And now for something completely different: Contraceptional Cash Transfers

This blog first appeared on the Wahenga website, under the pseudonym of Sissy Teese

The World Bank can only be doing this to provoke me! Just when I had vowed never to take up my pen in anger again (and when Wahenga had vowed never to air my pseudonymical rants) … they do this!!

We already know, because the Bank has told us, that Conditional Cash Transfers (CCT) can do everything! First we had Conspirational Cash Transfers. Then we had Connubial Cash Transfers. And now we have Contraceptional Cash Transfers. A paper just launched describes an experiment - “Rewarding STI Prevention and Control in Tanzania” (with the horrendously contrived acronym of RESPECT, no less!), which provides quarterly cash transfers, each equivalent to nearly one-tenth of average annual income, to those who avoid unsafe sex!

We hear that the study “has three separate arms [all the better to hold you with, my dear!!] – a control arm and two intervention arms (low-value cash rewards and high-value cash rewards).  Study participants were randomly allocated across the three study arms. All participants have been monitored on a regular basis (every 4 months over a 12 month period) for the presence of common sexually-transmitted infections (STIs) that are transmitted through unprotected sexual contact and therefore serve as a proxy for risky sexual behavior and vulnerability to HIV infection.  A small payment has been provided to all participants (regardless of arm assignment) to minimize attrition from the study.  Anyone testing positive for an STI (again, regardless of arm) received free STI treatment and counseling. Individual pre-test and post-test counseling was provided to study enrollees [the word “enrollees” has a wonderful ring to it in this context!!] at each testing interval, and monthly group counseling sessions were also made available to all study participants in all villages.”

And it works! And, what is more, it seems that the more you pay, the better it works!

By the end of one year, “study participants who were randomly selected to be eligible for a $20 payment every 4 months if they tested negative for a set of curable STIs, experienced a 25% reduction in the incidence of those STIs. After one year, 9% of individuals in the group that received the $20 quarterly payment were positive for one of the STIs, compared to 12% in the control group”.

We also learn that “the two year study cost $1.8m”, which must surely make it the most expensive condom in African history. And maybe this is where the reality check comes in: the finances. Let us look at this from two different perspectives.

First, the experiment. We have a sample of 2399 (why not 2400?). Of these, let’s assume one-third (remember the three arms?) received the higher transfer value - i.e. 800 people. Of these, 3% (i.e. the difference between 9% and 12%) avoided STIs as a result of the transfer - that is 24 individuals. So it cost probably 800 x $60 in transfers, plus all the costs of testing and administration - let’s say conservatively $100,000 in total annually - to prevent 24 individuals from getting an STI. That is over $4,000 each. Condoms would have been a cheaper option.

Second, consider this programme scaled up, nationally, to cover the whole of Tanzania. To be effective, it would need to be targeted universally, at all who were sexually active, so between the ages of 12 and 60. That is more than 22 million people. The pilot cost $750 per person, but we can assume some economies of scale, so let’s say $500 per person. That is a total programme cost of $11 billion, equivalent to 50% of GDP at official exchange rates. By way of comparison, the ILO calculated that Tanzania could afford a full “basic social protection package”, comprising a universal pension for all over-65s and all persons with disabilities, a universal child benefit to all under-15s and universal access to basic health care … all for 17% of GDP. Alternatively, $11 billion could buy you 110 billion condoms, more than five times the number currently produced worldwide annually!

But - since money is no object - what next for the World Bank? How else might they influence people’s behaviour for the better? My vote is for some form of Conflagrational Cash Transfer, providing nicotine vouchers to all who refrain from smoking cigarettes … or maybe Congregational Cash Transfers, distributing multiples of the collection plate to all who faithfully attend church every Sunday … or a Consumptional Transfer of unlimited maize meal to all who eschew junk food for the month … or a Convivial Cash Transfer to those who moderate their alcohol intake … or perhaps Constipational Cash Transfers, providing monthly supplies of suppositories to all those performing their ablutions regularly on a daily basis.

Maybe my writing days aren’t over yet …

An appeal against "Conditionalities"

As RHVP - and perhaps Wahenga - draw to a close, I would like to use our pages to make a personal and heartfelt appeal to the social transfers community: please can we stop using the horrible word “conditionalities”?

