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02.06.2013 - 27.06.2013

Social protection to protect and promote nutrition

The Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) in cooperation with IFAD, IFPRI, UNESCO, UNICEF, World Bank, WTO, WFP and the High Level Task Force on the Global Food Security Crisis (HLTF), are jointly organizing the Second International Conference on Nutrition (ICN2) at FAO Headquarters, Rome from 19 to 21 November 2014. The ICN2 will be a high-level ministerial conference which will seek to propose a flexible policy framework to adequately address the major nutrition challenges of the next decades. It will also seek to identify priorities for international cooperation on nutrition in the near and medium-term. As part of the preparatory process for the conference, a technical meeting is to be held at FAO Headquarters 13-15 November 2013. More information is available at: http://www.fao.org/food/nutritional-policies-strategies/icn2/en

To feed into and inform this meeting, a series of on-line discussions are scheduled to be held on selected thematic areas. This online discussion “Social protection to protect and promote nutrition”, promoted by IFPRI, ODI, IPC-UNDP, UNICEF, WFP and the World Bank as part of the ICN2 Social Protection and Nutrition Task Force, aims to explore how the most disadvantaged and nutritionally vulnerable groups of society - low income, resource poor, food insecure, economically marginalized and socially excluded (especially women and children) -  can be protected by an inclusive development process through the design and implementation of nutrition-enhancing social policies and social protection interventions. In this regard, please consult the Concept Note on “social protection to protect and promote nutrition”.

The outcome of this online discussion will be used to enrich the discussions at the preparatory technical meeting on 13-15 November 2013 and thereby feed into and inform the main high level ICN2 event in 2014.

We would like to invite you to comment upon and further develop this Concept Note as well as to share your experiences and views on this thematic area by responding to the following questions:

  • What are the main issues for policy-makers to consider in the design, formulation and implementation of nutrition-enhancing social protection measures?
  • What are the key institutional and governance challenges to the delivery of cross-sectoral and comprehensive social protection policies that protect and promote nutrition of the most vulnerable?
  • In your experience, what are key best-practices and lessons-learned in fostering cross-sectoral linkages to enhance malnutrition and poverty reduction through social protection?

Recent documents and fora that highlight the importance of these synergies include:

We look forward to your contributions.

Nyasha Tirivayi
Social Protection Specialist
On behalf of the ICN2 Secretariat

This discussion is now closed. Please contact fsn-moderator@fao.org for any further information.

Natalie Aldern World Food Programme, Italy
11.06.2013
Natalie

Dear all, 

Thank you for the opportunity to contribute to an interesting thread. I will respond to the facilitator by question, in italics. 

·         Studies have shown that the first 1000 days of life are a crucial window for preventing irreversible undernutrition like stunting. Yet other research rebuts this position by showing that catch-up growth is still possible even after the first 1000 days of life. From your experiences, who should we target when implementing nutrition enhancing social protection measures? Under 3 years? Over 3 years?

There is emerging consensus that the greatest gains may come from linking targeted nutrition interventions in the 1000 day window to Early Childhood Development programmes, as stunting and impaired cognitive development share many of the same risk factors. This means going beyond the 1000 days, and the World Bank has informally suggested that they are moving in the direction of always ensure their funding links nutrition-specific to ECD. However, it is quite clear that the primary target should be women and children in the 1000 day window, as well as women pre-conception (e.g. adolescent girls, in order to reach women before pregnancy)

·         Should we only always give cash or food transfers to women?

The high commitment of women to the diets and health of young children has been well documented.  Social safety nets often have multiple objectives, and the sex-selective targeting or lack thereof may support an objective other than enhanced nutritional outcomes. The balance of these multiple objectives should inform targeting, but what matters for nutrition may well be the household’s commitment to the diets of pregnant and lactating women and young children. If the commitment exists, the control of the transfer would be dependent more on the additional objectives of the social safety net programme (such as women’s empowerment, self-confidence, etc)

·         Should we only always target the poorest? Rural households? Or should we consider universal social protection schemes?

Social safety nets are a poverty reduction tool. As such, they should by definition target the poorest. This may well be those least able to access goods and services (which may be rural households, but this not a general rule as urban populations can be greatly affected by inequitable access or lack of quality services).

·         Recent research shows that stunting has far reaching consequences even affecting income earning capacities in adulthood and on a national scale leading to two –three percent losses in GDP (Bhutta, Sachdev et al. 2008). In that case, should we prioritize eliminating stunting over wasting or underweight? Or we should not prioritize one over the other?

I can only interpret this question in the context of the discussion theme related to social safety nets, which are a broader poverty reduction tool. The 2013 Lancet Series (Ruel et al- Paper 2) suggest that social safety nets and other nutrition-sensitive interventions can be used as a platform for the delivery of nutrition-specific programmes.  Social safety nets operate at scale and target the poorest, making them ideal platforms for expanding the coverage of nutrition-specific interventions as needed.  The nutrition-specific programme will depend on the objective (reduce stunting, wasting).  This will be informed by a detailed analysis of the nutrition situation to understand the causes of nutrition issues that are present.  As this will be context specific, it doesn’t seem appropriate to suggest prioritization of one over the other. While children with acute malnutrition are at a greater immediate risk of mortality, the mortality attributed to stunting is greater in absolute terms because of the number of individuals affected.

·         What are some of the lessons you have learned, best practices concerning social protection measures implemented to enhance food security and nutrition? E,g cash transfers, food transfers, school feeding, vouchers etc.

The evidence suggests that the positive impact comes to younger children and children exposed to the transfers for a longer period during the 1000 days.  Experience from CCT in Latin America suggests that positive nutrition outcomes may be greater when the social safety transfers cash and a fortified food for groups with high nutrient needs (PLWs and young children). Linking the transfer to health and/or education conditions may also increase the impact.  Including clear nutrition goals and actions is essential.  Finally, ensuring nutrition-sensitive programmes do no harm is crucial. This could mean re-designing school feeding programmes to take into account the growing risk of obesity.

