conditional cash transfers and health: unpacking the causal chain

This article was downloaded by: [University of Tennessee, Knoxville]On: 21 December 2014, At: 13:50Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Journal of Development EffectivenessPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/rjde20

Conditional cash transfers and health:unpacking the causal chainMarie M. Gaarder a , Amanda Glassman b & Jessica E. Todd ca International Initiative for Impact Evaluation (3ie) , New Delhi,Indiab Inter-American Development Bank , Washington, DC, USAc Economic Research Service , USDA, Washington, DC, USAPublished online: 14 Apr 2010.

To cite this article: Marie M. Gaarder , Amanda Glassman & Jessica E. Todd (2010) Conditional cashtransfers and health: unpacking the causal chain, Journal of Development Effectiveness, 2:1, 6-50,DOI: 10.1080/19439341003646188

To link to this article: http://dx.doi.org/10.1080/19439341003646188

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

http://www.tandfonline.com/loi/rjde20

http://www.tandfonline.com/action/showCitFormats?doi=10.1080/19439341003646188

http://dx.doi.org/10.1080/19439341003646188

http://www.tandfonline.com/page/terms-and-conditions

http://www.tandfonline.com/page/terms-and-conditions

Conditional cash transfers and health: unpacking the causal chain

Marie M. Gaardera*, Amanda Glassmanb and Jessica E. Toddc

aInternational Initiative for Impact Evaluation (3ie), New Delhi, India; bInter-American DevelopmentBank, Washington, DC, USA; cEconomic Research Service, USDA, Washington, DC, USA

This paper investigates whether conditional cash transfer (CCT) programmes thatinclude health and nutrition components improve health and nutritional outcomes,and if so, which components of the programmes, or combination thereof, are importantin achieving these improvements. Using evidence from Latin America, Africa, Asiaand the Middle East, the paper adopts a theory-based approach that spells out theassumptions behind the expectation that the CCT interventions will have a measurableimpact on health and nutrition outcomes. CCT impact evaluations provide unambig-uous evidence that financial incentives work to increase utilisation of those key healthservices by the poor upon which the cash transfer is conditioned, if the beneficiarieshave knowledge of this condition. However, results are mixed with respect to nutritionand health outcomes, suggesting that encouraging utilisation when the pertinence ofservices is unknown or of poor quality may not produce the expected effects. Incipientresults from Mexico indicate, however, that service quality is not necessarily exogen-ous to the programme, but may be positively affected by giving the poor women skills,information, and social support to negotiate better care from healthcare providers.Findings from Mexico indicate that there are direct routes by which the cash transfersaffect health, outside of the health sector interactions. In particular, the povertyalleviation achieved with the cash transfers may affect the mental health of benefici-aries, as well as their lifestyle choices. The main policy recommendation that ensuesfrom this review is the need to find the right mix of incentives and regulation toimprove the quality of care, while at the same time investing in the empowerment ofusers. Future research that explores the relative cost-effectiveness of investing in thesupply versus the demand-side within the health system will be crucial, along withfurther research on the need for conditionalities. Other areas that could benefit fromfurther evidence include morbidity outcomes from programmes other thanOportunidades, including mental health and chronic disease, impacts on health-relatedbehaviours and attitudes, and how these factors affect outcomes, and the effects onout-of-pocket expenditure.

Keywords: conditional cash transfer interventions; theory-based approach; health andnutritional outcomes

1. Introduction

Conditional cash transfer (CCT) programmes are spreading rapidly throughout the devel-oping world. Since 1997, seven countries in Latin America and the Caribbean haveimplemented and evaluated CCT programmes with health and nutrition components. CCTinterventions related to health behaviour have also been subject to recent evaluations in Asia

Journal of Development EffectivenessVol. 2, No. 1, March 2010, 6–50

*Corresponding author. Email: [email protected]

ISSN 1943-9342 print/ISSN 1943-9407 online# 2010 Taylor & FrancisDOI: 10.1080/19439341003646188http://www.informaworld.com

Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

and the Middle East. The existing evidence from these diverse programmes, interventions,and regions are the subjects of this paper, and include Brazil’s Bolsa Alimentacao/BolsaFamilia, Colombia’s Familias en Accion (FA), Honduras’ Programa de Asignacion Familiar(PRAF), Jamaica’s Program Advancement Through Health and Education (PATH), theMalawi Diffusion and Ideational Change Project (MDICP), Mexico’s PROGRESA/Oportunidades and Programa de Apoyo Alimentario (PAL) programmes, Nepal’s SafeDelivery Incentive Programme (SDIP), Nicaragua’s Red de Proteccion Social (RPS),Paraguay’s Tekopora, and Turkey’s Conditional Cash Transfer Program.1 Other CCTswith health components are in the process of development or of being evaluated in othercountries including Argentina, El Salvador, Panama, Bangladesh, Pakistan, Egypt andKenya.

A key question emerging from the literature on the impact of CCTs on health andnutrition outcomes is which components of the programmes, or combination thereof, areimportant in achieving these outcomes?Measured impacts could be due directly to increaseduse of preventive and prenatal care services, increased immunisation rates or improvedquality of care. Indirectly, effects could be due to the purchase of more or higher quality foodor medicines, the investment in household materials and equipment that could reduceexposure to infections, improved psychological well-being of family members, the receiptof nutritional supplements, or increased knowledge in topics covered by the health informa-tion lectures (such as proper hygiene and food preparation, best practices for breastfeedingand treatment of diarrhoea). Understanding the role of such factors in influencing outcomesis critical for developing more effective programmes.

Several review articles on what we know about the impact of CCT programmes onhealth and nutrition have been published recently (Glassman et al. 2006, 2007, Lagardeet al. 2007, Adato and Bassett 2008, Fiszbein and Schady 2009, Leroy et al. 2009). Thispaper constitutes an update on these in two ways: first, it reviews the results of the mostrecent rigorous impact evaluations; and second, it discusses to what extent the availableevidence can help us explain the causal chain and assumptions underpinning theprogrammes.

The paper reviews the evidence on the health and nutrition results from rigorous impactevaluations of CCT interventions in low-income and middle-income countries available todate. Building on the existing literature surveys, a rigorous search and screening of multipledatabases, as well as additional papers that have come to our attention through contacts andseminars, we have identified 41 studies related to 11 programmes/interventions, coveringfour different regions of the world.

While each component of the typical CCT programme may have been subject to impactevaluations independently in non-CCTcontexts, this review will concentrate on what can bedistilled about the contribution of each component within an integrated CCT programmesetting. It is important to note that causal inferences cannot be drawn from any findingsrelated to one component of the programme, as the effects observed are likely to bedependent on the integrated nature of the programme.

As we write, a number of the gaps in the causal chain are about to be further reduced. Forexample, Egypt and Morocco are both in the process of designing and implementingprogrammes in which they consider experimenting with conditional versus unconditionalcash transfers. New incentive mechanisms are also being explored; for example, in Pakistan,the National TB control Programme is planning to experiment with modern in-kindcontributions such as mobile phone minutes to incentivise compliance with tuberculosistreatment regimens.

Journal of Development Effectiveness 7

Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

The remainder of the paper is structured as follows. Section 2 describes the metho-dology used for the identification and inclusion of studies in this review, Section 3describes the key demand and supply-side factors that determine use and effectivenessof health care services and how CCT interventions address these, and Section 4 outlinesthe key assumptions that implicitly underlie the programme effect model and currentevaluation efforts with regards to CCT programmes, reviewing and critically examiningthe evidence available about the plausibility of these assumptions. Section 5 summarisesthe evidence on health indicators measured in more than two programmes, and Section 6concludes.

2. Methodology

The methodology used in this paper is two-fold, and calls for a fine balance between arigorous search for evidence on the health impacts of CCTs and drawing uponadditional literature to increase our understanding of the causal chain that leads tothese impacts.

The paper adopts a theory-based approach, spelling out the assumptions behind theexpectation that the CCT interventions will have a measurable impact on health and nutritionoutcomes. It then documents our state of knowledge around said assumptions using existingevidence.

The present study strives to follow the guidelines for a systematic review as closelyas possible. Nevertheless, it fails to meet some of the criteria for a systematic review asdefined by the Campbell Collaboration; specifically, the requirement of having a mini-mum of two trained reviewers for every article to ensure inter-rater reliability and thesystematic inclusion of the grey literature. However, in conformance with systematicreview standards, two people were involved in the collection and calculation of impactestimates reported in the papers. The benefits of the systematic review process areacknowledged and adhered to as far as possible in this review, and the fact that theauthors have been involved in the design and supervision of several of the programmesin question implied a direct knowledge and access to much of the grey literature. Arigorous search of multiple databases was carried out, in addition to the screening andinclusion of studies included in existing reviews on this topic and those found throughcontacting authors. We include rigorous impact studies of CCT interventions in low-income and middle-income countries that have explicit health and nutrition-relatedconditionalities and that assess the effects on healthcare utilisation and health andnutrition outcomes. Studies selected for our review use experimental (randomised con-trolled trials) or quasi-experimental methods (matching techniques, regression disconti-nuity, and multivariate regression techniques).

We searched Pubmed and Google Scholar along with Eldis, ID21, Inter-Science, ScienceDirect, (IDEAS [Repec]), the Cochrane Central Register of Controlled Trials, the Databaseof Abstracts of Reviews of Effectiveness and JOLIS. The following key terms and/or theircombinations were used in the search: (conditional) cash transfer, (monetary) incentives,social protection, social safety nets, family allowance programme, developing countries,low-income countries, health (services) (care) (coverage), health-seeking behaviour, pre-ventive healthcare, nutrition, health and nutrition outcomes, demand, randomised controlledtrials, multi cross-sectional studies, propensity score matching and interrupted time series.No limitation regarding publishing date was used, and searches were carried out both inSpanish and English. Table 1 presents the studies reviewed, as well as the evaluationmethod.2

8 M.M. Gaarder et al.

Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

3. Understanding the demand-side and supply-side factors and how CCTinterventions address these

Understanding the causal pathways that underpin an intervention is critical to evaluatinghow it works and what should be modified to improve effectiveness. This section brieflyreviews the factors that influence the demand for and supply of health services, and discusseshow CCT interventions address these factors.

Individuals invest in their health to avoid or minimise reductions in well-being andmarket and non-market productivity due to illness (Mushkin 1962, Grossman 1972, Gaarder2003). The extent to which the desire to invest in one’s health is reflected in the demand forhealthcare depends on whether an individual identifies illness and, most importantly, iswilling and able to seek appropriate healthcare (Ensor and Cooper 2004). The identificationof illness may depend both on the type of illness, as well as on the level of knowledge of theindividual. Willingness to seek care is affected both by knowledge and perceptions (socialnorms), the direct and opportunity costs of seeking treatment, household income and intra-household decision-making, as well as the costs, quality and availability of substituteproducts and services. Differences in preferences for males over females or for workingadults over children and the elderly can be expected to affect intra-household decision-making and the resulting investments in individual health.

As noted in Eichler (2006), the supply of healthcare services is determined by acombination of structural inputs (staff time, infrastructure, drugs and supplies, land, andso forth) and the processes (such as the available technology and the management capabilityof the provider) that transform these inputs into outputs. Central to the transformation ofinputs into outputs is the behaviour of the healthcare provider, both at the individual andinstitutional level, which is determined by the objective function of the particular provider.The provider objective function could include, in addition to the desire to cure patients, thedesire to make money and the desire for leisure time. Thus, deficiencies in the quality of care,which tend to impede the ability of health systems to improve health outcomes for the poor,are associated first and foremost with inappropriate incentives for providers along withinsufficient resources, organisational rigidities and lack of knowledge.

Given the potentially important role financial incentives can play in influencing sociallyoptimal investments in one’s own health, in the face of private underinvestment either becauseof lack of knowledge or because there is a public good element, as well as in improving healthproviders’ performance, how do CCT interventions tend to use this instrument?

3.1. Financial incentives

The traditional CCT programmes (which is how we will refer to the nine safety-net type ofprogrammes included in the study) were specifically designed to influence demand-sidefactors, and, in most cases, not the supply-side factors. In order to receive monthly cashtransfers, beneficiary households must comply with a set of conditions related to the use ofpreventive health services and attendance to health education sessions. The cash is supposedto address the direct and opportunity costs of seeking treatment, while the health educationsessions are designed to influence knowledge and perceptions. Although some programmessuch as Oportunidades, RPS and PRAF provide nutritional supplements, there are currentlyno explicit nutrition-related conditions related to the consumption of the supplement, nor dothe programmes usually impose restrictions on the use of the cash for nutritional foods or anyminimum attainments in terms of nutrition outcomes.4 Rather, nutritional improvements areexpected to result from the combination of the increased income from the transfers and the


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

nutrition knowledge provided by the education and training components of the programmes(as well as nutritional supplements in some cases). The programmes in Honduras and Turkeyboth include an additional cash incentive for institutional births and pre-birth and post-birthcheck-ups.5 The other two CCT interventions with studies reviewed in this paper aredesigned slightly differently, focusing on incentivising a single type of behaviour changerather than a composite. In the case of Nepal the targeted behaviour is to give birth in a publichealth facility, whereas the financial incentive in the Malawi intervention is related to thecollection of HIV test results at a nearby voluntary counselling and testing (VCT) centre.Table 2 provides an overview of the cash incentives, health conditionalities and targetingapproaches used in the 11 programmes covered by this review.

There have been a number of different approaches to determining the transfer amount inthe traditional CCT programmes. In Colombia, Jamaica and Mexico, the amount of thehealth/nutrition transfer was originally calculated to be the difference between the consump-tion of an average extreme poor household and the food poverty line, with some variations(for example, the per-capita indigence gap for children aged under six only) – although thisdesign was not necessarily maintained over time.6 The goal of this type of transfer is to – onaverage – move households living in indigence to a minimum consumption level. Minimumconsumption is also seen as a pre-requisite to human capital investment. Another approach,used in Honduras, is to base the transfer amount on the opportunity costs of accessinghealthcare, which has resulted in a lower average monthly transfer. For the purposes of thepresent paper, it is important to note that the health and nutrition grant’s lump sum structurefavours smaller families, which may affect programme effects, and that it is the combinedamount of the transfer, representing both schooling and health/nutrition subsidies, thatinfluence the results achieved in the evaluated programmes. In the majority of the pro-grammes, payment amounts fall in the range of 10–25 per cent of total pre-transferconsumption among beneficiary households (Handa and Davis 2006).

In the case of Nepal’s SDIP, the amount of the transfer delivered for an institutional birthwas the cost of transportation to the public facility where the delivery took place (and hencevaried by region). The transfer covered only one-quarter of the cost of normal delivery, onaverage. In Malawi, the incentive provided was a voucher of up to three dollars to beconverted to cash upon collection of the HIV test results and was randomly allocated toselected participants. The average incentive was worth about a day’s wage.

3.2. Health services supply

Since an important factor affecting the use of healthcare services and the health outcome oftheir use is the available supply and the quality of it, it is noteworthy that the mainmechanisms used to spur the demand side in these programmes, namely incentives andinformation, are not applied by the programmes on the supply side. Rather, more passiveapproaches are employed that may reflect the fact that the supply side is under a different‘jurisdiction’ (usually Ministry of Health). In Panama, a recently designed CCT – an inter-sectoral agreement with the Ministry of Health to provide services to programme benefici-aries – was signed, whereas in El Salvador, another recent addition to the CCT family, thiscommitment is made more explicit by actually tagging the budget-line going to the healthsector, so that it is earmarked for CCT programme beneficiaries.

