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Workshop on Cash Based Interventions for Health in Humanitarian Contexts, 3-4 November 2016, Geneva.

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Executive Summary

Cash based Interventions (CBI) for health in humanitarian contexts is a relatively new field. This

workshop, convened by WHO and the Global Health Cluster’s cash task team, was an important

step in driving this agenda forward, building on the momentum of the Grand Bargain and the

World Humanitarian Summit.

Based on available evidence, mostly from development contexts, the participants acknowledged

the potential benefits that CBIs can have impacts on health, and on access to and utilisation of

health services and goods. There was agreement that we should actively seek opportunities to

include CBIs in the health sector response analysis. A thorough and systematic pace is needed to

ensure that the implementation of cash in the health sector is done in such a way that it does no

harm, and is done in a transparent and accountable way.

Drawing on experiences in Ukraine, Zimbabwe, Sudan, Burkina Faso, among others, the

workshop also allowed representatives from the humanitarian, donor, academic, and NGO

communities to focus their efforts around developing a health-sector position on cash in health

programming; to develop a conceptual framework around cash programme design and

monitoring; and explore further avenues for research.

The workshop reconfirmed the humanitarian objective that services should be available,

accessible and provided free at the point of delivery, which also needs some alignments to

existing health financing arrangements aimed at Universal Health Coverage. This is

complementary to the aim of multi-purpose grants to meet basic welfare needs.

We must begin with an analysis of what the various challenges and barriers are to access health

services, and then explore how different cash modalities (conditional or unconditional and/or

vouchers) may work in addressing these; and how these can be complementary to other

interventions in support of access quality, and utilisation of services; and when a direct

intervention and a specific CBI modality are both possible, see if the CBI alternative has

comparative advantages, including efficiencies and strengthening existing systems.

It was widely agreed that contextual factors and the nature of the desired health outcome must

play a fundamental role in determining if and how cash can be implemented, in particular with

regards to the capacity and quality of available services, resources available to the health sector,

and if these resources are largely public or private.

It was also clear from the discussions that further research in the health sector is required.

Current evidence is heavily focused on food-security, and when evidence is health sector related

it is in a development context. While a research agenda will be launched to gather more

evidence, the health sector will endeavour more systematically to capture and share practices.

This continuous learning will be buttressed by an advocacy and communication strategy to

reach out to donors and to leverage external funding channels to implement research and learn

from ongoing practice. At the same time there will be a need for health sector partners to refine

and adapt the current tools used for assessment, analysis and programming.

The workshop was also an opportunity to align language, practice, expertise between cash

experts and the health sector. The workshop highlighted areas where health sector approaches

can learn and benefit from cash methodologies, and it brought to the fore that multipurpose

cash assessments and monitoring can better reflect health aspects.


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Summary Report (see agenda and list of participants annex 1)

1. Key Note

Peter Graaff, WHO

Cash based Interventions (CBI) for health in humanitarian contexts is a relatively new field. This workshop is an important step in driving this agenda forward, building on the momentum of the Grand bargain and the World Humanitarian Summit. Reflecting back on the Ebola response, CBIs are not just about improving efficiencies, but it is also about effectiveness. It is about giving a sense of choice and dignity.

Achieving a systematic use of cash in the health sector, in particular, will come with some challenges mainly around ensuring access; and establishing trust in the quality of both the services and the assistance. In this regard, this workshop will pave a concrete path forward on how best to frame the future of this work.

2. Introduction to the workshop

Rudi Coninx, WHO

The use of cash has captured the attention of many practitioners over the last few years. Its potential to improve effectiveness and efficiencies as a response modality is recognised by agencies and donors alike. While this new modality should be embraced in the health sector, we must see what it can and cannot be expected to do. This workshop has been organized to reflect on the challenges, bottlenecks, and opportunities how we can adapt this response modality to the health sector based on currently available evidence and field-experience..

Linda Doull, GHC

The aim of the workshop is to take stock of available evidence, supported by examples from the field, and have group work discussions around issues that will help inform a position paper that will be developed after the workshop. Furthermore, we will look at how the currently limited evidence in humanitarian contexts can be strengthened, through research and documenting practice, so we can eventually develop guidance and tools.

3. Cash Based Interventions and Current Evidence

Andre Griekspoor, WHO

The political momentum that has brought cash to the forefront of humanitarian action reflects its potential to change the way we provide humanitarian assistance, and to promote choice and dignity of affected people. In its original formulation, besides scaling up the volume of CBI, there was a push toward multipurpose cash (MPC), with the subsequent expectation that with MPC you could replace in-kind assistance. While this may be true in sectors that are largely based on the transfer of goods, this thinking does not entirely lend itself to social service delivery sectors such as health.

