摘要：Conditional cash transfer schemes, which use cash to incentivize uptake of basic health and educational services, are well established among social planners inlow- and middle-income countries and are now taking hold in high-income countries. We appraised these schemes within a social determinants framework and found some encouraging signs in their first decade of operation. Success, however, has been inconsistent, and it is unclear whether conditional cash transfer schemes can reliably secure meaningful improvements in participants’ health and nutritional status or educational attainment. Conditional cash transfer schemes’ objectives will not be met unless they are transformed in 3 ways: transferring power as well as resources, emphasizing entitlements alongside conditionality, and avoiding the trap of incoherent or residualized policy. Essential welfare services, such as preventive health care, often go underused by those who most need them; the consequences of this inverse relation between care and need are well known. 1 One response to the problem has been the emergence of conditional cash transfer schemes, an increasingly popular policy to improve the welfare of disadvantaged families. In essence, the schemes offer regular sums of cash if families comply with specified behaviors such as ensuring children's attendance at school and health checkups and mothers’ attendance at health and nutrition seminars. The policy arose in response to the deep economic recessions seen in Latin America during the 1980s. Municipalities in Brazil began experimenting with conditional welfare in 1995, 2 and Progresa, the first nationwide conditional cash transfer scheme, began in Mexico in 1997. Since then, schemes have been rapidly replicated across Latin America, Jamaica, Kenya, Macedonia, Pakistan, South Africa, and Turkey, as well as some higher-income settings. An evaluation of New York City's Opportunity NYC, the first such scheme in a high-income setting, was published recently. Closely modeled on Progresa, this scheme offers families eligible for food stamps in the boroughs of the Bronx, Brooklyn, and Harlem cash transfers ranging from $20 to $600 if they comply with conditions such as attendance at parent–teacher conferences and annual medical checkups. The core problem that conditional cash transfer schemes seek to solve is that of inadequate service uptake among disadvantaged households, even where services are believed to be accessible, appropriate, and of high quality. The deeper objectives are to break the intergenerational transmission of poverty by stimulating uptake of services that support children's early education, health, and nutrition. They are used to tackle social exclusion, both by contributing to the upward social mobility of future generations and by partially relieving the immediate poverty of beneficiary households. Good syntheses of evidence showing whether conditional cash transfer schemes meet these aims are available. 3 , 4 Conditional cash transfer schemes have generally been successful in targeting families most in need, 5 – 8 and it appears that, with few exceptions, they are strongly progressive. For example, in a cluster-randomized evaluation, Mexico's Progresa was found to significantly reduce poverty. During its first 2 years of operation, the number of people in poverty declined by 17%, the poverty gap by36%, and the severity of poverty by 46% 9 ; furthermore, the scheme's poorest infants consumed the most nutritional supplements and gained the most height (equivalent to about one quarter of their estimated height deficit). 10 Similarly, randomized evaluations from Ecuador and Nicaragua show progressive trends across socioeconomic position for primary school enrollment and completion and health checkups. Families participating in Opportunity NYC received more than $6000 on average during its first 2 years and reported less poverty and hardship as a result, although parents receiving the highest transfers were more educated and more likely to be working full time, married, or in a legal domestic partnership than were other parents. 11 Effects on health outcomes, however, are less clear. Conditional cash transfer scheme households are known to consume 10% to 20% more goods, particularly meat, fruits, vegetables, and children's clothing and footwear. Importantly, the consumption of alcohol and tobacco appears to remain constant. 12 , 13 Service uptake increases, as anticipated by the imposition of conditions. In Colombia, for example, Familias en Acción was associated with significant increases in preventive health care checkups for children younger than 2 years (from 17.2% to 40.0%) and children aged 2 to 4 years (from 21.3% to 66.8%). 14 Similar patterns were observed in Nicaragua, 15 Jamaica, 16 Honduras, 17 and Mexico. Nevertheless, although the Mexican, 18 Nicaraguan, and Colombian 19 schemes were associated with small but significant improvements in child growth, no effect was seen in Honduras or Brazil. 20 Mixed results have been seen in hemoglobin levels as well, 13 , 15 however, and the prevalence of both anemia and stunting remained high. Cognitive and educational test scores also have shown little if any improvement (around 0.2 standard deviations at best), 21 – 23 and the World Bank concluded of Mexico's flagship scheme that its effect on the intergenerational transmission of poverty may be but a “small dent.” 3 A similar picture emerges in New York City, where school attendance increased but overall school outcomes did not improve for elementary or middle school students. In regards to health-related outcomes, although preventive health care behaviors increased as mandated by the scheme's conditions, there were no effects on self-rated health, psychosocial well-being, smoking, body mass index, or rates of receipt of medical treatment. A possibly regressive effect is apparent: better-educated participants reported a significant reduction in health needs unmet because of cost, compared with those with less education. 11 Although the follow-up time for Opportunity NYC is 3 years, there is perhaps no reason to expect that its longer-run effects will be any different from the Progresa-type programs that it sought to replicate. Because of this uncertainty over outcomes, it may be necessary to consider a breadth of additional factors when judging the effectiveness and acceptability of conditional cash transfers. Specifically, conditional cash transfer schemes focus attention entirely on the way the individual or the household behaves and intervene at this level, without considering that there may be drivers of individual and household behavior that operate at, and thus require intervention at, the social level. Here we present a fresh analysis of conditional cash transfer schemes from a social determinants perspective, seeking to draw attention to the most deeply situated causes of health inequity, and highlighting the need for action to improve the conditions within which people live, tackle unfair distributions of power and resources, and quantify the drivers of health inequity and the effects of action. 24 We highlight a series of issues about which the literature onconditional cash transfer schemes, although copious, says little—namely, effects on empowerment, rights, service quality, social cohesion, interrelation with other welfare policy, and participants’ views on the schemes.
