Leveraging Social Protection Policies and Programs for Promoting Healthy Diets and Improved Nutrition

The Global Perspective

Olivier EckerSenior Research FellowInternational Food Policy Research Institute (IFPRI), Washington, DC

Link to HLPE framework of food systems for diets and nutrition

Social protection policies and programs

Source: HLPE (2017): “Nutrition and Food Systems.” CFS.

What do we mean by “social protection”?

• Social protection is generally understood to encompass three types of public interventions: (1) social safety nets, (2) state-contingent insurance, and (3) social-sector policies.

• Social safety nets (SSNs) are targeted, noncontributory programs and policies (i.e., interventions) that transfer resources to poor households that are deprived due to their income or social, physical, or nutritional status.

• SSN interventions include cash transfers through welfare payments, in-kind transfers and voucher programs, emergency response assistance (e.g., food aid), school feeding programs, public works schemes, and subsidies, quotas, and conditions for products that are consumed or produced primarily by poor populations.

Source: Based on Drime & Yosef (2016): “Reducing Risk, Strengthening Resilience: Social Protection and Nutrition.” In: Gillespie et al.: Nourishing Millions: Stories of Change in Nutrition. IFPRI.

Why do we care about “nutrition-sensitive” social protection?

• Income growth has significant—yet modest—effects on reducing undernutrition and micronutrient deficiencies.

• The Copenhagen Consensus workshops (in 2004, 2008, 2012) illustrate that nutrition interventions have high rates of economic return.1

• The 2013 Lancet series on Child and Maternal Nutrition estimated that scaling-up 10 proven effective nutrition-specific interventions would reduce child stunting globally by 20%.2

• This would be a major improvement but does not go far enough. There is a need for interventions that address the underlying determinants of malnutrition, incl. nutrition-sensitive social protection.

• SSNs can be utilized as well as enhanced to improve nutrition.

• Globally, 1.9 billion people receive some form of SSN assistance.3

• SSN interventions provide resources to beneficiaries and create or change (economic) incentives to which their (food) consumption responds, potentially improving—or worsening—dietary quality.

Source: 1 Lomborg (2004, 2009): Global Crises, Global Solutions, 1st and 2nd Editions. Cambridge Univ. Press. Lomborg (2013): Global Problems, Smart Solutions: Costs and Benefits. Cambridge Univ. Press.2 The Lancet (2013): “Maternal and Child Nutrition” Series.3 Alderman (2016): “Leveraging Social Protection Programs for Improved Nutrition.” World Bank.

Mechanisms by which social safety nets can improve nutrition

• SSNs are generally targeted to the poor, who are often food and nutrition insecure.• Transfers increase household resources and thus the purchase of necessities.• Many SSN interventions (esp. subsidies and vouchers) reduce the price of specific

food items, making them more affordable.• SSN interventions often influence households’ preference for spending additional

funds on food (e.g., by empowering women).• Some SSN programs provide incentives to use key health services.• SSN programs can include features designed to promote behavior change.• SSN interventions can serve as delivery platforms for nutrition-specific interventions

(e.g., micronutrient fortification), contributing to scale, coverage, and effectiveness.

Source: Based on presentation by Alderman: “Key Steps for Nutrition-Sensitive Social Protection.” World Bank; March 2017.

Indicative pathways from social protection to nutrition

Source: Adjusted from Alderman (2016): “Leveraging Social Protection Programs for Improved Nutrition.” World Bank.

Targ

etin

ge.

g., p

over

ty, 1

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-day

per

iod,

wom

en

Quotas, conditions

Cash transfers(CCT, UCT)

Public works

In-kind transfers, vouchers

School feeding

Emergency response assistance

Subsidies

Policies | programs

Prices

Income

Preferences

Knowledge

Behavior

Soci

al n

orm

s an

d va

lues

Food purchasequantity, quality

Health service use

Child care

NUTRITIONAL STATUS

Pathways Mediators Outcome

Evidence on nutritional impact of social protection is sobering.

• Neither SSN policies nor SSN programs have delivered improvements in nutrition commensurate with their successes in reducing poverty.1

• Meta-analysis of cash transfer programs (mainly in Latin America) show little impact on children’s height.2

• The path from increased household resources to improved nutritional status of individuals (esp. children) is not direct.

• Increased household income does not guarantee access to quality health services, improvements in sanitation, or nutrition-relevant behavioral change.

• Knowledge about child care is one of the pillars of good nutrition, but is not intrinsic to programs designed to transfer income.1

• Moreover, food subsidies and cash and in-kind transfers can have negative nutritional impacts, such as increasing overweight/obesity (in Egypt, Mexico, USA).3,4,5

Source: 1 Presentation by Alderman: “Key Steps for Nutrition-Sensitive Social Protection.” World Bank; March 2017.2 Manley et al. (2013): “How Effective are Cash Transfers at Improving Nutritional Status?” World Development 48, 133-155.3 Ecker et al. (2016): Nutrition and Economic Development: Exploring Egypt’s Exceptionalism and the Role of Food Subsidies. IFPRI.4 Leroy et al. (2013): “Cash and In-Kind Transfers Lead to Excess Weight Gain in a Population of Women with a High Prevalence of Overweight in Rural Mexico.” Journal of Nutrition 143, 378-383.5 Chen et al. (2005): “Effects of Food Stamp Participation on Body Weight and Obesity.” American Journal of Agricultural Economics 87, 1167-1173.

Evidence on consumption effects of social protection is encouraging.

