from EVIDENCE to POLICY Learning what works for better programs and policies July 2017 NEPAL: Can information and cash improve children’s development? EARLY CHILDHOOD DEVELOPMENT Convincing parents to invest in appropriate nutrition for In Nepal, researchers supported by the World Bank’s Stra- their young children isn’t always easy. Parents may not un- tegic Impact Evaluation Fund worked with the government derstand the importance of good nutrition to a child’s de- to develop a program to inform pregnant women and moth- velopment or they may not know which foods will provide ers of young children on how to best care for themselves and the necessary vitamins their children, using already ongoing community meetings to and minerals. Another deliver messages. An impact evaluation was designed to mea- problem is that even if sure the effectiveness of the information and to test whether they know, they may combining this with a short-term cash transfer for mothers not be able to afford made the it more effective. The evaluation found that moth- to make changes in the ers who received both information and cash reported a higher food they give their likelihood of breastfeeding their babies and reported that they children. Policymakers took recommended vitamins and their households consumed and development orga- more calories. Also, their children had better fine and gross nizations are trying to motor skills as compared to the control group, which didn’t identify the best routes receive this intervention. But there weren’t any reductions in for improving nutrition in low-income countries, where malnutrition. Two years later, after a devastating earthquake the problem is most acute. One approach is to make sure in 2015, researchers returned and found that while moth- that families in general, and women in particular, under- ers still retained more knowledge on good nutrition prac- stand the importance of appropriate nutrition for pregnant tices, their children didn’t show any continued development women and young children, including the need for moth- gains. The results are helping the Government of Nepal ers to breastfeed exclusively for the first six months of a as it considers new steps for improving child develop- child’s life. The question is what are the best methods for ment, and the materials used during the meetings to in- getting this information across and ensuring that it leads to form women about healthy nutrition have been adopted behavior change and healthier outcomes. for wider use. Context In poor communities in Nepal, malnutrition is a major According to 2014 statistics from the Government of Ne- health issue. Nearly half of all children under the age of pal, close to one-third of pregnant women in Nepal don’t five are stunted. The World Bank estimates that two to visit a doctor at least once during pregnancy, which is an three percent of Nepal’s GDP is lost every year because important time for receiving information on needed nu- of the costs associated with ill health and lost opportu- trition, about a quarter of babies are born with low birth nities for children who are malnourished and can’t reach weight, and almost half of babies aren’t exclusively breast- their full potential. The roots of the problem are varied: fed in the first six months. The Government, working with SIEF-supported re- one week of training on the technical issues they were sup- searchers, created a pilot program in 2014 for Nepal’s posed to cover and on techniques they could use to engage extreme poor in four of the country’s most marginalized with women attending the community meetings. They and food insecure districts. The program was designed to also were given cards describing best health and nutrition provide participants with information on best practices for practices and handouts to use during the sessions. nutrition, such as exclusive breastfeeding during the first To measure the impact of adding a cash transfer, some six months of a child’s life and regular health checkups. households received a monthly cash transfer of NPR 700 The program focused on villages where the govern- (about USD $7, or 10 percent off a median monthly in- ment’s Poverty Alleviation Fund had established local orga- come). This allowed the research team to measure whether EARLY CHILDHOOD DEVELOPMENT nizations to foster community-led development. These or- extra cash would help mothers implement what they were ganizations hold monthly community meetings to discuss learning. The cash was distributed during the meetings. infrastructure needs and income-generating plans, and the Mothers were told the money was for their children, but new maternal health and nutrition-focused campaign was in practice they were free to use it as they wanted. While delivered at the end of these meetings by a locally known the cash transfer part of the program lasted for five months female health volunteer. The curriculum was developed by (May 2014 through September 2014), the community ses- Helen Keller International, based on World Health Or- sions on nutrition and child care went on for nine months ganization standards, and the health volunteers received (January 2014 through September 2014). Evaluation Researchers used a randomized control trial design to eval- place from August 2014 through September 2014, and the uate the effects of the program on child development and endline survey took place from November 2014 through on mothers’ knowledge and behavior. December 2014. The trial used a stratified cluster design so that within Researchers conducted household surveys and mothers each of the four districts, each county, locally known as a were asked about their nutritional knowledge and habits. Village Development Committee, was randomly assigned Researchers also used the Ages and Stages Questionnaire, to one of three groups. One group would receive just in- which includes age-specific questions for mothers that formation, one group would receive information plus cash gauge children’s communication, gross motor, fine motor, payments, and one group would act as the control group problem solving, and personal social skills. A total of 4,228 and not receive any new information or cash. women and 3,695 children under two years old were sur- Within each county, researchers randomly selected ap- veyed at baseline, and at endline the sample was 2,338 proximately four villages—out of an estimated 30 in each women and 1,953 children. county—to be surveyed for the impact evaluation. The sample included 184 counties, with a total of 591 villages Information sessions focused on: that would be surveyed. Researchers conducted a baseline • Nutrition for pregnant women survey from August 2013 through October 2013 before • Breastfeeding practices the program began. In each of the 591 villages, every • Proper care for sick children household with either a pregnant