Some countries have required that minimum supply conditions had to be met prior toimplementation of the demand-side piece. In Colombia, this took the form of a minimumprovider/infrastructure to beneficiary ratio and the availability of ‘space’ to producemore visitswith respect to a standard ratio. In Mexico, minimum distances to facilities were established.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Rather than investing in the supply side to reach these requirements, it was used as one of theinclusion criteria for localities, thus excluding the most marginalised rural communities fromparticipating at the outset of the programmes. In other countries, such as Turkey, the supplyside was supposed to be strengthened through a parallel health sector strengthening process,although different incentive structures and implementation mechanisms have tended to pre-vent the latter keeping pace with the former. In Honduras and Nicaragua, however, the CCTprogrammes built in supply-side strengthening intended to respond to the pressures associatedwith increased demand for services and to help prevent a decline in quality as a result of higherusage. This strengthening took the form of contracting private providers for the provision of apackage of services and health education talks in Nicaragua, and the provision of some basicequipment, material and quality-improvement training for the public health centre workers inHonduras. In both cases, substantial delays were incurred in the implementation of thesecomponents, in particular due to procurement challenges.

The other two programmes addressed supply constraints differently. Nepal’s SDIP pro-gramme provided explicit incentives to the health providers for each birth attended (US$4.7),either at home or in the facility. The fact that the provider received payment for home deliveriesis partly inconsistent with the demand-side incentive for health facility use only, and may haveacted to dampen the impact on neonatal mortality and caesarean sections. In the Nepal project,the location of VCTcentres where HIV results were available was also randomised, and it wasfound that the distance needed to travel for the results was a significant factor in take-up rate.

3.3. Targeting

Traditional CCT programmes are directed to poor families; in most cases, families withchildren. A central feature of CCT programmes is the use of explicit targeting strategies todetermine eligibility for benefits. PRAF and RPS apply geographical targeting strategiesonly. Poor localities are identified using an index of well-being usually constructed oncensus and survey information, programme localities are selected randomly up to a budgetconstraint and all households within the selected localities are eligible to enrol in theprogramme. PROGRESA/Oportunidades (henceforth referred to as Oportunidades),Colombia’s FA programme, Turkey’s CCT programme, and Bolsa Familia apply a firstround of geographic targeting of localities, followed by the application of proxy meanstesting or direct income testing to identify individual households eligible to participate in theprogrammes. Other conditions for the participation of localities are sometimes established;for example, the FA programme requires that participating municipalities have a bankavailable within a given geographic reference area, as well as sufficient supply of healthand education services to be available to meet expected increases in demand. With theexception of Oportunidades, CCT programmes restrict entry to poor households with youngchildren, school-aged children or pregnant women; all other households are excluded.7

In the Malawi MDICP project, there was no direct poverty targeting and participants wererandomly selected from three rural districts. However, poverty levels in Malawi are generallyhigh, and a majority of respondents were subsistence farmers. Similarly, no explicit targetingwas built into the SDIP in Nepal; however, richer households were found to benefit dispro-portionately as they have a higher chance of delivering in a public health facility.8

3.4. Measuring impacts

Traditional CCT programmes have pioneered multisectoral interventions and rigorousimpact evaluation methodologies in the social development sphere. The CCT evaluations


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

have tended to adopt experimental (Honduras, Mexico, Nicaragua) or quasi-experimental(Colombia, Jamaica, Brazil, Paraguay, Turkey) designs. In addition, some of these pro-grammes have included school and health centre surveys and/or qualitative evaluations onaspects of the programme’s operation and effects (for example, Colombia, Honduras, Turkeyand Mexico).

The evaluation designs have varied in their ability to produce estimates of impacts thatcan be generalised to the full beneficiary populations or to similar programmes. For example,the evaluations of PRAF and RPS were conducted on pilot phases, which were implementedon a select portion of the country. In the case of PRAF, the pilot beneficiary grouprepresented the most impoverished communities in the country. In the case of RPS, thepilot phase was not offered to the poorest localities, but was still not representative of allpotential beneficiaries. In addition to the fact that generalisations of the impact results arelimited due to issues of sample selection, they have not usually been designed to answer thequestion of why the programme works (or not) since, instead of evaluating each componentseparately, the evaluations have focused on the impacts of the package of multiple interven-tions. Granted, separating the effects of the different components poses significant chal-lenges, but attempts in this regard were limited at the outset by the choices and/or design ofinstruments and the general approach to the evaluation.

The next section will critically examine the CCT programme effect model in health byspelling out the assumptions behind the expectation that the CCT interventions will have ameasurable impact on health and nutrition outcomes. Available impact evaluation results willbe presented as they relate to each assumption, and will feed into the discussion onwhether theimplicit assumptions made when designing the CCT programmes tend to hold.

4. Assumptions underlying the CCT programme effect model

CCT programmes, and the documents that describe them, do not tend to make explicit theassumptions underlying their design, particularly as regards the health conditionality.However, from the description of the situation prior to the programmes, as well as the designof the interventions, the programme effect model can be made explicit.

The CCT programme approach is to stimulate demand for health services and educationalhealth talks by transferring cash to the mothers conditional on attendance to health educationtalks and regular consultations at the public health centre by children and pregnant women.

Based on this design, a number of implicit assumptions are made:

l Assumption 1: CCT interventions lead to an increase in the use of preventive healthservices among the poor who are currently under-utilising these.

l Assumption 2: An increase in utilisation of healthcare services will improve healthstatus, and in particular an increase in public health services will have this effect.

l Assumption 3: Cash affects health primarily by ensuring service utilisation andimproved food consumption.

l Assumption 4: Poor women lack sufficient health knowledge and that a transfer ofinformation to them will induce behaviour changes.

l Assumption 5: Imposing conditions and monitoring compliance are necessary toincrease utilisation of services to the desired level.

l Assumption 6: Some programmes have assumed that the cash transfer and theconditions are not sufficient to ensure optimal child nutritional investment, and haveadded a food supplement.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

l Assumption 7: The existing supply of services is sufficient or will increase followingincreases in demand.

l Assumption 8: Programme beneficiaries and programme staff are correctly informedabout the programme.

l Assumption 9: The evaluation methods chosen implicitly assume that the outcomesimpacted by the programme are those that are measured.

Each of the assumptions is discussed in turn below, and the programme effect model isrepresented schematically in Figure 1.

4.1. Assumption 1: CCT interventions lead to an increase in use of preventive healthservices among the poor who are under-utilising these

Assuming that the poor make insufficient use of preventive health services, CCT programmescondition payments on regular check-ups at a health clinic or other healthcare service (forexample, childbirth assistance in Nepal). However, an optimal level of use, although clearlydefined in theory, is not well defined in practice. In economic terms, a private optimum amountof use is defined as the amount of use that would be observed if poor families had fullinformation about the costs and benefits of preventive healthcare. A social optimum amount ofuse is understood as the amount of use necessary to achieve a given level of positiveexternalities that one person’s preventive care has on the rest of society. To calculate theprivate or social optimal use of health services for each individual would require entering into adiscussion of the statistical value of life (and healthy life as opposed to disability-adjusted life).Although this is the kind of decision that governments and individuals make on a daily basis,by allocating a certain amount of budget to health services versus defence, or by wearing aseat-belt in the car, it is not one that is easily done in a programme context.

A distinct approach to determining the optimal amount of utilisation is rooted in thehuman rights and health equity perspectives, where the guiding principle is equal opportu-nity for health. In operational terms, pursuing equity in health means eliminating healthdisparities that are systematically associated with underlying social disadvantage or

Figure 1. Theory-based approach to CCTs and mapping of the implicit assumptions.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

marginalisation (Braveman and Gruskin 2003). It is a stylised fact that utilisation of effectiveservices is lowest among the least well off in developing countries, and that the poor alsotend to be the least healthy (O’Donnell 2007). The fact that those most in need make least useof healthcare is widely considered inequitable.

The aspect of systematic differences in use and fiscal impact among population groups isgenerally explored during the design of CCT programmes. Baseline health and nutritiondocumentation in CCTcountries prior to intervention has indicated significant inequalities inthe use and fiscal impact of healthcare by socio-economic strata. Poor and rural householdshave been found to be much less likely to identify illness and seek care when sick than theirbetter-off counterparts; their out-of-pocket spending on health is more significant as aproportion of their total expenditures compared with that of the wealthy, and direct andindirect costs associated with care-seeking have frequently been cited as a reason for non-useof services. Even in systems with strongly progressive public spending on health, the poordisplayed lower use rates. In Jamaica, for example, only 75 per cent of zero to six year oldshad visited a health practitioner in the 12 months prior to the programme start date. Theproportion was less than 60 per cent with respect to the use of preventive care (Levy and Ohls2007). In Mexico, as many as 17 per cent of poor expectant women were not receiving anypre-natal check-up (IADB 2001); and in Panama, 67 per cent of indigenous children underfive years of age suffering from respiratory problems and/or diarrhoea were not taken tohealth service facilities compared with a national average of around 30 per cent. Vaccinationcoverage for indigenous areas was found to be 10 percentage points below the nationalaverage (95%) (IADB 2007).

The CCT interventions rely on the notion that the conditions and the informationprovided to clients through health talks lead to an increase in the use of preventive healthservices. While effects on service use vary, the impact evaluations do indicate consistentlythat the programmes increase service use (see Table 3), measured in terms of one or more ofthe following: public clinic visits, growth monitoring visits, prenatal care visits, professionalcare at childbirth, and VCT centre visits. The exception is the Turkey CCT programme,where few if any beneficiaries knew about the check-up conditionality.9 There is also someevidence that the programmes can cause a substitution of providers. Gutie�rrez et al. (2004a)report that the use of public health services in rural Mexico increased in the same proportionthat private ones decreased, suggesting that beneficiary families in Oportunidades may havechanged their healthcare-seeking behaviour by substituting public for private services. Ifmost of the increase in utilisation of public health services is due to the substitution awayfrom private service providers, then most of the change in health outcomes would arguablybe due to quality differences between the two types of services rather than due to increasedutilisation. Indeed, the same paper does report on both lower health expenditure by house-holds due to this shift away from the private providers, as well as to reductions in the rate ofself-reported illness days among the rural beneficiary households.10

As for service use not subject to conditionality, a recent paper by Urquieta et al. (2009)indicates that Oportunidades had, at best, only a small effect on skilled attendance at deliveryin treatment communities, whereas no impact was found by Powell-Jackson et al. (2009) onprenatal care visits by the Nepal SDIP programme. Even though not a condition, one wouldhave expected that Oportunidades may increase the proportion of deliveries with skilledattendance given that women in enrolled households receive free delivery attendance whereaswomen not in enrolled householdsmay have to pay. The authors speculate that the influence ofhusbands and mothers-in-law on place of delivery may be a main explanation for the lack ofeffect on skilled attendance. Similar reasons were given by field officers of the HonduranPRAF programme for why there was no take-up of their cash transfer against institutional


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

delivery.11 This may suggest a need to more directly involve the latter in the communicationsstrategy of the programme. In the Nepal SDIP programme, only professional care at childbirthwas the conditionality, further accompanied by an incentive to health staff for each deliverythey attended, whereas prenatal care was not. Whether it was the lack of incentive on healthstaff or on the pregnant women that explained the lack of effect on prenatal visits is not clearfrom the paper, but the fact that the rate of skilled birth attendance increased with no effect oninfant mortality may be an indication that the programme had not chosen the optimalcombination of conditionalities on health-promoting behaviour to ensure the desired outcome.

That large enough CCTs can be successfully used to incentivise preventive health check-ups and attendance at health sessions has been demonstrated extensively, and need not be thefocus of future research (at least value could be added to the evidence by investigating howvarying the amounts of the transfer, the frequency of payment, and the means of payment mayaffect utilisation). We can, however, not conclude that since incentivising the demand led to anincrease in service use, the lack of demand was the main bottleneck. There has in general beenlittle ex-ante analysis conducted to directly test the proposition that the inequities in health andnutrition outcomes and outputs were primarily due to demand-side factors relative to supply-side factors. And even if both supply-side and demand-side factors are shown to be important,the question remains as towhich is themore cost-effective option for the government to pursue.

Flores et al. (2003) attempted to estimate the relative cost-effectiveness of supply-sideversus demand-side interventions in improving both health and education outcomes inHonduras. However, due to delays in the implementation of the supply-side incentives,what originally was designed as four groups of intervention (demand-side incentives,supply-side incentives, both, and none) in practice collapsed to little more than the tradi-tional two. While the evidence is hence still lacking, Handa and Davis (2006) note thathealthcare, particularly preventive healthcare, differs from education in that informationasymmetries are more acute and that poor households may be less likely to seek care for thisreason, which would justify government intervention to correct this market failure.

4.2. Assumption 2: utilisation of (public) healthcare services will improve health status

Since receipt of the cash transfer is conditional upon the utilisation of preventive healthcontrols, primarily in public-sector clinics, the CCT programmes are clearly assuming thatthe use of public healthcare services will improve health status. This prior is multilayered, inthat it relates both to the quality of the services given at the public clinics, as well as to thequality and effectiveness of substitute products and services. It presumes that qualityservices are provided to the programme participants who visit the health centre, and thatthe costs involved in service use are not so large as to jeopardise future health (even if currenthealth may be improved). In the following we will discuss each of these priors, as well as themain findings on health and nutrition outcomes.

4.2.1. Quality services are provided when visiting the health centre... Interestingly, therehas been little analysis during the design phase of the programmes as to the quality of theprivate alternatives to health services, and to our knowledge no research into the effect of theprogrammes on the quality of care provided in these as a result of the competition. We doknow that there is evidence of some substitution from private to public providers occurringas a result of the programmes (see Section 4.1).

We would assume that the outcome of visiting the health clinics would, at least in part,depend on the quality of care received at the clinics, approximated by measures of coverageof preventive health interventions. The only intervention that is reported in a number of


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

studies for a number of programmes is immunisation. For immunisation coverage, thefindings are rather bleak (see Table 4). Out of the seven studies reporting immunisationresults (see Table 3), only Barham and Maluccio (2008) and Ahmed (2007) find largeprogramme impacts on full vaccination coverage, for Nicaragua’s RPS and Turkey’s CCTprogramme, respectively. No significant effect was found in any of the other programmes,or, as in the case of Honduras, coverage was increased for DPT (a combine vaccine againstdiphtheria, Pertussis (whooping cough) and tetanus) but coverage of measles immunisation,as well as of tetanus toxoid immunisation in pregnant women, was not affected. Animportant question for these programmes is therefore why, despite complying with theconditionality of health clinic visits, beneficiary children are not obtaining their vaccines.The answer is bound to lie in a mixture of three factors; first, immunisation is often donethrough nationwide or region-wide campaigns rather than through the individual clinics(hence there is no significant difference in access between treatment and control); second,the health clinics are not being provided with the necessary medicines and vaccines to dealwith the increasing demand as a result of the conditionality; and third, in some of thecountries (for example, Mexico) immunisation coverage was so high at the outset that anysignificant increase could not be expected. For other interventions reported on in specificprogrammes, the results are mixed. Weighing of the child during the past 30 days in theHonduras PRAF programme was found to increase with a significant 20 per cent (Morriset al. 2004b), whereas no significant impact of the Jamaica PATH programme was found forblood and urine tests and height and weight measurements of children and the elderly (Levyand Ohls 2007).

