- Email: [email protected]
Conditional cash transfer: a magic bullet for health?
Comment
to the inhibition of angiotensin II at the tissue level.9 Because most angiotensin II is synthesised locally in tissues, whether this antibody can diffuse from the circulation into the extravascular space in concentrations high enough to block the actions of local angiotensin II is an interesting question. Hence whether this vaccine has any organ-protective effect needs to be shown in larger trials of longer duration. Treatment of hypertension is based on lifestyle interventions and drug therapy. However, both require patient adherence to be effective. Poor compliance is common for both approaches and is the main reason for inadequate blood-pressure control.10 If vaccination against high blood pressure were safe and effective in the long run, it might solve many problems of non-compliance. The present trial1 was, however, small and exploratory, and, as the authors point out, larger studies are needed to show the efficacy and safety of antibodies against angiotensin II in patients with hypertension. Nevertheless, the results of this new biotherapy for hypertension are intriguing and promising, and vaccination for hypertension may turn out to be very useful in many patients.
*Ola Samuelsson, Hans Herlitz Department of Nephrology, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden [email protected] We declare that we have no conflict of interest. 1
2
3 4
5
6 7 8 9
10
Tissot AC, Maurer P, Nussberger J, et al. Effect of immunisation with CYT006-AngQb against angiotensin II on ambulatory blood pressure: a double-blind randomised placebo-controlled phase IIa study. Lancet 2008; 371: 821–27. Brown MJ, Coltart J, Gunewardena K, Ritter JM, Auton TR, Glovers JF. Randomized double-blind placebo-controlled study of an angiotensin immunotherapeutic vaccine (PMD3117) in hypertensive subjects. Clin Sci 2004; 107: 167–73. Ménard J. A vaccine for hypertension. J Hypertens 2007; 25: 41–46. Hollenberg NK. Intrarenal and systemic actions of the renin-angiotensin system: implications for renal excretory function and sodium homeostasis. Contrib Nephrol 1984; 43: 102–13. Taylor JG, Zwillich CW, Kaehny WD, Levi M, Popovtzer MM. Hyperkalemia with watery diarrhoea: an unusual association. Am J Kidney Dis 2003; 42: E9–12. Senior K. Dosing in phase II trial of Alzheimer’s vaccine suspended. Lancet Neurol 2002; 1: 3. Schenk D. Amyloid-β immunotherapy for Alzheimer’s disease: the end of the beginning. Nat Rev Neurosci 2002; 3: 824–28. Spinney L. Update on Elan vaccine for Alzheimer’s disease. Lancet Neurol 2004; 3: 5. Johnston CI. Franz Volhard lecture. Renin-angiotensin system: a dual tissue and hormonal system for cardiovascular control. J Hypertens 1992; 10: S13–26. Borzecki AM, Oliveria SA, Berlowitz DR. Barriers to hypertension control. Am Heart J 2005; 149: 785–94.
