New research finds cash transfers reduce mortality

What do nearly 1.36 billion people – about one in five people on the planet – have in common? They received a cash transfer during the pandemic.

The pandemic was a “game changer” for cash transfers according to a World Bank report which counted a total of 962 programs across 203 countries – 672 of them launched during the pandemic. These include unconditional cash transfer programs, more common in sub-Saharan Africa, as well as conditional cash transfer programs, more common in Latin America.

As countries declare an end to the pandemic crisis, leaders find themselves at a crossroads and must determine the fate of many emergency-era programs, including cash transfers.

For insights into the question of the future of cash transfers, both those launched during emergencies and others which have functioned as long-standing social safety net programs, Exemplars News spoke with Dr. Aaron Richterman about his most recent research demonstrating the power of cash transfers as a health promotion tool.

Dr. Richterman’s research, across 37 low- and middle-income countries from 2000 to 2019, found that cash transfer programs were associated with significant reductions in mortality among children under five years of age and women over 18. Surprisingly, Dr. Richterman and his coauthors found a spill-over effect that reduced mortality across the entire population of children under five and women, not just among recipients of the cash transfers.

“Yes, they are poverty reduction programs and social protection programs,” said Dr. Richterman, who is an Instructor of Medicine specializing in Infectious Disease at the Perelman School of Medicine at the University of Pennsylvania. “But they are also more than that. They are also public health programs. These programs are powerful tools to improve population health.”

“And those kinds of population health improvements I don't think are commonly factored into the costs and benefits these programs when decision makers discuss starting, ending or expanding programs,” added Dr. Richterman. “By not including that as part of our calculation for these poverty reduction programs, we may not be accounting for the full benefits we derive from these programs.”

Dr. Richterman’s research adds to the already robust body of evidence demonstrating that large-scale, government-run cash transfer programs can reduce poverty, improve school attendance, child nutrition, women’s empowerment, and health-service use among beneficiaries. Exemplars in Global Health research has found that conditional cash transfer programs have helped drive reductions in childhood stunting in Nepal and Peru.

How did you get interested in the subject of cash transfers?

Dr. Richterman: It goes back to when I was working in an HIV clinic Central Haiti between 2016 and 2018. I kept hearing the same thing from the patients I met in the clinic, ‘How am I supposed to take my medications when I don't have enough to eat?’ This reflects the wide body of literature that associates poverty with poor health outcomes. We know that poverty is bad for health.

But what about poverty alleviation? How does that impact health? I really wanted to understand the relationship between poverty alleviation programs and the health outcomes that I really cared about. I wanted to better understand the close relationship between HIV outcomes and the social determinants of health and poverty.

So, you started looking at the impact of cash transfers on HIV/AIDS outcomes. What did you find?

Dr. Richterman: Over the last two decades, we've seen HIV/ AIDS deaths plummet. We've seen new infections go down. But, over the last decade progress has stagnated in both high- and low-income settings.

So, we looked at all low and middle-income countries with generalized HIV epidemics, meaning an HIV prevalence of 1% or greater. And then we identified all the cash transfer programs started in those countries from 1996 to 2019 that had enough beneficiaries to cover at least 5% of the people living in extreme poverty in that country.

Using a technique called the difference in differences approach, we found that these cash transfer programs were associated with a lower likelihood that women reported having a sexually transmitted infection within the last year. And then among women and men, a higher likelihood of having had an HIV test in the last year.

And at the country level, we found that these programs were associated with immediate decreases in the rate of new HIV infections and an immediate increase in the percentage of people who were receiving antiretroviral therapy for HIV. This is really important in the context of HIV where treatment is a form of prevention because someone on antiretroviral therapy can have virus levels so low that they are not passing along the virus and infecting others.

And a few years after the launch of the cash transfer program, we started to see this drop in AIDS-related deaths. It was quite pronounced. For example, in year six or seven of the program, death rates decreased by close to 30%.

We hypothesize that cash transfers can help people access diagnostics to know their status and access and adhere to treatment. And women who receive cash transfers, we hypothesize, may be less likely to need to engage in transactional sex, which is an important contributor to HIV transmission.