A study of the quality of health services provided to Oportunidades beneficiaries may shedsome further light on the challenges of providing quality care faced by the service providers(Gutie�rrez et al. 2008). Information was gathered from 455 public health centres providingservices to Oportunidades localities in Mexico. While the sample may suffer from biasesbecause the information could not be obtained in all centres of the sample localities, the pictureobtained is likely to understate the challenges as those not visited were either unwilling toprovide information or inaccessible due to climatic conditions. The survey highlighted anumber of factors impeding the provision of quality services, including lack of necessaryinstruments and medical inputs in a number of cases (for example, syringes), regular powercuts, lack of access to piped water (30% of cases) and sanitation (50% of cases), and longdistances to reference centres in the case of complications (average transport time of 1.4hours). An additional factor that could hamper the provision of adequate care was the fact thatvery few of the health personnel were consulting the official healthcare guidelines and norms.

4.2.2. The costs involved in current service use do not jeopardise future health. As notedin the introduction to this section, for public health services utilisation to increase health statusin the longer run, the costs involved in current service use should not jeopardise future health.One of the very rare studies that have looked at out-of-pocket (OOP) spending related to thehealth behaviours conditioned upon in the programmes gives some alarming insights. TheNepal SDIP evaluation study reports a high incidence of catastrophic expenditure associatedwith OOP spending on institutional delivery care, despite the inclusion of the CCT in theestimates. In particular, the study finds a 10 per cent increase in OOP budget share of non-foodexpenditures for normal deliveries, and a 36 per cent increase when caesarean sectionsare carried out. This implies that the SDIP, by incentivising greater use of institutionaldelivery, risks exposing more households to catastrophic payments. The traditional CCTprogrammes are less likely to encounter this tension because they have so far focused onlow-cost preventive interventions (typically given free of charge). But evidence from China


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

suggests that health insurance can increase the risk of catastrophic expenditure by raisingutilisation of care (Wagstaff and Lindelow 2008).

4.2.3. Use of preventive services results in better nutrition, morbidity and mortalityoutcomes. While noting that improvements in health and nutrition outcome indicators, aswell as decreases in visits to the hospital and hospitalisations, would be necessary but notsufficient indications that preventive healthcare utilisation improves health. We willnevertheless now turn to the evidence on outcomes. The reason it will not be sufficient isthe fact that other components of the programme, such as the increased householdconsumption, may be influencing these outcomes.

The effects on nutritional status outcome measures are mixed (Table 5). The CCTprogrammes in Honduras and Brazil have no significant effect on stunting (height-for-agez-score , –2), whereas a significant reduction is found in Mexico’s, Nicaragua’s andColombia’s CCT programmes. In urban areas of Mexico, this association was limited tochildren in intervention families younger than six months at baseline, who grew 1.5 cmmorethan the children in comparison families (Leroy et al. 2008). Results for the proportionunderweight (weight-for-age z-score , –2) are even less consistent; Nicaragua’s RPS showsa large and significant decline, while the Honduras programme finds no impact and theColombia programme shows impact only in rural areas for three to seven year olds. In thecase of Mexico, a positive effect of the CCT programme on weight of children zero to sixmonths old is found only in urban areas; whereas in the case of the Brazil programme, areduction in the rate of weight gain among programme pre-school children is observed(Morris et al. 2004a).

In a forthcoming publication, Barber and Gertler (2010) show that 10 years after theOportunidades programme initiation in Mexico there were no differences between the twointervention groups (with an 18-month difference in programme exposure) inmean height-for-age z-score and bodymass index (BMI)-for-age z-score. Nevertheless, children of womenwithno formal education showed greater height-for-age independent of the cash transfer given tothe family, consistent with other studies showing an effect of Oportunidades on height-for-ageonly in vulnerable subgroups (Rivera et al. 2004, Leroy et al. 2008). The authors suggest thatthis indicates that, for these groups, the fortified food distributed by the programme and thehealth and nutrition education and growth monitoring may have resulted in better care andfeeding practices (Fernald et al. 2009).

As for nutritional results for Mexican adults in rural areas, BMI was found to be lower(26.57 kg/m2 vs 27.16 kg/m2, p , 0.001), as was the prevalence of obesity (20.28% vs25.31%, p , 0.001) and overweight (59.24% vs 63.04%, p = 0.03) in the group that hadparticipated between three and a half and five years in the Oportunidades programme than inthe control group (Fernald et al. 2008c). The PAL programme also found an associationbetween programme participation and a reduction in the probability of having a large waistamong women.

Programme effect on birth weight has been estimated in Mexico and Colombia. In theformer, Oportunidades participation implied a 44.5 per cent lower incidence of low birthweight in rural areas (Barber and Gertler 2010), whereas in the latter no effect was found inrural areas but an increase in birth weight by 0.578 kg was detected in urban areas due to FA.

While one would expect that actual morbidity would decline with increasing healthcareand nutrition, measured morbidity may increase or decrease as a result of the CCT inter-vention. On the one hand, greater use of preventive care and higher levels of health knowl-edge may lead to fewer episodes of illness. On the other hand, greater levels of healthknowledge and more frequent visits to health centres may increase the probability that


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

mothers more frequently and/or accurately diagnose illnesses and seek care when it isrequired. Furthermore, the increased income due to the cash transfers could also lead toincreases in reported illness as a result of the behaviour choices that people make. In essence,people can afford to be more sick (and take time off sick) if they have more income, and thismay influence their willingness to recognise illness (Gaarder 2003). Except for the recentfindings by Fernald et al. (2008a) of no association between increased cash transfers and thenumber of sick days in the four weeks before the survey in the Oportunidades programme,these hypotheses have not been much explored by the evaluations. Nevertheless, where bothsubjective and more objective measures of morbidity have been estimated (mainly inMexico), CCTs appear to decrease the incidence and prevalence of morbidity (see Table 6).

In Colombia, FA reduced the probability of reporting diarrhoea symptoms by approxi-mately 0.10 for children aged less than 48 months who live in rural areas. The impacts of FAin urban areas and on respiratory disease could not be detected. In Honduras, the incidence ofdiarrhoea increased in the intervention and control groups, but more so in the interventiongroups, possibly indicating contamination of the control municipalities with alternativehealth interventions. No effects on anaemia were observed in Honduras.

The Mexico evaluation found that the impact of the programme on the probability ofchild illness is negative and statistically significant for all age groups, but not until a childhad been receiving benefits for at least a 12-month period (Gertler and Boyce 2001). In ruralareas, a small decrease in sick days for only the productive age population is observed, whilea larger effect and wider age range is seen in urban areas. Overall, the number of days lost toillness decreased by 20 per cent among beneficiary families (Gutie�rrez et al. 2004b).

AnOportunidades study of the effect of the programme on indigenous populations foundthat the programme decreased illness rates from 0.2 to 3.5 per cent, with the greatest effectsobserved among children under three years old (Quinones 2006). The average programmeeffect estimations differ substantially from Gertler’s findings, most probably due to differ-ences in sample population and approach used. Positive programme effects observed forindigenous beneficiaries were similar to those of non-indigenous beneficiaries. This findingcould be considered a weakness of the programme, as is argued by Quinones, given theimplicit assumption that the average effect of the programme should be larger on poorer andmore marginalised groups. On the other hand, it is remarkable that the benefits experiencedare equivalent for both groups when one takes into account evidence that indigenous groupshave a more difficult time complying with CCT conditions due to language and culturalbarriers.

With respect to chronic disease-related morbidity among youth and adults, the requiredregular check-ups and participation in health talks may have a positive effect on householdand social norms related food intake and activity. However, the income transfer to thehousehold could make some behaviours that increase the risk of chronic diseases moreaffordable (for example, junk foods, soft drinks, alcohol). Evidence from Mexico showsencouraging results. Fernald et al. (2004) find high baseline prevalence of obesity (20%),hypertension (39%), and diabetes (19%) among the rural poor in Mexico and thatOportunidades participation significantly reduces the prevalence of all except diabetes.Symptoms of hypertension and diabetes are also significantly reduced via programmeparticipation.

Gertler (2000) tests the hypothesis that Oportunidades’s prevention activities reduceillness, reflected by reduced curative care. A 58 per cent reduction in hospital visits is foundfor zero to two year olds, suggesting a significant reduction in major illness. Similarly, a verylarge (100%) reduction in hospitalisation for the over-50 age group is found. This suggeststhat Oportunidades had a positive impact on health status.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Mortality was not measured directly by the evaluations; only the Mexican programmeuses administrative data to analyse programme effects. Hernandez et al. (2003) examine theimpact of Oportunidades on maternal and infant mortality using data for the period1995–2002 from the Ministry of Health (SSA) and the National Institute of Statistics,Geography and IT (INEGI). For the entire period (1997–2003), maternal mortality was 11per cent lower in the municipalities with at least one locality incorporated in theOportunidades programme compared with those without any localities incorporated,whereas infant mortality was found to be 2 per cent lower. Estimates of absolute numbersindicate that in this period an average of 340 infant deaths per year have been avoided thanksto the programme. The impact of Oportunidades on infant mortality at the municipal levelincreases relative to the proportion of the population incorporated in the programme.Barham (2005a) also looked at infant mortality for Mexico, and found that Oportunidadesled to an 11 per cent decline in rural infant mortality among households treated in pro-gramme municipalities. At the municipality level, the percentage of rural householdscovered by the programme reached an average of 47 per cent, implying an average treatmenteffect of 5 per cent reduction in the rural infant mortality rate (IMR).

Nepal’s SDIP combines both demand incentives and provider incentives. It provides aCCT to households with an incentive to health staff for each delivery they attend. Whilethis programme is not intended as a social safety net, it seeks to change health-seekingbehaviour with cash transfers. However, the size and timing of the transfer minimises thelikelihood that any measured health outcomes are due to an income effect.12 The amount ofthe transfer is only 25 per cent of the cost of a normal delivery (5% of the cost of acaesarean section) and is only paid to both the mother and health worker after the deliveryat a health facility (and after the most risky period for neonatal mortality, which is withinthe first day of life). Nevertheless, the SDIP was found to reduce the probability of a homedelivery by 4.2 percentage points, and increase the chances of a delivery in a governmenthealth facility (2.6 percentage points), of attendance by a skilled birth attendant (2.3percentage points) and by any health worker (4.4 percentage points). However, the authorsfound no evidence that the SDIP had any impact on neonatal mortality or the caesarean-section rate.

It is notable how very few of the programme studies have measured the health impacts oftheir interventions; rather, they have been focusing on health outputs. This is understandable,as typically programme managers do not wish to include target indicators that are beyondtheir control; but on the other hand, as we have discussed in this paper, the rationale forsending poor households to the health clinics and health and nutrition chats is that this wouldimprove their health capital. While improvements in the incidence of stunting are observedin several programmes, the contribution of each type of intervention in the programmes hasnot been established, and while improvements in health status are measured and observedmostly in the Mexico programme, none of these impacts can be tied directly to the use ofhealthcare services.

In summary, while there is scant evidence on the type of interventions, and qualitythereof, that the programme participants receive when they visit the health centres, thepicture with respect to nutrition outcomes is mixed, and in the case of morbidity andmortality the evidence is still largely limited to the Mexican programme. Although theincome transfer and health talks may affect health outcomes independently of the visits to theclinics, the analysis suggests that encouraging utilisation when the pertinence of services isunknown may not produce the expected effects.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

4.3. Assumption 3: cash affects health by ensuring service utilisation and improved foodconsumption

Cash is usually assumed to be impacting on health and nutrition outcomes either indirectlyby working as an incentive for healthcare utilisation, or directly by allowing the household topurchase higher quality food. Other possible avenues for influencing these outcomes havebeen largely ignored up until recently.

Nevertheless, in a series of six recent studies based on data from the MexicanOportunidades programme, the role of cash has been further explored. Fernald et al.(2008a) finds that a doubling of cash transfers was associated with higher height-for-agescore, lower prevalence of stunting, lower BMI for age percentile, and lower prevalence ofbeing overweight among children in the ages of 24–68 months old. The analysis testswhether there is an association between greater amounts of cash received (measured ascumulative cash transfers) and child outcomes, using a dose–response analysis, whilecontrolling directly for the number of household members and proportion of children ineach age category at baseline, as well as length of time the household has been in theprogramme, to ensure that the cumulative cash transfer variable is not confounded byfamily composition effects or length of programme exposure. Furthermore, the analysisalso controls for differences in access to the fortified food and to healthcare services. Thestudy concludes that the cash component improves growth and health outcomes indepen-dently of these other pathways, either by allowing improved health-related purchases (forexample, of higher quality food or medicines or of household materials and equipment thatcould reduce exposure to infections), or by improving the psychological well-being offamily members and thereby the level of care provided. In a follow-up study of the samechildren four years later, Fernald et al. (2009) found a similar positive association betweencumulative cash transfers and height, but not the negative association with BMI. Althoughthe papers neither explain the initial finding of a lower prevalence of overweight asso-ciated with higher cash transfers nor the disappearance of this association in the follow-uppaper, one would nevertheless expect height to be a more consistent and irreversibleanthropometric measure than weight. In a separate paper, Fernald et al. (2008b) alsoexplore whether the cash transfers were associated with positive outcomes for adult health.They find that a doubling of cumulative cash transfers to the households is associated withhigher BMI, higher diastolic blood pressure, and higher prevalence of overweight andobesity among adults. Thus, they conclude that it is possible that adults consumed foods oflower nutrient density than what they provided for their children, or alternatively that thecyclical nature of the increased resources has a different effect on the physiology ofchildren compared with adults.

In two separate papers, the possible association between poverty alleviation (through thecash transfers) and mental health has been explored. Fernald and Gunnar (2009) evaluate theassociations between a rural family’s participation in the programme during children’s earlyyears of life and their salivary cortisol – a measure of stress level. The study finds that there isa large and significant programme effect of lowering cortisol in children of mothers withhigh depressive symptoms. Ozer et al. (2009) investigate the effect of the Oportunidadesprogramme on children’s behaviour, finding a 10 per cent decrease in aggressive/opposi-tional symptoms but no significant decrements in anxiety/depressive symptoms or totalproblem behaviours. Fernald et al. (2009) also found a significant negative associationbetween higher cash transfers and children’s behaviour problems, which they speculate maybe related to reductions in economic stress perceived by the family.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Finally, until now there has been little explicit thinking about how not only the cashtransfer per se affects health and nutrition, but also how the manner in which the transfer isdelivered may affect outcomes. An analysis by Gertler et al. (2008) shows that using banksto transfer the cash, rather than the traditional distribution of cash, had an effect on theconsumption pattern with important health implications. In particular, this way of transfer-ring money that does not leave it too readily available reduced impulse spending on junkfoods, carbohydrates and some non-food items.

