The effect of conditional cash transfers on tuberculosis incidence and mortality is determined by ethnoracial and socioeconomic factors: a cohort study of 54 million individuals in Brazil.

Background: Conditional Cash Transfers (CCT) are the world's most widely implemented interventions for poverty alleviation. Still, there is no solid evidence of the CCT effects on the reduction of the burden of Tuberculosis (TB) in marginalized and extremely vulnerable populations. We estimated the effect of the Bolsa Família Program (BFP), the largest CCT in the world, on TB incidence, mortality, and case-fatality rate using a nationwide cohort of 54.5 million individuals during a 12-year period in Brazil. Methods: We selected low-income individuals who entered in the 100 Million Brazilians Cohort and were linked to nationwide TB registries between 2004 to 2015, and compared BFP beneficiaries and non-beneficiaries using a quasi-experimental impact evaluation design. We employed inverse probability of treatment weighting (IPTW) multivariable Poisson regressions, adjusted for all relevant socioeconomic, demographic, and healthcare confounding variables - at individual and municipal level. Subsequently, we evaluated BFP effects for different subpopulations according to ethnoracial factors, wealth levels, sex, and age. We also performed several sensitivity and triangulation analyses to verify the robustness of the estimates. Findings: Exposure to BFP was associated with a large reduction in TB incidence in the low-income individuals under study (adjusted rate ratio [aRR]:0.59;95%CI:0.58-0.60) and mortality (aRR:0.69;95%CI:0.65-0.73). The strongest BFP effect was observed in Indigenous people both for TB incidence (aRR:0.37;95%CI:0.32-0.42), and mortality-aRR:0.35;95%CI:0.20-0.62), and in Black and Pardo people (Incidence-aRR:0.58;95%CI:0.57-0.59; Mortality -aRR:0.69;95%CI:0,64-0,73). BFP effects showed a clear gradient according to wealth levels and were considerably stronger among the extremely poor individuals for TB incidence (aRR:0.49, 95%CI:0.49-0.50) and mortality (aRR:0.60;95%CI:0.55-0.65). The BFP effects on case-fatality rates were also positive, however without statistical significance. Interpretation: CCT can strongly reduce TB incidence and mortality in extremely poor, Indigenous, Black and Pardo populations, and could significantly contribute to achieving the End TB Strategy targets and the TB-related Sustainable Development Goals.

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

BACKGROUND: Preterm 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. METHODS: A 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. RESULTS: 1,031,053 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). CONCLUSIONS: An 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.

Intersectorality in a conditional cash transfer programme: Actors, convergences and conflicts.

This study aimed to analyse intersectoral arrangements among the health, education and social assistance sectors in the operationalization of the Bolsa Família Program (BFP). A qualitative approach was carried out, in a peripheral region of a large urban centre of Southeast Brazil. Data content analysis was performed on the basis of reference in the Actor-Network Theory (ANT) using statements by the actors and considering ideas in dispute and work processes in the geopolitical territorial context. Seventeen managers of Municipal Secretariats of Health, Education and Social Assistance were interviewed, as were basic education, primary health care and social assistance professionals. One-off, episodic and discontinuous intersectoral actions were identified, with limited integration among sectors. Convergences and conflicts were found with respect to the institutional processes of BFP. The convergences referred to the conceptions shared among the actors about the role of intersectoral collaboration, as they recognize themselves as providing care to the same vulnerable population. Considering the multiple vulnerabilities of these families, the convergence of actions from different sectors can impact factors that condition inequalities. The conflicts were related to institutional conditions, to sectorized work processes and to a lack of understanding by professionals about the duties of their respective sectors.

The combined effect of social pensions and cash transfers on child mortality: evaluating the last two decades in Brazil and projecting their mitigating effect during the global economic crisis.

