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cash transfers

Cash transfers and health: It matters when you measure, and it matters how many health care workers are around to provide services

David Evans's picture

This post was co-authored with Katrina Kosec of IFPRI.

A whirlwind, surely incomplete tour of cash transfer impacts on health
Your run-of-the-mill conditional cash transfer (CCT) program has significant impacts on health-seeking behavior. Specifically, there are conditions (or co-responsibilities, if you prefer) that children get to school and/or that they get vaccinated or have some wellness visits. While the school enrollment effects are well established, the effects on both health seeking behavior and on health outcomes have been much more mixed. CCTs have led to better child nutritional status and improved child cognitive development in Nicaragua, better nutritional outcomes for a subset of children in Colombia, and had no impacts for child health in studies on Brazil and Honduras. CCTs conditioned only on school enrollment did not lower HIV infections among adolescent girls in South Africa; and in Indonesia CCTs increased health visits but did not translate into measurably improved health. Unconditional cash transfer programs have also had mixed results on health, with better mental health and food consumption in Kenya, better anthropometric outcomes for girls (not boys) in South Africa, no average impacts (although some for the poorest quarter) on child outcomes in Ecuador, and no average impacts on maternal health care utilization in Zambia (albeit yes effects for women with better access to such services).

CCTs for Pees: Cash Transfers Halloween Edition

Berk Ozler's picture

Subsidies to increase utilization are used in all sorts of fields and I have read more than my fair share of CCT papers. However, until last week, I had not come across a scheme that paid people to purchase their urine. Given that I am traveling and the fact that I am missing Halloween, I thought I’d share (I hope it’s not TMI)…
Here is the abstract of an article by Tilley and Günther (2016), published in Sustainability:
In the developing world, having access to a toilet does not necessarily imply use: infrequent or non-use limits the desired health outcomes of improved sanitation. We examine the sanitation situation in a rural part of South Africa where recipients of novel, waterless “urine-diverting dry toilets” are not regularly using them. In order to determine if small, conditional cash transfers (CCT) could motivate families to use their toilets more, we paid for urine via different incentive-based interventions: two were based on volumetric pricing and the third was a flat-rate payment (irrespective of volume). A flat-rate payment (approx. €1) resulted in the highest rates of regular (weekly) participation at 59%. The low volumetric payment (approx. €0.05/L) led to regular participation rates of only 12% and no increase in toilet use. The high volumetric payment (approx. €0.1/L) resulted in lower rates of regular participation (35%), but increased the average urine production per household per day by 74%. As a first example of conditional cash transfers being used in the sanitation sector, we show that they are an accepted and effective tool for increasing toilet use, while putting small cash payments in the hands of poor, largely unemployed populations in rural South Africa.”
 

Did Peru’s CCT program halve its stunting rate?

Berk Ozler's picture

On September 30, the Guardian ran several articles (see here, here, and an editorial here) linking the halving of Peru’s stunting rate (from 28 to 14% between mid-2000s and 2015) to its CCT program Juntos. Of course, it is great to hear that the share of stunted children in Peru declined dramatically over a short period. However, as I know that while CCT programs (conditional or not) have been successful in improving various outcomes including child health, the effect sizes are never this dramatic, I was curious to see whether the decline was part of a secular trend in Peru or actually could be attributed primarily to Juntos

Weekly wire: The global forum

Roxanne Bauer's picture

World of NewsThese are some of the views and reports relevant to our readers that caught our attention this week.

Gasoline, Guns, and Giveaways: Is the End of Three-Quarters of Global Poverty Closer than You Think?
Center for Global Development

Amartya Sen’s famous study of famines found that a nation’s people died not because of a food shortage but because some people lacked entitlements to that food. In a new CGD working paper with Chris Hoy, we ask if a similar situation is now the case for global poverty: are national resources available but not being used to end poverty?  The short answer is yes (but don’t stop reading…). We find that approximately three-quarters of global poverty, at the extreme poverty line of $1.90 per day, if not higher poverty lines, could now be eliminated—in principle—via redistribution of nationally available resources.

People-Powered Media Innovation in West Africa
Omidyar

As media ecosystems in West Africa are increasingly diversifying and opening up after decades of state control, innovative and independent journalism is advancing government transparency and accountability. New opportunities for funders are opening in tandem, with potential for both social and economic impact. This report explores several of these opportunities, surfaced through in-depth research on Nigeria and Ghana. While both countries lead the region in terms of both economic and media development, they operate under many of the same dynamics and constraints that exist across West Africa, and show how other markets may evolve, politically and commercially.
 

Weekly wire: The global forum

Roxanne Bauer's picture

World of NewsThese are some of the views and reports relevant to our readers that caught our attention this week.

Unlocking access to utility services: The transformational value of mobile
GSMA
The Mobile for Development Utilities Annual Report highlights the transformational role of mobile in improving the delivery of essential services to the underserved, and the increasing viability of the business models currently being implemented. The report covers three areas: emerging trends, MNO collaboration and funding in the mobile-enabled utility sector.

