Cash‐based approaches in humanitarian emergencies: a systematic review
Authors: Doocy Shannon , Tappis Hannah 
Published: January 2018

This Campbell systematic review examines the effectiveness, efficiency and implementation of cash transfers in humanitarian settings. The review summarises evidence from five studies of effects, 10 studies of efficiency and 108 studies of barriers and facilitators to implementation of cash‐based humanitarian assistance.Studies assessing effectiveness of cash‐based approaches were experimental and quasiexperimental studies. Studies analyzing efficiency were experimental, quasi‐experimental or observational studies with a cost analysis or economic evaluation component. Studies examining barriers and facilitators included these study types as well as other qualitative and mixed methods studies.Unconditional cash transfers and vouchers may improve household food security among conflict‐affected populations and maintain household food security among food insecure and drought‐affected populations. Unconditional cash transfers led to greater improvements in dietary diversity and quality than food transfers, but food transfers are more successful in increasing per capita caloric intake than unconditional cash transfers and vouchers. Unconditional cash transfers may be more effective than vouchers in increasing household savings, and equally effective in increasing household asset ownership. Mobile transfers may be a more successful asset protection mechanism than physical cash transfers. Cash transfers can be an efficient strategy for providing humanitarian assistance. Unconditional cash transfer programmes have a lower cost per beneficiary than vouchers which, in turn, have a lower cost per beneficiary than in‐kind food distribution. Cash transfer programs can also benefit the local economy. Voucher programmes generated up to $1.50 of indirect market benefits for each $1 equivalent provided to beneficiaries and unconditional cash transfer programmes generated more than $2 of indirect market benefits for each $1 provided to beneficiaries. Intervention design and implementation play a greater role in determining effectiveness and efficiency of cash‐based approaches than the emergency context or humanitarian sector. Factors which influence implementation include resources available and technical capacity of implementing agencies, resilience of crisis‐affected populations, beneficiary selection methods, use of new technologies, and setting‐specific security issues, none of which are necessarily unique to cash‐based interventions.Plain language summaryCash‐based humanitarian assistance approaches can increase food security and are more cost effective than in‐kind food transfersBoth cash‐based approaches and in‐kind food assistance can be effective means of increasing household food security for people who live in areas of conflict.The review in briefCash‐based approaches have become an increasingly common strategy for the provision of humanitarian assistance. Both cash‐based approaches and in‐kind food assistance can be effective means of increasing household food security among conflict‐affected populations and maintaining household food security among food insecure and drought‐affected populations. Cash transfers are more cost effective than vouchers which are more cost effective than in‐kind food assistance.What is this review about?This review assesses the effects of cash‐based approaches on individual and household outcomes in humanitarian emergencies. It also assesses the efficiency of different cash‐based approaches and identifies factors that hinder and facilitate programme implementation.What is the aim of this review?This Campbell systematic review examines the effectiveness, efficiency and implementation of cash transfers in humanitarian settings. The review summarises evidence from five studies of effects, 10 studies of efficiency and 108 studies of barriers and facilitators to implementation of cash‐based humanitarian assistance.What are the main findings of this review?What studies are included?Studies assessing effectiveness of cash‐based approaches were experimental and quasi‐experimental studies. Studies analyzing efficiency were experimental, quasi‐experimental or observational studies with a cost analysis or economic evaluation component. Studies examining barriers and facilitators included these study types as well as other qualitative and mixed methods studies.Unconditional cash transfers and vouchers may improve household food security among conflict‐affected populations and maintain household food security among food insecure and drought‐affected populations. Unconditional cash transfers led to greater improvements in dietary diversity and quality than food transfers, but food transfers are more successful in increasing per capita caloric intake than unconditional cash transfers and vouchers. Unconditional cash transfers may be more effective than vouchers in increasing household savings, and equally effective in increasing household asset ownership. Mobile transfers may be a more successful asset protection mechanism than physical cash transfers.Cash transfers can be an efficient strategy for providing humanitarian assistance. Unconditional cash transfer programmes have a lower cost per beneficiary than vouchers which, in turn, have a lower cost per beneficiary than in‐kind