the process was not yielding sufficient meaningful data to understand how the interventions or programmes took into account the factors that emerged from our findings.

Our findings of experiences and perceptions of cash transfers were at different levels, from the practical barriers to access to the unintended outcomes of hope and empowerment. These unintentional outcomes are not easily described in intervention trials and are difficult to account for in intervention design. Instead of comparing these reviews directly, we, therefore, suggest questions guiding the development and implementation of cash transfer programmes or interventions.

Results of the search

We found 127 studies eligible for inclusion and we sampled 41 of these studies for inclusion in the analysis (Figure 3). For the 86 studies that were included but not sampled, the reasons for not sampling included insufficient data quality (n = 44), over representations of country, health condition, or programme (n = 26), only focused on well‐being and/or nutrition (n = 10), and minimal focus on health (n = 6).

We excluded 110 full‐text studies. Their reasons for exclusion are listed inCharacteristics of excluded studies.

Additionally, after rerunning the search, we found 32 further studies that are awaiting classification (Afroz 2021;Alam 2020;Atkins 2021;Barrington 2022;Camlin 2022;Cena 2020;Cheetham 2019;Clifton 2022;Dave 2022;Ehlers 2022;Ezenwaka 2021;Galarraga 2020;Gangaramany 2021;Ghose 2021;Gong 2020;Iguna 2022;Kangwana 2022;Karakara 2022;Kenyon 2020;Krukowski 2022;Lees 2021a;Paajanen 2021;Packel 2021;Perez 2020;Reid 2022;Shay 2021;Spencer 2022;Stein 2022;Swartz 2022;Voils 2021;Wamoyi 2021;Zhang 2021). All studies sampled for analysis were published between 1998 and 2020.

Description of the studies

In this section, we describe the studies that we included and sampled. For a more detailed description of studies that were included and sampled as well as studies that were included but not sampled, seeCharacteristics of included studies. For a detailed description of studies awaiting classification, seeCharacteristics of studies awaiting classification.

Setting

The sampled studies comprised countries from all six World Health Organization (WHO) regions: African region (n = 17), region of the Americas (n = 7), European region (n = 7), South‐East Asian region (n = 6), Western Pacific region (n = 3); and one multiregional study covering countries from the African and the Eastern Mediterranean regions (n = 1).

Twenty‐nine studies were based in low‐ and middle‐income countries (LMICs): South Africa (n = 6) (Kelly 2019;Khoza 2018;MacPhail 2013;Plagerson 2011;Stoner 2020;Woolgar 2014); Ghana (n = 3) (Arkorful 2020;Owusu‐Addo 2020;Yeboah 2016); Nepal (n = 3) (Banks 2019b;Baral 2014;Gram 2019); Tanzania (n = 3) (Cooper 2017;Czaicki 2017;Wamoyi 2020); China (n = 2) (Wei 2009;Yin 2018); India (n = 2) (Nirgude 2019;Sidney 2016); Nigeria (n = 2) (Baba‐Ari 2018;Ukwaja 2017); Colombia (n = 1) (Balen 2018); Malawi (n = 1) (Miller 2012); Mexico (n = 1) (Adato 2000a); Turkey (n = 1) (Yildirim 2014); Viet Nam (n = 1) (Banks 2019a); Zambia (n = 1) (Banda 2019); Zimbabwe (n = 1) (Skovdal 2014) and one multiregional study including Kenya, Mozambique, Uganda, Yemen and the Occupied Palestinian Territory (n = 1) (Samuels 2016).

Twelve studies were based in high‐income countries (HICs): UK (n = 5) (De Wolfe 2012;Garthwaite 2015;Ploetner 2020;Shefer 2016;Thomson 2014); Canada (n = 3) (Gewurtz 2019;Jongbloed 1998;Struthers 2019); USA (n = 2) (Beskin 2019;Tolley 2018); Israel (n = 1) (Holler 2020); and New Zealand (n = 1) (Hikuroa 2017).

