EVIDENCE May, 2012 from to POLICY a note series on learning what works, from the Human Development Network Can Cash Transfers Help Children Stay Healthy? 69658 Societies have a stake in ensuring that their youngest popu- The World Bank is committed to helping countries pro- lations receive regular health check-ups and proper medical tect and nurture children’s health and education, two of the care when needed. Children whose health is protected and eight United Nations Millennium Development Goals. To nurtured have a better chance of enrolling in school, learn- help policymakers better understand what methods work, ing, and growing to be healthy and productive adults, which the World Bank supported a study of a pilot cash transfer in turns helps a country’s development. So how can policy- program in Burkina Faso to encourage families to bring makers and development experts promote this? Increasingly, their children to health clinics for regular growth monitor- cash transfers are being used to encourage families to take ing and to send them to school. The evaluation found that basic preventive care measures, including regular health care conditional cash transfers boosted routine preventive health visits for babies and young children and enrolling children care visits, regardless of whether the money was given to the in school. The transfers may be conditional, meaning fami- mother or father. On the other hand, unconditional cash lies get the money if they take children for regular check-ups transfers, regardless of which parent received the money, or enroll them in school; or they can be unconditional, in did not lead to more regular health visits. Conditional cash which case families receive the money without any strings transfers can be more expensive and complex to implement attached, under the assumption that the extra cash will give than unconditional transfers and policymakers may take parents the financial flexibility to ensure proper health visits this into account when devising programs. But it’s always and schooling. While both methods are being used in de- important to look at outcomes as well when deciding how veloping countries, there is still a need for information on to create and implement programs. which works best and under what circumstances. Case Study Burkina Faso A two-year pilot program, the Nahouri Cash Transfers Pi- As part of the pilot, 75 villages with primary schools lot Project, was implemented in Burkina Faso’s southern program were randomly allocated to one of five groups. In Nahouri province, about 100 miles from the country’s the first, fathers received the conditional cash transfer; in capital. The project used conditional and unconditional the second group, mothers received the conditional cash cash transfers to encourage poor families to enroll their transfer; in the third group, father received an uncondi- children in school and take them for regular health check- tional cash transfer; in the fourth group, mothers received ups. A random experimental design was incorporated into it; and the fifth group was the control group. Only poor the pilot to allow for evaluation of the relative effectiveness households qualified for the transfer program, and their of the different cash transfer programs. eligibility was determined using a combination of Burkina Faso national household data and a survey that looked at asset ownership, education, living conditions, and eco- Did You Know… nomic activities. Qualifying households were assigned to Close to 80 percent of people in Burkina Faso live in rural areas… either receive or not receive the particular transfer through . . .compared with 62 percent for Sub-Saharan Africa overall. But, overall, the immunization rate for children is around 95 percent. a lottery system. In all cases, researchers met with village leaders to explain the program, which helped maintain participation and build support. In total, about 3200 tween the ages of 7 and 10; and almost $38 a year for children households took part in the pilot project. between the ages of 11 and 15. There was no cap on the total The conditional cash transfer had a health and schooling amount a household could receive. Families who qualified for component. The money was distributed on a per child basis conditional cash transfers received booklets that were stamped and the amount differed based on the age of the child. To by teachers and health-care workers to show school enrollment receive the money, children under the age of six had to have and health care usage. quarterly health clinic visits for child growth monitoring, and This part of the two-year evaluation, which began in 2008 children aged seven through 15 had to be enrolled in school with a baseline survey, looked only at the usage of routine and show a 90 percent or better attendance rate. Households health services (as opposed to quarterly clinic visits to moni- that qualified for an unconditional cash transfer received a tor a child’s growth). Results are forthcoming in other areas of quarterly stipend for each child, regardless. In both cases, the the impact evaluation, including the effect of cash transfers on stipend was the same: approximately $9.64 for a full year for schooling and other impacts. a child under the age of 6; about $19 a year for each child be- Why Burkina Faso? Even when compared with other developing countries on national data, and only 60 percent of births are at- in Sub-Saharan Africa, Burkina Faso’s some 15 million tended by a trained health care provider. The probability people have very poor health and economic opportuni- of a child dying before reaching his or her fifth birthday ties and outcomes. Close to 50 percent of people live is also among the highest in the region, although it de- at or below the national poverty line; per capita GDP clined to 176 per 1,000 live births in 2010 from 188 per is below the average for developing countries in the re- 1,000 in 2002. This is still high compared with other gion; and life expectancy is 55 years. developing countries in Sub-Saharan Africa, which as a Health care is likewise poor. Some 35 percent of chil- whole saw a drop in under age 5 mortality from 148 per dren under the age of 5 are malnourished based on height 