Angela Céspedes Regional Nutrition Advisor Regional Office for Latin America and the Caribbean

1. Nutritional Dimension within Social Safety Nets in Central America and the Dominican Republic Angela Céspedes Regional Nutrition Advisor Regional Office for Latin America and the Caribbean World Food Programme Organization of American States (OAS) Third Meeting of the Inter-American Committee on Social Development April 6Th and 7Th 2010, Washington DC

2. Contents • Social Safety Nets Concept • Objectives of the Study • Methodology • Results • Main Survey • SWOT Analysis • Conclusions • Recommendations • Lessons Learned • Study Dissemination and Next Steps

3. What are Social Safety Nets? “Social Safety Nets (SSN) are instruments of social public policy that States can and should use to comply with their role in the guaranteeing of human rights, specially the Right to Food, giving priority to groups that are in a situation of major vulnerability to undernutrition, poverty, exclusion, discrimination and stigmatization. SSN are articulate mechanisms with a common end, consisting of free or subsidized programs that aim to: develop human capital, reduceinequity and social exclusion; ensure adequate levels of nutrition, health and well being; improveliving conditions; help families minimizenutritional and food related vulnerability; promoteself-sufficiency and empowerment; and redistribute income among groups in extreme poverty situation, aiming to obtain an immediate impact on poverty and inequity reduction” Adapted by WFP from the ILO,FAO, UK International Dept and others.

4. General Objective To understand the scope of the nutritional dimension and results of Social Safety Nets in Central America (Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama) and the Dominican Republic, as well as the priority given by these nets to children under 2 years, pregnant and lactating women, people with HIV, indigenous peoples and Afro-descendants populations.

5. Specific Objectives • Analyze if the Social Protection Programmes selected for the study incorporate objectives, components and nutritional indicators in the different steps: formulation or design; implementation; monitoring and evaluation, as well as the appropriateness of a nutritional scope. • Analyze if the selected programmes prioritize/target their interventions on children under 2 years, pregnant and lactating women, people with HIV, indigenous peoples and Afro-descendants as well as those living in situations of poverty or extreme poverty; and which criteria were selected for the targeting and the establishment of intervention priorities.

6. Specific Objectives • Provide outputs to governments and cooperation agencies in order to strengthen the role of social protection programmes, looking for a nutritional impact on priority groups in situations of major vulnerability. • Produce an advocacy tool that will facilitate the increasing of public, private and donor communities’ commitments in favor of nutritional security to priority groups in Central America and the Dominican Republic, and as a tool for their rights to be enforced.

7. MethodologyStudyParticipants About 200 people involved: Public institutions, NGOs and cooperation agencies from each country. A High Level Technical Group (HLTG) consisting of 26 experts from 16 institutions and from regional and international agencies. WFP technical team: from the regional and country offices focal points of the nutrition and HIV areas. Consultants, supported by a team of statisticians. A consultant for the analysis of the conditional transfer programmes.

8. MethodologyHigh Level Technical Group (HLTG) Conformation Integrated by experts and representatives from: the World Bank, ECLAC, Spain’s Hunger Studies Institute, IFPRI, INCAP, Mexico’s INSP, Chile’s INTA, Micronutrient Initiative, OAS, UNAIDS, PAHO, WFP, PRESANCA, UNICEF, Emory University, University of Chile and Tufts University. Roles and functions: guide, review and recommend. Face to face meeting : October 23rd, 2009.

