ABSTRACT

Objective

To 1) describe the benefits, conditions, coverage, funding, goals, governance, and structure of well-established conditional cash transfer programs (CCTs) in Latin America and 2) identify their health and nutritional impacts among children under 5 years old.

Methods

A realist review was conducted. CCTs were included if they met the following inclusion criteria: 1) current national-level program; 2) coverage of at least 50% of the target population; 3) continuous operation at scale for 10+ years; 4) clear description of structure, funding sources, and governance; 5) both health/nutrition- and education-related conditions for participation; and 6) available impact evaluation studies with health, development, and/or nutrition indicators among children under 5 years old. Three CCTs (one each in Brazil, Colombia, and Mexico) met the criteria.

Results

There was consistent evidence that the three CCTs selected for review had positive impacts on child health and nutrition outcomes in their respective countries. In all three countries, the programs were scaled up and positive impacts were documented relatively quickly. All three programs had strong political support and clear and transparent governance structures, including accountability and social participation mechanisms, which might explain their success and sustainability.

Conclusions

CCTs in Latin America have had a positive impact on child health and nutrition outcomes among the poorest families. A key challenge for the future is to reform these programs to help families move out of not only extreme poverty but all poverty in order to lead healthy and productive lives, as called for in the post-2105 Sustainable Development Goals.

Key words
Social welfare; social assistance; child nutrition; Brazil; Colombia; Mexico; Latin America

RESUMEN

Objetivo

(1) Describir los beneficios, requisitos, cobertura, financiamiento, objetivos, gobernanza y estructura de programas bien consolidados de transferencias de efectivo condicionadas (TEC) en América Latina y (2) determinar su efecto en la salud y el estado nutricional de los niños menores de 5 años.

Métodos

Se llevó a cabo una revisión realista. Se incluyeron en ella los programas de TEC que satisfacían los siguientes criterios de inclusión: (1) programa de alcance nacional en curso; (2) cobertura de 50% de la población destinataria como mínimo; (3) funcionamiento en gran escala sin interrupción durante 10 años o más; (4) descripción explícita de la estructura, fuentes de financiamiento y gobernanza; (5) requisitos para la participación basados en criterios de salud y nutrición, así como de educación; y (6) disponibilidad de estudios de evaluación de efectos con indicadores de salud, desarrollo o estado nutricional en niños menores de 5 años. Tres programas de TEC (uno en el Brasil, uno en Colombia y otro en México) satisficieron estos criterios.

Resultados

Hay pruebas contundentes de que los tres programas de TEC seleccionados para la revisión tuvieron efectos favorables en la salud y el estado nutricional de los niños en sus respectivos países. En los tres países los programas se ampliaron y los efectos positivos se documentaron con relativa rapidez. Los tres programas gozaron de un sólido apoyo político y tuvieron estructuras de gobernanza explícitas y transparentes con mecanismos de rendición de cuentas y de participación social, lo cual podría explicar sus buenos resultados y sostenibilidad.

Conclusiones

En América Latina, las TEC han tenido un efecto favorable en la salud de los niños y en el estado nutricional de las familias más pobres. Un reto para el futuro estriba en reformar estos programas para ayudar a las familias a salir no solo de la extrema pobreza, sino de la pobreza en general a fin de que puedan llevar vidas saludables y productivas, en conformidad con los Objetivos de Desarrollo Sostenible para después del 2015.

Palabras clave
Bienestar social; asistencia social; nutrición del niño; Brasil; Colombia; México; América Latina

During the last two decades, Latin American countries began to implement conditional cash transfer programs (CCTs) through their social protection systems with the purpose of lifting their most vulnerable populations out of extreme poverty (¹1 Ferreira HGF, Robalino D. Social Protection in Latin America: Achievements and Limitations. Policy Research Working Paper 5305 WPS5305. The World Bank, Latin America and the Caribbean Region Office of the Chief Economist & Human Development Network Social Protection and Labor Unit, May 2010. Available at: http://www10.iadb.org/intal/intalcdi/PE/2010/05495.pdf Accessed 28 November 2015.
http://www10.iadb.org/intal/intalcdi/PE/... –³3 Carutti P, Fruttero A, Grosh M, Kostenbaum S, Olivery ML, Rodriguez-Alas C, Strokova V. Social Assistance and Labor Market Programs in Latin America. Social Protection & Labor 88769. Discussion Paper No. 1401. The World Bank, June 2014. Available at: http://wwwwds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2014/06/27/000470435_20140627092449/Rendered/PDF/887690WP0P1321085243B00PUBLIC001401.pdf Accessed 28 November 2015.
http://wwwwds.worldbank.org/external/def... ). The first national CCT program was launched in Mexico in 1997. Today, 18 countries are operating CCTs in Latin America and the Caribbean and significant reductions in extreme poverty have been attributed to them (¹1 Ferreira HGF, Robalino D. Social Protection in Latin America: Achievements and Limitations. Policy Research Working Paper 5305 WPS5305. The World Bank, Latin America and the Caribbean Region Office of the Chief Economist & Human Development Network Social Protection and Labor Unit, May 2010. Available at: http://www10.iadb.org/intal/intalcdi/PE/2010/05495.pdf Accessed 28 November 2015.
http://www10.iadb.org/intal/intalcdi/PE/... –⁴4 Skoufias E, McClafferty B. “Is PROGRESA Working? Summary of the Results of an Evaluation by IFPRI. Report submitted to PROGRESA. Washington: International Food Policy Research Institute. 2001. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.58.3872&rep=rep1&type=pdf Accessed 28 November 2015.
http://citeseerx.ist.psu.edu/viewdoc/dow... ). The framework guiding CCTs is conceptually sound as it addresses multiple social determinants of health to break the cycle of poverty. CCTs provide cash benefits to poor families in exchange for meeting certain conditions. These conditions typically involve families keeping their children in school and both mothers and children attending primary health care services. The income transfer is expected to help beneficiaries improve the quality of their diets and other basic needs, while the increased access to health care is expected to promote their health and allow them to live more productive lives. As a result of the programs’ education condition it is expected that children will have better opportunities later in life. Cash benefits are usually given to children’s mothers as they are most likely to invest in their children and because it helps improve women’s empowerment (⁴4 Skoufias E, McClafferty B. “Is PROGRESA Working? Summary of the Results of an Evaluation by IFPRI. Report submitted to PROGRESA. Washington: International Food Policy Research Institute. 2001. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.58.3872&rep=rep1&type=pdf Accessed 28 November 2015.
http://citeseerx.ist.psu.edu/viewdoc/dow... , ⁵5 Adato M, Roopnaraine T. Womem’s Status, Gender Relations, and Conditional Cash Transfers. In: Adato M. and Hoddinott J., editors. Conditional Cash Transfers in Latin America. International Food Policy Research Institute (IFPRI) and The Johns Hopkins University Press Baltimore, 2010: 284-314. Available at: http://www.ifpri.org/publication/conditional-cash-transfers-latin-america Accessed 28 November 2015.
http://www.ifpri.org/publication/conditi... ). Most CCTs have limits on the number of children for whom cash benefits can be received to avoid increased fertility within families (⁵5 Adato M, Roopnaraine T. Womem’s Status, Gender Relations, and Conditional Cash Transfers. In: Adato M. and Hoddinott J., editors. Conditional Cash Transfers in Latin America. International Food Policy Research Institute (IFPRI) and The Johns Hopkins University Press Baltimore, 2010: 284-314. Available at: http://www.ifpri.org/publication/conditional-cash-transfers-latin-america Accessed 28 November 2015.
http://www.ifpri.org/publication/conditi... ). CCTs are considered powerful child nutrition–sensitive interventions as they address the underlying causes of undernutrition and can enhance the effectiveness of nutrition-specific interventions (⁶6 Ruel MT, Alderman H, the Maternal and Child Nutrition Group. Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? The Lancet. 2013;382(9891):536-551.). To the best of the authors’ knowledge, no previous reviews have examined, simultaneously, the characteristics of country-level operations and structure of CCTs and their health and nutritional impacts. Therefore, the objective of this review was to 1) describe the benefits, conditions, coverage, funding, goals, governance, and structure of well-established CCT programs in Latin America and 2) identify their health and nutritional impacts among children under 5 years old.

