Watson Institute for International and Public Affairs

Assessing Impact of Cash Transfer Programs in Reducing Child Malnutrition in Somalia IDP Camps

As a result of a prolonged state of conflict and instability, and exacerbated by natural disasters, Somalia has the highest prevalence of malnutrition worldwide. The people most affected by malnutrition and food insecurity are often internally displaced persons (IDPs). In a collaboration between the Institute for Global Health at University College London and Concern Worldwide, the Research on Food Assistance for Nutritional Impact, Somalia (REFANI-S) study is looking at whether the distribution of an unconditional emergency cash transfer program (CTP) reduces the risk of developing acute malnutrition in children living in IDP camps, aged 6-59 months, in the Afgoye Corridor region, close to Mogadishu. HI² International Fellow Mohamed Jelle, who is the study coordinator of REFANI-S, shares insight on this ongoing research project.

Q&A with Mohamed Jelle (HI² International Fellow)

HI² -- I understand you are currently carrying out a study with the Research on Food Assistance for Nutritional Impact Consortium (REFANI) in Somalia. Can you please tell us about the study design, aims and your primary research question?

Mohamed Jelle -- REFANI-Somalia (REFANI-S) study is a non-randomized, cluster controlled trial to assess the impact of cash transfer programmes in reducing the risk of acute malnutrition in children aged 6-59 months living in internally displaced person (IDP) camps. The primary research question is: Does distribution of cash reduce the risk of developing acute malnutrition in IDP children aged 6-59 months living in a peri-urban area of Mogadishu, Somalia? For more information, please visit the REFANI-S page.

HI² -- Who are the members of the REFANI consortium and who are the donor agencies funding this research project?

Mohamed Jelle -- The REFANI Consortium is comprised of Action Against Hunger, Concern Worldwide, ENN and the University College London (UCL). REFANI is a 3-year research project funded by the Department for International Development (DFID) and co-financed through humanitarian aid from the European Commission (ECHO). For more information, please refer to the REFANI website.

HI² -- In addition to the Somalia study, is REFANI conducting similar studies in other countries? 

Mohamed Jelle -- Yes, the REFANI project is implementing two additional country studies: (1) Niger; where UCL and Concern Worldwide are implementing a cluster randomized control trial (cRCT) on the effectiveness and cost-effectiveness of early initiation and longer duration of emergency/seasonal unconditional cash transfers on children’s nutritional status; and (2) Pakistan; where Action Against Hunger and ENN are implementing a cRCT on the effectiveness and cost-effectiveness of different cash transfer modalities and amounts on children’s nutrition status.

HI² -- What are some of the benefits and/or challenges of doing research in a consortium that is comprised of both academic institutions and NGOs? How is the management structure organized?

Mohamed Jelle -- Both academic institutions and NGOs are contributing their areas of expertise to the studies. For example, academic partners have research expertise and hence lead the design, implementation, and technical follow-up of the studies, whereas the NGOs have operational experience in the study countries and thus provide the administrative, logistics, finance and HR support. They also help with stakeholder engagement since they have been working in these countries for many years. A minor challenge is balancing different priorities and reporting timelines, which if not managed well, can create delays.

The management structure of the REFANI consortium is essentially a three tier system. At the country levels, the studies are managed by a team hired by the operational partners in their respective countries with technical support from the research institutions. At the international level, the consortium activities are coordinated by a research coordinator based in New York with the lead agency. Technical support is provided by advisors from the operational partners, while overall responsibility for the research lies with the principal investigators from the research institutions. The consortium is also supported by a Nutrition Research Steering Committee (NRSC) which provides guidance and input into all studies. This committee includes invited members from key stakeholder organizations and meets annually.

HI² -- What are the main challenges of doing research in an insecure environment like Somalia?

Mohamed Jelle -- These include, but are not limited to; restrictions on movement to field sites, difficulties in planning, variable in-country capacity/experience for implementing research, different funding streams for the research activities and the interventions, and population mobility.

HI² -- Can you please share with us the main components of the REFANI-S Study?

Mohamed Jelle -- The REFANI-S study has four components which are:

  • Surveys to measure the prevalence of risk factors for acute malnutrition in households that are receiving cash transfers compared to non-recipients;
  • A community surveillance system, using community health workers (CHWs), to measure the incidence of acute malnutrition (MUAC <12.5 cm) in children living in the intervention and control clusters for 4-6 months;
  • A process evaluation to detail the delivery of the cash transfer programme; and
  • A qualitative study to gain in depth understanding of the perceptions of malnutrition, its risk factors and the mechanisms by which cash transfers may operate to change these risk factors.

HI² -- Specifically, what is your role in the REFANI-S study?

Mohamed Jelle -- As the study coordinator, I contributed to the development of the study protocol and budget, team recruitment, training, piloting of research tools, and the supervision of the actual data collection on the ground. I also present the REFANI-S study in relevant national, regional, and international forums. Lastly, I support data cleaning, analysis, reporting, and writing of papers for publication.

HI² -- Can you share with us any preliminary results from this study?

Mohamed Jelle -- At present, we have completed one of the four REFANI-S study components, namely the surveys. Two surveys were implemented, one in March and another in September 2016. The initial survey included 240 households from 20 camps of which 231 (96%) were followed-up in the final survey; with a sample of 333 children and their mothers/carers (228 women). Our preliminary analysis suggests that cash distributions had a strong positive impact on the food security of the households, as a whole, and of women and children in the period of about six months.

In brief, when compared with non-beneficiary households, those receiving cash distributions showed an increase in their food diversity, consuming a diet with an average of one more food group (mainly the meat/fish/eggs and vegetable food groups). Beneficiary households also showed an increase in the availability of foods, as denoted by a greater food consumption score, with beneficiary households reporting a greater consumption of the food groups’ meat, fish and eggs, vegetables, and fats and oils than non-beneficiary households (1.5, 1.3 and 1 days more for each food group, respectively). We found similar results in women and children where their food diversity was also increased by the consumption of one more food group.

Similarly, we observed that coping mechanisms associated with food insecurity were lower among households receiving cash. That is, in a 7-day period, households receiving cash engaged less in restricting adult food consumption in order for children to eat, reducing the number of meals eaten in a day or limiting the portion sizes at mealtimes by almost two days in each coping strategy. Also, households receiving cash reported to engage less in borrowing food or relying on help from friends/family by a similar number of days.

However, despite the strong impact of cash transfers on food security indicators, we did not observe a similar impact on the nutritional status of the children in the survey sample. On this last observation, it is important to note that the surveys component was not designed in sample size to be able to detect a change in the nutritional status of children. This change in nutritional status will be assessed more accurately by looking at the difference in the incidence of malnutrition from data obtained by the community surveillance system. This analysis is currently the next step in our REFANI-S work. 

HI² -- Are there specific lessons learned from the REFANI Studies that may be useful in conducting future humanitarian focused research in the future?

Mohamed Jelle -- Given that we have not finalized the analysis, we cannot state confidently which other specific areas of research should be looked into for future projects. However, the REFANI Consortium has had many experiences in overcoming challenges of working as a consortium, and conducting research in difficult contexts, which we hope will be very valuable to others who are looking to pursue research in humanitarian fields. Furthermore, the Consortium has been working together to raise the visibility of the project and its results by implementing a thorough research uptake strategy (globally, regionally and locally) and this may also provide insights for projects committed to increasing the dissemination of their results.