There is a need to clarify this narrative by exploring how different cash modalities, conditional or unconditional and vouchers work in addressing various challenges, constraints, and barriers to access specific to health services; and how these can be complementary to other interventions in support of access quality, and utilisation of services. We must begin with an analysis of what the problem is, and then explore how, if at all, different CBIs may be applied to address underlying barriers and if these then garner the sort of efficiencies seen in other sectors.

Lara Ho, IRC Taking stock of the existing evidence, it is clear that cash transfers are among the most rigorously evaluated fields in social sciences. It has been used in a range of situations mostly in development settings. To learn more about its applicability to humanitarian situation, the Cash Learning Partnership (CaLP) was formed to share practical lessons learned and serve as a community of


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practice to consolidate knowledge from various programmes.

While most of the evidence comes from development interventions, the evidence shows that a) cash can be delivered more efficiently than in-kind, enabling people to meet their basic needs and improve health seeking behaviours; b) when asked, most recipients prefer cash, and c) there is a multiplier effect on local economies, estimated to be approximately 2 fold for every dollar given; Gaps remain in knowledge on the effectiveness of cash for a range of outcomes, namely as it relates to cash transfers support for health (in humanitarian settings) protection, Water Sanitation and Hygiene and to a lesser extent nutrition outcomes. How do we generate evidence in a systematic way to guide how we match various modalities to impact on health outcomes in humanitarian settings; which health outcomes are appropriate for cash, and how do we scale up cash transfers in a more predictable manner?

There is also a need to strengthen research and evidence around implementation of CBI. For example, IRC has been exploring Return on Investment (ROI) models, to see whether a business case can be developed to encourage digital service providers (ATM, mobile money services) in crisis prone areas to establish systems to access cash before an emergency.

Another example, is finding out ways to reduce the amount of staff time spent on targeting, selecting and registering cash recipients. In one study, the time spent before distribution was estimated to be 43% of the overall staff time. Greater efficiencies can be had by finding ways to partner with other social protections schemes and other partners who may already possess an idea of whom the most vulnerable people are.

Discussion Conceptually, what is missing to guide research in cash for health is an understanding of the health problems that we seek to redress, and a better understanding of the pathways how cash affects health outcomes. The evidence shows that in some respects more cash leads to more utilization, but the question remains utilization to what end?

There is also a need to properly sequence our rationale for cash based interventions. The modality – whether to use cash or not – shouldn't be the starting point of the discussion. We need to look at the health problems at play, then understand the capacity and structures in place, then whether or not there are any barriers between these structures and those who are in need. It is only after this assessment of capacities, barriers and other contextual factors, that we can design a mix of response option, one of which may very well be a CBI.

ACTION: Bring together available evidence as background document and initial position paper

4. Experiences from the Field

These contextual factors shape behaviour, access, willingness, and accessibility of essential health services, and require different approaches to cash. In contexts where market conditions, and medical supplies are available, but barriers to access exist, perhaps a voucher programme can ensure quality healthcare for the most vulnerable.

Elise Lesieur, Premiere Urgence

In eastern Ukraine, for example, Premiere Urgence is currently conducting programmes in both governmental and non-governmental controlled areas reaching over 10 thousand people. The objective of the programme is to address the needs of vulnerable population caught in a context in which primary and secondary health care is free, but the cost of medicine is borne on


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the patient.

To help beneficiaries overcome this barrier to complete quality care, a voucher programme was set up specifically targeting pregnant and lactating women, children under five, and people in need of surgical and post-surgical care. The programme is also complemented by health infrastructure rehabilitation, programmes. In this context, the voucher programme ensured the use of high quality drugs and services; allowed the beneficiaries to avoid the financial burden of purchasing these drugs; and allowed them to avoid negative coping mechanisms in access to health. Most importantly, the vouchers ensured that quality of care itself was improved since the intervention emphasised quality control on the supply side. It included a complaints mechanism through a hotline. Challenges included that the ‘one voucher only’ approach is not appropriate for people with Non Communicable Diseases, working remotely through a local partners in the Non-Government Controlled areas.

Mohira Babaeva, WHO

In other contexts, particularly in protracted conflict situations, perhaps the emphasis of programme design should centre on how best to transition the operation into the hands and ownership of local/community authorities, with clear understanding on where the responsibility to coordinate these interventions should lie.

This facet of CBI was highlighted in WHO’s country programme in Darfur, Sudan, which has a high burden of infectious diseases; with recurrent AWD outbreaks, Malaria, Whooping Cough, and Measles. Structurally, there are insufficient medical practitioners (28% of health care facilities are not functional), and equally insufficient financial allocation for health from the government. All of which is exacerbated by 12 years of forced displacement.

