The Impact of Maternal and Child Cash Transfers on Malnutrition - - PowerPoint PPT Presentation

The Impact of Maternal and Child Cash Transfers on Malnutrition

Evidence from the Randomized Controlled Trial of LEGACY Program (Dry Zone)

Elisa Maffioli, School of Public Health, University of Michigan December 2, 2019

Myanmar has one of the highest stunting rate in South East Asia 29% of children are stunted (DHS, 2015) Women lack:

• 1. Purchasing power
• 2. Knowledge on practices

Background

Focus: 1,000 days of life – pregnant mothers and their children under two years old.

• 1. Cash transfers
• 2. Social Behavioral Change Communication (SBCC)

Research: we measured impact of MCCT on health outcomes

Solution: Maternal and Child Cash Transfers (MCCT)

Cash transfers

• nly

Cash transfers + Social Behavioral Change Communication Comparison

• Timeline: 2016-2019
• Researchers: Elisa Maffioli (University of Michigan), Erica Field

(Duke University)

• Partners:

Project Information

• LEGACY: Learning, Evidence Generation, and Advocacy for

Catalyzing Policy

• Implemented by Save the Children
• Launched in April 2016
• Location: Pakokku, Yesagyo, Mahlaing Townships in the Dry Zone
• Eligible beneficiaries: pregnant women in 2nd or 3rd trimester

living in selected villages

Background

The LEGACY Program (Dry Zone)

• 1. Monthly Cash Transfers to mothers in their last two trimesters of pregnancy

until the child turns two years old (“first 1000 days”)

Ø Pact Global Microfinance (PGMF) delivered 10,000-15,000 MMK monthly

• 2. Monthly Social and Behavioral Change Communication (SBCC),

supplementing the cash transfers, covering topics including: IYCF, WASH, health care behavior and expenditures.

Ø Myanmar Nurses and Midwifes Association (MNMA) enrolled beneficiaries and delivered SBCC: mother groups, influential caregiver groups, individual counselling

Main elements

The LEGACY Program (Dry Zone)

Timeline

The LEGACY Program (Dry Zone)

Evaluating the LEGACY Program (Dry Zone)

The idea of the counterfactual illustrated

Population split into two groups

Before and After Comparison

Proportion of children well-nourished

The idea of the counterfactual illustrated

Population split into two groups

Study design

Evaluating the LEGACY Program (Dry Zone)

146 villages in 34 clusters 1,497 women interviewed 142 villages in 34 clusters 1,860 women interviewed 149 villages in 34 clusters 1,740 women interviewed T1 Cash only T2 Cash + SBCC C1 Comparison

Total sample: 5,097 women at Endline

• Anthropometric measures: stunting
• Dietary diversity
• Antenatal care (ANC) practices
• Infant and young child feeding (IYCF) practices
• WASH measures
• Other health and economic indicators

Outcomes

Studying LEGACY with a Randomized Evaluation (Dry Zone)

Results

Cash+SBCC Reduced Proportion of Children Stunted

No significant impacts for Cash-Only

30% 28.3% 26%*

0% 5% 10% 15% 20% 25% 30% 35% 40%

Comparison Cash Only Cash+SBCC

Proportion of Children Stunted (6-29 months old)

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

Cash+SBCC Reduced Proportion of Children Stunted

Impacts driven by moderately stunted children

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

30.0% 24.0% 6.0% 28.3% 22.5% 5.9% 26.0%* 19.6%** 6.5%

0% 5% 10% 15% 20% 25% 30% 35%

Proportion of Children Stunted Proportion of Children Moderately Stunted Proportion of Children Severely Stunted

Proportion of Children Stunted

Control Cash Only Cash+SBCC

Large Impacts For Families Receiving Program Longest

Gender differences are not robust

36% 39% 33% 32.5% 37.8% 25.9%** 30.6%* 36.7% 22.8%***

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Proportion of Children Stunted (Total) Proportion of Boys Stunted Proportion of Girls Stunted

Proportion of Children Stunted Whose Families Received Program the Longest (24-29 months old)

Comparison Cash Only Cash+SBCC

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

Cash+SBCC Effects Larger For Villages with Lower Average Education

36.0% 35.8% 28.0% 41.6% 14.4%***

0% 10% 20% 30% 40% 50%

Proportion of Children Stunted By Village’s Average Education Level

Control Cash (high avg. education) Cash (low avg. educatin) Cash+SBCC (high avg. education) Cash+SBCC (low avg. education)

Women’s level of education at village level

Comparison

Mechanisms

Which factors do explain these changes?