9. Methodology:Information Gathering MAIN SURVEY (Technical sheet) • Use of secondary data sources. • An inventory of programmes, policies, plans and strategies. • 70 questions that include multicausality, undernutrition determinants, poverty, exclusion and discrimination. • Survey Monkey, statistical analysis (SPSS and MS Excel) INTERVIEWS TO KEY INFORMANTS • Politicalleaders, current and formerpublicofficials, communityleaders, nutrition and breastfeedingexperts, artists, peoplewith HIV. • A Strengths,Weaknesses, Opportunities and Threats(SWOT) qualitativeanalysis. Main Survey Contents Identification, programme type and coordination. Duration and norms. Objectives, components, lines of action. Target population, targeting criterion, coverage, filtration. Human rights approach, gender approach, ethnic-cultural relevance and community participation. Human resources and training. Management, supervision, monitoring and evaluation. Investment, collateral effects, sustainability and degree of compliance to national strategies to fight poverty.

10. MethodologySample • This study did not intend to have a statistically representative sample, but rather extract a varied sample close to the universe in order to generate a description of how the programmes stand at the different countries (transversal analytical epidemiological design). • The data and findings represent the actual group of programmes, plans and policies analyzed. • The differences found allowed to establish an association between the variables analyzed.

11. Methodology:Study Innovation • The logical framework uses the human rights approach, gender approach, the intercultural perspective and scientific evidence. • A holistic approach and considers several undernutrition determinants. • Simultaneously prioritizes several excluded groups with no information available. • Analyzes a wide range of social programmes by using, in a combined way, qualitative and quantitative methods and instruments. • Incorporates into the analysis programmes from public sector, NGOs, privates and international cooperation agencies. COLLECTIVE ACTION TOWARD NUTRITION Evidence has demonstrated that the success of strategies and programmes to improve nutrition requires of the ownership and responsibility not only from governments, but also from civil society, NGOs , cooperation agencies and the private sector. Scaling up Nutrition: A framework for Action (2009)

12. Methodology: Selection Criteria • Population size: more than 10,000, or 10 communities or 1 municipality. • Type of Intervention: To include at least one programme: mother and child health and nutrition; conditional transfers (cash, in kind, vouchers); HIV; supplementation and fortification with micronutrients; biofortification; food based programmes; productive programmes; and, childhood and adolescence attention programmes. • Target population: The programme should be focused in at least one of the study’s priority groups. • Programme is active as of 2009: The programme should be active and have a minimum budget for 2009. • Officially Recognized Programmes: The Study should include government programmes as a priority, but also the ones carried out by NGOs and external cooperation agencies officially recognized.

13. Methodology: Types of Studied Programmes Conditional Transfers* Mother Child Nutrition** Mother Child Health** Food Based** Nutritional Recovery** Micronutrients Supplementation** Micronutrients Fortification Biofortification Productive Programmes Childhood and adolescence attention programmes HIV specific programmes * Cash, in kind, vouchers, others * *Classified as Food and Nutrition Programmes. More than 60% of the analyzed programmes are integrated.

14. Regional Results Transversal analytical and epidemiological Study, basically descriptive. The sample is close to the universe and reflects the diversity of existing programmes.

15. Source: Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Table 1. Number and types of programmes and plans analyzed by country (n=120) The sign (-) in some types of programmes does not mean that the country does not have this type of programme. It just means that it was not included within the sampling or that it is part of other integrated programmes. Notes: * To facilitate the presentation of tables and figures (and also because they share similar actions) Mother & child nutrition and health programmes, Food-based programmes, nutritional recovery and micronutrients supplementation have been grouped into one category: food and nutrition programmes (n = 54). ** Micronutrient supplementation in Belize, Costa Rica, El Salvador, Guatemala and Nicaragua are part of integrated programmes of nutrition, classified under the category Mother child nutrition in this study.

16. . Notes: In parenthesis number of programmes (n). ¨ Figure 1. Programmes execution times per country (n=110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009

17. Figure 2. Programmes that identified nutritional objectives (n =110) Notes: In parenthesis number of programmes (n). Source: Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009

18. Figure 3. Programmes that identified nutritional problems (n=110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n).

19. Figure 4. Identified nutritional problems(n=110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n).

20. i Figure 5. Target population identified in the programmes (n=110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n).

21. Figure 6.Priority actions identified in the programmes (n=110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n).