Subsidized health insurance for most vulnerable (poor, IDPs) was found to be the most promising solution for the protracted displacement and conflict affected in Darfur. Within this framework, cluster partners, and the cash working group platform served a support function by regularly revising the system for classification of poverty; and focusing on advocacy with donor or Government to cover the costs of the most vulnerable.

Albert Muraisa, World Vision

The Cash Working Group also played an important role in Zimbabwe, where a project involving unconditional and conditional cash transfers at a cash value of $7 per individual per month were used as part of the El Nino Response.

This program aimed to mitigate the effects of immediate food insecurity through mobile cash transfers to 78,000 people affected by the El Nino phenomenon, 50% of the household food basket and nutritional needs of men, women, boys and girls through an unconditional cash transfer.

Given that markets were functioning and commodities were available, the question was not “why cash” but “why not cash?” In addition, that there was widespread network coverage across Zimbabwe and a growing segment of the population already using mobile cash, allowed for efficient use of funds. Cash transfer transactions costs were found to be lower and safer that in-kind, with an administrative cost of 30% versus 70% respectively.

This program also showed that CBIs are possible even in contexts where the economy is in dire straits. Having several shopkeepers and retailers able to accepted mobile cash, allowed direct purchases of goods without the recipient ever needing to cash out their unconditional cash transfer. In addition to the convenience, the modality provided dignity and choice as how to pace consumption.

Jake Zarins, Lessons from other sectors show that there are many situations where quality


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Habitat control, safety and security should sometimes be prioritized over choice. In this sense, the advantages of unconditional cash transfers should be weighed against humanitarian imperatives to do no harm, including those that may arise through choice.

In the Shelter sector, for example, choice and client satisfaction while important should not be the only metrics of success when reviewing or designing accountability mechanisms (post distribution monitoring, or feedback and complaints mechanisms). There is a need for conditional grants to ensure that safe structures are built that meet specific structural integrity standards (next payment only after a first construction phase met the standards).

But beyond the engineering elements, the larger question of accountability to affected populations, do no harm, and avoiding exploitation resonate loudly in this and other sectors that are not just based on the service delivery itself but also ensuring a high quality of those services and service providers.

Conditionality is therefore an important tool to build in these control mechanisms directly in the program design and should not be deemed less adequate than unconditional modalities such as MPC transfers. In the Shelter sector, conditionality is essential. We need time to develop sector specific tools, and ensure that sectoral concerns and risks are taken into account

Discussion Combining and comparing these experiences in different contexts, first messages begin to emerge. First, that cash based interventions have a place in humanitarian action for health, and we should actively explore its potential.

While there is a general momentum and support for MPC , we need to develop a clear position towards it from a health sector perspective to communicate its potential benefit for health as well as its limitations, based on available evidence.

Some of the CBIs presented also focused on the service provider and not just the client/recipient. Vouchers and/or conditional grants that influence the supply side can ensure that there is the necessary quality in both the service delivery and service provider.

While commonalities exist, the importance of context-specificity cannot be understated. It is these constraints, barriers, and opportunities on the ground that should dictate which cash transfer modality on “the spectrum of conditionality” humanitarians should adopt in a given situation, and how these compliment other supply and demand side interventions to address underlying barriers.

One of the options on this spectrum – MPC – should not be seen as a way for sectors to meet their objectives. It is about households meeting some of their basic needs and lifting them above poverty thresholds. But we fail if we only focus on providing cash with the aim to meet peoples basic needs while not ensuring that sectoral objective are met alongside.

ACTION: Reflect issues from country experience and other sectors in the initial position paper

5. Initial Conceptual Framework for cash and health program

The question then is how we systematize our approaches in analysis, planning, and programming in health to better understand when and where a situation requires a CBI that falls in this spectrum of conditionality, alongside other interventions.


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Bayarsaikhan Dorsjuren, WHO

The first step in getting at this framework is to understand where cash assistance falls in the general health financing architecture. Cash transfer models do not work in isolation.

CBIs will only be effective if they are aligned, integrated and harmonized with existing health system financing arrangements. Their core functions include revenue collection; pooling; purchasing; benefit design and rationing; and governance.

Health financing for Universal Health Coverage (UHC) aims to ensure equitable access to comprehensive and quality health services for all people and make sure that health care is affordable for everybody (financial protection). There are various pathways in financing towards this goal. Thus countries need to make own choices that ensure efficient resource mobilization, equity in resource distribution and use that are transparent andaccountable. This is essential to strengthen health systems able to deliver quality health care (supply) needed for the entire population (demand), These tenets can be used to discuss the CBI dynamic in the context of health financing and health systems as a whole.

