Brazilian Conditional Cash Transfer Research Articles

Current and Projected Mortality and Hospitalization Rates Associated With Conditional Cash Transfer, Social Pension, and Primary Health Care Programs in Brazil, 2000-2030

The health outcomes of increased poverty and inequalities in low- and middle-income countries (LMICs) have been substantially amplified as a consequence of converging multiple crises. Brazil has some of the world's largest conditional cash transfer (Programa Bolsa Família [PBF]), social pension (Beneficio de Prestacão Continuada [BPC]), and primary health care (Estratégia de Saúde da Família [ESF]) programs that could act as mitigating interventions during the current polycrisis era of increasing poverty, slow or contracting economic growth, and conflicts. To evaluate the combined association of the Brazilian conditional cash transfer, social pension, and primary health care programs with the reduction of morbidity and mortality over the last 2 decades and forecast their potential mitigation of the current global polycrisis and beyond. This cohort study used a longitudinal ecological design with multivariable negative binomial regression models (adjusted for relevant socioeconomic, demographic, and health care variables) integrating the retrospective analysis from 2000 to 2019, with dynamic microsimulation models to forecast potential child mortality scenarios up to 2030. Participants included a cohort of 2548 Brazilian municipalities from 2004 to 2019, projected from 2020 to 2030. Data analysis was performed from September 2022 to February 2023. PBF coverage of the target population (those who were poorest) was categorized into 4 levels: low (0%-29.9%), intermediate (30.0%-69.9%), high (70.0%-99.9%), and consolidated (≥100%). ESF coverage was categorized as null (0), low (0.1%-29.9%), intermediate (30.0%-69.9%), and consolidated (70.0%-100%). BPC coverage was categorized by terciles. Age-standardized, all-cause mortality and hospitalization rates calculated for the entire population and by age group (<5 years, 5-29 years, 30-69 years, and ≥70 years). Among the 2548 Brazilian municipalities studied from 2004 to 2019, the mean (SD) age-standardized mortality rate decreased by 16.64% (from 6.73 [1.14] to 5.61 [0.94] deaths per 1000 population). Consolidated coverages of social welfare programs studied were all associated with reductions in overall mortality rates (PBF: rate ratio [RR], 0.95 [95% CI, 0.94-0.96]; ESF: RR, 0.93 [95% CI, 0.93-0.94]; BPC: RR, 0.91 [95% CI, 0.91-0.92]), having all together prevented an estimated 1 462 626 (95% CI, 1 332 128-1 596 924) deaths over the period 2004 to 2019. The results were higher on mortality for the group younger than age 5 years (PBF: RR, 0.87 [95% CI, 0.85-0.90]; ESF: RR, 0.89 [95% CI, 0.87-0.93]; BPC: RR, 0.84 [95% CI, 0.82-0.86]), on mortality for the group aged 70 years and older, and on hospitalizations. Considering a shorter scenario of economic crisis, a mitigation strategy that will increase the coverage of PBF, BPC, and ESF to proportionally cover the newly poor and at-risk individuals was projected to avert 1 305 359 (95% CI, 1 163 659-1 449 256) deaths and 6 593 224 (95% CI, 5 534 591-7 651 327) hospitalizations up to 2030, compared with fiscal austerity scenarios that would reduce the coverage of these interventions. This cohort study's results suggest that combined expansion of conditional cash transfers, social pensions, and primary health care should be considered a viable strategy to mitigate the adverse health outcomes of the current global polycrisis in LMICs, whereas the implementation of fiscal austerity measures could result in large numbers of preventable deaths.

