Anu Narayan Chief‐Nutrition

Presentation Outline

Current status of Nutrition in Bangladesh 

Social Protection, Conceptual Frameworks

Global Evidence for What works

Opportunities for Bangladesh

Evidence and Data systemsEvidence and Data systems

Key Takeaways

The Unfinished business of under nutrition in Bangladesh

• Solid progress in reducing chronic malnutrition (stunting)-45% i 2000 t 36% i 201445% in 2000 to 36% in 2014

• However, one in every three under 5 year child remainunder 5 year child remain stunted.

• The country is home to nearly y y5.5 million stunted children which accounts for 4% of the global burdenburden

• At the current rate of reduction, Bangladesh is unlikely to meet its WHO target for 2025 adopted by SDG

The overall decline hides inequities….

The rate of decline is lowest in the poorest families

Stunting more prevalent among children whose mothers are less educated, in food insecure the poorest families families, aged 18-23 months and in Sylhet

Prevalence of stunting in urban areas is only slightly better than rural. Children in urban slums are at a greater risk of stuntingPrevalence of stunting in urban areas is only slightly better than rural. Children in urban slums are at a greater risk of stunting

Stunting by Rural / Urban Stunting Prevalence:Slum & Non-Slum

(Per cent) (Per cent)

2014

2011

2007

49.6

33.42013

0 20 40 60

2007

2004 55.9

[VALUE].0

0 20 40 60

2006

0 20 40 60

Urban RuralCity Corporation Non-SlumCity Corporation Slum

Source: BDHS Source: Bangladesh Urban Health Survey

.

Micronutrient Deficiencies, Maternal malnutrition and the nutrition of Adolescent girls remains a challenge

Adolescent girls: • One-third of adolescent girls are short

Undernutrition (%) in adult women (19‐49 yrs.)

gfor their age. 5% are severely short,

• 31% of adolescent girls consumed inadequately diversified diet 15

11 11 10 10

15 1512

16 16 1513

16

2326

17

Percen

tage

Women of reproductive age group:• One fourth of women are anemic and

42% are iodine deficient

11 11 10 10

BARISAL CHITTAGONG DHAKA KHULNA RAJSHAHI RANGPUR SYLHET NATIONAL

Inadequate height (<145 cm) Low BMI

• One-fourth (23%) of pregnant women are undernourished (MUAC <230 mm)

• One-tenth are shorter than 145 cm. 55%

Infants with LBW according to category of risk factors

• Height between 140 and 150 cm associated with increased risk of low birth weight babies….

43%

19%

55%

State of Food Security and Nutrition in Bangladesh, 2013Effect of maternal status and breastfeeding practices on infant nutritional status- a cross sectional study in the south-west region of Bangladesh . The Pan African Medical Journal. 2013; 16:139

19%10%

<150 CM ≥165 CM ≤22 CM >29 CM

MATERNAL HEIGHT MATERNAL MUAC

So, What is Social Protection?

Policies and programmes aimed at preventing,   d d l d lreducing and eliminating economic and social 

vulnerabilities and poverty in order to ensure a minimum standard of dignity and well–beingminimum standard of dignity and well being throughout the life–cycle to all individuals , with a particular emphasis towards most disadvantaged groups Social Protection Inter Agency Boardgroups ‐ Social Protection Inter Agency Board

Social Protection could include social transfersSocial Protection could include social transfers, access to social services, legislative and policy reform

How can social protection programmes improvenutrition?