Thank you again for the opportunity to share some thoughts for discussion. I’ll add a final caveat that the views expressed are my own, and do not necessarily represent those of any organization.

Dr. Claudio Schuftan PHM, Viet Nam
11.06.2013
Claudio

Dear all,
please find below my responses - in italics - to the questions raised by the facilitator in her latest post:

What are the main issues for policy-makers to consider in the design, formulation and implementation of nutrition-enhancing social protection measures?

·         Studies have shown that the first 1000 days of life are a crucial window for preventing irreversible undernutrition like stunting. Yet other research rebuts this position by showing that catch-up growth is still possible even after the first 1000 days of life. From your experiences, who should we target when implementing nutrition enhancing social protection measures?

Under 3 years

·         Should we only always give cash or food transfers to women?

Not only cash, but cash has proven to work as social protection. Food transfers have a bad track record other than for emergencies: No.

·         Should we only always target the poorest? Rural households? Or should we consider universal social protection schemes?

As a Human Rights obligation always start with poorest and most marginalized. No option here.

·         Recent research shows that stunting has far reaching consequences even affecting income earning capacities in adulthood and on a national scale leading to two –three percent losses in GDP (Bhutta, Sachdev et al. 2008). In that case, should we prioritize eliminating stunting over wasting or underweight? Or we should not prioritize one over the other?

I may be conservative here, but I would prioritize eliminating stunting.

·         What are some of the lessons you have learned, best practices concerning social protection measures implemented to enhance food security and nutrition?

E,g cash transfers
work

food transfers
do not work other than emergencies

school feeding
is an educational and not a nutrition intervention!,

vouchers
work.

I see reference to the issue of food sovereignty importantly missing here!!

Mr. Pankaj Kumar Ethiopia
11.06.2013
Pankaj

Dear Moderator,

We would like to add our contributions on on-going debate to  social protection to protect and promote nutrition. We had two examples from Ethiopia which states how nutrition can be incorporated into  existing social protection programmes, or social protection programmes can become nutrition –sensitive.

First example is Integration of Infant and Young Child Feeding in to Productive Safety Net Programme (PSNP) of Government of Ethiopia, and second is promotion of Fresh Food Voucher as a nutrition sensitive social protection measure.

Integration of IYCF into PSNP programme

Three years ago, Concern Worldwide documented the poor nutritional situation in Ethiopia and the multiple obstacles hampering previous efforts to improve it. It concluded that a multi-sectoral approach to improve infant and young child feeding (IYCF) practices and to increase access to food were among the responses needed. The project also aimed how two national programmes of Government of Ethiopia- National Nutrition Programme (NNP) and Productive Safety Net Programme (PSNP) can be brought together which works in same geographical area with more or less similar targets. In 2010, the IYCF – Productive Safety Net Programme (PSNP) project was launched as a pilot multi-sectoral approach aimed at reducing malnutrition in Dessie Zuria. It targeted poor households enrolled in the existing PSNP as well as the general population and addresses both the direct and root causes of malnutrition. The project aimed to develop an effective, sustainable and scalable model to improve IYCF practices in the most vulnerable households. The final results have been impressive, with large improvements in IYCF practices and a positive response from the communities and stakeholders involved in the project.

A number of factors contributed to the success of the IYCF – PSNP project. The project took a multi-sectoral approach, involving actors across a wide range of groups and sectors. It went beyond simply behaviour change communication, targeting the enabling environment as well as social norms, and involving the community at large. The project used multiple platforms and approaches to disseminate messages, and used a targeted approach to behaviour change, basing project activities and messages on formative research and emphasizing simple, do-able actions rather than health education messages.

  • Multisectoral approach: This project engaged actors from a range of sectors, including agriculture, education, women’s affairs, and health. This aspect was described as a key strength of the project, with each sector working together towards a common purpose, leading to increased ownership and accountability. A multi-sectoral approach also provides greater opportunities for engaging with communities. Cooking demonstrations, school clubs, and agricultural support were all combined to provide an overall aim of preventing malnutrition among children.
  • A multi-level approach: As well as working across sectors, the project also created strong links between woreda, kebele and community levels through a cascading style of training and through the continued provision of support and supervision.
  • A social and behavioural change approach: Early assessments showed that simply providing behaviour change communication alone was unlikely to be effective, given widespread food insecurity and other barriers to behaviour change. This project went beyond simply carrying out BCC, to influencing the community and social norms as a whole, as well as addressing barriers to practicing recommended IYCF behaviours.

The results of this project suggest that it is effectively fostering behaviour change, and  increasing levels of awareness among woreda officials, kebele level leaders and community members alike. It has differed from previous efforts to reduce malnutrition because it has shown people how to make simple, practical changes and reinforced the messages through a multitude of actors, contact points and methods, vastly increasing the likelihood of behaviour change. It is also focused on prevention of malnutrition rather than cure. The approach has been able to reach a large number of people who are widely dispersed over challenging terrain. Channeling activities through the PSNP creates additional contact points and ensures targeting of the poorest households.

Experiences from this project was recently presented in an International Conference on Child Under-Nutrition, organized by UNICEF France (link to the presentation) and also published in Field Exchange, Issue 44.

For further information see also the full report.

Fresh Food Vouchers- a nutrition sensitive social protection measure

Wolaiyta zone in SNNPR of Ethiopia is one of the most densely populated zones in the region with a population of 1,792,682. Kindo Koysha woreda is one of13woredas in Wolaiyta zone and is extremely vulnerable to malnutrition. It was ranked a “no.1 hotspot” woreda by UNOCHA in 2012. A Concern baseline survey conducted in December 2012 found that the average household ‘food gap’ in Kindo Koysha is seven months.

