Inadequate nourishment in the first years of life can impair children’s physical and cognitive development, with long-term consequences on their earnings and productivity. In Myanmar, which has one of the highest rates of stunting in the Asia-Pacific region, IPA worked with researchers to evaluate the impact of cash transfers to mothers––both with and without social and behavioral change communication (SBCC) ––on determinants and indicators of child malnutrition. According to preliminary results, cash plus SBCC appears to have reduced in the proportion of stunted children on average, which is driven by significant impacts on determinants of malnutrition including dietary diversity and intake, feeding practices, and food consumption. Impacts were larger for children who were exposed to the program for a longer period of time and concentrated in poorer areas. The cash-only intervention had relatively limited impacts, with no impact on the proportion of stunted children on average.

Policy Issue 

The first 1,000 days of life comprise a critical period of physical and cognitive development. Children who are well-nourished during this period do better in school and as adults, earn 20 percent more in the labor market and are 10 percent more likely to own their own businesses.[1] On the other hand, inadequate nutrition during this period can cause stunting, lead to long-term developmental consequences, and may affect future productivity and earning potential. According to the World Bank, the economic costs of stunting can be enormous, with countries losing between 2 to 3 percent of their potential Gross Domestic Product (GDP) each year.[2]

Previous evidence suggests that providing poor households with cash transfers can have positive impacts on their children’s health and development, but significant impacts of cash on chronic measures of malnutrition, such as stunting, have been mixed. Some evidence also suggests that information may be effective at changing maternal knowledge and health behavior. However, more evidence on the combined effect of cash and information aimed at improving nutrition is needed. This research examined if and how cash transfers combined with social and behavioral change communication (SBCC) affect measures of child health and development, and particularly stunting, compared to cash transfers alone.

One promising response to address stunting is through cash transfers. Targeting cash transfers to women and young children may improve child nutrition, reduce stunting, and yield high returns over the long term, yet more research is needed on the impacts of this approach and on what extent information and behavior change interventions should be incorporated into these programs. Furthermore, questions remain about the effective implementation of large-scale cash transfer programs and which institutions can most effectively deliver the transfers.

Context of the Evaluation 

Myanmar has one of the highest rates of stunting in the Asia Pacific region. Of the 4.4 million children under five, approximately 1.6 million (35 percent) are stunted. Levels of stunting in the country vary by geographic region, location, wealth and maternal education, but they reach levels as high as 50 percent of children stunted in rural areas and in the poorest states.[3]

In December 2014, the Government of Myanmar announced it would launch a universal maternal cash transfer program for pregnant women and their children under the age of two as part of its National Social Protection Strategy. The program is projected to reach 2.25 million beneficiaries by 2024. This study, conducted in collaboration with Save the Children International (SCI), was designed to inform the national roll-out of the program. It took place in three townships in Myanmar’s Dry Zone during the pilot phase of the program between 2016 and 2019.

Details of the Intervention 

Innovations for Poverty Action worked with researchers to measure the impact of maternal cash transfers, both with and without  SBCC, on anthropometrics (child nutritional status, such as stunting) immediate determinants of child malnutrition (i.e., child dietary intake and health status) and underlying determinants of child malnutrition (i.e., household food security and diet, care for mothers and children, health environment and services).

Researchers randomly assigned 102 sub-rural health centers catchment areas (group of villages, for a total of 437 villages) in three townships to one of three groups:

Cash only: Eligible pregnant mothers receive a monthly unconditional cash transfer during pregnancy and through the child’s first two years of life (first 1,000 days). The transfer of 10,000 -15,000 MMK Myanmar kyats (about US$6-10) per month was designed to ensure the women are able to afford the purchase of nutritious foods and access antenatal and post-natal care.

Cash + SBCC: Eligible pregnant mothers received the monthly maternal cash transfer along with an intensive social and behavioral change communication focused on infant and young child feeding practices (IYCF), health-seeking behavior, hygiene, and household expenditures.

Comparison group: Eligible pregnant mothers in areas where the intervention was not implemented at the time of study.

Researchers measured impacts approximately 30 months after the cash transfers began.

Results and Policy Lessons 

Preliminary results:*

Overall, two years after program delivery, cash+SBCC led to a reduction in the proportion of stunted children, driven by a 4-percentage point reduction in the proportion of children who were moderately stunted (as opposed to severely). Impacts on stunting were larger for children who were exposed to the program for a longer period of time and concentrated in poorer areas. The cash-only intervention had relatively limited impacts, with no impact on the proportion of stunted children on average.

Stunting:

Cash+SBCC appears to have led to a 4-percentage point reduction in the proportion of stunted children, driven by a 4-percentage point reduction in the proportion of moderately stunted children.

The reduction in the proportion of stunted children was more pronounced for children covered by the program for the greatest number of months (24-29 months) and for female children. Researchers find a 5-percentage-point reduction in the proportion of stunted children between 24 and 29 months of age about 30 months after the launch of the program, and a 10-percentage-point reduction in the proportion of female stunted children between 24 and 29 months of age.

Moreover, the impacts on stunting were concentrated among lower socio-economic status households (using literacy, education, and drinking water access as proxies). Within areas with lower adult literacy rates, researchers found a 15-percentage-point reduction in the proportion of stunted children compared to areas with higher adult literacy rate. Similarly, researchers found a 22-percentage-point reduction in the proportion of stunted children in areas with lower average level of education (for women) compared to areas with higher average level of education. The proportion of stunted children in the cash+SBCC group was also lower in areas with limited drinking water access (a reduction of 5 percentage points) compared to areas with better drinking water access.

Cash-only did not lead to a reduction in the proportion of stunted children on average. Researchers found a 7-percentage-point reduction in the proportion of stunted female children who were between 24 and 29 months of age about 30 months after the launch of the program (had the longest exposure to the cash-only program).

Wasting and Underweight:

Researchers found that moderate wasting improved in the Cash+SBCC and cash-only groups, showing a 3-percentage-point reduction in the proportion of moderately acutely malnourished children (MAM), compared to the comparison group. They did not find effects on the proportion of children who were underweight.

Mechanisms:

The analysis of the mechanisms through which SBCC impacts child health reveals significant marginal impacts of SBCC on several immediate and underlying determinants of nutrition emphasized by the program, including mother dietary and nutrition knowledge, knowledge and adoption of IYCF practices, food consumption, child dietary intake, health seeking behavior with skilled health workers, iron tablet consumption during the antenatal period, and hand washing practices. In contrast, researchers did not observe any major changes in self-reported rates of child illness and post-natal care with skilled health personnel, relative to the comparison group.

Policy Lessons:

These findings underline the importance of complementing cash transfer programs with SBCC, and the value of ensuring full coverage for children in their first 1,000 days of life. The findings suggest that cash transfers should be combined with SBCC activities, and that the targeted beneficiaries—pregnant mothers in the last two trimesters of gestation and their under-2 children—are ensured full program coverage throughout the critical window of the first 1,000 days of the child’s life. ­­­These results suggest that combining cash with SBCC is more effective than cash alone at improving children's nutritional status.

*Results are preliminary and may change after further analysis and/or peer-review.

Sources

[1] IDS (2013) Delivering Demographic Dividend in Africa: Investing in Nutrition is the First Step.


[2] World Bank Nutrition Overview: http://www.worldbank.org/en/topic/nutrition/overview#1


[3] UNSCN. 2010. Sixth Report on the World Nutrition Situation: Progress in Nutrition: UNSCN Secretariat c/o WHO.