YPMED-03214; No.

of pages: 11; 4C:

Preventive Medicine xxx (2012) xxxxxx

Contents lists available at SciVerse ScienceDirect

Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed

Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of conditional cash transfer programmes
Meghna Ranganathan , Mylene Lagarde
Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK

a r t i c l e
Available online xxxx

i n f o

a b s t r a c t
Objective. To provide an overview of Conditional Cash Transfer (CCT) programmes in low and middle income countries and present the evidence to date on their contribution to improvements in health and the encouragement of healthy behaviours. Methods. Several bibliographic databases and websites were used to identify relevant studies. To be included, a study had to provide evidence of effects of a nancial incentive conditional upon specic healthrelated behaviours. Only experimental or quasi-experimental study designs were accepted. Results. We identied 13 CCT programmes, whose effects had been evaluated, mostly in Latin-American countries. Their results suggest that CCTs have been effective in increasing the use of preventive services, improving immunisation coverage, certain health outcomes and in encouraging healthy behaviours. Conclusion. CCTs can be valuable tools to address some of the obstacles faced by populations in poorer countries to access health care services, or maybe to modify risky sexual behaviours. However, CCTs need to be combined with supply-side interventions to maximise effects. Finally, some questions remain regarding their sustainability and cost-effectiveness. 2011 Published by Elsevier Inc.

Keywords: Cash transfer Conditional cash transfer Social protection Health behaviour

Introduction Conditional Cash Transfers (CCTs) are considered a particular form of performance-based payments, which make regular cash payments to individuals (or households) contingent on a set of behavioural requirements, such as attending regular health check-ups or sending one's children to school. Historically, the rst CCT programmes from Latin America were designed to act as social transfer mechanisms, aiming to provide a safety net to its recipients. Progresa, the seminal Mexican CCT programme (subsequently named Opportunidades) was developed during an economic crisis to replace a former social transfer mechanism, which included subsidies to the poor (mainly in the form of food subsidies) and was viewed as being administratively expensive (Grimes, 2008). The innovation proposed by Progresa was to use public money to target fewer and more needy households initially. The strings attached to the money given to beneciaries ensured that it was an investment into the future development of the country, through an investment in the poor population's human capital. By transferring cash to the beneciaries on the condition that they comply with a set of requirements (sending their children to schools and regular health check-ups, attending prevention workshop, etc.), the objectives of the programme were twofold. In addition to a

Corresponding author. E-mail address: Meghna.Ranganathan@lshtm.ac.uk (M. Ranganathan). 0091-7435/$ see front matter 2011 Published by Elsevier Inc. doi:10.1016/j.ypmed.2011.11.015

short-term poverty reduction created by the increase in income, it was designed to act as powerful incentives for households to adopt a behaviour that will positively impact on their well-being and break the cycle of poverty in the long run (Gaarder et al., 2010). Initially implemented in some areas only, Progresa was soon rigorously evaluated and found to be an effective mechanism, leading to the scaling-up of the programme at the national level. Its principles were soon emulated by other Latin American countries, and more than ten years later, very similar national programmes have ourished in almost every Latin American country (Fiszbein and Schady, 2009). In parallel, the successful use of nancial incentives in promoting changes in health-related behaviour in the area of addictions (Lussier et al., 2006; Pilling et al., 2007) provided the scientic base for the growing popularity of Results-Based Financing (RBF) mechanisms amongst policy-makers and funders in low and middle income countries. RBF mechanisms refer to nancial transfers linked to meeting particular outcomes (Oxman and Fretheim, 2008). On the supply-side, they target health care providers and propose incentives for improved performance on measures of quality and efciency. On the demand side, RBF mechanisms pay beneciaries (patients) money contingent on their meeting certain behavioural requirements. As RBF schemes were gaining momentum in low- and middleincome countries, African and Asian countries have seen the development of CCTs that have moved away from being used as a broad safety net mechanism, with multiple conditionalities (as they were traditionally designed in Latin-American countries) to being more

Please cite this article as: Ranganathan, M., Lagarde, M., Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of condition..., Prev. Med. (2012), doi:10.1016/j.ypmed.2011.11.015

Please cite this article as: Ranganathan, M., Lagarde, M., Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of condition..., Prev. Med. (2012), doi:10.1016/j.ypmed.2011.11.015

Table 1 Description of CCT programmes with health components. M. Ranganathan, M. Lagarde / Preventive Medicine xxx (2012) xxxxxx Country, programme name and reference Brazil Bolsa Alimentao (Morris et al., 2004b) Target population Poorest households from selected municipalities (chosen according to infant malnutrition prevalence). Transfer size Up to maximum of US$18.25. US$6.25 per person beneciary/per month in the household (pregnant women or children under 7). Conditionalities For pregnant and lactating women: attending educational workshops, regular check-ups, and vaccinations up-to-date. For children under 7: maintaining vaccinations up-to-date and growth monitoring. Through psychosocial support and cash, households need to meet minimum level of well-being along different dimensions (such as family dynamics, education, health, housing, employment, income) Parallel intervention(s) Children received nutrition supplements. Study design Cluster randomised controlled trial

Chile Chile Solidario (Galasso, 2011)

Poorest households in extreme poverty (identied through proxy means testing)

Colombia Familias en Accin (Attanasio and Mesnard, 2005; Attanasio et al., 2004)

Poorest households from selected municipalities (also chosen on poverty criteria).

