How cash-based

approaches affect
nutrition outcomes
A guidance note
June 2019
A HOW CASH-BASED APPROACHES AFFECT NUTRITION OUTCOMES
How cash-based approaches affect
nutrition outcomes
A guidance note
This guidance note outlines best practices and recommendations for cash-based programming
to improve nutrition outcomes for mothers and children in target populations. These
recommendations are based on findings of a 2019 case study comparing two World Vision cash
projects in Bangladesh and South Sudan. For full details on the methodology and findings of that
research, please refer to the full case study report.

1. Initial design and beneficiary targeting

1.1 In order to maximise the intended effect on nutrition outcomes, cash transfer
amounts should be informed by a minimum expenditure basket (MEB) calculation,
which should include an estimate of the basic needs and gaps that the cash transfer
intends to cover. In order to ensure that the cash transfers are achieving the programme’s
intended outcomes, it is recommended to use a minimum expenditure basket (MEB) approach
to inform cash transfer amounts. Even if a cash programme is simply intended to supplement
household income and not intended to cover all basic needs, the MEB amount should still be
calculated (along with average monthly household income) in order to determine how much
of a family’s basic needs will be supplemented by the cash transfer. Food security, health and
hygiene needs should all be considered, as all can impact the nutritional status of women and
children.
1.2 The duration of a cash-based programme depends on the ultimate objectives
of the programme. For programmes seeking to improve nutrition outcomes for
mothers and children, a duration of up to the first two years of a child’s life may
help to better support this crucial period of the child’s development. Adequate
nutrition for the mother during pregnancy and both the mother and child during the first
two years of a child’s life can substantially improve a child’s nutritional status. Cash-based
programmes should therefore aim to supplement nutritional needs throughout this period.
However, it is common for funding limitations to require organisations to
compromise between project reach, transfer amount and duration of the cash
transfer period. Therefore, decisions related to these factors will depend on
available funding as well as contextual factors. Additionally, more research should
be conducted into whether cash programmes of varying lengths affect nutrition
outcomes differently.
1.3 The type of cash transfer modality selected should be based on the local
context, including functionality of markets, the financial infrastructure available and
whether or not preconditions can be met by beneficiaries. In some contexts where
markets are unreliable, redeemable vouchers may be appropriate. However, where markets
are functioning, direct cash provides a more flexible and appropriate way for beneficiaries

1 HOW CASH-BASED APPROACHES AFFECT NUTRITION OUTCOMES

to meet their needs. Cash-in-hand has the benefit of being easier to use in contexts where
financial infrastructure is not in place, but it may pose specific protection risks. Bank and mobile
transfers can be more efficient and less risky in areas where financial infrastructure is available
and beneficiaries can access bank accounts and/or phones. However, cash recipients should be
sensitised to potential fraud risks. Mobile phone transfers have the added value of potentially
being linked to educational messages that can be transmitted via SMS or voicemail.
1.4 Beneficiary targeting should ensure that the most vulnerable
households are covered, using standard assessment criteria that
takes into account income, disability, age, household size and
structure, and other factors that influence vulnerability. When
there is a risk that certain vulnerable individuals will be ineligible to receive
cash, or are left out of the programme for any other reason, programmes
should attempt to ensure that alternate strategies of targeting these individuals are in place,
such as including them in behaviour change sessions or working to strengthen local social safety
nets. Beneficiary selection should also be conducted on a rolling basis in order to avoid missing
segments of the target population.

2. Conditions for receiving cash transfers

2.1 Conditional cash transfers (as opposed to unconditional transfers) help to
encourage nutrition outcomes by making attendance at health or education
sessions a requirement for cash recipients. Cash and cash conditions may have a
compounding effect on nutrition outcomes when employed in conjunction. Receiving cash
can incentivise cash recipients to attend health check-ups or nutrition/WASH trainings if they
are conditions of the cash transfer. In turn, these conditions encourage nutrition and hygiene-
related behaviour change and improved health-seeking behaviour. Cash also allows participants
to afford to put nutrition advice into practice and buy nutritious food.
2.2 Conditions to receive cash assistance should be appropriately tailored to
the intended outcomes, and there should be some degree of flexibility for cash
recipients to meet these conditions. For programmes intending to improve nutrition
outcomes, appropriate conditions may include: nutrition, hygiene and health education
sessions; health check-ups such as growth monitoring and promotion sessions; and livelihoods
or alternate income-generating activities. In order to increase the likelihood that recipients
can meet these conditions, an element of flexibility should be incorporated,
such as make-up sessions, nominating a family member to meet the condition
or delaying (but not cancelling) payments when possible. Staff should also
ensure that cash recipients are appropriately consulted and briefed about the
conditions, and that feedback mechanisms are in place.

