Driving Up Demand for Health Services in Latin America
(January 2008) Millions of people live in poverty in Latin America, and many young people often face few prospects for a bright future. To combat the cycle of poverty, over the past decade governments throughout Latin America have adopted a new approach—conditional cash transfers (CCTs). This strategy offers poor households cash in return for fulfilling specific requirements related to health, education, and nutrition.
Conditional cash transfers are used widely throughout Latin America. They are designed to reduce poverty, while expanding access to different types of interventions that contribute to long-term financial and physical security by giving the poor more life skills and knowledge.1 These programs have improved the lives of both women and children. Although reproductive health and family planning have not been a priority for many such programs, CCTs offer a way to reach the poor with information about reproductive health and family planning, as well as increase their access to contraceptives.
Conditional cash transfers sponsored by the government were used to provide social services to the poor in rural Mexico in 1997. Since then, they have been used in 14 countries throughout the region (see map).
Conditional Cash Transfers in Latin America and the Caribbean
These programs are designed to give money directly to poor families for completing specific health, educational, or nutritional requirements that contribute to long-term poverty reduction.2 Two of the most common conditions for receiving the funds are primary- and secondary-school attendance for children and the regular use of health services by pregnant and postpartum women, children, and in some programs, the general adult population. By providing an incentive for activities that foster human development over the long term, CCTs are supposed to increase demand for public education and health services. With the extra cash received for fulfilling the requirements, poor families can then buy food, clothes, school supplies, animals, seeds—essentials that maintain a household.
Unlike many older poverty reduction strategies that focused on short-term transfers to the poor, such as income supplements and the distribution of food, CCTs focus on long-term investment in youth through education and health over a period of years as a way to break the cycle of poverty.3 Experts have found CCTs to be less expensive than traditional social assistance programs, in part because they consolidate the administration of health, nutrition, and education programs that were previously run separately.4 Although CCTs foster school attendance and use of health facilities among the poor, governments still are responsible for providing enough high-quality services to respond to the demand. Some programs have provided additional assistance to the health facilities and schools to support the surge in demand for services created by CCTs. In Mexico, for example, facilities receive additional funds to ensure an adequate supply of medicines, equipment, and materials.5
Many CCTs directly support reproductive health services, such as prenatal and postpartum care, which can result in more women using health facilities. For women interested in a broader range of reproductive health services, such as birth spacing, prenatal care, and the prevention of sexually transmitted diseases, the facilities need to have adequate resources, skilled staff, and appropriate infrastructure to respond to an increased demand for family planning services.
The health and educational conditions associated with conditional cash transfers vary by program, but generally include childhood immunizations, growth monitoring, and regular visits to health centers. Some require pregnant and breastfeeding women to visit health centers regularly. The following examples illustrate how family planning and reproductive health have been addressed by CCT programs.
The Mexican CCT program—Oportunidades—has four objectives for its health component: to provide free basic health services to users; to prevent childhood malnutrition; to improve nutrition for children and pregnant women through cash transfers, dietary supplements, and nutrition education; and to improve basic health and hygiene by educating the mothers.6 In addition, the program includes activities directed toward other family members, including adolescents, men, and women who are not pregnant.
Reproductive health and family planning are among many of the specific activities that target Mexican adults and adolescents.7 Family planning is discussed during at least one of five required prenatal consultations and during two postpartum consultations. The interventions directed toward adolescents and adults also contain a reproductive health component. Adults and adolescents (other than mothers) are required to attend an annual health talk and obtain an annual physical checkup. One of the topics covered in the educational talk is family planning and birth spacing. These talks and checkups provide opportunities to dispel misinformation and myths related to contraceptives that frequently prevent poor women from using family planning services. Researchers found that both urban and rural women who participated in the Oportunidades program had a better knowledge of family planning than peers who did not participate.8 In addition, participants in rural areas used family planning methods more often than rural women who were not served by Oportunidades. By incorporating family planning and birth spacing into ongoing health talks and interventions directed at the very poor, these programs give women and men a greater chance of learning how contraceptives work, which may increase the likelihood that they will start using a method.
