How Pakistan Is Boosting Health Outcomes for Mothers and Babies

Faced with widening inequality, federal and municipal governments in countries like Mexico and Brazil began introducing conditional cash transfers, or CCTs, in the 1990s. In these programs, the government transfers funds, generally to lower-income households, after the recipient fulfills some sort of goal, such as visiting a health care facility, getting vaccinated, or attending school.?

Over three decades, CCTs have spread to more than 100 mostly low- and middle-income countries, where they have been used to tackle issues ranging from low school attendance rates to poor maternal and child health outcomes. While they are rarer in high-income countries, CCTs are now being explored in the United States for their potential to address health disparities.?

In Pakistan, where the maternal mortality rate is 186 deaths per 100,000 live births, CCTs have been implemented in two provinces to incentivize actions linked to better maternal and child health outcomes. The initial results have been promising, particularly an increase in hospital visits during pregnancy.?

Successes and Pitfalls of CCTs in Pakistan?

Khyber Pakhtunkhwa and Sindh provinces, which together make up over 40 percent of the country’s population, both introduced CCT programs to improve maternal and child health. The Khyber Pakhtunkhwa CCT program encourages marginalized women — in this case, those in rural areas with lower incomes — to seek professional medical care during pregnancy and childbirth. Participants received a stipend to go to public health centers, including for prenatal visits, postnatal checkups, and delivery. For the women who’ve participated, the program has resulted in an 18 percent to 29 percent increase in hospital visits during pregnancy and postnatal checkups compared to nonparticipants. In a country where maternal health services are often inaccessible to low-income women, especially in rural areas, this impact is significant.?

In 2021, Sindh province similarly introduced a CCT program that offered pregnant women cash for each prenatal visit, delivery in a health facility, postnatal visit, child immunization, and birth certificate registration. While the cash amount was modest, and extensive flooding in Sindh limited the compliance rate to only 36 percent, there is some evidence that the program positively impacted postnatal care and checkups, as well as children’s age-adjusted height, Dr. Warda Riaz, who heads the program, says. The impact on prenatal care and institutional deliveries was more limited.?

Both programs can serve as models for incentivizing maternal health-seeking behavior in marginalized communities and improving access for people who previously couldn’t afford these services. They illustrate the potential of CCTs in addressing health challenges in low-resource settings, while highlighting the vulnerability of these programs to external factors.?

Could CCTs Be a Stepping Stone to Broader Reforms in the U.S.??

Conditional cash transfer programs in the United States have so far been limited to local pilots focusing on improving access to things like transportation and nutrition rather than maternal health services. But with nearly two-thirds of U.S. maternal deaths occurring within one year of birth, and with many of these deaths being preventable with medical intervention, CCT programs have the potential to promote lifesaving, health-seeking behaviors among new mothers. In states where maternal mortality rates are highest, such as Mississippi and Tennessee, CCT programs could promote postpartum checkups and other care that is associated with improved outcomes for vulnerable populations.?

Pakistan’s experience, however, suggests the need for caution in how CCTs are framed and implemented in the American context: CCTs are a stopgap rather than a solution to problems like maternal mortality. While CCTs can incentivize people to seek out health care services, individual behavioral changes are inadequate in the face of problems that are ultimately caused by wider systemic issues. High rates of maternal deaths are often driven by factors like inadequate health care infrastructure, lack of access for people living in certain areas, unaffordable insurance, and social drivers such as lack of education, unemployment, and racism, among many other factors. And for some, cash transfers are not enough to overcome barriers like the lack of transportation or inability to take time off work in order to meet the conditions for receiving benefits. So if CCTs are not coupled with broader reforms, they risk ignoring the structural issues that undermine maternal health outcomes in the first place.

A potential solution to this criticism of CCTs is unconditional cash transfers, which remove the conditions and allow recipients more flexibility in how they use their funds. This is what GiveDirectly did for its Basic Income Pilot for Pregnant Women in New York City, whose unconditional cash payments were found to reduce hospital stays and emergency room visits for the participating women.

CCTs can drive behavior change and improve health outcomes, but their conditional nature raises valid concerns about equity and access — of critical importance in the U.S., where Black and Indigenous women experience the highest rates of maternal death. But in countries where universal coverage is yet to be achieved, CCTs could be a powerful mechanism for improving outcomes in the short-term while working toward more ambitious, systemic reforms.

The author would like to thank Dr. Muhammad Faisal Shahzad and Dr. Warda Riaz for their review of this Insight.?