CBI can be seen as instruments to influence demand and supply of health services. Cash transfers can address demand-side barriers relating to direct and indirect costs. Conditional cash transfers and vouchers often boost demand for specific health services among the population. Cash transfers can motivate health service providers to improve their performance, service quality and transparency in resource use.

Andre Griekspoor, WHO

Developing a framework should help us analyse the various constraints and barriers that may exist in a given context for access and use of quality health services. On the demand side, we find many of the problems that we seek to redress through our humanitarian programming. These include, geographic barriers (distance); financial (house hold income and expenditure priorities), socio-cultural barriers (perception, gender and behaviors), perceived quality of the service, information and awareness.

On the supply side, there are the issues of geographic barriers (availability), financial barriers, financial (direct charges, level of public spending), socio-cultural (people centered care, community involvement), quality and performance (standards, training of staff) and governance (regulation) related barriers,

Different cash modalities have different effects, strengths and weaknesses toward reducing barriers on either demand or supply side. From the framework it also becomes obvious that not all barriers on demand and supply sides can be addressed with cash. It also leads to new questions such as how do we arrive at the optimal balance in such response mix, how significant are indirect financial barriers compared to direct charges, or what percentage of a fixed amount should we spend on cash, and what percentage on health services.

ACTION:

Revise text on the relation between CBI and health financing as input for the initial position paper

Finalise framework for cash based interventions and health, as annex to the initial position paper

6. Working Groups for inputs to an initial position paper

Paula Gil Doing cash in a smarter and systematic way requires that we think through the


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Baizan, CaLP opportunities but also the risks of implementing a CBI. Acknowledging that issues around the feasibility and design challenges hinge on the context, how to we ensure the beneficiaries have access to quality health care services, in a way that is accountable and scalable.

Group 1, Feasibility Understanding feasibility and risk:

Feasibility and risk are the components of a CBI that are the most context-dependent. However, there are a few questions that we must ask in all contexts to ascertain the feasibility of a CBI. These include, whether or not there is a functioning health system, if so can beneficiaries access them, do they access them? If not, why not?

In cases where there no functioning health system, cash may not be feasible, and the focus of the intervention should focus on supply side/ system strengthening. If there is a functioning system but low utilization, then cash may be feasible: specifically conditional, where services and access exist but behaviour, awareness, or attitude is the main barrier; unconditional if the barriers are deemed to be expenditure driven usually for primary and secondary services; and vouchers if specific health problems would incur a catastrophic expenditure on the part of the household. The aspect of the quality of available services needs to be taken into account, to ensure people don’t pay for substandard services.

Group 2, Design Design challenges

With conditional cash or a voucher, it is relatively easier to track health outcomes as they are directly linked to the cash than it is with unconditional cash grants. Conversely, unconditional cash


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transfer reducing some of the monitoring and reporting costs as there is limited need to check peoples’ behaviours and choices against specific outcomes. UCT maintains inequitable health financing system or user fee system. Vouchers enable to negotiate with suppliers regarding quality of services and products, and hold them accountable.

For conditional, unconditional and voucher programmes alike there is need to understand the pathways and barriers for accessing services. However, for unconditional cash, the assessment of those pathways can be done after distribution, while vouchers and conditional cash transfers require this information at the programme design stage.

Some negative behaviour has been observed with conditional cash transfers, where beneficiaries intentionally stayed in the programme to receive funds (keeping children in malnutrition range to continue receiving cash). But overall recipients have shown that they make the right decisions when prioritizing their limited resources.

Group 3, Access Access to quality health services

For cash transfers to become part of a broader response strategy for accessing quality health services, a functioning health system that provides quality services is indispensable. In various contexts emergency or protracted situations this may be either filled by the international community, the national system, or the private sector. Depending on which it is, the aim should be transition as fast as possible away from internationally driven interventions, while concurrently implementing interventions to overcome non-financial barriers that cash cannot address, (health seeking behaviour, cultural norms, perception of quality etc). This approach would reduce the chances of dependence, improve self-reliance, and reduce the potential for undermining an already weak health system through competition.

Group 4, Financial Consider-ration

Financial considerations

Where health services are not available, it is likely that services are being provided by humanitarian agencies and that are free at point of care. In this setting there is a limited role of cash as the financial burden of the household is borne by agencies. Possible additional vouchers can be explored for specific needs such as hygiene and protection goods. Where services are available either through public or private entities, the health financing focus should examine whether they create financial barrier and burden on households and protect them against excessive, catastrophic health expenditures especially for those vulnerable and low income households.

In public financed settings (tax-based and/or social health insurance): cash can have a complementary role to support the existing system to expand coverage/utilisation of services to specific groups (refuges, vulnerable groups, etc.) or to improve quality.

