The Social Protection Pathways to Nutrition: Evidence in Asia and the Pacific
The webinar “Social Protection Pathways to Nutrition: Evidence in Asia and the Pacific” took place on April 23. As reflected in the title, the webinar unpacked the crucial role social protection can play in the fight against food insecurity and malnutrition in Asia and the Pacific, where half of the world’s undernourished people live. The webinar was organized by UNICEF and FAO in collaboration with the WFP and EPRI, drawing on the wealth of evidence gathered for the 2019 Asia and the Pacific Regional Overview of Food Security and Nutrition — aka SOFI report. Through the evidence available in the region and a case study from the Philippines, panelists and discussants reflected upon the possible reasons behind the lack of clear impact of these social protection programmes on nutrition outcomes.
You can watch the webinar recording here, access the webinar presentation here, and the working paper here.
Andrea Rossi (Regional Adviser Social Policy, UNICEF East Asia and the Pacific Regional Office - EAPRO), moderated the webinar with presenters Jessica Blankenship (Nutrition Specialist, UNICEF EAPRO), Ruben Villanueva (Social Policy consultant, UNICEF EAPRO), Jessica Owens (Social Protection Consultant, FAO Regional Office for Asia and the Pacific - FAORAP) and Nard Huijbregts (Lead Social Policy Advisor, Economic Policy Research Institute - EPRI); and discussants Mario Gyori (Researcher, International Policy Centre for Inclusive Growth – IPC IG) and Britta Schumacher (Senior Nutritionist, WFP Regional Bureau for Asia and the Pacific - RBB).
The conceptual framework of the determinants of nutrition
Jessica Blankenship started her presentation by providing an overview of the food security and nutrition in Asia-Pacific, where half a billion people remain undernourished and cannot obtain sufficient dietary energy to maintain normal, active, healthy lives. She went on by explaining that the problem is much more complex than a lack of enough calories. Addressing the triple burden of malnutrition requires more than just having access to enough food. Within the triple burden, not only undernutrition (i.e. stunting and wasting) is considered but also micronutrient deficiencies as well as overweight and obesity. Social protection, as a nutrition-sensitive intervention, can contribute to addressing some of the economic and social determinants of malnutrition: i.e. the enabling and underlying determinants shown in the framework.
Nutrition framework for action
To address the triple burden of malnutrition, a multi-stakeholder approach is needed to tackle this multi-faceted challenge. Achieving improved diets for all involves engagement through five systems together aiming at changing both norms and behaviors to improve practices:
- Improved access to food;
- Water, Sanitation and Hygiene (WASH);
- Health and nutrition services;
- Receipt of social protection.
On the one hand, families need money and knowledge of how to access and provide a healthy diet and support in times of financial stress. While cash transfers allow for households to spend the cash to meet their needs as they see fit, they also represent an opportunity for increasing coverage and finance for essential nutrition interventions, including fortified complementary foods and micronutrient powders (MNP), within social protection schemes.
A regional review of nutrition-sensitive social protection in Asia-Pacific
Ruben Villanueva followed with a regional overview of social protection systems and the introduction to the working paper, which was the basis for discussion. He introduced the why and the what before handing over to Jessica Owens for the how.
Why is nutrition-sensitive social protection relevant to Asia and the Pacific?
The potential of social protection as a platform for achieving nutrition outcomes is due to the scale of the programmes: the potential arising from their high coverage, their targeting methods and their capacity for rapid scale-up during crises. Social protection programmes command large resource flows compared with nutrition interventions, but their success in fighting poverty does not necessarily translate into success in reducing malnutrition. It is now well understood that the design of these programmes can be enhanced to maximize and sustain important food security and nutrition results, and this, in turn, will generate higher economic returns throughout people’s lifecycles.
What’s the state of social protection in the Asia-Pacific region?
