New Research: Conditional cash transfers have helped save the lives of 700,000 children in Latin America

A new study indicates that conditional cash transfer (CCT) programs in Brazil, Mexico, and Ecuador helped save the lives of more than 700,000 children from 2000 to 2019, adding to decades of research confirming the effectiveness of CCTs.

The research, published in JAMA Network Open, suggests that CCTs are a powerful tool for cushioning children in the lowest income brackets from economic shocks. Based on their findings, the study’s authors argue that CCTs should be expanded during the current economic crises in low- and middle-income countries.

“At a time when we see poverty increasing around the world, we can promptly launch or expand CCTs,” said Davide Rasella, associate research professor and head of the health impact assessment group at ISGlobal. “They have the potential to prevent hundreds of thousands of deaths.”

With ongoing regional conflicts driving up the price of food and climate-related shocks adding to food insecurity, the research indicates that "CCTs can prevent an additional 150,000 deaths of children under 5 years of age by 2030 in just those three countries – Brazil, Ecuador, and Mexico,” added Daniella Medeiros Cavalcanti, the first author of the study and a researcher from the Federal University of Bahia in Brazil.

The researchers analyzed data from 4,882 municipalities whose residents benefited from three national CCT programs: the first national CCT program in the world, Prospera in Mexico; the world’s largest CCT program, Bolsa Familia in Brazil; and Bono de Desarrollo Humano, in Ecuador.

The researchers found that the three programs were associated with a 24% reduction in overall child mortality. They found that higher CCT coverage in a given municipality also led to a greater impact on child mortality. The impact was most pronounced on rates of poverty-related illnesses such as malnutrition, diarrhea, tuberculosis, HIV/AIDS, respiratory infections, and malaria. The analysis indicated that child hospitalizations, particularly from poverty-related diseases, also declined as a result of the CCT programs.

The impact of CCT programs was strongest in areas where the primary health care systems were strongest, which was especially the case for Brazil. “Among these three nations, Brazil is the country that stands out for achieving the most significant reductions in child mortality and hospitalizations among children under 5 years old,” said Cavalcanti.

Brazil's community health worker (CHW) program, one of the largest in the world, magnified the impact of the country's CCT program by connecting poor communities with the health system. Exemplars in Global Health research has found that CHWs helped drive a 75% reduction in under-5 mortality and a 60% reduction in maternal mortality. Brazil’s CCT program has even been associated with lower suicide rates, according to research in 2022 by Brazil’s Centre for Data and Knowledge Integration for Health (CIDACS), whose researchers have been exploring the impact of Bolsa Familia for years.

Brazil's experience demonstrates that “investing in anti-poverty initiatives, such as conditional cash transfer programs, can reduce disparities in health outcomes and access to essential services among the most vulnerable segments of the population,” said Cavalcanti.

The researchers also found a linear relationship between the funds provided as part of a CCT and scale of impact, said Rasella. “The more vulnerable the family, generally, the bigger impact a CCT will have on their health.”

This research comes on the heels of a paper published in Nature earlier this year that found that cash transfer programs across 37 low- and middle-income countries from 2000 to 2019 were associated with significant reductions in mortality among children under 5 years of age and women over 18. Most surprising, the researchers found a spillover effect that reduced mortality across the entire population of children under 5 and women, not just among recipients of the cash transfers.

This evidence adds to the robust body of research showing that CCT programs, which have been popular poverty alleviation tools, can be powerful drivers for increasing demand for preventive health care and improving access to food, which can improve health and educational outcomes for children. Indeed, Exemplars in Global Health research partners have identified the Juntos program in Peru as a key driver of stunting reduction.

This latest piece of evidence on the impact of CCTs in Brazil, Ecuador, and Mexico comes at a time when many governments around the world are struggling with public debt that ballooned as a result of their COVID-related emergency responses. This financial crunch has prompted suggestions to trim or eliminate CCT programs to reduce government spending.

Rather than cut CCT programs, the researchers are calling on leaders to expand current poverty alleviation programs and launch new programs where they are absent.

Currently, there are 30 CCT programs operating in Latin America. Conditional cash transfers often focus on the first two years in a child’s life and might require, for example, that families vaccinate their children, pregnant women obtain prenatal care, or mothers attend regular infant checkups to receive a small monthly payment.

Research indicates that CCTs influence child nutrition and health through three pathways. First, the extra income they provide can allow poor families to invest in health promotional activities – such as more nutritious food – and better quality housing. Second, CCTs provide caregivers with information about what sort of activities should be prioritized, such as routine child immunizations and well-baby checkups. Third, CCTs have enforced conditions attached, which can act as an incentive to make the activities or behaviors more likely, such as visiting a health facility or attending school, even when those activities pose geographic, economic, or logistical challenges for the family.

Cavalcanti said their data indicated that in the context of these three countries, the money alone was a strong driver for improved mortality.

Indeed, new research by Rasella, Cavalcanti, and their colleagues published in the Lancet indicates that pensions for the elderly, which generally come with no strings attached, reduced child mortality dramatically. “There is a clear effect that when grandparents have money, they spend it on their grandchildren’s health,” said Rasella.

This finding is in line with Exemplars in Global Health research in the Kyrgyz Republic which found that monthly pensions of as little as $1 helped protect the poorest Kyrgyz children from starvation and helped the country reduce its childhood stunting rates from 30% to 11% from 2000 to 2021.

For more information on CCTs, read this interview with a J-PAL researcher on their review of 21 studies from 13 cash transfer programs in low- and middle-income countries and this interview with Dr. Aaron Richterman about his most recent research demonstrating the impact of CCTs on maternal mortality and under-5 mortality.