Unconditional cash transfers reduce homelessness.

Homelessness is an economic and social crisis. In a cluster-randomized controlled trial, we address a core cause of homelessness-lack of money-by providing a one-time unconditional cash transfer of CAD$7,500 to each of 50 individuals experiencing homelessness, with another 65 as controls in Vancouver, BC. Exploratory analyses showed that over 1 y, cash recipients spent fewer days homeless, increased savings and spending with no increase in temptation goods spending, and generated societal net savings of $777 per recipient via reduced time in shelters. Additional experiments revealed public mistrust toward the ability of homeless individuals to manage money and demonstrated interventions to increase public support for a cash transfer policy using counter-stereotypical or utilitarian messaging. Together, this research offers a new approach to address homelessness and provides insights into homelessness reduction policies.

The impact of a poverty reduction intervention on infant brain activity.

Early childhood poverty is a risk factor for lower school achievement, reduced earnings, and poorer health, and has been associated with differences in brain structure and function. Whether poverty causes differences in neurodevelopment, or is merely associated with factors that cause such differences, remains unclear. Here, we report estimates of the causal impact of a poverty reduction intervention on brain activity in the first year of life. We draw data from a subsample of the Baby's First Years study, which recruited 1,000 diverse low-income mother-infant dyads. Shortly after giving birth, mothers were randomized to receive either a large or nominal monthly unconditional cash gift. Infant brain activity was assessed at approximately 1 y of age in the child's home, using resting electroencephalography (EEG; n = 435). We hypothesized that infants in the high-cash gift group would have greater EEG power in the mid- to high-frequency bands and reduced power in a low-frequency band compared with infants in the low-cash gift group. Indeed, infants in the high-cash gift group showed more power in high-frequency bands. Effect sizes were similar in magnitude to many scalable education interventions, although the significance of estimates varied with the analytic specification. In sum, using a rigorous randomized design, we provide evidence that giving monthly unconditional cash transfers to mothers experiencing poverty in the first year of their children's lives may change infant brain activity. Such changes reflect neuroplasticity and environmental adaptation and display a pattern that has been associated with the development of subsequent cognitive skills.

Cost-effectiveness of differentiated care models that incorporate economic strengthening for HIV antiretroviral therapy adherence: a systematic review.

BACKGROUND: There is some evidence that differentiated service delivery (DSD) models, which use a client-centered approach to simplify and increase access to care, improve clinical outcomes among people living with HIV (PLHIV) in high HIV prevalence countries. Integrating economic strengthening tools (e.g., microcredit, cash transfers, food assistance) within DSD models can help address the poverty-related barriers to HIV antiretroviral therapy (ART). Yet there is minimal evidence of the cost-effectiveness of these types of multilevel care delivery models, which potentially prohibits their wider implementation. METHODS: Using a qualitative systematic review, this article synthesizes the literature surrounding the cost-effectiveness of differentiated service delivery models that employ economic strengthening initiatives to improve HIV treatment adherence in low- and middle-income countries. We searched three academic databases for randomized controlled trials and observational studies published from January 2000 through March 2024 in Sub-Saharan Africa. The quality of each study was scored using a validated appraisal system. RESULTS: Eighty-nine full texts were reviewed and 3 met all eligibility criteria. Two of the three included articles were specific to adolescents living with HIV. Economic strengthening opportunities varied by care model, and included developmental savings accounts, microenterprise workshops, and cash and non-cash conditional incentives. The main drivers of programmatic and per-patient costs were ART medications, CD4 cell count testing, and economic strengthening activities. CONCLUSION: All economic evaluations in this review found that including economic strengthening as part of comprehensive differentiated service delivery was cost-effective at a willingness to pay threshold of at least 2 times the national per capita gross domestic product. Two of the three studies in this review focused on adolescents, suggesting that these types of care models may be especially cost-effective for youth entering adulthood. All studies were from the provider perspective, indicating that additional evidence is needed to inform the potential cost-savings of DSD and economic strengthening interventions to patients and society. Randomized trials testing the effectiveness of DSD models that integrate economic strengthening should place greater emphasis on costing these types of programs to inform the potential for bringing these types of multilevel interventions to scale.

