Elsevier

The Lancet

Volume 382, Issue 9886, 6–12 July 2013, Pages 57-64
The Lancet

Articles
Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities

https://doi.org/10.1016/S0140-6736(13)60715-1Get rights and content

Summary

Background

In the past 15 years, Brazil has undergone notable social and public health changes, including a large reduction in child mortality. The Bolsa Familia Programme (BFP) is a widespread conditional cash transfer programme, launched in 2003, which transfers cash to poor households (maximum income US$70 per person a month) when they comply with conditions related to health and education. Transfers range from $18 to $175 per month, depending on the income and composition of the family. We aimed to assess the effect of the BFP on deaths of children younger than 5 years (under-5), overall and resulting from specific causes associated with poverty: malnutrition, diarrhoea, and lower respiratory infections.

Methods

The study had a mixed ecological design. It covered the period from 2004–09 and included 2853 (of 5565) municipalities with death and livebirth statistics of adequate quality. We used government sources to calculate all-cause under-5 mortality rates and under-5 mortality rates for selected causes. BFP coverage was classified as low (0·0–17·1%), intermediate (17·2–32·0%), high (>32·0%), or consolidated (>32·0% and target population coverage ≥100% for at least 4 years). We did multivariable regression analyses of panel data with fixed-effects negative binomial models, adjusted for relevant social and economic covariates, and for the effect of the largest primary health-care scheme in the country (Family Health Programme).

Findings

Under-5 mortality rate, overall and resulting from poverty-related causes, decreased as BFP coverage increased. The rate ratios (RR) for the effect of the BFP on overall under-5 mortality rate were 0·94 (95% CI 0·92–0·96) for intermediate coverage, 0·88 (0·85–0·91) for high coverage, and 0·83 (0·79–0·88) for consolidated coverage. The effect of consolidated BFP coverage was highest on under-5 mortality resulting from malnutrition (RR 0·35; 95% CI 0·24–0·50) and diarrhoea (0·47; 0·37–0·61).

Interpretation

A conditional cash transfer programme can greatly contribute to a decrease in childhood mortality overall, and in particular for deaths attributable to poverty-related causes such as malnutrition and diarrhoea, in a large middle-income country such as Brazil.

Funding

National Institutes of Science and Technology Programme, Ministry of Science and Technology, and Council for Scientific and Technological Development Programme (CNPq), Brazil.

Introduction

Conditional cash transfer programmes are interventions that transfer cash from governments to poor households with the requirement that parents comply with specific conditions (or conditionalities), usually focused on health and education for their children.1 The transfer of benefits aims to promptly alleviate poverty and the conditions encourage use of existing health and education services. The first conditional cash transfer programmes were implemented in the late 1990s in Mexico and Brazil, spreading rapidly to various countries worldwide, becoming an important strategy for alleviation of poverty and reduction of inequalities in low-income and middle-income countries.1, 2

In Brazil, the Bolsa Familia programme (Family Allowance, BFP), launched in 2003, merged four pre-existing national social programmes into one unique expanded programme.3 The BFP is the world's largest conditional cash transfer programme, and its coverage has expanded greatly in the past 10 years. It reached all 5565 Brazilian municipalities and enrolled 13·4 million families in 2011, with a total budget of US$11·2 billion.4 The cash transfers are intended for extremely poor families (with an income of less than $35 per person per month) and for other families deemed poor (with an income of between $35 and $70 per person per month) when they include children up to 17 years of age or pregnant or lactating women.5 Poor families receive about $18 for each pregnant woman, child, or adolescent up to 17 years of age (with an upper limit for each category), whereas extremely poor families, besides receiving the same benefits, receive an additional contribution of $35 irrespective of the composition of the family. According to these criteria, benefits can range from $18 to a maximum of $175 per month. The mother (when present) must receive the monthly payment on behalf of the whole family.

A family enrolled in the BFP has to comply with specific education and health-related conditions. To meet the health conditions children younger than 7 years must be vaccinated according to the Brazilian immunisation programme schedule and must comply with health check-ups and growth monitoring according to Ministry of Health guidelines, with a frequency from one to seven times per year, depending on a child's age. Pregnant and lactating women must attend scheduled prenatal and postnatal visits and health and nutritional educational activities. When possible, health-related conditions should be met using the facilities of the main primary health care programme in Brazil, the Programa Saúde da Família (Family Health Programme, FHP).6 The FHP is another large-scale national programme, implemented over the past several years. By 2011, it reached 94% of municipalities, covering 53% of the Brazilian population.7 FHP aims to broaden access to public health services, especially in deprived areas, by offering free, community-based health care.8

Brazil is characterised by large social inequalities, and it has undergone substantial health and social changes in the past 15 years, including a large reduction in deaths of children younger than 5 years (under-5), enabling the country to reach the fourth Millennium Development Goal.9, 10 FHP is one of the components that has brought about the substantial decrease in under-5 mortality.11, 12 We postulate that the BFP should reduce childhood mortality by acting on social determinants of health and by stimulating health care through its conditions. Previous studies have reported the effectiveness of BFP in reducing child malnutrition,13, 14 but no studies have addressed its effect on childhood morbidity or mortality. Therefore, the objective of the present study was to assess the effect of the BFP on under-5 mortality rates in Brazilian municipalities, focussing on causes of mortality associated with poverty (such as malnutrition, diarrhoea, and lower respiratory infections) and on some of the potential intermediate mechanisms (such as vaccination, prenatal care, and admission to hospital).

Section snippets

Study design

This study has a mixed ecological design, combining an ecological multiple-group design with a time-trend design. The municipality is the unit of analysis. We created a longitudinal dataset from several databases for the years 2004–09. From the 5565 Brazilian municipalities, we selected a subset that had adequate vital statistics (death and livebirth registration) during the first years of the period under study (2004–06; we assumed constant adequacy for the remaining years because of

Results

The criteria for adequate death and livebirth registration were met by 2906 municipalities. Of these, 2853 (51% of all Brazilian municipalities) had data available for all covariates and were included in our analysis. From 2004–09, the mean under-5 mortality rate decreased by 19·4% in the studied municipalities, and among the selected causes, the greatest decrease was associated with malnutrition (58·2%; table 1). Under-5 mortality associated with external causes decreased by 17·9%. Mean BFP

Discussion

The results of our study show that BFP had a significant role in reduction of under-5 mortality, overall and from poverty-related causes such as malnutrition and diarrhoea, in Brazilian municipalities from 2004–09. The effect was maintained even after the adjustment for socioeconomic covariables and FHP. The increase in BFP duration and in coverage of both the total and target populations strengthens the effect of the programme. The effect of the BFP was stronger when, with high municipality

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