Cash-based Interventions Research Articles

Incorporating cash-based interventions into food assistance programs in humanitarian settings.

Incorporating cash-based interventions into food assistance programs in humanitarian settings.

Effectiveness of Community Nutrition-Specific Interventions on Improving Malnutrition of Children under 5 Years of Age in the Eastern Mediterranean Region: A Systematic Review and Meta-Analysis.

Childhood malnutrition remains an important public health and development problem in low- and middle-income countries. This study aimed to systematically review the community-based nutrition-specific interventions and their effectiveness and/or cost-effectiveness on the nutritional status of children under 5 years of age in the Eastern Mediterranean Region (EMR). A systematic literature search of the English electronic databases, including PubMed, Scopus, ISI Web of Knowledge, Ovid, EMBASE, as well as Persian databases (SID and Magiran) was performed up to May 2019. Studies regarding the effectiveness/cost-effectiveness of the community-based nutrition-specific programs and interventions targeted at under-five-year children in EMR countries were selected. The primary outcomes were mean of Weight-for-age z-score (WAZ), Height-for-Age z-score (HAZ), and Weight-for-Height z-score (WHZ) of children or prevalence of wasting, stunting, and/or underweight among the children. Meta-analysis was also performed on the selected articles and intervention effects (mean differences) were calculated for each outcome for each study and pooled using a weighted random effects model. Risk of bias (ROB) of each included study was assessed based on the Cochrane Handbook for Systematic Reviews. The study protocol was registered in PROSPERO (CRD42020172643). Of 1036 identified studies, eight met the inclusion criteria. Amongst these, seven were from Pakistan and one from Iran. Only one study conducted in Pakistan reported the cost-effectiveness of nutrition-specific interventions in the region. Nutrition education/consultation and cash-based interventions were the most common nutrition-specific strategies used for management of child malnutrition in the EMR countries. Out of these eight studies, four were included in the meta-analysis. When different interventions were pooled, they had resulted in a significant improvement in WHZ of children (MD: 0.26; 95% CI: 0.07 to 0.46, three studies, I2 82.40%). Considering the high prevalence of child malnutrition in a number of countries in the region, capacity building and investigation regarding the implementation of new approaches to improve nutritional status of children and their effect(s) and cost-effectiveness assessment are highly recommended.

Logistics planning of cash transfer to Syrian refugees in Turkey

This paper addresses a humanitarian logistics problem connected with the Syrian refugee crisis. The ongoing conflict in Syria has caused displacement of millions of people. Cash-based interventions play an important role in aiding people in the post-crisis period to enhance their well-being in the medium and longer term. The paper presents a study on how to design a network of administrative facilities to support the roll-out of cash-based interventions. The resulting multi-level network consists of a central registration facility, local temporary facilities, mobile facilities and vehicles for door-to-door visits. The goal is to reach the maximum number of eligible beneficiaries within a specified time period while minimizing logistics costs, subject to a limit on total security risk exposure. A mixed integer programming model is formulated to optimize the inter-related facility location and routing decisions under multiple objectives. The authors develop a hierarchical multi-objective metaheuristic algorithm to obtain efficient solutions. An application of the model and the solution algorithm to real data from a region in the southeast of Turkey is presented, with associated managerial insights.

Effective Components on Cash-based Intervention to Affected People by Natural Disasters Using Information and Communication Technology in Iran

