evidence-based blog of Filippo Dibari

Posts Tagged ‘cash & vouchers’

Impact on birth weight and child growth of Participatory Learning and Action women’s groups with and without transfers of food or cash during pregnancy: Findings of the low birth weight South Asia cluster-randomised controlled trial (LBWSAT) in Nepal

In Under-nutrition on May 10, 2018 at 8:31 pm

from PlosOne website




Undernutrition during pregnancy leads to low birthweight, poor growth and inter-generational undernutrition. We did a non-blinded cluster-randomised controlled trial in the plains districts of Dhanusha and Mahottari, Nepal to assess the impact on birthweight and weight-for-age z-scores among children aged 0–16 months of community-based participatory learning and action (PLA) women’s groups, with and without food or cash transfers to pregnant women.


We randomly allocated 20 clusters per arm to four arms (average population/cluster = 6150). All consenting married women aged 10–49 years, who had not had tubal ligation and whose husbands had not had vasectomy, were monitored for missed menses. Between 29 Dec 2013 and 28 Feb 2015 we recruited 25,092 pregnant women to surveillance and interventions: PLA alone (n = 5626); PLA plus food (10 kg/month of fortified wheat-soya ‘Super Cereal’, n = 6884); PLA plus cash (NPR750≈US$7.5/month, n = 7272); control (existing government programmes, n = 5310). 539 PLA groups discussed and implemented strategies to improve low birthweight, nutrition in pregnancy and hand washing. Primary outcomes were birthweight within 72 hours of delivery and weight-for-age z-scores at endline (age 0–16 months). Only children born to permanent residents between 4 June 2014 and 20 June 2015 were eligible for intention to treat analyses (n = 10936), while in-migrating women and children born before interventions had been running for 16 weeks were excluded. Trial status: completed.


In PLA plus food/cash arms, 94–97% of pregnant women attended groups and received a mean of four transfers over their pregnancies. In the PLA only arm, 49% of pregnant women attended groups. Due to unrest, the response rate for birthweight was low at 22% (n = 2087), but response rate for endline nutritional and dietary measures exceeded 83% (n = 9242). Compared to the control arm (n = 464), mean birthweight was significantly higher in the PLA plus food arm by 78·0 g (95% CI 13·9, 142·0; n = 626) and not significantly higher in PLA only and PLA plus cash arms by 28·9 g (95% CI -37·7, 95·4; n = 488) and 50·5 g (95% CI -15·0, 116·1; n = 509) respectively. Mean weight-for-age z-scores of children aged 0–16 months (average age 9 months) sampled cross-sectionally at endpoint, were not significantly different from those in the control arm (n = 2091). Differences in weight for-age z-score were as follows: PLA only -0·026 (95% CI -0·117, 0·065; n = 2095); PLA plus cash -0·045 (95% CI -0·133, 0·044; n = 2545); PLA plus food -0·033 (95% CI -0·121, 0·056; n = 2507). Amongst many secondary outcomes tested, compared with control, more institutional deliveries (OR: 1.46 95% CI 1.03, 2.06; n = 2651) and less colostrum discarding (OR:0.71 95% CI 0.54, 0.93; n = 2548) were found in the PLA plus food arm but not in PLA alone or in PLA plus cash arms.


Food supplements in pregnancy with PLA women’s groups increased birthweight more than PLA plus cash or PLA alone but differences were not sustained. Nutrition interventions throughout the thousand-day period are recommended.

Trial registration


School Feeding: Can stunting be reversed? Yes, and Peru is showing us how

In Under-nutrition on October 27, 2014 at 7:59 am

From the web site of Schools & Health.


Children affected by the 2008 food crisis in Peru show stunting can be reversed. Is it time to focus beyond the first 1,000 days?

In 2008 there was a terrible food crisis in Peru. The price o​f rice doubled in three months and millions of families were struggling to put food on the table. Six years on, thousands of Peruvian children who were babies and toddlers during the food crisis are much smaller than they should be. And for many, their cognitive skills development has been negatively affected too.

Children’s bodies and brains develop fastest when they’re in the womb and during the first two years of their lives: the first thousand days. And it’s during this crucial period that physical stunting and cognitive impairment can really set in if pregnant mothers and babies miss out on adequate nutrition.

Research has suggested that early stunting and its effects are irreversible. So will these Peruvian children’s futures be permanently blighted because they weren’t getting enough to eat when they were little?

At Young Lives we’ve been studying the progress of 12,000 children in Peru, Vietnam, Ethiopia, and India – measuring all aspects of their physical, cognitive, and social development since 2002. We’ve been following the development of children who were undernourished early in their lives and we’ve discovered that the effects of early undernutrition aren’t always irreversible. Some children in our studies were able to recover from early stunting and develop normally.

In particular, our results show that around 50% of children in Peru who were stunted in 2002, when they were around a year old, were not stunted in 2009. The same figure was around 45% for India.

