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Designing CCT Programs to Improve Nutrition Impact

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Presentación de James Garrett and Lucy Basset, International Food Policy Research Institute IFPRI, durante el Tercer Seminario de Transferencias Condicionadas de Ingresos, realizado en Santiago de Chile el 01 y 02 de Diciembre de 2008.

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Designing CCT Programs to Improve Nutrition Impact

  1. 1. Designing CCT Programs to Improve Nutrition Impact Principles, Evidence, and Examples James Garrett 3d International Seminar on Conditional Cash Transfers December 1-2, 2008 Santiago, Chile *paper by James Garrett, Lucy Bassett, Marie Ruel, Alessandra Marini
  2. 2. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Overview of the Presentation • Pathways of Impact • Structuring Design Analysis • Effect Pathways: Summary of the Evidence • Enhancing a Focus on Nutrition • role of a CCT in a strategy for nutrition • considerations on design • Country Study: Peru Income Conditionalities (Co-responsibilities) Design & Operation
  3. 3. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Use of H&N Services Health Supply Health HH Income + Women Income Control Child Nutrition Food/ Nutrient Intake Long term Education Supply Education (Condition) HH Food Security – Diet Quality/ Quantity Women’s time Educated Girls ProgramUnderlyingCausesImmediateCausesOutcomes School Enrollment + Attendance Health visits (Condition) Cash to women Feeding & Care Practices Fortified Products Women’s Knowledge & Awareness Education in Health &Nutrition (H&N) to Women CCT Effect Pathways: Nutrition Seven Pathways  poverty and food insecurity, and diet  women’s income and control over resources  maternal knowledge  health services  women’s time  micronutrient fortification and supplementation  girls’ and boy’s education Source: Leroy et al. (2008)
  4. 4. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Categorizing Pathways: Structuring CCT Design for Nutrition •Poverty food insecurity, and diet quality •Women’s knowledge and awareness •Health services utilization and child health •Girls’ and boys’ education •Women’s income and control over resources •Women’s time •Micronutrient fortified foods and supplements Income Conditionalities (Co-responsibilities) Design & Operation
  5. 5. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Effect Pathways: Evidence Summary Poverty, Food Security, Diet Diversity Program (country) Poverty (numbers) Food Expend Diet Quality AP F&V Oportunidades (rural Mexico) -12 pp (-17 %) 3 % (kcal) 13 % 16 % Red de Protección Social (Nicaragua) -7 pp (-5 %) ~ 24 % 64 % 71 % (sweets 34 %) Familias en Acción (Colombia) NS (extreme rural poverty: -6 pp) ~ 24 % 20 % NS Programa de Asignación Familial (PRAF) (Honduras) NS NS NS NS 1
  6. 6. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Effect Pathways: Evidence Summary Effect on Women Program (country) Women’s Control over Resources Knowledge Time Oportunidades (rural Mexico) no change increase in autonomy? general no info on child h & n general burden not perc’d as problem Red de Protección Social (Nicaragua) na na na Familias en Acción (Colombia) na na na Programa de Asignación Familial (PRAF) (Honduras) na na na 1
  7. 7. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Effect Pathways: Evidence Summary Effect on Children Program (country) Children’s Health Services Use Micronutrient Status Health Status / Growth Oportunidades (rural Mexico) use immunization NS iron, zinc, vit A (w / fortified food) NS (w/o fortified food) overall illness -23 % / YES Red de Protección Social (Nicaragua) use immunization NS na na / YES Familias en Acción (Colombia) use immunization NS AP vegetables fruit NS diarrhea, resp NS : rural diarrhea / YES Programa de Asignación Familial (PRAF) (Honduras) ` na diarrhea NS / NS 1
  8. 8. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Enhancing Pathways Impacts on nutrition less than possible • pathways not thought through • actions not focused on supporting them Determine actions to support elements of the CCT • pay greater attention to design and implementation (3 areas) • income, co-responsibilities, operation
  9. 9. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Foundations of a Strategy  Co-responsibilities of greatest relative import • income effect on nutrition, by itself, is limited • other factors important (care and feeding practices, water and sanitation, health services) • higher incomes do not eliminate nutritional deficiencies • transfers may be on items with no / little nutrition impact  Use a Systems Analysis • how does each component / actor work to produce “good nutrition”? • alone and with other • how does the CCT fit into a broader strategy for nutrition / social protection? • purpose, cost- effectiveness, coordination / integration
  10. 10. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Essential Nutrition Actions • exclusive breastfeeding for 0-6 months • adequate complementary feeding 6-24 months • appropriate care for sick and severely malnourished children • adequate intake of vitamin A, iron, iodine • care: health and hygiene
  11. 11. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Country Health Check-ups Growth Monitoring Educ Workshops Micronutr Suppl Mexico  children & adults    iron & papilla Nicaragua  children 0-5    iron Colombia  children 0-6   enc, but not required Honduras  children & pregnant women  Peru  children 0-5 & pregnant women planned  hhs with children 6-36 mos planned CCTs in Latin America: Nutrition-Related Services and Conditionalities
