Cash transfers, payments provided by formal or informal institutions to recipients, are increasingly used in emergencies. While increasing autonomy and being supportive of local economies, cash transfers are a cost-effective method in some settings to cover basic needs and extend benefits of limited humanitarian aid budgets. Yet, the extent to which cash transfers impact health in humanitarian settings remains largely unexplored. This systematic review evaluates the evidence on the effect of cash transfers on health outcomes and health service utilisation in humanitarian contexts.
Studies eligible for inclusion were peer reviewed (quantitative,qualitative and mixed-methods). Nine databases (PubMed, EMBAS, Medline, CINAHL, Global Health, Scopus, Web of Science Core Collection, SciELO and LiLACS) were searched without language and without a lower bound time restriction through 24 February 2021. The search was updated to include articles published through 8 December 2021. Data were extracted using a piloted extraction tool and quality was assessed using The Joanna Briggs Critical Appraisal Tool. Due to heterogeneity in study designs and outcomes, results were synthesised narratively and no meta-analysis was performed.
30 673 records were identified. After removing duplicates, 17 715 were double screened by abstract and title, and 201 in full text. Twenty-three articles from 16 countries were included reporting on nutrition outcomes, psychosocial and mental health, general/subjective health and well-being, acute illness (eg, diarrhoea, respiratory infection), diabetes control (eg, blood glucose self-monitoring, haemoglobin A1C levels) and gender-based violence. Nineteen studies reported some positive impacts on various health outcomes and use of health services, 11 reported no statistically significant impact on outcomes assessed and 4 reported potential negative impacts on health outcomes.
Although there is evidence to suggest a positive relationship between cash transfers and health outcomes in humanitarian settings, high-quality empirical evidence, that is methodologically robust, investigates a range of humanitarian settings and is conducted over longer time periods is needed. This should consider factors influencing programme implementation and the differential impact of cash transfers designed to improve health versus multipurpose cash transfers.
CRD42021237275.
Previous studies have demonstrated the benefits of cash transfer interventions in low and middle-income countries on mitigating the health impacts from climate change, improving nutrition and advancing maternal health when markets are functional and quality services are available.
Cash and voucher assistance amount to over US$6 billion in humanitarian aid, with cash transfers accounting for almost three-quarters of this aid.
However, the extent to which cash transfers impact health in humanitarian settings remains largely unexplored.
To our knowledge, this is the first mixed-methods systematic review exploring the impact of conditional and unconditional cash transfers specifically on health outcomes and usage of health services in a humanitarian setting.
Health outcomes assessed in studies largely focused on diet and nutrition, mental and psychosocial health and self-reported general well-being.
Nineteen studies reported some positive impacts on various health outcomes and use of health services, eleven reported no statistically significant impact on outcomes assessed and four reported potential negative impacts on health outcomes.
Although our systematic review suggests that there may be a positive impact of cash transfers on health outcomes in humanitarian settings, high-quality empirical evidence, that is methodologically robust, investigates a range of humanitarian settings, and is conducted over longer time periods is needed.
Specific attention must be given to the intended/expressed purpose of grants, the actors involved in designing and implementing cash transfers, and the factors that affect implementation such as local involvement and context-specific considerations.
A record 274 million people are expected to need humanitarian assistance in the year of 2022,
Cash and voucher assistance account for 19% of international humanitarian aid, amounting to over US$6 billion in 2020.
Previous studies and systematic reviews have demonstrated the benefits of cash interventions on mitigating the health impacts from climate change, improving nutrition and advancing maternal health if markets are functional and quality services are available.
To date, multiple systematic reviews have explored the impact of cash transfers on human health or well-being.
This systematic review protocol was prospectively registered on PROSPERO (CRD42021237275). Findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (
Cash transfers were defined following The Cash Learning Partnership definition as cash payments (physical currency or e-cash) provided by formal and/or (eg, government, non-governmental organisations) informal (eg, hawala—an informal money transfer system largely used in the Middle East and South Asia)
The primary outcome(s) were changed in health outcomes, including mortality, morbidity, (mal)nutrition, mental health and well-being and acute or chronic disease status. Secondary outcome(s) were the utilisation of health services, measured by the frequency of visits or percentage of population eligible for a service attending the service.
A humanitarian setting was defined as an event or series of events that present a critical threat to the health, safety, security or well-being of a community or other large group of people, usually over a wide geographic area. Three types of humanitarian crises were specified: man-made crises (eg, civil and inter-state war, armed conflict, genocide), natural disasters including hydrological (eg, floods, avalanches), geophysical (eg, earthquakes, volcanic eruptions, earthquakes), climatological (eg, droughts, wildfires), meteorological (eg, storms, cyclones), biological events (eg, pandemics, epidemics, plagues) and complex emergencies (emergencies resulting from a combination of both natural and man-made causes).