Evaluating the relationship between conditional cash transfer programme on preterm births: a retrospective longitudinal study using the 100 million Brazilian cohort

BackgroundPreterm births increase mortality and morbidity during childhood and later life, which is closely associated with poverty and the quality of prenatal care. Therefore, income redistribution and poverty reduction initiatives may be valuable in preventing this outcome. We assessed whether receipt of the Brazilian conditional cash transfer programme - Bolsa Familia Programme, the largest in the world - reduces the occurrence of preterm births, including their severity categories, and explored how this association differs according to prenatal care and the quality of Bolsa Familia Programme management.MethodsA retrospective cohort study was performed involving the first live singleton births to mothersenrolled in the 100 Million Brazilian Cohort from 2004 to 2015, who had at least one child before cohort enrollment. Only the first birth during the cohort period was included, but born from 2012 onward. A deterministic linkage with the Bolsa Familia Programme payroll dataset and a similarity linkage with the Brazilian Live Birth Information System were performed. The exposed group consisted of newborns to mothers who received Bolsa Familia from conception to delivery. Our outcomes were infants born with a gestational age < 37 weeks: (i) all preterm births, (ii) moderate-to-late (32–36), (iii) severe (28–31), and (iv) extreme (< 28) preterm births compared to at-term newborns. We combined propensity score-based methods and weighted logistic regressions to compare newborns to mothers who did and did not receive Bolsa Familia, controlling for socioeconomic conditions. We also estimated these effects separately, according to the adequacy of prenatal care and the index of quality of Bolsa Familia Programme management.Results1,031,053 infants were analyzed; 65.9% of the mothers were beneficiaries. Bolsa Familia Programme was not associated with all sets of preterm births, moderate-to-late, and severe preterm births, but was associated with a reduction in extreme preterm births (weighted OR: 0.69; 95%CI: 0.63–0.76). This reduction can also be observed among mothers receiving adequate prenatal care (weighted OR: 0.66; 95%CI: 0.59–0.74) and living in better Bolsa Familia management municipalities (weighted OR: 0.56; 95%CI: 0.43–0.74).ConclusionsAn income transfer programme for pregnant women of low-socioeconomic status, conditional to attending prenatal care appointments, has been associated with a reduction in extremely preterm births. These programmes could be essential in achieving Sustainable Development Goals.

Factors Associated with Continued Breastfeeding Practice in Children Under 2 Years of Age Assisted by the Brazilian Conditional Cash Transfer Program, Bolsa Família

ABSTRACT Breastfeeding is the first guarantee of the human right to adequate food and the benefits of continued breastfeeding up to 2 years of age are well established. This cross-sectional study sought to explore the association between socioeconomic, demographic, and nutritional factors and the practice of continued breastfeeding in children aged 6 to 24 months assisted by the Brazilian conditional cash transfer program, Bolsa Família. Our findings emphasize the role of unfavorable socioeconomic conditions in diminishing the practice of continued breastfeeding. They also suggest the importance of policy-level actions to promote and support breastfeeding and to combat early ultra-processed foods consumption.

Ausência de impactos de projetos de desenvolvimento rural? Ausência de sinergias com CCTs? O Pró-Gavião no Brasil

Abstract: We estimate the impacts of an IFAD-supported rural development project (Pro-Gavião). Because public policies are frequently implemented simultaneously rather than in isolation, we also estimate the impacts of—and possible synergies with—the Brazilian conditional cash transfer (CCT) program Bolsa Família. Developed jointly by IFAD and the State Government of Bahia, Pro-Gavião was a rural development project in 13 contiguous municipalities between 1997 and 2005. Census tract level data were extracted for the analysis from the 1995-96 and 2006 Agricultural Censuses. The evaluation uses propensity score matching to construct a control group of untreated census tracts, and a difference-in-differences estimation to identify impacts. The outcomes analyzed include land productivity, agricultural income and child labor. Although Pro-Gavião involved significant investments in the region, the results suggest little if any program impact, or synergies between the two programs. The unexpected null findings are robust to alternative approaches to identifying the treated census tracts, matching techniques, and heterogeneity in several dimensions. We show that the lack of impacts is not driven by adverse rainfall in the treated communities, or the influence of other programs in the control communities. Alternative explanations for the null results are explored.

Influence of conditional cash transfer program on prenatal care and nutrition during pregnancy: NISAMI cohort study.