MATERIALS AND METHODS

An integrated realist literature review (⁷7 Wong G, Greenhalgh T, Westhorp G, Pawson R. Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Southampton (UK): NIHR Journals Library, 2014. Available at: http://www.ncbi.nlm.nih.gov/books/NBK260013/pdf/Bookshelf_NBK260013.pdf Accessed 28 November 2015.
http://www.ncbi.nlm.nih.gov/books/NBK260... ) was conducted in three steps following a priori criteria (Figure 1). The first step was to identify the CCTs to be reviewed—well-established programs in Latin America that met the inclusion criteria—through a Google Scholar search, using the following search string: conditional cash transfers OR cash transfer OR monetary incentives and social protection OR safety net and child health OR child development OR health services OR nutrition sensitive interventions for malnutrition and food security AND Latin America. The search resulted in 337 citations that led to five reports on CCTs that were reviewed in full (¹1 Ferreira HGF, Robalino D. Social Protection in Latin America: Achievements and Limitations. Policy Research Working Paper 5305 WPS5305. The World Bank, Latin America and the Caribbean Region Office of the Chief Economist & Human Development Network Social Protection and Labor Unit, May 2010. Available at: http://www10.iadb.org/intal/intalcdi/PE/2010/05495.pdf Accessed 28 November 2015.
http://www10.iadb.org/intal/intalcdi/PE/... , ²2 Stampini M, Tornarolli L. The growth of conditional cash transfers in Latin America and the Caribbean: did they go too far? Inter-American Development Bank, 2012.IDB Policy Brief; 185. Available at: http://publications.iadb.org/handle/11319/1448?locale-attribute=en Accessed 28 November 2015.
http://publications.iadb.org/handle/1131... , ³3 Carutti P, Fruttero A, Grosh M, Kostenbaum S, Olivery ML, Rodriguez-Alas C, Strokova V. Social Assistance and Labor Market Programs in Latin America. Social Protection & Labor 88769. Discussion Paper No. 1401. The World Bank, June 2014. Available at: http://wwwwds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2014/06/27/000470435_20140627092449/Rendered/PDF/887690WP0P1321085243B00PUBLIC001401.pdf Accessed 28 November 2015.
http://wwwwds.worldbank.org/external/def... , ⁸8 Bassett L. Can Conditional Cash Transfer Programs Play a Greater Role in Reducing child Undernutrition? SP Discussion Paper No. 0835. Social Protection & Labor. The World Bank. October 2008. Available at: http://siteresources.worldbank.org/SOCIALPROTECTION/Resources/SP-Discussion-papers/Safety-Nets-DP/0835.pdf Accessed 28 November 2015.
http://siteresources.worldbank.org/SOCIA... , ⁹9 Adato M, Hoddinott J. Conditional Cash Transfers in Latin America. International Food Policy Research Institute (IFPRI) and The Johns Hopkins University Press Baltimore, 2010. Available at: http://www.ifpri.org/publication/conditional-cash-transfers-latin-america Accessed 28 November 2015.
http://www.ifpri.org/publication/conditi... ). The CCT inclusion criteria were as follows: 1) current national-level program; 2) coverage of at least 50% of the target populations; 3) continuous operation at scale for 10+ years; 4) clear description of structure, funding sources, and governance; 5) both health/nutrition- and education-related conditions for program participation; and 6) available impact evaluation studies with health, development, and/or nutrition indicators among children under 5 years old. The second step identified research studies assessing the health and nutrition impacts of the three selected CCTs, using PubMed, Web of Science, and SciELO. The key term conditional cash transfer was used in combination with one of the following terms: México, PROGRESA, Oportunidades, Brazil, Bolsa Família, Colombia, Familias en Acción, child health, health services, malnutrition, nutrition-sensitive interventions, child development, safety net, and social protection. Studies with the following designs were included: randomized controlled, controlled before-and-after, interrupted time-series, cross-sectional using matching techniques, and cross-sectional with comparison group(s). This search produced 591 unduplicated articles, of which 457 were excluded based on the title, and 78 were excluded based on abstract reviews, leaving 56 that were reviewed in full, and a final sample of 17 that met the inclusion criteria for data extraction. The third step consisted of searches for gray literature on the operations and structure of the three selected CCTs, using the following agency/program websites: International Food Policy Research Institute (IFPRI), World Bank, Inter-American Development Bank (IDB), Bolsa Família, PROSPERA (formerly Oportunidades and PROGRESA), and Familias en Acción. This search generated five reports, and using a “snowball” approach, 18 additional reports were found. Thus this review was based on 17 peer-reviewed research articles and 23 gray literature reports (Figure 1).

RESULTS

The three well-established Latin American CCTs that met the study criteria were 1) PROSPERA in Mexico, 2) Bolsa Família in Brazil, and 3) Más Familias en Acción in Colombia.

