Effects of Palestinian National Cash Transfer Programme on children and adolescents – ODI/UNICEF report/Non-UN document

April 2014


Effects of the Palestinian National Cash Transfer Programme on children and adolescents

A mixed methods analysis

Executive summary

Over the past two decades, social protection programmes have been implemented in many developing countries to reduce poverty and vulnerabilities in the face of context-specific challenges such as economic crises, inequality and exclusion, and human development deficits. The multidimensional vulnerabilities experienced by poor households affect children and young people in specific ways, but their needs often remain only partially visible or even invisible to policy-makers and those designing social protection programmes and complementary interventions that tend to focus on the household unit.

This report presents findings from a mixed methods study of the effects of the Palestinian National Cash Transfer Programme (PNCTP) on children and their families, exploring impact across the four key dimensions of children's rights recognised in the United Nations Convention on the Rights of the Child (UNCRC): survival, development, protection and participation.

The situation of children in the SoP

The population of The State of Palestine (SoP) is predominantly young, with more than 40% under the age of 15. Household poverty (estimated at around 16% in the West Bank and almost 32% in Gaza) disproportionately affects children, partly because of the prevalence of larger families among the poorest, but also because of children's limited access to basic services and developmental opportunities.

Children's and adolescents' poverty status and wellbeing is, however, not only determined by their own or their household's income. It is also conditioned by the multiple dimensions of wellbeing that are closely aligned with children's rights to survival, development, protection and participation. Poverty among vulnerable households and communities in the SoP is both a cause and an outcome of an array of complex factors. Poor households often face a range of interrelated challenges, including caring for family members with physical, psychosocial and mental disabilities, chronic disease. Other common challenges include gender-based violence, stigma, discrimination, child labour and child abuse, school dropouts, domestic violence, and high-risk behaviours among young people.

Children's right to survival is compromised in a number of ways. Health shocks are a major source of household poverty. An illness or accident on the part of a parent (sometimes leading to death) triggers adverse coping strategies, with significant consequences for children: girls typically have to shoulder the domestic care burden while boys have to find work to generate income. Although child mortality rates in Palestine are relatively low due to improvements in neonatal services and prenatal care coverage, maternal mortality rates remain a cause for concern.

Child malnutrition is a persistent problem. Currently, 1 in 10 children under the age of five suffers chronic malnutrition, with the rate slightly higher in the West Bank than the Gaza Strip. Moreover, malnutrition rates are rising: between 2000 and 2010, child malnutrition in the Gaza Strip increased by 60% (over 40% nationally). Many families in both territories, but particularly in Gaza, have resorted to negative coping strategies to maintain their level of food consumption, such as reducing the number of meals eaten, eating smaller quantities, selling disposable assets, increasing levels of debt, taking children out of school, and even marrying daughters earlier while still under 17 years of age.

Access to clean water and adequate sanitation is also highly problematic, with constant fuel crises impeding safe water supply and sewage treatment. Diarrhoea is one of the most common illnesses among Gaza's refugee children, and clinics treating refugees in the Gaza Strip report a recent increase in cases of typhoid fever and watery diarrhoea in children under three.

Children's right to development is also severely constrained. Despite some important recent achievements (full gender equity in enrolment in basic education, and near universal access to basic education), the SoP's education system suffers from quality deficits and poor scholastic outcomes. In addition, violence in schools, either by peers or by teachers, generates a negative environment for learning. Many adolescents drop out of school after completing their basic education (grade 10, roughly age 16), typically because they need to work to help support their families. But many of those interviewed also said they did not enjoy school as they often faced violence, and were not able to learn much. Children and young people (and particularly refugee children in camp environments and children living in Area C in the West Bank) also lack safe spaces for play and recreational activities.

The protracted conflict and high levels of insecurity and violence in the SoP pose particular threats to children's right to protection. Exposure to violence in the home and in schools (physical and psychological) directly affects children's health and wellbeing.

Palestinian children with disabilities face numerous barriers in accessing public services. For example, despite near universal access to education for most Palestinian children, more than one-third of those with a disability aged 15 years and over had never enrolled at school. Of those that did enrol, a third dropped out because services and infrastructure had not been sufficiently adapted to meet their needs. Children with disabilities find it particularly difficult to realise their right to leisure due to high transport costs, lack of adequate facilities and appropriate activities, and the fear of stigma and discrimination, which can compound their social isolation.

