Child morbidity and mortality associated with alternative policy responses to the economic crisis in Brazil: A nationwide microsimulation study.

BACKGROUND: Since 2015, a major economic crisis in Brazil has led to increasing poverty and the implementation of long-term fiscal austerity measures that will substantially reduce expenditure on social welfare programmes as a percentage of the country's GDP over the next 20 years. The Bolsa Família Programme (BFP)-one of the largest conditional cash transfer programmes in the world-and the nationwide primary healthcare strategy (Estratégia Saúde da Família [ESF]) are affected by fiscal austerity, despite being among the policy interventions with the strongest estimated impact on child mortality in the country. We investigated how reduced coverage of the BFP and ESF-compared to an alternative scenario where the level of social protection under these programmes is maintained-may affect the under-five mortality rate (U5MR) and socioeconomic inequalities in child health in the country until 2030, the end date of the Sustainable Development Goals. METHODS AND FINDINGS: We developed and validated a microsimulation model, creating a synthetic cohort of all 5,507 Brazilian municipalities for the period 2017-2030. This model was based on the longitudinal dataset and effect estimates from a previously published study that evaluated the effects of poverty, the BFP, and the ESF on child health. We forecast the economic crisis and the effect of reductions in BFP and ESF coverage due to current fiscal austerity on the U5MR, and compared this scenario with a scenario where these programmes maintain the levels of social protection by increasing or decreasing with the size of Brazil's vulnerable populations (policy response scenarios). We used fixed effects multivariate regression models including BFP and ESF coverage and accounting for secular trends, demographic and socioeconomic changes, and programme duration effects. With the maintenance of the levels of social protection provided by the BFP and ESF, in the most likely economic crisis scenario the U5MR is expected to be 8.57% (95% CI: 6.88%-10.24%) lower in 2030 than under fiscal austerity-a cumulative 19,732 (95% CI: 10,207-29,285) averted under-five deaths between 2017 and 2030. U5MRs from diarrhoea, malnutrition, and lower respiratory tract infections are projected to be 39.3% (95% CI: 36.9%-41.8%), 35.8% (95% CI: 31.5%-39.9%), and 8.5% (95% CI: 4.1%-12.0%) lower, respectively, in 2030 under the maintenance of BFP and ESF coverage, with 123,549 fewer under-five hospitalisations from all causes over the study period. Reduced coverage of the BFP and ESF will also disproportionately affect U5MR in the most vulnerable areas, with the U5MR in the poorest quintile of municipalities expected to be 11.0% (95% CI: 8.0%-13.8%) lower in 2030 under the maintenance of BFP and ESF levels of social protection than under fiscal austerity, compared to no difference in the richest quintile. Declines in health inequalities over the last decade will also stop under a fiscal austerity scenario: the U5MR concentration index is expected to remain stable over the period 2017-2030, compared to a 13.3% (95% CI: 5.6%-21.8%) reduction under the maintenance of BFP and ESF levels of protection. Limitations of our analysis are the ecological nature of the study, uncertainty around future macroeconomic scenarios, and potential changes in other factors affecting child health. A wide range of sensitivity analyses were conducted to minimise these limitations. CONCLUSIONS: The implementation of fiscal austerity measures in Brazil can be responsible for substantively higher childhood morbidity and mortality than expected under maintenance of social protection-threatening attainment of Sustainable Development Goals for child health and reducing inequality.

[Child health environment in the context of relocating of camp site families to social housing]. / Salud ambiental infantil en el contexto de la reubicación de familias de campamentos a viviendas sociales.

INTRODUCTION: Housing interventions aimed at overcoming poverty can lead to changes in the health status of children by modifying risk factors in their physical and social environment OBJECTIVE: the aim was to identify children's environmental health factors to change with the relocation of families from slums to public housing. SUBJECTS AND METHOD: A cross-sectional study was conducted in children ages 2-8 years old of families relocated to public housing (n=115) who were compared to children residing in slums (n=88) in Santiago, Chile. Family socioeconomic characteristics, indoor environment and neighborhoods were collected. It was included respiratory symptoms, accidents and maternal-child care of children. χ2, Fisher and Mann-Whitney test were used to compare groups. RESULTS: There were differences in households related to pets keeping, presence of humidity/molds in homes, types of fuels, and perceived safety problems in neighborhoods (p<0.05). The families from slums reported higher tenancy of pets (73.8% v/s 32.2%%), humidity/molds in homes (43.,2% v/s 18.3%), use of wood for heating (39.8% v/s 0.0%), compared with families of public housing. Residents of public housing perceived more safety problems in neighborhood, and children have more asthma related symptoms and have lower diversity of accidents in home. CONCLUSION: Among the factors studied, indoor air quality and safety in neighborhoods could be linked to changes from the relocation of families. This reinforces the need to deepen the positive and negative influences of residential mobility of these groups focused on child welfare perspective.

