Latest news with #BolsaFamília
Mint
11-08-2025
- Politics
- Mint
Slums, swimming pools and Latin America's inequality
TO SEE REALITY in the Buenos Aires suburb of San Isidro, consider the drone's-eye view (pictured). A razor-straight line divides lush gardens and smooth clay tennis courts from a mess of corrugated iron roofs in one of the city's 'villas miserias". Santa Fe in Mexico City looks similar, the jewel-green of the golf club hemmed in by endless concrete boxes of the city's strugglers. Rio de Janeiro's favela of Rocinha sees makeshift dwellings spiral down the mountain, all but crashing into the turquoise swimming pools below. Such visceral inequality is the defining feature of Latin America's economies. The disparities in the region are rivalled only by those in sub-Saharan Africa. Yet because inequality is usually lower in richer places, and Latin America's GDP per person four times that in Africa, its inequality is extraordinary. Some countries such as Colombia and Guatemala are extremely unequal, others such as Uruguay less so. Yet there are no exceptions. The World Bank does not class a single country in the region as 'low-inequality". This shapes Latin America in countless ways beyond bird's-eye photography: physically, through the proliferation of high fences and security cameras; politically, in populism and leftward lurches; and economically, through low social mobility, large informal economies and weak internal demand. The Economist will publish several articles this year exploring this dynamic. To start, it helps to understand why Latin America made good progress to reduce inequality in the 2000s, and why that progress has slowed. The most common way to measure inequality is the Gini coefficient. This ranks a country's income inequality between zero and one. Zero means everyone in the country gets the same income; one means a single person receives everything. Other kinds of inequality matter, too, but none transcend income. Unequal access to good education and health care are both outcomes of income inequality as well as being important causes of it. The broad trend in Latin America is clear: inequality rose through the 1990s, peaked in about 2002 and then began to fall. Around 2014 the decline began to slow, and recently it has flatlined (see chart 1). There are exceptions—the Gini coefficient is still falling, though more slowly, in Peru and has been rising in Colombia—but the overall trend is plain. Two things drove the decline between 2000 and 2010. One was government handouts. Conditional cash-transfer programmes such as Bolsa Família in Brazil gave money to poor families if they sent their children to school and for health check-ups. Across the region, transfer programmes of all kinds accounted for about 20% of the fall in inequality on average. A second factor mattered much more: strong growth in wages for the poor. This accounted for over half of the fall. The backdrop to this was a long period of robust economic growth, helped along by a commodities boom. The lesson, says Ana María Ibáñez of the Inter-American Development Bank (IDB), is that 'If we want to reduce inequality, we need to grow." There is a series of smaller problems, too. One is the heavy influence of family background. A paper by Paolo Brunori of the University of Florence and co-authors finds that more than half of the current generation's inequality is in effect inherited, largely as a result of their parents' level of education and type of jobs. To see how this works, consider the cycle a family background can set off. As Ms Ibáñez and co-authors explain, toddlers of richer parents often get better food and more attention, so develop more skills. This helps them take advantage of the better (often private) schools they attend, which in turn push them on to university where attendance strongly boosts earnings in Latin America, in large part by helping students get formal jobs in big companies. Children born into poorer families tend to go to worse schools, often don't make it to university and end up working in Latin America's large, less productive informal sector. And so the cycle revolves. When inequality was falling, strong economic growth boosted poor Latin Americans' wages, helping break the cycle. Yet growth has stalled horribly. Real income per person in Latin America and the Caribbean increased by a dismal 4% in total between 2014 and 2023. In South Asia, by contrast, it increased by 46%. Governments have turned to other less effective remedies. A popular choice is to up the minimum wage. Mexico's last president, Andrés Manuel López Obrador, doubled it in real terms during his six years in office. Claudia Sheinbaum, his successor, has promised annual increases of 12%. This has helped reduce poverty and inequality in Mexico, in part because the minimum wage was very low when Mr López Obrador took office. But there are limits. If productivity does not also increase, a rising minimum wage tends to increase informal jobs, dragging people back into the inequality