To save the lives of infants and small children living in low- and middle-income countries, there are a handful of tried and tested tools, like anti-malarial drugs, bed nets and vaccines. The results from a massive experiment in rural Kenya suggests another: cash.
Infants born to people who received $1,000, no-strings-attached, were nearly half as likely to die as infants born to people who got no cash, according to a report published Monday by the National Bureau of Economic Research. Cash cut mortality in children under 5 by about 45%, the study researchers found, on par with interventions like vaccines and anti-malarials.
"This paper is really well done, and the result itself is pretty stunning," says Heath Henderson, an economist at Drake University who wasn't involved in the study. Historically, it's been "difficult to study the impacts of cash transfers on mortality with any sort of rigor," he says. "This study is different," he says, and suggests cash can help people get life-saving care.
Over the past decade or so, the idea of simply giving people living in poverty cash has gained traction, in part by evidence that it can work. The best evidence comes from what researchers call randomized controlled trials. In this set-up, an experimental group gets cash, a control group doesn't, and researchers look for differences in measurable outcomes, like income or savings, to understand what difference cash made.
While studies have found clear links between cash transfers and economic well-being, health has been harder to pin down, especially for the most dire health outcomes.
"Infant and child mortality in rural Kenya is an order of magnitude higher than it is in the U.S.," says Edward Miguel, an economist at the University of California Berkeley and study co-author. "But it's still a relatively rare event to have a child die. Statistically speaking, that means we need a really large sample size to have precise and reliable estimates of the effect of cash on child mortality."
$1,000 to 10,000 families
In 2014, the nonprofit GiveDirectly began a massive experiment. Over the next three years, they gave $1,000 to over 10,000 low-income households across 653 villages in Western Kenya.
"It was designed as a randomized control trial," says Miguel. "So some areas got more cash. Some got less cash, and we can study the impact of that cash."
To study that impact, Miguel and his colleagues collected a lot of data. They completed a kind of birth census for all children that had been born and died before age 5 over the previous decade in the study area. "We ended up collecting data on over 100,000 births. It took a year to do."
They found that cash had major benefits for infant and child mortality, especially when it was delivered close to birth.
Cash payments were associated with a 48% drop in infant mortality, from roughly 40 deaths per 1,000 births to about 21 deaths. Deaths of children under five were 45% lower in households who got cash, dropping to 32 per 100,000 births from 57.
Cash played an outsized role in reducing deaths during birth and in the few weeks after, falling by 70% compared to controls. "That really pointed toward a key role for access to health services right at the moment of delivery being very important," says Miguel.
Why cash cut deaths
For many living across rural sub-Saharan Africa, getting to a health facility, and paying for care there, can be difficult, especially when pregnant.
"When I worked in rural parts of Uganda, one of the things that was really clear for pregnant women was they did not attend antenatal care, because it's so difficult to get to a health care facility," says Miriam Laker-Oketta, GiveDirectly's senior research adviser.
"You're making the decision between, should I go for antenatal care and have my family sleep hungry, or should I stay home and hope that my baby is fine because I'm not feeling sick and we can have a meal that day," she says, since often women would have to forgo work for a day to go to the doctor. "Those are some of the decisions people have to make."
Extra cash seems to make those decisions easier, as long as health care facilities weren't too far away.
Cash made the biggest difference for families who live roughly 30 minutes or less away from a health care facility staffed with physicians. When the distance is greater, the benefits of cash for infants start to wane, though do not disappear entirely.
The researchers saw 45% more hospital deliveries among pregnant people who received cash than those who didn't. It's often more expensive to deliver at a hospital than a smaller clinic, says Laker-Oketta. "We've given people the means to access the care that they need and not to make some of these really difficult choices between getting care and feeding a family."
The extra cash also helped put more food on the table. Children were about 44% less likely to go to bed hungry in households that received cash, the study found. Women who got cash while pregnant also worked about half as much — roughly 21 fewer hours per week — in their first trimester and the months after delivery than women who didn't get cash. Work in these rural areas can often be physically taxing, says Laker-Oketta.
"That's great for the mother's health, but also gives time for her baby to develop well," she says. "She's also available after the baby is born to take the child to any early health visits."
A 'very important' data point
Altogether, the results impressed Aaron Richterman, a physician who studies poverty reduction at the University of Pennsylvania and wasn't involved in the study.
"It's one data point, but it's a very important data point. We can be very certain that in this case, the cash caused these benefits in mortality that we're seeing," he says. In an environment of shrinking foreign aid, he says cash could offer a simple way of reducing infant mortality.
Just how big a difference cash could make may depend, in part, on how readily people in other locations can use the extra money to get health care.
"I think this paper underscores the point that it's really adequate access to health care that's making all the difference," said Henderson, the Drake economist and author of the book Poor Relief: Why Giving People Money Is Not The Answer To Global Poverty. "It just so happens that in this particular place, people needed cash to access health care."
That's likely the case in many places across sub-Saharan Africa after years of investment in bolstering health care systems, says Laker-Oketta, but not all.
"The answer is not we give cash alone, or we just focus on improving the health care system," she says. "What's obvious in this study is that you need both to be working together."
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