We searched nine electronic databases (PubMed, EMBASE via Ovid, Medline via Ovid, CINAHL via EbscoHost, Global Health via EbscoHost, Scopus, Web of Science Core Collection, SciELO and LiLACS) without restriction of language and without a lower bound time restriction for articles published through 24 February 2021. An updated search was conducted to include articles published during the COVID-19 crisis through 8 December 2021. Using a combination of free-text terms and subject headings, we used vocabulary related to ‘cash transfers’ and ‘humanitarian settings’. The full-search strategy, developed with a librarian/information specialist, is provided in
Eight researchers were involved in the study selection and extraction. After removing duplicates using Endnote, abstracts and titles were screened independently by two researchers according to the selection criteria by using the software Rayyan (
Data from included studies were independently extracted in duplo using a pretested extraction tool. Any discrepancies between authors extracting the same studies were discussed until consensus was reached. Likewise, a third arbiter was involved when consensus could not be reached. The following information was extracted for each study: author, year, study title, study design, study population, participant demographics (eg, age, country), type of humanitarian setting, sampling and recruitment procedures, total number of participants, outcome (use of health services, health outcomes), outcome(s) ascertainment, type of cash transfer, percentage/number of individuals reporting the outcome, association measures with summary estimate and 95% CI. An open field to record any additional relevant information was available. The quality of individual included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tool to explore methodological quality of the synthesised knowledge.
Due to the heterogeneity of the included studies (in type of cash transfer, outcome and setting), the quantitative data were descriptively synthesised, and no meta-analysis was performed. Studies with qualitative data underwent additional qualitative thematic analysis. Authors independently used inductive analysis to develop and agree on a codebook. This codebook was then applied to all qualitative studies by two independent authors (inter-rater reliability kappa score 0.96).
Due to the nature of this study (systematic review), no patients or public were involved in conceptualising or conducting the study.
We identified 30 673 records from the databases. After removing duplicates, 17 715 records were screened by title and abstract and 201 were screened in full text (
Flow diagram of included studies.
Summary characteristics of included studies
Study | Study design | Study period | Country | Type of humanitarian setting | Type of cash transfer (intervention) | Health outcome/services | Population source | N participants |
Abu-Hamad | Mixed-methods | April–May 2013 | Gaza, Palestine | Man-made crises | Unconditional cash transfer | -Psychological health | Children (<18 years) benefiting from the Palestinian National Cash Transfer Programme (PNCTP) and caregivers living in Gaza | Quantitative: 4497 people Small group discussion: 74 children In-depth interviews: 10 children Observations: 2 HH FGD: 14 adults Key informant interviews: 11 |
Aker | Randomised control trial | August/September 2011–March 2012 | Democratic Republic of the Congo | Man-made crisis | Unconditional cash transfer | Household member affected by illness or died Expenditure on medicine | Informal camp in the Masisi territory of DRC, total population ~2500 individuals. | 474 households |
Bliss | Longitudinal cohort study | April–September 2012 | Niger | Environmental | Unconditional cash transfer | Presence of acute malnutrition (WHZ <2 or MUAC <125 mm) MUAC WHZ Child dietary diversity Child meal frequency Child illness Maternal mental health | Children aged 6–36 months in 420 households enrolled in an emergency cash transfer programme in Niger | 420 households |
Bliss | Quasi-experimental | July–September 2012 | Niger | Environmental | Conditional cash transfer | Weight gain Weight gain velocity (g/kg/d) MUAC WHZ Presence of acute malnutrition (WHZ <2 or MUAC <125 mm or the presence of bilateral pitting oedema) Meal frequency Dietary diversity | Households in a conditional emergency CTP programme that occupied the second-lowest wealth category and had a child 6–23 months that was not wasted or had diseases. | 423 households |
Doocy | Prospective cohort study | November 2018–April 2019 | Somalia | Man-made crises (human conflict) | Unconditional cash transfer combined with in-kind food and electronic vouchers. | Household Hunger Scale (HHS) Minimum Dietary Diversity for Women (MDDW) MUAC, with MUAC <21.0 cm classified as acute malnutrition Meal frequency | Pregnant and lactating women in El-bon Camp in the District of Wajid and adjacent neighbourhoods for 'non-assistance' group. | 514 pregnant and lactating women (baseline and endline comparison) |
Doocy | Prospective cohort study | November 2018–April 2019 | Somalia | Man-made crises (human conflict) | Unconditional cash transfer combined with in-kind food and electronic vouchers. | Household Hunger Scale (HHS) Children’s dietary diversity Meal frequency Minimum acceptable diet (MAD) Mean MUAC Acute malnutrition (defined as MUAC <12.5 cm) | Households in El-bon Camp in the District of Wajid and adjacent neighbourhoods for 'non-assistance' group with children aged 6–59 months. | 490 households (n=269 mixed transfer group (cash, in-kind, voucher), n=162 food voucher group comparison group, n=59 no assistance comparison group) |