feedback loop. Governments also hope redistribution can deal with inequality. The immediate problem with this is that soft growth means thin government revenues, so less money to redistribute. Still, Latin American tax and welfare systems could do far better. When the region's income inequality is measured before taxes and redistribution, it is only slightly higher than in rich countries. But whereas taxes and transfers reduce the Gini coefficient by almost 40% in rich countries, in Latin America they only reduce it by about 5%. Shockingly, in about half the region this translates into an increase in poverty. The biggest problem is taxation. Across the OECD, a club of mainly rich countries, personal income taxes, which are usually progressive, are worth 8% of GDP. In Latin America they are worth just 2%. Instead, the region relies more on indirect taxes, such as VAT on goods and services (see chart 2). These are often regressive, as the rich and poor pay the same rate but the poor consume a larger portion of their income, so are hit harder. Many welfare programmes are also riddled with problems. An IDB study of transfer programmes in 17 countries found that targeting is wayward. Only about half of people living in poverty benefit, while about 40% of those not in poverty get at least one kind of transfer. The amounts being transferred are often too small. The circle is still vicious Fixing this could put a big dent in inequality. But even as anger about disparities dominates election campaigns and sometimes explodes in the streets, as it did during violent protests in Chile in 2019, there is little progress. Though cross about the status quo, voters are not keen to change tax and welfare systems either. A study by Matias Busso of the IDB and co-authors surveyed eight countries and found that, while respondents are unhappy about inequality and support redistribution in theory, they are reluctant to pay extra taxes to fund it. One reason is that many mistrust the state and ruling elites. All this adds up to a daunting challenge. Sustained growth, last seen over a decade ago, would provide the sharpest relief. Political reforms that build trust in government and allow for improvements to taxation and welfare would help. Both would be ideal. Neither seems likely. Sign up to El Boletín, our subscriber-only newsletter on Latin America, to understand the forces shaping a fascinating and complex region.
Hindustan Times
25-05-2025
- Business
- Hindustan Times
Reimagining DBT for education
Every year, as school terms begin across India, millions of mothers quietly become financiers of their children's futures. An alert from the bank confirms that the government has deposited a subsidy into their account—meant for books, uniforms, and tuition. In that moment, a welfare policy meets a parent's promise. The implementation of India's Direct Benefit Transfer (DBT) model in school education has taken a unique approach to welfare by shifting trust and choice to families - an act rooted in ensuring dignity. Yet this move towards efficiency and inclusion leaves a critical question unanswered: how do we ensure that this money meant for education is actually spent as intended? The scale of education-linked DBT programmes in India is significant. Several states allocated large amounts to such schemes including Uttar Pradesh ( ₹1,000 crore in 2024-25) and Gujarat ( ₹313 crore in 2025) among others. These programmes mirror international examples—Mexico's Prospera, Brazil's Bolsa Família, and Bangladesh's Female Secondary School Assistance Programme—where direct cash transfers have supported educational outcomes through both conditional and unconditional models. While these programmes seem powerful, their success relies not just on disbursal but also appropriate usage of funds and this is where the gap lies. In 1985, former Prime Minister Rajiv Gandhi had said that of every rupee spent by the government, only 15 paise reached the beneficiary. Now, DBT is streamlining subsidy delivery and improving transparency in the disbursal of funds in India saving ₹3.48 lakh crore up till March 2023. However, tracking and monitoring final spending still remains a blind spot. This is especially important when the total expenditure under such schemes across sectors now crosses crores annually ( ₹7.05 lakh crore in FY 24-25). Without expenditure visibility, we lose the opportunity to generate data-driven insights about the impact of government subsidies. This is especially true where support intended for school supplies or tuition may be redirected towards other pressing household needs. So, we are left asking: How do we translate financial transfers into educational outcomes? India has already begun solving similar challenges in other segments through tech-enabled systems. The e-RUPI digital voucher system, introduced by the National Payments Corporation of India (NPCI), offers such a blueprint. This is a pre-paid, purpose-specific digital instrument that does not require a bank account for the