Nutrition supplementation plus standard of care versus standard of care alone or standard of care plus unconditional cash transfer in the prevention of chronic malnutrition in Southern Angola: study protocol for the MuCCUA study, a cluster randomized controlled trial.

BACKGROUND: Chronic malnutrition is a condition associated with negative impacts on physical and cognitive development. It is multi-causal and can start very early in life, already in utero, thus it is especially challenging to find appropriate interventions to tackle it. The government of Angola is implementing a standard of care program with potential to prevent it, and the provision of cash transfers and the supplementation with small quantity lipid-based nutrients (SQ-LNS) are also promising interventions. We aimed to evaluate the impact of the standard of care program alone and of the standard of care plus a cash transfer intervention in the lineal growth of children less than 2 years old and compare it to the effectiveness of a nutrition supplementation plus standard of care program in Southern Angola. METHODS/DESIGN: The three-arm parallel cluster randomised controlled trial is set in four communes of Huila and Cunene provinces. Clusters are villages or neighbourhoods with a population around 1075 people. A total of twelve clusters were selected per arm and forty pregnant women are expected to be recruited in each cluster. Pregnant women receive the standard of care alone, or the standard of care plus unconditional cash transfer or plus nutritional supplementation during the first 1000 days, from pregnancy to the child reaching 24 months. The primary outcome is the prevalence of stunting measured as height-for-age Z-score (HAZ) < -2 in children below 2 years. Impact will be assessed at 3, 6, 12, 18 and 24 months of children's age. Secondary outcomes include mortality, morbidity, caring, hygiene and nutrition behaviours and practices, and women and children's dietary diversity. Quantitative data are also collected on women's empowerment, household food security, expenditure and relevant clinical and social events at baseline, endline and intermediate time points. DISCUSSION: The results will provide valuable information on the impact of the standard of care intervention alone as well as combined with an unconditional cash transfer intervention compared to a nutrition supplementation plus standard of care intervention, carried out during the first 1000 days, in the children´s growth up to 2 years and related outcomes in Southern Angola. TRIAL REGISTRATION: Clinical Trials NCT05571280. Registered 7 October 2022.

Evaluating the relationship between conditional cash transfer programme on preterm births: a retrospective longitudinal study using the 100 million Brazilian cohort.

BACKGROUND: Preterm births increase mortality and morbidity during childhood and later life, which is closely associated with poverty and the quality of prenatal care. Therefore, income redistribution and poverty reduction initiatives may be valuable in preventing this outcome. We assessed whether receipt of the Brazilian conditional cash transfer programme - Bolsa Familia Programme, the largest in the world - reduces the occurrence of preterm births, including their severity categories, and explored how this association differs according to prenatal care and the quality of Bolsa Familia Programme management. METHODS: A retrospective cohort study was performed involving the first live singleton births to mothersenrolled in the 100 Million Brazilian Cohort from 2004 to 2015, who had at least one child before cohort enrollment. Only the first birth during the cohort period was included, but born from 2012 onward. A deterministic linkage with the Bolsa Familia Programme payroll dataset and a similarity linkage with the Brazilian Live Birth Information System were performed. The exposed group consisted of newborns to mothers who received Bolsa Familia from conception to delivery. Our outcomes were infants born with a gestational age < 37 weeks: (i) all preterm births, (ii) moderate-to-late (32-36), (iii) severe (28-31), and (iv) extreme (< 28) preterm births compared to at-term newborns. We combined propensity score-based methods and weighted logistic regressions to compare newborns to mothers who did and did not receive Bolsa Familia, controlling for socioeconomic conditions. We also estimated these effects separately, according to the adequacy of prenatal care and the index of quality of Bolsa Familia Programme management. RESULTS: 1,031,053 infants were analyzed; 65.9% of the mothers were beneficiaries. Bolsa Familia Programme was not associated with all sets of preterm births, moderate-to-late, and severe preterm births, but was associated with a reduction in extreme preterm births (weighted OR: 0.69; 95%CI: 0.63-0.76). This reduction can also be observed among mothers receiving adequate prenatal care (weighted OR: 0.66; 95%CI: 0.59-0.74) and living in better Bolsa Familia management municipalities (weighted OR: 0.56; 95%CI: 0.43-0.74). CONCLUSIONS: An income transfer programme for pregnant women of low-socioeconomic status, conditional to attending prenatal care appointments, has been associated with a reduction in extremely preterm births. These programmes could be essential in achieving Sustainable Development Goals.