Rescue and relief organizations start their operations from the first moments after the occurrence of a disaster. Moreover, they set up emergency accommodation camps after the emergency period to deliver aid and health packages with standard content based on the general needs of the affected people. However, if a family has infants, children, elderly, or sick members, these packages will not be able to meet their needs. Cash donations instead of goods respect the human dignity of the affected people after the emergency period and result in the recovery of the families and the economy of the region. Usage of information technology for this purpose leads to speed, accuracy, and transparency in the implementation of the above-mentioned method. Given the differences between the situation in Iran and the international community, the present study aimed to find localized components that affect the provision of cash-based interventions to the affected people by natural disasters using information and communications technology. METHODS: This mixed method research was performed in two stages; meta-synthesis was used in the first stage and Fuzzy Delphi was used in the second stage to extract the domestic components of the cash-based interventions. The statistical population in the meta-synthesis stage was the local and international journals as well as the performance reports of international aid agencies published during 2004-2019. Finally, through sample selection and systematic selection based on the defined keywords, 71 out of 388 studies were selected for the purposes of the research. In the second stage, the statistical population consisted of executive directors of local aid agencies and crisis management instructors at universities and international workshops. Eventually, 14 experts were selected judgmentally who participated in three Delphi rounds. FINDINGS: In the first stage, 18 components in four categories were determined using the seven-step model of Sandelowski and Barroso. In the first round of Delphi, one component was omitted and six other components were added according to the opinions of the experts. However, in the second and third rounds, all the components were approved by them without any further changes. According to the obtained Kendall’s rank correlation coefficient which was about 0.703, the local components were agreed upon by the selected experts. CONCLUSION: The determined local components that affect the process of transferring cash-based interventions to the affected people by natural disasters using information and communications technology consisted of 23 components that were screened and confirmed by the experts. These components can be used as a basis for the development of a process model for the systematic electronic transfer of money to the affected people by natural disasters in Iran after the emergency response period.

Cash-Based Interventions to Enhance Dignity in Persistent Humanitarian Refugee Crises: A System Dynamics Approach

Cash-based interventions (CBIs) as one form of aid have recently received substantial interest from humanitarian organizations in persistent humanitarian crises. This article proposes a system dynamics (SD) approach to study the CBIs’ impact factors on all aspects of the beneficiaries’ dignity in longstanding refugee crises, such as the case of Syrian refugees in Turkey. Reviewing the humanitarian management literature, we first develop a set of holistic causal loops to better understand the building boxes of refugees’ dignity and their interactions. Then, an SD model is proposed and calibrated by field data from humanitarian organizations. The result of CBI amount sensitivity and payment time periods shows that CBIs are significantly more effective in diminishing child labor rates and to improve in health and accommodation service reception by the refugees in short terms, but to be as much effective in longer terms, humanitarian organizations must be more directly contribute to service capacity-building activities that are strategies by the hosting governments and supported by the international bodies, such as EU and UN. Otherwise, long-term or enhanced CBI supports can only lead to accelerated service capacity saturation and thus put extra pressure on already strained services and cause tensions between hosting and refugee communities.

Do nutrition and cash-based interventions and policies aimed at reducing stunting have an impact on economic development of low-and-middle-income countries? A systematic review

BackgroundChildhood stunting is the most common manifestation of chronic malnutrition. A growing body of literature indicates that stunting can have negative repercussions on physical and cognitive development. There are increasing concerns that low- and middle-income countries (LMICs) are particularly susceptible to adverse consequences of stunting on economic development. The aim of this review is to synthesize current evidence on interventions and policies that have had success in reducing stunting and explore the impact of successes on economic indicators.MethodsThis review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were searched through MEDLINE via PubMed and Ovid, Cochrane Library, Web of Science and ProQuest. Only articles that addressed the effects of nutrition and cash-based interventions and/or policies on stunting and reported effects on childhood mortality and/or human capital indicators were included. Two reviewers independently abstracted data and assessed quality.ResultsSeventeen studies from Africa (47%), South America (41%), and South Asia (12%) met the eligibility criteria: 8 cohort studies, 4 case studies, 4 Randomized Control Trials (RCTs) and 1 quasi-trial. Three types of interventions/policies were evaluated: multisectoral policies, nutritional supplementations and cash-based interventions (CCT). Overall, 76% of the included studies were successful in reducing stunting and 65% of interventions/policies reported successes on stunting reductions and economic successes. Five of the 11 successful studies reported on nutritional supplementation, 4 reported on multisectoral policies, and 2 reported on CCT interventions. Average Annual Rate of Reduction (AARR) was calculated to assess the impact of multisectoral policies on childhood mortality. AARR for under 5 mortality ranged from 5.2 to 6.2% and all countries aligned with the global target of 4.4% AARR. Quality assessment yielded positive results, with the biggest concerns being attrition bias for cohort studies, blinding for trials and generalizability of results for case studies.ConclusionsEvidence suggests that investment in fighting chronic malnutrition through multisectoral policies, multi-year nutritional supplementation (protein or multiple micronutrient supplementation) and possibly CCTs can have a long-term impact on economic development of LMICs. More evidence is needed to inform practices in non-represented regions while prioritizing standardization of economic indicators in the literature.

