Elsevier

Preventive Medicine

Volume 55, Supplement, 1 November 2012, Pages S95-S105
Preventive Medicine

Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of conditional cash transfer programmes

https://doi.org/10.1016/j.ypmed.2011.11.015Get rights and content

Abstract

Objective

To provide an overview of Conditional Cash Transfer (CCT) programmes in low and middle income countries and present the evidence to date on their contribution to improvements in health and the encouragement of healthy behaviours.

Methods

Several bibliographic databases and websites were used to identify relevant studies. To be included, a study had to provide evidence of effects of a financial incentive conditional upon specific health-related behaviours. Only experimental or quasi-experimental study designs were accepted.

Results

We identified 13 CCT programmes, whose effects had been evaluated, mostly in Latin-American countries. Their results suggest that CCTs have been effective in increasing the use of preventive services, improving immunisation coverage, certain health outcomes and in encouraging healthy behaviours.

Conclusion

CCTs can be valuable tools to address some of the obstacles faced by populations in poorer countries to access health care services, or maybe to modify risky sexual behaviours. However, CCTs need to be combined with supply-side interventions to maximise effects. Finally, some questions remain regarding their sustainability and cost-effectiveness.

Introduction

Conditional Cash Transfers (CCTs) are considered a particular form of performance-based payments, which make regular cash payments to individuals (or households) contingent on a set of behavioural requirements, such as attending regular health check-ups or sending one's children to school.

Historically, the first CCT programmes from Latin America were designed to act as social transfer mechanisms, aiming to provide a safety net to its recipients. Progresa, the seminal Mexican CCT programme (subsequently named Opportunidades) was developed during an economic crisis to replace a former social transfer mechanism, which included subsidies to the poor (mainly in the form of food subsidies) and was viewed as being administratively expensive (Grimes, 2008). The innovation proposed by Progresa was to use public money to target fewer and more needy households initially. The strings attached to the money given to beneficiaries ensured that it was an investment into the future development of the country, through an investment in the poor population's ‘human capital’.

By transferring cash to the beneficiaries on the condition that they comply with a set of requirements (sending their children to schools and regular health check-ups, attending prevention workshop, etc.), the objectives of the programme were twofold. In addition to a short-term poverty reduction created by the increase in income, it was designed to act as powerful incentives for households to adopt a behaviour that will positively impact on their well-being and break the cycle of poverty in the long run (Gaarder et al., 2010).

Initially implemented in some areas only, Progresa was soon rigorously evaluated and found to be an effective mechanism, leading to the scaling-up of the programme at the national level. Its principles were soon emulated by other Latin American countries, and more than ten years later, very similar national programmes have flourished in almost every Latin American country (Fiszbein and Schady, 2009).

In parallel, the successful use of financial incentives in promoting changes in health-related behaviour in the area of addictions (Lussier et al., 2006, Pilling et al., 2007) provided the scientific base for the growing popularity of Results-Based Financing (RBF) mechanisms amongst policy-makers and funders in low and middle income countries. RBF mechanisms refer to financial transfers linked to meeting particular outcomes (Oxman and Fretheim, 2008). On the supply-side, they target health care providers and propose incentives for improved performance on measures of quality and efficiency. On the demand side, RBF mechanisms pay beneficiaries (patients) money contingent on their meeting certain behavioural requirements.

As RBF schemes were gaining momentum in low- and middle-income countries, African and Asian countries have seen the development of CCTs that have moved away from being used as a broad safety net mechanism, with multiple conditionalities (as they were traditionally designed in Latin-American countries) to being more narrowly focused around specific health outcomes or healthy behaviours. Recent examples include CCT programmes that have incentivised women to give birth in health care facilities (Powell-Jackson et al., 2009b) or tried to promote safe sexual behaviours (Kohler and Thornton, 2012, World Bank, 2010).

Section snippets

The rationale behind Conditional Cash Transfers

Several arguments have been made to promote the use of CCTs.

As mentioned before, the first argument that was put forward relate to the benefits granted by the provision of an innovative safety net that would help break the cycle of poverty. This argument was particularly relevant for the original Latin American programmes, which included several conditionalities focused on health and education components, both considered essential for the promotion of human capital.

When presented as a

Methods

This overview is restricted to CCT programmes that define at least one of their conditionalities upon health-related behaviour. This led to excluding some studies which did look at the effects of CCTs on health outcomes. For example, several programmes have been developed providing cash transfers to households who keep children enrolled in school. Research into the effects of some of these programmes has included health outcomes such as a reduction in HIV incidence (Baird et al., 2009). Yet

Description of programmes

Table 1 describes briefly the main characteristics of the 13 CCT programmes that were identified for inclusion in this overview.

The geographic variation of CCT programmes is somewhat matched by differences in their focus.

Inspired by the success of the seminal Progresa programme in Mexico, many Latin American and Caribbean countries have introduced CCT programmes where the compliance with health related conditionalities is only one dimension of a broader intervention (see Table 1). We found

Discussion

One of the strengths of the literature on CCTs is the relative abundance of rigorous research on the impact of large-scale programmes, which have been implemented in different countries. This broad and reasonably robust body of evidence suggests that CCTs are powerful instruments to improve health outcomes and to increase the uptake of health services including immunisation coverage in low and middle-income countries. On the other hand, while these programmes share common approaches, “the devil

Conclusion

As one of the most evaluated social interventions for the poor, there is enough rigorous evidence suggesting that CCTs are a valuable tool at the disposal of policy-makers in low- and middle incomes countries to tackle certain health issues. These programmes, often implemented on a very large scale and rigorously evaluated, have been found particularly successful at decreasing barriers to access for poorest populations, and incentivising them to increase the use of health services. Recently,

Conflict of interest

The authors declare there is no conflict of interest.

References (51)

  • O. Attanasio et al.

    The impact of a conditional cash transfer programme on consumption in Colombia

    (2005)
  • O. Attanasio et al.

    Baseline Report on the evaluation of Familias en Accion

    (2004)
  • O. Attanasio et al.

    The short-term impact of a conditional cash subsidy on child health and nutrition in Colombia

    (2005)
  • S. Baird et al.

    The Short-term impacts of a schooling conditional cash transfer program on the sexual behaviour of young women

    Health Econ.

    (2009)
  • S. Baird et al.

    Cash or Condition? Evidence from a Randomized Cash Transfer Program

  • T. Barham

    The Impact of the Mexican Conditional Cash Transfer on Immunization Rates

    (2005)
  • T. Barham et al.

    Beyond 80 %: Are There New Ways of Increasing Vaccination Coverage?

  • J.R. Behrman et al.

    Programme evaluation with unobserved heterogeneity and selective implementation: the Mexican PROGRESA impact on child nutrition

    Oxford Bull. Econ. Stat.

    (2005)
  • N. Caldés et al.

    The cost of conditional cash transfers

    J. Int. Dev.

    (2005)
  • G. Charness et al.

    Incentives to exercise

    Econometrica

    (2009)
  • Dugger, C., 2010. African studies give women hope in H.I.V. fight. New York Times....
  • J. Farrington et al.

    Introduction: Cash Transfers: Panacea for poverty reduction or money down the drain?

    Dev. Policy Rev.

    (2006)
  • L.C. Fernald et al.

    Oportunidades program participation and body mass index, blood pressure, and self-reported health in Mexican adults

    Prev. Chronic Dis.

    (2008)
  • A. Fiszbein et al.

    Conditional Cash Transfers: Reducing Present and Future Poverty

    (2009)
  • M.M. Gaarder et al.

    Conditional cash transfers and health: unpacking the causal chain

    J. Dev. Eff.

    (2010)
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