In August 2012, Concern initiated Fresh Food Vouchers in Kindo Koysha  to supplement the foods provided by the TSFP and improving caretakers’ knowledge and skills using local foods to promote child nutrition over the long term.  The FFVP offered a practical means of exposing mothers to nutritious local fresh foods while actively demonstrating how to incorporate them into their children’s meals. The aim of the project was to contribute to a reduction of mortality, morbidity and suffering associated with moderately acute malnutrition (MAM) amongst children aged 6-59 months and PLW in the target area. This was to be achieved by improving dietary diversity of target beneficiaries through the provision of Fresh Food Vouchers which were exchanged for fresh fruit, vegetables and eggs at weekly distributions. A voucher scheme was also considered more appropriate than a cash distribution due to the  limited availability of fresh foods in local markets, limited existing knowledge of the importance of fresh fruit and vegetables and eggs in a child’s diets. Prior to initiation of the activities, a market assessment (based on the Emergency Market Mapping and Analysis tool) was undertaken to assess available fresh foods in the community and to identify vendors who were already in the market and trucking foods to neighbouring towns for sale.  The ration for FFV was followings .

Table 1: Ration size

 

Type

Servings per day per beneficiary

Servings per month

Fruits

Mango

0.66 pcs

19 pcs

 

Avocado

0.66 pcs

19 pcs

 

Banana

0.66 pcs

19 pcs

Vegetables

Dark green leafy veg

200 g

6 kg

 

Carrot

115 g

3.45 kg

 

Tomato

155 g

3.45 kg

Animal Products

Egg

0.28 pcs

8 pcs

Cost of the fresh foods for the programme was on average 381 Ethiopian birr (17 euro) per individual per month.  The cost included transport cost and other related cost, excluding Concern staff to monitor the programme.

The programme findings indicate that the proportion of children 6 – 59 months of age who consumed different numbers of food groups based on the baseline (at admission) and endline (at discharge) questionnaires[1].

Figure 1: Percentage of children who ate at least one item of the food group the previous day (24 hours dietary recall)

The mean dietary diversity score changed from 1.96 at admission to 4.17 at discharge and the proportion of children who received more than four food groups increased from 4.2% to 71.4%. Children who predominantly ate from one food group at admission, increased to eating three or more food groups by discharge, with increased consumption of dark green vegetables, egg and fruits especially.

Conclusions and recommendations

The FFVP was well received by communities. The beneficiaries based on qualitative study reported health and nutrition benefits for their children above those from the TSFP alone. The awareness of importance of fresh foods seems to have been raised by the project – not just by the beneficiaries, but also the wider community, vendors, health workers, Concern WW staff and local government employees. This is an additional benefit and more lasting aspect of the project. This project can be also taken as nutrition sensitive social protection measure, or complement existing Government of Ethiopia’s social protection programme- Productive Safety Net Programme (PSNP).

Experiences from the initial pilot was published in recent Field Exchange, Issue 45 (http://www.ennonline.net/pool/files/fex/fx-45-web.pdf)

The project is further piloted this year to test following assumptions

1. Whether such food based approach can be an alternative or complement existing CMAM programming in Ethiopia and in medium to long term help in reducing under-nutrition rate and decreasing the overall need of humanitarian emergency nutrition interventions?
2. Whether such approach can also be taken as a social protection measure and complement existing PSNP programme where target beneficiaries could be those who are nutritionally vulnerable and can be provided with such support during hunger season when malnutrition rates usually peak?
3. Whether food based approach or cash vouchers along with IYCF practices will lead to change that can be rolled at the national scale in lieu of food aid?

We will be very happy to share further details of these two initiatives with interested participants. I am also sharing this training guide.

Thank you once again.

Warm Regards,

Pankaj Kumar
Concern Worldwide
Ethiopia


[1] The seven food groups per international guidelines consisted of cereals, grains, roots and tubers; pulses, legumes and nuts; milk and dairy products; meat & poultry; eggs; vitamin-A rich fruits and vegetables; and other vegetables and fruits. Oils and fats were not included as a food group.

 

 

 

 

Nyasha Tirivayi facilitator of the discussion, FAO, Italy
10.06.2013
Nyasha

Dear all

I would like to thank the contributors to the discussion last week. The discussion covered a lot of interesting issues. Some of the key points raised were as follows:

·         That social protection measures need to have clear goals and objectives

·         Social protection schemes should explicitly aim to improve nutrition rather than just raise food intake. Increased food intake does not guarantee the elimination of malnutrition.

·         The design of social protection measures should consider the influence of contextual factors such as access to clean water, sanitation, hygiene, maternal knowledge, which all affect nutrition. An example  was given of the Integrated Child Development Services in India which to date has not met its goals possibly due to these factors.

·         That developing countries should consider moving away from external aid and place emphasis on designing home grown, community/locally driven social protection measures to combat undernutrition. Examples given include strengthening informal institutions such as informal protection mechanisms e.g. private transfers between households, remittances, etc.

 

As we continue with the discussion, I would like to ask you to think further on one of our main questions:

What are the main issues for policy-makers to consider in the design, formulation and implementation of nutrition-enhancing social protection measures?

-          Studies have shown that the first 1000days of life are a crucial window for preventing irreversible undernutrition like stunting. Yet other research rebuts this position by showing that catch-up growth is still possible even after the first 1000 days of life. From your experiences, who should we target when implementing nutrition enhancing social protection measures? Under 3 years? Over 3 years?

-          Should we only always give cash or food transfers to women?

-          Should we only always target the poorest? Rural households? Or should we consider universal social protection schemes?

-          Recent research shows that stunting has far reaching consequences even affecting income earning capacities in adulthood and on a national scale  leading to two –three percent losses in GDP (Bhutta, Sachdev et al. 2008). In that case, should we prioritize eliminating stunting over wasting or underweight? Or we should not prioritize one over the other?