The cost of preventing undernutrition: cost, cost-efficiency and cost-effectiveness of three cash-based interventions on nutrition outcomes in Dadu, Pakistan.

Cash-based interventions (CBIs) increasingly are being used to deliver humanitarian assistance and there is growing interest in the cost-effectiveness of cash transfers for preventing undernutrition in emergency contexts. The objectives of this study were to assess the costs, cost-efficiency and cost-effectiveness in achieving nutrition outcomes of three CBIs in southern Pakistan: a ‘double cash’ (DC) transfer, a ‘standard cash’ (SC) transfer and a ‘fresh food voucher’ (FFV) transfer. Cash and FFVs were provided to poor households with children aged 6–48 months for 6 months in 2015. The SC and FFV interventions provided $14 monthly and the DC provided $28 monthly. Cost data were collected via institutional accounting records, interviews, programme observation, document review and household survey. Cost-effectiveness was assessed as cost per case of wasting, stunting and disability-adjusted life year (DALY) averted. Beneficiary costs were higher for the cash groups than the voucher group. Net total cost transfer ratios (TCTRs) were estimated as 1.82 for DC, 2.82 for SC and 2.73 for FFV. Yet, despite the higher operational costs, the FFV TCTR was lower than the SC TCTR when incorporating the participation cost to households, demonstrating the relevance of including beneficiary costs in cost-efficiency estimations. The DC intervention achieved a reduction in wasting, at $4865 per case averted; neither the SC nor the FFV interventions reduced wasting. The cost per case of stunting averted was $1290 for DC, $882 for SC and $883 for FFV. The cost per DALY averted was $641 for DC, $434 for SC and $563 for FFV without discounting or age weighting. These interventions are highly cost-effective by international thresholds. While it is debatable whether these resource requirements represent a feasible or sustainable investment given low health expenditures in Pakistan, these findings may provide justification for continuing Pakistan’s investment in national social safety nets.

Cash-based response in relief: the impact for humanitarian logistics

PurposeThe purpose of this paper is to evaluate the financial and material flows in cash-based responses (CBRs) and their implications for humanitarian operations. This research proposes to view cash as a commodity used by humanitarian actors in emergency operations and therefore aims to explore how CBRs impact on humanitarian logistics and ultimately, affect beneficiaries.Design/methodology/approachThe methodological approach of grounded theory was chosen for this inquiry because it allowed the researchers to generate a general explanation for the process of CBRs in emergency situations based on the views of participants interviewed. Interviews were conducted with senior managers, supply chain managements and logistics officers from international humanitarian organisations (HOs), United Nations agencies and commercial organisations involved in humanitarian operations. Examples of topics covered during the field work included, procedures and policy; knowledge and information management; systems and technology; actors and agents.FindingsThe impact of CBRs on humanitarian operations can though not be understated. They alter supply chain design, the very role of beneficiaries as well as HOs, and change the strategy of aid delivery from push to pull. Perhaps, the most important factor is the elimination of many logistical activities that needed to be performed by HOs. Delivering cash diminishes the needs for lengthy procurement and assessment processes, pre-positioning, transportation and distribution. This bears the potential of significant reductions in costs for delivering humanitarian aid at the same time as it is an important move from aid to trade.Practical implicationsThe challenge for humanitarian agencies in the coming years is to overcome their fears surrounding CBRs, and to implement cash programmes where they are judged to be the most appropriate response. This will require not only a change in donor policies, but also a fundamental change in the skill set of humanitarian logisticians, who are used to identifying needs and providing commodities and thus to maintaining control over the provision of assistance.Originality/valueThe contribution of this research is twofold: this is the first examination of cash-based interventions in humanitarian operations through the prism of supply chain management. Second, the research is field based and grounded in empirical observations thus adding to the literature and offering insights to practice.

UNHCR and the pursuit of international protection: accountability through technology?

