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TRANSCRIPT
CAN CCTS IMPROVE MATERNAL HEALTH
OUTCOMES? EVIDENCE FROM EL SALVADOR
Alan de Brauw and Amber PetermanInternational Food Policy Research Institute
CONDITIONAL CASH TRANSFER PROGRAMS
In general, CCT programs give cash grants for families conditional on specific behaviorsUsually have to do with health (e.g. growth monitoring) or education (children going to school)
Programs often require or hold meetings for beneficiaries on specific topics
Programs also notable for being accompanied by rigorous impact evaluations
Now widespread in Central/South America
IMPACTS OF CCTS ON MATERNAL HEALTH?
CCTs well positioned to affect maternal health outcomes at birth, but few studies have attempted to measure benefits of CCTs for maternal health
Most evidence from Oportunidades in Mexico (pre-natal care; Barber and Gertler, 2009; c-sections increased as well), and
JSY in India (Lin et al., 2010); one time inducement for in-facility birth
Several mechanisms by which CCTs might affect maternal health, even if not included as a condition for transfers
POSSIBLE MECHANISMS FOR IMPACT
1. Free Health Care included as a benefit of program (e.g. Oportunidades)
2. Co-responsibilities may include pre- or post-natal care
3. May stimulate demand through health or nutrition trainings
4. CCTs may at the same time increase supply of health services through investments
5. Income effect increases demand
A.May be gender differentiated impacts due to transfer
OUTCOMES WE STUDY
1. Adequate pre-natal care (defined as 5 visits or more during pregnancy)
2. Skilled attendance at birth
3. Birth in hospital4. Post-natal care (defined
as visit to health care for mother within 2 weeks of birth)
METHODOLOGY
We use an innovative RDD methodology (de Brauw and Gilligan, 2011) to measure impacts of Comunidades Solidarias Rurales on maternal health outcomes in rural El Salvador
Methodology allows us to use RDD without explicit forcing variable
Also use double difference to control for pre-program conditions
REGRESSION DISCONTINUITY DESIGN
Identification Assumption: A threshold exists that splits treatment and control
From the beneficiaries’ perspective, threshold is exogenous
Typically determined through a proxy means test or another forcing variable
Observations just above and just below threshold can be compared to measure impact of program
Problem in this case is a lack of an explicit forcing variable
IMPLICIT FORCING VARIABLE
A
A
S
S
A
S
S
S
S
SS
S
SS
A
A
S
A
SSS
S
A
A
A
A
A
A
A
S
A
A
05
1015
Per
cent
age
of C
hild
ren
Sev
erel
y S
tunt
ed
30 40 50 60Poverty Rate
Forcing Line Cluster Centers
Threshold
Seve
re S
tunt
ing
Rate
DATA
Come from evaluation surveys of CSR conducted by IFPRI-FUSADES
Collected in the beginning and end of 2008
Treatment and control groups for this part of evaluation entered program in 2006 and 2007
In initial survey, asked about birth history over past three years to construct a before and after comparison
TREATMENT AND CONTROL GROUPS
2006 entry group
2007 entry group
October 1st, 2006
Before Treatment
Before Treatment After Treatment
After TreatmentEntry Date
DESCRIPTIVE CHANGES, 2006 ENTRY GROUP
0
25
50
75
100
Pre-Natal Skilled Att. Hospital Post-Natal
Pre-CSR Post-CSR
RESULTS: ADEQUATE PRE-NATAL CARE
-.6-.4
-.20
.2.4
-15 -10 -5 0 5 10 15Distance to Cluster Threshold
2006 Entry 2007 Entry
Cha
nge
in A
dequ
ate
Pre-
nata
l car
e
RESULTS: SKILLED ATTENDANCE AT BIRTH
-.4-.2
0.2
.4
-15 -10 -5 0 5 10 15Distance to Cluster Threshold
2006 Entry 2007 Entry
Cha
nge
in S
kille
d A
ttend
ance
at B
irth
RESULTS: BIRTH IN HOSPITALS
-.4-.2
0.2
.4
-15 -10 -5 0 5 10 15Distance to Cluster Threshold
2006 Entry 2007 Entry
Cha
nge
in B
irth
in
Hos
pita
ls
RESULTS: POST-NATAL CARE
-.20
.2.4
-15 -10 -5 0 5 10 15Distance to Cluster Threshold
2006 Entry 2007 Entry
Cha
nge
in P
ost-N
atal
C
are
PRIMARY RESULTS
Outcome no control variables Individual + Household Controls
Adequate pre-natal monitoring
-0.112(0.084)
-0.089(0.086)
Skilled attendance at birth
0.174(0.057)***
0.164(0.075)**
Birth in hospital 0.223(0.052)***
0.214(0.052)***
Post-natal care -0.094(0.138)
-0.093(0.140)
IMPACT PATHWAYS
Not a co-responsibility of program to have birth attended by qualified personnel or in a hospital
Overall income effect also unlikely (transfer is relatively small)
So three remaining possibilities:
Through training (capaciticiones)
Through supply side (increase in access to facilities)
Through increase in women’s decision making power
CAPACITICIONES?
Impact cannot all be through trainings
Trainings only began after transfers did
Short time period for trainings to affect such large change
SUPPLY SIDE?
Access to facilities increased in a non-linear manner throughout communities that were to enter CSR
So cannot be supply side in isolation of stimulated demand
Definitely played a role
WOMEN’S DECISION MAKING POWER
Women definitely empowered by CSR, through transfers and knowledege (Adato et al., 2009)
Not clear how to quantify impact, but with increased supply and awareness, may have affected changes around birth
CONCLUSION
El Salvador’s CCT, Comunidades Solidarias Rurales, has improved outcomes at birth along some lines
Not other measures of women’s health during fertility however
To increase impacts, perhaps should also condition program on pre- and post-natal visits
Could potentially replace one capaciticion, if women feel burdened by program