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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. INTERNATIONAL FOOD POLICY RESEARCH INSTITUTE • END
Editor's Notes
- The basic question asked in this presentation is: if we want to improve the impact of a CCT on nutrition, what do we need to do? We must go beyond evaluations that tell us whether nutritional status was improved or not to pay attention to design, implementation, and operation. We must know how a CCT affects nutrition, and know what to do affect those different elements of the program that impact nutrition. First, we can use a conceptual model to identify the potential pathways of impact. To structure the analysis to make it useful for design we can then divide them into 3 categories to reflect the ways that a CCT affects nutrition: by giving income to the household, by requiring certain behaviors (“the conditionalities” or co-responsibilities), and by making sure the design makes sense to achieve program goals and the program itself works well. I will then present some of the limited empirical evidence we have on those pathways…and then suggest how we might support those pathways through improved design and operation. Finally, I will briefly discuss some of these issues using a case study from Peru, which is now modifying their current CCT to develop a more nutrition-focused CCT.
- In a recent paper, Leroy and other authors identified 7 different pathways by which a CCT could improve or affect child nutritional status: - Building on standard conceptual model of Determinants of Nutrition (food, health / environment, care): 1. giving income can directly reduce poverty and food insecurity, and improve diet quality (because normally the diet becomes more diverse with an increase in income); 2. giving the transfer to women increase their status within the household and increase their control over how to allocate money, which usually results in greater attention and greater expenditures to child health, education, and nutrition; 3. requiring mothers to attend classes on health, household hygiene, and nutrition, especially caring and feeding practices, can improve the mother’s knowledge about what to do; 4. this can be effectively complemented with more specialized knowledge and preventive or curative treatments received from the health services – especially prenatal checkups and growth monitoring, promotion, and counseling; 5. although the idea is that the time will be well-spent getting health care or participating in counseling and courses, the program still does require the beneficiary to take time out of her day to receive or deposit the transfer, and to satisfy conditionalities, perhaps time that could be otherwise spent in directly earning more income or taking care of the children 6. some programs directly give micronutrient supplements, such as Sprinkles or tablets, or foods that have been fortified with micronutrients and energy, una papilla, to the household, or they make receipt one of the conditions: this can also directly improve nutritional status; 7. in the long term, the common requirements that girls and boys attend school will improve their own knowledge and awareness – their human capital – and so improve their own productivity
- These pathways can reasonably align with the structure for analysis set out at the beginning. The CCT has effects through the income transfer (reducing poverty and hunger, improving diet quality); through imposing certain conditionalities or complying with certain co-responsibilities (so educating mothers and children or improving use of health services); and through choices made in terms of design and operation, which do not directly relate to the fundamental aspects of providing an income transfer or determining which behaviors to change. Also: Outcomes (poverty, food security, mn status), Intermediate Effects on Women (knowledge, empowerment, time) and Children (health services utilization, education)[STOP] Operation and design choices would affect the decision to provide the transfer to the mother (as opposed to someone else); ways to improve the efficiency of providing services or delivering the transfer, and so reduce the burden on women’s time; and the direct provision of fortified foods or supplements. The usefulness of this rather simplistic scheme is that it separates out the different operational components so policymakers and programmers can look at them individually, and understand that they can indeed make individual choices about each of the categories, even though they all, in the end, work together.