ABSTRACTBACKGROUND:There are few studies on the influence of a cash transfer program on nutritional outcomes from pregnancy.OBJECTIVES:To analyze how a Brazilian conditional cash transfer program (Bolsa Familia Program, BFP) was associated with changes in body mass index (BMI) and food consumption among pregnant women.DESIGN AND SETTING:Cohort study on 250 pregnant women (≥ 18 years of age) in Brazilian prenatal services.METHODS:A food frequency questionnaire was used to evaluate dietary intake. Weight was measured in each gestational trimester. Generalized estimation equations and structural equation modeling were used for statistical analyses. Correlations were analyzed using standardized coefficients (SCs).RESULTS:Women benefitting from the BFP were of greater age and had lower education. The BFP exerted a direct negative effect on the pregnant women’s consumption choices regarding refined grains, regional foods, vegetable oil, sausages, salted meats and snacks (SC = -0.10) and on maternal BMI (SC = -0.12). Among the intermediate variables, we observed that the time elapsed since pregnancy and the month of prenatal onset had direct negative effects; and that the number of visits to doctors, family income and number of years of education had direct positive effects.CONCLUSIONS:Beneficiaries were less likely to increase their BMI outside of the recommended standards and had a greater tendency to receive prenatal care. Participation in the BFP had a direct negative effect on adherence to unhealthy diets.

The effect of Bolsa Familia Program on mitigating adolescent school dropouts due to maternity: An area analysis

This study evaluates the effect of the Brazilian conditional cash transfer program, Programa Bolsa Familia (PBF), on the school attendance of adolescent mothers. Given the previously documented effect of PBF on the school attendance of young people who are not usually mothers, we investigate to what extent this effect differs between adolescent mothers and non-mothers. A two-stage analysis was performed using the 2010 Brazilian census, enabling us to compare results from regions across the country. The results indicate that a higher incidence of PBF is not associated with a smaller gap in school attendance between mothers and non-mothers, i.e, young mothers do not benefit from the program as much as non-mothers in areas where the benefit is more prevalent.

Health literacy status among pregnant women in a Brazilian conditional cash transfer programme: a cross-sectional investigation

Objective: To investigate the overall score and the variables associated with health literacy of pregnant women benefited from a conditional cash transfer programme. Methods: A cross-sectional survey was conducted with pregnant women benefited from a Brazilian conditional cash transfer programme. We used a validated short health literacy survey developed for research on public health and health promotion. The level of health literacy (high or low) was considered a determining variable. Descriptive, bivariate and multivariate analysis was applied to the data collected. Results: Only the two following variables were associated with health literacy: participation in health education activities and the choice of mothers to seek advice regarding pregnancy. Functional health literacy was higher when pregnant women participated in health education activities. Critical health literacy was higher when pregnant women sought advice from their mothers, friends, and other family members. Conclusion: Health education and a social network of pregnant women should be part of prenatal care.

Governmental programmes associated with food insecurity among communities of descendants of enslaved blacks in Brazil.

To assess the access to government programmes and their association with food insecurity (FI) in families from quilombolas communities in Brazil. An analysis of secondary data from the 2011 Quilombolas Census was performed in Brazilian territories. The Brazilian Household Food Insecurity Measurement Scale (Escala Brasileira de Insegurança Alimentar, EBIA) was used to assess the household FI status. The relationships of governmental programmes with the levels of FI were estimated using logistic regression models. Greater national survey census of food and nutritional security of the recognised Quilombolas Brazilian territories. Totally, 8743 quilombolas families. The prevalence of household FI was 86·1 % (moderate/severe FI: 55·9 %, 95 % CI 54·8, 56·9). After adjustment for socio-demographic variables, access to rural development programmes (Food Acquisition Program: OR: 0·6, 95 % CI 0·4, 0·8, P-value < 0·01) and health programmes (Center for Family Health Support: OR: 0·5, 95 % CI 0·5, 0·7, P-value < 0·001) is inversely and significantly associated with moderate/severe FI. The Brazilian conditional cash transfer programme (Bolsa Família) was associated with quilombolas families with moderate/severe levels of FI (OR: 3·3, 95 % CI 2·8, 4·0, P-value < 0·001). The prevalence of FI was high among quilombolas families. Despite reduced participation in governmental programmes, rural development, agriculture and conditional cash transfer programmes are fundamental to the autonomy of quilombolas communities. In spite of the low participation, when families are able to access these programmes, the study revealed the importance of these initiatives in reducing the likelihood of severe levels of FI.