Mapping of Interventions of Social Protection for Tuberculosis Patients in Africa: A Scoping Review Protocol.

BACKGROUND: Tuberculosis (TB) is a public health problem worldwide, particularly in resource-limited countries. It is considered a social disease with a medical component that persists over time due to several social determinants, most of which are closely linked to poverty and difficult socioeconomic conditions. The objective of this exploratory study is to describe the social protection interventions available for people with TB in Africa. METHODS: Searches will be carried out systematically in MEDLINE (PubMed), Embase (Ovid), Web of Science, Scopus and The Cochrane Library, Africa-Wide Information (EBSCOhost), Google Scholar. Articles will be considered if they describe the social protection, successes and challenges associated with the implementation and delivery of social protection interventions offered to people with TB in African countries. Data from the grey literature will also be considered. PRESENTATION OF RESULTS: We will present a narrative description highlighting the successes and challenges of the social protection interventions identified, and a synthesis accompanied by maps (Africa), figures or tables to summarize the data. CONCLUSION: This exploratory study will map the existing literature on social protection interventions for TB patients and guide future research to inform policy and practice decisions.

CONTEXTE: La tuberculose (TB) est un problème de santé publique dans le monde entier, en particulier dans les pays à ressources limitées. Elle est considérée comme une maladie sociale avec une composante médicale qui persiste dans le temps en raison de plusieurs déterminants sociaux, dont la plupart sont étroitement liés à la pauvreté et à des conditions socio-économiques difficiles. L'objectif de cette étude exploratoire est de décrire les interventions de protection sociale disponibles pour les personnes atteintes de TB dans les pays d'Afrique. METHODE: Des recherches seront effectuées systématiquement dans MEDLINE (PubMed), Embase (Ovid), Web Of Science, Scopus et The Cochrane Library, Africa-Wide Information (EBSCOhost), Google Scholar. Les articles seront pris en considération s'ils décrivent la protection sociale, les succès et les défis associés à la mise en œuvre et à l'exécution des interventions de protection sociale offertes aux personnes atteintes de TB dans les pays d'Afrique. Les données issues de la littérature grise seront également prises en compte. PRESENTATION DES RESULTATS: Nous présenterons une description narrative soulignant les succès et les défis des interventions de protection sociale identifiées, ainsi qu'une synthèse accompagnée de cartes (Afrique), de figures ou de tableaux pour résumer les données. CONCLUSION: Cette étude exploratoire permettra de cartographier la littérature existante sur les interventions de protection sociale pour les patients atteints de tuberculose et d'orienter les recherches futures afin d'éclairer les décisions politiques et pratiques.

A Causal Mediation Analysis for Investigating the Effect of a Randomized Cash-Transfer Program in Nicaragua.

