Impact Assessment

What are the impacts of conditional cash transfers on non-beneficiaries?

Conditional cash transfers (CCTs) are social programmes started towards the end of the 20th century with the aim of alleviating current poverty and build future human capital (Fiszbein & Schady, 2009). Typically, eligible households receive a stipend dependent on certain conditions, such as ensuring their children attend school and regular health checks. The impact of these programmes on beneficiaries has been thoroughly evaluated, and studies have found that they are effective in improving the health utilisation (Lagarde et al., 2009) and school attendance (Reimers et al., 2006) of beneficiary children.

A more recent strain of the literature has explored whether these programmes have had impacts on non-beneficiaries (Angelucci & de Giorgi, 2009), also called spillover effects or externalities. Where these are present, it means that non-beneficiaries are bearing costs or enjoying benefits of the programme, which are not accounted for in the programme evaluation. Therefore, if there are significant externalities of CCTs, this means that the programme may be over- or under-valued.

Researchers from the Institute for Global Health have studied the externalities of a particular CCT programme in Colombia, called Familias en Acción. This programme was implemented in 2000 and currently has near-national coverage (Urrutia & Baez, 2018). The most deprived families are eligible to receive a stipend equivalent to about a tenth of a household’s basic food basket, provided they ensure their children aged under 7 attend regular health checks and children aged between 7 and 18 attend school (Attanasio et al., 2005). This programme has been successful in its intended impacts on beneficiaries. Research by Ana Correa, Neha Batura, Lara Goscè, and Jolene Skordis into its externalities is detailed below.

The local economy effects of a Colombian CCT

In Colombia, healthcare investment projects are funded from central taxation revenue. However, projects cannot be funded unless they are first submitted to the Ministry of Health within the Biannual Investment Plans. This dataset collates all investment requests from healthcare providers around the country, from small village health centres to large city hospitals. Using this dataset, researchers from the Institute for Global Health explored whether the implementation of the Familias en Acción programme had impacted healthcare investment requests.

The research found that, as the proportion of programme beneficiaries increased in a municipality, the number and value of investment requests increased. This result was also present while controlling for existing infrastructure, size of the local population, income per capita, and level of rurality. The magnitude of the effect was larger when considering only the proportion of beneficiaries that needed to comply with healthcare conditions. Further, the impact of the programme on the value of investment requests was greater in urban localities, which are in a better position to undertake costlier investments (WHO, 2016).

The public health effects of a Colombian CCT

In Colombia and many other low- and middle-income countries, the burden of disease from communicable diseases remains significant (James et al., 2018). Many of these communicable diseases are transmitted via vectors, such as mosquitos or small insects. Therefore, control of these vectors is vital to the reducing the incidence of communicable diseases. One of the most effective ways of vector control includes improving sanitation and construction materials, as poor and unsanitary dwellings constitute optimal habitats for the vectors (WHO, 2017). Researchers from the Institute for Global Health investigated whether the beneficiaries of Familias en Acción used their increased income to improve the sanitation and construction of their homes, and whether this had an impact on the incidence of vector-borne communicable diseases in their community. The five diseases evaluated were dengue fever, diarrhoeal diseases, Chagas disease, and leishmaniasis.

The results showed that the programme had a positive and significant impact in improving the construction and sanitation of households in a community. The consequence of this on the communicable diseases evaluated was less clear. An improvement in construction materials only had a significant impact on the incidence rate of Chagas disease. The insects transmitting the Chagas-causing parasite have a wide range of climactic tolerability and have shown insecticide resistance, making household improvements a stronger prevention strategy (Gürtler & Cecere, 2021). The other diseases investigated may be more vulnerable to other factors such as temperature, humidity, and vector control campaigns.

Conclusion

The results of these two studies by UCL economists showed that the impact of CCTs on non-beneficiaries is not always in a clear direction. The local economy effects research showed that the programme has put pressures on local healthcare supply. If these pressures turn into increased investment and expansion of local health supply, this would benefit the larger community. On the contrary, if investment is restricted, this would lead to overcrowding and poorer health outcomes. A similar study by UCL researchers focused on a CCT in India, showed that the latter result is certainly possible (Andrew & Vera-Hernández, 2020). These types of externalities may mean that the impact of Familias en Accion may be over-valued.