- Most program evaluations (the few rigorous ones that exist) look at the effect of the program as a whole on desired objectives, such as reduced poverty or malnutrition. We do not have studies that separate out the specific effect of each of the potential pathways of impact from that of others in a CCT. Still, we do have some indication, from these evaluations and from the literature, of how CCTs affect these pathways or how the factors associated with the pathways (improved maternal education, for instance) can affect nutrition. Let’s summarize the evidence relating to the pathways using results from 4 available impact evaluations (Mex, Nicaragua, Colombia, Honduras):More details in the paper; results are from endline surveys when there is more than one – effects are those after approx. 2 years. AP = animal products (meat in Nicaragua). First, what have been the effects of a CCT on the “first” pathway – poverty, expenditures, and dietary quality. Generally, significantly reduced poverty and increased food exp, improved dietary quality (AP, F&V) in the hh, which should improve mn status. [More detail in other presentation…] Of course, sometimes expenditures on dietary “bads” also go up…like the 34% increase in sweets in Nicaragua. [STOP] Effects on poverty: substantial and significant in Mexico and Nicaragua, 7 to 12 percentage point drop. The impact on overall poverty in Colombia was insignificant but extreme poverty in rural areas declined by 6 pp. Food expenditures went up substantially in Nicaragua and Colombia, except Honduras, and calorie consumption went up in Mexico. The data were not very complete but they suggest that dietary quality also improved, with expenditures increasing on on key dietary items, like animal proteins and fruits & vegetables, by more than the increase in hh expenditures.
- What is really lacking, however, is knowledge about how the income transfer or conditionalities reduce poverty or improve nutrition. We have very little information on some of the key assumed pathways of impact: such as changes in women’s status, and maternal knowledge about how to care and feed the child. Of the four rigorous evaluations examined here, 3 of them had no information on how the program affected women’s power and decisionmaking within the household, how it changed their knowledge of health and nutrition, or how the program affected the use of their time. The evaluation in rural Mexico suggested the program had no effect on women’s status within the household, although it may have had some effect on general knowledge of health and nutrition (but it asked no specific questions on child health and nutrition), and although there was some additional burden placed on women to participate in the program, they did not generally perceive that to be a problem. We don’t really know what time shifts this caused, however, because no study has yet looked at it.
- As far as the effects on pathways for children, the picture is generally positive but more or less mixed. It is clear we do not have a clear idea of how or why the programs have effects on child health. For example, generally health service use increased – but I put only a general trend because the actual numbers of increase vary greatly, from say 5 pp to 50 pp. And this changes across programs, and depending on preventive or curative care, the age of the child, and the length of time the household has been “exposed” to the program (generally declining over time). Somewhat surprisingly the program had little effect on rates of immunization – but this may be due to generally already high levels across the beneficiary and non-beneficiary populations. Micronutrient status of children, when measured, also seems to have improved, although in Mexico this seems to be from the provision of the food rather than a cash-effect. It is also worth noting this is probably a *minimum* because the food was not always prepared properly or given completely or consistently to the target child. This is again a design and operational consideration that the program should take into account to improve impact. As we know, the programs did generally positively affect child health and growth, though again we have little hard evidence about why or how. *** The prevalence of illness in Mexican children dropped precipitously – but in Colombia and Honduras the impact was not significant. Child growth – the standard measure of child malnutrition – improved in Mexico, Nicaragua, and Colombia – again showing the programs have impacts on the outcomes but we have less idea about why or how.
- Although CCT clearly have some general impacts on outcomes (poverty, food security, malnutrition), the impacts on nutrition are most certainly less than they could be because the pathways are not well thought through. What should be the specific conditionalities to promote actions that will improve nutrition (supporting the pathways)? [STOP] Can a CCT do that? Even if we determine the appropriate conditionalities, we have not paid sufficient attention to the implementation (that is, the management) of the programs to make sure they work well, even if they have a good basic design. Improving CCTS for nutrition means paying more attention to the larger issues of design and operation, regarding the transfer, the coresponsibilities, and management.
- Most probably the coresponsibilities are of greatest importance to have an impact on child nutrition, because the impact of income alone on nutrition is relatively limited. [SEE SLIDE] So getting the coresponsibilities right is essential. And this means making both beneficiaries and government fulfill their responsibilities to make the program work. In addition to design considerations (such as the size of the transfer), the fact that the determinants of good nutrition are multisectoral, and involve many actors, public and private, and many layers of government and civil society, from national to the community, means it is also important to take a systems analysis of the program itself – how each component and actor works with the other to produce the outcomes - -and of how the CCT fits within a broader strategy of social protection.
