Malnutrition, Brain Development and Growth Stunting: Cash Transfers the Answer?

Here’s an article that ties together many of the themes we have been discussing (and some we are about to discuss) — from fetal brain development and early childhood origins of disease to economic choice and behavior. Can a policy intervention as simple as transferring cash from wealthy areas to poor areas improve long term outcomes? PHS 795 student Alexandra Bryant writes:

Dr. Jim Yong Kim, President of the World Bank, says that childhood stunting is not only an issue of decreased height, but it also leads to diminished mental capacity in children. He calls health professionals around the world to start paying more attention to this issue and innovative ways to combat this problem. Dr. Kim continues to say that the diminished mental capacity further leads to negative consequences in social capital for the entire nation those children live in.

In Peru, policial and social instabilities in the 1990s are believed to have contributed to 1 in every 3 children suffering from effects of chronic malnutrition. I applaud Dr. Kim for his retrospective look at SES and political factors that contributed to damaging health outcomes. There was a turn from 2007-2015; however, Peru cut stunting by half – from 29% to 14% through the use of conditional cash transfers. This brought my attention back to Dr. Robert’s lecture and her brief example about moving families out of poor neighborhoods, or providing money to families to improve their health. Peru did it right: the conditions were pre- and post-natal care, child vaccinations, supplements (folic acid, iron, Vit A) and older children had to be in school at least 85% of the time. The Juntos project invested in human capital in a major way, and incentivized health behavior improvements to an extremely successful end. I implore communities in the US to look into programs such as these that provide resources and establish accountability in efforts to increase wealth, and therefore, health.

http://www.globalhealthhub.org/2016/09/19/mri-evidence-favor-cash-transfers/

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3 thoughts on “Malnutrition, Brain Development and Growth Stunting: Cash Transfers the Answer?

  1. Thanks for the interesting article Alexandra! This reminds me of a This American Life episode that I listened to a few years ago. The episode featured a non-profit called GiveDirectly, which allows donors to give unconditional cash transfers to people who live in extreme poverty in Kenya or Uganda. The non-profit gained quite a bit of traction and is relatively successful.

    As someone who is less familiar with population health outside of the United States, I thought about how cash transfers would impact this country’s population health relative to that of Peru. The results that you presented are quite promising – Peru benefitted from a nearly 50% decrease in the stunting rate – but some of the countries with cash transfer programs (such as Peru, Kenya, and Uganda) are developing and may not have the existing social safety net programs like that of the United States.

    Two opposing arguments arise from this. The first suggests that the marginal benefits of cash transfers in the United States outweigh their costs. In a country without social safety net programs, cash transfers can be extremely effective because there’s no way to go but up. In the United States where there are already such programs (holding aside their effectiveness), providing cash transfers to those in poverty may yield little additional “measurable” benefit, as people already have access to food stamps, welfare, etc. (Indeed, welfare is possibly a type of cash transfer? Maybe that’s what we call it in the US to politicize it?) I note “measurable,” since policy makers and stakeholders like to quantitatively assess the success of social programs.

    It also brings me to the second and contending argument: The marginal “measurable” benefit is not crucial, but what is significant is the recipient’s perceived growth of his/her autonomy as a result of the cash transfer. In Deborah Ehrenthal’s talk on Tuesday (9/26/16), she mentioned that one’s sense of agency can have a meaningful impact on their health and prosperity. This point reminded me of two books — ‘Promises I Can Keep’ and ‘American Dream: Three Women, Ten Kids, and a Nation’s Drive to End Welfare’ — both of which interview women who relied on welfare (that was conditional, so I guess it was a conditional cash transfer!), and these women thought of it less as a handout (recalling the racist “welfare queen” stereotype) and more as a means of opportunity. From their perspective, such benefits bolstered their sense of agency, and that success tended to impact other areas of their lives (and their families’ lives, too). If the marginal benefits of those cash transfer programs may not seem “significant” from a policy maker’s point of view, maybe it’s because the true benefit (autonomy/agency) is not something that can be easily measured.

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    • I agree–very interesting article reviewing a very successful intervention curtailing childhood malnutrition! David, you brought up some very similar arguments that crossed my mind as I read the article, especially with regards to the measurability of the benefit.

