CCTs: closing the gap between children and the care they need

A recent review of conditional cash transfer (CCT) programs around the world shows they can be powerful tools for increasing demand for health care and driving improvements in health and educational outcomes for children. The review of 21 studies on 13 cash transfer programs in low- and middle-income countries (LMICs) was carried out by the Abdul Latif Jameel Poverty Action Lab (J-PAL).

Globally, under-five mortality has fallen by roughly half since 2000, dropping from 75 deaths per 1,000 births in 2000 to 38 deaths per 1,000 births in 2019. Despite this remarkable progress, children in LMICs are still 12 times more likely to die before their fifth birthday.

Researchers posit that limited use of preventive care and low health-seeking behaviors contribute to this gap. Poorer households may lack the funds to seek regular preventive care and may live in communities where there is a high cost, in terms of financial and geographic accessibility, to seeking care.

The review found that CCTs have helped a number of countries, from Mexico to Indonesia, close the gap between children and the care they need, and may be a useful tool for health leaders in other geographies.

CCTs often focus on the first two years of a child’s life and might require, for example, that families vaccinate their children, pregnant women obtain prenatal care, or infants get regular checkups, as a condition of payment.

We spoke with Anupama Dathan, policy manager at J-PAL Global, about the findings and their implications.

Could you tell us about the impact of conditional cash transfers (CCTs)?

Dathan: Researchers have observed improvements in health care utilization as well as improved health outcomes as a result of CCTs. For example, Indonesia’s CCT program helped drive a decline in childhood stunting by 23 percent. Tanzania’s CCT program increased the number of clinic visits and take-up of health-related products in the first 1.5 years, with improvements in reported child health visible after 2.5 years. And the Pantawid CCT program in the Philippines helped reduce severe stunting.

Recently, researchers have started to see long-term generational impact from CCTs. Researchers are seeing an impact on economic and educational outcomes of adults whose families received CCTs when they were infants.

The theory is that investing in child health when children are at a very young age can increase educational attainment, which can in turn improve labor market outcomes and reduce poverty over the long term.

We don’t have too many studies on this yet. We are waiting for these children to grow up. But researchers examining the impact of Progresa, a 20-year-old CCT program in Mexico, see improved income. Researchers examining the impact of PRAF-II (Programa de Asignación Familiar-II), a 13-year-old program in Honduras, see improved educational outcomes for non-indigenous children who were beneficiaries as young children.

What makes CCTs effective?

Dathan: CCTs may be effective through three pathways. First, you are providing cash. That income support allows households to invest in different activities that could improve their health outcomes. Second, CCTs provide information about what sort of activities should be prioritized. Third, some CCTs have enforced conditions attached, which can act as an incentive to make the activities or behaviors more likely.

So, for example, it could be that a household doesn’t know that it is important to bring their newborn to the health clinic every month or ensure they receive the full range of childhood immunizations. Providing CCTs with those requirements provides information to the household that makes these behaviors more likely and provides income support that can remove financial barriers to taking up these behaviors.

How should health leaders think about using CCTs?

Dathan: This is an effective tool for increasing health-seeking behavior and can have very real effects on health outcomes. But it is also important to build up the health systems' capacity so that people who want to respond to the CCT can access the care and receive the health and economic benefits. The health system needs to be supported to respond to the demand generated by the CCT.

The experience of Nicaragua demonstrates this. Nicaragua’s program aimed to reduce poverty and future poverty by increasing health and education. It provided a CCT for health and education attainment. Beneficiaries needed to attend education workshops and health checks for their child. But the government was concerned that the health system couldn’t manage the demand the CCT would spark. So they trained private health providers to help meet the demand and ensured that those who sought care could receive care, even from private providers, for free.

The lesson here is that you can’t have a demand-side program that generates interest in care without making sure that the health system is robust enough to provide for all those people.

What does the research tell us about the conditions that are effective at driving improvements to health outcomes for children?

Dathan: You want the conditions to reflect the goal of the program. If the goal is to increase use of preventive care, then the conditions should require regular use of preventive care. If the goal is to improve newborn care, then the conditions might require the use of skilled birth attendants or educational sessions for mothers on newborn care.

One of the things you want to keep in mind is that the conditions shouldn’t require individuals to do something that they physically can’t do. So, for example, in a low-resource setting, requiring take up of a range of health services might be very hard to do if those services are unavailable or there isn't the capacity to meet the demand.

Does it matter who in the household receives the cash?

Dathan: There has been a lot of debate about this. There isn’t strong evidence one way or another. We often hear that giving cash to mothers can increase children’s well-being. But that may depend on women’s household bargaining power and social norms. In Macedonia, CCTs to mothers increased expenditures on food. That’s an exciting finding. But the evidence isn’t clear that this outcome would be replicated in other settings. The context matters.

Certainly, when you are targeting young children, you want the benefit to go to the caretakers, whoever they are. But for older children, it may be that they could be the recipient themselves.

How big does the benefit need to be to be effective?

Dathan: We don’t have strong evidence on this one way or another. CCT are effective because they provide income support, but also because they are providing information and incentivizing certain behaviors. If there is a lot of cost in terms of seeking services, in terms of effort and transportation costs, then you can imagine that a bigger benefit might be necessary to elicit behavior change.

Are CCTs primarily a tool for closing equity gaps in health use and outcomes between high and low income?

Dathan: CCTs provide information on what behaviors are recommended. Plus, an incentive for taking up those activities. Plus, income support that helps poor households afford the activity. For the poorest households, in particular, having that income support is critical. Money is often a major constraint.

But CCTs can also be relevant for other income levels because even if a household can afford the behavior, the CCT may still be effective because it provides information about behaviors that should be prioritized.

But there are instances where a CCT cannot close the equity gap. For example, in many contexts, the poorest households live in areas with poor availability of services. And if the availability issue is not fixed, the CCT alone can’t be effective in addressing the equity .

Are unconditional cash transfers (UCT) as effective as conditional cash transfers in improving health outcomes?

Dathan: UCTs and CCTs have slightly different intents. While they both provide income, UCTs are often much more of a social protection tool. That is a different goal than CCTs. Both types of transfers provide households with supplemental income, CCTs also provide information and incentives for taking up certain healthy behaviors. CCTs allow policymakers to be much more prescriptive in saying what behaviors they want to incentivize, while UCTs give the cash no matter the behavior. UCTs do improve household well-being by allowing households to invest in the things they prioritize – that may be healthy foods, livestock, or paying down debt. But, in general, we see they are less likely to increase the use of health services or uptake in healthy behaviors.

Research in Burkina Faso, Kenya, Rwanda, and Zambia, found that households that received a UCT prioritized expenditures on food and often consumed nutritious meals more regularly than households not receiving a cash transfer. The programs in Burkina Faso and Zambia didn’t measure the impact on use of health services. The research in Rwanda and Kenya didn’t find an increase in health-seeking behavior, preventive care visits, or vaccination rates. But researchers in Rwanda did find an improvement in child mortality rates for children whose families received the largest UCT.