SCN News No 36 - UNSCN

www.unsystem.org/scn FEATURES 25
by the program), and on the baseline levels of schooling (e.g. whether school enrolment and attendance in
primary and secondary school were low or high at baseline) (Adato and Bassett 2007).
The impact of CCTs on the use of health services and health outcomes has also been reviewed, especially in
Latin American countries where most of the experience exists. Overall, the picture again is one of positive
impacts on the use of preventive health services (e.g. increased number and frequency of preventive health
visits), while impacts on immunization coverage and health outcomes are more mixed (see Glassman et al
2007, Lagardeet al 2007). Lack of impact on immunization and health outcomes is believed to be related to
weaknesses in the supply side – i.e. if services are of poor quality, increased attendance is unlikely to lead to
positive health outcomes.
Impacts on child anthropometry are also mixed, but significant and large impacts were found in Nicaragua,
where a reduction in the prevalence of underweight of 6 percentage points in 2 years was found among
children less than 5 years of age (Maluccio and Flores 2005). Results from Mexico also suggest a significant
impact of the programme on reducing childhood undernutrition, but the exact magnitude of impact is difficult
to report, as results differ depending on the round of data collection, the population groups studied, and the
analytical models used (Glassman et al 2007, Lagarde et al 2007). Overall, however, the results are
consistent in showing a reduction in stunting prevalence. There is also evidence of a small reduction in the
prevalence of anaemia among children participating in the programme in Mexico, but no impact was found in
Nicaragua (Rivera et al 2004, Maluccio and Flores 2005).
This brief overview of the impact of CCT programmes on health and nutrition outcomes raises several
questions. Although the programmes clearly seem to increase the demand for health services, the impacts on
health and nutrition outcomes are less consistent. As noted above, this is likely due to variations in the quality
of health services, and in the availability of supplies such as vaccines or micronutrient supplements at the
health centers. The impacts on child anthropometry outcomes, which in the case of Nicaragua are of large
magnitude (6 percentage points in 2 years) are also observed in some, but not all countries where this
outcome was assessed.
The main factor that complicates interpretation of the nutrition impacts of CCT programmes is the lack of
initial conceptualization of what these programmes are expected to achieve in terms of nutritional impacts,
and how they may achieve these impacts. There is a dearth of information throughout the CCT evaluation
literature on what the mechanisms by which these programmes are expected to improve nutrition are;
similarly, there is lack of analysis, using appropriate modelling techniques, of the mechanisms by which
nutrition improvements actually do occur (or not). Future evaluations of these programmes should use a
programme theory framework to conceptualize and document the specific pathways by which CCT
programmes are impacting nutrition (Rossi et al 2004, Loechl et al forthcoming). Referring to Figure 1, we
can expect that CCT programmes could affect nutrition through a combination of several pathways; one
potential pathway is through increasing income and access to food, thereby increasing household food
consumption; another pathway may be through improved child care and feeding practices (e.g., as a result of
greater maternal control over income and/or improved knowledge from exposure to nutrition education); and
another potential pathway is through improved water and sanitation and/or greater use of health services and
the resulting prevention and better control of infectious diseases. Understanding the pathways of impact of
CCTs is important because it will help better define the package, dose, and combinations of interventions that
should be incorporated in these programmes to enhance their nutritional impact, and it will allow more
effective and successful replication and scaling up of the programmes in different contexts. As CCTs are
becoming increasingly popular and are being replicated widely in Africa and Asia, it is time for nutritionists to
start paying attention to how these programmes’ nutrition intervention packages are designed and
implemented, which mechanisms and pathways ensure maximum impacts on nutrition, and how they can be
replicated and scaled up most successfully. It is also important to collect appropriate data on the supply side
to better understand the role of service delivery and quality in achieving nutritional impacts. Through the
conditions they impose on households, CCT programmes necessarily establish a link to health systems and
thus may provide an opportunity for mainstreaming and strengthening nutrition within the health sector.
back to contents SCN NEWS # 36