• Poor households spend most of any additional income on food (Engel’s law).1

• Compared with general income increases, food-oriented transfers (even without conditions) nudge consumers to devote more of the additional income to food purchases (in Colombia, Ecuador, Mexico, Nicaragua, USA).2,3

• Linking behavior change communication (BCC) with (cash or in-kind) transfers increases household dietary quality and reduces the risk of overweight/obesity associated with income growth (in Mexico).4,5

• By providing financial incentives, conditional cash transfers (CCTs) work to increase use by the poor of those key health services upon which the cash transfer is conditioned.6

Source: 1 Engel (1851). “"Die vorherrschenden Gewerbezweige in den Gerichtsämtern mit Beziehung auf die Productions- und Consumtionsverhältnisse des Königreichs Sachsen.” Zeitschrift des Königlich Sächsischen Statistischen Bureaus3, 153-182.2 Attanasio et al. (2012): “Food and Cash Transfers: Evidence from Colombia.” Economic Journal 122, 92-124.3 Beatty & Tuttle (2015): “Expenditure Response to Increases in In-Kind Transfers: Evidence from the Supplemental Nutrition Assistance Program.” American Journal of Agricultural Economics 97, 390-404.4 Leroy et al. (2010): “Cash and In-Kind Transfers in Poor Rural Communities in Mexico Increase Household Fruit, Vegetable, and Micronutrient Consumption but Also Lead to Excess Energy Consumption.” Journal of Nutrition 140, 612-617.5 Leroy et al. (2014): “Maternal Education Mitigates the Negative Effects of Higher Income on the Double Burden of Child Stunting and Maternal Overweight in Rural Mexico.” Journal of Nutrition 144, 765-770.6 Lagarde et al. (2007): “Conditional Cash Transfers for Improving Uptake of Health Interventions in Low- and Middle-Income Countries: A Systematic Review.” JAMA 298, 1900-1910.

Linkages to nutrition agenda remain untapped.

• Existing SSNs’ lack of success in improving diets and reducing malnutrition points to the need for reforms and greater nutrition sensitivity.

• SSNs—esp. in North Africa, the Near East, and Asia—are still focused on the major nutrition problems of the past (mainly undernourishment), even though today’s key nutrition challenges are different (overweight/obesity, non-communicable diseases, micronutrient deficiencies).1

• In many countries, the social protection sector is disconnected from the health/nutrition sector and generally has a different agenda.

• Some countries (e.g., Mexico, Brazil, Peru, USA) successfully linked social protection to other development goals (health, nutrition, education, women’s empowerment). Their experiences may provide important lessons for others.2,3

• Social protection is often intertwined with other government support systems (as in Egypt, India, Indonesia) such as subsidy and procurement policies for producers (e.g., farmers), processors (e.g., millers), and outlets (e.g., shop owners).1,2,3

Source: 1 Ecker et al. (2016): Nutrition and Economic Development: Exploring Egypt’s Exceptionalism and the Role of Food Subsidies. IFPRI.2 Adato & Hoddinott (2010): Conditional Cash Transfers in Latin America. IFPRI.3 Alderman et al (2017): The 1.5 Billion People Questions: Food, Vouchers, or Cash Transfers? World Bank.

General steps for making SSNs nutrition-sensitive

• Understand the nutritional status of the target population and the vulnerable groups within that population.

• Identify which vulnerable groups can be reached through a specific SSN intervention.• For each vulnerable group, identify the key nutritional issues and the direct or underlying

causes of those nutritional issues.• Define nutrition objectives for the SSN intervention. • Select the nutrition-sensitive programmatic opportunities that are most likely to achieve the

selected nutrition objectives by addressing immediate and underlying determinants of nutrition or that will improve the enabling environment for nutrition.

• Address the immediate determinants of nutrition while simultaneously addressing the underlying determinants of nutrition and/or the enabling environment for nutrition.

Source: Based on presentations by Olney et al.: “Making WFP’s Programmes More Nutrition-Sensitive.” WFP; December 2016; and Alderman: “Key Steps for Nutrition-Sensitive Social Protection”, World Bank; March 2017.

• Remove or reduce (economic) incentives for nutritionally adverse behavior.• Target activities to the most vulnerable groups, monitor progress, and adjust if needed.• Include BCC activities to increase household awareness of health, nutrition, and caregiving

needs and to encourage use of health services.• Enhance the quality of nutrition-related activities included in the SSN interventions (e.g., health

services in CCTs, micronutrient fortification in in-kind transfers).• Use school feeding and emergency response programs as delivery platforms for micronutrient

supplementation and deworming campaigns (combined with nutrition and health messaging).• Scale up in times of crisis in order to reduce the long-term negative impacts of external

shocks.• Involve independent researchers for rigorous impact evaluation (already during the

intervention design phase) to achieve long-term success.

Source: Based on presentations by Olney et al.: “Making WFP’s Programmes More Nutrition-Sensitive.” WFP; December 2016; and Alderman: “Key Steps for Nutrition-Sensitive Social Protection.” World Bank; March 2017.

Specific steps for making SSNs nutrition-sensitive

The future of SSNs: Food, vouchers, or cash transfers?

• Globally, there is a general trend toward cash transfers, and there are good reasons for that: Basic economic theory Improved technology for delivery and monitoring Extensive evidence on impacts Evidence that the cost of assistance is 13-23% less than with an equivalent food-based transfer

• The path to cash transfers is not linear.• Recently, even food-based programs have become more integrated with the countries’ social

protection systems, adopted multiple objectives (e.g., poverty reduction, improved nutrition, support to agriculture), and, on average, improved their performance.

• The fact that a program is food- or cash-based does not necessarily determine performance in coverage, targeting accuracy, impact, or other dimensions.

• The policy choices available at any given time are not just about optimal strategies, but also, in part, the legacy of previous policies. Historically, crises have marked critical junctures, opening political space and generating opportunities for reform.

Source: Alderman et al (2017): The 1.5 Billion People Questions: Food, Vouchers, or Cash Transfers? World Bank.

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