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
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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
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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)
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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
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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
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Effect Pathways: Evidence SummaryEffect on Women
Program(country)
Women’sControl over Resources Knowledge Time
Oportunidades(rural Mexico)
no changeincrease 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
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Effect Pathways: Evidence SummaryEffect 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 vegetablesfruit NS
diarrhea, resp NS
: rural diarrhea / YES
Programa de Asignación Familial (PRAF)(Honduras)
` na diarrhea NS / NS
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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
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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
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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
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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
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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
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• 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
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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)
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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
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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
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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?
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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
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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
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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
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• END