Edmond | Non-randomised population-based intervention study | December 2016–December 2017 | Afghanistan | Man-made crises | Conditional cash transfer | Child delivery in a health facility Receiving at least one ANC visit Receiving one PNC visit Receiving at least one CHW home visit | Women that had given birth to one or more children in the last 12 months residing in the study districts of the three provinces (Badghis, Bamyan and Kandahar) | 4929 women |
Falb | Mixed methods | March–August 2018 | Syria | Man-made crises | Unconditional cash transfer | Food insecurity via HFIAS Depressive via PHQ-9 Disability status, via an adapted version of the WG-SS Women’s experiences of violence | All HH with a woman aged 18–59 years from a beneficiary household in Raqqa Governorate, Syria. | 512 women at baseline, 456 at endline |
Freccero | Qualitative study (focus groups+in-depth interviews) | 2017–2018 | Cameroon, Afghanistan | Man-made crises | Cameroon: multipurpose cash programme (~US$300 over a 6-month period in monthly disbursements) | Self-reported changes in health | Participants receiving multipurpose cash transfers through International Red Cross programmes in Cameroon and Afghanistan. | 211 individuals, 100 Afghanistan, 111 Cameroon |
Green | Cluster-randomised trial | April 2009 | Uganda | Man-made crises | Unconditional cash transfer | Depression using modified version APAI depression subscale | 120 communities (villages, transit sites, and displacement camps in Gulu and Kitgum districts) in Northern Uganda | 1800 individuals (868 intervention receiving cash, 866 comparison group not receiving cash) |
Grijalva-Eternod | Non-randomised cluster trial | March–November 2016 | Somalia | Man-made crises | Unconditional cash transfer | Mean child, household and women DDS values Incidence acute malnutrition, defined by low MUAC or oedema Prevalence acute malnutrition, defined by low WHZ or oedema Mean WHZ value Mean FCS Mean HFIAS score Mean Reduced Coping Strategies Index (rCSI) score | IDP camps located in Weydow area, Deyniile district, Mogadishu. | 228 households |
Gros | Mixed-methods | May 2016–October 2017 | Bangladesh | Environmental | Unconditional cash transfer (forecast-based) | Psychosocial distress Health expenses | Poor households in flood-prone communities of the Brahmaputra river basin. | 390 households (174 intervention, 216 comparison not receiving cash) |
Hagen-Zanker | Qualitative study (focus groups+in-depth semi-structured interviews) | 2016 | Jordan | Man-made crises | Unconditional cash transfer | Self-reported effect on access to health, stress, and anxiety | Working age Syrian refugees in Jordan and key informants (policy-makers, practitioners at national level) | Over 140 Syrian refugees across 60 interviews and FGDs |
Hidrobo | Randomised control trial | May–October 2011 | Ecuador | Man-made crises | Unconditional cash transfer | DDS HDDS FCS Caloric intake per capita (daily) | Colombian refugees and Ecuadorian locals in seven urban centres in the provinces of Carchi and Sucumbíos | 2087 households receiving either cash, food or control |
Hou 2010 | Randomised control trial | 1998–2000 | Mexico | Environmental | Conditional cash transfer | Total calorie consumption Diversity of diet including vegetables, fruits and animal products | HH across seven states in Guerrero, Hidalgo, Michoacan, Puebla, Queretaro, San Luis Potosi, and Veracruz | 10 541 (6362 intervention, 4179 controls not receiving cash) |
Kurdi 2021 | Cluster randomised control trial | Baseline sample: December 2014–January 2015 | Yemen | Man-made crisis | Conditional cash transfer | HDDS CDDS Height-for-age | HH with young children in Yemen. To meet treatment arm criteria women had to be “second priority” potential beneficiaries. | Baseline: 2000 HH (1001 treatment, 999 control HH) |
Lyles | Quasi-experimental prospective cohort | October 2018–January 2020 | Jordan | Man-made crisis | CHV intervention +conditional cash transfer group | Health service utilisation (diabetes care visits) Diabetes medication adherence Blood glucose self-monitoring BMI HbA1C Blood pressure Health expenditure | Syrian refugees with type II diabetes residing outside of camps in Amman and Zarqa governorates of Jordan | Baseline: 560 (156 CHV only, 203, CHV +CCT, 201 MPC) |
Lyles | Prospective cohort | May 2018–July 2019 | Lebanon | Man-made crisis | Multi-purpose unconditional cash transfer | Health service utilisation (care-seeking for children and chronic or acute illness among adults) Access to medication Health expenditure | Vulnerable Syrian refugee households sampled from UNHCR registration lists receiving MPCs (intervention) and similarly vulnerable households not receiving MPCs | Baseline: 617 HH (173 MPC intervention, 444 control group) |
MacPherson and Sterck 2021 | Quasi-experimental | September–October 2017 | Kenya | Man-made crises | Cash transfer (unclear whether conditional or unconditional) | DDS Calories per adult equivalent HFIAS Subjective well-being | Refugees in Kakuma camp and Kalobeyei settlement in Kenya | 1874 refugees (1126 households) |