The direct transfer is set at US$22.73 per month for the rst six months of the program; decreases to US$ 17.32 in the second six months of the program. In the second year it decreases to US$ 11.9 and nally to US$7.57 for the last six months, an amount equivalent to the family allowance (SUF), one of the main cash assistance transfers. US$50 on average US$20 per family; US$6 per primary school child per month; US$12 per secondary school child. Approximately 30% of household consumption. US$17 on average (US$4 per family, US$5 per child) per month. Approximately 10% of household consumption. Rs700 in rural areas and Rs600 in urban areas per month.

Strengthening supply side of public services. Chile Solidario works directly with municipalities (local providers of services) to make sure local needs are met

Panel Survey with matched comparison group using propensity score matching

Honduras Programa de Asignacin Familiar (Morris et al., 2004a) India Janani Suraksha Yojana (Lim et al., 2010b)

Jamaica Programme for Advancement Through Health and Education (Levy and Ohls, 2007)

Children and women from poor households, living in designated beneciary municipalities (chosen on socio-economic criteria). Pregnant women belonging to poorest households, aged older than 19 years, and for up to 2 live births (extended after the third live birth if the mother chooses to undergo sterilization immediately after the delivery). Children under 17 years old, pregnant and lactating women, elderly over 65 years, destitute adults under 65 years.

For children under 7: attending health and nutrition check-ups. For children aged 818 year old: attending school. For mothers: attending health education workshops. Attending primary school and regular health visits.

n/a

Controlled before and after design

n/a

Cluster randomized controlled trial

Attending at least 3 ante-natal and post-birth check-ups and delivering in a public health facility (programme benets are supposed to be extended to women delivering in private facilities too). For children aged 617 year old: attending school. For other beneciaries: complying with required health visits per year(number depends on beneciary age and status).

In low-performing States (with low institutional delivery rates), an incentive is paid to the accredited health worker for each delivery (Rs600 in rural areas and Rs 200 in urban areas). n/a

Quasi-experimental design using 3 analytical methods exact matching, with-versu- without and differences-in-differences

US$9/month per child eligible for education component, US$9/month per household member eligible for the health component.

Participant-comparison group design

Table 1 (continued) Country, programme name and reference Malawi (Thornton, 2008) Target population Individuals doing a HIV test, in rural areas Transfer size US$ 1.04 on average vouchers of values between US$0-3 per individual were randomly assigned on learning HIV test results. Incentive amounts for individuals are zero, 500 kwacha (~$4) or 2000 kwacha (~$16) and for a couple, zero, 1600 kwacha or 4000 kwacha (~$32) given after a year. US$20 on average; US$13 per family; US$8-17 per primary school child per month; US$2532 per secondary school child; US$1222 grant once a year for school supplies approximately 25% of household consumption. Fixed sum of 1,500 NRs in mountain areas, 1,000 NRs in hill areas, 500NRs in the lowlands (3050% of the mean transport cost to the health facility). Conditionalities Collecting HIV test results. Parallel intervention(s) n/a Study design Cluster randomised controlled trial

Please cite this article as: Ranganathan, M., Lagarde, M., Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of condition..., Prev. Med. (2012), doi:10.1016/j.ypmed.2011.11.015

Malawi Incentives Project (Kohler and Thornton, in press)

Males and females (1,312) who accepted to take an HIV test. 45% are males and sample is rural.

Mexico Progresa (renamed Oportunidades) (Barham, 2005; Fernald et al., 2008a; Gertler, 2000, 2004)

Eligible households (selected on poverty criteria) among selected communities (selected on poverty criteria).

Nepal Safe Delivery Incentive Programme (Powell-Jackson et al., 2009b)

Pregnant women with no more than 2 living children or an obstetric complication.

Maintaining HIV status (Please note that payment was not tied to the condition of remaining negative. This was to prevent disclosure of HIV status to outsiders) For children: attending primary and secondary school attendance; and complying with regular health visits and immunisation schedule. For pregnant women: complying with regular health visits and attending health education workshops. Giving birth in a public health facility.

n/a

Individual randomised controlled design

Children received nutrition supplements allocation was not random and children in control areas could also have received them.

Cluster randomised controlled trial

Nicaragua Red de Proteccin Social (Barham and Maluccio, 2009; Maluccio and Flores, 2004)

42 municipalities chosen to participate in the pilot phase: randomly selected for intervention.

US$25 on average bi-monthly US$18 per family; US$9 per family with school-age child; US$20 once a year for supplies. Approximately 20% of household consumption. US$50 per month per household

Panama Red de Oportunidades (Arraiz and Rozo, 2010)

Beneciaries were selected based on the probability of being extremely poor using different criteria depending on their area of residency: urban, rural, or indigenous

Tanzania RESPECT (Rewarding STD Prevention and Control in Tanzania) (World Bank, 2010)

Young male and female participants (2399) in 10 villages in rural Tanzania

Intervention arm consisted of both high value and low value amounts. High value was $60 over the course of the study ($20 every 4 months) and low value was $30 over the course of the study ($10 every 4 months)

For mothers of children under 5: attending educational workshops and bringing children to preventive health programmes For children aged 713 year old: attending school. Households enrolling and sending their children, ages 4 to 17, to school. Pregnant women and children under 5 years of age needed to periodically visit an assigned health care provider where children's development and growth was monitored and women received prenatal and post-partum controls. Negative results of periodic screenings for incident STDs such as Chlamydia, gonorrhoea, trichonomas, mycoplasma genitaliam and syphilis.

Trained health workers receive an incentive of NRs 300 for each delivery, and facilities are reimbursed NRs 1,000/delivery to recover the cost (as deliveries are free of charge for women). The programme trained and contracted private providers to deliver the health services required.

