Assessing conditional cash transfers on health outcomes: evidence from Bataan, Philippines Mitzie Irene Conchada and Marites Tiongco The PES 52 nd Annual Meeting Hotel Intercontinental Manila November 14, 2014

Outline Motivation Program Description Methodology Estimation Results Summary

Reviewof Literature Enhanced human capital of the poor through changes in household behavior (Usui, 2011; Janvry and Sadoulet, 2005; Castillo, 2013) Reduced health, nutrition and education inequities (Nazmul, Friedman and Onishi 2013) –Enrollment rates of preschool- and daycare-aged children are 10.3 percentage points higher among the 4Ps –primary school completion rates are higher and dropout rates are lower –Lower rate of severe stunting by 10.1 percentage points among 6 to 36-month old children among the 4Ps

Background: Pantawid Pamilyang Pilipino Program (4Ps) 4Ps is one of the responses of the Philippine Government to the challenge of meeting the Millennium Development Goals (MDGs), particularly: Eradicating extreme poverty Achieving universal primary education Promoting gender equality and empowering women Reducing child mortality Improving maternal health

4Ps Objectives Social Assistance Provide assistance to the poor to alleviate their immediate needs (short term). Social Development Break the intergenerational cycle of poverty through investment in human capital, i.e., education, health and nutrition (long term)

Criteria for eligible households Households below poverty threshold with children 0-14 years old or pregnant mother The poorest households are selected through a Proxy Means Test (PMT) which determines the socio-economic category of families.

Benefits of eligible households PhP500 for health grant or P6,000 per year PhP300 per child (up to 3 children) for education grant (for 10 months a year) Maximum of PhP1,400 per household per month (approx. 26% of poverty threshold for a family of 5) A household with three qualified children receives a subsidy of P15,000 annually as long as they comply with the conditionalities

Conditionalities: Health and Nutrition Pregnant Household Member –Visit local health center to avail of pre-and post-natal care –Avail of appropriate child delivery services by a skilled health professional –Avail at least one post-natal care within 6 weeks after childbirth Children 0-5 Years Old –Visit the health center to avail immunization –Have monthly weight monitoring and nutrition counseling for children 0-24 months old –Have quarterly weight monitoring for children 25 to 73 months old –Have clinical management for sick children Children 6-14 Years Old –Must receive deworming pills twice a year

Conditionalities: Education Children 3-5 years old –Enrolled in day care or pre-school program and maintain a class attendance rate of at least 85% per month Children 6-14 Years Old –Enrolled in elementary and/or high school and maintain a class attendance rate of at least 85% per month

Conditionalities: Family development sessions –Parents or Guardians Attend Family Development Sessions at least once a month –Attend Responsible Parenthood Sessions and Family Counseling Sessions –Participate in community activities

Program logic

Main Question Does 4Ps foster investment on health care? What is the impact of 4Ps on utilization pre and post-natal health care services, and other health facilities—child birth in a health facility and attended by health professionals? –what would have happened had the beneficiaries not received 4Ps

Data Baseline data: Community Based Monitoring System CBMS) data collected in 2008 for Bagac (treatment; N=15,117) and the year 2009 for Pilar (control; N=7,844); we take the poorest 20% Follow-up survey to measure intermediate outcomes: data collected from Bagac and Pilar on April-May 2014 (4 years after 4Ps-set A was implemented in Bagac); sample size=460 HH (determined by the standard power calculation=90%)

Data actual sample = 441 HHs For Bagac, randomly sampled from targeted beneficiaries based on proxy means test generated by the National Household Targeting System for Poverty Reduction based on the Annual Poverty Income Survey; For Pilar, a logit regression was used to determine poverty status based on income and wealth index Poorest 20%; Poverty threshold in Bataan= Php17,643/ capita

Methodology Propensity Score Matching –Available observational data allowed us to estimate the impact of an intervention –It helps establish the counterfactual (what would have happened to the beneficiaries without the grant) by matching a beneficiary to non- beneficiary –It mimics an experiment by creating sample of units that received the treatment vs those who did not

Methodology Used time invariant observable variables: age, educational attainment of household head, educational attainment of mother, gender of household head Other characteristics of the family: family size, employment of the household head Limitation of PSM: assumes that there are no non- observables that may influence the outcome

Impact measure ATT is the impact of 4Ps eligible households that actually participated Underlying assumptions:

Health outcomes measured

Supply side Health facility delivery Prevalence of underweight 0-59 mos Fully immunized children Maternal care package

Focus group discussion

Descriptive statistics ps number of times mother received pre-natal check- up frequency of prenatal care weight of child whose mom received pre- natal check-up of baby after delivery no 4Ps mean sd N with 4Ps mean sd N Total mean sd N

Descriptive statistics ps famsi zeAge highest educ (HS) highest educ (Col) highest educ (Grad) Mother educ (HS) Mother educ (Col) Mother educ (Grad) employ ment statussex no4P s mean sd N with 4Ps mean sd N Total mean sd N

Propensity score distribution showing common support Common support for outcomes: LL= 0.27 UL=0.85 #Treatment=68 #control=38 The distribution between both groups is similar between the average propensity score and the mean of X to satisfy the balancing property

Estimation results OutcomesTreatedControlATT Std. Errort-stat number of times mother received pre-natal check-up bootstrapped SEs frequency of prenatal care bootstrapped SEs weight of child whose mom received pre-natal bootstrapped SEs check-up of baby after delivery bootstrapped SEs positive impact means those who are expected to gain the most from 4Ps actually do

Results Average treatment effects on 4Ps beneficiaries improves the health outcomes related to pre-natal, post-natal care, as well as the health of the new born child in Bagac, Bataan. Significant difference(after sensitivity analysis) in Bagac and Pilar in terms of the health outcomes: –New born babies of mother beneficiaries are 3 lbs heavier than non-beneficiaries. –number of times a new born baby is checked-up increases by 2 more visit if the household is a CCT beneficiary

Conclusions Pre-natal health care received by 4Ps beneficiaries is effective in improving the health of the mother and baby which contribute to an increase in weight. Babies who are born underweight are most likely to be sickly, thus affecting their productivity and performance when they grow older. Investment in human capital has to be supplemented by other welfare enhancing strategies such as improving the supply side factors such as the barangay health care units and professional health workers. –Doctor/popn =B: 1/26,700; P: 1/42,278 –Midwife/popn= B: 1/1,907; P: 1/4,698 –Nurse/popn = B: 1/26,700; P: 1/21,139