75105 Improving Nutrition Through Multisectoral Approaches Social Protection How can social protection improve nutrition? • Investing in nutrition and early child development are integral components of a coherent social protection system aimed at preventing the intergenerational transmission of poverty— and key determinants of long-term economic growth. Proper child nutrition increases human capital and productivity. • Social protection programs typically increase income and can influence the control of this income. Who controls income can improve nutritional status to some degree. Social protection programs can also improve nutrition by fostering linkages with health services or sanitation programs, and specifically through activities related to nutrition education and/or micronutrient supplementation. • When targeted to the critical window of opportunity, social protection programs can enhance nutrition investments. The window of opportunity opens during pregnancy and closes at about two years of age. The consequences of malnutrition during this period are severe and largely irreversible. • An income or in-kind transfer alone may be insufficient to improve nutrition. Impact can and should be augmented by specific design features, which can play an essential role in generating impact of transfers and other types of social protection programs, such as welfare, pension, or insurance. Priority actions for nutrition specific and nutrition sensitive social protection 1. Target activities to the most nutritionally vulnerable populations. nclude education activities in social protection (SP) interventions to increase household awareness of 2. I health and nutrition care giving and health seeking behaviors. ntegrate nutrition services into SP interventions, e.g., growth monitoring and promotion, and/or 3. I activities for improved growth and diet quality.  educe the acute and long-term negative impacts of external financial, price, and weather shocks by 4. R scaling up programs in times of crises. Improving Nutrition Through Multisectoral Approaches This brief analyzes the different policy choices related to the elements of SP programs that affect nutritional outcomes, such as: • Income/Consumption: Size, frequency, control, and nature of transfer (cash/in-kind)  inks with health and sanitation services: Program conditionalities or co-responsibilities (firm/soft), • L promoting access to services (supply side) • Targeting of the most vulnerable: By income, nutritional status, age group Figure 1 provides a roadmap for decision-making when designing a social protection program, taking into account special considerations related to targeting, type of transfer, and linkage to other services, which can increase impact on nutrition. There is high variability in SP program design based on contextual factors, and this roadmap highlights key features and considerations that need to be taken into account on a case- by-case basis in order to design an adequate social protection program that directly responds to the needs and access levels of beneficiaries. Boxes 1 and 2 discuss examples of elements of SP programs that can improve nutrition. The three main pathways through which social protection programs can impact nutrition are: 1. Improving income.  romoting access and delivery of health and 2. P sanitation services through social protection programs, e.g., micronutrient supplements, nutritional counseling, health and hygiene education, and other health and sanitation services affecting nutrition.  argeting nutritionally vulnerable 3. T populations, e.g., pregnant women and young children. Box 1. Nutrition-relevant indicators for monitoring and evaluating SP programs • Anthropometric measures of nutritional status: are commonly collected to gauge undernutrition in children, and reflect early deprivation including prenatal undernutrition. • Dietary diversity or meal frequency: relatively easy to monitor and can be collected for individuals in a target group rather than for a household as a unit. • Food consumption: reveals information about inputs into nutrition. • Participation in health and nutrition activities: including public awareness and national health and nutrition campaigns. Improving Nutrition Through Multisectoral Approaches Social Protection Figure 1. Roadmap for nutrition sensitive SP program design Size of transfer Frequency of transfer  ow much of a transfer would • H What frequency of transfers would be •  make a difference? most beneficial to program participants •  Is there one standard household (monthly, bimonthly, weekly)? transfer or does it vary by number of household members? Smaller and more frequent transfers have the advantage of covering daily necessities, including key nutritional inputs. Targeting Control of income • Who should the program reach? • Who should the transfer go to? Targeting by age or at-risk groups o C  hildren younger than two and Female control of income has been pregnant women associated with shifts in household expenditure patterns towards ndividuals already undernourished or o I children’s needs, except in MENA at risk of undernutrition