Type of programme

We included studies on unconditional cash transfer programmes (UCT), conditional cash transfer programmes (CCT) and cash‐plus programmes, as previously defined. Nineteen studies focused on UCT programmes (Arkorful 2020;Banks 2019a;Banks 2019b;Baral 2014;De Wolfe 2012;Garthwaite 2015;Gewurtz 2019;Holler 2020;Jongbloed 1998;Kelly 2019;Miller 2012;Nirgude 2019;Plagerson 2011;Samuels 2016;Shefer 2016;Struthers 2019;Ukwaja 2017;Wamoyi 2020); 13 studies corresponded to CCT programmes (Adato 2000a;Baba‐Ari 2018;Balen 2018;Beskin 2019;Czaicki 2017;MacPhail 2013;Sidney 2016;Stoner 2020;Thomson 2014;Wei 2009;Woolgar 2014;Yildirim 2014;Yin 2018); five studies were on cash‐plus programmes, out of which three were cash‐plus CCT (Cooper 2017;Hikuroa 2017;Tolley 2018) and two were on cash‐plus UCT (Banda 2019;Gram 2019). There were also studies with mixed types of programmes with different cash transfer branches: three studies were on UCT and CCT (Owusu‐Addo 2020;Skovdal 2014;Yeboah 2016); and one study was on UCT and cash‐plus CCT (Khoza 2018).

Health conditions

Thirteen studies covered infectious diseases, seven of which were related to HIV (Czaicki 2017;Khoza 2018;MacPhail 2013;Miller 2012;Tolley 2018;Wamoyi 2020;Woolgar 2014), five were about tuberculosis (Baral 2014;Nirgude 2019;Ukwaja 2017;Wei 2009;Yin 2018) and one was on human papillomavirus (HPV) (Beskin 2019). Ten studies corresponded to maternal and child health and sexual and reproductive health (Baba‐Ari 2018;Balen 2018;Banda 2019;Cooper 2017;Gram 2019;Sidney 2016;Skovdal 2014;Stoner 2020;Yildirim 2014). Six studies were related to programmes for people with disabilities (Arkorful 2020;Banks 2019a;Banks 2019b;Holler 2020;Kelly 2019;Samuels 2016); one study covered mental health (Plagerson 2011); five studies were related to health prevention or did not have a specified health condition, such as sickness and incapacity benefits, pension plan and smoking cessation (De Wolfe 2012;Garthwaite 2015;Hikuroa 2017;Jongbloed 1998;Thomson 2014); three studies focused on programmes for mental health (Gewurtz 2019;Plagerson 2011;Ploetner 2020); three studies focused on programmes targeted for improving maternal and child health and nutrition (Adato 2000a;Owusu‐Addo 2020;Yeboah 2016); and, one study was focused on disability and mental health (Shefer 2016).

Participants

As part of our selection criteria, all studies reported perceptions and experiences of cash transfer recipients, collected through qualitative methods. In some studies, beyond the recipient, participants included staff from the programme, health professionals, members of the family of the recipient or other non‐recipient members of the community. For the purpose of this review, only the data from recipient participants were selected for analysis. Nine studies presented the experiences and perceptions of adult patients of healthcare services (Czaicki 2017;Khoza 2018;Miller 2012;Nirgude 2019;Tolley 2018;Ukwaja 2017;Wei 2009;Woolgar 2014;Yin 2018). Thirty‐two studies explored the perspectives of the general adult population where the programme was assessed in terms of health impact or provided for purposes of increasing, initiating or maintaining preventive or curative health behaviours, or the cessation of unhealthy behaviours (Adato 2000a;Arkorful 2020;Baba‐Ari 2018;Balen 2018;Banda 2019;Banks 2019a;Banks 2019b;Baral 2014;Beskin 2019;Cooper 2017;De Wolfe 2012;Garthwaite 2015;Gewurtz 2019;Gram 2019;Hikuroa 2017;Holler 2020;Jongbloed 1998;Kelly 2019;MacPhail 2013;Owusu‐Addo 2020;Plagerson 2011;Ploetner 2020;Samuels 2016;Shefer 2016;Sidney 2016;Skovdal 2014;Stoner 2020;Struthers 2019;Thomson 2014;Wamoyi 2020;Yeboah 2016;Yildirim 2014). Six studies explored the perspectives of recipient women only, which included adolescent girls and young women (Baba‐Ari 2018;Banda 2019;Gram 2019;Jongbloed 1998;MacPhail 2013;Stoner 2020;Thomson 2014). Three studies included the perceptions of adult caregiver recipients where the cash transfers are intended to benefit those receiving care, including but not limited to, children (Banks 2019a;Banks 2019b;Owusu‐Addo 2020). One study did not present clear sample criteria but included recipients of the cash transfer programme (Balen 2018).

