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Given the attractiveness of cash hand-outs, implementation of the programme was marred by elite capture, leakages, and corruption (see, among others, Drèze, 1990; Guhan, 1980; Rath, 1985; Shankar, 1991). In India, recent programmes involving cash payments have also faced the problem of significant leakages (see, for example, Mann and Pande, 2012; Shankar and Gaiha, 2013; Usami and Rawal, 2012).
Dealing with under-5 child and maternal nutrition deficiencies It is now well recognized that preventing stunting and other forms of severe undernutrition requires special attention to nutrition deficiencies afflicting mothers and children under 5 years of age. Recent studies suggest that the first thousand days from conception until reaching the age of 2 are the most important for long-term human development. Inadequate nutrition during this period is the most important cause of long-term undernutrition.
Securing improvements in the nutrition of pregnant and lactating women, infants and young children requires that specific nutrition programmes be linked with general social protection programmes, as well as programmes for improving access to safe water, sanitation, and health care.
Access to nutritious food for mothers and children under 5 can be improved by community child-care facilities as well as other social protection policies. Statistical evidence from various conditional cash transfer programmes in Latin America shows significant improvements in the nutritional status of infants and young children when social protection programmes are linked with nutritional programmes. For example, evaluations of Mexico’s Oportunidades show an increase of about 1 cm in height among children from beneficiary households compared to controls, and an increase of 0.13 kg in birth weight among children born in beneficiary households compared to controls. Various studies have found improvements in the Z-scores of height-for-age of children from beneficiary households of various social protection programmes, in comparison with controls (WHO, 2013). Improvements in the access of pregnant women from beneficiary households to antenatal care have also been noted (UNICEF, 2008).
Social Protection 57 The WHO’s comparison of improvements in child nutrition in different programmes across the world with the programme intensity – measured in terms of the number of community health and nutrition workers (CHNWs) deployed – found that the extent of contact between trained community workers and mothers with children is crucial. Programmes with more than 30 CHNWs per 1,000 children achieved 1–2 percentage points per year reduction in prevalence of underweight. However, owing to considerable variation in the way resources are used, no clear relationship could be seen between the amount of resources provided under nutrition programmes and outcomes (WHO, 2013).
It is important to note that not all nutrition programmes have significantly impacted maternal and child nutrition. For example, studies of India’s Integrated Child Development Services (ICDS) have found little or no impact on child undernutrition (Lokshin et al., 2005).
An important lesson to draw from the experience of implementing nutrition programmes is that when nutrition programmes work in isolation, without utilizing synergies with social protection programmes and programmes for improving access to safe water, sanitation, and health care, the impacts are limited. On the other hand, synergies among various programmes ensure significant gains in nutritional outcomes of infants and young children.
Coverage of social protection programmes Social protection is most effective when designed to provide basic universal coverage. Providing basic social protection coverage to everyone is also important from a human rights-based perspective. Universal social protection programmes need to be combined with specific interventions targeted at nutritionally vulnerable populations, such as children, as well as pregnant and lactating women.
The coverage of social security systems has been narrowed and public spending on social security cut by the structural adjustment programmes implemented in developing countries across the world from the 1980s.
As part of the conditions of these programmes, leading international finance institutions argued to minimize social provisioning. Instead, social safety nets, narrowly targeted at the poorest and most vulnerable, were introduced from the 1990s for the purpose of providing security against shocks (Holzmann, Sherburne-Benz, and Tesliuc, 2003; Mkandawire, 2005).
It has long been recognized that means-tested targeting entails considerable costs. Sen (1995) argues that targeting involves significant direct and indirect costs. Targeting subsidies can affect economic behaviour, stigmatize beneficiaries, involve considerable administrative costs, and be invasive by requiring extensive disclosures to become eligible for benefits.
58 Ending Malnutrition He argues that programmes targeted narrowly at the very poor are difficult to sustain politically because the beneficiaries are likely to have limited political clout. On the other hand, programmes that provide a universal minimum entitlement are likely to find much greater political support.
In a detailed review of targeting in social protection programmes, Mkandawire (2005) identifies three major problems. First, given the limited capacity of governments in poor countries and the predominance of informal economic relations, targeting based on assessment of incomes and means is necessarily imprecise, involving very high administrative costs, and inviting problems of corruption, theft, and fraud.³ Other, more blunt forms of targeting involve more likely errors of both wrongful exclusion and wrongful inclusion. Given serious asymmetries of information, targeting produced “perverse incentives” and was “an open invitation to rent seeking and corruption”. Secondly, targeting creates serious political problems.
These arise from overall reductions in budgets, the stigmatizing effects of targeting, the invasiveness of measurement for targeting purposes, and the compounding “paternalistic and clientelistic practices of bureaucracies”.
Thirdly, targeting creates a disincentive for beneficiaries to achieve outcomes that would disqualify them from receiving benefits. Ellis (2012) argues that, with the high prevalence of poverty and vulnerability, narrowly targeted cash transfers that privilege a few of the many poor and vulnerable are socially divisive.
