Together for Nutrition 2015

1. Guush Berhane, ESSP, IFPRI
John Hoddinott, Cornel University (formerly, IFPRI)
Neha Kumar, IFPRI
June 15, 2015
Addis Ababa, Ethiopia
IMPACTS OF SOCIAL PROTECTION PROGRAMS
ON CHILD NUTRITION
IN ETHIOPIA

2. Introduction: evidence on malnutrition
• Reducing child malnutrition remains stubbornly a huge global challenge.
• Substantial progress made over the last 15-20 years in reducing prevalence of
(and not necessarily absolute) malnutrition.
• The pace of progress varies by region, with Africa below the Sahara remaining
one of the slowest.
• Ethiopia has one of high levels of chronic undernutrition. DHS (2011):
• 44% of children under five are stunted (Have a height for age z (HAZ)
score < -2)
• 10% of children under five are wasted (Have a weight for height z (WHZ)
score < -2)

3. Introduction: why should we care?
• Intrinsic. Chronic undernutrition is a marker of high levels of deprivation.
Healthy, well-nourished children is an important development objective in
itself.
• Instrumental. Children who are undernourished are less likely to complete
school, have poorer cognitive skills in adulthood and are less economically
productive. Evidence from other countries shows that a one SD reduction in
HAZ increases the likelihood of being poor in adulthood by 10 percentage
points

4. Introduction: what determines malnutrition/child growth?
• Two groups of factors come into play
• Immediate:
• dietary quality and intake,
• health status
• Underlying factors:
• food security, resource availability,
• knowledge of and care for (mothers and) children,
• quality of health environment
• Clearly, improving food security, or resource availability is only a
necessary but not sufficient condition to improving nutritional status

5. Data: social protection programs in Ethiopia

6. 1. The Productive Safety Nets Programme (PSNP)
• Ethiopia runs one of the largest social protection programmes in Africa: The
Productive Safety Net Programme (PSNP).
• The PSNP reaches more than 7 million people in drought-prone woredas in Afar,
Amhara, Oromiya, SNNP, Somale and Tigray
• The objective of the PSNP is to stabilize household asset levels (thereby
preventing recurrent shocks from forcing households into destitution) and
improve household food security
• The PSNP:
• Is well targeted; delivers significant resources (cash and food) to beneficiaries
• Reduces the food gap; Stabilizes assets
• The PSNP was a good opportunity to tackle child undernutrition in rural Ethiopia,

7. 1. The Productive Safety Nets Programme (PSNP)
• However, the PSNP was “loosely meshed” with direct efforts to reduce
undernutrition in rural Ethiopia: chronic undernutrition reduction was not a
specific objective of the PSNP.
• Example:
Health Extension Workers were not explicitly embedded in the PSNP’s
administrative structures that oversee beneficiary selection and that hear
appeals;

8. 2. The social cash transfer pilot program (SCT), Tigray
• The SCT aims to improve the quality of life for vulnerable children, older
persons, and persons with disabilities. Three overarching objectives:
• Reduce poverty, hunger, and starvation in all households that are extremely
poor and at the same time labor constrained;
• Increase access to basic social welfare services such as healthcare and
education.
• Generate information on the feasibility, cost-effectiveness, and impact of a
social cash transfer schemes, including for national scaling up.

9. 2. The social cash transfer pilot program (SCT), Tigray
• The SCT is piloted in two woredas in Tigray, reaching around 5000 households.
• The SCT is well targeted and well received by the communities.
• Targeting was effective – done entirely through community-based social
protection committees – the Community Care Coalition (CCC).
• Again, the SCT did not embed carefully designed nutrition knowledge efforts
into the program.

