Assessing conditional cash transfers on health outcomes: evidence from

Bataan, Philippines Mitzie Irene Conchada and Marites

TiongcoThe PES 52nd Annual MeetingHotel Intercontinental Manila

November 14, 2014

Outline

• Motivation• Program Description• Methodology• Estimation Results• Summary

Reviewof Literature

• Enhanced human capital of the poor through changes in household behavior (Usui, 2011; Janvry and Sadoulet, 2005; Castillo, 2013)

• Reduced health, nutrition and education inequities (Nazmul, Friedman and Onishi 2013) – Enrollment rates of preschool- and daycare-aged

children are 10.3 percentage points higher among the 4Ps

– primary school completion rates are higher and dropout rates are lower

– Lower rate of severe stunting by 10.1 percentage points among 6 to 36-month old children among the 4Ps

Background: Pantawid Pamilyang Pilipino Program (4Ps)

• 4Ps is one of the responses of the Philippine Government to the challenge of meeting the Millennium Development Goals (MDGs), particularly: Eradicating extreme poverty

• Achieving universal primary education • Promoting gender equality and

empowering women • Reducing child mortality • Improving maternal health

4Ps Objectives

• Social Assistance •Provide assistance to the poor to alleviate their immediate needs (short term).

• Social Development •Break the intergenerational cycle of poverty through investment in human capital, i.e., education, health and nutrition (long term)

Criteria for eligible households

•Households below poverty threshold with children 0-14 years old or pregnant mother

The poorest households are selected through a Proxy Means Test (PMT) which determines the socio-economic category of families.

Benefits of eligible households

• PhP500 for health grant or P6,000 per year

•PhP300 per child (up to 3 children) for education grant (for 10 months a year)

•Maximum of PhP1,400 per household per month (approx. 26% of poverty threshold for a family of 5)

• A household with three qualified children receives a subsidy of P15,000 annually as long as they comply with the conditionalities

Conditionalities: Health and Nutrition

• Pregnant Household Member– Visit local health center to avail of pre-and post-natal care – Avail of appropriate child delivery services by a skilled

health professional – Avail at least one post-natal care within 6 weeks after

childbirth • Children 0-5 Years Old – Visit the health center to avail immunization – Have monthly weight monitoring and nutrition counseling

for children 0-24 months old – Have quarterly weight monitoring for children 25 to 73

months old – Have clinical management for sick children • Children 6-14 Years Old – Must receive deworming pills twice a year

Conditionalities: Education

• Children 3-5 years old– Enrolled in day care or pre-school

program and maintain a class attendance rate of at least 85% per month

• Children 6-14 Years Old – Enrolled in elementary and/or high

school and maintain a class attendance rate of at least 85% per month

Conditionalities: Family development sessions

–Parents or Guardians Attend Family Development Sessions at least once a month

– Attend Responsible Parenthood Sessions and Family Counseling Sessions

– Participate in community activities

Program logic

Main Question

• Does 4Ps foster investment on health care?

• What is the impact of 4Ps on utilization pre and post-natal health care services, and other health facilities—child birth in a health facility and attended by health professionals?– what would have happened had the

beneficiaries not received 4Ps

Data• Baseline data: Community Based Monitoring

System CBMS) data collected in 2008 for Bagac (treatment; N=15,117) and the year 2009 for Pilar (control; N=7,844); we take the poorest 20%

• Follow-up survey to measure intermediate outcomes: data collected from Bagac and Pilar on April-May 2014 (4 years after 4Ps-set A was implemented in Bagac); sample size=460 HH (determined by the standard power calculation=90%)

Dataactual sample = 441 HHs•For Bagac, randomly sampled from targeted beneficiaries based on proxy means test generated by the National Household Targeting System for Poverty Reduction based on the Annual Poverty Income Survey;•For Pilar, a logit regression was used to determine poverty status based on income and wealth index•Poorest 20%; Poverty threshold in Bataan= Php17,643/ capita

Methodology

• Propensity Score Matching – Available observational data allowed us to

estimate the impact of an intervention– It helps establish the counterfactual (what

would have happened to the beneficiaries without the grant) by matching a beneficiary to non-beneficiary

– It mimics an experiment by creating sample of units that received the treatment vs those who did not

Methodology

• Used time invariant observable variables: age, educational attainment of household head, educational attainment of mother, gender of household head