-          What are some of the lessons you have learned, best practices concerning social protection measures implemented to enhance food security and nutrition? E,g cash transfers, food transfers, school feeding, vouchers etc..

George Kent Department of Political Science, University of Hawai'i, United States of ...
09.06.2013
George

Shambhu Ghatak has given us some interesting views on the costs of hunger and the status of India’s Integrated Child Development Service. I would like to offer alternative perspectives on these two themes.

I appreciate the many efforts to assess the human and economics costs of hunger. However, to understand its persistence, we need to recognize that while hunger produces great disadvantages for some people it also produces great advantages for others. I discuss this in:

“The Benefits of World Hunger.” UN Chronicle, Vol. XLV, No. 2/3 (2008), p. 81. http://www2.hawaii.edu/~kent/BenefitsofWorldHunger.pdf

Regarding India’s ICDS, I agree that it provides important benefits for India’s children, but it falls far short of meeting the needs. I offer thoughts on how it might be managed to be more effective, in:

“ICDS: Steering an Ungainly Ship.” Economic & Political Weekly, Vol. XLVII, No. 37, September 15, 2012. http://www2.hawaii.edu/~kent/ICDS_Steering_an_Ungainly_Ship.pdf

Aloha, George

 

 

 

George Kent Department of Political Science, University of Hawai'i, United States of ...
09.06.2013
George

Greetings –

I am delighted to see this discussion of Social Protection to Protect and Promote Nutrition. It has been very good, but there is a point that deserves more attention: the first layer of social protection normally should be the informal protection provided by the local community. Social protection by governments of various levels is needed mainly when there is no effective local community.

Here is how I described this in Freedom from Want: The Human Right to Adequate Food, beginning at p. 98. The book is available as a no-cost download at http://press.georgetown.edu/book/georgetown/freedom-want

“In some ways, all of us are vulnerable. We face threats to our families, our freedoms, and our resources. We aspire to take care of ourselves, but at times we need support from others. Thus we do not live as hermits, but as social beings who provide support to and draw support from the people around us. We aspire to a measure of self-sufficiency, but we are vulnerable, especially at the beginning of the life cycle and at the end.

Consider the example of children, those who are in training for independence. As highly dependent beings, small children need to have others take care of them. Who should be responsible for children? The first line of responsibility is with the parents, of course, but others have a role as well. In asking who is responsible, the question is not whose fault is it that children suffer so much (who caused the problems?) but who should take action to remedy the problems? Many different social agencies may have some role in looking after children. What should be the interrelationships among them? What should be the roles of churches, nongovernmental organizations, businesses, and local and national governments?

Most children have two vigorous advocates from the moment they are born, and even before they are born. Their parents devote enormous resources to serving their interests. These are not sacrifices. The best parents do not support their children out of a sense of obligation or as investments. Rather, they support their children as extensions of themselves, as part of their wholeness.

In many cases, however, that bond is broken or is never created. Fathers disappear. Many mothers disappear as well. In some cities hundreds of children are abandoned each month in the hospitals in which they are born. Bands of children live in the streets by their wits, preyed upon by others. Frequently children end up alone as a result of poverty, disease, warfare or other sorts of crises. Many children are abandoned because they are physically or mentally handicapped. Some parents become so disabled by drugs or alcohol or disease that they cannot care for their children.

In many cases the failures are not the parents’ own fault, but a result of the fact that others have failed to meet their responsibility toward the parents. For example, there are cases in which parents are willing to work hard, and do whatever needs to be done to care for their children, but cannot find the kind of employment opportunities they need to raise their children adequately.

In some cases others look after children who cannot be cared for by their biological parents. In many cultures children belong not only to their biological parents but also to the community as a whole. The responsibility and the joy of raising children are widely shared.

In many places, especially in "developed" nations, that option is no longer available because of the collapse of the idea and the practice of community. Many of us live in nice neighborhoods in well-ordered societies, but the sense of community–of love and responsibility and commitment to one another–has vanished. In such cases the remaining hope of the abandoned child is the government, the modern substitute for community. People look to government to provide human services that the local community no longer provides.

As children mature the first priority is to help them become responsible for themselves. So long as they are not mature, however, children ought to get their nurturance from their parents. Failing that, they ought to get it from their relatives. Failing that, they ought to get it from their local communities. Failing that, they ought to get it from the local governments. Failing that, it should come from their national governments. Failing that, they ought to get it from the international community. The responsibility hierarchy looks something like this:

Child

Family

Community

Local Government

State Government

National Government

International Nongovernmental Organizations

International Governmental Organizations

. . .  this can be pictured as a set of nested circles, with the child in the center of the nest, surrounded, supported, and nurtured by family, community, government, and ultimately, international organizations. Of course there are sometimes exceptions. For example, there are many cases in which central governments provide services to the needy directly, bypassing local government. Often this is based on an agreed division of labor, and an understanding that services are likely to be distributed more equitably if they are funded out of the central treasury. Similarly, some programs, such as immunization, cannot be completely managed locally. Nevertheless, the general pattern is that we expect problems to be handled locally, and reach out to more distant agents only when local remedies are inadequate.

This is straightforward. The idea that needs to be added is that in cases of failure, agents more distant from the child should not simply substitute for those closer to the child. Instead, those who are more distant should try to work with and strengthen those who are closer, in order to help them become more capable of fulfilling their responsibilities toward children. Agencies in the outer rings should help to overcome, not punish, failures in the inner rings. They should try to respond to failures in empowering, positive ways. To the extent possible, local communities should not take children away from inadequate parents but rather should help them in their parenting role. State governments should not replace local governments, but instead should support local governments in their work with children. The international community should help national governments in their work with children.

Government’s responsibilities with regard to ordinary children in ordinary circumstances should be limited. The family should provide daily care and feeding. However, for children in extreme situations who are abused or who suffer from extremely poor health or serious malnutrition, governments have a role to play. If there has been a failure in the inner rings of responsibility and no one else takes care of the problem, government must step in.