A clear outcome of the ongoing conflict is an increase in mental health conditions among people in the SoP, particularly children. Children exposed to high levels of trauma are more likely to report higher levels of post-traumatic stress disorder (PTSD), depression and anxiety.

Finally, children's right to participation is also constrained. The everyday problems children face severely limit their ability to exercise this right, as there are few safe spaces where they can participate. Hierarchical social norms also represent a major barrier to children's participation; girls in particular face strong restrictions on their mobility and social activities outside the home.

The Palestinian National Cash Transfer Programme (PNCTP)

The PNCTP is the SoP's flagship social protection programme, managed and administered by the Ministry of Social Affairs (MoSA). Beneficiaries are selected according to a consumption-based proxy means test formula (PMTF) that estimates the welfare of each applicant household. Eligible households receive be­tween 750 and 1,800 new Israeli shekels (NIS) (US$195-468) per quarter to bridge 50% of the household poverty gap. Beneficiary households are also entitled to other state-provided assistance, including health insurance, food support (in the form of dry food rations in Gaza and in isolated areas of the West Bank, and vouchers in urban areas of the West Bank), school fee waivers, and cash grants to help with one-off emergency needs.

According to MoSA, as of September 2013, 105,678 households were receiving the cash transfer (57,449 in Gaza and 48,229 in the West Bank). Given the average number of children per family, it is estimated that the total number of children living in beneficiary households is 287,794. Most of these households are classed as extremely poor.

While the PNCTP was not designed as a child-focused programme, given the large family sizes common in the SoP — particularly among poorer households — household expenses and consumption goods are often prioritised, although these include meeting children's needs, principally for food, but also clothing and schooling.

Other sources of support for vulnerable children

In addition to the PNCTP there are multiple government and non-governmental organisation (NGO) programmes that provide social protection support for children, addressing a range of vulnerabilities that cut across the four dimensions of children's rights (see above). Unfortunately, however, there is still limited communication and coordination across agencies, and no strong referral mechanism which could ensure that vulnerable children's needs are more effectively identified and addressed. For example, there is no coordination between social workers implementing the PNCTP and child protection services; yet the social workers could make referrals of suspected cases of abuse identified during the home visits they undertake (currently, these visits are mostly used to gain the information needed to determine the applicant household's PMTF score). The existing child protection network established by MoSA in 2006 would be a good forum for raising child protection issues. But again, there are no linkages between the PNCTP and this network, nor other support services.

Another problem frequently mentioned by respondents was the discontinuation of targeted programmes for children with disabilities or other specific vulnerabilities following the 2010 launch of the PNCTP, which resulted from the merger of a number of smaller fragmented programmes. While the PNCTP has generally been welcomed, as some families are receiving more cash income due to the changes, other families have suffered from the loss of valuable in-kind support. This includes equipment (e.g. provision and maintenance of wheelchairs and hearing aids) and personal care items (including diapers and sanitary towels), as well as access to therapeutic services. The merger of the different strands of support in 2010 was not focused on addressing child-specific vulnerabilities; as a result, some of these were indirectly deprioritised at a programming level.

Conceptual framework for the study

The study is underpinned by a conceptual framework that draws on Devereux and Sabates-Wheeler's (2004) transformative social protection framework, which emphasises that to meaningfully empower poor and vulnerable populations, an interrelated system of social protection programming is critical, combining protective, preventive, promotive and transformative elements. Protective social protection aims to alleviate the worst of economic and social deprivation by safeguarding household income and consumption. Cash transfers and humanitarian relief fall into this category. Preventive social protection, such as health insurance, is designed to reduce household vulnerability by mitigating the impact of shocks. Promotive social protection seeks to strengthen vulnerable people's agency by bolstering their capacity for productive activities through the provision of assets or subsidies. Finally, transformative social protection addresses the power imbalances which create or sustain the economic and social vulnerabilities that disadvantage individuals and groups based on one or more of their social identities (including gender, religion, ethnicity, race, class, or disability).

