Conditional cash transfers and the creation of equal opportunities of health for children in low and middle-income countries: a literature review

Conditional cash transfers (CCTs) are regular money transfers to poor households given under conditions related to the use of health services, the uptake of food and nutritional supplementation, the enrollment and attendance of children and adolescents in school [1]. CCTs were initially implemented in Mexico, Brazil and Bangladesh in the 1990s, but they have been largely used in the world during the past decades, including programs initiated in more advanced economies such as the US [2].

Their success is based on the assumption that they are able to enhance children’s human development [3] through improvements of health and schooling of poor and vulnerable children, contributing to breaking the intergenerational poverty cycle [4] and social inclusion of the deprived groups [5]. In other words, CCTs seek to create life chances for children to overcome poverty and exclusion, thus reducing inequality of opportunity.

An integrative literature review was conducted with the purpose to comprehend if CCTs create equality of opportunity in health for children. Differently from other types of reviews, this method discusses and summarizes a particular topic, contributing to theory development and influencing practice and policymaking [17] An integrative research review was conducted because a meta-analysis was not feasible due to the heterogeneity of the studies.

The literature search resulted in 1443 papers, including empirical and theoretical studies. During the second phase of the literature selection process, 114 articles were fully screened, and 17 articles were selected for analysis after applying the inclusion and exclusion criteria (Fig. 1). The majority of selected articles focused on CCTs programs located in Latin America (n = 13) following studies about CCTs based in Asia (n = 3) and Africa (n = 1) (Table 1). Moreover, the majority of the articles were delineated as quasi-experimental and experimental study designs (n = 8) and six papers were classified as observational studies. There were also studies that used a mixed ecological design, combining an ecological multiple-group design with a time-trend design (n = 3) (Table 1).

The articles presented studies of five CCT initiatives. Eighty two percent of the articles presented CCTs programs (n = 14) focused in alleviating household immediate poverty and in improving children’s health or/and schooling status by transferring cash to participants under the condition of children’s school attendance, health visits and, in some cases, the attendance of health education talks (Table 2). The remaining articles (n = 3) were based on the Janani Suraksha Yojana program, a CCT designed to prevent maternal and neonatal mortality by providing cash to vulnerable women at the time of delivery (Table 2).

Although the majority of the studies reported poverty as the main children’s vulnerability for participating in a CCT program (n = 16), it was possible to identify other SDHs in the households of the beneficiaries, impacting the conditions in which their children are born, grow, work, live and age [10].

Households that were CCT beneficiaries were associated with lower educational level for one or both parents or the head of household (n = 5). CCT participants were also likely to live in an underprivileged location (n = 5), such as rural areas and minority groups regions. Gender issues (n = 1) were also associated with participants, including the existence of more female-headed households. Other SDHs of the participants were related to age (elderly-headed households, older women and child-headed households), race and ethnicity, coping with people with illness and disabilities and having or being an orphan in the household (Table 1).

The effects of CCTs on children’s health outcomes under the cited SDH were mostly positive. Studies that used immunization rates or vaccination coverage reported that CCT programs “led to a significant increase in childhood immunization rates” especially in high-priority locations (most vulnerable) in India [20] and the vaccination coverage increased more than 95% in Nicaragua for “children who live further away from a health facility or whose mothers are less educated” [21]. In Africa, the CCT arm of the randomized trial of a cash transfer program in Zimbabwe also showed an increase in up-to-date vaccination for children under 5 years old [22]. Improvements in child morbidity were also reported in Mexico where the incidence of diarrhea and acute respiratory infections has been reduced because of the participation in the CCT [23]. In the case of diarrhoeal diseases, the program had a significant positive effect among children in the most deprived households [23].

Nevertheless, the effects of CCTs were mixed for the child mortality indicators and biochemical or biometric health outcomes. Many of the CCTs in the present study reported reduction of infant, perinatal and postnatal mortality [24‐27]. In Mexico, for example, larger reductions in neonatal and infant mortality were among groups with higher illiteracy rates and reduced access to electricity [24]. Studies concerning CCTs in India had conflicting results for the same indicators [20, 28]. The main explanation for this may be the difference in study designs and methods of these papers [20].

Biochemical or biometric health outcomes had also shown opposite results. In the case of Bolsa Familia, children enrolled in the program were more likely to have normal height-for-age and weight-for-age z-scores than non-beneficiaries, being both groups from impoverished areas [29]. Nonetheless, two other assessments of nutritional outcomes for children under 5 years old showed that no significant differences were found for underweight and stunting between children participants and non- participants of this CCT program [30]. These indicators were also not different from the child population of Brazil [31]. In both studies, authors prompted for more actions in health education in order to enhance population awareness of better food and nutrition practices.

The present integrative review was conducted in order to investigate if CCT programs create equality of opportunity in health for children under 5 years old. This particular life stage was chosen because it is critical for human development [13], which is the main purpose of traditional CCT programs. In order to identify the creation of equality of opportunity in health the present study applied Roemer’s conceptual framework of equality of opportunity and its capacity to mitigate the effects of unfair inequalities on health outcomes [6].

Although the selected studies applied a myriad of approaches and broad definitions for SDH, the literature review identified some trends in the creation of equality of opportunity in health for children by CCTs. First, we identified that CCTs created health opportunities for children because there were improvements in the health status of children with a vulnerable SDH. Nevertheless, creation of equality of opportunity in health for children was more reliable in quasi-experimental and experimental studies, considering that these study designs are more able to reduce causality bias.

In addition to this, it should be noticed that differences in the implementation phase, features and contexts of CCT programs could have affected the study outcomes. For example, Bolsa Familia, the Brazilian CCT, does not have health education lectures’ attendance as a condition for the participants receiving the cash transfer, even though these activities are seen as an important tool for the adoption of healthier behavioral practices [32]. On the other hand, Brazil has a large school feeding program in public schools that could complement the potential CCT effects on health and nutrition.

Income transfers alone or the use of conditional mechanisms to improve health may not be able to mitigate health inequalities in the presence of poor access to health services. Therefore investment in the supply-side of health services in the geographic locations targeted by the CCTs would improve health outcomes [33].

In addition, it should also be noticed that CCTs were mainly created for poverty reduction and development. Since many of the vulnerable groups are negatively affected by health inequities, the lack of access to financial resources could limit improvements in health status [33].

From a SHD perspective, income transfer alone is insufficient to mitigate unfair health inequalities because there is also a need to empower the most vulnerable and marginalized groups [34]. Although there is evidence of women empowerment through the participation of CCTs [35] and important advances in social inclusion [5], CCTs could inhibit social participation since the large-scale programs operate with a top-bottom approach in which governments dictate the eligible criteria and cash transfer conditions without any participation of the targeted population. Therefore, hierarchy powers in the case of CCTs could undermine the control that individuals and communities have over their lives [36].

CCTs seek to create life chances for children to overcome poverty and exclusion, thus reducing inequality of opportunity. We identified that CCTs created health opportunities for children, even though there was a variety of study design and methods that made it a challenge to compare study results.

The creation of health opportunities for children by the CCTs could have positively impacted health inequalities, but these results are reduced in face of poor health services and limited social participation of beneficiaries in the decisions regarding the implementation and conditions of the program.

Moreover, we noticed that there is a lack of methodological research focused in describing the mechanisms of how this equality of opportunity functions, especially in health. Our study tried to fulfill this gap by suggesting a definition for the creation of equality of opportunity in health based on the case of CCTs. In depth theoretical studies regarding this concepts are important to improve the construction of a framework to guide policy decisions in health.