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Concerns about the demands that conditions place on beneficiaries are addressed in Tanzania’s CB-CCT, which exempts children who are household heads and the chronically ill from fulfilling conditions. In addition, households receive transfers for one year before they can be financially penalized for not complying with conditions. In all households, failure to comply with conditions initially results in a warning and a visit to the household to determine if there is a valid reason for noncompliance. Further noncompliance results in another warning and a payment reduction for each noncomplying household member (equivalent to 25 percent of elderly persons’ payments and 50 percent of children’s payments). Continuing noncompliance eventually results in suspension from the program, although beneficiaries may return later. This flexibility, combined with the fact that some payments are automatically paid without penalty because of the timing of monitoring, helps to ensure 122 The Cash Dividend that households are not inappropriately excluded from the program (Ayala Consulting 2008).
Other CCTs in the region still provide transfers, albeit reduced, to households that do not comply with conditions. In Kenya’s CT for OVC, a household will forfeit K Sh 400 (US$5.60) of their total transfer for every child or adult not complying with conditions. When households fulfill conditions, they receive transfers of K Sh 1,000 (US$14) for households with one or two OVC, K Sh 2,000 (US$28) for households with three to four OVC, and K Sh 3,000 (US$42) for households with five or more OVC (World Bank 2009d). This reduction for noncompliance with conditions theoretically allows households to receive at least K Sh 200 (US$2.80) in households with seven or fewer noncomplying members.
Frequency of monitoring is another issue that should be considered in Sub-Saharan Africa’s conditional programs, keeping in mind both the demands every round of verification will place on the program and the constraints beneficiary households face in fulfilling conditions. For instance, Zambia’s Monze SCT was expected to verify compliance with education conditions only once per school term, rather than monthly. This plan was put in place to allow rural agricultural households to use household labor during key parts of the agricultural season without failing to meet the 80 percent school attendance requirement (Schüring 2010b).5 In some countries, communities support conditions. In some cases, Africans support conditioning transfers. Communities benefiting from the pilot of Kenya’s CT for OVC requested that transfers be conditioned.
In general, the argument that conditions are politically appealing is based on the idea that conditions satisfy the tax base that their money is being spent well, although the Kenyan communities’ request was unrelated to this argument.
Similar support for conditional transfers was found in households of varied income levels and urban-rural locations in Zambia. The support was attributed to the conditions’ ability to help beneficiaries know how to spend transfers and avoid misusing them. Favorable opinions of conditions were not unqualified, however. Individuals’ support for CCTs depended on the group targeted for the transfers and the availability of necessary supply-side infrastructure (Schüring 2010b).
Interestingly enough, the same study found that most beneficiaries thought conditions were empowering. This finding was particularly true in the case of illiterate households. The conditions guided beneficiaries toward behaviors that they may have had little information about Design and Implementation of Cash Transfers in Sub-Saharan Africa 123 previously. The conditions also helped beneficiaries bargain over household expenditures with their spouses because of the clear expectations about households’ responsibilities with respect to transfer receipt. The study noted, however, that the sense of empowerment may have been generated through another, possibly more cost-effective method, such as an awareness campaign (Schüring 2010b).
Issues to consider when using soft conditions include credibility, communications, and cost-benefit assessments. Programs interested in using soft conditions must consider several factors. A program that does not expect to enforce conditions but says it will do so is willingly being disingenuous and is potentially undermining trust between the state and citizens. Programs that plan to enforce conditions but do not make progress toward that goal should keep in mind that the relevant ministry’s credibility may decrease if it does not align its communication and practices (Regalia 2006).
Programs that plan to enforce conditions but are unable to immediately do so have to make a strategic decision regarding how to present the conditions. They can initially present the conditions as highly encouraged behaviors without threatening beneficiaries with penalties for noncompliance. A communication campaign alerting beneficiaries to the conditional nature of the program could be launched once the program is able to monitor conditions. However, the program may have to deal with opposition from beneficiaries whose transfers shift from UCTs to CCTs.
If a CT program makes the strategic decision to use soft conditions because of concerns that the cost of compliance with hard conditions would be too high for beneficiaries, it should be careful not to present soft conditions in a way that is counterintuitive to the program rationale.
To the extent that beneficiaries feel obliged to keep their commitment, even when no penalty for noncompliance is threatened, the program may be inadvertently placing conditions on beneficiaries.
Either way, programs interested in using soft conditions should consider the costs and benefits involved with this approach versus those of a simple social marketing campaign.
Concurrent Supply-Side Initiatives in Conditional Cash Transfer Programs: The African Approach Cash transfers often uncover weaknesses in service delivery systems.