1. They can address some of the underlying or core determinants of Nutrition‐ Food, Health and Care!

2 The are implemented at Scale some 1 9 billion people recei e2. They are implemented at Scale – some 1.9 billion people receive some form of social safty net assistance (Alderman, 2015)

3. Can serve as an important delivery platform for Nutrition specific interventionsinterventions

4. Can bridge the concept of transfers for equity and transfers for investment (no impact on labor participation etc)

5. Practically, social safety nets can• Increase resources controlled by hhs and their purchasing power. Hhsincrease expenditure on food and diet diversity increases 

• Reg utilization of health service also has positive results but some specific• Reg utilization of health service,  also has positive results‐ but some specific results are mixed…

• With  non cash grants, social safety nets can help fortify diets (eg VGD programs) 

Conceptual Pathway: How Social protection can bepositioned to improve nutrition outcomes

Pillars of a universal SocialPillars of a universal Social Protection System

Social Transfers:FoodC h/ hCash/vouchersCash for work

Programmes to ensure: access to services

School feedingHealth insurance

Social support and care:Empowerment

Legislation and regulation:Price subsidies(to increase 

Source: Nutrition and social protection » FAO 2015

consumption)

Indonesia: Program Keluarga Harapan(Conditional Cash Transfer)

• Targeting very poor households (bottom 7%) with:• Children aged 0‐15 years and/or• Pregnant and postpartum mother

3 00 3.504 e e 

Increased uptake of health servicesunclear impact on nutritional status

• Quarterly cash transfer ($60 to $220 per year, depending on HH size and child age)

2 673.34

0 72 0.821.10

1.50

2.40

3.00

1.50

2.00

2.50

3.00

1.5

2

2.5

3

3.5

neficiatry Co

verage

(Millions)

eographic Co

verage

(Tho

usands)

HH size and child age)• Conditionality: Health and 

Education• Community facilitator

0.12 0.17 0.50 0.500.34 0.64 0.78 0.951.39

1.912.67

0.50 0.64 0.72 0.82

0.00

0.50

1.00

0

0.5

1

2007 2008 2009 2010 2011 2012 2013 2014

BeGe

Districts Subdistricts RTSM

Community facilitator• Availability regular of 

verification and monitoring mechanism 

• Monthly regular meeting among beneficiaries (Mothers’ group)

• Increased uptake of health services, unclear impact on nutritional status

Meta-analysis published in 2013:Impact of cash transfers on height-for-age

Source: Manley & Gitter, 2012: 21 papers on 17 programmes in 13 countries

Meta-analysis published in 2013:Impact of cash transfers on height-for-age

• CCT with work or savings conditionalities negatively impact on g g y pheight for age

• UCT can be equally effective as CCT with health conditionalities.

• Focusing on younger children has greater impact- using the 1000 day- opportunity window

• Larger positive impacts on girls, younger children and in disadvantaged areas

• Providing cash is often insufficient to reduce stunting, even if associated with increased food consumption and/or food diversity

need to link behavioral change communication to enhance child gcare

Strong evidence base linking social transfers with improved access to nutrition, health and care

• Improved diet quantity, quality, and diversity

• Decreased lnerabilit to• Decreased vulnerability to shifting patterns of agriculture and climate

• Decreased childhood mortality• Decreased childhood mortality

• Helping children reach their full potential

• Strengthened women’s empowerment and household investments

Social Protection Programs in Bangladesh

Ref. Implementation of the National Social Security Strategy (NSSS) of Bangladesh SSPS Programme, Cabinet Division and General Economics Division 

Design features to enhance the impact of social transfers on nutrition

• Use evidence that exits in country- TMRI, USAID /FFP programs,

• Size of cash transfer should reflect the cost of a nutritious diet

• Administer transfers in a gender-sensitive manner (e.g. give transfers to women).

• Target populations at greatest risk of economic stress, food insecurity and undernutrition, and women/children during first 1000 days of life.days of life.

• Conditionalities only appropriate when services are available and of adequate quality - even so, UCT can be equally effective and more

i l t d i i teconomical to administer.

• Link beneficiaries with services to address prevailing causes of undernutrition (nutrition-specific interventions WASH health etc)undernutrition (nutrition specific interventions, WASH, health etc)

• Use nutrition indicators to monitor and assess effectiveness, such as child growth indicators or food diversity.

