david evans world bank joint work with brian holtemeyer and katrina kosec (ifpri) july 9, 2015
DESCRIPTION
Source: Fiszbein et al 2009TRANSCRIPT
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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
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Cash transfers have expanded
dramatically around the world!
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1997
Source: Fiszbein et al 2009
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2008
Source: Fiszbein et al 2009
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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)
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… and so has evidence
surrounding their impacts!
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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)
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To date, limited evidence base
(a) from Africa, conditioning on health
(b) relying on local communities to run program / deliver payments
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Operational experience and contextual expertiseInternational expertise on cash transfers and on impact evaluation
Initial funding for the program & evaluation
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What it looked like
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How big was it?
≈≈
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Where was it?
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What households received (in 2010)
per child (US$3) per month
per adult (US$6) per month
on average
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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
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Who did what
Identification of the poor…by communities
Distribution of payments…by communities
Monitoring of conditions…by communities
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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
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How we evaluated it
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3 provinces selected to pilot
Initial Treatment Initial Comparison
80 eligible villages
but only cash for 40
Treatment
2 years laterwith additional
funding
randomization
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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
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When it happened
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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
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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)
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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”
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What were the impacts of the program on health and health-related outcomes for the poor?
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Outcome: Health clinic visits in the last 12 months
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Outcome: Illness & injury in last 4 weeks
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Outcome: Participation in government-run health insurance program
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Outcome: Use of public facilities
Private
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Outcome: Satisfaction with health facilities
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Outcome: Objective facility quality
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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
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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
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Asanteni sana!