Cash, COVID-19 and aid cuts: a mixed-method impact evaluation among South Sudanese refugees registered in Kiryandongo settlement, Uganda

Abstract

ObjectivesIn this paper, we estimate the impact after 4–8 months of a large one-off unconditional cash transfer delivered to refugees during a time of dual shocks: the COVID-19 pandemic and cuts to monthly aid. We focus on four key outcomes: (1) health-seeking behaviour; (2) COVID-19 specific preventive health practices; (3) food security and (4) psychological well-being.MethodsWe use both quantitative and qualitative data to understand the impact of a cash transfer in this context. Quantitatively, we use a baseline survey of 1200 households (Q4 2019) and follow-up with three rounds of phone surveys in Q2 and Q3 2021, capturing at least half the sample in each round. We exploit an experimental variation in the timing of the cash transfer to assess the effect of the cash transfer through ordinary least squares regressions of intention to treat. Controlling for key baseline characteristics, we analyse the effect of the cash transfer on health access, COVID-19 health practices, food security and psychological well-being. Qualitatively, we make use of a longitudinal, small-n sample of refugee respondents, each of whom we interviewed up to 15 times between February and September 2020 to understand change over time and to go deeper into key topics.ResultsWe do not find a statistically significant effect (6.2%, p=0.188) of receiving the cash transfer on preventative measures against COVID-19. However, households receiving the cash transfer were more food secure, with a 14.4% (p=0.011) improvement on the food security index, have better psychological well-being (24.5%, p=0.003) and are more likely to seek healthcare in the private health facilities (10.4%, p=0.057) as compared with control households. We do not find significant results on the value of food consumption. Overall, we find stronger treatment effects for households that were the first to receive the cash transfers.ConclusionTaken together, we find significant support for the importance of cash transfers to refugee households mitigating against declines in food security and mental well-being in the face of shocks.

An Unconditional Cash Transfer Program for Low-Income New Yorkers Affected by COVID-19

“…Studies of cash transfer programs, while heterogeneous in quality and findings, suggest that such interventions may have positive impacts on health [ 9 – 13 ]. Cash transfer programs have been implemented across the globe in response to the COVID-19 pandemic, with international studies finding effects on food security and access to healthcare [ 14 – 16 ]. In the USA, government and private philanthropy deployed various cash transfer programs during the pandemic, [ 17 – 19 ] but it is rarer for a health system to be explicitly involved in the design and implementation of such a program [ 20 ].…”

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

“…Cash-based interventions have the potential to influence a range of public health outcomes, but evidence on their impacts is mixed in low-income and middle-income settings where aid is given (13-15). Evaluations of the World Food Program's delivery of cash assistance in conjunction with food parcels in refugee camps have revealed that offering refugees the choice to receive cash in lieu of food parcels yield dietary improvements, higher diet diversity, increased financial stability and food security, and greater feelings of self-sufficiency (11,12,16,17). Multiple evaluations of cash-based programs have also demonstrated improvements in height, HAZ scores, and newborn birth weight in addition to positive pregnancy outcomes across age groups and geographical contexts (18,19).…”

“…Other non-nutritional impacts identified in evaluations of cash-based interventions in refugee settings include improved psychological wellbeing, which has been associated with food security in observational studies (16,21). Empirical evidence on the impact of cash-based interventions on other health outcomes is sparse; however, simulation studies have not supported that replacing traditional food assistance with cash led to meaningful changes in a range of chronic diseases and other health outcomes.…”

Unconditional cash transfer to reduce the burden of unmet surgical needs

“…Unconditional cash transfer has been effective in several countries affected by humanitarian catastrophes but not utilized for alleviating planned, non-emergent surgical procedures in LMIC. Stein et al [ 11 ] used both quantitative and qualitative data to understand the impact of unconditional cash transfer to refugees in the setting of the COVID-19 pandemic and subsequent cuts to monthly aid. Through telephonic surveys in 1,200 households, the authors investigated the effect of these cash transfers on COVID-19 specific preventative health practices, food security and psychological well-being.…”