Quasi-experimental design with propensity score matching M. Ranganathan, M. Lagarde / Preventive Medicine xxx (2012) xxxxxx

Cluster randomised controlled trial

n/a

Quasi-experimental design use of propensity score matching with Living Standards Measurement Survey

n/a

Individual randomised controlled design

M. Ranganathan, M. Lagarde / Preventive Medicine xxx (2012) xxxxxx

narrowly focused around specic health outcomes or healthy behaviours. Recent examples include CCT programmes that have incentivised women to give birth in health care facilities (Powell-Jackson et al., 2009b) or tried to promote safe sexual behaviours (Kohler and Thornton, in press; World Bank, 2010). The rationale behind Conditional Cash Transfers Several arguments have been made to promote the use of CCTs. As mentioned before, the rst argument that was put forward relate to the benets granted by the provision of an innovative safety net that would help break the cycle of poverty. This argument was particularly relevant for the original Latin American programmes, which included several conditionalities focused on health and education components, both considered essential for the promotion of human capital. When presented as a demand-side nancing mechanism in the health care literature, CCTs rely on the recognition that there are nancial barriers that prevent individuals from using basic curative and preventative health services. These barriers consist of the various nancial costs individuals must bear when they decide to use health services. These costs include the direct cost (when they are not completely free), the indirect cost of service use (such as transportation costs), and nally the opportunity cost, which is typically dened as the loss of revenue virtually incurred by the time spent on accessing health services instead of spending it on income-generating activities. In this perspective, CCTs provide a nancial transfer that is aimed to cover some or all of the costs associated with the use of health services. Furthermore, CCTs seek to address non-nancial obstacles to accessing health care services. This relies on a body of evidence showing that there are more deep-rooted obstacles, such as cultural barriers, or the failure by individuals to perceive the benets of some interventions (Fiszbein and Schady, 2009; Gaarder et al., 2010; Medlin and de Walque, 2008). By providing an incentive, CCTs are meant to overcome these issues which limit the uptake of certain interventions, in particular preventive ones. It is sometimes hoped that CCTs might thereby trigger virtuous circles of good habits, as individuals would come to recognise the benets of the conditionalities. Finally, some economists have recently supported the development of CCTs as effective mechanisms to nudge' people towards healthy behaviours. In that respect, they build upon the impressive body of work developed by psychologists in contingency management (Higgins, 2010). Whilst standard economic theory assumes that individuals make rational choices after weighing the costs and benets of the different choices they face (Medlin and de Walque, 2008), recent developments in behavioural economics have underlined the shortcomings of human rationality or miscalculations made by individuals in certain instances. For example, although weighing the actual risks and benets associated with unprotected sex in certain settings should encourage people to be cautious and avoid risky sexual behaviours, some individuals are likely to miscalculate the costs and benets, by underweighting future costs, such as the probability of being infected with a sexually transmitted disease (STD), and overweighting immediate benets or gratication (Medlin and de Walque, 2008). In such circumstances, CCTs can offer an innovative alternative to traditional behavioural strategies. Indeed, when made conditional on remaining free of STDs, in the short term, the provision of cash can substitute for potentially risky sexual behaviour and thus prevent acquiring a sexually transmitted infection in the future. In essence, they are designed to bring forward the costs of risky behaviours in order to correct irrational choices made by individuals. In developed countries, this area of work has led to the design of CCTs to encourage smoking cessation (Gin et al., 2009; Volpp et al., 2009) and losing weight (Charness and Gneezy, 2009; Volpp et al., 2008), while in

low- and middle-income countries the few similar experiments have focused on the promotion of safe sexual behaviours (Kohler and Thornton, in press; World Bank, 2010). Building on and updating a previous review (Lagarde et al., 2007), this paper provides an overview of CCT programmes in low and middle income countries, and present the evidence available to date on how they have contributed to improvements in health outcomes and the encouragement of healthy behaviours in these settings.

Methods This overview is restricted to CCT programmes that dene at least one of their conditionalities upon health-related behaviour. This led to excluding some studies which did look at the effects of CCTs on health outcomes. For example, several programmes have been developed providing cash transfers to households who keep children enrolled in school. Research into the effects of some of these programmes has included health outcomes such as a reduction in HIV incidence (Baird et al., 2009). Yet this paper takes the restrictive view that only CCTs directly addressing health should be included, even if health benets might arise from broader social development interventions. In addition, studies evaluating the effects of in-kind or unconditional cash transfers were excluded from this review. Finally, the scope of the review was restricted to interventions in low and middle-income countries 1 as dened by the World Bank. 2 To review the evidence on the effects of CCTs, we included studies with the following designs: randomized controlled trials, multi cross-sectional studies using matching techniques, controlled before-after studies, interrupted time series analysis. Several bibliographic databases (PubMED, EMBASE, JSTOR and EconLit) were searched using the following key terms and/or their combinations: cash transfer conditional cash transfer social protection safety nets health services, and health behaviour. Key terms were generated based on the usual terms currently used in the literature to refer to CCT schemes, identied by expert knowledge and examination of already known papers. No limitation regarding publishing date was used. In addition, we also used Google Scholar and searched working papers on the websites of the World Bank, Inter-American Bank of Development, the Jameel-Poverty Action Lab, Eldis, United Nations Development Programme and the Overseas Development Institute.

