Why do families still not receive the child support grant in South Africa? A longitudinal analysis of a cohort of families across South Africa

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Study Justification:
This study aimed to investigate the factors associated with successful receipt of the child support grant (CSG) in South Africa. The CSG is the largest cash transfer program in Africa and has the potential to reduce poverty and improve health outcomes. However, no previous studies have examined the factors that influence CSG receipt. Understanding these factors is crucial for improving access to the program and promoting children’s rights.
Highlights:
– The study used longitudinal data from a community-based cluster-randomized trial promoting exclusive breastfeeding in South Africa.
– Data was collected from three different settings in South Africa: Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal.
– The study found that possession of a birth certificate was the strongest predictor of CSG receipt.
– Other factors associated with CSG receipt were having an HIV-positive mother and a household income below R1100.
– The uptake of the CSG among eligible children was suboptimal, highlighting the need for improved access to the program.
Recommendations:
– Efforts should be made to improve and ease access to the child support grant program in South Africa.
– Administrative requirements, such as possessing a birth certificate, should be addressed as a barrier to access.
– Strategies should be implemented to support HIV-positive mothers in accessing the CSG.
– Measures should be taken to address the financial constraints faced by households with incomes below R1100.
Key Role Players:
– Government agencies responsible for administering the child support grant program.
– Department of Home Affairs to address issues related to birth certificates.
– Non-governmental organizations working with HIV-positive mothers.
– Community-based organizations and peer-counsellors involved in promoting exclusive breastfeeding.
Cost Items for Planning Recommendations:
– Public awareness campaigns to inform eligible families about the child support grant program.
– Training and capacity-building for government officials and staff involved in administering the program.
– Outreach programs to assist families in obtaining birth certificates.
– Support services for HIV-positive mothers, including counseling and healthcare.
– Financial assistance programs or social welfare initiatives to support households with low incomes.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study used longitudinal data from a community-based cluster-randomized trial, which provides a solid foundation for the research. The sample size of 1148 mother-infant pairs is relatively large, increasing the statistical power of the study. The study also adjusted for study arm and clustering, which helps control for potential confounding factors. However, there are a few limitations that could be addressed to improve the evidence. First, the study only collected detailed information on CSG application and receipt at the final follow-up interview, which may introduce recall bias. It would be beneficial to collect this information at multiple time points to ensure accuracy. Second, the study did not explore other potential factors associated with CSG receipt, such as maternal education or employment status. Including these variables in the analysis could provide a more comprehensive understanding of the factors influencing CSG receipt. Finally, the study was conducted between 2006 and 2008, and it would be valuable to assess if the findings are still applicable today. Conducting a more recent study would strengthen the evidence and ensure its relevance.

Background: Child cash transfers are increasingly recognised for their potential to reduce poverty and improve health outcomes. South Africa’s child support grant (CSG) constitutes the largest cash transfer in the continent. No studies have been conducted to look at factors associated with successful receipt of the CSG. This paper reports findings on factors associated with CSG receipt in three settings in South Africa (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal). Methods. This study used longitudinal data from a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding by peer-counsellors in South Africa (ClinicalTrials.gov: NCT00397150). 1148 mother-infant pairs were enrolled in the study and data on the CSG were collected at infant age 6, 12, 24 weeks and 18-24 months. A stratified cox proportional hazards regression model was fitted to the data to investigate factors associated with CSG receipt. Results: Uptake of the CSG amongst eligible children at a median age of 22 months was 62% in Paarl, 64% in Rietvlei and 60% in Umlazi. Possessing a birth certificate was found to be the strongest predictor of CSG receipt (HR 3.1, 95% CI: 2.4 -4.1). Other factors also found to be independently associated with CSG receipt were an HIV-positive mother (HR 1.2, 95% CI: 1.0-1.4) and a household income below R1100 (HR1.7, 95% CI: 1.1 -2.6). Conclusion: Receipt of the CSG was sub optimal amongst eligible children showing administrative requirements such as possessing a birth certificate to be a serious barrier to access. In the spirit of promoting and protecting children’s rights, more efforts are needed to improve and ease access to this cash transfer program. © 2012 Zembe-Mkabile et al.; licensee BioMed Central Ltd.

