What is the effect of Bolsa Família on child health?

Responsible researcher: Viviane Pires Ribeiro

Article title: 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

Article authors: Jeremy A. Labrecque, Jay S. Kaufman, Laura B. Balzer, Richard F. Maclehose, Erin C. Strumpf, Alicia Matijasevich, Iná S. Santos, Kelen H Schmidt and Aluísio JD Barros

Location of intervention: Brazil

Sample size: 1703 children

Big topic: Health

Variable of main interest: Child health

Assessment method: Maximum likelihood estimation

Assessment Context

Conditional Bank Transfers are government programs that provide cash assistance to poor families, as long as they meet specific requirements. Most requirements relate to improving child health and education, such as requiring health screenings, vaccinations, prenatal care for the mother, school enrollment, or a specific level of school attendance. Bolsa Família (BF) is a Brazilian program of monthly transfers that began in 2004 and beneficiary families that met the requirements (children's health exams, up-to-date vaccinations and school attendance greater than or equal to 85%) received between R$15 -95 monthly, depending on per capita family income and number of children. In 2015, Bolsa Família covered more than 27 million low-income households, paying a total of R$28.5 billion in 2016, according to data from the General Comptroller of the Brazilian Union.

Lebrecque et al. (2018) argue that although a variety of anthropometric measurements are used to assess children's nutritional status, height-for-age or length-for-age are of particular interest for two reasons: they are good proxies of accumulated nutritional status, which allows studying the nutritional consequences of BF in the long term; and poor child growth, particularly in the first 24 months, is an important predictor of future health. Weight-for-age is also used to assess nutritional status and can indicate short-term changes in nutritional status. In this context, Lebrecque et al. (2018) estimate the effect of the Brazilian conditional transfer program, Bolsa Família, on child nutritional status, measured by length-for-age and weight-for-age, from birth to 24 months.

Intervention Details

The data used by the authors were obtained from the Pelotas Birth Cohort, which recruited 99% of hospital births in all five hospitals within the limits of the Brazilian city of Pelotas in 2004. Length-for-age and weight-for-age were calculated using the 2006 World Health Organization growth standards. Field researchers conducted home visits to measure children and administer questionnaires to parents. Thus, information was obtained on prenatal, parental and socioeconomic variables. Lebrecque et al. (2018) used data from birth, 12 and 24 months, twins and babies who died before 24 months were excluded from the analysis. The authors also limited the study to families reporting a per capita income of R$100 or less, as families with a higher per capita income were not eligible to receive the BF.

Data on the amount of money received by BF beneficiaries were obtained from the Transparency Portal website ( http://www.portaltransparencia.gov.br ). The relationship between the money received from BF and length-for-age and weight-for-age was made probabilistically, using the child's name, date of birth, parents' name and age. Totaling 1703 children eligible to receive the benefit.

Methodology Details

Lebrecque et al. (2018) divided children into three groups of total amount of BF received in the first 24 months: no BF (received R$0), low BF (received R$1000 or less) and high BF (received more than R$1000) . The authors used a maximum likelihood estimation method, a doubly robust, semiparametric, efficient substitution statistical parameter estimator, to estimate the effect of receiving low and high levels of BF on child nutritional status, measured by length-for-age and weight-for-age, from birth to 24 months.

Results

Of the 1703 families studied, 110 belonged to the low BF group and 319 were in the high BF group in the first 12 months. At 24 months, 291 families were in the low BF group and 355 in the high BF group. On average, participating families received BF for 16 of the 24 months after the child was born (with a standard deviation of 8). Of the families that started BF, 96% were still receiving it 24 months after the birth of their child.

The pattern of mothers who received BF and who participated in the analysis is: older, shorter height, low level of education, had few prenatal consultations, gained less weight during pregnancy, more likely to smoke and less likely to work during pregnancy when compared to mothers who did not receive BF. Birth length, birth weight, gestational age, and reported health problems at birth were all similar by BF level. All socioeconomic variables indicated that exposed families were notably poorer and had larger families.

The authors found a negative association between BF and height-for-age and weight-for-age at almost all BF levels. The association was greater for high BF in height-for-age and weight-for-age at 24 months, with a reduction of around 0.19 z-scores in both cases. The comparisons between low BF and high BF were all negative, but there were confidence intervals also consistent with positive values. Estimates were lower at 12 months than at 24 months.

Public Policy Lessons

What is the effect of Bolsa Família on child health? The results obtained by Lebrecque et al. (2018) indicate that in the first two years of the child's birth, families that received Bolsa Família were negatively associated with child nutritional status. Over 24 months, this negative association is equivalent to approximately three weeks of delayed growth in height-for-age and five weeks of delayed growth in weight-for-age.

The authors emphasize that, despite their efforts, the possibility of residual confusion cannot be eliminated. But if the results are not due to residual confusion in the estimates, there are possible causal mechanisms that explain why Bolsa Família has a negative effect on the child's height-for-age and weight-for-age. Some studies suggest that receiving BF may be associated with the purchase of less nutritious foods. Another study in northeastern Brazil found that families who received BF were three times more likely to consume nutrient-poor foods than families who did not receive BF. A poorer diet can lead to an increase in infections or micronutrient deficiencies which can, in turn, reduce height-for-age. There is also, however, some research demonstrating a positive relationship between BF and diet and nutrition. Therefore, Lebrecque et al. (2018) argue that additional studies with more recent data are needed to determine whether this negative relationship between Bolsa Família and child health continues at present, given that the authors used data from the first years of BF payment.

References

LABRECQUE, Jeremy A. et al. 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. Social Science & Medicine , vol. 211, p. 9-15, 2018.