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

Cash transfer programs have increasingly become the strategy of choice for poverty alleviation in middle and low-income regions such as Latin America and Caribbean countries (LAC), Asia, and Africa [1, 2]. Many of these programs have been found to be effective in improving child outcomes such as learning outcomes, child growth and nutrition. However, several of the child cash transfer programs that have been evaluated and rolled out at scale are conditional cash transfers (CCTs). Conditionality refers to post-grant conditions that require recipients to change their behaviour for purposes of human capital development. Very few developing countries have unconditional child cash transfer programs although they are common in developed countries such as the United Kingdom and several other European Union countries. In Africa, there are a number of unconditional cash transfer programs that exist in countries such as Zambia, Malawi, Ghana, and Kenya but these are either small scale (often pilot programs covering less than 100 000 beneficiaries) or they are not exclusively targeted at children [3].

Debates on conditional and unconditional cash transfers centre on two main contending arguments. Proponents of conditional cash transfers argue that conditioning transfers on behavioural change helps to address not only immediate poverty but long-term poverty through its insistence on human capital investment [4]. However, advocates of unconditional cash transfers believe that human capital investment in beneficiaries can be enhanced without enforcing conditionality. This group assert that conditionality is a violation of social protection as a human right since it interferes with beneficiaries’ right to choose on what and how the transfer should be spent [5].

CCTs which have garnered world-wide praise and great interest are from the LAC countries, specifically Bolsa Familia in Brazil and Opportunidades in Mexico (formerly called Progresa). Both programs are targeted and non-contributory, focusing on the health, education and nutrition of children from the poorest households in the two countries [4, 6‐8]. The two CCTs have been associated with high rates of school enrolment and attendance, improved child growth (lower prevalence of stunting), increased utilisation of health care services, and in the case of Bolsa Familia, contributing to a reduction in inequality [7, 8].

South Africa is unique among developing countries for establishing a large scale cash transfer program, the Child Support Grant (CSG), for children of poor families. While the CSG is not conditional on behavioural change it does have requirements, which need to be met by prospective recipients. These are: possession of a birth certificate for the child, an identity document for the mother, hospital card, Road to Health Card (infant health record), and a parental income that is currently set at less than R2800 (US$340) per month for single parents, and R5600 (US$680) for married couples. At the time of the study eligibility was below R1100 parental income per month for urban areas and below R800 for rural areas. Recently other requirements for school enrolment and attendance for children between the ages of 7 and 18 years have been added. This new amendment to CSG legislation emphasises that proof of school enrolment and attendance is not a condition for continued receipt of the CSG, but is there to help identify and help children who are struggling to remain in the school system [9]. The CSG was introduced 14 years ago as a response to childhood poverty and it constitutes the largest cash transfer in the continent, both in terms of coverage ( over 10 million children) and the state budget allocated to it (US$695 million per annum) [10]. Over the years, the age limit for eligibility has been repeatedly extended, most recently to 18 years of age. The target set by the Department of Social Development is to reach 100% of all eligible children in the country.

During the early stages of its implementation the CSG was plagued with roll out challenges such as low uptake rates, which have since improved [11]. More recently there have been other debates around conditionality and targeting, with some advocating for continued receipt of the grant to be tied to conditions, and others arguing for universal access instead of means testing for eligibility [12, 13]. The discourse on conditionality in South Africa has been spurred in part by the success of conditional cash transfer programs in LAC countries.

There has been a general paucity of empirical evidence on the performance of the CSG. The few studies that have been conducted have looked at the grant’s reach, utilisation and impact. A national survey conducted by Delany and colleagues in 2008 with some 2700 households in South Africa showed that the CSG is reaching 80% of its intended beneficiaries among all eligible children 0–14 years, constitutes 40% of the household income in poor families, and that 80% of it is used for food, clothing and school related costs [14]. Additionally, more recent evidence shows that take up rates of the CSG are highest between the ages of 7 to 10 years and are lower for infants and adolescents, and that early receipt of the grant is associated with improved child height for age for children whose mothers have higher education levels; and more grades in school for girl children whose mothers have lower education attainment, as well as reduced risky behaviours amongst adolescents [15]. Another study showed that the CSG is positively correlated with improved child nutritional status, and that early receipt of the grant in the first few months of life is critical to achieving this outcome [16]. These studies validate the importance of CSG access and timing of receipt in maximising the benefits of the grant for each child. The study by Delany and colleagues while showing that receipt of the CSG may be high at a national level, conversely highlights the 20% of eligible children who are not receiving the grant, and hides the variations in take up rates present at the provincial level and within age categories [17, 18].

In the absence of strong evidence on the effectiveness of unconditional cash transfers on poverty alleviation and human capital development, there has been a significant move towards replicating the LAC model of conditional cash transfer programs in developing countries all over the world, including Sub-Saharan Africa [2, 13]. The CSG thus presents a unique opportunity to further our understanding of how an unconditional cash transfer works in a developing country context. This paper presents findings on the factors associated with receipt of the unconditional CSG across three diverse settings in South Africa.