Moussa | Quasi-experimental | Survey (wave 1): February–March 2019 | Lebanon | Man-made crises | Multi-purpose unconditional cash transfer (monetary value unclear) | Acute illness Diarrhoea Respiratory infection Needed primary healthcare Accessed primary healthcare | Syrian refugee children (<19 years) from discontinued cash recipient households, short-run and long-term recipient households living in Lebanon | 6,207 HH (2992 wave 1, 3215 wave 2) with 24 859 observations (11 843 wave 1, 13 016 wave 2) |
Schwab 2020 | Cluster randomised control trial | November 2011–October 2012 | Yemen | Man-made crises | Unconditional cash transfer | HDSS FCS Value of food consumed Caloric intake | 135 village clusters in rural Yemen. | 1983 people (982 intervention receiving cash, 1001 comparison receiving in-kind food) |
Sibson | Cluster randomised control trial | March 2015–November 2015 | Niger | Environmental | Unconditional cash transfer Standard intervention = ~£144 over 4 month period in 4 monthly disbursements Modified intervention = ~ £144 over 6 month period in 6 monthly disbursements | Acute Malnutrition MUAC WHZ Dietary diversity | Children aged 6–59 months, living in villages receiving unconditional cash transfer. | 1130 HH standard intervention |
Tossou 2021 | Cross-sectional | July 2020 | Togo | Environmental | Unconditional cash transfer | Health service and healthcare utilisation | National household survey covering 44 districts in six health regions in Togo: HH heads, consenting adults, children 10–17 years were surveyed | 955 beneficiaries |
ANC, antenatal care; APAI, Acholi Psychosocial Assessment Instrument; CHV, community health volunteer; CHW, community healthcare worker; CTP, cash transfer program.programme; DDS, dietary diversity score; DRC, Democratic Republic of the Congo; FCS, food consumption score; HFIAS, household food insecurity access scale; HH, household; HHS, household hunger scale; IDP, internally displaced people; MAD, minimum acceptable diet; MDDW, minimum dietary diversity for women; MUAC, mid-upper arm circumference; PHQ-9, Patient Health Questionnaire; PNC, postnatal care; PNCTP, Palestinian National Cash Transfer Programme; WG-SS, Washington group disability short set; WHZ, waist-to-hip ratio.
Summary of main results and conclusions
Study | Country | Type of humanitarian setting | Type of cash transfer | Health outcome/services | Main results and/or conclusion |
Abu-Hamad | Gaza, Palestine | Man-made crises | Unconditional cash transfer | Psychological health measured by a Self-Esteem Scale containing nine questions, paying for healthcare | A Self-Esteem Scale showed that the intervention group had a higher overall score (0.73) compared with the comparison group on the waiting list to receive cash transfers (0.68). 7.55% of children in the intervention group had an abnormal Strength and Difficulties Questionnaire (behavioural health screening tool) score compared with 9.18% in the comparison group. |
Aker 2017 | Democratic Republic of the Congo | Man-made crisis | Unconditional cash transfer | Household member affected by illness or died Expenditure on medicine | Affected by illness: −0.01 (0.08) cash, 0.59 (0.50) comparison using voucher ( Death: 0.03 (0.05) cash, 0.11 (0.31) comparison using voucher (p value 0.57) Households receiving cash transfers were more likely to use the funds to pay for health expenses |
Bliss | Niger | Environmental | Unconditional cash transfer | Presence of acute malnutrition (WHZ <2 or MUAC <125 mm) MUAC WHZ Child dietary diversity Child meal frequency Child illness Maternal mental health | Factors found to be associated with risk of acute malnutrition in households receiving cash transfers included low WHZ, household poverty status, and occurrence of child illness. Household food expenditures and other diet-related factors were not found to be associated with the risk of acute malnutrition. Over the course of the study, 18% (n=74) children in the cash transfer programme became acutely malnourished. |
Bliss | Niger | Environmental | Conditional cash transfer | Weight gain Weight gain velocity (g/kg/d) MUAC WHZ Presence of acute malnutrition (WHZ <2 or MUAC <125 mm or bilateral pitting oedema) Meal frequency Dietary diversity | |
Doocy | Somalia | Man-made crises (human conflict) | Unconditional cash transfer combined with in-kind food and electronic vouchers. | Household Hunger Scale (HHS) Minimum Dietary Diversity for Women (MDDW) MUAC (MUAC <21.0 cm classified as acute malnutrition) Meal frequency | |
Doocy | Somalia | Man-made crises (human conflict) | Unconditional cash transfer combined with in-kind food and electronic vouchers. | Household Hunger Scale (HHS) Children’s dietary diversity Meal frequency Minimum acceptable diet (MAD) Mean MUAC Acute malnutrition (MUAC <12.5 cm) | |
Edmond | Afghanistan | Man-made crises | Conditional cash transfer | Child delivery in a health facility Receiving at least one ANC visit Receiving one PNC visit Receiving at least one CHW home visit | |