10. Results: household level impacts

11. Both the PSNP and SCT have improved household level food security

12. • The PSNP has (among others) causally,
• reduced food gap by 1.05 months in
2010 and 1.48 months in 2012;
• increased food and (some) nonfood
consumption;
• increased dietary hh-level
diversity/quality.
• The SCT has (among others) causally,
• reduced food gap by 0.24 months in
May 2012.
• increased food consumption (calorie
availability per adult equivalent) but
not nonfood;
• increased hh-level diet
diversity/quality.
Both the PSNP and SCT have improved household level food security

13. Results: impact on child malnutrition

14. • We find no impact of the two programs on children of their respective beneficiary
households on any of the following anthropometric measures:
• Height-for-Age Z-scores (HAZ)
• Height-for-Age Z-score of less than -2 (Stunting)
• Weight-for-Height Z-score (WHZ)
• Weight-for-Height Z-score of less than -2 (Wasting)
Both programs did not have any impact on child health and nutrition

15. Why?
No difference in access to nutrition information by PSNP status
In the last month: Have you (been)
PSNP Beneficiary
status in 2012
visited by a
Health
Extension
Worker
visited by
someone from
the Women’s
Development
Army
given
information
about foods to
feed young
children
heard
information
about foods to
feed young
children on the
radio
boiling drinking
water before
use?
PSNP beneficiary 33.3% 18.2% 26.0% 14.9% 11.4%
Non-beneficiary 33.4 14.5 28.5 20.2 11.2

16. Why?
Child diet quality/diversity is poor
Percent consuming any:
Region Pulses Dark, leafy
vegetables, or
Vitamin A rich
fruits
Other
fruits, or
vegetables
Milk, or
other
dairy
products
Eggs Meat,
poultry or
fish
Fats or
oils
Tigray 22.5 14.7 8.5 12.4 20.9 3.9 17.1
Amhara 16.0 16.0 12.3 21.7 7.5 6.6 21.7
Amhara HVFB 15.5 7.7 4.5 13.5 3.9 5.8 8.4
Oromiya 7.5 14.5 13.7 48.6 9.8 3.5 15.7
SNNP 4.0 30.5 12.0 37.5 5.5 2.5 15.5
All 11.5 17.3 10.7 30.7 9.1 4.1 15.3
Source: PSNP survey, 2012. Foods consumed by children 6-24 months, previous day, by region, 2012Source: PSNP survey, 2012. Foods consumed by children 6-24 months, previous day, by region, 2012

17. Why?
Some improvements on child nutrition with maternal schooling but not as
evidenced internationally (i.e., 43% of improvement was due to schooling)
-2.4-2.2-2-1.8-1.6-1.4-1.2-1
Length/height-for-ageZ-score
0 1 2 3 4 5 6 7 8
Grades of schooling, mother
95% CI lpoly smooth
kernel = epanechnikov, degree = 0, bandwidth = 1.08, pwidth = 1.62
• No change in HAZ for mothers
with grades 0-2;
• HAZ improves with schooling
beyond grade 2 but slowly &
less certainly;
• Meaning, schooling at this
stage does not seem to bring
about significant changes in
HAZ.

18. Why?
Evidence of chronic undernutrition at early age (at 6 months)
-2.4-2.2-2-1.8-1.6-1.4-1.2-1
Length/height-for-ageZ-score
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
Age (months)
95% CI lpoly smooth
kernel = epanechnikov, degree = 0, bandwidth = 2.7, pwidth = 4.05
• Swift decline of HAZ from ages
6 to 24 months
• Shows how badly
undernourished children are
by the time they get to an
age where the PSNP or any
other program might have
some impact

19. Conclusions

20. • Both the PSNP and the SCT dealt with the underlying resource constraint at the household level – food
availability and food security.
• Both have improved household level (calorie) availability and food security. Both also improved dietary
diversity at the household level.
• However, these improvements are not seen at the child level. Child diet quality is poor.
• Clearly, the other critical conditions for the improvements to be sufficient are missing: namely
• Nutrition knowledge of mothers and the household at large:
• Most mothers have not had contact with health extension workers, nor have they received information
on good feeding practices.
• Poor hygiene and water practices observed – e.g., likelihood of mothers boiling water is low. This may
be one sources of infection for young children and hence reason for the poor chronic nutrition status
found.
• The new PSNP (PSNP 4) aims to achieve some of these – by wedding some of these nutrition knowledge
components with the PSNP.
conclusions

21. Thanks!
guush.berhane@cigar.org