Mediation analysis can be applied to data from randomized trials of health and social interventions to draw causal inference concerning their mechanisms. We used data from a cluster-randomized trial in Nicaragua, fielded between 2000 and 2002, to investigate whether the impact of providing access to a conditional cash-transfer program on child nutritional outcomes was mediated by child health check-ups and household dietary diversity. In a sample of 443 children 6-35 months old, we estimated the controlled direct (CDE) effect of random assignment on measured height-for-age z scores had we intervened so that all children received a health check-up and had the same level of household dietary diversity, using inverse-probability weighted marginal structural models to account for mediator-outcome confounding. Sensitivity analyses corrected the CDE for potential nondifferential error in the measurement of dietary diversity. Treatment assignment increased height-for-age z score by 0.37 (95% CI: 0.05, 0.69) standard deviations. The CDE was 0.20 (95% CI: -0.17, 0.57) standard deviations, suggesting nearly one-half of the program's impact on child nutrition would be eliminated had we intervened on these factors, although estimates were relatively imprecise. This study provides an illustration of how causal mediation analysis can be applied to examine the mechanisms of multifaceted interventions.

Are People Generous When the Financial Stakes Are High?

How generous are people when making consequential financial decisions in the real world? We took advantage of a rare opportunity to examine generosity among a diverse sample of adults who received a gift of U.S. $10,000 from a pair of wealthy donors, with nearly no strings attached. Two-hundred participants were drawn from three low-income countries (Indonesia, Brazil, and Kenya) and four high-income countries (Australia, Canada, the United Kingdom, and the United States) as part of a preregistered study. On average, participants spent over $6,400 on purchases that benefited others, including nearly $1,700 on donations to charity, suggesting that humans exhibit remarkable generosity even when the stakes are high. To address whether generosity was driven by reputational concerns, we asked half the participants to share their spending decisions publicly on Twitter, whereas the other half were asked to keep their spending private. Generous spending was similar between the groups, in contrast to our preregistered hypothesis that enhancing reputational concerns would increase generosity.

An Unconditional Cash Transfer Program for Low-Income New Yorkers Affected by COVID-19.

Early in the pandemic, New York City's public hospital system partnered with multiple philanthropic foundations to offer an unconditional cash transfer program for low-income New Yorkers affected by COVID-19. The $1000 cash transfers were designed to help people meet their most immediate health and social needs and were incorporated into healthcare delivery and contact tracing workflows as a response to the public health emergency. To better understand program recipients' experiences, researchers conducted 150 telephone surveys with randomly sampled cash transfer recipients and 20 in-depth qualitative interviews with purposefully sampled survey participants. Survey participants were predominantly Latinx (87%) and women (65%). The most common reported uses of the $1000 were food and rent. Most participants (79%) reported that without the $1000 cash transfer they would have had difficulty paying for basic expenses or making ends meet, with specific positive effects reported related to food, housing, and ability to work. The majority of survey participants reported that receiving the cash assistance somewhat or greatly improved their physical health (83%) and mental health (89%). Qualitative interview results generally supported the survey findings.

Mixed-method study on the association between inclusion to conditional cash transfer program and the multiple faces of malnutrition in children and adolescents aged 3 to 19 years: a school-based evidence from Caraga Region, the Philippines.

BACKGROUND: This study aimed to investigate the association between inclusion to Pantawid Pamilyang Pilipino Program (4Ps), a CCT program in the Philippines, and malnutrition in children and adolescents and examine the perceptions and experiences of parents and other stakeholders on how 4Ps influenced child nutrition. METHODS: A concurrent mixed-method study was conducted in the Caraga Region, Philippines. Quantitative data from 5541 children and adolescents aged 3 to 19 were analyzed using multilevel mixed-effect logistic models. To allow in-depth understanding of the programmatic components that support the findings from the quantitative study, eight focused group discussions (FGDs) were concurrently conducted, cumulating 33 participants, including 4Ps parents, school coordinators/teachers, and school nurses. A constructivist grounded theory approach was used for analysis, and joint displays were employed to integrate quantitative and qualitative results. RESULTS: Quantitative findings revealed high rates of malnutrition, with significant rates of stunting (12.0%), wasting/thinness (9.4%), and overweight/obesity (16.4%) among children and adolescents. 4Ps beneficiaries had higher odds of stunting and overweight/obesity compared to non-4Ps beneficiaries (AOR = 1.43, 95%CI: 1.08-1.91; AOR = 1.21, 95%CI: 1.01-1.45, respectively). However, no significant association was observed between inclusion to 4Ps and concurrent stunting and wasting/thinness or overweight/obesity (AOR = 1.05, 95%CI: 0.72-1.55). Geographic variations were observed, with 4Ps children in Agusan del Sur having lower odds of stunting than those in Agusan del Norte (AOR = 0.41, 95%CI: 0.23-0.71). Age and gender also showed significant associations with malnutrition. The qualitative analysis provided insights into the challenges contributing to malnutrition, including child labor, sickness, long distances to school, limited access to healthy food, and larger families. Unintended consequences such as cash card mismanagement, inappropriate cash grant allocation, and falsification of school attendance were identified. However, teachers and parents demonstrated resilience by implementing adaptive approaches to enhance child nutrition. CONCLUSIONS: While 4Ps beneficiaries exhibit higher odds of stunting and overweight/obesity, the program's association with malnutrition was significantly influenced by geographic variations. It is crucial for social protection programs to prioritize comprehensive support strategies that effectively counter unintended consequences and challenges faced by beneficiaries and other stakeholders and address malnutrition in children and adolescents.