The public health effects research showed that the increased income of beneficiaries can have unintended effects beyond the originally planned outcomes. Especially in the context of vector-borne diseases, small improvements to sanitation by beneficiaries can have positive consequences for the wider community. This is a largely under-researched area, outside of some ecological studies in Brazil (Rasella et al., 2013; Nery et al. 2014; Souza et al. 2021). Communicable diseases still present a large burden of disease in many low- and middle-income countries, needing cost-effective ways to prevent them. The research results showed that Familias en Acción reduced incidence of Chagas disease in the wider community, which means that the impact of the programme in this respect is under-valued.

To ensure more efficient CCT designs, policymakers need to understand the complex system in which they operate, and the externalities they may cause. Further, policymakers can implement complementary policies that augment positive externalities, such as public health campaigns regarding sanitation, or diminish negative externalities, such as expanding local health supply. Considering the externalities into the valuation and design of the programme will aid policymakers in turning CCTs into very cost-effective programmes that can improve the wellbeing and health of the wider population.

References: Andrew, A., & Vera-Hernández, M. (2020). Incentivizing demand for supply-constrained care: Institutional birth in India (No. W20/05). IFS Working Papers.         Angelucci, M., & De Giorgi, G. (2009). Indirect effects of an aid program: how do cash transfers affect ineligibles' consumption?. American economic review, 99(1), 486-508.         Attanasio, O., Gómez, L. C., Heredia, P., & Vera-Hernández, M. (2005). The short-term impact of a conditional cash subsidy on child health and nutrition in Colombia.         Fiszbein, A., & Schady, N. R. (2009). Conditional cash transfers: reducing present and future poverty. World Bank Publications.         Gürtler, R. E., & Cecere, M. C. (2021). Chagas disease vector control. In Triatominae-The biology of chagas disease vectors (pp. 491-535). Springer, Cham.         James, S. L., Abate, D., Abate, K. H., Abay, S. M., Abbafati, C., Abbasi, N., ... & Briggs, A. M. (2018). Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet, 392(10159), 1789-1858.         Lagarde, M., Haines, A., & Palmer, N. (2009). The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane database of systematic reviews, (4).         Nery, J. S., Pereira, S. M., Rasella, D., Penna, M. L. F., Aquino, R., Rodrigues, L. C., ... & Penna, G. O. (2014). Effect of the Brazilian conditional cash transfer and primary health care programs on the new case detection rate of leprosy. PLoS neglected tropical diseases, 8(11), e3357.         Rasella, D., Aquino, R., Santos, C. A., Paes-Sousa, R., & Barreto, M. L. (2013). Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. The lancet, 382(9886), 57-64.         Reimers, F., Da Silva, C. D., & Trevino, E. (2006). Where is the" education" in conditional cash transfers in education? (pp. 1-75). Montreal: UNESCO Institute for Statistics.         de Souza, A. A., Mingoti, S. A., Paes-Sousa, R., & Heller, L. (2021). Combination of conditional cash transfer program and environmental health interventions reduces child mortality: an ecological study of Brazilian municipalities. BMC public health, 21(1), 1-13.         Urrutia, M., & Robles Báez, C. (2018). Las transferencias condicionadas en Colombia: una historia del programa Familias en Acción (2001-2018).         World Health Organization. (2016). Global report on urban health: equitable healthier cities for sustainable development.         World Health Organization. (2017). Keeping the vector out: housing improvements for vector control and sustainable development.

How to target public health interventions in low- and middle-income countries: the role of provision of information and public perceptions?

Public health interventions are programmes aimed at enhancing the mental and physical well-being of the general public. Most of these programmes induce behavioural responses in their target population. A major concern in the designing of public interventions is to avoid “perverse incentives”, that is, unintended responses that may make the programme less effective or that may even be harmful to individuals. Understanding the role of individuals’ perceptions and how the provision of information shapes behavioural responses, is therefore essential for designing and scaling up public policy programmes.

Researchers from the UCL Department of Economics studied two public health interventions in Eritrea and Nigeria that led to changes in perception and behaviours. They assessed the impact of these interventions on private investment in malaria control, child outcomes and household income.

Do public health interventions crowd out private investment in health? The IRS intervention in Eritrea.

Malaria is transmitted to humans by the bite of infected female mosquitoes. The main technologies to reduce transmission include insecticide-treated mosquito bed nets (ITNs), larval habitat management (LHM) and indoor residual spraying (IRSs). It is often argued that the introduction of public campaigns for IRSs may discourage the possession and use of ITNs. Public investment in one technology may change beliefs about the risk of malaria infection, resulting in reduced private investment in the other technology.

