Jose Luis (IFPRI Egypt)
On December 11th, 2017 IFPRI organized a session as part of FAO-WHO-WFP Regional Symposium on Sustainable Food Systems for Healthy Diets and Improved Nutrition. The session (see agenda) aimed at discussing the potential of social protection policies and programs (SPP) to improve nutrition and promote healthy diets in the NENA region. The session started with the presentation by Dr. Olvier Ecker, IFPRI’s Senior Research Fellow, who provided state of the art evidence on the potential of SPP for improving nutrition. The second presentation focused on the experience of Egypt, whose ambitious program for reforming the social protection system offers an opportunity to improve the nutrition of the Egyptians in the coming years. Dr. Habiba Hassan-Wassef, Nutrition Research Consultant at the National Research Centre in Egypt, gave a presentation on the case of Egypt.
Nutrition sensitive social protection: a global perspective
According to the 2013 Lancet Series on Child and Maternal Nutrition, scaling-up the most 10 proven effective nutrition-specific interventions would only decrease stunting by 20%. Hence, additional efforts will be needed if the world wants to eradicate all forms of malnutrition by 2030 as targeted by SDG 2. In that sense, SPP have great potential because a substantial part of the vulnerable population in the world today is covered by some kind of SPP assistance (about 2 billion people), and these interventions are designed to, directly or indirectly, address the underlying causes of malnutrition (e.g., poverty).
During the first presentation, Dr. Ecker explained the mechanisms through which SPP interventions can potentially affect nutrition. For example, most SPP programs are targeted to the poor, who are often food insecure. When programs provide monetary transfers, poor households can afford foods that normally are off their budget. In other schemes, households can be entitled to voucher or other forms of assistance that modify the relative price of foods, making them more affordable. Also, SPP often require beneficiaries to comply with specific criteria to be eligible for program participation; for example, in some programs household’s members need to regularly attend health services, especially children and women, who are often more vulnerable to suffer malnutrition. Additional mechanisms through which SPP affect nutrition include women’s empowerment that results when resources are given directly to women, as well as behaviour change communication components which directly transfer nutritional knowledge to SPP beneficiaries.
So, what can policy makers and stakeholders in the NENA region learn from other international experiences? First of all, although SPP are very effective in reducing poverty, their effectiveness in improving nutrition is less obvious. Experiences in other regions (especially in Latin America) suggest that the link between additional household resources and better nutrition of household members is not direct. In general, more household income does not guarantee access to better health services, sanitation, or nutrition-relevant behavioural change, which altogether is crucial for achieving meaningful nutritional improvements. Moreover, in some cases, additional resources have been found to affect the nutritional status of SPP’s beneficiaries by increasing overweight and obesity (like in the case of Mexico and Egypt). Also, studies from other regions have found that knowledge about child care is often missing in the design of programs, which is key for improving nutrition.
Second, the evidence suggests that SPP encourages poor households to increase their food consumption. Studies from Latin American countries demonstrate that food-oriented transfers incentivize participants to spend on food, even when transfers are unconditional. This suggests that when coupled with behavioural change communication (BCC), SPP can increase dietary quality and reduce the risk of overweight/obesity associated with income growth.
Finally, Dr. Ecker stressed the unmet potential of SPP schemes to improve nutrition as well as some steps that countries can follow in the future. Specifically, he pointed to the need of a nutritional agenda that explicitly includes the most pressing nutritional challenges of the countries in the region. Most NENA countries still consider undernourishment the biggest nutritional challenge, whereas, today’s challenges are different: overweight/obesity, non-communicable diseases, and micronutrient deficiencies. Some key recommendations on how SPP can be used as a platform to leverage nutrition-sensitive interventions are:
- Improving SPP targeting, which includes have a better understanding of the needs of those who are more vulnerable to suffer from malnutrition (women, children, elderly, etc.)
- Identify the main underlying causes of malnutrition in the population that can be addressed by SPP schemes.
- Explicitly include nutrition objectives for SPP interventions.
- Address the immediate determinants of nutrition while simultaneously addressing the underlying determinants of nutrition and/or the enabling environment for nutrition.
- Monitor progress and encourage independent, rigorous impact evaluations, to keep track of progress and adjust interventions when needed.
Potential pathways for increasing Egypt’s nutrition returns of social protection programmes
The second presentation, given by Dr. Wassef, focused on the experience of one of the largest countries in the region: Egypt. With a long tradition of a generous subsidy scheme for more than 50 years in place, the country has engaged a series of reforms to move away from a generalized subsidy scheme to implement more targeted interventions. However, there is great scope for increasing the nutrition returns of the extensive and broad range of SP programs in the country.
As most countries in the region, Egypt has been affected by the global economic crisis of the late 2000s with negative consequences for the nutrition of the population, particularly of the poor. As a response, the Government embarked in series of efforts to protect the poor and revert the observed deterioration of the nutritional status of the population. These efforts include the expansion of the SP system, which in turn, changed the social assistance landscape of the country. Today, Egypt has a broad spectrum of social protection programs and policies: food subsidies (accounting about 20%), Conditional Cash Transfers, networks of public nurseries (today 14,000 at the national level), school feeding programs (covering 11 million pupils), a series of subsidies on energy and transportation (accounting about 42%), health insurance programs, etc. In addition, some recent initiatives have been launched. For example, the “Forsa” program which provides training and work opportunities, the “Decent housing” scheme to improve housing and sanitation conditions in poor villages, and a recent pilot which conditions SP participation of pregnant women to attendance to nutrition and education sessions.
These vast array of SP interventions expand across the human life course, covering from pre-conception to old age, which is expected to improve the nutritional conditions of the population in the country. However, there is an untapped potential of the recent implemented SP schemes to improve nutrition. Some actions that could boost the nutrition returns of SP programs include the provision of training and awareness of government personnel (MoSS, MoHP, etc) on the importance of nutrition, promote nutrition literacy and education in the country, include action to improve health within school feeding programs, and improve the coordination between relevant government actors. Above all, Dr. Wassef called for the promotion of enabling environments that actively support nutrition goals: data generation for decision makers and stakeholders, alignment of programs with national nutritional goals, and integrate nutrition specific and/or sensitive goals into SP schemes in the country.