I would like to stress that this plea has nothing to do with the debate about the relative merits of conditional and unconditional cash transfers that has been raging on Wahenga’s pages recently (Sissy Teese v World Bank): it is aimed squarely at writers at both ends of that seemingly unbridgeable spectrum. But let me at least draw on those Wahenga exchanges to quote a couple of examples:

“why bother with the moral hazard, additional cost and complexity of imposing, monitoring and enforcing conditionalities, when unconditional programmes appear to have the same effects?” (Ms Teese) 

“[CCTs] combine three key mechanisms: grants that increase the income of poor households, awareness promotion that emphasises the importance of human capital, and conditionalities that link the two” (EPRI “Designing and Implementing Social Cash Transfers” [2006], quoted by Ms Teese)

The danger is that this ugly terminology is becoming firmly entrenched in the literature: it is used over 200 times in the EPRI manual cited above[i], it has sneaked into the World Bank’s seminal “tome” on “Conditional Cash Transfers” (2009), and it is being replicated in countless papers, articles and journals.

What is wrong with the word “conditionalities”? First, it is not a word; second, if it were, it would mean something quite different; and third, it is wholly unnecessary, since we already have a perfectly good word that we can use in its place.

1)    It is not a word because it does not appear in any dictionaries, and because the irreproachable Microsoft Word gives it a red squiggly underline, in whatever language you are using.

2)    Even if were to be coined as a neologism, it would be meaningless: we can apply a “condition”, or multiple “conditions”. We can thereby make things “conditional” (ie “dependent on the fulfilment of one or more conditions”); and we can therefore have a system that is based on the concept of “conditionality” (ie the “state of being conditional”). But we cannot have multiple “conditionalities” - and, if we could, it could only mean “multiple states of being conditional”.

3)    So, if we can’t use the word “conditionalities”, what can we use instead? We need a word that has the definition of “actions stipulated as requirements before the performance or fulfilment of other actions”. Does such a word exist? Miraculously, it does: the word is … “conditions”! Try it for yourself in each of the examples cited above: you must agree that it improves them!

So this is my plea: let us have no more “conditionalities” in social transfers! But - lest this sounds as if I am aligning myself with the sassy Sissy - let us equally have no hesitation in applying “conditions” to cash transfers wherever they are agreed to be appropriate!

It is important to nip this awful usage in the bud now, because the use of conditions in social transfers is clearly a ubiquitous and fast-growing phenomenon, both in the World Bank’s portfolio and elsewhere. Or to put it another way: without wishing to cause confrontationalities, in order to have confirmationalities of the proliferationalities of the utilisationalities of conditionalities in social transfers, in both connurbationalities and rural locationalities, you need only to make random observationalities in the World Bank’s “Manual of Operationalities”!

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[i] The otherwise excellent EPRI manual is to be republished soon. Please can we ensure that it drops the use of the term “conditionalities” in its second edition?

Connubial Cash Transfers

This blog first appeared on the Wahenga website, under the pseudonym of Sissy Teese

With some reluctance, I take up the cudgel again!

I have recently had the good fortune to read the Bank’s latest Policy Research Working Paper (No 5259)[i]. This is another fascinating, meticulously researched and well-argued paper about the same cash transfer programme in southern Malawi that was cited in our earlier wahenga exchanges about the impact of conditionality on schooling - the Zomba Cash Transfer Program (ZCTP). Entitled “Cash or Condition”, the Paper’s specific objective is to disentangle the impact of the condition from the impact of the cash transfer by reporting on the first “ideal experiment to answer this question – i.e. a randomized controlled trial with one treatment arm receiving conditional cash transfers, another receiving unconditional transfers, and a control group receiving no transfers” [emphasis in original].

Not even I could fail to be impressed by the refreshing candour of the Abstract, which states unequivocally that:

 “the authors find that the program reduced the dropout rate by more than 40 percent and substantially increased regular school attendance among the target population of adolescent girls. However, they do not detect a higher impact in the conditional treatment group” [emphasis added].

After such an admirable display of openness, it might seem churlish to complain! But there are a couple of more worrying findings which emerge from the Working Paper that shed further significant light on the debate between CCTs and UCTs. One of these is clearly recognised in the paper (although, noticeably, it doesn’t make it into the Abstract!), while the other is tucked away unobtrusively in a footnote.

The first is that UCTs dramatically reduce the probability of early marriage, while CCTs do not:

 “the unconditional treatment reduced the probability of marriage by 2.7 percentage points (or by 56%), whereas the marriage rate in the conditional group was identical to that in the control group”.

The paper suggests a dispassionate economic argument to evoke “the possibility that a CCT offer could actually trigger marriage by presenting the girl with an untenable schooling alternative and forcing the household into a decision [of early marriage] at the time of the offer” [emphasis added]. But might there not be another, more human, explanation: that beneficiaries of unconditional transfers feel more empowered, and more independent, and more confident of making sensible life-choices than recipients of conditional transfers from an intrusively paternalistic nanny-state? This would after all, conform to standard economic theory, helpfully reiterated in this Working Paper, that “in the absence of externalities, conditional cash transfers are worse than distributing an equivalent amount of unconditional cash”. 

