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