transfer of benefits and can only be redeemed for approved goods or services from designated service providers. A successful pilot in the fertiliser sector saw farmers receiving e-RUPI vouchers ( ₹100,000 for government schemes and ₹10,000 for private entities). This has facilitated real-time tracking of voucher redemption and reduced misuse by restricting the subsidy to its intended purpose. With a successful pilot in this sector, the question is: why can't we apply the same principle to educational subsidies? Now imagine mothers receiving vouchers as QR codes or SMS messages that could be redeemed for school supplies, tuition, transportation, nutrition supplements, or even health check-ups. A free hand to address the needs of their children will enable them to retain control and choice but within a framework that ensures the subsidy fulfills its purpose. This offers three major advantages: · Expenditure tracking: Governments can analyse how funds are used, enabling better planning. · Leakage prevention: Vouchers cannot be diverted for unrelated purchases. · Behavioural nudges: Tying funds to specific usage nudges families to invest in their child's education. While the concept of purpose-restricted DBT is promising, any shift in welfare architecture must be implemented with political and social sensitivity. Any abrupt overhaul of existing schemes risks triggering resistance or unintended fallout while a phased approach may offer a politically viable transition. For instance: ● Year 1: Introduce purpose-linked vouchers for 10–20% of the total DBT amount. ● Year 2: Expand this proportion to 30–40%, based on feedback from beneficiaries and system stability. ● Year 3 onward: Aim for a target composition of 80% vouchers and 20% cash, ensuring most of the support goes directly into education-related spending This phased approach accounts for the time mothers, vendors, and administrators may need to adjust while giving policymakers space to refine systems based on empirical evidence. India is uniquely placed to implement this reform. The administrations have already built core digital infrastructure—such as UPI, DigiLocker, and the JAM trinity (Jan Dhan accounts, Aadhaar, and mobile numbers)—that can be leveraged to roll out the e-vouchers at scale. With collaboration between National Payments Corporation of India (NPCI), state governments, and education departments, state-specific voucher ecosystems can be created without starting from scratch. Most importantly, e-RUPI (used to disburse fertilizer subsidies) does not require smartphones or internet access. It can work on basic phones using SMS, making it inclusive for rural and low-income households. However, a common concern with any technology-driven model is access. To address this, governments can earmark the first tranche of DBT funds to help eligible households acquire a basic mobile phone through direct provisioning or installment-based payments. This could ensure that no child is left behind due to lack of access to the very device that enables the benefit. A redesigned DBT framework that retains trust and empowerment while adding a layer of expenditure fidelity is both necessary and achievable as seen in the pilot programmes. For every ₹100 spent on DBT, we must ask: did this contribute to a child's book, bus pass, nutrition, tutoring, or health care? If we can't answer that question, we fail to connect public spending to public good. The era of DBT has rightfully shifted the conversation from welfare delivery to ensuring lives of dignity. The next leap must be from transfer to transformation. Because when that alert pings on a mother's phone, it should do more than confirm a deposit. It should signal a system that trusts her, supports her, and helps empower her child. This article is authored by Praveen Prakash, former principal secretary, School Education, Government of Andhra Pradesh.
CNN
11-03-2025
- Politics
- CNN
Guest essay: To be anti-trafficking requires support for education rights
In an era of often-deep political divide, human trafficking should be one issue where there is consensus. Indeed, the vast majority of us recognize that human trafficking and forced labor are human rights violations that must not be tolerated. Yet millions of children today are exploited in forced labor. Instead of attending school, they work in hazardous conditions in agriculture, manufacturing, mining, construction, fishing, and other sectors. While we need to be innovative in addressing such exploitation, a key pillar of any solution already exists in communities across the globe: education. Education is a foundational human right that has been recognized since the beginnings of the modern international human rights movement following World War II. It can enable children and their families to break out of the cycle of poverty. It can strengthen communities. Nelson Mandela once called education 'the most powerful weapon which you can use to change the world.' In addition to this transformative power, education helps reduce