Designing CCT Programs to Improve Nutrition Impact

Designing CCT Programs to Improve Nutrition Impact

Principles, Evidence, and Examples

James Garrett3d International Seminar on Conditional Cash TransfersDecember 1-2, 2008Santiago, Chile

*paper by James Garrett, Lucy Bassett, Marie Ruel, Alessandra Marini

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


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

ProgramU

nderlying CausesIm

mediate Causes

Outcom

esSchool

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)


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


Effect Pathways: Evidence SummaryPoverty, 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


Effect Pathways: Evidence SummaryEffect on Women

Program(country)

Women’sControl over Resources Knowledge Time


no changeincrease in autonomy?

general no info on child h & n

general burden not perc’d as problem


na na na


na na na


na na na

1


Effect Pathways: Evidence SummaryEffect on Children

Program(country)

Children’s Health

Services Use Micronutrient Status Health Status / Growth


use immunization NS

iron, zinc, vit A (w / fortified food)

NS (w/o fortified food)

overall illness -23 % /

YES


use immunization NS

na na / YES


use immunization NS

AP vegetablesfruit NS

diarrhea, resp NS

: rural diarrhea / YES


` na diarrhea NS / NS

1


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


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


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


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


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

IncomeTransfer

Conditionalities(Co-responsibilities)

Design and Operation


• 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

IncomeTransfer


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)


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.)







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.)







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?


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

JUNTOSOpen clinical history Fill out conditionalities

formSet 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 listand provide to

community promoters


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


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


• END

Designing CCT Programs to Improve Nutrition Impact

Government & Nonprofit

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