from EVIDENCE to POLICY Learning what works for better programs and policies September 2017 NIGER: Can cash and behavioral change programs improve child development? EARLY CHILDHOOD DEVELOPMENT The first 1,000 days of a child’s life are critical to healthy The Government of Niger created a national social development. In poor countries, governments and interna- safety nets project in 2012 that uses monthly cash trans- tional development groups are trying to design programs to fers to help combat poverty and improve food security give families, particularly mothers, the knowledge and ser- for the country’s poorest families. An experimental study vices they need so that was built into the project’s initial phase to determine the babies and young chil- added value of combining the cash transfers with com- dren get the healthcare, munity meetings, group discussions, and home visits to nutritious foods, and provide information to women about healthy child de- stimulation necessary velopment. The evaluation found that these behavioral for the best possible change activities improved women’s knowledge and prac- start in life. Deliver- tices related to children’s health, nutrition, and cognitive ing these programs isn’t development. But there was little impact on children’s easy, especially when ex- physical growth or cognitive development, underscoring treme poverty, climatic the complexity of the challenge and indicating that in- shocks such as droughts, and a lack of basic services often formation isn’t always enough. As the safety nets project mean families don’t have the resources to purchase healthy has been scaled up—it has now reached approximately food or the ability to get adequate healthcare for their chil- 100,000 households—the Government of Niger and the dren. Experts are looking at twinning cash transfers for the World Bank are using lessons from the evaluation to en- poorest with measures to improve parents’ knowledge about courage improvements in health, education, and nutri- what they can do to promote child development. But what tion services in villages where people receive cash trans- does it take to ensure that the messages are effective? And even fers, so that beneficiaries can better access services that when women’s knowledge improves, does this lead to better support healthy child development. A study is also under child development in countries with weak health and educa- way to test whether improving access to clean water and tional services? sanitation can contribute to positive change. Context Niger has one of the highest fertility rates in the world—7.6 In 2012, with support from the World Bank and children per woman—and children under the age of five UNICEF, the Government of Niger launched the Niger make up a quarter of the population. Almost half of these Safety Nets project to combat poverty and food insecurity in children are stunted from chronic malnutrition. Indeed, a the five poorest regions: Maradi, Tahoua, Tillabery, Zinder, large share of Niger’s population is estimated to suffer from and Dosso. The project includes cash transfers of about food insecurity, meaning they don’t have reliable access to a US$20 a month to the poorest households for 24 months. sufficient quantity of affordable, nutritious food. For many, The cash transfers are delivered with various accompanying this is a persistent state. Recurrent, countrywide droughts measures, including activities that encourage households have exacerbated food insecurity. to save some of the money to develop income-generating activities (World Bank Policy Research Working Paper 7839, issues related to child stimulation and protection, such as September 2016). Another set of activities, which was the the importance of talk and play, positive disciplining, and focus of this impact evaluation, seeks to increase community socio-emotional development. The information is delivered knowledge of children’s nutrition and development issues, during monthly village assemblies for both beneficiaries and to encourage positive parenting practices through and non-beneficiaries; monthly discussions among social activities that encourage behavioral changes for mothers safety net beneficiaries only; and regular home visits to and for the community as a whole. The topics covered in provide mothers with information on nutrition, health, the activities are based partially on UNICEF’s “Essential child protection, and psycho-social stimulation. The Family Practices” modules, which promote, among other village meetings are delivered by a local non-governmental EARLY CHILDHOOD DEVELOPMENT things, exclusive breastfeeding for the first six months, organization, while specially trained community educators adding nutritious foods to a child’s diet, and sleeping under conduct the group discussions and home visits, which were insecticide-treated mosquito nets. The activities also address held monthly. All activities continued for 18 months. Evaluation A randomized control trial was used to evaluate the groups. The evaluation team conducted a follow-up sur- effectiveness of the added behavioral change activities vey between January and June 2015, around the time that related to parenting practices on households receiving cash households were exiting from the cash transfer program, transfers. The impact evaluation focused on the first cycle to determine the impact of the behavioral change activities of approximately 10,000 households receiving cash transfers on parenting and child development. in the Dosso and Maradi region, starting in February and Niger at a glance March 2013 and ending between March and April 2015. • Niger is one of the least developed countries in the world. Households eligible for cash transfers were divided by villages into 100 clusters, and among these, half of the • It ranked last in the 2015 United Nations Human Development Index (188 out of 188 countries). clusters were randomly selected by public lottery to receive additional information about positive parenting practices. • The fertility rate is 7.6 children per woman. The baseline survey was conducted in 2012, right be- • Two-thirds of the population live below the poverty line, fore implementation of the safety nets project and prior surviving on less than 1 dollar per day, and hunger is a daily to the randomization of the villages into the two different challenge for many families. Results The behavioral change activities, which include Mothers who received both cash and the behavioral change meetings and home visits, significantly improved component of meetings and home visits were 55 percent nutrition practices among households receiving more likely to report that they exclusively breastfed their the cash transfer program: Parents reported that children for the first six months, as compared to mothers babies were more likely to be breastfed and were who received cash only. Children between six and nine given