child labor. Research shows that the longer we can keep kids in school, the better the chance they have of avoiding exploitative labor settings. Although 88% of children globally complete primary school, only 59% complete upper secondary school. That leaves millions of children and adolescents at risk. However, we know a number of steps that will improve access to education and help support children to stay in school. First, ensuring that education is free, from pre-school through secondary school, is critical. Eliminating school fees helps improve attendance, often significantly. So-called hidden fees, such as additional costs for books, school uniforms, and transportation, must also be accounted for to ensure that children from the poorest families and communities can attend and complete school. Second, providing free breakfast and free lunch programs at schools has been shown to improve attendance in many countries. It also helps address food insecurity and boosts academic performance while children are at school, even in wealthier countries such as the United States. Third, investing in teachers and schools is key to providing quality education for all children. Teacher shortages and other challenges due to inadequate resources can make it harder for many children to access a quality education. Larger class sizes and other burdens on teachers and schools can lead to higher drop-out rates, leaving children at risk of exploitation. Conversely, investing in schools and teachers can improve the quality of education and reduce the risk of dropping out. Finally, implementing and sustaining programs that support low-income and poor families helps alleviate the pressure for children to work, so they can continue their schooling instead. For example, cash transfer programs, such as Brazil's Bolsa Família program, have helped improve school attendance and reduce dropout rates by providing financial support to low-income families allowing their children to continue their education. Other steps are needed, of course. A strong legal framework and active enforcement of child labor laws is necessary to identify abuses early, protect children from exploitation, and hold violators accountable. However, focusing on, and investing in, education is vital not only to protecting children now, but also to ensuring that they can develop to their full potential and be positioned as adults to obtain safe, secure employment opportunities that pay a living wage. In a world where AI and technological advances often dominate the headlines, it is tempting to want to find the newest innovation to address the exploitation of children. We absolutely should continue to look for new tools and pathways to prevent forced labor and exploitation of children. But we must also remember that sometimes an essential part of the solution is right in front of us. Education is that powerful asset that can help reduce the vulnerability of children to exploitation. We simply have to invest in it. Ensuring every child has the freedom to learn and grow to their full potential by securing access to free, quality education for all children is a formidable tool in the fight against forced labor and exploitation. In short, being an anti-trafficking ally means standing up for every child's right to education.
Yahoo
10-02-2025
- Health
- Yahoo
Cash as medicine: How Brazil slashed TB by tackling poverty
Crislaine Souza lives with her husband and one-year-old son in a rural community in Ourolândia, a municipality in Brazil's north-east that suffered centuries of neglect. She is unemployed and, though her husband works as an electrician and does what he can to support his wife and children, the family is among the poorest in the country. The family is on the brink – her husband and her one-year-old son are both deficient in iron, vitamin B12 and vitamin D – but it has a lifeline. Every month, she receives government cash to spend on essentials like nutritious food, health supplements and gas for cooking. Across Brazil, there are around 21 million other families in a similar situation, and they all receive monthly payments as part of the Bolsa Família scheme – one of the largest and longest-running conditional cash transfer programmes to be found anywhere. Ms Souza has been on the programme for four months and receives about $120 (£97) in monthly support. In return, she must ensure her children are vaccinated, attend school and meet nutrition guidelines. If she doesn't comply with these conditions, her payments could be stopped. Her family regularly travel on foot along unpaved roads to a primary health clinic in Ourolândia to attend health checks. 'My son started taking supplements for anaemia and deficiencies and is happy, smiling and lively, very intelligent and developing well. I am dividing the supplements between him and my oldest daughter, because she eats little variety, so she needs them too,' she said. Ms Souza worries about money, but says Bolsa Família has helped a lot. 