In the past few years, the use of cash transfers in humanitarian crises has increased, partly due to the more complex and protracted nature of crises, a change that has only been increased through the COVID-19 pandemic (Aurino & Giunti, 2021). A substantial portion of humanitarian aid is targeted toward protracted crises in fragile and conflict-affected states (FCAS), where the national social protection capacity is often highly compromised due to security concerns, market dysfunction, corruption, data issues, and lack of trust (Aurino & Giunti, 2021).
In an increasingly uncertain world, conflict has become a major driver of not only humanitarian crises (Kurdi et al., 2019), but also serious public health issues. Conflict increases malnutrition, infant mortality, and infectious diseases, reduces life expectancy, access to health services, and proper WASH, and can have devastating effects on those with the most need for quality health care, such as women and children (Ramos Jaraba et al. (2020)). These effects have a wide reach, as disruptions in, for example, prenatal and sexual and reproductive health services can lead to pregnancy complications, increased maternal mortality, and an increase in teenage pregnancies, sexually transmitted infections, gender violence, and child marriages. (Ramos Jaraba et al., 2020.) To mitigate these effects, the Global Health Cluster and WHO Cash Task Team (2018) suggest that cash transfer programming (CTP) could be used to reduce barriers to health services in humanitarian settings.
The argument is supported by the International Committee of the Red Cross (ICRC, 2018) which argues that when used strategically, with clear goals in mind, cash can be an extremely versatile tool also in conflict-affected settings.
However, cash transfers alone may not achieve the outcomes in crises different actors are aiming for, and ‘cash plus’ programmes, offering additional components or linkages to existing services in addition to cash, may help address these shortcomings (Roelen et al., 2018; Little et al., 2021). ‘Cash plus’ is a more holistic approach to social protection, and by definition of Roelen et al. (2018), combines cash transfers with one or more types of complimentary support. This can mean
“components that are provided as integral elements of the cash transfer intervention, such as through the provision of additional benefits or in-kind transfers, information or behaviour change communication, or psychosocial support, and components that are external to the intervention but offer explicit linkages into services provided by other sectors, such as through the direct provision of access to services, or facilitating linkages to services” (Roelen et al., 2018).
‘Cash-plus’ interventions can be either solely implemented by humanitarian actors, or more in co-operation with the state social protection systems. There are some studies on the outcomes of ‘cash plus’ programmes on maternal and child health in FCAS. One of these is a recent, non-randomized, population-based intervention study by Edmond et al. (2019), that aimed to assess the impact of a programme conducted in six districts of Afghanistan by the government and UNICEF. The programme consisted of a cash transfer given to women for institutional delivery, and messages by trained health workers on the importance of professional intrapartum, antenatal and postnatal care. At the time, conflict levels were increasing and partly due to this the programme coverage remained poor. The only statistically significant increase was seen in the visits to antenatal care, which could indicate the importance of the health education component in this programme. The challenges caused by the conflict restricted movements and reduced the home visits of volunteering health workers, but the decrease was smaller in the intervention areas. This suggested that more research is needed to make sure that these types of interventions are truly progressive and inclusive (Edmond et al., 2019).
Another example (Kurdi et al. (2019)) examined Yemen’s Cash for Nutrition programme, which is a CCT programme implemented by the Yemen Social Fund for Development (SFD) targeting households of Social Welfare Fund (SWF) beneficiaries with children under 2 years or pregnant mothers to improve their nutritional outcomes. As the ‘plus component’, the intervention had local women working as community health educators, providing malnutrition screening and monthly nutrition education sessions on healthy child feeding and sanitation practices, which programme beneficiaries were required to attend. However, this was implemented as ‘soft conditionality, meaning that community health educators reach out to non-attendees. The programme had some effects on malnutrition, diet diversity, and early breastfeeding, with some spillover effects to the wider community. Based on this, Kurdi et al. (2019) concluded that a ‘cash plus’ intervention with nutritional education in a conflict setting can have significant positive impacts on maternal and child nutrition and child growth, with the greatest impacts among the poorest households included in the programme. They suggest ‘soft conditionality as a more encouraging alternative to unconditional or strictly conditional cash transfer programmes in conflict settings, without concern of negative impacts on families.
However, despite cash plus approaches being promising for health and wellbeing during conflicts as described above, conflict poses challenges to social protection systems and efforts. For example, Ethiopia´s Productive Safety Net Programme (PSNP) was particularly successful in Tigray region – before the conflict erupted in November 2020 (Lind 2022). Designed to address food security related to seasonal droughts, the PSNP was not able to respond to a sudden, severe conflict shock. Continuity of benefits was disrupted by degradation of response capacities – many ground-level workers were displaced, shops and banks closed or robbed, and markets were not operating. The humanitarian crisis was made worse by restrictions on humanitarian access in large areas due to damage to infrastructure and the threat of attacks on responders (Lind et al., 2022.) This highlights the complexity of cash approaches during conflicts.