woman or a child un- • Supplemental feeding for older babies der the age of two was surveyed. The midline survey took This policy note is based on “The Role of Information and Cash Transfers On Early Childhood Development: Evidence from Nepal,” Michael Levere, Gayatri Acharya, Prashant Bharadwaj, World Bank, Policy Research Working Paper 7931, December 2016. Results Mothers who received the information through women didn’t receive the cash didn’t report an increase community meetings knew more than those in in daily calorie intake. When it came to eating a more the control group about how best to care for their varied diet, however, mothers who lived in areas where children and themselves—and the women who also only the informational meetings were available, reported got cash showed the most substantial increase in an improvement, but the group that also received cash knowledge. didn’t. It’s unclear why this was seen in the information group only. Before the program began, just half of the mothers said that babies should be exclusively breastfed, and only half said that pregnant women should eat more than women who aren’t pregnant. Mothers who received the informa- tion and cash improved their knowledge about the impor- tance of things such as breastfeeding, taking Vitamin A and health checkups. For women who received informa- tion only, the increase in knowledge was about half as large as that seen among women who received also cash. Women who received the cash may have learned more because the money was distributed at the information ses- sions; or perhaps those who received the money were more invested in what they learned because they saw cash as a way for making changes for themselves and their children. Mothers who received information and cash were more likely to report going for prenatal checkups, Children whose mothers received both cash and breastfeeding their babies, and taking a information showed improved development recommended vitamin A supplement. measurements, concentrated in better gross and fine motor skills. Mothers who received both information and cash not only improved their knowledge of best childcare practices For children born before the program, the improvement when compared with women who didn’t receive any spe- amounted to a statistically significant increase of nearly 0.1 cial information sessions, but they also reported changes standard deviations on the Ages and Stages Questionnaire. in behavior. They were more likely to report giving their Also known as ASQ, it measures cognitive, communica- babies only breastmilk and more likely to say they had tion, socio-emotional, and motor skills. The changes were gone for prenatal visits and had taken vitamin A supple- mainly in better motor skills. Children whose mothers re- ments. In addition, mothers in this group also reported ceived only information didn’t show similar improvements. that their families consumed about 100 more calories per person per day. Physical health for these children whose mothers Among women who received information sessions received information and cash didn’t improve. without cash, there were also positive changes in reported behavior when it came to breastfeeding, prenatal check- For children born prior to the program, anthropomet- ups, and supplements. The big difference between the ric measurements, which look at a child’s size along a two groups was around calorie intake: households where growth curve, and the likelihood of having an illness in the previous 30 days remained unchanged in areas group also showed significant declines in measures of com- where informational meetings alone were held and in munication, gross motor, and socio-emotional skills. It’s un- areas where mothers also received cash transfers. clear why this was the case. However, children born after the program started to mothers who received information and Results were mixed when it came to the impact cash didn’t show any differences from the control group in on children born after the program started and terms of wasting or cognitive and physical skills. whose mothers went to informational meetings. Two years later, after a devastating earthquake in Given the increase in knowledge among mothers and the April 2015 that killed an estimated 9,000 people, EARLY CHILDHOOD DEVELOPMENT improvement in reported health practices, it would be ex- researchers went back to see how mothers and pected that babies born during or after the period when in- children who had been in the pilot program had formational sessions were held would benefit. That wasn’t fared. always the case. Children born after the program started were less likely to be suffering from extreme and chronic Mothers who had received information and cash contin- malnutrition, known as wasting (about 10 percent of chil- ued to show better knowledge and to report better behav- dren in Nepal under the age of five suffer from wasting), if ioral practices around infant health and feeding practices. their mothers were in the group that received informational However, there was no discernable impact on children’s meetings but didn’t receive cash. However, children in this physical, cognitive, or socio-emotional development. Conclusion Providing mothers information—and the cash to see results that require further scrutiny, such as why children changes through—may be a good route for helping fami- born after the program started—and thus should have lies understand the importance of nutrition and giving benefited the most from their mothers’ new knowledge -- them the financial means to improve nutritional practices either didn’t benefit or actually showed some declines in in the home. However, the impacts of this evaluation were skills. Further research might focus on testing longer in- mixed, a possible sign that information and short-term terventions, involving both for cash and information, and cash injections might not be sufficient to generate lasting exploring whether there are other routes for reinforcing the change in children’s development. There were also some messages. The Strategic Impact Evaluation Fund, part of the World Bank Group, supports and disseminates research evaluating the impact of development projects to help alleviate poverty. The goal is to collect and build empirical evidence that can help governments and development organizations design and implement the most appropriate and effective policies for better educational, health and job opportunities for people in developing countries. For more information about who we are and what we do, go to: http://www.worldbank.org/sief. The Evidence to Policy note series is produced by SIEF with generous support from the British government’s Department for International Development. THE WORLD BANK, STRATEGIC IMPACT EVALUATION FUND 1818 H STREET, NW WASHINGTON, DC 20433 Series editor: Aliza Marcus; Writer: Daphna Berman