So while the first thousand days are very important, the rest of a child’s life is too. It now seems clear that children can recover from stunting after their first thousand days.

Our findings indicate that factors like household income, maternal education and health, local water, sanitation and health infrastructure, which are key to stunting prevention, are also important for recovery from stunting.

Recovery from stunting after the first thousand days may also lead to the reversal of developmental setbacks such as cognitive impairment. Our findings suggest that children who recovered from early stunting performed better in vocabulary and mathematics tests than children who remained stunted.

School meals, cash transfer and health programmes can help

This and other evidence suggests that school feeding programmes may help undernourished children to recover from stunting. Young Lives fin​dings show that India’s national school feeding programme helped children to recover from a decline in growth due to a severe drought when they were one-year-old. In Peru, national feeding programmes, such as Qali Warma and Vaso de Leche may have helped children who became stunted as a result of the food crisis to recover.

Conditional cash transfer programmes that provide financial incentives to poor households to invest in children’s health may also be a powerful instrument in the fight against child undernutrition​. An example of such a programme in Peru is Juntos, which requires that children below the age of five in families that receive the support, must attend health facilities for comprehensive healthcare and nutrition.

To prevent stunting, there are potential benefits to extending the coverage of early child development programmes to older children. For example, Cuna Mas in Peru, which aims to improve development for children living in poverty, could be extended from children younger than three to children younger than six-years-old.

There’s no doubt about the importance of the first thousand days for a child’s growth and development, so nutrition intervention needs to start early. But intervention shouldn’t always end when the child reaches two. It needs to be sustained throughout childhood and target the most stunted and undernourished children so they have a decent chance to recover.​

Financial incentives and coverage of child health interventions: a systematic review and meta-analysis

In Under-nutrition on November 29, 2013 at 3:28 pm


by Diego G Bassani, Paul Arora, Kerri Wazny, Michelle F Gaffey, Lindsey Lenters, Zulfiqar A Bhutta

BMC Public Health 2013, 13(Suppl 3):S30

(download the paper)


Background: Financial incentives are widely used strategies to alleviate poverty, foster development, and improve health. Cash transfer programs, microcredit, user fee removal policies and voucher schemes that provide direct or indirect monetary incentives to households have been used for decades in Latin America, Sub-Saharan Africa, and more recently in Southeast Asia. Until now, no systematic review of the impact of financial incentives on coverage and uptake of health interventions targeting children under 5 years of age has been conducted. The objective of this review is to provide estimates on the effect of six types of financial incentive programs: (i) Unconditional cash transfers (CT), (ii) Conditional cash transfers (CCT), (iii) Microcredit (MC), (iv) Conditional Microcredit (CMC), (v) Voucher schemes (VS) and (vi) User fee removal (UFR) on the uptake and coverage of health interventions targeting children under the age of five years.

Methods: We conducted systematic searches of a series of databases until September 1st, 2012, to identify relevant studies reporting on the impact of financial incentives on coverage of health interventions and behaviors targeting children under 5 years of age. The quality of the studies was assessed using the CHERG criteria. Metaanalyses were undertaken to estimate the effect when multiple studies meeting our inclusion criteria were available.

Results: Our searches resulted in 1671 titles identified 25 studies reporting on the impact of financial incentive programs on 5 groups of coverage indicators: breastfeeding practices (breastfeeding incidence, proportion of children receiving colostrum and early initiation of breastfeeding, exclusive breastfeeding for six months and duration of breastfeeding); vaccination (coverage of full immunization, partial immunization and specific antigens); health care use (seeking healthcare when child was ill, visits to health facilities for preventive reasons, visits to health facilities for any reason, visits for health check-up including growth control); management of diarrhoeal disease (ORS use during diarrhea episode, continued feeding during diarrhea, healthcare during diarrhea episode) and other preventive health interventions (iron supplementation, vitamin A, zinc supplementation, preventive deworming). The quality of evidence on the effect of financial incentives on breastfeeding practices was low but seems to indicate a potential positive impact on receiving colostrum, early initiation of breastfeeding, exclusive breastfeeding and mean duration of exclusive breastfeeding. There is no effect of financial incentives on immunization coverage although there was moderate quality evidence of conditional cash transfers leading to a small but non-significant increase in coverage of age-appropriate immunization. There was low quality evidence of impact of CCT on healthcare use by children under age 5 (Risk difference: 0.14 [95%CI: 0.03; 0.26]) as well as low quality evidence of an effect of user fee removal on use of curative health services (RD=0.62 [0.41; 0.82]).

Conclusions: Financial incentives may have potential to promote increased coverage of several important child health interventions, but the quality of evidence available is low. The more pronounced effects seem to be achieved by programs that directly removed user fees for access to health services. Some indication of effect were also observed for programs that conditioned financial incentives on participation in health education and attendance to health care visits. This finding suggest that the measured effect may be less a consequence of the financial incentive and more due to conditionalities addressing important informational barriers.

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