Mexico

Key program characteristics

The selected CCT from Mexico, now known as PROSPERA, was launched in 1997 as the Programa Nacional de Educación, Salud y Alimentación (PROGRESA)—an antipoverty strategy in response to the 1994 Mexican economic crisis. Designed to improve children’s access to schooling and families’ access to primary health and nutrition services, PROGRESA was first implemented in marginalized rural areas with health and education infrastructure. The program was designed to increase its coverage gradually, which allowed for use of an integrated, lagged, randomized controlled impact evaluation component (⁴4 Skoufias E, McClafferty B. “Is PROGRESA Working? Summary of the Results of an Evaluation by IFPRI. Report submitted to PROGRESA. Washington: International Food Policy Research Institute. 2001. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.58.3872&rep=rep1&type=pdf Accessed 28 November 2015.
http://citeseerx.ist.psu.edu/viewdoc/dow... , ⁹9 Adato M, Hoddinott J. Conditional Cash Transfers in Latin America. International Food Policy Research Institute (IFPRI) and The Johns Hopkins University Press Baltimore, 2010. Available at: http://www.ifpri.org/publication/conditional-cash-transfers-latin-america Accessed 28 November 2015.
http://www.ifpri.org/publication/conditi... ). Since its inception, the program has offered cash incentives to the female head of household as long as family members complied with conditions related to health/nutrition (use of preventive health services) and education (school attendance), with the total amount of monthly cash benefits per family determined by the number of children in the household, and their age, gender, and grade level (⁴4 Skoufias E, McClafferty B. “Is PROGRESA Working? Summary of the Results of an Evaluation by IFPRI. Report submitted to PROGRESA. Washington: International Food Policy Research Institute. 2001. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.58.3872&rep=rep1&type=pdf Accessed 28 November 2015.
http://citeseerx.ist.psu.edu/viewdoc/dow... , ⁵5 Adato M, Roopnaraine T. Womem’s Status, Gender Relations, and Conditional Cash Transfers. In: Adato M. and Hoddinott J., editors. Conditional Cash Transfers in Latin America. International Food Policy Research Institute (IFPRI) and The Johns Hopkins University Press Baltimore, 2010: 284-314. Available at: http://www.ifpri.org/publication/conditional-cash-transfers-latin-america Accessed 28 November 2015.
http://www.ifpri.org/publication/conditi... ). The health and nutrition preventive services were provided through primary health clinics (⁴4 Skoufias E, McClafferty B. “Is PROGRESA Working? Summary of the Results of an Evaluation by IFPRI. Report submitted to PROGRESA. Washington: International Food Policy Research Institute. 2001. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.58.3872&rep=rep1&type=pdf Accessed 28 November 2015.
http://citeseerx.ist.psu.edu/viewdoc/dow... , ⁹9 Adato M, Hoddinott J. Conditional Cash Transfers in Latin America. International Food Policy Research Institute (IFPRI) and The Johns Hopkins University Press Baltimore, 2010. Available at: http://www.ifpri.org/publication/conditional-cash-transfers-latin-america Accessed 28 November 2015.
http://www.ifpri.org/publication/conditi... ). PROGRESA’s impact evaluation studies found 1) an increase in secondary school enrollment rates; 2) improved preventive care and health outcomes among children under 5 years old; 3) an increase in the number of visits to health care units during the first trimester of pregnancy; and 4) an increase in household food expenditures (⁴4 Skoufias E, McClafferty B. “Is PROGRESA Working? Summary of the Results of an Evaluation by IFPRI. Report submitted to PROGRESA. Washington: International Food Policy Research Institute. 2001. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.58.3872&rep=rep1&type=pdf Accessed 28 November 2015.
http://citeseerx.ist.psu.edu/viewdoc/dow... , ⁹9 Adato M, Hoddinott J. Conditional Cash Transfers in Latin America. International Food Policy Research Institute (IFPRI) and The Johns Hopkins University Press Baltimore, 2010. Available at: http://www.ifpri.org/publication/conditional-cash-transfers-latin-america Accessed 28 November 2015.
http://www.ifpri.org/publication/conditi... ). In 2000, PROGRESA became the Programa de Desarrollo Humano “Oportunidades,” and program benefits were extended to those who met school attendance requirements at the high school level. Between 2001 and 2002, the program was expanded to urban areas, which required that the sampling methodology be adapted to enable identification of eligible households (¹⁰10 Gutiérrez JP, Bertozzi S, Gertler P. Evaluación de la identificación de familias beneficiarias en el medio urbano. Evaluación de Resultados de Impacto del Programa de Desarrollo Humano Oportunidades. Instituto Nacional de Salud Pública. Marzo 2003. Available at: http://www.2006-2012.sedesol.gob.mx/work/models/SEDESOL/EvaluacionProgramasSociales/2002/EE_Oportunidades_2002/Evaluacion_Focalizacion_Final_marzo03.pdf Accessed 28 November 2015.
http://www.2006-2012.sedesol.gob.mx/work... ). In 2003, the “Jóvenes con Oportunidades” component was added, providing additional cash incentives for high school graduation and continued education or training thereafter. During 2001–2006, the program continued to show positive impacts in school outcomes in rural areas, a reduction in maternal and child mortality, and an impressive 78% increase in preventive medical appointments (¹¹11 Cruz C, De la Torre R, Velázquez C. Evaluación externa de impacto del Programa Oportunidades 2001-2006. Informe compilatorio. Instituto Nacional de Salud Pública, Cuernavaca, México 2006 (HN113.5/E83/2006). Available at: https://www.prospera.gob.mx/EVALUACION/es/wersd53465sdg1/docs/2006/insp_2001_2006_compilatorio.pdf Accessed 28 November 2015.
https://www.prospera.gob.mx/EVALUACION/e... ). In urban locations, the program was associated with a 52% utilization of health care services (¹¹11 Cruz C, De la Torre R, Velázquez C. Evaluación externa de impacto del Programa Oportunidades 2001-2006. Informe compilatorio. Instituto Nacional de Salud Pública, Cuernavaca, México 2006 (HN113.5/E83/2006). Available at: https://www.prospera.gob.mx/EVALUACION/es/wersd53465sdg1/docs/2006/insp_2001_2006_compilatorio.pdf Accessed 28 November 2015.
https://www.prospera.gob.mx/EVALUACION/e... ). A survey conducted in 2007 among beneficiaries from rural areas found an increase in expenditures on food consumption as well as food production for self-consumption; for every peso spent on food, 32 cents went to self-production activities (¹²12 Arroyo Ortiz, JP, Ordaz Díaz J., Li Ng, J.J. and Zaragoza López, ML. A diez años de intervención: Evaluación externa del Programa Oportunidades 2008 en zonas rurales (1997-2007). Available at: http://evaluacion.oportunidades.gob.mx:8010/es/wersd53465sdg1/docs/2008/2008_consumo_inversion.pdf Accessed 28 November 2015.
http://evaluacion.oportunidades.gob.mx:8... ). The latter expenditure was remarkable, especially given the fact that there was little opportunity for savings or investments based on income, even though beneficiary families were using the cash benefit to meet their basic needs (¹²12 Arroyo Ortiz, JP, Ordaz Díaz J., Li Ng, J.J. and Zaragoza López, ML. A diez años de intervención: Evaluación externa del Programa Oportunidades 2008 en zonas rurales (1997-2007). Available at: http://evaluacion.oportunidades.gob.mx:8010/es/wersd53465sdg1/docs/2008/2008_consumo_inversion.pdf Accessed 28 November 2015.
http://evaluacion.oportunidades.gob.mx:8... ). By 2013, the program was serving 5.9 million families distributed across 107 337 communities in all 32 Mexican states, and 25% of the families lived in indigenous areas (¹³13 Government of Mexico. CONEVAL. Programa de Desarrollo Humano Oportunidades. Ficha de Monitoreo 2013, Mexico. Available at: http://evaluacion.oportunidades.gob.mx:8010/en/ficha/ficha12_13.php Accessed 28 November 2015.
http://evaluacion.oportunidades.gob.mx:8... ). In 2014, Oportunidades was renamed PROSPERA and adopted a priority goal of strengthening social inclusion and ending extreme poverty. Mexico’s plan for social inclusion includes three broad actions: 1) improving the public health care system, 2) expanding the social security system, and 3) increasing access to housing, basic social infrastructure, and land development (¹⁴14 Government of Mexico. SEDESOL. National Coordination of the Human Development Program Opportunities: A New Generation Social Policy. May, 2014. Available at: http://www.ilo.org/wcmsp5/groups/public/---arabstates/---ro-beirut/documents/genericdocument/wcms_246597.pdf Accessed 28 November 2015.
http://www.ilo.org/wcmsp5/groups/public/... ). PROSPERA is part of the National Crusade Against Hunger (Cruzada Nacional Contra el Hambre, CNCH), a government initiative to improve food security for all that has strong links with community development opportunities. Specifically, PROSPERA has added more cash incentives and helps improve beneficiaries’ access to financial services, the labor market, microcredit opportunities, and early childhood education initiatives (¹⁴14 Government of Mexico. SEDESOL. National Coordination of the Human Development Program Opportunities: A New Generation Social Policy. May, 2014. Available at: http://www.ilo.org/wcmsp5/groups/public/---arabstates/---ro-beirut/documents/genericdocument/wcms_246597.pdf Accessed 28 November 2015.
http://www.ilo.org/wcmsp5/groups/public/... , ¹⁵15 Government of Mexico. SEDESOL/PROSPERA. Diario Oficial de la Federación, DOF: 30/12/2013 ACUERDO por el que se emiten las Reglas de Operación del Programa de Desarrollo Humano Oportunidades, para el ejercicio fiscal 2014. Available at: https://www.prospera.gob.mx/Portal/wb/Web/documentos_de_normatividadp. Accessed 28 November 2015.
https://www.prospera.gob.mx/Portal/wb/We... ) (Table 1). PROSPERA is a multi-sectoral program under the Mexican Secretariat of Social Development (Secretaría de Desarrollo Social, SEDESOL). PROSPERA’s National Coordination team works very closely with the Secretariat of Public Education (Secretaría de Educación Pública, SEP) and the Secretariat of Health (Secretaría de Salud), which are in charge of providing the education and health services for beneficiaries and verifying their compliance with program conditions. It also works with the Secretariat of Economy (Secretaría de Economía, SE); the Secretariat of Labor and Social Welfare (Secretaría del Trabajo y Previsión Social, STPS); and the Secretariat of Agriculture, Livestock, Rural Development, Fisheries and Food (Secretaría de Agricultura, Ganadería, Desarrollo Rural, Pesca y Alimentación, SAGARPA). PROSPERA also has strong links with state and municipal programs for implementation, with the latter entities helping to organize local committees composed of PROSPERA beneficiary mothers (known as vocales, or “spokepersons” in English). Funding and program norms come directly from the federal government (¹⁴14 Government of Mexico. SEDESOL. National Coordination of the Human Development Program Opportunities: A New Generation Social Policy. May, 2014. Available at: http://www.ilo.org/wcmsp5/groups/public/---arabstates/---ro-beirut/documents/genericdocument/wcms_246597.pdf Accessed 28 November 2015.
http://www.ilo.org/wcmsp5/groups/public/... , ¹⁵15 Government of Mexico. SEDESOL/PROSPERA. Diario Oficial de la Federación, DOF: 30/12/2013 ACUERDO por el que se emiten las Reglas de Operación del Programa de Desarrollo Humano Oportunidades, para el ejercicio fiscal 2014. Available at: https://www.prospera.gob.mx/Portal/wb/Web/documentos_de_normatividadp. Accessed 28 November 2015.
https://www.prospera.gob.mx/Portal/wb/We... ). The National Council for the Evaluation of Social Development Policy (Consejo Nacional de Evaluación, CONEVAL) is in charge of conducting PROSPERA’s annual and biannual evaluations (Table 2).