food distribution. Cash transfer programs can also benefit the local economy. Voucher programmes generated up to $1.50 of indirect market benefits for each $1 equivalent provided to beneficiaries and unconditional cash transfer programmes generated more than $2 of indirect market benefits for each $1 provided to beneficiaries.Intervention design and implementation play a greater role in determining effectiveness and efficiency of cash‐based approaches than the emergency context or humanitarian sector. Factors which influence implementation include resources available and technical capacity of implementing agencies, resilience of crisis‐affected populations, beneficiary selection methods, use of new technologies, and setting‐specific security issues, none of which are necessarily unique to cash‐based interventions.What do the findings of this review mean?Unconditional cash transfers and vouchers can be effective and efficient ways to provide humanitarian assistance.Each assistance modality has different advantages and disadvantages that should be considered in the design of future interventions. However, no definitive conclusions on the effectiveness of cash transfer or voucher programmes could be drawn that are universally applicable for humanitarian policy.Further development of the evidence base, with more rigorous evaluations comparing the effectiveness of different cash‐based approaches and transfer modalities, as well as approaches to comparing costs and benefits of cash‐transfer and voucher programmes, is needed to further strengthen the evidence base.How up‐to‐date is this review?The review authors searched for studies published up to November 2014. This Campbell systematic review was published in December 2017.Executive summaryBACKGROUNDHumanitarian actors have a responsibility to ensure that assistance is provided in a way that minimizes risks and maximizes benefits to people affected by crisis. However, there are many challenges in evaluating ‘what works’ in addressing the needs of crisis‐affected populations, and translating research evidence into practice in complex environments with limited resources.Humanitarian assistance has traditionally been provided in the form of in‐kind goods and services: temporary shelters, food and non‐food items, water and medical care. However, as the nature of humanitarian crises has shifted over the last few decades, cash‐based approaches have become an increasingly common strategy for the provision of humanitarian assistance and are widely considered an appropriate, and sometimes preferable, substitute for in‐kind assistance when conditions permit.Increasing use of cash‐based approaches has been accompanied by efforts to evaluate cash‐based interventions and develop recommendations for implementation in a range of settings. Systematic reviews of evidence in humanitarian settings are,however,relatively rare, and, to the best of our knowledge, this is the first systematic review of the effects of cash‐based approaches in emergencies to date.OBJECTIVESThe primary objective of this review wasto assess and synthesize existing evidence on the effects of cash‐based approaches on individual and household outcomes in humanitarian emergencies. The secondary objective was to assess the efficiency of different cash‐based approaches and identify factors that hinder and facilitate programme implementation.REVIEW METHODSWe followed standard methodological procedures for review of experimental and quasi‐experimental studies to assess the effects of unconditional cash transfer, conditional cash transfer and voucher programmes for crisis‐affected populations. We also adapted these procedures to review economic studies assessing the efficiency of cash‐based approaches and observational, qualitative and mixed method studies assessing the factors that facilitate or hinder the implementation of cash‐based approaches in different settings.We conducted comprehensive searches of published and unpublished literature in November 2014. Two independent research assistants screened all identified studies to determine eligibility for inclusion in the review. We then extracted data from all included studies using a standardized coding tool and critically appraised the studies using existing tools appropriate for the different study designs.Due to the heterogeneity of the comparisons and outcomes reported in the included studies, we were not able to synthesize the studies using meta‐analysis. Instead, we have presentedthe results in tables and synthesised the findings narratively. We used narrative and thematic synthesis to address the secondary objective. We conducted these analyses in parallel, and have reported on each separately in subsequent chapters of this review.REVIEW FINDINGSOut of 4,094 studies identified in the initial search, a total of 113 publications (108 unique studies) were included in this systematic review. Only nine studies were found in peer‐reviewed publications. Overall, we have considered the body of evidence reviewed to have been of low quality due to methodological limitations. While the evidence reviewed offers some insights, the paucity of rigorous research on cash‐based approaches limits the strength of the conclusions. This is not uncommon amongtopics related to humanitarian assistance. The following table summarizes the types of studies reviewed in each section of this report:

