1. CAN CCTS IMPROVE
MATERNAL HEALTH
OUTCOMES?
EVIDENCE FROM EL SALVADOR
Alan de Brauw and Amber Peterman
International Food Policy Research Institute

2. CONDITIONAL CASH
TRANSFER PROGRAMS
In general, CCT programs give cash grants for
families conditional on specific behaviors
Usually have to do with health (e.g. growth
monitoring) or education (children going to school)
Programs often require or hold meetings for
beneficiaries on specific topics
Programs also notable for being accompanied by
rigorous impact evaluations
Now widespread in Central/South America

3. IMPACTS OF CCTS ON
MATERNAL HEALTH?
CCTs well positioned to affect maternal health
outcomes at birth, but few studies have attempted to
measure benefits of CCTs for maternal health
Most evidence from Oportunidades in Mexico (pre-natal
care; Barber and Gertler, 2009; c-sections increased as
well), and
JSY in India (Lin et al., 2010); one time inducement for in-
facility birth
Several mechanisms by which CCTs might affect
maternal health, even if not included as a condition
for transfers

4. POSSIBLE MECHANISMS
FOR IMPACT
1. Free Health Care included as a benefit of program (e.g.
Oportunidades)
2. Co-responsibilities may include pre- or post-natal care
3. May stimulate demand through health or nutrition
trainings
4. CCTs may at the same time increase supply of health
services through investments
5. Income effect increases demand
A.May be gender differentiated impacts due to transfer

5. OUTCOMES WE STUDY
1. Adequate pre-natal care
(defined as 5 visits or
more during pregnancy)
2. Skilled attendance at
birth
3. Birth in hospital
4. Post-natal care (defined
as visit to health care for
mother within 2 weeks of
birth)

6. METHODOLOGY
We use an innovative RDD methodology (de Brauw
and Gilligan, 2011) to measure impacts of
Comunidades Solidarias Rurales on maternal health
outcomes in rural El Salvador
Methodology allows us to use RDD without
explicit forcing variable
Also use double difference to control for pre-
program conditions

7. REGRESSION
DISCONTINUITY DESIGN
Identification Assumption: A threshold exists that
splits treatment and control
From the beneficiaries’ perspective, threshold is exogenous
Typically determined through a proxy means test or another
forcing variable
Observations just above and just below threshold can be
compared to measure impact of program
Problem in this case is a lack of an explicit forcing
variable

8. IMPLICIT FORCING
15
VARIABLE
Percentage of Children Severely Stunted
A
A Threshold
Severe Stunting Rate
S
10
S S
A S
A S
A
A
A
5
A A
A S
A A A
A S
S SS S
S
A S
S S
S
S
0
30 40 50 60
Poverty Rate
Forcing Line Cluster Centers

9. DATA
Come from evaluation surveys of CSR conducted by
IFPRI-FUSADES
Collected in the beginning and end of 2008
Treatment and control groups for this part of
evaluation entered program in 2006 and 2007
In initial survey, asked about birth history over past
three years to construct a before and after comparison

10. TREATMENT AND
CONTROL GROUPS
Entry Date
Before Treatment After Treatment
2006 entry group
October 1st, 2006
Before Treatment After Treatment
2007 entry group

11. DESCRIPTIVE CHANGES,
2006 ENTRY GROUP
Pre-CSR Post-CSR
100
75
50
25
0
Pre-Natal Skilled Att. Hospital Post-Natal

12. RESULTS: ADEQUATE
PRE-NATAL CARE
.4
Change in Adequate
.2
Pre-natal care
0
-.2
-.4
-.6
-15 -10 -5 0 5 10 15
Distance to Cluster Threshold
2006 Entry 2007 Entry

13. RESULTS: SKILLED
ATTENDANCE AT BIRTH
.4
Attendance at Birth
Change in Skilled
.2
0
-.2
-.4
-15 -10 -5 0 5 10 15
Distance to Cluster Threshold
2006 Entry 2007 Entry

14. RESULTS: BIRTH IN
HOSPITALS
.4
Change in Birth in
.2
Hospitals
0
-.2
-.4
-15 -10 -5 0 5 10 15
Distance to Cluster Threshold
2006 Entry 2007 Entry

15. RESULTS: POST-NATAL
CARE
.4
Change in Post-Natal
.2
Care
0
-.2
-15 -10 -5 0 5 10 15
Distance to Cluster Threshold
2006 Entry 2007 Entry

16. PRIMARY RESULTS
Individual +
Outcome no control variables
Household Controls
Adequate pre-natal -0.112 -0.089
monitoring (0.084) (0.086)
Skilled attendance 0.174 0.164
at birth (0.057)*** (0.075)**
0.223 0.214
Birth in hospital
(0.052)*** (0.052)***
-0.094 -0.093
Post-natal care
(0.138) (0.140)

17. IMPACT PATHWAYS
Not a co-responsibility of program to have birth
attended by qualified personnel or in a hospital
Overall income effect also unlikely (transfer is
relatively small)
So three remaining possibilities:
Through training (capaciticiones)
Through supply side (increase in access to facilities)
Through increase in women’s decision making power

18. CAPACITICIONES?
Impact cannot all be
through trainings
Trainings only began
after transfers did
Short time period for
trainings to affect such
large change

19. SUPPLY SIDE?
Access to facilities
increased in a non-linear
manner throughout
communities that were
to enter CSR
So cannot be supply
side in isolation of
stimulated demand
Definitely played a role

20. WOMEN’S DECISION
MAKING POWER
Women definitely
empowered by CSR,
through transfers and
knowledege (Adato et al.,
2009)
Not clear how to quantify
impact, but with increased
supply and awareness, may
have affected changes
around birth

21. CONCLUSION
El Salvador’s CCT, Comunidades Solidarias Rurales,
has improved outcomes at birth along some lines
Not other measures of women’s health during
fertility however
To increase impacts, perhaps should also condition
program on pre- and post-natal visits
Could potentially replace one capaciticion, if
women feel burdened by program