Nutritional dimension - Programa Mundial de Alimentos

Transcripción

Nutritional Dimension of the Social
Safety Nets in Central America
and the Dominican Republic
Subregional Report
June 2010
The subregional report “Nutritional Dimension of the Social Safety Nets in Central
America and the Dominican Republic” covers eight countries: Belize, Costa Rica,
El Salvador, Guatemala, Honduras, Nicaragua, Panama and the Dominican Republic.
Produced by:
World Food Programme
Regional Bureau for Latin America and the Caribbean
Gaillard Avenue, Vicente Bonilla Street, Buildings 124 and 125
City of Knowledge, Clayton
P.O. Box: 0819-10751, Zone 6, El Dorado
Panama, Republic of Panama
Phone: (507) 317-3900
Fax: (507) 317-3903
www.wfp.org/es
Copyright © World Food Programme, 2010.
First edition, June 2010.
All rights reserved. This document may be utilized, cited, reproduced freely with
social purposes related to social protection programmes strengthening, in part or in
its entirety with credit given to the World Food Programme. It cannot be sold or used
for commercial purposes. The electronic version of this document can be downloaded
from: www.wfp.org and www.wfp.org/es.
Original Version in Spanish: Dimensión Nutricional de las Redes de Protección Social
en Centroamérica y la República Dominicana. Junio de 2010. A Céspedes,
A Lechtig , R Francischi, M Lovón, G Hernández.
Translation to English: J Vásquez.
Cover Design: J Moya.
Editorial Design: P Montes de Oca.
ISBN: 978-9962-8950-3-9
The findings, opinions, interpretations, conclusions and recommendations expressed
in this document do not necessarily reflect the views of the World Food Programme.
Acknowledgements
To the representatives of governments, non-governmental organizations, cooperation agencies and
key informants from: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama
and the Dominican Republic, for sharing information and reflections on the social protection programmes.
Recognition and special thanks to the expert members of the High Level Technical Group (HLTG)
and the institutions they represent: The World Bank (WB); the Economic Commission for Latin
America and the Caribbean (ECLAC); Emory University; the University of Chile-Faculty of Medicine; the United Nations Children´s Fund (UNICEF); the Institute of Hunger Studies-Spain (IEH);
the International Food Policy Research Institute (IFPRI); the Central America and Panama Nutrition
Institute (INCAP); the National Institute of Public Health-Mexico (INSP); the Institute of Nutrition
and Food Technology-Chile (INTA); the Micronutrient Initiative (MI); the Organization of American
States (OAS); the Pan American Health Organization (PAHO); the United Nations HIV/AIDS Joint
Programme (UNAIDS); the Food and Nutritional Security Regional Programme for Central America
(PRESANCA); and, Tufts University, for their guidance and technical contributions throughout the
Study process.
Appreciation is also directed to the World Food Programme (WFP) staff and consultants for their
contributions and dedication to the Study.
The Study “Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic” has been developed with the financial contribution from the Spanish Government
through the Ministry of Foreign Affairs and Cooperation and specific contributions from the Canadian International Development Agency (CIDA) and UNICEF. Technical support was provided by the
High Level Technical Group (HLTG) participating institutions.
Contents
FOREWORD | viii
TABLES, FIGURES AND MAPS INDEX
ABOUT THE AUTHORS | x
Tables
1. Prevalence of chronic undernutrition (H/A < - 2 SD) and anemia (Hb < 11 mg/dL) in
children under 5 and 2 years in Central America and the Dominican Republic | 4
2. List of analyzed plans and policies (n=10) | 30
3. Number and type of analyzed programmes by country (n=110) | 35
4. Type of micronutrient supplementation (n=50) | 59
5. Normative documents of analyzed programmes (n=97) | 66
6. Nutritional indicators used according to type of programme (n=110) | 74
7. Community participation in the programmes (n=110) | 82
8. Ways of community participation in the programmes (n=86) | 83
9. Programmes sustainability according to country (n=110) | 88
10. Funding sources according to country (n=110) | 88
11. Sustainability according to type of programme (n=110) | 89
12. Funding sources according to type of programme (n=110) | 90
ACRONYMS | xi
EXECUTIVE SUMMARY | xiii
I. POVERTY, FOOD INSECURITY AND MALNUTRITION IN CENTRAL
AMERICA AND THE DOMINICAN REPUBLIC – THE ROLE OF SOCIAL
SAFETY NETS AND SOCIAL PROTECTION PROGRAMMES | 1
A.Food and nutritional context | 3
B.Social safety nets and social investment | 13
II. STUDY OBJECTIVES | 15
A.General objective | 17
B.Specific objectives | 18
III. METHODOLOGY, STAGES AND ORGANIZATION OF THE STUDY | 19
A.Programmes selection criteria | 21
B.Stages of the Study | 22
C.Personnel and institutions involved | 26
D.Limitations | 26
IV. RESULTS AND ANALYSIS | 27
A.General context of plans and policies | 29
B.General characteristics of the programmes studied | 33
C.Nutritional dimension in social protection programmes | 37
D.Target population, targeting criteria, coverage and filtering | 46
E.Management and implementation of programmes | 55
F.Monitoring and evaluation and nutritional surveillance | 67
G.Human rights approach, gender perspective, cultural relevance and
community participation | 75
H.Duration, sustainability, investment, collateral effects and degree of
compliance towards national strategies for poverty reduction | 84
I. Strengths, Weaknesses, Opportunities and Threats Analysis | 92
V.
CONCLUSIONS | 95
VI. RECOMMENDATIONS | 101
VII. LESSONS LEARNED | 107
VIII.STUDY DISSEMINATION AND NEXT STEPS | 111
ANNEXES | 115
i. Study collaborators | 117
ii. List of programmes and plans or policies by country | 128
iii. Malnutrition terminology | 134
iv. Political and technical support meetings for the eradication of child
undernutrition, for the promotion of food and nutritional security and social
protection | 135
v. References | 137
Figures
1. Prevalence of chronic undernutrition (H/A < - 2 SD) in children under 5 years in rural
and urban areas in Central American countries and the Dominican Republic | 5
2. Prevalence of chronic undernutrition (H/A < - 2 SD) in indigenous and non indigenous
children under 5 years in Central American countries | 6
3. Classification of programmes according to main executing institution (n=110) | 36
4. Programmes that identified nutritional problems (n =110) | 38
5. Main nutritional problems identified in the programmes (n=110) | 39
6. Programmes that identified nutritional objectives (n=110) | 40
7. Main objectives identified in the programmes (n=110) | 42
8. Priority actions identified in the programmes (n= 110) | 44
9. Target population identified in the programmes (n=110) | 47
10. Targeting criteria identified in the programmes (n=110) | 49
11. Targeting criteria by age identified in the programmes (n=90) | 50
12. Geographical targeting criteria identified in the programmes (n=110) | 51
13. Micronutrient supplementation according to type of programme (n=110) | 58
14. Human resources (professional staff) according to their academic background (n=110) | 60
15. Nutrition training of the different human resources (n=110) | 62
16. Programmes with management normative (n=110) | 65
17. Nutritional baseline according to type of programme (n=110) | 68
18. Presence and type of evaluation referred and conducted in the programmes (n=110) | 70
19. Impact evaluation referred and conducted in the programmes (n=110) | 71
20. Human rights approach (n=110) and implementation ways (n=85) | 77
21. Cultural relevance in the different stages of the programmes (n=110) | 80
22. Execution time according to type of programme (n=110) | 85
23. Programmes duration according to country (n=110) | 86
24. Positive collateral effects identified in the programmes (n=110) | 91
Maps
1. Number of programmes with national coverage by country | 52
2. Geographical distribution of programmes with subnational coverage by country | 53
3. Geographical location of programmes with subnational coverage in comparison with stunting
prevalence in school children | 54
I
It has been ten years since the world reached
a critical consensus on human development
goals for the long term, including the reduction in child undernutrition and the release of a
large portion of humanity from the shackles of
poverty, extreme hunger, illiteracy and diseases, among other barriers that impede the human development. The Millennium Development Goals (MDGs) form a blueprint agreed
to by all nations of the world and leading development institutions. The countries pledged
to spare no effort in realizing that vision. The
MDGs have galvanized unprecedented support to help the poorest in the world. Important decisions have been made that would have
been unthinkable a decade ago. And progress
to date has been made that should be and can
be learned from.
education and productivity of people throughout their course of life, leading to serious implications for the development of nations. Due
to the gravity of this situation, it is imperative
that countries implement a series of social, economic and political measures in the short, medium and long term. Among these measures are
comprehensive social protection systems, which
must be universal, in the framework of the human rights approach, which in turn gives priority to those who most need social protection.
In this context, the Study Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic was undertaken, the results of which we are pleased to
present in this report.
This report briefly reviews the context of poverty, food and nutrition insecurity, child undernutrition, nutritional and epidemiological transition, the situation of the HIV epidemic in the
participating countries, as well as the role of
social safety net programmes. It also presents
the location and duration of the Study, the objectives and actors involved, methodological
aspects and finally the conclusions, recommendations, lessons learned, analysis of strengths,
weaknesses, opportunities and threats (SWOT)
and the next steps. It suggests concrete actions
to strengthen social programmes with a nutritional dimension in the framework of human
rights approach.
In addition, the world is facing a global financial crisis, along with the food and environmental crises, whose effects are already evident. It is known that these additional crises
are holding back progress in achieving the
MDGs as they are plunging millions of people
into poverty and extreme poverty, increasing
hunger, food and nutrition insecurity, child undernutrition and raising the risk of social and
political problems in many countries. Latin
America and the Caribbean, particularly Central America and the Dominican Republic have
been principally affected. These countries share
a common history linked to social conflict, frequent natural disasters, and accelerated migration, events that put them at greater social risk
and difficulty in coping with these problems.
a technical and advocacy instrument to mobilize and expand public, civil society and the private sector commitments, in favor of the nutritional protection for priority groups. In the
short term, the report should assist countries to
address the global crisis by protecting the most
vulnerable population and strengthen the existing social protection programmes, and, in the
medium to long term, the strengthening of public social policies that lead to the construction
of effective social protection systems. We also
hope the Study will provide important inputs
to redirect external cooperation toward these
needs and that priority groups find the Study a
useful tool for the exercise of their rights, mainly the Right to Food.
Pedro Medrano Rojas
World Food Programme Regional Director
Latin America and the Caribbean Regional Office
The Study identified positive examples, gaps and
opportunities to address the nutritional components of a wide range of social programmes to
achieve the nutritional impact on the target population: children under two years, pregnant and
lactating women, people living with HIV, indigenous peoples and afrodescendants populations.
Despite great efforts, one area that records the
least progress is the reduction of child undernutrition, especially chronic undernutrition and
anemia. However, there is abundant evidence to
show, first, that nutrition interventions are crucial to achieving the Millennium Development
Goals, and moreover demonstrates that undernutrition causes negative impacts on health,
We hope that the Study, through the subregional report presented here, as well as the specific
reports of the 8 participating countries, provide
viii
ix
POVERTY, FOOD INSECURITY AND MALNUTRITION IN CENTRAL AMERICA AND THE DOMINICAN REPUBLIC
– THE ROLE OF SOCIAL SAFETY NETS AND SOCIAL PROTECTION PROGRAMMES
Foreword
I
Acronyms
Angela Céspedes is a nutritionist who holds
postgraduate degrees in various areas of social
development. She has been a United Nations official for the past 26 years: currently serves as
Regional Nutrition Advisor for the World Food
Programme (WFP); she was a UNICEF official
for 20 years occupying various technical and
managerial positions and was also a consultant to PAHO. She has over three decades of
experience in the development of public policies and programmes for the improvement of
nutrition and the reduction of poverty as well
as social and ethnic-cultural exclusion in the
Latin America and the Caribbean Region. She
is an author of several publications and books
in these areas.
Caribbean Region of the United Nations World
Food Programme (WFP).She has ten years of
experience in community nutrition and nutrition related social sciences. She is a professor
in postgraduate and undergraduate nutrition
courses at universities in Panama and Brazil.
She has various scientific publications.
Margarita Lovón is a nutritionist and holds a
masters degree in food and nutrition planning
from INTA-University of Chile. She is an international consultant in topics related to emergencies as well as food and nutritional security. She has over fifteen years of experience in
managing food and nutritional security programmes at community level, as well as the assessment and programming of the response to
emergency situations in various countries of
Latin America and the Caribbean and Asia.
Aaron Lechtig is a medical doctor. Class Valedictorian, MPH, PhD. He serves as Director of
the Institute of Food and Nutritional Security and is a Public Nutrition Professor for the
Agricultural University in Lima, Peru. He is a
Senior Nutrition Advisor to several regions:
Latin America and the Caribbean, Africa, Central Asia and Eastern Europe (INCAP-PAHO/
WHO, UNICEF, IADB and WFP). Has over
fifty years of experience in public nutrition
programmes. He advised, participated and/or
evaluated several programmes, among them:
INCAP Longitudinal Study in Eastern Guatemala; Pastoral da Crianza in Northeastern Brazil; and, Good Start in Peru. Author of hundreds of scientific publications (peer reviewed),
as well as books and manuals. Distinguished
with various awards; the most prized being:
Liberator Don Simon Bolivar Honor Order,
First Degree, of his alma mater the National
University of Trujillo, Peru.
Gabriela Hernández is an economist from the
University of Economic Sciences in Budapest,
Hungary, with several postgraduate degrees
in different areas of international cooperation.
For the last 12 years she has served as Programme Officer for the Cuba Country Office
of the United Nations World Food Programme
(WFP). She has twenty three years of experience
in international cooperation and social development in Latin America and the Caribbean.
Rachel Francischi is a nutritionist from the
Faculty of Public Health (USP, Brazil), with a
masters degree in cellular and molecular biology with emphasis in biochemistry from UNICAMP, Brazil. She currently serves as Programme Officer for Latin America and the
x
AFASS
AIDS
ARI
ART
BMI
CBICC
DHS
EB
ECLAC
EFSA
FAO
FHNS (FESAL)
FNS
GDP
HIV
HLTG
IADB
ICESCR
IDIAP
IEC
IEH
IFPRI
ILO
IMAS
IMCI (AIEPI)
INCAP
INEC
INSP
INTA
LAC
LSMS (ECV)
LSS (ENV)
MCHNS (ENSMI)
MDG
MI
MICS
MNP
NCHS
NGO
NNS (ENN)
NSRCU (ENRDC)
OAS
PAF
PAHO
PANI
PLHIV
PRCU (PRDC)
PRESANCA
SESAN
SICA
SSN
SWOT
UN
UNAIDS
UNDP
UNICEF
WB
WFP
WHO
Acceptable, Feasible, Affordable, Sustainable, Safe
Acquired Inmune Deficiency Syndrome
Acute Respiratory Infection
Antiretroviral Treatment
Body Mass Index
Community Based Integrated Care For Children
Demographics and Health Survey
Exclusive Breastfeeding
Economic Commission for Latin America and the Caribbean
Emergency Food Security Assessment
Food and Agriculture Organization of the United Nations
Family Health National Survey
Food and Nutritional Security
Gross Domestic Product
Human Inmunodeficiency Virus
High Level Technical Group
Inter American Development Bank
International Covenant on Economic, Social and Cultural Rights
Institute of Agricultural Research of Panama
Information, Education and Communication
Hunger Studies Institute - Spain
International Food Policy Research Institute
International Labor Organization
Joint Social Welfare Institute - Costa Rica
Integrated Management of Childhood Illness
Institute of Nutrition for Central America and Panama
National Statistics and Census Institute - Costa Rica
National Institute of Public Health - Mexico
Institute of Nutrition and Food Technology - Chile
Latin America and the Caribbean
Living Standards and Measurement Survey
Living Standards Survey
Mother and Child Health National Survey
Millennium Development Goals
Micronutrient Initiative
Multiple Indicators Cluster Survey
Micronutrients Powder
National Center for Health Statistics
Non Government Organization
National Nutritional Survey
National Strategy for the Reduction of Chronic Undernutrition - Guatemala
Organization of American States
Family Assignment Programme - Honduras
Pan American Health Organization
National Foundation for Children - Costa Rica
People living with HIV
National Programme for the Reduction of Chronic Undernutrition - Guatemala
Food and Nutritional Security Regional Programme for Central America
Food and Nutritional Security Secretariat
Central American Integration System
Social Safety Nets
Strengths, Weaknesses, Opportunities and Threats
United Nations Organization
United Nations Joint HIV/AIDS Programme
United Nations Development Programme
United Nations Children´s Fund
The World Bank
World Food Programme
World Health Organization
xi
About the authors
THE CENTRAL AMERICAN AND DOMINICAN
REPUBLIC SUBREGION: MAGNITUD
OF THE FOOD AND NUTRITION PROBLEMS
consequence of poverty. The magnitude of the
problems and the damage it inflicts constitute
the major violation to the Right to food. This
complex situation imposes the urgent necessity to protect the human capital, giving priority to those who most need social protection
within the framework of the human rights approach. The States have the responsibility and
the obligation to conduct all the necessary efforts to respect, guarantee, satisfy, protect and
promote the human rights of their population
and among these, the Right to food.
Despite the advances obtained in the countries
of the Subregion, child and maternal undernutrition still represents a serious public health
problem and a human and economic challenge
for the States; serious territorial, social, ethnic-cultural and economic gaps persist inside
the countries and between the countries. The
main nutritional problems that affect children
under five years are stunting (chronic undernutrition or low height for age) and micronutrient deficiencies, particularly anemia (disorder caused mainly by Iron deficiency). Anemia
is also the worst undernutrition problem for
pregnant women. The countries of the Subregion are facing a nutritional and epidemiological transition, in which nutritional deficiency
problems coexist with problems of unbalanced
diets and food excesses, alongside with a progressive increase in overweight and obesity and
their direct association with chronic diseases.
Concerning HIV, the increasing incidence of
infection among women and girls proves that
the epidemic is wide spreading in these priority
groups with the consequent nutritional deterioration and increased morbidity and mortality.
THE POSSIBLE SOLUTIONS
During the last decade, nutrition has recovered
its importance in the social and economic life
of the countries of the Latin America and the
Caribbean Region and among them in the Central America Subregion as well as in the Dominican Republic. In turn, the scientific evidence generated worldwide has steered the
States, the international cooperation organizations and other key stakeholders on the most
cost-effective interventions that are needed to
reduce the different forms of undernutrition
problems. In recent years several international initiatives have been developed with broad
consensus on the urgency to act in order to resolve these problems –particularly in regards to
undernutrition on children under two years– a
period when the highest rates of return on social investments are obtained. Thus, to improve
children and women’s nutritional situation has
become an ethical mandate and an essential
requirement to accelerate the countries social
progress and to achieve the Millennium Development Goals (MDGs).
The global financial crisis, together with the
food and environmental crises are increasing hunger and food and nutritional insecurity, thus declining the nutritional situation for
millions of families and large segments of the
population to unexpected levels. Those families are in a condition of increased vulnerability to poverty, undernutrition and social exclusion; particularly children under two years,
pregnant and lactating women, indigenous
peoples and afrodescendants populations,
with the subsequent permanent and irreversible damage to countries human capital and to
their social and economic development possibilities. Undernutrition is a cause as well as a
xii
Several international conferences have been
conducted so far in order to propose actions to
eliminate hunger and poverty and to guarantee food and nutrition security for all. Alongside, in support Declarations have been emitted
xiii
EXECUTIVE SUMMARY
Executive summary
THE NEED FOR THIS STUDY
One of the first steps to achieve these scaling up
efforts –that requires only of technical investments– is the formulation and/or strengthening
of social protection programmes and policies
with a nutritional approach. The Study “Nutritional Dimension of the Social Safety Nets
in Central America and the Dominican Republic”, object of this report, aims to contribute to
this purpose. It constitutes one of the regional
responses to the mandate emanated from the
OAS First Meeting of Ministers and High Level Authorities of Social Development, held in
Chile in 2008.
problems, the groups of populations and zones
affected as well as the incorporation of objectives, interventions/actions and nutritional indicators among the different phases of a programme cycle.