Impacts on child health and nutrition outcomes

The seven PROGRESA, Oportunidades, and PROSPERA studies found impacts on the health of children less than 5 years old using experimental or quasi-experimental designs (Table 3). A PROGRESA evaluation conducted in 1998–2000 found that newborns whose mothers were receiving benefits while pregnant and children exposed to the program between 0 and 3 years of age at baseline were 25.3% (P = < 0.005) and 23.3% (P = 0.001) less likely respectively to be ill during the month preceding the survey. This effect was stronger among those exposed to the program for 24 months versus those exposed for 18 months. In addition, beneficiary children 12–36 months old were almost 1 cm taller than those from the control group (P = 0.004), and during the first year of the program, beneficiary children were also 25.5% less likely than their counterparts in the control group to have anemia (P = 0.012) (¹⁶16 Gertler P. Do Conditional Cash Transfers Improve Child Health? Evidence from PROGRESA’s controlled randomized experiment. Am. Econ Rev. 2004;94;336-41.). A second analysis of the same study found that infants < 6 months old from the poorest families who were exposed to the program were 1.1 cm taller compared with the control group (¹⁷17 Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican Program for Education, Health, and Nutrition (Progresa) on rates of Growth and Anemia in Infants and Young Children. JAMA. 2004;291 (21): 2563-70.). Hemoglobin levels among children 12 months or older at baseline were significantly higher after one year of program exposure compared to the unexposed control group (11.12 g/dL versus 10.75 g/dL; P = 0.01) (¹⁷17 Rivera JA, Sotres-Alvarez D, Habicht JP, Shamah T, Villalpando S. Impact of the Mexican Program for Education, Health, and Nutrition (Progresa) on rates of Growth and Anemia in Infants and Young Children. JAMA. 2004;291 (21): 2563-70.). Another study using PROGRESA’s baseline and a follow-up survey conducted in 2003 found that higher cumulative cash transfer was significantly associated with increased height-for-age Z-scores; lower prevalence of stunting and overweight; and improved gross motor development long-term memory, visual integration, and language development. However, no association was found with number of sick days or hemoglobin concentration (¹⁸18 Fernald LC, Gertler PJ, Neufeld LM. Role of cash in conditional cash transfer programmes for child health, growth, and development: an analysis of Mexico’s Oportunidades. Lancet 2008;371(9615): 828-37.).

A study assessing the impact of PROGRESA on reproductive health outcomes found that being born to a beneficiary mother at the time of birth was significantly associated with a higher birth weight (127.3 g) and a 4.6% reduction in low birth weight (¹⁹19 Barber SL, Gertler PJ. The impact of Mexico’s conditional cash transfer programme, Oportunidades, on birthweight. Trop Med Int Health. 2008;13(11):1405-14.). Urban children exposed to Oportunidades when they were less than 6 months old grew 1.5 cm taller and gained 0.76 kg more than children from control families (²⁰20 Leroy JL, García-Guerra A, García R, Dominguez C, Rivera J, Neufeld LM. The Oportunidades program increases the linear growth of children enrolled at young ages in urban Mexico. J Nutr. 2008;138(4): 793-8.). In rural areas, PROGRESA was associated with a lower incidence of diarrhea and respiratory infection diseases among children less than 5 years old (²¹21 Huerta MC. Child Health in Rural Mexico: Has Progresa Reduced Children’s Morbidity Risks? Social Policy & Administration. 2006;40(6):652-677.). Another study found a large decline (17%) in rural infant mortality among PROGRESA beneficiaries (²²22 Barham T. A Healthier start: The effect of conditional cash transfer on neonatal and infant mortality in rural Mexico. Journal of Development Economics. 2011;94(1):74-85.). Thus, all included studies showed positive impacts of the program on diverse child health and growth outcomes, especially among the youngest and poorest children. As a result, PROGRESA’s well-recognized antipoverty effectiveness (²³23 The World Bank. Implementation Completion and Result Report (IBRD-77080 IBRD 79680) Support to OPORTUNIDADES Project. Report No. ICR2932. June 26,2014. Available at: http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/LCR/2013/04/13/090224b081ab0b77/1_0/Rendered/PDF/Mexico000Suppo0Report000Sequence008.pdf Accessed 28 November 2015.
http://www-wds.worldbank.org/external/de... ), together with its health and nutrition benefits, has played a key role in the expansion of CCTs in Latin America and beyond.

