And the way they work is by offering small cash payments to poorer people, with strings very much attached. In other words, recipients (often mothers) are only awarded a stipend on the condition that they attend pre-natal check-ups, get their babies vaccinated or make sure that their children attend school.
New Incentives, a non-profit out of Uyo, Nigeria, is a big believer in the power of CCTs. It was founded in 2011 by Svetha Janumpalli, following her research at the Center for Effective Global Action at the University of California Berkeley with faculty who conducted evaluations of leading CCT programs. CCTs are, according to Janumpalli, among the most well-studied, evidence-based development tools in the world - and the most effective.
Since then, New Incentives has gone through several incarnations, first as a crowdfunding platform helping other nonprofits raise and distribute CCTs, then implementing its own programme in Nigeria in 2014, providing CCTs for mothers who agree to give birth in hospital rather than at home. As of late 2016, it’s shifted again, to focus 100% on the vaccination of babies, also in Nigeria, as Patrick Stadler, chief strategy officer at New Incentives, explains:
There are five vaccinations to be given in a baby’s first year of life, and for each of the visits attended, our staff member hands out an amount of between $1 and $4 to the mother. The reason, of course, is that many childhood illnesses and unavoidable deaths can be prevented through vaccination, especially in a country like Nigeria.
But while much has been done by organizations including the Gates Foundation, UNICEF and the World Health Organisation to tackle the supply side of getting vaccines to clinics, even in remote rural areas, challenges remain on the demand side, he says.
Poorer mothers still face huge challenges in accessing vaccines that are now readily available. They must get to the clinic, for a start, and transport is a huge issue in these regions and it’s not cheap for them. They have to believe that vaccination is good for their child, and here we see an issue with traditional beliefs that can be overcome with cash. And, as a poorer mother in Nigeria, you face a lot of tough decisions - should you travel to the clinic to get your baby vaccinated or should you spend that time at the market selling goods to earn money to feed your family?
Against that background of tough decisions, and to kickstart behavior change, it’s helpful to alert mothers to their infants’ upcoming vaccination appointments, along with the opportunity to earn CCTs through attendance. This is where Twilio comes in: New Incentives has implemented the cloud-based communications platform for building SMS, voice and messaging applications to provide mothers with helpful reminders via mobile phones, Stadler explains:
We basically transcribe the child health cards that mothers are issued, containing all the details of vaccinations and appointments, into our database. We’ve then linked that database to a platform called TextIt, where we can set up certain rules - for example, send a message to the mother two days before the vaccination appointment. TextIt is then linked with Twilio, which triggers a send command once the rule has been fulfilled.
Around four out of five women that New Incentives works with, says Stadler, have access to a mobile phone. It’s typically just a feature phone, and it may be shared by the family, or belong to their husband, but that’s sufficient to make sure messages reach them and achieve a marked uplift in attendance at health clinics.
So far, New Incentives has used Twilio to serve 20,000 beneficiaries, each receiving about 10 message each. It’s still early days for the vaccination programme, which only got underway this year, but with New Incentives’ previous programme to boost labor and delivery in healthcare facilities through the use of CCTs, a randomized control trial was shown to achieve a 100% increase in facility deliveries among participants, he says.
This year, we’ll do another randomized control trial on a vaccination programme, but I’m happy to say that from our early internal data, it looks really promising, with a massive boost in retention. And we’re already seeing that mothers who had stopped attending clinics with their babies are now coming back. If this programme works, it has huge potential, because there are around 7 million babies born every year in Nigeria alone.
We’ll definitely keep using Twilio for SMS sending for any expansion of our programme. The messages are generally in English and we work to keep them simple, direct and personalized, using the mother’s name, the baby’s name and the hospital name. But we might also start using Twilio’s ‘robot calls’ option, so that we can send pre-recorded calls to mothers as reminders in local languages.
The overall thinking here is that transfers of income made via CCTs ensure that families need less help over time. By assisting them to invest today in raising healthier, better educated youngsters, a new generation will enter the labor market in a better position to earn income through its own efforts, thus escaping the intergenerational poverty trap. It also empowers women to make choices for their own family, says Stadler.
They know best what their family needs. It might be a bike or a cow - but they’re the one to make that decision. They receive the money and they can invest it how they like.