THE METHODOLOGY
From June to December 2009, the Study was
undertaken in the eight countries that belong
to the Central American Integration System
(SICA): Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the
Dominican Republic. These countries share
common histories linked to poverty and undernutrition situation; social and ethnic-cultural exclusion, frequent natural disasters, social
conflicts and accelerated migration, events that
put them at greater social risk and difficulty in
coping with these problems. Also these countries share a common regional vision of development, integration and solidarity between nations, facts that strengthen them to overcome
their challenges. The Study on the Social safety nets was led by the World Food Programme
THE OBJECTIVE
The Study´s overall objective is to know the
scope of nutritional dimension of social safety nets in Central America and the Dominican
Republic and what is the priority they give to
children under two years, pregnant and lactating women, people living with HIV, indigenous peoples and afrodescendants populations. Nutritional dimension is understood as
the adequate identification of main nutritional
xiv
The Subregional report presented here includes
the findings and results of the Study in the 8
participating countries and takes into consideration all the components analyzed in the
comprehensive Survey. These components explore the nutritional dimension existing in programmes with a holistic approach and include
the social, economic, cultural and political determinants of undernutrition. The programmes
nutritional dimension was analyzed in all the
phases of the programme cycle: design, implementation, monitoring and evaluation.
The Study was based on secondary data analysis and review of recent national surveys. Also
direct data was collected in countries through
interviews conducted with programme managers and key informants. It is an epidemiological transversal and analitical Study and as such
it is basically descriptive. Based on pre-established criteron and the design of methodological tools (a comprehensive cuantitative Survey
and a qualitative Key informants interview), information was gathered and examined for 120
social protection programmes, including 10
plans and policies related to food and nutrition.
Although they do not constitute a statistically
representative sampling from all the existing
programmes in the participating countries (because the real universe is unknown) they reflect
the current situation and diversity of them. The
programmes were classified into 11 categories:
i) Conditional transfers programmes; ii) Mother and child nutrition programmes; iii) Mother
and child health programmes; iv) Food-based
programmes; v) Nutritional recovery programmes; vi) Micronutrient supplementation
programmes; vii) Micronutrient fortification
programmes; viii) Biofortification programmes;
ix) Productive programmes; x) Childhood and
adolescence attention programmes; and, xi)
HIV specific programmes.
THE CONCLUSIONS
AND RECOMMENDATIONS
The conclusions and recommendations presented cover the following areas: i) Political commitment; ii) Institutional coordination and safety
nets conformation; iii) Nutritional dimension;
iv) Targeting and priority groups; v) Coverage;
vi) Human resources; vii) Supplies and logistics;
viii) Monitoring and evaluation and nutritional
surveillance; ix) Human rights approach, gender perspective, cultural relevance and community participation; and, x) Sustainability, funding and programme duration.
Among the main recommendations, the report
proposes:
•• To strengthen the political commitment of
governments in favor of the nutrition of
their population, particularly the priority
groups.
•• To gradually move forward in the formation of genuine social safety systems that
encourage intersectoral and multidisciplinary concurrence and coordination in
social programmes; to provide integrated
and participatory social services and interventions based on scientific evidences that
address the various determinants of undernutrition and food insecurity.
Thirty five interviews were directed towards
Key Informants in the 8 countries. Based on
these interviews the analysis of strengths,
weaknesses, opportunities and threats (SWOT)
was prepared. The results of this analysis complement the main survey findings.
xv
EXECUTIVE SUMMARY
THE FINDINGS AND RESULTS
(WFP) through a broad participative process
with multiple actors; in total more than 200
people participated in the Study. Among them:
representatives from public institutions, NGOs
and cooperation agencies from the 8 participating countries; a High Level Technical Group
(HLTG) formed by experts from technical regional institutes, from diverse international organizations, including UN agencies; and, WFP
staff and consultants from nutrition and HIV
areas at regional as well as local levels.
and new commitments have been assumed by
global leaders –including the UN General Secretary– who have recognized the necessity to
adopt urgent measures and to develop short,
medium and long term actions in order to find
solutions to these barriers. Among the measures to be taken it has been identified the importance of scaling up the support for Nutrition as well as for social protection safety nets,
including its funding, as one of the main ways
to develop the human capital and to reduce social exclusion, inequalities and poverty conditions. The Social Safety Nets (SSN) are instruments of social policy from which States can
and should play their role in guaranteeing human rights, notable the Right to food. A Social Safety Net is only an articulated part of a
broader Social Protection System.
•• To incorporate objectives, interventions/actions and nutritional indicators (nutritional
dimension) in the different stages of social
protection programmes: design, implementation, monitoring and evaluation. On the
social protection programmes that do not
depend on the health sector, it is required
to establish effective coordination with this
sector in order to obtain a preventive approach, adequate coverage and provision
of quality services to achieve impact and
improve the nutritional status of priority
groups.
EXECUTIVE SUMMARY
and, that people with HIV have better access to social protection of the public sector. To achieve this goal, statistics should be
disaggregated by age group, sex, ethnic-cultural group and by special conditions.
•• Expand the coverage and review the geographical location of programmes incorporating the preventive approach and the
quality of health and nutrition services.
Identify potential duplication of interventions or areas that may have multiple programmes for the same target population.
Guarantee that the populations covered by
the programmes correspond to the pre-established targeting criteria with the intention of increasing the nutritional impact.
•• To review or change the design and operation of Conditional Transfer Programmes
(including cash, in kind,vouchers and others) in order to increase their nutritional impact, incorporating specific purposes from
the start to improve household nutrition,
especially of infant and young children and
of women. In parallel, while the offered and
demand of services are being strengthened,
it is also important to move forward in the
discussions about the use of conditionality,
since in some way it is in counterposition
to the human rights approach: the access to
food, health and education is provisional or
temporary, since it lasts the timeframe on
which the individuals or families are participating within the programmes.
•• To strengthen human resources capacity
–particularly at local and community level–
in nutrition and health topics that are up to
date and relevant (based on evidences) and
also in social programmes management. To
develop a comprehensive plan for training
human resources, including the monitoring
and evaluation of training results, with a
short, medium and long term vision.
•• T
o organize and maintain an adequate system of procurement, storage and distribution of inputs and food (donated, imported
or locally produced) ensuring their quality
–especially of the fortified complementary
foods- and the continuous and timely delivery to the target population and the proper
functioning of the programmes.
•• To review the programmes and plans for
HIV epidemic reduction, with an intersectoral and multidisciplinary approach, ensuring the incorporation of food and nutrition components; to integrate diagnosis
and nutritional counseling to counseling
for treatment adherence and include information and education to people who provide the services on non discriminatory issues as well as to PLHIV on their rights.
•• To resolve technical and financial constraints
in monitoring and evaluation and nutritional surveillance and incorporate these aspects
into the design of programmes. The establishment of a baseline should be the start
to the definition of nutritional indicators to
measure progress on an ongoing basis and
evaluate the impact in the medium and long
term, to allow the necessary adjustments
and establish accountabilities.
•• To check the guidelines or targeting criteria
with the intent to focus the interventions
on priority groups, specially children under
2 years of age, pregnant women, indigenous
peoples and afrodescendants populations,
xvi
•• T
o incorporate the human rights approach
as the larger framework for all social protection activities from the design to the evaluation stage of programmes, ensuring that
gender perspective, the cultural relevance
and community participation are explicitly considered in the programmes. Among
other aspects this means: human resources
should be informed and trained at different
levels and sectors, and also the general public about human rights approach, including interculturality and gender perspective;
and, to evolve from a utilitarian and passive participation of community members
towards the vision of fundamental social
actors in the improvement of nutrition and
their own development.
•• T
o ensure programmes sustainability since
its design stage. Especial consideration deserves the financial and environmental sustainability, because without them it would
be impossible to achieve and to maintain the desired impact in the population
through time. To gradually increase the allocation of public budget in nutrition for
social programmes in a framework of State
policies looking to ensure sustainability of
interventions, gradually decreasing external economic dependence.
xvii
•• The report is a technical reference tool (unplanned contribution that adds value to the
Study) on a number of issues that are crucial for programmes managers, in its broadest sense. These include the standardization
of definitions, terminology and concepts,
frequently not well known and often used
inappropriately by the program staff. Some
of these terms are: sustainability, coverage,
rights-based approach, cultural relevance,
gender perspective, filtering, monitoring,
evaluation, side effects, and the nutritional
dimension.
•• This Study represents an innovation due to:
i) It has the human rights approach, gender perspective, cultural relevance and scientific evidence as its framework; ii) It has
a holistic approach and considers various
determinants of undernutrition; iii) It simultaneously prioritizes in several excluded groups, for which there is generally no
information; iv) It analyzes a wide range
of social programmes using methods and
quantitative and qualitative instruments
in a combined manner; and, v) It incorporates into the analysis public, NGOs and
international cooperation agencies programmes.
•• Some social programmes studied are being strengthened. It is expected that by
improving the nutritional dimension of
programmes in all its phases, these can
contribute to the achievement of the Millennium Development Goals, in particular
MDGs 1, 4, 5 and 6.
•• The methodology, the instruments and the
process generated during the Study’s implementation, as well as the results, conclusions and recommendations constitute a
Public Good. They can be used and adapted by other countries and institutions from
the Region and also by other world regions.
•• I n the short term, the report helps countries
to address the global crisis by protecting
their priority populations. In the medium
and long term, it will contribute to consolidate and build social public policies and social protection systems.
•• T
he Report establishes a baseline in regards
to the design and operation of a significant
number of social protection programmes,
which will enable the monitoring of their
advance or recoil in the Subregion through
time and perform the necessary adjustments.
•• T
he Report represents an important tool
to advocate for the promotion, respect and
exercise of human rights (in particular the
Right to Food), whose scope is universal,
but in turn gives priority to groups in condition of greater vulnerability and social risk.
xviii
THE USE OF THE REPORT:
ADVANCES AND FUTURE PLANS
The results of the Study have been shared in
several regional and international meetings, including the WFP Executive Board in November 2009, in which the Study was supported by
governments and other authorities involved in
the meeting; and, the “Global South-South Development Expo 2009” where the Study won
an award as an innovative solution to support
the MDGs achievements.
The Study –in its final version– was presented
on the Third Meeting of the Interamerican Commission for Social Development (ICSD) of the
Organization of American States (OAS) in April,
2010. The report will also be considered and officially distributed during the upcoming Meeting
of Ministers and High Level Authorities of Social Development to be held in July 2010.
WFP has planned to share the final reports
(subregional and for the eight countries) of the
Study with the active participation of governments, NGOs, communities and cooperation
agencies for which a dissemination plan will
be devised with the countries involved. The Report will be used as an advocacy tool to obtain
better public and private commitments in favor
of the incorporation of the nutritional dimension in the social protection programmes and
as an instrument for the priority groups to demand and for the exercise of their rights, mainly the Right to Food.
During this year (2010) under WFP coordination, it is expected a preparation of a manual or guide on the design, implementation and
monitoring of social programmes with nutritional dimension. This tool which be based on
this Report, will facilitate a standarized training of human resources in charge of the programmes; key issue to improve the quality of
their performance at their duties.
The Report will be submitted for publishing
in prestigious scientific magazines and peer-reviewed journals, both in Spanish and in English,
in order to disseminate it with the international science community. This frequently forgotten
step by public institutions as well as by cooperation agencies is very important because it can
incorporate national and international advisors, scientific researchers and university professors as strategic partners who are responsible for the academic upbringing of nutrition
and other social sciences professionals in each
country. In this way, the incorporation of the
nutritional dimension in the programmes will
be facilitated.
Besides, there will be coordination to support
countries in the context of the overall multipartner proposal “Scaling Up Nutrition: A
framework for Action, 2009” to which the nutrition related international community has adhered to. This Study is totally in line with the
above mentioned proposal as it emphasizes the
importance of mainstreaming nutrition in multiple sectors, including evidence based cost-effective interventions. It also gives high priority
to children under two years of age and pregnant women in order take advantage of “The
Window of Opportunity”, and proposes the
substantial increase in the internal and external support to governments in the area of nutrition, within the framework of the principles
of effective international aid expressed in the
Paris Declaration and the Accra Agenda for
Action (AAA).
EXECUTIVE SUMMARY
THE CONTRIBUTIONS DERIVED
FROM THE STUDY AND THE REPORT
© PAHO, Chessa Lutter, 2010
In this regard, to implement the recommendations, there will be support and channeling
of direct technical assistance to countries according to their needs, capabilities, limitations,
challenges and priorities in order to strengthen the nutritional dimension of the social protection programmes studied, as well as other
similar programmes implemented in the same
countries or in different contexts.
It is necessary to take into consideration that
these recommendations are valid, applicable and adaptable to any other context where
there is a need to incorporate the nutritional
dimension into social protection programmes.
Finally, during the last quarter of 2010, it is
expected by WFP for this Study to be replicated in 4 priority countries of the Andean Subregion: Bolivia, Colombia, Ecuador and Peru.
The Study will be adapted to the socioeconomic, ethnic-cultural and geographic territorial
countries particularities, taking into consideration the process and lessons learned from the
first Study.
I
xx
POVERTY, FOOD INSECURITY AND MALNUTRITION
IN CENTRAL AMERICA AND THE DOMINICAN REPUBLIC
– THE ROLE OF SOCIAL SAFETY NETS
AND SOCIAL PROTECTION PROGRAMMES
I
is a proxy indicator that reflects the insufficient consumption of energy to maintain body
weight and carry on a healthy life.
According to FAO4, in the 2004-2006 periods,
there were 7.4 million undernourished people
in Central America and the Dominican Republic. More than 70% of the undernourished
population from these countries was concentrated in only three of them: Guatemala, Nicaragua and the Dominican Republic (5.3 million). In addition, the food prices increase effect
has meant 6 million more undernourished people between 2008 and 2009, according to disaggregated available information for the whole
Latin America and the Caribbean Region5.
Income distribution inequity2 distinguishes Latin America and the Caribbean, and in particular the Central American countries, among
one of the world’s most inequitable regions.
The population’s poorest 40% receives approximately 10% of the income while the richest 10% receives from 40% to 45% of the income, depending on the country. Guatemala
and Honduras, as well as Brazil and Colombia
are identified as the countries with the most
income distribution inequity in Latin America. In Honduras, the income for the richest
quintile of the population surpasses 33 times
the income of the poorest quintile and in Guatemala this relationship is approximately 25
times3.
In this region, there are different forms of child
undernutrition (see malnutrition terminology,
Annex iii) caused by micronutrients and macronutrients deficiencies, as well as other risk
factors. According to the new WHO growth
parameters, 23.5% of children under 5 years
suffer from stunting (chronic undernutrition or
low height for age) as consequence of a history of diets with insufficiency in the quality and
quantity of nutrients, inadequate feeding and
child care practices and recurring infections,
especially in the first stages of life6. As it can
be observed in Table 1, stunting affects in different proportions children under 5 years from
the eight participating countries in the Study,
with ranges that go from 54.5% in Guatemala
to 5.6% in Costa Rica. These prevalences are
worsened at local situations within the countries, with levels higher than 70% of stunting,
especially in areas where indigenous peoples
are concentrated7.
A. FOOD AND NUTRITIONAL CONTEXT
One of the indicators of the food situation at
country levels is the subnutrition rate, which is
expressed through the percentage of the population under the minimum level of food energy intake. Subnutrition (undernourishment)
Nutritional problems due to lack of nutrients
are not limited to height and weight deficits,
but micronutrients deficiencies are also present.
ECLAC, WFP (2009).
A Gini coefficient of zero indicates a completely equal
income distribution; higher levels of the coefficient signal high inequity. With a Gini coefficient of 58.3,only
Brazil surpasses Guatemala’s inequity in Latin America
(ECLAC, WFP 2009).
3
ECLAC, WFP (2009) ibid.
1
2
FAO (2009)a.
FAO (2009)b.
6
PAHO (2008).
7
Hall and Patrinos (2006).
4
5
3
Despite the efforts in reducing poverty and
achievements obtained, nearly half of the Central America population and more than one
third of Dominicans are still living in poverty situation. A quarter of the total of the Central American population face extreme poverty. The incidence of the phenomena is much
higher in the rural areas, were 67% of the region’s poor population and 76.6% of those living under extreme poverty lives. With important differences between countries, 3 of every 5
households present at least one unfulfilled basic need1.
I
Table 1
Prevalence of chronic undernutrition and
anemia in children under 5 and 2 years in
Central America and the Dominican Republic
Children under 5 years
Children under 2 years
Belize
22,0%
NA
NA
Costa Rica
5,6%
7,6%
37,2%
El Salvador
19,2%
22,9%
37,7%
39,7%
55,6%
Guatemala
Figure 1
Prevalence of chronic undernutrition
(H/A < - 2 SD) in children under 5 years in
rural and urban areas in Central American
countries and the Dominican Republic
Anemia (Hb < 11 mg/dL)
Chronic Undernutrition in children
under 5 years (H/A < - 2 SD)
according to WHO reference
Countries
Following the same pattern as poverty, the hunger and undernutrition distribution is not homogeneous in the population. Disparities between countries and within themselves are
enormous. On average, the prevalence of chronic undernutrition among children in rural areas
is almost double in regards to children in urban
areas (Figure 1).
54,5%
Honduras
30,1%
29,9%
45,3%
Nicaragua
21,7%
17,0%
29,4%
Panama
19,1%
36,0%
52,5%
Dominican Republic
9,8%
25,0%
NA
Source: Produced by WFP in 2010 with data from last available national surveys according to new WHO standards: Panama LSS 2008; Dominican Republic DHS, 2007; Nicaragua DHS 2006/2007; Guatemala MCHNS 2008/2009 (according to NCHS growth standards).
Source: Produced by WFP in 2010 using last available data, according to new WHO growth standards:
For stunting: Demographics and Health Surveys, UNICEF (The State of the World ´s Children, 2010) and PAHO (Undernutrition in infants and young children in Latin America and the Caribbean: achieving the Millennium Development Goals, 2008). Belize: UNICEF, 2010. Costa Rica: NNS, 2008-2009. El
Salvador: FHNS, 2008. Guatemala and Honduras: PAHO, 2008. Nicaragua: DHS, 2006/2007. Panama: LSS, 2008. Dominican Republic: DHS, 2007.
For anemia: WHO. Vitamin and Mineral Nutrition Information System, 2010; Costa Rica: NNS, 2008-2009 (for children under 5 years); WHO, 2010 (children under 2 years); El Salvador: FHNS, 2008; Dominican Republic: Estimated values according to Mason et al. Food and Nutrition Bulletin, 2005; 25
(1): 57-162.
NA: Not available.
8
9
4
WHO ( 2008).
WHO (2010).
5
Anemia (mostly caused by iron deficiency) is
the most extended and frequent nutritional problem in countries. In the regional scope
(Latin America and the Caribbean), 39.5% of
children under 5 years have anemia; 31.1% of
pregnant women; and, 23.5% of childbearing
women8. In countries such as Guatemala and
Panama, more than one third of children under
5 years, and more than half of children under
2 years9 have anemia, as it can be observed in
Table 1.
I
Figure 2
Prevalence of chronic undernutrition
(H/A < - 2 SD) in indigenous and non
indigenous children under 5 years
in Central American countries.
By its part, wasting (low weight for height or
emaciation) has notoriously increased in the
majority of the countries as a consequence of
recent crises. A recent study undertaken by
several international agencies in Guatemala’s
Dry Corridor reveals an average prevalence of
11%; this rate has increased by five times in
relation to previous national data11. The situation among children from 6 to 11 months
and from 12 to 23 months is much worse, with
prevalences of 17% and 15% respectively.
Only 22% of the families have adequate access
to food and 34% is living in a food insecurity situation. In Honduras, wasting has also tripled, particularly in the Southwestern region12.
infectious diseases –mainly diarrhea and respiratory infections– are among undernutrition
immediate causes.
According to what is reported in the latest national health surveys of the participating countries in the Study14, the prevalence of exclusive
breastfeeding (EB) in children under 6 months
is barely 7.8% in the Dominican Republic;
10.2% in Belize; 18.7% in Costa Rica; 29.7%
in Honduras; 30.6% in Nicaragua; 31% in
El Salvador; 34.8% in Panama; and, 49.6%
in Guatemala. However, only four countries
(the Dominican Republic, Honduras, Nicaragua and Guatemala) used the same age range,
which fluctuates between 0–5 months. In the
case of Belize, Costa Rica, El Salvador and Panama, that used different age groups, it was not
possible to show the real trend that exists in regards to EB percentage distribution in children
under 6 months. This demonstrates the need to
standardize the age ranges with the purpose of
homogenizing the indicators used.
1. Causes or determinant factors
of child undernutrition in Central America
and the Dominican Republic
Source: Produced by WFP in 2010 with data from last available national surveys: Guatemala MCHNS 2008/2009 (according to NHCS growth standards);
Panama LSS 2008 (according to WHO growth standards); Belize LSMS, 2002 (according to NHCS growth standards).
