Presentation by Harold Alderman (International Food Policy Research Institute) at the FAO/WHO International Symposium on Sustainable Food Systems for Healthy Diets and Improved Nutrition that took place at the FAO Headquarters in Rome on December 1-2. Read more here: http://pim.cgiar.org/2016/12/16/making-social-protection-more-nutrition-sensitive/

2. NUTRITION-SENSITIVE SOCIAL
PROTECTION POLICIES AND
PROGRAMMES: WHAT CHALLENGES
AND GAPS STILL REMAIN?
Harold Alderman
International Food Policy Research Institute

3. Why Focus on Nutrition Sensitive Programs?
The 2013 Lancet Nutrition Series estimated that scaling up
10 proven effective nutrition specific interventions to
cover 90% of at risk children would reduce stunting
globally by 20 percent.
While this would be a major improvement in the health
and development of children, it does not go far enough.
Thus, there is also a need for programs that address the
core determinants of undernutrition including nutrition
sensitive social protection

5. A few stylized facts about nutrition sensitive
social protection - I
While transfers improve food security as indicated by increased
consumption and diet diversity. Most beneficiaries also
increased participation in health care. But both conditional
and unconditional cash transfers have not delivered
improvements in anthropometric measures of nutrition
commensurate with their success in addressing poverty.
In particular, they have had only modest impact on stunting or
anemia
A combination of cash assistance for households and specific
supplements tailored to a child’s needs has proven
advantageous as components of CCTs or UCTs as well as part
of emergency response programs.

6. A few stylized facts about nutrition sensitive
social protection - II
While many of the differences between cash and in-kind
transfers are context specific, cash transfers are almost always
less expensive to deliver, by as much as 15-25%
In-kind transfers (including school feeding) have proven an
effective vehicle for micronutrient fortification
School feeding has also a proven track record in advancing
education and in serving as a means of providing food
security including as a response to financial emergencies
The track record on school feeding on nutrition, however, is far
more ambiguous

7. One gap is understanding how to use safety
nets for micronutrient fortification
In-kind transfers (including food subsidies) are still core elements of
many safety net systems. Both Egypt and India, for example, spend
$billions on such programs.
Yet the former ceased fortification of its highly subsidized flour in the
absence of WFP support.
Similarly, according the Global Alliance for Improved Nutrition
(GAIN) only one of 10 state programs for fortification at public
distribution shops in India initiated this century were still in place in
2015.
This despite the fact that they work; Gujarat’s multiple micro-nutrient
fortification of flour reduced the share of safety net beneficiaries with
inadequate iron intakes by 94%.

8. The reasons for failing to take advantage of
opportunities for fortification vary
In Gujarat resistance came initially from small millers. In other
settings there is a reluctance – or even legal obstacle – to pass
on the additional costs or to subsume them into the overall SP
budget.
This is often the case for school feeding programs as well. Again,
despite the fact that one clear nutritional gain from school
meals is the potential to reduce anemia.
But given the experience in various means of fortification not
only of wheat and maize flour but of double fortified salt and
even extruder rice, the obstacles for making such programs
more nutrition sensitive are not, however, primarily technical.

9. Behavioral Change Communication
There are programs that have increased the nutritional impact of
either cash transfers or in-kind supplements by linking them to
behavioral change communication as recently reconfirmed in a
RCT in Bangladesh. In that study cash alone did not lead to
improvements in anthropometry, but the combination of cash
and BCC had a significant impact on height for age as well as
on nutritional knowledge and behaviors
This is by no means a new idea, but it is still a challenge to set
up the necessary cross-sectoral coordination especially when
the transfer program is unconditional or uses soft conditions.
Additionally, the staffing and training challenges for scaling up
some of the successful small scale pilot programs in BCC imply
a need for innovation in communication

10. Making emergency relief nutrition sensitive
For obvious reasons this is an area where research is challenging
with most evidence coming from slow onset emergencies or
even lean seasons.
Relief is designed to meet the needs of households rather than to
meet the dietary needs of vulnerable children, but it should be
possible to enhance the nutritional impacts with i)
micronutrient fortification of grains and vegetable oil; ii)
iodized salt in general food deliveries; and iii) specialized
lipid based supplements for vulnerable individuals for which
various trials are underway
Still, the biggest challenge is to find means of financing to make
emergency response more timely.

11. School Feeding as a platform
Nutrition sensitive social protection can be a platform for nutrition
specific programs.
Deworming is often mentioned in this context yet remains
controversial (and thus to my mind worthy of further
investigation).
There are similar programs to promote iron supplementation,
some use novel incentive structures for teachers
While there are also innovative programs for school curricula
aiming at increasing exercise and limiting obesity as well as
targeted programs to reduce risky behavior among adolescents, I
have not seen experimentation or guidelines on curricula for
teaching nutrition for child care in schools.

12. HGSF: new opportunities with new dilemmas
School feeding traditionally has three goals: to enhance schooling,
to improve nutrition and to serve as an instrument of social
protection.
HGSF adds an additional objective: to enhance farmer’s income
(and community market integration).
This comes with some potential tradeoffs.
First, in in regard to fortification. Since fortification is easiest in
centralized settings HGSF makes it harder (but not impossible)
to fortify staples.
In principle this could be offset by diet diversity but at a cost.
Few programs can provide meat or milk on a regular basis.
HGSF can also fortify meals in the process of cooking.

13. Further on HGSF
A second potential drawback is the risk that HGSF may have
irregular supply. This is a logistic problem even in settings
when the food is supplied from a central market (or imported).
However in food insecure areas this may be a greater issue
especially in seasons of low availability or periodic harvest
failure.
In such circumstances HSGF may not have the market
connections to procure grain even if it is available in other
parts of the country.
Current studies will give insight into the potential of HGSF but
it might take time to understand the stability of the approach.

14. One further caveat on HGSF
If a market is functioning well, then farmers with a surplus have
outlets (especially for grain; perishables may be less easily
marketed).
There may be an indirect effect of HSGF in increasing
production and thus surplus to sell. But this is most likely if
prices are higher than previously offered (as well as via
extension and assistance in inputs).
This may require a rationing system (if there will be two prices
in local markets) with attendant problems of equity.

15. Conclusion
This last point in regards to HGSF is largely about supportive
administrative frameworks
As are my observations about the missed opportunities for
micronutrient fortification
And maybe even the gap in nutrition specific programs in schools
fits this characterization
Not every challenge is about commitment and the enabling
environment – the need to understand addressing children’s
needs in emergencies, for example, is largely about a need for
field research – but many of the gaps in making social
protection more nutrition sensitive are about putting what is
already known into practice