{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T13:31:49Z","timestamp":1788787909012,"version":"build-2803163510"},"reference-count":55,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Mhealth Uhealth"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n Mobile money\u2013based 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.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n This mixed-methods study aims to analyze the impact and factors influencing the success of a mobile money\u2013based conditional cash transfer intervention for health care utilization at 4 primary and 11 secondary facilities in Madagascar.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n The interrupted time series analysis showed a significant negative impact on health care utilization, indicating a reduction in health care\u2013seeking behavior after the end of the cash transfer intervention. The effect was stronger in the slope change of patient numbers per month (defined as\n P<\/jats:italic>\n <.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 (\n P<\/jats:italic>\n <.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.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/60811","type":"journal-article","created":{"date-parts":[[2025,3,3]],"date-time":"2025-03-03T11:01:49Z","timestamp":1740999709000},"page":"e60811-e60811","source":"Crossref","is-referenced-by-count":3,"title":["Impact of a Mobile Money\u2013Based Conditional Cash Transfer Intervention on Health Care Utilization in Southern Madagascar: Mixed-Methods Study"],"prefix":"10.2196","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7548-4423","authenticated-orcid":false,"given":"Mara Anna","family":"Franke","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-5506-678X","authenticated-orcid":false,"given":"Anne","family":"Neumann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2211-9603","authenticated-orcid":false,"given":"Kim","family":"Nordmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-8075-1539","authenticated-orcid":false,"given":"Daniela","family":"Suleymanova","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-1944-7526","authenticated-orcid":false,"given":"Onja Gabrielle","family":"Ravololohanitra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3393-0840","authenticated-orcid":false,"given":"Julius Valentin","family":"Emmrich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3046-9075","authenticated-orcid":false,"given":"Samuel","family":"Knauss","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1010","published-online":{"date-parts":[[2025,3,3]]},"reference":[{"key":"R1","doi-asserted-by":"crossref","unstructured":"Ricci LA Ahokpossi C Belianska A . Digital currency innovations in sub-saharan africa. In: Regional Economic Outlook: Sub-Saharan Africa\u2014Living on the Edge. International Monetary Fund (IMF); 2022. URL: https:\/\/www.imf.org\/en\/Publications\/fintech-notes\/Issues\/2024\/03\/26\/Central-Bank-Digital-Currency-and-Other-Digital-Payments-in-Sub-Saharan-Africa-A-Regional-546859 [Accessed 17-02-2025] [doi: 10.5089\/9798400273025.063] ISBN: 9798400273025","DOI":"10.5089\/9798400273025.063"},{"key":"R2","unstructured":"State of the industry report on mobile money. GSMA. 2023. URL: https:\/\/www.gsma.com\/mobilefordevelopment\/resources\/state-of-the-industry-report-on-mobile-money-2023-2 [Accessed 16-02-2024]"},{"key":"R3","unstructured":"Garcia MH Moore CMT . The cash dividend: the rise of cash transfer programs in Sub-Saharan Africa. World Bank Group. 2022. URL: https:\/\/documents.worldbank.org\/en\/publication\/documents-reports\/documentdetail\/435291468006027351\/the-cash-dividend-the-rise-of-cash-transfer-programs-in-sub-saharan-africa [Accessed 17-02-2025]"},{"key":"R4","unstructured":"Joint United Nations Programme on HIV\/AIDS. Burkina Faso: providing cash transfers for vulnerable people living with HIV and key populations. UNAIDS and World Food Programme 2022. 2022. URL: https:\/\/www.unaids.org\/sites\/default\/files\/media_asset\/2022_WCA-cash-transfers-UNAIDS-WFP-BurkinaFaso_en.pdf [Accessed 02-01-2024]"},{"key":"R5","doi-asserted-by":"publisher","DOI":"10.1016\/j.worlddev.2021.105392","article-title":"Mobile money and healthcare use: Evidence from East Africa","volume":"141","author":"Ahmed","journal-title":"World Dev"},{"key":"R6","unstructured":"Madagascar. The World Bank. URL: https:\/\/data.worldbank.org\/country\/madagascar [Accessed 02-01-2024]"},{"key":"R7","doi-asserted-by":"publisher","DOI":"10.1051\/shsconf\/202316301039","article-title":"The economic impact of COVID-19 on African countries: the case of Madagascar","volume":"163","author":"Harisoa","journal-title":"SHS Web Conf"},{"key":"R8","unstructured":"Institut National de la Statistique. Troisi\u00e8me recensement G\u00e9n\u00e9ral de la population et de l\u2019Habitation. antananarivo, madagascar. [french]. INSAT Madagascar. 