For afrodescendants, the magnitude of the disparities in the nutritional situation is frequently underestimated because of the inexistence
of studies or surveys with disaggregated data
by ethnic-racial origin in this subregion. This
hides the problem’s real dimension, the exclusion and discrimination suffered by this people
for centuries10.
10
6
Bello and Rangel (2002).
The period from pregnancy until 24 months of
age is the most risk prone in regards to undernutrition and its adverse effects. It is also considered the “window of opportunity”13, a period were the biggest social investment return
rates are obtained. Being this life stage the one
with the biggest physical and psychomotor development, physical and cognitive damage derived from undernutrition is in most cases irreversible. In this sense, it is fundamental that
the nutritional interventions prioritize the attention to pregnant women and children from
0 to 2 years of age.
It is acknowledged that complementary feeding, frequently, is inadequate in the countries
of the region15. Complementary foods offered
to children do not have energy and nutrients
density, or the diversity in order to cover their
nutritional requirements. At a very early age of
life, a lot of liquids are offered with low or null
nutritional density (like sweetened and aromatized water, teas, infusions, fruit juices, soups
and “atoles16”, among others), which disfavors
exclusive breastfeeding. These foods continue
In general, breastfeeding, hygienic and complementary feeding inadequate practices, as well
as the lack of child care, substantially affect
the genesis of undernutrition at countries level. Insufficient food intake, its low quality and
Belize: MICS 2006. Costa Rica: INEC 2006. El Salvador: FHNS 2008. Guatemala: MCHNS 2008/2009. Honduras: DHS 2005/2006. Nicaragua: DHS 2006/2007.
Panamá: LSS 2008. República Dominicana: DHS 2007.
15
Lutter and Rivera (2003).
16
The atole, also known as atol in some regions, it is
a pre-Hispanic beverage consumed mainly in Mexico,
Guatemala and other Central American countries. In its
original form is a sweet cooked corn flour in water, in
proportions such that at the end of cooking has a moderate viscosity and served as hot as possible.
14
Humanitarian Network (2009).
TRANSTEC International Project Management
(2009).
13
From under 9 to 24 months (from pregnancy until 2
years of age). The Lancet “Maternal and Child Undernutrition” Series, 2008.
11
12
7
Chronic undernutrition among indigenous
children is more than double or even triple of
the prevalence among children of non indigenous families, as reflected in Figure 2.
I
The underlying causes of undernutrition are
multiple and the value of each one of them
varies according to each country context. In
general, low schooling and information level, especially among mothers, lack of access to
drinking water and basic sanitation, linked to
food insecurity, directly influence families’ nutritional problems.
In the case of Guatemala (one of the 36 countries in the world that contribute to the 90%
stunting rate and being the one with the biggest prevalence in Latin America), the main
determinants of chronic undernutrition have
been identified18. Among the immediate causes,
inadequate feeding practices (including low
breastfeeding and inadequate complementary feeding in children under 2 years). Among
the underlying ones, there are: limited access
to health and education services; insufficient
access to food in quantity and variety; lack of
access to safe water, very precarious sanitation
infrastructure and poor hygiene practices. As
structural causes of stunting (chronic undernutrition) in this country the following are identified: unemployment, underemployment and
the informal market without social protection
coverage; the insufficient agricultural sector
minimum wage; the low tax collection; remittances reduction; and the limited food sovereignty (high dependency on imports of staple
foods such as beans, which is 60% imported).
2. Undernutrition consequences
is characterized by the presence of nutritional deficiencies, such as stunting and anemia,
with a progressive increase in the prevalence of
overweight and obesity and its direct association with chronic diseases, including cardiovascular disease, diabetes, high blood pressure and
some types of cancer.
A third of all children deaths in developing
countries are related to undernutrition19. The
consequences of child undernutrition, including micronutrients deficiencies, are being reflected in irreversible damages to physical
growth and development, in intellectual and
productive capacity diminishment and deterioration in the quality of life. The negative impact
of an inadequate nutrition is reflected through
the course of life at the individual and collective level, in the health, education, productivity and the socio economical development of
countries20,21. They seriously affect human capital and perpetuate poverty intergenerational
transition22,23.
Of the ten risk factors identified by WHO as
key for the development of chronic diseases, five are closely related to inadequate diets
caused by excesses and unbalances in the dietary intake and lack of physical activity. Deficit problems as well as problems caused by food
excesses are related to poverty25. They substantially contribute into the morbidity-mortality burden in developing countries –66% of all
deaths resulting from chronic diseases occur
in these countries26– hence the need for these
problems to be faced in a joint manner27.
According to an ECLAC and WFP Study24,
child undernutrition suffered during the last decades generated a cost of 6,659 million dollars
in Central America and the Dominican Republic up to the year 2004. The resulting economic
impact is significant, representing up to 1.7%
and 11.4% of Costa Rica and Guatemala’s
GDP respectively. Productivity losses caused by
higher death occurrences and lesser educational
levels represent up to 90% of the costs.
The double burden imposes that efforts directed at the reduction of child undernutrition are
priority targeted towards the diminishment of
stunting, and not in weight gain.
According to the latest national surveys, using
WHO growth standards, 8.1% of children under 5 years in Costa Rica as well as the Dominican Republic have a weight for height classified
as high (superior to two standard deviations).
In El Salvador, this prevalence is of 6.0%.
3. Epidemiological and nutritional transition:
The double burden
The prevalences of overweight observed in
children under 5 years in Panama clearly reveal
the magnitude of the double burden, mainly in
indigenous children: while 25.5% of non indigenous children under 5 years from rural areas are classified as in overweight risk (have a
weight for height superior to one standard deviation), practically the double (45.8%) of indigenous children of that age suffer this risk. The
stunting prevalence in these same indigenous
The nutritional situation has evolved differently in the countries of Latin America and the
Caribbean. Malnutrition by deficit and excess
coexist, which is characteristic of nutritional
epidemiological transition in which countries
in the Study are immersed. This transition in
Central America and the Dominican Republic
UNICEF (2009).
Black et al (2008).
21
ECLAC,WFP (2007).
22
Hoddinott et al (2008).
23
Martorell et al (1995).
24
ECLAC,WFP (2007) ibid.
19
20
Guatemala: MCHNS 2008/2009. Honduras: DHS
2005/2006. Nicaragua: DHS 2006/2007. República Dominicana: DHS 2007.
18
PAHO (2009).
17
Uauy et al (2008).
WHO (2004).
27
SCN (2006).
25
26
9
to be the staple foods for the child even until
reaching one year of age. Furthermore, the addition of non mother’s milk/mother’s milk substitutes before 6 months of age is a non advisable practice and still extended in the region.
The 41.7% of children under 6 months in
the Dominican Republic, 34% in Nicaragua,
19.4% in Guatemala and 16.2% in Honduras
consume this type of food17.
I
4. Emerging crises effects in food
and nutritional security
The global financial crisis, the food crisis and
the environment deterioration, are exacerbating food insecurity and undernutrition, putting at serious risk the achievement of the Millennium Development Goals (MDG). This
affects especially the groups in condition of
most vulnerability to poverty, social exclusion,
undernutrition, discrimination and stigmatization: children under two years, pregnant and
lactating women, people living with HIV, indigenous peoples and afrodescendants populations.
By effect of the increase in food prices, in Guatemala, El Salvador, Honduras and Nicaragua, in an 18 month period between 2006 and
2008, the number of poor people increased in
1.5 million individuals28.
comparison to the same period in 2008. The
diminishment reached near 10% in Guatemala and El Salvador, and was lesser (4%) in Nicaragua.
On the other hand, the world financial crisis
strongly reduced the economic growth of the
regions countries; exports, employment and
fiscal incomes. Maybe the most visible impact
of the crisis is the loss of jobs, making that the
majority of affected individuals become “new
poor”29. Other significant effect is the slowdown of remittance inflows, which are considered the biggest “social safety nets” in this subregion, and that in previous crises were “the
lifeline” for a lot of families in poverty and
extreme poverty situation. In countries with
available updated data: Guatemala, Nicaragua and El Salvador, the volume of remittances decreased in the first semester of 2009 in
28
29
The chain effects of the food and financial crises have determined the decrease in households’ income thus a reduction in their purchasing power, bringing as consequence the
decrease in food consumption. The WFP Study
about Food Prices Increase30 estimated that
among the poorest families, food consumption
decreased between 6% and 26% in Guatemala,
Honduras, El Salvador and Nicaragua. The diminishment is more evident in the animal protein rich foods as well as vegetables and fruits
consumption. According to the same study, in
WFP (2008).
ECLAC, WFP (2009) ibid.
Guatemala, more than 70% of the households
interviewed in the municipalities of biggest
vulnerability indicated they consume now less
meat, including chicken, as well as less fruits
and vegetables.
Aside from causing economic losses, natural
disasters have had a devastating effect in the
food security and nutritional situation of the
neediest populations. According to WFP Assessment about Food Security in Emergencies
(EFSA), between 2005 and the first semester
of 2009, natural disasters that occurred in the
four aforementioned countries, provoked that
half a million people fell in food insecurity situation because of the loss of their crops, employment sources and food reserves. The outlook
becomes more somber in attention to climate
change effects. It is estimated that there will
be an increase in the frequency of extreme climate phenomena such as hurricanes and tropical storms, more climate variability will be generated and the apparition of plagues, affecting
agricultural production.
In addition, Central America is one of the
worlds regions with more probability of natural disasters occurrence. Disasters, far from
moving back, have increased progressively during the last decades: the number of catastrophic events has doubled between 2000 and 2007
in comparison to those that occurred between
1980 and 1990 (Increment from 72 events to
167)31.
Coordination Center for the Prevention of Natural
Disasters in Central America (2006).
31
30
10
WFP (2008) ibid.
11
children reaches 62% (compared to 17.3% of
non indigenous children). That is, out of every
10 Panamanian indigenous children, almost 6
of them are stunted, and almost 5 are in risk of
overweight and obesity.
I
B. SOCIAL SAFETY NETS AND SOCIAL
INVESTMENT
5. The HIV epidemic and the nutritional
situation
The nutritional situation of a woman living
with HIV before and during pregnancy influence in her health status and in the risk of
Mother-Child Transmission or vertical transmission (it is known as vertical transmission
the situation in which a child is infected with
the HIV virus during pregnancy, delivery or
through breastfeeding). Children born from
HIV infected mothers have a bigger risk of being underweight at birth. That is why it is advisable to guarantee an adequate nutrition, especially to the pregnant and lactating women
living with HIV.
Nearly 2 million people are living with HIV in
Latin America and the Caribbean. The most
recent data suggests that the epidemic remains
stable in the region, with a regional prevalence
of 0.6%. In the countries of the Study, the
prevalences oscillate between 0.2% and 2.1%
of the adult population in Nicaragua and Belize respectively. Others affected by the epidemic are the Dominican Republic, Panama
and Honduras, with prevalences from 0.7%
to 1.1%32.
People living with HIV have a bigger risk of
suffering from undernutrition because of the
impact opportunistic diseases have on the organism. Thus, it is fundamental to strengthen
the immune system of this population through
an adequate nutrients intake, guaranteeing access to an optimum nutrition.
Although the magnitude of the problem in relative terms is very distant from malnutrition
(as for deficit as well as for excess), the increasing occurrence of infection among women and
girls evidences that the epidemic is generalizing
in these priority groups with the consequent
nutritional deterioration and increase in morbidity-mortality.
An adequate nutrition is essential for the success
of the antiretroviral therapy (ART). Investments
in ART and programmes to prevent mother to
child transmission or vertical transmission have
to be accompanied by food and nutritional support to guarantee the treatment results.
To control the negative effects of the HIV, poverty and food and nutritional insecurity cycle
it is required to integrate attention, prevention
and the services of HIV mitigation in food and
nutritional interventions.
32
An SSN is only an articulate piece of a policy –or system– of broader social protection. An
effective SSN is much more than the set of well
designed and well implemented programmes;
it must have the following attributes35: be appropriate, adequate, equitable (with the human
rights approach), cost-effective, compatible in
incentives, sustainable and dynamic. Its quality
depends directly of the details and care in its
design, monitoring, management, implementation and evaluation. The SSN in Latin America and the Caribbean are in permanent state
of construction and dynamics; they integrate
government programmes and agreements with
NGOs and multilateral organisms with protection and promotion actions. The ideal design assumption is that they examine the quality and quantity of the demand and adequate
it with the existing services offer in different
scopes: central, regional, departmental, municipal and local. They have an overseeing organism (Ministry, Secretariat) in charge of designing, articulating, targeting and promoting
the participation of communities, implementing, doing follow up, evaluating and making
the appropriate adjustments in accordance to
monitoring and evaluation results.
The Social Safety Nets (SSN) are instruments of
social policy by which States can and must fulfill their function in the guaranteeing of human
rights, especially the right to food and the enjoyment of an adequate nutrition, ensuring that
the whole population at the level of persons,
families and communities –especially priority
groups– have availability and sufficient and stable access to food in quantity and quality; that
their consumption and biological use be adequate to produce well being and development.
On the other hand, there are evidences of the
inversely proportional relationship between
social investment (social expenditure) and the
prevalence of child undernutrition: stunting36
as well as underweight37. Countries that currently present the least undernutrition prevalences in Latin America and the Caribbean,
such as Chile, Brazil, Costa Rica, Mexico and
the Dominican Republic are the ones with the
biggest per capita social investments in health
and nutrition. On the contrary, countries with
the highest chronic undernutrition prevalences
(Guatemala, Bolivia, Honduras and Haiti) are
those with the least social investment in these
areas.
The SSN are articulate mechanisms with common goals, formed by free or subsidized programmes that look to: develop human capital;
reduce inequity and social exclusion; ensure adequate levels of nutrition, health and well being; improve on living standards; help families
minimize food and nutrition vulnerability; assist on risk management to any negative event;
promote self-sufficiency and empowerment;
and redistribute income among the poorest
with the intention of obtaining an immediate
impact upon poverty and inequity reduction34.
WHO/UNAIDS/UNICEF/UNFPA (2008).
Definition adapted by WFP (2009)a, based upon
other definitions from ILO, FAO,WB, United Kingdom
Department for International Development and the Asian
Development Bank.
33
34
One of the critical aspects in the prevention
of vertical transmission (especially through
breastfeeding) is counseling directed towards
UNAIDS (2009).
12
Grosh et al (2008).
WFP (2009)a.
37
ECLAC, WFP (2009).
35
36
13
mothers about an appropriate children feeding.
In order for the mother to make an informed
decision she must understand the best options
regarding her children´s feeding according to
her individual context. The World Health Organization (WHO) recommends exclusive
breastfeeding during the first six months of life
for children born to women infected with HIV,
unless substitute feeding is acceptable, feasible,
affordable, sustainable and safe (AFASS)33. At
no moment during the first 6 months mixed
feeding is recommended.
In response to the previously described context, since June of 2009, the World Food Programme (WFP) Regional Bureau for Latin
America and the Caribbean, led the development of a comprehensive study on the scope
of the nutritional dimension in the social protection programmes of the 8 countries that
integrate SICA: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the Dominican Republic. In the context of the global crisis, WFP looks to support
these countries in order to strengthen the policies and social protection programmes in favor
of the population groups that are in situation
of major vulnerability in regards to undernutrition, poverty, exclusion and discrimination.
The Central America and the Dominican Republic Subregion has been prioritized considering that in the actual juncture they are the most
affected countries by the impact of the world
crisis, the recurrence of natural phenomena
and the lowering in the flow of remittances.
The following are the key aspects of the Study:
II STUDY OBJECTIVES
14
II
STUDY OBJECTIVES
A. GENERAL OBJECTIVE
Understand the scope of the nutritional dimension38 of Social Safety Nets in Central America
and the Dominican Republic, as well as the priority given within these nets to children under
2 years, pregnant and lactating women, people living with HIV, indigenous peoples and afrodescendants populations.
Nutritional dimension understood as the adequate
identification of the main nutritional problems, the most
affected population groups and zones and, the explicit
incorporation of objectives, interventions/actions and
nutritional indicators in the different phases of the programme cycle.
38
16
17
B. SPECIFIC OBJECTIVES
1. To analyze whether the selected social protection programmes in the Study incorporate objectives, components and nutritional
indicators at different stages: design, implementation, monitoring and evaluation as
well as the relevance of the nutritional dimension.
2. To analyze whether the programmes selected for the Study prioritize/target its interventions in children under 2 years, pregnant and lactating women, people living
with HIV, indigenous peoples and afrodescendants populations; and what were the
criteria used for targeting and setting intervention priorities.
3. To provide input to the governments of
the countries involved and the cooperation agencies to resize and strengthen the
role of social protection programmes, seeking their nutritional impact in these priority groups that are in a situation of greater
vulnerability.
4. To have an advocacy tool that allows the
increase in public, private and donor community commitments in favor of the nutritional protection of priority groups of the
Central American and Dominican Republic
population, as part of the strengthening of
social safety nets in the region.
III METHODOLOGY, STAGES
AND ORGANIZATION OF THE STUDY
18
III
II
3. Target population: Regardless of whether
or not to include nutritional components,
the programme must be directed to at least
one of these target groups: children under 2
and 5 years, pregnant and lactating women,
people with HIV, indigenous peoples and
afrodescendants populations; population
living in poverty and/or extreme poverty.
4. In effect as of 2009: The programme must
place and have a minimum budget for 2009,
regardless of whether the funding source is
public or private. In this approach there
is one exception: the plans, strategies and/
or policies that do not necessarily have an
assigned budget (i.e. food security policies
and nutrition) must be included because
they provide the framework and context for
most programmes.
A. PROGRAMMES SELECTION CRITERIA
Taking into account that there are numerous
social programmes in the 8 countries (inventories carried out by regional institutions estimate that between 200 to 400 programmes
exist), criteria was initially agreed for selecting
programmes to be included in the Study, in order to take a “sample” to represent the existing
diversity; without that meaning having a statistically significant sample (since the real universe is unknown). These criteria were:
5. Programmes with official recognition: Primarily government programmes are included (public institutions such as Health, Social Development, Agriculture Ministries;
Secretariats or Food and Nutritional Security Councils; Integral Attention Centers for Pre-School Children; First Ladies
Offices; among others). Also programmes
run by NGOs and external cooperation
agencies are included, whether interagency or not, that meet the requirements mentioned above. Importantly, this Study has
as its goal to support public programmes
with priority. In this sense, the programmes
carried out by NGOs to be included in the
Study must not be isolated programmes,
but rather concerted and/or coordinated
with governments.
1. Population covered: Include programmes
that assist over 10,000 inhabitants, or 10
communities or a municipality. This criterion is relative and applied to the reality and
population size of each country. For example, a programme with a target population
of 5,000 people in Belize is different from
one that reaches the same number of people in Guatemala.
2. Types of programmes: Include at least one
of the programmes in the following areas: conditional transfers; mother and
child nutrition and health; food-based programmes, micronutrient supplementation
and fortification, biofortification, productive programmes, childhood and adolescence attention programmes and HIV-specific programmes. It does not include
20
21
METHODOLOGY, STAGES AND ORGANIZATION OF THE STUDY
school feeding programmes and emergency
response programmes nor programmes for
adults (with the exception of HIV ones).
The Study of the Social Safety Nets is based
on the analysis of secondary sources of information, review of primary data (as the latest
Demographics and Health Survey) and the
collection of data through direct interviews
with officials responsible for the different programmes and also interviews with individual
key informants. It is a transversal analytical
epidemiological study, and as such is basically descriptive. In this sense, the data and findings represent the set of programmes, plans
and policies analyzed. The differences found
allowed the establishment of an association between the variables studied.
III
II
The HLTG functions were:
The different stages of the Study are described
as follows:
a. The general orientation of the process.
b. Review the terms of reference of the Study.
1. Formation of a High Level Technical
Group (HLTG)
c. Review of the comprehensive survey of the
Study and the Interview directed to key informants.