Child-sensitive social protection adds an additional aspect to this analytical framework, in that it highlights the unique set of intersecting risks and vulnerabilities that characterise childhood. Child poverty differs from adult poverty in that it has distinct causes and effects. Poverty affects children more acutely than adults because of their vulnerability due to age and dependency, and can cause lifelong cognitive and physical damage, leading to permanent disadvantages that in turn perpetuate the cycle of poverty across generations. However, understanding child-sensitive social protection also means understanding that for children, who are uniquely dependent on the adults in their environment, social vulnerability is especially important. These relational dimensions mean that it is critical for social protection to not only target child-specific vulnerabilities but also support the caregivers, families, households, and communities who, because they are responsible for protecting and nurturing children, must be protected and nurtured themselves.

Study methodology

The study used a mixed methods approach to assess the effects of the PNCTP on children and their families. Cross-sectional quantitative data were collected from an intervention and a comparison group alongside qualitative data from a purposive sample of individuals and groups (including adolescents and adults) using participatory methods. In Gaza, qualitative data collection was carried out in the following sites: Jabalia and Beit Hanoun in the north, which included some rural areas; and Gaza City, including a refugee camp setting (Beach camp), a primarily urban context. Qualitative data in the West Bank were collected in Jericho district and Jordan Valley to include a sample of urban, rural, refugee and Bedouin beneficiaries. The five villages where research was conducted were Alnwe'ma, Aldyouk, Al-Jiftlik, Alouja and Anata.

Data were then triangulated to give a layered analysis. Data collection was sequenced, with quantitative data collected first so that preliminary findings could inform the design of the qualitative data collection instruments and sample, enabling the study team to explore in much more depth the effects of the programme and its complementary social services on children, their caregivers and families.

Key findings

Overall, our findings reveal that the PNCTP is not sufficiently child-sensitive to fully address children's poverty from a multidimensional perspective. While the programme contributes to children's right to survival, its effects on children's rights to development, protection and participation are less evident. Moreover, many caregivers commented that they had to choose how they allocated their limited household resources, including the cash transfer, between providing for their children and servicing debts incurred to cover basic expenses.

Children's right to survival:

For those who need to access health services, the health insurance component of the PNCTP was considered its most important element, because without it, they might not have been able to get necessary treatment or surgeries (including those accessed abroad), or would have had to incur significant debt to pay for these services. However, health insurance does not cover some of the recurrent (everyday) costs involved in caring for children with disabilities (such as diapers and the maintenance costs of specialised equipment/ assistive devices), or treatment for specific illnesses. Paying for these items meant families often had to go without other basic items given their limited incomes. Many respondents also expressed concerns about the high cost of medicines and equipment, which are often a common source of debt. Although the health insurance covers a package of basic medicines, these are often out of stock at government hospitals so patients need to purchase them privately, partly using the cash transfer. Where families cannot afford to pay for repair and maintenance of their child's hearing aid or wheelchair (for example), this further limits the child's prospects of attending school or taking part in any activities outside the home.

The research paid particular attention to the impact of the PNCTP on children with disabilities. In line with the quantitative findings, families interviewed for the qualitative component emphasised that the unmet needs of children with disabilities represent a significant economic and psychosocial burden on families. While PNCTP beneficiaries are entitled to health insurance, there were mixed views about how adequate this was for meeting the needs of children with disabilities. Overall, families with children with disabilities felt that the cash transfer had helped them, mainly through the entitlement to health insurance; the cash transfer itself had also helped, enabling them to pay for goods and services for the disabled family member, which they had previously found it very difficult to afford. However, although these families receive equipment for their children with disabilities — such as wheel chair or hearing aids —no provision are made for what are generally expensive maintenance costs such as new wheels or new batteries etc. which they then cannot afford, making it difficult to use the equipment. Additionally, the expenses generated by these households tend to be greater, limiting the purchasing power of the cash transfer.

In relation to nutrition, the cash transfer has enabled beneficiary households to buy larger quantities and a greater variety of more nutritious food — particularly animal proteins — which has played an important part in improving the nutritional status of children in beneficiary households. For example, some respondents noted that they can now buy meat, chicken, fruits and vegetables (either once per payment cycle, or more regularly). Indeed, adolescents in the study highlighted this as a particularly positive outcome of the programme for them, as they value having a more varied diet and food they enjoy eating.

While housing and living conditions are a significant element in determining children's wellbeing, the cash transfer amount is too low to enable families to make significant improvements to their housing conditions. However, respondents used the transfer to help pay for water and energy costs, which would otherwise have been unaffordable. In Gaza in particular, beneficiaries were less at risk of having their power cut because of payment than the comparison group.

