'There is no point giving cash to women who don't spend it the way they are told to spend it' – Exploring women's agency over cash in a combined participatory women's groups and cash transfer programme to improve low birthweight in rural Nepal

Lu Gram,Jolene Skordis-Worrall,Naomi Saville,Dharma S Manandhar,Neha Sharma,Joanna Morrison

doi:10.1016/j.socscimed.2018.12.005

Lu Gram, Jolene Skordis-Worrall + Show 4 more

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https://doi.org/10.1016/j.socscimed.2018.12.005

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Abstract

Cash transfer programmes form an integral part of nutrition, health, and social protection policies worldwide, but the mechanisms through which they achieve their health and nutritional impacts are incompletely understood. We present results from a process evaluation of a combined participatory women's groups and cash transfer programme to improve low birth weight in rural Nepal. We explored the ways in which context, implementation, and mechanism of the intervention affected beneficiary women's agency over cash transfers. Informed by a grounded theory framework, we conducted and analysed semi-structured interviews with 22 beneficiary women, 15 of their mothers-in-law, 3 of their elder sisters-in-law and 20 husbands, as well as a focus group discussion with 7 supervisors of the women's group intervention. Our study reveals how women's group facilitators, their supervisors and community members developed a shared dynamic around persuading and compelling recipients of unconditional cash transfers into spending them according to criteria developed by the group. We found these dynamics effectively constituted ‘soft conditions’ on beneficiary spending which restricted women's ability to make decisions over their cash transfers, but also increased their likelihood of spending them on their own pregnancy. Our findings demonstrate the importance of understanding how programmes are implemented and responded to in order to understand their implications for beneficiary agency and empowerment.

Highlights

Cash transfer programmes have become a ubiquitous feature of nutrition, health, and social protection policy worldwide (Honorati et al, 2016)
Our present study describes and analyses the process through which a complementary participatory women's group intervention may have affected beneficiary agency over cash transfers in a combined women's group and cash transfer intervention to improve birth weight in rural Nepal (Saville et al, 2018)
We present our results using the UK Medical Research Council's process evaluation framework (Moore et al, 2015): context refers to the social, economic and cultural factors shaping the implementation and mechanism of an intervention; implementation refers to intervention delivery such as the training and performance of staff or the reach and coverage of an intervention; mechanism refers to participant responses and interactions with an intervention and causal mediators of intervention impact; output refers to beneficiary agency over cash transfers

Summary

Introduction

Cash transfer programmes have become a ubiquitous feature of nutrition, health, and social protection policy worldwide (Honorati et al, 2016). Beneficiary spending of cash transfers does not happen in a vacuum, but is influenced by individual beliefs, attitudes and relationships to other household members (Zembe-Mkabile et al, 2018; Scott et al, 2017; Tonguet-Papucci et al, 2017; Junior et al, 2016). These influences are frequently the target of complementary behaviour change components

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