Effectiveness of cash-plus programmes on early childhood outcomes compared to cash transfers alone: A systematic review and meta-analysis in low- and middle-income countries

Abstract

Background To strengthen the impact of cash transfers, these interventions have begun to be packaged as cash-plus programmes, combining cash with additional transfers, interventions, or services. The intervention’s complementary (“plus”) components aim to improve cash transfer effectiveness by targeting mediating outcomes or the availability of supplies or services. This study examined whether cash-plus interventions for infants and children <5 are more effective than cash alone in improving health and well-being. Methods and findings Forty-two databases, donor agencies, grey literature sources, and trial registries were systematically searched, yielding 5,097 unique articles (as of 06 April 2021). Randomised and quasi-experimental studies were eligible for inclusion if the intervention package aimed to improve outcomes for children <5 in low- and middle-income countries (LMICs) and combined a cash transfer with an intervention targeted to Sustainable Development Goal (SDG) 2 (No Hunger), SDG3 (Good Health and Well-being), SDG4 (Education), or SDG16 (Violence Prevention), had at least one group receiving cash-only, examined outcomes related to child-focused SDGs, and was published in English. Risk of bias was appraised using Cochrane Risk of Bias and ROBINS-I Tools. Random effects meta-analyses were conducted for a cash-plus intervention category when there were at least 3 trials with the same outcome. The review was preregistered with PROSPERO (CRD42018108017). Seventeen studies were included in the review and 11 meta-analysed. Most interventions operated during the first 1,000 days of the child’s life and were conducted in communities facing high rates of poverty and often, food insecurity. Evidence was found for 10 LMICs, where most researchers used randomised, longitudinal study designs (n = 14). Five intervention categories were identified, combining cash with nutrition behaviour change communication (BCC, n = 7), food transfers (n = 3), primary healthcare (n = 2), psychosocial stimulation (n = 7), and child protection (n = 4) interventions. Comparing cash-plus to cash alone, meta-analysis results suggest Cash + Food Transfers are more effective in improving height-for-age (d = 0.08 SD (0.03, 0.14), p = 0.02) with significantly reduced odds of stunting (OR = 0.82 (0.74, 0.92), p = 0.01), but had no added impact in improving weight-for-height (d = −0.13 (−0.42, 0.16), p = 0.24) or weight-for-age z-scores (d = −0.06 (−0.28, 0.15), p = 0.43). There was no added impact above cash alone from Cash + Nutrition BCC on anthropometrics; Cash + Psychosocial Stimulation on cognitive development; or Cash + Child Protection on parental use of violent discipline or exclusive positive parenting. Narrative synthesis evidence suggests that compared to cash alone, Cash + Primary Healthcare may have greater impacts in reducing mortality and Cash + Food Transfers in preventing acute malnutrition in crisis contexts. The main limitations of this review are the few numbers of studies that compared cash-plus interventions against cash alone and the potentially high heterogeneity between study findings. Conclusions In this study, we observed that few cash-plus combinations were more effective than cash transfers alone. Cash combined with food transfers and primary healthcare show the greatest signs of added effectiveness. More research is needed on when and how cash-plus combinations are more effective than cash alone, and work in this field must ensure that these interventions improve outcomes among the most vulnerable children.

Behaviour change communication for child feeding in social assistance: A scoping review and expert consultation

“…Although there is already a good understanding of what works when it comes to BCC for IYCF in LMIC (Graziose et al, 2018;Lamstein et al, 2014;Webb Girard et al, 2020), there is limited evidence on how best and most effectively to integrate BCC for IYCF with social assistance programming to improve IYCF practices and child nutrition outcomes (Little et al, 2021) Our results suggest that a variety of BCC strategies were used in combination with social assistance-with group sessions with predetermined topics and individual nutrition counselling being the most common strategies. Limited context-specific adaptation, passive or top-down one-way delivery and a failure to design the BCC based on existing IYCF knowledge in the target communities were common shortcomings in the design and implementation of BCC for IYCF in social assistance programmes.…”

“…Although there is already a good understanding of what works when it comes to BCC for IYCF in LMIC (Graziose et al, 2018 ; Lamstein et al, 2014 ; Webb Girard et al, 2020 ), there is limited evidence on how best and most effectively to integrate BCC for IYCF with social assistance programming to improve IYCF practices and child nutrition outcomes (Little et al, 2021 )…”

“…Linking social assistance programmes with BCC for IYCF may enable poor families to address the economic and time constraints that prevent them from adopting improved practices (Alderman, 2015). While there is interest in leveraging the impact of social assistance on child nutrition by adding BCC for IYCF, there is only limited knowledge about the different BCC strategies that may be used in social assistance programmes and their respective effectiveness on IYCF practices and nutrition outcomes (Little et al, 2021). Although, separately, well‐designed social assistance and well‐designed BCC for IYCF programmes can have positive effects on various proximal and distal determinants of child nutrition, field evidence (see e.g., Nisbett et al, 2016) shows that finding ways to implement these quite different programme modalities—often drawing separately on different types of social protection and nutrition expertise—is not simple and not always effective.…”

More evidence on cash transfers and child nutritional outcomes: a systematic review and meta-analysis

“…In particular WASH/hygiene BCC is effective in improving a variety of outcomes, a result that differs from another recent review. 14 Yet another review 15 comparing cash against cash plus nutrition-sensitive BCC finds that a meta-analysis of seven studies, including one study of cash for work, shows no significant association with stunting. That same work finds an intriguing impact of cash combined with food, something we had not tracked.…”

Act now before Ukraine war plunges millions into malnutrition

“…Interventions could be in the form of food transfers, in which households receive packages that include staple grains, such as rice or flour fortified with micronutrients; vouchers that can be used only to purchase nutritious foods; or cash transfers. Even before the pandemic, cash transfers were well-established in LMICs as tools for increasing the ability of women to direct spending towards improving families' diets and overall health 18 .…”