Children's right to development:

The cash transfer was reported to have made a mixed contribution to children's access to education. The main contribution of the PNCTP to education is the exemption of school fees, which although typically low, can be a barrier for very poor households. Nevertheless, some beneficiary caregivers reported poor coordination between MoSA and the education authorities, which meant that supporting documentation often failed to arrive in time for enrolment, forcing households to pay (even if the fee was subsequently refunded).

Additional barriers, however, are the indirect and opportunity costs of schooling. For some families, the extra cash provided through the transfer was enough to enable children to continue to attend school by allowing them to pay for transport, books, uniforms and school bags. But for the poorest households, the small amount of the cash transfer was not enough to cover school expenses after other expenses (food and health care) had been prioritised. For the poorest households, the opportunity costs for adolescents (particularly boys who are better able to find paid work outside the household) are also important. When beneficiary households were asked what difference the cash transfer had made to their or their families' lives, only a small minority who were previously working mentioned that children had been able to stop working and start going to school again. This may, however, be partly due to the very small amount of the transfer; it is not sufficient to substitute for a younger member of the family working to provide additional income for the family.

The PNCTP has had some effect on children's capacity to enjoy recreational activities — such as summer camps which require the payment of transport costs — within the constraints of the local environment. A few caregivers also reported being able to buy toys or other 'treats', but most households used the transfer to cover other more basic and urgent needs.

Still, children continue to have very limited recreational time and opportunities and limited resources with which to enjoy these. An important gender dimension was uncovered in relation to children's ability to enjoy recreational activities: boys and girls both expressed the view that girls faced a more difficult situation, given the limits to their mobility outside the home imposed by restrictive social norms.

Children's right to protection:

Quantitative data suggest that the PNCTP does not have a significant effect in reducing violence at the household, community or school levels. Quantitative and qualitative findings showed that violence is widely practised — by children and adolescents themselves, their parents, teachers, and service providers. Qualitative interviews did, however, indicate that the cash transfer has had some impact in terms of reducing intra-household violence, partly reflecting lower stress levels due to a slight easing of financial pressures on the household head.

Violence in schools was widely reported and generally accepted as the norm, especially in relation to how teachers discipline children from poor households. Although there are counselling staff in some schools, some children talked of not being able to trust that their problems would remain confidential„ and only in a few cases were teachers identified as sources of support. School violence was in fact one of the main reasons reported by adolescents for not attending or dropping out of school, which goes against one of the aims of the PNCTP — to support children's continuation in school.

On child labour, the quantitative and qualitative data produced some contradictory findings. The quantitative data suggest that the number of boys working outside the household is relatively low (particularly in Gaza), while the qualitative component indicates that a number of children — even those from beneficiary families — are working; boys tend to do paid work outside the home while girls support activities in the home (and, in rural areas, also do agricultural work).

In terms of children's mental health and emotional wellbeing, despite the heavy psychosocial burden on poor households in the SoP — particularly those with children with physical or mental disabilities — access to psychosocial support and counselling is very limited, and the services that do exist are of poor quality. Support from informal sources that people used to rely on (such as extended family and neighbours) is no longer forthcoming, because of the extent of hardships facing families in the SoP.

While many children who are experiencing mental and emotional health problems live in beneficiary households, the lack of outreach by social workers who visit these households on a semi-regular basis, and the limited information about the support services available, mean they are not receiving the support they need. School counsellors are available (in state schools and those run by the United Nations Relief and Works Agency (UNRWA) for refugee children). But there are too few of them (one counsellor for approximately 1,000 pupils) and most have had insufficient training to deal with children's psychosocial problems. Overall, the cash transfer appears to have had limited impact in addressing children and adolescents' psychosocial vulnerabilities.

In general terms, the findings also indicate that children's safety was being jeopardised by the fact that a considerable percentage of children were often left without any kind of supervision for several hours of the day.

Children's right to participation:

The context of poverty in the SoP and hierarchical cultural norms have combined to limit children's opportunities to participate in family decisions or in schools, and even their awareness of their rights.

Participation and decision-making are also highly gendered, being the realm of men and young boys rather than women and young girls.

