Conditional Cash Transfer Programs and Nutrition in Latin America: Assessment of Impacts and Strategies for Improvement

1. Conditional Cash Transfer Programs and Nutrition in Latin America: Assessment of Impacts and Strategies for Improvement John Hoddinott and Lucy Bassett International Food Policy Research Institute December 2008

2. Introduction • There are many reasons why improvements in the nutritional status of pre-school children, and their mothers, should be part of Conditional Cash Transfer (CCT) programs. • Improved nutrition has: • Intrinsic value– Being well nourished is a “good thing” • Instrumental value - Malnutrition has high costs in terms of poor health, cognitive development and loss of earnings • The preschool period—in addition to the prenatal period—represents a window of opportunity to improve nutrition that, if not taken, is lost. • There is evidence, discussed in our paper, that pre-school nutritional status can be improved in the context of CCTs; and • There are a number of promising approaches that can make CCTS even more powerful policy tools for reducing malnutrition in Latin America Page 2

3. Dimensions of Malnutrition • In preschool children, nutritional status is often assessed in terms of anthropometry. The basic principle of anthropometry is that prolonged or severe nutrient depletion eventually leads to retardation of linear growth. • Height-for-age reflects the cumulative impact of events affecting nutritional status and thus is an indicator of chronic nutritional deprivation. The prevalence of low height for age - stunting - has been falling in Latin America, but this trend masks uneven progress across and within countries • Micronutrient status is another important dimension of nutrition. Of greatest concern in Latin America are iron and zinc deficiencies and, to a lesser extent, deficiencies in vitamin A. • Adequate iron intake is necessary for brain development. • Zinc deficiencies are associated increased risk of mortality and morbidity as well as poor physical growth and neurobehavioral development. • Lack of Vitamin A leads to increased severity of infections and higher mortality in children. Page 3

4. Role of CCTs in Combating Malnutrition Well designed and implemented CCTS can combat malnutrition through a number of mechanisms: Page 4

5. Impact of Selected CCTs on Nutrition: Programs, Data and Methods • Our paper considers four CCTs that IFPRI has evaluated: • PROGRESA – Mexico – using two rounds of household and anthropometric data collected in 1998 and 1999 from households located in 342 localities • Programa de Asignación Familiar – Fase II (PRAF-II) – Honduras – using two rounds of household and anthropometric data collected from households located in 70 localities in 2000 and 2002 • Red de Protección Social (RPS)– Nicaragua – using using two rounds of household and anthropometric data collected from households located in 42 localities in 2000 and 2002 • Bolsa Alimentação (BA) – Brazil – anthropometric data were collected and merged with records from health cards and administrative data • In three studies, Honduras, Mexico and Nicaragua, the core evaluation method is a randomized design together with estimates of impact using double differencing (ie compare change in children exposed to treatment to changes in children in control localities) • In Brazil, matching methods were used Page 5

6. Impacts • Stunting: • The preponderance of evidence shows that PROGRESA reduced stunting in children under 36 months; a conservative estimate being 7.3 – 10.0 percentage points • In Nicaragua, compared to children in control localities, stunting fell by 5.3 percentage points among children aged 0 to 5 years in RPS (treatment) communities. • PRAF in Honduras and BA in Brazil had essentially no effects on preschool anthropometric status • Micronutrient deficiency – Iron status • Two evaluations of PROGRESA show a large impact — reductions of 10.6 – 25.5 percent - on the probability of being anemic • Neither PRAF-II nor RPS had an impact on blood hemoglobin levels or on rates of anemia. • The RPS results are of interest because an iron supplement was provided to pre-school children. However, consumption of the supplement was low Page 6

7. Design modifications: Stunting • Target group. • Children 0-2 • Pregnant and lactating women • Key low cost modification: Improve quality of pláticas by • Age-specific child feeding messages • Hygiene and sanitation messages • Take-home materials • Consider food supplements • Cautiously consider growth monitoring and promotion given its mixed record Page 7

8. Design modifications: Micronutrient deficiencies • Target group. • Children 0-5 • Pregnant women • For Children: • Zinc supplements • Dispersible micronutrient preparations • For Pregnant women: • Iron-folate with accompanying counseling to improve compliance • Consider multiple-micronutrient supplements Page 8

9. Design modifications: Stunting and micronutrient deficiencies • Target group • Children 0-2 • Zinc supplements • Improve morbidity and growth • Dispersible micronutrient preparations • Chispitas, Sprinkles • Improve iron status and encourage the timely introduction of complementary feeding

10. Conclusions • CCTs in Latin America have had important impacts on preschool nutritional status, but their potential has not been met • Several low-cost, evidence-based design modifications could likely improve CCT impacts on children’s growth and micronutrient status • These will require improvements in the quality of service delivery to be effective