# Introduction

Maternal and child mortality rates have reduced significantly in Sub-Saharan Africa between 1990 and 2015. It is estimated that the under-five mortality rate reduced by 52 percent and maternal mortality rate by 49 percent (United Nations 2015). However, both mortality rates in the region remain about twice as high as the corresponding world averages, and the ambitious targets set by the Millennium Development Goals have not been achieved. Further reducing these rates has remained in the heart of the post-2015 international development agenda and new targets were set to be achieved by 2030 by the Sustainable Development Goals.<sup>1</sup> In an attempt to further improve maternal and child survival, a focus has been put on increasing coverage rates of antenatal care, skilled-attended delivery and postnatal care of both mothers and children.

This study evaluates the impact of an intervention that incentivized users of health services with in-kind conditional transfers. In particular, the intervention endowed women with gifts for receiving timely antenatal and postnatal care, as well as for delivering in health facilities. The objective of the demandside incentives strategy was to increase use of these targeted services in order to diagnose and treat preventable threats to maternal and neonatal health. The intervention was introduced in the context of the Community Performance-Based Financing (CPBF) program, an extension to the national Performance-Based Financing (PBF) program at the health facility level.

The evaluation relies on an experimental design in which funding for the implementation of the demand-side incentives was given to health centers in randomly selected sectors (sub-districts). Facilities received this funding for a period of about two and a half years. The analysis relies on a baseline household survey conducted prior to the launch of the program and a follow-up survey of households and health centers conducted about nine months after last funds were transferred to the facilities.

The results show that demand-side in-kind incentives can effectively increase utilization of targeted services. They caused an increase of 7.7 percentage points in the rate of women who initiated antenatal care within the first 4 months of their pregnancy and an increase of 8.6 percentage points in the rate of women who received postnatal care in the ten days following delivery. No significant impact was found on the rate of women who delivered in a health facility attended by a skilled health provider. However, the rate of in-facility skilled-assisted deliveries sharply increased across the board and reached 95 percent at the time of the follow-up survey.

These results are consistent with previous studies of schemes that conditioned demand-side transfers on health service utilization.<sup>2</sup> Banerjee, Duflo et al. (2010) report results of a clustered randomized controlled study in rural India in which provision of lentils and metal plates to families whose children got immunized significantly increased rates of full immunization. They conclude that the small incentives had a large impact and were more cost effective than improving the reliability of the availability of the immunization services. Other studies have evaluated the impacts of financial incentives. For example, Thornton (2008) finds that even small monetary incentives can double the share of individuals who learn results of HIV tests in Malawi. A cluster of studies evaluate the impacts of multi-sectoral social

> 1 www.un.org/sustainabledevelopment 2 Lagarde et al. (2008) and Gopalan et al. (2014) provide relevant reviews of the literature.

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