Falb | Syria | Man-made crises | Unconditional cash transfer | Food insecurity via (HFIAS) Depressive symptoms via the PHQ-9 Disability status, via an adapted version of the WG-SS Women’s experiences of violence | , Between baseline and endline, Food insecurity items decreased by 0.92 points (95% CI: −1.17 to −0.68; p<0.0001) in the unadjusted linear model This significant decrease in food insecurity remained robust when adjusting for demographics (β=−0.90; 95% CI: −1.14 to −0.65; p<0.0001) Or when includinghousehold fixed effects (β=−0.95; 95% CI: −1.19 to −0.71; p<0.0001) Women agreed on average with 12.08 statements at baseline (SD: 3.32) on the 20 item HESPER scale. This signifieshigh household daily stressors and perceived serious needs. This was similar at endline (Mean: 12.11; SD: 3.87). Unadjusted, adjusted and household fixed effects models were not statistically significant (β=0.04; p=0.83; β=0.05; p=0.81; β=0.12; p=0.52, respectively). Women had a mean of 11.08 on the PHQ-9 scale on average at baseline and 11.93 at endline. Between baseline and endline, depressive symptoms changed by 0.86 points (95% CI: 0.32 to 1.40; p=0.002) in the unadjusted model. This was similar in the adjusted model (β=0.92; 95% CI: 0.35 to 1.49; p=0.001) as well as in the household fixed effects model (β=0.89; 95% CI: 0.34 to 1.43; p=0.001). |
Freccero | Cameroon, Afghanistan | Man-made crises | Cameroon: multipurpose cash programme (~US$300 over a 6 month period in monthly disbursements) | Self-reported changes in health | At the individual and household levels, many respondents reported improvements in health. |
Green | Uganda | Man-made crises | Unconditional cash transfer | Depression using modified version APAI depression subscale | There were decreases in depression severity in both the treatment and control groups over time. At endline, the treatment group mean decreased by 29%, from 0.85 to 0.60. Likewise, the control group mean decreased by 21%, from 0.75 to 0.59 The average treatment effect on symptoms of depression was not statistically significant and small |
Grijalva-Eternod | Somalia | Man-made crises | Unconditional cash transfer | Mean child, household and women DDS values Incidence acute malnutrition, defined by low MUAC or oedema Prevalence acute malnutrition, defined by low WHZ or oedema Mean WHZ value Mean FCS Mean HFIAS score Mean Reduced Coping Strategies Index (rCSI) score | Increased Child Dietary Diversity score by 0.53 (95% CI 0.01 to 1.05) Increased monthly household expenditure by US$29.60 (95% CI 3.51 to 55.68) Increased household Food Consumption Score by 14.8 (95% CI 4,83 to 24.8) Decreased Reduced Coping Strategies Index by 11.6 (95% CI 17.5 to 5.96) Did not reduce risk of acute childhood malnutrition |
Gros | Bangladesh | Environmental | Unconditional cash transfer (forecast-based) | Psychosocial distress Health expenses | No significant difference in change in dietary quality observed between food voucher and mixed transfer recipients A significant difference in change in mean meal frequency was observed (0.3 meals/day, CI: 0.1 to 0.5, p=0.001). Mean MUAC increased significantly among both voucher (0.9 cm, CI: 0.6 to 1.3, p=0.001) and mixed transfer recipients (1.3 cm, CI: 1.1 to 1.5, p=0.001) Fewer households in the mixed transfer group had moderate or severe hunger (35.4% compared with 44.0% and 94.9% in voucher and non-assistance groups, respectively) After the flood, households not receiving FbF assistance felt miserable or unhappy significantly more frequently compared to the intervention group not receiving cash assistance In the last seven days before the survey, compared to the intervention group, FbF-assisted households were significantly less likely to have felt anxious or depressed. |
Hagen-Zanker | Jordan | Man-made crises | Unconditional cash transfer | Self-reported effect on access to health, stress and anxiety | A third of participants reported the cash transfer improved their mental well-being. The cash transfers also alleviated stress or anxiety related to paying rent. The cash transfer helped to reduce small health expenditures by enabling recipients to partially cover the costs of treatment or medication. For other beneficiaries it helped to secure a loan covering healthcare expenses. Whilst the cash transfers alleviated some financial burdens of accessing healthcare, this was not a decisive factor in recipients' behaviours related to accessing health treatment. |
Hidrobo | Ecuador | Man-made crises | Unconditional cash transfer | DDS HDDS FCS Caloric intake per capita (daily) | All three groups (cash, food vouchers, food transfers) experienced significant improvements in households’ caloric intake and dietary diversity, however caloric intake increased by 21% in the food group and only by 12% in the cash group (p=0.05). The FCS, which measures households’ food consumption, increased by 11% in the cash group, 12% in the food group, and 16% in the voucher group. However, only the voucher and food groups saw statistically significant reductions in the percentage of households with poor to borderline FCS |
Hou 2010 | Mexico | Environmental | Conditional cash transfer | Total calorie consumption Diversity of diet including vegetables, fruits, and animal products | When drought affects income, households tend to buy cheaper calories (such as grains), which results in a net increase in total calories consumed, but these calories are more likely to cause chronic diseases. The CCT (PROGRESA) mitigates the negative effects of drought on calorie availability from fruits, vegetables and other sources. The CCT does not mitigate the impact of drought on calories from grains. |
