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

Abstract

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.

Keywords

Bolsa Família Program nutrition programs and policies conditional cash transfer intersectoral collaboration public policy

Introduction

Conditional cash transfer programs (CCTPs) have been adopted in countless developing countries over the last decades and aim to fight poverty and social inequalities through direct cash transfer and access to universal public policies, particularly health, education and work, on a conditional basis, to receive cash transfers (1).

Among the impacts of CCTPs around the world, the literature reports a reduction of income inequalities (2), improvement in the nutritional status and reduction of child labor (3), increase in use of health services (4), a significant reduction in chronic malnutrition (5), reduction in maternal mortality (6), and increase in education (7), among others.

In Brazil, the Bolsa Família Program (BFP), established in 2003, is the largest CCTP in the world and the one that requires most of the monetary resources destined to the Política Nacional de Segurança Alimentar e Nutricional (National Food and Nutritional Security Policy, PNSAN) (8).

In parallel to the monetary resource intended for families in situations of poverty and extreme poverty, the Program provides access to health and education services in the form of conditionalities, in addition to intersectoral actions to be agreed upon by the municipal administrations of these two sectors and the social assistance sector. Thus, the design of the BFP endeavors to interrupt the typical fragmentation of Brazilian assistance public policies (9).

Intersectoriality is understood as a process of combining knowledge and practice of subjects, groups and sectors for the development of shared interventions, establishing links, co-responsibility and co-management for common objectives (10 –12). Although intersectoriality is a theme for reflection in different fields of knowledge, its applicability is unclear (11,13).

Among the effects of the BFP is the increased use of primary healthcare services, especially those related to the fulfillment of health conditionalities (odds ratio (OR) = 3.1; 95% confidence intervals (CI) 1.9–5.1 (14)). Consequently, there has been a decrease in the post-neonatal infant mortality rate (when BFP coverage was 60%, predicted post-neonatal infant mortality was 1.38) (15) and in the children under five years old rate, whose death was related to poverty and malnutrition (relative risk (RR) 0.35; CI 95% 0.24–0.50) (16). Neves et al. (17) identified, in a literature review, that the BFP is a potent intersectoral policy for reducing inequities; however, the interruption of an intergenerational cycle of poverty was not observed. In turn, there are few records in the literature on intersectoral actions in the context of the CCTP and the BFP, more precisely, although it is recognized that more promising results can be obtained if the actions of the Program go beyond those predicted by the conditionalities (14).

The aim of this study was to analyze and compare whether or not there is a difference in being entitled to the BFP regarding access to health services, intersectoral actions and the identification of social control mechanisms between families entitled to the BFP and those not entitled to BFP, in a suburban region of a large urban center in Southeastern Brazil.

Method

This is a cross-sectional comparative study, conducted in 2017 with families entitled and not entitled to the BFP. It was carried out in a region with high levels of social vulnerability in an urban center in southeastern Brazil, which contains the largest portion of families entitled to the BFP in the municipality (18).

A sampling procedure was used to define and select the study population, that is, families entitled or not to the BFP, using a test power (β) of 95% and a significance level (α) of 5% (19). A representative sample of the population was obtained, consisting of 380 families, of which 190 families were entitled to the BFP and 190 families were not. The two groups of the study share sociodemographic characteristics and access to public services.

Interviews were conducted with the population using semi-structured questionnaires divided into the following stages: (a) identification of the interviewee; (b) socioeconomic profile; (c) access to services and participation in the actions of the region; (d) social control; and (e) intersectoral actions. The interviews were conducted by professionals trained in the use of such instruments. The interviewed population signed a free and informed consent form and the collected data were organized and validated by double typing in Excel spreadsheets.

A simple descriptive analysis of the data was performed. Chi-square test or Fisher’s exact test were used to compare regular and non-regular families in relation to socioeconomic variables, social control mechanisms and access to intersectoral actions in the region. The level of significance was set at 5% (p = 0.05).

To investigate the behavior of the variable group (families entitled or not to the BFP) with those whose statistical significance was verified, multiple correspondence analysis (MCA) was performed, which is a multivariate technique for exploratory analysis of categorized data. The data were analyzed using the R software, with the FactoMineR package (20).

