Health outcomes of the Bolsa Família program among Brazilian Amazonian children.

OBJECTIVE: One of the primary objectives of Brazil's conditional cash transfer program, Bolsa Família, is to break the intergenerational transmission of poverty by improving human capital via conditionalities. In this study, we hypothesized that health indicators of Bolsa Família participants would be comparable to those of other local children who were nonparticipants after two years of follow-up in the city of Acrelândia, Acre state, Western Brazilian Amazon. METHODS: Data from a population-based longitudinal study were analyzed to examine school enrollment, vaccination coverage, height and body mass index for age z-scores, and biomarkers of micronutrient deficiencies (iron and vitamin A) between Bolsa Família participants (n = 325) and nonparticipants (n = 738). RESULTS: Out of 1063 children 10 years and younger included in the 2007 baseline survey, 805 had anthropometric measurements and 402 had biochemical indicators in the 2009 follow-up survey. Prevalence rate ratio (PRR) for non-enrollment in school at 4 years of age was 0.58 (95%CI: 0.34-1.02) when comparing Bolsa Família participants with nonparticipants. No difference was found for vaccination coverage, which was insufficient for most vaccine-preventable diseases. Bolsa Família participants were less likely to show a positive change in body mass index for age z-scores compared with nonparticipants (PRR = 0.81, 95%CI: 0.70-0.95), while a positive change in height for age z-scores was similar in the groups. No differences in micronutrient deficiencies were found between groups after 2 years. CONCLUSIONS: Early school enrollment and consistent nutritional indicators between Bolsa Família participants and nonparticipants suggest Bolsa Família was facilitating similarities between groups over time.

Health outcomes of the bolsa família program among Brazilian Amazonian children

ABSTRACT OBJECTIVE One of the primary objectives of Brazil's conditional cash transfer program, Bolsa Família, is to break the intergenerational transmission of poverty by improving human capital via conditionalities. In this study, we hypothesized that health indicators of Bolsa Família participants would be comparable to those of other local children who were nonparticipants after two years of follow-up in the city of Acrelândia, Acre state, Western Brazilian Amazon. METHODS Data from a population-based longitudinal study were analyzed to examine school enrollment, vaccination coverage, height and body mass index for age z-scores, and biomarkers of micronutrient deficiencies (iron and vitamin A) between Bolsa Família participants (n = 325) and nonparticipants (n = 738). RESULTS Out of 1063 children 10 years and younger included in the 2007 baseline survey, 805 had anthropometric measurements and 402 had biochemical indicators in the 2009 follow-up survey. Prevalence rate ratio (PRR) for non-enrollment in school at 4 years of age was 0.58 (95%CI: 0.34-1.02) when comparing Bolsa Família participants with nonparticipants. No difference was found for vaccination coverage, which was insufficient for most vaccine-preventable diseases. Bolsa Família participants were less likely to show a positive change in body mass index for age z-scores compared with nonparticipants (PRR = 0.81, 95%CI: 0.70-0.95), while a positive change in height for age z-scores was similar in the groups. No differences in micronutrient deficiencies were found between groups after 2 years. CONCLUSIONS Early school enrollment and consistent nutritional indicators between Bolsa Família participants and nonparticipants suggest Bolsa Família was facilitating similarities between groups over time.

Health profile differences between recipients and non-recipients of the Brazilian Income Transfer Program in a low-income population.

We investigated the relationship between living in a household that receives the Brazilian Income Transfer Program (Bolsa Família, in Portuguese - BF), a Brazilian conditional cash transfer program, and aspects of health and whether these relationships are heterogeneous across the 27 Brazilian states. According to data from the 2013 Brazilian National Health Survey, 18% of households participated in BF. Among households with household per capita income below BRL 500, many aspects of health differed between people living in BF and non-BF houses. For example, BF households were less likely to have medical coverage but more likely to have visited the doctor in the last 12 months as well as being more likely to smoke and less likely to do exercise. They ate nearly one less serving of fruits and vegetables a week but were less likely to substitute junk food for a meal. They reported worse self-rated health but did not differ importantly on reporting illnesses. Moderate amounts of heterogeneity in the difference in health characteristics were found for some variables. For instance, medical coverage had an I2 value of 40.7% and the difference in coverage between BF and non-BF households ranged from -0.09 to -0.03. Some illnesses differed qualitatively across states such as high cholesterol, asthma and arthritis. This paper is the first to outline the health profile of people living in households receiving payments from a cash transfer program. It is also the first to find geographic heterogeneity in the relationship between a cash transfer program and health variables. These results suggest the possibility that the effect of cash transfer programs may differ based on the population on which it is implemented.