Background: The world is currently experiencing multiple economic crises due to the COVID-19 pandemic, war in Ukraine, and inflation surge, which disproportionately affect children, especially in low- and middle-income countries (LMICs). We evaluated if the expansion of Social Assistance, represented by Social Pensions (SP) and Conditional Cash Transfers (CCT), could reduce infant and child mortality, and mitigate excess deaths among children in Brazil, one of the LMICs most affected by these economic crises. Methods: We conducted a retrospective impact evaluation in a cohort of Brazilian municipalities from 2004 to 2019 using multivariable fixed-effects negative binomial models, adjusted for relevant demographic, social, and economic factors, to estimate the effects of the SP and CCT on infant and child mortality. To verify the robustness of the results, we conducted several sensitivity and triangulation analyses, including difference-in-difference with propensity-score matching. These results were incorporated into dynamic microsimulation models to generate projections to 2030 of various economic crises and Social Assistance scenarios. Findings: Consolidated coverage of SP was associated with significant reductions in infant and child mortality rates, with a rate ratio (RR) of 0.843 (95% CI: 0.826-0.861) and 0.840 (95% CI: 0.824-0.856), respectively. Similarly, CCT consolidated coverages showed RRs of 0.868 (95% CI: 0.842-0.849) and 0.874 (95% CI: 0.850-0.899) for infant and child mortality, respectively. The higher the degree of poverty in the municipalities, the stronger the impact of CCT on reducing child mortality. Given the current economic crisis, a mitigation strategy that will increase the coverage of SP and CCT could avert 148,736 (95% CI: 127,148-170,706) child deaths up to 2030, compared with fiscal austerity measures. Interpretation: SP and CCT programs could strongly reduce child mortality in LMICs, and their expansion should be considered as an effective strategy to mitigate the impact of the current multiple global economic crises. Funding: Bill & Melinda Gates Foundation, Grant_Number:INV-027961. Medical Research Council(MRC-UKRI),Grant_Number:MC_PC_MR/T023678/1.

The impact of cash transfer participation on unhealthy consumption in Brazil.

We assess the impact of the Brazilian government's conditional cash transfer program Bolsa Família on unhealthy consumption by households, proxied by expenses with ultra-processed food, alcohol, and tobacco products. Using machine learning techniques to improve the propensity score estimation, we analyze the intensive and extensive margin effects of participating in the program on the household purchase of unhealthy products. Our results reveal that program participants spend more on food in general, but not necessarily more on unhealthy options. While we find evidence that participants increase their probability of spending more on food away from home, they do not significantly alter their expenditures on packaged food, alcohol, or tobacco products.

The Impact of Conditional Cash Transfers on Poverty, Inequality, and Employment During COVID-19: A Case Study from Brazil.

The policy responses to the COVID-19 pandemic varied widely between countries. Understanding how effective these responses were is important to improve preparedness for future crises. This paper investigates how one of largest scale conditional cash transfer COVID relief policies in the world-the Brazilian Emergency Aid (EA)-impacted poverty, inequality, and the labor market amidst the public health crisis. We use fixed-effects estimators to analyze the impact of the EA on labor force participation, unemployment, poverty, and income at the household level. We find that inequality, measured by per capita household income, reduced to a historical low and was accompanied by substantial poverty declines-even as compared to pre-pandemic levels. Furthermore, our results suggest that the policy has effectively targeted those in most need-temporarily reducing historical racial inequalities-while not incentivizing reductions in labor force participation. Absent the policy, adverse shocks would have been significant and are likely to occur once the transfer is interrupted. We also observe that the policy was not enough to curb the spread of the virus, suggesting that cash transfers alone are insufficient to protect citizens.

The effects of emergency government cash transfers on beliefs and behaviours during the COVID pandemic: Evidence from Brazil.

This paper examines the impacts of emergency cash-transfers on individuals' social distancing behaviour and beliefs about COVID-19. We focus on the impacts of "Auxilio Emergencial" (AE): a large-scale cash-transfer in Brazil targeting low-income individuals who were unemployed or informally employed during the pandemic. To identify causal effects we exploit exogenous variation, arising from the AE design, in individuals' access to the cash-transfer programme. Using data from an online survey, our results suggest that eligibility to the emergency cash transfer led to a reduced likelihood of individuals contracting COVID-19, likely to have been driven by a reduction in working hours. Moreover, the cash transfer seems to have increased perceptions about the seriousness of coronavirus, while also exacerbating misconceptions about the pandemic. These findings indicate effects of emergency cash-transfers in determining individuals' narratives about a pandemic, in enabling social distancing and potentially in reducing the spread of the disease.

A Causal Mediation Analysis for Investigating the Effect of a Randomized Cash-Transfer Program in Nicaragua.

