Impact of Community-Based Conditional Cash Transfers on Health in Tanzania

1. David Evans World Bank Joint work with Brian Holtemeyer and Katrina Kosec (IFPRI) July 9, 2015 The Health Impacts of Community-Based Conditional Cash Transfers:.Evidence from Tanzania

2. Cash transfers have expanded dramatically around the world!

3. 1997 Source: Fiszbein et al 2009

4. 2008 Source: Fiszbein et al 2009

5. 2010 Countries in which CT programs have been implemented (35) Countries in which CT programs have been discussed, planned, or implemented (39) Source: Garcia & Moore 2012

6. … and so has evidence surrounding their impacts!

7. Studies of impact of cash transfers as of 2013 Source: Andrews et al (forthcoming)

8. To date, limited evidence base(a) from Africa, conditioning on health(b) relying on local communities to run program / deliver payments

9. Operational experience and contextual expertise International expertise on cash transfers and on impact evaluation Initial funding for the program & evaluation

10. What it looked like

11. How big was it? ≈ ≈

12. Where was it?

13. What households received (in 2010) per child (US$3) per month per adult (US$6) per month on average

14. What households had to do (in 2010)

15. Who did what • Identification of the poor…by communities • Distribution of payments…by communities • Monitoring of conditions…by communities

16. Summary of Findings • Initial (after 18 mos.) positive impacts on health clinic visits disappeared by 2.5 years • Health benefits take 2.5 years to materialize (not present at 18 mos.), and are mostly driven by young children aged 0‐5 (not elderly) • Large increase in use of health insurance • Shift toward using publicly‐provided healthcare • Initial (after 18 mos.) increase in satisfaction with healthcare disappeared by 2.5 years (habituation) • No increase in objective healthcare quality

17. How we evaluated it

18. 3 provinces selected to pilot 80 eligible villages but only cash for 40 randomization Initial Treatment Initial Comparison 2 years later with additional funding Treatment

19. Randomizing led to balance on observable characteristics

20. When it happened

21. How difference-in-differences works Outcome Roll out program Diff at endline Comparison Treatment Diff at baseline Difference at endline - Difference at baseline Impact of program Time Baseline Endline

22. Difference-in-differences Specification • i indexes individuals (or households, for household-level outcomes) • t indexes the survey round • hit is a health outcome • αi are individual fixed effects • Ti=1 in CCT treatment group (zero otherwise) • 2011t=1 at time of midline survey (18-21 months of transfers) • 2012t=1 at time of endline survey (31-34 months of transfers)

23. Two sub-samples among our poor HHs • Carried out a principal components analysis (PCA) using dummy variables for ownership of 13 HH assets • Took the first principal component as our index of HH wealth • Households with above-median wealth: “moderately poor” • Households with below-median wealth: “extremely poor”

24. What were the impacts of the program on health and health-related outcomes for the poor?

25. Outcome: Health clinic visits in the last 12 months

26. Outcome: Illness & injury in last 4 weeks

27. Outcome: Participation in government-run health insurance program

28. Outcome: Use of public facilities Private

29. Outcome: Satisfaction with health facilities

30. Outcome: Objective facility quality

31. Multiple Hypothesis Testing • Use three methods to correct • Median significant results after correction

32. Conclusions • Conditional cash transfers effectively increase health for children • Initial increase in clinic visits (conditions) • Major increase in health insurance take-up (not conditioned) • Beware of satisfaction measures: Effects may disappear

33. Asantenisana!