Health profile differences between recipients and non-recipients of the Brazilian Income Transfer Program in a low-income population / Diferenças no perfil de saúde entre beneficiários e não-beneficiários do programa Bolsa Família em uma população de baixa renda / Diferencias en el perfil de salud entre beneficiarios y no-beneficiarios del programa Bolsa Familia en una población con bajos ingresos

Abstract: We investigated the relationship between living in a household that receives the Brazilian Income Transfer Program (Bolsa Família, in Portuguese - BF), a Brazilian conditional cash transfer program, and aspects of health and whether these relationships are heterogeneous across the 27 Brazilian states. According to data from the 2013 Brazilian National Health Survey, 18% of households participated in BF. Among households with household per capita income below BRL 500, many aspects of health differed between people living in BF and non-BF houses. For example, BF households were less likely to have medical coverage but more likely to have visited the doctor in the last 12 months as well as being more likely to smoke and less likely to do exercise. They ate nearly one less serving of fruits and vegetables a week but were less likely to substitute junk food for a meal. They reported worse self-rated health but did not differ importantly on reporting illnesses. Moderate amounts of heterogeneity in the difference in health characteristics were found for some variables. For instance, medical coverage had an I2 value of 40.7% and the difference in coverage between BF and non-BF households ranged from -0.09 to -0.03. Some illnesses differed qualitatively across states such as high cholesterol, asthma and arthritis. This paper is the first to outline the health profile of people living in households receiving payments from a cash transfer program. It is also the first to find geographic heterogeneity in the relationship between a cash transfer program and health variables. These results suggest the possibility that the effect of cash transfer programs may differ based on the population on which it is implemented.

Resumo: Os autores investigaram a relação entre pertencimento a uma família beneficiária do programa Bolsa Família (BF) e características de saúde, e se tais relações são heterogêneas, comparando os 26 estados e Distrito Federal, Brasil. De acordo como dados da Pesquisa Nacional de Saúde de 2013, 18% dos domicílios brasileiros participavam do BF. Entre as famílias com renda per capita abaixo de R$ 500,00, havia diferenças entre diversas características de saúde, comparando pessoas de famílias beneficiárias e não beneficiárias do BF. Por exemplo, pessoas de famílias matriculadas no BF mostraram menor probabilidade de ter cobertura médica, mas maior probabilidade de haverem consultado um médico nos últimos 12 meses, além de maior probabilidade de serem fumantes e menor probabilidade de serem fisicamente ativas. Consumiam quase uma porção a menos de frutas e verduras por semana, mas tinham menor probabilidade de substituir refeições com lanches. Apresentavam pior percepção da própria saúde, mas não mostravam diferenças importantes no relato de doenças. Houve uma heterogeneidade moderada nas características de saúde em relação a algumas variáveis. Por exemplo, a cobertura de saúde mostrou um valor de I2 de 40,7%, enquanto a diferença de cobertura entre famílias com e sem BF variou entre 0,09 e -0,03. Houve diferenças qualitativas entre estados em relação a algumas doenças, tais como hipercolesterolemia, asma e artrite. Este estudo foi o primeiro a definir o perfil de saúde de pessoas em famílias beneficiárias do BF. Também é o primeiro a encontrar uma heterogeneidade geográfica na relação entre o programa e variáveis de saúde. Os resultados sugerem que o efeito de um programa de renda mínima pode variar de acordo com a população na qual é implementado.