After developing the terms of reference draft
for the Study, various institutions were invited
to technically steer its execution. A High Level Technical Group (HLTG) was formed, composed of 26 experts. The institutions that comprise the HLTG are: The World Bank (WB);
Economic Commission for Latin America and
the Caribbean (ECLAC); Emory University;
United Nations Children’s Fund (UNICEF); International Food Policy Research Institute (IFPRI); National Institute of Public Health (INSP)
of Mexico; Institute of Nutrition of Central
America and Panama (INCAP); Institute of Nutrition and Food Technology (INTA) of Chile,
Micronutrient Initiative (MI); Institute of Hunger Studies (IEH of Spain); Organization of
American States (OAS;) Pan American Health
Organization (PAHO); World Food Programme
(WFP); Regional Programme for Food Security
and Nutrition for Central America (PRESANCA); Joint United Nations Programme on HIV/
AIDS (UNAIDS); Tufts University; and, University of Chile (Medical School).
d. Review the report with the findings of the
Study.
e. Contribution to the development of specific recommendations for the governments
of the countries and the international community to strengthen the nutritional dimension of the SSN.
2. Collection of information at regional level
and in the countries
analysis, studies conducted in previous years
with the support of WFP in Latin America and
the Caribbean were taken, among them: diagnosis and inventories about characterization
of nutritional programmes and focus on determinants, made by regional bodies such as the
INCAP39 and INSP40,41; GESA World42 studies
on food security and nutritional programmes;
inventory of maternal and child health programmes of Nutrinet.org43 and studies by various agencies on conditional cash transfers and
other nutritional programmes. At the same
time, baseline data collected and shared by
the National Public Health Institute of Mexico (Nutritional component of the Mesoamerican Initiative for Public Health) was analyzed,
within the framework of a cooperation agreement between the INSP and WFP. Finally, the
national programmes information available via
internet was reviewed.
A quantitative Comprehensive Survey was designed and applied that explores the existing
nutritional dimension in the programmes with
a holistic approach, and includes social, economical, cultural and political determinants of
undernutrition. Through this survey the following aspects were studied:
a. Types of programmes and geographical location.
b. Duration, executing institutions, dependencies and responsible sectors. Collaboration
and coordination.
c. Normative.
Through a participatory process, all members
of the HLTG were able to contribute their technical criteria and experience in different phases
of the Study, mainly by electronic means. On
October 23rd, 2009 there was a face to face
meeting, where preliminary results and general conclusions of the Study were presented and
discussed and recommendations were received
to complete the information analysis phase and
for preparation of the final report.
d. General and specific objectives.
It also required the review of other countries
positive experiences, which have a holistic approach and have been evaluated as effective,
among them, the “Opportunities” programme
in Mexico (Ex Progresa)44 , and “Families in
Action” programme of Colombia45. Another programme labeled as having “good nutritional design” is the conditional transfer programme “Juntos”46 in Peru, which envisages a
significant nutritional impact by including the
nutritional dimension, since the design stage.
e. Components, lines of action and services
provided.
f. Target population, targeting criteria, coverage and filtering.
g. Preventive, therapeutic and promotional
approach.
h. Human rights approach, gender perspective, cultural relevance, and community
participation.
i. Human resources and training.
INCAP (2005).
Leroy et al (2006).
41
Neufeld et al (2006).
42
IADB, Gesaworld (Investment opportunities in Preventive Nutrition for Guatemala, Honduras, Nicaragua
and El Salvador).
43
http://nutrinet.org (2007-2008). Knowledge management platform launched by WFP in the region of Latin
America and the Caribbean to fight hunger and undernutrition. In present times it is a regional foundation.
44
Rivera et al (2004).
45
Attanasio et al (2005).
46
Perova and Vakis (2009).
39
40
j. Management, monitoring, evaluation and
collateral effects.
k. Sustainability, investment and funding
sources.
l. Relationship with national poverty reduction strategies.
At the regional level, various sources of secondary information were reviewed. As basis of
22
23
B. STAGES OF THE STUDY
III
II
Threats (SWOT) was prepared in order to enrich and complement the findings of the comprehensive survey.
Data was collected from 110 social protection
programmes and 10 plans and policies related
to food and nutrition (see the complete list on
Annex ii).
ii. Simultaneously prioritizes in several excluded groups, for which there is generally
no information.
While in the past there have been other studies
and inventories that account for the existence
of numerous programmes and projects about
food and nutritional security, this Study represents an innovation as its design has enabled to
obtain pioneer information on its genre, highlighting the following aspects:
i. It has a holistic approach and considers
various determinants of undernutrition.
iii. Analyzes a wide range of social programmes
and uses, in a combined manner, methods
and quantitative and qualitative tools.
As indicated, programmes were classified into
11 categories: i) Conditional transfers programmes; ii) Mother and child nutrition programmes; iii) Mother and child health programmes; iv) Food-based programmes; v)
Nutritional recovery programmes; vi) Micronutrient supplementation programmes; vii)
Micronutrient fortification programmes; viii)
Biofortification programmes; ix) Productive
programmes; x) Childhood and adolescence
attention programmes; and, xi) HIV-specific
programmes.
iv. Incorporates into the analysis public,
NGOs and international cooperation agencies programmes.
v. It has as its framework, the human rights
approach, the gender perspective, the cultural relevance and the scientific evidence.
3. Information analysis
On the other hand, there were key informant
interviews (qualitative) to collect their opinions on the SSN. Those interviewed were political leaders, current and former government
officials, community leaders, artists, nutrition
and breastfeeding experts, people living with
HIV and entrepreneurs. It is considered that as
key informants in the country they are recognized as “opinion makers” and their opinion
has, has had or may have any influence, –either positive or negative– in the decisions over
the course or content of these programmes. In
total 35 interviews were conducted in the 8
countries. From this information, an Analysis
of Strengths, Weaknesses, Opportunities and
The information collected in the countries was
organized into databases or summary matricies. The data entry was made in the SurveyMonkey® web platform (SurveyMonkey, 640
Oak Grove Avenue Menlo Park, CA 94025).
Subsequently, the information had to be transferred to Excel spreadsheets in order to be
processed. Once databases were organized, a
thorough inspection and cleaning of them was
done as part of the process in close consultation with the staff responsible for the collection
of information in countries. An analysis plan
was conducted previously arranged with the
HLTG. Further processing of quantitative data
24
was done in SPSS® (SPSS Inc., 233 S. Wacker
Drive, 11th floor, Chicago, Illinois 60606) and
consisted primarily of a descriptive analysis:
frequency tables and cross tabulations of two
or more variables.
and their causes; if they incorporate objectives aimed at reducing or improving nutritional status; if they incorporated components that have demonstrated high cost
effectiveness according to current scientific
evidence and whether they targeted priority population groups to prevent and reduce
child and maternal undernutrition. It was
also inquired whether programmes included
nutritional indicators and monitoring and
evaluation actions since the design stage.
The Study´s unit of analysis are the programmes themselves. Nonetheless, the multiple-choice answers were also analyzed, generating percentages that exceed the 100% in
most cases.
b. Implementation: The availability and quality of food and supplies (supplements, educational materials, vouchers and others) that
programmes distribute was analyzed by examining the nutritional content of foods and
supplements, to which groups they are going and whether there was sufficient availability to guarantee a continuous distribution. Also was reviewed the availability and
types of human resources training and capacity development in nutrition in both the
technical staff and the community staff.
With regards to sample size, the total of 110
programmes is one of the largest samples reported in the literature on this subject, which
was enough to answer the most important
questions of the Study. However, the analysis by country reduced significantly the size of
each sample to an average of 15 programmes.
When analyzing by type or category of programmes, 11 different types of programmes
were obtained (detailed previously), a much
higher number than expected in the analysis
plan. When the data was broken down by country and by type of programme, the sample was
considerably reduced (less than 5 programmes
and in occasions without programmes). With
this data in many cases it was impossible to
conduct internal analysis among multiple variables (multivariate).
c. Monitoring and evaluation: It was examined
whether the programmes have a nutritional baseline and established monitoring and
evaluation systems. The nutritional dimension was considered based on whether these
systems incorporate indicators of nutrition
and at what stages; whether they monitor
the accomplishment of the programmed activities; evaluate the impact of interventions
and feedback from the information generated in order to apply corrective actions or
lessons learned that enable to improve the
programmes and its effects in the nutrition
of priority groups and their families.
Due to what was previously stated, most of the
inferences made in this Study –based on the frequency and bivariated analysis of the total 110
programmes– are valid and are supported by a
sample size sufficiently representative of reality. By contrast, statements that are proposed as
a result of multivariate analysis should be seen
as quite probable hypothesis to be verified by
more specific studies.
d. Cross-cutting issues: For the stages outlined above, it was examined whether the
programmes are based on the human rights
and gender approaches, and whether they
take into account cultural relevance and
community participation. Additionally, it
was described the ways these approaches
implemented in practice.
The nutritional dimension analysis was done
for each one of the stages of the programmes
cycle:
a. Design: It was analyzed to what extent the
formulation of programmes and plans is
based on a diagnosis of nutritional problems
25
With the information gathered at the regional level a matrix of different programmes by
country was prepared. It was shared with WFP
country offices for review in accordance with
national counterparts. The final selection of
the programmes to be included in the Study
was made at the country level, according to established criteria. Interviews were conducted
with managers and technicians in charge of the
studied programmes. These were conducted by
WFP nutrition officers or consultants in countries where WFP representation exists, and by
specifically hired consultants in those countries
without WFP representation.
D. LIMITATIONS
e. Sustainability and funding sources: An analysis was made of the main sources of funding for the programmes considering both internal public resources as well as external
funds, either donated or loaned. The examination of the sustainability (social, institutional, legal, financial and environmental)
was conducted based on the survey data and
on the interviewed officials own opinions.
•• The number of programmes studied by
country (11 types of programmes) affected the “n” of some answers. As previously indicated, when the sample by country
was disaggregated by type of programme,
it reduces itself considerably, impeding the
bi and multivariate analysis.
•• In spite of the fact that in the selection criteria it was defined the inclusion of at least
one programme of each type, in some countries certain types of programmes relevant
to the Study were not considered, for example, the Mother and Child Health ones.
C. PERSONNEL AND INSTITUTIONS
INVOLVED
The personnel involved were numerous and diverse; more than 200 people participated:
1. High Level Technical Group (HLTG) formed
by 26 experts from aforementioned institutions and agencies (See Annex i).
•• The Study did not contemplate conducting field visits, so the analysis of the implementation and operational aspects of the
programmes is only based on secondary
sources of information and data provided
by officials of the institutions involved and
key informants.
2. National institutions representatives, in
charge of the direction and/or implementation of the programmes and also of providing and validating information of the
comprehensive survey. Opinion leaders in
charge of providing the Study’s qualitative
information (See Annex i).
•• In Honduras, the participation of public institutions was very limited because of political difficulties, thus the information collected could not be supplemented by formal
interviews with officials responsible for the
programmes. Subsequently, the information could only be partially revised by the
counterparts.
3. WFP regional team of HIV and Nutrition
Areas, being Nutrition the area responsible
for the coordination and technical steering
of the Study. The WFP team at each country office level (nutrition and HIV officers
or focal points and a temporary consultant)
in charge of collecting the information in
a coordinated manner with the national
counterparts.
Despite of the aforementioned limitations, it
is considered that the Study met its objectives.
The methodology used as well as the process
generated during its implementation can be
totally replicated in other programmes of the
same countries of the Study, in other countries
of the Latin America and the Caribbean region
and in other regions of the world. The recommendations can be applied by adapting them
to different contexts.
4. Study consultants, supported by statisticians. Along with the WFP Nutrition Area,
they were in charge of the design and/or
review of the information collecting instruments; of the database cleaning; and
supported the preparation of the Study’s
subregional report. A specific consultant for
the analysis of the conditional transfer programmes has also participated in the Study.
IV RESULTS AND ANALYSIS
26
III
IV
II
In recent years, governments of Latin America
and the Caribbean countries have taken up interest and political commitment in improving
the nutrition of their populations, particularly
children and women. Through technical consultations, forums, high-level ministerial summits and multiple advocacy actions, the WFP
together with other UN agencies, regional technical institutes and other international organizations (many of them are part of the HLTG of
the Study) have contributed with governments
of the region in order to position nutritional issues as the fundamental axis of the countries
social and economic development.
A. General context in regards to plans and
policies
B. General characteristics of the programmes
C. Nutritional dimension in social protection
programmes
D. Target population, targeting criteria, coverage and filtering
E. Management and implementation of programmes
As a result of this regional effort, started in
2005, technical support was provided to LAC
priority countries, mainly to Central American
countries and the Dominican Republic for the
design of the “Regional Initiative towards the
Eradication of Child Undernutrition”. In different forums and regional political scenarios such
as the Health Sector of Central America and
the Dominican Republic meetings (RESSCAD),
of the Central American Integration System
(SICA), of the IADB governors and the OAS
General Assembly, among others, resolutions
were approved in support to the efforts for the
eradication of child undernutrition and in favor of food and nutritional security and social
protection (see complete list in Annex iv). Support was provided for the development of strategies and action plans for its implementation.
Furthermore, other regional initiatives that are
promoted by different agencies and institutions
have emerged and contribute to strengthen the
work in the countries.
F. Monitoring and evaluation and nutritional
surveillance
G. Human rights approach, gender perspective, cultural relevance and community participation
H. Sustainability, investment, side effects and
degree of adaptation to national strategies
for the reduction of poverty
I. Analysis of Strengths, Weaknesses, Opportunities and Threats (SWOT)
Taking into account the diversity and specificity
of the programmes in terms of their approach,
components and key objectives, the analysis of
the nutritional dimension is presented in a disaggregated manner and it is made accordingly
to each type of programme.
In some aspects where significant differences
were observed, the results are presented disaggregated by country, helping to identify the
strengths and weaknesses of the programmes.
28
The commitment of the governments participating in the Study, in addition to external support,
has propitiated the creation and/or strengthening of legal frameworks and the design of policies favorable to nutrition. Practically all the
countries have laws and Food and Nutritional
Security policies framed under the human rights
29
RESULTS AND ANALYSIS
A. GENERAL CONTEXT OF PLANS
AND POLICIES
Based on the findings from the Study’s Integrated Survey and Key Informant Interviews,
the results presented are divided into the following sections:
III
IV
II
In addition, there are areas of high-level intersectoral coordination –such as the Secretariats
and the National Food and Nutritional Security Councils in El Salvador, Guatemala and Panama– concurred by all sectors involved in improving food and nutritional security.
Nowadays, there is a favorable environment
with strategies and national plans –approved
and mostly in implementation– to prevent and
reduce different forms of child undernutrition,
including micronutrient deficiencies (see list of
plans and policies analyzed in Table 2).
Table 2
List of analyzed plans and policies (n=10)
Plan or Policy
Country
Main Institution Responsible
Start year
National Food Plan
Costa Rica
Ministry of Agriculture
2008
National Plan for the Eradication of Child Undernutrition 2008-2012
Costa Rica
Ministry of Health
2007
National Plan For the Eradication of Child Undernutrition (contents
from this plan are being implemented under the new Government
policies)
El Salvador
Ministry of Health, Technical
Secretariat of the Presidency and
Secretariat of Social Inclusion
2007
Strategic plan for the implementation of the Food and Nutritional
Security Policy 2006-2015
Honduras
Secretariat of the Presidency
2006
Mother Child Health National Policy
Honduras
Secretariat of Health
2005
Long term Food and Nutritional Security Policy with citizen
participation
Honduras
2006
Country Plan for the Eradication of Chronic Child Undernutrition
in Honduras
Honduras
2007
Country Plan for the Eradication of Chronic Child Undernutrition
2006-2015
Nicaragua
General Secretariat of Health,
Ministry of Health
2006
National Plan for the Prevention and Control of Micronutrient
Deficiencies 2008-2015
Panama
National Plan for Tackling of Child Undernutrition 2008-2015
Panama
Ministry of Health
Ministry of Health
Source: Study on the Nutritional Dimension in the Social Safety Nets of Central America and the Dominican Republic, 2009.
30
2008
2008
All the analyzed plans have been formulated
starting from 2005, coinciding with the momentum given to the prioritization of reducing
child undernutrition in the political agenda of
countries in Latin America and the Caribbean
in general and particularly in Central America
and the Dominican Republic. It is worth noting
that Belize and Guatemala also have national
plans for the Eradication of Child Undernutrition. In Guatemala, currently the “plan” corresponds to the National Strategy for the Reduction of Chronic Undernutrition (ENRDC),
whose main component: the National Programme for Reducing Chronic Undernutrition
(PRDC) is being implemented and will be discussed in the programme analysis section.
both children and the general population of
Central America: chronic undernutrition and
micronutrient deficiencies, particularly anemia.
The plans raise nutritional objectives. The challenge consists in transforming those objectives
into quantifiable and measurable nutritional impact goals (i.e. in how many points it is planned
for the prevalence of chronic undernutrition to
be reduced per year, or in the next five years).
On the other hand, by proposing a framework
for action aimed at improving the nutritional
status and food security of the priority groups,
plans are also a political instrument of advocacy for the fulfillment of the Right to Food.
In operational terms, the lines of action proposed in the plans show significant progress
by incorporating highly cost effective interventions such as promotion of exclusive breastfeeding, provision of micronutrient supplements (especially iron supplementation and folic acid for
pregnant women) or fortified complementary
food for children and women47,48. Most of them
also include information and social communication, growth monitoring/growth promotion and
nutritional surveillance systems. From the analysis, one can see that only half of the plans include
communication or counseling to improve complementary feeding (which is one of the major
determinants of undernutrition in Central America). The action lines are then translated into programmes and specific or intersectoral projects.
Similarly, actions under the Plan towards the
Eradication of Child Undernutrition in Belize have been considered in the analysis of the
Mother and child Health Programme of the
Ministry of Health, which is the executing agency of the Plan. Panama also has a 2009-2015
National Plan for Food and Nutritional Security, which provides the framework for all other
food and nutrition plans. This plan is integrated
and was developed with extensive intersectoral
participation, and includes the human rights
and gender approaches and multicultural relevance.
The responsibility for formulating and implementing plans for the eradication of child undernutrition lies mostly in the health sector,
while food or food security plans are the responsibility of the Ministry/Secretariat of the
Presidency or the Ministry of Agriculture.
Most of the plans for the eradication of undernutrition have as a target group children under
5 years, pregnant and lactating women, families in extreme poverty and indigenous peoples. However, attention to children under two
years is not prioritized, to whom direct nutrition interventions should be specially directed,
if preventing and/or eradicating child undernutrition in its different forms, especially chronic
undernutrition, is what is wanted.
The analysis of the plans and policies shows that
there is significant progress in incorporating nutritional dimension into their formulation, thus
these plans provide a sound framework of action for more effective implementation of programmes to reduce undernutrition.
Analyzed plans are formulated on the basis of
proper identification and recognition of the
most important nutritional problems affecting
47
48
31
Bhutta et al (2008).
Hourton et al (2008).
approach. Even more, some countries such as
Guatemala incorporate them in their State Political Constitution. The majority of countries
include these policies and laws under their National Strategies for the Reduction of Poverty.
III
IV
II
and children. It can also consider food and
nutritional security programmes. The actions are: promotion of breastfeeding, nutritional education, micronutrient supplementation and in some cases distribution of
fortified complementary foods. They also
include nutritional counseling and monitoring/growth promotion.
The analysis conducted for the plans and policies of the Study allows framing and providing
context to the different social protection programmes that are presented as follows.
c. Mother and child health programmes: Programmes oriented towards ensuring health
care especially for mothers and to children
under 5 years. Generally prioritize actions
for preventing and treating the most prevalent diseases in these groups (for children
under 5 years there is a package incorporated known as IMCI-Integrated Management of Childhood Illness).
B. GENERAL CHARACTERISTICS
OF THE PROGRAMMES STUDIED
guarantee implementation of both approaches.
Similar situation occurs with community participation that is taken into account by most of
the plans, but mechanisms for its implementation are unknown. No actions or concrete recommendations have been planned on how to
incorporate the population in all stages of the
plans or programmes and projects that derive
from them.
Relatively few plans include measures to address the underlying and structural causes of
undernutrition such as access to water and sanitation, food production and improvement of
incomes, being approaches more linked to the
health sector.
Whereas the plans and policies are the normative instruments that guide the actions of governments or agencies for the reduction of undernutrition it is important that countries have
intersectoral comprehensive plans or policies
that include measures both in the short as well
as in the medium and long term. This should
strengthen the links between the Health Sector and other sectors to ensure the inclusion of
interventions that address the underlying and
structural causes of undernutrition49.
