Improving the Nutritional Impact of Safety Net Interventions

Transcription

1 Improving the Nutritional Impact of Safety Net Interventions Margaret Grosh Lead Economist for Human Development, Latin America Region The World Bank With inputs from Leslie Elder and Alessandra Marini Safety Nets Core Course Dec 13, 2011 Washington DC

2 Outline 1- The importance of malnutrition 2 Understanding the problem 3- How much will income growth or an income transfer matter? 4- What can we do to improve on that?

3 REDUCING UNDER-NUTRITION: A DEVELOPMENT IMPERATIVE

4 Consequences of undernutrition At least 35% of child deaths can be attributed to undernutrition globally. (Black et al. 2008, Pelletier et al. 2005) 4

5 Damage suffered in early life leads to permanent impairment Child s height for age is best predictor of human capital Diminished immune response Reduced adult size Reduced intellectual ability Lower economic productivity Poorer reproductive outcomes Greater risk of chronic diseases in adulthood Stunting = loss of 5-11 IQ points Low birth weight = loss of 5 IQ points Iodine deficiency = loss of IQ points Iron def. in childhood = up to 25 IQ point loss Lancet, 2008

6 Malnutrition reduces the efficiency of development investments Malnutrition reduces school performance: Well nourished children stay in school 1.2 years longer Well nourished children have 17% better reading comprehension Low birth weight children 2.6 times less likely to attain higher education

7 Malnutrition reduces the efficiency of development investments Malnutrition reduces productivity: Well nourished children had wages in adulthood 34-47% higher and incomes 14-28% higher than malnourished (Guatemala) Anemia (low iron) = 5-17% lower adult productivity Overall, an estimated 10% of individual lifetime earnings and 2-3 % GDP lost to malnutrition

8 UNDERSTANDING THE PROBLEM

9 Can you recognize the malnourished child?

10 Know Where to Intervene, for what 171 million children under 5 are stunted Source: WHO Global Database on Child Growth and Malnutrition, May 2009

11 Know where to intervene, for what Pregnant Women Women of reproductive age (15-49yrs) Asia presents the largest numbers of anemic women, but the prevalence of anemia is the most severe in Africa. Source: WHO (2008) Worldwide prevalence of anemia

12 Know where to intervene, for what Fuente: Uauy, 2011

13 Know where to intervene, for what Stunting Overweight Belize Argentina Chile Uruguay Peru Bolivia Dominican Republic Mexico Brazil Guyana El Salvador Honduras Guatemala Nicaragua Ecuador Trinidad and Tobago Colombia Haiti

14 Z-scores (WHO) Focus on the Window of Opportunity: the first 1000 days of a child s life Timing of growth faltering, 54 DHS surveys Weight Height Age (months) Source: Victora, de Onis, Hallal, Blössner, Shrimpton. Pediatrics (15 Feb 2010)

15 INCOME AND MALNUTRITION

16 Greater income seems important Poor Nutrition Adapted from UNICEF, 1998 Diet Infectious Diseases Food (access/quality) Care Health Hygiene Buys more and better food Can allow time for more or better caregiving Buys access to health care, to soap, water & sanitation BUT alone, income may not be enough and not work fast enough

17 Repositioning Nutrition, World Bank 2006 The trickle-down effect is modest The income-malnutrition relationship Income growth will improve nutrition, but at a slow rate that will not be sufficient to achieve the MDGs

18 Data Malnutrition rates can be high even among those who are not poor Prevalence of Child Underweight by Wealth Quintiles Regions Country Lowest 2nd 3rd 4th Highest South Asia Bangladesh India Pakistan Africa Benin Burkina Ethiopia Mozambique Rwanda Tanzania Uganda Source: Gwatkin et al, Country Reports on HNP and Poverty: Socio-economic Differences in Health, Nutrition and Population, April 2007 Note: Data for children <5 yrs. Below 2SD