The second, perhaps even more serious, concern is tucked away in a footnote:

 “the program led to substantially elevated stress and psychological morbidity among adolescent girls in the conditional group relative to the unconditional arm”.

Again, the implication is clear. The imposition of conditionality places additional stress on the recipient, and creates tensions within the household between those that must adhere to the conditions (in this case, the school-age girls) and those that benefit from the transfer (siblings, parents, carers, grandparents). What is worse, the authors “also find that the mental health of the CCT recipients worsen [sic] when the transfer amount offered to the parents is larger, while the mental health of UCT recipients is uncorrelated with the transfers offered to the parents”. In other words, the higher the value of the transfer that rests on fulfilling the conditions, the greater the stress for CCT recipients.

Surely these are serious concerns, and a reason to argue more forcefully in favour of unconditional transfers? What this impressive study tells us is not only the already important message contained in the conclusion that: 

“given that the marginal impact of imposing a schooling conditionality is at best low [it is in fact absent!], and that monitoring school attendance to enforce the conditionality is costly, it seems that policymakers can consider unconditional cash transfers as a viable alternative”.

It also raises two potentially damaging criticisms of conditionality, and therefore two significant advantages of UCTs, which - at the very least - merit critical attention and further research. These are:

1)    That, “while unconditional cash transfers nearly eliminate marriage in our study population, the conditional cash transfers have no effect on it”. Early marriage is seriously detrimental to girls’ education (in Latin America and elsewhere, as well as in Malawi), so reducing it, through whatever mechanism, would be a highly desirable outcome in building human capital and reducing the inter-generational transmission of poverty.

2)    That - as might indeed rationally be expected - imposing conditions can inflict psychological damage and create intra-household tensions. Instead of feeling empowered and independent, recipients may feel bullied, pressured and ultimately overwhelmed by the conflicting demands imposed on them, forced into making behavioural choices (like early marriage) that they would otherwise eschew.

Should these two issues not have been given greater prominence in a truly balanced Working Paper, intended as it is to “inform policymakers as to which combination of contract parameters might allow cash transfer programs to deliver the largest impacts per dollar spent”? Should policymakers not be told, upfront, that, on the evidence emerging from Malawi, unconditional transfers have identical benefits in terms of school enrolment and attendance to conditional transfers, while being far less complex and less expensive to implement; and that they appear to be much more effective in reducing disruptive early marriage and minimising psychological stress?

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[i] Baird, S., McIntosh, C. and Özler, B., ‘Cash or Condition? Evidence from a Randomized Cash Transfer Program’, World Bank, March 2010

Conspirational Cash Transfers

This blog first appeared on the Wahenga website, under the pseudonym of Sissy Teese

Is there a conspiracy afoot? Practitioners of social protection have long debated the relative merits of conditional and unconditional cash transfers. Now the World Bank appears to have introduced a third category. We label these conspirational cash transfers: cash transfer programmes about which the evidence is either suppressed or massaged in a conspiracy to support the case for conditional cash transfers!

Before looking at two examples of such schemes (or schemings), let us take stock. Conditional cash transfers (CCT) require beneficiaries to meet one or more conditions before they receive their transfer: for example, to ensure their children are enrolled in, or attend, school, or to have their children inoculated or regularly visit health clinics. Unconditional cash transfers (UCT) do not: they provide the transfer to everyone eligible, regardless of their behaviour.

CCTs fit much better with the World Bank’s philosophy of seeing social protection in dispassionate, purely economic terms. As a recent publication by the Brooks World Poverty Institute puts it: 

The World Bank conceptualizes social protection as social risk management and proposes policies that seek ‘to assist individuals, households and communities in better managing income risks’ (Holzmann and Jorgensen, 1999: 4). It moves beyond what it sees as ‘traditional’ social protection by adding the goals of macroeconomic stability and financial market development. The emphasis on risk assumes that vulnerability to hazards is a significant constraint on economic and human development, and that efforts to reduce the likelihood of hazards, or to ameliorate their effects on living standards, are essential for economic growth and development [emphasis added]

So the World Bank has been promoting CCTs all over the world, and has recently published a 383-page eulogy on CCTs. There can be no doubt in the reader’s mind after perusing this (or even its 28-page “Overview”) that CCTs have been remarkably successful in achieving their objectives of better education, nutrition and health outcomes for their recipients.