'I feel more relieved knowing that I don't have to depend on my husband to buy everything. Just knowing that I'll have the money next month makes me feel more at ease, and I can be sure that I can resolve anything my children need.' The programme was launched in 2003 by Luiz Inacio Lula da Silva, the Leftist president better known as Lula, with the goal of reducing poverty. The politicians and experts behind the pioneering scheme never anticipated the remarkable effects it would have on the country's health. In just over two decades, it has been credited with reducing new AIDS cases by over 40 per cent, cutting maternal mortality by 18 per cent, deaths from leprosy by 14 per cent, and preventing more than eight million hospitalisations. But it has also been busy working its magic on the world's top infectious killer – tuberculosis. Researchers from the Barcelona Institute for Global Health (ISGlobal), the Institute of Collective Health, and CIDACS-FIOCRUZ in Bahia, Brazil, analysed TB outcomes among 54 million low-income Brazilians. What they found was a drop in TB cases and deaths by over 50 per cent among the extremely poor. Cases and deaths among indigenous beneficiaries – whose income can double or even triple under Bolsa Família – fell by over 60 per cent. Their findings, published recently in Nature Medicine, are a stark reminder that diseases of poverty cannot be addressed by scientific innovation alone. Dr Davide Rasella, coordinator of the study and a Social Epidemiologist who has published extensively on Bolsa Família, said: 'These numbers are close to biomedical treatments like a new drug or vaccine.' 'We knew that giving $100 a month to someone earning $1 or $2 a day transforms their life dramatically, but we didn't expect the effect to be this strong.' Yet the data doesn't tell us anything new about who is most at risk of falling ill or dying from TB, an ancient bacterium that attacks the lungs and has plagued humans for thousands of years. And this lack of revelation is precisely why policymakers should pay close attention. Last year the WHO cautioned that the world will not hit its targets to cut TB without urgent technological breakthroughs. But what use does a new vaccine serve to the labourer who cannot afford a taxi to the clinic? 'It's extremely important that from one side we invest in biomedical innovation, but we must be sure that the extremely poor live in the right conditions to take advantage of it,' Dr Rasella said. Bolsa Família's success provides a case study on why medical innovation alone cannot address the structural barriers keeping healthcare out of reach for so many. Is it possible for the rest of the world to replicate Brazil's approach? Today, almost every country in the world operates a cash transfer programme, and their use in humanitarian settings has doubled in recent years. In Britain, we call them benefits. Across the pond, it's welfare. Experts agree these schemes save lives and maximise the impact of medicine. 'Money is a necessary component for good health. Without money, you can't prevent disease or benefit from the great outcomes we know are possible with modern medicine,' said Dr Miriam Laker-Oketta, Research Director at GiveDirectly, a nonprofit that sends cash to the mobile phones of poor families. Dr Rasella agrees: 'We are showing that it is fundamental to eradicate poverty to reduce the burden of disease in the poorest populations.' Yet how cash transfers reach the people who need them matters, and so do the terms. Brazil's central bank last year revealed that millions of beneficiaries had sent three billion reais (around £400 million) to online gambling companies. The government later banned betting with benefits, adding another rule, or condition, beneficiaries must abide by. But what are conditions and why do they matter? Mandatory vaccinations, health checks and minimum attendance at school are conditions that form the contract between beneficiary and state. They are what study authors Dr Rasella and Priscila Gestal believe the success of Bolsa Família hinges on. Brazil's well-oiled administrative infrastructure makes conditions work. A central database, Cadastro Único, ensures cash goes to the neediest families, while local governments verify eligibility, monitor compliance, and deliver payments. Even under welfare critic Jair Bolsonaro, the programme persisted under a new name. But what would happen if Bolsa Familia cash came without strings? Ms Gestal said that without conditions, its impact would not be as strong. 'Conditions ensure people engage with public services for health and education. Child mortality reductions are linked to vaccinations, growth monitoring, and prenatal care. In the case of TB, mothers bringing children for check-ups may themselves get diagnosed and treated,' she said. But Dr Laker-Oketta argues enforcement costs could go directly to families, and Jessica Hagen-Zanker, a Senior Research Fellow at ODI Global, said enforcing conditions isn't possible everywhere. 