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Nutrition-sensitive social protection policies and programmes: What challenges and gaps still remain?

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Presentation by Harold Alderman (International Food Policy Research Institute) at the FAO/WHO International Symposium on Sustainable Food Systems for Healthy Diets and Improved Nutrition that took place at the FAO Headquarters in Rome on December 1-2. Read more here:

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Nutrition-sensitive social protection policies and programmes: What challenges and gaps still remain?

  2. 2. Why Focus on Nutrition Sensitive Programs? The 2013 Lancet Nutrition Series estimated that scaling up 10 proven effective nutrition specific interventions to cover 90% of at risk children would reduce stunting globally by 20 percent. While this would be a major improvement in the health and development of children, it does not go far enough. Thus, there is also a need for programs that address the core determinants of undernutrition including nutrition sensitive social protection
  3. 3. A few stylized facts about nutrition sensitive social protection - I While transfers improve food security as indicated by increased consumption and diet diversity. Most beneficiaries also increased participation in health care. But both conditional and unconditional cash transfers have not delivered improvements in anthropometric measures of nutrition commensurate with their success in addressing poverty. In particular, they have had only modest impact on stunting or anemia A combination of cash assistance for households and specific supplements tailored to a child’s needs has proven advantageous as components of CCTs or UCTs as well as part of emergency response programs.
  4. 4. A few stylized facts about nutrition sensitive social protection - II While many of the differences between cash and in-kind transfers are context specific, cash transfers are almost always less expensive to deliver, by as much as 15-25% In-kind transfers (including school feeding) have proven an effective vehicle for micronutrient fortification School feeding has also a proven track record in advancing education and in serving as a means of providing food security including as a response to financial emergencies The track record on school feeding on nutrition, however, is far more ambiguous
  5. 5. One gap is understanding how to use safety nets for micronutrient fortification In-kind transfers (including food subsidies) are still core elements of many safety net systems. Both Egypt and India, for example, spend $billions on such programs. Yet the former ceased fortification of its highly subsidized flour in the absence of WFP support. Similarly, according the Global Alliance for Improved Nutrition (GAIN) only one of 10 state programs for fortification at public distribution shops in India initiated this century were still in place in 2015. This despite the fact that they work; Gujarat’s multiple micro-nutrient fortification of flour reduced the share of safety net beneficiaries with inadequate iron intakes by 94%.
  6. 6. The reasons for failing to take advantage of opportunities for fortification vary In Gujarat resistance came initially from small millers. In other settings there is a reluctance – or even legal obstacle – to pass on the additional costs or to subsume them into the overall SP budget. This is often the case for school feeding programs as well. Again, despite the fact that one clear nutritional gain from school meals is the potential to reduce anemia. But given the experience in various means of fortification not only of wheat and maize flour but of double fortified salt and even extruder rice, the obstacles for making such programs more nutrition sensitive are not, however, primarily technical.
  7. 7. Behavioral Change Communication There are programs that have increased the nutritional impact of either cash transfers or in-kind supplements by linking them to behavioral change communication as recently reconfirmed in a RCT in Bangladesh. In that study cash alone did not lead to improvements in anthropometry, but the combination of cash and BCC had a significant impact on height for age as well as on nutritional knowledge and behaviors This is by no means a new idea, but it is still a challenge to set up the necessary cross-sectoral coordination especially when the transfer program is unconditional or uses soft conditions. Additionally, the staffing and training challenges for scaling up some of the successful small scale pilot programs in BCC imply a need for innovation in communication
  8. 8. Making emergency relief nutrition sensitive For obvious reasons this is an area where research is challenging with most evidence coming from slow onset emergencies or even lean seasons. Relief is designed to meet the needs of households rather than to meet the dietary needs of vulnerable children, but it should be possible to enhance the nutritional impacts with i) micronutrient fortification of grains and vegetable oil; ii) iodized salt in general food deliveries; and iii) specialized lipid based supplements for vulnerable individuals for which various trials are underway Still, the biggest challenge is to find means of financing to make emergency response more timely.
  9. 9. School Feeding as a platform Nutrition sensitive social protection can be a platform for nutrition specific programs. Deworming is often mentioned in this context yet remains controversial (and thus to my mind worthy of further investigation). There are similar programs to promote iron supplementation, some use novel incentive structures for teachers While there are also innovative programs for school curricula aiming at increasing exercise and limiting obesity as well as targeted programs to reduce risky behavior among adolescents, I have not seen experimentation or guidelines on curricula for teaching nutrition for child care in schools.
  10. 10. HGSF: new opportunities with new dilemmas School feeding traditionally has three goals: to enhance schooling, to improve nutrition and to serve as an instrument of social protection. HGSF adds an additional objective: to enhance farmer’s income (and community market integration). This comes with some potential tradeoffs. First, in in regard to fortification. Since fortification is easiest in centralized settings HGSF makes it harder (but not impossible) to fortify staples. In principle this could be offset by diet diversity but at a cost. Few programs can provide meat or milk on a regular basis. HGSF can also fortify meals in the process of cooking.
  11. 11. Further on HGSF A second potential drawback is the risk that HGSF may have irregular supply. This is a logistic problem even in settings when the food is supplied from a central market (or imported). However in food insecure areas this may be a greater issue especially in seasons of low availability or periodic harvest failure. In such circumstances HSGF may not have the market connections to procure grain even if it is available in other parts of the country. Current studies will give insight into the potential of HGSF but it might take time to understand the stability of the approach.
  12. 12. One further caveat on HGSF If a market is functioning well, then farmers with a surplus have outlets (especially for grain; perishables may be less easily marketed). There may be an indirect effect of HSGF in increasing production and thus surplus to sell. But this is most likely if prices are higher than previously offered (as well as via extension and assistance in inputs). This may require a rationing system (if there will be two prices in local markets) with attendant problems of equity.
  13. 13. Conclusion This last point in regards to HGSF is largely about supportive administrative frameworks As are my observations about the missed opportunities for micronutrient fortification And maybe even the gap in nutrition specific programs in schools fits this characterization Not every challenge is about commitment and the enabling environment – the need to understand addressing children’s needs in emergencies, for example, is largely about a need for field research – but many of the gaps in making social protection more nutrition sensitive are about putting what is already known into practice