Conditional cash transfer: a magic bullet for health? During the past decade, countries with transitional and middle-income economies have introduced programmes that transfer money to poor households on the condition that they comply with a set of requirements, including attendance for health care, food and nutritional supplementation, and enrolment of children in school. Conditional cash transfer (CCT), a type of social contract, is both an alternative to more traditional social assistance with handouts and a complementary strategy to the provision of health and education services.1 Because poor families usually face the greatest barriers to health interventions, CCT helps to redistribute resources and thus reduces health inequities.2 For very poor families, cash provides emergency assistance, while the conditions promote longer-term investments in human capital. Nancy Birdsall, president of the Center for Global Development, has said: “I think these programs are as close as you can come to a magic bullet in development…They are creating an incentive for families to invest in their own children’s futures. Every www.thelancet.com Vol 371 March 8, 2008
decade or so, we see something that can really make a difference, and this is one of those things.”3 CCT programmes started in the late 1990s in Mexico with Progresa (now Oportunidades), which serves more than 20 million Mexican families and has been replicated and piloted in more than 20 countries with transitional economies and some low-income developing countries.4 Even in the heart of the most developed economy in the world, Mayor Michael Bloomberg and leaders of several New York City foundations announced the creation of a major pilot CCT project, called Opportunity NYC, in 2007.4 Does this new health and human-development initiative work and, if so, how? Unlike most development initiatives, most CCT programmes are rigorously assessed for effectiveness.1 A recent systematic review of six CCT programmes in Latin America and Africa showed a fairly consistent picture of the effects of such programmes on the use of health-care and education programmes and, to some extent, growth and health outcomes for children early in life, despite some methodological concerns.2
See Articles page 828
789
Comment
Reuters
The printed journal includes an image merely for illustration
Cash distribution in Acacoyagua, Mexico under CCT programme
In today’s Lancet, an analysis of Mexican datasets by Lia Fernald and colleagues5 provides additional evidence on the effect of CCT on children’s growth, health, and development. The authors took advantage of the variation in total cumulative cash transfer received by families that enrolled in CCT, and assessed the effect of the cash transfer component on such outcomes by holding other components of the programme constant. A multivariate regression analysis suggests that a doubling of cumulative cash transfer to the household was associated with an increase in 0·16 standard deviations in height-for-age Z score, a 9% lower prevalence of stunting, slightly higher haemoglobin concentrations, and improvements in test scores for motor development (endurance), short-term and long-term memory, visual integration, and language development. This study5 has two important implications. First, no previous studies assessed the effect of CCT on cognitive, language, and motor development in children,6 which affect the ability to live a healthy life, to have freedom of choice, to engage in economic activities, and to escape the vicious cycle of poverty.7,8 Second, disentangling the relative importance of different components of the programmes is a challenge. For example, nutritional and health outcomes are probably influenced by health interventions, nutritional supplements provided 790
to children, and cash transfer itself.2,9 Fernald and colleagues’ study shows an independent effect of the cash transfer component. In families in the programme, more cash transfer was associated with better growth, health, and development in children. Those outcomes could have come from increased purchasing power or better care and support of children from the improved wellbeing of family members, or both. Due to its design, however, the study could not show how cash transfer worked. Fernald and colleagues’ study further supports CCT as a potentially effective approach to improve health and development outcomes in children.2 Several questions remain that will affect whether CCT becomes a magic bullet for health and human development in resource-poor settings. First, the effect size of each component of CCT programmes (eg, health interventions, food supplements, and cash transfer) needs to be studied with comparable and consistent health-outcome measures, including overall disability and mortality. Second, CCT is contingent on the presence of effective health interventions and education services, and systems to deliver them. Information systems are needed to identify poor communities and eligible families, follow up compliance, and regularly monitor payments and their use. In many low-income countries, these requirements are rarely met. Third, compared with scaling up the coverage of health interventions, the whole package of CCT can be large and expensive. The cash transfer component requires targeting and calibration rules to be efficient.10 Hence careful piloting of CCT and analysis of its cost-effectiveness in low-income countries is urgently needed. After these questions are answered, CCT might be an attractive option for scaling up effective health coverage (defined as the proportion of potential health gain that could be delivered by the health system to that which is actually delivered).11 CCT could be combined with ongoing efforts to enhance the provision of health services to poor people in many low-resource settings—through performance-based funding and health-systems strengthening—and simultaneously introduce behavioural changes and incentives. Above all, as shown for Mexico’s Oportunidades,5 strong leadership by government www.thelancet.com Vol 371 March 8, 2008
Comment
to improve children’s health and development and a commitment to accountability through monitoring and evaluation are key to the success of CCT programmes.
4
Kenji Shibuya
6
WHO, Geneva CH-1211, Switzerland [email protected]
7
I declare that I have no conflict of interest. 1 2
3
Rawlings LB, Rubio GM. Evaluating the impact of conditional cash transfer programs. World Bank Res Obs 2005; 20: 29–55. Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review. JAMA 2007; 298: 1900–10. Dugger CW. To help poor be pupils, not wage earners, Brazil pays parents. New York Times Jan 3, 2004. http://query.nytimes.com/gst/fullpage.html? res=9D02E7DA1731F930A35752C0A9629C8B63&sec=health (accessed Feb 19, 2008).