In private financed settings (OOP, other private sources): cash can help to reduce financial barriers and, to a certain extent,


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catastrophic expenditure for low income households. If any kind of health insurance exists, then cash can be used to boost such system while in parallel helping the population to overcome any other financial barriers (external to the Health System).

From the outset of emergencies the guiding principle should be to limit the degree to which parallel structures are created in the service of the CBI. When possible, inject funds into pre-existing health financing and social safety net schemes and services to reduce the financial barriers and burdens caused by various factors (user fees, co-payments medicine price, etc] and improve quality of services.

Group 5, Multi- Sector Needs

Multi sectoral needs

Through multi-sectoral action, there are many opportunities to improve health by addressing all its determinants. . - Stronger linkages with other sectors can create a platform through which we can change behaviour in different sectors towards health outcomes (nudge theory)

Multipurpose grants mean that basic welfare needs are met before sectoral interventions – if basic needs are not being met then families may prioritise these away from health to other immediate needs. The risk of monetising healthcare is at odds with the stated aim of ‘universal and humanitarian healthcare that is free at the point of use’, which is complementary to the MPG aim, and not be replaced by it.

An analysis is required which identifies the barriers and enablers to accessing quality health care, with evidence supporting the assumption which of these can effectively be addressed with MPG.

What is needed is a multi-sectoral assessment and response analysis that aims to understand the totality of basic needs at the household level, and a common understanding of gender and intra-household dynamics.

It is difficult to plan how people will use unconditional cash grants and therefore it will be difficult to predict how it may address possible health needs before the intervention – this flips the planning cycle.

ACTION: Use inputs from the working groups to inform the initial position paper

7. Developing Research Agenda and Promoting Research:

Aniek Woodward, LSHTM

Cash transfer programming is increasingly used and promoted, however there is limited evidence on the link between cash transfers and health in humanitarian contexts and so far there is no consensus on a research agenda to guide research based on agreed priorities. The target audience; donors, academics, implementing partners, policy makers and also people from health ministries in humanitarian settings.

Research questions should include issues around transactional costs such as the effects of cash on health outcomes; appropriateness; and indirect effects of cash. It will also be important to differentiate the impact on cash in relation to preventative or curative care; the quality and capacity of existing


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health systems; thresholds for household expenditure where cash would be considered or rule out. Other non-financial related questions in the research agenda may include household dynamics, and gender research. Lastly, what coordination models are most appropriate? What role can the cluster play in this regard?

A process started in October to develop such research agenda, supported by an advisory group, which is planned to be ready by July 2017. All participants were asked to write down their research questions, as pilot to inform an online survey that will be done early next year with all stakeholders.

Kevin Savage, WV There is a need to advocate for funding and operational support for research on this topic (such as through the next round of R2HC for example). To do so, the research topics should be condensed into a few priority research areas to share and promote with donors and with operational decision-makers in humanitarian agencies. In advocating with them, it is important to keep the field realities in mind and align research with programming. Clear justification for carrying out research within humanitarian responses must be presented and it is essential that response operations and programming accepts and supports such research. It will be crucial to ensure that the purpose of the research can clearly be seen as improved humanitarian outcomes, either by making improvements in operational decision making, tools and guidance or by changes to policy that will have an impact at the field level. With this in mind, funded research can be matched and aligned with programme funding and implementation, so that the research can actually be carried out.

ACTION:

Use inputs from the group work on designing an online survey and selecting the target audience, to collect and prioritise research needs.

Develop a strategy to promote research and its funding Develop a strategy to link research with programme

funding and design in advance

8. Documenting Experiences in a Systematic Way

Egbert Sondorp, WHO As we move ahead with the research agenda, there is a need to systematize the way we capture experiences from the field. Experience Capitalization for continuous learning is a good model on which we can begin to define those good practices that are considered successful, and which can be tested, validated and repeated. Among others, we need to agree on a template/checklist to systematically document experience (before looking at good practice), and identify different approaches who and how we will gather the experiences; asking each project to do this, or health advisors when they visit the project, or an external person/one partner to visit selected countries and partner projects, or a mix. Funds integrated in project budget, or funding for knowledge management. CaLP could host a community of practice for health.

Freddy Houngbe, ACF

Conditional cash transfers in Latin America have showed their efficacy to improve food security, health outcomes and child nutritional status. Less evidence is available on Unconditional Cash Transfer (UCT) designed with nutritional objectives, particularly in West Africa. ACF’s aim was to evaluate the


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effectiveness and cost-effectiveness of multiannual seasonal and unconditional cash transfers (msUCT) to prevent acute malnutrition in young children.