But - and this is the nub of the problem - UCTs have done exactly the same. Unconditional programmes, for example in South Africa, Namibia and Malawi, have been every bit as successful in improving health and education indicators among their beneficiaries as CCTs. So there is a legitimate question to be asked of the World Bank: why bother with the moral hazard, additional cost and complexity of imposing, monitoring and enforcing conditionalities, when unconditional programmes appear to have the same effects?

Answering this question is difficult, because it is almost impossible to unpick the reasons why a CCT programme works: is it because of the conditionality, because of the attendant awareness-raising, or simply because of the cash transfer itself. As Samson et al put it when discussing Mexico’s Oportunidades programme: 

[CCTs] combine three key mechanisms: grants that increase the income of poor households, awareness promotion that emphasises the importance of human capital, and conditionalities that link the two – making the grants conditional on behaviours that reinforce human capital development. The evaluations have successfully demonstrated that all three of these ingredients together can generate very positive results. However, the studies so far have been unable to identify which is most important – the income, the awareness or the conditionality[i]

But, just occasionally, the opportunity arises for the Bank to try to demonstrate that it is the impact of conditionality that determines the beneficial impact. And we document here two example of the lengths to which it will go to take full advantage of these opportunities - two Conspirational Cash Transfer schemes in Ecuador and Malawi.

The first, less flagrant but still revealing, comes from an evaluation of the impact of Ecuador’s Bono de Desarrollo Humano (BDH) cash transfer program on school enrolment and child work among poor children. The unusual thing about this programme was that (unlike most other such programmes in Latin America) it was not in fact conditional … though a number of its beneficiaries were under the impression that it was. This allowed a comparison of impact between recipients who were “conditioned” (i.e. who thought there were conditions attached) and those who were “unconditioned” (i.e. who thought there were no such conditions), which is discussed in a paper by Schady and Araujo[ii].

What is interesting here is the marked difference in the conclusions between a first version of the report dated November 27, 2005 (now virtually unobtainable), and the version published officially as World Bank Policy Research Working Paper 3930 in June 2006. The respective abstracts are already instructive. The earlier version reads as follows: 

We conclude that the program had positive effects on enrolment, and negative effects on child work. Enrollment effects are concentrated among the poorest children in our sample. We also show that the impact of the BDH program was largest among households who believed that transfers were conditional on school enrolment, although the effect of the (unenforced) condition appears to have interacted in important ways with baseline socioeconomic status [emphasis added]

The published version reads very differently:

The main results in the paper are two. First, the BDH program had a large, positive impact on school enrollment, about 10 percentage points, and a large, negative impact on child work, about 17 percentage points. Second, the fact that some households believed that there was a school enrollment requirement attached to the transfers, even though such a requirement was never enforced or monitored in Ecuador, helps explain the magnitude of program effects.

What has happened to the caveat about “interaction with baseline socio-economic status”? In the body of the first report, it is clear that - even at baseline - there are marked, observable differences between the “conditioned” and “unconditioned” samples: 

Conditioned households had significantly higher levels of both paternal and maternal education, children in these households were significantly more likely to be enrolled in school, and conditioned households were significantly more likely to have a television.

Such differences may well explain any differences in subsequent impact between the two groups. [There is also the obvious consideration, that, since the evaluation was based on self-reported school attendance and not on objective evidence such as school records, it is far more likely that respondents who believed the transfer to be conditional upon school enrolment would lie about it, compared with those who knew that telling the truth would have no impact on their entitlement. This would greatly inflate the apparent impact on enrolment for “conditioned” households.]

Overall, the findings in the earlier version are hedged around with provisos, recognising that: 

… enrolment regressions at baseline suggest that observable rather than unobservable differences between conditioned and unconditioned households explain differences in their enrolment decisions. We do not have the data to conclusively rule out this possibility [emphasis added] 

… we believe that it is most likely that the perceived, although unenforced conditions played some causal role explaining the large program effects among better-off, conditioned households [emphasis added]

And the conclusion is correspondingly circumspect: 

It would not be wise to conclude from our results that simply announcing that households have to comply with certain conditions, without enforcing them, will substantially affect household behavior in the long run, in Ecuador or elsewhere

In the published Working Paper (only six months later) such doubts are swept away: 

Although the comparison of lottery effects for conditioned and unconditioned is not experimental, we conclude that the general pattern of results is most consistent with the (unenforced) BDH schooling requirement having a causal effect on outcomes

 and the same paper ends now with a ringing endorsement of conditionality: 

In Ecuador, significant program effects on enrollment are only found among households who believed that there was an enrollment requirement associated with the program; this suggests that this unenforced condition was important

Interestingly, another contemporary study of the same programme in Ecuador[iii] finds “no significant impact of the program on school enrolment” and concludes that “the enforcement of conditionality has not any significant effect on school enrolment among the less poor”. This further underlines the need to retain the important caveats of the first version of the World Bank report.