5
8 9
10
11
Rockefeller Foundation. Opportunity NYC: recognizing the day-to-day challenges faced by the poor. http://www.rockfound.org/efforts/ nycof/opportunity_nyc.shtml (accessed Jan 23, 2008). Fernald LCH, Gertler PJ, Neufeld LM. Role of cash in conditional cash transfer programmes for child health, growth, and development: an analysis of Mexico’s Oportunidades. Lancet 2008; 371: 828–37. Grantham-McGregor S, Cheung YB, Cueto S, and the International Child Development Steering Group. Developmental potential in the first 5 years for children in developing countries. Lancet 2007; 369: 60–70. Sen A. Commodities and capabilities. Oxford: Oxford University Press, 1985. Alkire S. Valuing freedoms: Sen’s capability approach and poverty reduction. Oxford: Oxford University Press, 2002. Gertler PJ. Do conditional cash transfers improve child health? Evidence from PROGRESA’s controlled randomized experiment. Am Econ Rev 2004; 94: 336–41. de Janvry A, Sadoulet E. Making conditional cash transfer programs more efficient: designing for maximum effect of the conditionality. World Bank Econ Rev 2006; 20: 1–29. Lozano R, Soliz P, Gakidou E, et al. Benchmarking of performance of Mexican states with effective coverage. Lancet 2006; 368: 1729–41.
Fast-track colorectal surgery Perioperative care has been improved with newer anaesthetic and analgesic techniques, development of minimally invasive surgery, and drugs to reduce surgical stress.1,2 Fast-track surgery or enhanced postoperative recovery programmes have been developed by combining these techniques with evidence-based adjustments to the use of nasogastric tubes, drains, and urinary catheters, preoperative bowel preparation, and early initiation of oral feeding and mobilisation. The aim of these programmes has been to provide pain-free and stress-free operations with lower rates of organ dysfunction, thereby reducing morbidity and enhancing recovery. If successful, the need for hospitalisation after surgery will be reduced. Standard elective colorectal resection is usually associated with a complication rate of 20–30% and a postoperative hospital stay of 8–12 days. Limiting factors for early recovery and discharge are pain, paralytic ileus, and other organ dysfunctions. The potential for a multimodal intervention with a fast-track clinical pathway to improve recovery after colonic resection was first reported in the mid-1990s, with a reduction of hospital stay to 2–3 days under standard discharge criteria.1 Efforts have since been made in several countries to develop and document the results of standardised and evidence-based programmes of perioperative care after colorectal procedures. A systematic review of controlled and randomised controlled studies supports the use of fast-track colorectal surgery.3,4 www.thelancet.com Vol 371 March 8, 2008
Effective analgesia that allows early mobilisation is a prerequisite for improved recovery;1 and in open colorectal surgery, thoracic epidural analgesia followed by multimodal non-opioid analgesia is the most effective evidence-based method.1 Epidural analgesia might not be necessary in laparoscopic colorectal surgery and can be replaced by opioid-sparing multimodal analgesia,1,2 including oral paracetamol, non-steroidal anti-inflammatory drugs, gabapentanoids, systemic local anaesthetics, or continuous infusion of the wound with local anaesthetic.2 Traditional care in colorectal surgery includes preoperative bowel preparation, but a systematic review of randomised trials showed this approach to be unnecessary and with the potential to increase morbidity, at least in segmental resections.5 However, more safety data are needed for very low mesorectal resections. Avoidance of preoperative bowel preparation might also hinder preoperative dehydration. There has recently been an increased focus on perioperative fluid management, and several large randomised trials in major abdominal surgery, including colorectal procedures, showed that fluid excess increases morbidity.1,6 Additionally, results from several trials, including four colorectal studies, show that perioperative optimisation of haemodynamic function—by the goal-directed approach with individualised optimisation of stroke volume by small colloid challenges—reduces morbidity and hospital 791
to the inhibition of angiotensin II at the tissue level.9 Because most angiotensin II is synthesised locally in tissues, whether this antibody can diffuse from the circulation into the extravascular space in concentrations high enough to block the actions of local angiotensin II is an interesting question. Hence whether this vaccine has any organ-protective effect needs to be shown in larger trials of longer duration. Treatment of hypertension is based on lifestyle interventions and drug therapy. However, both require patient adherence to be effective. Poor compliance is common for both approaches and is the main reason for inadequate blood-pressure control.10 If vaccination against high blood pressure were safe and effective in the long run, it might solve many problems of non-compliance. The present trial1 was, however, small and exploratory, and, as the authors point out, larger studies are needed to show the efficacy and safety of antibodies against angiotensin II in patients with hypertension. Nevertheless, the results of this new biotherapy for hypertension are intriguing and promising, and vaccination for hypertension may turn out to be very useful in many patients.
