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Which strings attached: ethical considerations for selecting appropriate conditionalities in conditional cash transfer programmes
  1. Carleigh B Krubiner1,
  2. Maria W Merritt1,2
  1. 1Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA
  2. 2Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
  1. Correspondence to Dr Carleigh B Krubiner, Johns Hopkins Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21205, USA; ckrubiner{at}


Conditional cash transfers (CCTs) present a promising approach to simultaneously tackle chronic poverty and poor health. While these programmes clearly embody beneficent aims, questions remain regarding the ethical design of CCTs. Limited guidance exists for the ethical evaluation of the defining feature of these programmes: the conditionalities. Drawing upon prominent public health ethics frameworks and social justice theories, this paper outlines five categories of morally relevant considerations that CCT programme designers should consider when assessing which behaviours or outcomes they select as conditionalities for payment: (1) likelihood of yielding desired health outcomes, (2) risks and burdens, (3) receptivity, (4) attainability and (5) indirect impacts and externalities. When evaluating potential conditionalities across these five categories of considerations, it is important to recognise that not all beneficiaries or subgroups of beneficiaries will fare equally on each. Given that most CCTs aim to reduce inequities and promote long-term health and prosperity for the most disadvantaged, it is critical to apply these considerations with due attention to how different segments of the beneficiary population will be differentially affected. Taken on balance, with due reflection on distributional effects, these five categories represent a comprehensive set of considerations for the moral analysis of specific conditionalities and will help ensure that CCT designers structure programmes in a way that is both morally sound and effective in achieving their goals.

  • Autonomy
  • Behaviour Modification
  • Distributive Justice
  • Philosophical Ethics
  • Public Health Ethics

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  • Contributors CBK conducted the research and drafted the manuscript as part of her doctoral thesis research. MWM oversaw this research, engaged in critical refinement of the framework and the approach for its development, and helped to edit the manuscript for publication.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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