The Role of Income on the Relationship Between the Brazilian Cash Transfer Program (Programa Bolsa Família) and Intimate Partner Violence: Evidence From a Multigroup Path Analysis

Several initiatives are being proposed to reduce the incidence of intimate partner violence (IPV) worldwide. Actions aimed at women's economic empowerment through income transfer programs are one of those. Still, the literature on their impact is scarce and controversial. This study attempts to shed some light on this matter assessing whether the Brazilian Conditional Cash Transfer Program (Programa Bolsa Família [PBF]) is a protective factor for psychological and physical IPV against women in families of different levels of income. This is a cross-sectional, household-based study conducted in the city of Duque de Caxias, Rio de Janeiro, Brazil. The sample comprised 807 women reporting some intimate relationship in the 12 months before the interview. Information on IPV and participation on PBF were collected through face-to-face interviews using the Revised Conflict Tactics Scales (CTS2) and a direct question, respectively. A multigroup path analysis was applied to study the relations between PBF and psychological and physical IPV, considering confounding factors, some mediators, and moderation by income. The prevalence of both psychological and physical IPV are high, be it in the poverty and the extreme poverty income strata (psychological IPV: 66.2% and 72.7%, respectively; physical IPV: 26.2% and 40.6%, respectively). Results also showed a positive and direct association between PBF and psychological violence, yet only among families above the poverty line (β = .287, p = .001). The same could be found regarding physical violence, but the effect of PBF was indirect, mediated by psychological violence (β = .220, p = .003). Findings suggest that actions aimed at preventing IPV should go hand in hand with the PBF and, perhaps, other income transfer programs. This is even more relevant in relation to the less extreme poverty group where cash transfer may further raise conflicts and violence.

The Brazilian conditional cash transfer program and cardiovascular mortality: a data linkage study

Abstract Background Conditional cash transfer programmes (CCTs) make monetary transfers to poor families conditional on health check-ups and/or education attendance. CCTs have been key in reducing poverty and improving child and maternal health in low- and middle-income countries (LMICs) but their impact on cardiovascular mortality have not been studied. We aimed to evaluate the effect of the CCT Bolsa Familia Program (BFP) on premature all-cause and cardiovascular mortality in Brazil. Methods The 100 Million Brazilian Cohort combined information about individuals applying for social programmes, the BFP and mortality data. We analysed ∼8 million individuals aged 30-69 who applied from 2011 to 2015. We calculated inverse probability weights (IPW) for the probability to receive BFP based on baseline observed characteristics (age, education, race, geographical location, household characteristics and year of application). Individuals were followed until they reached 70 years of age, died by any cause, or until 31st Dec 2015. We used Poisson regression (with person-years as the offset) and IPWs to compare BFP recipients to a comparable control population. Females and males were analysed separately. Results By following individuals for up to 4 years, 43,562 deaths by all-causes occurred among 4,197,658 females and 69,209 deaths among 3,672,393 males. Female BFP beneficiaries had approximately 60% lower all-cause mortality (IRR=0.40;95%CI=0.37-0.42) and CVD mortality (IRR=0.42;95%CI=0.37-0.47) than non-beneficiaries. Males who are BFP beneficiaries had ∼50% lower all-cause (IRR=0.53;95%CI=0.52-0.55) and 60% lower cardiovascular mortality (IRR=0.40;95%CI=0.38-0.42) than non-beneficiaries. Conclusions BFP, the world's largest CCT, may substantially decrease premature mortality. CCTs might have important implications for the growing burden of non-communicable diseases, with impacts potentially due to improved nutrition, socioeconomic conditions and improved primary care access. Key messages The Brazilian CCT, a widely recognized programme for poverty alleviation, have showed to be associated with lower overall and cardiovascular premature mortality in both women and men. Other countries, particularly LMICs, may learn from the health benefits of CCTs and should consider its potential large effect on mortality when planning austerity policies.

Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study

SummaryBackgroundIndirect financial costs and barriers to health-care access might contribute to leprosy treatment non-adherence. We estimated the association of the Brazilian conditional cash transfer programme, the Programa Bolsa Família (PBF), on leprosy treatment adherence and cure in patients in Brazil.MethodsIn this quasi-experimental study, we linked baseline demographic and socioeconomic information for individuals who entered the 100 Million Brazilian Cohort between Jan 1, 2007, and Dec 31, 2014, with the PBF payroll database and the Information System for Notifiable Diseases, which includes nationwide leprosy registries. Individuals were eligible for inclusion if they had a household member older than 15 years and had not received PBF aid or been diagnosed with leprosy before entering the 100 Million Brazilian Cohort; they were excluded if they were partial receivers of PBF benefits, had missing data, or had a monthly per-capita income greater than BRL200 (US$50). Individuals who were PBF beneficiaries before leprosy diagnosis were matched to those who were not beneficiaries through propensity-score matching (1:1) with replacement on the basis of baseline covariates, including sex, age, race or ethnicity, education, work, income, place of residence, and household characteristics. We used logistic regression to assess the average treatment effect on the treated of receipt of PBF benefits on leprosy treatment adherence (six or more multidrug therapy doses for paucibacillary cases or 12 or more doses for multibacillary cases) and cure in individuals of all ages. We stratified our analysis according to operational disease classification (paucibacillary or multibacillary). We also did a subgroup analysis of paediatric leprosy restricted to children aged up to 15 years.FindingsWe included 11 456 new leprosy cases, of whom 8750 (76·3%) had received PBF before diagnosis and 2706 (23·6%) had not. Overall, 9508 (83·0%) patients adhered to treatment and 10 077 (88·0%) were cured. After propensity score matching, receiving PBF before diagnosis was associated with adherence to treatment (OR 1·22, 95% CI 1·01–1·48) and cure (1·26, 1·01–1·58). PBF receipt did not significantly improve treatment adherence (1·37, 0·98–1·91) or cure (1·12, 0·75–1·67) in patients with paucibacillary leprosy. For patients with multibacillary disease, PBF beneficiaries had better treatment adherence (1·37, 1·08–1·74) and cure (1·43, 1·09–1·90) than non-beneficiaries. In the propensity score-matched analysis in 2654 children younger than 15 years with leprosy, PBF exposure was not associated with leprosy treatment adherence (1·55, 0·89–2·68) or cure (1·57, 0·83–2·97).InterpretationOur results suggest that being a beneficiary of the PBF, which facilitates cash transfers and improved access to health care, is associated with greater leprosy multidrug therapy adherence and cure in multibacillary cases. These results are especially relevant for patients with multibacillary disease, who are treated for a longer period and have lower cure rates than those with paucibacillary disease.FundingCONFAP/ESRC/MRC/BBSRC/CNPq/FAPDF–Doenças Negligenciadas, the UK Medical Research Council, the Wellcome Trust, and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior–Brazil (CAPES).

The Vicious Cycle in the Bolsa Fam\xedlia Program\u2019s Implementation: Discretionality and the Challenge of Social Rights Consolidation in Brazil

This article aims to consider conceptions of the Brazilian conditional cash transfer Bolsa Família Program as elaborated by both those responsible for its implementation and its beneficiaries in Northeast Brazil. Most innovative in this study is the adoption of the program’s municipal social workers, who are responsible for the implementation of the program, as the main observation point, by conceptualizing them as street-level bureaucrats. The research is based on ethnographic fieldwork that took place between 2013 and 2015, for a total of six months, combined with in-depth interviews with the program’s beneficiaries in a middle-sized municipality of the State of Ceará. Social workers enjoy a range of discretion that directly affects the distribution of benefits. Their efforts to better apply what they see as scarce resources are embedded in their representations of poverty—separating “deserving” from “undeserving” poor—generating insecurity among beneficiaries. By doing so, beneficiaries’ understanding of the program as a social right is compromised, which is reinforced by a fragile legal status enjoyed by the Bolsa Família and ambiguous bureaucratic procedures.

