The Lancet  
Jul 06, 2013  Volume 382  Number 9886  p1 – 100
http://www.thelancet.com/journals/lancet/issue/current

Comment
Promise, and risks, of conditional cash transfer programmes
Lia CH Fernald
Preview
What do we know about how to help poor children in low-income and middle-income countries? Various approaches have worked—improved nutrition, reduced exposure to infection, and introduction of parenting or preschool programmes—but there is still a long way to go.1,2 Conditional cash transfer programmes try to go deeper than these other approaches and get at the root causes of poverty. These programmes use cash to help households deal with their most pressing financial needs and also as an incentive to promote certain behaviours.

Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities
Davide Rasella PhD a, Rosana Aquino MD a, Carlos AT Santos PhD a b, Rômulo Paes-Sousa MD c, Prof Mauricio L Barreto MD a d
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960715-1/abstract

Summary
Background
In the past 15 years, Brazil has undergone notable social and public health changes, including a large reduction in child mortality. The Bolsa Familia Programme (BFP) is a widespread conditional cash transfer programme, launched in 2003, which transfers cash to poor households (maximum income US$70 per person a month) when they comply with conditions related to health and education. Transfers range from $18 to $175 per month, depending on the income and composition of the family. We aimed to assess the effect of the BFP on deaths of children younger than 5 years (under-5), overall and resulting from specific causes associated with poverty: malnutrition, diarrhoea, and lower respiratory infections.

Methods
The study had a mixed ecological design. It covered the period from 2004—09 and included 2853 (of 5565) municipalities with death and livebirth statistics of adequate quality. We used government sources to calculate all-cause under-5 mortality rates and under-5 mortality rates for selected causes. BFP coverage was classified as low (0·0—17·1%), intermediate (17·2—32·0%), high (>32·0%), or consolidated (>32·0% and target population coverage ≥100% for at least 4 years). We did multivariable regression analyses of panel data with fixed-effects negative binomial models, adjusted for relevant social and economic covariates, and for the effect of the largest primary health-care scheme in the country (Family Health Programme).

Findings
Under-5 mortality rate, overall and resulting from poverty-related causes, decreased as BFP coverage increased. The rate ratios (RR) for the effect of the BFP on overall under-5 mortality rate were 0·94 (95% CI 0·92—0·96) for intermediate coverage, 0·88 (0·85—0·91) for high coverage, and 0·83 (0·79—0·88) for consolidated coverage. The effect of consolidated BFP coverage was highest on under-5 mortality resulting from malnutrition (RR 0·35; 95% CI 0·24—0·50) and diarrhoea (0·47; 0·37—0·61).

Interpretation
A conditional cash transfer programme can greatly contribute to a decrease in childhood mortality overall, and in particular for deaths attributable to poverty-related causes such as malnutrition and diarrhoea, in a large middle-income country such as Brazil.

Funding
National Institutes of Science and Technology Programme, Ministry of Science and Technology, and Council for Scientific and Technological Development Programme (CNPq), Brazil.