Mediation analysis can be applied to data from randomized trials of health and social interventions to draw causal inference concerning their mechanisms. We used data from a cluster-randomized trial in Nicaragua, fielded between 2000 and 2002, to investigate whether the impact of providing access to a conditional cash-transfer program on child nutritional outcomes was mediated by child health check-ups and household dietary diversity. In a sample of 443 children 6-35 months old, we estimated the controlled direct (CDE) effect of random assignment on measured height-for-age z scores had we intervened so that all children received a health check-up and had the same level of household dietary diversity, using inverse-probability weighted marginal structural models to account for mediator-outcome confounding. Sensitivity analyses corrected the CDE for potential nondifferential error in the measurement of dietary diversity. Treatment assignment increased height-for-age z score by 0.37 (95% CI: 0.05, 0.69) standard deviations. The CDE was 0.20 (95% CI: -0.17, 0.57) standard deviations, suggesting nearly one-half of the program's impact on child nutrition would be eliminated had we intervened on these factors, although estimates were relatively imprecise. This study provides an illustration of how causal mediation analysis can be applied to examine the mechanisms of multifaceted interventions.

Association between cash transfer programs and oral health-A scoping review.

OBJECTIVES: The aims of this scoping review are to assess the literature investigating the association between cash transfer programs and oral health; and to identify the theoretical frameworks applied to guide this literature. METHODS: A search strategy to identify studies published until December 2020 was applied to a range of databases. Observational and interventional studies that had cash transfer programs as exposure/intervention and oral health as outcome were considered. Dental health services utilization, as well as access to dental health services, were considered secondary outcomes. Cash transfer programs were considered programs based on conditional or unconditional cash transfer carried out as part of national social protection schemes, and interventional studies on the impact of cash transfer on oral health were also considered eligible. Data charting was performed in two steps and a narrative synthesis was conducted. RESULTS: Of 6344 articles identified, four articles were included. These articles investigated three different conditional cash transfer programs, Universal Child Allowance (Argentina), Bolsa Família (Brazil) and Family Rewards (USA). Inconsistencies were identified in findings on the effect of conditional cash transfer programs on the prevalence of dental caries and these differences may be due to the comparison group selected for each study. Concerning dental visits, the results point in different directions, which makes these findings still inconclusive. No explicit theoretical framework was reported in the articles to guide the expected association. CONCLUSION: Although cash transfers play an important role in improving certain health outcomes, there is limited evidence to suggest an association between cash transfers and oral health.

Contemporaneidade dos Programas de Transferência Monetária no Brasil: proteger ou mitigar a pobreza? / Contemporaneity of the Cash Transfer Programs in Brazil: to protect or to mitigate the poverty?

Resumo: O artigo aborda Programas de Transferência Monetária no Brasil; o contexto socioeconômico e político; modalidades e orientação político-ideológica dos programas; o Auxílio Emergencial e a substituição do "Bolsa Família" pelo "Auxílio Brasil". A metodologia contempla resultados de pesquisas; revisão bibliográfica e documental; dados secundários e acesso a websites. Os resultados destacam: funções; mitigação da pobreza e proliferação desses programas, deslocados do Sistema de Proteção Social.

Abstract: This article approaches Cash Transfer Programs in Brazil; socioeconomic and political context; modalities and politic-ideological orientation; the Auxílio Emergencial" and the substitution of the "Bolsa Família" by "Auxílio Brasil". The applied methodology was results of researches; bibliographic and documental studies; secondary data and access to websites. The outcomes pointed out the functions; poverty alleviation and proliferation of those programs displaced of the Social Protection System.

Impact of Brazil's Bolsa Família Programme on cardiovascular and all-cause mortality: a natural experiment study using the 100 Million Brazilian Cohort.

