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Designing CCT Programs to Improve Nutrition Impact. Principles, Evidence, and Examples. James Garrett 3d International Seminar on Conditional Cash Transfers December 1-2, 2008 Santiago, Chile * paper by James Garrett, Lucy Bassett, Marie Ruel, Alessandra Marini. Overview of the Presentation.

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Designing CCT Programs to Improve Nutrition Impact

Principles, Evidence, and Examples

James Garrett

3d International Seminar on Conditional Cash Transfers

December 1-2, 2008

Santiago, Chile

*paper by James Garrett, Lucy Bassett, Marie Ruel, Alessandra Marini


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Overview of the Presentation

  • Pathways of Impact

  • Structuring Design Analysis

  • Effect Pathways: Summary of the Evidence

  • Enhancing a Focus on Nutrition

    • role of a CCT in a strategy for nutrition

    • considerations on design

  • Country Study: Peru

Conditionalities

(Co-responsibilities)

Design & Operation

Income


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CCT Effect Pathways: Nutrition

Seven Pathways

  • poverty and food insecurity, and diet

  • women’s income and control over resources

  • maternal knowledge

  • health services

  • women’s time

  • micronutrient fortification and supplementation

  • girls’ and boy’s education

Source: Leroy et al. (2008)


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Categorizing Pathways:

Structuring CCT Design for Nutrition

Income

Conditionalities

(Co-responsibilities)

Design & Operation

  • Poverty food insecurity, and diet quality

  • Women’s knowledge and awareness

  • Health services utilization and child health

  • Girls’ and boys’ education

  • Women’s income and control over resources

  • Women’s time

  • Micronutrient fortified foods and supplements


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Effect Pathways: Evidence SummaryPoverty, Food Security, Diet Diversity

1




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Enhancing Pathways

Impacts on nutrition less than possible

pathways not thought through

actions not focused on supporting them

Determine actions to support elements of the CCT

pay greater attention to design and implementation (3 areas)

income, co-responsibilities, operation


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Foundations of a Strategy

  • Co-responsibilities of greatest relative import

    • income effect on nutrition, by itself, is limited

    • other factors important (care and feeding practices, water and sanitation, health services)

    • higher incomes do not eliminate nutritional deficiencies

    • transfers may be on items with no / little nutrition impact

  • Use a Systems Analysis

    • how does each component / actor work

      to produce “good nutrition”?

      • alone and with other

    • how does the CCT fit into a broader strategy

      for nutrition / social protection?

      • purpose, cost- effectiveness,

        coordination / integration


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Essential Nutrition Actions

  • exclusive breastfeeding for 0-6 months

  • adequate complementary feeding 6-24 months

  • appropriate care for sick and severely malnourished children

  • adequate intake of vitamin A, iron, iodine

  • care: health and hygiene


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CCTs in Latin America:Nutrition-Related Services and Conditionalities


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Enhancing Pathways

Income

Transfer

Conditionalities

(Co-responsibilities)

Design and Operation

  • target groups (women, 0-3 y.o.)

  • efficiency of transfer and service delivery (education, health care)

  • micronutrient suppl / fortification

  • supply-side quality, incl feedback mech

  • interagency and actor coordination

  • transfer amount

  • essential nutrition actions

  • beneficiaries, program operators / providers (all levels)


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Enhancing Pathways: Income

  • provide a substantial incentive

    • 20 to 40 % of hh income?

  • cover costs of compliance

    • o.c. of time, travel, etc

Income

Transfer

  • transfer amount


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Enhancing Pathways: Co-responsibilities

  • consider how system (including other agencies, legal framework) works to achieve essential nutrition actions

  • CCT can coordinate, integrate, or incentivize actions

  • others have responsibilities, too – and services must be available and of high quality

  • incentives must exist for everyone to do their part

    • different ministries / agencies, and their staff; public, private, hh; national, subnational, local

  • essential nutrition actions

  • beneficiaries, program operators / providers (all levels)

Conditionalities

(Co-responsibilities)


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Enhancing Pathways: Design & Operation

  • evidence on unconditional transfers?

    • easier administration

    • same effect?

  • whom to target

    • fathers, non-traditional hh, community

  • transfer efficiency

    • electronic transfers

    • easy access (networks of state banks, community NGOs, etc)

    • convenient times (non-work hours)

  • effective delivery (health, education)

    • excellent guides on training / counseling – use them!

  • target groups (pregnant / lactating women, 0-3 y.o.)

  • efficiency of transfer and service delivery (education, health care)

  • micronutrient suppl / fortification

  • supply-side quality, incl feedback mech

  • interagency and actor coordination

Design and Operation


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Enhancing Pathways: Design & Operation

  • supply-side

    • ensure accountability (as with hh!)

    • reimburse based on performance?

    • public reporting, citizen scorecards, and oversight committees

    • channels for comments, complaints, and appeals

  • interagency / actor coordination: lateral leadership

    • linking mechanisms

    • incentivize partnerships::

    • transparent decisions, funding, accountability

    • ownership: shared understanding, vision, participation

    • known roles and responsibilities

  • target groups (pregnant / lactating women, 0-3 y.o.)

  • efficiency of transfer and service delivery (education, health care)

  • micronutrient suppl / fortification

  • supply-side quality, incl feedback mech

  • interagency and actor coordination

Design and Operation


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Nutrition-Focused CCT: Example from Peru

Holistic Analysis Renewed emphasis on:

  • Co-responsibilities

  • Management and Capacity

    Co-responsibilities

    • key age group: pregnant/ lactating women; 0-3 year olds

    • eliminate papilla: add “dispersible micronutrients”

    • pay per number of conditionalities and household members

      • change requirement that all conditions always have to be met

    • identify state responsibilities

      • coordinate, integrate, incentivize?


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Multi-Actor Production Function: Providing Services to Beneficiaries

SIS

Health Center

JUNTOS

Household

Take beneficiary list and provide to local health center

Complete form to join SIS

Take beneficiary list

and provide to community promoters

Synchronize lists between SIS and JUNTOS

Open clinical history

Fill out conditionalities form

Set beneficiary appointment schedule

Promoter visits household, determines services

and conditionalities

Validate application

JUNTOS – Beneficiary signs contract,

including conditionalities

Provide services as scheduled

Promoter visits non-compliant households

Reimburse health center for services provided

Bill SIS for services

Report lack of compliance to JUNTOS

Apply algorithm to determine beneficiary payment, taking compliance into account

Beneficiary receives payments, including first incentive

File end-of-month reports with SIS, JUNTOS, and municipality

MUNICIPALITY

reports to community


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Nutrition-Focused CCT: Example from Peru

Management and Capacity

  • ensure verification is independent

    • informally transferred to promotoras (incentive to report compliance)

  • make payment / verification timeline more realistic / less burdensome

  • focus on results (political commitment, RBB)

  • integrate into social protection / child nutrition strategy

    • work with others who provide information and services (ID, MINSA

    • MINED? water / sanitation? MINAG?

  • interagency ownership and integration

    • inter- sector, actor, agency working group

    • merge information systems


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Conclusions: Improving CCT for Nutrition

  • Consider pathways

    • appropriate targets and nutrition actions

    • consider characteristics of income transfer, co-responsibilities, and design & operation

  • Think holistically

  • Think how CCT can enhance pathways

    • but also complement other ongoing or potential actions and actors

    • cost effectiveness of actions within a CCT are, or better simply to complement others

    • attention to operations and management

      • institutional arrangements, capacity, incentives



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