The absence of monitoring and evaluation systems adequately funded is another weakness
identified in the formulation of plans. Half of
the plans have foreseen a regular system of
monitoring the progress of the implementation,
incorporating nutritional indicators. The other
half of cases (including plans with nutritional
objectives) consider that having a monitoring
evaluation system with nutritional indicators
“does not apply”, despite the fact that the prevision of a monitoring system is a prerequisite
for measuring progress in the execution of any
plan. Also, the plans have previsions for conducting evaluations, but it is unknown whether there is a specific budget allocated for this
purpose.
While most of the plans are framed within
the human rights approach and take into account the cultural relevance, operational mechanisms have not been specified or planned to
49
Bryce et al (2008).
32
As follows, here are the different types of social
protection programmes included in the Study,
the main executing institutions and the intra
and interinstitutional coordination between
them.
d. Food based programmes: This group includes programmes that either provide food
rations to families or to specific groups such
as mothers and children. Usually the food
distribution is accompanied by promotion
of adequate food and nutrition.
1. Definition and type of programmes
e. Nutritional recovery programmes: These
programmes include various actions for the
recovery of children with severe wasting in
specialized centers, as well as the prevention of other forms of child undernutrition.
The Study covered 110 social protection programmes (see Table 3). It included a large diversity of programmes. For better understanding and analysis, programmes were categorized
into 11 categories:
f. Micronutrient supplementation programmes:
Provide different micronutrient supplements
(mostly iron, vitamin A and folic acid, in
different compositions and shapes) generally to children under 5 years and pregnant
women or in childbearing age.
a. Conditional transfer programmes: Programmes that transfer cash, in kind, vouchers, food or other inputs (i.e. seeds and fertilizers, among others) giving families (target
population) responsibilities to be met in exchange for the transfer. Co-responsibilities
relate primarily to the “obligation” to send
children to school and to attend health facilities. These programmes are mostly aimed
at poverty reduction and human capital investment.
g. Micronutrient fortification programmes:
Geared toward the fortification of massive
consumption food: salt with iodine and fluorine; wheat flour with iron and complex B
vitamins; and, sugar with vitamin A.
b. Mother and child nutrition programmes:
This group includes programmes that develop nutritional actions aimed at mothers
h. Biofortification programmes: These programmes incorporate essential micronutrients from the time of production of food,
33
Only five plans have information about funding and, in two cases, the funding source is a
combination of public resources with external cooperation ones. The exception is Costa
Rica’s National Food Plan, which is entirely
funded with public resources. In half of the cases, there was no answer to the question about
the plan funding sources.
III
IV
II
i. Productive programmes: Promote the improvement of agricultural production,
whether for consumption or to generate
some surplus for sale. Programmes of family
orchards, basic grains production and small
livestock rising are included in this group.
k. HIV-specific programmes: Correspond to
programmes oriented towards the provision of comprehensive support and/or to
facilitate access to treatment for people
with HIV. They carry out educational activities for HIV prevention, including the
prevention of vertical transmission.
Most of the programmes are integral, for example, the mother and child health and nutrition programmes. Other programmes are specific, such as supplementation or fortification
with micronutrients, or those designed to address the problem of HIV.
In turn, some of the comprehensive programmes
contain specific actions that are not mutually
exclusive. This is the case of the Nutrition Programme of El Salvador, being a comprehensive
programme, includes supplementation and fortification with micronutrients. Similarly in Belize, Costa Rica, Guatemala and Nicaragua,
mother and child nutrition programmes include micronutrient supplementation.
The fact that some countries do not present certain kinds of programmes does not mean the
absence of these programmes in the country,
but rather that they were not included in the
study sample. Such is the case of mother and
child health programmes of Belize, Costa Rica,
El Salvador and Panama.
© UNICEF / NYHQ2006-2405 / Susan Markisz
j. Childhood and adolescence attention programmes: This group includes alternative
centers or homes where children in vulnerable social situation (orphans, abandoned
children) are welcomed and provided with
food, care, education and protection. The
assisted children remain in those centers
through adolescence and in some cases up
to even their youth.
As indicated, most programmes do not have
a single component, but rather they are composed of a variety of them. Specifically, programmes such as mother and child nutrition,
mother and child health, food based, micronutrient supplementation and nutritional recovery, share similar lines of action that include
advocacy on nutrition and micronutrient supplementation, among others, so for purposes of
facilitating the analysis they have been grouped
as Food and Nutrition Programmes (n=54). In
other programmes, the classification and names
that were originally allocated is maintained.
For purposes of analysis, each programme was
classified as the main component among these
11 categories, according to the list by country
presented on Table 3.
Table 3
Number and type of analyzed programmes by
country (n=110)
Type of Programme
Belize
Costa Rica
El Salvador
Guatemala
Honduras
Nicaragua
Panama
Dominican
Republic
Total
Conditional Transfers
1
2
1
2
4
1
2
2
15
Mother-Child Nutrition*
1
3
8
5
3
5
2
2
29
Mother-Child Health*
-
-
-
1
1
2
-
2
6
Food Based*
-
1
1
3
1
2
2
2
12
Nutritional Recovery*
-
-
2
-
-
1
-
-
3
Micronutrient
Supplementation*
**
**
**
**
1
**
2
1
4
Micronutrient
Fortification
-
1
-
1
-
1
2
1
6
Biofortification
-
-
-
1
-
1
1
1
4
Productive Programmes
-
-
2
-
-
4
-
-
6
Childhood and
Adolescence Attention
Programmes
2
3
-
-
-
-
-
-
5
HIV Specific Programmes
3
1
2
2
6
1
4
1
20
TOTAL
7
11
16
15
16
18
15
12
110
Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009.
The sign (-) in determined types of programmes in some countries does not mean that the country does not have these programmes; it just means that they
were not included within the sampling of the Study or that they are part of other integrated programmes.
Notes:
* To facilitate the presentation of tables and figures (and also because they share similar actions) Mother and child nutrition and health programmes, Foodbased 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 and child nutrition in this Study.
The complete list of programmes, plans and policies by country are presented in Annex ii of this document.
35
using special cultivation techniques, which
can substantially increase the amount of
micronutrients and make them available in
the diet of priority groups. They are relatively new to the region.
III
IV
II
The participation of public institutions is relevant, becoming responsible for 62% of the
programmes (Figure 3). In turn, the role of
NGOs, both national and international (they
run 35% of the programmes), allows for some
intersectoral integration. In addition, several NGOs implement their programmes using
the norms of the Ministry of Health and other public institutions and promote the human
rights approach, ensuring more participative
programmes. For their part, United Nations
agencies do not directly run programmes, but
rather cooperate with national institutions.
The institutional analysis of programmes demonstrates the existence of multiple actors and
organizations responsible for social protection
programmes in general, and food and nutrition
programmes in particular. While this is a positive fact that shows interest of the players in
the solution of nutritional problems, it also results in the dispersion of efforts and resources,
which in turn can lead to less effectiveness, duplication and higher costs.
As a result of this analysis, supplemented by interviews with programme officials and key informants, it was concluded that there is a weak
and sometimes even nonexistent articulation
and coordination among different programmes
and ministries.
The solution to the nutritional problem needs
the confluence of different sectors and institutions effectively coordinated to achieve synergy and converge on common goals. In practical
terms, the successful nutritional interventions
have been those whom while being managed
by several ministries or agencies, are coordinated by intersectoral bodies that oversee the
proper fulfillment of the objectives and provide
guidelines and common norms50.
Figure 3
Classification of programmes according to main executing institution (n=110)
C. NUTRITIONAL DIMENSION IN SOCIAL
PROTECTION PROGRAMMES
Institutional dispersion is particularly noticeable in the public sector. The Health sector focuses an important part of the implementation
of programmes (29%), especially in the mother
and child health and nutrition programmes, micronutrient supplementation and fortification,
and HIV programmes. Other programmes such
as the food and nutrition and the conditional
transfer ones are under the partial responsibility of various ministries and departments.
* Includes Social Investment Fund (SIF) of El Salvador; Family Assignment Programme (FAPR) of Honduras; Joint Social
Assistance Institute (IMAS) of Costa Rica.
** Others include Agricultural Research Institutes, Offices/Secretariats of the First Lady, Food Security Secretariats, Ministries of
the Family.
Note: In parenthesis number of programmes (n).
36
Some aspects of the nutritional dimension,
mainly related to the design stage of programmes, such as proper identification of the
core nutritional problems, the explicit incorporation of nutritional objectives as well as the
interventions/actions are presented as follows.
The rest of the topics associated to the nutritional dimension in the stages of management,
implementation, monitoring and evaluation are
discussed in greater detail in their respective
sections.
More than 80% of the programmes indicated
that they have participation and collaboration
from other sectors or institutions, although
there is no information about how fluid are
these interinstitutional coordination mechanisms and what does this cooperation means
in practical terms. The intersectoral coordination is variable between countries and between
different types of programmes. For example,
some programmes get highlighted by the efficient interinstitutional coordination, and the
articulation between central government programmes with local governments. By contrast,
in other cases there is a lack of coordination
between both national and international institutions, creating duplication of interventions
and causing fragmentation in the attention to
the target population.
1. Identification of nutritional problems
to be faced
The proper identification of nutritional problems and their causes is the first step in designing effective programmes to reduce undernutrition. Understanding the nutritional problems
affecting the population, its causes and consequences will allow to: identify appropriate
objectives; carry out proper targeting; select
50
37
The World Bank (2006).
2. Executing institutions and coordination
III
IV
II
The types of identified problems, only partially
agree with the most prevalent problems in the
countries of the region (stunting and micronutrient deficiencies). It is important to note that
each programme can have more than a nutritional problem identified.
The comprehensive Survey results show that
72% of the programmes analyzed have identified the major nutritional problems to be addressed (Figure 4), although there is no information on the extent to which the causes have
been identified. Food and nutrition, productive as well as fortification programmes are
the ones that mostly have identified nutritional
problems. Only 27% (n=4) of the conditional transfer programmes identified a nutritional
problem as part of its design.
In Figure 5, it can be seen that just over half
of the programmes have identified chronic undernutrition and barely 37% (n=41) identified
anemia as problems to be solved. Very few programmes (15% and 14% respectively) identify
the deficiency of folates and zinc.
Figure 5
Main nutritional problems identified
in the programmes (n=110)
Figure 4
Programmes that identified nutritional
problems (n=110)
Multiple answers. The sum of all percentages is more than 100%.
38
39
strategies and effective action to respond to
the magnitude and nature of the problems and
their causes; identify and design an appropriate
monitoring and evaluation system and allocate
funds and resources for its implementation at
different stages.
III
IV
II
2. Programme objectives
The objectives of social programmes analyzed
are various, including the reduction of undernutrition, improving food security, poverty reduction, promotion of good health and nutrition practices and increase the access and use
of services and health programmes.
In Figures 6 and 7 it can be seen that just under half of the programmes (44.5%) have an
explicit nutritional objective in its design, being food and nutrition programmes (mother
and child nutrition and health, micronutrient
supplementation, nutrition recovery and food
based programmes) the ones that mostly incorporate such objectives in its design, such as reducing child undernutrition and improving the
nutritional status.
Figure 6
Programmes that identified nutritional
objectives (n=110)
It is worth noting that none of the childhood
and adolescence attention programmes include
nutritional objectives. By its part, productive programmes do not seek to improve nutritional status, but rather the household food
security through local food production, acting
upon one of the immediate factors of undernutrition, which is food availability. Some incorporate also objectives of improving on feeding
and health practices.
These assumptions are not necessarily fulfilled,
especially in poorer areas because of the absence
or low coverage of health services, or weakness
of nutritional programmes. Therefore, incorporating objectives or actions to reduce undernutrition could contribute to the success of these
programmes, preventing the negative effects of
undernutrition. Failure to act on child undernutrition, for example, will impede the good academic achievements of children despite the efforts of these programmes to increasing it.
In addition, only 13% (2 of 15) of conditional transfer programmes reviewed include nutritional objectives. The objectives of these programmes are mainly the reduction of poverty
and to break its intergenerational transmission cycle by favoring a better access to education and health care for children, as well as the
health care for pregnant and lactating women
and children under 5 years.
40
Undernutrition is a cause and a consequence of
poverty, which constitutes a threat to the sustainability of achievements in reducing poverty.
The irreversible effects of child undernutrition
affect the present and future ability of children,
which means that when adults they will have
lower productivity and thus, fewer opportunities to improve their incomes, making them repeat the intergenerational cycle of poverty.
These programmes are not expected to directly impact the nutritional status, but rather
through other ways. It is assumed that through
the fulfillment of co-responsibilities by benefited families, access to and the use of health services will improve and thus nutrition will be
promoted. In the same manner, it is expected
that the transfer in cash or in kind contributes
to improve access to food, which in turn will
positively increase the quality and quantity of
food consumption of the family, resulting in a
better nutritional status.
As for HIV programmes, the main objective is
to ensure health care for people with HIV, including antiretroviral treatment facilities. Only
five of the 20 programmes of this type include
among its objectives the improvement or maintenance of the nutritional status of people living with HIV (PLHIV).
41
III
IV
II
Figure 7
Main objectives identified in the programmes (n=110)
3. Programmes priority actions
other determinants of undernutrition, such as
mother education, access to water and sanitation and improvement of income.
Both in the Lancet series51 on child and maternal undernutrition, as in the 2008 Copenhagen
Consensus52 it is demonstrated which actions/
interventions whose effectiveness in reducing
the different types of nutritional deficiencies
have been verified. However, it is important to
recognize that these actions are linked mostly
to the immediate causes of undernutrition, allowing to get solved about 30% of the problem. Thus, it reiterates the need to work with
an integrated and intersectoral approach, incorporating actions that directly influence on
Figure 8 shows the proportions of the various
priority actions included in the programmes. It
considers that about half of the programmes
include two of the most cost effective interventions: (56%) promotion of breastfeeding (exclusive breastfeeding up to 6 months and continued breastfeeding up to 24 months) and
(52%) micronutrient supplementation. Also
45% of the programmes include the promotion of hygiene practices (though not always
accompanied by actions to facilitate access to
safe water and sanitation).
51
52
42
Bhutta et al (2008) ibid.
Horton et al (2008) ibid.
43
III
IV
II
Priority actions identified in the programmes (n=110)
to their social, economic and cultural condition56. Nutritional education and counseling
should focus on key messages that are standardized and context-specific, for example by
the age of the child57.
A third of the programmes include among its actions the promotion of appropriate complementary feeding practices. This type of intervention
is recommended as it is recognized that the major causes of nutritional deterioration at an early age are related to inadequate complementary
feeding, for example, the early introduction of
liquids, food preparations based on zero or low
energy density or micronutrients, incorrect frequency of feeding and poor hygiene conditions.
The Comprehensive Survey does not allow
further analysis to know whether the actions
of information, education and communication (IEC) of programmes are effective or not.
However, the review of some reports together with responses from key informant interviews reveal that IEC activities occur mostly in
the form of “chatter” groups, addressing many
general health, basic nutrition and feeding issues. In some cases, such as food based or supplementation programmes, they are focused
more towards the use of food or supplements
that are being distributed, rather than promoting positive behavioral changes. Undoubtedly,
this limits their effectiveness in many cases.
On the other hand, it is not sufficient that effective policies and programmes in reducing undernutrition focus on actions that have proven
effectiveness. It is also important to exclude ineffective interventions in order to prevent the
dispersion and wasting of the already limited human and financial resources. Lancet recent studies53,54 show that feeding programmes
for pre-school children older than 3 years and
school feeding programmes that focus on children older than 5 years do not have much
impact on reducing chronic undernutrition.
Interventions such as growth monitoring/promotion should be accompanied by an appropriate nutritional counseling or concrete solution answers to have an impact on nutrition55.
In the case of conditional transfer programmes,
the effectiveness also depends on other components and compliance of co-responsibilities.
Thus, in the case of Mexico’s Opportunities
(Oportunidades) Programme (formerly PROGRESA), the impact on height improvement
has been attributed largely to the inclusion of
complementary foods fortified with micronutrients (particularly zinc)58.
Just over one third (38%) of the programmes analyzed allocate resources to growth monitoring/
promotion. No information has been collected in
depth on how to perform this activity and if it is
accompanied by education or nutritional counseling, so it is difficult to judge its effectiveness.
Finally, while 24%, 22% and 18% of the programmes analyzed respectively include interventions to improve household food security,
income improvement and food production, it is
important to highlight that they require more
time to be effective (considering the longest
route to overcome undernutrition). Both short
term interventions, as well as long-term ones,
are complementary and the latter give sustainability to the former. Hence, there is a need for
a two stage strategies.
This present analysis shows that over 65% of
the programmes are running activities education in nutrition and health. It was found that
the effectiveness of these in the positive behavioral change for the nutrition of young children
occurs under certain conditions, such as individual counseling based on the particular situation of each children and/or mother according
53
56
54
57
Horton et al (2010).
Creed (2009).
58
Hoddinott and Basset (2009).
Bhutta et al (2008) ibid.
Ruel et al (2008).
55
Horton et al (2008).
44
45
Figure 8
An example of this is the experience of Brazil,
which with the application of short and long
term measures in recent years has succeeded in
reducing chronic undernutrition by 50% (from
13.5% in 1996 to 6.8% in 2006-2007). Two
thirds of this reduction can be attributed to four
factors: 25.7% to an increase in mothers schooling; 21.7% to an increase of family’s purchasing
power; 11.6% to the expansion of health services and; 4.3% to improved sanitation59.
Target population identified in the programmes (n=110)
D. TARGET POPULATION, TARGETING
CRITERIA, COVERAGE AND FILTERING
1. Target population
The results of the analysis of programmes (Figure 9) show that most have multiple target
groups. This situation can cause dispersion of
actions and resources.
In summary, although there are a greater number of programmes reviewed that promote
breastfeeding, deliver micronutrient supplements or promote hygiene practices, there is
still a large number (about 50%) that does not
implement these actions. A considerable part of
the studied social programmes are not implementing interventions and strategies that have
proven to be effective in addressing the problem of undernutrition nationwide. In some cases, this is because since their formulation the
programmes had other objectives not necessarily linked to nutrition. This Study therefore
allows the identification of opportunities for
the inclusion of priority and relevant interventions in relation to nutritional situation faced
by Central American countries and the Dominican Republic.
59
Figure 9
In fact, as a result of the analysis under this
Study, the Solidarity (Solidaridad) Programme,
the largest conditional cash transfer programme in the Dominican Republic, has been
reviewed to strengthen the nutritional dimension with technical support from WFP. The
government has incorporated nutritional objectives, indicators, actions/interventions specifically targeted towards the most vulnerable population, including children from 6-36
months. One of the first actions in current implementation is the prevention and treatment
of micronutrient deficiencies with the distribution of micronutrients powder in four provinces in the central and north-central areas of the
country. From the results, this intervention will
be extended nationwide.
III
IV
II
Less than half are concentrated in the priority
groups such as pregnant women and children
under two years, to address nutritional problems effectively and timely.
In regards to the ethnic cultural variable, only
12 of the 110 programmes have as a target
group the indigenous peoples and just six programmes considered the afrodescendants. This
is partly because the programmes studied are
located in areas with lower concentration of indigenous peoples (with the exception of Guatemala) and also because in countries like Costa
Rica, El Salvador and the Dominican Republic,
indigenous peoples and afrodescendants are
not disaggregated in the statistics and national
surveys.
number of programmes (n).
*FNINS: Food and Nutritional insecurity.
Monteiro et al (2009).
46
47
Note:
In
parenthesis
III
IV
II
On the other hand, when analyzing the target
group by type of programme, it was found that
food and nutrition programmes (mother and
child health and nutrition, food based, nutritional recovery and micronutrient supplementation) are those which focus more on children
under five years, pregnant and lactating women.
2. Targeting criteria/Geographical location
The conditional transfer programmes and productive programmes –according to its design
and objectives– are more focused on families in poverty and extreme poverty situation.
Only a few (20%) of the conditional transfer
programmes consider children under 2 years,
pregnant and lactating women as their target
group. On the other hand, only 13% (2 out
of the 15 programmes) of this kind consider
indigenous peoples as the target group, even
though they are the most affected by extreme
poverty in Central American countries.
For the selection of the target population, the
process usually begins with the identification
of geographic areas with the highest concentration of people living in poverty or extreme poverty. In other cases, this selection is made accordingly to the prevalence of undernutrition
(such as the Programme for the Reduction of
Chronic Undernutrition in Guatemala-PRCU/
NSRCU). Also some areas are determined by
the presence of the executing agencies of the
programmes.
The proper targeting (defined as the concentration of the provision of goods and/or services in
a clearly identified target population) is an important component of successful programmes
in the reduction of nutritional problems.