When a CT’s major objective is to increase human capital investments, 124 The Cash Dividend supply-side issues often need to be addressed. CTs, and especially CCTs, may expose limitations of the current services as increased demand is placed on those services. Such weaknesses may affect programs’ longterm results. Fiszbein and Schady (2009) assessed evidence on the effects of CCTs throughout the world and found that though intermediate effects of such programs are often positive, final outcomes, such as children’s height-for-age or test scores, are often more mixed. They suggest that one factor contributing to this result is that CCTs may place more children in inferior health and education services, thereby resulting in poorer outcomes.6 This issue is particularly important to address in SubSaharan Africa, where supply-side infrastructure is often not capable of meeting increased demand.
Rather than not enforcing conditions in areas with limited supply-side capacity, CCT programs may simply limit their coverage to areas with sufficient supply-side infrastructure. For example, Eritrea’s RBF recognizes that quality of health services is crucial to program outcomes, and eligible sublocations must have at least one health center with proper sanitation practices, a clean water source, and proper lighting (Ayala Consulting 2009). Alternatively, NGOs or other agencies are sometimes engaged to improve supply-side infrastructure and services.7 However, this practice can generate conflict with line ministries or other involved parties when other organizations appear to encroach on territory within their jurisdiction. Engaging NGOs is a stopgap measure rather than a long-term solution.
Other CT programs have capitalized on potential synergies with successful supply-side programs already being implemented. Although it is a UCT, Senegal’s CF-SCT provides a helpful example. It uses some of the systems already developed in the successful Nutrition Enhancement Program to lessen the programming burden on the CT, and it confines its work to areas that have already received extensive support for maternal and children’s health (World Bank 2009a). The health care system, which was recently expanded at the community level, is able to support the increased demand that the SCT is expected to generate. Similarly, Eritrea’s RBF is expected to complement a World Bank–funded project known as HAMSET-II (the Second HIV/AIDS/STI, Tuberculosis, Malaria and Reproductive Health Project), which is working to improve the health sector through training employees, providing supplies, and promoting appropriate behavioral changes (Ayala Consulting 2009).
Another strategy that deals with supply-side constraints is to work to improve service delivery infrastructure through the program itself.
Design and Implementation of Cash Transfers in Sub-Saharan Africa 125 Although this approach may be successful, it places significant pressure on programs, especially those at the pilot stage, and the programs require agreement and significant coordination between the CT and line ministries. Each such layer of organizational complexity introduces new variables and risks that will have to be managed if the program is to succeed.
Once again, Eritrea’s RBF provides a good example of a program that is addressing supply-side weaknesses. The RBF includes a component of CCTs that are paid to local health officials provided that they fulfill agreed-on health targets. Individual outcome-based payments to frontline workers are combined with larger supplemental transfers to health systems. Considerable flexibility is given to local managers to allow them to decide how to use these additional funds. Those efforts can motivate local providers to find ways to decrease access costs to health care. RBF’s supply-side investment is supposed to help health providers meet the increased demand generated by the program’s transfers, which are conditioned on use of the health system (Ayala Consulting 2009).
Services may sometimes be available but underused owing to other constraints that CTs may be able to address. Eritrea’s RBF CCT also recognized that a major limitation keeping women from giving birth in an appropriate facility was a lack of timely transportation to medical institutions. In addition to providing traditional CCTs to women, the program raises awareness among transport providers and awards vouchers to individuals who transport women to health facilities when they are about to give birth or are facing complications (Ayala Consulting 2009).
Although CCTs will ideally be able to work with line ministries to coordinate increasing demand and supply for health care, education, and more, these efforts often take significant time, resources, and patience to achieve. Ministries may need to expand their collaboration with other agencies both at the top and at the ground levels and both vertically and horizontally. Buy-in of significant political players at multiple levels of government must be won, and this support has to be backed with appropriate resources that allow civil servants to execute mandates of increased interagency coordination. Additional personnel may need to be hired and trained, and spheres of responsibility must be negotiated. Coordination efforts must be ongoing. Although the most obvious capacity issue with CCTs is often seen at local supply-side bottlenecks, capacity at the central level in human resources, planning, logistics, and execution is just as important for improving delivery of key services crucial to program outcomes.
126 The Cash Dividend Areas for Future Study Related to Conditions and Supply-Side Capacity Given the challenges inherent in applying conditions in many SubSaharan African countries, the use of conditions in Sub-Saharan Africa must be analyzed more thoroughly and within a wider variety of contexts. Early quantitative analysis of CCTs versus UCTs in Sub-Saharan Africa suggests that conditions may be important to achieve certain outcomes, although a CCT is not necessarily the right instrument to achieve all goals (see box 3.5). Results may be closely tied to which activities are conditioned.