19 HOW CAN WE BOOST IMPACTS OF TRANSFERS ON NUTRITION?

20 Options Link SSN participants to nutrition services, nutrition education and health care whether mandatory/conditional or not in all kinds of programs cash, food, public works, etc. consider micro-nutrient supplements or deworming treatments for SSN clients If food is being used as part of transfer, consider fortification In public works programs respect women s care-giving needs; use labor in ways that will improve access to health care and clean water Details, not just the broad notion of these options, matter a lot to impacts

21 Improving the impact of a CCT program on nutrition: Peru s Juntos Program Preliminary results showed: Families buy more and better food Positive impacts on some health indicators Impacts get larger with time and continuity of the program But Not all impacts are sufficiently large No impact on final outcomes (malnutrition, anemia)

22 Key bottlenecks identified in Juntos implementation Directly afffecting impact on nutrition Transfer scheme inappropriate for desired incentives (unique and fixed transfer) Sub-coverage in target population for addressing chronic malnutrition (< 2 years old) Inaccurate verification of compliance with co-responsibilities in health and nutrition Lack of clear definition in basic health and nutrition package More general, preventing proper functioning of the program Lack of clear monitoring system Weak institutional structure Lack of clear operational rules Inadequate operational and labor structure Now implementing a plan of action to improve impacts on nutrition

23 Djibouti: Workfare cum Nutrition Integrated approach: all [family members] against malnutrition Common Goal: Prevent Malnutrition Workfare: Increased household income Offers short-term employment in: - Community works (for all) chosen (and built) by the community from catalogue (e.g. containment walls) - Services (for women only), mainly plastic bags collection, community level recycling and transformation into blocks to pave footpaths Nutrition: Enhanced nutrition practices. Targets vulnerable non-working members (young children and pregnant women) Focus on first 1,000 days of life - Monthly community meetings (e.g. sensitization on exclusive breastfeeding) - Bi-weekly home visits by a community worker - Food supplements distributed during the lean season. 23

24 Improving Nutritional Impact Doesn t Necessarily Mean Using Food Programs Doing food programs isn t easy either -- most of the same issues of other transfer programs, plus some unique ones: Inherent costs and logistics of procuring, storing, transporting, distributing food Added layers of pressure groups from food producers Fortification Most school feeding programs still don t use fortified foods New drives toward local purchase introduce a goal that can be countervailing to fortification, though New technologies beginning to allow smaller scale fortification

25 PRONAA Vaso de Leche Programa de Complementación Alimentaria - PCA (Gob. Locales) Wawa Wasi Programa Nacional de Infra. Educativa Electrificacion Rural JUNTOS SIS FONCODES Techo Propio Agua para Todos Provias Descentralizado Construyendo Peru Agro rural Programa de Movilizacion Nacional para la Alfabetizacion COFOPRI INABIF FITEL Pro Joven PNCVFS Porcentaje Millones de S/. Peru 2010, food programs represent 22% of expenditures on social programs, with little impact on poverty or malnutrition 120% % 80% 60% 40% 20% 0% % Fuente: SIAF. Devengado Elaboración propia

26 Peru: food programs missing the potential to reduce malnutrition Intervene too late in the life cycle Focus on food provision, not enough nutrition education or behavior, little link to health system Food used are high in calories and proteins but not adequately fortified, promote weight gain but not growth Poor targeting, weak monitoring and evaluation Procurement issues potential to reduce costs by 30-40% Fuente: Banco Mundial, 2006 y 2007, Francke, 2006

27 Summary Reducing malnutrition is imperative Good safety nets can contribute to the solution to malnutrition But getting the best impact of safety nets in lowering malnutrition will require explicit attention to the issue

28 With thanks to Leslie Elder, Alessandra Marini, Meera Shekar, Luc LaViolette, Anna Herforth, Julie Bergeron (World Bank) and Karin Lapping (Save the Children/US) and others