Prof. Pedro Carneiro, from the UCL Department of Economics, along with colleagues from the Institute for Fiscal Studies, Bank of Italy, University of Navarra, Tulane University, and from the National Malaria Control Program in Eritrea, carried out the impact evaluation of a randomised control trial conducted in Eritrea. The aim of this study was to quantify the impact of the IRSs intervention on individual and household malaria prevention behaviours. The intervention was implemented between June and July 2009 in the Gash Barka region, the most malarious area in Eritrea. Free spraying was carried out in each treatment village to control the adult mosquito population.

The campaign for IRSs in Eritrea did not lead to a reduction in the possession or use of ITNs in the short term, nor did it have a negative impact on any of the other risk reduction behaviours of villagers, such as participation in LHM. On the contrary, public provision of IRSs was found to increase average ownership and use of ITNs. Households in the treated villages owned, on average, 0.24 more ITNs than households in non-treated villages. Moreover, treated households reported using, on average, 0.22 more ITNs the night before their interview than non-treated households. The campaign also brought about a positive change in beliefs about the seriousness of the disease. This suggests that the public provision of IRSs led individuals to update their beliefs about the importance of malaria.

Can cash transfers and information provision on childcare and sanitation improve health outcomes and human capital accumulation? The Child Development Grant Program (CDGP) in Northern Nigeria.

In Eritrea, public provision of IRSs has had a positive impact on public beliefs and malaria risk mitigation behaviour in the short term. In this context, the provision of IRSs has served to highlight the importance of malaria control efforts. However, in other cases, interventions include direct information delivery mechanisms to change individuals’ beliefs.

Prof. Pedro Carneiro and Prof. Imran Rasul, from the UCL Department of Economics, along with researchers from the Institute for Fiscal Studies, Competition and Markets Authority and

Oxford Policy Management, investigated the impact of an intervention in northern Nigeria aimed at reducing informational and monetary barriers to improve early life nutrition.

They studied a large-scale and long-term randomised controlled trial to evaluate the Child Development Grant Program (CDGP), an intervention designed to improve early-life nutrition and well-being among households in extreme poverty. The intervention consisted of an unconditional monthly cash transfer to pregnant women from the beginning of pregnancy until the child was 24 months old (about 26% of monthly food expenditures). Households also received information messages related to childcare practices, child nutrition, food intake during pregnancy and good hygiene and sanitation practices.

Researchers found that the intervention led to significant and sustained improvements in the health of the children, including an 8% reduction in stunting four years after the intervention. These impacts are partly driven by information channels. Parents’ knowledge of pregnancy and childcare practices has improved, resulting in better peri-, ante- and post-natal practices. However, the improvements generated by the intervention are also due to the certain and substantial flow of cash transfers. This has induced positive labour responses among women and enabled them to undertake productive investments in livestock. These investments provided children with a more diversified, protein-rich diet and generated higher household income flows, even long after the cash transfers had ended. Overall, the net resources available to households increased by more than double the value of the cash transfer itself.

Conclusion

The results of the UCL economists' work on these two studies showed that information provision and public perceptions play an important role in the impact of public health interventions. In the Eritrean case, the free IRSs intervention has encouraged higher private investment. In this case, where individuals have little information about the impact of their actions, a public intervention reveals information that can lead to a change in beliefs about the importance of private actions, such as net use. In the Nigerian case, the combined intervention information and cash transfer intervention not only improved human capital accumulation among children, but also had positive impacts on women’s behaviours.

To ensure the effectiveness of interventions and to avoid potential unintended impacts, policymakers need to understand the central role that information and public perception play in the impact of health interventions. If implemented appropriately, in line with the research evidence, health interventions could have a sustainable and cost-effective effect on the outcomes of interest.

References: Armand, A., Carneiro, P., Locatelli, A., Mihreteab, S. and Keating, J., 2017. Do public health interventions crowd out private health investments? Malaria control policies in Eritrea. Labour Economics, 45, pp.107-115.        Carneiro, P., Kraftman, L., Mason, G., Moore, L., Rasul, I. and Scott, M., 2021. The impacts of a multifaceted prenatal intervention on human capital accumulation in early life. American Economic Review, 111(8), pp.2506-49.