Review Topic
Studies Reviewed
Study Characteristics

Effects of cash‐based approaches on:

Individual and household‐level economic outcomes
Sector‐specific humanitarian outcomes
Cross‐cutting humanitarian outcomes

5
Settings: DR Congo, Ecuador, Niger, Lebanon, Yemen Interventions: Unconditional cash transfers, vouchers Study designs: Randomized control trials (factorial and stratified cluster designs), regression discontinuity

Efficiency of cash‐based approaches in achieving humanitarian objectives
10
Settings: DR Congo, Ecuador, Niger, Lebanon, Yemen Interventions: Unconditional cash transfers, vouchers Study designs: Cost, cost‐efficiency, cost‐effectiveness, cost‐benefit, market impact

Factors facilitating and hindering realization of cash programme activities and the achievement of humanitarian objectives in different contexts
108
Settings: Afghanistan, Bangladesh, Belize, Bosnia and Herzegovina, Burundi, Chile, DR Congo, Ecuador, Ethiopia, Haiti, India, Indonesia, Kenya, Japan, Jordan, Lebanon, Lesotho, Niger, Malawi, Mozambique, Occupied Palestinian Territory, Pakistan, the Philippines, Somalia, South Sudan, Sri Lanka, Sudan, Swaziland, Turkey, Uganda, Vietnam, Yemen, Zambia, Zimbabwe Interventions: Unconditional cash transfers, vouchers, conditional cash transfers (cash for work) Study designs: descriptive (quantitative), qualitative (narrative or thematic analysis), mixed methods

Main findings:Effectiveness of cash‐based approaches (chapter 5):Five studies assessed the effects of cash‐based approaches, four of which assessed effects on household level food security outcomes. Unconditional cash transfers and vouchers may improve household food security among conflict‐affected populations and maintain household food security within the context of food insecurity crises and drought. Studies found that unconditional cash transfers led to greater improvements in dietary diversity and quality than food transfers. Food transfers were found to be more successful in increasing per capita caloric intake than unconditional cash transfers and vouchers.Few studies measure changes in household economic indicators, other sectoral outcomes and cross‐cutting outcomes. Unconditional cash transfers may be more effective than vouchers in increasing household savings, and equally effective in increasing household assets. Mobile transfers may be a more successful asset protection mechanism than physical cash transfers.Efficiency of cash‐based approaches (chapter 6):Ten studies assessed the efficiency of cash based approaches. Cash transfers and vouchers may be more cost‐efficient than in‐kind food distribution. Studies found that unconditional cash transfer programmes have a lower cost per beneficiary than comparison interventions (either vouchers, in‐kind food distribution or both); and vouchers have a lower cost per beneficiary than in‐kind food distribution. In‐kind food distribution has substantially higher administrative costs per dollar value provided to a beneficiary than unconditional cash transfers.Cash‐based approaches may have positive economic multiplier effects. Voucher programmes generated up to $1.50 of indirect market benefits for each $1 equivalent provided to beneficiaries and unconditional cash transfer programmes generated more than $2 of indirect market benefits for each $1 provided to beneficiaries.Factors facilitating and hindering implementation of cash‐based approaches (chapter 7):Evidence suggests that intervention design and implementation play a greater role in determining effectiveness and efficiency of cash‐based approaches than the emergency context or humanitarian sector.Specific factors shown to influence implementation include resources available and technical capacity of implementing agencies, resilience of crisis‐affected populations, beneficiary selection methods, use of new technologies, and setting‐specific security issues, none of which are necessarily unique to cash‐based interventions.CONCLUSIONS AND RECOMMENDATIONSDespite the widespread use and increasing number of evaluations of cash‐based humanitarian assistance, there is a paucity of rigorous evidence about how best to address the needs of crisis‐affected populations. This is not surprising, as studies meeting the methodological criteria for inclusion in most systematic reviews are relatively rare in emergency settings.Findings suggests that both cash‐based approaches and in‐kind food assistance can be effective means of increasing household food security among conflict‐affected populations and maintaining household food security among food insecure and drought‐affected populations; each assistance modality has different advantages and disadvantages that should be considered in the design of future interventions. However, no definitive conclusions on the effectiveness of cash transfer or voucher programmes could be drawn that are universally applicable for humanitarian policy. Further development of the evidence base, with more rigorous evaluations comparing the effectiveness of different cash‐based approaches (or combinations of approaches) and transfer modalities, as well as standardized approaches to documenting and comparing both costs and benefits of cash‐transfer and voucher programmes, is needed to further strengthen the evidence base in this area.