2019. URL: https:\/\/www.instat.mg\/?page_id=229, Accessed January 2, 2024 [Accessed 02-01-2024]"},{"key":"R9","unstructured":"World Food Programme Madagascar. 2022 annual country report highlights. 2022. URL: https:\/\/docs.wfp.org\/api\/documents\/WFP-0000148580\/download [Accessed 02-01-2024]"},{"key":"R10","unstructured":"Minist\u00e8re de la Sant\u00e9 Publique. Plan de D\u00e9veloppement du secteur sant\u00e9 2020-2024. World Health Organization Country Planning Cycle Database. 2019. URL: https:\/\/extranet.who.int\/countryplanningcycles\/planning-cycle-files\/plan-de-developpement-du-secteur-sante-2020-2024 [Accessed 02-01-2024]"},{"issue":"3","key":"R11","doi-asserted-by":"publisher","first-page":"325","DOI":"10.1007\/s40258-020-00580-x","article-title":"COVID-19 pandemic, a war to be won: understanding its economic implications for Africa","volume":"18","author":"Ataguba","journal-title":"Appl Health Econ Health Policy"},{"issue":"10","key":"R12","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pgph.0001852","article-title":"The impact of COVID-19 on health financing in Kenya","volume":"3","author":"Kairu","journal-title":"PLOS Glob Public Health"},{"key":"R13","unstructured":"United Nations Human Development Reports. Human development index (HDI). URL: https:\/\/hdr.undp.org\/data-center\/human-development-index [Accessed 02-01-2024]"},{"key":"R14","unstructured":"Lang E Saint-Firmin P Olivetti A et al. Analyse Du Syst\u00e8me de Financement de La Sant\u00e9 \u00e0 Madagascar Pour Guider de Futures R\u00e9formes, Notamment La CSU. Washington [USA]\u202f: Health Policy Plus; 2018. URL: https:\/\/p4h.world\/app\/uploads\/2023\/03\/2018_February_Analyse20du20systC3A8me20de20financement20de20la20SantC3A9_Madagascar.x23411.pdf [Accessed 02-01-2025] ISBN: 978-1-59560-165-0"},{"key":"R15","unstructured":"World Health Organization. Madagascar. URL: https:\/\/www.who.int\/countries\/mdg [Accessed 02-01-2024]"},{"key":"R16","unstructured":"mTOMADY. Powering access to healthcare. URL: https:\/\/www.mtomady.com [Accessed 13-05-2024]"},{"key":"R17","unstructured":"Creswell JW Plano Clark VL Westfall GJ . Designing and Conducting Mixed Methods Research. 3rded. Sage Publications; 2017. ISBN: 9781483344379"},{"issue":"2","key":"R18","doi-asserted-by":"publisher","first-page":"195","DOI":"10.1080\/07350015.1987.10509578","article-title":"Durbin\u2013Watson and generalized Durbin\u2013Watson tests for autocorrelations and randomness","volume":"5","author":"Ali","journal-title":"J Bus Econ Stat"},{"key":"R19","unstructured":"RStudio Team. RStudio: integrated development for R.* Boston, MA. RStudio, PBC; 2020. URL: http:\/\/www.rstudio.com [Accessed 27-02-2024]"},{"issue":"2","key":"R20","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"Braun","journal-title":"Qual Res Psychol"},{"issue":"2","key":"R21","doi-asserted-by":"publisher","first-page":"270","DOI":"10.5195\/jmla.2022.1271","article-title":"NVivo","volume":"110","author":"Dhakal","journal-title":"J Med Libr Assoc"},{"issue":"4","key":"R22","doi-asserted-by":"publisher","first-page":"344","DOI":"10.1016\/j.jclinepi.2007.11.008","article-title":"The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies","volume":"61","author":"von Elm","journal-title":"J Clin Epidemiol"},{"issue":"9","key":"R23","doi-asserted-by":"publisher","first-page":"1245","DOI":"10.1097\/ACM.0000000000000388","article-title":"Standards for reporting qualitative research: a synthesis of recommendations","volume":"89","author":"O\u2019Brien","journal-title":"Acad Med"},{"issue":"8","key":"R24","doi-asserted-by":"publisher","first-page":"1443","DOI":"10.1377\/hlthaff.2016.1419","article-title":"In Madagascar, use of health care services increased when fees were removed: lessons for universal health coverage","volume":"36","author":"Garchitorena","journal-title":"Health Aff (Millwood)"},{"issue":"11","key":"R25","doi-asserted-by":"publisher","first-page":"1453","DOI":"10.1002\/bjs.10249","article-title":"A global country-level comparison of the financial burden of surgery","volume":"103","author":"Shrime","journal-title":"Br J Surg"},{"key":"R26","doi-asserted-by":"publisher","DOI":"10.11604\/pamj.2021.38.198.27115","article-title":"Challenges in healthcare financing for surgery in sub-Saharan Africa","volume":"38","author":"Okoroh","journal-title":"Pan Afr Med