Improving Nutrition Through Multisectoral Approaches

Transcription

1 Imprving Nutritin Thrugh Multisectral Appraches Scial Prtectin Hw can scial prtectin imprve nutritin? Investing in nutritin and early child develpment are integral cmpnents f a cherent scial prtectin system aimed at preventing the intergeneratinal transmissin f pverty and key determinants f lng-term ecnmic grwth. Prper child nutritin increases human capital and prductivity. Scial prtectin prgrams typically increase incme and can influence the cntrl f this incme. Wh cntrls incme can imprve nutritinal status t sme degree. Scial prtectin prgrams can als imprve nutritin by fstering linkages with health services r sanitatin prgrams, and specifically thrugh activities related t nutritin educatin and/r micrnutrient supplementatin. When targeted t the critical windw f pprtunity, scial prtectin prgrams can enhance nutritin investments. The windw f pprtunity pens during pregnancy and clses at abut tw years f age. The cnsequences f malnutritin during this perid are severe and largely irreversible. An incme r in-kind transfer alne may be insufficient t imprve nutritin. Impact can and shuld be augmented by specific design features, which can play an essential rle in generating impact f transfers and ther types f scial prtectin prgrams, such as welfare, pensin, r insurance. Pririty actins fr nutritin specific and nutritin sensitive scial prtectin 1. Target activities t the mst nutritinally vulnerable ppulatins. 2. Include educatin activities in scial prtectin (SP) interventins t increase husehld awareness f health and nutritin care giving and health seeking behavirs. 3. Integrate nutritin services int SP interventins, e.g., grwth mnitring and prmtin, and/r activities fr imprved grwth and diet quality. 4. Reduce the acute and lng-term negative impacts f external financial, price, and weather shcks by scaling up prgrams in times f crises.

2 Imprving Nutritin Thrugh Multisectral Appraches This brief analyzes the different plicy chices related t the elements f SP prgrams that affect nutritinal utcmes, such as: Incme/Cnsumptin: Size, frequency, cntrl, and nature f transfer (cash/in-kind) Links with health and sanitatin services: Prgram cnditinalities r c-respnsibilities (firm/sft), prmting access t services (supply side) Targeting f the mst vulnerable: By incme, nutritinal status, age grup Figure 1 prvides a radmap fr decisin-making when designing a scial prtectin prgram, taking int accunt special cnsideratins related t targeting, type f transfer, and linkage t ther services, which can increase impact n nutritin. There is high variability in SP prgram design based n cntextual factrs, and this radmap highlights key features and cnsideratins that need t be taken int accunt n a caseby-case basis in rder t design an adequate scial prtectin prgram that directly respnds t the needs and access levels f beneficiaries. Bxes 1 and 2 discuss examples f elements f SP prgrams that can imprve nutritin. The three main pathways thrugh which scial prtectin prgrams can impact nutritin are: 1. Imprving incme. 2. Prmting access and delivery f health and sanitatin services thrugh scial prtectin prgrams, e.g., micrnutrient supplements, nutritinal cunseling, health and hygiene educatin, and ther health and sanitatin services affecting nutritin. 3. Targeting nutritinally vulnerable ppulatins, e.g., pregnant wmen and yung children. Bx 1. Nutritin-relevant indicatrs fr mnitring and evaluating SP prgrams Anthrpmetric measures f nutritinal status: are cmmnly cllected t gauge undernutritin in children, and reflect early deprivatin including prenatal undernutritin. Dietary diversity r meal frequency: relatively easy t mnitr and can be cllected fr individuals in a target grup rather than fr a husehld as a unit. Fd cnsumptin: reveals infrmatin abut inputs int nutritin. Participatin in health and nutritin activities: including public awareness and natinal health and nutritin campaigns. Imprving Nutritin Thrugh Multisectral Appraches