Children and adolescents — particularly children with a disability — spoke of their frustration at their limited opportunities to participate in everyday life, including going out to meet friends and generally socialising with their peers.

Finally, there was little evidence of efforts to involve children from beneficiary households in programme governance, including participation in the community forums that support targeting decisions and grievance redress.

Implications for policy and programming to strengthen the impact of the PNCTP on children's lives

The PNCTP contributes positively to children's right to survival; it helps households cope with economic hardship and meet children's basic needs, such as buying more nutritious food, paying some school- and health-related costs and, importantly, contributing to household debt repayment, which is a major source of stress in Gaza and the West Bank. The provision of health insurance as a complementary entitlement for beneficiaries means that households with people (including children) who have a disability or severe or chronic illness are able to cover some of the economic costs related to their care — support that is greatly valued by the families concerned. As such, the PNCTP contributes to meeting many essential household needs that affect children directly, and contributes to improving their emotional and mental wellbeing in an extremely pressured and challenging situation. The PNCTP is thus an important programme, valued by beneficiaries, and as such one which should continue with greater support and investment in order to strengthen and improve it, particularly with regard to its impacts on the lives of children and adolescents living in poverty and with multiple vulnerabilities.

The PNCTP however would have greater impact on children's lives and wellbeing if it were more closely linked to other complementary programmes that address the multidimensional nature of poverty and vulnerability and its specific impacts on children. Specifically, programme managers should consider implementing the following measures.

 Streamline social workers' caseload and role: Social workers should engage with all members of beneficiary families, not just parents, so that they can identify children's needs and make appropriate referrals. To do this, they need additional training and a reduction in caseloads to a manageable level, with sufficient time allocated to each family for regular follow-up. Social workers need to clearly understand that their role includes identifying the physical and emotional wellbeing of children and young people in beneficiary households and referring them to the appropriate services. The PNCTP could also consider using volunteers as 'community facilitators' to provide routine follow-up (other social protection programmes have used community facilitators to good effect — often recruiting women on a voluntary basis, who are based in and therefore trusted by the community). This could fulfil the dual objective of improving regular communication between the programme and beneficiaries, and providing local women with a rare opportunity to develop skills. Their remit should include meeting the needs of individual family members with specific vulnerabilities, as well as the wellbeing of the household as a whole.

 Invest in capacity-building: MoSA should provide training for social workers in children's rights to survival, development, protection and participation, as part of a broader cultural shift away from a policing approach to the programme (concerned with identifying 'undeserving' beneficiaries) to a supportive, rights-based approach. PNCTP social workers also need to develop specialist skills — for example, in issues facing children living with disabilities; children coping with extreme psychosocial stress; children struggling with low school performance/literacy issues; children at risk of abuse, exploitation and harm; children with post-traumatic stress disorder; children with violence/anger management issues; and issues facing children from marginalised communities such as the Bedouin. Training for social workers needs to be followed through with regular performance monitoring of individual staff as well as directorates to reinforce the principles of child-sensitive programming.

 Strengthen capacity of other government staff interacting with children, and strengthen referral systems: Given that the PNCTP aims to reduce household poverty and vulnerability, meeting the needs of children — who face specific challenges and are fundamental to breaking the cycle of poverty — should take a multidimensional approach. With this purpose, teachers need training in non-violent forms of discipline so that they can respect children's rights, and improve school performance and pupils' mo­tivation. The role of school counsellors also needs to be reassessed, as they are not the confidantes they should be for vulnerable children. Counsellors could be based in health centres as well as schools to reach children who are out of school. MoSA could use its strong links with the ministries of education and health to explore opportunities for coordinated capacity-building and learning processes, as well as for strengthening cross-sectoral referral systems to support the most vulnerable children.

 Address gender-specific vulnerabilities: Because girls are more socially isolated than boys, the need for gender-segregated safe spaces is acute, particularly in Gaza, given the influence of prevailing religious norms. Girls would benefit from being able to regularly discuss issues affecting their lives with girls in similar situations (along the lines of the focus group discussions undertaken for this research), mediated by an independent third party. Practical support is also needed: given that girls are more likely to be called on by their parents to help shoulder family care burdens, provision of respite care — such as community-based crèches or centres to care for people with disabilities — could potentially help girls to better manage their educational and domestic care responsibilities/duties, and, in the case of older adolescents, facilitate access to additional employment opportunities.