Kurdi 2021 | Yemen | Man-made crisis | Conditional cash transfer | HDDS CDDS Height-for-age z score (HAZ) | Positive significant (large) impact on dietary diversity across full sample, strongest in poorest HH Overall the intervention increased the CDDS by 0.61 food groups across all HH Average estimated programme impact on HAZ across all HH was not significant HAZ of HH in lowest tercile statistically significant and large impact of 0.31 SD |
Lyles | Jordan | Man-made crisis | CHV intervention +conditional cash transfer group | Health service utilisation Diabetes medication adherence Blood glucose self-monitoring BMI HbA1C Blood pressure Health expenditure | Regular diabetes care visits increased in the CHV + CCT group (15.1%, CI: 5.4,24.8%; p= 0.002) Specialist visits increased among CHV +CCT group (16.8%, CI: 6.6 to 27.0%; p= 0.001) Specialist visits decreased in the CHV only participants (− 27.8%, CI: − 41.5,% to 14.0%; p < 0.001) (group difference in change p < 0.001) Pharmacist consultation decreased significantly in CHV only (− 24.1%, CI: − 37.9% to 10.4%; p = 0.001) and CHV +CCT (− 12.7%, CI: − 22.2% to 3.2%; p= 0.009) Decreased hospital visits among CHV only (−11.5%, CI: − 22.9% to 0.1%; p= 0.049) Increase in adherence in the CHV + CCT group (6.8%, CI: 2.2 to 11.5%; p= 0.004) Decrease in self-monitoring CHV only participants (− 16.3%, CI: − 25.2% to 7.4%; p≤ 0.001) Decrease in BMI in the CHV + CCT group (− 1.0 kg/m2, CI: − 1.7 to –0.3; p= 0.005) Decrease in HbA1C in CHV only 0.7% (CI: − 1.1% to 0.4%; p < 0.001), CHV +CCT − 0.5% (CI: − 0.7% to 0.3%; p < 0.001) and MPC group −0.2% (CI: −0.5 to 0.0%; p= 0.028) Increase in CHV+CCT group of normal blood pressure 11.3% (CI: 3.2 to 19.4%; p= 0.007) |
Lyles | Lebanon | Man-made crisis | Multi-purpose unconditional cash transfer | Health service utilisation (care-seeking for children and chronic or acute illness among adults) Access to medication (Health expenditure) | No significant changes observed within or between groups. |
MacPherson and Sterck 2021 | Kenya | Man-made crises | Cash transfer (unclear whether conditional or unconditional) | DDS Calories per adult equivalent HFIAS Subjective well-being | Refugees who received the transfer were found to have more diverse diets (20% higher DDS), higher caloric intake (p=0.12), and be less food secure (92% vs 79%) than those arriving just before. There was suggestive evidence that refugees living in Kalobeyei felt happier and more independent from aid than their counterparts in Kakuma. These results are robust to various tests and specification changes. kitchen-garden agriculture improves refugee diets |
Moussa | Lebanon | Man-made crises | Multi-purpose unconditional cash transfer (monetary value unclear) | Acute illness Diarrhoea Respiratory infection Required primary healthcare Used primary healthcare | Lower likelihood of children 0–5 years reporting acute illnesses with MPCs Lower incidence of diarrhoea and respiratory infections in children 0–5 years with MPCs Lower likelihood of needing PHC with MPCs More likely to use PHC when needed with MPCs Short-run improvement not sustainable when MPC benefits are discontinued, except for respiratory infections which don’t change Second cycle of cash transfer results in initial improvements of acute illnesses; needing PHC and using PHC maintain in the longer term |
Schwab 2020 | Yemen | Man-made crises | Unconditional cash transfer | HDSS FCS Value of food consumed Caloric intake | Cash beneficiaries had a more diverse diet, fed infants and young children a wider variety of foods and consumed higher quality food. Cash beneficiaries also consumed approximately 150 less calories per day than food recipients. Self-reported measures of food insecurity incidents and non-food expenditures, including qat use, did not differ by transfer type. |
Sibson | Niger | Environmental | Unconditional cash transfer standard intervention = ~£144 over 4-month period in 4 monthly disbursements modified intervention = ~ £144 over 6-month period in 6 monthly disbursements | Acute malnutrition MUAC WHZ Dietary diversity | There was no observable difference in the nutritional impact among children in the modified and standard cash transfer interventions. The odds of children having GAM and the adjusted mean WHZ were the same in each intervention arm and the general population. In children under 5, the GAM was 13.5% (95% CI: 10.8 to 16.8) at baseline and 14.7% (95% CI: 12.9 to 16.9, p=0.161) at endline. There was no significant difference in either the standard intervention (p=0.426) or the modified intervention (p=0.231). |
Tossou | Togo | Environmental | Unconditional cash transfer | Healthcare utilisation | For beneficiary households a positive impact of cash transfers on the use of healthcare services (66.6% higher in treatment group) |
ANC, antenatal care; APAI, Acholi Psychosocial Assessment Instrument; CHV, community health volunteer; CHW, community healthcare worker; CTP, cash transfer programme; DDS, dietary diversity score; DRC, Democratic Republic of the Cong; FCS, food consumption score; HFIAS, household food insecurity access scale; HH, household; HHS, household hunger scale; IDP, internally displaced people; MAD, minimum acceptable diet; MDDW, minimum dietary diversity for women; MUAC, mid-upper arm circumference; PHQ-9, patient health questionnaire; PNC, postnatal care; PNCTP, Palestinian National Cash Transfer Programme; WG-SS, Washington group disability short set; WHZ, waist-to-hip ratio.