Empowerment--or development--means increasing one's capacity to analyze and act on one's own problems. Thus, empowerment is about gaining increasing autonomy, and decreasing one's dependence on others. The concept applies to societies as well as to individuals.

There are similar rings of responsibility for others who cannot care for themselves, such as victims of disasters, the physically disabled, and mentally ill. These responsibilities need to be clarified so that the care of those who are unable to care for themselves is not left to chance. Thus this framework may be used in relation to all individuals who need protection and support, and not only children.”

The main point here is that we should not just automatically assume that it is government, at various levels, that should solve our problems. We should first do what we can locally, with our own resources. Both local people and governments should do what they can to increase local communities’ capacity to take care of themselves. That is better than having governments function as substitutes for failed communities.

Aloha, George

 

Edward Mutandwa Mississippi State University, United States of America
07.06.2013
Edward

Dear Moderator,

Thank you for bringing up a very interesting set of questions but I am particularly focusing on the 3rd one. It is everyone's desire that malnutrition should be booted out of humanity. However, when you look at existing data for Sub Saharan Africa and the developing world in general, malnutrition seems to be on the increase although this is not true in some countries. Typically, this challenge is viewed as a structural problem, by the West and so they usually intervene by using food aid (best practice?). However, most eminent economists like FA Hayek, a Nobel Prize winning Austrian economist, indicated that transferring food aid suffers from knowledge and incentive problems. Thats why you find that food aid can be used to further the "nests of rationally self interested politicians" (Stigler, 1971). A recent book by Dr. Dambisa Moyo (an eminent African scholar) about Food Aid clearly indicates that food aid is not a solution to malnutrition. I think that we can have differing viewed on this point. So, then whats the solution? Western solutions suggest gravitation towards free market mechanism (more than 100 years of evidence). In other words, there is need for governments in the LDCs to create an institutional environment (property rights, laws, contract enforcement) that will guarantee that resources will flow to areas where there are most valued. Here political will is important.

We usually look to government to proffer solutions but what about in anarchic situations (where there are no governments) (see Buchanan) In these cases, capacity building of micro institutions will help alleviate malnutrition. An example is community driven orphan programs that focus on food and nutrition security needs of orphaned and vulnerable children (OVCs). In these programs people are self motivated and don't need external handouts. In a nutshell, there are antecedents that must be solved first before articulating good nutrition policies because a policy is just a piece of paper. It only becomes effective if institutional conditions and political will coincide.

 

 

07.06.2013
Vincenzo Maria
Only 20% of the world population has adequate social security coverage, and more than half has none. These people are exposed to risks in the workplace and benefit from inadequate or non-existent health care and social security.
This coverage regards a wide range of possibilities: minimum income in case of need, medical care, sickness, old age and disability, unemployment, accidents at work, maternity leave, family responsibility, and death. There will also be many activities designed to improve the social protection of migrant workers.
It is very interesting and positive that various international organizations join forces and knowledge to deal with synergy a global problem such as nutrition. I believe that this congerence (ICN2) will draw new ideas and policies for the development of disadvantaged countries and territories.
Shambhu Ghatak Planning Commission, India
07.06.2013
Shambhu

I want to thank the Forum Moderator - Renata Mirulla for giving me the space to voice my views. In this discussion, I would like to focus on two aspects: a. Main issues for policy-makers to consider in the design, formulation and implementation and b. Key institutional and governance challenges.

At the outset, I would like to mention that Stein and Qaim (2007) in their study: The human and economic cost of hidden hunger, Food and Nutrition Bulletin, 28(2): 125–134, have estimated that the combined economic cost of iron-deficiency anaemia, zinc deficiency, vitamin A deficiency and iodine deficiency amounts to around 2.5 percent of GDP in the case of India (see attachment).

The two most important social protection programmes in India (at the national level) to protect and promote nutrition are: Integrated Child Development Services (ICDS) scheme and Mid Day Meal Scheme (MDMS). Apart from them, there is the Nutrition Programme for Adolescent Girls (NPAG). I will concentrate on the ICDS here.

Integrated Child Development Services (ICDS)

The programme was launched in 1975 seeking to provide an integrated package of services in a convergent manner for the holistic development of the child.  It began with 33 pilot projects in different parts of the country. It is the only major national programme that addresses the health and nutrition needs of children under the age of six. It seeks to provide young children with an integrated package of services, including supplementary nutrition, health care and pre-school education. Since the needs of a young child cannot be addressed in isolation from those of his or her mother, the programme also extends to adolescent girls, pregnant women and nursing mothers. ICDS services are provided through a vast network of ICDS centres, better known as "Anganwadis".

Goals

• Lay the foundation for proper psychological development of the child

• Improve nutritional & health status of children 0-6 years

• Reduce incidence of mortality, morbidity, malnutrition and school drop-outs

• Enhance the capability of the mother and family to look after the health, nutritional and development needs of the child

• Achieve effective coordination of policy and implementation among various departments to promote child development   

The Ministry for Women & Child Development launched the World Bank assisted ICDS Systems Strengthening and Nutrition Improvement Project (ISSNIP) on 9 May, 2013. The programme aims at improving child development and nutritional outcomes for children in selected districts having higher proportional of child under nutrition. For more, go to: Smt. Krishna Tirath Launches the World Bank Assisted ISSNIP, http://pib.nic.in/newsite/pmreleases.aspx?mincode=64

Many independent studies provided evidence that the ICDS was effective in combating child malnutrition and improving school enrolment. Despite all this, the Central Government was reluctant in universalising the scheme. In 2001, the Supreme Court in its landmark judgment (after a PIL was filed by People’s Union for Civil Liberties-PUCL, Rajasthan) ordered the Central government to universalise the scheme to cover all children in India. Universalisation of the ICDS took place around 2006 after the Supreme Court was compelled to chastise the Central government in several consecutive orders. Please read: Supreme Court Orders on the Right to Food, http://sccommissioners.org/CourtOrders/tool_for_action.pdf    