*Ola Samuelsson, Hans Herlitz Department of Nephrology, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden [email protected] We declare that we have no conflict of interest. 1
2
3 4
5
6 7 8 9
10
Tissot AC, Maurer P, Nussberger J, et al. Effect of immunisation with CYT006-AngQb against angiotensin II on ambulatory blood pressure: a double-blind randomised placebo-controlled phase IIa study. Lancet 2008; 371: 821–27. Brown MJ, Coltart J, Gunewardena K, Ritter JM, Auton TR, Glovers JF. Randomized double-blind placebo-controlled study of an angiotensin immunotherapeutic vaccine (PMD3117) in hypertensive subjects. Clin Sci 2004; 107: 167–73. Ménard J. A vaccine for hypertension. J Hypertens 2007; 25: 41–46. Hollenberg NK. Intrarenal and systemic actions of the renin-angiotensin system: implications for renal excretory function and sodium homeostasis. Contrib Nephrol 1984; 43: 102–13. Taylor JG, Zwillich CW, Kaehny WD, Levi M, Popovtzer MM. Hyperkalemia with watery diarrhoea: an unusual association. Am J Kidney Dis 2003; 42: E9–12. Senior K. Dosing in phase II trial of Alzheimer’s vaccine suspended. Lancet Neurol 2002; 1: 3. Schenk D. Amyloid-β immunotherapy for Alzheimer’s disease: the end of the beginning. Nat Rev Neurosci 2002; 3: 824–28. Spinney L. Update on Elan vaccine for Alzheimer’s disease. Lancet Neurol 2004; 3: 5. Johnston CI. Franz Volhard lecture. Renin-angiotensin system: a dual tissue and hormonal system for cardiovascular control. J Hypertens 1992; 10: S13–26. Borzecki AM, Oliveria SA, Berlowitz DR. Barriers to hypertension control. Am Heart J 2005; 149: 785–94.