Similar implementation challenges were also raised on the humanitarian and social protection efforts in Ukraine since the beginning of the conflict in Eastern Ukraine in 2014, with people in occupied areas not being able to collect their payments (Sojka et al. (2022)). During the war, the Ukrainian Government has quickly adapted its systems to be able to deliver payments, but large-scale displacement has posed significant challenges. There are many questions on how and what to deliver -how can payments be delivered to internally displaced people, refugees, and people in the occupied areas, are the transfers enough, are the markets functioning, and how much and what in-kind support is needed. While more understanding of the impacts of social protection during acute conflict and answers to implementation challenges are needed (Lind et al., 2022; Sojka et al., 2022) conducting research in these settings is extremely challenging.
The questions in these contexts include, for example, who can provide support and how much they are trusted; how existing social protection systems match with needed support; and how to graduate from small scale pilots to wider, conflict-resilient programmes (Lind et al 2022). Further, cash transfers alone cannot achieve the wider impacts for development, and more studies are needed on how social protection can be linked with complementary services and what are the outcomes in FCAS (Longhurst & Slater, 2022).
There is clearly a need for more evidence on how ‘cash plus’ interventions can improve maternal and child health outcomes in FCAS. Conflicts are a major factor in most of the current humanitarian crises in the world and pose unique challenges to social protection efforts, health – and research. Different actors in the humanitarian and social protection field require evidence on how cash transfers can be used to mitigate the negative health impacts of conflicts, and what are the contexts in which cash or ‘cash plus’ is the best and most viable option. As ‘cash plus’ shows great promise in changing the lives of mothers and children living amidst conflict for the better, innovative approaches for improving health outcomes when combining cash with other elements could truly make a difference. But urgent action is needed, as intertwining conflicts, climate change, pandemic and food crisis threaten millions now and in the near future.
Aurino, E. & Giunti, S. (2021). Social Protection for Child Development in Crisis: A Review of Evidence and Knowledge Gaps. The World Bank Research Observer, lkab007, https://doi.org/10.1093/wbro/lkab007
Edmond, K., Foshanji, A. I., Naziri, M., Higgins-Steele, A., Burke, J. M., Strobel, N., & Farewar, F. (2019). Conditional cash transfers to improve use of health facilities by mothers and newborns in conflict affected countries, a prospective population based intervention study from Afghanistan. BMC Pregnancy and Childbirth, 19(1), 193–193. https://doi.org/10.1186/s12884-019-2327-2
Global Health Cluster and WHO Cash Task Team. (March 5th, 2018). Working paper for considering cash transfer programming for health in humanitarian contexts. https://healthcluster.who.int/publications/m/item/working-paper-for-considering-cash-transfer-programming-for-health-in-humanitarian-contexts
International Committee of the Red Cross (ICRC). (2018). Cash Transfer Programming in Armed Conflict: The ICRC’s Experience. https://www.icrc.org/en/publication/cash-transfer-programming-armed-conflict-icrcs-experience
Idris, I. (August 30th 2017). Conflict-sensitive cash transfers: unintended negative consequences. Helpdesk Report. https://assets.publishing.service.gov.uk/media/59df6771e5274a11ac1c4964/200-Conflict-Sensitive-Cash-Transfers-Unintended-Negative-Consequences.pdf
Kurdi, S., Breisinger, C., Ibrahim, H., Ghorpade, Y. & Al-Ahmadi, A. (2019). Responding to conflict: Does “Cash Plus” work for preventing malnutrition?: New evidence from an impact evaluation of Yemen’s Cash for Nutrition Program. IFPRI Policy Brief. Washington, DC: International Food Policy Research Institute (IFPRI). https://doi.org/10.2499/9780896293601
Little, M.T., Roelen, K., Lange, B.C.L., Steinert, J.I., Yakubovich, A.R. & Cluver, L., et al. (2021) Effectiveness of cash-plus programmes on early childhood outcomes compared to cash transfers alone: A systematic review and meta-analysis in low- and middle-income countries. PLoS Med, 18(9): e1003698. https://doi.org/10.1371/journal. pmed.1003698
Longhurst, D. & Slater, R. (2022). Shock-Responsive Social Protection: What is Known About What Works in Fragile and Conflict-Affected Situations? BASIC Research Working Paper 5. Brighton: Institute of Development Studies. DOI: 10.19088/BASIC.2022.005
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Roelen, K., Palermo, T. & Prencipe, Leah. (2018). ‘Cash Plus’: Linking Cash Transfers to Services and Sectors. Innocenti Research Briefs no. 2018-19. https://www.unicef-irc.org/publications/976-cash-plus-linking-cash-transfers-to-services-and-sectors.html
Sojka, B., Harvey, P. & Slater, R. (March 15th 2022). Ukraine – can social protection be sustained and support a humanitarian response? https://cidt.org.uk/ukraine-can-social-protection-be-sustained-and-support-a-humanitarian-response/