Challenges for Integrated Child Development Services (ICDS)

If we look at the key findings of the Report of the Comptroller and Auditor General of India on Performance Audit of ICDS, CAG Report no. 22 of 2012-13, http://saiindia.gov.in/english/home/Our_Products/Audit_Report/Government_Wise/union_audit/recent_reports/union_performance/2012_2013/Civil/Report_22/Report_22.html it will help us to understand the key institutional and governance challenges to the delivery of ICDS:

•    The CAG chose to audit the ICDS since India's status on key child development and health indicators did not compare well with its own targets as well as with the neighbouring and other regions. The Infant Mortality Rate (IMR) was 48 per 1000 live birth and the Child Mortality Rate (CMR) 63 per 1000 live birth in 2010 as against the targets of 30 and 31 respectively. These indicators were (IMR and CMR) for the neighbouring countries were: China (IMR: 16, CMR: 18) and Sri Lanka (IMR: 14, CMR: 17). In industrialized countries, the IMR and CMR were as low as 5 and 6 respectively.

•    The performance audit covered 2730 of the test checked Anganwadi Centres (AWCs) from 273 project offices of 67 districts from 13 states (Andhra Pradesh, Bihar, Chhattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Madhya Pradesh, Meghalaya, Odisha, Rajasthan, Uttar Pradesh and West Bengal) for the period 2006-07 to 2010-11 on 3 services viz. supplementary nutrition, pre-school education and nutrition and health education under scheme. The selection of the states was made on the basis of population, funding and nutrition indicators as per the NFHS-3, 2005.

•    To universalise the ICDS, Hon'ble Supreme Court had directed the Central and state Governments to operationalise 14 lakh AWCs by December, 2008. The Ministry sanctioned 13.71 lakh AWCs and could operationalise 13.17 lakh. This left a shortfall of 0.54 lakh. Similarly, out of 7075 sanctioned ICDS projects, 7005 projects were operationalised.

•    61 percent of the test-checked AWCs did not have their own buildings and 25 percent were functioning from semi-pucca/ kachcha buildings or open/ partially covered space. Separate space for cooking, storing food items and indoor and outdoor activities for children was not available in 40 to 65 percent of the test-checked AWCs.

•    Poor hygiene and sanitation were noticed in the AWCs due to the absence of toilets in 52 percent of the test checked AWCs and non-availability of drinking water facility for 32 percent of the test checked AWCs.

•    Functional weighing machines for babies and adults were not available in 26 and 58 percent, respectively, of the test-checked AWCs. The essential utensils required for providing supplementary nutrition to the beneficiaries were also not available in several test-checked AWCs.

•    Medicine kits were not available in 33 to 49 percent of the test checked AWCs due to failure of the state governments in spending the funds released to them by the Centre.   

•    53 percent of the test checked AWCs did not receive annual flexi-fund of Rs. 1000 from the state governments during the period 2009-2011.

•    There were shortages of staff and key functionaries at all levels.

•    The shortfall under various categories of training ranged from 19 to 58 percent of the targets fixed under the State Training Action Plan (STRAP).

•    The shortfall in expenditure on Supplementary Nutrition (SN) ranged between 15 percent and 36 percent of the requirements during the period 2006-2011. The average daily expenditure per beneficiary on SN was Rs. 1.52 to Rs. 2.01 against the norm of Rs. 2.06 during 2006-09 and Rs. 3.08 to Rs. 3.64 against the norm of Rs. 4.21 during 2009-2011.

•    33 to 47 percent children were not weighed for monitoring their growth during 2006-07 to 2010-11. The data on nutritional status of children had discrepancies and were not based on WHO's growth standards.

•    There was a gap of 33 to 45 percent between the number of eligible beneficiaries identified and those receiving the SN during 2006-07 to 2010-11.

•    The Wheat Based Nutrition Programme suffered from lack of proper coordination among the Ministry of Women and Child Development, the Department of Food and Public Distribution and the state governments. The Ministry could allocate 78 percent of foodgrains demanded by the states. The actual take-offs by the states was merely 66 percent of total demand placed by them.

•    Pre-school education (PSE) kits were not available at 41 to 51 percent of the test-checked AWCs during the period 2006-11.

•    In 6 of the test checked states (Bihar, Haryana, Jharkhand, Madhya Pradesh, Uttar Pradesh and West Bengal) data on beneficiaries of PSE who joined mainstream education were not available. In 5 states (Andhra Pradesh, Chhattisgarh, Odisha, Rajasthan and Karnataka) shortfall in the number of children who actually joined the formal education during 2006-2011 ranged between 7 and 30 percent.     

•    Shortfall of 40 to 100 percent was noted on the expenditure against the funds released for Information, Education and Communication (IEC) in many states.

•    Against the total release of Rs. 1753 crore to 13 states during 2008-09 and 15 states during 2009-2011 for meeting the expenditure on salary of ICDS functionaries, the actual expenditure was Rs. 2853 crore indicating unrealistic budgeting and consequent diversion of funds from other critical components of the scheme.

•    Rs. 57.82 crore were diverted to activities not permitted under the ICDS in 5 of the test-checked states and Rs. 70.11 crore were parked in civil deposits/ personal ledger accounts/ bank accounts / treasury resulting in blocking of funds.

•    The Central Monitoring Unit (CMU) under the ICDS failed to efficiently carry out assigned tasks, which included concurrent evaluation of the scheme, monitoring through the progress reports received from the states.

•    Impact assessment of the services under the SN and the PSE based on outcome indicators, such as nutritional status of the children, was not being done.

•    The follow-up action on internal monitoring and evaluation by the Ministry was inadequate and resulted in recurrence of shortcomings and lapses in the scheme implementation.    