The effects of emergency government cash transfers on beliefs and behaviours during the COVID pandemic: Evidence from Brazil.

This paper examines the impacts of emergency cash-transfers on individuals' social distancing behaviour and beliefs about COVID-19. We focus on the impacts of "Auxilio Emergencial" (AE): a large-scale cash-transfer in Brazil targeting low-income individuals who were unemployed or informally employed during the pandemic. To identify causal effects we exploit exogenous variation, arising from the AE design, in individuals' access to the cash-transfer programme. Using data from an online survey, our results suggest that eligibility to the emergency cash transfer led to a reduced likelihood of individuals contracting COVID-19, likely to have been driven by a reduction in working hours. Moreover, the cash transfer seems to have increased perceptions about the seriousness of coronavirus, while also exacerbating misconceptions about the pandemic. These findings indicate effects of emergency cash-transfers in determining individuals' narratives about a pandemic, in enabling social distancing and potentially in reducing the spread of the disease.

Effects of a single cash transfer on school re-enrollment during COVID-19 among vulnerable adolescent girls in Kenya: Randomized controlled trial.

COVID-19 related school closures in Kenya were among the longest in Africa, putting older adolescent girls nearing the end of secondary school at risk of permanent dropout. Using a randomized-controlled trial we evaluated a logistically simple cash transfer intervention in urban areas designed to promote their return to school. There were no required conditions for receiving the transfer and the intervention is interpreted as a labeled cash transfer. It had substantial significant effects on re-enrollment of adolescent girls, with greater effectiveness for older girls and even for some not enrolled earlier in the school year. The program effectiveness demonstrates feasibility of the approach and underscores the potential importance of additional resources for schooling during the pandemic, when a large majority of households had suffered income losses.

Targeting Cash Transfers on the "Poorest of the Poor" in the Slums: How Well Did the Kenya's Older Persons Cash Transfer Programme Perform?

In resource poor environments, identifying those most in need of limited available resources is challenging. Kenya's older persons cash transfer programme (OPCT) targeted at the most poor used a 2-stage targeting process to identify beneficiaries, combining community-based selection with a proxy means-test. This paper investigates whether the process "correctly" identified targeted vulnerable older people in Nairobi's informal settlements and whether receipt of the OPCT resulted in an improvement in perceived financial wellbeing. Regression results show that individuals with greater need were covered under the OPCT. Using propensity score matching, the paper evidences that the OPCT improved subjective financial wellbeing among beneficiaries.

Estimating the costs for implementing a maternity leave cash transfer program for women employed in the informal sector in Brazil and Ghana.