Only 3% of the programmes apply the criterion of ethnicity to target their actions; although
this does not necessarily mean that the indigenous peoples or afrodescendants populations
are totally excluded. It is likely that by the criterion of extreme poverty, these groups are included, being those with the higher poverty
prevalence.
Figure 10
Targeting criteria identified
As shown in Figure 10, most programmes use
multiple criteria at once for targeting interventions, being geographical basis the most widespread (72%), followed by a target in function
of the age group (63%).
For HIV programmes, as it might be expected,
the major groups are people living with HIV
(adult men and women). Some programmes (5
out of 20) have also pregnant, lactating and
childbearing aged women as the target populations, important for the prevention of vertical
transmission.
Another important targeting criterion in the
programmes studied is the situation of extreme
poverty (39%) and poverty (28%). Recent
studies show that poverty rates are somehow
correlated with the prevalence of undernutrition, but there is a significant difference among
them60. Nutritional intervention focusing solely
Finally, the target group for the childhood and
adolescence attention programmes is constituted by children, adolescents and youth at risk
(from birth to 18 years).
Given its nature, for food fortification programmes for massive consumption, the target
group is the general population.
Tufts University/ Friedman School of Nutrition Sciences and Policies, WFP (2007).
60
48
49
on poverty could omit coverage to municipalities with a significant number of children suffering undernutrition. For example, in the Dominican Republic there are 225 municipalities
in the country, 47 show poverty rates that differ from the rates of undernutrition in more
than two quartiles.
III
IV
II
The 41% of programmes use the biological criteria (pregnancy and breastfeeding) to target
their interventions.
In analyzing the targeting criteria by age, HIV
programmes are excluded because due to its
characteristics, adults are their priority group.
According to these criteria (Figure 11), over
50% of programmes target children under five
years. It captures the attention that only 14%
target interventions towards children under two
years, when 30% of the programmes have this
population as a target group, as shown in Figure 9. The same inconsistency was noted in regards to children under 3 years, while 12% of
the programmes target this group, only one programme has children as the target population.
Figure 11
Figure 12
Targeting criteria by age identified
in the programmes (n=90)*
Geographical targeting criteria identified
The targeting under geographical criteria gives
priority to rural areas (44%) and only 16%
acts on urban areas (Figure 12). Additionally,
about 20% of programmes focus on the municipal or community level.
*Include all the programmes except HIV specific ones.
50
51
III
IV
II
Successful experiences in the diminishment of
undernutrition show that concentrating on a
few effective programmes of national coverage is a fundamental aspect in order to achieve
nutritional impact61. A reduced number of national programmes framed on public policies
allow optimizing the use of resources, facilitating management and monitoring and the implementation of the fundamental principles of
the human rights approach.
Map 1
Number of programmes with national
coverage by country
61
52
Map 2 shows the geographical coverage of the
total of programmes analyzed at the subnational levels (departments, municipalities and
communities) that had specific information.
Some programmes cover very small areas that
are not shown. This is the case of Costa Rica,
which also has the most programmes with national coverage.
In several countries on one hand there are geographical areas with the highest concentration
of programmes (5-7). Depending on the actions
of each of these programmes, this finding suggests possible duplications. On the other hand,
there are areas without subnational coverage
programmes such as the Atlantic coasts of Honduras and Nicaragua. A deep analysis of the exact location of social programmes will allow
the identification of gaps and consequently the
increase of their coverage.
Map 2
Geographical distribution of programmes with subnational coverage by country
The World Bank (2006).
53
Map 1 shows the number of social programmes
analyzed that cover the whole national territory in each country. Honduras, Panama and the
Dominican Republic have the largest number
of these programmes, followed by Costa Rica
and Nicaragua.
III
IV
II
the same manner, in the studied programmes
in Panama and Nicaragua it is noticeable that
some areas with high prevalence of undernutrition are being under assisted. Guatemala presents a better distribution of programmes based
on the prevalence of chronic undernutrition.
Costa Rica and the Dominican Republic have
a low prevalence of chronic undernutrition,
which is reflected in the map.
It is observed that in the reviewed programmes,
countries like Honduras have a lower concentration of programmes in the areas with high
prevalence of stunting in school children. The
actions are concentrated in the municipalities
near the capital city and the Dry Corridor. In
It is important to highlight that some programmes evaluated did not identify the geographical coverage of their actions, so this limitation should be considered in this analysis.
Map 3
Geographical location of programmes with subnational coverage in comparison with stunting
prevalence in school children
3. Coverage and filtering of programmes
Based on the responses reported in the comprehensive Survey, as well as through interviews
with officials responsible for programmes,
only 18% (n=20) of the analyzed programmes
properly manage information on coverage (expressed as a percentage, calculated by dividing
the number of benefited people who belong to
the target population by the total target population). This reveals that there is still a lack
of knowledge about the concept. The majority (59%) provided information on the absolute number of people benefited, or percentage
of people assisted in relationship to the goal of
the programme –and not the total population–,
or indicated only a general reference. For example: “national coverage”, “assists 2 municipalities”.
Similar to the coverage, most programmes do
not have information about the filtering (which
is calculated by dividing the number of people that do not belong to the target population
by the total number of people covered). Only
21% of the programmes could report information about the filtering, and almost all said that
it is practically zero.
E. MANAGEMENT AND IMPLEMENTATION
OF PROGRAMMES
This section discusses aspects related to food
and supplies (supplements, educational materials, vouchers and others), as well as the available human resources, training in food and
nutrition topics and normative that steer the
implementation of programmes.
1. Supplies provision and logistics
The implementation capability is a determining factor for the success of a programme and
as part of this the provision of inputs and other
resources required for implementation must be
continuous and without interference.
Significant proportions (65%) of the studied
programmes that distribute food, supplements
or other type of inputs maintain a sufficient
availability throughout the year. In the remaining 35%, availability of inputs is insufficient or
is present only in certain seasons. It is recognized that this situation becomes more critical
in the local and community levels, where logistics and procurement and distribution mechanisms of the inputs are topics that need further
development to ensure timely attention.
a) Supplies and services provided by
programmes: Food
One third (n=34) of the analyzed programmes
distribute food to the target population. Among
these, most are food and nutrition programmes
(including nutritional rehabilitation centers and
children feeding centers) and half of the HIV
programmes (n=10). Four of the 15 conditional
transfer programmes distribute food, either as a
complement to the cash or in kind transfer.
54
The food baskets that are distributed are not
diverse. Most include oil, one or two cereals
(rice and/or corn) and one legume (beans). In
less than half (45%) of the programmes that
Map 3 compares the action areas of programmes with the prevalence of stunting in
school children. Although school age population is not a group at higher nutritional risk,
height surveys are an excellent source of information for having the disaggregation of data a
lower geographical level and also because they
present accumulative stunting data.
III
IV
II
This situation is a weakness that affects the
programme effectiveness in improving nutritional status. Only childhood and adolescence
attention programmes in Costa Rica mentioned that they have nutritionists responsible
for providing nutritional guidance to personnel
responsible for child care centers, including the
preparation of nutritious meals.
i) Nutritional value of the food ration
Fifteen of the 34 programmes (44%) provided information on the energy value of food rations and only eight programmes (23.5%) reported micronutrients value of food rations
they deliver, although the most important nutritional problems in the countries of this Study
are related to vitamins and minerals deficiencies and less to do with the lack of energy and
macronutrients.
b) Inputs and services provided by the
programmes: Micronutrient supplements
ii) People benefited (target population)
In the few programmes that have information
on the micronutrients value, it varies between
100% of the iron, vitamin A, zinc and folic acid
requirements for children from 6 to 36 months
and between 30% to 50% for pregnant and lactating women, as in the case of the “Recovery
and Prevention of Undernutrition Programmes
in favor of Vulnerable Groups” and the NPRCU (PRDC), both in Guatemala. Other programmes cover from 25% to 50% of the micronutrients requirements of the benefited people.
However, it should be noted that these figures
are not comparable between countries or programmes due to the use of different nutritional
requirements for each target group.
Among the programmes that have information
about the nutritional value of food delivered, it
is noticed that in the nutritional recovery centers in El Salvador and Nicaragua, the food provided to children suffering from undernutrition
cover a 100% of their energy and micronutrient
requirements. In two of the food and nutrition
programmes in Panama (The Food and Health
Programme of NutreHogar and the Pre-School,
School Feeding and Community Development
Programme of the Pro Niños del Darien Foundation) the food rations cover 80% or more of
the energy requirements of the benefited people. In other programmes of this type, supplementary rations are provided besides food given at home, covering between 15% to 30% of
energy requirements of the children, or 70% to
100% of the additional pregnancy and lactating requirements. For their part, the conditional transfer programmes provide family food
rations from 1,800 to 2,500 kilocalories per
person per month.
To have a positive effect on food and nutritional status, the distributed rations or food baskets should be designed on the basis of an analysis of the energy and nutritional requirements
of the target population. This analysis should
include the valuation of possible deficits in access and food consumption, the conditions for
56
Micronutrient supplementation is usually recommended on the basis of the prevalence of certain nutritional deficit of a population group in
a situation of vulnerability to undernutrition,
especially young children and women. The delivery of specific micronutrient supplements is
performed both for therapeutic purposes (to
“treat” micronutrient deficiency) or preventive
purposes (to guarantee an adequate intake of
micronutrients and prevent deficiency).
It is documented that when the woman is the
person who directly receives the food, money
or other goods and services, they will have a direct effect on food consumption, nutrition and
health of children, as well as other household
members62.
About 40% of the analyzed programmes that
distribute food do it directly to women (mothers or caregivers). Most HIV programmes distribute food rations to people living with HIV.
In both cases the distribution of food rations
is well oriented, since it is directly delivered to
the appropriate population groups. Only four
programmes distribute food indifferently to
both men and women, while 25% of the programmes did not provide details.
In the context of Central America and the Dominican Republic, micronutrient supplementation is an essential strategy especially considering that deficiencies of certain micronutrients
(iron, zinc and folate) are highly prevalent in
children and women. In this regard, Figure 13
shows the proportion of programmes including
the distribution of micronutrient supplements.
It is shown that just under half of the analyzed
programmes (45%) include the distribution of
various micronutrient supplements to pregnant
women as well as children under 5 years, being the food and nutrition programmes the one
who mainly includes it (70 %).
Nor is there information on intra family distribution or dilution of food received, which
could be influenced by cultural patterns that
favor male household members, being this aspect one that needs further investigation.
62
The World Bank (2006) ibid.
57
The vast majority of programmes that distribute food indicate that they accompany the distribution with educational and communication
actions. Information and education is provided mainly through “chatter” or group workshops on various aspects of food and nutrition. In many cases the emphasis is on the use
and methods of preparation of food distributed. No programme explicitly referred to appropriate complementary feeding or the feeding of
children in the first two years of life as a topic
to be included in the educational events. The
talks are in charge of health personnel, counselors or trained promoters. In other cases, education campaigns are conducted at the municipal level, such as in Honduras.
their preparation as well as the habits and cultural preferences. In this regard, as the Study
evidences, there is a lack of information, rules
and clear normative and guidelines for the
planning of food rations in most programmes.
In most cases, it is not known the nutritional
or caloric value of the rations and much less
is known whether these correspond to the real
needs of people in the target group.
distribute food, this basic basket includes a fortified complementary food (usually a mixture
of cereal flour fortified with micronutrients as
in the case of Vitacereal in Guatemala). Seven
of the 34 programmes (23%) distribute only
fortified complementary foods, especially targeted to children under age 5, pregnant and
lactating women. Very few programmes also
include milk powder, however it should be noted that most HIV programmes that distribute
food include the provision of milk powder.
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II
Figure 13
Micronutrient supplementation according
to type of programme (n=110)
Supplements are delivered mainly to pregnant
women, mothers or caregivers. Other programmes provide direct supplements to children at health centers during the visits of health
personnel to the community, and also in nutritional recovery centers or attention centers for
abandoned children.
Table 4
Type of micronutrient
supplementation (n=50)*
Type of supplements
Within the programmes, including micronutrient supplementation, the main supplements distributed are iron and folic acid (68%) to pregnant women and vitamin A supplement (52%)
to children (Table 4).
Number of programmes
Percentage (%)
Iron supplementation / folic acid for pregnant women
34
68%
Vitamin A supplementation
26
52%
Zinc supplementation / zinc in case of diarrhea
18
36%
Micronutrient powder supplementation
16
32%
Iron supplementation
15
30%
Calcium supplementation
4
8%
Micronutrient supplementation in general
3
6%
Flour supplementation
1
2%
Note: Multiple answers. The sum of all percentages is more than 100%.
* In the programmes that include supplementation.
Zinc supplementation is not yet widespread
and also needs studies to know the magnitude
of this deficiency, despite the important role of
this mineral in the immune system. There are
58
63
64
59
Hess et al (2009); Brown et al (2002).
Horton et al (2008) ibid.
also investigations into their influence on linear growth63. Considering that supplementation with micronutrients is one of the most cost
effective interventions in the reduction of nutritional deficiencies64, it would be expected for
more programmes to include this component
since their design.
Figure 13 also shows that only 20% of HIV
and conditional transfer programmes include
the distribution of micronutrient supplements
among their activities.
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However, in the analysis by type of programme,
it was found that most conditional transfer programmes and childhood and adolescence attention programmes do not have nutrition or public health personnel. According to an analysis
by country, there are higher proportions of programmes in Belize and Honduras that do not
have staff trained in nutrition or public health.
2. Human resources
In the analyzed programmes, the human resources information disaggregated by gender
is still insufficient. With the limited data available, it was found that on average there is a
greater participation of female professionals,
technicians and promoters compared to male
staff, in an approximate ratio of 3:1.
The existence of trained human resources capable of designing and implementing policies
and activities in nutrition at all levels is one of
the key elements of a country’s ability to reduce child undernutrition65. That is why training opportunities and the existence of specialized institutions to train personnel in nutrition
play an essential role in this aspect.
Figure 14
Human resources (professional staff)
according to their academic background
(n=110)
The results show that the majority of programmes surveyed (72%) have staff trained in
public health and nutrition (Figure 14).
There are some differences by type of programme: in productive programmes and in
fortification and biofortification programmes,
professionals and technicians are mostly men;
equally in the mother and child health programmes, community promoters are mostly
men. In 99% of the programmes the traditional midwives are female. The presence of female
staff is very important especially for working
with mothers and women in those rural indigenous areas, where for cultural reasons women
do not have the same openness and trust with
male staffers.
a) Training of human resources in nutrition
Between 45% and 51% of programmes indicated that they train professional and technicians human resources in food and nutrition
topics (Figure 15). It is emphasized that this
training benefits some more the technicians
and professionals than community leaders and
promoters.
65
60
Morris et al (2008).
Particularly in local and community levels,
there are an insufficient number of trained personnel in nutrition in relationship to the needs,
with the exception of Costa Rica. The language
barrier is also a limiting factor especially in areas with indigenous peoples.
Most programmes indicated that they accompany the distribution of supplements with IEC actions. Education and information that are taught
through lectures by health personnel is concentrated in indications for the proper consumption
of micronutrients to avoid or minimize potential
side effects and better biological utilization.
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Figure 15
Nutrition training of the different human
resources (n=110)
b) Traditional midwives training
training process includes relevant issues (breastfeeding, feeding during pregnancy, complementary feeding by age of the child, hygiene in food
handling and methods of individual counseling,
among others) according to nutritional problems of the populations most affected by undernutrition.
Relatively few programmes train traditional
midwives in nutrition. This training is not continuous, usually given only once as a workshop
or training course for midwives at the start or
early in the programme. Later on, monitoring/
coaching sections are planned by the health
personnel with variable periodicity.
Other programmes indicated only general topics such as: healthy eating, food handling and
preparation, basic nutrition module, among
others, without specifying what the contents
are. Likewise, there are also programmes where
the nutritional training to community leaders
only focuses on growth control or measurement of the nutritional status or in preventing
and treating prevalent childhood illnesses.
The training of traditional midwives is focused
on techniques and skills for clean delivery, signs
of danger in pregnancy, puerperium and newborn care as well as prevention and treatment
of childhood prevalent illnesses (IMCI strategy). The treatment of key nutritional aspects
seems to be very weak. It has been shown, for
example, that nutrition topics such as breastfeeding and feeding during pregnancy or puerperium, are presented as “a short session”
at the beginning of the workshops. Only the
breastfeeding programme in Nicaragua offers
a more structured and in depth training, including topics such as advantages and benefits
of breastfeeding for the child, mother, family
and community; extraction and milk storage
techniques, and proper positions for breastfeeding.
Exclusively one case (Programme for Food and
Nutritional Security from Plan International in
El Salvador) stated that the training of leaders includes topics related to the Right to Food
and gender perspective.
Most programmes did not report the type of
methodology used for the training of leaders;
some indicate that workshops are held once
or twice a year. Only one programme (Food
Security Programme of Save the Children Nicaragua) said that the appropriate methodology is applied to adult education and training
and it is aimed at achieving behavioral changes, critical attitude and capacities to analyze
nutritional problems and take actions in the
community.
Note: In parenthesis number of programmes (n). Multiple answers. The sum of all percentages is more than 100%.
c) Community leaders training
In the analysis by types of programme, it was
found that food and nutrition programmes,
productive programmes and HIV programmes
are the ones that train the most human resources in nutrition, while the conditional transfer
and food fortification programmes are the ones
that less implement this type of training.
Less than half of the 110 programmes (39%)
provide nutrition training to community leaders. Among these, only 9 maintained that the
According to an analysis by country, the vast
majority of programmes (more than 75%) in
Costa Rica, El Salvador, Nicaragua, Panama
and the Dominican Republic train human resources in nutrition, while in Belize, Honduras
and Guatemala, this proportion reaches only
50% of programmes.
62
63
In practice, the nutritional actions at community level are integrated into the routine work
of support or basic health staff that already
have many other responsibilities, thus nutrition
is often not the priority. For this reason, it is
necessary to further strengthen this important
staff training at this level because of the direct
links they have with the community.
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d) Technicians training
The training for the technicians is centered
mainly on the knowledge and handling of the
norms and protocols of attention of the mother and child programmes, including the normative on nutrition and IMCI or general topics such as healthy feeding or basic nutrition.
Of the 49 programmes that perform nutrition
training directed towards technicians, only
2 indicated that specific topics are addressed
such as breastfeeding, complementary feeding
at different ages, and the hygiene in food handling. The training in the other programmes refers to general contents.
Three of the HIV programmes train the technicians in the nutrition and HIV relationship. In
these cases, the training is offered by other institutions or international agencies.
As a summary of the findings in regards to
the training of human resources in the analyzed programmes, it is identified the need to
strengthen the capabilities of the staff in up to
date and relevant nutritional topics, including
the human rights approach and gender perspective. These topics should also be incorporated in the training aimed at the target population.
e) Professionals training
As in the case of technicians, training for professionals is focused mainly on the knowledge
and use of norms and protocols of attention
and IMCI strategy, including the normative
on nutrition. Only 5 out the 56 programmes
that train professional staff on nutrition specify that they provide training in specific topics such as breastfeeding, complementary feeding, counseling techniques, and prevention of
childhood obesity, among others. In the rest
of the programmes, training includes general
food issues and nutrition. There are some programmes that trained professionals in the new
WHO growth standards. Finally, six of the 20
HIV programmes indicated that they train professionals in areas such as the importance of
nutrition in the management of patients with
HIV.
From the comprehensive Survey it is not known
in detail the methodology used in the training
of the different levels of human resources, but
it is reported that short and group workshops
are the most widespread form to train staff on
nutrition. There is no evidence that these trainings are effective, there are no structured training plans, nor evaluation of the results is made.
3. Normative (Norms)
The vast majority of programmes (87%) reported that they have updated norms and
guidelines for the management and implementation of programmes (Figure 16). However,
when requesting specific information regarding the content of normative, only 56% of the
programmes included reference documents.
There were no differences observed by country
or type of programme.
Figure 16
Programmes with management
normative (n=110)
On the other hand, there are cases where the
high mobility of staff, especially in the public
sector, substantially limits the capacity development of public institutions on nutrition topics.
This is one aspect that must be taken into account when designing policies and plans that
promote nutrition.
The training to professionals is usually done
once or twice a year, even though this type of
staff has more facilities to attend courses, seminars and other events organized by institutions
even outside the country.