This study used data from a community-based cluster-randomized trial promoting exclusive breastfeeding by peer-counsellors in three South African sites between 2006 and 2008. A total of 34 clusters from three separate areas in South Africa were chosen: Paarl in the Western Cape Province (peri-urban), Umlazi (urban) and Rietvlei (rural) in KwaZulu-Natal Province. Infant mortality rate (IMR) and antenatal HIV prevalence at the time of the study were 40/1000 and 10% in Paarl, 60/1000 and 42% in Umlazi and 99/1000 and 34% in Rietvlei. Full trial study methods are described elsewhere [19]. In the intervention arm women received 5 visits from peer supporters to promote exclusive breastfeeding and in the control arm women received the same number of visits from peer supporters but they were counselled on how to apply for the child support grant. The visits took place antenatally, and at 1 week, 4 weeks, 7 weeks and 10 weeks after birth. The trial found no effect of peer support visits on uptake of the child support grant at six months of age. Results of CSG receipt by arm were 54% in the infant feeding arm and 46% in CSG arm, but these results were not significant (Relative risk 1.0, 95% CI: 0.9 -1.2), therefore this paper analysed the study as a longitudinal cohort adjusting for study arm and clustering. A total of 1276 mother-infant pairs were recruited. Among these, 128 were excluded due to relocation or being lost-to-follow-up, twin delivery, death of infant or mother before 3 weeks after birth. Thus, 1148 mother-infant pairs remained in the analysis. The mother-infant pairs were scheduled to be interviewed at recruitment (antenatally) for socio-demographic information and at 3, 6, 12 and 24 weeks after birth for data regarding CSG uptake, with a final follow up visit amongst a sub sample of 741 children at a median age of 22 months (range 9–36 months) to assess final grant receipt. Detailed information on CSG application and receipt was only collected at the final follow-up interview to allow enough time for families to have gone through the grant process. Contact was made with mothers for the final follow up visit through home visits by data collectors. Where possible, mothers were first called on their cell phones to determine a suitable time for the visit. A structured paper based questionnaire was administered at the recruitment, 3, 6, 12 and 24 week data collection points by a trained data collector. Items in the questionnaire included socio demographics, infant feeding practices, grant application and receipt. At the final follow up interview data collectors captured the data using questionnaires loaded onto cell phones purchased for the study with built in range checks and skip logic. The questionnaires were automatically transferred to a central server once each one was completed. Items in this final questionnaire included timing of CSG application, barriers to CSG access, use of the CSG, anthropometry, and infant health. Data collectors were not involved in the implementation of the intervention. Data collected on paper were double entered using EpiData (http://www.epidata.dk) and merged with the data collected from the final interview on the cell phones. CSG receipt was defined as a mother reporting receipt of the grant at any of weeks 12, 24 or the final data collection point (median age 22 months). Possession of a birth certificate was defined as the mother reporting possessing a birth certificate for her child at any of weeks 6, 12 or 24. A survival analysis approach was used to model time to receipt of a CSG on a set of determinants. A stratified Cox proportional hazards model was fitted and hazard ratio estimates were obtained, with equal coefficients across strata (sites) but with a baseline hazard unique to each strata. The Breslow method was used for handling tied successes due to the limited number of data collection points. An epidemiological approach was undertaken in selecting variables for the model including demographic and socio-economic factors relevant to the South African context. In case of collinearity, one of the variables, such as Identity Document (ID) was collinear with Birth Certificate, and was subsequently dropped from the model. The models were adjusted for arm and clustering to account for the community randomised trial design. Possible interaction terms which included maternal education and arm; maternal education and birth certificate; birth certificate and arm were inserted into the model but none were found significant to include in the model. A socioeconomic wealth index was constructed with the use of multiple correspondence analysis based on ownership of assets including mobile phone and television, and house characteristics including water source, roof material and toilet type. This method is analogous to principal component analysis, and better suited for categorical data [20]. The infants’ households were grouped into quintiles on the basis of socioeconomic rank. Data analysis was done with SAS version 9.2 and STATA/IC 12.0. Ethics approval for the cluster randomised controlled trial was received from the Ethics Committee of the Medical Research Council South Africa. Signed or thumb-printed informed consent was obtained from each mother prior to study participation. Additional ethics approval was granted in a subsequent application to the Medical Research Council Ethics Committee for the additional data collection point when the children were at median age of 22 months. An information sheet explaining the purpose of the additional interview was read to each participant and each participant who agreed to participate signed a consent form. This study is registered with ClinicalTrials.gov, number {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00397150″,”term_id”:”NCT00397150″}}NCT00397150.

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Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Streamlined application process: Simplify and streamline the process for applying for the child support grant, making it easier for eligible families to access the funds.