1,000 in 2002 to 121 per 1,000 (for the world as a whole, for age and 36 percent of the population has access to ba- the average is 58). sic health care. The health system is understaffed, based The Findings Conditional cash transfers boosted preventive over the average number of routine visits, which was 1.03 health care visits for children by more than 40 visits a year percent… … and it didn’t matter whether fathers or Children under the age of five years old had 0.43 more mothers received the money. In both cases, the routine health care visits than children in the control number of routine visits rose. group households. This represented a 42 percent increase This bulletin is based on the paper, “Alternative Cash Transfer Delivery Mechanisms: Impacts on Routine Preventative Health Clinic Visits in Burkina Faso,� by Richard Akresh, Damien de Walque and Harounan Kazianga (Policy Research Working Paper Series 5958, The World Bank). The pilot project was funded by, among other funds, the Spanish Impact Evaluation Fund and the Bank-Netherlands Partnership Program. Households that were eligible to receive the cash transfers all were below the estimated national poverty line. Extreme- ly poor households are defined as being below the median household per capita expenditure level in the baseline survey. There were no significant differences between the impacts for cash transfers given to extremely poor or less poor households. Unconditional cash transfers didn’t have the same effect. There was no significant impact on use of routine health-care services. Regardless of whether the unconditional cash transfer was giv- en to mothers or fathers, there was no increase is the number of regular health clinic visits of their children. In both cases, children in households receiving unconditional cash transfers were no better off than those in the control group. The impact of conditional cash transfers on health care visits was driven by increased visits for older children, aged 24 to 59 months. This may be because parents already were bringing their younger children in for fairly regular visits. On average, babies in Burkina Faso have 1.43 visits a year, compared There are long-standing questions whether it’s more effec- with 0.80 visits for children aged two to five. So there was tive to give conditional cash transfers to mothers or fathers. more room to improve when it came to bringing older This evaluation found that there was no statistically signifi- cant difference. When money was given to fathers, children had 0.415 more visits to health clinics. When the money was given to mothers, the number of visits rose by 0.446. Nor was the gender of the child significant when it came to the effect of conditional cash transfers. There was suggestive evidence that when fathers received the money, there was a bigger impact on routine health clinic vis- its for girls (an additional 0.580), while transfers to mothers had a larger impact on health clinic visits for boys (an addi- tional 0.505 visits). However, the difference is not statistically significant. children for check-ups. When broken down by age, con- The impact of conditional cash transfers was ditional cash transfers increased the number of visits for the same whether the household receiving older children by between 70 percent and 79 percent, the money was classified as “extremely poor� depending on whether the mother or father received the or “less poor.� transfer. Conclusion Making policy from evidence Cash transfers are being used across the world to encourage ence – usually pregnant women and children – get the care better use of education and health services by offering eco- or education that is intended. In Burkina Faso, conditional nomic incentives that can significantly boost the incomes of cash transfers successfully boosted routine health clinic use. poor households. This effect has been seen in programs in By contrast, unconditional cash transfers didn’t raise the other countries, such as the Progresa/Oportunidades pro- number of health care visits by any significant degree. gram in Mexico, which gives families cash transfers in ex- From a policy perspective, conditional cash transfers did change for ensuring their children are enrolled in school and successfully encourage greater use of routine health-care. receive proper health care. In some cases, what is transferred In this pilot in Burkina Faso, families also received cash is not cash but food, which has also been successfully used transfers for enrolling and sending older children to school, in, for example, Burkina Faso and Uganda (see previous Evi- which may have had an impact on the use of health care dence to Policy Notes), to raise student enrollment. services (perhaps because parents whose older children are Transfer programs can be conditional or unconditional, in school have either more time or more opportunities to and development experts are still evaluating which works take younger children to a health clinic). Additional evalua- best and under what circumstances. Unconditional cash tions will look at other aspects of the program, while further transfers are easier and less expensive to implement, which evaluations are likely needed to measure whether cash trans- can make them very cost-effective. But the lack of condi- fers linked solely to health clinic visits are equally effective. tionality means less control over ensuring the intended audi- The Human Development Network, part of the World Bank Group, supports and disseminates research evaluating the impact of development projects to help alleviate poverty. The goal is to collect and build empirical evidence that can help governments and development organizations design and implement the most appropriate and effective policies for better educational, health and job opportunities for people in developing countries. For more informa- tion about who we are and what we do, go to: http://www.worldbank.org/hdchiefeconomist This Evidence to Policy note series is produced with the generous support of the Spanish Impact Evaluation Fund (SIEF) THE WORLD BANK, HUMAN DEVELOPMENT NETWORK 1818 H STREET, NW WASHINGTON, DC 20433 Produced by Office of the Chief Economist, Human Development Network, Communications