The above collection of findings suggest that large-scale poverty alleviation initiativespaired with health behaviour requirements may exert longer-term ripple effects on children’sdevelopment and be a first step toward curbing the rapidly increasing prevalence of non-communicable diseases, including mental health disorders, around the world.Simultaneously, in the short to medium term, CCT programmes will have to address thepotential perverse effect of cash transfers on BMI, overweight, and hypertension in the adultpopulation. The findings from Mexico are suggestive of the increased importance of theincorporation of chronic disease prevention in CCT programmes, and of the role thefinancial sector can play in people taking control of their lives.

4.4. Assumption 4: information induces behaviour change

The inclusion of educational health talks, mainly targeted towards the women of beneficiaryhouseholds, as part of the conditionalities implies an assumption that it is not only insuffi-cient income that is the reason for inadequate health investments in the household, but also alack of information and education. However, direct measurement of health knowledge andattitudes has generally not been a component of the evaluations in spite of the inclusion ofhealth education components in all programmes. As knowledge, attitudes and practices areposited to be critical elements in health outcome changes, understanding the evolution ofthese factors is critical to explaining the health results observed.

The fact that others, such as men or the mothers-in-law, have not been targeted by thehealth education component does not imply that these are expected to have superior healthknowledge, but rather that they have less influence over the nutritional and health status ofthe children. This is an implicit assumption that, if wrong, may imply important missedopportunities. Who is in charge of specific household activities and decisions will tend to beculturally specific – in Bangladesh it was found that mothers-in-law were in charge ofhousehold nutrition, when present (White 2009) – and may even vary between rural andurban areas within a country.

Expecting that educational health talkswill have an effect on the health-seeking and health-inducing behaviour of households implies an assumption that information in and of itself willinduce behaviour change. A study dedicated to evaluating the educational health talks in theOportunidades programme, using qualitative information to help triangulate the quantitativefindings, found that knowledge of healthy practices improved considerably more among thebeneficiaries than practice (Duarte et al. 2004). As is to be expected, those behaviours that arewithin the control of the person attending the sessions are more likely to be positively affected,such as nutrition and childcare, than those that involve cultural and psychosocial changes in thefamily and community, such as gender equality and domestic violence.

Much of the evidence that suggests information is being transferred through the healthlectures is found in the impact on diet quality. Increases in consumption of more diverse,high nutritional quality foods, such as fruits, vegetables and animal products, was foundfor Oportunidades (Hoddinott et al. 2000, Hoddinott and Skoufias 2004), FA in Colombia(Attanasio et al. 2005) and RPS in Nicaragua (Maluccio and Flores 2005). Ruiz-Arranz


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

et al. (2002) find that the impact of Procampo (a transfer programme designed tocompensate farmers for lost crop income after NAFTA) on dietary diversity was greaterwhen the family was also an Oportunidades beneficiary, further indicating that theinformation transfer positively influenced health-related behaviours. Although theincrease in dietary diversity may have been in part a result of the increased budgetavailable to the households, the fact that higher quality foods increased as a percentage oftotal food expenditure is a strong indication that dietary decisions were affected by thehealth talks. In the case of the other CCT programme in Mexico, Programa de ApoyoAlimentario, where one group of beneficiaries receives only in kind transfers (foodbasket), a second receives the in-kind transfer conditional on attending educationalsessions, a third receives cash instead of the in-kind transfer, and a fourth is the control,Avitabile (2009) finds that for those groups receiving in-kind transfer, attendingthe health and nutrition-related courses is associated with a significant drop in theprobability that women have excessive calorie intake.

There is also evidence suggesting the information provided affected other healthbehaviours. Gutie�rrez et al. (2004a) attempts to isolate the effects of the Oportunidadeshealth talks on smoking and alcohol consumption, an analysis that is also interesting giventhat a potential income effect of the transfer is to increase consumption of these goods. Thestudy finds that rural youth consumed less alcohol and cigarettes than the control groups,whereas the effect of the programme was significantly lower in urban areas. The authorshypothesise that this could be due to the shorter exposure time to the health talks in urbanareas, but recognise that the difference in environment may play an important part – inparticular, the higher exposure to mass media and others factors that incentivise alcoholand cigarette consumption. For the PAL programme, on the other hand, Avitabile (2009)finds that the health talks do not affect drinking and smoking behaviour. In the latter case,it is important to notice that the study only reported on the groups receiving the in-kindtype of transfer, however, which makes the income effect less direct.

Moreover, Hernandez-Prado et al. (2004) report an increased knowledge of familyplanning methods in both urban and rural areas of Oportunidades, and higher use ofmodern family planning methods in rural areas (but not in urban). In a more recent studyassessing the effect of the programme on contraceptive use and birth spacing among thefemale household heads (the ones actually attending the health talks) in rural areas,Feldman et al. (2009) reported impact on birth spacing and a positive effect on contra-ceptive use. When comparing women enrolled in the programme for six years with thoseenrolled for four years there was no significant difference, however, suggesting a flatten-ing trend of the impact. Lamadrid-Figueroa et al. (2010) further disaggregate the effectsand find a markedly larger programme impact on contraceptive use for the poorest of thepoor (a 25–40 percentage point increase) that can be attributed to Oportunidades. Theyhypothesise that it could be the case that the poorest subjects felt more compelled to attendthe health talks in order to retain the benefits of the programme or, alternatively, that thevery poorest group may have been the most marginalised with regards to knowledge aboutcontraceptive practices. In a study looking at the effect of the breastfeeding initiation andduration was included in many questionnaires, but few reported on results. The evaluationof the Colombia FA programme found an increase in the time that children are breastfed by1.44 months in urban areas and 0.84 months in rural areas.

To address the fact that the potential impact on child malnutrition from the nutritionalsupplement was attenuated by problems of household utilisation in the Oportunidadesprogramme, a specific communication intervention was developed. A randomised trialestablished that the intervention increased the prevalence of reported correct behaviours in


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

three out of the four recommended behaviours (Bonvecchio et al. 2007); preparing thesupplement as a pap, administering it daily, and administering between breakfast and dinner.Administering the supplement only to target children was a behaviour that increased inVeracruz but not in Chiapas, where the authors argue that this may have not have beenculturally acceptable.

From the evidence reviewed above, mainly fromMexico, it appears that health educationmay indeed change behaviour – in particular, if it is targeted at a concrete behaviour that ismainly within the control of the person receiving the session, such as diet quality and thepreparation of food supplements.

4.5. Assumption 5: conditioning necessary to induce desired levels of utilisation

In each benefit period, CCT beneficiary households must comply with a set of conditionsrelated to the use of preventive health services and attendance to health education sessions.By conditioning the transfer on certain types of desired behaviour, CCT programmes areimplicitly assuming that the relaxation of the budget constraint brought about by themonetary transfer will not be sufficient to induce major changes in human capital invest-ment. Instead, a condition that transforms the income effect into a price effect, for example,by requiring regular health check-ups, needs to be in place. However, there may be a levelof transfer that would induce the desired behaviour without conditioning. In that case, amajor potential source of inefficiency in the CCT programmes is paying people for whatthey were already going to do. An additional consideration is that effective conditioning(that is, the one that induces a behaviour that otherwise would not have taken place) willtypically reduce at least someone’s welfare in the household. The welfare implications ofconditioning have been analysed in Martinelli and Parker (2003) in the context of ahousehold bargaining model. The study concludes that, as long as a family is bequest-constrained even after the transfer, conditional transfers are better for children thanunconditional transfers, and may be better for mothers’ welfare if she puts more weightthan the father on the child’s consumption. In order to reduce potential efficiency leakage,the relative cost-effectiveness of a conditioned and non-conditioned transfer schemeshould be calculated. Ideally, this would be done by modelling the probability that agiven beneficiary will attend the conditioned health services under different transferscenarios.

The few well-documented studies on this subject do not provide conclusive evidencethat conditionality leads to larger impacts than cash alone. A comparative ex-post impactevaluation by Davis et al. (2002) of the Mexico Oportunidades and an unconditionedtransfer to poor farmers known as Procampo found that while overall increases in foodconsumption were comparable between the two programmes, the effects on health andschooling were significantly greater under Oportunidades, suggesting that conditionalitydid make a difference for total programme’s effects. However, the transfer recipient is mostusually a male in Procampo, while in the CCT programme mothers or primary females arethe main recipient, which could be the source of differences in outcomes, rather than theconditions.

Although not a comparative study, Aguero et al. (2006) finds that an unconditionalcash transfer programme in South Africa, where only the title of the grant (Child SupportGrant) implies the expected use of the money, increases nutritional status of children, asmeasured by height-for-age. Significant impacts are found only when households benefitbefore the child’s second year of life, consistent with nutrition literature that indicates thatthe first two years of life are most critical for a child’s growth (Martorell 1999, Allen and


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Gillespie 2001, World Bank 2006) and with impacts found in CCT programmes (see TableA5). Similarly, Paxson and Schady (2007) find that Ecuador’s unconditional cash transferprogramme Bono de Desarrollo Humano improves children’s nutrition. However, childrenin the treatment group were not found to be more likely to visit health clinics for growthmonitoring. The Malawi Social Cash Transfer programme also finds a 13 percentage pointdifference in the proportion of underweight zero to three year olds between treatment andcontrol groups, as well as a 0.5 cm gain in height among five to 18 year olds, and a 10percentage point reduction in reported illnesses among children aged zero to 18 years(Miller et al. 2009).

Programme designers have feared that, without monitored conditionality and penaltiesfor non-compliance (docking transfers when conditions are not met), CCT beneficiaries willnot comply with programme conditions. Two important aspects may counter this effect. Thefirst is that the mere signalling by the authorities (or programme officials) that compliancewill be monitored passes a message to the beneficiaries of the importance of the activity.Second, the presence of conditions implies that there is a risk of losing the transfers, whichmay linger for a long time.

While conditions are stated in CCT programmes, compliance is not necessarilymonitored. Of the cases where there was effective monitoring (Colombia, Mexico,Nicaragua and Jamaica), compliance was generally extremely high, ranging from a highof 99 per cent of Oportunidades households in Mexico (Fernald et al. 2008b) to a low of 94per cent in Jamaica (Mathematica 2004). In cases without monitoring, evidence is mixed.Morris et al. (2004b) find null effects in the Honduran programme where conditionalitywas not enforced, although payments were also irregular and may be responsible for theabsence of observed effects. Schady and Araujo (2006), on the other hand, argue that in theBono de Desarrollo Humano programme in Ecuador, the mere announcement of condi-tionality, even if not enforced, was the main reason behind the large and significant changein school attendance.

Thus, the findings in this section indicatethat conditionality is not required for a cashtransfer programme to have some desired nutrition impact. However, there is currently noevidence of whether conditioning under the same circumstances would have improvednutritional and health status further. Similarly, the mere threat of monitoring may in theshort term ensure compliance, but there is limited knowledge about how long this threat willbe credible.

4.6. Assumption 6: nutritional supplements necessary to ensure adequate child growthand nutrition

Some programmes have assumed that the cash transfer and the conditions are not sufficientto ensure optimal child nutritional investment, and have added a nutritional supplement.Nevertheless, in the case of Oportunidades, supply and distribution problems limited therole that the nutritional supplement had in improving child growth and nutrition. It wasfurther found that the doses provided to targeted children were commonly reduced due tosharing with non-targeted household members or improper preparation and that moreattention should be paid to ensuring on-time delivery of the supplements to localities(Gaarder 2004a, 2004b, Neufeld et al. 2005). In addition, the form of some nutrients (inparticular iron) was found to be less easily absorbed, which recently led to modifications ofthe formulation (IADB 2005). Thus, without this careful study of the delivery process anduse of the supplements by beneficiaries, these issues would have continued to limit theeffectiveness of at least one component of the programme. As mentioned earlier, as a result


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

of the findings from Neufeld et al. (2005), a specific communication intervention wasdeveloped with respect to the use of the supplement and implemented experimentally, withvery positive results on correct behaviour. A second-round evaluation would therefore beinteresting to see whether the problem behaviours identified and addressed were indeedthe correct ones to improve its effectiveness.

The fact that the nutrition supplements were often not prepared and consumed properlyby beneficiaries in Mexico suggests that the growth improvements observed among youngchildren may have been mainly due to increases in the quantity and variety of householdfood consumption and perhaps increased information received in the lectures.

4.7. Assumption 7: supply-side of services is in place or will follow demand

In countries that did not purposely boost supply in tandem with the cash transfers, the hopewas that governments and providers would increase supply-side inputs if beneficiariesbegan to demand services and provider accountability. In other words, as a response toconditions, beneficiaries may be empowered to insist on receiving better care or use part oftheir additional cash to encourage providers to work longer hours or obtain drugs andsupplies.

Two studies, one of which is published in this issue, shed contrasting light on this topic.Bautista et al. (unpublished) investigate how supply-side constraints (defined as size ofcatchment area, given identical sizes, and part-time versus full-time clinics) modulate theimpact of the Oportunidades programme on primary healthcare utilisation in rural settings,and find that incentivising demand is less effective in stimulating utilisation of healthservices in the presence of supply constraints. Barber and Gertler (2010), on the otherhand, in a paper estimating the effect of Oportunidades on birth outcomes, show by theelimination method that out of the three potential pathways by which the programme canaffect this outcome – namely, increased utilisation of prenatal care, improved quality ofprenatal care, and maternal nutrition – the improvements in birth weight are almost entirelyattributable to the programme’s impact on prenatal care quality. They conclude thatOportunidades affected quality by providing the participating women with informationabout what content to expect, and by giving them skills and social support to negotiatebetter care from healthcare providers.

So, while utilisation may be hampered by limited opening hours or over-crowded clinics,it appears that once the patients do get to see the medical personnel they may be able toinfluence the quality of services they receive by being better versed on what they have theright to expect.

4.8. Assumption 8: programme beneficiaries and programme staff are correctly informedabout the programme

A major assumption for these programmes to have the intended effects is that they areimplemented as designed, and this includes in particular the crucial assumption that thebeneficiaries and programme staff are correctly informed about the programme and itsconditionalities and eligibility criteria. While no studies that fit the screening criteria hadinvestigated this question, a couple of the included studies reported either the results ofqualitative surveys or interpretations of results based on programme implementationinsights that can highlight some lessons. Conditions and incentives are a powerful combi-nation, as we have already discussed, and the misunderstanding of conditionalities oreligibility criteria can drive the observed outcomes in a programme and lead to unintendedand possibly adverse effects. In the case of Honduras, a misunderstanding of the eligibility


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

criteria may have led to increases in fertility rates (Morris et al. 2004b); and in the case ofBrazil, fear that the good performance in the growth monitoring would lead to expulsionfrom the programme or failure to requalify may have led some parents to underinvest in thechildren’s health, and hence to the reduction in the rate of weight gain among programmepreschool children (Morris et al. 2003). As for Turkey, we saw no effect of the programmeon preventive services utilisation but a positive effect on immunisation, which wassupported by evidence from qualitative surveys that beneficiaries did not know theprogramme had health check-up conditionalities, and that those who knew about theexistence of conditionalities in the health area tended wrongly to believe they were relatedto immunisation. In none of these cases do we know, however, whether the misunder-standing happened at the level of the beneficiaries, or was due to the lack of information orerroneous information from programme staff.