It is common to assess targeting in terms of errors of wrongful exclusion of the eligible (Type I errors) and wrongful inclusion of those not eligible (Type II errors). One of the most detailed and careful studies of errors in targeting by Cornia and Stewart (1993) concluded that replacement of universal schemes by targeted schemes in a number of countries has been associated with a major increase in errors of wrongful exclusion, with some reduction in errors of wrongful inclusion. Large-scale exclusion of those eligible has been a feature of most narrowly targeted social protection programmes. For example, Ellis, Devereux, and White (2009) estimated that 83 percent of poor aged persons were excluded from the Food Subsidy Programme in Mozambique that provides targeted cash transfers to the old, people with disabilities, and the chronically ill among the poor. Several studies of targeting in Asia have also reported large errors of exclusion and leakages (see, for example, Swaminathan, 2000; Swaminathan and Misra, 2001; and Weiss, 2005) ³ In a review of targeted programmes, Coady, Grosh, and Hoddinott (2004) observe that “in most cases it appears that corruption and theft contribute more to total program expenses than legitimate administrative expenses”. Various contributions in Weiss (2005) record serious problems of corruption and malpractices in targeted programmes in Asia.
Social Protection 59
Box 3.3 ICN2 Framework for Action: Recommended actions on social protection
The ICN2 Framework for Action calls for incorporation of nutrition objectives into social protection programmes, and use of cash and food transfers to ensure that people have access to nutritionally adequate food, and to take action to improve incomes of the vulnerable population through decent jobs and improved prospects of self-employment.
• Recommendation 22: Incorporate nutrition objectives into social protection programmes and into humanitarian assistance safety net programmes.
• Recommendation 23: Use cash and food transfers, including school feeding programmes and other forms of social protection for vulnerable populations to improve diets through better access to food which conforms with the beliefs, culture, traditions, dietary habits and preferences of individuals in accordance with national and international laws and obligations, and which is nutritionally adequate for healthy diets.
• Recommendation 24: Increase income for the most vulnerable populations by creating decent jobs for all, including through the promotion of self-employment.
Evidence from three decades of implementation of targeted anti-poverty and social protection schemes in the developing countries shows that the combination of narrow targeting and reduced benefits can render social protection ineffective in countries where deprivation is widespread and poverty high. In view of this, a consensus is emerging that it is best to have broad-based or universal coverage of social protection that provides rights-based guarantees to a nationally determined minimum set of goods and services. Endorsing the idea of a universal social protection floor, the High Level Panel of Eminent Persons on the Post-2015 Development Agenda convened by the United Nations Secretary-General called for “leaving noone behind”.
Synergies among different types of interventions When social protection programmes are integrated with rural or agricultural development policies and nutrition initiatives, the synergies have strong multiplier effects. Social protection measures are key to protect the poor from hunger and food insecurity, especially when decent employment growth has been sluggish. When integrated with rural and agricultural development policies as well as special nutrition initiatives, impressive results follow.
60 Ending Malnutrition Countries should implement programmes for a nationally determined basic social protection floor, and strive to ensure that such programmes cover everyone and can provide those in need with adequate nutritious food. Where such programmes have been implemented, even modest public expenditures have been found to have significant positive impacts on investment, productivity, and incomes. Integrating social protection programmes with programmes for agricultural development can maximize the impact on incomes and productivity, particularly of small-scale producers. Integration of nutrition programmes with social protection programmes is crucial for ensuring that special nutritional support for women, infants, and young children translates into positive nutritional outcomes.
Role of Fortification and Supplementation Nutrition is complex and multidimensional. While there has not been a consensus on a broad-based plan to tackle malnutrition across the world, the problems are better understood now, with options for addressing malnutrition increasingly well known. The underlying cause of micronutrient deficiencies is the poor quality of diet, lacking sufficient nutrient-dense animal-source foods, fruit, and vegetables. Food-based approaches – which focus on ensuring that the diets of people include diverse, nutritionally rich foods – provide sustainable long-term solutions for controlling and overcoming micronutrient deficiencies.
In addition to improving the composition of diets, enhancement of the nutrient content of staple food through chemical and agronomic fortification is known to be a cost-effective and complementary means to deliver specific nutrients such as iron, zinc, and vitamins. Fortification has been used across many countries through most of the twentieth century.
More recently, two other approaches have been advocated to tackle micronutrient deficiencies: genetic biofortification and supplementation.
Genetic biofortification refers to breeding varieties and hybrids rich in specific nutrients, and introducing these nutrient-rich foods into people’s diets. Supplementation refers to the direct intake of micronutrients, usually in the form of tablets/capsules. Of late it has been argued – most importantly, in the June 2013 issue of the Maternal and Child Nutrition Series of the British Medical Association’s influential journal, The Lancet – that nutritional supplements provide a rapid and cost-effective means of dealing with the widespread problem of malnutrition.
What part can fortification – chemical, agronomic, and genetic – play in ending malnutrition? Can ending malnutrition be led by supplementation?
This chapter examines the evidence to seek answers to these questions.
62 Ending Malnutrition
Chemical fortification of food Large-scale fortification has been used since the early twentieth century to deal with micronutrient deficiencies. Before discussing the experiences with fortification and their potential, it is important to distinguish between regulated fortification as part of public initiatives to deal with specific nutritional deficiencies, and unregulated commercial uses of fortification, often to claim health benefits from otherwise not-so-healthy and energydense foods. The discussion here specifically deals with the potential of regulated fortification in dealing with the problem of micronutrient deficiencies.
In general, fortification has been effectively deployed in conditions where
• a specific micronutrient deficiency is widespread in the population;
• the desired micronutrient requirement is more or less uniform across different sections of the population;
• specific agro-ecological limitations make it difficult to meet micronutrient requirements through food systems, at least in the short run;
• desired micronutrients can be provided along with a widely consumed component of the diet without adverse implications of adding the micronutrient to the item.
Fortification has often been made mandatory to ensure widespread adoption of micronutrient-fortified food. In many countries across the world, governments have made iodization of salt mandatory (see Box 4.1).