22. 72% (79) Geographical Age groups 63% (69) Undernutrition 44% (48) Biological 41% (45) 39% (43) ExtremePoverty Poverty 28% (31) HIV Positive 20% (22) Others* 5% (6) Ethnic-cultural groups 3% (3) 0% 20% 40% 60% 80% 100% Porcentage of programmes Figure 7. Programmes using targeting criteria (n=110) * Others included: abandoned children, scholarity, sex of the head of the family. Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n).

24. Figure 8. Nutritional baselines according to types of programmes (n=110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n).

25. Table 2. Nutritional indicators included according to types of programmes (n=110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n).

26. Figure 9. Presence and types of evaluations conducted in the programmes (n=110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n).

27. Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n). ¨ The same programmes can have more than one type of impact evaluation. DHS: Demographics and Health National Survey. Figure 10. Impact evaluations (n=110)

28. Table 3. Funding sources according to types of programmes (n=110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n).

29. Table 4. Community participation (n=110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009

30. Table 5. Main forms of community participation (n=86) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009

31. Figure 11. Human rights approach (n= 110) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: In parenthesis number of programmes (n).

32. Table 6. Implementation of the human rights approach (n=85) Source. Study on Nutritional Dimension of Social Safety Nets in Central America and the Dominican Republic, 2009 Notes: Answersrelatedtothe total of programmes thathavethehumanrightsapproach (n=85). * Theseanswers are directlyrelatedtothehumanrightsapproach. ** Theseanswersnotnecessarily are framedwithinthehumanrightsapproach.

33. SWOT Analysis

34. …. SWOT Analysis.

35. CONCLUSIONS • One of the most significative advances reflected in the social programmes analyzed is the gradual increase of political commitment at the highest levels of governments in order to position the eradication of child and maternal undernutrition as central to human and economic development. • In most countries a supportive legal framework and areas of high level of multisectoral coordination have been formed, such as the Secretariats and National Councils for Food and Nutritional Security in El Salvador, Guatemala and Panama- where sectors involved in the improvement of nutrition and food security concur. However, coordination –both intersectoral and multisectoral – among institutions that manage the programmes is variable and ineffective, being the establishment of articulate and coherent social safety nets yet a challenge to be overcome in those countries. Social protection programmes generally work in isolation with different approaches and objectives.

36. … CONCLUSIONS Nutritional dimension reflected through the explicit incorporation of objectives, actions/interventions and nutritional indicators is rare in most social protection programmes. Programmes such as conditional transfers and childhood and adolescence attention programmes have great potential that is not being properly used to improve child nutrition and of other priority groups. Conditional cash transfer programmes, which currently have high priority for governments, since their inception have had goals related to poverty reduction and investment in human capital, but did not explicitly incorporated the nutritional dimension into it. It is expected on them that the improved nutritional status will be attained by the compliance with co-responsibilities (health care center attendance, pre natal control, school attendance) or through other sectors intervention (i.e. health sector). Through conditionality there is an increase in the demand for health services, although there is no guaranteed impact on health and nutrition if the health services in turn do not enhance coverage and quality of care.

37. … CONCLUSIONS Most of the actions are concentrated on children under five years old, pregnant and lactating women; and in families on poverty and extreme poverty. There is no prioritizing for children under 2 years old (window of opportunity), nor on indigenous peoples (even though they show the worst indicators). In general, peoplewith HIV are not included in the public social safety net programmes; their attention is through HIV specific programmes. Programme coverage is low or unknown; less than 20% of the programmes analyzed have adequate information on their coverage. On the other hand, there are geographical areas with higher concentration of programmes, suggesting possible overlaps and in turn, there are priority areas with child and maternal undernutrition problems that do not have extensive coverage sub national programmes. In the area of human resources, there are insufficient numbers of nutritional and social programmes qualified/trained individuals in relation to needs. There is no evidence of training being effective. This issues may limit the achievement of objectives of the programmes, particularly in local and community levels.

