Abstract
BackgroundFour Andean countries of Bolivia, Colombia, Ecuador, and Peru introduced national health-focused conditional cash transfer (CCT) programs in the 2000s. This study probes whether policymakers in these countries targeted CCT programs to subregions with the highest prevalence of ill-health or those with the lowest socioeconomic status (SES) to evaluate the equity of geographic targeting and means-testing, as well as the potential role of normative frames, bounded rationality, and clientelism as explanatory mechanisms for inequities in social spending.MethodsThe distribution of vaccination coverage, underweight, stunting, and child deaths is established both within and between subnational regions and SES quintiles from 1998 to 2012 using every available nationally representative household survey. The equity of CCT program targeting and strength of association with subregional SES and health outcomes are measured using generalized entropy index decomposition and meta-regression. Finally, simple predictive models for CCT targeting are created using lagged subregional SES, health outcomes, and concentration indices.ResultsBolivia and Peru both effectively targeted at-risk subregions, but subregions in Peru with no CCT program coverage result in higher mistargeting rates for the country as a whole. Only Bolivia failed to attain CCT coverage concentration indices that are at least as large as the health inequalities they are targeting. Despite this insufficient progressivity, Bolivia has the most efficient subregional targeting, while the lowest rates of mistargeting for child deaths are found in Colombia and Ecuador. Finally, the simple predictive model performs as well or better than observed CCT coverage distribution for every country, year, and outcome.ConclusionsBoth Peru and Ecuador have targeted programs to their poorest populations effectively, demonstrating that this is possible with both universal and geographic targeting. No clear evidence of clientelism was found, while the dominant normative frame underlying CCT program targeting decisions appears to be the relative SES of subregions, rather than absolute SES, prevalence of health outcomes, or health inequalities. To reduce the inequitable impacts of bounded rationality, policymakers can use simple predictive models to target CCT coverage effectively and without leaving behind the most vulnerable populations that happen to live in more affluent subregions.
Highlights
Four Andean countries of Bolivia, Colombia, Ecuador, and Peru introduced national health-focused conditional cash transfer (CCT) programs in the 2000s
The way policymakers perceive determinants of health and cope with information gaps at the time of decision-making can have a large effect on the impacts these policies will have. While these inner thought processes, [1,2,3] the consequences of making decisions with less than perfect information, [1, 4] and hidden motivations [5, 6] can never be known with certainty, it is possible to probe the potential impacts of these effects with careful study of illustrative cases
Two of the CCT programs relied on geographic targeting (MFA and Juntos) and three programs developed a quantitative instrument to target vulnerable households (MFA, Bono de Desarrollo Humano (BDH), and Juntos)
Summary
Four Andean countries of Bolivia, Colombia, Ecuador, and Peru introduced national health-focused conditional cash transfer (CCT) programs in the 2000s. The way policymakers perceive determinants of health and cope with information gaps at the time of decision-making can have a large effect on the impacts these policies will have While these inner thought processes (i.e. normative frames), [1,2,3] the consequences of making decisions with less than perfect information (i.e. bounded rationality), [1, 4] and hidden motivations (e.g. clientelism) [5, 6] can never be known with certainty, it is possible to probe the potential impacts of these effects with careful study of illustrative cases. The long-term goals of these programs, and the effectiveness of reaching those goals is disputed, [11] there is evidence that these programs are achieving progress in improving health, school attendance, and social cohesion while reducing poverty with low administrative costs and rapid implementation [7, 12,13,14,15,16,17,18]
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