where male control is more closely  hose at heightened risk in the wake o T linked to child and health service of weather, price, or financial shocks usage. In-kind transfers: May perform better in poor markets or in the Type of transfer aftermath of a disaster. • When do in-kind transfers have an advantage over cash transfers? • How do markets work? Coupons or food stamps: Additional logistical costs but fewer food distribution costs. • Are food prices volatile? • Is there an emergency? Cash transfers: Lower logistical costs and more freedom for household to spend on their own priority needs. Conditional versus unconditional transfers What are the expected gains of monitoring and reporting the conditionalities of a transfer versus •  having no conditionalities? Will the impact of a conditional cash transfer be so much larger that it makes an additional 8-15% •  spending worthwhile? Unconditional Conditional Cash Transfer Conditional In-Kind Transfer Cash Transfer Link a targeted transfer to health-seeking behaviors • School feeding: impact most apparent on Assume that preferred through “conditionalities� or “co-responsibilities.� school attendance, especially among girls. expenditures, e.g., on • What is the objective you are trying to achieve? • Take-home rations: can have an impact on nutritious foods can younger siblings. • What is the quality of services, and what services be achieved simply by are available? • School-based health and nutrition an increase in income. • What is the cost of monitoring these conditions, program: vehicle for nutrition education and how do you want to monitor them (soft vs. and other nutrition-related behaviors and firm)? health services. Soft versus firm conditions • Soft conditions: co-responsibilities that are advocated but not strongly enforced. Firm conditions: co-responsibilities are monitored and enforce compliance. These have higher impact. •  Improving Nutrition Through Multisectoral Approaches Improving Nutrition Through Multisectoral Approaches Box 2. Options for making additional types of SP programs more nutrition-sensitive • Public works: help to generate employment and income for vulnerable households. o Accommodation of time demands on women.  rovision of a crèche/mobile crèches to facilitate participation of women and simultaneously o P insure the provision of adequate nutrition care for children.  rograms suited to increased energy demands of pregnant and lactating women/substitution o P of labor-intensive work for lower-intensity work. o Include attendance of nutrition education programs as fulfilling work requirements. • Insurance: helps to smooth consumption over time and across households. o Community-level weather index insurance to address droughts, cyclones, floods: payout when there is a shock.  ealth insurance to smooth income in times of health shocks. Health insurance also o H encourages service utilization, especially preventive and primary care, e.g., for young children. • Microfinance: can assist in entrepreneurial opportunities as well as income smoothing. o Savings promotion. o Some forms of insurance. o Credit provision. • Community-based programs: Community-based growth promotion programs: incorporate key nutrition interventions and o  strengthen knowledge and capacity while increasing demand for health and nutrition services by bringing those services closer to the community.  ommunity-Driven Development and Social Funds: can incorporate nutrition into basic o C service provision, involves communities in strengthening and establishing mechanisms to promote nutrition activities. Improving Nutrition Through Multisectoral Approaches Social Protection Examples of SP projects that integrate nutrition objectives1 Peru: Strengthening the nutrition impact of the Juntos conditional cash transfer (CCT) program Peru’s CCT program, Juntos, began in 2005, and serves more than half a million households. The program targets poor rural households with children under 14 years, with co-responsibilities of regular health visits for pregnant women and children under 5 years, and school attendance of at least 85% for school-age children who have not yet completed elementary education. In 2008, a renewed effort was made to strengthen the Juntos program to obtain better nutrition outcomes. An analysis of the program’s bottlenecks and improvements were analyzed to guide the project’s strengthening. The results are summarized in Table 1. Table 1. Juntos review process for project readjustment Bottleneck Line of readjustment Inadequate (low) coverage of target Improved targeting (priority for children aged 0-2yrs) population (<2yrs old) Transfer scheme inappropriate for desired Adjustment of incentive scheme, i.e., amount, co- incentives responsibilities, frequency of payment Cash transfers to households without New process of cash transfer delivery; Compliance information about the compliance and/or verification through health and education sectors without compliance of co-responsibilities Limited supply capacity of health and Guarantee the supply of health and education services education services through the standardization