Hence, misinterpretations of conditions or eligibility criteria can have real, unexpectedand sometimes adverse implications that may diminish or undo the desired effects of aprogram.

4.9. Health impacts measured are those affected by the programme, and they are measuredat a time when one could expect to observe an impact

This final assumption relates to our ability to measure the true impacts of a CCT programmeon health and nutrition status. This will depend on what we measure and when we carry outthe evaluation. As we have seen, the most common health indicators measured are thoserelated to health services utilisation, vaccination, nutrition (anthropometric measures), anddiarrhoea. While service use of preventive and prenatal care are conditions for receipt oftransfers, and it is therefore nearly obvious that the programmes lead to increases, vaccina-tion rates are often addressed in nationwide campaigns rather than at the clinic level, inwhich case significant effects of the programmes are unlikely to be found. Hence, theinformative value of the outcome on these indicators is limited. More interestingly, thenutrition-related indicators such as stunting, wasting and diarrhoea, which one would expectto be significantly affected by a number of the components of the programme (nutrition talks,preventive care, growth monitoring, food supplements, more diverse diet), show very mixedresults. A number of factors can play a role in this finding. In contrast to utilisation andvaccination, nutrition-related measures are much more dependent on the timing of themeasurement. For example, the fact that no impact was found on wasting and stunting inHonduras was argued to be due to the premature mid-term evaluation (for election reasons).Furthermore, in some cases underweight was (mis)understood to be a criteria for programmeeligibility (Brazil), thus creating a perverse incentive to keep the children underweight.Finally, since increasingly in the poor populations under investigation the dual nutritionalepidemics of stunting and obesity are co-existing, some of the programme components, suchas additional cash, can work in the opposite direction, permitting the consumption of moreunhealthy foods.

CCT programme evaluations have given limited attention to morbidity measurements,the exception being Mexico’s Oportunidades programme, as well as to the impact onhealth-related behaviours, attitudes and household decision-making and how these factorscontribute or limit impacts on outcomes. A particularly under-investigated area is that ofmental health, which both from a theoretical standpoint and from the limited empiricalevidence from Mexico is one that could see large impacts due both to poverty alleviationeffects of the programmes and to their rights-based approach to health and public servicesmore generally.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Furthermore, although the programme rationale and effect model indicate that thereduction of out-of-pocket and opportunity costs associated with healthcare seeking isboth the principal mechanism to increase utilisation, and thus one of the outcome variableson which one would expect to observe impact, few evaluations have analysed these aspects.

To briefly summarise; although CCT interventions have pioneered rigorous impactevaluation methodologies in the social development sphere, with the exception of theMexican Oportunidades programme, they have tended to delve on the measurement ofthose health inputs that are a condition of the programme, and hence within the programmes’control, rather than on non-conditioned inputs such as health expenditure, or on the intendedhealth outcome indicators.

5. Summarising the evidence

Due to the differences in the specifications and implementation practices of all theprogrammes discussed in this paper, as well as the differences in the definition of indicatorsmeasured, the time periods covered and the countries of implementation, the existingevidence does not lend itself to meta-analysis and there is no truly scientific way ofaggregating and summarising the findings for policy purposes.

Nevertheless, in the major indicator categories for which we have findings from morethan two programmes, including visits to the public clinic, immunisation, stunting, andwasting, we have generated forest plots with the estimated effect sizes, measured by therisk ratio. Figure 2 presents the forest plots for all four categories of indicators, and isordered in such a way that the we move from an indicator at the level of input, in this casepublic clinic visits, at the top of the table, to an output indicator, in this case immunisation(full or DPT), and finally, at the bottom of the table, we report on outcome indicators in thearea of nutrition (in this case anthropometric measures). As we move down the table, wecan observe a tendential decrease in the estimated ratios, indicating how the programmeshave been successful at incentivising public clinic visits, have had rather more limitedeffect on immunisation, and a less than inspiring measured effect, to date, on the incidenceof stunting and wasting.

However, as has been highlighted throughout this paper, these differences in findings maybe due to a range of issues, including programme-specific problems encountered during theimplementation phase, as well as other interventions external to the programme influencing theimpact of the programmes (or the measurement thereof). Furthermore, as has been shown in anumber of papers (for example, Behrman andHoddinott 2005, Lamadrid-Figueroa et al. 2010),the averaged impacts often reported on in the studies may mask heterogeneous effects at thesubgroup levels, such as in certain age or income groups. An evenmore serious limitation on thevalidity of this type of summary is that of multiple biases, such as publication bias, reportingbias, censorship in the type of indicators being evaluated, and so forth. Nevertheless, with allthose caveats underlined, we believe that, after the in-depth discussions of the previous chapters,Figure 2 may be useful to some in terms of giving a bird’s-eye perspective of what has beendocumented to date. It is therefore important to note that no conclusion should be drawn fromthe table as to the actual impacts of CCT interventions on the different outcomes, since it can beassumed that the above-mentioned biases are in effect, nor should conclusions be drawn as to thepotential impacts on these outcomes once services are provided in the most efficient manner, tothe people most in need of these, and once measured and reported upon correctly (that is, withproper identification, no contamination issues, no reporting and publication biases).

The effects on morbidity and mortality have mostly been measured in Mexico, mostlywith positive or insignificant results (and without much satisfactory explanation as to


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

why the impact of the programme is positive for some age groups for some indicators,and not for other age groups and/or other indicators). More research around theseindicators from other programmes and regions would be important to expand theevidence.

Clinic visitsGertler and Boyce (2001) (Mexico, 0–5 years*)Gertler (2000) (Mexico, 0–5 years, public clinic visits*)Maluccio and Flores (2005) (Nicaragua, 0–3 years*)Gertler (2000) (Mexico, 0–5 years, growth monitoring*)Levy and Ohls (2007) (Jamaica, 0–6 years)Morris et al. (2004) (Honduras, 0–3 years)Attanasio et al. (2005) (Colombia, all children*)Subtotal

Immunisation – DPTLevy and Ohls (2007) (Jamaica, 0–6 years)Attanasio et al. (2005) (Colombia, all children*)Barham and Maluccio (2008) (Nicaragua, 0–4 years*)Morris et al. (2004) (Honduras, 0–3 years)Subtotal

Immunisation – FullVeras Soares (2010) (Paraguay, 0–5 years*)Levy and Ohls (2007) (Jamaica, 0–6 years)Barham (2005) (Mexico, TB or measles*)Maluccio and Flores (2005) (Nicaragua, 0–2 years*)Barham and Maluccio (2008) (Nicaragua, 0–4 years*)Ahmed et al. (2006) (Turkey, 0–5 years)Subtotal

Nutritional improvements – stuntingMorris et al. (2004) (Brazil, 0–7 years, average HAZ)Flores et al. (2003) (Honduras, 0–2 years, % HAZ>–2)Attanasio et al. (2005) (Colombia, 0–7 years, % HAZ>–2*)Leroy et al. (2008) (Mexico, 0–2 years, average HAZ)Maluccio and Flores (2005) (Nicaragua, 0–2 years, % HAZ>–2)Subtotal

Nutritional improvements – wastingFlores et al. (2003) (Honduras, 0–5 years, % WAZ>–2)Morris et al. (2004) (Brazil, 0–7 years, average WAZ)Maluccio and Flores (2005) (Nicaragua, 0–5 years, % WAZ>–2)Subtotal

IDStudy

Please note that an online annex with a complete table of estimated effects in the health and nutrition area will be available athhtp ://WWW.informaworld.com/mpp/uploads/465127_online_table.pdf

0.91 (0.79, 1.06)1.15 (0.63, 2.10)1.17 (0.99, 1.37)1.28 (1.16, 1.40)1.38 (1.14, 1.68)1.46 (1.23, 1.74)1.64 (1.24, 2.16)1.26 (1.09, 1.45)

1.01 (1.01, 1.01)1.07 (0.99, 1.16)1.07 (0.90, 1.27)1.10 (1.01, 1.18)1.08 (1.03, 1.14)

0.94 (0.86, 1.03)1.01 (1.01, 1.01)1.02 (0.98, 1.08)1.21 (0.75, 1.95)1.22 (0.98, 1.52)1.31 (1.11, 1.54)1.09 (0.97, 1.22)

0.88 (0.77, 1.01)1.01 (1.01, 1.01)1.08 (0.91, 1.29)1.09 (0.94, 1.26)1.16 (0.99, 1.36)1.04 (0.92, 1.18)

0.68 (0.68, 0.68)0.83 (0.70, 0.98)1.83 (1.13, 2.94)1.19 (0.55, 2.57)

ES (95% CI)

1.04 (0.92, 1.18)

Favours intervention

1.25 .5 1 1.25 1.5 3

Figure 2. Forest plots: public clinic visits, immunisation, stunting and wasting.

Notes:

1. HAZ indicates height for age z score; WAZ is weight for age z score.

2. *Estimates are summary measures where we have averaged across age groups and, in some cases,

over different exposure periods for the same group. For the pooled variance calculations, the

covariance between estimates for pooling different age groups is assumed to be 0.5 (so assuming

correlation between those children of different ages living in the same households) and one for

pooling across time periods (so assuming the same children are being measured at one-year impact,

two-year impact, and so forth). The estimates for those studies that did not provide standard errors

(Levy and Ohls 2007, Flores et al. 2003) are not included in the pooled effectiveness estimates.

3. For the anthropometric measures, the reported ratios were inverted in order to reflect impact on a

positive outcome, in this case nutritional improvements (reductions in stunting and wasting), so that

the graphic interpretation of these findings is in line with the other indicators reported on in the

figure. It is worth noting that % HAZ is bigger than –2 standard deviations and average HAZ are not

strictly comparable. 95% CI (confidence interval).


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

http://www.informaworld.com/mpp/uploads/465127_online_table.pdf

Please note that an online annex with a complete table of estimated effects in the healthand nutrition area is available online.

6. Conclusions and recommendations

CCT interventions that focus on health are specifically designed to influence demand-sidefactors of healthcare-seeking behaviour. Based on evidence from Latin America, Africa,Asia and the Middle East, the paper confirms that financial incentives work to increaseutilisation of those key health services by the poor upon which the cash transfer is condi-tioned, as long as the beneficiaries have knowledge about the programme requirements.

However, the mixed picture with respect to outcomes – nutritional status and, where wehave data, morbidity and mortality – suggest that encouraging utilisation when the perti-nence of services is unknown or of poor quality may not produce the expected effects.Moreover, the mixed results suggest that assumptions about needs, household decision-making and causal relationships might not be entirely correct and thus our expectations forimpacts, given the current programme designs, may be incorrect.

The assumption that cash affects health primarily by ensuring service utilisation andimproved food consumption is challenged by recent findings from Mexico, indicating thatthere are direct routes by which the cash transfers affect health, outside of the health sectorinteractions. In particular, the poverty alleviation achievedwith the cash transfersmay affect themental health of beneficiaries, aswell as their lifestyle choices. Themanner inwhich the transferis delivered may also affect outcomes, as less readily available money (for example, throughbank accounts rather than cash) may reduce impulse spending on unhealthy foods and drinks.

A key design question relates to identifying the marginal benefit of conditioned overunconditioned transfers. Monitoring conditionality is costly, and complying with the co-responsibilities is time-consuming for the household. Thus, it is important to determinewhether conditions are necessary. Findings indicate that conditionality is not required for acash transfer programme to have some desired health and nutrition impact. However, there iscurrently no evidence from one programme to readily compare conditional versusunconditional.

An important policy recommendation ensuing from this review is the need to find the rightmix of incentives and regulation to improve the quality of care, while at the same time investingin the empowerment of users. Future research that explores the relative cost-effectiveness ofinvesting in the supply side versus the demand side within the health system will be crucial.Supply and demand are jointly determined and, while paying poor households to use preventiveservices works at increasing utilisation, it is still unclear what happens at the health post. Ifquality decreases, or non-beneficiaries are crowded out, the programmes may pay too much forthe care that beneficiaries receive. In other words, negative spillovers in service quality fromdemand-side programmes may be greater than the net gain to beneficiaries. On the other hand,increased demand andmore informed users of the healthcare services may encourage improve-ments in efficiency and quality, as we have seen. Regardless, these questions stress the need foran assessment of the supply-side and ex-ante modelling of the demand for healthcare.

The multidimensionality of CCT programme benefits is their main attraction, as itrecognises that the barriers to better health and service use are part of a broader problem ofhousehold resource scarcity; but in terms of evaluation, it is also their main challenge.Despite the relative abundance of rigorous research and evidence from the CCT area,critical questions remain unanswered, among which this paper highlights the relative cost-effectiveness of investing in the supply side versus the demand side within the healthsystem, as well as the marginal benefit of conditioned over unconditioned transfers.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Table1.

Studies

selected

forthepresentreview

.

Cou

ntry

Study

Outcomes

repo

rted

Evaluationmetho

d

Brazil

Bolsa

Fam

ilia

Morrisetal.(20

04a)

Nutrition

(anthrop

ometric)

PSM,retrospective

coho

rtanalysis

Colom

bia

FAAttanasio

etal.(20

05)

Service

use

PSM,D

DVaccination

Nutrition

(anthrop

ometric)

Morbidity

(incidence

ofdiarrhoea)

Hon

duras

PRAF

Floresetal.(20

03)

Service

use

RCT(cluster)

Servicesreceived

(vaccination

;weigh

ting

)Nutrition

(anthrop

ometric)

Con

sumption(foo

d)Morbidity

(diarrho

ea;anaemia)

Morrisetal.(20

04b)

Service

use

RCT(cluster)

Servicesreceived

(vaccination

;weigh

ing)

Jamaica

PATH

LevyandOhls(200

7)Service

use

RDD

Servicesreceived

(vaccination

,bloo

d,urine,height,

weigh

t)Perceived

health

status

Malaw

iMDICP

Tho

rnton(200

8)Service

use

RCT(cluster)

Mexico

Gertler

(200

0)Service

use

RCT(cluster)

Morbidity

PROGRESA/

Opo

rtun

idades

Hod

dino

ttetal.(20

00)

Con

sumption(foo

d)RCT(cluster)

Behrm

anandHod

dino

tt(200

1)Nutrition

(anthrop

ometric)

RCT(cluster),correctedforheterogeneityusing

child-specificfixedeffects

GertlerandBoy

ce(200

1)Service

use

RCT(cluster)

Nutrition

(anthrop

ometric)

Morbidity

Hernand

ezPrado

etal.

(200

3)Mortality

Tim

e-series

regression

analysis

Gertler

(200

4)Nutrition

(anthrop

ometric)

RCT(cluster)


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Morbidity

(anaem

ia,repo

rted

illness)

Gertler

andFernald

(200

4)Child

developm

ent(foo

d)RCT(cluster);laterPSM

andmultivariateregression

Hod

dino

ttandSko

ufias

(200

4)Con

sumption

RCT(cluster)

Hernand

ezPrado

etal.

(200

4)Service

use(prenatalcare;childbirthcare)

RCT(cluster)

Servicesreceived

(num

bero

factions

undertaken

compared

withno

rmal)

PSM

Fernald

etal.(20

04)

Morbidity

(chron

ic)

RCT(cluster)

PSM

Hernand

ezAvilaetal.

(200

4)Service

use

RCT(cluster)

Servicesreceived

PSM

Morbidity/detection

DuarteGom

ezetal.

