Cash transfers and improved child nutrition: Where did all the impacts go?

During a recent trip to Ghana, we presented the baseline findings from an impact evaluation of the “LEAP 1000” cash transfer programme to UNICEF colleagues, government and development partners. LEAP 1000, an extension of Ghana’s Livelihood Empowerment Against Poverty programme, targets households with young children. It is designed to improve the nutritional status of children in the first 1000 days of life. Implementers are up for a tough challenge, as most of the evidence to date does not show consistent positive impacts of cash transfers on child nutrition. Why is this the case?

Cash transfers have become an increasingly popular development intervention. An estimated 89 programmes are currently operating in Africa alone, most of them launched in the last 5 years. Cash has become a popular policy tool because rigorous studies have shown that they can have consistent impacts on the well-being of beneficiaries.

For example, findings from the Transfer Project in sub-Saharan Africa (SSA) demonstrate a broad range of impacts on household consumption, food security, human capital and productive activity.

But what about impacts on child nutrition? During the latest Transfer Project workshop in Addis Ababa, participants debated the question of why relatively few impacts on child nutrition emerge from evaluations across the African continent while in Latin America cash programmes have shown strong effects on nutrition. But is this actually the case?

In reality, the impacts of the Latin American programmes on nutrition are not as widespread as one might think. A meta-analysis by Manley, Gitter and Slavchevska identified 79 impact estimates from 8 countries on the height-for-age z-score of children, an indicator of chronic malnutrition. It turns out that only 12 of these estimates were statistically significant, and these impacts came from Mexico (5), Colombia (5), Ecuador (1) and Nicaragua (1). The vast majority of programmes did not significantly improve child nutrition. These  conclusions are consistent with other evidence reviews conducted in recent years.

But what explains such limited impacts on nutrition? In a recent paper, we use a conceptual model which shows the pathways that lead to better nutrition and we present evidence on how cash transfers could impact on these pathways. In this framework, household income is an underlying determinant of nutrition, and can only have an effect through one of the three pathways at the household level: 1) improved food security, 2) improved care for mothers and children, or 3) improved health environment.

These three pathways lead to improvements in dietary intake and health of the child, which together determine the nutritional status. So, for a cash payment to have an impact on nutrition, there need to be changes at the household level, which should lead to improved nutritional status. One can see that this process can be quite complex and a lot of the impact can be ‘lost along the way’.
Cash and Nutrition Blog Conceptual Framework
Of course, there have been some cash transfer programmes showing positive effects on nutrition. What can we learn from them? The impacts observed in Mexico and Colombia are often attributed to the size of the cash grant, which is relatively large, about 25–30 er cent of the household’s pre-programme expenditures.

Also in the Philippines, where the Pantawid Pamilya programme reduced severe stunting by 10 per cent, the grant constituted about 23 per cent of beneficiaries’ income. However, a later report, using a different methodology and looking at a longer time horizon did not find any impacts.

Nevertheless, it makes sense that more cash in the hands of households may have a stronger effect on the pathways laid out in the framework, as well as potential to affect multiple pathways at the same time. Furthermore, supply-side interventions like health infrastructure and providing market access to diverse types of food help recipients to make the most of their cash. For example, the Child Grant in Zambia had an impact on stunting, but only for households with a protected source of water in the home.

For the research community, it is important to pay attention to the mechanisms through which cash transfers affect pathways to better nutrition, instead of looking at the direct impacts. By understanding the way programmes can affect the underlying determinants of nutrition, we can disentangle the relationship between getting cash on the one hand, and improving nutrition of children on the other.

Moreover, the lack of consistent impacts on nutrition has motivated programme designers to implement nutritional interventions on top of their programmes, such as nutrition information sessions, communication efforts or health insurance. This is a smart move, as cash transfers can offer an effective entry point to deliver complementary health and nutrition services.

Fortunately, Ghana LEAP 1000 is among the programmes using this cash plus approach, with linkages to the national health insurance scheme, providing free health insurance to all beneficiaries. We are excited to follow this and other programmes to evaluate their impact, along with the added effect of the “plus” components in addressing malnutrition.

Richard de Groot holds a Master’s degree in International Economics Studies and is currently a PhD fellow at the Maastricht Graduate School of Governance. He has experience implementing evaluations and quantitative research in collaboration with Plan International, the World Bank and UNICEF.

The Office of Research – Innocenti is UNICEF’s dedicated research centre undertaking research on emerging and current priorities to shape policy and practice for children. Subscribe to UNICEF Innocenti emails here. Follow UNICEF Innocenti on Twitter here.