What policy can help alleviate the burden of undernutrition? Recent research from UNICEF Innocenti unpacks new evidence from impact evaluations in Ghana.

1. unite for
children
Elsa Valli & Richard de Groot
On Behalf of the Ghana LEAP 1000 Evaluation Team
Impact of a cash plus program on
health: new evidence on cash
transfers integrated with health
insurance

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LEAP 1000 Evaluation Team
UNICEF Office of Research – Innocenti: Tia Palermo (co-Principal
Investigator), Richard de Groot, Elsa Valli;
Institute of Statistical, Social and Economic Research (ISSER), University
of Ghana: Isaac Osei-Akoto (co-Principal Investigator), Clement Adamba,
Joseph K. Darko, Robert Darko Osei, Francis Dompae and Nana Yaw;
Carolina Population Center, University of North Carolina at Chapel Hill:
Clare Barrington (co-Principal Investigator), Gustavo Angeles, Sudhanshu
Handa (co-Principal Investigator), Frank Otchere, Marlous de Miliano;
Navrongo Health Research Centre (NHRC): Akalpa J. Akaligaung (co-
Principal Investigator) and Raymond Aborigo.

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VIDEO

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• Started in 2008
• Implemented by the LEAP Management
Secretariat (LMS) and the Department of Social
Welfare (DSW) under the Ministry of Gender,
Children and Social Protection (MoGCSP)
• Ghana’s flagship social protection programme

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Objective of LEAP
Broad Objective
• To reduce poverty by increasing consumption and;
promoting access to services and opportunities for the
extreme poor and vulnerable.
Specific Objectives
• To improve basic household consumption and nutrition
• To increase access to health care services
• To increase basic school enrollment, attendance and
retention
• To facilitate access to complementary services

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What is LEAP
• Cash Transfer Programme and one of the Five (5) Social
Protection Interventions under the Social Protection Policy
• Targeted and categorical programme
• Extremely Poor Persons (determined by a PMT score) who
belong to the following categories:
• Elderly 65+ without support
• Persons with severe disability
• Pregnant women
• Households with children < 1 yr
• Households with orphans or vulnerable children
LEAP 1000

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Integration with NHIS
• Collaboration between the National Health Insurance Agency
(NHIA) and the DSW starting in 2011
• LEAP beneficiaries (all household members) are entitled to
free health insurance under the National Health Insurance
Scheme (NHIS)
• No fees for NHIS including card processing fees, premiums
and renewals
• Access to out-patient and in-patient services, (including
medicines), dental services, and maternal health services.
• Membership to be renewed annually (!)

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Payments
• Payment amount of LEAP grants is based on the number of
eligible beneficiaries per household (1, 2, 3 or 4+)
• Latest inflation adjustment was made in September, 2015
• 1 person=GH₵64; 2=GH₵76; 3=GH₵88 and GH₵4+=106
• Payment of grants is on bi-monthly basis through GhIPSS E-
Zwich platform (e=payments)
• Biometric verification and the use of deputy Caregivers

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Evaluation Design and sample
 2-year mixed method, quasi-
experimental, longitudinal study
 8,058 households targeted by
government and 3,619 deemed
eligible
 PMT scores range: 6.1 – 8.7
 Evaluation aimed to include 1,250
households + 10% on either side
of PMT cut-off: 7.0 – 7.3
 Baseline (Jul-Sept 2015), Endline
(Jun-Aug 2017)
 Final evaluation sample N=2,497
households (1,262 T and 1,235 C) Districts: Yendi, Karaga, East
Mamprusi, Bongo Garu Tempane

10. unite for
children
NHIS ENROLMENT
& RENEWAL
Photo: Elsa Valli

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Background
• Broad-ranging benefits of cash transfers widely recognized.
• Poverty reduction, food security, improved living conditions, enhanced
psyco-social well-being
• However, evidence shows that they often fall short in achieving
longer-term second-order impacts related to nutrition, learning
outcomes and morbidity.
• Mixed impacts on health status, mostly from LAC (CCTs)
• Positive impacts on utilization of health services BUT fewer impacts on an
actual improved health

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Background
• Cash plus: complement cash with additional inputs, service
components or linkages to external services
• Cash not sufficient to generate sufficient behavioural change
• Cash not sufficient in case of access and supply-side constraints
• Malaria, Acute Respiratory Infections (ARI) and Acute Diarreheal
Diseases (ADD) major contributor to mortality in LIC and in Ghana
• Preventable and treatable diseases
• Cost major barrier in seeking healthcare
• LEAP + NHIS: “protective” + “preventive” functions
transformative change