Methodological limitations of the studies

In some of the included studies, there was a lack of adequate consideration of the relationship between the researcher and participants. We also found poor reporting of ethical issues across many of the studies. All studies gave some description, even if very brief, of the context, participants, sampling strategy, methods and analysis. Details of the assessments of methodological limitations for individual studies can be found inTable 3.

Confidence in the review findings

Using the GRADE‐CERQual approach and the iSoQ (GRADE‐CERQual 2022) Beta programme, we assessed seven findings as high confidence, seven findings as moderate confidence and one finding as low confidence.

Our main concerns were related to the methodological limitations of the studies and the adequacy of the data. Common methodological limitations included a lack of adequate consideration of the relationship between the researcher and participants as well as poor reporting of ethical considerations. Additionally, in some studies, the appropriateness of the recruitment strategy to the aims of the research was unclear. The data were often assessed as being only partially adequate, mainly because some findings were supported by a small number of studies, some of which were more descriptive and rated 3 out of 5 on the richness scale. Some review findings presented concerns regarding coherence due to exceptions to the phenomenon synthesised in the finding or heterogenous explanations used to summarise the data.

Our explanation of the GRADE‐CERQual assessment for each review finding is shown in the evidence profiles table (Table 2).

Review findings

We developed a set of individual findings organised into themes. In the themes described below, we synthesised the perceptions and experiences of cash transfer recipients in relation to the usage and the role of the cash transfer, the positive and negative impacts of the cash given its intended purpose, and also unintended consequences of the cash transfer, and the effects and outcomes of the cash within the household and the community. We used direct quotes from study participants to illustrate and contextualise the meaning.

We presented the summary of findings and our assessment of confidence in the summary of qualitative findings table (Table 1). Details and explanations of the confidence assessment are presented in the evidence profiles table (Table 2).

Summary of the main findings

For a summary of the main findings, see the Plain Language Summary.

Comparison with other reviews and implications for the field

Our findings make it clear that the pathway from a cash transfer, whether conditional or unconditional, to health outcomes or health behaviours is complex and the experiences of different individuals in different contexts can vary vastly. Many inter‐related factors, related to the implementation of the programme, the sociocultural context of the programme, and individual views and experiences influence recipients' experiences and perceptions of cash transfer programmes and are therefore likely to impact their effects. We have tried to make these relationships clear inFigure 4, but recognise that some of the factors that may influence outcomes are beyond the reach of this review, such as the cash value of transfers given in the programmes.

The review contributes to existing debates on the need for cash‐plus approaches to help improve impacts on health outcomes. Many recipients across different health issues and settings suggested that cash alone is not enough to impact behaviour and that additional interventions, such as education, health services, or other support, are necessary to impact health behaviour. This is less important where a cash transfer is explicitly geared towards changing behaviour through conditions but, even here, cash may not be sufficient for building motivation for change.At the same time, our review points out that while cash can cover basic needs in many settings, it is frequently seen by recipients as not being sufficient to meet needs or to change behaviour.

Another key area in which our review contributes is the importance of community buy‐in, clear communication, and participatory approaches to building programmes. Another meta‐ethnography, specifically examining the philosophical, ethical and political underpinnings of conditional cash transfers highlighted how decisions around conditional transfers are not apolitical, but relate to the particular context and should be decided upon transparently, considering ethical implications (Scheel 2020). One mechanism through which this could be achieved might be by using a participatory approach to programme design, including perspectives of recipients, and designing assessment, eligibility, and inclusion processes so that they seem fair and justifiable. Through this process, it may be possible to reduce the tensions sometimes created by these programmes.

Our review has some similarities with Owusu Addo and colleagues review on cash transfers and their impact on social determinants of health and health inequalities in low‐ and middle‐income countries (Owusu‐Addo 2020). They also found the reduction of stress and other pathways to health outcomes; our review also highlighted this in high‐income settings.We did not find a clear pattern in differences in experiences and perceptions according to a country or regional context.