Brazil

Key program characteristics

In 2004, The Bolsa Família Program (BFP) was created by merging four programs (Bolsa Escola, Bolsa Alimentação, Cartão Alimentação, and Auxílio Gás). The Ministry of Social Development and Hunger Eradication (Ministério do Desenvolvimento Social e Combate à Fome, MDS) oversees the program through the National Secretariat of Citizenship Income (Secretaria Nacional de Renda de Cidadania, SENARC), which is responsible for BFP’s management, including its beneficiaries registry (Cadastro Único), and the Caixa Econõmica Federal (CEF), the distributor of cash incentives to beneficiaries through an electronic card (²⁴24 Lindert K, Linder A, Hobbs J, De la Brière B. The Nuts and Bolts of Brazil’s Bolsa Família Program: Implementing Conditional Cash Transfers in a Decentralized Context. Available at: http://siteresources.worldbank.org/INTLACREGTOPLABSOCPRO/Resources/BRBolsaFamiliaDiscussionPaper.pdf Accessed 28 November 2015.
http://siteresources.worldbank.org/INTLA... –²⁶26 The World Bank. Implementation Completion and Result Report (IBRD-72340) Bolsa Familia. Report No. ICR00001486. June 28, 2010. Available at: wwwds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2010/07/21/000333037_20100721025323/Rendered/PDF/ICR14860P087711fficial0Use0Only0191.pdf Accessed 28 November 2015.
wwwds.worldbank.org/external/default/WDS... ). SENARC works with multiple ministries, including the Ministry of Health and the Ministry of Education, on implementation and monitoring of the health/nutrition and education conditions for program participation (²⁴24 Lindert K, Linder A, Hobbs J, De la Brière B. The Nuts and Bolts of Brazil’s Bolsa Família Program: Implementing Conditional Cash Transfers in a Decentralized Context. Available at: http://siteresources.worldbank.org/INTLACREGTOPLABSOCPRO/Resources/BRBolsaFamiliaDiscussionPaper.pdf Accessed 28 November 2015.
http://siteresources.worldbank.org/INTLA... , ²⁵25 Campello T, Côrtes Neri M. Bolsa Familia Program: a decade of social inclusión in Brazil. Executive Summary. Institute for Applied Economic Research. 2014. Brazil. Available at: http://www.ipea.gov.br/portal/images/stories/PDFs/140321_pbf_sumex_ingles.pdf Accessed 28 November 2015.
http://www.ipea.gov.br/portal/images/sto... ). BFP is implemented using a national decentralized strategy that includes an indicator to assess the quality of implementation across multiple domains (24–26). BFP oversight also relies on an advisory group that includes municipal-level representatives working in health, education, and food security, and representatives from the government and civil society (²⁴24 Lindert K, Linder A, Hobbs J, De la Brière B. The Nuts and Bolts of Brazil’s Bolsa Família Program: Implementing Conditional Cash Transfers in a Decentralized Context. Available at: http://siteresources.worldbank.org/INTLACREGTOPLABSOCPRO/Resources/BRBolsaFamiliaDiscussionPaper.pdf Accessed 28 November 2015.
http://siteresources.worldbank.org/INTLA... , ²⁵25 Campello T, Côrtes Neri M. Bolsa Familia Program: a decade of social inclusión in Brazil. Executive Summary. Institute for Applied Economic Research. 2014. Brazil. Available at: http://www.ipea.gov.br/portal/images/stories/PDFs/140321_pbf_sumex_ingles.pdf Accessed 28 November 2015.
http://www.ipea.gov.br/portal/images/sto... ). BFP is a well-established program with clear operational rules and processes. BFP outcomes are measured by an autonomous entity, the Secretariat of Evaluation and Information Management (Secretaria de Avaliação e Gestão da Informação, SAGI), which is in charge of implementing a comprehensive evaluation of the program’s impact. Fiscal oversight of the BFP is conducted by the General Controllers Office, the Federal Audits Court, and the Office of The Public Prosecutor (Table 2).

BFP provides two types of monthly cash incentives—a basic benefit to families living under extreme poverty, and a variable benefit based on household size and composition for families that are poor but not extremely poor (²⁷27 Ministry of Social Development Official Website. Government of Brazil. Available at: http://www.mds.gov.br Accessed 28 November 2015.
http://www.mds.gov.br... ) (Table 1). Initiatives such as Brasil Sem Miséria, launched in 2010 as a national umbrella initiative to address the needs of the 16.2 families still living in extreme poverty, and Brasil Carinhoso, an integrated early childhood development program targeting families with children 0–6 years old, launched in 2014 to increase access to early education and health care, have built upon and strongly complement the BFP (²⁵25 Campello T, Côrtes Neri M. Bolsa Familia Program: a decade of social inclusión in Brazil. Executive Summary. Institute for Applied Economic Research. 2014. Brazil. Available at: http://www.ipea.gov.br/portal/images/stories/PDFs/140321_pbf_sumex_ingles.pdf Accessed 28 November 2015.
http://www.ipea.gov.br/portal/images/sto... , ²⁷27 Ministry of Social Development Official Website. Government of Brazil. Available at: http://www.mds.gov.br Accessed 28 November 2015.
http://www.mds.gov.br... ). BFP currently reaches 13.8 million families representing almost a quarter of the total country’s population (²⁵25 Campello T, Côrtes Neri M. Bolsa Familia Program: a decade of social inclusión in Brazil. Executive Summary. Institute for Applied Economic Research. 2014. Brazil. Available at: http://www.ipea.gov.br/portal/images/stories/PDFs/140321_pbf_sumex_ingles.pdf Accessed 28 November 2015.
http://www.ipea.gov.br/portal/images/sto... , ²⁷27 Ministry of Social Development Official Website. Government of Brazil. Available at: http://www.mds.gov.br Accessed 28 November 2015.
http://www.mds.gov.br... ).