BACKGROUND: Cardiovascular disease (CVD) has a disproportionate effect on mortality among the poorest people. We assessed the impact on CVD and all-cause mortality of the world's largest conditional cash transfer, Brazil's Bolsa Família Programme (BFP). METHODS: We linked administrative data from the 100 Million Brazilian Cohort with BFP receipt and national mortality data. We followed individuals who applied for BFP between 1 January 2011 and 31 December 2015, until 31 December 2015. We used marginal structural models to estimate the effect of BFP on all-age and premature (30-69 years) CVD and all-cause mortality. We conducted stratified analyses by levels of material deprivation and access to healthcare. We checked the robustness of our findings by restricting the analysis to municipalities with better mortality data and by using alternative statistical methods. RESULTS: We studied 17 981 582 individuals, of whom 4 855 324 were aged 30-69 years. Three-quarters (76.2%) received BFP, with a mean follow-up post-award of 2.6 years. We detected 106 807 deaths by all causes, of which 60 893 were premature; and 23 389 CVD deaths, of which 15 292 were premature. BFP was associated with reductions in premature all-cause mortality [hazard ratio (HR) = 0.96, 95% CI = 0.94-0.98], premature CVD (HR = 0.96, 95% CI = 0.92-1.00) and all-age CVD (HR = 0.96, 95% CI = 0.93-1.00) but not all-age all-cause mortality (HR = 1.00, 95% CI = 0.98-1.02). In stratified and robustness analyses, BFP was consistently associated with mortality reductions for individuals living in the two most deprived quintiles. CONCLUSIONS: BFP appears to have a small to null effect on premature CVD and all-cause mortality in the short term; the long-term impact remains unknown.

Impact of Cash Transfers on the Use of Oral Health Services and Oral Health Outcomes: A Systematic Review.

Objective: The objective of the present study was to summarize the evidence available on the impact of cash transfers on the use of oral health services and oral health outcomes. Materials and Methods: 9 databases were searched for studies on cash transfers and oral health: PubMed, Embase, The Cochrane Library, CINAHL, EconLit, Dentistry and Oral Sciences Source, Scopus, Web of Science, and LILACS. We conducted a systematic review of studies that evaluated the impact of cash transfers on the use of oral health services and other oral health outcomes. Results: Three studies with more than 13,000 participants conducted in Brazil and Argentina were included. One study from Brazil found that participants in the Bolsa Familia Program (BFP) were more likely not to use oral health services (aPR: 6.18; 95% CI: 3.07-12.45; P < 0.001) and had a higher probability of presenting dental caries (aPR: 2.00; 95% CI: 1.47-2.69) and severe caries (aRR: 1.53; 95% CI: 1.18-2.00). Another study conducted in Brazil found that the BFP was associated with fewer dental caries among those enrolled in the first 2 years of the BFP as well as after six years. On the other hand, the Argentina study found that the Universal Child Allowance program did not have a statistically significant average treatment effect (ATE = -0.05; P > 0.05) on the use of dental health services. Conclusion: There is a lack of evidence about the impact of CT on the use of oral health services and oral health outcomes. The evidence suggests that cash transfers might not have a positive impact on the use of oral health services. The results regarding the impact of receiving cash transfers on dental caries are contradictory. However, more evidence is needed to draw stronger conclusions for policy taking. Registration: The protocol was registered in PROSPERO (CRD42021268234).

Estimating the costs for implementing a maternity leave cash transfer program for women employed in the informal sector in Brazil and Ghana.

BACKGROUND: Maternity leave policies are designed to protect gender equality and the health of mothers in the workforce and their children. However, maternity leave schemes are often linked to jobs in the formal sector economy. In low- and middle-income countries a large share of women work in the informal sector, and are not eligible to such benefit. This is worrisome from a social justice and a policy perspective and suggests the need for intervening. Costing the implementation of potential interventions is needed for facilitating informed decisions by policy makers. METHODS: We developed and applied a costing methodology to assess the cost of a maternity leave cash transfer to be operated in the informal sector of the economy in Brazil and Ghana, two countries with very different employment structures and socioeconomic contexts. We conducted sensitivity analysis by modeling different numbers of weeks covered. RESULTS: In Brazil, the cost of the maternity cash transfer would be between 0.004% and 0.02% of the GDP, while in Ghana it would range between 0.076% and 0.28% of the GDP. The relative cost of rolling out a maternity intervention in Brazil is between 2.2 to 3.2 times the cost in Ghana depending on the benchmark used to assess the welfare measure. The differences in costs between countries was related to differences in labor market structure as well as demographic characteristics. CONCLUSIONS: Findings show how a standard methodology that relies on routinely available information is feasible and could assist policymakers in estimating the costs of supporting a maternity cash transfer for women employed in the informal sector, such intervention is expected to contribute to social justice, gender equity, and health trajectories.