Health profile differences between recipients and non-recipients of the Brazilian Income Transfer Program in a low-income population.

We investigated the relationship between living in a household that receives the Brazilian Income Transfer Program (Bolsa Família, in Portuguese - BF), a Brazilian conditional cash transfer program, and aspects of health and whether these relationships are heterogeneous across the 27 Brazilian states. According to data from the 2013 Brazilian National Health Survey, 18% of households participated in BF. Among households with household per capita income below BRL 500, many aspects of health differed between people living in BF and non-BF houses. For example, BF households were less likely to have medical coverage but more likely to have visited the doctor in the last 12 months as well as being more likely to smoke and less likely to do exercise. They ate nearly one less serving of fruits and vegetables a week but were less likely to substitute junk food for a meal. They reported worse self-rated health but did not differ importantly on reporting illnesses. Moderate amounts of heterogeneity in the difference in health characteristics were found for some variables. For instance, medical coverage had an I2 value of 40.7% and the difference in coverage between BF and non-BF households ranged from -0.09 to -0.03. Some illnesses differed qualitatively across states such as high cholesterol, asthma and arthritis. This paper is the first to outline the health profile of people living in households receiving payments from a cash transfer program. It is also the first to find geographic heterogeneity in the relationship between a cash transfer program and health variables. These results suggest the possibility that the effect of cash transfer programs may differ based on the population on which it is implemented.

Conditional cash transfer programme: Impact on homicide rates and hospitalisations from violence in Brazil.

BackgroundHomicide kills more people than war globally and is associated with income inequality. In Brazil, one of the most unequal countries of the world, the homicide rate is four times higher than the world average. Establishing if the Brazilian conditional cash transfer programme [Bolsa Familia Programme (BFP)], the largest in the world, is associated with a reduction in the rate of homicide is relevant for violence prevention programs. We aimed to assess the effect of BFP coverage on homicide and hospitalization rates from violence.MethodsBFP coverage and rates of homicide (overall and disaggregated by sex and age) and hospitalizations from violence from all 5,507 Brazilian municipalities between 2004 and 2012 were explored using multivariable negative binomial regression models with fixed effect for panel data. Robustness of results was explored using sensitivity analyses such as difference-in-difference models.FindingsHomicide rates and hospitalization from violence decreased as BFP coverage in the target population increased. For each percent increase in the uptake of the BFP, the homicide rate decreased by 0.3% (Rate Ratio:0.997; 95%CI:0.996–0.997) and hospitalizations from violence by 0.4% (RR: 0.996;95%CI:0.995–0.996). Rates of homicide and hospitalizations from violence were also negatively associated with the duration of BFP coverage. When, coverage of the target population was at least 70% for one-year, hospitalizations from violence decreased by 8%; two-years 14%, three-years 20%, and four years 25%.InterpretationOur results support the hypothesis that conditional cash transfer programs might have as an additional benefit the prevention of homicides and hospitalizations from violence. Social protection interventions could contribute to decrease levels of violence in low-and-middle-income-countries through reducing poverty and/or socioeconomic inequalities.

Effect of the Brazilian cash transfer programme on suicide rates: a longitudinal analysis of the Brazilian municipalities.

