Designing CCT Programs to Improve Nutrition Impact

1. 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

2. 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

3. 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)

4. 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

5. Effect Pathways: Evidence SummaryPoverty, Food Security, Diet Diversity 1

6. Effect Pathways: Evidence SummaryEffect on Women 1

7. Effect Pathways: Evidence SummaryEffect on Children 1

8. 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

9. 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

10. 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

11. CCTs in Latin America:Nutrition-Related Services and Conditionalities

12. 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)

13. 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

14. 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)

15. 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

16. 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

17. 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?

18. 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

19. 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

20. 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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