The intergenerational relationship between conditional cash transfers and newborn health.

BACKGROUND: Lack of nutrition, inadequate housing, low education and limited access to quality care can negatively affect children's health over their lifetime. Implemented in 2003, the Bolsa Familia ("Family Stipend") Program (PBF) is a conditional cash transfer program targeting poor households in Brazil. This study investigates the long-term benefits of cash transfers through intergenerational transmission of health and poverty by assessing the early life exposure of the mother to the PBF. METHODS: We used data from the 100M SINASC-SIM cohort compiled and managed by the Center for Data and Knowledge Integration for Health (CIDACS), containing information about participation in the PBF and socioeconomic and health indicators. We analyzed five measures of newborn health: low (less than 2,500 g) and very low (less than 1,500 g) birth weight, premature (less than 37 weeks of gestation) and very premature (less than 28 weeks of gestation) birth, and the presence of some type of malformation (according to ICD-10 codes). Furthermore, we measured the early life exposure to the PBF of the mother as PBF coverage in the previous decade in the city where the mother was born. We applied multilevel logistic regression models to assess the associations between birth outcomes and PBF exposures. RESULTS: Results showed that children born in a household where the mother received BF were less likely to have low birth weight (OR 0.93, CI; 0.92-0.94), very low birth weight (0.87, CI; 0.84-0.89), as well as to be born after 37 weeks of gestation (OR 0.98, CI; 0.97-0.99) or 28 weeks of gestation (OR 0.93, CI; 0.88-0.97). There were no significant associations between households where the mother received BF and congenital malformation. On average, the higher the early life exposure to the PBF of the mother, the lower was the prevalence of low birth weight, very low birth weight and congenital malformation of the newborn. No trend was noted for preterm birth. CONCLUSION: The PBF might have indirect intergenerational effects on children's health. These results provide important implications for policymakers who have to decide how to effectively allocate resources to improve child health.

Health services, intersectoriality and social control: a comparative study on a conditional income transfer program.

The Bolsa Família Program (BFP) is one of the largest conditional cash transfer programs in the world, providing cash transfers and intersectoral actions. The aim of this study was to compare whether there is a difference in access to health services, intersectoral actions and social control, between families entitled or not, to the BFP. A cross-sectional study was carried out. A representative sample of a peripheral, socioeconomically vulnerable population from a large urban center in southeastern Brazil was calculated, totaling 380 families. Chi-square or Fisher's exact tests and multiple correspondence analysis were used to compare groups. Families entitled to the BFP had worse living conditions in general and greater access to health services, such as: medical care (p-value 0.009), community healthcare agent (p-value 0.001) and home visits (p-value 0.041). Being entitled or not affected the variability in the pattern of access to services by 31%; low access to intersectoral actions was identified in both groups; social control was incipient. There was an adequate focus on the program; greater access to health services was related to compliance with conditionalities; low access to intersectoral actions can restrict the interruption of the cycle of intergenerational transmission of poverty.

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 (ß = .287, p = .001). The same could be found regarding physical violence, but the effect of PBF was indirect, mediated by psychological violence (ß = .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 Determinants of Infant Mortality in Brazil, 2010-2020: A Scoping Review.

Despite the implementation of social and health policies that positively affected the health of the populations in Brazil, since 2009 the country has experienced a slower decline of infant mortality. After an economic and political crisis, Brazil witnessed increases in infant mortality that raised questions about what are the determinants of infant mortality after the implementation of such policies. We conducted a scoping review to identify and summarize those determinants with searches in three databases: LILACS, MEDLINE, and SCIELO. We included studies published between 2010 and 2020. We selected 23 papers: 83% associated infant mortality with public policies; 78% related infant mortality with the use of the health system and socioeconomic and living conditions; and 27% related to individual characteristics to infant mortality. Inequalities in the access to healthcare seem to have important implications in reducing infant mortality. Socioeconomic conditions and health-related factors such as income, education, fertility, housing, and the Bolsa Família. Program coverage was pointed out as the main determinants of infant mortality. Likewise, recent changes in infant mortality in Brazil are likely related to these factors. We also identified a gap in terms of studies on a possible association between employment and infant mortality.

Long-term impact of a conditional cash transfer programme on maternal mortality: a nationwide analysis of Brazilian longitudinal data.