You’ve just published a new paper in Nature finding that large cash transfer programs reduce mortality for children under five and women. Can you tell us about this research?

Dr. Richterman: To follow our HIV research, we wanted to see if there was a more general population benefit outside of HIV. We built survival timelines for 4 million adults and 3 million children in 37 countries, about half of which had implemented cash transfer programs over a 20-year period. And then we looked at how the cash transfer programs affected risk of death for men, women, and children.

We found a large reduction in risk of death among adult women, a reduction of about 20%. Among children, we saw a statistically significant reduction of 8%. The impact on men was less convincing, with no statistically significant reduction in death associated with cash transfer programs.

The larger the program, in terms of cash amount and in terms of the number of beneficiaries, saw the largest effects on mortality. This is an important takeaway from our research – in the most generous transfers, we see reductions in mortality in almost every group. Interestingly, we saw mortality reductions in both conditional and non-conditional cash transfer programs.

How should leaders understand this body of research? Earlier this year, Exemplars News featured J-PAL research documenting the powerful impact of conditional cash transfers specifically on health outcomes.

Dr. Richterman: I think what is clear from the literature is that conditionalities generally incentivize and improve the particular behavioral target of that conditionality. So, in circumstances where there is a certain behavior that is the goal, such as childhood immunizations, then conditionalities make sense.

But there is a cost and administrative burden of documenting and monitoring conditionalities. So, in some cases, conditionalities may not be worth it or necessary because, as it turns out, people are generally pretty good judges of what they need. This study would support that notion. So, there's a role for both conditional and unconditional cash transfers depending on the setting and the local circumstances.

How do you hope your research will change the global discourse around cash transfers?

Dr. Richterman: Most fundamentally, I would love to see a shift in the conversation around what the purpose of these cash transfer programs are. Yes, they are poverty reduction programs and social protection programs. But they are also more than that. They are also public health programs. These programs are powerful tools to improve population health.

And those kinds of population health improvements I don't think are commonly factored into the costs and benefits of these programs when decision makers discuss starting, ending, or expanding programs. By not including that as part of our calculation for these poverty reduction programs, we may not be accounting for the full benefits we derive from these programs.

Over the course of the pandemic, hundreds of new cash transfer programs have been introduced across low- and highincome settings. And governments are right now thinking about what to do with these programs designed during the COVID emergency. There is also a growing interest in the idea of basic income programs, either guaranteed or universal basic incomes. So, we are at a turning point. I hope that we can keep the health benefits of these programs in mind when we are calculating their costs and benefits.

You found reductions in mortality across entire populations, not just among recipients of the cash transfers. How does that work?

Dr. Richterman: For the surveys that we used, they don't allow us to know whether a specific person that we're looking at was receiving the cash transfer or not. With cash transfers, I think it's under-recognized how much secondary benefit non- beneficiaries get. There are what we call spillover effects on people that are not the direct beneficiaries. And this makes sense because, when you look at what people do with cash transfers, this money is often shared among families and households, but also between households and families and in communities and among like social groups. And there's also some recent evidence that large programs in these low and middle-income settings may have general favorable benefits for the regional economy itself.

What are you working on next?

Dr. Richterman: We’ll be looking at the pathways through which cash transfer programs have an impact and why they might have a disproportionate impact on women. There is a fair bit of evidence that cash transfers seem to disproportionately benefit women.

Some of that may be related to things like women's empowerment within and outside of the household. Among young women, one of the principle risks of mortality is around the time of pregnancy and childbirth time and thereafter.

So, we will be looking at whether cash transfers help women access prenatal care where risky conditions can be identified and managed or whether the cash transfer programs help women deliver at a facility where obstetrical emergencies can better be managed. And perhaps these women are better positioned to access and use family planning so that they can plan their pregnancies. And we’ll look at whether children in cash transfer programs have better access to more nutritious food, and to vaccinations to help explain the reduction in mortality.

But cash transfers don’t just impact economic barriers. They also impact the psychological implications of poverty. They impact stress levels. Do these programs change the way people think about risk? We want to get into the weeds on these questions.