Enabling factors and challenges for SP-nutrition coordination and joint work

Enabling• High political commitment to increase attention to both social

protection and nutritionp• Multi-sector national and sub-national coordination teams within

government (under the new NPAN)

From CCTs to UCTs?UNICEF to invest in costing of alternative social assistance schemes (e.g. universal child grant) by end 2014 as a futureschemes (e.g. universal child grant) by end 2014 as a future economic investment option

Challenges:Challenges:• Dynamic SP national context – government decisions on scale-

up has major consequences• Data management systems at district level for SP not necessarily• Data management systems at district level for SP not necessarily

combined and linked with nutrition systems.

Effective Coverage of Basic Social Services Survey (ECSSS) in Bangladesh, 20162016• Partners – UNICEF along with the Bangladesh Bureau of Statistics (BBS), Implementation Monitoring and Evaluation Division (IMED), Ministry of Planning, Government of BangladeshMinistry of Planning, Government of Bangladesh 

• Objective ‐ to track changes in effective coverage, as well as basic knowledge and behaviours in relation to child health nutritionknowledge and behaviours in relation to child health, nutrition, WASH, education and protection. 

• Coverage – Covered 211,000 households survey from 7 divisions across the country focused on 11 modules. 

• Nutrition sensitive modules included were (1) Early breastfeeding, (2) Exclusive breastfeeding, (3) Complementary feeding, (4) Maternal Diet, (5) IFA, (6) Sanitation, (7) drinking water and (8) handwashing

Considerations

• Target the Nutritionally Vulnerable• Establishing key beneficiaries groups: Children under 2, pregnant women, Adolescent girls; in Rural and Urban areasAdolescent girls; in Rural and Urban areas

• Establish multisectorial approaches:⁻ Ensuring integration of behavior change communication for longer term outcomes⁻ Embed social protection in other sectors and broader development agenda⁻ Create institutional mechanisms and coordination within multi‐sectorial approach (health, agriculture, and education), and at different levels

• Enhance the Quality of Nutrition Servicesh h i ( h l f di G ) hi l f• Use other mechanisms (school feeding, VGD) as vehicles for MN 

supplementation • Create bridge between humanitarian and development programming:

⁻ Build on the responsiveness of SP programmes to certain types of shocks and crisisBuild on the responsiveness of SP programmes to certain types of shocks and crisis ⁻ Scale up in times of crises and create linkages between social protection/humanitarian activities and longer term approaches to livelihoods, resilience, food security and nutrition

• Invest in data systems single beneficiary registration systems RTM etc• Invest in data systems‐ single beneficiary registration systems, RTM etc

Considerations

• Financing⁻ Ensuring adequate financial and human resources, as well as information systems and logistical arrangementssystems and logistical arrangements

⁻ Implementing progressive taxation and ensuring predictability of financial streams

⁻ Ensuring durability/longevity of projects for sustained positive effects on f d d t iti itfood and nutrition security

⁻ Ensuring funding for SP programmes to be responsive in times of crisis (contingency funds)

• Evaluating impact and building evidence base based on improvedEvaluating impact and building evidence base based on improved programme design and nutrition outcomes

What can Nutrition Sector contribute?

In collaboration with SP colleagues and other stakeholders:

• Advocate for the integration of nutrition, food security, gender in social protection legislation and policy frameworks (including objectives and indicators)j )

• Support the development of social transfer programmes that have a child focus

• Strengthen SP linkages with behaviour change and activities and programs that deliver nutrition, food security and WASH services.

• Support the generation of evidence on how social protection policies and progammes affect nutrition outcomes.

THANK YOU!

• Thank you!

Impact of cash transfers on height-for-age

Age in years

Increase in HAZ

age

years HAZ

Colombia Familias en Accion CCT 0-2 0.16

Mexico Progresa CCT 0-5 0.14

Nicaragua RPS CCT 0-5 0.13g

South Africa Child support grant UCT 0.19*

*For children of mothers who had completed Grade 8 

Unconditional cash transfers (UCT) are equally, if not more, ( ) q yeffective as conditional cash transfers (CCT)