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Evidence and Guidance Note on the Use of Cash and Voucher Assistance for Nutrition Outcomes in Emergencies (August 2020)

Nutrition Cluster
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Executive Summary

Evidence Note

There is a growing recognition that Cash and Voucher Assistance (CVA) can contribute to improving maternal and child nutrition by impacting on the underlying determinants of adequate nutrition. This can occur in three main ways.

  1. CVA allows targeted households and individuals to purchase goods and access services that can have a positive impact on maternal and child nutrition.
    These include nutritious foods, items to prepare food, hygiene items, safe water, health services and medication, transportation, and productive inputs.

  2. If provided conditionally, CVA can improve participation in nutrition Social Behaviour Change (SBC) activities and attendance to priority preventive health services.

  3. Further, the increase in household income associated with CVA can reduce economic pressures and household tensions, in turn increasing the time available for caregiving, enhancing women’s decisionmaking power, and improving psychological wellbeing of caregivers.

CVA can be effective in addressing economic barriers to adequate nutrition. These include financial barriers related to the lack of purchasing power at the household level to access goods and services, as well as opportunity costs of care giving behaviours. The potential of CVA to address economic barriers depends on a functioning supply side (e.g. the availability of nutritious foods in the market). The precise pathways of how CVA impacts nutrition are to a large extent determined by the spending decisions of households and individuals, which are again determined by social and cultural norms, programmatic decisions in relation to design and targeting and other contextual factors.

There is a sizable and growing body of evidence about CVA and nutrition outcomes, derived mainly from development settings but increasingly also from humanitarian settings. The evidence base for the impact of CVA on acute and chronic malnutrition is mixed. At the level of immediate determinants of nutrition, the evidence for the impact of CVA on the dietary diversity of children is mostly positive, while the evidence for impact on the health status of children is limited. At the level of underlying determinants, the evidence for the impact of CVA on household food security indicators and the uptake of preventative health services is relatively strong and mostly positive. There is no evidence for an impact of CVA on care behaviours.

Based on the existing evidence, there is a broad consensus within the nutrition sector that CVA alone is in most circumstances not sufficient to impact nutrition outcomes. CVA is most effective when complemented with other nutrition-specific and nutrition-sensitive interventions. Based on this consensus, many humanitarian organizations have developed cash plus or complementary programming approaches that call for household cash transfers to be complemented by additional measures to holistically address the most important demand and supply-side barriers.

Based on a review of peer-reviewed studies and operational examples, this Evidence Note identifies five main approaches to integrate CVA in nutrition response to prevent or treat malnutrition. These approaches can sometimes form the basis of a response on their own, can be combined with each other, or can be part of a wider integrated response. They include:

  • Use CVA for household assistance and/or individual feeding assistance: CVA modalities can be considered for both components with important limitations on individual feeding assistance. Combining household cash transfers with specialised nutritious foods is a promising approach to prevent malnutrition that warrants further exploration. Also, various humanitarian organizations have had positive operational experiences with the provision of fresh food vouchers to diversify diets.

  • Combine household CVA with SBC interventions: There is relatively strong evidence that combining household cash transfers with SBC can be an effective strategy to prevent child malnutrition. The two components seem to mutually reinforce each other in the sense that SBC activities seem to promote child/women-centred spending decisions, while the cash transfers allow caregivers to put some of their acquired knowledge and skills into practice. Therefore, CVA modalities that aim to contribute to nutrition outcomes need to be accompanied with context-specific SBC interventions.

  • Provide conditional cash transfers as an incentive to attend to priority health services: There is relatively strong evidence (mainly from development settings) that cash transfers conditional on the attendance of free priority preventative health services can improve the uptake of these services.

  • Cash or vouchers to facilitate access to treatment of malnutrition: CVA can be effective in addressing indirect costs to accessing treatment of malnutrition related to transportation as well as food and accommodation if the child requires in-patient care and the caregiver needs to stay at the treatment centre.