Impacts on child health and nutrition outcomes

Nine studies and two literature reviews assessing the impact of BFP on child health and nutrition outcomes were found in this review (Table 4). A study analyzing National Health and Nutrition Survey (Pesquisa Nacional sobre Saúde e Nutrição, PNSN) data found that children under 5 years old enrolled in BFP were significantly more likely to have adequate height-for-age and weight-for-age compared with those not enrolled in the program, and that after adjusting for confounders, this effect was greater among children 36–59 months old (²⁸28 Paes-Sousa R, Santos LM, Miazaki ÉS. Effects of a conditional cash transfer programme on child nutrition in Brazil. Bull World Health Organ. 2011;89(7):496-503). A quasi-experimental cohort study of children 0–72 months old living in three Northeast municipalities found a significantly higher weight-for-age and height-for-age among children exposed to the Bolsa Alimentação program for a whole year compared to those that were never exposed to it (²⁹29 Assis AM, Costa PR, Santana ML, Pitanqueira JC, Fonseca NS, Pinheiro SM, Santos SM. Effectiveness of the Brazilian Conditional Cash Transfer Program –Bolsa Alimentação- on the variation of linear and ponderal increment in children from northeast of Brazil. Nutr Hosp. 2014;31(2):689-97.). A cross-sectional study among children 6–89 months old did not find an association between the BFP and risk of anemia and other malnutrition indexes (³⁰30 Oliveira Fde C, Cotta RM, Sant’Ana LF, Priore SE. Bolsa Família Program and child nutritional status: strategic challenges. Cien Saude Colet. 2011;16 (7): 3307-16). On the other hand, one cross-sectional study assessing the nutritional status of urban children under 5 years old did not find any impact from BFP on their nutritional status (³¹31 Dias-Médici, S.S, Ferraz Silvia F.R., and Nascimiento Saldivia P.H., Anthropometric assessment and food intake of children younger than 5 years of age from a city in the semi-arid area of the Northeastern region of Brazil partially covered by the bolsa família program. Revista de Nutricao-Brazilian Journal of Nutrition. 2010;23 (2):221-229). Another cross-sectional study found that children under 3 years old exposed to the BFP had significantly lower weight gain compared with those of the same age excluded from the program due to administrative errors. The authors of that study hypothesized that this result might have stemmed from a misunderstanding among participants that in order to remain eligible their children had to be malnourished (³²32 Morris SS, Olinto P, Flores R, Nilson EA, Fiqueiró AC. Conditional cash transfers are associated with small reduction in the rate of weight gain of preschool children in northeast Brazil. J Nutr. 2004 September;134(9):2336-41). A literature review found that BFP beneficiaries had higher food intakes than non-beneficiaries, and three of the cross-sectional studies reviewed found improvements in food security among BFP beneficiaries, while two found better height-for-age and weight-for-age Z-scores and less stunting among BFP beneficiaries, but three other studies reviewed did not find any association between the BFP and child anthropometric outcomes (³³33 Martins AP, Canella DS, Baraldi LG, Monteiro CA. Cash transfer in Brazil and nutritional outcomes: a systematic review. Rev Saude Publica. 2013;47(6):1159-71.). Another literature review examining 12 cross-sectional studies concluded that the BFP was not associated with nutritional status as proxied by anthropometric indicators (³⁴34 Wolf MR, Barros Filho Ade A. Nutritional status of beneficiaries of the ¨Bolsa Família¨ Program in Brazil a systematic review. Cien Saude Colet. 2014;19(5):1331-8.). A prospective study of children under 7 years old found that the BFP had a positive association with vaccinations, attendance at medical checkup and growth monitoring sessions, and psychosocial health (³⁵35 Shei A, Costa F, Reis MG, Ko AI. The impact of Brazil’s Bolsa Família conditional cash transfer program on children’s health care utilization and health outcomes. BMC Int Health Hum Rights. 2014 (April 1);14:10.). Time-series analyses corresponding to the 2004–2009 period (n = 2 853) documented a significant decrease in under-5 mortality rates associated with higher BFP coverage (³⁶36 Rasella D, Aquino R, Santos CA, Paes-Sousa R, Barreto ML. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet. 2013;382(9886):57-64.).

In sum, evidence for the impact of the BFP on child anthropometry are mixed. Two of the studies with positive anthropometric findings were conducted among the poorest areas in Brazil (²⁸28 Paes-Sousa R, Santos LM, Miazaki ÉS. Effects of a conditional cash transfer programme on child nutrition in Brazil. Bull World Health Organ. 2011;89(7):496-503, ²⁹29 Assis AM, Costa PR, Santana ML, Pitanqueira JC, Fonseca NS, Pinheiro SM, Santos SM. Effectiveness of the Brazilian Conditional Cash Transfer Program –Bolsa Alimentação- on the variation of linear and ponderal increment in children from northeast of Brazil. Nutr Hosp. 2014;31(2):689-97.). Moreover, studies suggest that the program does improve food security and food intake among young children as well as children’s overall health and survival.

