The MRI evidence in favor of cash transfers

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Martha Vega

Martha Vega

Martha is a Paul Farmer Global Surgery Research Fellow at the Program in Global Surgery and Social Change and a graduate student at Harvard Medical School’s Master of Medical Sciences in Global Health Delivery Program. Her current research involves studying the surgical care system in the Andes and Amazon of Ecuador as well as understanding how Cinterandes Mobile Surgery can optimize rural surgical care delivery. She also collaborates with the Lancet Commission on Global Surgery Health Delivery and Management working group through GIS mapping of surgical facilities around the world and efforts in Latin America. In addition, she is collaborating with a research team along with Socios en Salud to address surgical care for MDR-TB patients in Peru.
Martha Vega

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On July 15th, 2016, Dr. Jim Yong Kim, President of the World Bank and co-founder of the non-governmental organization Partners in Health, presented striking evidence that childhood stunting is not simply an issue of decreased height, but of diminished mental capacity in children and its damaging consequences for the social capital of a nation. In Peru, the stunting rate for children under 5 had reached a startling 31% in the year 2000, meaning that 1 in every 3 children suffered from the effects of chronic malnutrition.[1] The political and social instabilities of the 1990s had primed the platform for such detrimental realities. The growth delay in children was only the tip of the iceberg as the “hidden face of poverty” began to be revealed through Magnetic Resonance Imaging (MRI). [2]

The consequences of malnutrition and stunting include increased morbidity and mortality from infections such as pneumonia, diarrhea, or in more severe cases, sepsis, meningitis, tuberculosis, hepatitis, and cellulitis. Yet the “hidden face” of stunting is revealed by MRI evidence of decreased brain mass. In a study by Hazin et al of children with severe protein energy malnutrition, out of the 20 children in the study between 2 to 24 months old, 85% of the children had cerebral atrophy, while 10% with severe stunting had myelination delay. [3] Similarly in his presentation, Dr. Jim Kim showed the MRI scans of stunted children in which they had a 40% reduction in brain mass, which affects cognitive function!


But Peru made an astonishing turnaround. From 2007 to 2015, they decreased the stunting rate by half, from 29% to 14%.[4] This has been one of the greatest accomplishments in global health in the recent years. Dr. Kim identified three key factors that made this intervention successful: Peru’s strong political commitment, a multi-sectorial approach for implementation, and budgeting for results. One of the core components of this implementation model was the use of conditional cash transfers.

Through the program Juntos, meaning together, an active effort was made to target household-level poverty and promote human capital in Peru.[5] Effective change stemmed from having a system in place which united the international community and the Peruvian government to empower parents to fight against stunting and malnutrition. The conditions that were established included obtaining pre- and post-natal care, child vaccinations, the provision of supplements such as folic acid, iron, and vitamin A. Children were required to receive health and nutrition controls, including height and weight monitoring. Additionally, older children were required to attend school at least 85% of the time.

Despite the great accomplishments in Peru,  45% of child mortality worldwide is due to malnutrition. [6] These cases cannot be ignored. As we move into the 2030 agenda of achieving the Sustainable Development Goals, we must consider Peru’s successful implementation model to eradicate not only malnutrition but also the landscape of many preventable diseases to promote resilient societies.

Investing money and strategically placing it in the hands of the right people, in this case the parents, proved to be a highly effective model to achieve tangible health improvements. It is not a bad idea to give money to parents to escape the cycle of poverty. As the data show, cash transfers are a good investment to regulate behavior for health improvement.

We should not be afraid to invest in human capital. As Rifat Atun mentions in reference to universal healthcare coverage in Latin America, bureaucracy and a rigid public sector have hindered effective health related management. [7] As we move towards universal health coverage, we need innovative financial models to escape bureaucratic barriers that slow the progress of global health.

The tactical use of cash transfers or incentives to empower civil society and modify human behavior in a moral and effective manner can help societies move towards achieving desired health outcomes. In order for global health delivery to be scalable, human behavior management is necessary. As Sema Sgaier described through her studies on behavioral economics, one of the main reasons why good health interventions fail is due to human behavior discrepancies such as the “intention to action gap.”[8] In retrospective analysis, the cash transfers in the Juntos program actually modified human behavior, incentivizing parents to seek healthcare services for their child, as well as health monitoring and education. One of the main results was the drastic decrease in stunting in a relatively short time.

The outcomes of good, strategic investment in human capital should outweigh the fear of placing money in the hands of the civil society that is on the frontline of fighting disease. Although there were other factors in place, the Juntos cash transfers of $30 dollars per month per household was an investment which produced significant results. In the long term, the returns in the form of human and social capital would outweigh the small financial investments made.


[1] Marini, Alessandra. The three factors to halving childhood stunting in Peru over just a decade. Investing in Health. World Bank Blog. April 12, 2016. (

[2] UNICEF. Progress how stunting in children can be defeated – UNICEF. Press Release. Dublin, April 15, 2013. (

[3] Hazin AN, Alves JG, Rodrugues Falbo A. The myelination process in severely malnourished children: MRI findings.  International Journal of Neuroscience. 2007 Aug;117(8):1209-14.

[4] Kim, Jim. Preferential option for the poor in Healthcare (Oral presentation). Partners in Health Headquarters, Boston, MA. July 15, 2016.

[5] Gahlaut, Abhimanyu. An Analysis of the Juntos Cash Transfer Programme in Peru, with Special Emphasis on Child Outcomes. Young Lives, August, 2011

[6] World Health Organization. Children reducing mortality. Media Centre. Jan. 2016.

[7] Atun, Rifat et al. Universal health coverage in latin America 1, Health-system reform and universal helaht coverage in Latin America. Lancet 2015;385:1230-47.

[8] Sgaier, Sema et al. Toward a Systematic Approach to Generating Demand for Voluntary Medical Male Circumcision: Insights and Results From Field Studies. Global Health: Science and Practice 2015:3(2):209-229