(200

4)Behaviour

(kno

wledg

eandpractices)

RCT(cluster)

PSM

qualitative

Gutie�rrez

etal.(20

04a)

Service

use

RCT(cluster)

Morbidity

PSM

Riveraetal.(20

04)

Nutrition

RCT(cluster)

Morbidity

(anaem

ia)

Barham

(200

5a)

Mortality

Interrup

tedtime-series

Barham

(200

5b)

Vaccination

RCT(cluster)

Behrm

anandHod

dino

tt(200

5)Nutrition

(anthrop

ometric)

RCT(cluster),correctedforheterogeneityusingchild

specificfixedeffects

Neufeld

etal.(20

05)

Nutrition

PSM

Con

sumption

Bon

vecchioetal.(20

07)

Healthbehaviou

rchange

RCT(cluster)

Leroy

etal.(20

08)

Nutrition

(anthrop

ometric)

PSM,D

DFernald

etal.(20

08a)

Nutrition

(anthrop

ometric)

Multivariateregression

Fernald

etal.(20

08b)

Morbidity

(chron

icdisease)

Multivariateregression

Fernald

etal.(20

08c)

Morbidity

(chron

icdisease)

PSM

Feldm

anetal.(20

09)

Fam

ilyplanning

(con

traceptive

use,birthspacing)

RCT(cluster)

Ozeretal.(20

09)

Mentalhealth

RCT(cluster);laterPSM

andmultivariateregression

(Con

tinu

ed)


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Table1.

(Con

tinu

ed)

Cou

ntry

Study

Outcomes

repo

rted

Evaluationmetho

d

Fernald

andGun

nar

(200

9)Stress(salivarycortisol)

PSM

Urquietaetal.(20

09)

Service

use

RCT(cluster)

Fernald

etal.(20

09)

Nutrition

(anthrop

ometric)

RCT(cluster)andmultivariateregression

BarberandGertler

(201

0)Nutrition

(anthrop

ometrics)

RCT(cluster)

PAL

Avitable(200

9)Service

use/attend

ance

RCT(cluster),compo

nent

Risky

behaviou

rNutrition

(anthrop

ometric)

Con

sumption(foo

d)Nepal

SDIP

Pow

ell-Jacksonetal.

(200

9)Service

use

Interrup

tedtimeseries

Mortality

Nicaragua

RPS

Barham

andMaluccio

(200

8)Vaccination

RCT(cluster)

MaluccioandFlores

(200

5)Service

use

RCT(cluster)

Vaccination

Nutrition

Con

sumption(foo

d)Morbidity

Paraguay

Tekop

ora

Soaresetal.(20

08)

Service

use

PSM,retrospective

coho

rtanalysis

Vaccination

Con

sumption(foo

d)Turkey

CCT

Ahm

edetal.(20

06,

2007

)Vaccination

RDD

Con

sumption(foo

d)Morbidity

Note:DD=difference

indifference;PSM

=propensity

scorematching;

RCT=rand

omised

controltrial;RDD=regression

discon

tinu

itydesign

.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Table2.

Program

mecharacteristics:monetarybenefits,h

ealthconditions

andtargeting.

Cou

ntry,

prog

ramme

Mon

etarybenefit

Healthcond

itions

(i)Targeting

poverty(yes/no);(ii)metho

dology

Brazil,Bolsa

Fam

ilia

(i)$1

8/HH;5/child

(upto

3children);

(ii)Av.mon

thly:

US$2

4

(i)Upd

ated

immun

isationcardsforchildren

0–6yearsold;

(ii)Pregn

antandbreastfeedingwom

enfor‘regular’visitsto

health

centres;

(iii)Children0–

15yearsoldfor‘regular’visitsto

health

centres

(i)Yes;

(ii)Poo

restho

useholds

from

selected

mun

icipalities

(selectedaccordingto

infant

malnu

trition

prevalence)

Colom

bia,

Fam

iliasen

Accion

(i)$2

0/HH;$6

/child

prim

aryage;$1

2/childsecond

ary

age;

(ii)Av.mon

thly:

US$5

0

(i)Childrenaged

0–4yearsattend

inggrow

thmon

itoring

visitsaccordingto

aMOHprotocol

(6/yearforage0–

1,2/year

forages

1–3,

1/year

forage3–

4);

(ii)Mothers’attend

ance

tobimon

thly

health

education

worksho

ps

(i)Yes;

(ii)Locality(m

eetfour

criteria)andho

usehold

(SISBEN)

Hon

duras,PRAF

(i)$4

/HH;$5/child;

(ii)Av.mon

thly:

US$1

7

(i)Childrenattend

inggrow

thmon

itoringvisits

accordingto

MOHprotocol;

(ii)Pregn

antwom

enforatleastfour

prenatalcare

visits

(i)Yes;

(ii)Locality(priorityindex)

Jamaica,PATH

(i)$9

/eligibleHH

mem

ber(child,

elderly,disabled);

(ii)Av.mon

thly:

US$4

5

Childrenaged

0–6attend

check-up

severytwomon

ths

during

ages

0–1andtwiceayear

thereafter

(i)Yes;

(ii)Poo

restho

useholds

(proxy

means

testing)

Malaw

i,MDICP

Upto

US$3

for

collection

oftest

(mean:US$1

.04)

Collectinghu

man

immun

odeficiencytestresults

(i)No;

(ii)Individualswho

underw

enthuman

immunodeficiencytestingin

ruralareas

Mexico,

Opo

rtun

idades

(i)$1

3/HH;$8–

17/

child

prim

ary;$2

5–32

/childsecond

ary;

onetimegrant

$12–

22/child

for

scho

olsupp

lies;

(ii)Av.mon

thly:

US$2

0

(i)Childrenaged

0–23

mon

thsfullyim

mun

ised

and

attend

inggrow

thmon

itoringvisitseverytwomon

ths;

(ii)Childrenaged

24–6

0mon

thsattend

inggrow

thmon

itoringvisitseveryfour

mon

ths

(iii)Pregn

antwom

enforatleastfour

pre-natalcare

visits;

(iv)

Breastfeeding

wom

enforatleasttwopo

stpartum

care

visits;

(i)Yes;

(ii)Localityandhousehold(m

arginality

index)

(v)Other

familymem

berson

ceayear

forph

ysical

check-up

s;(vi)Adu

ltfamilymem

bersto

attend

health

talks–female

headsof

householdeverytwomon

ths;

otheradultson

ceayear

(Con

tinu

ed)


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Table2.

(Con

tinu

ed)

Cou

ntry,

prog

ramme

Mon

etarybenefit

Healthcond

itions

(i)Targeting

poverty(yes/no);(ii)metho

dology

Mexico,

PAL

Av.mon

thly:US$1

3in

cash

orin

kind

(foo

dbasket)

Mothers’attend

ance

tohealth

andnu

tritioneducationworksho

ps(i)Yes;

(ii)Locality(m

arginalisedrurallocalities)

Nepal,S

DIP

US$1

5.6fordelivery

inpu

blichealth

facility

Givingbirthin

apu

blic

health

facility

(i)No;

(ii)Pregnantwom

en(nomorethan

twoliving

children

oran

obstetriccomplication)

Nicaragua,R

edde

Proteccion

Social

(i)$1

8/HH;

addition

al$9

/HH

withascho

ol-aged

child;

$20/year/

childforsupp

lies;

(ii)Av.mon

thly:

US$2

5

(i)Mothers’attend

ance

tobimon

thly

health

education

worksho

ps;

(ii)Uptodatevaccinationschemeforchildren

aged

0–1year

old(not

enforced

dueto

supp

lyfailures);

(iii)Childrenun

der2yearsoldattend

ingmon

thly

grow

thmon

itoring/well-baby

visits;

(iv)

Childrenbetween2and5yearsoldattend

ingbimon

thly

medicalcheck-up

s

(i)Yes;

(ii)Mun

icipality(70withlowestHAZof

firstgraders)

Paraguay,

Tekop

ora

(i)Regular

visitsto

health

centre

(ii)Upd

atingof

immun

isations

(i)Yes;

(ii)Locality(Poo

restdistricts;IG

P)andho

usehold

(quality

oflife

index)

Turkey,CCT

(i)$11/HH;$1

2–15

/childprim

ary;

$19–

26/child

second

ary;

$11/

pregnant

wom

an;

one-timegrant$37

forbirthat

hospital;

(ii)Av.mon

thly:NA

(i)Childrenaged

0–6mon

thsattend

mon

thly

check-up

s,everytwomon

thsdu

ring

ages

7–18

mon

ths;andtwicea

year

forages

19–7

2mon

ths;

(ii)Pregn

antwom

enattend

mon

thly

check-up

s;birthgiven

inho

spital;po

st-birth

check-up

s.

(i)Yes;

(ii)Poo

restho

useholds

(proxy

means

testing)

inpilot

prov

inces.

Av.=average;HAZ=height

forage;HH=household;

MOH=Ministryof

Health;

SISBEN=Sistemade

Seleccion

deBeneficiarios

(Beneficiary

Selection

System).


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Table3.

Program

meeffectson

utilisation.

Mexico,

1997

–200

3Hon

duras

Nicaragua

Colom

bia

Paraguay

Jamaica

Malaw

iNepal

Pub

licclinic

visits

Rural,

1997

–200

00–

3years

old:

0–3yearsold:

0–2yearsold:

0–5yearsold:

0–6years

old:

0–2yearsold

20pp increase

12.4

ppincrease

23pp

increase

7%morelikely

toattend

clinicsixtimes

ormore;4%

morelikely

toattend

four

orfive

times

27.8%

increase

NS

0–3yearsold:

2–4yearsold:

–25%

(decrease)

17.5%

and23

.6%

increase,for

alland

extrem

elypo

or,

respectively

(past6

mon

ths)

33pp

increase

3–5yearsold:

.4yearsold:

36%

increase

1.5pp increase

(com

pleted

age-

approp

riate

visit)

NS

6–17

yearsold:

44%

increase

22%

increase

18–5

0yearsold:

30%

increase

22%

increase

50+years:

47%

increase

20%

increase

(Con

tinu

ed)


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Table3.

(Con

tinu

ed)

Mexico,

1997

–200

3Hon

duras

Nicaragua

Colom

bia

Paraguay

Jamaica

Malaw

iNepal

Pub

licho

spital

visits

Rural,

1997

–200

30–

2yearsold

–0.007

(mon

thly

average0.12

)50

+years:

0.00

6(m

onthly

average

0.00

6)Healthcontrol

andweigh

ting

ofchildren

Rural,

1997

–200

018

.7%

increase

(5or

more;

last

pregnancy)

0–2yearsold:

30–6

0%increase

3–5yearsold:

25–4

5%increase

Prenatalcare

visits(num

ber

ofvisits;

details)

Rural

NS

NS

Urban

6.12

%increase

(4or

more;

Kessner

Index)


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Professional

care

atchildb

irth

Rural,

1997

–200

02.6pp

increase

inprob

ability

ofdelivery

ingo

vernment

facility;

NS(not

acond

ition)

2.3pp

increase

inprob

ability

ofskilledbirth

attend

ance;

4.4pp

increase

inattend

ance

byanyhealth

worker

10-day

postpartum

exam

ination

5.6% de

crease

VCTcentre

visit

80–1

26%

increase

(any

value

voucher)

Note:NS=no

tsign

ificant


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Table4.

Vaccination

.

Outcome

Age

rang

eBaseline

Impact,

percentage

points(SE)

Evaluation

metho

d

Colom

bia

Attanasio

etal.

(200

5)

Com

pliancewith

DPT

vaccination

,24

mon

ths

77.4 (urban)

8.9*

(4.7)

PSM,D

D

24–2

8mon

ths

73.2 (rural)

3.5(2.6)

.48

mon

ths

3.2(3.9)

Hon

duras

Morrisetal.

(200

4b)

DPT

73.2

6.9*

**(3.0)

RCT

Tetanus

59.6

4.2(7.1)

Measles

82.2

–0.2

(4.7)

Jamaica

Levyand

Ohls

(200

7)

OPV

,5years

95.8

NS

RDD

DPT

,5years

98.5

NS

BCG

,5years

98.2

NS

Measles

,5years

87.3

NS

Mexico

Barham

(200

5)Tub

erculosis

,12

mon

ths

88.0

1.6(2.4)

RCT

12–2

3mon

ths

97.0

–23

–35mon

ths

98.0

-Measles

12–2

3mon

ths

92.0

2.8(2.8)

23–3

5mon

ths

96.0

–

Nicaragua

Barham

and

Maluccio

(200

8)

Fullcoverage

(FVC)

,3years

RCT

2001

54.0

14.0*(8.0)

2002

84.0

13.0

(9.0)

Catch-upFVC

2001

68.0

7.0(9.0)

2002

91.0

17.0*(9.0)


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

FVCfor

popu

lation

with

health

facility

.5km

away

2001

38.0

26.0**

(8.0)

2002

75.0

39.0*(16.0)

Maluccio

and

Flores

(200

5)

Up-to-date

vaccinations

12–2

3mon

ths

38.9

4.6(11.0)

RCT

Paraguay

Soaresetal.

(200

8)Propo

rtionof

children

with

vaccination

cards

,60

mon

ths

PSM

(nearest

neighb

our)

Declared

95.0

(-)6.6

(3.6)

Sho

wn

60.0

(-)2.0

(4.5)

Propo

rtionof

updated

vaccinations

forthosewho

show

edtheir

cards

,60

mon

ths

(-)2.7

(3.1)

Turkey

Ahm

ed(200

6)Prevalenceof

preschoo

lchildren

fully

immun

ised

,6years

43.8

14.2**

*(4.2)

RDD

Note:BCG=BacilleCalmette-G

ue�rin;

OPV=oralpo

liovaccine.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Table5.

Program

meeffectson

nutrition-relatedindicators.

Program

me

Mexico,

(199

7–19

99a ,

1997

–200

3b,

2002

–200

4c )

Hon

duras

(200

0–20

02)

Nicaragua

(200

0–20

02)

Colom

bia(200

1–20

03)

Brazil

Propo

rtion

stun

ted;

HAZ

,–2

.0(or

impacton

height)

Rural,1

997–

1999

0–4yearsold:NS

0–4yearsold:

5.5pp

decrease

0–2yearsold:

6.9pp

decrease

Allchildren:

NS

12–3

6mon

ths:

decrease

(coefficient

forlogitestimate

repo

rted)

2–7yearsold:

NS

12–3

6mon

thsat

baseline:1cm

increase

Rural,1

997–

2003

24–7

2mon

ths:29

%decrease

(girls),11%

decrease

(boy

s)Urban

,200

0–20

020–

6mon

thsatbaseline:

1.5cm

increase**

Propo

rtion

underw

eigh

t;WAZ

,–2

.0(orim

pacton

weigh

t)

Rural,1

997–

2003

0–4yearsold:NS

0–4yearsold:

6.0pp

decrease

Rural:0–

3yearsold,

NS;3–

7years

old,

3.4pp

decrease

Allchildren:–0

.183

kg(difference

after6mon

thsof

intervention

s)

NS

Urban:NS

0–12

mon

ths:–0

.274

kgUrban

,200

2–20

040–

6mon

thsatbaseline:

0.76

kg.6mon

thsatbaseline:

NS


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Weigh

tatbirth

Rural,1

997–

2003

(note11):0.04

5(0.025

)

Rural:NS

Urban

:0.57

8(0.143

)Mean

haem

oglobin

value(g/dl)of

children

Aged12

mon

ths

(baseline)

after1

year

ofprog

ramme

participationvs

noexpo

sure

inthe

controlgrou

p:0.37

Aged6–

59mon

ths:–0

.1Aged6–

59mon

ths:

–0.2

Prevalenceof

anaemia(%

)forchildren

Aged12

mon

ths

(baseline)

after1

year

ofprog

ramme

participationvs

noexpo

sure

inthe

controlgrou

p:10

.6

0–4yearsold:NS

After

2yearsof

prog

ramme

participationvs

1year

inthecontrol

grou

p:–2

.8

Sou

rce:

a Behrm

anandHod

dino

tt(200

0,20

01).

bGertler

andFernald

(2004).B

arberandGertler

(2010),F

ernald

etal.(20

08c).cLeroy

etal.(20

07).