Salud ambiental infantil en el contexto de la reubicación de familias de campamentos a viviendas sociales / Child health environment in the context of relocating of camp site families to social housing

Introducción: Intervenciones habitacionales destinadas a superar la pobreza pueden generar cambios en la situación de salud de la población infantil, modificando factores de riesgo en el entorno físico y social de niños y niñas. El objetivo fue identificar indicadores de salud ambiental infantil susceptibles de ser modificados con la reubicación de familias desde campamentos a vivienda social. Sujetos y método: Estudio transversal en niños de 2-8 años. Se comparó dos grupos de familias provenientes de campamentos. Un grupo fueron familias reubicadas en viviendas sociales entre 2001 y 2002 (n = 115). El otro grupo corresponde a niños cuyas familias permanecieron en campamentos (n = 88) de la zona poniente de Santiago. Se recolectó información sobre: características socioeconómicas, ambiente intradomiciliario y de barrios, y eventos en salud: síntomas respiratorios, accidentabilidad y cuidado materno infantil. Se emplearon pruebas de x², Fisher y Mann-Whitney para la comparación de los grupos. Resultados: Se identifican diferencias entre los grupos comparados en relación a la tenencia de mascotas, presencia de hongos/humedad en el hogar, tipo de combustibles utilizados y problemas de seguridad percibidos en los barrios (p<0,05). Las familias de campamentos reportan una mayor tenencia de mascotas (73,8% v/s 32,2%%), presencia de huellas de humedad/hongos en el hogar (43,2% v/s 18,3%), uso de leña (39,8% v/s 0,0%), en comparación con familias de viviendas sociales. Residentes de viviendas sociales perciben mayores problemas de seguridad en el barrio, mientras que los niños presentan mayor frecuencia de síntomas relacionados con asma y menor diversidad de accidentes en el hogar comparado con el grupo residente en campamentos. Conclusiones: Entre los factores estudiados, aquellos susceptibles de ser modificados con la reubicación de familias desde campamentos a vivienda social se vinculan a indicadores de calidad del aire interior y seguridad en los barrios. Lo anterior refuerza la necesidad de profundizar en las influencias positivas y negativas de la movilidad residencial de estos grupos, desde una perspectiva centrada en el bienestar infantil.

Introduction: Housing interventions aimed at overcoming poverty can lead to changes in the health status of children by modifying risk factors in their physical and social environment Objective: the aim was to identify children's environmental health factors to change with the relocation of families from slums to public housing. Subjects and method: A cross-sectional study was conducted in children ages 2-8 years old of families relocated to public housing (n=115) who were compared to children residing in slums (n=88) in Santiago, Chile. Family socioeconomic characteristics, indoor environment and neighborhoods were collected. It was included respiratory symptoms, accidents and maternal-child care of children. x², Fisher and Mann-Whitney test were used to compare groups. Results: There were differences in households related to pets keeping, presence of humidity/molds in homes, types of fuels, and perceived safety problems in neighborhoods (p<0.05). The families from slums reported higher tenancy of pets (73.8% v/s 32.2%%), humidity/molds in homes (43.,2% v/s 18.3%), use of wood for heating (39.8% v/s 0.0%), compared with families of public housing. Residents of public housing perceived more safety problems in neighborhood, and children have more asthma related symptoms and have lower diversity of accidents in home. Conclusion: Among the factors studied, indoor air quality and safety in neighborhoods could be linked to changes from the relocation of families. This reinforces the need to deepen the positive and negative influences of residential mobility of these groups focused on child welfare perspective.

Microcredit participation and child health: results from a cross-sectional study in Peru.

BACKGROUND: Childhood malnutrition is a major consequence of poverty worldwide. Microcredit programmes-which offer small loans, financial literacy and social support to low-income individuals-are increasingly promoted as a way to improve the health of clients and their families. This study evaluates the hypothesis that longer participation in a microcredit programme is associated with improvements in the health of children of microcredit clients. METHODS: Cross-sectional data were collected in February 2007 from 511 clients of a microcredit organisation in Peru and 596 of their children under 5 years of age. The primary predictor variable was length of participation in the microcredit programme. Outcome variables included height, weight, anaemia, household food security and parent-reported indicators of child health. Multivariate linear and logistic regressions assessed the association between the number of loan cycles and child health outcomes. Pathways through which microcredit may have influenced health outcomes were also explored via mediation analyses. RESULTS: Longer participation in microcredit was associated with greater household food security and reduced likelihood of childhood anaemia. No significant associations were observed between microcredit participation and incidence of childhood illnesses or anthropometric indicators. Increased consumption of red meat may mediate the association between the number of loan cycles and food security, but not the association with anaemia. CONCLUSIONS: The effects of microcredit on the health of clients' children are understudied. Exploratory findings from this analysis suggest that microcredit may positively influence child health, and that diet may play a causal role.

Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities.

BACKGROUND: In the past 15 years, Brazil has undergone notable social and public health changes, including a large reduction in child mortality. The Bolsa Familia Programme (BFP) is a widespread conditional cash transfer programme, launched in 2003, which transfers cash to poor households (maximum income US$70 per person a month) when they comply with conditions related to health and education. Transfers range from $18 to $175 per month, depending on the income and composition of the family. We aimed to assess the effect of the BFP on deaths of children younger than 5 years (under-5), overall and resulting from specific causes associated with poverty: malnutrition, diarrhoea, and lower respiratory infections. METHODS: The study had a mixed ecological design. It covered the period from 2004-09 and included 2853 (of 5565) municipalities with death and livebirth statistics of adequate quality. We used government sources to calculate all-cause under-5 mortality rates and under-5 mortality rates for selected causes. BFP coverage was classified as low (0·0-17·1%), intermediate (17·2-32·0%), high (>32·0%), or consolidated (>32·0% and target population coverage ≥100% for at least 4 years). We did multivariable regression analyses of panel data with fixed-effects negative binomial models, adjusted for relevant social and economic covariates, and for the effect of the largest primary health-care scheme in the country (Family Health Programme). FINDINGS: Under-5 mortality rate, overall and resulting from poverty-related causes, decreased as BFP coverage increased. The rate ratios (RR) for the effect of the BFP on overall under-5 mortality rate were 0·94 (95% CI 0·92-0·96) for intermediate coverage, 0·88 (0·85-0·91) for high coverage, and 0·83 (0·79-0·88) for consolidated coverage. The effect of consolidated BFP coverage was highest on under-5 mortality resulting from malnutrition (RR 0·35; 95% CI 0·24-0·50) and diarrhoea (0·47; 0·37-0·61). INTERPRETATION: A conditional cash transfer programme can greatly contribute to a decrease in childhood mortality overall, and in particular for deaths attributable to poverty-related causes such as malnutrition and diarrhoea, in a large middle-income country such as Brazil. FUNDING: National Institutes of Science and Technology Programme, Ministry of Science and Technology, and Council for Scientific and Technological Development Programme (CNPq), Brazil.

Child and young adult-headed households in the context of the AIDS epidemic in Zimbabwe, 1988-2006.

The emergence of child-headed households (CHH) is considered an indicator of the erosion of the traditional safety nets in sub-Saharan African countries and a direct consequence of the increasing number of orphans in the region. Using four available waves of the Zimbabwe Demographic and Health Surveys (1988, 1994, 1999, 2005/2006), we find that the proportion of households with no adults remained stable in the last years, although the number of orphans increased significantly. In fact, a large number of children living in CHH are nonorphans, which suggests that this kind of living arrangement is not always a direct consequence of parental death. Moreover, our analysis shows that children living in CHH and young adult households are less likely to have unmet basic needs than children in households headed by working-age adults and in other vulnerable households.

Putting two and two together? Early childhood education, mothers' employment and care service expansion in Chile and Mexico.

In recent years, several middle-income countries, including Chile, Mexico and Uruguay, have increased the availability of early childhood education and care (ECEC) services. These developments have received little scholarly attention so far, resulting in the (surely unintended) impression that Latin American social policy is tied to a familialist track, when in reality national and regional trends are more varied and complex. This article looks at recent efforts to expand ECEC services in Chile and Mexico. In spite of similar concerns over low female labour force participation and child welfare, the approaches of the two countries to service expansion have differed significantly. While the Mexican programme aims to kick-start and subsidize home- and community-based care provision, with a training component for childminders, the Chilean programme emphasizes the expansion of professional ECEC services provided in public institutions. By comparing the two programmes, this article shows that differences in policy design have important implications in terms of the opportunities the programmes are able to create for women and children from low-income families, and in terms of the programmes' impacts on gender and class inequalities. It also ventures some hypotheses about why the two countries may have chosen such different routes.

The role of international remittances in health outcomes in Ecuador: prevention and response to shocks.

This article evaluates the impact of remittances on health outcomes in Ecuador using an instrumental-variables approach. Although we do not find significant impacts on long-term child health variables, we find that remittances do have an impact on health expenditures, and on some preventive issues such as de-worming and vaccination. In addition, we find significant effects of remittances on medicine expenditures when illness occurs. In this regard, remittances are used for both preventive and emergency situations. Interestingly, we also find a significant and positive effect of remittances on health knowledge.

Costs of interventions for AIDS orphans and vulnerable children.

