Can combining social programs reduce child mortality?

Responsible researcher: Viviane Pires Ribeiro

Article title: COMBINATION OF CONDITIONAL CASH TRANSFER PROGRAM AND ENVIRONMENTAL HEALTH INTERVENTIONS REDUCES CHILD MORTALITY: AN ECOLOGICAL STUDY OF BRAZILIAN MUNICIPALITIES

Article authors: Anelise Andrade de Souza, Sueli Aparecida Mingoti, Rômulo Paes-Sousa and Leo Heller

Location of intervention: 5,570 Brazilian municipalities

Sample size: 38,137 observations

Sector: Healthcare

Type of Intervention : Interactive effects of Brazilian public interventions

Variable of main interest: Infant mortality

Assessment method: Others - Longitudinal data analysis

Assessment Context

Brazil is among the countries with the highest levels of income inequality. After a period of sharp and sustained decline in poverty and inequality, this progress has been reversed by the economic slowdown since 2014. In this scenario, the list of deficits faced by the country includes income, food, adequate housing and public services, such as health, education , water, sanitation and garbage collection.

In relation to environmental health interventions, the main deficits that still prevail in Brazil are mainly related to sanitation. Houses with piped water facilities (water systems or wells) represent approximately 95.6% of Brazilian households. However, when considering only households with adequate access, according to the National Basic Sanitation Plan (PLANSAB), this coverage drops to 57.7%. Furthermore, only 48% of Brazilian households have adequate access to the sewage network and only 64.9% of the population has access to urban cleaning and adequate waste management.

The populations most affected by inadequate sanitation conditions are those living in peri-urban and rural areas, that is, the poorest population groups and, consequently, the most vulnerable. Given this, the economic and social vulnerability of a large part of the Brazilian population makes these groups more likely to maintain the poverty-disease cycle.

Aiming to reduce economic and social vulnerability, the Brazilian government created the Bolsa Família Program (PBF), one of the main conditional income transfer programs. The Program began in 2003, covering 3.6 million families, increasing to 11.2 million families in 2006. In 2019, all 5,570 Brazilian municipalities had already implemented the PBF, benefiting 13.8 million families.

Intervention Details

In the context of environmental health, de Souza et al. (2021) state that the study of interactive effects with other interventions is important to evaluate the combined effects of public interventions to improve access to quality water, adequate sanitation and solid waste collection. Thus, the authors sought to evaluate the interactive effects of Brazilian public interventions, environmental health programs (access to water, sanitation and solid waste collection) and the Conditional Income Transfer Program (Bolsa Família Program), in reducing mortality from diarrhea and malnutrition in children under 5 years of age.

The data used in the research were collected from the Ministry of Health (Mortality Information System/SIM), the Ministry of Social Development (Social Information Matrix/MIS) and the Brazilian Institute of Geography and Statistics (2000 and 2010 population censuses, and intercensal estimates). The analysis covered the period from 2006 to 2016, including 3,467 municipalities from all regions of the country, totaling 38,137 observations.

Methodology Details

The study carried out by de Souza et al. (2021) is framed as an ecological project with exploratory and analytical analyses. It is possible to carry out a longitudinal study to evaluate temporal changes in mortality rates due to malnutrition and diarrhea, as well as investigate the association between average exposure to independent variables (access to the Conditional Cash Transfer Program and environmental health variables) and rates of mortality among children under 5 years of age. The design also allowed evaluating the interaction between independent variables, mainly access to the Conditional Cash Transfer Program (PBF) and environmental health variables.

The generalized linear models were adjusted considering the Negative Binomial (BN) distribution for the number of deaths due to malnutrition and diarrhea, with fixed effects. BN models with and without zero inflation were evaluated. Subsequent interaction models were applied to evaluate the combined effects of the two public policies.

Results

The results of the study show that the average mortality rates from diarrhea and malnutrition in children under 5 years of age decreased when comparing the years 2006 and 2016, in the Brazilian municipalities observed. The biggest drops in mortality from diarrhea occurred in the South region, followed by the Central-West region. The biggest drops in mortality due to malnutrition occurred in the Southeast region.

On the other hand, the analysis of longitudinal data shows a concentration of higher average mortality rates due to malnutrition in the North, Northeast and Central-West regions and due to diarrhea in the North region.

In relation to the drop in mortality rates due to diarrhea in the municipalities, a change in the positive effect was observed in the presence of: high coverage of the target population by the Conditional Cash Transfer Program and access to water, 0.54 (0.28- 1.04) / 0.55 (0.29-1.04); high coverage of the total population by the PBF and access to water, 0.97 (0.95-1.00) and high coverage of the total population by the PBF and access to sanitation, 0.98 (0.97-1.00). Declining mortality from diarrhea was also observed in the combined presence of high solid waste collection coverage and access to water, categories 1 (>60% ≤ 85%): 0.98 (0.96–1.00), 0, 98 (0.97–1.00) and 2 (>85% ≤ 100%): 0.97 (0.95–0.98), 0.97 (0.95–0.99).  

Negative effect modifications were observed for mortality due to malnutrition in the simultaneous presence of high coverage of the total population by the Conditional Cash Transfer Program and access to sanitation categories 1 (≥ 20 <50%): 1.0061 (0.9991- 1.0132) and 2 (≥ 50 <100%): 1.0073 (1.0002-1.0145) and high coverage of the total population by the PBF and solid waste collection, 1.0004 (1.0002–1.0005), resulting in increased mortality rates due to malnutrition.  

Public Policy Lessons

The analysis carried out by de Souza et al. (2021) indicates the importance of associating different social programs with the approach to combating poverty. Systemic interventions, which aim to protect individuals or families from poverty associated with precarious environmental conditions, are essential to eliminate the transmission routes of infectious and parasitic diseases, reducing child mortality.

The maintenance of Conditional Income Transfer Programs, with full coverage of the target population, combined with universal environmental health policies, for all Brazilian municipalities and with greater attention to the North, Northeast and Central-West regions, must be a government priority, as it will provide greater beneficial effects on children's health. The maintenance and expansion of these programs requires prioritization and planning by the federal government to meet the demand, together with municipal authorities, in adapting their health, education and housing structures, in order to allow beneficiary care and compliance with conditionalities. of the program.

In this sense, the authors highlight a clear downward trend in the main social protection variables, especially in 2016, indicating the need for: (i) comprehensive assistance to the target population of the Conditional Income Transfer Program; (ii) universal public environmental health policies; (iii) increasing literacy among people aged 15 and over; (iv) increase in population coverage by the Family Health Strategy, through the strengthening of the Unified Health System (SUS), thus allowing: the construction of safer environments, the survival of children and the improvement in the development of quality of life.

References

DE SOUZA, Anelise Andrade et al. Combination of conditional cash transfer program and environmental health interventions reduces child mortality: an ecological study of Brazilian municipalities. BMC public health, vol. 21, no. 1, p. 1-13, 2021.