- We know the essential actions to improve nutrition, that we can use to build on these principles of a strategy. [SEE SLIDE] (John and Lucy: international best practices…)
- Many of the programs already have many of these essential actions, or mechanisms that could promote them (such as educational workshops), in their programs. For example, through the health checkups, growth monitoring and counseling sessions, or educational workshops, mothers could learn about the importance of essential actions such as exclusive breastfeeding and high-quality complementary foods, and they could receive micronutrient supplements. But unless the program conditionalities and operations specifically address the known essential nutrition actions (and just checking off the box doesn’t tell us) it probably will not have an impact on nutrition.
- So we need to make sure that actions in each of these areas actually 1) follow recommended international practice (eg., not just “program requires health checkups” but that conditionalities matches up with the international recommendation of the appropriate number of prenatal checkups or well-baby visits); and 2) beneficiaries can access the services; and 3) the services are of high quality. Keeping these in mind, what are specific actions to take to design a more effective CCT for nutrition? using the categories for strategic analysis we developed at the beginning…
- INCOME: size of the transfer: 20-40% of household income to make a difference: provide an incentive, allow coverage of costs of compliance (e.g., opportunity costs of time or direct costs of undertaking co-responsibilities, such as travel costs or complementary purchases). One reason we think the CCT program in Honduras did not have a significant impact is bc the transfer size was so small, only about 4 percent of household income.
- The conditionalities should focus on what the individuals need to do to achieve the essential nutrition actions. But 1. determinants of nutrition are complex and multisectoral, and multiple actors: need to see what others are doing (water / sanitation, education and early childhood development, for example): 2. the CCT’s role can be to coordinate, integrate or provide incentives for them to act; 3. as mentioned, other sectors have to provide high quality services, as part of the conditionalities, or rather their co-responsibilities, in making sure the program works; 4. but incentives may need to exist so that everyone does their part…across sectors, and across levels of action [more later: using accumulating evidence from examples of working multisectorally and building political commitment in nutrition]
- [BASICALLY READ SLIDE] guides and experience: many national and international organizations and NGOs (CARE, UNICEF, WFP) on logistics; on training (USAID – models like BASICS, HEARTH, PROFILES); WB on GMP in Central America
- varied modalities for interagency coordination
- Now to finish a quick illustration from how Peru’s CCT program, called JUNTOS, is dealing with some of these issues as it refocuses its CCT to be more nutrition-centered… 1. they undertook a holistic analysis…leading them to a renewed emphasis on: [SEE SLIDE]
- Let’s take just one example to illustrate the complexity of management and the importance of coordination and capacity in designing a nutrition-focused CCT. This is just one aspect of JUNTOS. I won’t go into all the links, but it is just to show that just in providing health services to beneficiaries – which is a conditionality for beneficiaries but is a responsibility of the state to provide them – determining which households should get which services are the responsibility of community-level promotoras who are part of JUNTOS staff…but almost all the rest of whether this system works and gets the required services to the households is beyond JUNTOS’ control. We often focus on what incentives the household has to comply with the conditionalities (the cash transfer) – but this diagram shows how involved other agencies are in making the system work. SIS, the health insurance program for the poor, has to validate applications and reimburse the health center for services provided. And the local health center must complete forms, check lists, provide services, bill services, report lack of compliance…and then prepare end of the month reports for the other actors in the system: SIS, JUNTOS and the municipality. What is their incentive for working with JUNTOS? Just that they should? What power does JUNTOS have over them, or their lead ministry? or the regional governments or localities to which they are also accountable. For example, if there are breaks or delays in payments between SIS and the health center, this may lead to poorer service and may impact the effect of JUNTOS – and it’s a headache for JUNTOS but they have little direct control over whether the situation gets resolved. And there is a public accountability mechanism, with reports to the municipality, who should report to the community…but there is not a way for the community and municipality to report back and AFFECT what these higher-level agencies are doing.
- This just shows the complexity of the system..and the need for serious attention to supply-side quality, including operation and management, and interagency collaboration. What is JUNTOS doing on this front? [SEE SLIDE]