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