Health effects of the Brazilian Conditional Cash Transfer programme over 20 years and projections to 2030: a retrospective analysis and modelling study

Background: In 2024, Brazil celebrated the 20th anniversary of the Bolsa Família Program (BFP), one of the world's oldest and largest conditional cash transfer (CCT) programmes, covering more than 50 million Brazilians. This study aimed to evaluate the effect of the BFP on overall mortality and hospitalisation rates over the past two decades, and to forecast the potential effects of expanding this programme until 2030. Methods: This study combined retrospective impact evaluations in Brazil from 2000–19 with microsimulation models up to 2030. First, the effect of the BFP on overall mortality and hospitalisation rates was estimated across different age groups, adjusting for all relevant demographic, socioeconomic, and health-care factors. Fixed-effect multivariable Poisson models were then applied to 3671 municipalities with adequate quality vital statistics data. The three exposure variables of BFP were target coverage, benefits adequacy (average transfer per family), and the interaction of coverage and adequacy. Several sensitivity and triangulation analyses were conducted, including difference-in-difference models with propensity-score matching. Previous longitudinal datasets were then integrated with validated dynamic microsimulation models to project trends up to 2030. Findings: High coverage of BFP was associated with a significant reduction in overall age-standardised mortality rates (rate ratio [RR] 0·824 [95% CI 0·807–0·842]). High adequacy of BFP was associated with a reduction in overall age-standardised mortality (0·849 [0·833–0·866]). Our models estimated that the BFP prevented 8 225 390 (95% CI 8 192 730–8 257 014) hospitalisations and 713 083 (702 949–723 310) deaths in 2000–19. Stronger effects were found in BFP high coverage and high adequacy scenario, resulting in large reductions in under-5 mortality (RR 0·67 [95% CI 0·65–0·69]) and hospitalisation of individuals older than 70 years (0·52 [0·50–0·53]). Expanding BFP coverage could avert an additional 8 046 079 (95% CI 8 023 306–8 068 416) hospitalisations and 683 721 (676 494–690 843) deaths by 2030, compared with scenarios of reduced coverage. Interpretation: CCT programmes have strongly contributed to the reduction of morbidity and mortality in Brazil, having prevented millions of hospitalisations and deaths in the past two decades. During the current period of polycrisis, the expansion of CCTs in terms of coverage and benefits could prevent a large number of hospitalisations and deaths worldwide, and should be considered a crucial strategy for achieving the UN health-related Sustainable Development Goal 3. Funding: UK Foreign, Commonwealth and Development Office, UK Medical Research Council, and the Wellcome Trust (grant number MC_PC_MR/T023678/1). Translation: For the Portuguese translation of the summary see Supplementary Materials section.