I have a background in both development studies and public health. Through the former I’ve become fascinated by direct cash transfer programmes. Recently a friend asked me what public health research and professionals had to say about them. Little, it turned out after having a quick look. But I did find a WHO document from 2011 that addressed this issue. It asked why there was so little interest in cash-transfers from public health professionals, reviewed evidence for health effects of cash-transfer programmes, and made recommendations on what public health pros should be doing about it.
I became interested in cash transfers from working in NGOs. I used to ask myself: “Is this organisation adding more value to the beneficiary than just putting the cash in their hands?” The answer was usually, “no.” But I hadn’t yet heard about programmes that took the obvious next step.
What are cash transfers?
Cash transfers is a general term for any social assistance programme that gives money directly to beneficiaries rather than giving in kind or providing services or infrastructure. This can include old-age pensions, child grants, disability grants, unemployment assistance, and general basic income supplementation. While some, such as pensions, are well-accepted throughout much of the world, others such as unemployment assistance and basic income grants, are controversial.
Supporters argue that the poor know what they need most, that cash enables dignity and autonomy not afforded by traditional social programmes, that it alleviates the stresses of poverty allowing longer-term decision making (such as planting riskier but more profitable crops), and that cash has a knock-on stimulating effect by increasing the cashflow in the community–rather than diverting donor funds into the pockets of aid professionals. Universal basic income schemes are argued to cost less to administer than other kinds of grants.
But others feel that subsistence grants would discourage people from seeking employment. And many feel that the poor would not use the income in their best interests. They often suggest that the poor would spend the extra cash on substance-abuse.
The need to answer these concerns has made direct cash transfer programmes–particularly those around basic income supplementation–some of the best researched social programmes.
Do they spoil people?
A Save the Children review of 16 programmes showed that transfers did not discourage people from looking for work. Our own South African pensions system increased job-seeking as adults were able to look for work while children grand-parents looked after kids. In Maharashtra, farmers planted riskier, higher yield crops to reap greater profits. And grants have been found to allow people to be able to access credit to unlock economic opportunities.
Reviews have shown no meaningful increase in alcohol and tobacco use.
Conditional cash transfer programmes saw Mexico spend 11% and Brazil 15% more on food. Other programmes had similar results. Other studies showed that those on grants were buying food of higher quality. Even when exposed to economic shocks–such as a decline in coffee prices in Nicaragua–those receiving grants were less affected. All programmes increased school enrolment, but didn’t seem to cause those who had left to return (and conditional transfer schemes–in which receiving the grant came with certain conditions such as attending antenatal visits or keeping children in schools–were much more successful at keeping them there). Programmes generally found that participants used the health services more, especially for prenatal and infant preventive check-ups.
There is also some evidence that cash transfer programmes improved child care, and that the policy of giving to women increased equality in decision making between women and men in households.
Cash transfers and health
But if income supplementation isn’t doing harm, and is improving upstream factors that affect health, what is the effect on health indicators? Mexico’s Progresa programme saw an 11% decline in maternal mortality and a 2% decline in infant mortality. Several programmes showed large reductions (16%-27%) in reported illness and diarrhoeal disease for all age-groups except teenagers–who were assumed to be healthy irrespective of participation. A programme in Malawi found a 60% risk reduction of contracting HIV among girls–possibly from later marriage, less transactional sex, staying in school, and better nutrition. The evidence for reduction of childhood anaemia is equivocal. But 12-36 month-old children grew an extra 1cm per year in Mexico, South Africa’s child grant increased adult heights of beneficiaries by a mean 3.5cm, and Namibia’s prevalence of underweight children dropped from 47% to 11%. But these effects were not seen in every setting–although recipients always at least matched controls. A more recent Kenyan study reported that cash-transfers slashed beatings of women in the household (73%-82%) and rape (78%).
The strong effect on poverty and inequality reduction in Latin America suggests that even more health benefits may follow in the long term.
I don’t want to get bogged down in the technicalities of conditional vs. unconditional grants (both have their merits, and a combination is likely most effective), or approaches to targeting (except to say that ensuring that money gets to the poor can be expensive and divisive if not well considered). Let’s ask ourselves, if cash transfers seem to have beneficial effects on health, why has the public health community been so little involved? And how should we be involved?
Public health pros and cash transfers
The report suggests that we might see conditional transfers as bribing poor people to behave in more healthy ways. Or that we dismiss them as being poverty reduction with nothing to do with us. Or that we think that an intervention that throws cash at the problem sounds too simple to have any effect, and is outside the framework of the complex programmes with which we’re used to working.
But the days of ignoring the social determinants of health are dying. Evidence suggests that reducing the most extreme poverty with cash-transfers has a range of positive health effects. These benefits take place at the primary, preventive level. We don’t need to take over these programmes, but we have particular skills relevant to getting the best out of cash-transfer programmes in combination with welfare departments. We can caution that cash-transfer programmes are important, but not enough for health–which also needs good facilities and standalone programmes. And we can have an impact on the very real ethical issues by advocating a nuanced consideration of the effect of cash-transfer programmes on the poor, and advocating roll-out and long term sustainability if they are tied to political brands.
The WHO report concludes that public health bodies should be taking cash-transfers seriously as an instrument for improving public health, that we should be building collaborations across departments to support these programmes, and we should be offering our technical help in designing the programmes, strengthening the supporting health services, asking the hard questions about the ethics and fairness of targeting and conditions under which cash is handed out, and evaluating the health effects of these programmes.