Conditional cash transfer: a magic bullet for health? During the past decade, countries with transitional and middle-income economies have introduced programmes that transfer money to poor households on the condition that they comply with a set of requirements, including attendance for health care, food and nutritional supplementation, and enrolment of children in school. Conditional cash transfer (CCT), a type of social contract, is both an alternative to more traditional social assistance with handouts and a complementary strategy to the provision of health and education services.1 Because poor families usually face the greatest barriers to health interventions, CCT helps to redistribute resources and thus reduces health inequities.2 For very poor families, cash provides emergency assistance, while the conditions promote longer-term investments in human capital. Nancy Birdsall, president of the Center for Global Development, has said: “I think these programs are as close as you can come to a magic bullet in development…They are creating an incentive for families to invest in their own children’s futures. Every www.thelancet.com Vol 371 March 8, 2008
decade or so, we see something that can really make a difference, and this is one of those things.”3 CCT programmes started in the late 1990s in Mexico with Progresa (now Oportunidades), which serves more than 20 million Mexican families and has been replicated and piloted in more than 20 countries with transitional economies and some low-income developing countries.4 Even in the heart of the most developed economy in the world, Mayor Michael Bloomberg and leaders of several New York City foundations announced the creation of a major pilot CCT project, called Opportunity NYC, in 2007.4 Does this new health and human-development initiative work and, if so, how? Unlike most development initiatives, most CCT programmes are rigorously assessed for effectiveness.1 A recent systematic review of six CCT programmes in Latin America and Africa showed a fairly consistent picture of the effects of such programmes on the use of health-care and education programmes and, to some extent, growth and health outcomes for children early in life, despite some methodological concerns.2
See Articles page 828
789
Comment
Reuters
The printed journal includes an image merely for illustration
Cash distribution in Acacoyagua, Mexico under CCT programme
In today’s Lancet, an analysis of Mexican datasets by Lia Fernald and colleagues5 provides additional evidence on the effect of CCT on children’s growth, health, and development. The authors took advantage of the variation in total cumulative cash transfer received by families that enrolled in CCT, and assessed the effect of the cash transfer component on such outcomes by holding other components of the programme constant. A multivariate regression analysis suggests that a doubling of cumulative cash transfer to the household was associated with an increase in 0·16 standard deviations in height-for-age Z score, a 9% lower prevalence of stunting, slightly higher haemoglobin concentrations, and improvements in test scores for motor development (endurance), short-term and long-term memory, visual integration, and language development. This study5 has two important implications. First, no previous studies assessed the effect of CCT on cognitive, language, and motor development in children,6 which affect the ability to live a healthy life, to have freedom of choice, to engage in economic activities, and to escape the vicious cycle of poverty.7,8 Second, disentangling the relative importance of different components of the programmes is a challenge. For example, nutritional and health outcomes are probably influenced by health interventions, nutritional supplements provided 790
to children, and cash transfer itself.2,9 Fernald and colleagues’ study shows an independent effect of the cash transfer component. In families in the programme, more cash transfer was associated with better growth, health, and development in children. Those outcomes could have come from increased purchasing power or better care and support of children from the improved wellbeing of family members, or both. Due to its design, however, the study could not show how cash transfer worked. Fernald and colleagues’ study further supports CCT as a potentially effective approach to improve health and development outcomes in children.2 Several questions remain that will affect whether CCT becomes a magic bullet for health and human development in resource-poor settings. First, the effect size of each component of CCT programmes (eg, health interventions, food supplements, and cash transfer) needs to be studied with comparable and consistent health-outcome measures, including overall disability and mortality. Second, CCT is contingent on the presence of effective health interventions and education services, and systems to deliver them. Information systems are needed to identify poor communities and eligible families, follow up compliance, and regularly monitor payments and their use. In many low-income countries, these requirements are rarely met. Third, compared with scaling up the coverage of health interventions, the whole package of CCT can be large and expensive. The cash transfer component requires targeting and calibration rules to be efficient.10 Hence careful piloting of CCT and analysis of its cost-effectiveness in low-income countries is urgently needed. After these questions are answered, CCT might be an attractive option for scaling up effective health coverage (defined as the proportion of potential health gain that could be delivered by the health system to that which is actually delivered).11 CCT could be combined with ongoing efforts to enhance the provision of health services to poor people in many low-resource settings—through performance-based funding and health-systems strengthening—and simultaneously introduce behavioural changes and incentives. Above all, as shown for Mexico’s Oportunidades,5 strong leadership by government www.thelancet.com Vol 371 March 8, 2008
Comment
to improve children’s health and development and a commitment to accountability through monitoring and evaluation are key to the success of CCT programmes.
4
Kenji Shibuya
6
WHO, Geneva CH-1211, Switzerland [email protected]
7
I declare that I have no conflict of interest. 1 2
3
Rawlings LB, Rubio GM. Evaluating the impact of conditional cash transfer programs. World Bank Res Obs 2005; 20: 29–55. Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review. JAMA 2007; 298: 1900–10. Dugger CW. To help poor be pupils, not wage earners, Brazil pays parents. New York Times Jan 3, 2004. http://query.nytimes.com/gst/fullpage.html? res=9D02E7DA1731F930A35752C0A9629C8B63&sec=health (accessed Feb 19, 2008).
