Principal investigator: 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 the intervention: 5.570 Brazilian municipalities
Sample size: 38.137 observations
Sector: Health Insurance
Type of InterventionInteractive effects of Brazilian public interventions
Primary variable of interest: Infant mortality
Evaluation method: Others Analysis of longitudinal data
Evaluation 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.
Regarding interventions in environmental health, the main deficits that still prevail in Brazil are primarily related to sanitation. Homes with piped water installations (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 system, and only 64,9% of the population has access to urban cleaning and proper waste management.
The populations most affected by inadequate sanitation conditions are those living in peri-urban and rural areas, that is, the poorest and, consequently, the most vulnerable population groups. Given this, the economic and social vulnerability of a large part of the Brazilian population makes these groups more prone to perpetuating the cycle of poverty and disease.
Aiming to reduce economic and social vulnerability, the Brazilian government created the Bolsa Família Program (PBF), one of the main conditional cash transfer programs. The program began in 2003, covering 3,6 million families, increasing to 11,2 million families in 2006. By 2019, all 5.570 Brazilian municipalities had implemented the PBF, benefiting 13,8 million families.
Intervention Details
In the context of environmental health, de Souza et al. (2021) state that studying the 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 Cash Transfer Program (Bolsa Família Program), on 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 (population censuses of 2000 and 2010, 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 conducted by de Souza et al. (2021) is framed as an ecological project with exploratory and analytical analyses. It was possible to carry out a longitudinal study to evaluate the temporal changes in mortality rates due to malnutrition and diarrhea, as well as to investigate the association between average exposure to independent variables (access to the Conditional Cash Transfer Program and environmental health variables) and mortality rates in children under 5 years of age. The design also allowed for the evaluation of the interaction between the independent variables, mainly access to the Conditional Cash Transfer Program (CCP) and environmental health variables.
Generalized linear models were fitted considering the Negative Binomial (NB) distribution for the number of deaths due to malnutrition and diarrhea, with fixed effects. NB models with and without zero inflation were evaluated. Subsequent interaction models were applied to assess the combined effects of the two public policies.
Results
The study results show that 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 largest decreases in mortality from diarrhea occurred in the South region, followed by the Central-West region. The largest decreases in mortality from malnutrition occurred in the Southeast region.
On the other hand, 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.
Regarding the decrease in diarrhea mortality rates 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). A decline in diarrhea mortality 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.
Lessons in Public Policy
The analysis carried out by de Souza et al. (2021) indicates the importance of associating different social programs with the approach of combating poverty. Systemic interventions, which aim to protect individuals or families from poverty associated with precarious environmental conditions, are fundamental to eliminating the transmission routes of infectious and parasitic diseases, reducing infant mortality.
Maintaining Conditional Cash Transfer Programs, with full coverage of the target population, combined with universal environmental health policies for all Brazilian municipalities, with greater attention to the North, Northeast, and Central-West regions, should be a government priority, as it will provide greater beneficial effects on children's health. Maintaining and expanding 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 to allow for beneficiary care and compliance with program conditions.
In this sense, the authors highlight the clear downward trend in the main social protection variables, especially in 2016, indicating the need for: (i) comprehensive care for the target population of the Conditional Cash Transfer Program; (ii) universal public policies for environmental health; (iii) increased literacy among people aged 15 and over; (iv) increased 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.