There is a growing awareness of the economic and contextual factors that may play a role in the aetiology of suicide. The Programa Bolsa Família (PBF) the Brazilian conditional cash transfer programme, established in 2004, aims to attenuate the effects of poverty of Brazilians. Our study aims to evaluate the effect of Bolsa Família Programme (BFP) coverage on suicide rates in Brazilian municipalities. We conducted an ecological study using 2004-2012 panel data for 5507 Brazilian municipalities. We calculated age-standardized suicide rates for each municipality and year. BFP coverage was categorized according to three levels (< 30%, ≥ 30% and < 70% and ≥ 70%) and duration (coverage ≤ 70% for all years, ≥ 70% for 1year, ≥ 70% for 2years, ≥ 70% for 3 or more years). We used negative binomial regression models with fixed effects, adjusting for socio-economic, demographic and social welfare co-variables. An increase in BFP coverage was associated with a reduction in suicide rates. The strongest effect was observed when in addition to greater municipal coverage (RR 0.942, 95% CI 0.936-0.947), the duration of the high coverage was maintained for 3 years or more (RR 0.952 95% CI 0.950-0.954). The results provide evidence that the conditional cash transfer programme may reduce suicide in Brazilian municipalities, mitigating the effect of poverty on suicide incidence.

The association of the Bolsa Familia Program with children\u2019s oral health in Brazil

BackgroundSeveral studies have demonstrated that Conditional Cash Transfer (CCT) programs reduce poverty/inequity and childhood mortality. However, none of these studies investigated the link between CCT programs and children’s oral health. This study examines the association between receiving the Brazilian conditional cash transfer, Bolsa Familia Program (BFP), and the oral health of five-year-old children in the Northeast of Brazil.MethodsWe conducted a cross-sectional study with 230 caregivers/children randomly selected in primary health care clinics in the city of Fortaleza in 2016. Interviews and oral health examinations were performed. Descriptive statistics and multiple logistic regression analyses were conducted to identify factors associated with dental caries among five-year-old children enrolled in the BFP.ResultsAround 40% of children enrolled in the BFP had dental caries. However, those who received Bolsa Familia (BF) for a period up to two years (OR = 0.13, 95% CI 0.05–0.35) had substantially lower adjusted odds of having dental caries than those who had never received BF. In addition, the association of BF and dental caries was more prominent among extremely poor families (OR = 0.05, 95% CI 0.01–0.28).ConclusionsAlthough initial enrolment in the BFP predicted low dental caries among five-year-old children, the prevalence of dental caries in this population is still high, thus, public health programs should target BF children’s oral health. An ongoing effort should be made to reduce oral health inequalities among children in Brazil.

Modelling the impact of social protection on tuberculosis: the S-PROTECT project

BackgroundTackling the social determinants of Tuberculosis (TB) through social protection is a key element of the post-2015 End TB Strategy. However, evidence informing policies are still scarce. Mathematical modelling has the potential to contribute to fill this knowledge gap, but existing models are inadequate. The S-PROTECT consortium aimed to develop an innovative mathematical modelling approach to better understand the role of social protection to improve TB care, prevention and control.MethodsS-PROTECT used a three-steps approach: 1) the development of a conceptual framework; 2) the extraction from this framework of three high-priority mechanistic pathways amenable for modelling; 3) the development of a revised version of a standard TB transmission model able to capture the structure of these pathways. As a test case we used the Bolsa Familia Programme (BFP), the Brazilian conditional cash transfer scheme.ResultsAssessing one of these pathways, we estimated that BFP can reduce TB prevalence by 4% by improving households income and thus their nutritional status. When looking at the direct impact via malnutrition (not income mediated) the impact was 33%. This variation was due to limited data availability, uncertainties on data transformation and the pathway approach taken. These results are preliminary and only aim to serve as illustrative example of the methodological challenges encountered in this first modelling attempt, nonetheless they suggest the potential added value of integrating TB standard of care with social protection strategies.ConclusionsResults are to be confirmed with further analysis. However, by developing a generalizable modelling framework, S-PROTECT proved that the modelling of social protection is complex, but doable and allowed to draw the research road map for the future in this field.