  • Provide household cash or vouchers as part of treatment of severe acute malnutrition (SAM): The provision of household CVA to caregivers who bring their child for the treatment of SAM has demonstrated potential to improve recovery and reducing defaulting and nonresponse to treatment. At the same time, there is anecdotal evidence that some caregivers may keep or make their child malnourished in order to access assistance.

Guidance Note

The Guidance Note identifies seven steps throughout the humanitarian programme cycle and four transversal issues that need to be considered when incorporating CVA in a nutrition response. All steps require close collaboration and coordination between the nutrition sector, the Cash Working Group (CWG), and other sectors notably food security, health, WASH and protection. The nutrition cluster/sector coordination team is responsible for the overall coordination of CVA components of a nutrition in emergency response.

  • In the first step, the sector needs to determine whether CVA can contribute to nutrition outcomes by analysing the role of economic barriers in maternal and child malnutrition.
    Nutrition assessment tools as well as tools from other sectors can help to gain a comprehensive overview of barriers to adequate nutrition, including economic barriers.

  • In the second step, the feasibility of using CVA as part of a nutrition response is determined. The feasibility assessment should be primarily based on already available information on the capacity of markets for the supply of food and non-food items, the availability of health and delivery services, the availability of transfer mechanisms and other feasibility considerations.

  • In the third step, feasible CVA approaches should be included in the response options analysis. While CVA does not change the way nutrition practitioners define objectives and select nutrition response options, they are additional modalities to be considered. In contexts where communities face economic barriers to the underlying determinants, feasible CVA modalities and approaches should be considered as part of response options analysis.

  • In the fourth step, the CVA component of the response is designed. The quality of design of the CVA component is a major contributor to its potential impact on maternal and child nutrition. Design decisions need to be taken regarding targeting, conditionality, transfer amount, frequency, timing and duration. Targeting criteria are largely determined by the programme objectives and type of response rather than the assistance modality. When considering conditionality to enhance participation in SBC activities and attendance to priority health services, the expected benefits of introducing the conditionality, i.e. improved participation or uptake, need to be weighed against estimated costs, resource requirements and other factors. A softer approach to conditionality can reduce costs and resource requirements and might be a more suitable approach in emergency settings. While transfer amount, duration and frequency of transfers depend on the objective of the CVA component, more generous transfers, a longer duration and more regular transfers are more likely to have a positive impact on nutrition.

  • Steps five, six and seven cover the mobilization of resources, and the implementation and monitoring of the CVA component. The implementation of the CVA component should follow existing organizational guidelines and procedures and available best practice. The definition of indicators to monitor nutrition outcomes depends on the programme objective and is not tied to the assistance modality. When the CVA component aims to provide access to a nutritious diet, it is important to measure dietary diversity and food consumption at the level of children and women to be able to capture intra-household differences. Furthermore, the use of CVA needs to be monitored to understand whether the assistance was used to access nutrition relevant goods and services.

Transversal issues cut across the humanitarian programme cycle and include preparedness, coordination, information management and risk analysis and mitigation. Preparedness actions should be extended to CVA in contexts where cash and/or vouchers are likely to be feasible and adequate response options in nutrition in emergencies. All relevant risks of the CVA component need be identified and measures to mitigate these need to be adopted. Most risks associated with CVA can be mitigated through project design and a strong accountability framework.

With the rapidly increasing use of household cash transfers (including multi-purpose cash (MPC)) in humanitarian response, there is an opportunity to better incorporate nutrition considerations in cash-based responses. Household cash transfers alone, including MPC, should not be expected to contribute to nutrition outcomes of individual household members. However, different measures can be taken to increase the likelihood that they do. These measures include the integration of context-specific SBC with household cash transfers; appropriately reflecting nutrition in the minimum expenditure basket and transfer amount calculation; choosing nutrition sensitive targeting criteria; and including nutrition objectives and indicators in the project design.