Our synthesis complements the findings of the effectiveness reviews conducted by Pega (Pega 2022) and Lagarde (Lagarde 2009). Pega and colleagues aimed at investigating whether receiving UCT would improve people's use of health services and their actual health, compared with not receiving a UCT, receiving a smaller amount or receiving a CCT. Additionally, it also aimed to assess the effects of UCTs on living conditions that influence health and healthcare spending. The findings of Pega's effectiveness review suggested that UCTs may not impact the use of health services among children and adults in LMICs. However, UCTs may improve health expenditure, some health outcomes, such as secure access to food, and some social determinants of health, such as school attendance and reduction of poverty (Pega 2022). On the other hand, Lagarde and colleagues aimed to assess the effectiveness of CCT in improving access to care and health outcomes, with a focus on poorer populations in LMICs. Their findings suggested that CCTs can be an effective way to increase the uptake of preventive services and encourage some preventive behaviours, with a noted improvement in health outcomes in some cases. However, it is still unclear which components lead to this positive effect (Lagarde 2009). Our findings contribute to the findings of the review effectiveness of Pega (Pega 2022) and Lagarde (Lagarde 2009), as we further examined the mechanisms through which cash transfer programmes can have positive and negative effects, based on the perspectives and experiences of recipients. To complement Lagarde's review, our findings suggest which components from the recipient's perspective, in relation to the programme's design and implementation, may increase programme impacts. Our findings highlight the impacts of the sociocultural context on the functioning of programmes and interactions between the individual, family and the programme. Our review also highlights that, even where the goals of a programme are explicitly health‐related, the outcomes may be far broader than health only, and may include, for example, reduced stigma, empowerment and increased agency of the individual. When measuring programme outcomes, therefore, these broader impacts could be considered for understanding the health and well‐being benefits of cash transfers.

Overall completeness and applicability of the evidence

Our sampling strategy was intended to be global in coverage. While we did search for relevant studies across all the WHO settings, and sampling ensured that all were reflected, we found that there were rather few studies from the Middle East and North Africa (MENA) regions in our global review. Our focus on rich data could be one reason for this gap, but the lack of social protection systems in MENA countries, or gaps in our search strategy, keywords used or language, could be other drivers for the lack of studies.

We did not exclude studies based on an assessment of their methodological limitations. We found several eligible studies in our search, but we could not analyse all of them, as the method of qualitative synthesis does not allow for analysing such a large body of work. For that reason, our sampling strategy sought to sample for analysis the studies with higher data richness, seeking maximum variation in terms of health condition and country.

In our initial search, we found a large body of research specifically on disability benefits from the UK, which focused explicitly on stigma and shame. We also found a large number of studies on HIV from South Africa, which is also a well‐studied area. This could also have influenced our findings, e.g. stigma was mostly perceived by people with a disability or long‐term illness, and most studies with disabilities, mental disorders or long‐term illnesses as health conditions came from the UK. We noted that certain health conditions were linked to specific geographic locations, as can be seen from the global burden of diseases. However, we tried to take this into account in our sampling strategy, where we sought to balance the health conditions and geographic locations of the studies, sampling for analysis the studies with richer data. Overall, we are fairly confident that we covered a wide range of settings and conditions in our review, although the review included only English‐language texts.

When synthesising the findings, we sought to identify patterns across types of cash transfer programmes, target groups, health conditions and geographic locations. We first tried to organise the findings based on a division by type of cash transfer programme. We then identified similar themes across all types of programmes and decided to synthesise the findings based on broader thematic domains. Noting that the synthesis by type of programme resulted in only some patterns, we opted to present the findings based on overall themes, pointing at specificities (where relevant) for each type of programme or target group. This approach may have influenced the findings in the sense that most of them apply to all types of programmes. However, we sought to emphasise that some phenomena are more relevant to a specific type of programme (e.g. inappropriate eligibility criteria for UCT or non‐punitive conditions for CCT).

The confidence assessment was also influenced by this approach, especially the assessment of the relevant domain. Since our sampling criteria sought to cover variation in terms of health conditions, geographic locations and types of programmes, most findings were supported by studies covering all types of programmes and different health conditions and, therefore, presented no or minor concerns regarding relevance. We did not downgrade our assessment based on this, since we considered our sample a subset with high‐quality data of the total number of studies eligible globally.