38. … CONCLUSIONS Availability of food and inputs is sufficient in two thirds of the programmes during the whole year. Limitations on the logistics to guarantee the timely delivery of products to the target population are observed, specially at local and community levels. The lack of evaluation and monitoring systems with their respective financing constitutes a weakness that impedes advances, precluding the undertaking of timely corrective measures or the reinforcement of what was working adequately. A little over half of the programmes report to have made a nutritional baseline, but less than a third cited or manifested to have specific documents pertaining to that. On the other hand, although in 76% of the programmes is indicated that evaluations have been performed (design, processes and impact), just about half of these refer to impact evaluations. Besides, only 6% of the totality of the analyzed programmes have rigorous nutritional impact evaluations, documented and publicly disseminated (Positive example PANAMA) . Even though, some programmes gather up information about nutritional indicators, there is no evidence that the information is being used to reroute the interventions, strategies and programmes approaches in order to accomplish that those programmes be efficient and effective in the improvement of the nutritional situation.

39. … CONCLUSIONS • The majority of the programmes use the framework of human rights (related to the principles of universality, interdependency, non discrimination, participation and accountability) and take account of interculturality, community involvement and gender approach. Practically all the countries have laws on food and nutrition security framed onto those approaches, even some such as Guatemala incorporates them into their National Constitution. However, failures are detected during the implementation of these approaches. There are still large gaps in knowledge about them, at the level of the institutions that offer the services as well as the target population that demands them. Additionally, these approaches – in particular community participation- are confined to the stage of programme implementation. • Public social investment, specially in nutrition, is low. The largest funding source (Table 3) of the programmes is external cooperation (donations and loans). Positive example Costa Rica, with greater social investment and longer duration programmes, shows lower prevalence rates of undernutrition.

40. Recommendations • Strengthen the political commitment of governments for the improvement of the nutritional situation of the population, specially in regards to the priority groups. • Advance gradually in the formation of genuine social safety nets that encourage concurrence in the multi-sectoral interventions and programmes and offer integrated and participatory social services that address the various determinants of undernutrition and food insecurity to reduce inequity, inequality and social, economic and ethno-cultural gaps. • Promote a greater and better knowledge of the legal and regulatory frameworks conducive to nutrition in each country and strengthen intra-and inter-sectoral coordination with other areas/institutions responsible for the strategies for poverty reduction and the national development.

41. … Recommendations Incorporate objectives, components and nutritional indicators (nutritional dimension) at different stages of social protection programmes: design, implementation, monitoring and evaluation. In the social programmes that do not depend on the health sector, it is required to establish effective coordination with the health sector in the attempt to obtain a preventive approach, adequate coverage and provision of quality services to achieve an impact and improve the nutritional status of priority groups. Regarding the Conditional transfer programmes: Review or modify the design and operation of these programmes to increase their nutritional impact, incorporating from the start specific objectives to improve nutrition, especially children under 2 and women (Positive example: the Dominican Republic). The following aspects are fundamental and should be considered in the review of programmes, which can increase or inhibit the effects of income or conditionalities: criteria and targeting mechanisms; time or hours that the people served have to spend; the amount and the type or composition of the transfer or input; the delivery mechanisms for transfers or other services; the quality of supplies and services delivered; and intersectoral coordination and integration.

42. … Recommendations • Check the targeting criteria to ensure that interventions are targeted at priority groups, especially children under 2 years, pregnant women, indigenous and afro-descendants, and people with HIV have better access to social protection of the public sector. To reach this goal, the statistics should be disaggregated by age groups, especially for children under 6 months, after 6 to 12 months, and 12 to 24 months. Also it needs include a breakdown of the data by sex, ethnic, cultural and special conditions. • Review the geographical location of programmes to identify potential duplication of interventions and verify that the populations covered correspond to the targeting criteria.

