3ie el s_adb_2011

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3ie el s_adb_2011

  1. 1. CAN CCTS IMPROVE MATERNAL HEALTH OUTCOMES?EVIDENCE FROM EL SALVADOR Alan de Brauw and Amber Peterman International Food Policy Research Institute
  2. 2. CONDITIONAL CASHTRANSFER PROGRAMSIn general, CCT programs give cash grants forfamilies conditional on specific behaviorsUsually have to do with health (e.g. growthmonitoring) or education (children going to school) Programs often require or hold meetings for beneficiaries on specific topicsPrograms also notable for being accompanied byrigorous impact evaluations Now widespread in Central/South America
  3. 3. IMPACTS OF CCTS ON MATERNAL HEALTH?CCTs well positioned to affect maternal healthoutcomes at birth, but few studies have attempted tomeasure benefits of CCTs for maternal health Most evidence from Oportunidades in Mexico (pre-natal care; Barber and Gertler, 2009; c-sections increased as well), and JSY in India (Lin et al., 2010); one time inducement for in- facility birthSeveral mechanisms by which CCTs might affectmaternal health, even if not included as a conditionfor transfers
  4. 4. POSSIBLE MECHANISMS FOR IMPACT1. Free Health Care included as a benefit of program (e.g. Oportunidades)2. Co-responsibilities may include pre- or post-natal care3. May stimulate demand through health or nutrition trainings4. CCTs may at the same time increase supply of health services through investments5. Income effect increases demand A.May be gender differentiated impacts due to transfer
  5. 5. OUTCOMES WE STUDY1. Adequate pre-natal care (defined as 5 visits or more during pregnancy)2. Skilled attendance at birth3. Birth in hospital4. Post-natal care (defined as visit to health care for mother within 2 weeks of birth)
  6. 6. METHODOLOGYWe use an innovative RDD methodology (de Brauwand Gilligan, 2011) to measure impacts ofComunidades Solidarias Rurales on maternal healthoutcomes in rural El Salvador Methodology allows us to use RDD without explicit forcing variable Also use double difference to control for pre- program conditions
  7. 7. REGRESSIONDISCONTINUITY DESIGNIdentification Assumption: A threshold exists thatsplits treatment and control From the beneficiaries’ perspective, threshold is exogenous Typically determined through a proxy means test or another forcing variable Observations just above and just below threshold can be compared to measure impact of programProblem in this case is a lack of an explicit forcingvariable
  8. 8. IMPLICIT FORCING 15 VARIABLEPercentage of Children Severely Stunted A A Threshold Severe Stunting Rate S 10 S S A S A S A A A 5 A A A S A A A A S S SS S S A S S S S S 0 30 40 50 60 Poverty Rate Forcing Line Cluster Centers
  9. 9. DATACome from evaluation surveys of CSR conducted byIFPRI-FUSADES Collected in the beginning and end of 2008 Treatment and control groups for this part of evaluation entered program in 2006 and 2007In initial survey, asked about birth history over pastthree years to construct a before and after comparison
  10. 10. TREATMENT ANDCONTROL GROUPS Entry DateBefore Treatment After Treatment 2006 entry group October 1st, 2006Before Treatment After Treatment 2007 entry group
  11. 11. DESCRIPTIVE CHANGES, 2006 ENTRY GROUP Pre-CSR Post-CSR 100 75 50 25 0 Pre-Natal Skilled Att. Hospital Post-Natal
  12. 12. RESULTS: ADEQUATE PRE-NATAL CARE .4Change in Adequate .2 Pre-natal care 0 -.2 -.4 -.6 -15 -10 -5 0 5 10 15 Distance to Cluster Threshold 2006 Entry 2007 Entry
  13. 13. RESULTS: SKILLED ATTENDANCE AT BIRTH .4Attendance at Birth Change in Skilled .2 0 -.2 -.4 -15 -10 -5 0 5 10 15 Distance to Cluster Threshold 2006 Entry 2007 Entry
  14. 14. RESULTS: BIRTH IN HOSPITALS .4Change in Birth in .2 Hospitals 0 -.2 -.4 -15 -10 -5 0 5 10 15 Distance to Cluster Threshold 2006 Entry 2007 Entry
  15. 15. RESULTS: POST-NATAL CARE .4Change in Post-Natal .2 Care 0 -.2 -15 -10 -5 0 5 10 15 Distance to Cluster Threshold 2006 Entry 2007 Entry
  16. 16. PRIMARY RESULTS Individual + Outcome no control variables Household ControlsAdequate pre-natal -0.112 -0.089 monitoring (0.084) (0.086)Skilled attendance 0.174 0.164 at birth (0.057)*** (0.075)** 0.223 0.214 Birth in hospital (0.052)*** (0.052)*** -0.094 -0.093 Post-natal care (0.138) (0.140)
  17. 17. IMPACT PATHWAYSNot a co-responsibility of program to have birthattended by qualified personnel or in a hospitalOverall income effect also unlikely (transfer isrelatively small)So three remaining possibilities: Through training (capaciticiones) Through supply side (increase in access to facilities) Through increase in women’s decision making power
  18. 18. CAPACITICIONES?Impact cannot all bethrough trainingsTrainings only beganafter transfers didShort time period fortrainings to affect suchlarge change
  19. 19. SUPPLY SIDE?Access to facilitiesincreased in a non-linearmanner throughoutcommunities that wereto enter CSRSo cannot be supplyside in isolation ofstimulated demandDefinitely played a role
  20. 20. WOMEN’S DECISION MAKING POWERWomen definitelyempowered by CSR,through transfers andknowledege (Adato et al.,2009)Not clear how to quantifyimpact, but with increasedsupply and awareness, mayhave affected changesaround birth
  21. 21. CONCLUSIONEl Salvador’s CCT, Comunidades Solidarias Rurales,has improved outcomes at birth along some linesNot other measures of women’s health duringfertility howeverTo increase impacts, perhaps should also conditionprogram on pre- and post-natal visits Could potentially replace one capaciticion, if women feel burdened by program

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