Colombia

Key program characteristics

Familias en Acción (FA), modeled after PROGRESA, was launched in 2000 as a temporary poverty relief program at a time when the country was immersed in an economic recession and experiencing a worsening of internal armed conflicts (³⁷37 The World Bank. Implementation Completion and Result Report. Familias en Acción (IBRD-73370-IBRD-74330) Report No. ICR0000775. June 29, 2009. Available at: http://wwwwds.worldbank.org/servlet/WDSContentServer/IW3P/IB/2009/08/11/000333038_20090811233307/Rendered/PDF/ICR77500P089441C0disclosed081101091.pdf Accessed 28 November 2015.
http://wwwwds.worldbank.org/servlet/WDSC... ). An external evaluation that documented a positive impact of FA on children’s health and nutrition outcomes led to its stepwise scaling up at the national level (³⁸38 Attanasio O, Syed M, Vera-Hernández M. (2003), Early Evaluation of a New Nutrition and Education Programme in Colombia. The Institute for Fiscal Studies (IFS) Briefing Note no. 44. Available at: www.ifs.org.uk/publications.php?publication_id=1792 Accessed 28 November 2015.
www.ifs.org.uk/publications.php?publicat... ). FA was initially implemented in 672 Colombian municipalities with 100000 or less inhabitants that had a bank, and program eligibility was determined via the welfare index generated by the Colombian System for the Selection of Beneficiaries of Social Programs (Sistema de Selección de Beneficiarios de Programas Sociales, SISBEN), which targeted families living in extreme poverty, who were classified as “SISBEN Level 1” (³⁷37 The World Bank. Implementation Completion and Result Report. Familias en Acción (IBRD-73370-IBRD-74330) Report No. ICR0000775. June 29, 2009. Available at: http://wwwwds.worldbank.org/servlet/WDSContentServer/IW3P/IB/2009/08/11/000333038_20090811233307/Rendered/PDF/ICR77500P089441C0disclosed081101091.pdf Accessed 28 November 2015.
http://wwwwds.worldbank.org/servlet/WDSC... , ³⁸38 Attanasio O, Syed M, Vera-Hernández M. (2003), Early Evaluation of a New Nutrition and Education Programme in Colombia. The Institute for Fiscal Studies (IFS) Briefing Note no. 44. Available at: www.ifs.org.uk/publications.php?publication_id=1792 Accessed 28 November 2015.
www.ifs.org.uk/publications.php?publicat... ). In 2003, the Ministry of Social Protection was created and FA was scaled up to reach the 1.5 million families living in extreme poverty, including 413000 internally displaced families—a goal that was met by 2007 (³⁹39 Arias Duarte, JF. Seminario Internacional: Evolución y desafíos de los programas de Transferencia Condicionales. El Caso de Colombia: Programa Familias en Acción. November 2007. Available at: http://www.cepal.org/dds/noticias/paginas/1/30291/Colombia_JFArias_DNP.pdf Accessed 28 November 2015.
http://www.cepal.org/dds/noticias/pagina... ). The program became part of the Red Unidos (Unidos Network), a complementary government strategy to reduce poverty (⁴⁰40 Comisión Económica para América Latina y el Caribe (CEPAL) and Unión De Naciones Suramericanas. Transferencias de ingresos para la erradicación de pobreza. Dos décadas de experiencias en los países de la Unión de Naciones Suramericanas (UNASUR). Naciones Unidas. 14-20810 Santiago de Chile, Noviembre de 2014. Available at: http://repositorio.cepal.org/bitstream/handle/11362/37390/S1420810_es.pdf?sequence=1 Accessed 28 November 2015.
http://repositorio.cepal.org/bitstream/h... ). In 2011, FA was renamed Más Familias en Acción (MFA) and a law was enacted that formally recognized the program as part of the Ministry of Social Protection’s Department of Social Prosperity (Departamento para la Prosperidad Social, DPS), which was responsible for its coordination (⁴⁰40 Comisión Económica para América Latina y el Caribe (CEPAL) and Unión De Naciones Suramericanas. Transferencias de ingresos para la erradicación de pobreza. Dos décadas de experiencias en los países de la Unión de Naciones Suramericanas (UNASUR). Naciones Unidas. 14-20810 Santiago de Chile, Noviembre de 2014. Available at: http://repositorio.cepal.org/bitstream/handle/11362/37390/S1420810_es.pdf?sequence=1 Accessed 28 November 2015.
http://repositorio.cepal.org/bitstream/h... , ⁴¹41 Gobierno de Colombia. Normatividad Ley 1532 de Junio de 2012. Por medio de la cual se adoptan unas medidas de política y se regula el funcionamiento del programa Familias en Acción. Available at: http://wsp.presidencia.gov.co/Normativa/Leyes/Documents/ley153207062012.pdf Accessed 28 November 2015.
http://wsp.presidencia.gov.co/Normativa/... ). MFA targeted families living under extreme poverty, families that had been internally displaced, and indigenous and Afro-Colombian communities, and by the end of 2012 was serving 2.1 million families (³⁹39 Arias Duarte, JF. Seminario Internacional: Evolución y desafíos de los programas de Transferencia Condicionales. El Caso de Colombia: Programa Familias en Acción. November 2007. Available at: http://www.cepal.org/dds/noticias/paginas/1/30291/Colombia_JFArias_DNP.pdf Accessed 28 November 2015.
http://www.cepal.org/dds/noticias/pagina... ). All indigenous and displaced families receive the maximum benefit regardless of number of children (⁴²42 Departamento Administrativo para la Prosperidad Social. Agosto, 2015. Gobierno de Colombia , August, 2015 available from: https://www.gobiernoenlinea.gov.co/web/guest/home/-/government-agencies/7967/maximized?entidad=Departamento%20Administrativo%20para%20la%20Prosperidad%20Social
https://www.gobiernoenlinea.gov.co/web/g... ). Enrollment into the program is always open for displaced families but for other groups is only during specific enrollment periods (⁴²42 Departamento Administrativo para la Prosperidad Social. Agosto, 2015. Gobierno de Colombia , August, 2015 available from: https://www.gobiernoenlinea.gov.co/web/guest/home/-/government-agencies/7967/maximized?entidad=Departamento%20Administrativo%20para%20la%20Prosperidad%20Social
https://www.gobiernoenlinea.gov.co/web/g... ). MFA also has an “income for prosperity” component known as Jóvenes en Acción, a cash incentive program for low-income youth and young adults that wish to continue their post-secondary education (⁴²42 Departamento Administrativo para la Prosperidad Social. Agosto, 2015. Gobierno de Colombia , August, 2015 available from: https://www.gobiernoenlinea.gov.co/web/guest/home/-/government-agencies/7967/maximized?entidad=Departamento%20Administrativo%20para%20la%20Prosperidad%20Social
https://www.gobiernoenlinea.gov.co/web/g... , ⁴³43 Gobierno de Colombia. El Abecé de Más Familias en Acción. July 1, 2015. Available at: http://www.urnadecristal.gov.co/gestion-gobierno/abc-mas-familias-en-accion Accessed 28 November 2015.
http://www.urnadecristal.gov.co/gestion-... ). In 2013, MFA began working in coordination with the early childhood development government initiative known as De Cero a Siempre (⁴⁴44 Gobierno de Colombia. De Cero a Siempre. Todos por un nuevo país. Agosto 2015. Available from: http://www.deceroasiempre.gov.co/QuienesSomos/Paginas/Documentos.aspx Accessed 28 November 2015.
http://www.deceroasiempre.gov.co/Quienes... ). Colombia’s CCT evolved from being an emergency response program to becoming the main national program for poverty reduction and child health.

Impacts on child health and nutrition outcomes

An external quasi-experimental evaluation of FA found that in 2002–2003 the program was associated with an increase in food consumption in both rural and urban areas and that the increase was more pronounced for animal protein food sources such as milk, chicken, and meat (³⁸38 Attanasio O, Syed M, Vera-Hernández M. (2003), Early Evaluation of a New Nutrition and Education Programme in Colombia. The Institute for Fiscal Studies (IFS) Briefing Note no. 44. Available at: www.ifs.org.uk/publications.php?publication_id=1792 Accessed 28 November 2015.
www.ifs.org.uk/publications.php?publicat... , ⁴⁵45 The Institute for Fiscal Studies. How Effective are Conditional Cash Transfers? Evidence from Colombia. Briefing note No.44. Available from: http://www.ifs.org.uk/bns/bn54.pdf Accessed 28 November 2015.
http://www.ifs.org.uk/bns/bn54.pdf... ). The study also found that a higher percentage of beneficiary children < 24 months and between 24 and 48 months old were brought to preventive health care visits compared with children from the same age groups that were not participating in the program (40% versus 17.2% and 66.8% versus 33.6% respectively). Infants exposed to the program ended up being taller than non-beneficiary children, with a 0.44-cm differential reported among 1-year-old boys.

