Conditional Cash Transfers and Health Outcomes - RBF Health

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					Conditional Cash Transfers for
Improving Utilization of Health
Health Systems Innovation
Abuja, January 25th-29th, 2010
Conditional Cash Transfers (CCTs)
• Cash transfers are conditioned when in addition to
  satisfying a selection criteria, beneficiaries are
  required to regularly undertake some pre-specified

• CCTs Government programs that transfer cash to
  poor families on the condition that those families
  make investments in human capital, usually:
  ▫ Sending children to school regularly
  ▫ Taking children to regular health and nutrition check
For example –Colombia
• The program transfers about US$40 per month
  (about 30% of household consumption) to extremely
  poor families with children less than 18 living in
  rural areas
• To receive the transfers:
  ▫ Children 6-18 have to attend school regularly (85%)
  ▫ Children less than 6 have to be taken to health centers
    every two (0-1) or six months (2-5).
• Transfer has two parts:
  ▫ A single transfer if the family has children less than 5
  ▫ Additional transfers for every school age child
• Two broad objectives:
 ▫ Short-term: support household
   consumption/income protection
 ▫ Mid-term: accumulate human capital and break the
   intergeneration transmission of poverty
• Specific objectives depend on the defined sector
  goals (e.g., schooling, health status, nutrition)
• Cash Transfers to
  ▫ Help poor families to access basic services
  ▫ Create incentives to change behaviors
• CCTs reach their long-term goals by boosting
  demand for specific social services
• Therefore, CCTs make sense only if supply of
  social services is available for, and reachable by
CCTs are effective to reach the
….help them to improve their consumption

• Colombia: higher consumption of proteins
  (milk, meat, eggs) and cereals; and children
  cloths. No evidence of additional consumption of
  alcohol or goods for adults
• In Brazil, 60% of the transfer spent in food; in
  75% of families enhanced variety of food,
  increased the number of meals, and improved
  quality of food (more proteins).
CCTs assisted families to use health
facilities for their children…
  ▫ Growth monitoring check ups
     México (+30-60%), Nicaragua (29%), Honduras
      (+12-20%), Colombia (+23-30%)
  ▫ Visit to clinics
     Colombia: (+30% (0-2), +50% (2-4)), Honduras
  ▫ Pre-natal check ups:
     México (+6%), Honduras (+19%), Brazil (+6%)
…helping to reduce stunting…
•   In México, beneficiary children are 1cm taller
    than non-beneficiaries after 2 years

•   In Colombia and Nicaragua stunting among
    beneficiaries is 6.9 and 5.3 percentage points

•   In Brazil, after two years of exposure to Bolsa
    Familia birth weight is approximately 200 gms
    more among beneficiaries.
… and increase immunization coverage
•   Colombia: +9% (DPT3)
•   Honduras: +7% (DPT3)
•   Nicaragua: +18% (full)
•   Turkey: +14% (full)

(difference between beneficiaries and non-beneficiaries)
             Key implementation issues:
                The CCT basic cycle
                        Define target
Program                  population
objectives                                   Selection of
   and                                      beneficiaries
expected                                                      Registry of
outcomes                                                     beneficiaries
                                                            (and information

       Program authorizes                 receive payment

             Program monitors               comply with
                 and verify                  conditions
• Selecting beneficiaries of the program
 ▫ Depends on the objectives of the program and the
 ▫ Windows of opportunities
• How
 ▫ Geographical
 ▫ At household level (Proxy means tested)
 ▫ Community participation
• Simple

• Easy to understand by beneficiaries

• Easy to monitor

• Linked to transfer
Registry of Beneficiaries
• At the core of the program

• Data base with all the information of all
  beneficiaries (surveys)

• Needs to be updated

• Basis for monitoring compliance with
  conditions and authorizing payments
Verification of conditionalities
• Central issue to a CCT program

• May be difficult and expensive, but critical for
  the credibility and impact of the program

• Close coordination between Ministries and
  implementing agencies

• Following and support to families that fail to
• CCT programs require a careful management of
 ▫ Large CCT programs require to manage
   considerable amount of information regularly
   (e.g., Brazil -10m payments per month; Mexico:
   5m payments every two months)
 ▫ Information of compliance with conditions
 ▫ Information on non-compliant families
Benefits and payments
• Single transfer per family or per eligible member
• High enough to be an incentive
• Low enough to avoid interfering in household
  decisions on labor options
• Frequency is key to keep families aware of
  conditionality and change behaviors
• Clear definition and application of consequences
  for families that fail to comply
Other implementation issues
• Institutional coordination (horizontal and vertical)

• Transparency in the operation: using banking
  system to transfer cash to families

• Community feedback

• Monitoring and evaluation to adjust program

• Exit and link with other strategies
Gradual expansion
• Most programs started from small and simple
  ▫ Only selected areas
  ▫ Straightforward and simple conditions
  ▫ Categorical targeting
• … for several reasons…
  ▫ Lack of supply of social services,
  ▫ Institutional capacity at central and local level
  ▫ Adjust the program and ensure credibility
• … and nationwide expansion is a mid-term process
  (if at all)
Size of the program
 Annual program budget as % of GDP

% of household consumption

                             Amount of the benefit
Concluding remarks
• Start simple but complete
• CCT instruments to reach its goals
 ▫ Targeting
 ▫ Conditionalities
 ▫ Benefits
• Critical elements
 ▫ Available supply of services
 ▫ Regular monitoring of compliance
 ▫ Information

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