The evaluation design was a two-arm cluster Randomized Controlled Trial (32 clusters). Tools and quality control were done through the development of an impact pathways framework, a mixed approach of data collection (quantitative + qualitative), and data quality check: monthly supervision process + data entry.

Preliminary results were shared, which will be published, supported by workshops and other approaches to stimulate uptake and discuss implications.

ACTION:

Develop a template that can be used to document practice systematically

Further explore support from CaLP on developing capacity and tools (including possibility to request support from CashCAP)

9. Taking stock of tools used for assessment, analysis and programming

Shannon Doocy, JHU

A total of 21 assessment tools that aimed to inform planning of cash transfer programs in emergencies were identified and analysed to see how health is factored in: Health market/systems/situation assessments and analysis, as a consideration for household vulnerability criteria, and/or as a component of household expenditures.

The analysis indicated that current practice does not sufficiently consider health in planning for cash transfer programs, and there is a paucity of tools currently applied that provide adequate information on health to inform cash transfer program design. Given this gap, one possibility is to adapt tools already used in the health sector to inform cash transfer planning in health

Information we need to inform cash transfer programs include a health market analysis/health systems assessment to characterize service provision (i.e. supply side), and an understanding of population health needs, priorities and barriers to care (i.e. demand side). Tools that exist that could provide this information include: Health systems assessments/analysis, MICS/DHS and other population health services, KAP surveys or other population-based surveys with a health component done during the emergency (ex: UNHCR Health Access Surveys).

Ibrat Djabbarov, SC UK

For the development of an assessment tool for the health sector to inform a response analysis that includes cash modalities, there seems to be five key contextual factors that need to be ascertained. Using the ‘prospective patient pathway’ framework, and building on the concept of supply side and demand side,

cash program design needs to take into account dynamics at the household; community; societal; health system; and service provider(facility) level).

Whilst all the factors identified in the table below will have an influence on health outcomes, not all of them will act as barriers to seeking health services or goods. The next task is to select the factors that are likely to serve as direct barriers and those behind the direct barriers. Followed by that, we need to consider a) are


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those resource or non-resource barriers and b) can they be addressed more cost-effectively by CBI or non-CBI interventions?

Household

-Gender -Prioriti- zation. -Income -Food security -Values -Beliefs -Expenditure -Information -Livelihoods -WaSH

Community

-informal/ traditional healers? -Gender -Communal dynamics -Ethnic tensions? -Insecurity -Age demographic -geographical barriers

Structural

-poverty index -security -banking system -DRR/DRM -Public? -Private? -national Expenditures -Budget -Governance -Human Rights -Social Safety Net/Protection

Health Sstm

-HS building blocks -availability of medicine -quality -governance -inclusiveness

Facility

-costs -quality -funding -accessibility -corruption -HR/staff -scale up potential -supply chain

ACTION:

Complete analyses of existing cash assessment tools, and propose ways how health can better be reflected in them

See which existing health sector specific assessment tools can be used to inform the analysis of barriers on the demand and supply side

10. Coordination

Andre Griekspoor WHO

Looking into the opportunities that CBI can have for health will require some changes in the current coordination arrangements around cash and in raising awareness and communicating to health colleagues the potential benefits of a more systematic implementation of cash for health. It would require that the health clusters integrate CBIs in response option analyses within the health programs. In addition, the health cluster needs to become more proactive in engaging with the Cash Working Groups. The cash working group is seen as the natural interlocutor, but it needs to become more inclusive of inputs from social sectors for the full benefits of multi-purpose cash grants to be realized.

Multi-purpose cash is already being implemented by various CWGs to meet the basic needs of households, including health. Through these group we can have the mapping of cash programs (4Ws for cash); we need to provide our inputs from health on the calculation of a minimum expenditures basket, inputs in criteria for selection of vulnerable populations to be targeted with cash; post transfer monitoring tools (how money is spent, if and how much people use cash for health costs), market assessment tools.

As we move the agenda forward on CBI in health, we can also learn from the Cash Working Groups who have already developed several methodologies, that when adapted can become very useful for the health sector, particularly on demand side assessments.

The accountability to affected population work stream both at the IASC level and on the field need to be brought into the conversation since many of the tools used for cash transfers in terms of feedback and complaints mechanisms and participatory approaches to programme design can greatly inform the demand side assessments that the health sector will need to develop.

ACTION: Using the inputs from the session to draft a new text on coordination for the initial position paper


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11. Conclusions and next steps for the workplan up to December 2017

Andre Griekspoor WHO

The workshop acknowledged the potential benefits that CBIs can have on health, and on access to and utilisation of health services and goods. Based on the discussions from the workshop, we are now able to draft an initial position paper that should give guidance on how to actively seek opportunities to include CBIs in the health sector response analysis.