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Table6.

Program

meeffectson

morbidity

andmortality.

Program

me/

indicator

Reportedillness

Diarrho

eaRespiratory

disease

Mortality

Colom

bia,

(200

1–20

03)

Rural

Rural:NS

,48

mon

ths:

–11%

Urban:NS

.48

mon

ths:

NS

Urban:NS

Hon

duras

0–3yearsold:

5.9pp

(25%

)Nepal

Neonatalmortality:

NS

Mexico,

(199

7–19

99a ,

1997

–200

3b,

2002

–200

4c)

Urban

1995

–200

2

–0.97days/m

onth

Maternalmortality:

–11%

(RR

=0.89

,95%

CI=0.82

,0.95)

Rural

Infant

mortality

(IMR):–2

%(RR

=0.98

,95%

CI=0.97

,0.99)

Overallillness:–2

3.3%

1997

–200

119

97–2

000

IMR(m

unicipal

level):–11%

Childrenwho

semother

repo

rted

they

wereillin

past4weeks:

IMR(ATE):–5

%

Aged0–

2yearsat

baseline:–1

2%


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Aged3–

5yearsat

baseline:–11%

1997

–200

0Age

0atbaseline:

6mon

thsprog

ramme

expo

sure:NS

12mon

thsprog

ramme

expo

sure:–1

3%Age

1atbaseline:

6mon

thsprog

ramme

expo

sure:NS

12mon

thsprog

ramme

expo

sure:–1

4%Age

2–3atbaseline:

6mon

thsprog

ramme

expo

sure:NS

12mon

thsprog

ramme

expo

sure:–1

4%Likelihoo

dof

children

aged

,3yearsat

baseline

tobe

repo

rted

ill:0.78

Impactafter2moof

prog

ramme:0.94

Impactafter8moof

prog

ramme:0.75

Impactafter14

moof

prog

ramme:0.84

Impactafter20

moof

prog

ramme:0.61

Rural,1

997–

2003

Medium-effortADL(%

):0.03

(0.01–

0.05

)Num

berof

sick

days

inpast4weeks:–0

.48

(–1.16

to0.19

)

(Con

tinu

ed)


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Table6.

(Con

tinu

ed)

Program

me/

indicator

Reportedillness

Diarrho

eaRespiratory

disease

Mortality

Num

berof

days

notableto

doADL:–0.55

(–0.85

to–0

.25)

Rural,1

997–

2000

d

Daysof

difficulty

with

dailyactivities

6–17

years:NS

18–5

0years:19

%decrease

50+years:19

%decrease

Daysincapacitated

6–17

years:NS

18–5

0years:NS

50+years:21

%decrease

Dayssick

inbed

6–17

years:NS

18–5

0years:NS

50+years:22

%decrease

Note:ADL=activities

ofdailyliving;ATE=averagetreatm

enteffect.

Sou

rce:

a Behrm

anandHod

dino

tt(2000,20

01).

bGertlerandFernald(200

4),B

arberandGertler(201

0),F

ernaldetal.(20

08c).cLeroy

etal.(20

07).

dGertler(2000)

andGertlerandBoyce

(200

1)reporton

thesameindicatorsforthesamedatasetand

period

,but

withminor

differencesin

results.Non

eof

thepapersalludesto

thedifferences;ho

wever,theydo

notchang

ethe

find

ings

inanysubstantialmanner.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

AcknowledgementsThanks to HughWaddington for providing statistical assistance and generating the forest plots included inthis paper. Thanks also to Howard White and Jere Behrman for providing comments, and Birte Snilstveitand AnjiniMishra for research assistance. The views expressed in this paper are those of the authors and donot necessarily reflect the views of the International Initiative for Impact Evaluation (3ie), the EconomicResearch Service, the US Department of Agriculture, or the Inter-American Development Bank.

Notes1. Chile’s Solidario programme and Ecuador’s social cash transfer programme have been excluded

from this review given that the transfer is not conditional on any health or nutrition-relatedbehaviour.

2. There exist more countries with CCT interventions underway than those included in this review,but these have either not been in operation long enough to have results from evaluations, do notinclude health conditions, or the evaluations have been screened out.

3. In addition to the studies referenced elsewhere in this paper, the chapter has drawn on thefollowing references: Adato et al. (2000), Adato and Roopnaraine (2004), Alvarez et al.(2005), Behrman and Todd (1999b), Belik et al. (2003), Bourguignon et al. (2002), Calde�set al. (2004), Coady (2000), Coady and Harris (2000), Coady and Parker (2004), Coady et al.(2003, 2004), IFPRI (2000, 2001a, 2003) for Honduras, IFPRI (2001b, 2001c, 2002a, 2002b) forNicaragua, Morris (2001), Rawlings and Rubio (2003), Skoufias et al. (1999), Union TemporalIFS-Econometrıa S.A.-SEI (2000, 2001a, 2001b, 2004).

4. In the early phase of the Honduran PRAF programme, there were conditions related to the weightgain of the infants; however, this condition was later dropped when qualitative assessmentsreported on cases in which the mothers had been filling the infants up with water before themonthly weighing sessions.

5. In the case of Honduras the prenatal check-ups are part of the regular health conditions, whereas inthe case of Turkey there is an additional cash incentive per pregnant woman conditional on these.

6. Sze�kely et al. (2000), and personal communication with sector specialists at the Inter-AmericanDevelopment Bank involved in the design of these programmes.

7. For a more detailed discussion on the pros and cons of different targeting strategies used in CCTprogrammes, see Glassman et al. (2007) and Coady et al. (2004).

8. The incentive was only supposed to be available to women with two or fewer children, althoughthis was found difficult to verify and was later scrapped.

9. The lack of impact found on public clinic visits for the zero to two year olds in the Oportunidadesprogramme was explained by the author by the fact that in this age group the conditionalityrelated to the growth monitoring visits, which did exhibit a substantial increase.

10. An analysis of the implications of this substitution of private service providers for public ones hasto our knowledge not been carried out. If private service providers have been driven out by theprogramme, then this may among others affect the availability of health care for non-participants.

11. Verbal communication received by M. Gaarder during the preparation of the second phase of thesaid programme, 2004, IADB.

12. Although there is the possibility that the expected future payment was internalised in thehousehold budget planning, the fact that the programme experienced lengthy delays in thedisbursement of funds would have reduced the chance of this happening.

References

General

Adato, M. and Bassett, L., 2008.What is the potential of cash transfers to strengthen families affectedby HIVand AIDS? A review of the evidence on impacts and key policy debates. Washington, DC:International Food Policy Research Institute.

Allen, L.H. and Gillespie, S.R., 2001.What works? A review of the efficacy and effectiveness of nutritioninterventions. Geneva: United Nations Administrative Committee on Coordination Subcommitteeon Nutrition, Asian Development Bank, and International Food Policy Research Institute.

Braveman, P. and Gruskin, S., 2003. Poverty, equity, health and human rights. Bulletin of the WorldHealth Organisation, 81 (7), 539–545.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Calde�s, N., Coady, D. and Maluccio, J.A., 2004. The cost of poverty alleviation transfer programs: acomparative analysis of three programs in Latin America. Washington, DC: IFPRI, Discussion Paper 174.

Coady, D., Grosh, M. and Hoddinott, J., 2003. Targeted anti-poverty interventions: a selectedannotated bibliography. Washington, DC: International Food Policy Research Institute.

Coady, D., Grosh, M. and Hoddinott, J., 2004. Targeting outcome redux. World Bank researchobserver, 19 (1), 61–85.

Eichler, R., 2006. Can ‘pay for performance’ increase utilization by the poor and improve the quality ofhealth services? Discussion paper for the First Meeting of the Working Group on Performance-Based Incentives, 7 February. Washington, DC: Center for Global Development.

Ensor, T. and Cooper, S., 2004. Overcoming barriers to health service access: influencing the demandside. Health policy and planning, 19 (2), 69–79.

Fiszbein, A. and Schady, N., 2009. Conditional cash transfers: reducing present and future poverty.Washington, DC: World Bank Publications.

Gaarder, M., 2003. The distributional effects of illness when recuperation is endogenous. Washington,DC: Inter-American Development Bank, Economics and Sector Study Series RE2-03-004.

Glassman, A., Gaarder, M. and Todd, J., 2006. Demand-side incentives for better health for the poor:Conditional cash transfer programs in Latin America and the Caribbean. Washington, DC:Economic and Sector Study Series. IADB.

Glassman, A., Todd, J. and Gaarder, M., 2007. Performance-based incentives for health: conditionalcash transfer programs in Latin America and the Caribbean. Washington, DC: Center for GlobalDevelopment Working Paper #120.

Grossman, M., 1972. On the concept of health capital and the demand for health. Journal of politicaleconomy, 80, 223–255.

Handa, S. and Davis, B., 2006. The experience of conditional cash transfers in Latin America and theCaribbean. Development policy review, 24 (5), 513–536.

IADB, 2001.Mexico. Proposal for a loan for a multiphase consolidation and expansion project for theeducation, health and nutrition program [PROGRESA] (Phase I). Washington, DC: Inter-American Development Bank.

Lagarde. M., Haines, A. and Palmer, N., 2007. Conditional cash transfers for improving uptake of healthinterventions in low- and middle-income countries: a systematic review. JAMA, 298 (16), 1900–1910.

Leroy, J., Ruel, M. and Verhofstadt, E., 2009. The impact of conditional cash transfer programmes onnutrition: a review of evidence using a programe theory framework. Journal of developmenteffectiveness, 1 (2), 103–129.

Martinelli, C. and Parker, S., 2003. Should transfers to poor families be conditional on schoolattendance? A household bargaining perspective. International economic review, 44 (2), 523–544.

Martorell, R., 1999. ‘Is wasting (thinness) a hidden problem in Latin America’s children? Journal ofnutrition, 131, 1133–1134.

Mushkin, S.J., 1962. Health as an investment. Journal of political economy, 70 (5), 129–157.O’Donnell, O., 2007. Access to health care in developing countries: breaking down demand side

barriers. Cad Saude Publica, 23 (12), 2820–2834.Rawlings, L. and Rubio, G.M., 2003. Evaluating the impact of conditional cash transfer programs:

lessons from Latin America. Washington, DC: The World Bank.Wagstaff, A. and Lindelow, M., 2008. Can insurance increase financial risk? The curious case of health

insurance in China. Journal of health economics, 27 (4), 990–1005.White, H., 2009. Theory-based impact evaluation: principles and practice. Journal of development

effectiveness, 1 (3), 271–284.World Bank, 2006. Repositioning nutrition as central to development. A strategy for large-scale action.

Washington, DC: The World Bank.

Brazil

Belik,W. and Del Grossi, M., 2003. Brazil’s zero hunger program in the context of social policy. Brazil:Unicamp.

Bourguignon, F., Ferreira, F.H.G. and Leite, P.G., 2002. Ex-ante evaluation of conditional cashtransfer programs: the case of Bolsa Escola. Ann Arbor, MI: University of Michigan BusinessSchool, William Davidson Working Paper Number 516.

Morris, S.S., et al., 2004a. Conditional cash transfers are associated with a small reduction in age-related weight gain in children in Northeast Brazil. Journal of nutrition, 134, 2336–2341.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Colombia

Attanasio, O., Gomez, L.C., Heredia, P. and Vera-Hernandez, M., 2005. The short-term impact of aconditional cash subsidy on child health and nutrition in Colombia. London: Institute for Fiscal Studies.

Sze�kely, M., Hilgert, M. and Glassman, A., 2000. Criterios para estimar el valor de un subsidiocondicionado en Colombia. Technical note. Washington, DC: Inter-American Development Bank.

Union Temporal IFS-Econometrıa S.A.-SEI, 2000. Evaluacion del Impacto del Programa de Familiasen Accion: Informe Metodologico. Bogota: DAPR-FIP y DNP.

Union Temporal IFS-Econometrıa S.A.-SEI, 2001a. Evaluacion del Impacto del Programa deFamilias en Accion: Informe de Focalizacion. Bogota: DAPR-FIP y DNP.

Union Temporal IFS-Econometrıa S.A.-SEI, 2001b. Evaluacion del Impacto del Programa deFamilias en Accion: Informe Final Lınea de Base. Bogota: DAPR-FIP y DNP.

Union Temporal IFS-Econometrıa S.A.-SEI, 2004. Evaluacion del Impacto del Programa de Familiasen Accion: Informe del Primer Seguimiento. Bogota, Colombia: DAPR-FIP y DNP.

Ecuador

Paxson, C. and Schady, N., 2007. Does money matter? The effects of cash transfers on child health anddevelopment in rural Ecuador. Washington, DC:World Bank Policy ResearchWorking Paper 4226.

Schady, N. and Aravjo, M.C., 2006. Cash transfers, conditions, school enrollment, and child work: evidencefrom a randomized experiment in Ecuador.Policy research working paper series 3930, TheWorld Bank.

Honduras

Alvarez, C., Santiago, A. and Todd, J., 2005. PRAF: the family allowance program. Draft. IADB.Washington, DC: Inter-American Development Bank.

Flores, R., Morris, S., Olinto, P., Medina, J. and Neidecker, O., 2003. Evaluation of the familyallowance program (PRAF) in Honduras: health and nutrition impacts. Atlanta, GA: EmoryUniversity; London: London School of Hygiene and Tropical Medicine; Washington, DC:International Food Policy Research Institute.

IFPRI, 2000. Third report: monitoring and evaluation system. Washington, DC: International FoodPolicy Research Institute.

IFPRI, 2001a. Fourth report of the PRAF Series PRAF/ IDB Phase II: analysis of the situation beforethe beginning of distribution of vouchers and project implementation. Washington, DC:International Food Policy Research Institute.

IFPRI, 2003. Sexto Informe: Proyecto PRAF/BID Fase II: Impacto Intermedio. Washington, DC:International Food Policy Research Institute.

Morris, S., Flores, R. Olinto, P. and Medina, J.M., 2004b. Monetary incentives in primary health careand effects on use and coverage of preventive health care interventions in rural Honduras: clusterrandomised trial. Lancet, 364, 2030–2037.

Jamaica

Bronte-Tinkew, J., 1999. Family structure, resource dilution and child nutrition: an analysis of Jamaica.University Park, PA: Population Research Institute – The Pennsylvania State University, WorkingPaper 99-05.