Resumen: Investigamos la relación entre vivir en un hogar que recibe ayudas del programa Bolsa Familia (BF), programa brasileño de transferencia monetaria condicionada, y aspectos de salud, además de estudiar si estas relaciones son heterogéneas entre los 27 estados brasileños. De acuerdo con los datos de 2013 en la Encuesta Nacional de Salud brasileña, un 18% de los hogares participaron en BF. Entre los hogares con unos ingresos per cápita por debajo de BRL 500, muchos aspectos de salud difirieron entre la gente que vivía en hogares con BF y sin BF. Por ejemplo, los hogares con BF fueron menos propensos a contar cobertura médica, pero era más probable que hubieran visitado al doctor en los últimos 12 meses, al igual que más probabilidad de fumar y menos propensos a hacer ejercicio. Comían frutas y verduras menos de casi una vez a la semana y eran menos propensos a sustituir la comida basura por una comida. Informaban de una peor salud autoevaluada, pero no difieren significativamente respecto a las enfermedades relatadas. Se encontraron algunas variables de heterogeneidad en cantidades moderadas, respecto a la diferencia en las características de salud. Por ejemplo, la cobertura médica tenía una cobertura con un valor I2 de 40,7% y la diferencia en la cobertura entre hogares con BF y no-BF oscilaba en un rango de -0.09 a -0.03. Algunas enfermedades se diferenciaban cualitativamente entre estados como el colesterol alto, asma y artritis. Este trabajo es el primero en resaltar el perfil de salud de la gente que vive en hogares que reciben pagos del programa brasileño de transferencia monetaria condicionada. Asimismo, es el primero en encontrar una heterogeneidad geográfica en la relación entre el programa brasileño de transferencia monetaria condicionada y variables de salud. Estos resultados sugieren la posibilidad de que el efecto del programa brasileño de transferencia monetaria condicionada puede ser diferente en función de la población en la que se implementa.

Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation.

OBJECTIVE: Conditional cash transfer programs are popular internationally and represent a large investment in child health. Evidence of their impact on child nutrition status remains weak and inconsistent, particularly for Bolsa Família, the Brazilian conditional cash transfer program and one of the world's largest. Our objective was to estimate the effect of the Brazilian conditional cash transfer program, Bolsa Família (BF), on child nutritional status as measured by length-for-age z-score (LAZ) and weight-for-age z-score (WAZ) at 24 months. METHODS: We analyzed the 1703 children eligible for BF from the 2004 Pelotas Birth Cohort. Children were divided into three exposure groups by total amount of money their household received from BF in 24 months: no BF, low BF (≤R$1000) and high BF (>R$1000). Using a doubly robust semiparametric estimation method we estimated the effect of receiving low and high levels of BF on LAZ and WAZ at 24 months. RESULTS: After adjustment for measured confounders, the expected difference in LAZ between children that received low or high levels of BF compared to no BF was -0.14 [95% confidence interval (CI): -0.27, -0.02] and -0.20 (95% CI: -0.33, -0.08) respectively. For WAZ the estimated differences were -0.04 (95% CI: -0.17, 0.08) for low levels versus no BF and -0.18 (95% CI: -0.30, -0.05) for high levels versus no BF. The expected difference in population LAZ had all eligible households received it and population LAZ under no BF was -0.15 (95% CI: -0.26, -0.04). Sensitivity analyses suggested only a strong confounder could explain away these results. CONCLUSIONS: Among participants of the 2004 Pelotas Birth Cohort, BF was associated with a reduction in LAZ and WAZ in 24 month old children.

Social Pension Income Associated With Small Improvements In Self-Reported Health Of Poor Older Men In Colombia.

The countries of Latin American are aging rapidly. Because most countries in the region lack adequate social protection systems, many Latin American governments have introduced noncontributory pension programs to reduce poverty and food shortages. This study assessed the effects of a large national noncontributory pension program on the health and health care use of older people in Colombia. Using an instrumental variables approach that exploited differential rollout of the program across municipalities, we found evidence that the program led to significant but small improvements in self-reported health and reductions in hospitalizations among men. No significant effects were found among women or among men for other health and health care use outcomes. A small noncontributory pension was associated with improvements in self-reported measures of health for vulnerable older men, but these effects are small in magnitude. Researchers and policy makers should assess ways to maximize the health benefits of cash transfers to poor older people.