BACKGROUND: Maternity leave policies are designed to protect gender equality and the health of mothers in the workforce and their children. However, maternity leave schemes are often linked to jobs in the formal sector economy. In low- and middle-income countries a large share of women work in the informal sector, and are not eligible to such benefit. This is worrisome from a social justice and a policy perspective and suggests the need for intervening. Costing the implementation of potential interventions is needed for facilitating informed decisions by policy makers. METHODS: We developed and applied a costing methodology to assess the cost of a maternity leave cash transfer to be operated in the informal sector of the economy in Brazil and Ghana, two countries with very different employment structures and socioeconomic contexts. We conducted sensitivity analysis by modeling different numbers of weeks covered. RESULTS: In Brazil, the cost of the maternity cash transfer would be between 0.004% and 0.02% of the GDP, while in Ghana it would range between 0.076% and 0.28% of the GDP. The relative cost of rolling out a maternity intervention in Brazil is between 2.2 to 3.2 times the cost in Ghana depending on the benchmark used to assess the welfare measure. The differences in costs between countries was related to differences in labor market structure as well as demographic characteristics. CONCLUSIONS: Findings show how a standard methodology that relies on routinely available information is feasible and could assist policymakers in estimating the costs of supporting a maternity cash transfer for women employed in the informal sector, such intervention is expected to contribute to social justice, gender equity, and health trajectories.

Relationship of cash transfers with risk of overweight and obesity in children and adults: a systematic review.

BACKGROUND: Cash transfer (CT) programs are an important type of social protection meant to reduce poverty. Whether CT programs increase the risk of overweight and obesity is unclear. The objective was to characterize the relationship between CT programs and the risk of overweight and obesity in children and adults. METHODS: We searched articles in PubMed, Embase, Cochrane, EconLit, Global Health, CINAHL Plus, IBSS, Health & Medical Collection, Scopus, Web of Science, and WHO Global Index Medicus in August 2021. Studies involving CT as the intervention, a control group, body mass index, overweight, or obesity as an outcome, and sample size > 300 were included. The Newcastle-Ottawa Scale was used for quality assessment. RESULTS: Of 2355 articles identified, 20 met the inclusion criteria. Because of marked heterogeneity in methodology, a narrative synthesis was used to present results. Thirteen of the studies reported that CT programs were associated with a significantly lower risk of overweight and obesity, eight studies showed no significant association, and one study reported a significantly increased risk of obesity in women. Quality assessment showed that most studies lacked sample size and power calculations, validation of exposure, descriptions of non-respondents or those lost to follow-up, and blinded outcome assessment. CONCLUSIONS: Overall, the studies were suggestive that CT programs either have no impact or decrease the risk of overweight and/or obesity in children, adolescents, and adults, but no firm conclusions can be drawn from the available evidence. This review demonstrated limitations in the available studies of CT programs and overweight/obesity.

The intergenerational relationship between conditional cash transfers and newborn health.

BACKGROUND: Lack of nutrition, inadequate housing, low education and limited access to quality care can negatively affect children's health over their lifetime. Implemented in 2003, the Bolsa Familia ("Family Stipend") Program (PBF) is a conditional cash transfer program targeting poor households in Brazil. This study investigates the long-term benefits of cash transfers through intergenerational transmission of health and poverty by assessing the early life exposure of the mother to the PBF. METHODS: We used data from the 100M SINASC-SIM cohort compiled and managed by the Center for Data and Knowledge Integration for Health (CIDACS), containing information about participation in the PBF and socioeconomic and health indicators. We analyzed five measures of newborn health: low (less than 2,500 g) and very low (less than 1,500 g) birth weight, premature (less than 37 weeks of gestation) and very premature (less than 28 weeks of gestation) birth, and the presence of some type of malformation (according to ICD-10 codes). Furthermore, we measured the early life exposure to the PBF of the mother as PBF coverage in the previous decade in the city where the mother was born. We applied multilevel logistic regression models to assess the associations between birth outcomes and PBF exposures. RESULTS: Results showed that children born in a household where the mother received BF were less likely to have low birth weight (OR 0.93, CI; 0.92-0.94), very low birth weight (0.87, CI; 0.84-0.89), as well as to be born after 37 weeks of gestation (OR 0.98, CI; 0.97-0.99) or 28 weeks of gestation (OR 0.93, CI; 0.88-0.97). There were no significant associations between households where the mother received BF and congenital malformation. On average, the higher the early life exposure to the PBF of the mother, the lower was the prevalence of low birth weight, very low birth weight and congenital malformation of the newborn. No trend was noted for preterm birth. CONCLUSION: The PBF might have indirect intergenerational effects on children's health. These results provide important implications for policymakers who have to decide how to effectively allocate resources to improve child health.