The second egregious example of a Conspirational Cash Transfer is more recent, and comes from a World Bank experiment in Malawi. This was an evaluation of the impact of a randomized conditional/unconditional cash transfer intervention targeting young women in Zomba district that provides incentives (in the form of school fees and cash transfers) to current schoolgirls and young women who have recently dropped out of school to stay in or return to school. Splitting the sample - between some that received a transfer conditionally, some that received it unconditionally and some that received no transfer at all - allowed a comparison of different impacts between the three different groups.

Here again we can observe an unexpected evolution in the published results. The first set of findings is drawn from a publicly available PowerPoint presentation[iv] of the study. This concludes unequivocally that: 

We don’t find any evidence that the conditional transfers are more effective in improving schooling

And it suggests that the best way to design a cost-effective program, based on the lessons learned, would be “possibly foregoing the conditionality”!

Indeed, looking at the data presented (which unfortunately appears on slides in the PowerPoint that cannot be cited), it is clear that there is no significant difference at all between the conditioned and unconditioned groups in terms of school enrolment or literacy in English; and that it is the unconditioned group that performs better in terms of avoiding early marriage. Altogether, on this basis, the study would not appear to present a strong argument in favour of CCTs!

Yet what do we find when the same study is published as official World Bank Policy Research Working Paper 5089[v]? Miraculously the selfsame findings are used to proclaim: 

Overall, these results suggest that conditional (sic) cash transfer programs not only serve as useful tools for improving school attendance, but may also reduce sexual activity, teen pregnancy, and early marriage

 How has this come about? First of all by ignoring entirely the set of data from the unconditional sample. Tucked away in an unobtrusive footnote on page 11 is the following: 

283 of these girls resided in EAs where the offers for baseline schoolgirls were not conditional on school attendance, and, as such, are not part of the analysis for this paper

How convenient! Secondly by arrogating to conditional cash transfers all of the benefits that should rightly be ascribed to cash transfers. Another footnote on page 12 brushes this aside:

Finally, baseline schoolgirls in a randomly selected small percentage of the EAs received unconditional offers, meaning that the transfers were not conditional on school attendance, or any other behavior other than showing up to collect monthly payments, for these beneficiaries in those EAs. The analysis of the heterogeneity of the impacts with respect to each of these design features is beyond the scope of this paper. Here, we aim to establish the average effect of the conditional treatment arms, which may not equal the treatment effect of the average treatment if these impacts are nonlinear [emphasis added]

Quite so! The result is that an experiment which has actually demonstrated that unconditional transfers are every bit as effective as conditional transfers has now been manipulated to support a claim that: 

schooling CCTs (sic) for young women in the context of poor Sub-Saharan countries with high HIV rates seem like “win-win” programs, as they may not only increase schooling for young women, but also significantly reduce their risk of HIV infection.

Yes, the Zomba programme does appear to have extremely promising impacts: large increases in self-reported school enrolment, and declines in early marriage, teenage pregnancy, sexual activity, and risky sexual behaviour. But to claim that this has anything to do with conditionality per se is highly disingenuous. It is self-evidently the cash transfer and not the conditionality that is the cause.

Here we have an important debate, but it is one that should be aired openly and honestly. Policy-makers should be aware of both sides of the argument, and should not allow themselves to be pushed into Conditional - and still less into Conspirational - Cash Transfer programmes!

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[i] Samson, M., van Niekerk, I., and MacQuene, K. (2006) ‘Designing and Implementing Social Transfer Programmes’, Economic and Policy Research Institute Press, Cape Town: EPRI

[ii] Schady, N., and Araujo, M. ‘Cash transfers, conditions, school enrollment, and child work: Evidence from a randomized experiment in Ecuador’

[iii] Ponce, J., The Impact of a Conditional Cash Transfer on School Enrollment: the Bono de Desarrollo Humano of Ecuador”, FLACSO Documento de Trabajo 06/302, April 2006

[iv] Available at http://www.fundp.ac.be/eco/recherche/cred/SUMMERSCHOOL/amid/ozler2.pdf, June 2009

[v] Baird, S., Chirwa, E., McIntosh, C. and Özler, B., The Short-Term Impacts of a Schooling Conditional Cash Transfer Program on the Sexual Behavior of Young Women, World Bank, Oct 2009