64
65
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Table 5
Normative documents of analyzed
programmes (n=97)
Type of normative documents
Percentage (%)
Implementation normatives, attention model
13
13%
Plan and logical framework, operating plans
11
11%
Health normatives manuals
8
8%
Protocols, guiding manuals for attention of PLHIV
6
6%
Process indicators control system, monitoring
5
5%
Executive orders, political framework, regulations
3
3%
Operating rules
3
3%
Registry files
3
3%
Conventions, agreements
2
2%
Does not specify
43
44%
Note: Multiple answers. The percentages do not have to total 100%.
66
F. MONITORING AND EVALUATION
AND NUTRITIONAL SURVEILLANCE
This section discusses the use of baselines,
monitoring and evaluation systems and nutritional indicators in analyzed social protection
programmes.
1. Baseline
A well-designed programme to address the most
important nutritional problems of a country or
a particular geographic area must have valid
and reliable information about the nature and
magnitude of the problem/problems, their main
causes and determinant factors. It must also
identify the most affected population groups
and their characteristics, strengths and limitations as well as the socio-economic and institutional surroundings. This information should
be available preferably before starting the programme design or early implementation. This
will guarantee not only a clear understanding of
the reality that the programme or project seeks
to modify, but also the parameters that will later serve to evaluate the effects and its impact.
It is therefore necessary to perform an initial
analysis or baseline study and to take into account the existing nutritional surveillance system –or to design an effective one adapted to
country needs– to serve as a basis for defining objectives, and for designing strategies,
interventions and the monitoring and evaluation system. In practice, a baseline study on
food and nutrition may require a prolonged
time, especially when it comes to national programmes. In this regard, if the realization of a
complete baseline is not feasible, the initial design of the programme can substantiate itself
on a rapid situational analysis or secondary information from other studies.
In Figure 17 it is shown that of a total of 110
analyzed programmes, 56 (51%) referred that
they conducted a nutritional diagnosis or specific baseline before or at the beginning of the
implementation phase of the programme. In
addition, ten programmes (9%) indicated that
the baseline consists of the National Nutrition
Surveys or the Height Surveys and those did
not conduct specific studies.
On the other hand, it was found that among the
programmes that have made specific nutritional
diagnosis (n=56), only 16 programmes (28%)
cited a document or reference where the results
of the baseline study were presented. However,
the contents of those documents were not available for review. Additionally, 14 programmes
reported that studies are conducted for some
programme components (i.e. deworming). Other programmes indicated that the reference
documents are the plans or feasibility studies,
or that the diagnosis is in process.
By type of programme, it is noted that there is
a higher proportion of productive (100%) and
food and nutrition (61%) programmes who
have completed basic nutritional baselines.
Only 40% of conditional transfer and HIV
programmes have a baseline. None of the childhood and adolescence attention programmes
has conducted a nutritional baseline diagnosis. A significant proportion (20%) of the conditional transfer programmes and childhood
and adolescence attention programmes consider that the initial measurement of the nutritional status is not a part of the objectives and the
purpose of the programme (“does not apply”).
Among the programmes that have normative
documents, in higher proportion, it was indicated that they consist of models of attention
or guidelines for the implementation of the
programmes (Table 5). Others reported that
the planning document, logical framework,
or operational plans are the documents guiding the implementation and management of
programmes. To a lesser extent, it was reported that normative manuals of the health sector areas are used, as well as protocols and attention manuals for people living with HIV.
Fewer programmes reported other types of
documents such as operating rules of transfer
programmes, executive orders and agreements,
among others.
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II
vii.7% did not specify who/whom is/are responsible for monitoring the actions of the
programme.
An important factor in the success of programmes in countries like Chile, that have reduced undernutrition at the lowest levels, is the
planning of the monitoring from the beginning.
Nutritional baseline according to type
of programme (n=110)
Many of the food and nutrition programmes
carry out monthly monitoring of the attention
coverage of prevalent diseases (diarrhea, pneumonia, ARI), prenatal control attention, growth
control/promotion and other activities related
to health care. The information is analyzed generally in the monthly staff meetings. This type
of monitoring also includes some nutritional indicators such as the proportion of children or
pregnant women with insufficient weight gain,
according to the growth chart, depending on
the normative from the central level.
According to the results of the Study, 90%
(n=99) of the analyzed programmes reported having a monitoring system, which could
be considered a strength of these programmes.
However, it draws the attention that only 42%
specified the way to carry out this system or presented descriptive documentation. The remainder did not cite any document or reference.
According to the information gathered, 11 programmes prepare monthly reports as part of their
monitoring activities. Seven programmes do it
annually, and 16 with no scheduling set. The others did not have information on this subject.
According to the programmes reports, the
main use for the information generated by the
monitoring activities are: i) for programme improvement, identifying weaknesses and seeking
ways to overcome them; ii) to reconsider the
attention models and programme strategy and
improve the quality of the services; iii) to know
about the progress in implementing actions
and to redefine the performance goals and; iv)
to allocate budgets and plan for the future.
In the 99 programmes that reported having a
monitoring system, it is observed that different people or institutions are responsible for it:
i. 36% of the programmes refer that the
monitoring is under the responsibility of
the staff or institution in charge of field level execution.
3. Evaluation
ii. 18% has staff or a technical team exclusively responsible for monitoring, even at
regional or department level.
2. Monitoring
Monitoring is defined as the gathering, review,
analysis and use of systematically obtained information on the performance of inputs, activities, outputs and outcomes of the programme,
in relation to predetermined criteria (inference
of adequacy). It is done in order to identify actions fulfillment, problems and causes of non
compliance, and thus take the corrective measures necessary to reach the objectives (equivalent to performance measurement)66.
66
68
Adapted from Dary (2006)
Evaluation is the systematic and objective measurement of projects, programmes or policies in
implementation or completed, which covers its
design, implementation, results, outcomes and
impact. Its purpose is to establish the relevance
in the fulfillment of objectives, quality of performance, scope of the effects, cost effectiveness and
sustainability67. It is a process that implies to look
critically and to compare the actual situation
as to what was defined as desirable or normative in a programme; the suitability, compliance
with the objectives, efficiency, efficacy, effectiveness, impact and sustainability. There are three
main types of evaluation: of the design (on the
iii. 17% indicates that monitoring is done by
technical teams from central or regional
level through regular on the field visits.
iv. 13% refers that the monitoring of the actions is carried out exclusively by the Ministry of Health and its various dependencies, in which the nutrition responsible unit
is included.
v. 4% mentioned that the monitoring is carried out by interinstitutional teams.
vi. 4% stated that monitoring is conducted
alongside users.
67
69
Adapted from Dary (2006) ibid.
Figure 17
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II
The results of the evaluation must be translated into lessons learned in order to be incorporated into the improvement and reformulation
process of existing programmes and/or the development of new and better programmes.
Figure 18 reveals that 76% of the programmes
refer to have made evaluations. Of these, a large
proportion (80%) indicates that process evaluation has been performed, while the impact evaluation has been reported in 42 programmes
(50%).To a lesser proportion, there is the evaluation of programme design with 31%. For the
most part, the referred evaluations were internal.
Figure 18
Presence and type of evaluation referred
and conducted in the programmes (n=110)
In regards to measuring impact, Figure 19
shows that 25 programmes refer that the impact on nutritional status has been evaluated.
Another 21 programmes have done it on the
food security of the target population, while 15
programmes claim to have measured the impact on poverty. Comparing this proportion
with answers to other questions such as the existence of an adequately verified/documented
baseline (16 programmes) or funding for the
evaluation (only 8 programmes indicated that
they had planned a budget allocation for evaluation), it may be assumed that the actual number of nutritional impact evaluations solidly
documented and publicly circulated, must be
very small or nonexistent.
It must be noted that of the 25 programmes
that declare to have nutritional impact evaluations, only seven of them quoted or attached
documentation or the specific studies mentioned. Some programmes quote, for example,
the National Demographics and Health Surveys of their countries or their nutritional surveillance systems as if they were their impact
evaluations. These facts reveal the lack of clarity about the concept of nutritional impact evaluation and nutritional surveillance. That is, 18
programmes that claim to have nutritional impact evaluations (out of the total of 25) probably have not done a proper evaluation since
there is no documented evidence. This is a basic problem in the professional upbringing of
human resources in charge of the programmes.
Figure 19
Impact evaluation referred and conducted in the programmes (n=110)
Note: In parenthesis number of programmes (n). The same programmes can have more than one type of evaluation. Multiple answers; the sum of all percentages is more than 100%. * Lack of specific documentation that demonstrates the impact evaluations (these programmes consider as impact evaluation the
results of different national surveys such as DHS, height census in school children, living condition surveys, as well as process
evaluations and specific monitoring reports performed).
Measuring the impact is critical to the success,
continuity, ownership and political support for
the programmes. Showing tangible results has
allowed, in cases such as the “Opportunities”
(Oportunidades) Programme of Mexico, to ensure the continuity of the programme and that it
will not suppressed when government changes.
70
Note: In parenthesis number of programmes (n). The same programmes can have more than one type of evaluation. Multiple answers; the percentages do not have to total 100%. DHS: Demographics and Health Survey.
LSS: Living Standards Survey.
71
formulation of the programme), of the processes
or performance (focused on the operation of the
programme) and of the impact or effectiveness
(determines the results that are attributable to the
programme, whether or not they were planned).
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b. Service indicators or activities indicators:
Related to the services delivered by the programme. They measure the actions taken or
the work done with inputs such as funds,
technical assistance and other resources.
Examples would be: changes in the coverage of services as a result of the actions
of the programme, attendance to pre natal
monitoring, growth control/promotion, attendance to food and nutrition training sessions, among others.
4. Nutritional indicators for monitoring
and evaluation
On the other hand, it was found that the proportion of programmes that have made an impact evaluation is independent of the duration
of the programme. There are a similar number
of programmes with ten or more years of implementation and of programmes with three
or more years of implementation that have not
measured the impact.
Indicators are qualitative or quantitative variables that provide in a simple and reliable manner data for measuring achievements, reflect
the changes associated with the intervention,
and determine the degree of performance of
the intervention68.
The 70% (n=77) of the analyzed programmes
did not answer on the allocation of funding for
their nutritional impact evaluations. From the
remaining third who answered (n=33), a total
of 25 programmes indicated that they received
no budgetary allocation for this type of evaluation and only eight reported having funds,
varying from 1% to 15% of the programme
annual budget. Belize and Nicaragua are the
countries with the highest proportion of programmes studied that allocate some funding
for the nutritional impact evaluation.
A monitoring and evaluation system should incorporate indicators for different stages of the
programme cycle:
a. Inputs indicators: Related to financial, human and material resources used in the programmes. It can measure the expenditures
execution and the use of other resources,
68
72
Dary (2006) ibid.
On the other hand, 40% (n=6) of the conditional transfer programmes have nutritional indicators for monitoring and evaluation, while
27% (n=4), believes that the use of this kind of
indicators “does not apply”. This might be because the objectives of these programmes are
directly related to poverty reduction and income improvement, as seen above.
It brings to the attention that only half of the
fortification and biofortification programmes
have nutritional indicators.
c. Results indicators: They measure the products, goods and services obtained as a result
of the intervention and that are relevant to
the achievement of effects. Examples of indicators are: proportion of infants aged 0 to
5 months exclusively breastfed; proportion
of infants aged 6-8 months receiving solid,
semi solid or soft foods; proportion of children 6 to 23 months old receiving iron rich
foods or infants and young children specially designed foods that are iron fortified or
fortified in the household; number of households with access to the basic food basket.
Only 7 of the 20 HIV programmes (35%) consider nutritional indicators, although it is known
that nutritional status is one of the important
factors for success and adherence to ART.
In Table 6 it is shown the main nutritional indicators used in the programmes studied. Less
than half of the programmes (44.5%) consider chronic undernutrition and only 23% the
prevalence of anemia among other indicators,
despite their relevance of those indicators in
the context of nutritional problems in Central
America and the Dominican Republic.
d. Impact indicators: They measure the effects
achieved in the target population through
interventions. Through these indicators, it
can be known the changes in nutritional status, infant and maternal mortality, among
others. Examples of these indicators are:
prevalence of chronic undernutrition, anemia prevalence, infant mortality rate or percentage of the population in poverty or extreme poverty situation.
A fifth of the programmes also include low
birth weight, the same proportion of programmes indicates that they use weight gain
during pregnancy as an indicator. About 14%
of the programmes refer that they included input indicators like the amount of supplements
or foods distributed. Finally, about 10% uses
energy or micronutrient intake as an indicator.
The data obtained from the main Survey reflects
the extent to which programmes incorporate
nutritional indicators for monitoring their activities and evaluating the achievement of their objectives. The majority (71%) of the programmes
referred that they incorporate the nutritional indicators for both monitoring and evaluation.
By type of programme, the food and nutrition
ones (n=54) primarily use nutritional status
indicators like the prevalence of underweight
(n=41), wasting (n=39) and chronic undernutrition (n=38). Some of these programmes
(around 20) also include as indicator the anemia prevalence.
73
As expected, food and nutritional programmes
(94%) are the ones that mostly include such
indicators as well as the childhood comprehensive attention programmes (100%).
for example: quantity of food distributed,
number of micronutrients supplements distributed.
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Table 6
weaknesses or none existence of sustainable
nutritional surveillance systems hampers the
availability of reliable and updated information
on the geographical distribution of nutritional
problems; the identification of the most affected groups and the short term identification of
nutritional problem trends. This information is
essential to make accurate informed decisions.
Nutritional indicators used according to type
of programme (n=110)
G. HUMAN RIGHTS APPROACH, GENDER
PERSPECTIVE, CULTURAL RELEVANCE
AND COMMUNITY PARTICIPATION
According to type of programme
% (n)
% (n)
% (n)
% (n)
Childhood and
Adolescence
Attention
Programmes
(n=5)
% (n)
% (n)
% (n)
Underweight prevalence
76% (41)
20% (3)
20% (2)
33% (2)
60% (3)
10% (2)
48.2% (53)
Wasting prevalence
72% (39)
20% (3)
20% (2)
17% (1)
40% (2)
20% (4)
46.4% (51)
Chronic undernutrition
prevalence
70% (38)
13% (2)
20% (2)
17% (1)
60% (3)
15% (3)
44.5% (49)
Anemia prevalence
37% (20)
-
20% (2)
-
-
15% (3)
22.7% (25)
Low birth weight
37% (20)
-
10% (1)
-
20% (1)
10% (2)
21.8% (24)
Weight gain during
pregnancy
35% (19)
-
-
-
-
10% (2)
19.1% (21)
Body Mass Index (BMI)
20% (11)
7% (1)
10% (1)
-
20% (1)
30% (6)
18.2% (20)
Amount of micronutrients
supplements distributed
24% (13)
-
-
-
-
10% (2)
13.6% (15)
Amount of food distributed
19% (10)
-
-
-
60% (3)
5% (1)
12.7% (14)
Micronutrients intake
13% (7)
-
20% (2)
-
-
20% (4)
11.8% (13)
Energy intake
6% (3)
-
10% (1)
-
60% (3)
20% (4)
10.0% (11)
Arm circunference
9% (5)
-
-
-
-
15% (3)
7.3% (8)
Urinary iodine / Goiter
prevalence
7% (4)
-
40% (4)
-
-
-
7.3% (8)
Macronutrients intake
4% (2)
-
10% (1)
-
-
20% (4)
6.4% (7)
Children weight gain
2% (1)
-
-
-
-
10% (2)
2.7% (3)
Adequately iodized salt
consumption
2% (1)
-
10% (1)
-
-
-
1.8% (2)
Indicators
Fortification and Productive
Food-Nutritional
Conditional
Biofortification Programmes
Programmes
Transfers (n=15)
(n=10)
(n=6)
(n=54)
HIV Spec.
Programmes
(n=20)
74
An analysis of key transversal aspects that were
included in the social protection programmes
of the Study is presented as follows.
Total (n=110)
The absence of nutritional indicators does not
necessarily mean that programmes could not
have an impact on the nutritional status, but
rather that the measurement of the nutritional
impact is not part of its internal system of monitoring and evaluation. In fact, productive and
conditional transfer programmes can have an important effect on the nutritional status through
an improved access to nutritious foods together
with an increase in the purchasing power, as part
of incorporating the nutritional dimension.
1. The human rights approach
The concept of human rights developed by the
United Nations recognizes them as the set of
material and spiritual conditions inherent to the
human being, aimed at his/her full realization;
that is, realization in his/her material, rational
and spiritual levels. Human rights are all those
universally accepted principles and norms that
must govern the acts of individuals, communities and institutions to preserve human dignity,
promote justice, progress and peace69.
The inclusion of nutritional indicators as part
of the incorporation of the nutritional dimension in social safety nets has additional benefits
to their success as well as for the sustainability
of its achievements. Having systematic information on the nutritional status of the target
population will allow establishing and reviewing the strategies used in order to guarantee the
desired nutritional impact.
On the other hand, since September 2007, the
United Nations General Assembly adopted
the UN Declaration on the Rights of Indigenous Peoples, after over 22 years in the making. Among several aspects, it recognizes the
urgent need to respect and promote the inherent rights of indigenous peoples which derive
from their political, economic and social structures and from their cultures, spiritual traditions, histories and philosophies, especially
their rights to their lands, territories and resources70.
In summary, the lack of monitoring and evaluation systems –adequately funded and with nutritional indicators– constitutes a weakness to
be overcome in several social programmes analyzed. In many programmes, because of not
considering the nutritional dimension since the
design stage, it does not form part of the monitoring and evaluation systems. Moreover, the
69
70
75
UNICEF (2006).
UN (2007)
HIV programmes for their part, given its objectives and the type of population they assist,
are focused more on indicators such as Body
Mass Index (BMI), wasting and energy, macro
and micronutrients intake. Many of these programmes indicated that they perform an initial
evaluation of the nutritional status of patients
before starting treatment.
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Figure 20
Human rights approach (n=110) and implementation ways (n=85)
Ways to implement the human rights approach
The human rights approach includes the following principles: universality and inalienability; indivisibility; interdependence and interrelatedness; nondiscrimination and equality;
participation and inclusion; and, accountability
or transparency. In this sense, acting within the
framework of human rights requires States, individuals and international cooperation, among
other aspects:
“The human right to food subscribed by governments in treaties or other international instruments including the Universal Declaration
of Human Rights (1948), the International
Covenant on Economic, Social and Cultural
Rights (ICESCR, 1966) and the Convention
on the Rights of the Child (1989), gives a judicial dimension by which, governments have a
legal obligation to act so that progressively all
people within its territory not only do not go
hungry, but can also produce or procure, in a
fully consistent manner accordingly with their
human dignity, adequate food for an active and
healthy life”71.
a. Identify the groups in situation of major
vulnerability and marginalization who are
not enjoying the right to food and good nutrition.
b. Analyze the underlying and structural
causes of food and nutritional vulnerability that hamper access to food, and the exclusion of individuals in order to guarantee them the benefits of public policies and
Social Safety Nets; access and ownership
of inputs as well as of productive and economic resources, employment and credit.
In light of these guidelines, the analysis of the
human rights approach in social programmes
studied showed that most of these (77%) indicated that they work within this framework
(Figure 20). The 22% of the programmes did
not specify the implementation ways of this
approach, while another 22% stated that they
act in the framework of the laws and principles that uphold the human rights approach,
without specifying what specific measures or
actions are adopted by the programme to encourage compliance.
c. Create appropriate environments and
adopt holistic measures to enable people
and their families to feed properly in the
long term and permanently.
Programmes are executed within the framework of
the principles and international legislation about
human rights; there are existing laws and national
normatives for its application*
22% (19)
Attention is given to all people who require the
services, without discrimination*
22% (19)
Attention is targeted towards groups in situation
of major vulnerability*
9% (8)
Operating mechanisms have been formed in order
to have political incidence**
6% (5)
Implementation of actions to create a favorable
environment for the accomplishment of food and
nutritional security**
5% (4)
Programmes promote children´s rights*
4% (3)
Training for population and production of
educational materials about the human rights
approach and the rights to health and food*
5% (4)
Promotion of community participation*
2% (2)
Legal support and training for PLHIV in order to
guarantee comprehensive treatment, including
access to ART**
2% (2)
Does not specify
22% (19)
TOTAL
100% (85)
Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009
PLHIV: People living with HIV, ART: Antiretroviral treatment.
* These answers are directly related to the human rights.
** These answers are not necessarily framed within the human rights approach.
71
76
Programmes % (n)
FAO (2006).
77
Attention to all people of the target group,
without discrimination, is the most widespread
form of implementing the human rights approach in the analyzed programmes (22%).