Compulsory voting results in more evenly distributed political knowledge
LSE Blog

Given interminably low rates of voter turnout across most Western democracies, looking to compulsory voting as a panacea for democracy’s ills seems sensible. Comparatively low – or declining – voter turnout is viewed generally as a symptom of civic disengagement from politics. Compulsory voting can also mitigate inequality in participation and representation. Citizens with the most resources and influence are typically the most likely to vote, and by voting for candidates and parties who reflect their interests, their participation can perpetuate systemic social biases.

There is enough evidence on humanitarian cash transfers. Or perhaps not?

Ugo Gentilini's picture

Take these two numbers: 165 and 1. The former is the number of children in millions who are chronically malnourished or ‘stunted’; the latter is the number of robust impact evaluations comparing cash and in-kind transfers on malnutrition.
 
I emphasize ‘comparing’ since there is plenty of evidence on individual cash and in-kind (and voucher) programs, but very few studies deliberately assessing them under the same context, design parameters, and evaluation framework.

GiveDirectly just announced a basic income grant experiment. Here is how to make it better.

Berk Ozler's picture

In an article in Slate yesterday, co-founders of GiveDirectly announced that they will provide at least 6,000 people in Kenya with a basic income grant (BIG) for a period of 10-15 years, which will cost about $30 million. The proposal is scant in details at the moment, but this article in Vox suggests that dozens of villages will randomly be selected in an already selected region of Kenya for this exercise and everyone within will be given roughly a dollar a day per person for a decade.

Just give them the money: Why are cash transfers only 6% of humanitarian aid?

Duncan Green's picture

Paul Harvey, ODIGuest post from ODI’s Paul Harvey

Giving people cash in emergencies makes sense and more of it is starting to happen.  A recent high level panel report found that cash should radically disrupt the humanitarian system and that it’s use should grow dramatically from the current guesstimate of 6% of humanitarian spend.  And the Secretary General’s report for the World Humanitarian Summit calls for using ‘cash-based programming as the preferred and default method of support’.

European Commission’s Humanitarian aid and Civil Protection department (ECHO) finances basic services for 100,000 Eritrean refugees in EthiopiaBut 6% is much less than it should be. Given the strong case for cash transfers, what’s the hold-up in getting to 30%, 50% or even 70%? The hold-up isn’t the strength of the evidence, which is increasingly clear and compelling. Cash transfers are among the most rigorously evaluated and researched humanitarian tools of the last decade. In most contexts, humanitarian cash transfers can be provided to people safely, efficiently and accountably. People spend cash sensibly: they are not likely to spend it anti-socially (for example, on alcohol) and cash is no more prone to diversion than in-kind assistance. Local markets from Somalia to the Philippines have responded to cash injections without causing inflation (a concern often raised by cash transfer sceptics). Cash supports livelihoods by enabling investment and builds markets through increasing demand for goods and services. And with the growth of digital payments systems, cash can be delivered in increasingly affordable, secure and transparent ways.

People usually prefer receiving cash because it gives them greater choice and control over how best to meet their own needs, and a greater sense of dignity. And if people receive in-kind aid that doesn’t reflect their priorities they often have to sell it to buy what they really need as, for example, 70% of Syrian refugees in Iraq have done. The difference in what they can sell food or other goods for and what it costs to provide is a pure waste of limited resources. Unsurprisingly people are better than aid agencies at deciding what they most need.

Will cash replace staff?

Suvojit Chattopadhyay's picture

Consultation workshop in Jessore, BangladeshShould field staff in implementing organisations be made redundant? Do communities not need technical guidance and hand-holding? They also perhaps do not need support from external resource persons in solving collective action problems.

As a corollary to the push for ‘cash transfers’, the role of development workers has come under scrutiny. Last year, evidence from a couple of projects made this point quite strongly.

First, Chris Blattman, who based his argument on a review of the ultra-poor evaluations as well as his own research on ‘cash plus training’ intervention in Uganda:

The biggest expense across all the programs was staff time. Especially for supervision. Delivering training and cows takes skilled labor, and it’s hard to cut this back. But supervision? … should it cost 50 or 60 percent of the program? Is it more valuable than the cow or the grant itself? It’s hard to believe.

We tried to test this with cash-plus program in Uganda. Supervising the women cost about $377, about half the cost of the program and 2.5 times as much as the grant itself…

…and found that the supervision helped the women maintain the new businesses they started, but there was virtually no effect on consumption. We have no idea whether the supervision helps another year down the road. Maybe, eventually, it pays for itself. But the simple fact is this: taking away the most expensive part of the program had little effect on benefits after a whole year.

And Howard White made a similar point, reflecting on the evidence from Community Driven Development (CDD) projects:

In many CDD projects, the decision-making and application process is facilitated by outsiders. A chunk of project resources are used not for funding things communities want, but paying NGOs to train communities in how to hold meetings and help communities decide on what they want.

Now, facilitation may be useful. It can help ensure that the voices of the marginalised are heard, that poorer communities without the skills and connections get to apply and develop skills in project management. But I do wonder if communities that already have community-level decision-making bodies need outsiders to help them hold meetings and to decide their priority needs.

On one hand, Chris is saying supervision and monitoring isn’t worth the money, and on the other, Howard is saying the same might not even be good development strategy.


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