TY  - JOUR
AU  - Franke, Mara Anna
AU  - Neumann, Anne
AU  - Nordmann, Kim
AU  - Suleymanova, Daniela
AU  - Ravololohanitra, Onja Gabrielle
AU  - Emmrich, Julius Valentin
AU  - Knauss, Samuel
PY  - 2025
DA  - 2025/3/3
TI  - Impact of a Mobile Money–Based Conditional Cash Transfer Intervention on Health Care Utilization in Southern Madagascar: Mixed-Methods Study
JO  - JMIR Mhealth Uhealth
SP  - e60811
VL  - 13
KW  - cash transfer intervention
KW  - Madagascar
KW  - Sub-Saharan Africa
KW  - health care utilization
KW  - humanitarian assistance
KW  - Africa
KW  - mobile
KW  - mixed methods study
KW  - money
KW  - quantitative
KW  - qualitative
KW  - thematic analysis
KW  - policy
KW  - service
KW  - delivery
KW  - health care system
KW  - cash
KW  - economic
KW  - financial
KW  - payment
KW  - time series
AB  - Background: Mobile money–based cash transfer interventions are becoming increasingly utilized, especially in humanitarian settings. southern Madagascar faced a humanitarian emergency in 2021-2022, when the second wave of the COVID-19 pandemic and a severe famine affected the fragile region simultaneously. Objective: This mixed-methods study aims to analyze the impact and factors influencing the success of a mobile money–based conditional cash transfer intervention for health care utilization at 4 primary and 11 secondary facilities in Madagascar. Methods: We obtained quantitative data from 11 facility registers, detailing patient numbers per month, categorized into maternity care, surgical care, pediatric care, outpatient care, and inpatient care. An interrupted time series analysis, without a control group, was conducted using the end of the intervention in July 2022 as the cut off point. For qualitative data, 64 in-depth interviews were conducted with health care providers, NGO staff, policymakers, beneficiaries, and nonbeneficiaries of the intervention, and was interpreted by 4 independent researchers using reflexive thematic analysis to identify facilitators and barriers to implementation. Results: The interrupted time series analysis showed a significant negative impact on health care utilization, indicating a reduction in health care–seeking behavior after the end of the cash transfer intervention. The effect was stronger in the slope change of patient numbers per month (defined as P<.05), which significantly decreased in 39 of 55 (70%) models compared to the step change at the end of the intervention, which showed a significant but lower change (P <.05) in 40% (22/55) of models. The changes were most pronounced in surgical and pediatric care. The key factors that influenced the success of the implementation were grouped across three levels. At the community level, outreach conducted to inform potential beneficiaries about the project by community health workers and using the radio was a decisive factor for success. At participating facilities, high intrinsic staff motivation and strong digital literacy among facility staff positively influenced the intervention. Confusion regarding previous activities by the same implementing NGO and perceptions of unfair bonus payments for health care providers included in the project negatively affected the intervention. Finally, at the NGO-level, the staff present at each facility and the speed and efficiency of administrative processes during the intervention were decisive factors that influenced the intervention. Conclusions: The conditional cash transfer intervention was overarchingly successful in increasing health care utilization in southern Madagascar in a humanitarian setting. However, this success was conditional on key implementation factors at the community, facility, and NGO levels. In the future, similar interventions should proactively consider the key factors identified in this study to optimize the impact. 
SN  - 2291-5222
UR  - https://mhealth.jmir.org/2025/1/e60811
UR  - https://doi.org/10.2196/60811
DO  - 10.2196/60811
ID  - info:doi/10.2196/60811
ER  -