Results Description of programmes Table 1 describes briey the main characteristics of the 13 CCT programmes that were identied for inclusion in this overview. The geographic variation of CCT programmes is somewhat matched by differences in their focus. Inspired by the success of the seminal Progresa programme in Mexico, many Latin American and Caribbean countries have introduced CCT programmes where the compliance with health related conditionalities is only one dimension of a broader intervention (see Table 1). We found eight of them that could be included in this overview. We found two studies describing the effects of CCTs in SouthAsian countries, specically in Nepal and India. In both countries, they were national programmes introduced to incentivise women to give birth in a health care facility (Lim et al., 2010b; Powell-Jackson et al., 2009b).
1 The rationale for limiting the scope of this review to low and middle income countries (LIMC) is because in low LMICs, CCTs typically play a poverty alleviation role (contingent on meeting certain behavioural requirements). Other than the most recent programme in New York City, which recently introduced a CCT programme for its low income population, most conventional CCT models are typical of LMICs. In high income countries, demand side incentives are mostly around behaviour change, such as for smoking cessation or weight loss. 2 http://data.worldbank.org/about/country-classications/country-and-lending-groups.

Please cite this article as: Ranganathan, M., Lagarde, M., Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of condition..., Prev. Med. (2012), doi:10.1016/j.ypmed.2011.11.015

M. Ranganathan, M. Lagarde / Preventive Medicine xxx (2012) xxxxxx

Finally in sub-Saharan Africa, three programmes were identied, two in Malawi and one in Tanzania. There, CCTs have been used to encourage particular preventive health behaviours, specically around risky sexual behaviours. In the oldest programme in Malawi, CCTs were designed to incentivise individuals to collect the results of their HIV tests (Thornton, 2008). In a more recent programme in the same country, beneciaries were given cash transfers as long as they maintained their HIV status for a year (Kohler and Thornton, in press). The incentive scheme was not tied to whether the individual was HIV positive or negative. This was done in order to avoid disclosure of HIV status to outsiders, in case of possible exclusion from the study. A similar study, called the Rewarding STD Prevention and Control in Tanzania (RESPECT) provided incentives to people for remaining free of a set of curable sexually transmitted infections, including chlamydia, gonorrhoea and syphilis (World Bank, 2010). Most of the original programmes implemented in Latin America have targeted the poorest groups of the population, or those living in the poorest areas, since these populations face the greatest barriers to access to health services. In addition, in these countries, CCTs were also designed to act as transfer mechanisms that would redistribute resources to reduce health inequities. As they were replicated in other countries, in particular in lower-income ones, CCTs have been in general, designed without a specic targeting mechanism. This is because targeting requires a sophisticated information system, which tends to be costly. In addition, more often than not, CCTs were seen as part of a general demand-side strategy seeking to increase dramatically the initial low uptake rates of interventions in the population without looking at the equity implications of focusing on the poorest (Powell-Jackson et al., 2009b). Finally, a point worth noting is that the design and implementation of CCT programmes permit a robust evaluation of their impact (see Table 1). This is a rare feature for such large scale social interventions, which perhaps originated from the initial commitment of the Mexican team to rigorous design of the evaluation of Progresa. In some occasions, randomised evaluations have been difcult to implement for either political or logistical reasons. However, close monitoring and adequate data collection before and after the intervention have usually allowed independent researchers to carry out good impact evaluations, sometimes using sophisticated statistical techniques (Gaarder et al., 2010). In this respect CCT programmes have demonstrated that it is possible from an administrative and political perspective to randomise access to potentially benecial interventions when their benets have not yet been shown. Evidence of effects Table 2 presents a brief summary of evidence of the main effects of the CCT programmes reviewed in this overview. Uptake of preventive and curative health care services CCTs have been found to improve signicantly the uptake of health care services in ten studies. In the Oportunidades programme in Mexico, families beneting from the programme visited health facilities twice as more than non-beneciary families (Gertler, 2000). In Colombia, the CCT programme, Familias en Accin, was found to increase the uptake of preventive health care visits for children aged less than 4 years old (Attanasio and Mesnard, 2005; Attanasio et al., 2004). In Nicaragua, the Red de Proteccin Social scheme improved the proportion of infants (03 years old) taken to public health clinics in the past 6 months by 17.5% for all children and by 23.6% for disadvantaged infants (Maluccio and Flores, 2004). In Honduras, the Programa de Asignacin Familiar (PRAF) programme signicantly increased health service utilisation for pre-school children through the uptake of routine health check-ups and growth monitoring visits, and the use of