3 Scial Prtectin Figure 1. Radmap fr nutritin sensitive SP prgram design Size f transfer Hw much f a transfer wuld make a difference? Is there ne standard husehld transfer r des it vary by number f husehld members? Frequency f transfer What frequency f transfers wuld be mst beneficial t prgram participants (mnthly, bimnthly, weekly)? Smaller and mre frequent transfers have the advantage f cvering daily necessities, including key nutritinal inputs. Targeting Wh shuld the prgram reach? Targeting by age r at-risk grups Children yunger than tw and pregnant wmen Individuals already undernurished r at risk f undernutritin Thse at heightened risk in the wake f weather, price, r financial shcks Cntrl f incme Wh shuld the transfer g t? Female cntrl f incme has been assciated with shifts in husehld expenditure patterns twards children s needs, except in MENA where male cntrl is mre clsely linked t child and health service usage. Type f transfer When d in-kind transfers have an advantage ver cash transfers? Hw d markets wrk? Are fd prices vlatile? Is there an emergency? In-kind transfers: May perfrm better in pr markets r in the aftermath f a disaster. Cupns r fd stamps: Additinal lgistical csts but fewer fd distributin csts. Cash transfers: Lwer lgistical csts and mre freedm fr husehld t spend n their wn pririty needs. Cnditinal versus uncnditinal transfers What are the expected gains f mnitring and reprting the cnditinalities f a transfer versus having n cnditinalities? Will the impact f a cnditinal cash transfer be s much larger that it makes an additinal 8-15% spending wrthwhile? Uncnditinal Cash Transfer Assume that preferred expenditures, e.g., n nutritius fds can be achieved simply by an increase in incme. Cnditinal Cash Transfer Link a targeted transfer t health-seeking behavirs thrugh cnditinalities r c-respnsibilities. What is the bjective yu are trying t achieve? What is the quality f services, and what services are available? What is the cst f mnitring these cnditins, and hw d yu want t mnitr them (sft vs. firm)? Cnditinal In-Kind Transfer Schl feeding: impact mst apparent n schl attendance, especially amng girls. Take-hme ratins: can have an impact n yunger siblings. Schl-based health and nutritin prgram: vehicle fr nutritin educatin and ther nutritin-related behavirs and health services. Sft versus firm cnditins Sft cnditins: c-respnsibilities that are advcated but nt strngly enfrced. Firm cnditins: c-respnsibilities are mnitred and enfrce cmpliance. These have higher impact. Imprving Nutritin Thrugh Multisectral Appraches

4 Imprving Nutritin Thrugh Multisectral Appraches Bx 2. Optins fr making additinal types f SP prgrams mre nutritin-sensitive Public wrks: help t generate emplyment and incme fr vulnerable husehlds. Accmmdatin f time demands n wmen. Prvisin f a crèche/mbile crèches t facilitate participatin f wmen and simultaneusly insure the prvisin f adequate nutritin care fr children. Prgrams suited t increased energy demands f pregnant and lactating wmen/substitutin f labr-intensive wrk fr lwer-intensity wrk. Include attendance f nutritin educatin prgrams as fulfilling wrk requirements. Insurance: helps t smth cnsumptin ver time and acrss husehlds. Cmmunity-level weather index insurance t address drughts, cyclnes, flds: payut when there is a shck. Health insurance t smth incme in times f health shcks. Health insurance als encurages service utilizatin, especially preventive and primary care, e.g., fr yung children. Micrfinance: can assist in entrepreneurial pprtunities as well as incme smthing. Savings prmtin. Sme frms f insurance. Credit prvisin. Cmmunity-based prgrams: Cmmunity-based grwth prmtin prgrams: incrprate key nutritin interventins and strengthen knwledge and capacity while increasing demand fr health and nutritin services by bringing thse services clser t the cmmunity. Cmmunity-Driven Develpment and Scial Funds: can incrprate nutritin int basic service prvisin, invlves cmmunities in strengthening and establishing mechanisms t prmte nutritin activities. Imprving Nutritin Thrugh Multisectral Appraches

5 Scial Prtectin Examples f SP prjects that integrate nutritin bjectives 1 Peru: Strengthening the nutritin impact f the Junts cnditinal cash transfer (CCT) prgram Peru s CCT prgram, Junts, began in 2005, and serves mre than half a millin husehlds. The prgram targets pr rural husehlds with children under 14 years, with c-respnsibilities f regular health visits fr pregnant wmen and children under 5 years, and schl attendance f at least 85% fr schl-age children wh have nt yet cmpleted elementary educatin. In 2008, a renewed effrt was made t strengthen the Junts prgram t btain better nutritin utcmes. An analysis f the prgram s bttlenecks and imprvements were analyzed t guide the prject s strengthening. The results are summarized in Table 1. Table 1. Junts review prcess fr prject readjustment Bttleneck Inadequate (lw) cverage f target ppulatin (<2yrs ld) Line f readjustment Imprved targeting (pririty fr children aged 0-2yrs) Transfer scheme inapprpriate fr desired incentives Cash transfers t husehlds withut infrmatin abut the cmpliance and/r withut cmpliance f c-respnsibilities Limited supply capacity f health and educatin services Lack f a managerial mnitring system Inadequate institutinal implementatin structure Adjustment f incentive scheme, i.e., amunt, crespnsibilities, frequency f payment New prcess f cash transfer delivery; Cmpliance verificatin thrugh health and educatin sectrs Guarantee the supply f health and educatin services thrugh the standardizatin f basic packages, including nutritin such as distributin f micrnutrient pwders Establish a mnitring system that tracks the supply f service i.e., are services dependably available and high quality Establish an adequate and prfessinalized structure, e.g., clarify peratinal rules and staff, fill vacant directr psitin The changes were first pilt-tested in ne district f Peru t validate the functining f the revamped prgram and t fine-tune aspects fr natinal scale up. A multisectral inter-agency wrking grup was established t crdinate acrss sectrs (particularly between Junts and the Ministry f Health), linking the delivery f transfers and demand incentives t targeted husehlds by prviding a basic package f health and nutritin interventins. In 2010, the prgram apprved a new peratinal manual and the implementatin f the refrms is expected t cntribute t imprving final nutritinand pverty-related utcmes. 1 These case studies were selected based n their innvative design and integratin f nutritin int scial prtectin; hwever, because they are recent and new, results are nt yet available. Imprving Nutritin Thrugh Multisectral Appraches

