Understanding use of health services in conditional cash transfer programs: insights from qualitative research in Latin America and Turkey.

Conditional cash transfer programs provide cash grants to poor households conditional on their participation in primary health care services. While significant impacts have been demonstrated quantitatively, little attention is paid to why CCTs have these observed impacts, and as importantly- why impacts are not greater than they are. This article draws on qualitative research from four countries over a ten year period (1999-2009) to provide insights into why expected health and nutrition impacts do and do not occur. In Nicaragua, El Salvador, and Turkey, ethnographic methods were used, involving between 87 and 120 households per country, and in Mexico, focus groups were conducted with 230 people. Key informant interviews were conducted with health care providers in all countries. While CCTs operate primarily on the assumption that a cash incentive will produce behaviour change, we found multiple sociocultural and structural influences on health care decisions that compete with cash. These include beliefs around traditional and modern biomedical practices, sociocultural norms, gender relations, and the quotidian experience of poverty in many dimensions. We conclude that impacts can be increased through a better understanding of multiple contextual influences on health care decisions, and greater attention to the health education components and complementary interventions.