Unconditional Cash Transfers, Women’s Empowerment and the Use of Maternal Healthcare: Evidence from BISP Beneficiaries in Multan Division, Pakistan

Abstract

Pakistan’s maternal mortality ratio remains well above the Sustainable Development Goal target, and much of the shortfall is linked to women’s limited ability to decide on, pay for and travel to care. This study examined whether receipt of the Benazir Income Support Programme (BISP), an unconditional cash transfer paid to women, and women’s multidimensional empowerment were associated with the use of antenatal care, skilled birth attendance and postnatal care. Primary data were collected from 768 ever-married women in the four districts of Multan Division, Punjab, split equally between BISP beneficiaries and locality-matched non-beneficiaries. Economic, social, familial and political empowerment indices, together with an overall index, were constructed through Principal Component Analysis from 31 survey items. Because women’s empowerment is plausibly endogenous, instrumental-variable probit models were estimated with women’s house ownership and land ownership as two instruments and each empowerment index entered in a separate model, for the pooled division and separately for each district. BISP receipt was positively associated with all three maternal care outcomes; the average marginal effect was largest for skilled birth attendance. Economic empowerment was the strongest single empowerment dimension, political empowerment the weakest, and familial empowerment was only weakly and inconsistently associated with care. The interactions of BISP with the economic, social and overall empowerment indices were positive and mostly significant, pointing to complementarity between cash and women’s bargaining power; the interactions with familial and political empowerment were largely insignificant. The cost of visits and distance to a facility were the largest barriers, while television was the information channel most strongly associated with care. Associations were strongest in Multan district and weakest in Lodhran. The findings supported protecting BISP coverage while pairing it with economic empowerment, transport and fee support, and district-targeted health infrastructure.