'Conditions can be expensive to administer, adding to the cost of the programme, and are ineffective in areas with insufficient or low-quality supply of services,' said Dr Hagen-Zanker. For example, today more than 83 million people in Nigeria live in extreme poverty, and 45 per cent of all deaths in young children are linked to malnutrition. Last year, Nigeria's Minister of Humanitarian Affairs and Disaster Management, Betta Edu, was removed from cabinet after she siphoned £500,000 of conditional cash transfer grants meant for the most vulnerable into a personal bank account. What hope is there, then, for the millions of people living in countries where corruption or poor infrastructure make Bolsa Família's success impossible to replicate? It's simple – just give cash without conditions directly to people who need it. Nonprofit GiveDirectly gives cash without strings to the world's poorest families. Administrative overheads aren't a problem because payments are sent straight to mobile phones. Rory Stewart, former Secretary of State for International Development and Advisor to GiveDirectly, said these programmes directly improve key indicators like health, education, and nutrition, while outperforming traditional aid interventions in cost effectiveness and long-term impact. 'In low-income countries, most health facilities are in urban centres, and underutilisation by the rural poor often boils down to costly travel time to health facilities,' he told The Telegraph. But cash transfers can remove these barriers to access overnight. 'Cash makes it easier to get to health facilities and pay for medicines. After GiveDirectly sends cash, villages quickly fill up with bicycles and motor taxis. Families can now afford trips to the clinic and medicines they're prescribed.' It isn't only the logistics of accessing healthcare that direct cash can improve. When people have money, they adopt healthy behaviours even if they aren't told to. 'In our Rwanda childhood nutrition programme, families who received unconditional cash without any other information were more likely to take up vaccinations,' Dr Laker-Oketta says. 'And in this same programme, cash led to a 70 per cent drop in child mortality.' The key to this, Mr Stewart says, is quite simple – people know what is best for them. 'We spend tremendous time and money telling people what they should do to improve their health, ignoring that they are far too poor to act on this 'advice,' most of which they already know.' So is private actor cash the answer, or just part of it? It depends on who you ask. Economists argue that the only way to reduce global poverty and its associated diseases at scale, is by making poor countries more productive across the board. William Easterly, Professor of Economics at NYU, said the evidence suggests cash grants help individuals but do not transform whole countries from poverty to prosperity. 'If a country is poor, it is often because of institutions like corruption and public mismanagement,' he said. Lant Pritchett, a Development Economist and RISE Research Director at Oxford University's Blavatnik School of Government, agrees. 'My slogan is that the world is not full of poor people, it is full of people in poor places. National development is a machinery that nominates and solves people's problems, including health.' But while GiveDirectly may not have the power to fix corrupt governments, its programmes are certainly generating interesting economic data. 'Cash transfer programmes consistently deliver a high return on investment, with some studies showing a multiplier effect – every dollar invested generates up to $2.50 in economic benefit,' said Mr Stewart. In Brazil, Bolsa Família has slashed TB rates and prevented millions of deaths from infectious diseases by tying financial support to vaccinations, health check-ups, and school attendance. GiveDirectly's programmes show how direct, no-strings cash can improve health and economic outcomes in ways even the most ambitious aid programmes have failed to achieve, especially in places with poor administrative infrastructure. Dr Rasella, the study coordinator, said: 'You can't think about developing incredibly effective vaccines if the extremely poor can't access them because it's too far away, or their immune systems are too weak to respond to an antiretroviral because they're undernourished.' Cash transfers may not be a cure-all, but they are one of the most simple and effective prescriptions we have to address the structural barriers that keep healthcare out of reach for so many. In Ourolândia, the Bolsa Família payments that Ms Souza receives have allowed her to feel hopeful about the future. 'I want to go back to work, wait for my son to grow up and have a job, and maybe one day open a restaurant, that's one of my dreams.' Protect yourself and your family by learning more about Global Health Security Broaden your horizons with award-winning British journalism. Try The Telegraph free for 1 month with unlimited access to our award-winning website, exclusive app, money-saving offers and more.