OBJECTIVE: To review the published and grey literature for information regarding the costs and cost-effectiveness of interventions aimed at improving the welfare of orphans and vulnerable children owing to HIV/AIDS in low- and middle-income countries. METHOD: We carried out a search of the peer-reviewed literature through PubMed, EconLit, and Web of Science for the period January 2000 to December 2010. We also extensively reviewed the grey literature through generalized web searches and consultations with experts and searches of the web pages of the main organizations active in providing services to orphans and vulnerable children (OVC). The search yielded 216 articles; cross-sectional or longitudinal studies and articles that did not address specific interventions were not considered. The remaining 21 articles were categorized by domain and by type of intervention strategy. RESULTS: All studies reviewed were carried out in sub-Saharan Africa. All outcomes are expressed as cost per child per year (in 2010 USD). Foster care estimates range from $614 to $1921. Educational support for primary school ranged from $30 to $75. Health interventions that would ensure child survival can be delivered for about $55. CONCLUSION: More research is needed to improve planning and delivery of interventions for OVC. The paucity of cost and cost-effectiveness data reflects the limited number of effectiveness studies. Nevertheless, this systematic literature review shows evidence that suggests that in the area of housing, foster care appears to be more cost effective than institutional care (orphanages).

The effect of early interventions in health and nutrition on on-time school enrollment: evidence from the Oportunidades Program in rural Mexico.

This article assesses whether early intervention to improve children's health and nutrition increases the probability of enrolling in primary school on time. Using experimental data from the Mexican conditional cash transfer (CCT) program, Oportunidades, a cross-sectional double-difference estimator on observations from two age cohorts of children is used to identify the impact of early intervention. The results indicate that early health and nutrition interventions can have a positive impact on the timing of enrollment and that caregiver characteristics affect the magnitude of the impact. Early intervention also appears to decrease days of school missed. Overall the results indicate that the full impact of CCT programs on education cannot be measured in the short run as benefits of early health and nutrition interventions may be also felt in the distant future.

Do family policy regimes matter for children's well-being?

Researchers have studied the impact of different welfare state regimes, and particularly family policy regimes, on gender equality. Very little research has been conducted, however, on the association between different family policy regimes and children's well-being. This article explores how the different family policy regimes of twenty OECD countries relate to children's well-being in the areas of child poverty, child mortality, and educational attainment and achievement. We focus specifically on three family policies: family cash and tax benefits, paid parenting leaves, and public child care support. Using panel data for the years 1995, 2000, and 2005, we test the association between these policies and child well-being while holding constant for a number of structural and policy variables. Our analysis shows that the dual-earner regimes, combining high levels of support for paid parenting leaves and public child care, are strongly associated with low levels of child poverty and child mortality. We find little long-term effect of family policies on educational achievement, but a significant positive correlation between high family policy support and higher educational attainment. We conclude that family policies have a significant impact on improving children's well-being, and that dual-earner regimes represent the best practice for promoting children's health and development.

Preschool and maternal labor market outcomes: evidence from a regression discontinuity Design.

In developing countries, employment rates for mothers with young children are relatively low. This study analyzes how maternal labor market outcomes in Argentina are affected by the preschool attendance of their children. Using pooled household surveys, we show that 4-year-olds with birthdays on June 30 have sharply higher probabilities of preschool attendance than children born on July 1, given enrollment-age rules. Regression-discontinuity estimates using this variation suggest that preschool attendance of the youngest child in the household increases the probability of full-time employment and weekly hours of maternal employment. We find no effect of preschool attendance on maternal labor outcomes for children who are not the youngest in the household.

Is child labor harmful? The impact of working earlier in life on adult earnings.

This paper explores the question: is working as a child harmful to an individual in terms of adult outcomes in earnings? Although this is an extremely important question, little is known about the effect of child labor on adult outcomes. Estimations of an instrumental variables earnings model on data from Brazil show that child labor has a large negative impact on adult earnings for male children even when controlling for schooling and that the negative impact of starting to work as a child reverses at around ages 12­14.

Household shocks, child labor, and child schooling: evidence from Guatemala.

Using data from the National Survey of Standards of Living conducted in Guatemala in 2000, this article tests the hypothesis that Guatemalan households use child labor and reduce child schooling to cope with household shocks. First, the authors use factor analysis to estimate the latent household propensity to natural disasters and socioeconomic shocks. Then, they estimate bivariate probit models to identify the determinants of child labor and schooling, including household propensity to natural disasters and socioeconomic shocks. Results suggest that households use child labor to cope with natural disasters and socioeconomic shocks. In contrast, the authors found no evidence that suggests that households reduce child schooling to cope with shocks. Findings also indicate that poor households are more likely to use child labor and schooling reduction as strategies to cope with socioeconomic shocks.