Cash transfers were implemented by governments (n=4)
Qualitative data analysis
Abu-Hamad | Falb | Freccero | Gros | Hagen-Zanker | |
Palestine | Syria | Afghanistan; Cameroon | Bangladesh | Jordan | |
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Though no article was excluded from the review synthesis based on quality, the results of the individual study quality appraisals are available in
The included settings ranged across different types of humanitarian crises. Broadly, they can be divided into man-made disasters (n=17)
The majority of the cash transfer programmes examined was unconditional (n=17).
Only two studies reported on general health and well-being. Internally displaced persons in Cameroon (US$75–US$100 monthly over 5 months, US$43–US$84 monthly over 6 months) and Afghanistan (one-time US$80–US$198 over 2 months) reported general improvements in health, nutrition and housing after receiving multipurpose cash (MPC) transfers through an International Red Cross programme.
The most commonly investigated health outcomes were related to diets and nutrition.
Assessment of the impact of emergency CCTs (US$250 over 3 months) on the nutritional status of children in Niger found that the intervention was associated with a 1.27 kg overall weight gain (p value <0.001) and 1.82 greater increase in WHZ (p value <0.001) compared with the concurrent control group that did not receive the cash transfer. Furthermore, the odds of having acute malnutrition were 25 times higher for the comparison group.
Several studies compared the provision of cash transfers with other aid modalities. Two studies in Somalia assessed the impact of different emergency assistance modalities on acute malnutrition including in-kind food provision, food vouchers and UCTs (US$450 over 4 months).
One quasiexperimental study explored the impact of cash on diabetes control. The combined health education and CCT intervention programme (
The second most commonly examined health outcome related to psychosocial and mental health. These findings were often self-reported or measured by validated tools/questionnaires (eg, the patient health questionnaire). While psychosocial and mental health were not always the intended targets of cash transfer programmes, multiple studies reported on these effects.
A study in Raqqa Governorate, grappling with a dual crisis from the Islamic State of Iraq and Syrian occupation and civil conflict, found that an UCT (US$228 over 3 months) implemented by the IRC resulted in no change in perceived serious household needs and daily stressors (β=0.12; 95% CI −0.24 to 0.48) and an increase in depressive symptoms (β=0.89; 95% CI 0.34 to 1.43) before and after cash distribution.
Despite this, several studies reported positive impacts of cash transfers on mental health (n=4), despite this not being the intent of the cash transfer. Several women in the Raqqa Governorate reported in qualitative interviews that their levels of stress, as well as feelings of humiliation and shame, were reduced in the period of cash assistance delivery. ‘
A singular study explored the impact of cash on acute illnesses, comparing discontinued recipient households, short-term recipient households, long-term recipient households and non-beneficiary households of MPC transfers. In children under five, short-term and long-term participants suffered less acute illnesses than non-recipients. This finding was further confirmed with lower incidence of specific acute diseases such as diarrhoea and respiratory infections in recipient children versus non-recipient children.
The five studies on health service utilisation in this review focused on overall healthcare utilisation,
Two studies reported on how CCTs affected maternal and child healthcare utilisation. Mothers who received US$15 if they delivered a child at a health facility in Afghanistan reported an increase in both maternal and newborn service usage and CHW home visits. However, only the increase in antenatal care (ANC) visits was statistically significant (adjusted mean difference 45% (95% CI 0.18 to 0.72),
A study conducted in a population of Syrian refugees compared the effects of CCTs alone, health education alone and CCTs plus health education on healthcare utilisation for diabetes.
A study on survey data in Togo showed that a government CCT programme, the NOVISSI scheme, improved healthcare utilisation during the economic hardship from COVID-19.
Only a few studies reported on enabling or constraining factors around cash transfer implementation. Enabling factors mentioned were lower costs for implementing agencies compared with other modalities (eg, vouchers),
This review presents evidence on the impact of cash on health in humanitarian settings. Most studies were on UCTs in human conflict or food crisis settings discussing their impact on nutrition, psychosocial and mental health or general health and well-being. While the purpose of several programmes was specifically aimed at improving food security and preventing malnutrition, few were specifically designed with as purpose to address other health outcomes.
Our findings are broadly in line with evidence from research on cash transfers’ impact on health outside of humanitarian settings. For example, a 2010 Cochrane review on CCTs in low and middle-income countries (LMICs) reported that despite methodological weaknesses, the evidence suggests that cash transfers may contribute to health benefits.
The included studies were heterogeneous in their approaches to examine the effect of cash. Some studies investigated the impact of cash compared with food vouchers or in-kind food, while others used a comparison group that did not receive any assistance, tested the value/distribution method of cash transfers or performed pre–post implementation comparisons. Testing the implementation of cash transfers in one group against a group with no aid assistance also posed ethical challenges. Consequently, it is difficult to ascribe the extent or magnitude of the effect due to cash transfers versus other mechanisms. Studies comparing cash to vouchers, for example, often reported there was not a statistically significant difference in their impact. However, there is often a preference for cash transfers over other aid forms.