6 Imprving Nutritin Thrugh Multisectral Appraches Latin America and the Caribbean: Additinal examples f nutritin c-respnsibilities in CCT prgrams Cuntry Prgram Nutritin c-respnsibilities Brazil Blsa Familia Children <7 yrs: cmplete immunizatins and attendance at grwth mnitring 2x/year Pregnant and lactating wmen: attendance at ANC and PNC checkups and health and nutritin educatin sessins Blivia Dminican Republic Guatemala Bn Juana Azurduy Slidaridad Mi Familia Prgresa Children <2 yrs (with n ther siblings <2 yrs): attendance at bimnthly checkups Pregnant and lactating wmen (with n children <2 yrs): attendance at 4 prenatal checkups, institutinal birth, and pstnatal checkups Children <6 yrs: immunizatins and attendance at regular health checkups Pregnant and lactating wmen: attendance at ANC and PNC visits Children <7 yrs: attendance at regular health checkups (immunizatins, grwth mnitring, dewrming, vitamin A supplementatin, supplementary feeding) Children 6-15 yrs: irn flic acid and fluride supplementatin, dewrming Pregnant and lactating wmen: attendance at ANC and PNC visits, irn flic acid supplementatin, educatin n cmplementary feeding and health Mexic Oprtunidades All family members: attendance at health checkups 2x/year Pregnant wmen, children <2 yrs, malnurished children: attendance at mnthly health educatin sessins Clmbia Panama Familias en Acción Red de Oprtunidades Children < 7 yrs: attendance at regular health checkups (grwth mnitring, nutritinal status and develpment; hygiene and diet educatin; vaccinatins) Children < 5 yrs: regular health checkups Pregnant wmen: ANC visits every 2 mnths Djibuti: Scial safety net prject that cmbines wrkfare with a nutritin interventin Djibuti has high rates f childhd malnutritin (affecting 33% f the children), unemplyment (hvering at 55%), and pverty (affecting 42% f the ppulatin). In additin, the cuntry has been cnfrnted ver the last fur years with recurrent drughts that negatively affected pr and vulnerable husehlds, and created emergency needs. In respnse, the gvernment is implementing an innvative scial safety net (SSN) prgram Djibuti Crisis Respnse: Emplyment and Human Capital Scial Safety Nets, cmbining shrt-term emplyment with a nutritin interventin fr the pr and vulnerable. The prject supprts a crisis respnse that prvides the basis fr a (prductive) safety net by (i) imprving the design and effectiveness f a public wrks prgram s it becmes an effective scial safety net, (ii) generating new shrt-term jb pprtunities fr the pr and vulnerable; and (iii) imprving nutritin practices amng participating husehlds thrugh behaviral change interventins. The prgram links creatin f emplyment pprtunities t imprvement f nutritinal practices by adding a nutritin and grwth prmtin cmpnent t the traditinal cash-fr-wrk prgram t leverage the effect f the additinal incme n the family s nutritinal status. Integrated apprach: all [family members] against malnutritin Wrkfare: Increased husehld incme Offers shrt-term emplyment in: Cmmunity wrks (fr all) chsen (and built) by the cmmunity frm catalgue (e.g. cntainment walls) Services (fr wmen nly), mainly plastic bags cllectin, cmmunity level recycling and transfrmatin int blcks t pave ftpaths Cmmn Gal Prevent Malnutritin Nutritin: Enhanced nutritin practices Targets vulnerable nn-wrking members (yung children and pregnant wmen) Fcus n first 1,000 days f life Mnthly cmmunity meetings (e.g. sensitizatin n exclusive breastfeeding) Bi-weekly hme visits by a cmmunity wrker Fd supplements distributed during the lean seasn THE WORLD BANK