To our knowledge this is the first longitudinal study in South Africa to describe factors associated with receipt of the CSG. Across the three sites around 60% of children who were eligible for the CSG received it by a median age of 22 months. While this take up rate is notably lower than national estimates previously reported by other authors [14], it reveals the variations that exist within specific age cohorts. Importantly, Samson et al. using a General Household Survey panel dataset reported similar take up rates (61%) for children < 2 [18]. This is disconcerting as this is the age group where children are more vulnerable to negative health and nutritional outcomes which have been shown to impact on life chances and economic productivity [21].

The income thresholds used to establish CSG eligibility during the study period show that low income thresholds can prevent the poor from accessing a cash transfer program designed to help them. The poorest site in the study, rural Rietvlei had a low eligibility rate of 56% when using the < R800 income threshold applied at the time, and thus a large number of children who were poor but were just above that threshold could not access the grant. It is thus encouraging to see that the CSG income threshold has since been raised substantially and no longer distinguishes between rural and urban inhabitants.

The study indicates that barriers to access for eligible families are still present. The most important barrier faced by families was the lack of a birth certificate for their child. A recent evaluation of the Bolsa Familia conditional cash transfer programme in Brazil found lack of a birth certificate to be related to poor anthropometric indicators in children since lack of a birth certificate is seen as an indicator of extreme poverty [22]. Obtaining a birth certificate is the final step in a series of steps which start with the child’s mother needing an identity document, transport and money to apply for the documents. In our study Rietvlei site had the lowest proportion of children with birth certificates and the highest proportion of participants in the poorest socio-economic status quintile highlighting the role that poverty plays in accessing the CSG.

There are several measures that could be taken to improve access to the CSG which include mobile outreach programs and activities, interim grants, and strengthened collaboration between departments. The proposed re engineering of Primary Health Care (PHC) in South Africa which includes the establishment of ward based outreach teams with community health workers, could be used to identify households with newborns early and link them with appropriate service providers that would help with CSG application and receipt. The Community Development Workers (CDWs), present in some provinces could also be resource persons to assist families with grant applications. The CDW program exists within the Department of Public Service and Administration to ensure access to housing, child grants, old-age pensions and other services [23].

Opportunities also exist to utilise outreach efforts to improve collaboration between departments responsible for furnishing documents necessary for CSG application. An example is the use of mobile offices which target rural far-out areas; these could have representatives from both the South Africa Social Security Agency who issue grants, as well as the Department of Home Affairs who issue birth certificates and IDs. Areas such as Paarl, where birth certificates are issued in hospitals where women give birth, illustrate the kind of inter-departmental collaboration that is needed to improve access to the CSG.

To deal with the problem of children failing to access the CSG because of outstanding documents such as birth certificates and IDs, the Department of Social Development could provide interim grants to applicants who provide proof of legitimate delays in obtaining required documents. In one area of Kwazulu-Natal such interim grants are provided (personal communication D Sanders). Interim grants would ensure that the rights of needy, deserving children, whose health and development are otherwise compromised by lack of access to the CSG, are protected.

In addition to the above mentioned supply side problems, the finding that most mothers applied for the grant when their children were older than 3 months indicates that some attention should also be paid to demand side issues including raising awareness about the grant at antenatal clinics and possibly through community radio stations.

This study found higher grant receipt amongst HIV positive mothers than HIV negative mothers. One factor that could explain this finding is that HIV positive mothers are likely to have greater access to health services where they can be advised about applying for social grants both for themselves and their children. Access to the CSG also appears to be appropriately reaching the poorest families in South Africa as receipt was associated with a low monthly income. This shows that the CSG is well targeted, reaching its intended recipients.

Our study had some potential limitations. The sites where this research was undertaken were purposely selected and the infrastructural conditions differed greatly between them hence they are not statistically representative of South Africa. They do, however, reflect the most common settings in South Africa, namely urban, peri-urban and rural areas. Due to the observational research design there may be confounders which we did not measure which could be related to CSG access that are not reported on here. The study also has several strengths. The total study sample was large, it included both HIV positive and HIV negative mothers and data on CSG receipt were rigorously collected at four time points. The survival analysis approach enabled optimal use of all available data.

This paper has shown that administrative requirements for CSG receipt act as barriers to access for children at a crucial early age. In the spirit of promoting and protecting children’s rights, more efforts are needed to improve and ease access to this cash transfer program which is considered to be the most effective poverty alleviation strategy in South Africa [24].

Finally, the fact that the requirements identified in this paper are strongly associated with access raises questions about how much worse take up issues would get were formal conditions to be attached to CSG receipt. As such this calls for careful thought to be given to the decision to implement further barriers in the form of formal conditionalities.