A GUIDANCE NOTE 2
3. Integrated programming strategies
3.1 Cash-based programmes can contribute to improved nutrition outcomes for
mothers and children, but are most effective as part of an integrated approach that
includes behaviour-change programming and is linked to social safety nets. Cash can
lead to improved purchasing power, which can allow cash recipients to increase their spending
on WASH items, healthcare and nutritious food. However, it is education and behaviour change
communication that will enable cash recipients to improve their knowledge and practices
related to WASH, health and nutrition, and make informed decisions on how to spend the
cash. In addition, the access to and awareness of social safety nets and health systems is key to
ensuring mother and child health. Programmes should aim to align with or strengthen these
systems.
3.2 Social and behaviour change communication is a key component of cash
projects aimed at improving nutrition outcomes. Multi-pronged messaging
strategies should be employed, including community training sessions, messages
from health workers, and digital messages where appropriate. Key education topics
include: infant and child feeding, dietary diversity, WASH practices, maternal and child health,
household gardening and livelihoods skills. Face-to-face community-based education works
particularly well, because it allows cash recipients to engage and practice the skills that they are
being trained. Facilitators should have appropriate training in leading these education sessions,
and should ideally be based in the community. This would allow them to better conduct follow-
up visits to reinforce messaging and verify if the targeted knowledge and practices are being
employed.
3.3 The additional purchasing power provided by cash transfers, combined with
clinical treatment programmes for malnutrition and behaviour change sessions
can lead to improved health outcomes among mothers and children. Cash can
not only incentivise recipients to attend health sessions and allow recipients to better afford
medical care, but it may also directly help to reduce negative coping mechanisms and issues
such as food or RUTF sharing. In turn, this can contribute to increased child response rates to
malnutrition treatment programmes. Greater attendance at growth monitoring
sessions can also increase caregiver awareness of their child’s nutritional status.
In addition, increased spending on WASH NFIs, along with improved WASH
practices, and lead to improved health due to lower rates of communicable
diseases.
3.4 Continuous sensitisation and counselling for beneficiaries on how to spend
their money can encourage spending patterns that are in line with improving
nutrition outcomes. Strong messaging from programme staff about how to spend the cash
(this may depend on the context, but should include a focus on nutritious food and healthcare)
can encourage cash recipients to see cash as a means to improve their children’s nutrition.
If the programme has a livelihoods component, counselling on how to invest in livelihoods
and alternative income-generating activities should be a focus. Spending patterns should also
be systematically tracked to ensure that they are in line with programme objectives. If cash
recipients have clear needs that fall outside of the project objectives, the amount of cash
provided or the objectives of the project may have to be adjusted to account for this.

3 HOW CASH-BASED APPROACHES AFFECT NUTRITION OUTCOMES

3.5 Cash-based projects should include strategies for promoting the
sustainability of health and nutrition outcomes, since there is a risk that
quantity and quality of beneficiary diets may decrease once cash stops.
Although behaviour change related to hygiene and nutrition will likely lead to a
degree of sustainability, additional programming strategies should be included to
promote sustainability. Encouraging and supporting in improved livelihoods and
income-generating activities could enable more sustainable income generation after
cash ends. An additional stipend should be considered to support these activities. Additionally,
local health systems and social safety nets could be strengthened in order to promote
sustainability. Working closely with existing government services throughout the project can
increase alignment with existing health infrastructure.

4. Monitoring, evaluation and further research

4.1 Monitoring and evaluation strategies for cash-based programmes should be
set up at the design phase in order to better measure the impact of cash and
cash conditions on nutrition outcomes.This should include a longitudinal baseline,
endline, and post-project evaluation, if possible. PDM surveys should include questions
related to the targeted output and outcome indicators, so that this may be easily analysed
throughout the life of the project. A baseline, endline, and post-project evaluation should be
conducted in order to determine the effect of cash during the life of the project as well as after
the project is completed (to measure long-term outcomes). Indicators that should be tracked
include dietary diversity, employment of nutrition-related coping mechanisms, WASH behaviour/
practices, maternal health care and young child feeding practices, and child nutritional status
(including SAM recovery and relapse rates). In addition, ongoing market analyses should be
conducted in order to track the purchasing power of cash recipients and make programmatic
adjustments accordingly.
4.2 More research should be conducted into the gender-related aspects of cash
programming, including the role of men in improving maternal and child nutrition
outcomes, as well as how undernutrition may affect boys and girls differently. In
programmes that tackle undernutrition, mothers and women are highly targeted since they
are often the primary caregivers. However, there is some evidence that including men in
gender, health and nutrition sensitisation sessions may be an enabling factor
for improving overall nutrition incomes for children. More research is needed
on this topic. Also, in order for cash-based projects and nutrition sensitisation
sessions to maximise their effectiveness, the causes of gender differences in
malnutrition among target populations need to be fully understood.

A GUIDANCE NOTE 4
 This report was produced for:
World Vision
by:
Action Against Hunger UK’s Monitoring, Evaluation,
Accountability and Learning Services.
Author:
Elizabeth Smith
Technical Advisors:
Katherine Dunlop and Hannah Wichterich

For full copies of the report, please email

[email protected]