J"},{"issue":"3","key":"R27","doi-asserted-by":"publisher","first-page":"567","DOI":"10.1016\/j.surg.2023.05.010","article-title":"Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa","volume":"174","author":"Yap","journal-title":"Surgery"},{"issue":"1","key":"R28","doi-asserted-by":"publisher","first-page":"010408","DOI":"10.7189\/jogh.06.010408","article-title":"Cost of management of severe pneumonia in young children: systematic analysis","volume":"6","author":"Zhang","journal-title":"J Glob Health"},{"key":"R29","doi-asserted-by":"publisher","DOI":"10.1016\/j.prrv.2020.01.001","article-title":"Economic burden of childhood asthma in children attending a follow-up clinic in a resource-poor setting of southeast Nigeria","volume":"37","author":"Ughasoro","journal-title":"Paediatr Respir Rev"},{"issue":"9","key":"R30","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.CD011247.pub2","article-title":"Unconditional cash transfers for assistance in humanitarian disasters: effect on use of health services and health outcomes in low- and middle-income countries","volume":"2015","author":"Pega","journal-title":"Cochrane Database Syst Rev"},{"issue":"1","key":"R31","doi-asserted-by":"publisher","first-page":"121","DOI":"10.1080\/19439342.2017.1363804","article-title":"The effectiveness and value for money of cash-based humanitarian assistance: a systematic review","volume":"10","author":"Tappis","journal-title":"J Develop Effect"},{"issue":"Suppl 2","key":"R32","doi-asserted-by":"publisher","first-page":"167","DOI":"10.1057\/s41271-016-0040-1","article-title":"The impact of digital technology on health of populations affected by humanitarian crises: Recent innovations and current gaps","volume":"37","author":"Mesmar","journal-title":"J Public Health Policy"},{"issue":"11","key":"R33","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1003388","article-title":"Evaluation of an unconditional cash transfer program targeting children\u2019s first-1,000-days linear growth in rural Togo: a cluster-randomized controlled trial","volume":"17","author":"Briaux","journal-title":"PLOS Med"},{"issue":"3","key":"R34","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0173068","article-title":"The effects of cash transfers and vouchers on the use and quality of maternity care services: a systematic review","volume":"12","author":"Hunter","journal-title":"PLOS One"},{"issue":"9","key":"R35","doi-asserted-by":"publisher","DOI":"10.2196\/30372","article-title":"Effectiveness of cash transfer delivered along with combination HIV prevention interventions in reducing the risky sexual behavior of adolescent girls and young women in Tanzania: cluster randomized controlled trial","volume":"8","author":"Kuringe","journal-title":"JMIR Public Health Surveill"},{"key":"R36","doi-asserted-by":"publisher","DOI":"10.2196\/45301","article-title":"Digital adherence technologies and mobile money incentives for management of tuberculosis medication among people living with tuberculosis: mixed methods formative study","volume":"7","author":"Musiimenta","journal-title":"JMIR Form Res"},{"key":"R37","unstructured":"World Health Organization. What do we know about community health workers? A systematic review of existing reviews. Geneva; (human resources for health observer series no. 19). Licence: CC BY-NC-SA 3.0 IGO. 2020. URL: https:\/\/creativecommons.org\/licenses\/by-nc-sa\/3.0\/igo"},{"issue":"1","key":"R38","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1046\/j.1525-1446.2002.19003.x","article-title":"Outcome effectiveness of community health workers: an integrative literature review","volume":"19","author":"Swider","journal-title":"Public Health Nurs"},{"issue":"1","key":"R39","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1186\/s12960-018-0304-x","article-title":"What do we know about community-based health worker programs? A systematic review of existing reviews on community health workers","volume":"16","author":"Scott","journal-title":"Hum Resour Health"},{"issue":"1","key":"R40","doi-asserted-by":"publisher","first-page":"113","DOI":"10.1186\/s13012-015-0301-6","article-title":"Narrative review of models and success factors for scaling up public health interventions","volume":"10","author":"Milat","journal-title":"Implement Sci"},{"issue":"2","key":"R41","doi-asserted-by":"publisher","first-page":"219","DOI":"10.1093\/heapol\/czz140","article-title":"Factors influencing the scale-up of public health interventions in low- and middle-income countries: A qualitative systematic literature review","volume":"35","author":"Bulthuis","journal-title":"Health Policy Plan"},{"key":"R42","unstructured":"Ergo A Paina L Morgan L Washington, DC: United States Agency for International Developmentet al. Creating stronger incentives for high-quality healthcare in low- and middle-income countries. Vol34. 