According to the article titled: Who do ICDS and PDS Exclude and What Can be Done to Change This? by Biraj Swain and M Kumaran (IDS Bulletin, Volume 43, Issue Supplement s1, pages 32–39, July 2012), the ICDS is implemented through 12.41 lakh centres known as anganwadi centres (AWCs), each located in a habitation of 400-800 population. Despite being in the final year of 11th Five Year Plan, India is 1.5 lakh short of the targeted number of AWCs meant to cover at least 1.17 crore potential beneficiaries. Despite planning universal access under ICDS, only 8.37 crore children were officially covered against the targeted 15.88 crore children aged 0-6 years.

According to the article: Elimination of Identity-based Discrimination in Food and Nutrition Programmes in India by Rajendra P Mamgain and G Dilip Diwakar (IDS Bulletin, Volume 43, Issue Supplement s1, pages 25-31, July 2012), there are 3 different types of exclusion and discrimination faced by SCs and STs in ICDS and MDMS namely—the location of infrastructure, the nature of human resources managing the scheme at the grassroots level and discriminatory practices in providing the service. Location of the infrastructure facility helps certain groups and hinders access for other social groups. The ICDS and the MDMS have been criticized for irregularities, non-adherence to guidelines and malpractices leading to leakages of benefits to non-beneficiaries and complete denial of service to some target groups.

The "Right to Food Campaign", which is quite active in suggesting the strengthening of the ICDS and MDMS under the National Food Security Bill 2013 has provided critique to the Parliamentary Standing Committee's report, which can be accessed here: Why the Parliament should reject the standing committee’s recommendations on the Food Security Bill: RTFC, http://www.im4change.org/latest-news-updates/why-the-parliament-should-reject-the-standing-committees-recommendations-on-the-food-security-bill-rtfc-19099.html   

A critique on restructuring of the ICDS is available: Privatising the ICDS?-Jayati Ghosh, Frontline, 31 May, 2013, http://www.im4change.org/latest-news-updates/privatising-the-icds-jayati-ghosh-21237.html

I prepared a short note on budgetary allocations on ICDS by the Central Government.

Design, Formulation and Implementation: Monitoring Malnutrition and Hunger in India

One of the main issues for policy-makers to consider in the design, formulation and implementation of ICDS is to monitor the levels of malnutrition and hunger in India. The State of Food and Agriculture 2013: Food Systems for Better Nutrition, http://www.fao.org/docrep/018/i3300e/i3300e.pdf explains that undernutrition is the outcome of insufficient food intake and repeated infections (UNSCN, 2010). Undernutrition or underweight in adults is measured by the body mass index (BMI), with individuals with a BMI of 18.5 or less considered to be underweight. Measures of undernutrition are more widely available for children: underweight (being too thin for one’s age), wasting (being too thin for one’s height) and stunting (being too short for one’s age).

It is alleged that the Central Government is not monitoring the state of malnutrition and hunger since the time the last National Family Health Survey-3 (NFHS-3) got published in 2005-06. For more, please read my blogpost: India’s nutrition and hunger data is too old, http://talkative-shambhu.blogspot.in/2012/10/indias-nutrition-and-hunger-data-is-too.html

The 2013 UNICEF report Improving Child Nutrition: The achievable imperative for global progress, http://www.unicef.org/publications/files/Nutrition_Report_final_lo_res_8_April.pdf informs that during 2012, the Government of Maharashtra commissioned the first-ever statewide nutrition survey (independent of the Central Government) to assess progress and identify areas for future action. Results of this Comprehensive Nutrition Survey in Maharashtra indicated that prevalence of stunting in children under 2 years of age was 23 per cent in 2012 – a decrease of 16 percentage points over a seven-year period. The other observations are:

•    From 2005–2006 to 2012, the percentage of children 6 to 23 months old who were fed a required minimum number of times per day increased from 34 to 77 and the proportion of mothers who benefited from at least three antenatal visits during pregnancy increased from 75 to 90 per cent.

•    The provisional results of the Maharashtra survey showed that in spite of more frequent meals, only 7 per cent of children 6–23 months old received a minimal acceptable diet in 2012.

The aforementioned CAG report on ICDS found:

•    Total number of malnourished children (Grade I, II, III and IV) exceeded the 40 percent mark in 10 states/ UTs (Andhra Pradesh: 49 percent, Bihar: 82 percent, Haryana: 43 percent, Jharkhand: 40 percent, Odisha: 50 percent, Rajasthan: 43 percent, UP: 41 percent, Delhi: 50 percent, Daman and Diu: 50 percent and Lakshadweep: 40 percent), as on 31 March, 2011.   

•    The number of severely malnourished children (Grade III and IV) exceeded 1 percent of total weighed children in 8 states (Bihar: 26 percent, Chhattisgarh: 2 percent, Gujarat: 5 percent, Karnataka: 3 percent, Madhya Pradesh: 2 percent, Maharashtra: 3 percent, Uttarakhand: 1 percent and West Bengal: 4 percent) as on 31 March, 2011.

•    There was substantial decrease in the malnourished children in 6 states between 31 March 2007 and 31 March 2011 (Gujarat: from 71 percent to 39 percent, Karnataka: from 53 to 40 percent, Maharashtra: from 45 to 23 percent, UP: from 53 to 41 percent, Uttarakhand: 46 to 25 percent and West Bengal: 53 to 37 percent.

•    North-eastern states fared better in respect of the nutritional status of children, where percentage of normal children was satisfactory vis-a-vis the total weighed children as on 31 March 2011 (Arunachal Pradesh: 98 percent, Assam: 69 percent, Manipur: 86 percent, Meghalaya: 71 percent, Mizoran: 77 percent, Nagaland: 92 percent, Sikkim: 89 percent and Tripura: 63 percent).