Unconditional cash transfers and maternal substance use: findings from a randomized control trial of low-income mothers with infants in the U.S.

BACKGROUND: Policy debates over anti-poverty programs are often marked by pernicious stereotypes suggesting that direct cash transfers to people residing in poverty encourage health-risking behaviors such as smoking, drinking, and other substance use. Causal evidence on this issue is limited in the U.S. Given the prominent role of child allowances and other forms of cash assistance in the 2021 American Rescue Plan and proposed Build Back Better legislation, evidence on the extent to which a monthly unconditional cash gift changes substance use patterns among low-income mothers with infants warrants attention, particularly in the context of economic supports that can help improve early environments of children. METHOD: We employ a multi-site, parallel-group, randomized control trial in which 1,000 low-income mothers in the U.S. with newborns were recruited from hospitals shortly after the infant's birth and randomly assigned to receive either a substantial ($333) or a nominal ($20) monthly cash gift during the early years of the infant's life. We estimate the effect of the unconditional cash transfer on self-report measures of maternal substance use (i.e., alcohol, cigarette, or opioid use) and household expenditures on alcohol and cigarettes after one year of cash gifts. RESULTS: The cash gift difference of $313 per month had small and statistically nonsignificant impacts on group differences in maternal reports of substance use and household expenditures on alcohol or cigarettes. Effect sizes ranged between - 0.067 standard deviations and + 0.072 standard deviations. The estimated share of the $313 group difference spent on alcohol and tobacco was less than 1%. CONCLUSIONS: Our randomized control trial of monthly cash gifts to mothers with newborn infants finds that a cash gift difference of $313 per month did not significantly change maternal use of alcohol, cigarettes, or opioids or household expenditures on alcohol or cigarettes. Although the structure of our cash gifts differs somewhat from that of a government-provided child allowance, our null effect findings suggest that unconditional cash transfers aimed at families living in poverty are unlikely to induce large changes in substance use and expenditures by recipients. TRIAL REGISTRATION: Registered on Clinical Trials.gov NCT03593356 in July of 2018.

Does the unconditional cash transfer program in South Africa provide support for women after child birth? Barriers to accessing the child support grant among women in informal work in Durban, South Africa.

BACKGROUND: The child support grant (CSG) is the largest unconditional cash transfer program in Africa and aims to alleviate poverty and improve child health and nutrition in low-income families in South Africa. Among informal working women, the CSG is an important source of income after childbirth when informal workers are unable to work, but reports suggest that women experience delays in accessing the CSG. We explore experiences and challenges of accessing the CSG among informal workers in Durban, South Africa. METHODS: We undertook a longitudinal mixed-methods cohort study. Women informal workers were recruited during pregnancy and followed-up for up to one year after the baby was born. Quantitative questionnaires and semi-structured in-depth interviews were used to collect data about women's plans for applying for the CSG, the application process, use of the CSG in the household, and household food insecurity. Interviews were conducted in IsiZulu by experienced researchers. Descriptive analysis of quantitative data used SPSS v26, and framework analysis using NVIVO v12.3 was used for qualitative analysis. RESULTS: Twenty-four informal working women were enrolled. The CSG received for older children was reported as an important and reliable source of income for mothers after childbirth. However, delays receiving the CSG for the new baby meant this support was unavailable to first-time mothers. The complex application process for the CSG required mothers to travel to various government departments to complete the required documentation, often taking the baby with them. This was costly and time-consuming for mothers who were already vulnerable, and led to delays in obtaining CSG funds. Many women experienced moderate or severe food insecurity before and after the baby was born. As a result, some mothers had to return to work earlier than planned, disrupting childcare and breastfeeding. CONCLUSIONS: Cash transfer programmes can effectively support low income households and improve outcomes for mothers and children. In South Africa there is a need for innovative approaches to streamline CSG applications, so women can access the funds immediately post-delivery to fill a resource gap and provide support at a vulnerable time for mothers and their children.