DISCUSSION

The three programs presented in this review began as antipoverty strategies seeking to effectively address the roots of poverty in the context of each country’s economic and political crises. In all three countries, the programs began as small-scale projects with a strong and clear vision, mission, and design and were quickly scaled up due in part to strong political commitment, good focalization of the target population, and their ability to show short-term positive antipoverty, education, and health and nutrition outcomes. All of the CCTs reviewed became part of their countries’ social protection strategies, allowing them to secure funding and develop clear, strong, and transparent structures rooted in rigorous monitoring and evaluation systems and social participation mechanisms. The combination of these factors may explain their political resilience, including their implementation at scale and sustainability (⁴4 Skoufias E, McClafferty B. “Is PROGRESA Working? Summary of the Results of an Evaluation by IFPRI. Report submitted to PROGRESA. Washington: International Food Policy Research Institute. 2001. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.58.3872&rep=rep1&type=pdf Accessed 28 November 2015.
http://citeseerx.ist.psu.edu/viewdoc/dow... , ²⁵25 Campello T, Côrtes Neri M. Bolsa Familia Program: a decade of social inclusión in Brazil. Executive Summary. Institute for Applied Economic Research. 2014. Brazil. Available at: http://www.ipea.gov.br/portal/images/stories/PDFs/140321_pbf_sumex_ingles.pdf Accessed 28 November 2015.
http://www.ipea.gov.br/portal/images/sto... , ⁴⁰40 Comisión Económica para América Latina y el Caribe (CEPAL) and Unión De Naciones Suramericanas. Transferencias de ingresos para la erradicación de pobreza. Dos décadas de experiencias en los países de la Unión de Naciones Suramericanas (UNASUR). Naciones Unidas. 14-20810 Santiago de Chile, Noviembre de 2014. Available at: http://repositorio.cepal.org/bitstream/handle/11362/37390/S1420810_es.pdf?sequence=1 Accessed 28 November 2015.
http://repositorio.cepal.org/bitstream/h... , ⁴⁶46 Pérez-Escamilla R. Can experience-based household food security scales help improve food security governance? Glob Food Sec. 2012;1(2):120-125.) despite numerous changes in government administrations. Furthermore, these CCTs evolved over time, based on evaluation data, which has helped strengthen their countries’ social policies. As shown in the current findings, all three programs seek to improve their beneficiaries’ ability to break the poverty cycle and thus become less reliant on the program over time.

CCT benefits, structure, and governance

Unlike previous reviews (⁴⁷47 Lagarde M, Haines A, Palmer N. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane Database Syst Rev. 2009;(4):CD008137., ⁴⁸48 Owusu-Addo E, Cross R. The Impact of conditional Cash transfers on child health in low-and middle-income countries: a systematic review. International Journal of Public Health. 2014:59(4): 609-618), this review analyzed CCT impacts within the context of the programs’ operations and structure, including governance. This realist review is likely to have generated results more useful to policy-makers than those from previous studies. Although it has not been without challenges overall, the experience with CCTs has demonstrated that it is possible to provide adequate oversight of cash transfers and participant compliance with health/nutrition- and education-related program conditions. This has been accomplished through complex intersectoral coordination based on clear operational principles and processes overseen by transparent governance structures that include the participation of civil society. Brazil’s CCT had the strongest management information system of the three programs. The strength of this system has allowed for strong decentralization of implementation decisions as well as in-depth analyses of process indicators and program impacts from the national to the municipal level, supporting the hypothesis that proper monitoring and evaluation can affect program governance (⁴4 Skoufias E, McClafferty B. “Is PROGRESA Working? Summary of the Results of an Evaluation by IFPRI. Report submitted to PROGRESA. Washington: International Food Policy Research Institute. 2001. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.58.3872&rep=rep1&type=pdf Accessed 28 November 2015.
http://citeseerx.ist.psu.edu/viewdoc/dow... , ²⁵25 Campello T, Côrtes Neri M. Bolsa Familia Program: a decade of social inclusión in Brazil. Executive Summary. Institute for Applied Economic Research. 2014. Brazil. Available at: http://www.ipea.gov.br/portal/images/stories/PDFs/140321_pbf_sumex_ingles.pdf Accessed 28 November 2015.
http://www.ipea.gov.br/portal/images/sto... , ³⁸38 Attanasio O, Syed M, Vera-Hernández M. (2003), Early Evaluation of a New Nutrition and Education Programme in Colombia. The Institute for Fiscal Studies (IFS) Briefing Note no. 44. Available at: www.ifs.org.uk/publications.php?publication_id=1792 Accessed 28 November 2015.
www.ifs.org.uk/publications.php?publicat... ). Brazil’s CCT also had the strongest program oversight mechanisms at all levels, including exemplary structures for social participation. The Colombian CCT demonstrated the feasibility of implementing the social protection strategy, even in areas with internally displaced populations. The fact that CCTs have spread rapidly across Latin America and continue to show similar education, health, and nutrition benefits in very diverse contexts indicates that the CCT model is extremely relevant and replicable as a social protection system. The pioneering Mexican CCT generated important know-how on intersectoral program coordination at the national level. The robust, quasi-experimental evaluation component of the Mexican program, included since its inception, has allowed for relatively quick documentation of the health and nutrition impacts and thus very likely contributed to its political resilience. In that way, the Mexican CCTs greatly benefitted the design of the CCTs in Brazil, Colombia, and beyond.

CCT impacts on children’s health and nutrition

In agreement with a previous review (⁷7 Wong G, Greenhalgh T, Westhorp G, Pawson R. Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project. Southampton (UK): NIHR Journals Library, 2014. Available at: http://www.ncbi.nlm.nih.gov/books/NBK260013/pdf/Bookshelf_NBK260013.pdf Accessed 28 November 2015.
http://www.ncbi.nlm.nih.gov/books/NBK260... ) that did not examine Brazil’s BFP, and a review that examined all CCTs without grouping them by country (⁴⁸48 Owusu-Addo E, Cross R. The Impact of conditional Cash transfers on child health in low-and middle-income countries: a systematic review. International Journal of Public Health. 2014:59(4): 609-618), this review found strong evidence, based on data from the three largest and most long-standing programs in Latin America, that the CCT model for social protection has benefitted health and nutrition outcomes, especially among the most vulnerable children. However, none of the 17 reviewed research studies were able to disentangle the proportion of health and nutrition benefits that can be attributed to the different benefits and conditions of the CCTs. This might be a useful question to consider in future research to 1) help determine program costs per sector (e.g., health/nutrition versus education and/or social development); 2) avoid redundancies across sectors; and 3) identify any gaps.

Implications

These results strongly support the notion that well-designed CCTs that are launched with strong and sustained political support and include transparent policies and adequate monetary, health, and education resources are effective at improving the health and nutrition outcomes of young children in Latin America.

Limitations

The main limitation of this review was that it only included three of the 18 CCTs in Latin America. However, a small sample was chosen by design, using very specific inclusion criteria, to ensure that the CCTs that were studied were the most mature and stable in the region and would thus generate data that would be most useful to policy-makers.

Conclusions

Analysis of the CCT framework developed in Latin America and now benefiting the rest of the world clearly illustrates that social protection models that are conceptually sound and address social determinants of health can have a positive impact on education, health, and nutrition outcomes among the poorest families in the region. A key future challenge is how to reform these programs in the region so that, together with more equitable economic policies, they can help families escape not only extreme poverty, but any kind of poverty, in order to lead healthy and productive lives, as called for in the post-2105 Sustainable Development Goals.

Acknowledgments

The authors thank Luis Galicia Cano for his insights and support with the development of this manuscript.

Funding

This review was commissioned by PAHO with funding from the Micronutrient Initiative (Ottawa, Canada).

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