BACKGROUND: Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world's largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years. METHODS: The study had an ecological longitudinal design and used all 2548 Brazilian municipalities with vital statistics of adequate quality during 2004-2014. BFP municipal coverage was classified into four levels, from low to consolidated, and its duration effects were measured using the average municipal coverage of previous years. We used negative binomial multivariable regression models with fixed-effects specifications, adjusted for all relevant demographic, socioeconomic, and healthcare variables. RESULTS: BFP was significantly associated with reductions of maternal mortality proportionally to its levels of coverage and years of implementation, with a rate ratio (RR) reaching 0.88 (95%CI 0.81-0.95), 0.84 (0.75-0.96) and 0.83 (0.71-0.99) for intermediate, high and consolidated BFP coverage over the previous 11 years. The BFP duration effect was stronger among young mothers (RR 0.77; 95%CI 0.67-0.96). BFP was also associated with reductions in the proportion of pregnant women with no prenatal visits (RR 0.73; 95%CI 0.69-0.77), reductions in hospital case-fatality rate for delivery (RR 0.78; 95%CI 0.66-0.94) and increases in the proportion of deliveries in hospital (RR 1.05; 95%CI 1.04-1.07). CONCLUSION: Our findings show that a consolidated and durable CCT coverage could decrease maternal mortality, and these long-term effects are stronger among poor mothers exposed to CCT during their childhood and adolescence, suggesting a CCT inter-generational effect. Sustained CCT coverage could reduce health inequalities and contribute to the achievement of the Sustainable Development Goal 3.1, and should be preserved during the current global economic crisis due to the COVID-19 pandemic.

The association between a conditional cash transfer programme and malaria incidence: a longitudinal ecological study in the Brazilian Amazon between 2004 and 2015.

BACKGROUND: Malaria causes 400 thousand deaths worldwide annually. In 2018, 25% (187,693) of the total malaria cases in the Americas were in Brazil, with nearly all (99%) Brazilian cases in the Amazon region. The Bolsa Família Programme (BFP) is a conditional cash transfer (CCT) programme launched in 2003 to reduce poverty and has led to improvements in health outcomes. CCT programmes may reduce the burden of malaria by alleviating poverty and by promoting access to healthcare, however this relationship is underexplored. This study investigated the association between BFP coverage and malaria incidence in Brazil. METHODS: A longitudinal panel study was conducted of 807 municipalities in the Brazilian Amazon between 2004 and 2015. Negative binomial regression models adjusted for demographic and socioeconomic covariates and time trends were employed with fixed effects specifications. RESULTS: A one percentage point increase in municipal BFP coverage was associated with a 0.3% decrease in the incidence of malaria (RR = 0.997; 95% CI = 0.994-0.998). The average municipal BFP coverage increased 24 percentage points over the period 2004-2015 corresponding to be a reduction of 7.2% in the malaria incidence. CONCLUSIONS: Higher coverage of the BFP was associated with a reduction in the incidence of malaria. CCT programmes should be encouraged in endemic regions for malaria in order to mitigate the impact of disease and poverty itself in these settings.

Autism screening and conditional cash transfers in Chile: Using the Quantitative Checklist (Q-CHAT) for early autism detection in a low resource setting.

LAY ABSTRACT: Getting a diagnosis of autism can take long, because autism is different across people, but also because it depends on the way it gets diagnosed. This is especially important in poorer countries or in the case of poor people living in wealthier countries that have significant groups of disadvantaged communities. We adapted a 10-item version of the Q-CHAT-25 questionnaire for use in routine health check-ups programme in Chile and recruited 287 participants under the age of three divided into three groups: Controls (125), Developmental Delay (149) and Autism Spectrum Condition (13). Our results show that a short questionnaire for autism screening can be successfully applied in a health-check programme in poor resource settings. Our results show that our questionnaire had good overall performance, not different to its longer version, the Q-CHAT-25. Our questionnaire was autism specific, with good sensitivity and reliability, and is suitable to be used in a screening setting. This study provides evidence that the implementation of Autism Spectrum Condition screening programmes using the Q-CHAT-10 provides value for money and improves diagnosis of Autism Spectrum Condition in those participating in routine health check-up programmes in developing countries or poor areas of wealthy countries.