  12. 12. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Enhancing Pathways • transfer amount • essential nutrition actions • beneficiaries, program operators / providers (all levels) • target groups (women, 0-3 y.o.) • efficiency of transfer and service delivery (education, health care) • micronutrient suppl / fortification • supply-side quality, incl feedback mech • interagency and actor coordination Income Transfer Conditionalities (Co-responsibilities) Design and Operation
  13. 13. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE • transfer amount Enhancing Pathways: Income  provide a substantial incentive  20 to 40 % of hh income?  cover costs of compliance  o.c. of time, travel, etc Income Transfer
  14. 14. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Enhancing Pathways: Co-responsibilities  consider how system (including other agencies, legal framework) works to achieve essential nutrition actions  CCT can coordinate, integrate, or incentivize actions  others have responsibilities, too – and services must be available and of high quality  incentives must exist for everyone to do their part  different ministries / agencies, and their staff; public, private, hh; national, subnational, local • essential nutrition actions • beneficiaries, program operators / providers (all levels) Conditionalities (Co-responsibilities)
  15. 15. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Enhancing Pathways: Design & Operation  evidence on unconditional transfers?  easier administration  same effect?  whom to target  fathers, non-traditional hh, community  transfer efficiency  electronic transfers  easy access (networks of state banks, community NGOs, etc)  convenient times (non-work hours)  effective delivery (health, education)  excellent guides on training / counseling – use them! • target groups (pregnant / lactating women, 0-3 y.o.) • efficiency of transfer and service delivery (education, health care) • micronutrient suppl / fortification • supply-side quality, incl feedback mech • interagency and actor coordination Design and Operation
  16. 16. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Enhancing Pathways: Design & Operation  supply-side  ensure accountability (as with hh!)  reimburse based on performance?  public reporting, citizen scorecards, and oversight committees  channels for comments, complaints, and appeals  interagency / actor coordination: lateral leadership  linking mechanisms  incentivize partnerships::  transparent decisions, funding, accountability  ownership: shared understanding, vision, participation  known roles and responsibilities • target groups (pregnant / lactating women, 0-3 y.o.) • efficiency of transfer and service delivery (education, health care) • micronutrient suppl / fortification • supply-side quality, incl feedback mech • interagency and actor coordination Design and Operation
  17. 17. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Nutrition-Focused CCT: Example from Peru Holistic Analysis Renewed emphasis on:  Co-responsibilities  Management and Capacity Co-responsibilities • key age group: pregnant/ lactating women; 0-3 year olds • eliminate papilla: add “dispersible micronutrients” • pay per number of conditionalities and household members • change requirement that all conditions always have to be met • identify state responsibilities • coordinate, integrate, incentivize?
  18. 18. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Multi-Actor Production Function: Providing Services to Beneficiaries Take beneficiary list and provide to local health center Reimburse health center for services provided Synchronize lists between SIS and JUNTOS Open clinical history Fill out conditionalities form Set beneficiary appointment schedule Report lack of compliance to JUNTOS File end-of-month reports with SIS, JUNTOS, and municipality Promoter visits household, determines services and conditionalities JUNTOS – Beneficiary signs contract, including conditionalities Beneficiary receives payments, including first incentive Promoter visits non- compliant households Validate application Provide services as scheduled Bill SIS for services Apply algorithm to determine beneficiary payment, taking compliance into accountMUNICIPALITY reports to community SIS Complete form to join SIS Health Center JUNTOS Household Take beneficiary list and provide to community promoters
  19. 19. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Nutrition-Focused CCT: Example from Peru Management and Capacity • ensure verification is independent • informally transferred to promotoras (incentive to report compliance) • make payment / verification timeline more realistic / less burdensome • focus on results (political commitment, RBB) • integrate into social protection / child nutrition strategy • work with others who provide information and services (ID, MINSA • MINED? water / sanitation? MINAG? • interagency ownership and integration • inter- sector, actor, agency working group • merge information systems
  20. 20. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE Conclusions: Improving CCT for Nutrition • Consider pathways • appropriate targets and nutrition actions • consider characteristics of income transfer, co-responsibilities, and design & operation • Think holistically • Think how CCT can enhance pathways • but also complement other ongoing or potential actions and actors • cost effectiveness of actions within a CCT are, or better simply to complement others • attention to operations and management • institutional arrangements, capacity, incentives
  21. 21. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE • END

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