Better management and new technological solutions are increasingly portrayed as the way to improve refugee protection and enhance the accountability of humanitarian actors. Taking concepts of legibility, quantification and co-production as the point of departure, this article explores how techno-bureaucratic practices shape conceptions of international refugee protection. We do this by examining the evolving roles of results-based management (RBM), biometrics and cash-based interventions as ‘accountability technologies’ in the United Nations High Commissioner for Refugees’ international protection efforts. The article challenges the assumption that these technologies produce a seamless form of accountability that is equally attentive to donor requests and the protection needs of refugees. By focusing on how the constitution of these techniques as ‘accountability solutions’ shapes conceptions of the very meaning of protection (ie the problem to be addressed), we also show what dimensions of protection get omitted in this co-production of technical solutions and socio-political problems.

Impact evaluation of different cash-based intervention modalities on child and maternal nutritional status in Sindh Province, Pakistan, at 6 mo and at 1 y: A cluster randomised controlled trial.

BackgroundCash-based interventions (CBIs), offer an interesting opportunity to prevent increases in wasting in humanitarian aid settings. However, questions remain as to the impact of CBIs on nutritional status and, therefore, how to incorporate them into emergency programmes to maximise their success in terms of improved nutritional outcomes. This study evaluated the effects of three different CBI modalities on nutritional outcomes in children under 5 y of age at 6 mo and at 1 y.Methods and findingsWe conducted a four-arm parallel longitudinal cluster randomised controlled trial in 114 villages in Dadu District, Pakistan. The study included poor and very poor households (n = 2,496) with one or more children aged 6–48 mo (n = 3,584) at baseline. All four arms had equal access to an Action Against Hunger–supported programme. The three intervention arms were as follows: standard cash (SC), a cash transfer of 1,500 Pakistani rupees (PKR) (approximately US$14; 1 PKR = US$0.009543); double cash (DC), a cash transfer of 3,000 PKR; or a fresh food voucher (FFV) of 1,500 PKR; the cash or voucher amount was given every month over six consecutive months. The control group (CG) received no specific cash-related interventions. The median total household income for the study sample was 8,075 PKR (approximately US$77) at baseline. We hypothesized that, compared to the CG in each case, FFVs would be more effective than SC, and that DC would be more effective than SC—both at 6 mo and at 1 y—for reducing the risk of child wasting. Primary outcomes of interest were prevalence of being wasted (weight-for-height z-score [WHZ] < −2) and mean WHZ at 6 mo and at 1 y.The odds of a child being wasted were significantly lower in the DC arm after 6 mo (odds ratio [OR] = 0.52; 95% CI 0.29, 0.92; p = 0.02) compared to the CG. Mean WHZ significantly improved in both the FFV and DC arms at 6 mo (FFV: z-score = 0.16; 95% CI 0.05, 0.26; p = 0.004; DC: z-score = 0.11; 95% CI 0.00, 0.21; p = 0.05) compared to the CG. Significant differences on the primary outcome were seen only at 6 mo. All three intervention groups showed similar significantly lower odds of being stunted (height-for-age z-score [HAZ] < −2) at 6 mo (DC: OR = 0.39; 95% CI 0.24, 0.64; p < 0.001; FFV: OR = 0.41; 95% CI 0.25, 0.67; p < 0.001; SC: OR = 0.36; 95% CI 0.22, 0.59; p < 0.001) and at 1 y (DC: OR = 0.53; 95% CI 0.35, 0.82; p = 0.004; FFV: OR = 0.48; 95% CI 0.31, 0.73; p = 0.001; SC: OR = 0.54; 95% CI 0.36, 0.81; p = 0.003) compared to the CG. Significant improvements in height-for-age outcomes were also seen for severe stunting (HAZ < −3) and mean HAZ. An unintended outcome was observed in the FFV arm: a negative intervention effect on mean haemoglobin (Hb) status (−2.6 g/l; 95% CI −4.5, −0.8; p = 0.005). Limitations of this study included the inability to mask participants or data collectors to the different interventions, the potentially restrictive nature of the FFVs, not being able to measure a threshold effect for the two different cash amounts or compare the different quantities of food consumed, and data collection challenges given the difficult environment in which this study was set.ConclusionsIn this setting, the amount of cash given was important. The larger cash transfer had the greatest effect on wasting, but only at 6 mo. Impacts at both 6 mo and at 1 y were seen for height-based growth variables regardless of the intervention modality, indicating a trend toward nutrition resilience. Purchasing restrictions applied to food-based voucher transfers could have unintended effects, and their use needs to be carefully planned to avoid this.Trial registrationISRCTN registry ISRCTN10761532

Assessing the Impact of U.S. Food Assistance Delivery Policies on Child Mortality in Northern Kenya.

