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A Mixed Methods Study on the Influence of a Seasonal Cash Transfer and Male Labour Migration on Child Nutrition in Tahoua, Niger

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A Mixed Methods Study on the Influence of a Seasonal Cash Transfer and Male Labour Migration on Child Nutrition in Tahoua, Niger A mixed methods study on the influence of a seasonal cash transfer and male labour migration on child nutrition in Tahoua, Niger Victoria Louise Sibson Institute for Global Health Thesis submitted for degree of Doctor of Philosophy University College London 2014-2019 2 Declaration I, Victoria Sibson, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Signed…………………………………… Date……………………………………… 3 4 Abstract Unconditional cash transfers (UCTs) are used to prevent acute malnutrition in emergencies but evidence on their effectiveness is lacking. In Niger, NGOs implemented annual UCTs with supplementary feeding during the June–September lean season, despite feeding programme admissions sometimes rising earlier. I hypothesised that starting the UCT earlier would reduce acute malnutrition prevalence in children 6-59 months old, but also, that this would promote early return of seasonal male labour migrants (exodants), limiting the effectiveness of the modified UCT. A cluster-randomised trial involved the poorest households receiving either the standard monthly UCT (June-September) or a modified UCT (April-September); both providing a total of 130,000 FCFA/£144. Pregnant and lactating women and children 6–<24 months old in beneficiary households also received supplementary food (June-September). We collected quantitative data from a cohort of households and children in March/April and October/November 2015 and conducted a process evaluation. The modified UCT did not reduce acute malnutrition prevalence compared with the standard UCT. Among beneficiaries in both arms the prevalence of GAM remained elevated at endline (14.7, 95%CI 12.9, 16.9), despite improved food security, possibly due to increased fever/reported malaria. Exode was highly prevalent (baseline population prevalence of short- term exode: 28.0, 95%CI 24.0, 32.4) and multi-annual, mostly to Libya. Probably because of distance and travel cost, the modified UCT did not affect exodant returns. Short-term exode was associated with greater odds of stunting (1.93, 95%CI (1.24, 3.00), P=0.003) and underweight (1.95, 95%CI (1.10, 3.45), P=0.021) among left-behind children. The greater odds of underweight persisted in exodant households recently receiving remittances (2.40, 95%CI (1.17, 4.92), P=0.017), suggesting remittances were inadequate. Non-food related drivers of malnutrition, including disease, may limit the effectiveness of UCTs to reduce acute malnutrition prevalence in Niger. Efforts to tackle undernutrition should consider the greater vulnerability of children in exodant households. 5 6 Impact Statement I undertook my research in Tahoua, Niger, studying the effectiveness of seasonal unconditional cash transfers (UCT) against childhood acute malnutrition, alongside the influence of male labour migration (exode) on the nutritional status of left-behind children. My findings both add academic knowledge and have influenced, or have the potential to influence, policy and practice locally and globally. Firstly, I found that modifying the standard UCT, starting it earlier and disbursing the same total amount of cash in six smaller monthly transfers made no difference to its effectiveness to reduce acute malnutrition in children 6-59 months old. Secondly, neither UCT reduced the global acute malnutrition prevalence below the WHO emergency threshold. These findings were published in Maternal and Child Nutrition in 2018, and I recommended a broader approach to reducing seasonal acute malnutrition which informed changes in Concern’s efforts to tackle acute malnutrition, emphasising support for 1. Government health services, 2. Peer-led awareness raising/education at community/household levels to improve preventive practices, and 3. Livelihoods/natural resource management to build resilience to climate shocks and the hunger gap. The second finding has relevance beyond Niger, as it is consistent with research elsewhere showing that UCTs alone can be insufficient to effect nutrition impacts, often needing to be linked to other services. My third finding, that exode was multi-annual and fourthly, that the migrants’ movements were unaffected by the seasonal UCT are also relevant to policy and practice in Niger and beyond. The extent of exode suggests that organisations working to tackle poverty/improve wellbeing in Niger should acknowledge it in their strategies; having shared my thesis with Concern, this influence is a work in progress. In addition, given an increasing policy focus on stopping cross- border movements, if there is future interest in using cash-based interventions (CBI) to discourage exode, it will be important to consider their design. My findings highlight, however, the importance of undertaking studies on the longer-term impacts of typical-term exode (i.e. 2-3 years) before actively seeking to curb it. My fourth finding is relevant globally in relation to implementing CBIs to prevent migration, although any CBI designed to do so needs to be predictable and flexible, and care needs to be taken not to negate any positive benefits that may accrue to migrants and their families. 7 My fifth and sixth findings were that exode under a year long, was associated with greater odds of stunting and underweight among 6-59 month old children left behind, and recent receipt of remittances by short-term exodant households was associated with a greater odds of underweight among these children. As above, these findings are highly relevant to organisations working to tackle undernutrition in Tahoua, and in other exodant-sending hot-spots in Niger, who should acknowledge exode in the design and delivery of their interventions. They indicate that migrant-sending households should be considered vulnerable and targeted with appropriate interventions accordingly. As above, having shared my thesis with Concern, this influence is a work in progress. Given the extent of economic migration, these key findings also have global policy relevance. 8 Contents CHAPTER ONE: Introduction and Background ............................................................................ 21 1.1 Undernutrition in the context of humanitarian emergencies .......................................... 21 1.2 The rise of cash transfers as humanitarian assistance and evidence of nutrition impact 24 1.3 The REFANI-N trial: testing a modified seasonal UCT to prevent acute malnutrition in the context of exode ..................................................................................................................... 28 1.4 Migration, its impact on child nutrition and how it is affected by cash transfers ............ 35 1.4.1 Migration .................................................................................................................... 35 1.4.2 The impact of migration on the nutritional status of children left behind ................ 39 1.4.3 The impact of cash transfers on migration ................................................................ 62 1.5 Aim, objectives, research questions and hypotheses ....................................................... 65 1.6 Overview of dissertation ................................................................................................... 72 CHAPTER TWO: Study setting, interventions and methods ....................................................... 73 2.1 Study setting ..................................................................................................................... 73 2.1.1 Niger ........................................................................................................................... 73 2.1.2 Study site: Tahoua ...................................................................................................... 77 2.2 The REFANI-N trial and my roles and responsibilities ....................................................... 90 2.3 The interventions .............................................................................................................. 92 2.4 Methods ............................................................................................................................ 95 2.4.1 Overview .................................................................................................................... 95 2.4.2 Ethics .......................................................................................................................... 97 2.4.3 Quantitative methods (Cohort study) ........................................................................ 98 2.4.4 Secondary data collection and analysis ................................................................... 109 2.4.5 Qualitative methods ................................................................................................ 111 CHAPTER THREE: The effect of modifying the UCT on child nutrition outcomes - findings from the randomised controlled trial ................................................................................................ 121 3.1 Intervention implementation and uptake ...................................................................... 121 3.2 Participant flow ............................................................................................................... 122 3.3 Baseline characteristics ................................................................................................... 124 3.3.1 Beneficiaries ............................................................................................................
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