A further limitation in our findings is our dependence on Samuels and colleagues (Samuels 2016), which described the findings from five different programmes in five different countries (Kenya, Mozambique, Uganda, Yemen and the Occupied Palestinian Territories of West Bank and Gaza). We chose to include Samuels and colleagues because they represented two countries from the WHO Eastern Mediterranean region (Palestine and Yemen), which were otherwise not represented in our sampled studies. There were three other studies from the EMR eligible for inclusion, but they were not sampled due to insufficient data quality or their focus only on nutrition and well‐being. SinceSamuels 2016represents five different cases, it appears often in our findings, but the study's analysis in that respect is also fairly superficial (Samuels 2016). Unfortunately, the cases presented inSamuels 2016were not published as separate papers.

Limitations of the review

We consider that our sample of studies gives a good overview of the global experiences of cash transfers. The experiences were surprisingly similar across high‐, middle‐ and low‐income settings. However, our study was limited by the need to sample from the 127 studies identified. A different sample may have yielded different results. However, we are confident that our findings reflect the key issues in the included papers, and represent global perspectives.

As part of our review process, we sampled those studies that where we considered that they had richer data. This could have affected the GRADE‐CERQual assessments by increasing our confidence in the data. Previous meta‐ethnographies have suggested that papers that provide more descriptive data may contribute less to the synthesis (Atkins 2008) and we, therefore, considered this sampling approach appropriate. We recognise that not sampling for analysis all the studies included can have an impact on the confidence assessment of our findings.

As our approach was global, we could not conduct an in‐depth assessment of how the settings of each study impacted our findings. We did investigate the effect of different social protection mechanisms but are aware that the setting (e.g. the urban or rural nature of the programme implementation site) might impact the type of barriers experienced by some recipients. Another layer of analysis, focused on the rural/urban dimension, could lead to more nuanced findings. In addition, given a large number of studies from heterogeneous settings, some of our descriptions could be seen as superficial. For instance, we included a paper describing several cash transfer programmes (Samuels 2016) ‐ this provided useful but not in‐depth data.

We also combined papers that examined established government‐provided social protection policies with intervention studies. In the latter, there was a division into intervention and control groups, which may have contributed to conflict, and suspicion within the setting. However, since we found the unfairness of distribution and suspicion created by cash transfers in both types of programmes, we think that these effects can be present wherever there is a division, and where programme goals are not communicated clearly.

Lastly, while reviewing the intervention effects studies included in Lagarde and colleagues (Lagarde 2009) and Pega and colleagues (Pega 2022), we could only identify sibling qualitative studies that were published before the intervention paper, and there is a possibility that other post‐intervention sibling qualitative studies were not captured. Future updates of this review could include forward citation searching of relevant intervention effects studies.

Implications for practice

From our review, we have the following implications for practice when designing and implementing cash transfer programmes. While many of these may seem generically relevant to all implementation programmes, there are specific considerations for cash transfer programmes.

To begin this process, we have included questions to consider when developing cash transfer interventions or programmes. These questions have been reviewed by five global members of the SPARKS Network (SPARKS Network 2022), who are actively involved in developing, implementing and evaluating cash transfer programmes. The members were working in Argentina, Nepal, Sweden, Viet Nam, Uganda, and Zimbabwe.

1. Have you considered participatory methods in designing the programme?

a. Have you considered potential recipients’ views of the intervention?

Our findings suggest that cash transfer programmes where recipients felt they could influence the programme and the eligibility criteria are clear, could be more acceptable. If time and funding allow, participatory approaches could further a feeling of ownership over the programme.

2. Have you designed a communication strategy for the programme that takes into account different target audiences?

a. Have you engaged the public in discussions about the programme?

b. Have you ensured the eligibility criteria are fair, appropriate and transparent?

c. Have you ensured the conditions, if any, of the programme, including duration, are clearly described?

d. Have you been transparent about the goals of the programme and its programme theory?

Also suggested by our findings, media has a role to play in how recipients are perceived in the community. Engaging in public discussion about the goals of the programme and its implementation could be useful. Knowing eligibility criteria, programme conditions and duration could help make the programme transparent, and help recipients in understanding goals. One of our findings suggests that people sometimes perceive eligibility criteria as unfair to others, and clear communication and working through a participatory approach may help to prevent this.

3. Have you surveyed the population, the setting and the context before implementation?

a. Have you conducted a needs assessment to establish the needs and acceptability of the programme?

b. Have you conducted a gender and intersectional analysis of your programme to inform your design?

c. Have you considered piloting and refining the intervention through process evaluation and feedback from people receiving/delivering it?