43. … Recommendations Strenghten the human resources capacities on up to date and relevant (evidence based) nutrition and health topics and on social programmes management. Elaborate a comprehensiveplan of human resources regarding training that includes the monitoring and evaluation of the results with a short, medium and long term vision. Organize and maintain an appropiate system of acquisitions, storage and distribution of inputs and food to ensure a timely and continuous delivery to the target population and the regular operation of the programmes. Solve the technical and financial limitations in monitoring and evaluation and incorporate these aspects since the programmes design. Start from the establishment of a baseline and the definition of nutritional indicators in order to measure progress in a permanent way and evaluate the mid and long term impact, make the necessary adjustments and establish accountabilitiess.

44. … Recommendations • Incorporate the human rights approach as the major framework for all of the social safety net actions from the programmes design to the evaluation stages, ensuring that the gender perspective, cultural relevance and community participation are explicitly considered in the programmes. To evolve from the passive or utilitarian participation of the community members toward a social actors vision, which is fundamental in nutrition improvement and their own development. • Gradually increase the allocation of public nutrition budget for social programmes in a framework of policies that exceed government cycles, with a view to ensure sustainability of interventions, gradually decreasing external economic dependence. In this line, States must progressively assume the financing of conditional cash transfer programmes.

45. Lessons learned • Urgency to mainstream nutritional dimension at different stages of social programmes studied, and the feasibility of applying this dimension to similar programmes in different contexts. • Preparation of the study: a forum for discussion and reflection, allowing program managers to identify by themselves strengths, weaknesses and some suggested solutions. • Need for these programmes to be framed within public policies and government commitments to ensure sustainability. • Aspects related to the expanded coverage, prevention, quality of services, monitoring and evaluation, and training of human resources are crucial. They should be housed within the larger framework of human rights and guarantee gender, multiculturalism and community participation. • The need to review the programs and improve intersectoral coordination to ensure that the shares covering the different levels of causality of undernutrition and have a holistic approach. Scientific evidence generated by the Lancet Series on Maternal and Child Undernutrition (2008) and the Copenhagen Consensus (2008). In parallel, improving quality and efficiency of programs or interventions that directly affect other determinants of undernutrition, such as maternal education, water and sanitation and improving incomes for maximum nutritional impact.

46. Study dissemination and next steps • Preliminary study results have been shared in different regional and international meetings, among them the WFP Executive Board ant the “Global South-South Development Expo 2009” (awarded for being an innovative solution contributing to MDG achievements). • WFP has programmed sharing the final reports (subregional and eight countries) with the active involvement of various actors (dissemination plan with involved countries). • Use the study results and strengthen the coordination with other regional initiatives to optimize cooperation with the countries and to increase –in a substantial way- internal and external support to governments in the nutritional area, within the foreign aid principles expressed in the Paris Declaration and the Accra Action Agenda (AAA). • To put into practice the recommendations: support and technical assistance will be channeled to countries based on their necessities, capacities, limitations, challenges and priorities with the aim of strengthening the nutritional dimension of the social safety net programmes studied as well as other similar programmes implemented on those same countries or in different contexts.

47. “ A Social Safety Net should be an instrument and a central concept to advance towards equity, and also to achieve it in concrete and particular circumstances. But under the evidence that for different social risks (traditional and new), the coverage is not universal, there has to be a recognition of the lack of a real protection net. Countries in the region have programmes, activities, regulations and experiences pertaining to almost all the risks and even though the vision pretends to be comprehensive, in reality there is misprotection and inequity, because not every programme functions, or because each one does not function at full capacity, meaning that there is no universal coverage on any of the risks”. Olga Lucía Acosta and Juan Carlos Ramírez: Social Safety Networks: incomplete model, ECLAC, Development Financing Series, No. 141, Santiago , Chile, February 2004, pp. 50-51.

48. Thank you!