The study was approved by the Research Ethics Committee of Federal University of São Paulo (process no. 2.351.259).

Results

Data from 380 families from the suburb of a large urban center in southeastern Brazil were analyzed, of which 190 families were entitled to the BFP and 190 were not; all respondents were women, with a mean age of 33 and 31 years, respectively. The average income of BFP family members was R$592.12 and the average income transfer was R$186.89. Families not entitled to the BFP had an average income of R$1977.37 (p = 0.001).

Most of the families not entitled to the BFP were married or were in a stable relationship (p = 0.002). The number of children was higher among families entitled to the BFP (p = 0.001). Most families not entitled lived in brick houses (p = 0.001) (Table 1). They had more access to public infrastructure services, with statistical significance for the following variables: water supply by urban network (p = 0.001), public lighting (p = 0.001), garbage collection (p = 0.049) and bathroom at home (p = 0.024).

Table 1.

Sociodemographic characteristics of family members entitled or not to the Bolsa Família Program (BFP) (n = 380) from a suburban area in a large urban center in Southeastern Brazil, 2017.

Characteristics	Entitled to BFP				p-value^a
	Yes		No
	n	%	n	%
Marital status
Married/stable relationship/lives together	80	42.1	114	60	0.002
Single	75	39.5	55	28.9
Separated/divorced/widowed	35	18.4	21	11.1
Number of children
One	35	18.6	87	49.7	0.001
Two	42	22.3	40	22.9
Three	64	34	25	14.3
Four	27	14.4	12	6.9
Five or more	20	10.6	11	6.3
Habitation
Finished masonry house	82	43.2	133	70	0.001
Unfinished masonry house	54	28.4	37	19.5
Wooden house	28	14.7	7	3.7
Rudimentary house	26	13.7	13	6.8
General water supply network
Yes	120	63.2	158	83.2	0.001
No	70	36.8	32	16.8	0.001
Public lighting
Yes	122	64.2	165	86.8	0.001
No	68	35.8	25	13.2	0.001
Sewage system
Yes	144	75.8	158	83.2	0.099
No	46	24.2	32	16.8	0.099
Garbage collection system
Yes	158	83.2	172	90.5	0.049
No	32	16.8	18	9.5	0.049
Home bathroom
Yes	179	94.2	188	98.9	0.024
No	11	5.8	2	1.1	0.024
Schooling
Incomplete elementary school	71	37.4	33	17.4	0.001
Elementary school	21	11.1	20	10.5
Incomplete high school	38	20.0	39	20.5
High school	56	29.5	79	41.6
Incomplete higher education	1	0.5	5	2.6
University education	3	1.6	14	7.4
Employment
Yes	90	47.4	105	55.3	0.151
No	100	52.6	85	44.7	0.151
Work relationships
Employee without a formal contract	7	7.7	9	8.6	0.001
Wage labor	8	8.8	62	59.0
Self-employed without establishment	70	76.9	26	24.8
Self-employed with establishment	3	3.3	6	5.7

Chi-square or Fisher’s exact test.

Access to secondary education was also greater among families not entitled to the BFP (p = 0.001). Regarding the work relationships of families entitled to the BFP, self-employment without formal employment was more common; among families not entitled, wage labor with formal contract was frequent (p = 0.001).

Routine consultations were more frequently accessed by families not entitled to the BFP (p = 0.001). In turn, healthcare provided by a doctor, nutritionist and community healthcare agent (CHA) prevailed among families entitled to the BFP. Similarly, children’s immunization and home visits were more frequent, as shown in Table 2.

Table 2.

Access to health services by family members entitled or not to the Bolsa Família Program (BFP) (n = 380) from a suburban area in a large urban center in Southeastern Brazil, 2017.

