'Poverty can break a home': Exploring mechanisms linking cash plus programming and intimate partner violence in Ghana.

A growing body of research in West Africa and globally shows that cash transfers can decrease intimate partner violence (IPV). The purpose of this study was to explore how the government of Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 program, an unconditional cash transfer plus health insurance premium waiver targeted at pregnant women and women with young children, influenced IPV experiences. Existing program theory hypothesizes three pathways through which cash transfers influence IPV, including: 1) increased economic security and emotional wellbeing; 2) reduced intra-household conflict; and 3) increased women's empowerment. Informed by this theory, we conducted qualitative in-depth interviews with women in northern Ghana (n = 30) who were or had been beneficiaries of LEAP 1000 and had reported declines in IPV in an earlier impact evaluation. We used narrative and thematic analytic techniques to examine these pathways in the context of gender norms and household dynamics, as well as a fourth potential pathway focused on interactions with healthcare providers. Overall, the most prominent narrative was that poverty is the main determinant of physical IPV and that by reducing poverty, LEAP 1000 reduced conflict and violence in households and communities and improved emotional wellbeing. Participant narratives also supported pathways of reduced intra-household conflict and increased empowerment, as well as interplay between these three pathways. However, participants also reflected that cash transfers did not fundamentally change gender norms or reduce gender-role strain in a context of ongoing economic insecurity, which could limit the gender transformative potential and sustainability of IPV reductions. Finally, while health insurance increased access to healthcare, local norms, shame, fear, and minimal provider screening deterred IPV disclosure to healthcare providers. Additional research is needed to explore interplay between pathways of impact across programs with different design features and implementation contexts to continue informing effective programming to maximize impact.

Impact evaluation of a social protection programme paired with fee waivers on enrolment in Ghana's National Health Insurance Scheme.

OBJECTIVES: The study aimed to understand the impact of integrating a fee waiver for the National Health Insurance Scheme (NHIS) with Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer programme on health insurance enrolment. SETTING: The study was conducted in five districts implementing Ghana's LEAP 1000 programme in Northern and Upper East Regions. PARTICIPANTS: Women, from LEAP households, who were pregnant or had a child under 1 year and who participated in baseline and 24-month surveys (2497) participated in the study. INTERVENTION: LEAP provides bimonthly cash payments combined with a premium waiver for enrolment in NHIS to extremely poor households with orphans and vulnerable children, elderly with no productive capacity and persons with severe disability. LEAP 1000, the focus of the current evaluation, expanded eligibility in 2015 to those households with a pregnant woman or child under the age of 12 months. Over the course of the study, households received 13 payments. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes included current and ever enrolment in NHIS. Secondary outcomes include reasons for not enrolling in NHIS. We conducted a mixed-methods impact evaluation using a quasi-experimental design and estimated intent-to-treat impacts on health insurance enrolment among children and adults. Longitudinal qualitative interviews were conducted with an embedded cohort of 20 women and analysed using systematic thematic coding. RESULTS: Current enrolment increased among the treatment group from 37.4% to 46.6% (n=5523) and decreased among the comparison group from 37.3% to 33.3% (n=4804), resulting in programme impacts of 14 (95% CI 7.8 to 20.5) to 15 (95% CI 10.6 to 18.5) percentage points for current NHIS enrolment. Common reasons for not enrolling were fees and travel. CONCLUSION: While impacts on NHIS enrolment were significant, gaps remain to maximise the potential of integrated programming. NHIS and LEAP could be better streamlined to ensure poor households fully benefit from both services, in a further step towards integrated social protection. TRIAL REGISTRATION NUMBER: RIDIE-STUDY-ID-55942496d53af.

Multidimensional Child Poverty in three Countries in Sub-Saharan Africa.

This paper describes and reviews the process of constructing a Multidimensional Child Poverty Measure in three sub-Saharan Africa countries: Mali, Malawi, and Tanzania. These countries recently (in 2015 and 2014) constructed such indicator using UNICEF's Multiple Overlapping Deprivation Analysis (MODA) methodology and conducted a comprehensive Child Poverty study including both deprivation and monetary poverty. This work describes how the indicator was adapted in the different contexts, discussing critical issues arisen during the process of the study, and it discusses the results of these studies in comparison. The goal is to offer an overview of the different national processes and how similar or different factors influence the results.

ANALYSING MULTIDIMENSIONAL CHILD POVERTY IN SUB-SAHARAN AFRICA: FINDINGS USING AN INTERNATIONAL COMPARATIVE APPROACH.

This study provides with a first indication on the number of multidimensionally poor children in sub-Saharan Africa. It presents a methodology measuring multidimensional child deprivation within and across countries, and it is in line with the Sustainable Development Goal 1 focusing on multidimensional poverty by age and gender. Using the Multiple Overlapping Deprivation Analysis (MODA) methodology, the study finds that 67% or 247 million children are multidimensionally poor in the thirty sub-Saharan African countries included in the analysis. Multidimensional poverty is defined as missing two to five aspects of basic child well-being captured by dimensions anchored in the Convention on the Rights of the Child, namely nutrition, health, education, information, water, sanitation, and housing. The analysis also predicts the multidimensional child poverty rates for the whole sub-Saharan African region estimating 64% or 291 million children to be multidimensionally poor. In comparison, monetary poverty rates measured as less than USD 1.25 PPP per capita spending a day and weighted by the child population size finds 48% poor children. The results of this study highlight the extent of multidimensional poverty among children in sub-Saharan Africa and the need for children to have a specific poverty measure in their own right.

Accountability for the human right to health through treaty monitoring: Human rights treaty bodies and the influence of concluding observations.

Employing novel coding methods to evaluate human rights monitoring, this article examines the influence of United Nations (UN) treaty bodies on national implementation of the human right to health. The advancement of the right to health in the UN human rights system has shifted over the past 20 years from the development of norms under international law to the implementation of those norms through national policy. Facilitating accountability for this rights-based policy implementation under the right to health, the UN Committee on Economic, Social and Cultural Rights (CESCR) monitors state implementation by reviewing periodic reports from state parties, engaging in formal sessions of 'constructive dialogue' with state representatives, and issuing concluding observations for state response. These concluding observations recognise the positive steps taken by states and highlight the principal areas of CESCR concern, providing recommendations for implementing human rights and detailing issues to be addressed in the next state report. Through analytic coding of the normative indicators of the right to health in both state reports and concluding observations, this article provides an empirical basis to understand the policy effects of the CESCR monitoring process on state implementation of the right to health.