5
8 9
10
11
Rockefeller Foundation. Opportunity NYC: recognizing the day-to-day challenges faced by the poor. http://www.rockfound.org/efforts/ nycof/opportunity_nyc.shtml (accessed Jan 23, 2008). Fernald LCH, Gertler PJ, Neufeld LM. Role of cash in conditional cash transfer programmes for child health, growth, and development: an analysis of Mexico’s Oportunidades. Lancet 2008; 371: 828–37. Grantham-McGregor S, Cheung YB, Cueto S, and the International Child Development Steering Group. Developmental potential in the first 5 years for children in developing countries. Lancet 2007; 369: 60–70. Sen A. Commodities and capabilities. Oxford: Oxford University Press, 1985. Alkire S. Valuing freedoms: Sen’s capability approach and poverty reduction. Oxford: Oxford University Press, 2002. Gertler PJ. Do conditional cash transfers improve child health? Evidence from PROGRESA’s controlled randomized experiment. Am Econ Rev 2004; 94: 336–41. de Janvry A, Sadoulet E. Making conditional cash transfer programs more efficient: designing for maximum effect of the conditionality. World Bank Econ Rev 2006; 20: 1–29. Lozano R, Soliz P, Gakidou E, et al. Benchmarking of performance of Mexican states with effective coverage. Lancet 2006; 368: 1729–41.
Fast-track colorectal surgery Perioperative care has been improved with newer anaesthetic and analgesic techniques, development of minimally invasive surgery, and drugs to reduce surgical stress.1,2 Fast-track surgery or enhanced postoperative recovery programmes have been developed by combining these techniques with evidence-based adjustments to the use of nasogastric tubes, drains, and urinary catheters, preoperative bowel preparation, and early initiation of oral feeding and mobilisation. The aim of these programmes has been to provide pain-free and stress-free operations with lower rates of organ dysfunction, thereby reducing morbidity and enhancing recovery. If successful, the need for hospitalisation after surgery will be reduced. Standard elective colorectal resection is usually associated with a complication rate of 20–30% and a postoperative hospital stay of 8–12 days. Limiting factors for early recovery and discharge are pain, paralytic ileus, and other organ dysfunctions. The potential for a multimodal intervention with a fast-track clinical pathway to improve recovery after colonic resection was first reported in the mid-1990s, with a reduction of hospital stay to 2–3 days under standard discharge criteria.1 Efforts have since been made in several countries to develop and document the results of standardised and evidence-based programmes of perioperative care after colorectal procedures. A systematic review of controlled and randomised controlled studies supports the use of fast-track colorectal surgery.3,4 www.thelancet.com Vol 371 March 8, 2008
Effective analgesia that allows early mobilisation is a prerequisite for improved recovery;1 and in open colorectal surgery, thoracic epidural analgesia followed by multimodal non-opioid analgesia is the most effective evidence-based method.1 Epidural analgesia might not be necessary in laparoscopic colorectal surgery and can be replaced by opioid-sparing multimodal analgesia,1,2 including oral paracetamol, non-steroidal anti-inflammatory drugs, gabapentanoids, systemic local anaesthetics, or continuous infusion of the wound with local anaesthetic.2 Traditional care in colorectal surgery includes preoperative bowel preparation, but a systematic review of randomised trials showed this approach to be unnecessary and with the potential to increase morbidity, at least in segmental resections.5 However, more safety data are needed for very low mesorectal resections. Avoidance of preoperative bowel preparation might also hinder preoperative dehydration. There has recently been an increased focus on perioperative fluid management, and several large randomised trials in major abdominal surgery, including colorectal procedures, showed that fluid excess increases morbidity.1,6 Additionally, results from several trials, including four colorectal studies, show that perioperative optimisation of haemodynamic function—by the goal-directed approach with individualised optimisation of stroke volume by small colloid challenges—reduces morbidity and hospital 791