Conditional cash transfers can also foster gender equity by offering larger educational subsidies to girls than to boys to boost girls’ enrollments, because girls are less likely to be enrolled in school and more likely to leave school early than boys. This effort has been successful, especially for girls, in both primary and secondary schools. Primary school dropout rates dropped by 14 percent for boys and by 17 percent for girls. Girls’ enrollment rates in secondary and high school in more urban areas also significantly increased after Oportunidades was implemented. Researchers also report that women involved in the program felt more empowered, based on increased self-confidence, ability to control their own actions, and greater control over family resources.9
Peru has pilot-tested Juntos, its CCT program, in several regions of the country and is now expanding it to the entire country. By the end of 2007, the program had been implemented in 14 of Peru’s poorest regions. The program is directed toward the poorest households in rural communities, focusing on households with pregnant women, widowed parents, the elderly, or persons with custody over children under age 15.10 The program also insists on school attendance, nutritional supplements, immunization, growth monitoring, and birth registration for all children. Juntos provides 100 soles monthly (approximately US$31) to women after they meet certain conditions, including reproductive health requirements. Women in the Juntos program are expected to receive prenatal care, deliver their babies in a health center, and receive post-natal care. In addition, pregnant women have the opportunity to attend “chats” that address reproductive health and family planning, nutrition, and food preparation. As in Mexico, participation in the program does not depend on whether a woman chooses a family planning method. Nevertheless, program results from the pilot areas indicate that an increase in the number of people participating in chats on family planning and reproductive health is building demand for services. Researchers report that among Juntos participants, the number of women seeking family planning counseling almost doubled from 568 per month to 999 per month in 11 months between 2006 and 2007.11 In addition, Juntos has contributed to a 65 percent increase in prenatal and postnatal visits, as well as an increase in the number of births taking place in health facilities.12
Juntos also promotes gender equity. Researchers have found that women participating in the program are better able to negotiate household decisions with their partners. In addition, family violence has decreased and more men have become involved in child care and household activities.13
Jay Gribble is director of the BRIDGE Project at the Population Reference Bureau.
- Todd A. Glassman and Marie Gaarder, “Performance-based Incentives for Health: Conditional Cash Transfer Programs in Latin America and the Caribbean,” Center for Global Development Working Paper 120 (April 2007).
- Laura B. Rawlings, “A New Approach to Social Assistance: Latin America’s Experience With Conditional Cash Transfer Programs,” Social Protection Discussion Paper 0416 (2004).
- Rawlings, “A New Approach to Social Assistance.”
- Jose Marques, A Review of Social Safety Net Assessments for Central America (Washington, DC: World Bank Human Development Group, Latin America and Caribbean Region, 2003).
- Laura B. Rawlings and Gloria M. Rubio, “Evaluating the Impact of Conditional Cash Transfer Programs: Lessons from Latin America,” World Bank Policy Research Working Paper 3119 (2003).
- Gustavo Nigenda and Luz Maria Gonzalez Robledo, Lessons Offered by Latin American Cash Transfer Programmes, Mexico’s Oportunidades and Nicaragua’s SPN. Implications for African Countries (London: DFID Health Systems Resource Centre, 2005).
- Nigenda and Gonzalez-Robledo, Lessons Offered by Latin American Cash Transfer Programmes.
- Bernardo Prado et al., Impacto de Oportunidades en la Salud Reproductive de la Poblacion Beneficiaria (preliminary version), cited in Glassman and Gaarder, “Performance-Based Incentives for Health,” Center for Global Development Working Paper 120 (April 2007).
- Emmanuel Skoufias et al., Is PROGRESA Working? Summary of the Results of an Evaluation (Washington, DC: International Food Policy Research Institute, 2000).
- Gobierno del Peru, Juntos: Programa Nacional de Apoyo a los mas Pobres, accessed online at www.juntos.gob.pe/quienes_impactos.php, on Nov. 10, 2007.
- Suneeta Sharma and Elaine Menotti, “Mobilizing Public Sector Resources for the Poor in Peru,” paper presented at the 2007 annual meeting of the American Public Health Association, Washington, DC, Nov. 5. 2007.
- Nicola Jones, Rosana Vargas, and Eliana Villar, Conditional Cash Transfers in Peru: Tackling the Multi-Dimensionality of Poverty and Vulnerability, accessed online at www.equityforchildren.org, on Jan 16, 2008.
- Jones, Vargas, and Villar, Conditional Cash Transfers in Peru.