antenatal care. However, there was no evidence that the programme improved the uptake of post-natal care (Morris et al., 2004a). In the Chilean programme, Chile Solidario, a positive effect on the number of health visits for preventive care was found for children below six years of age, but only in rural areas (Galasso, 2011). A positive impact on the uptake of a screening test for cervical cancer by women aged 35 or older in both rural and urban areas (Galasso, 2011). In Jamaica, the Program Advancement through Health and Education (PATH) was found to be effective at increasing the number of health care visits for children between the ages of 06 years by approximately 38% in recipient families (Levy and Ohls, 2007). In Panama, the Red de Oportunidades programme had no impact on visits to health care providers in both rural and indigenous areas, however, there was a positive impact of the programme on the proportion of women aged more than 15 years who screened for cervical cancer (Arraiz and Rozo, 2010). The programme was also associated with an increase in the number of pregnancies in rural areas, but not in indigenous areas (Arraiz and Rozo, 2010). A study in Malawi found that conditional monetary incentives increased the percentage of individuals collecting HIV test results, and that the effect was increasing with the amount of the cash transfer (Thornton, 2008). Lastly, the two CCT programmes seeking to promote safe motherhood also found positive effects. The Safe Delivery Incentive Programme in Nepal was found to be effective in increasing the use of skilled attendance at delivery and reducing the probability of a woman delivering at home (Powell-Jackson et al., 2009b). A similar scheme in India was recently found to have had a similar positive effect, increasing the uptake of antenatal care by 10.9 percentage points and increasing the proportion of women giving birth in facilities by 49.2 percentage points (Lim et al., 2010a). Immunisation coverage We found four studies reporting evidence on the impact of CCT programmes on immunisation rates amongst children, and the evidence is mixed. In Mexico, there were positive effects for tuberculosis vaccination rates for children under 12 months and for measles for children between 1223 months (Barham, 2005). In Honduras, there was a positive impact on the coverage of the rst dose of the diphtheria pertussistetanus (DPT)/pentavalent vaccine (Morris et al., 2004a). In Colombia, there was a positive impact on the probability of children aged 24 months old to have complied with the DPT vaccination schedule (Attanasio and Mesnard, 2005). Finally, in Nicaragua, for children living further from a health facility, there was a positive impact for polio vaccination in the rst year (Barham and Maluccio, 2009). However, in Mexico, no evidence was found that CCT had an impact on immunisation rates in the long-run (Barham, 2005) In addition, for three programmes (in Mexico, Honduras and Colombia), there was no evidence of an increase in vaccination coverage for certain age groups, although the reasons behind these differences in ndings are unclear, except in one case where contamination in control groups might have hidden a positive effect (Barham et al., 2007). Nutritional and health outcomes Five of the CCT programmes reviewed here presented evidence of effects on health outcomes. Four of them have found that they led to improved health outcomes, while one did not nd evidence of such effects. The Colombian programme Familias en Accin, was found to have improved the nutritional status of newborns and infants (Attanasio et al., 2005) but only for those less than 2 years. The Mexican programme, Oportunidades was associated with a better nutritional status and greater growth of children as shown by 2 separate studies (Behrman and Hoddinott, 2005; Rivera et al., 2004), as well as a

Please cite this article as: Ranganathan, M., Lagarde, M., Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of condition..., Prev. Med. (2012), doi:10.1016/j.ypmed.2011.11.015

Table 2 Summary of evidence of effects. Country, programme name and reference Brazil Bolsa Alimentao (Morris et al., 2004b) Impact on uptake of health care services n/a Impact on immunisation coverage n/a Impact on nutritional and health outcomes Evidence of a statistically signicant reduction in the mean Height-for-Age Z score for children under 7 years old ( 0.13*) No evidence of a change in the Weight-for-Age Z score for children under 7 years old ( 0.11) n/a Impact on health-related behaviour change n/a

Please cite this article as: Ranganathan, M., Lagarde, M., Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of condition..., Prev. Med. (2012), doi:10.1016/j.ypmed.2011.11.015

Chile Chile Solidario (Galasso, 2011)

Colombia Familias en Accin (Attanasio and Mesnard, 2005; Attanasio et al., 2004)

No evidence of a change in the proportion of children b 6y going to regular check-ups in rural areas (0.002) or urban areas ( 0.029). No evidence of a change in the proportion of pregnant women attending regular check-ups in rural and urban areas ( 0.09) Evidence of an increase in the number of health visits for children b 6 yrs of age of the order of 46 percentage points, only in rural areas Evidence of a change in the proportion of women aged 35 or older having their regular pap smear of the order of 6-7%, mostly in 2004 for rural areas and in 2003 in urban areas Evidence of an increase in the proportion of children b 24 months (22.8**), children aged 2448 months (33.2**), and children >48 months (1.5*) with up-to-date schedule of preventive healthcare visits

n/a

n/a

M. Ranganathan, M. Lagarde / Preventive Medicine xxx (2012) xxxxxx

Honduras Programa de Asignacin Familiar (Morris et al., 2004a)

India Janani Suraksha Yojana (Lim et al., 2010b)

Jamaica Programme for Advancement Through Health and Education (Levy and Ohls, 2007)

Malawi (Thornton, 2008)

Evidence of an increase in the proportion of women having completed more than 5 antenatal care visits (18.7***) No evidence of a change in the proportion of women attending a 10-day post partum check-up ( 5.6). No evidence of a change in the proportion of children taken to a health centre at least once in the past month (20.2). Signicant increase in the proportion of women attending three Antenatal care visits (+10.7 pp) Signicant increase in the proportion of women giving birth in facilities (+49.2 pp ) Evidence of an increase in the frequency of preventive health visits by children (06 years) by 37% No evidence of effects of PATH on the frequency of health care visits by the elderly. Evidence of an increase in the proportion of individuals who attended a VCT centre to learn their results (27.4***)

Evidence of an increase in the probability of compliance with DPT vaccination, for children under 24 months old (0.089*). No evidence of a change in the probability of compliance with DPT vaccination, for children 2448 months old (0.035) or over 48 months old (0.032) Evidence of an increase in the proportion of children under age 3 vaccinated with DPT1/pentavalent (6.9***). No evidence of a change in the proportion of children under age 3 vaccinated for Measles ( 0.2) or tetanus toxoid (4.2). n/a

Evidence of a statistically signicant increase in Height-for-Age Z-score of children under 24 months old (0.161*). No evidence of a change in Height-for-Age Z-score for children aged 2448 months (0.011) or children over 48 months old (0.012).