Effect of a conditional cash transfer program on length-for-age and weight-for-age in Brazilian infants at 24 months using doubly-robust, targeted estimation

ObjectiveConditional cash transfer programs are popular internationally and represent a large investment in child health. Evidence of their impact on child nutrition status remains weak and inconsistent, particularly for Bolsa Família, the Brazilian conditional cash transfer program and one of the world's largest. Our objective was to estimate the effect of the Brazilian conditional cash transfer program, Bolsa Família (BF), on child nutritional status as measured by length-for-age z-score (LAZ) and weight-for-age z-score (WAZ) at 24 months. MethodsWe analyzed the 1703 children eligible for BF from the 2004 Pelotas Birth Cohort. Children were divided into three exposure groups by total amount of money their household received from BF in 24 months: no BF, low BF (≤R$1000) and high BF (>R$1000). Using a doubly robust semiparametric estimation method we estimated the effect of receiving low and high levels of BF on LAZ and WAZ at 24 months. ResultsAfter adjustment for measured confounders, the expected difference in LAZ between children that received low or high levels of BF compared to no BF was −0.14 [95% confidence interval (CI): −0.27, −0.02] and −0.20 (95% CI: −0.33, −0.08) respectively. For WAZ the estimated differences were −0.04 (95% CI: −0.17, 0.08) for low levels versus no BF and −0.18 (95% CI: −0.30, −0.05) for high levels versus no BF. The expected difference in population LAZ had all eligible households received it and population LAZ under no BF was −0.15 (95% CI: −0.26, −0.04). Sensitivity analyses suggested only a strong confounder could explain away these results. ConclusionsAmong participants of the 2004 Pelotas Birth Cohort, BF was associated with a reduction in LAZ and WAZ in 24 month old children.

Effect of Brazil’s Conditional Cash Transfer Programme on the new case detection rate of leprosy in children under 15 years old

Background: Poverty and other socio-environmental determinants may contribute to the occurrence of leprosy. However, there is no previous evidence on the effectiveness of cash transfer programmes in reducing leprosy case detection among children under 15 years old. Objective: This study aimed to assess the effect of the Brazilian conditional cash transfer programme (Bolsa Família Programme, BFP) on the reduction of new case detection rates (NCDR) of leprosy in Brazilians under 15 years old. Methods: We performed a mixed ecological study with the Brazilian municipalities as units of analysis, during 2004–2015. The main independent variables were: BFP coverage of target population (poor and extremely poor families) and BFP coverage of the total population of the municipalities. Data were obtained from public databases. We included 1,120 (of 5,570) municipalities in the analysis, using fixedeffects negative binomial models for panel data, adjusted for the municipal coverages of the Brazilian primary health care programme (Family Health Strategy, FHS) and for a set of sociodemographic covariates. Results: We found an increasing trend in the median BFP coverages and a decreasing trend in the NCDR of leprosy in individuals under 15 years old. This indicator was significantly reduced in municipalities with higher BFP coverages of target population (RR = 0.75; CI 95% 0.63–0.88) and higher BFP coverages of the total population of the municipalities (RR = 0.85; CI 95% 0.79–0.93). Conclusions: During the study period, BFP was associated with a reduction of the NCDR of leprosy among Brazilians aged less than 15 years old, living in municipalities with a high risk of leprosy transmission.

A next generation of conditional cash transfer programs

Abstract This article evaluates the role of the Brazilian federal Conditional Cash Transfer programs (CCTs) such as Bolsa Família and Bolsa Escola during the past recent years and discusses their future. Based on previous empirical evidence based on my own work, I propose an integrated framework with two complementary perspectives. The first perspective is a goal approach based on the short term aggregated influences exerted by these programs, organized under four headings, namely: equality, prosperity, stability and sensibility. The emphasis here is to compare the results of Bolsa Família with other official programs such as BPC and Social Security benefits. The second perspective follows a means approach inspecting the microeconomic mechanisms through which CCTs operate, comparing the impacts on CCTs beneficiaries versus non-beneficiaries. Such perspective helps in dialoguing about the relevance of different CCTs attributes, and to discuss possible desirable upgrades.