WASHINGTON — An impact evaluation of a “cash plus” malnutrition program in Yemen found that soft conditionality used in a conflict situation has had significant positive impacts on diet and nutrition indicators — results that were obtained by chance.
Previous data that measured results of such interventions during conflict was scarce, due to the ethical hesitations of conducting a randomized controlled trial during a crisis situation.
“You’re limited to natural experiment or to working in areas that are adjacent to the conflict,” said Sikandra Kurdi, lead author of the April 2019 report “Responding to Conflict: Does ‘Cash Plus’ Work for Preventing Malnutrition?”
But researchers with the International Food Policy Research Institute who were already studying the impact of Yemen’s Cash for Nutrition program in an RCT, found themselves with a unique opportunity to gather such data as the country descended into war.
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The World Bank-funded nutrition program was being implemented before Yemen’s civil war broke out in 2015, and initial baseline data was gathered by IFPRI in early 2015. Then, as the conflict began, the Yemen Social Fund for Development continued providing soft conditional cash transfers to the same beneficiaries as the humanitarian crisis deepened.
“The randomization ended up being the default list that they used when they rolled out the program as a much larger part of the emergency response program, just because it was easier for them to use the list of beneficiaries that had already been started, and so, as a result, we have the randomization. We didn’t mean for it to happen during the conflict,” Kurdi explained.
The Social Fund for Development eventually scaled the program to more recipients — but not before IFPRI was able to gather a second round of data from beneficiaries in the original group. Comparing the nutrition indicators from 2015 before the war began and then again in August 2017 gave researchers a window into how the soft conditional cash transfers were improving nutrition outcomes relative to households that were not participating.
“It was not intentional to keep the randomization, and it was a surprise for us that it happened just due to the administrative inertia because it was time-consuming for them to go back and to register the households that we had originally not included in the program,” Kurdi said.
Measurable cash transfer impacts
Even before the war began, Yemen had poor malnutrition indicators: In 2015, 46.5% of children under 5 were stunted, and 16.3% suffered from acute malnutrition, according to the report. The Yemen Social Fund for Development, which Kurdi describes as “a quasi-governmental” public organization, targeted beneficiary households of the Social Welfare Fund that had pregnant mothers or children under 2 years in three districts in Al Hodeida Governorate. They received cash transfers while being required to attend monthly nutrition education sessions conducted by community health educators.
Those receiving the cash transfers saw improvements on maternal and child dietary diversity, child weight-for-height, and child height-for-age. The largest impact was seen in the poorest third of participants, where children who were between 7 and 30 months of age when baseline data was taken showed “substantial and statistically significant program impacts” on height-for-age z-scores, which the World Health Organization uses as a metric for measurement, and on weight-for-height scores.
“Being able to show how much of the food is being spent on nonstaple food items is important because it really solidifies the evidence about how cash transfers are especially effective at increasing dietary diversity.”— Sikandra Kurdi, associate research fellow, IFPRI
“We could actually see the impacts on anthropometrics,” Kurdi said. “It’s not that often that you actually find measurable impacts of cash transfers on anthropometrics, because from getting the cash to purchasing the food … is so long. Most other studies haven’t found impacts there, so I think the fact that we did find that points a lot to first how bad the situation was, but then also points to the fact that the program was functioning quite well.”
When the follow-up data was collected in 2017, households were being given 10,000 Yemeni rials ($40) per month, or about 25% of their average monthly food spending. Researchers saw participating households increase diversity in their diets, using the cash transfer funds to purchase more fruits, vegetables, and animal products rather than just buying more staples.
This caused “significant positive impacts,” according to the report, in both child and maternal diet diversity, which has severely declined during the war.
The poorest third also showed the greatest improvements in diet diversity as a result of the cash transfers, with those households showing statistically significant increases in purchases of milk, fruits, and vegetables, and a marginally significant increase in the purchase of eggs.
“Being able to show how much of the food is being spent on nonstaple food items is important because it really solidifies the evidence about how cash transfers are especially effective at increasing dietary diversity,” Kurdi said.
There were also improvements made in behavior, including an increased practice of exclusive breastfeeding and the use of water treatment to improve water quality.
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Program households that did not show up for the monthly nutrition sessions did not have their “cash plus” benefits cut off. Instead, community health workers reached out to assess barriers to participation. If people were not able to attend the sessions in person, the health workers could travel to homes and provide the education there.
Kurdi said the soft conditionality strategy the program used is a more “intermediate” way of structuring cash transfers.
“There’s the whole debate right now about should you do conditional or unconditional,” Kurdi said. “Soft conditionality is a moderate way in between those two. It’s still trying to change people’s behavior in a certain way, but it doesn't have the conditions [of] traditional cash transfers where you have to actually punish people that are not able to meet the conditions.”