Elsevier

The Lancet

Volume 371, Issue 9615, 8–14 March 2008, Pages 828-837
The Lancet

Articles
Role of cash in conditional cash transfer programmes for child health, growth, and development: an analysis of Mexico's Oportunidades

https://doi.org/10.1016/S0140-6736(08)60382-7Get rights and content

Summary

Background

Many governments have implemented conditional cash transfer (CCT) programmes with the goal of improving options for poor families through interventions in health, nutrition, and education. Families enrolled in CCT programmes receive cash in exchange for complying with certain conditions: preventive health requirements and nutrition supplementation, education, and monitoring designed to improve health outcomes and promote positive behaviour change. Our aim was to disaggregate the effects of cash transfer from those of other programme components.

Methods

In an intervention that began in 1998 in Mexico, low-income communities (n=506) were randomly assigned to be enrolled in a CCT programme (Oportunidades, formerly Progresa) immediately or 18 months later. In 2003, children (n=2449) aged 24–68 months who had been enrolled in the programme their entire lives were assessed for a wide variety of outcomes. We used linear and logistic regression to determine the effect size for each outcome that is associated with a doubling of cash transfers while controlling for a wide range of covariates, including measures of household socioeconomic status.

Findings

A doubling of cash transfers was associated with higher height-for-age Z score (β 0·20, 95% CI 0·09–0·30; p<0·0001), lower prevalence of stunting (−0·10, −0·16 to −0·05; p<0·0001), lower body-mass index for age percentile (−2·85, −5·54 to −0·15; p=0·04), and lower prevalence of being overweight (−0·08, −0·13 to −0·03; p=0·001). A doubling of cash transfers was also associated with children doing better on a scale of motor development, three scales of cognitive development, and with receptive language.

Interpretation

Our results suggest that the cash transfer component of Oportunidades is associated with better outcomes in child health, growth, and development.

Introduction

Worldwide, more than 200 million children under the age of 5 years are not fulfilling their potential for growth, cognition, or socioemotional development.1 Infants and toddlers growing up in poverty are exposed to poor sanitation, large family size, lack of psychosocial stimulation, and fewer household resources.2 As they grow up, children living in poverty in the developing world are likely to have substantially lower wages than do healthier adults,3 and are thus less likely to be able to provide increased stimulation and resources for their own children, thereby perpetuating the effect of poverty.4 Early childhood is a period of rapid change and physiological development and is thus a period critical for intervention.5

The question of how best to intervene to improve child health and wellbeing is of paramount importance.6 Many governments in developing countries, particularly in Latin America, have turned to conditional cash transfer (CCT) programmes to address the larger issue of poverty alleviation.7 In traditional cash transfer or welfare programmes, families receive cash benefits because the household falls below a certain income cutoff or lives within a geographically targeted region, and these are the only criteria determining eligibility for participation. In CCT programmes, however, families receive a cash payment only if they comply with a set of certain requirements. For example, most CCT programmes distribute benefits conditional on mandatory attendance at preventive health-care services and health and nutrition education sessions designed to promote positive behavioural changes, and some programmes also require school attendance for school-age children.8 In other CCT programmes, fortified food or micronutrient supplements are distributed to vulnerable subgroups in the population (eg, pregnant women and young children), which is conditional on the same factors as the cash transfer. The conditional nature of the benefits separates CCT programmes from other cash or in-kind distribution programmes. There are several CCT programmes already in place in Latin America, including Oportunidades (previously Progresa) in Mexico, Bolsa Alimentação in Brazil, Red de Protección Social in Nicaragua, Programa de Asignación Familial in Honduras, Familias en Acción in Columbia, Subsidio Unico Familiar in Chile, and the Program of Advancement through Health and Education in Jamaica.9 A CCT programme is also currently being planned for implementation in New York City.10

CCT programmes have the simultaneous goals of immediate poverty reduction—through cash transfers that can be spent without restrictions—and long-term poverty reduction through human capital development, defined as investing in a person's health, knowledge, and skills.9 Children are often the focus of the human capital investments, with the intention of giving children the tools with which to break the inter-generational transfer of poverty.4 CCT programmes use cash transfers as incentives for parents to invest in their children's health and wellbeing so that their children will have the capabilities to be able to escape poverty when they reach adulthood.11

There is substantial evidence that, in the short term, CCT programmes improve health and nutritional outcomes for children early in life,12, 13, 14 and that these outcomes are achieved in part due to increased use of preventive services mandated by programme participation.8 However, no studies to date have looked at the effect of CCT programmes on child cognitive, language, or motor development. Additionally, no analyses of CCT programmes thus far have been able to disaggregate the mechanisms by which such programmes could affect outcomes. Investigators have only been able to compare programme participation with non-participation and have not been able to separate the effect of the cash transfer on the desired outcome from the effect of other programme components. Understanding the pathways by which CCT programmes could be operating could guide policy makers who are faced with the challenge of how to design the most effective and cost-effective interventions.

Our aim was to determine the effect of the cash component of Oportunidades while holding all other aspects of the programme constant. We took advantage of the variation in total cumulative amounts of cash received by the families (determined by year of programme incorporation and family demographic structure) to explore the relation between cumulative cash transfers received over the course of the programme and child growth, health, and development outcomes.

Section snippets

Procedures

Oportunidades was established in 1997 with the dual goals of alleviating immediate suffering and breaking the intergenerational transmission of poverty by inducing parents to invest in their children's development. Oportunidades is the largest conditional cash transfer programme of its kind, and is a model for programmes throughout the world. In part, this is a result of the investment made by the Mexican government in external assessments of the programme and in the extensive dissemination of

Results

Baseline data for households are shown in table 2. On average, households had more than six members, with one or two children under the age of 5 years, two older children, and two working-age adults. About a fifth of mothers and a fifth of fathers had not completed any school, and the head of about half the households spoke an indigenous language. Maternal scores on the working vocabulary test were low compared with the expected standardised mean of 100. Families at baseline owned small amounts

Discussion

Our results suggest that larger cumulative transfers to the household as part of the Oportunidades intervention in Mexico were associated with significantly better outcomes in many aspects of child physical, cognitive, and language development. These outcomes include increased height for age, decreased BMI for age percentile, decreased prevalence of stunting and being overweight, and increased performance on one scale of motor development, all cognitive function subscales, and language

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