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NHIS enrollment by age group
ADULTS (aged 18+)CHILDREN (aged 7-17)
44.7%
44.8%45.1%
31.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Endline
Treated Comparison
31.9%
41.4%
32.6%
27.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Baseline Endline
Treated Comparison
15pp***14pp***

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NHIS enrolment at household level
98%
78%
16%
96%
69%
8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HH has at least one member ever
NHIS insurance
HH has at least one member with
valid NHIS insurance card
HH has all members with valid NHIS
insurance card
Treatment Comparison
7.7pp***
5pp
0.1pp

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Reasons for not renewing NHIS
1
1
6
8
11
80
2
5
7
10
12
70
0 10 20 30 40 50 60 70 80 90 100
Has not been sick
Waiting time at renewal too long
Not aware had to be renewed annually
Travel time/cost too high
Did not realised card expired
Enrolment fee/premium too expensive
Treatment Comparison
Other responses: <1%
(office closed, poor
quality care, card lost,
no time, etc.)

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Amount paid for last renewal
45%
23%
5%
27%
43%
25%
4%
27%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
1-5 GHS 6-10 GHS 11-20 GHS >21 GHS
Comparison Treatment

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children
MORBIDITY,
HEALTH SEEKING
BEHAVIOUR &
HEALTH
EXPENDITURES
Photo: Elsa Valli

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No impacts on
morbidity
12%
70%
19%
72%
12%
75%
19%
65%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Illness in last 2 weeks Sought care for illness in
last 2 weeks
Illness in last 2 weeks Sought care for illness in
last 2 weeks
Treatment Comparison
0.2pp
Positive impacts on
health-seeking (adults)
Children (7-17 years) Adults (18+ years)
11pp***
0.9pp
-9pp

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No impacts on health expenditures
2.3
1.4
7.7
4.8
3.1
2.0
7.8
5.0
0
1
2
3
4
5
6
7
8
9
Real health expenditures Real medication and
consultation expenditures
Real health expenditures Real medication and
consultation expenditures
Treatment Comparison
Children (7-17 years) Adults (18+ years)

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Do results change by quality and
distance of the health facility?
Nearest health facility within 5 KM
• Larger effect on health seeking for adults (22pp). Still not significant
for children (but positive and larger)
• No impact on morbidity or health expenditures
Nearest health facility top tertile of quality
• Positive impact on health expenditures for adults (5.9 GH₵). Still not
significant for children (but larger)
• No differential impact on morbidity or health seeking

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Summary on NHIS enrolment and
health-seeking
• Positive impacts on NHIS enrolment, but lingering
gaps for full household coverage and renewal
• Cost is the most common reason for not
enrolling/renewing NHIS
• No impact on morbidity or health expenditure
• Positive impact on health seeking behaviour (adults
only)
• Quality of health facilities matters for health
expenditures; distance matters for health seeking
behaviour

22. unite for
children
CHILD HEALTH &
NUTRITIONAL
STATUS
Photo: Elsa Valli

23. unite for
children
Can cash transfers targeted to children in the
first 1,000 days of life improve nutritional
status? The impact of Ghana LEAP 1000 on
young child nutrition and its determinants
Richard de Groot, UNICEF Office of Research – Innocenti
&
Jennifer Yablonski, UNICEF Ghana
On Behalf of the LEAP 1000 Evaluation Team

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Background
• Over 155 million children under 5 are stunted around
the world, negatively affecting their development
• In Ghana, 19% of children under 5 are stunted and
levels of stunting are higher for children in rural areas,
from poorly educated mothers, and living in poor
households.
• The Northern region, one of the regions under study in
this paper, shows the highest prevalence of stunting with
a rate of 33%.