2012. URL: https:\/\/api.semanticscholar.org\/CorpusID:53054518 [Accessed 28-02-2024]"},{"issue":"1","key":"R43","doi-asserted-by":"publisher","first-page":"77","DOI":"10.1186\/s12992-016-0213-5","article-title":"The inescapable question of fairness in pay-for-performance bonus distribution: a qualitative study of health workers\u2019 experiences in Tanzania","volume":"12","author":"Chimhutu","journal-title":"Global Health"},{"issue":"2","key":"R44","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2021-049499","article-title":"Effect of a multifaceted intervention on the utilisation of primary health for maternal and child health care in rural Nigeria: a quasi-experimental study","volume":"12","author":"Okonofua","journal-title":"BMJ Open"},{"issue":"4","key":"R45","doi-asserted-by":"publisher","first-page":"485","DOI":"10.1080\/00346764.2014.958901","article-title":"NGOs, the state, and development in Africa","volume":"72","author":"Nega","journal-title":"Rev Soc Econ"},{"issue":"5","key":"R46","doi-asserted-by":"publisher","DOI":"10.2196\/10235","article-title":"Factors determining the success and failure of eHealth interventions: systematic review of the literature","volume":"20","author":"Granja","journal-title":"J Med Internet Res"},{"key":"R47","doi-asserted-by":"publisher","DOI":"10.7554\/eLife.79615","article-title":"Lack of ownership of mobile phones could hinder the rollout of mHealth interventions in Africa","volume":"11","author":"Okano","journal-title":"Elife"},{"issue":"2","key":"R48","doi-asserted-by":"publisher","first-page":"74","DOI":"10.12856\/JHIA-2019-v6-i2-262","article-title":"Digital empowerment for health workers, and implications on EMRs utilisation","volume":"6","author":"Kanjo","journal-title":"J Health Inform Afr"},{"key":"R49","doi-asserted-by":"publisher","DOI":"10.1016\/j.imu.2022.100934","article-title":"Digital health literacy to share COVID-19 related information and associated factors among healthcare providers worked at COVID-19 treatment centers in Amhara region, Ethiopia: a cross-sectional survey","volume":"30","author":"Chereka","journal-title":"Inform Med Unlocked"},{"key":"R50","doi-asserted-by":"publisher","DOI":"10.3389\/fpubh.2023.1130894","article-title":"Digital literacy level and associated factors among health professionals in a referral and teaching hospital: an implication for future digital health systems implementation","volume":"11","author":"Tegegne","journal-title":"Front Public Health"},{"key":"R51","doi-asserted-by":"publisher","DOI":"10.3389\/fdgth.2022.876957","article-title":"Digital solutions for community and primary health workers: lessons from implementations in Africa","volume":"4","author":"Owoyemi","journal-title":"Front Digit Health"},{"issue":"2","key":"R52","doi-asserted-by":"publisher","first-page":"164","DOI":"10.3390\/healthcare8020164","article-title":"Determinants of motivation among healthcare workers in the East African community between 2009\u20132019: a systematic review","volume":"8","author":"Muthuri","journal-title":"Healthcare (Basel)"},{"key":"R53","doi-asserted-by":"publisher","DOI":"10.11604\/pamj.2020.35.84.19630","article-title":"Measles outbreak in 2018-2019, Madagascar: epidemiology and public health implications","volume":"35","author":"Nimpa","journal-title":"Pan Afr Med J"},{"key":"R54","unstructured":"Plague \u2013 madagascar (online). World Health Organization. URL: https:\/\/www.who.int\/emergencies\/disease-outbreak-news\/item\/15-november-2017-plague-madagascar-en [Accessed 02-01-2024]"},{"key":"R55","unstructured":"Institut National de la Statistique et ICF. Enqu\u00eate D\u00e9mographique et de sant\u00e9 \u00e0 Madagascar, 2021 [French]. The DHS Program. INSTAT and ICF; Aug2022. URL: https:\/\/www.dhsprogram.com\/publications\/publication-FR376-DHS-Final-Reports.cfm [Accessed 02-02-2024]"}],"container-title":["JMIR mHealth and uHealth"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/mhealth.jmir.org\/2025\/1\/e60811","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T22:31:39Z","timestamp":1785537099000},"score":1,"resource":{"primary":{"URL":"https:\/\/mhealth.jmir.org\/2025\/1\/e60811"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,3,3]]},"references-count":55,"URL":"https:\/\/doi.org\/10.2196\/60811","relation":{},"ISSN":["2291-5222"],"issn-type":[{"value":"2291-5222","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,3,3]]},"article-number":"v13i3e60811"}}