Included were limited in the time frames; studies were conducted over a few months (2 months) to a few years (18–24 months). Additionally, the length of cash transfers varied, from one-time disbursements to monthly allotments over a 7-month period. Going forward, it will be important to measure outcomes on a larger scale over a longer period of time, to fully understand whether cash can offer sustainable, long-lasting positive health impacts. Future research and aid provision could also consider the length of time covered by the cash transfers themselves and the effect of distributing the same monetary value over shorter versus longer time periods. The health outcomes examined across the studies were also fairly limited in scope, with only one study exploring the impact of cash on acute illnesses. This could be due to the requirement of laboratory-intensive or invasive measurements for some health outcomes in order to ascertain disease/health. Yet, cash transfers may also positively contribute to a range of other communicable (eg, COVID-19, Ebola) and non-communicable diseases. Several cash transfer programmes have been brought in place in the response to COVID-19 over 2020–2021 globally. This includes the expansion of the two largest existing cash transfer programmes in Colombia (Families in Action and Youth in Action) by lowering eligibility thresholds and including education and mental and psychosocial health targets.
Interestingly, the vast majority of cash transfers included were not specifically designed to cover health expenses. This has two important implications. First, there could be potential bias induced when cash is distributed for a specific purpose and communicated as such—resulting in recipients aiming to conform to what they were told the cash should be spent on (eg, food). Second, if the cash transfer value has not been designated to cover health expenses, households may likely trade-off and prioritise different expenses including health. As cash transfers become increasingly common, it will be important for implementers to collect, analyse and share the data on the effectiveness of their interventions in order to inform future programmes and evidence-based. Documenting best practices and considerations on safe and ethical implementation are important considerations. Therefore, it may be useful for future studies to adapt a similar framework or investigate a consistent group of core metrics in order to assuage some of the heterogeneity of this literature base. Additionally, future research and documentation of evidence could consider the roles of the different actors involved in the conceptualisation, development and delivery of cash transfers. It is important to consider how different implementers may have different motives and do not necessarily obey the same humanitarian principles, which can expose beneficiaries to different risks.
The type of data collected and reported is also an important consideration; qualitative data may provide further detail and insight into the experiences and perspectives of recipients and implementers. The qualitative data synthesised here highlighted some of the possible unintended consequences or impacts such as social exclusion, community tension and verbal abuse.
One of the limitations of this study is that it focuses on cash and does not include vouchers, which have been increasingly used to improve accessibility to health facilities. Second, we focused on the direct impact of cash transfers on health outcomes and service utilisation without exploring wider social determinants indirectly affecting health, such poverty reduction, clean water and sanitation access and education. Third, the available evidence was limited, and studies often had significant limitations, complicating robust information synthesis and preventing the performance of additional analysis (eg, meta-analyses). Yet, opportunities for rigorous approaches in acute emergencies are limited due to inaccessibility and the short planning cycles of intervention design and implementation. Finally, we focused on the inclusion of peer-reviewed academic journals in order to limit potential biases and confounders, inaccuracies and incomplete information and to ensure the replicability of this review.
The findings from this systematic review exhibit not only the potential impact of cash transfers on health outcomes and health service utilisation but also calls for future research. There is urgent need for high-quality quantitative and qualitative empirical evidence that is methodologically robust, investigates a range of humanitarian settings, and is conducted over longer time periods to better understand the long-term impacts of cash transfers on health and health service utilisation in humanitarian settings. Future research must investigate this area in further detail to better understand the specific variables that influence the effectiveness of cash transfers on health outcomes. For example, considering the types of crises (armed conflict vs epidemics) or health metrics (chronic vs infectious diseases). These lines of investigation could also provide insight to the impact of cash transfers on health outcomes beyond nutrition and mental/psychosocial health that were most examined in this review. Additionally, there is a need for further and clearer evidence on implementation factors that shape how cash transfers may function in a setting. For example, across health and international development interventions, it is highly encouraged and even expected to involve stakeholders directly at the beginning of a programme rather than to introduce an intervention from the outside or top-down approaches. Humanitarian or emergency settings may pose unique challenges when it comes to the timeliness and logistics of response and so future work may consider the role of building local capacity within cash transfer and other programme that can be leveraged in times of need. The findings of this review, as well as this call for further research, can have implications for both policy and practice by informing the development of evidence-based cash transfer programmes as they are implemented across humanitarian settings.
The authors thank the peer-reviewers for their constructive feedback that enabled the improvement of the manuscript.
Seye Abimbola
@daalenkim, @dadasara3, @rosiejames96, @HenryCAshworth, @ciaranmmooney, @EssarYasir, @ilk21, @BlanchetKarl
KRvD conceived the presented idea and developed the research protocol with support from SD, RJ, HCA, PK, JL, CM, YK, MYE and IK. KRvD, SD, RJ, HCA, PK, JL, CM, YK, MYE and IK collected, analysed, and synthesised the data. KB and HJ provided critical feedback and expertise on the protocol, analysis and write-up. All authors have made substantial, direct and intellectual contributions to the work and approved it for publication. KRvD is responsible for the overall content.
This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector. KRvD received funding from the Gates Cambridge Trust (OP114) for her PhD studies and received funding for publication of this article from the Gates Foundation.
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