n/a

n/a

n/a

n/a

No evidence of the effect of JSY on neonatal mortality ( 2.3 per 1000 live births) No evidence effect of JSY on perinatal mortality ( 3.7 per 1000 pregnancies) No evidence of effect of JSY on maternal mortality ( 100.5 per 100 000 live births) n/a

n/a

n/a

n/a

n/a

n/a

Table 2 (continued) Country, programme name and reference Malawi Incentives Project (Kohler and Thornton, in press) Impact on uptake of health care services n/a Impact on immunisation coverage n/a Impact on nutritional and health outcomes n/a Impact on health-related behaviour change Evidence among men who received any incentive, a 13 pp more likely to engage in any vaginal sex and had 0.6 additional days of sex. Men who received incentives were also signicantly more likely to report using a condom during sex (6.9 pp more likely), but overall, they were 8.5 pp more likely to engage in riskier sex. Evidence among women who received any incentive, less likely to any vaginal sex and there was no impact on reported condom use. Overall, women were 7.5 pp less likely to engage in risky sex n/a

Please cite this article as: Ranganathan, M., Lagarde, M., Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of condition..., Prev. Med. (2012), doi:10.1016/j.ypmed.2011.11.015

Mexico Progresa (renamed Oportunidades) (Barham, 2005; Behrman and Hoddinott, 2005; Fernald et al., 2008a; Gertler, 2000, 2004)

No evidence of a change in the number of visits to a public clinic in the 4 weeks preceding the survey for children aged 02y ( 0.011), children aged 35y (0.027), children aged 6-17y (0.015), or adults aged 18-50y (0.015).

Evidence of an increase (after 6 months) in the proportion of children under 12 months old (at baseline) vaccinated for TB (5.2***), and children aged 1223 months old (at baseline) vaccinated for Measles (3.0**) No evidence of a change (after 12 months) in the proportion of children under 12 months old (at baseline) vaccinated for TB (1.6), and children aged 1223 months old (at baseline) vaccinated for Measles (2.8)

Nepal Safe Delivery Incentive Programme (Powell-Jackson et al., 2009b)

Nicaragua Red de Proteccin Social (Barham and Maluccio, 2009; Maluccio and Flores, 2004)

Evidence of a 5% decrease in the likelihood of delivering at home ( 0.042***) Evidence of a 24% increase in the likelihood of delivering at government facility (0.023***). Evidence of an increase in the proportion of children age 03 taken to a health centre and weighed in the past 6 months (17.5 pp**). Evidence of an increase in the proportion of children age 03 from extremely poor groups taken to health control and weighed in the past 6 months (23.6 pp**)

n/a

Evidence of an increase (+1.1 cm***) in the growth of children aged under 6 months old (at baseline), from poorest households (after 2 years of programme participation versus 1 in the control group). In addition, evidence of an increase in mean growth per year (over 1 cm compared to controls)* between 1236 months.No evidence of a change ( 0.6 cm) in the growth of children aged 6-12 months old (at baseline), from poorest households (after 2 years of programme participation versus 1 in the control group). Evidence of an increase in mean Haemoglobin (0.37** g/dL) value among children (after a year of Progresa vs. No exposure in the control group) Evidence of a decrease in the prevalence of anaemia (after a year of Progresa vs. no exposure in the control group) (10.6** ) Evidence of improved child growth of about 1.5 cm as height-for-age Z for an additional 18 months of the programme before age 3 years, for children aged 810 years whose mothers had no education, independent of cash received. For children between 2468 months, evidence of a statistically signicant increase in height-for-age Z score (0.2***) , lower prevalence of stunting ( 0.1***), lower prevalence of being overweight ( 0.08**) and decrease in BMI for age percentile ( 2.85*) with the doubling of the cash transfers after 5.5 years. n/a

M. Ranganathan, M. Lagarde / Preventive Medicine xxx (2012) xxxxxx

n/a

No evidence of an increase in the proportion of children aged 1223 months old with up-to-date vaccinations (6.1 pp) Evidence of an increase in vaccinations for children living further from a health facility in 2001 (27 pp*).

Evidence of an increase in the Height-for-Age Z score for children under 5 (0.17 pp**) Evidence of a decrease in the proportion of children under age 5 who are stunted ( 5.3*), and who are underweight ( 6.0**) No evidence of a change in the proportion of children under age 5 who are stunted ( 5.3*), and who are wasted ( 0.4).

No evidence of a change in the proportion of children 6-to-59 months with anemia ( 0.2) or in their level of Hemoglobin ( 0.1).

(continued on next page)

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Table 2 (continued) Country, programme name and reference Panama Red de Oportunidades (Arraiz and Rozo, 2010) Impact on uptake of health care services Evidence of an increase in the proportion of women aged more than15 year old who took a cervical cancer screening test in rural areas (11.7 pp). Evidence of an increase in the proportion of women who were pregnant (3.2 pp) Evidence of an increase in the proportion of women aged more than15 year old who took a cervical cancer screening test in indigenous areas (14.7 pp) n/a Impact on immunisation coverage n/a Impact on nutritional and health outcomes n/a Impact on health-related behaviour change n/a

Tanzania RESPECT (Rewarding STD Prevention and Control in Tanzania) (World Bank, 2010)

n/a

n/a

Evidence of a decrease in the proportion of individuals tested positive for STDs ( 3 pp)

Notes: pp means percentage points; n/a not applicable; *** Signicant at the 0.1% level, ** Signicant at the 1% level, * Signicant at the 5% level.