The other sessions were very useful to inform the work that needs to be done on developing better assessment tools, strengthening the evidence base through research and by systematically documenting practice.

The draft workplan for the cash task team was updated (see annex 2). Partners will be contacted to see who can assist or take the lead on the various activities.

Annex 1: Agenda of the Workshop on Cash based Interventions for health in humanitarian contexts

3 November – Thursday: Venue M605 Time Topic Chair/speakers Expected outcomes

8.30-9.00 Registration and welcome coffee 9.00-9.15 1. Opening session Peter Graaff, Acting Deputy

Executive Director, WHE

9.15-9.30 2. Introduction to the cash workshop Linda Doull, GHCC Rudi Coninx, EMO/HPG

Objectives agreed and introduction of participants

9.30-10.00 3. Introduction on cash based interventions and current evidence

Outline of key issues, challenges and opportunities

Taking stock of existing evidence

Andre Griekspoor, EMO/HPG Lara Ho, IRC

Consensus reached on the need to develop initial GHC positioning on cash programming and strengthening the evidence base.

10.00-10.30 4. Sharing experiences from the field

PU’s Cash programs in eastern Ukraine

Protracted displacement strategy and cash in Darfur

Elise Lesieur, Premiere Urgence Mohira Boboeva, Health Cluster Coordinator Nyala

Field experience shared and discussed on cash programs and participation in national cash working groups

10.30-11.00 Coffee break

11.00-12.00 Sharing experiences from the field (continued)

WV’s cash program in Zimbabwe

Experiences from the shelter cluster

Albert Muraisa, World Vision Jake Zarins, Habitat

(continued)

12.00-12:45 5. Initial conceptual framework for cash and health programming

Presentation on cash within health financing

Presentation of a proposed conceptual framework

Discussion on the framework

Bayarsaikhan Dorsjuren, HIS/HGF Andre Griekspoor , EMO/HPG

Initial cash conceptual framework agreed

12.45-13.45 Lunch

13.45-14.15 6. Working Groups for inputs to an initial position paper

To reach consensus on initial positions and recommendations around key issues for an initial position paper

Paula Gil Baizan, CaLP

Objectives of working group session clarified

Importance to have a position paper

Explanation of the tasks

14.15-15.45 Working group sessions

Break up in five working groups

Discuss initial positions on identified topics (e.g. potential roles for conditional, unconditional/multipurpose and restricted cash transfer

modalities to address specific health needs)

15.45-16.15 Coffee break

16.15-17.15 World cafe on findings from the groups

Five stations

Paula Gil Baizan, CaLP

Consensus reached on key issues for the initial position paper to guide cash programming for health (for GHC partners and donors

17.15-17.45 Closure in plenary and Wrap up of day one Paula Gil Baizan, CaLP Andre Griekspoor EMO/HPG

4 November – Friday: venue M605 Time Topic Chair/Speakers Expected outcomes

8.30-9.00 Welcome coffee 9.00-10.30 7. Developing the research agenda and promoting research on cash programming for

health in humanitarian contexts

Presentation of the approach to develop such research agenda

Brainstorm on research needs

Discussion on proposed steps to promote research on this topic

Aniek Woodward, LSHTM Kevin Savage, WV

Approach agreed to develop research agenda for cash programming for health, and next steps to promote research

10.30-11.00 Coffee break 11.00-12.30 8. Documenting experiences in a systematic way

Presentation of methods to document field experience on cash programming for health

The MAM’Out Project. Evaluation of multiannual and seasonal cash transfers

to prevent children’s acute malnutrition

Discussion on the way forward with partners to document and share their experiences in a systemic way

Egbert Sondorp, KIT/RTI Freddy Houngbe, ACF

Methods for documenting field experiences discussed and consensus on follow-up actions & recommendations reached.

12.30-13.30 Lunch

13.30-15.00 9. Taking stock of tools used for assessment, analysis and programming

Existing assessment and analysis tools for cash programming and how these

reflect health

Existing assessment and analysis tools for health financing/expenditures and health seeking behaviour, and their applicability tom inform cash

programming

Shannon Doocey, JHU Peter Lesiak, JHU Ibrat Djabbarov, SC UK

Consensus on follow up to improve as needed existing generic cash assessment and analysis tools, and adaptation of specific health tools to inform assessment and analysis for cash programming

15.00-15.30 Coffee break 15.30-16.30 10. Coordination

Survey results engagement of health clusters in technical cash working groups

Engagement in intersectoral cash coordination groups

Andre Griekspoor EMO/HPG

Guidance for engaging in intersectoral cash coordination, and integrating cash analyss in health cluster coordination

