Social protection has the potential to protect or improve nutritional status in a number of ways. Improved economic status can enable households to access more nutritious diets, health care, and education, and to make improvements in water, sanitation and hygiene. All of these can help people remain well-nourished and to grow and develop properly. However, the evidence for the impact of social protection on nutrition remains mixed.
While cash transfer programmes are found to play a positive role in increasing resources for food, health care and other care for children, evidence on whether cash transfers positively impact growth-related outcomes among children is mixed, particularly in sub-Saharan Africa (de Groot et al., 2015: 2). Cash transfer pathways of impact tend not to be analysed, leaving it ‘unclear why some cash transfer programmes have a significant impact on nutritional outcomes, while others do not’ (ibid.: 19).
A 2016 rigorous review of cash transfer evidence found that for dietary diversity, cash transfers consistently show increases (Bastagli et al., 2016: 8). Of the 12 studies reporting on dietary diversity, seven showed a statistically significant improvement. However, the review found a lower proportion of significant results on child stunting, wasting and underweight. This more limited evidence on cash transfers improving children’s nutritional status may be because nutrition is the outcome of a complicated process involving multiple factors in addition to a household’s access to food (Manley & Slavchevska, 2019: 205). Bastagli et al. (2016: 8) conclude that ‘changes in design or implementation features, including complementary actions (e.g. nutritional supplements or behavioural change training), may be required to achieve greater and more consistent impacts on child anthropometric measures’. Results from a programme in Bangladesh show that the provision of cash plus behaviour change communication significantly improves nutrition outcomes compared to cash alone (Ahmed et al., 2016).
There have been relatively few evaluations of the impact of food transfers on nutrition outcomes. Comparing cash and in-kind food transfers and vouchers in 10 developing counties, Gentilini (2016: 22) finds both modalities improve food consumption, income, dietary diversity, poverty and malnutrition compared with control groups. There is a fairly consistently reported – some stress ‘mild’ (ibid.: 22) – tendency for cash transfers to be more effective than food in enhancing expenditure on/value of food consumed by the household and dietary diversity, while food leads to an increased household caloric intake (ibid.; McIntosh & Zeitlin, 2018: 3). However, Gentilini (2016: 22) cautions against generalising about overall comparative effectiveness of the modalities, as impacts vary according to context, specific objectives, and their measurement. The costs of in-kind food tend to be higher than for cash transfers and vouchers, but rigorous cost-effectiveness evidence is limited, and more standardised, robust efficiency analyses are needed (ibid.).
Reviews have shown that school feeding is not an effective way of improving nutrition outcomes, primarily because it fails to target children during the first 1,000 days of their development (Alderman & Bundy, 2012). This is widely viewed as the critical window of opportunity for preventing malnutrition. However, a recent study finds that school feeding can lead to small but significant gains in growth and can promote macronutrient and micronutrient adequacy (Drake et al., 2018: 56–57). Schools might provide a useful platform for promoting nutrition messages and for reaching adolescent girls, although there is scant evidence on the impact of nutrition education (Bhutta et al., 2013; Drake et al., 2018: 58). The costs of school feeding vary significantly across countries, while estimating overall cost-effectiveness of school feeding is complicated by the multiple potential education and nutrition benefits of the intervention (Drake et al., 2018: 60). While school feeding has been shown to have higher non-transfer costs than conditional cash transfers, further research is needed to ensure valid comparisons with other interventions (ibid.: 60, 62).
Manley, J., & Slavchevska, V. (2019). Are cash transfers the answer for child nutrition in sub‐Saharan Africa? A literature review. Development Policy Review, 37(2), 204–224.
This literature review of 20 cash transfer schemes, including 12 from sub-Saharan Africa, finds cash transfer programmes ‘have shown improvements in household diet and in some cases to agriculture, but have not always improved child health. However, a larger perspective focusing on two key time periods for nutrition – adolescence and the first 1000 days of life – reveals more opportunities for impact. In particular the opportunity to empower young women to get secondary education and cut adolescent pregnancy rates can improve the health of African children’ (p. 204).
Bastagli, F., Hagen-Zanker, J., Harman, L., Barca, V., Sturge, G., & Schmidt, T. (2016). Cash transfers: What does the evidence say? A rigorous review of programme impact and of the role of design and implementation features. London: ODI.
See summary in Poverty, inequality and vulnerability – Key texts.
Gentilini, U. (2016). The revival of the ‘cash versus food’ debate: New evidence for an old quandary? (Policy Research Working Paper 7584). Washington, DC: World Bank.
This paper reviews key issues and presents new evidence from randomised and quasi-experimental evaluations comparing cash and in-kind food transfers in 10 developing counties (Bangladesh, Cambodia, Democratic Republic of Congo, Ecuador, Ethiopia, Mexico, Niger, Sri Lanka, Uganda and Yemen). Findings show that ‘relative effectiveness cannot be generalized: although some differences emerge in terms of food consumption and dietary diversity, average impacts tend to depend on context, specific objectives, and their measurement. Costs for cash transfers and vouchers tend to be significantly lower relative to in-kind food. Yet the consistency and robustness of methods for efficiency analyses varies greatly’ (abstract).
de Groot, R., Palermo, T., Handa, S., Peterman, A., & Ragno, L. P. (2015). Cash transfers and child nutrition: What we know and what we need to know (Innocenti Working Paper 2015-07). Florence: UNICEF Innocenti Research Centre.
A ‘comprehensive overview of the impacts of cash transfer programmes on the immediate and underlying determinants of child nutrition, including the most recent evidence from impact evaluations across Sub-Saharan Africa’ (p. 2). Key gaps to address in future include ‘cash transfer impacts on more proximate nutrition-related outcomes such as children’s dietary diversity, as well as caregiver behaviours, intra-household violence, and stress, all of which have implications for child health and well-being’ (p. 2).
Drake, L., Fernandes, M., Aurino, E., Kiamba, J., Giyose, B., Burbano, C., Alderman, H., Mai, L., Mitchell, A., & Gelli, A. (2018). School feeding programs in middle childhood and adolescence. In Bundy, D. A. P., de Silva, N., Horton, S., Jamison, D. T., & Patton, G. C., Optimizing education outcomes: High-return investments in school health for increased participation and learning. Washington, DC: World Bank.
Bhutta, Z. A., Das, J. K., Rizvi, A., Gaffey, M. F., Walker, N., Horton, S., Webb, P., Lartey, A., Black, R. E., Lancet Nutrition Interventions Review Group, & Maternal and Child Nutrition Study Group. (2013). Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost? The Lancet, 382(9890), 452–477.
Ruel, M. T., & Alderman, H. (2013). Nutrition-sensitive interventions and programmes: How can they help to accelerate progress in improving maternal and child nutrition? The Lancet, 382(9891), 536–551.
The Lancet. (2013). A four-paper series on maternal and child nutrition
Webinar: Seminar series on nutrition and social protection. Five country presentations on how social protection programmes address nutrition behaviour change. (2016). Moderated by Secure Nutrition. (2hr:3)
 No public link is available for this document: Ahmed, A., Hoddinott, J., Roy, S., Sraboni, E., Quabili, W., & Margolies, A. (2016). Which kinds of social safety net transfers work best for the ultra poor in Bangladesh? Operation and impacts of the Transfer Modality Research Initiative. Dhaka: IFPRI & World Food Programme.