• Dietary diversity
• Antenatal care (ANC) practices
• Infant and young child feeding (IYCF) practices
• WASH measures
• Other health and economic indicators

Cash+SBCC Increased Mothers’ Dietary Diversity

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

28.0% 31.0% 42.8%***

0% 10% 20% 30% 40% 50%

Control Cash Cash+SBCC

Proportion of Mothers Meeting Minimum DDS for Women

3.940 4.046* 4.384***

3.7 3.8 3.9 4.0 4.1 4.2 4.3 4.4 4.5

Control Cash Cash+SBCC

Mothers’ Dietary Diversity Score

Comparison Comparison

Cash+SBCC Improved Children’s Dietary Diversity

Child Dietary Diversity

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

2.89 3.059 3.551***

1 2 3 4 Mean Child Dietary Diversity Score

34.0% 25.0% 45.0% 38.0% 30.6% 55.7% 52.6%*** 46.1%* 64.7%*** 0% 20% 40% 60% 80%

• Prop. of Children Meeting

Minimum DDS

• Prop. of Children Meeting

Minimum Acceptable Diet

• Prop. of Children Receiving Iron

Rich Foods

Control Cash Only Cash+SBCC

Cash+SBCC Increased Mothers’ Knowledge of Breastfeeding

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

94.0% 82.0% 79.0% 93.6% 88.3%*** 83.6%** 97.2%*** 90.2%*** 88.1%***

0% 20% 40% 60% 80% 100%

• Prop. of Mothers Who Know the Meaning of Exclusive

Breastfeeding

• Prop. of Mothers Who Know the Optimal Length of

Breastfeeding

• Prop. of Mothers Who Know the Best Time to

Introduce Complementary Feeding

Women’s Knowledge of Breastfeeding

Control Cash Cash+SBCC

Cash+SBCC Increased Mothers’ Practice of Exclusive Breastfeeding

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

50.0% 70.3%* 88.6%**

0% 20% 40% 60% 80% 100%

Comparison Cash Only Cash+SBCC

Percentage of Children Receiving Exclusive Breastfeeding (0-5 months)

Recipients In Both Groups Spent More on Food

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

21,809.48 23,256.27*** 25,244.69***

5,000 10,000 15,000 20,000 25,000 30,000

Comparison Cash Only Cash+SBCC

Expenditures on Food Consumption (last 7 days)

(+6.6%) (+15.7%)

Mothers in Both Groups Made More Visits for Antenatal Care

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

69.0% 78.1%*** 82.9%***

0% 20% 40% 60% 80% 100%

Comparison Cash Only Cash+SBCC

Percentage of Mothers with At Least 4 ANC Visits to Skilled Health Personnel

Cash+SBCC Increased Participants’ Hand-Washing Behavior

Cumulative score of all adopted practices (from 1 to 9)

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

2.51 2.631 3.001***

1 2 3 4 5 6 7 8 9

Comparison Cash Only Cash+SBCC

Average Score on Index of Hand-Washing Behavior

Households in Both Groups Reduced Informal Debt

*** statistically significant at 1%; ** statistically significant at 5%; * statistically significant at 10%

224,500.34 155,277.74*** 161,748.81*** 0.00 50,000.00 100,000.00 150,000.00 200,000.00 250,000.00 Comparison Cash Only Cash+SBCC Amount of Informal Debt (MMK, last 12 months)

The Government Model

Cash delivered by midwifes

§ Government Model: cash delivered by midwifes § Microfinance Model: cash delivered by PGMF § Pakokku township: 40 GOV villages vs 48 Cash-Only villages § We select comparable villages in the two models

The Government Model

Cash delivered by midwifes

50.0% 11.0% 8.6% 76.0% 15.0% 44.0% 10.6% 5.5%* 94.4%** 5.6%** 0% 20% 40% 60% 80% 100% Woman Meets All Eligibility Criteria Inclusion Error: Woman Not Pregnant or Not a Resident in Treatment Area Exclusion Error: Woman is Pregnant and a Resident in Treatment Area Woman Received Full Frequency and Amount

• f Transfers

Woman Exited Program

MFI (cash only) Gov

16.3 18.3** 2 4 6 8 10 12 14 16 18 20

• No. of Transfers (Based on

Enrollment Date)

Key Takeaways

• 1. Cash transfers aiming to benefit young children should be

combined with SBCC.

• According to monitoring data, more than 90% of enrolled

women participated in SBCC (81% attended 5 times or more).

• 99.6% of mothers reported to be responsible to make

decisions on cash transfer amount.

• Cash transfers alone may not be enough to influence mothers’

behavior and children’s health outcomes.

Importance of SBCC

Policy Lessons

• 2. Results underscore the importance of reaching children in the

first 1,000 days of life.

• Impacts of the program are more pronounced in children that

received nearly 30 months of cash and SBCC exposure.

Importance of first 1,000 days of life

Policy Lessons

Q&A

Contact Elisa Maffioli elisamaf@umich.edu Contact (IPA) Ricardo Morel rmorel@poverty-action.org