16.30-17.00 11. Conclusions and next steps for the workplan up to December 2017 Rudi Coninx, EMO/HPG Andre Griekspoor, EMO/HPG

Workplan up to December 2017 agreed

NAME DEPARTMENT/PARTNER EMAIL

1 GRIEKSPOOR Andre WHO/HQ/WHE [email protected]

2 CONINX Rudi WHO/HQ/WHE [email protected]

3 BAYARSAIKHAN, Dorjsuren WHO/HQ/HIS/HGF/HFP [email protected]

4 HOREMANS Dirk WHO/HQ/HIS/SDS [email protected]

5 KAOJAROEN, Kanokporn WHO/HQ/HIS/SDS [email protected]

6 KHOSLA Rajat WHO/HQ/FWC/RHR [email protected]

7 TISDAL Brian WHO/EMRO [email protected]

8 DOULL Linda WHO/HQ/WHE/OPR/GHC [email protected]

9 BOBOEVA Mohira WHO/EMRO [email protected]

10 SAVAGE Kevin World Vision [email protected]

11 BECK Claire World Vision [email protected]

12 MURAISA Albert WVI [email protected]

13 Marumbo Ngwira World Vision [email protected]

14 LESIEUR Elise Premiere Urgence [email protected]

15 HO Lara International Rescue Committee [email protected]

16 NOORANI Azim International Rescue Committee [email protected]

17 ANTOINE Caroline Action Contre la Faim [email protected]

18 HOUNGBE Freddy G.E. Action Contre la Faim [email protected]

19 SINITZKY Céline Action Contre la Faim [email protected]

20 CUMMINGS Rachael Save the Children [email protected]

21 DJABBAROV, Ibrat Save the Children [email protected]

22 LOCHMANN Barbara Malteser International [email protected]

23 RASSLAN Ossama Emergency and Relief Agency-Arab Medical [email protected]

24 BRENNAN Muireann UNICEF [email protected]

25 DAKKAK Henia UNFPA [email protected]

26 BURTON Ann UNHCR [email protected]

27 VAN ENGELGEM Ian ECHO [email protected]

28 LAGES MIGUEL Alexandra DFID [email protected]

29 MILLARD Philippa DFID [email protected]

30 WALIA Sonia USAID/OFDA [email protected]

31 SONDORP Egbert Royal Tropical Institute Amsterdam [email protected]

32 MALDONADO Fernando Royal Tropical Institute Amsterdam [email protected]

33 WOODWARD Aniek LSHTM [email protected]

34 DOOCY Shannon Johns Hopkins School of Public Health (JHU)[email protected]

35 LESIAK Peter Johns Hopkins School of Public Health (JHU)[email protected]

36 GIL BAIZAN Paula Cash Learning Partnership (CaLP) [email protected]

37 Hieber-Girardet Loretta OCHA Loretta [email protected]

38 IPPE Josephine Global Nutrition Cluster [email protected]

39 BROWN James Global WASH cluster [email protected]

40 McCARTHY Reuben UNICEF Inter-cluster coordinator [email protected]

41 ZARINS Jake Global Shelter cluster [email protected]

42 POKU Kwame WHO/EMO/HPG [email protected]

43 KIM Hyo Jeong WHO/EMO/HPG [email protected]

44 Minelli Elisabetta GHC unit [email protected]

45 GATCHELL Valerie UNHCR [email protected]

46 SOSSOUVI Kokoevi UNHCR [email protected]

Provisional list of participants

Annex 2: Updated work plan for the cash task team

Q3 Q4 Q1 Q2 Q3 Q4

1 Develop a conceptual framework

First draft conceptual framework X

First draft agreed with partners in workshop X

Conceptual framework reviewed X

2 Develop a position paper and eventually guidance

Drafting position paper X

Position paper agreed with partners in workshop X

Position paper reviewed and updated X X

3 Develop standards for documenting current practice

Draft standards X

Discuss draft and finalisation with partners X

Document and collect current practice X X X

Analyse lessons learned from current practice X

4 Take stock of existing evidence, tools and guidance

Take stock of available evidence/literature review X X

Collect relevant tools and guidance X X

Discuss application, adaptation and gaps with partners X

Develop guidance and toolkit for 'health market analysis' X X

Pilot tools X X X

5 Develop a research agenda and promote operational research

Choose method & process for setting research agenda X X

Initial scoping of main research domains X

Discuss research domains with partners X

Elaborate on research questions and related methods X X X

Develop a plan for funding and operationalising research collaboratively X X

Take stock of new research and evidence X X

6 Meetings of the GHC cash TT

Creation of the TT online, ToR and workplan X

1st workshop, togeher with other partners X

Meeting of the cash TT prior to GHC partner meeting X

2nd workshop, together with partners X

2016 2017

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