The Research on Food Assistance for Nutritional Impact (REFANI) Project
According to the State of the World’s Cash Report, approximately 10% (2.8 billion USD) of all international humanitarian assistance in 2016 was used for cash-based interventions (CBI) – up 2.5% from 2015. The use of this intervention modality is quickly increasing, however, many knowledge gaps that still exist, particularly regarding their ability to: achieve nutrition objectives in young children, and protect household nutrition security against stress, shocks, or natural disasters. Aiming to strengthen the evidence base on the nutritional impact and cost-effectiveness of cash and voucher-based food assistance programs, as well as identify the mechanisms through which this effectiveness is achieved, partners came together to form the Research on Food Assistance for Nutritional Impact (REFANI) project.
The REFANI project implemented three complementary country study trials:
|Niger||Two-arm cluster randomized control trial of the effectiveness and cost-efficiency of early initiation and longer duration of seasonal unconditional cash transfers on child nutrition status.|
|Pakistan||Four-arm cluster randomized control trial of the effectiveness and cost-effectiveness of different cash transfers (standard cash, double cash, and fresh food voucher) programs on child nutrition status.|
|Somalia||Two-arm cluster non-randomized controlled trial of the effectiveness of an unconditional cash transfer on child nutrition status risk factors for undernutrition.|
In the Niger trial (results published in 2018), researchers found no difference in effect between the standard and earlier/extended interventions. The study team noted that peaks in disease prevalence, such as a sharp spike seen in the number of malaria cases over the intervention period, may have limited the effectiveness of the CBI in preventing undernutrition. This suggests that health factors may be key drivers in undernutrition in Niger and therefore, health-related interventions should be delivered in conjunction with CBIs to achieve an impact on protecting the nutrition status of children 6-59 months.
In the Pakistan trial (results published in 2017), researchers found that the larger amount of cash was the most effective for improving children’s weight-based growth in the short-term, however, these effects were not sustained over time, indicating that the larger amount of cash may only be effective at addressing short-term weight-based growth. Meanwhile, each of the CBIs demonstrated an impact on height-based growth, with all arms showing significant improvements in comparison to the control group, over both the short and longer-terms. The larger amount of cash was the most cost-efficient intervention, however when cost to beneficiaries were included, the most cost-efficient intervention was the voucher arm (cost-effectiveness results published in 2018.)
In the Somalia trial (results published in 2018), researchers found that diet diversity improved in children from the households who were receiving the cash intervention. Diet diversity and most food security indicators improved among mothers (or primary caregivers) in the cash intervention cluster. However, no significant reduction was observed in the risk of children becoming acutely malnourished in the camps receiving the cash intervention.
These REFANI country studies demonstrate the complexity of the pathways which lead to undernutrition, as well as the variety of ways in which CBIs may work in humanitarian contexts to protect the nutrition status of children. The trials contribute to the growing body of evidence that confirms the positive impacts cash transfers can have on aspects such as household expenditure, food security, diet diversity, and negative coping strategies; while illustrating that their impacts on key humanitarian indicators such as acute malnutrition are much more variable, less predictable, and highly dependent on context. For a complete overview of the results from this project, and implications for policy and practice, please refer to the REFANI Synthesis Report (please refer to the REFANI Summary Report for an abridged version).