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lower prevalence of obesity and hypertension amongst adults (Fernald et al., 2008b). Oportunidades also led to a large decline in rural infant mortality (Barham, 2011) and ve and a half years from programme inception, the doubling of cash transfers was associated with increased growth of children, lower prevalence of stunting and of being overweight (Fernald et al., 2008a). In Nicaragua, the programme was found to have signicantly reduced the proportion of under-weight and stunted children amongst the beneciaries (Maluccio and Flores, 2004). The potential positive effects of CCTs on anaemia are more subject to debate. The positive effects found for the Mexican programme (Rivera et al., 2004) might have been biased due to leakage issues and non-randomization in the allocation of the nutrition supplements, which could have contributed to underestimating the true effects of Progresa (Gertler, 2004). On the other hand, the Nicaraguan intervention showed no impact on anaemia prevalence among infants. (Maluccio and Flores, 2004). In addition, two programmes demonstrated some positive effects on children's health, such as reducing the magnitude of stunting (net average improvement of the height-for-age score by 0.17) and reducing the proportion of underweight children aged 0 to 5 years old (a net impact of 6 percentage points after 2 years) as reported by their mothers (Attanasio et al., 2005; Gertler, 2004). Finally, there was a negative impact on weight-for-age scores for children under 7 in the Brazilian programme Bolsa Alimentao. This was probably due to a misunderstanding of the eligibility criteria for the programme by participating mothers (Morris et al., 2004b) who were under the impression that having one malnourished child in the household was a condition to remain eligible. Health related behaviour change Two studies were identied that measured the impact of CCTs on health behaviour change. A trial in Malawi found no evidence that CCTs had an impact on HIV status or on reported sexual behaviour. 3 However, men who received the cash transfer were more likely and women were less likely to engage in risky sex (unprotected sex or a larger number of partners) (Kohler and Thornton, in press). By contrast, the RESPECT study in Tanzania recorded a 25-percent drop in the incidence of STDs (World Bank, 2010). After one year, 9% of individuals in the treatment group were positive for one of the STDs, compared to 12% in the control group. Discussion One of the strengths of the literature on CCTs is the relative abundance of rigorous research on the impact of large-scale programmes, which have been implemented in different countries. This broad and reasonably robust body of evidence suggests that CCTs are powerful instruments to improve health outcomes and to increase the uptake of health services including immunisation coverage in low and middle-income countries. On the other hand, while these programmes share common approaches, the devil is in the details and they have many important design differences, which is evident from Table 1. In addition, more evidence is still needed to determine whether CCTs can be effective interventions to change health related behaviours, such as risky sexual behaviours. Not only are these programmes more recent, but they also have a slightly different focus, targeting behavioural mechanisms that are undoubtedly of a different nature than the ones targeted by the original CCT programmes. Despite the evidence accumulated over the past decade or so generally supporting the effectiveness impact of CCTs, several questions
3 Reported sexual behaviour includes being pregnant (among women), having any vaginal sex (during the nine days of writing in the sexual diary), number of days having vaginal sex, whether or not the respondent used a condom during the week (conditional on having sex), and if condoms were present at home.

remain regarding their impact. Considering the complexity of the original CCT programmes in some instances and with the available body of evidence until now, it is virtually impossible to disentangle the effects of the different components of the programme. For example, in the case of the original Latin American programmes, health status is likely to have been improved by nutritional supplements provided to children, better diet resulting from increased revenue of households or the benets of mothers attending health education meetings. More work is required to investigate the causal mechanisms that can explain how CCTs work (Gaarder et al., 2010). Equally, several CCT programmes were implemented alongside support programmes improving quality of care (see Table 1), which are likely to have contributed to an increase in the demand of services by the population. Moreover, the question of whether cash transfers should be conditional upon certain requirements is still heavily debated (de Brauw and Hoddinott, in press). In the contingency management literature, there is strong evidence supporting the need for the conditionality to achieve behavioural change amongst drug addicts (Lussier et al., 2006). However, in the context of large-scale CCT programmes typically implemented in low-income countries, the same evidence is missing. A randomised intervention for keeping young girls in school in Malawi showed the rst experimental evidence on the lack of effectiveness of the conditionality (Baird et al., 2009). The randomised trial featured three arms, one where payment was conditional, the other arm where the payment was unconditional and the control group. Whilst the programme reduced the school dropout rate by more than 40%, it did not show a higher impact in the conditional treatment group (Baird et al., 2010). This questions the rationale for conditioning the cash transfer, in particular if it comes with high administrative costs, associated with the monitoring and enforcement of the conditionality (Calds and Maluccio, 2005), particularly in low-resource settings where monitoring might be very difcult (Schubert and Slater, 2006). On the other hand, proponents of CCTs have argued that the conditionalities guarantee the existence of positive externalities or benets to the entire society that would not be otherwise obtained, if it was left to individual decisions. Typically, girls' education or vaccinations provide broader societal benets that can never be taken into account by individuals themselves (Fiszbein and Schady, 2009). Finally, conditioning cash transfers has been argued to increase the credibility and political support for such programmes, as they provide some guarantee that at least desirable outcomes will be achieved (Farrington and Slater, 2006). In that respect, they address the fear that cash transfers can be a waste of public money if they are spent by beneciaries on undesired goods. If evidence on the positive impact of CCTs can be judged as being robust, evidence on the cost-effectiveness of CCTs is still absent. Yet, CCTs carry a proportion of administrative costs that constitute an important part of the programme budget, as monitoring conditionalities can be quite costly (Calds and Maluccio, 2005). For example, in Nicaragua, administrative costs of the CCT represented half of the cash transfer (Calds and Maluccio, 2005). To echo the critiques voiced against CCTs, their cost-effectiveness remains to be tested against at least three types of interventions. First, as discussed above, the relative cost-effectiveness of conditional vs. unconditional cash transfers urgently needs to be explored. Second, research that explores the relative cost-effectiveness of CCTs versus investing in the supply side is crucial. Many argue that scarce resources should be used to strengthen the supply side of services (e.g. building better clinics, addressing staff shortages), in particular as it represents a necessary preliminary prerequisite to meet the increased demand created by CCTs (Fiszbein and Schady, 2009). Third, it is essential to know whether CCTs are more cost-effective than other traditional (and less trendy) interventions that can improve the uptake of health services or change healthrelated behaviours. In some countries, increasing the coverage of health infrastructures and/or strengthening the health system is