The impact of the Brazilian Family Health Strategy and the conditional cash transfer on tuberculosis treatment outcomes in Rio de Janeiro: an individual-level analysis of secondary data.

Background: Unsuccessful tuberculosis outcomes are frequent; bold policies are needed to end the tuberculosis (TB) epidemic to attain the third Sustainable Development Goal (SDG) by 2030. We examined the effect of the Family Health Strategy (FHS) and its interactions with the conditional cash transfer programme (CTP) on TB outcomes in Rio de Janeiro, Brazil. Methods: We performed individual-based analyses of a database resulting from deterministic and probabilistic linkages of the TB information system, FHS registries and CTP payrolls. Patients ≥15 years old treated with the standard RHZE regimen were included. The rates of successful outcomes were analysed according to coverage by FHS. Effects from the CTP and its interactions with the FHS were examined among the poorest. Results: FHS coverage increased the likelihood for successful outcomes by 14% (12-17%) among 13 482 new cases, and by 35% (25-47%) among 1880 retreatment cases. The CTP had an independent effect but no interaction with the FHS among the poorest. Conclusions: This is the first individual-based study to show a relevant protection of poor urban communities regarding patient-important health outcomes by the Brazilian FHS and CTP. These findings support strategies of universal health coverage, primary care strengthening and social protection to achieve a major SDG.

Cash transfers and domestic violence.

Violence against women is a major health and human rights problem yet there is little rigorous evidence as to how to reduce it. We take advantage of the randomized roll-out of Ecuador's cash transfer program to mothers to investigate how an exogenous increase in a woman's income affects domestic violence. We find that the effect of a cash transfer depends on a woman's education and on her education relative to her partner's. Our results show that for women with greater than primary school education a cash transfer significantly decreases psychological violence from her partner. For women with primary school education or less, however, the effect of a cash transfer depends on her education relative to her partner's. Specifically, the cash transfer significantly increases emotional violence in households where the woman's education is equal to or more than her partner's.

Effects of a conditional cash transfer programme on child nutrition in Brazil.

OBJECTIVE: To examine the association between Brazil's Bolsa Familia programme (BFP), which is the world's largest conditional cash transfer programme, and the anthropometric indicators of nutritional status in children. METHODS: Using the opportunity provided by vaccination campaigns, the Brazilian government promotes Health and Nutrition Days to estimate the prevalence of anthropometric deficits in children. Data collected in 2005-2006 for 22 375 impoverished children under 5 years of age were employed to estimate nutritional outcomes among recipients of Bolsa Família. All variables under study, namely child birth weight, lack of birth certificate, educational level and gender of family head, access to piped water and electricity, height for age, weight for age and weight for height, were converted into binary variables for regression analysis. FINDINGS: Children from families exposed to the BFP were 26% more likely to have normal height for age than those from non-exposed families; this difference also applied to weight for age. No statistically significant deficit in weight for height was found. Stratification by age group revealed 19% and 41% higher odds of having normal height for age at 12-35 and 36-59 months of age, respectively, in children receiving Bolsa Familia, and no difference at 0-11 months of age. CONCLUSION: The BFP can lead to better nutritional outcomes in children 12 to 59 months of age. Longitudinal studies are needed to confirm these findings.

Decentralization and equity of resource allocation: evidence from Colombia and Chile.

OBJECTIVE: To investigate the relation between decentralization and equity of resource allocation in Colombia and Chile. METHODS: The "decision space" approach and analysis of expenditures and utilization rates were used to provide a comparative analysis of decentralization of the health systems of Colombia and Chile. FINDINGS: Evidence from Colombia and Chile suggests that decentralization, under certain conditions and with some specific policy mechanisms, can improve equity of resource allocation. In these countries, equitable levels of per capita financial allocations at the municipal level were achieved through different forms of decentralization--the use of allocation formulae, adequate local funding choices and horizontal equity funds. Findings on equity of utilization of services were less consistent, but they did show that increased levels of funding were associated with increased utilization. This suggests that improved equity of funding over time might reduce inequities of service utilization. CONCLUSION: Decentralization can contribute to, or at least maintain, equitable allocation of health resources among municipalities of different incomes.