The needs assessment will inform your programme design in terms of acceptability, but also in terms of the amount and value of your cash transfer and possible additional interventions. If the area in which your programme is implemented does have job opportunities, consider giving additional services e.g. in a job application, training or entrepreneurship. In some areas, these are not realistic. Our findings also suggest that women and men and different target groups may have different experiences of the cash transfer programmes. As part of the needs assessment, gender and intersectional analyses would be important to understand the potential differences and for tailoring the intervention appropriately.

4. Have you fully considered the staff and the health system's readiness to implement the programme?

a. Are there mechanisms e.g. dedicated programme staff who can assist recipients with the registration process?

b. Have you trained staff e.g. on the use of non‐stigmatising language, and recipient‐centred behaviour to protect empowerment?

c. Have you set up accountability mechanisms where staff misconduct can be reported by recipients?

d. Have you set up monitoring mechanisms for the implementation process?

e. Have you established confidential communication channels for recipients in case of negative interactions with the staff?

Our findings suggest that staff may pressure recipients to use their cash transfers in certain ways. Staff may also strongly influence how recipients interact with the programme. There were also some hints of possible misconduct in distributing grants and incidents of negative behaviour among staff. Accountability mechanisms, such as anonymous "whistleblower" lines may help programme implementers to decrease the risk of misconduct and ensure that everyone is accountable.

5. Have you evaluated your eligibility and assessment processes?

a. Have you ensured assessment processes are appropriate for the target group (e.g. people living with depression)?

b. Are assessment and eligibility processes as simple as possible and easy to navigate?

c. Are eligibility criteria fair, transparent and clearly communicated within the programme area?

Our findings suggested that some eligibility and application processes were considered by recipients to be too strenuous and difficult to navigate, especially among those who were unwell. Not understanding or being able to deal with application processes can create a barrier to access, and inequity within the programme, possibly excluding those who need support the most.

6. Have you sought to remove potential physical, institutional, or social barriers to receiving the cash transfer to increase equity?

a. Have you made sure distances to collection points are not insurmountable; that recipients can set up bank accounts close to their home if needed; etc.?

Our findings suggested that access barriers existed particularly in hard‐to‐reach places. The administration of the programme was also challenging, as people did not have the necessary documentation. Potential implementation issues should be identified during a context assessment and addressed during the implementation phase of the programme.

7. Have you carefully considered your support alternatives?

a. Have you considered what the cash transfer amount would translate into in the context of your programme (e.g. how much staples and other goods recipients can purchase)?

b. For CCTs: Is the amount of cash transfer sufficient to achieve programme goals?

c. Could you combine the cash transfer with other services (e.g. health communication, health services)?

Linking closely to implementation considerations, considering the different support alternatives, including the value of the grant, both in terms of absolute spending power and also achieving programme goals is important. In some settings, recipients stated a desire for opportunities to work in addition to cash. Findings support the use of "cash‐plus" strategies for impacting health behaviour and health service use, as well as overall well‐being.

8. Have you considered how the cash transfer will be used and shared in the household?

a. Have you considered that family or community members may pressure the recipient on how they spend the cash transfer?

b. Have you considered if and how the cash spending will be monitored or asked about during process evaluation?

Household members may interfere in how a recipient will spend the money. It is also possible that the cash transfer is shared within the household. These dynamics, as well as individuals’ priorities, may influence the outcome of a programme.

9. Have you considered the long‐term perspective of the programme?

a. Are you able to give the cash transfer consistently to foster a feeling of security?

b. Have you ensured that you communicated the amount, frequency and duration of support, at regular intervals?

c. Have you developed an exit strategy or transition programme for the cash transfer, if your programme is not indefinite in duration?

d. Have you considered mechanisms to be incorporated that would allow recipients to sustain themselves beyond the programme?

Our findings suggest that when cash transfers are provided regularly, they may support building a sense of security, especially in high‐poverty settings. Evidence also suggested that the fear of payments ending and the actual ending of payments could negatively impact the recipient’s mental health. It is important to consider the sustainability of your programme.

10. Have you included feedback mechanisms for recipients to report back on programme implementation and any concerns?

a. Can you create a user‐friendly platform for recipients to provide feedback on their experiences with the programme (e.g. delays or non‐payments, satisfaction)?

Linked closely with setting up feedback mechanisms for staff treatment of recipients, overall feedback mechanisms, whether through programme evaluation or as part of the programme implementation, would be useful.