Please cite this article as: Ranganathan, M., Lagarde, M., Promoting healthy behaviours and improving health outcomes in low and middle income countries: A review of the impact of condition..., Prev. Med. (2012), doi:10.1016/j.ypmed.2011.11.015

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likely to increase access to health care services. Similarly, prevention campaigns aiming at raising awareness about STDs and changing behaviours, might not have such dramatic effects in the short-run than a CCT programme, but the relative cost-effectiveness of the latter in the long-run is not proven either. Finally, when CCTs have not targeted the poorest, like in the Nepali national programme, there has been evidence suggesting that better-off groups have beneted from the programmes disproportionally (Powell-Jackson et al., 2009b). In the absence of targeting, this is not a surprising effect, since better-off patients usually use services more, and therefore are the rst ones to benet from the CCTs. This is a classic equity problem of programmes seeking to achieve a universal coverage (Gwatkin and Ergo, 2011). In the case of CCTs, it further raises the issue of their cost-effectiveness, as the marginal cost per additional poor user may be extremely high, a lot of resources being rst spent on wealthier groups before the most disadvantaged can be convinced. Furthermore, whilst they benet from a lot of attention and positive publicity, some important factors need to be taken into account when judging the desirability or feasibility of implementing CCTs in low-income settings. In particular, a lot of attention should be given to supply-side factors or the broader environment in which they are introduced. Indeed, CCTs require adequate monitoring, targeting and follow-up, which require reliable information systems and infrastructure in place, as well as sufcient human technical capacity. The early CCT programmes for which evidence of impact is the most robust and positive have been implemented in middle-income countries. Their implementation in these settings typically relied on the existence of adequate infrastructure (banks, roads and health facility network) and information systems that have undoubtedly contributed to their success. In particular, the availability of reliable information on individuals' assets has allowed decision-makers to target beneciaries without too much leakage. Decision-makers should bear in mind that the absence of similar infrastructure might mitigate the success of CCTs. In Nepal there is evidence suggesting that failure to provide basic support measures, in the form of good quality care and referral transportation, is likely to have compromised the success of CCTs to incentivise women to give birth in health care facilities (Powell-Jackson et al., 2009a). Moreover, CCT programmes are complex interventions whose design and implementation require substantial human and technical capacity, which might not be adequate in some settings. Evidence from the Nepal and Jamaica (Levy and Ohls, 2007; Powell-Jackson et al., 2009a) shows that lack of communication around the CCTs, failure to provide clear guidelines to health workers, and nancial mismanagement resulting in payment delays can jeopardise their success. Finally, public debate on the ethical aspects of such schemes should also be encouraged, particularly where they are designed to incentivise procedures that may be irreversible (e.g. sterilising procedures) or may have unintended adverse consequences, such as depicted by Stecklov et al. (2007). In addition, incentive programmes that address risky behaviours can potentially be quite controversial. Critics have underlined that their design exacerbates the stigma associated with STDs, when individuals who become infected suffer from the additional penalty of losing the cash transfer (Harman, 2010). Such programmes can also represent potential threats to traditional prevention programmes, as they could directly undermine the idea of personal responsibility. Critics of CCTs argue that conditionality associated with a cash transfer might be viewed as being paternalistic or undermining people's autonomy as they are being told what to do, as opposed to letting them freely decide which actions are best for them (Fiszbein and Schady, 2009). Finally, while supporters claim that CCTs can introduce virtuous circles and change behaviours in the long run, this remains to be proved. Until it is, the question of the sustainability of such prevention programmes is fundamental. Lastly, perverse incentives need to be considered when designing programmes, as there could be unintended consequences. For

example, some authors have suggested that CCTs might have resulted in an increase in fertility of 2 to 4 percentage points in Honduras because only pregnant women were eligible for the subsidy (Stecklov et al., 2007). A similar undesired association between CCTs and fertility was found in Panama although this result was not robust to all analyses (Arraiz and Rozo, 2010). Conclusion As one of the most evaluated social interventions for the poor, there is enough rigorous evidence suggesting that CCTs are a valuable tool at the disposal of policy-makers in low- and middle incomes countries to tackle certain health issues. These programmes, often implemented on a very large scale and rigorously evaluated, have been found particularly successful at decreasing barriers to access for poorest populations, and incentivising them to increase the use of health services. Recently, they have been introduced as a new strategy in Sub-Saharan Africa to address risky sexual behaviours, with early promising results resulting in a lot of media buzz at the Vienna HIV/AIDS conference in 2010 (Dugger, 2010; Jack, 2010; Over, 2010). However, it would not be reasonable to consider CCTs as silver bullets for promoting healthy behaviours and improving health outcomes in low- and middle-income countries. They can address demand-side obstacles, and will often need to be implemented in combination with supply-side interventions to maximise their effects. Besides, there is still scope for more research to understand how they work and whether they constitute sustainable and cost-effective interventions compared to standard interventions. As they have acted as a catalyst for rigorous impact evaluations of complex nation-wide programmes, one can be optimistic about the fact that funders and decision-makers involved in the future design of CCTs will support this programme of work.
Conict of interest The authors declare there is no conict of interest.

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