higher-quality foods. months old whose mothers received the full program were also more likely to get higher-quality foods, according to This policy note is based on the report on the evaluation, “Transferts Monétaires, Valeur Ajoutée de Mesures d’Accompagnement Comportemental, et Développement de la Petite Enfance,” Report No: ACS18664, World Bank, June 2016; and “Promoting Positive Parenting Practices in Niger through a Cash Transfer Programme,” Oumar Barry, Ali Mory Maïdoka, Patrick Premand, Early Childhood Matters, Bernard van Leer Foundation, 2017. their mothers, with an increase in eggs, biscuits, cereals, and Children’s socio-emotional development, in terms of how fish. Children’s overall food security—meaning that their they scored on various measures, improved by three percent, parents reported they had a diversified diet—also increased while children’s physical development, in terms of weight by about 11 percent. for height and other growth measurements, wasn’t any better than that for families that only participated in the Mothers who received the behavioral change cash program. Similarly, the evaluation found no impact on component were more likely to report engaging in children’s cognitive development. As impacts were measured practices that stimulated their children and less shortly after completion of the behavioral change activities likely to use violence or negative practices in started, more time may be needed before any changes disciplining their children… materialize in child development. The evaluation found an increase of 17 percent in children’s The behavioral change component itself was very “stimulation index,” which included a mix of activities popular. undertaken by adults with young children, such as reading, storytelling, playing, naming, counting, or drawing. While the On average, 92 percent of beneficiaries in the cash transfer percentage of children who played with an adult household program who were eligible for the meetings and home visits member didn’t change, children engaged in more varied play. took part regularly. In addition, many individuals who didn’t Families were also 15 percent less likely to use negative forms of discipline, such as yelling, slapping, or hitting, based on mothers’ reports. For example, there was a 20 percent drop in hitting children with an object, a 25 percent decline in yelling at children, and a 22 percent drop in slapping children. …and more likely to carry out recommended preventative health practices. Children aged 12 months to 24 months whose mothers received the parenting training were 19 percent more likely— or 11 percentage points up from 59 percent—to have had all necessary vaccinations. The rate of receiving iron supplements receive the cash transfers also participated in the community rose by 9.6 percentage points from about 17 percent. meetings in targeted villages. In fact, the evaluation found a positive effect also on villagers who weren’t eligible for the Reports of disease were less common among cash transfer program. They also reported better nutrition children whose families received the behavioral practices, more stimulation activities, and a lower likelihood change component, and when kids did get sick, of using violence as a form of discipline for their children. parents were more likely to report that they took them to a health center. It is likely some improvements in implementation of the parenting component could yield better For children under age five, reported illness decreased by five results, though overall implementation was percentage points, and the probability of using health services satisfactory. in case of illness increased by six percentage points. However, there was no impact on vitamin A supplementation, the The delivery model for the behavioral change component share of children sleeping under a treated mosquito net, or was designed in a way to allow implementation at scale in the likelihood that children would have a birth certificate. a low-income setting. The community educators are local people who are not beneficiaries of the safety net program Nevertheless, despite positive impacts on reported and they are paid about $20 a month for their work. They behavior, the evaluation found only limited receive two weeks of training at the start, followed by two- developmental improvement on children themselves. week refresher courses after 6 months and 12 months of implementation of the parenting program. NGO field Another challenge is that child development is staff who organize the village assemblies—and themselves really a multi-sectoral issue, and it’s hard to receive the same training at the outset—are responsible for improve children’s health and development if providing coaching for these community educators. there’s limited access to clean water and some Although an implementation study found that the health services aren’t functioning well enough. community meetings and home visits were carried out well overall, it identified some weaknesses in terms of expected Some participants reported that when they took their mentoring by NGO field staff of the community educators young children to the health clinic because of suspected doing the home visits and running the discussion groups. malnutrition, they sometimes were sent home without EARLY CHILDHOOD DEVELOPMENT About 25 percent of the community educators did not anyone checking their child’s condition. In other cases, it may have the required knowledge to effectively conduct be that the lack of adequate water and sanitation facilities in their activities, in large part due to widespread illiteracy. these villages caused children to fall ill with conditions that Some household visits were found to be shorter and less can harm development and that can’t be addressed through interactive than planned. the parenting classes alone. Conclusion Policymakers know that setting up young children for suc- may not be enough to promote positive change for chil- cess is critical to breaking the cycle of intergenerational dren—even when parents are eager to learn more and poverty. Ensuring that children have enough food and make positive changes. The results underscore the need for stimulation is an important first step. But as the results of more research to better understand ways to improve the this evaluation show, teaching parents important skills may physical, cognitive, and socio-emotional development of not be enough to make a real difference in the lives of the the world’s most vulnerable children, and, in particular, world’s most vulnerable children. Indeed, for families in to ensure that interventions for families are matched by rural Niger, where poverty is so extreme and environmen- improvements in the education, health, and other services tal conditions so challenging, behavioral change programs that they are being encouraged to use. 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