A decade of conditional cash transfer programs for reproductive health in India: How did equality fare?

BACKGROUND: Since 2005, India has implemented conditional cash transfer [CCT] programs to promote the uptake of institutional delivery services [ID]. The study aims to assess changes in wealth-based inequality in the use of ID and other maternal health care services during the first decade of Janani Suraksha Yojana and related CCT programs. METHODS: Data from two Demographic and Health Surveys were used to calculate changes in service inequality from 2005 to 2015-16 in the use of three or more antenatal care [ANC] visits, ID, and postnatal care [PNC]. The changes were assessed at the national level, within high and low performing states [HPS and LPS, respectively] and within urban and rural areas of each state category. Erreygers Index [EI] and Wagstaff Index [WI], superior to concentration index, were used to gain different insights into the nature of inequality. EI is an objective measure of inequality irrespective of prevalence while WI is a combined measure of inequality and the average distribution of an indicator that puts more weight on the poor. RESULTS: The results suggest that wealth-based inequalities decreased significantly at the national level. For ID, both indices showed a decline in both HPS and LPS though the change in WI in HPS was insignificant. For ANC, there was a significant decrease in inequality using both indices in HPS but not in LPS. For PNC, there was a significant decrease in inequality using both indices in HPS, and when using WI in LPS, but not when using EI in LPS. CONCLUSION: Overall, the first decade of India's CCT programs saw an impressive reduction in EI for ID but less so for WI suggesting that the benefit of CCTs did not go disproportionately to the poor, which suggests that there is a need to reduce or eliminate the evident leakages. The improvement in uptake and inequality in ANC and PNC was not at par with ID, stressing the need to place greater focus on the continuum of care. The urban rural difference in HPS versus LPS in the changes in inequality reveals that infrastructure is important for CCTs to be more effective.

Long-term impact of a conditional cash transfer programme on maternal mortality: a nationwide analysis of Brazilian longitudinal data.

BACKGROUND: Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world's largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years. METHODS: The study had an ecological longitudinal design and used all 2548 Brazilian municipalities with vital statistics of adequate quality during 2004-2014. BFP municipal coverage was classified into four levels, from low to consolidated, and its duration effects were measured using the average municipal coverage of previous years. We used negative binomial multivariable regression models with fixed-effects specifications, adjusted for all relevant demographic, socioeconomic, and healthcare variables. RESULTS: BFP was significantly associated with reductions of maternal mortality proportionally to its levels of coverage and years of implementation, with a rate ratio (RR) reaching 0.88 (95%CI 0.81-0.95), 0.84 (0.75-0.96) and 0.83 (0.71-0.99) for intermediate, high and consolidated BFP coverage over the previous 11 years. The BFP duration effect was stronger among young mothers (RR 0.77; 95%CI 0.67-0.96). BFP was also associated with reductions in the proportion of pregnant women with no prenatal visits (RR 0.73; 95%CI 0.69-0.77), reductions in hospital case-fatality rate for delivery (RR 0.78; 95%CI 0.66-0.94) and increases in the proportion of deliveries in hospital (RR 1.05; 95%CI 1.04-1.07). CONCLUSION: Our findings show that a consolidated and durable CCT coverage could decrease maternal mortality, and these long-term effects are stronger among poor mothers exposed to CCT during their childhood and adolescence, suggesting a CCT inter-generational effect. Sustained CCT coverage could reduce health inequalities and contribute to the achievement of the Sustainable Development Goal 3.1, and should be preserved during the current global economic crisis due to the COVID-19 pandemic.