Informing Decisions with Disparate Stakeholders: Cross-sector Evaluation of Cash Transfers in Malawi

Overview

Journal Health Policy Plan

Date 2021 Nov 18

PMID 34791229

Citations 4

Authors

Francesco Ramponi

Dominic Nkhoma

Susan Griffin

Affiliations

Soon will be listed here.

Abstract

The Social Cash Transfer Programme (SCTP) in Malawi is a cross-sectoral policy with impacts on health, education, nutrition, agriculture and welfare. Implementation of the SCTP requires collaboration across sectors and across national and international stakeholders. Economic evaluation can inform investment by indicating whether benefits exceed costs, but economic evaluations that provide an overall benefit-cost ratio typically assume a common agreed objective and agreed set of value judgements. In reality, the various stakeholders involved in the delivery of the SCTP may have different remits and objectives and may differ in how they value the impacts of the programme. We use the SCTP as a case study to illustrate a cross-sectoral analytical framework that accounts for these differences. The stakeholders that contribute to the SCTP include the Ministry of Gender, Ministry of Finance, Ministry of Economic Planning and Development and Global Fund. We estimate how the SCTP changes outcomes in education, health, net production and poverty, and distinguish outcomes in three groups: SCTP recipients; population in Malawi not eligible for the SCTP and population in other countries. After estimating the direct effects and opportunity costs from investing in the SCTP, we summarize the results according to different perspectives. The SCTP is estimated to provide benefits in excess of costs from the perspective of national stakeholders. From the perspective of an international donor interested in health outcomes, its health benefits do not outweigh the opportunity costs unless health improvement in SCTP recipients is valued at 18 times that of other potential spending beneficiaries or the donor values broader outcomes than health alone. This work illustrates the potential of a cross-sectoral economic evaluation to guide debate about stakeholder contributions to the SCTP, and the value judgements required to favour the SCTP above other policy options.

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References

Remme M, Martinez-Alvarez M, Vassall A . Cost-Effectiveness Thresholds in Global Health: Taking a Multisectoral Perspective. Value Health. 2017; 20(4):699-704. DOI: 10.1016/j.jval.2016.11.009. View

Wilford R, Golden K, Walker D . Cost-effectiveness of community-based management of acute malnutrition in Malawi. Health Policy Plan. 2011; 27(2):127-37. DOI: 10.1093/heapol/czr017. View

Walker S, Griffin S, Asaria M, Tsuchiya A, Sculpher M . Striving for a Societal Perspective: A Framework for Economic Evaluations When Costs and Effects Fall on Multiple Sectors and Decision Makers. Appl Health Econ Health Policy. 2019; 17(5):577-590. PMC: 6748888. DOI: 10.1007/s40258-019-00481-8. View

McDonald C, Olofin I, Flaxman S, Fawzi W, Spiegelman D, Caulfield L . The effect of multiple anthropometric deficits on child mortality: meta-analysis of individual data in 10 prospective studies from developing countries. Am J Clin Nutr. 2013; 97(4):896-901. DOI: 10.3945/ajcn.112.047639. View

Gelli A, Cavallero A, Minervini L, Mirabile M, Molinas L, de la Mothe M . New benchmarks for costs and cost-efficiency of school-based feeding programs in food-insecure areas. Food Nutr Bull. 2012; 32(4):324-32. DOI: 10.1177/156482651103200403. View

Bennett S, Glandon D, Rasanathan K . Governing multisectoral action for health in low-income and middle-income countries: unpacking the problem and rising to the challenge. BMJ Glob Health. 2018; 3(Suppl 4):e000880. PMC: 6195144. DOI: 10.1136/bmjgh-2018-000880. View

Woods B, Revill P, Sculpher M, Claxton K . Country-Level Cost-Effectiveness Thresholds: Initial Estimates and the Need for Further Research. Value Health. 2016; 19(8):929-935. PMC: 5193154. DOI: 10.1016/j.jval.2016.02.017. View

Teerawattananon Y, McQueston K, Glassman A, Yothasamut J, Myint C . Health technology assessments as a mechanism for increased value for money: recommendations to the Global Fund. Global Health. 2013; 9:35. PMC: 3848836. DOI: 10.1186/1744-8603-9-35. View

Ochalek J, Revill P, Manthalu G, McGuire F, Nkhoma D, Rollinger A . Supporting the development of a health benefits package in Malawi. BMJ Glob Health. 2018; 3(2):e000607. PMC: 5898345. DOI: 10.1136/bmjgh-2017-000607. View

10.

Siddiqi A, Rajaram A, Miller S . Do cash transfer programmes yield better health in the first year of life? A systematic review linking low-income/middle-income and high-income contexts. Arch Dis Child. 2018; 103(10):920-926. DOI: 10.1136/archdischild-2017-314301. View

11.

Shillcutt S, Walker D, Goodman C, Mills A . Cost effectiveness in low- and middle-income countries: a review of the debates surrounding decision rules. Pharmacoeconomics. 2009; 27(11):903-17. PMC: 2810517. DOI: 10.2165/10899580-000000000-00000. View

12.

Batura N, Hill Z, Haghparast-Bidgoli H, Lingam R, Colbourn T, Kim S . Highlighting the evidence gap: how cost-effective are interventions to improve early childhood nutrition and development?. Health Policy Plan. 2014; 30(6):813-21. PMC: 4451167. DOI: 10.1093/heapol/czu055. View

13.

Samb B, Evans T, Dybul M, Atun R, Moatti J, Nishtar S . An assessment of interactions between global health initiatives and country health systems. Lancet. 2009; 373(9681):2137-69. DOI: 10.1016/S0140-6736(09)60919-3. View

14.

Poore P . The Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM). Health Policy Plan. 2003; 19(1):52-3. DOI: 10.1093/heapol/czh006. View

15.

Remme M, Vassall A, Lutz B, Luna J, Watts C . Financing structural interventions: going beyond HIV-only value for money assessments. AIDS. 2014; 28(3):425-34. DOI: 10.1097/QAD.0000000000000076. View

16.

McGuire F, Vijayasingham L, Vassall A, Small R, Webb D, Guthrie T . Financing intersectoral action for health: a systematic review of co-financing models. Global Health. 2019; 15(1):86. PMC: 6918645. DOI: 10.1186/s12992-019-0513-7. View

17.

Dake F, Natali L, Angeles G, de Hoop J, Handa S, Peterman A . Cash Transfers, Early Marriage, and Fertility in Malawi and Zambia. Stud Fam Plann. 2018; 49(4):295-317. PMC: 6662603. DOI: 10.1111/sifp.12073. View

18.

Robinson L, Hammitt J, Jamison D, Walker D . Conducting Benefit-Cost Analysis in Low- and Middle-Income Countries: Introduction to the Special Issue. J Benefit Cost Anal. 2020; 10(Suppl 1):1-14. PMC: 7672367. DOI: 10.1017/bca.2019.4. View

19.

Kilburn K, Handa S, Angeles G, Mvula P, Tsoka M . Short-term Impacts of an Unconditional Cash Transfer Program on Child Schooling: Experimental Evidence from Malawi. Econ Educ Rev. 2018; 59:63-80. PMC: 5844286. DOI: 10.1016/j.econedurev.2017.06.002. View

20.

Sculpher M, Claxton K, Pearson S . Developing a Value Framework: The Need to Reflect the Opportunity Costs of Funding Decisions. Value Health. 2017; 20(2):234-239. DOI: 10.1016/j.jval.2016.11.021. View