2. Mobile applications: Develop a mobile application that allows mothers to apply for the child support grant directly from their smartphones, reducing the need for physical paperwork and making the process more convenient.

3. Birth certificate registration: Implement initiatives to increase birth registration rates, ensuring that all children have a birth certificate, which was found to be a strong predictor of CSG receipt in the study.

4. Community outreach: Increase community outreach efforts to raise awareness about the child support grant and provide information on how to apply, targeting areas with lower uptake rates.

5. Peer support networks: Establish peer support networks for mothers, where experienced mothers can provide guidance and support to new mothers, including information on accessing the child support grant.

6. Financial literacy programs: Provide financial literacy programs to help mothers understand the importance of the child support grant and how to effectively manage the funds for the benefit of their children’s health and well-being.

7. Collaboration with healthcare providers: Collaborate with healthcare providers to integrate information about the child support grant into antenatal and postnatal care visits, ensuring that eligible mothers are informed about the grant and how to apply.

8. Targeted interventions for vulnerable populations: Develop targeted interventions for vulnerable populations, such as HIV-positive mothers and households with low income, to address specific barriers they may face in accessing the child support grant.

9. Monitoring and evaluation: Implement a robust monitoring and evaluation system to track the impact of interventions aimed at improving access to the child support grant, allowing for continuous improvement and refinement of strategies.

10. Policy advocacy: Advocate for policy changes that address the barriers identified in the study, such as administrative requirements, to improve and ease access to the child support grant.
AI Innovations Description
The study mentioned in the description focuses on factors associated with successful receipt of the child support grant (CSG) in South Africa. The study found that possessing a birth certificate was the strongest predictor of CSG receipt. Other factors associated with CSG receipt were having an HIV-positive mother and a household income below R1100. The study suggests that administrative requirements, such as possessing a birth certificate, can be a barrier to accessing the CSG.

Based on the findings of this study, a recommendation to improve access to maternal health could be to streamline the administrative process for applying and receiving the child support grant. This could involve simplifying the documentation requirements, providing assistance to families in obtaining necessary documents, and ensuring that the application process is easily accessible to all eligible families. By reducing the administrative burden, more families would be able to access the CSG and receive the financial support they need for maternal health.
AI Innovations Methodology
The study you provided focuses on factors associated with successful receipt of the child support grant (CSG) in South Africa. To improve access to maternal health, here are some potential recommendations:

1. Streamline the application process: Simplify and streamline the application process for the CSG to reduce administrative barriers. This could include providing clear instructions, reducing paperwork, and improving accessibility through online or mobile application options.

2. Increase awareness and education: Implement targeted awareness campaigns to inform eligible families about the CSG and its benefits. This could involve community outreach programs, educational materials, and partnerships with healthcare providers to ensure that families are aware of their entitlements.

3. Improve documentation requirements: Address the issue of birth certificates being a barrier to access by exploring alternative forms of identification or simplifying the process of obtaining birth certificates. This could involve working with government agencies to streamline the documentation process or exploring digital identification options.

4. Enhance support services: Provide additional support services to help families navigate the application process and overcome any barriers they may face. This could include establishing dedicated helplines, providing assistance with filling out application forms, and offering guidance on required documentation.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that measure access to maternal health, such as the percentage of eligible families receiving the CSG, the time taken to process applications, and the number of families reporting barriers to access.

2. Collect baseline data: Gather data on the current state of access to maternal health, including the percentage of eligible families receiving the CSG, the average time taken to process applications, and the main barriers reported by families.

3. Implement the recommendations: Introduce the recommended innovations, such as streamlining the application process, increasing awareness and education, improving documentation requirements, and enhancing support services.

4. Monitor and collect data: Continuously monitor the implementation of the recommendations and collect data on the indicators identified in step 1. This could involve surveys, interviews, and analysis of administrative data.

5. Analyze the data: Analyze the collected data to assess the impact of the recommendations on access to maternal health. Compare the baseline data with the data collected after implementing the recommendations to identify any changes or improvements.

6. Evaluate the results: Evaluate the results of the analysis to determine the effectiveness of the recommendations in improving access to maternal health. This could involve assessing the percentage of eligible families receiving the CSG, the time taken to process applications, and the reduction in reported barriers.

By following this methodology, it would be possible to simulate the impact of the recommendations on improving access to maternal health and assess their effectiveness in addressing the barriers identified in the study.

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