Although there is regional variation, the general trend in social protection in Asia-Pacific is positive, with several countries having created new schemes or significantly extending coverage. Despite this momentum, large coverage gaps remain in the areas of child and family benefits, maternity and parental protection and unemployment protection. One of the region’s most notable characteristics is the wide variation in the maturity of social protection systems and their coverage. While 40 percent of the East Asia and the Pacific (EAP) population receive no social protection transfers at all, only 24 percent in South Asia are not covered. In contrast, EAP nations achieve better benefit adequacy (i.e. higher generosity) than do South Asian nations. To the extent that the level of resources allocated is not sufficient to respond adequately to the income security needs of children and families, their nutritional status will be also affected.
Jessica Owens drew on the available evidence to reflect on how can we better achieve nutrition outcomes through social protection in Asia-Pacific?
Evidence on the underlying determinants shows that while social protection can improve food security, yet there is mixed evidence. A few cash transfers and workfare programs increase expenditure on food as well as caloric intake (e.g. the Philippines and Bangladesh), but failed to achieve enough gains in consumption (Indonesia and Nepal). Evidence pointed out to improved access to health services for children, but not so much for women. Cash transfers, in general, have increased the average per capita expenditure on medical services and have increased health-seeking behaviour especially for children. Health seeking behaviour for pre- and postnatal care differ nonetheless (e.g. Indonesia and India), depending on the messaging/emphasis and the incentives for the supply. Only limited impacts on WASH have been recorded. No change in intra-household dynamics and power has been found, with no effect on women’s decision-making or mobility (e.g. Myanmar, India, Bangladesh) and limited change in attitudes on violence against women (VAW) (e.g. Philippines). Mixed results on child feeding practices.
Evidence on immediate determinants are mixed on child health status, with a reduction in maternal and neonatal mortality, but still modest reduction in perinatal and neonatal mortality (e.g. India). There are, however, mixed but promising results on dietary intake, with increased intake of healthy foods such as vegetables, milk, eggs, protein (e.g. Indonesia, Philippines).
Finally, evidence on nutrition outcomes shows a mixed but positive trend in the region. An increasing number of programmes show improvements in stunting (e.g. Indonesia, Nepal, Bangladesh, Pakistan), wasting or underweight (e.g. Bangladesh, Nepal, Pakistan), while a few others show mixed results (e.g. Indonesia and the Philippines). Factors that have been raised to explain mixed results include duration, rise in local prices of quality foods, practices prior to children being conceived. Yet, few studies report reductions in micronutrient deficiencies such as in Anaemia and zinc deficiency (e.g. India and Bangladesh).
After examining the evidence, it is clear the need for revisiting the design of existing social protection programmes, as many of the key indicators of human and cognitive capital development are not being achieved. There are multiple competing priorities on transfers affecting nutrition outcomes such as the size of the transfer, the cost of nutritious diets or intertwined intra-household decisions between consumption and livelihoods needs. In terms of gender, there is a need to move beyond aiming cash transfers to women towards changing intra-household dynamics. The importance of cultural practices and knowledge is also an issue that needs to be considered within the Social Behaviour Change and Communication (SBCC). Finally, it is clear that comprehensive approaches including multiple sectors, such as social protection, health, education and agriculture and WASH, can better tackle complex challenges of malnutrition and poverty.
Case study: the Pantawid Pamilyang Pilipino Program (4Ps)
Nard Huijbregts unpacked some of the successes and failures of the 4Ps in the Philippines, the largest social safety net in the region and one of the best-evaluated programmes in the world, revealed by a rapid qualitative assessment of the impact of 4Ps on nutrition outcomes.
Findings suggest that the 4Ps programme positively influences beneficiary households’ overall situation, food security and also mental well-being. Positive outcomes were observed more when the payment cycle was frequent, timely and reliable. Very importantly, the scheme contributes to achieving outcomes only in those cases it supplements an existing household income. Linkages between different, mutually reinforcing interventions show improved outcomes at the household level. Household priorities are decisive for programme outcomes, as the 4Ps is based on the assumption of families seeking health services in the interests of prioritising their own and their children’s health. Children’s nutritional status and malnourishment are better among households where caretakers’ own well-being and self-care practices are good. Financial constraints and varying willingness and ability to change behaviour prevent households from experiencing stronger positive outcomes from the 4Ps.
The webinar concluded with an engaged discussion and interactive Q&A session, accessible here.