•    In 5 other states/ UTs the percentage of normal children exceeded 70 percent as of 31 March 2011, viz. MP: 72 percent, Maharashtra: 77 percent, Uttarakhand: 75 percent, A & N Islands: 82 percent and Dadra & Nagar Haveli: 75 percent.

 

Present debate on malnutrition

Some experts have opined that ICDS doesn’t impact nutrition since it is determined not only by food and nutrition intake but also by people’s knowledge about nutrition and hygiene, accessibility and availability of clean drinking water and sanitation etc. It has been argued that early marriage (due to social prejudice) when female body is not prepared to give birth is the main reason behind low birth weight. (Nearly 47 percent Indian girls get married before age 18). Exclusive breast feeding is not done in many cases in the first 6 months, which affects child nutrition. Poor people emulate things, which are not healthy practices. Immunization rate in India is worse than that in Bangladesh and China. [Vaccine coverage in the case of DTP3 (third dose of diphtheria and tetanus toxoid and pertussis vaccine) is 72 percent and in the case of measles is 74 percent in 2011]. ICDS should concentrate on children below 3 years instead of children between 3 years and 6 years since most of the damage due to malnutrition is done to the children below 3 years.

Economists have questioned the way height and weight for Indian children (for a particular age) are measured with reference to 2006 norms set by the WHO to arrive at malnutrition figures without taking into consideration the genetic differences.

For more on the debate, please consult the following links:

The Myth of Child Malnutrition in India-Arvind Panagariya, Columbia University, September 2012 Conference, Paper 8 http://indianeconomy.columbia.edu/sites/default/files/paper_8-panagariya.pdf

When myth is reality-Stuart Gillespie, Transform Nutrition, January, 2013, http://www.transformnutrition.org/2013/01/24/when-myth-is-reality/

Is Child Malnutrition Overstated in India? A Reponse to Arvind Panagariya--By Deepankar Basu and Amit Basole, December 30, 2012 http://sanhati.com/excerpted/5950/

A nutritional crisis in India, Live Mint, 14 May, 2013, http://www.im4change.org/latest-news-updates/a-nutritional-crisis-in-india-21167.html

Is malnutrition in India a myth? -Pramit Bhattacharya, Live Mint, 16 May, 2013, http://www.im4change.org/latest-news-updates/is-malnutrition-in-india-a-myth-pramit-bhattacharya-21166.html

Arvind Panagariya, a professor of Indian economics at Columbia University interviewed by Ullekh NP, The Economic Times, 17 May, 2013, http://www.im4change.org/interviews/arvind-panagariya-a-professor-of-indian-economics-at-columbia-university-interviewed-by-ullekh-np-21165.html

Stuck record: Why Amartya Sen is wrong on food security again -R Jagannathan, Firstpost.com, 7 May, 2013, http://www.im4change.org/latest-news-updates/stuck-record-why-amartya-sen-is-wrong-on-food-security-again-r-jagannathan-21031.html

Food Security Bill: Freedom from hunger?, NDTV, 19 May, 2013 http://www.ndtv.com/video/player/we-the-people/food-security-bill-freedom-from-hunger/275900?hp

Growth vs Development: Nobel winner Amartya Sen discusses way ahead for India with NDTV, NDTV, 4 May, 2013 http://www.ndtv.com/video/player/ndtv-special-ndtv-24x7/growth-vs-development-nobel-winner-amartya-sen-discusses-way-ahead-for-india-with-ndtv/273449

Politics stalling Food Security Bill: Amartya Sen to NDTV, NDTV, 7 May, 2013

http://www.ndtv.com/video/player/news/politics-stalling-food-security-bill-amartya-sen-to-ndtv/273824

After doing a literature survey, The State of Food and Agriculture 2013-Food Systems for Better Nutrition observed:

•    Household surveys from Bangladesh, Egypt, Ghana, India, Kenya, Malawi, Mexico, Mozambique and the Philippines find that dietary diversity is strongly associated with household consumption expenditure (Hoddinott and Yohannes, 2002).

•    Fortifying rice served in school lunches in India led to statistically significant declines in iron-deficiency anaemia, from 30 percent to 15 percent for the treatment group, while anaemia remained essentially unchanged for the control group (Moretti et al., 2006).

•    Agricultural productivity growth was associated with reductions in the prevalence of child malnutrition in most countries, including India, during the period of rapid adoption of Green Revolution technologies and up until the early 1990s. Since 1992, however, agricultural growth has not been associated with improved nutrition among children in many Indian states (Headey, 2011).

•    Various explanations have been offered for the persistence of high levels of undernutrition in India. These include economic inequality, gender inequality, poor hygiene, lack of access to clean water and other factors beyond the performance of the agriculture sector. However, the phenomenon remains largely unexplained and additional research is needed (Deaton and Drèze, 2009; Headey, 2011).

•    Evidence from farm input subsidy programmes in India and Malawi indicates that they can significantly boost agricultural production and farmers’ incomes, albeit at a high budgetary cost (HLPE, 2012), but the impact of such policies on nutrition has not been well studied.

Regards,

Shambhu Ghatak
Researcher
Inclusive Media for Change project
www.im4change.org
Centre for the Study of Developing Societies
29, Rajpur Road
India

See the attachment:Stein and Qaim.pdf
Nyasha Tirivayi facilitator of the discussion, FAO, Italy
07.06.2013
Nyasha

Nestor

Thank you for your contribution. You raise interesting issues. Indeed increasing the quantity of food production does not guarantee a decrease in malnutrition. Research has shown that micronutrient deficiencies can still persist even after well meaning food security interventions. Indeed some cash transfer programs in Latin America have been found to have had little impact on child nutrition as the nutrition objectives of the programs were not communicated and others in literature have called for the integration of nutrition education with social protecton programs like you recommend. 

Yet, some argue that nutrition education might fail in areas with little availability of food, let alone diverse and nutritious foods. In that case in what other ways can you see social protection promoting nutrition? Please feel free to share more examples.