The U.S. is the main country in the world that delivers its food assistance primarily via transoceanic shipments of commodity-based in-kind food. This approach is costlier and less timely than cash-based assistance, which includes cash transfers, food vouchers, and local and regional procurement, where food is bought in or nearby the recipient country. The U.S.’s approach is exacerbated by a requirement that half of its transoceanic food shipments need to be sent on U.S.-flag vessels. We estimate the effect of these U.S. food assistance distribution policies on child mortality in northern Kenya by formulating and optimizing a supply chain model. In our model, monthly orders of transoceanic shipments and cash-based interventions are chosen to minimize child mortality subject to an annual budget constraint and to policy constraints on the allowable proportions of cash-based interventions and non-US-flag shipments. By varying the restrictiveness of these policy constraints, we assess the impact of possible changes in U.S. food aid policies on child mortality. The model includes an existing regression model that uses household survey data and geospatial data to forecast the mean mid-upper-arm circumference Z scores among children in a community, and allows food assistance to increase Z scores, and Z scores to influence mortality rates. We find that cash-based interventions are a much more powerful policy lever than the U.S.-flag vessel requirement: switching to cash-based interventions reduces child mortality from 4.4% to 3.7% (a 16.2% relative reduction) in our model, whereas eliminating the U.S.-flag vessel restriction without increasing the use of cash-based interventions generates a relative reduction in child mortality of only 1.1%. The great majority of the gains achieved by cash-based interventions are due to their reduced cost, not their reduced delivery lead times; i.e., the reduction of shipping expenses allows for more food to be delivered, which reduces child mortality.

Are cash-based interventions a feasible approach for expanding humanitarian assistance in Syria?

The conflict in Syria is the largest driver of displacement worldwide with 4.1 million Syrian refugees, more than 6.5 million internally displaced people (IDPs), and 13.5 million people in need (PiN) of protection and humanitarian assistance inside Syria. Over the past decade, cash-based interventions (CBIs), including both conditional and unconditional cash transfers and voucher programs, have become increasingly common. While the cash-based response within Syria to date has been small compared to in-kind assistance, there is widespread interest in expanding the use of CBIs. This study explores the feasibility of cash-based modalities with the aim of informing future humanitarian assistance delivery strategies in northern Syria. The feasibility of CBIs is examined in terms of acceptability, infrastructure, humanitarian agency implementation capacity, value for money, risks, and responsiveness to changes in beneficiary needs. A mixed methods approach was used consisting of a literature review in addition to a household survey and key informant interviews (KIIs) conducted in early 2016 in four governorates of Syria (Aleppo, Hama, Idlib, and Al-Hasakeh). Overall, 64.5% of surveyed households received assistance during the 4-month period from October 2015 through January 2016. In-kind assistance was most common, with 59.2% of households receiving in-kind food aid. More than half of households received only one or two distributions of assistance in any form. Unmet needs were ubiquitous, and food was the priority in 74.1% of households. Despite relatively limited coverage of cash and voucher assistance programs to date, stakeholders voiced a widespread preference for cash transfers as did household survey participants. When analyzed by sector, cash assistance was preferred by survey respondents for all sectors except WASH. The most significant challenge in implementing CBIs in Syria is the lack of a regulated cash transfer system for movement of funds into the country. The bulk of humanitarian money is currently transferred through informal value transfer networks (hawala), which appears to have the capacity to handle larger-scale cash transfer programming. Technical guidance and standardized procedures are needed to ensure due diligence is conducted to mitigate fiduciary risks and ensure accountability to both beneficiaries, donors, and other stakeholders. The possibility of more sustained, continuous assistance provided through cash transfer or voucher mechanisms negates many of the barriers faced in providing in-kind assistance. Consideration of the feasibility of cash as an alternative modality relies on local-level assessment of capacity, resources, political environment, beneficiary needs and preferences, and lessons learned from previous programs in those areas.