• Other characteristics of the family: family size, employment of the household head

• Limitation of PSM: assumes that there are no non-observables that may influence the outcome

Impact measure

• ATT is the impact of 4Ps eligible households that actually participated

Underlying assumptions:

Health outcomes measured

Supply side0

2040

6080

100

02 11

mean of facdel11 mean of facdel12mean of facdel13

02

46

8

02 11

mean of undrwt11 mean of undrwt12mean of undrwt13

Health facility delivery Prevalence of underweight 0-59 mos0

2040

6080

100

02 11

mean of fic11 mean of fic12mean of fic13

Fully immunized children

010

2030

4050

02 11

mean of RHUMcp13 mean of RHUMcp12mean of RHUMcp11

Maternal care package

Focus group discussion

Descriptive statistics

ps

number of times mother received pre-natal check-up

frequency of prenatal care

weight of child whose mom received pre-natal

check-up of baby after delivery

no 4Psmean 6.49 2.23 6.36 0.80

sd 3.07 0.98 2.66 0.97N 134 101 110 126

with 4Psmean 7.40 2.43 8.43 1.95

sd 9.57 0.90 12.16 5.08N 124 104 108 120

Totalmean 6.93 2.33 7.38 1.36

sd 6.99 0.94 8.81 3.66N 258 205 218 246

Descriptive statistics

psfamsize Age

highest educ (HS)

highest educ (Col)

highest educ (Grad)

Mother educ (HS)

Mother educ (Col)

Mother educ (Grad)

employment status sex

no4Psmea

n 4.5935.1

0.41 .08 .07 .25 .04 .00 .21 1.17

sd 1.6214.1

9.49 .27 .26 .43 .20 .09 .41 0.38N 213 209213 213 213 213 213 213 213 213

with 4Ps

mean 5.39

39.26 .39 .04 .03 .31 .01 .00 .35 1.10

sd 1.6212.5

7 .48 .19 .16 .47 .11 .06 .48 0.30N 228 192 228 228 228 228 228 228 228 228

Total

mean 5.00

37.09 .40 .06 .05 .28 .02 .00 .28 1.13

sd 1.6713.5

8 .49 .23 .21 .45 .16 .08 .45 0.34N 441 401 441 441 441 441 441 441 441 441

Propensity score distribution showing common support

01

23

Den

sity

0 .2 .4 .6 .8psmatch2: Propensity Score

Common support for outcomes:LL= 0.27UL=0.85#Treatment=68#control=38

The distribution between both groups is similar between the average propensity score and the mean of X to satisfy the balancing property

Estimation results

OutcomesTreated

Control ATT

Std. Error t-stat

           number of times mother received pre-natal check-up 192 60 1.489 0.79 1.886 bootstrapped SEs 192 60 1.489 1.142 1.304

frequency of prenatal care 192 43 0.273 0.172 1.581 bootstrapped SEs 192 43 0.273 0.223 1.224

weight of child whose mom received pre-natal 192 45 3.012 1.051 2.866 bootstrapped SEs 192 45 3.012 1.616 1.864

check-up of baby after delivery 192 55 1.515 0.43 3.527 bootstrapped SEs 192 55 1.515 0.567 2.673

positive impact means those who are expected to gain the most from 4Ps actually do

Results• Average treatment effects on 4Ps beneficiaries

improves the health outcomes related to pre-natal, post-natal care, as well as the health of the new born child in Bagac, Bataan.

• Significant difference(after sensitivity analysis) in Bagac and Pilar in terms of the health outcomes: – New born babies of mother beneficiaries are 3

lbs heavier than non-beneficiaries. – number of times a new born baby is checked-

up increases by 2 more visit if the household is a CCT beneficiary

Conclusions• Pre-natal health care received by 4Ps beneficiaries is

effective in improving the health of the mother and baby which contribute to an increase in weight. Babies who are born underweight are most likely to be sickly, thus affecting their productivity and performance when they grow older.

• Investment in human capital has to be supplemented by other welfare enhancing strategies such as improving the supply side factors such as the barangay health care units and professional health workers.– Doctor/popn =B: 1/26,700; P: 1/42,278– Midwife/popn= B: 1/1,907; P: 1/4,698– Nurse/popn = B: 1/26,700; P: 1/21,139