Yemen’s ‘Cash for Nutrition’ programme

Yemen is the world’s largest humanitarian crisis, with 24 million out of 30 million Yemenis needing assistance and 1.8 million children acutely malnourished. The civil war has led to price increases, lost income and reduced public health provision, exacerbating already high levels of poverty and child malnutrition.

With rising humanitarian needs, continued access challenges and funding shortfalls, national institutions are playing an increasingly important role in providing humanitarian aid. At the World Humanitarian Summit in 2016 the long-standing divide between humanitarian and development interventions was challenged, with a call for new collective responses that both meet humanitarian needs and protect human and social capital. As the Yemen response shifts towards more protracted crisis programming, the need for a social protection system that provides a reliable, predictable, effective response to the country’s poorest and most vulnerable people is becoming increasingly urgent.

The Yemen Emergency Crisis Response Project (ECRP) was the first World Bank project to test this approach before developing a full emergency response package. Approved in 2016, the ECRP works through UN agencies, national social protection institutions, the private sector and local communities. It is also increasingly driving transformational policy reform to improve nexus programming and build local governance capacity for social assistance delivery.

The Social Fund for Development ‘Cash for Nutrition’ intervention

One key Yemeni institution supported under the ECRP is the Social Fund for Development (SFD). Established in 1997, the SFD is a quasi-governmental organisation with a strong reputation as an independent and neutral actor able to operate across the country. Its objectives are to improve basic services, enhance economic opportunities and reduce the vulnerability of poor Yemenis through a community-led development approach.

SFD’s ‘Cash for Nutrition’ intervention is an example of how local agencies in countries affected by protracted conflict can successfully blend models from the development world with the flexible implementation a crisis context requires. The programme was originally designed as a reaction to high levels of child stunting and poverty, but after the conflict broke out it was rapidly expanded and incorporated into the Yemen ECRP supported by the World Bank. As of mid-2019, 88,000 impoverished mothers in 21 districts across Yemen had received cash transfers and nutritional training through the programme, and more than 115,000 malnourished women and children had received treatment. A new wave of implementation planned for 2020–2021 will include an additional 17 districts.

The programme provides beneficiary women with children under five with one year of monthly cash transfers and nutritional training sessions led by locally recruited Community Health Volunteers trained and employed by the programme. Beneficiaries also receive help to access treatment centres if their children are diagnosed with malnutrition.

Impact evaluation findings

An impact evaluation of the ‘Cash for Nutrition’ programme was designed and initiated prior to the conflict and completed by the SFD in collaboration with the International Food Policy Research Institute in 2018. See Sikandra Kurdi, Yashodhan Ghorpade and Hosam Ibrahim, The cash for nutrition intervention in Yemen: impact evaluation study, MENA RP Working Paper 19 (Washington, DC and Cairo: International Food Policy Research Institute (IFPRI), 2019) (https://doi.org/10.2499/p15738coll2.133219). The evaluation showed the decline in household welfare between the start of the pilot programme in 2015 and the second round of data collection in 2017, as well as significant positive impacts of the programme on both immediate consumption and more long-term indicators of well-being.

Rather than increasing consumption of the types of staple foods usually distributed in food baskets, households in the programme used the cash to maintain the nutritional quality of their diets. In the poorest households in the sample, the evaluation found that, relative to non-beneficiaries, households receiving the cash transfer bought significantly more milk, fruits and vegetables and eggs, and were more likely to report having consumed meat at least once a week. Relative to non-beneficiary households, child dietary diversity for participating households was 0.8 food groups higher at the follow-up, partially making up for the background decrease of 1.3 food groups seen between the pre-conflict baseline and 2017 follow-up.

The evaluation also found that the nutritional training improved some key practices targeted by the Community Health Volunteers. Relative to non-beneficiaries, beneficiaries were more likely to report early initiation of breastfeeding and exclusive breastfeeding for infants under six months, both of which are associated with lower child mortality. They were also more likely to treat their drinking water and to give infants formula or breastmilk more frequently.

Finally, among the poorest third of households, the evaluation found substantial and statistically significant impacts on height-for-age z-scores, indicating an improvement in children’s long-term nutritional status.

Policy lessons for protracted crisis contexts

The conflict affected not only the welfare of the population being served by the ‘Cash for Nutrition’ programme, but also the implementation of the programme itself. The programme has reacted to the challenges presented by the security situation by becoming more flexible. In areas of active conflict where there is a risk of air strikes, group nutritional training sessions have been replaced with home visits and cash transfers are distributed at less frequent intervals. The programme also opened a telephone hotline to respond to questions about the changing situation, and allowed women who were forced to leave their homes due to the conflict to participate in training sessions and receive cash transfers in other districts where the programme is active.

In general, cash transfers are easier to deliver and generally perceived to be preferable to food distributions, but they rely on functional markets. Bailey and K. Hedlund, The impact of cash transfers on nutrition in emergency and transitional contexts: a review of evidence (London: ODI, 2012).

While conflict may destabilise markets and mean that in-kind aid delivery is preferable in the short term, in countries in protracted conflict cash transfers may often be feasible, reflecting the resilience of economic activity even in the face of increased transportation and transaction costs. For the districts where data was collected, the evaluation confirmed that there were no significant changes in the availability of key food items, although the average price level increased. (The evaluation did not find that the cash transfers themselves had affected prices.)

This study offers some important findings that further the evidence base on cash and nutrition programming. Compared to the conditional cash transfer programmes popular in development circles in stable countries, the ‘Cash for Nutrition’ programme demonstrated the effectiveness of a flexible approach labelled ‘soft conditionality’. Beneficiaries were formally required to attend the training sessions, but the programme did not withhold the cash transfers in the case of non-attendance. Nevertheless, attendance at the training sessions was high and the programme succeeded in increasing awareness and changing behaviour. The evaluation also helped to map the pathway from cash and training to improved nutrition outcomes.

Strengthening national institutions

The success of the ‘Cash for Nutrition’ programme also highlights the importance of local institutions for sustainability. The ability to implement the programme in the unstable and constantly changing political conditions in Yemen relied on the local connections and trust built up by the SFD. The programme also benefitted from the recruitment of highly motivated local women as community health educators. Their effectiveness is evident in their ability to convince beneficiaries of the value of the information shared at nutritional training sessions. There is also anecdotal evidence that the community health volunteers continued to promote the programme’s goals in their community after their contracts ended. Building on the evidence of this study and strengthening national social protection systems through trusted national institutions such as the SFD will be critical to addressing the complex and protracted humanitarian challenges facing Yemen.

Lamis Al-Iryani is Monitoring and Evaluation Unit Head at the Social Fund for Development, Yemen. Sikandra Kurdi is Associate Research Fellow at the International Food Policy Research Institute. Sarah Palmer-Felgate is Social Development Adviser for DFID Yemen.

The impact evaluation underlying this research was managed by the World Bank and funded by the Nordic Trust Fund. Data collection was funded under the Yemen Emergency Crisis Response Project, funded by the International Development Association (IDA) of the World Bank Group and implemented by the United Nations Development Programme and its implementing partner the Yemen Social Fund for Development (SFD). This work was undertaken as part of the CGIAR Research Program on Policies, Institutions, and Markets (PIM) led by the International Food Policy Research Institute (IFPRI).