By: Richard Skolnik
The use of conditional cash transfers (CCTs) is spreading. Originating in Mexico and Brazil, CCTs are incentive payments that governments make to people to encourage them to engage in selected programs, often in health or education. The payments are “conditional” on people’s participating in those program in an agreed way. CCTs are now used in a number of countries to promote better nutrition, improved health in young children, and safer pregnancy outcomes for mothers and children, among other goals. The evidence suggests that CCTs might be a cost-effective approach to improving a number of health outcomes, especially in settings where there are important social and economic constraints to people’s accessing key health services.
As the use of CCTs expands, I look forward to seeing more research on: the ethics of paying people for making certain choices; how to sustain the behavioral impacts of CCTs; how to pay for them; and how to retain community-based approaches to behavior change when appropriate.
It will be valuable to see more explicit attention paid to ethical issues related to cash incentives for poor people to engage in certain behaviors. To date, there does not appear to have been a systematic examination of them, either broadly or as they have played out in the CCT programs thus far. Ethicists are working with economists to address these questions and a seminar at Harvard in April on CCTs and ethics is a welcome step. I hope that in the future additional research and writing can be commissioned, and thoughtful guidance offered, on ethical issues in the design and implementation of CCTs. First order questions include the fairness of CCT programs, the degree to which they avoid coercion or the perception of coercion, and the extent to which participants are clearly informed of and understand the rights and obligations of the program in which they are participating.
People tend to see government programs as entitlements and this matter will also need to be treated carefully for CCT programs. The design of CCTs should make clear the extent to which CCTs are meant to promote long lasting behavior change and if so, how they will do that and how CCTs will be phased out. For the moment, it looks like some CCTs are focusing largely on needed short-term changes. This may be necessary. However, it may not be enough to set a foundation for socially and financially sustainable changes in behavior across communities in the long run. This may be an especially important question in lower-income countries.
The achievements and promise of CCTs is encouraging. However, the development community has a long history of following “fads”. It is important that CCTs are based on a careful assessment of alternative approaches and a growing body of evidence about how CCTs work in the medium and longer term. Some important development successes have been achieved on the basis of community-based approaches, such as those that dealt with nutrition in Tamil Nadu, total sanitation in parts of Bangladesh and Indonesia, oral re-hydration in Bangladesh and Egypt, and the reduction of the burden of several neglected tropical diseases in sub-Saharan Africa. We should be sure that CCTs are used when they are likely to be cost-effective approaches to sustainable behavior change. We should use other approaches when they appear more likely to achieve the best outcome, at the lowest cost, in what we also hope will be a sustainable way.
Richard Skolnik is a half-time Lecturer in Global Health at the George Washington University. He previously served 25 years at the World Bank, two years as Executive Director of the Harvard PEPFAR Program, and two years as Vice-President for International Programs at PRB. He was involved in the establishment of STOP TB and is the author of Essentials of Global Health. Richard would like to thank Anthony Measham, Rob Hecht, and Rachel Nugent for comments on the draft of this blog