Telegraph
10-02-2025
- Health
- Telegraph
Cash as medicine: How Brazil slashed TB by tackling poverty
Crislaine Souza lives with her husband and one-year-old son in a rural community in Ourolândia, a municipality in Brazil's north-east that suffered centuries of neglect. She is unemployed and, though her husband works as an electrician and does what he can to support his wife and children, the family is among the poorest in the country. The family is on the brink – her husband and her one-year-old son are both deficient in iron, vitamin B12 and vitamin D – but it has a lifeline. Every month, she receives government cash to spend on essentials like nutritious food, health supplements and gas for cooking. Across Brazil, there are around 21 million other families in a similar situation, and they all receive monthly payments as part of the Bolsa Família scheme – one of the largest and longest-running conditional cash transfer programmes to be found anywhere. Ms Souza has been on the programme for four months and receives about $120 (£97) in monthly support. In return, she must ensure her children are vaccinated, attend school and meet nutrition guidelines. If she doesn't comply with these conditions, her payments could be stopped. Her family regularly travel on foot along unpaved roads to a primary health clinic in Ourolândia to attend health checks. 'My son started taking supplements for anaemia and deficiencies and is happy, smiling and lively, very intelligent and developing well. I am dividing the supplements between him and my oldest daughter, because she eats little variety, so she needs them too,' she said. Ms Souza worries about money, but says Bolsa Família has helped a lot. 'I feel more relieved knowing that I don't have to depend on my husband to buy everything. Just knowing that I'll have the money next month makes me feel more at ease, and I can be sure that I can resolve anything my children need.' The programme was launched in 2003 by Luiz Inacio Lula da Silva, The politicians and experts behind the pioneering scheme never anticipated the remarkable effects it would have on the country's health. In just over two decades, it has been credited with reducing new AIDS cases by over 40 per cent, cutting maternal mortality by 18 per cent, deaths from leprosy by 14 per cent, and preventing more than eight million hospitalisations. But it has also been busy working its magic on the world's top infectious killer – tuberculosis. Researchers from the Barcelona Institute for Global Health (ISGlobal), the Institute of Collective Health, and CIDACS-FIOCRUZ in Bahia, Brazil, analysed TB outcomes among 54 million low-income Brazilians. What they found was a drop in TB cases and deaths by over 50 per cent among the extremely poor. Cases and deaths among indigenous beneficiaries – whose income can double or even triple under Bolsa Família – fell by over 60 per cent. Their findings, published recently in Nature Medicine, are a stark reminder that diseases of poverty cannot be addressed by scientific innovation alone. Strongest impact among the poorest Brazilians Dr Davide Rasella, coordinator of the study and a Social Epidemiologist who has published extensively on Bolsa Família, said: 'These numbers are close to biomedical treatments like a new drug or vaccine.' 'We knew that giving $100 a month to someone earning $1 or $2 a day transforms their life dramatically, but we didn't expect the effect to be this strong.' Yet the data doesn't tell us anything new about who is most at risk of falling ill or dying from TB, an ancient bacterium that attacks the lungs and has plagued humans for thousands of years. And this lack of revelation is precisely why policymakers should pay close attention. Last year the WHO cautioned that the world will not hit its targets to cut TB without urgent technological breakthroughs. But what use does a new vaccine serve to the labourer who cannot afford a taxi to the clinic? 'It's extremely important that from one side we invest in biomedical innovation, but we must be sure that the extremely poor live in the right conditions to take advantage of it,' Dr Rasella said. Bolsa Família's success provides a case study on why medical innovation alone cannot address the structural barriers keeping healthcare out of reach for so many. Is it possible for the rest of the world to replicate Brazil's approach? 'Money is a necessary component for good health' Today, almost every country in the world operates a cash transfer programme, and their use in humanitarian settings has doubled in recent years. In Britain, we call them benefits. Across the pond, it's welfare. Experts agree these schemes save lives and maximise the impact of medicine. 'Money is a necessary component for good health. Without money, you can't prevent disease or benefit from the great outcomes we know are possible with modern medicine,' said Dr Miriam Laker-Oketta, Research Director at GiveDirectly, a nonprofit that sends cash to the mobile phones of poor families. Dr Rasella agrees: 'We are showing that it is fundamental to eradicate poverty to reduce the burden of disease in the poorest populations.' Yet how cash transfers reach the people who need them matters, and so do the terms. Brazil's central bank last year revealed that millions of beneficiaries had sent three billion reais (around £400 million) to online gambling companies. The government later banned betting with benefits, adding another rule, or condition, beneficiaries must abide by. But what are conditions and why do they matter? How Brazil's cash-transfer system works Mandatory vaccinations, health checks and minimum attendance at school are conditions that form the contract between beneficiary and state. They are what study authors Dr Rasella and Priscila Gestal believe the success of Bolsa Família hinges on. Brazil's well-oiled administrative infrastructure makes conditions work. A central database, Cadastro Único, ensures cash goes to the neediest families, while local governments verify eligibility, monitor compliance, and deliver payments. Even under welfare critic Jair Bolsonaro, the programme persisted under a new name. But what would happen if Bolsa Familia cash came without strings? Ms Gestal said that without conditions, its impact would not be as strong. 