For caregivers, while cash transfer programmes that target women as beneficiaries (such as those in Latin America) are thought to have an important but limited empowering effect on women at the intra-household level, evidence from this study and other recent PNCTP evaluations' suggests that women are often subject to strong social control by male members of the extended family, even when they are not financially dependent on them. Thus, while targeting women as beneficiaries may have some impact on increasing child-sensitive spending, this would be limited by their inability to control or make decisions over the use of resources. Arguably, it would be more important to provide fora for women to regularly meet with other women and discuss issues of importance to them and their families, thereby breaking down the social isolation and some of the psychosocial stresses that the qualitative findings indicated were pervasive among programme participants, enabling to provide better care and support to their children.

 Develop a broader and better tailored package of comprehensive child-sensitive social protection services: Although a package of services already exists as part of the PNCTP, additional complementary services should be considered to maximise the programme's impact on the intersecting social and economic vulnerabilities facing children. Areas that need to be specifically addressed include: psychosocial counselling; awareness-raising about gender-based violence and related support services; child protection services; support for children with disabilities; low-cost recreational activities for girls and boys in the poorest households who are unable to access existing ones; awareness-raising about longer-term effects/risks of early marriage; subsidised transport; vocational counselling; awareness-raising about the risks of child labour and children's right to education; and housing renovation support. While it is clearly not MoSA's remit to provide all these services, it could play a key coordination role through its beneficiary database and the outreach role of social workers, ensuring good provision of information about available services to the poorest and most vulnerable families with children. Social workers could meet regularly with community providers (including non-government and faith-based organisations) to understand what services are currently available, and discuss referral options when they visit beneficiary households.

 Improve communication of MoSA's mandate: In order for MoSA to play an effective coordination role, it needs to improve its communication mechanisms — with beneficiaries and non-beneficiaries —explaining its role, the characteristics of the PNCTP (including targeting criteria and benefit levels), the services it offers, its procedures, and the rationale for any reforms. It should invest in a communications strategy to achieve coherence in its information dissemination and messaging.

 Ensure the provision of disability-specific support: The PNCTP needs to do more to address the specific needs of children with disabilities; at present, there is no guarantee that their needs will be prioritised over the (often pressing) needs of other adult family members. There is also a need for regular monitoring of impact, as well as training for social workers to specialise in disability care issues to provide the multi-layered support needed by children living with disabilities, and their families.

 Expand coverage and improve quality of psychosocial services: Given the important number of individuals in beneficiary households — including children and adolescents — experiencing mental and emotional health issues that hinder their ability to pursue a pathway out of poverty with the help of the PNCTP, there is an urgent need for MoSA to link to specialist institutions and undertake a referral system for families and children in need. (In Area C of the West Bank, a regular mobile service should be introduced so that the programme can reach out and identify vulnerable households rather than expect people to attend the directorate, given the travel distance and expense involved.) Given the limited number of social workers in the SoP, community health centres will need to play a key role, so good coordination between MoSA and the Ministry of Health will be important. The introduction of community facilitators (proposed earlier) could also help in identifying families and individuals in need of specialist psychosocial support.

 Link beneficiaries to technical and vocational training for adolescent girls / boys and youth: Improving the quality of education and providing alternative forms of higher education such as technical and vocational training might enable adolescent boys and girls from beneficiary households to earn an income to support themselves and help their families. Given the limited scope for young people to gain formal sector jobs in the SoP, it is also necessary to promote entrepreneurship by fostering ideas for setting up innovative small businesses.

 Work with parents from vulnerable and extremely poor households to improve parenting skills and behaviour towards children: MoSA, through social workers or community facilitators, could do more at the family and community levels to raise parents' awareness on issues related to positive parenting, gender equality, non-violent discipline, and the challenges facing adolescents. It could organise community discussion sessions to sensitise parents to children's rights and needs, thereby encouraging positive parenting practices (such as appropriate disciplining), as well as healthy social behaviour, such as taking children out for entertainment or recreational purposes. In this way, lower levels of stress and improved emotional wellbeing of children in the poorest households could contribute to children and adolescents being better able to find a pathway out of extreme poverty.

1 See Jones and Shaheen, 2012; Pavanello and Hamad, 2012

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