Implications for future research

We did not identify sufficient data from the WHO region of the Middle East and North Africa. In contrast, we did have an over‐representation of studies from South Africa and the UK. This could be due to the types of conditions included (disability and HIV), the language of the search being primarily English, and the advanced social protection settings in these countries. However, we would have expected more studies from Nordic countries, with expanded welfare states and social protection systems.Further research should therefore focus on bringing these perspectives into analysis, both Middle Eastern and North African region (MENA) countries, and Nordic countries.

Additionally, not all outcomes and impacts identified in this review have corresponding outcome measures. Our review has implications for intervention development, programme theory, and outcome measurement of interventions, as some of the key recipient perspectives, such as the sufficiency of the cash transfer that we identified are not measured routinely within effectiveness studies. Further methodological development is needed to assess how these dimensions could be integrated into future interventions and trials.

Our findings in this review were assessed to be of moderate or high confidence, and the findings were broad. We did find specific recommendations for conditional cash transfers more than other types of cash transfers. Further, perhaps separate reviews could be conducted for cash‐plus approaches, and people’s experiences of these. Detailed reviews on each of the three main forms of cash transfers may allow for a more detailed analysis of the issues that are specific to the different programme models.

Within our sample, most studies failed to report on the relationship between the researcher and the participant. Given that cash transfer programmes are closely linked with poverty and vulnerability, future studies should pay more attention to expanding on these issues. While this did not strongly affect our confidence in findings, where there is a power differential, participants may want to reflect on the interviewer’s attitudes, whether expressed or implicit.

Our review focused on recipient perspectives of cash transfers, where they reported relations with programme staff and families. Future research could focus also on family dynamics and how decisions are made within the household on spending cash transfers. This would give a more rounded perspective to these issues and could help designers of cash transfer interventions.

When preparing this protocol/review, we used EPOC’s Protocol and Review Template for Qualitative Evidence Synthesis (Glenton 2022).

The Norwegian Satellite of Cochrane Effective Practice and Organisation of Care supported the authors in developing this review. The following people conducted the editorial process for this article:

• Sign‐off Editor (final editorial decision): Simon Lewin, Norwegian University of Science and Technology;

• Contact Editor (provided comments/methods review): Meghan Bohren, School of Population and Global Health, University of Melbourne;

• Managing Editor (selected peer reviewers, collated peer‐reviewer comments, provided editorial guidance to authors, edited the article): Elizabeth Paulsen, Norwegian Institute of Public Health;

• Information Specialist (provided support in designing, running, and reporting the searches): Marit Johansen, Norwegian Institute of Public Health;

• Copy Editor (copy editing and production): Anne Lethaby;

• Peer‐reviewers (provided comments and recommended an editorial decision): Elizabeth Lutge, Department of Public Health Medicine, University of KwaZulu‐Natal; Jane Noyes, Bangor University, UK; Laura dos Santos Boeira, Instituto Veredas, Brazil.

We would like to acknowledge and thank Jaana Isojärvi from Tampere University library for her help with specific searches on Econlit; and Sabina Gillsund from Karolinska Institutet Library for her help in searches on AnthroSource. We would like to acknowledge and thank Maria Ribas Closa from Tampere University for her support in managing the database of studies. We would also like to acknowledge and thank Professor Knut Lönnroth from Karolinska Institutet for his support of the review. Finally, we would like to acknowledge and thank Maxine Caws from Liverpool School of Tropical Medicine, UK and Birat Nepal Medical Trust (BNMT), Nepal; Fernando Rubinstein from the Institute for Clinical Effectiveness and Health Policy and the University of Buenos Aires, Argentina; Gunnel Hensing from the University of Gothenburg, Sweden; Collins Timire from Ministry of Health and Child Care, National TB control programme Harare, Zimbabwe and the London School of Hygiene and Tropical Medicine, UK; and Talemwa Nalugwa from Makerere University College of Health Sciences, Uganda for their contributions in revising the list of questions from the implications for practice.

For salary support, we acknowledge Tampere University; Karolinska Institutet; Swedish Research Council (Vetenskapsrådet); Liverpool School of Tropical Medicine; Norad for support of Beatrice Wangari Kirubi; and Swedish Institute for Clara Akie Yoshino.

Characteristics of included studies [ordered by study ID]