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Background
• What policies can help to alleviate the burden of
undernutrition?
• Social protection, in the form of cash transfers, has been
identified as a potential nutrition-sensitive intervention
• BUT, evidence to date shows inconclusive evidence of
a positive impact on child nutritional status and
pathways of impact are not clearly understood

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The way to improved nutrition is complex

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Indicators and indices
Outcome/
determinant
Indicators
Outcomes
Malnutrition HAZ, WAZ, WHZ, stunted, wasted, underweight
Immediate determinants
Food intake Infant and young child feeding (IYCF) index, breastfeeding,
diet diversity and meal frequency
Health Diarrhea, fever and acute respiratory infections (ARI)
Underlying determinants
Household food
security
Household food expenditure, household food security
(HFIAS), household diet diversity
Care for mothers Women’s agency, subjective health, stress, social support,
nutritional knowledge
Household health
environment
Source of water, sanitation facility, hand washing facility,
floor material

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Baseline situation and validity checks
• 31% stunted, 15% wasted and 20% underweight
• Poor dietary intake
• High levels of food insecurity, poor health environment
and low levels of care for mothers
• Strong balance on key indicators (except health)
• No differential attrition in T & C groups, but some
selective attrition
• No manipulation of eligibility status

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Main results: overview

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Main results
31.0% 30.8%
14.9%
8.6%
19.8% 19.6%
0%
5%
10%
15%
20%
25%
30%
35%
Baseline Endline Baseline Endline Baseline Endline
Stunted Wasted Underweight
Treatment Comparison
-0.1 pp 1.7 pp 2.3 pp

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Further details
• Immediate determinants
• Negative impact on meal frequency (-0.12** SD) and fever (-0.10*
SD)
• Underlying determinants
• Positive impact on food expenditures (0.15** SD) and diet
diversity (0.14** SD)
• For care, positive impact on social support (0.16** SD)

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Discussion – what about other CTs?
Impacts
Zambia CGP Malawi SCTP Zimbabwe
HSCT
Ethiopia
Tigray
SCTPP
Kenya HSNP
HAZ No No No No No (stunting)
WHZ No No No No No (wasting)
WAZ No No No n/a No
(underweight)
IYCF Yes (meal
frequency)
Yes (meal
frequency)
n/a Yes (children
< 12)
n/a
Health No No Negative
impact
n/a No (children <
18)
Food
security
Yes Yes Yes (diet
diversity)
Yes Yes
Care No Yes (stress) n/a No (health
and stress)
n/a
Health
environment
Yes (toilet and
cement floors)
n/a n/a No (housing
quality)
n/a

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Summary
• Child malnutrition is a complex process with multiple
determinants
• LEAP1000 had a strong impact on household food
consumption, modest impacts on care for women and no
impact on health environment
• No impact on child health and food intake and no impact on
child malnutrition
• Heterogeneity analysis: no differential impacts by age group;
quality of health facility important for food security and care;
and worse outcomes in case of shocks and better health and
food security with other development programmes

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OVERALL DISCUSSION

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Discussion
• Transfer size is relatively low (14%)
• Impacts on health and nutrition might take longer to
occur
• Links to additional programming need to be considered
(e.g. Bangladesh TMRI), but highly context-specific to key
drivers of malnutrition and health (behavior change
communication may not be priority need; e.g. sanitation,
health service quality/access)
• NHIS linkages not fully functional – barriers in terms of
awareness, time to register/renew and costs

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Discussion
• Future research should focus on effective and context-
specific linkages between cash transfer programmes
and additional social services, that together are able to
improve underlying and immediate determinants of health
and malnutrition.

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Acknowledgements
We are grateful for the support of the Government of Ghana for the implementation
of this evaluation, in particular William Niyuni, Mawutor Ablo and Richard Adjetey
from the Ministry of Gender, Children and Social Protection. In addition, the
UNICEF Ghana team was instrumental to the success of this report: Sara
Abdoulayi, Luigi Peter Ragno, Jennifer Yablonski, Sarah Hague, Maxwell Yiryele
Kuunyem, Tayllor Spadafora, Christiana Gbedemah and Jonathan Nasonaa
Zakaria.
We would also like to acknowledge the hard-working field teams of ISSER and
NHRC, who conducted the data collection for this study to the highest standards.
Funding for the evaluation was generously provided by the United States Agency
for International Development (USAID) and the Canadian International
Development Agency (CIDA). Additional funding to include intimate partner violence
modules in the evaluation and to produce this paper was received from an
Anonymous donor and the American World Jewish Services by the UNICEF Office
of Research—Innocenti via the US Fund for UNICEF. We thank Laura Meucci and
Michelle Kate Godwin for grant administrative support.

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Meda ase
Asante
Zikomo
Thank you
Grazie!
Ghana LEAP 1000
(© Michelle Mills)

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