The Health Impacts of Community-Based Conditional Cash Transfers: .

Evidence from Tanzania

David EvansWorld BankJoint work with Brian Holtemeyer and Katrina Kosec (IFPRI)July 9, 2015

Cash transfers have expanded

dramatically around the world!

1997

Source: Fiszbein et al 2009

2008

Source: Fiszbein et al 2009

2010

Source: Garcia & Moore 2012

Countries in which CT programs have been implemented (35)

Countries in which CT programs have been discussed, planned, or implemented (39)

… and so has evidence

surrounding their impacts!

Studies of impact of cash transfers as of 2013

Education Health & Nutrition Consumption0

20

40

60

80

100

120

140

160

0 0 0

1999

Education Health & Nutrition Consumption0

20

40

60

80

100

120

140

160

113 2

2001

Education Health & Nutrition Consumption0

20

40

60

80

100

120

140

160

163 5

2003

Education Health & Nutrition Consumption0

20

40

60

80

100

120

140

160

38

9 10

2005

Education Health & Nutrition Consumption0

20

40

60

80

100

120

140

160

54

15 18

2007

Education Health & Nutrition Consumption0

20

40

60

80

100

120

140

160

94

2329

2009

Education Health & Nutrition Consumption0

20

40

60

80

100

120

140

160

122

3240

2011

Education Health & Nutrition Consumption0

20

40

60

80

100

120

140

160142

41 45

Source: Andrews et al (forthcoming)

To date, limited evidence base

(a) from Africa, conditioning on health

(b) relying on local communities to run program / deliver payments

Operational experience and contextual expertiseInternational expertise on cash transfers and on impact evaluation

Initial funding for the program & evaluation

What it looked like

How big was it?

≈≈

Where was it?

What households received (in 2010)

per child (US$3) per month

per adult (US$6) per month

on average

What households had to do (in 2010)

Education HealthChildren (age 0-5)

Visit clinic 6x per year

Children (age 7-15)

Be enrolled with 80% attendance

Elderly Visit clinic 1x per year

Who did what

Identification of the poor…by communities

Distribution of payments…by communities

Monitoring of conditions…by communities

Summary of Findings Initial (after 18 mos.) positive impacts on health clinic

visits disappeared by 2.5 years

Health benefits take 2.5 years to materialize (not present at 18 mos.), and are mostly driven by young children aged 0‐5 (not elderly)

Large increase in use of health insurance

Shift toward using publicly‐provided healthcare

Initial (after 18 mos.) increase in satisfaction with healthcare disappeared by 2.5 years (habituation)

No increase in objective healthcare quality

How we evaluated it

3 provinces selected to pilot

Initial Treatment Initial Comparison

80 eligible villages

but only cash for 40

Treatment

2 years laterwith additional

funding

randomization

Randomizing led to balance on observable characteristics

Piped

water

Impro

ved r

oof

Litera

te ho

useho

ld he

ad

Child e

ver in

scho

ol

% hh sic

k in p

ast m

onth

0%

20%

40%

60%

80%

Treatment Comparison

When it happened

How difference-in-differences works

Time

Outc

om

e

Baseline Endline

Roll

out

prog

ram

TreatmentComparison Diff at

baseline

Diff at endline

Difference at endline - Difference at baseline Impact of program

Difference-in-differences Specification

i indexes individuals (or households, for household-level outcomes)

t indexes the survey round hit is a health outcome αi are individual fixed effects Ti=1 in CCT treatment group (zero otherwise) 2011t=1 at time of midline survey (18-21 months of

transfers) 2012t=1 at time of endline survey (31-34 months of

transfers)

Two sub-samples among our poor HHs Carried out a principal components analysis

(PCA) using dummy variables for ownership of 13 HH assets

Took the first principal component as our index of HH wealth

Households with above-median wealth: “moderately poor”

Households with below-median wealth: “extremely poor”

What were the impacts of the program on health and health-related outcomes for the poor?

Outcome: Health clinic visits in the last 12 months

Outcome: Illness & injury in last 4 weeks

Outcome: Participation in government-run health insurance program

Outcome: Use of public facilities

Private

Outcome: Satisfaction with health facilities

Outcome: Objective facility quality

Multiple Hypothesis Testing Use three methods to correct Median significant results after

correctionOutcome area # significant

results (90%)# significant results (corrected)

Health clinic visits 5 5Illness or injury 8 3Health insurance 6 6Type of health provider

14 6

Satisfaction 2 2

Conclusions

Conditional cash transfers effectively increase health for children

Initial increase in clinic visits (conditions)

Major increase in health insurance take-up (not conditioned)

Beware of satisfaction measures: Effects may disappear

Asanteni sana!