The REFANI Pakistan study—a cluster randomised controlled trial of the effectiveness and cost-effectiveness of cash-based transfer programmes on child nutrition status: study protocol

BackgroundCash-based transfer programmes are an emerging strategy in the prevention of wasting in children, especially targeted at vulnerable households during periods of food insecurity or during emergencies. However, the evidence surrounding the use of either cash or voucher transfer programmes in the humanitarian context and on nutritional outcomes is elusive. More evidence is needed not only to inform the global community of practice on best practices in humanitarian settings, but also to help strengthen national mitigation responses.Methods/DesignThe Research for Food Assistance on Nutrition Impact Pakistan study (REFANI-P) sets out to evaluate the impact of three cash-based interventions on nutritional outcomes in children aged less than five years from poor and very poor households in Dadu District. This four-arm parallel cluster randomised controlled trial is set among Action Against Hunger (ACF) programme villages in Dadu District, Sindh Province. Mothers are the target recipients of either seasonal unconditional cash transfers or fresh food vouchers. A comparison group receives ‘standard care’ provided by the ACF programme to which all groups have the same access. The primary outcomes are prevalence of wasting and mean weight-for-height Z-score (WHZ) in children. Impact will be assessed at 6 months and at 1 year from baseline. Using a theory-based approach we will determine ‘how’ the different interventions work by looking at the processes involved and the impact pathways following the theory of change developed for this context. Quantitative and qualitative data are collected on morbidity, health seeking, hygiene and nutrition behaviours, dietary diversity, haemoglobin concentration, women’s empowerment, household food security and expenditures and social capital. The direct and indirect costs of each intervention borne by the implementing organisation and their partners as well as by beneficiaries and their communities are also assessed.DiscussionThe results of this trial will provide robust evidence to help increase knowledge about the predictability of how different modalities of cash-based transfer work best to reduce the risk of child wasting during a season where food insecurity is at its highest. Evidence on costing and cost-effectiveness will further aid decisions on choice of modality in terms of effectiveness and sustainability.Trial registrationCurrent Controlled Trials ISRCTN10761532. Registered 26 March 2015.

Cash Grants in Humanitarian Assistance: A Nongovernmental Organization Experience in Aceh, Indonesia, Following the 2004 Indian Ocean Tsunami

Historically, cash interventions, as opposed to material or in-kind aid, have been relatively uncommon in the humanitarian response to emergencies. The widespread implementation of cash-based programs following the 2004 Indian Ocean tsunami provided an opportunity to examine cash distributions following disasters. The Mercy Corps cash grant program in Aceh, Indonesia, was a short-term intervention intended to assist in recompensing losses from the December 2004 tsunami. An evaluation of the Mercy Corps cash grant program was conducted for the 12-month period following the tsunami using program monitoring data and a systematic survey of cash grant beneficiaries. in 2005, the cash grant program disbursed more than US$3.3 million to more than 53,000 beneficiaries; the average cash grant award was US$6390, which was shared by an average of 108 beneficiaries. In a beneficiary survey, more than 95% of respondents reported the grant allocation processes were fair and transparent and that grant funds were received. The Mercy Corps experience with cash programs suggests that cash interventions in the emergency context, when properly administered, can have an immediate impact and serve as an efficient mechanism for providing assistance. Organizations involved in humanitarian relief, particularly donors and nongovernmental organizations, should consider incorporating cash-based interventions as an element of their response in future emergencies.

Cash‐based interventions: lessons from southern Somalia

Commodity distributions, the predominant relief response, are subject to growing criticism, while donors and humanitarian actors are increasingly viewing cash-based interventions as a viable alternative. This paper aims to contribute to the current debate on cash-based interventions by drawing on the experience of Action Contre la Faim in southern Somalia, where it has implemented cash for work programmes since 2004. The authors conclude that cash-based interventions are a feasible option in complex emergencies as well as in highly insecure environments as long as appropriate modalities are employed and objectives are clearly set in accordance with the needs and the context. Cash as a relief response offers wide-reaching possibilities for the future from both the perspective of the donor/agency and the standpoint of the beneficiary. It enables the beneficiaries to take control of the relief themselves and to adapt it to their individual requirements in a timely manner.