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‘Cash plus’ interventions have potential for greater impact than cash alone

New working paper identifies challenges and criteria for improving cash transfer programmes
cash plus  article main photo The Livelihood Empowerment Against Poverty (LEAP) programme provides cash to extremely poor households across Ghana to ease short-term poverty and encourage long-term human capital development.  

(5 September 2017) New Innocenti Working Paper: “How to Make ‘Cash Plus’ Work: Linking Cash Transfers to Services and Sectors”, sets out to evaluate what factors contribute to more successful ‘cash plus’ programme outcomes. 

The paper asserts that while cash transfers alone have contributed to numerous positive impacts in reducing poverty and promoting well-being, the provision of cash alone falls short in achieving long-term positive impacts on nutrition, learning, and morbidity. ‘Cash plus’ programmes aim to rectify this impact gap by complementing cash transfers with additional inputs, services, and linkages to other services in order to more effectively achieve successful outcomes and ensure long-term sustainability. The new working paper is a collaboration between the Centre for Social protection, Institute for Development Studies, the Transfer Project, the University of Ghana and UNICEF.

‘Cash plus’ programming evolved from the theory that while cash transfers can be effective alone in the most ideal circumstances, the effect of cash transfers can be constrained by behavioural mediators, such as financial security, or broader moderators, such as quality or availability of health services.  Cash transfers alone, for example, may not prompt effective behavioural change to ensure successful outcomes for better nutrition, education, or health – these moderators may need their own additional inputs in the form of infrastructure support to improve the quality and availability of services to recipients.  Complementing cash transfers with programmes to improve access and quality of services aims to address these gaps to augment the effects of income. 

Complementary inputs for ‘cash plus’ can include the provision of information, such as educational training or nutrition seminars for new mothers on best practices for feeding their children, as well as the provision of support, such as psycho-social counselling, and the facilitation of access to services, such as health insurance, or strengthening the quality of existing services and linkages.

[Ghana LEAP 1000 Impact Evaluation: Overview of Study Design]

The study aimed to identify criteria for successful ‘cash plus’ initiatives as well as challenges in development and delivery of such programmes, specifically targeting the health, nutrition, and education sectors.  The study reviewed the emerging evidence assessing the impact of ‘cash plus’ versus stand-alone cash and examined case studies in three countries:

Tia Palermo, social policy specialist at UNICEF Innocenti and co-author of the working paper, discussed how ‘cash plus’ programming in Ghana augmented existing transfers to include vulnerable mothers and children. “Innocenti is leading a study evaluating the LEAP programme extension studying pregnant and nursing mothers in Ghana. What we found is that these programs were not reaching households with young children since the previous program targeted the mostly vulnerable elderly population. In order to reach these households, the ‘cash plus’ programme, which included cash transfers ‘plus’ free access to healthcare, was extended to pregnant women and mothers of children under one year old in order to achieve greater impact on child stunting in the first 1000 days,” she said. “This is particularly a problem in Ghana.”

One aim of the LEAP ‘cash plus’ programme was to improve basic household consumption and nutrition and access to health care services. A need for complementary health insurance was identified after evidence of LEAP beneficiaries using their cash transfers to pay for high health insurance premiums, and often the cash transfers weren’t enough to cover that. The ‘cash plus’ intervention supplemented the cash benefit with free access to health insurance in Ghana. Previously, this wasn’t something impoverished mothers had access to in Ghana. 

The three case studies identified key factors that were likely to contribute to more effective ‘cash plus’ programmes:

  • Policy-level factors: including the importance of political champions in advocating for cash plus programmes and the establishment of formal agreements;
  • Programme-level factors: including the need for awareness and engagement on behalf of all parties involved, such as the availability of a skilled workforce and better resources;
  • Supply-side-level factors: including greater investment in availability and quality of services;
  • Fit-for-purpose interventions: meaning additional components should appropriately match their intended purpose and also take into account local considerations.

The paper concludes that the assessment of the three case studies indicates that effective implementation of ‘cash plus’ components has contributed to more successful programme outcomes. Where cash alone fails to address non-financial and structural barriers, ‘cash plus’ has the potential to contribute to greater, more sustainable impacts, overall. Through ‘cash plus’ programmes, the most vulnerable households living in poverty can be targeted beyond financial limitations.

While ‘cash plus’ proves to be a promising intervention for social protection, more innovative monitoring and evaluation is called for, especially to understand the impact of the many variations of ‘cash plus’ programming as well as identifying ways to examine the impacts of additional components in isolation from the cash benefit, as well as to gain more insight into how greater impacts can be achieved.

    Download the working paper here. For more information on cash transfer programmes and ‘cash plus’ studies, please visit our webpage on Social Protection & Cash Transfers and follow our partner project: Transfer Project. Follow @UNICEFInnocenti and @TransferProjct on Twitter for real-time updates on cash transfer social protection programmes.

     

     

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    The broad-ranging benefits of cash transfers are now widely recognized. However, the evidence base highlights that they often fall short in achieving longer-term and second-order impacts related to nutrition, learning outcomes and morbidity. In recognition of these limitations, several ‘cash plus’ initiatives have been introduced, whereby cash transfers are combined with one or more types of complementary support. This paper aims to identify key factors for successful implementation of these increasingly popular ‘cash plus’ programmes, based on (i) a review of the emerging evidence base of ‘cash plus’ interventions and (ii) an examination of three case studies, namely, Chile Solidario in Chile, IN-SCT in Ethiopia and LEAP in Ghana. The analysis was guided by a conceptual framework proposing a menu of ‘cash plus’ components. The assessment of three case studies indicated that effective implementation of ‘cash plus’ components has indeed contributed to greater impacts of the respective programmes. Such initiatives have thereby addressed some of the non-financial and structural barriers that poor people face and have reinforced the positive effects of cash transfer programmes. In design of such programmes, further attention should be paid to the constraints faced by the most vulnerable and how such constraints can be overcome. We conclude with recommendations regarding the provision of complementary support and cross-sectoral linkages based on lessons learned from the case studies. More research is still needed on the impact of the many variations of ‘cash plus’ programming, including evidence on the comparative roles of individual ‘plus’ components, as well as the knowledge, attitudes and behaviour pathways which influence these impacts.