'Conditions ensure people engage with public services for health and education. Child mortality reductions are linked to vaccinations, growth monitoring, and prenatal care. In the case of TB, mothers bringing children for check-ups may themselves get diagnosed and treated,' she said. But Dr Laker-Oketta argues enforcement costs could go directly to families, and Jessica Hagen-Zanker, a Senior Research Fellow at ODI Global, said enforcing conditions isn't possible everywhere. 'Conditions can be expensive to administer, adding to the cost of the programme, and are ineffective in areas with insufficient or low-quality supply of services,' said Dr Hagen-Zanker. For example, today more than 83 million people in Nigeria live in extreme poverty, and 45 per cent of all deaths in young children are linked to malnutrition. Last year, Nigeria's Minister of Humanitarian Affairs and Disaster Management, Betta Edu, was removed from cabinet after she siphoned £500,000 of conditional cash transfer grants meant for the most vulnerable into a personal bank account. What hope is there, then, for the millions of people living in countries where corruption or poor infrastructure make Bolsa Família's success impossible to replicate? It's simple – just give cash without conditions directly to people who need it. Nonprofit GiveDirectly Rory Stewart, former Secretary of State for International Development and Advisor to GiveDirectly, said these programmes directly improve key indicators like health, education, and nutrition, while outperforming traditional aid interventions in cost effectiveness and long-term impact. 'In low-income countries, most health facilities are in urban centres, and underutilisation by the rural poor often boils down to costly travel time to health facilities,' he told The Telegraph. But cash transfers can remove these barriers to access overnight. 'Cash makes it easier to get to health facilities and pay for medicines. After GiveDirectly sends cash, villages quickly fill up with bicycles and motor taxis. Families can now afford trips to the clinic and medicines they're prescribed.' It isn't only the logistics of accessing healthcare that direct cash can improve. When people have money, they adopt healthy behaviours even if they aren't told to. 'In our Rwanda childhood nutrition programme, families who received unconditional cash without any other information were more likely to take up vaccinations,' Dr Laker-Oketta says. 'And in this same programme, cash led to a 70 per cent drop in child mortality.' The key to this, Mr Stewart says, is quite simple – people know what is best for them. 'We spend tremendous time and money telling people what they should do to improve their health, ignoring that they are far too poor to act on this 'advice,' most of which they already know.' So is private actor cash the answer, or just part of it? It depends on who you ask. Economists argue that the only way to reduce global poverty and its associated diseases at scale, is by making poor countries more productive across the board. William Easterly, Professor of Economics at NYU, said the evidence suggests cash grants help individuals but do not transform whole countries from poverty to prosperity. 'If a country is poor, it is often because of institutions like corruption and public mismanagement,' he said. Lant Pritchett, a Development Economist and RISE Research Director at Oxford University's Blavatnik School of Government, agrees. 'My slogan is that the world is not full of poor people, it is full of people in poor places. National development is a machinery that nominates and solves people's problems, including health.' But while GiveDirectly may not have the power to fix corrupt governments, its programmes are certainly generating interesting economic data. 'Cash transfer programmes consistently deliver a high return on investment, with some studies showing a multiplier effect – every dollar invested generates up to $2.50 in economic benefit,' said Mr Stewart. How to tackle diseases of poverty In Brazil, Bolsa Família has slashed TB rates and prevented millions of deaths from infectious diseases by tying financial support to vaccinations, health check-ups, and school attendance. GiveDirectly's programmes show how direct, no-strings cash can improve health and economic outcomes in ways even the most ambitious aid programmes have failed to achieve, especially in places with poor administrative infrastructure. Dr Rasella, the study coordinator, said: 'You can't think about developing incredibly effective vaccines if the extremely poor can't access them because it's too far away, or their immune systems are too weak to respond to an antiretroviral because they're undernourished.' Cash transfers may not be a cure-all, but they are one of the most simple and effective prescriptions we have to address the structural barriers that keep healthcare out of reach for so many. In Ourolândia, the Bolsa Família payments that Ms Souza receives have allowed her to feel hopeful about the future. 'I want to go back to work, wait for my son to grow up and have a job, and maybe one day open a restaurant, that's one of my dreams.' Protect yourself and your family by learning more about