of basic packages, including nutrition such as distribution of micronutrient powders Lack of a managerial monitoring system Establish a monitoring system that tracks the supply of service i.e., are services dependably available and high quality Inadequate institutional implementation Establish an adequate and professionalized structure, structure e.g., clarify operational rules and staff, fill vacant director position The changes were first pilot-tested in one district of Peru to validate the functioning of the revamped program and to fine-tune aspects for national scale up. A multisectoral inter-agency working group was established to coordinate across sectors (particularly between Juntos and the Ministry of Health), linking the delivery of transfers and demand incentives to targeted households by providing a basic package of health and nutrition interventions. In 2010, the program approved a new operational manual and the implementation of the reforms is expected to contribute to improving final nutrition- and poverty-related outcomes. 1 These case studies were selected based on their innovative design and integration of nutrition into social protection; however, because they are recent and new, results are not yet available. Improving Nutrition Through Multisectoral Approaches Improving Nutrition Through Multisectoral Approaches Latin America and the Caribbean: Additional examples of nutrition co-responsibilities in CCT programs Country Program Nutrition co-responsibilities Brazil Bolsa Familia • Children <7 yrs: complete immunizations and attendance at growth monitoring 2x/year • Pregnant and lactating women: attendance at ANC and PNC checkups and health and nutrition education sessions Bolivia Bono Juana Children <2 yrs (with no other siblings <2 yrs): attendance at bimonthly checkups •  Azurduy Pregnant and lactating women (with no children <2 yrs): attendance at 4 prenatal •  checkups, institutional birth, and postnatal checkups Dominican Solidaridad Children <6 yrs: immunizations and attendance at regular health checkups •  Republic Pregnant and lactating women: attendance at ANC and PNC visits •  Guatemala Mi Familia Children <7 yrs: attendance at regular health checkups (immunizations, growth •  Progresa monitoring, deworming, vitamin A supplementation, supplementary feeding) Children 6-15 yrs: iron folic acid and fluoride supplementation, deworming •  Pregnant and lactating women: attendance at ANC and PNC visits, iron folic acid •  supplementation, education on complementary feeding and health Mexico Oportunidades All family members: attendance at health checkups 2x/year •  Pregnant women, children <2 yrs, malnourished children: attendance at monthly health •  education sessions Colombia Familias en Children < 7 yrs: attendance at regular health checkups (growth monitoring, nutritional •  Acción status and development; hygiene and diet education; vaccinations) Panama Red de Children < 5 yrs: regular health checkups •  Oportunidades Pregnant women: ANC visits every 2 months •  Djibouti: Social safety net project that combines workfare with a nutrition intervention Djibouti has high rates of childhood malnutrition (affecting 33% of the children), unemployment (hovering at 55%), and poverty (affecting 42% of the population). In addition, the country has been confronted over the last four years with recurrent droughts that negatively affected poor and vulnerable households, and created emergency needs. In response, the government is implementing an innovative social safety net (SSN) program “Djibouti Crisis Response: Employment and Human Capital Social Safety Nets,� combining short-term employment with a nutrition intervention for the poor and vulnerable. The project supports a crisis response that provides the basis for a (productive) safety net by (i) improving the design and effectiveness of a public works program so it becomes an effective social safety net, (ii) generating new short-term job opportunities for the poor and vulnerable; and (iii) improving nutrition practices among participating households through behavioral change interventions. The program links creation of employment opportunities to improvement of nutritional practices by adding a nutrition and growth promotion component to the traditional cash-for-work program to leverage the effect of the additional income on the family’s nutritional status. Integrated approach: “all [family members] against malnutrition� Common Goal–Prevent Malnutrition Workfare: Increased household income Nutrition: Enhanced nutrition practices Offers short-term employment in: Targets vulnerable non-working members •  Community works (for all) chosen (and built) by the (young children and pregnant women) community from catalogue (e.g. containment walls) Focus on first 1,000 days of life •  Services (for women only), mainly plastic bags Monthly community meetings (e.g. sensitization on •  collection, community level recycling and exclusive breastfeeding) transformation into blocks to pave footpaths Bi-weekly home visits by a community worker •  Food supplements distributed during the lean season •  THE WORLD BANK