Characteristics	Entitled to BFP				p-value^a
	Yes		No
	n	%	n	%
Routine or scheduled appointments	100	52.6	117	61.6	0.001
Doctor care	182	95.8	167	87.9	0.009
Nurse care	141	74.2	124	65.3	0.074
Nutritionist care	23	12.1	10	5.3	0.018
Community healthcare agent	171	90.0	147	77.4	0.001
Dental care	68	35.8	63	33.2	0.666
Assistant nurse care	101	53.2	96	50.5	0.681
Immunization of children	161	84.7	143	75.3	0.029
Home visit	122	64.2	102	53.7	0.048
Participation in group activities	27	14.2	18	9.5	0.204

Chi-square or Fisher’s exact test.

Table 3 shows the social control mechanisms identified by the families. The knowledge of the existence of councils for social participation is rarely mentioned in both groups. Even so, among families not entitled to the BFP, the knowledge about the performance of these public policy instruments is more frequently mentioned (p = 0.026).

Table 3.

Social control mechanisms offered to family members entitled or not to the Bolsa Família Program (BFP) (n = 380) from a suburban area in a large urban center in Southeastern Brazil, 2017.

Characteristics	Entitled to BFP				p-value^a
	Yes		No
	n	%	n	%
Participation in social control council	10	5.3	6	3.2	0.444
Municipal health council	65	34.2	76	40.0	0.288
School feeding council	40	21.1	39	20.5	0.999
Municipal council for food and nutritional security	22	11.6	25	13.2	0.755
Municipal council for education	78	41.1	90	47.4	0.256
Municipal council for social assistance	90	47.4	96	50.5	0.608
Knowledge about the performance of the councils	48	25.3	69	36.3	0.026

Chi-square or Fisher’s exact test.

The participation in intersectoral actions by families is shown in Table 4. Access to cultural activities was the only variable that showed a statistically significant difference, when comparing families entitled or not to the BFP (p = 0.001).

Table 4.

Access to intersectoral actions or services of family members entitled or not to the Bolsa Família Program (BFP) (n = 380) from a suburban area in a large urban center in Southeastern Brazil, 2017.

Characteristics	Entitled to BFP				p-value^*
	Yes		No
	N	%	n	%
Child participation in activities in the territory	58	30.5	41	21.6	0.061
Training, qualification, languages or professional activity	8	4.2	11	5.8	0.266
Sport activities	44	23.2	29	15.3	0.077
Cultural activities	31	16.3	8	4.2	0.001
Activities for parents or guardians of children	16	8.4	16	8.4	0.999

Chi-square or Fisher’s exact test.

According to the multiple correspondence analysis, two patterns were observed that may explain 31.2% of the variability in the access between the groups. According to the first standard, families entitled to the BFP had access to cultural activities, received healthcare from doctors, nutritionists and CHA, used the healthcare service for vaccinations, routine and emergency consultations and received home visits, even if they did not know the role of social participation councils. On the other hand, the second pattern revealed that families not entitled to the BFP did not receive healthcare from nutritionists, did not have access to cultural activities, did not use the healthcare service for vaccination and did not receive home visits (Figure 1).

Figure 1.

Correspondence map of variables of access to health services, identified social control mechanisms and access to intersectoral actions, by families entitled or not to the Bolsa Família Program from a suburban area in a large urban center in Southeast Brazil, 2017.

Discussion

In this study, access to healthcare services, intersectoral actions and social control mechanisms by families entitled or not to the BFP, who lived in a suburban area in a large urban center in Southeastern Brazil, were comparatively analyzed.

Compared to women who were not entitled to the Program, those entitled had worse living conditions in general, which include habitation, basic sanitation, schooling, working conditions and three times less income. In addition, they had a greater number of children and less marital bond. Such data indicate an adequate focalization of BFP on the population entitled to the Program considering that, although the two groups are from the same suburban area, the population entitled to the BFP are more vulnerable, which demands the development of actions and services as well as income transfer.

Unlike the findings in this study, Schmidt et al. (21) and Silva et al. (22) identified low percentages of focus of the BFP, 32.4 and 33.8%, respectively. Conditional cash transfer programs developed in Ecuador and Mexico also have a low percentage of focus (23). The focus is an indicator that allows for an assessment of whether the conditional cash transfer program is properly aimed at its target audience.

