The Government of Ethiopia, with support from development partners, has been implementing a range of social protection programmes to reduce poverty and strengthen the economic resilience of poor and vulnerable populations, particularly in rural areas where nearly three-quarters of the population reside. Two of the country’s flagship interventions are the Productive Safety Net Program (PSNP) and the Community-Based Health Insurance (CBHI) scheme. Building on these efforts, UNICEF supported the government in launching a pilot Integrated Safety Net Program (ISNP) in 2018, designed to deliver coordinated, multisectoral interventions to improve household welfare and child outcomes in the Amhara Region.
The ISNP was conceived as a “cash-plus” initiative that complemented the existing PSNP by addressing gaps across health, education, and social protection. The programme focused on four main components: providing CBHI premium waivers to permanent direct support households and encouraging enrolment among public works households; strengthening the social worker workforce to support families with malnourished or out-of-school children; facilitating timely transitions for pregnant and lactating women from public works to temporary direct support; and enhancing behaviour change communication within the PSNP. Implementation began in 2019 and concluded in 2023.
The programme’s theory of change was built on the premise that coordinated interventions could strengthen household economic, social, educational, and health capital. Cash transfers were expected to stabilize consumption and reduce financial barriers to essential services, while CBHI enrolment aimed to lower out-of-pocket health expenditures. Behaviour change communication, social worker support, and community engagement were intended to improve knowledge, social support networks, school attendance, gender norms, and health and nutrition practices. Improvements in these areas were expected to translate into better food security, resilience, child nutrition, educational outcomes, and long-term human capital development.
An impact evaluation of the ISNP was conducted using a mixed-methods, quasi-experimental design. Because programme assignment at the district level was not random, two treatment districts were matched with two comparable districts based on geography and socioeconomic characteristics. Baseline data were collected between late 2018 and early 2019, before programme implementation, and endline data were gathered four years later, between December 2022 and March 2023, following delays caused by COVID-19 and armed conflict. The evaluation covered more than 5,300 households at baseline, with an 89 per cent follow-up rate at endline, and was complemented by focus group discussions and key informant interviews.
The evaluation took place against a backdrop of significant disruptions, including conflict, the COVID-19 pandemic, high inflation, changes in health service availability, and reforms within the PSNP itself. While most shocks affected treatment and comparison areas similarly, some differences were observed, particularly in relation to conflict-related asset losses and access to health services. These factors were accounted for in the analysis, but they also meant that the ISNP was implemented in a far more challenging context than originally anticipated.
Findings show that the ISNP achieved moderate success in implementing its additional components. Enrolment in the CBHI increased significantly among both permanent direct support and public works households, and overall awareness of the benefits of health insurance improved. However, enrolment among permanent direct support households fell slightly short of the programme’s universal coverage target, possibly due to information gaps or household transitions during PSNP reforms. The programme also contributed to improved transitions of pregnant and lactating women to temporary direct support, though this process was not consistently applied, largely due to challenges in pregnancy verification.
Other components were less effectively implemented. Case management for malnourished and out-of-school children reached only a small fraction of eligible households, and behaviour change communication sessions were severely disrupted, with very limited participation reported. While awareness of frontline workers increased, actual contact with these workers did not improve significantly.
In terms of outcomes, the ISNP produced mixed results. Positive effects were observed in reduced household indebtedness, increased use of CBHI cards for health services, stronger perceived social support among women, and greater participation in community groups. Dietary diversity improved modestly, driven by higher consumption of legumes and vegetables. The programme also contributed to small gains in women’s agency and more progressive attitudes towards child marriage.
However, the evaluation found no significant improvements in food security, nutrition knowledge, child feeding practices, or most health-seeking behaviours. Child outcomes remained particularly concerning, with no measurable impact on stunting, wasting, underweight prevalence, school attendance, preventive healthcare, or birth registration. High levels of child malnutrition and school absenteeism persisted across both treatment and comparison areas. Household resilience also declined, as more families reported negative coping strategies and distress asset sales in response to shocks.
The evaluation highlights two key lessons. First, negative perceptions about the quality of health services accessed through insurance schemes may discourage both enrolment and effective use, underscoring the need to address service delivery alongside coverage. Second, improving child nutrition outcomes through cash-plus programmes remains a complex challenge that requires further research and more intensive, context-specific interventions.
Overall, the findings suggest that while the ISNP delivered some important social and economic benefits, its impact on child outcomes was limited. Given the multiple shocks and partial implementation of programme components, the results are not unexpected. The experience underscores the need for stronger, more comprehensive interventions and stable implementation environments to achieve transformative and lasting improvements for vulnerable households and children.
