Socio-economic factors such as income poverty, low level of education, poor living conditions, lack of social cohesion, limited access to water and sanitation, and food insecurity have been identified as key drivers of the worsening health conditions and increased health inequalities in SSA (Munodawafa, Sookram, & Nganda, 2013). To promote health in the region, therefore, there is the need to pay attention to the call from WHO that, biomedical interventions alone are inadequate to address the detrimental effects of poor social conditions and that there is the need for government policies and programs which promote health equity (Commission on Social Determinants of Health, 2008; WHO, 2011). A particularly promising and popular intervention that could help in this direction is cash transfer programs (CTs).

CTs in SSA generally aim to (a) reduce short-term poverty; (b) reduce long-term poverty by improving the accumulation of human capital; and (c) reduce food insecurity and other vulnerabilities (e.g. HIV/AIDs, orphans and vulnerable children crisis).

CTs are non-contributory safety net programs that give cash grants to poor households and vulnerable groups to satisfy their basic consumption needs. They are classified into two: conditional cash transfers (CCTs) and unconditional cash transfers (UCTs). CCTs transfer money to households or individuals on condition that beneficiaries adopt certain ‘healthy’ behaviours such as school enrolment and attendance, child growth monitoring, utilisation of health services and avoidance of risky behaviours (e.g., prevention of sexually transmitted infections (STIs)). UCTs, similarly, provide money transfer, but do not have any explicit conditions (Fiszbein & Schady, 2009; Garcia & Moore, 2012).

Community participation and institutional collaboration. CT programs in SSA rely heavily on communities to help target the most vulnerable groups in society to receive the transfers. Relatedly, due to their complex nature and their broadly defined activities, inter-sectoral collaboration is required for CTs effective implementation.

Meeting felt needs. The uniqueness of CTs in SSA (be they UCTs or CCTs) is that they are designed to respond to the specific challenges facing the region, particularly poverty, food insecurity, and low human capital. Others also focus on improving reproductive health outcomes, including STI prevention and forced or early marriage, and many are put in place to support orphans and vulnerable children. The proliferation of CTs in SSA is justified on the grounds that social policy actions of this nature play a significant role in the fight against intergenerational poverty and health inequalities (Owusu-Addo, Renzaho, Mahal, & Smith, 2016).

Evidence-based practice. A key feature of CTs in SSA is their rigorous evaluations (Davis et al., 2016) which is essential for evidence-based policymaking and practice. The extant literature indicates that CTs in the region impact on a broad range of SDoH. For instance, a recent systematic review by Owusu-Addo et al. (2016) which examined the impacts of 24 CT programs on SDoH and health inequalities in SSA showed that CTs had a strong effect on structural and intermediate determinants of health, and a moderate effect on health outcomes. The review further showed that CTs could potentially reduce health inequalities particularly among extremely poor households, families with small household sizes, female headed households, and children aged 0-5 years.

CT programs align with health promotion principles of participation, empowerment, equity, social justice and inter-sectoral collaboration. Active community participation is at the centre of CTs from the targeting stage to the implementation stage. The programs rely on participation and mobilization of community structures, and draw upon community experiences and knowledge for program delivery. For example, in Ghana, community implementing committees must engage community members in the selection of program beneficiaries before forwarding the list of eligible persons to the District for subsequent submission to the national program unit. The national program unit then reviews the list from the community, and sends it back to the community for approval before beneficiaries are finally enrolled into the program. Community empowerment in the program is achieved through capacity building programs for community program implementation committees.

With a focus on the poor and the vulnerable in society, CTs work to tackle the root causes of poor health, injustice in society and the social gradient in health. For instance, the emphasis within CTs on child education can lead to increased school enrolment and educational attainment for children which could potentially increase employment opportunities in adulthood, and ultimately improve socio-economic status.

Similarly, CTs align with the health promotion principle of inter-sectoral collaboration. This is evident by their objectives (e.g. health, education, nutrition, agriculture, and poverty reduction) which require inter-sectoral action on the SDoH. This ‘whole of government approach’ to CT programs for health improvement was a fundamental tenet of the Alma Ata Declaration, and a foundation of the recommendations of the Commission on Social Determinants of Health.

The implementation of CTs is consistent with the process adoption described by diffusion of innovation theory (Dearing, 2009). The programs generally start as pilot programs designed to foster the diffusion of operational innovation with regard to program feasibility, impact, and scalability, taking into consideration institutional capacity (e.g. at national, regional and local levels) for implementation, and the capacity of supply-side institutions to meet the demands of the program. Results of the pilot phase are often adapted to the needs of the program in the innovation process.

• Commission on Social Determinants of Health. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: Switzerland, World Health Organization.

• Davis, B., Handa, S., Hypher, N., Rossi, N. W., Winters, P., & Yablonski, J. (2016). From evidence to action: the story of cash transfers and impact evaluation in Sub Saharan Africa. New York: Oxford University Press.

• Dearing, J. W. (2009). Applying diffusion of innovation theory to intervention development. Research on Social Work Practice, 19(5), 503–518.

• Fiszbein, A., & Schady, N. (2009). Conditional cash transfers: Reducing present and future poverty. Washington, DC: World Bank.

• Garcia, M., & Moore, C. M. T. (2012). The cash dividend: The rise of cash transfer programs in sub-Saharan Africa. Washington, DC: World Bank.

• Munodawafa, D., Sookram, C., & Nganda, B. (2013). A strategy for addressing the key determinants of health in the African Region. Brazzaville: WHO, Regional Office for Africa.

• Owusu-Addo, E., Renzaho, A. M., Mahal, A. S., & Smith, B. J. (2016). The impact of cash transfers on social determinants of health and health inequalities in Sub-Saharan Africa: a systematic review protocol. Systematic Reviews, 5(1): 114.

• WHO. (2011). Closing the gap: Policy into practice on social determinants of health: Discussion Paper. Geneva: WHO.