According to the findings of this study, there was greater access by families entitled to the BFP to medical and routine consultations, nutritionists and healthcare workers, vaccination, emergency care, home visits and cultural activities. Whether or not one is entitled to the Program seemed to affect 31% of the variability in the pattern of access to some of these services, which reinforces the results of the association tests.

The service with different health professionals and home visits, which is greater for the families entitled to the BFP, can be explained by the commitment to fulfill health conditionalities required by the design of the BFP. In a study on differences in the profile of access to health services between families entitled or not to the BFP, using data from the 2013 National Health Survey, families entitled had a greater likelihood of receiving medical professional advice (24). However, activities within groups and access to professional nutritionists are less expressive, which can restrict integrality in health, since these are important tools for health promotion (25).

In spite of the debate around the conditionalities in income transfer programs (26), we found that this mechanism is reaffirmed by the potential to facilitate access to health services, enabled by access to medical consultations and home visits.

The social control is unknown to the population of this study, particularly those entitled to the BFP. This is a weakness in the operationalization of the Program and other Brazilian social public policies, since social control is a relevant mechanism to support broader changes for the development of food and nutrition security policies in Brazil, ensured by the Federal Constitution (27,28).

The weakness identified became more evident after the recent demise of the Conselho Nacional de Segurança Alimentar e Nutricional (National Council for Food and Nutrition Security - CONSEA), an agency that was part of the Sistema Nacional de Segurança Alimentar e Nutricional (National System for Food and Nutrition Security - SISAN), and directly assisted the Presidency of the Republic in proposing interventions to address food insecurity and nutrition in Brazil (8,29). The decentralization for Brazilian states and municipalities of the model of intersectoral governance with social participation, after the re-establishment of CONSEA (30), is one of the great challenges of the Brazilian food and nutrition policies (28,30).

Although there are few reports available in the literature on social control in CCTPs, Ndlovu and Ndlovu (31) reported the experience in a region of great social vulnerability in sub-Saharan Africa, in which social participation in the design, implementation and evaluation of the program boosted the development of the local economy.

The low access to intersectoral actions in both groups participating in this study, reinforces the historical neglect suffered by vulnerable populations in Latin America (32). In this specific case, belonging or not to an income transfer policy of an intersectoral nature, which offers services and actions in addition to income transfer, did not result in greater access of the population entitled to the Program. Although intersectoral actions are considered strategic to improve equity in health systems, they continue to be major challenges in different countries, as they demand deeper changes in the organization and in intra and intersectoral management (33 –36).

Although this research is representative of the population from a poor region in a large urban center in Southeastern Brazil, it is not a population-based study, which may limit more robust inferences. Otherwise, it contributes to the advancement of knowledge, as it is unprecedented comparative research on the access to intersectoral actions between families entitled or not to the BFP. Additionally, the results presented here open possibilities for new investigations, such as the timely aggregation of qualitative analysis regarding those involved with the BFP. The expectation is that these findings contribute to the proposition of public policies by local managers, in order to improve intersectoral actions provided in the design of the Program.

Conclusion

Adequate focus of the BFP was observed, but its actions were limited to income transfer and those established by the conditionalities, such as greater access to health services by the families entitled. Access to intersectoral actions did not differ between families entitled or not, which could compromise the potential to interrupt the cycle of intergenerational transmission of poverty intended by the BFP, highlighting a legacy of the historical assistantialism which characterizes Brazilian social public policies. It is necessary to strengthen and combine complementary policies to expand the effects of BFP.

Footnotes

Authors’ contributions

JAN contributed to the study design, data collection, analysis, discussion of results and writing of the manuscript. LTOZ contributed to the analysis, discussion of results and review. MAT de M contributed to the study design, analysis, discussion and critical review of the manuscript for intellectual content. All authors approve the version submitted to Global Health Promotion.

Authors’ note

The present article is part of the doctoral thesis of José Anael Neves, entitled ‘Intersectoriality in the Bolsa Família Program – a study in Morros de Santos’. Federal University of São Paulo: 2020.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was granted funding from the National Council for Scientific and Technological Development (CNPq). Universal process MCTI/CNPq No 14/2014. Process No. 459027 / 2014-0.

ORCID iD

Maria Angélica Tavares de Medeiros

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