Fawcett, C., 2004. Social safety net report. IMPAQ International, LLC, Mathematica Policy Researchand the Government of Jamaica.

IADB, 2001. Jamaica. Proposal for a loan and nonreimbursable technical-cooperation. funding for asocial safety net reform program. PR-2612. Washington, DC: Inter-American Development Bank.

Levy, D. and Ohls, J., 2007. Evaluation of Jamaica’s PATH program: final report. Mathematica PolicyResearch Inc.

World Bank, 2003. Programme of advancement through health and education (PATH).

Malawi

Miller, C., Tsoka, M. and Reichert, K., 2009. TheMalawi social cash transfer and the impact of $14 permonth on child health and growth. Health policy and planning, forthcoming.

Thornton, R., 2008. The demand for, and impact of, learning HIV status. American economic review,98 (5), 1829–1863.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Mexico

Adato, M., Coady, D. and Ruel, M., 2000. An operations evaluation of PROGRESA from theperspective of beneficiaries, promotoras, school directors, and health staff. Washington, DC:International Food Policy Research Institute.

Avitable, C., 2009. Does conditionality matter for adult’s health: evidence from a randomized experi-ment, Center for Studies in Economics and Finance, Working Paper no. 222.

Barber, S. and Gertler, P.J., 2010. Empowering women: how Mexico.s conditional cash transfer programraised prenatal care quality and birth weight. Journal of development effectiveness, 2 (1), 51–73.

Barham, T., 2005a. Providing a healthier start to life: the impact of conditional cash transfers on infantmortality. Center for Economic Analysis, Department of Economics, University of Colorado atBoulder, Working Paper No. 06-02.

Barham, T., 2005b. The impact of the Mexican conditional cash transfer on immunization rates. Draft,Department of Agriculture and Resource Economics, UC Berkley, CA.

Bautista, S., Do health care supply constraints limit the effectiveness of Mexico’s conditional cashtransfer program. Unpublished.

Behrman, J.R. and Hoddinott, J., 2001. An evaluation of the impact of PROGRESA on pre-school childheight. Washington, DC: International Food Policy Research Institute.

Behrman, J.R. and Hoddinott, J., 2005. Program evaluation with unobserved heterogeneity andselective implementation: the Mexican PROGRESA impact on child nutrition. Oxford bulletinof economics and statistics, 67 (4), 547–569.

Behrman, J.R. and Todd, P., 1999b.Randomness in the experimental samples of PROGRESA (Education,Health and Nutrition Program). Washington, DC: International Food Policy Research Institute.

Bonvecchio, A., et al., 2007. Maternal knowledge and use of a micronutrient supplement was improvedwith a programmatically feasible intervention in Mexico. Journal of nutrition, 137, 440–446.

Coady, D., 2000. The application of social cost–benefit analysis to the evaluation of PROGRESA.Washington, DC: International Food Policy Research Institute.

Coady, D. and R. Harris, 2000. A general equilibrium analysis of the welfare impact of PROGRESA.Washington, DC: International Food Policy Research Institute.

Coady, D. and Parker, S., 2004. A cost-effectiveness analysis of demand- and supply-side educationinterventions: the case of Progresa in Mexico. Review of development Economics, 8 (3), 440–451.

Davis, B., et al., 2002. Conditionality and the impact of program design on household welfare:comparing two diverse cash transfer programs in rural Mexico. IDB, FAO, Harvard University,and Pisa: Scuola Sant’Anna, October.

Duarte Gomez, M.B., et al., 2004. Impact of Oportunidades on knowledge and practices of beneficiarymothers and young scholarship recipients: an evaluation of the educational health sessions. In: B.Hernandez Prado and M. HernandezAvila, eds. External evaluation of the impact of the humandevelopment programOportunidades 2004. Cuernavaca,Mexico: National Institute of Public Health.

Feldman, B., et al., 2009. Contraceptive use, birth spacing, and autonomy: an analysis of theOportunidades program in rural Mexico. Studies in family planning, 40 (1), 51–62.

Fernald, L.C. and Gunnar, M.R., 2009. Poverty-alleviation program participation and salivary cortisolin very low-income children. Social science and medicine, 68, 2180–2189.

Fernald, L.C., Gertler, P. andOlaiz, G., 2004. Impacto demediano plazo del ProgramaOportunidades sobre laobesidad y las enfermedades cronicas en areas rurales. In: B. Hernandez Prado and M. HernandezAvila,eds. Evaluacion externa de impacto del Programa Oportunidades 2004. Mexico: INSP – CIESAS.

Fernald, L.C.,Gertler, P.J. andNeufeld, L.M., 2008a. Role of cash in conditional cash transfer programmes forchild health, growth, and development: an analysis of Mexico’s Oportunidades. Lancet, 371, 828–837.

Fernald, L.C., Gertler, P.J. and Hou, X., 2008b. Cash component of conditional cash transfer program isassociatedwith higher bodymass index and blood pressure in adults. Journal of nutrition, 138, 2250–2257.

Fernald, L.C., Hou, X. and Gertler, P.J., 2008c. Oportunidades program participation and body mass index,blood pressure, and self-reported health in Mexican adults. Preventing chronic disease, 5 (3), 1–12.

Fernald, L.C., Gertler, P.J. and Neufeld, L.M., 2009. 10-year effect of Oportunidades, Mexico’sconditional cash transfer programme, on child growth, cognition, language, and behaviour: alongitudinal follow-up study. The lancet, 374 (9706), 1997–2005.

Gaarder, M., 2004a. Desempeno de los mecanismos de auditorıa operativa del Programa deDesarrollo Humano Oportunidades. Banco Interamericano de Desarrollo, Nota Te�cnica No.4.

Gaarder, M., 2004b. La eficiencia operativa del sistema de distribucion de suplementos alimenticios delPrograma de Desarrollo Humano Oportunidades. Banco Interamericano de Desarrollo, NotaTe�cnica No 5.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

Gertler, P.J., 2000. Final report: the impact of PROGRESA on health. Washington, DC: InternationalFood Policy Research Institute.

Gertler, P.J., 2004. Do conditional cash transfers improve child health? Evidence fromPROGRESA’s control randomized experiment. American economic review papers and pro-ceedings, 94 (2), 336-341.

Gertler, P.J. and Boyce, S., 2001. An experiment in incentive-based welfare: the impact of Progresa onHealth in Mexico. Berkley, CA: University of California. Available at: http://www.sctis-jhu.edu/bin/y/x/gertler_boyce.pdf.

Gertler, P.J. and Fernald, L.C., 2004. The medium term impact of Oportunidades on child developmentin rural areas. Final report. Berkley, CA: University of California. Available at: http://www.sarpn.org.za/documents/d0001264/P1498-hild_dev_terminado_Idic04.pdf.

Gertler, P., Martinez, S. andMorgan, J., 2008. Does money burn a hole in your pocket?. Presentation atIADB/WB CCT conference, Cartagena, Colombia.

Gutie�rrez, J.P., Bautista, S., Gertler, P., Hernandez Avila, M. and Bertozzi, S.M., 2004a. Impacto deOportunidades en la morbilidad y ol estado de salud de la poblacion beneficiana y en lautilizacion de los servicios de salud. Resultados de corto plazo en zonas urbanas y de medianoplazo en zonas rurales. In: B. Hernandez Prado and M. Hernandez Avila, eds. Evaluacionexterna de impacto del Programa Oportunidades 2003. Curnavaca, Mexico: INSP.

Gutie�rrez, J.P., Gertler, P., Hernandez-Avila, M. and Bertozzi, S., 2004b. Impacto deOportunidades enlos comportamientos de riesgo de los adolescentes y en sus consecuencias inmediatas. Resultadosde corto plazo en zonas urbanas y de mediano plazo en zonas rurales. In: B. Hernandez Prado andM. HernandezAvila, eds., Evaluacion externa de impacto del Programa Oportunidades 2004.Mexico: INSP – CIESAS.

Gutie�rrez, J.P., Leroy, J. Lopez Ridaura, R., De Maria, L., Walker, D., Campuzano, J.C., Moreno, K.,Edson, S., Sosa Rubı, S. and Bertozzi, S., 2008. Evaluacion de la calidad de los servicios deatencion a la salud asignados a la poblacion beneficiaria de Oportunidades. In: A diez anos deintervencion Evaluacion externa del Programa Oportunidades 2008 en zonas rurales(1997–2007), Tomo II, El reto de la calidad de los servicios: resultados en salud y nutricion.Mexico: SEDESOL.

Hernandez Avila, M., Meneses Gonzalez, F., Te�llez Rojo, M.M., Manzano, A. and Lopez Ridaura, R.,2004. Evaluacion de la atencion me�dica para la poblacion diabe�tica usuaria de Oportunidades. In:B. Hernandez Prado and M. Hernandez Avila, eds. Evaluacion externa de impacto del ProgramaOportunidades 2004. Me�xico: INSP.

Hernandez Prado, B., Ramırez, D.,MorenoH. andN. Laird, 2003. Evaluacion del impacto deOportunidadesen la mortalidad materna e infantil. In: B. Hernandez-Prado and M. /Hernandez-Avila, eds. Evaluacionexterna de impacto del Programa Oportunidades 2003. Curnavaca, Mexico: INSP.

Hernandez Prado, B., Urquieta Salomon, J., Ramirez Villalobos, M. and Figueroa, J., 2004. Impacto deOportunidades en la salud reproductiva de la poblacion beneficiaria. In: B. Hernandez Prado andM. Hernandez Avila, eds. External evaluation of the impact of the human development programOportunidades 2004. Cuernavaca, Mexico: INSP.

Hoddinott, J. and Skoufias, E., 2004. The impact of PROGRESA on food consumption. Economicdevelopment and cultural change, 53, 37–61.

Hoddinott, J., Skoufias, E. and Washburn, R., 2000. The impact of PROGRESA on consumption: afinal report. Washington, DC: International Food Policy Research Institute.

IADB, 2005.Mexico. Propasal for a loan for amultiphase program for the consolidation and expansion ofthe Oportunidades Human Development Program, Phase II. Washington DC, Inter-American Bank.

Lamadrid-Figueroa, H., et al., 2010. Heterogeneous impact of the social programme Oportunidades oncontraceptive methods use by young adult women living in rural areas. Journal of developmenteffectiveness, 2 (1), 74–86.

Leroy, J., et al., 2008. The Oportunidades program increases the linear growth of children enrolled atyoung ages in urban Mexico. Journal of nutrition, 138, 793–798.

Neufeld, L., Garcia-Guerra, A., Leroy, J., Flores Lopez, M., Fernandez Gaxiola, A.C. and Rivera-Dommarco, J. A., 2005. Impacto del programa Oportunidades en nutricion y alimentacion enzonas urbanas de Me�xico. Mexico: INSP.

Ozer, E., Fernald, L.C., Manley, J.G. and Gertler, P.J., 2009. Effects of a conditional cash transferprogram on children’s behavior problems. Pediatrics, 123, e630–e637.

Quinones, E., 2006. The indigenous heterogeneity of Opportonidades: ample or insufficient humancapital accumulation? Munich Personal RePec Archive. Unpublished.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

http://www.sctis-jhu.edu/bin/y/x/gertler_boyce.pdf.

http://www.sctis-jhu.edu/bin/y/x/gertler_boyce.pdf.

http://www.sarpn.org.za/documents/d0001264/P1498-hild_dev_terminado_Idic04.pdf.

http://www.sarpn.org.za/documents/d0001264/P1498-hild_dev_terminado_Idic04.pdf.

Rivera, J., et al., 2004. Impact of the Mexican program for education, health, and nutrition (Progresa)on rates of growth and anemia in infants and young children: a randomized effectiveness study.JAMA, 291 (21), 2563–2570.

Ruiz-Arranz, M., et al., 2002. More calories or more diversity? An econometric evaluation of theimpact of the PROGRESA and PROCAMPO transfer programs on food security in rural Mexico.ESAWorking Paper No. 02-09.

Skoufias, E., Davis, B. and Behrman, J., 1999. Final report: an evaluation of the selection ofbeneficiary households in the education, health, and nutrition program (PROGRESA) ofMexico. Washington, DC: International Food Policy Research Institute.

Urquieta, J., et al., 2009. Impact of Oportunidades on skilled attendance at delivery in rural areas.Economic development and cultural change, 57, 539–558.

Nepal

Powell-Jackson, T., et al., 2009. The impact ofNepal’s national incentive programme to promote safe deliveryin the district of Makwanpur. Advances in health economics and health services research, 21, 221–249.

Nicaragua

Adato, M. and Roopnaraine, T., 2004. Informe Preliminar. Sistema de Evaluacion de la Red deProteccion Social de Nicaragua: Un Analisis Social De La Red De Proteccion Social.Washington, DC: IFPRI.

Barham, T. and Maluccio, J., 2008. Eradicating diseases: the effect of conditional cash transfers onvaccination coverage in rural Nicaragua. IBS, University of Colorado Boulder, Working Paper.

IFPRI, 2001a. Informe: Sistema de Evaluacion de la Fase Piloto de la Red de Proteccion Social deNicaragua. Washington, DC: IFPRI.

IFPRI, 2001b. Sistema de Evaluacion de la Fase Piloto de la Red de Proteccion Social de Nicaragua:Lınea de Base 2000. Washington, DC: IFPRI.

IFPRI, 2002a. Informe Final – Sistema de Evaluacion de la Fase Piloto de la Red de Proteccion Socialde Nicaragua: Evaluacion de Impacto. Washington, DC: IFPRI.

IFPRI, 2002b. Informe Final – Sistema de Evaluacion de la Fase Piloto de la Red de Proteccion Socialde Nicaragua: Evaluacion de Focalizacion. Washington, DC: IFPRI.

Maluccio, J. and Flores, R., 2005 . Impact evaluation of a conditional cash transfer program: theNicaraguan Red de Proteccion Social. IFPRI Research Report.

Panama

IADB, 2007. Panama. Proposal for a loan for Social Protection Program–Phase I. Washington, DC:Inter-American Development Bank.

Paraguay

Soares, F.V., Ribas, R. and Guilherme, H., 2010. The impact evaluation of a rural CCT programme onoutcomes beyond health and education. Journal of development effectiveness, 2 (1), 138–157.

Soares, F.V., Ribas, R. and Hirata, G.I., 2008. Achievements and shortfalls of conditional cashtransfers: impact evaluation of Praguay’s Tekopora programme. Brasilia: International PovertyCenter.

South Africa

Aguero, J.M., Carter,M.R. andWoolard, I., 2006. The impact of unconditional cash transfers on nutrition:the South African child support grant. International Poverty Center, Working Paper no. 39.

Turkey

Ahmed, A., et al., 2006. Interim impact evaluation of the conditional cash transfer program in Turkey:a quantitative assessment. Washington, DC: IFPRI.

Ahmed, A., et al., 2007. Impact evaluation of the conditional cash transfer program in Turkey: finalreport. Washington, DC: IFPRI.


Dow

nloa

ded

by [

Uni

vers

ity o

f T

enne

ssee

, Kno

xvill

e] a

t 13:

50 2

1 D

ecem

ber

2014

conditional cash transfers and health: unpacking the causal chain

Documents