      Firstly, I, again, agree the true benefit of increased autonomy and sense of agency is very subjective. Despite being different for everyone, autonomy factors into self perception, mental health, social networks, education, job status, socioeconomic status. These are all major health determinants, and I am sure autonomy plays into many more. Thus, it seems imperative to quantify autonomy and a sense of agency to truly progress in the evidence-based practices of public health.

      Two other aspects of this paper caught my attention–funding and behavior. According to The World Bank, the gross national income, per capita, in Peru is $6200 USD, compared to $54,960 USD in the United states. In the article Peruvian households received $30 per month, totally $360 per year, providing roughly an additional 6% of that households yearly income. If we translated this to the United States, yearly, an additional $3300 would be distributed to designated households yearly, i.e. $275 monthly. The real question, though, is how is this money being used or to be used? If it is being allocated to food, the Supplemental Nutritional Assistance Program, on average provides $255 to households falling 130% below the national poverty level, i.e. household income of $1680 per month, or $20,160 per year. So is the United States already providing similar benefits to Peru’s cash transfer model? Should the financial assistance just be allocated to food? Rather, what is the most effective way to use these additional benefits to promote health? This prompted me to relate this topic to the recent “Allocation of Time” lecture and behavioral change. Specifically, in pilot studies of universal healthcare in the US, regardless of healthcare being free, healthcare behaviors did not significantly change. This brings me to my next point.

      Will this additional financial assistance initiate a behavior change? I entirely agree these families deserve additional assistance, but think its important to remember that it must induce a behavioral change in order to break the cycle of poverty, poor health etc. This “intention to action gap” was addressed in the article with specific reference to Sema Sgaier’s work in behavioral economics. Interestingly, this program was able to effectively change the behavior of the population in Peru. I ask, then, why? Why is it that these Peruvian families changed their behavior? Will we see the same behavioral changes in the US? If not, what can we do to facilitate this necessary change in behavior?

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  2. I am a little hesitant about the results of the Juntos program. I appreciate that stunting rates have decreased by half in Peru, which is an astounding achievement that unlikely occurred without influence. I also recognize that this change is a perceived positive feedback on the effectiveness of the program. However, I do think some factors may have been overlooked amongst all the excitement.

    The first concern that crossed my mind was the education requirement. Children participants were “required to attend school at least 85% of the time.” This stipulation is an additional variable that could definitely have influenced brain development and stunting reduction. If the child’s family had not received a cash incentive, the child’s school attendance likely would not have been enforced. How can Dr. Kim then claim that cash transfers reduce stunting without expanding on the influence of education? I am not sure if there is another, more detailed publication of the program’s results, but at least for this article I felt like education as a confounder was completely overlooked.

    As Aaron and David both commented on, I am also concerned about the generalizability of this program’s results. Specifically, I am curious about the inclusion criteria and sample size and how these effect results. For example, were all families with malnourished children under the age of 2 equally likely to be included? Or, possibly, were families excluded if parents did not have a job or if one/both parents had an addiction or mental health disease? Did the investigator control for genetic factors of brain development? I question this because certain parents might be more likely to exploit cash incentives that are not strictly regulated. For example, in “Evicted” I read that people may sell food stamps at discounted rates for cash. In this case, incentives are not being used as the investigator had intended. Furthermore, exclusion of families with mental illness or heritable brain development abnormalities creates bias. The remaining eligible children would obviously be less likely to be stunted, therefore, creating a drastic but artificial decrease in stunting rates.

    Lastly, I feel the article did not specify how cash transfer differs from other monetary incentives. I am wondering, specifically, if incentive use was restricted. Could financial assistance be allocated only to food and healthcare or could parents use the money any way they desired? If cash transfer was limited to food and healthcare, then how does cash transfer differ from food stamps and universal health coverage? Food stamps are not overly effective in WI as described in “Evicted” and universal coverage is not offered in the U.S., bringing me again to my concern of generalizability. I think it would be beneficial for ensuing studies to investigate how to optimize results by manipulating the extent of restriction on use of financial assistance.

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