For other programmes, the human rights approach is implemented with attention to vulnerable groups, aiming to reduce inequity and
social exclusion (9%).
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IV
II
and women; the participation of women and
men in different phases of the programmes; the
existence and training of male and female human resources in an equitable manner; the active role of women as principal recipient of inputs and services provided by the programmes,
as well as their leading role in improving the
nutrition of the whole family; and the positive
impact of some programmes on women self esteem, among others aspects.
Some answers are not necessarily linked to the
human rights approach. For example, five programmes (6%) have promoted the creation
of mechanisms and operational instances (intersectoral committees, networks) especially
at the municipal level to have a political incidence, and two of the HIV programmes (2%)
provide legal support and training to PLHIV in
order to guarantee comprehensive treatment,
including access to ART. In the same sense
some programmes (5%) indicated that the promotion and implementation of actions in food
and nutrition security is another way to implement the human rights approach.
of birth sex and learned in the process of socialization73. As a socio cultural construction is
specific to each culture and changes over time.
The gender approach or perspective on the other hand, is a category of analysis and a working
tool that can identify different roles assumed
by both men and women in a society as well
as asymmetries, power relationships and inequalities. Its use helps to recognize the causes
that produce them and develop mechanisms to
overcome these gaps and discrimination; for
example, affirmative action that directly benefit women. The gender perspective is based on
equal rights between men and women.
On the other hand, it was found that few programmes conduct training and information to
the population on topics related to this approach.
In summary, much remains to be done in terms
of human rights promotion and practical application, mainly the Right to food, giving priority
to children under two years and women. Special efforts have to be developed on the promotion of the Indigenous peoples rights, considering that these peoples are the ones who most
suffer discrimination and social exclusion.
The Study included variables related to gender
perspective in order to verify the existence of
this approach and its transversal implementation ways in the studied programmes. Information was analyzed in regards to the existence
of laws and standards about the equality of
rights between men and women; the disaggregation of data by sex and the severity of the
nutritional situation and the HIV among girls
2. Gender perspective
First, it is worth noting that gender is the set
of social, cultural, political, legal and economic socially assigned characteristics in function
Based on the Convention on the Rights of the Child
(1989)
72
73
78
UNDP (2004).
or human community defined by racial, cultural or linguistic affinity (Group of people
who share racial, religious and linguistic traits,
among others)74.
The Central American and Dominican Republic population is characterized by its ethnic and
cultural diversity, which implies the coexistence of population groups with different ways
of seeing, conceiving, interpreting and relating
themselves to the world (cosmovision).
It was evidenced that the criterion persists of
considering that the programmes have gender perspective when they exclusively incorporate actions targeted at women or there is a
greater involvement of them in the execution
of interventions. Moreover, there is a tendency to consider the improvement of nutritional
and socioeconomic status of women primarily
as a means to achieve progress in other family members, especially children, ignoring the
needs and interests of women themselves.
Starting from the same human rights approach,
acting with cultural relevance (or ethnic-cultural) implies the need to recognize the coexistence and contributions of various ethnic
groups and cultures, to respect and promote
cultural diversity in order to achieve a more inclusive society.
The dimension or cultural relevance is a key
aspect to be taken into account in the design,
implementation, monitoring and evaluation of
policies and social programmes on the basis
of dialogue and articulation between State instances or other implementing entities and people belonging to the different ethnic groups75.
The findings allow to conclude that, despite
existing progress in mainstreaming gender perspective into the programmes, it is further required more knowledge and put in practice of
this topic, both at the level of the institutions
offering the services as well as the population
that demands them. Additionally, programmes
are required to explicitly incorporate actions
or interventions that directly benefit girls and
women for their own condition (beyond their
families) in order to reduce the inequality gaps
between men and women. It is also important
to review the women work overload that some
programmes are generating.
From the perspective of nutrition, is essential to
respect and recognize practices of feeding, nutrition and health from different cultures at all
stages of the programme cycle (design, implementation, monitoring and evaluation). For this
it must be rescued and valued those practices
that are favorable to nutrition and health, and
improve or eliminate the ones that discourage
good nutrition, in a process of mutual learning.
In that sense, ethno-cultural relevance not only
relates to speaking the same language, but rather to foster intercultural dialogue to find solutions to major problems (in this case food and
nutrition), being the community participation
the most appropriate way to attain this goal.
3. Cultural Relevance
Culture is the set of all the life forms and expressions of a given society. As such, it includes
knowledge, beliefs, customs, practices, codes,
languages, rules and regulations of self being,
dress, art, religion, rituals, and norms of behavior and belief systems. Moreover, the term ethnia or ethnic group means “peoples or nations”
74
75
79
UNICEF (2006) ibid.
Cunningham (2006).
Relatively few programmes indicated that they
have a proactive role in the human rights approach implementation. Four programmes
(5%) train and disseminate information on the
rights of individuals to health, education and
food, both for the institutional staff as well as
the benefited population. Some even develop educational materials about it. Three programmes
(4%) do the promotion of children’s rights72.
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Figure 21
In this regard, the analysis of the information
collected shows that less than half (46%) of
the studied programmes answered that they
take into account cultural relevance, including socio-linguistic diversity, at some stage of
the programme (Figure 21). There was a 22%
of programmes that did not consider cultural
relevance, and the remaining 32% did not respond, or indicated that the cultural relevance
“is not applicable” to the programme.
Cultural relevance in the different stages
of the programmes (n=110)
4. Community participation
The programmes that take into account the
ethnic and cultural relevance refer various
ways to translate these approaches into practice. Among them, the following is mentioned:
Participation of the population in the policies
and social protection programmes is one of the
fundamental principles of the human rights
approach. Multiple field level interventions in
various parts of the world show evidence that
a high level of community participation facilitates ownership of interventions, promotes co
responsibility in the formulation of solutions
to the problems identified and in the execution
of activities; generates empowerment of individuals and their communities. This will guarantee social control, accountability and promotes the desired impact.
i. Use of local foods and consideration of the
particular food habits of the population
(mentioned by 20% of programmes).
ii. The recruitment of staff who speak local
languages (19%).
iii. Development of educational materials and
documents in local languages (14%).
iv. Respect for the culture and traditions
(10%).
When analyzing on which programme stage
cultural relevance is considered, half of the 51
programmes include it only in the execution or
implementation stage (n= 24). Relatively few
programmes consider this aspect in the design
stage and very few in the monitoring and evaluation ones.
80
Community participation guarantees that the
interventions meet the conditions, experiences and expectations of communities, which in
turn ensures its cultural relevance and strengthens sustainability76.
v. Adaptation of procedures, methods and
content to different cultures, such as vertical
delivery (10%).
vi. The incorporation of indigenous knowledge
(8%).
76
81
SESAN, 2006.
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Table 7
Community participation in the programmes
(n=110)
Percentage (%)
Existence of community participation
The Comprehensive Survey sought to better understand how to implement community
participation in the programme (Table 8). The
22% of programmes did not answer this question, and among those who gave an answer it
is noted that:
promotion, health and nutritional counseling, home visits, among others.
iii. Other forms of active participation, including participation in the planning, management and social control, have been mentioned in 13% of the programmes.
i. 31% mentioned that community participation is materialized as assistance to the programme activities, either individually or by
forming committees or groups to support
implementation of activities.
From the analysis, it is positive that most of
the programmes consider the participation of
the community, although it is generally limited to the implementation stage. It needs to be
strengthened and extended to other stages of
the programme cycle, thus guaranteeing more
active ways of participation by different actors
in the community, such as participatory planning, joint management and social control.
ii. 12% said that participation occurs through
the voluntary efforts of promoters, counselors and guiding mothers, who executed
some activities such as growth monitoring/
Yes
86
78%
No
11
10%
Does not know / Does not answer
13
12%
Table 8
TOTAL
110
100%
Ways of community participation in the programmes (n=86)
Broad
66
60%
Limited
25
23%
Null or almost null
2
Does not know / Does not answer
TOTAL
Grass-roots organizations participation
Percentage (%)
Participation in the execution stage, attendance to activities,
organization of committees and support groups for actions
27
31%
2%
Community volunteers participation in the programmes activities
(promoters, counselors and guiding mothers)
10
12%
17
15%
Management and social control participation
11
13%
110
100%
Identification of benefited people and their needs
7
8%
Joint planning and activities monitoring
4
5%
Economic contribution for the execution of activities
2
2%
Weight and height measurement, growth monitoring / promotion
2
2%
Work conducted through self help groups
2
2%
Communities are informed about the programme
1
1%
Co responsibilities achievements
1
1%
Does not specify
19
22%
TOTAL
86
100%
Nevertheless, the participation of grass-roots
organizations is mainly in the execution stage
(40% of programmes). Only one fifth of the
programmes referred that these organizations
are involved in all stages from design to evaluation. Additionally, about 30% reported that
the diagnosis of nutritional problems was done
with community participation, but do not have
information on how this participation is done
in practice.
82
Main ways of community participation
Note: Answers about the total of programmes that have community participation (n=86).
83
Most social programmes analyzed (78%) indicated that they promote community participation and 60% that the participation of grassroots organizations is broad (Table 7). The
massive food fortification programmes and
some HIV programmes are the ones who most
responded not having community participation.
but at the same time they shall be dynamic and
be able to adapt to changes and new challenges,
such as crises.
Figure 22
Execution time according to type of programme (n=110)
In the analysis of this aspect, it was found that
the average duration of the studied programmes
is 11 years. Half of them are relatively new with
a duration of five years or less, while 39% (n=
43) has an implementation period of more than
10 years (Figure 22).
In this section, key issues are addressed related to the duration and sustainability (social, financial, legal, environmental and institutional)
of the programmes, their funding as well as the
collateral effects (positive or negative) and the
integration of social protection programmes
within national strategies for poverty reduction.
The findings by type of programme highlight the
fact that most of the conditional transfer and
productive programmes (74% and 83% respectively) have duration of five years or less. On the
other hand, childhood and adolescence attention
programmes and food fortification programmes
are mostly longer than 10 years. Finally, among
HIV and food and nutritional programmes,
there is a similar proportion among the ones of
recent start (five years or less) and long term existent programmes (more than ten years).
1. Duration of the programmes
The eradication of child undernutrition requires
of State policies and that social protection programmes are not temporary measures of each
government. In other words, they should have
continuity and transcend government terms,
in policies and programmes is one of the fundamental factors for achieving this purpose77.
By country (Figure 23), it was found that most
of the programmes in Costa Rica (73%) have
duration of more than 10 years. In this country,
the promotion of public policies and comprehensive programmes to promote good nutrition
throughout the entire course of life began in the
60s, and measures have transcended periods of
government. One example is the Nutrition and
Child Development Programme that has been
executed continuously for more than 50 years.
Panama is another country where there are also
a greater proportion of long term programmes,
such as the Complementary Food Programme
and the Vitamin A and Iron Supplementation
Programmes that date back 15 years.
At the same time, it appears that in countries
with higher prevalence of undernutrition such
as Guatemala and Honduras, there are only
about 30% of programmes with duration of
more than six years. Most of the social protection programmes in these countries are recently
This could be one of the reasons for Costa Rica’s
success in reducing child undernutrition significantly. This country, along with Chile and Cuba,
is among those with the lowest prevalence of undernutrition in the continent. The experience of
Chile, which has successfully eradicated child undernutrition, reaffirms the fact that the continuity
84
77
85
WFP (2006) ibid.
H. DURATION, SUSTAINABILITY,
INVESTMENT, COLLATERAL EFFECTS
AND DEGREE OF COMPLIANCE TOWARDS
NATIONAL STRATEGIES FOR POVERTY
REDUCTION
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II
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Figure 23
Programmes duration according
to country (n=110)
2. Sustainability and funding sources
created programmes with five or fewer years of
implementation. This could indicate that in these
countries, the prioritization of the food and nutritional problem has taken a greater impulse on
the political agenda of the last five years.
From the human perspective, sustainability is
related to the ability of maintaining the satisfaction of needs over time, preserving the balance between the present generation and future
generations78. A programme, policy, intervention or service can be considered sustainable
when it maintains itself, without outside help
and it is not done at the expense of others (regardless of the time it takes to do so). Sustainability should be measured from different
angles. In the present Study five types of sustainability were taken into account:
funding sources when analyzing these variables
by country (Tables 9 and 10). The vast majority
of programmes refer to be sustainable. Among
these, 75% have social sustainability and 60%
have institutional and legal sustainability. However, it appears that the broad political support
and social demands do not necessarily translate
into allocation of sufficient and stable financial resources, since less than half of the programmes say they have financial sustainability.
i. Social: The population has appropriated,
participates and constantly demands the
programme, service or intervention.
ii. Financial: Sufficient and stable availability
of financial resources from the State.
iii. Institutional: Broad political commitment
and sustained existence of “institutionality”.
In Costa Rica, practically all programmes
(91%) have financial, institutional and legal
sustainability. Programmes are funded almost
entirely with public funds.
iv. Legal: It has strong, approved and implemented laws and legal frameworks.
v. Environmental: In balance with the resources of its environment, without sacrificing them, preserving the possibility of future satisfaction.
There are interesting trends observed regarding the sustainability of programmes and their
In countries like El Salvador, Guatemala, Honduras and Nicaragua only 20% to 38% of the
programmes analyzed have financial sustainability. In these countries, from 25% to 40% of
the programmes studied are funded exclusively
by foreign donations, while the rest is funded
in part with public funds, international cooperation and private businesses. For these four
countries, very few of the programmes included
in the study are funded entirely by public funds
(none of them in Nicaragua and Honduras).
Adapted from the Brundtland Report, 1987. The
term sustainable or perdurable development applies to
socio-economic development and was first formalized in
the document known as the Brundtland Report (1987),
the result of the work of the United Nations World Commission on Environment and Development.
In the Dominican Republic and Panama, although a considerable number of the analyzed
programmes reported to have financial sustainability, only a fourth and fifth of the total respectively is funded exclusively by public
funds. At the same time, Belize has 43% of the
programmes funded in this same way.
The programmes sustainability will be accomplished as long as there are mechanisms that
look for it or propitiate from the programme
design stage as part of integral processes.
78
86
87
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The sustainability analysis (Table 11) and
sources of funding according to programme
type (Table 12) reveal that:
Programmes sustainability according to country (n=110)
Belize
(n=7)
Costa Rica
(n=11)
El Salvador
(n=16)
Guatemala
(n=15)
Honduras
(n=16)
Nicaragua
(n=18)
Panama
(n=15)
Dominican
Republic
(n=12)
Total
(n=110)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
Financial
57% (4)
91% (10)
38% (6)
20% (3)
31% (5)
28% (5)
80% (12)
50% (6)
46% (51)
Social
71% (5)
91% (10)
81% (13)
40% (6)
81% (13)
83% (15)
87% (13)
67% (8)
75% (83)
Institutional
57% (4)
91% (10)
81% (13)
47% (7)
44% (7)
67% (12)
47% (7)
42% (5)
59% (65)
Legal
71% (5)
91% (10)
63% (10)
47% (7)
50% (8)
67% (12)
40% (6)
25% (3)
55% (61)
-
9% (1)
6% (1)
7% (1)
6% (1)
17% (3)
-
8% (1)
7% (8)
Types of
Sustainability
Environmental
Table 10
Funding sources according to country (n=110)
Belize
(n=7)
Costa Rica
(n=11)
El Salvador
(n=16)
Guatemala
(n=15)
Honduras
(n=16)
Nicaragua
(n=18)
Panama
(n=15)
Dominican
Republic
(n=12)
Total
(n=110)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
Public resources
exclusively
43% (3)
91% (10)
6% (1)
20% (3)
-
-
20% (3)
25% (3)
21% (23)
Public resources and
external cooperation
(loan and donation)
14% (1)
-
19% (3)
13% (2)
56% (9)
50% (9)
27% (4)
42% (5)
30% (33)
private sector
-
9% (1)
-
7% (1)
6% (1)
-
20% (3)
8% (1)
6% (7)
Funding sources
Public resources, private
sector and external
donations
External cooperation
(donation) exclusively
-
-
13% (2)
-
-
-
13% (2)
8% (1)
recent years. However, only 27% of these
programmes are funded entirely by public funds, while most of these programmes
are financed by combining public resources
with international cooperation funds in the
form of loans or donations.
•• As it was mentioned before, most of the
programmes claim to have social sustainability (75%), followed by institutional sustainability (59%). In the meanwhile, the financial and environmental sustainability
are the weakest (46% and 7% respectively).
•• Less than half (around 45%) of the analyzed HIV programmes have financial, institutional and legal sustainability. Most of
these programmes have social sustainability (70%). As to funding, these programmes
rely to a greater extent on international cooperation, the generation of own resources
or the private sector. Only 15% of which is
financed exclusively by public funds.
•• Of the total of 54 food-nutritional programmes, fewer than half (43%) indicated having financial sustainability. This is in
line with the funding source, since a significant proportion (28%) depends exclusively on international donations. The greater
sustainability of this type of programme is
social (76%).
•• There are marked differences in relationship to legal sustainability among the types
of programmes. The productive and HIV
programmes are the ones with the least legal sustainability, while 80% of childhood
and adolescence attention programmes and
70% of the fortification and biofortification
programmes have this kind of sustainability.
•• The conditional transfer programmes, for
the most part, report having financial, social, institutional and legal sustainability,
coinciding with the priority that governments have given to such programmes in
Table 11
Sustainability according to type of programme (n=110)
Food-Nutritional
Prog. (n=54)
Conditional
Transfers
(n=15)
Fortification and
Biofortification
(n=10)
Productive
Programmes
(n=6)
Childhood and
Adolescence
Attention
Prog. (n=5)
HIV spec.
programmes
(n=20)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
Financial
43% (23)
60% (9)
60% (6)
-
80% (4)
45% (9)
46% (51)
Type of
Sustainability
5% (5)
Total
(n=110)
14% (1)
-
25% (4)
40% (6)
31% (5)
28% (5)
-
17% (2)
21% (23)
-
-
6% (1)
-
-
11% (2)
-
-
3% (3)
Social
76% (41)
87% (13)
50% (5)
83% (5)
100% (5)
70% (14)
75% (83)
29% (2)
-
19% (3)
-
-
6% (1)
-
-
5% (6)
Institutional
63% (34)
60% (9)
50% (5)
67% (4)
80% (4)
45% (9)
59% (65)
Others (sponsorship, own
resources)
63% (34)
53% (8)
70% (7)
17% (1)
80% (4)
35% (7)
55% (61)
-
13% (2)
-
6% (1)
-
20% (3)
-
5% (6)
Legal
-
Environmental
11% (6)
-
10% (1)
17% (1)
-
-
7% (8)
Without information
about funding
-
Private sector exclusively
Private sector and
-
-
20% (3)
-
6% (1)
-
-
4% (4)
88
89
Table 9
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3. Collateral effects and degree of compliance
towards national poverty reduction strategies
Funding sources according to type of programme (n=110)
Food-Nutritional
Prog.
(n=54)
Conditional
Transfers
(n=15)
Fortification and
Biofortification
(n=10)
Productive
Programmes
(n=6)
Childhood and
Adolescence
Attention
Prog. (n=5)
% (n)
% (n)
% (n)
% (n)
% (n)
% (n)
Public resources
exclusively
19% (10)
27% (4)
20% (2)
-
80% (4)
15% (3)
21% (23)
(loan and donation)
30% (16)
67% (10)
30% (3)
17% (1)
-
15% (3)
30% (33)
private sector
4% (2)
-
30% (3)
-
-
10% (2)
6% (7)
Public resources,
private sector and
external donations
7% (4)
-
-
-
-
5% (1)
5% (5)
28% (15)
-
10% (1)
50% (3)
-
20% (4)
21% (23)
Private sector
exclusively
2% (1)
-
-
17% (1)
-
5% (1)
3% (3)
Private sector and
7% (4)
-
-
-
20% (1)
5% (1)
5% (6)
Others (sponsorship,
own resources)
2% (1)
-
-
17% (1)
-
20% (4)
5% (6)
Without information
about funding
2% (1)
7% (1)
10% (1)
-
-
5% (1)
4% (4)
Funding Sources
External cooperation
exclusively
HIV spec.
programmes
(n=20)
Most programmes identified positive collateral
effects. In addition to the beneficial effects on
health, food, nutrition and/or poverty reduction, the programmes generate support and social demand. As a result, many organizations
are created and/or strengthened that in turn become instruments of social demand for the fulfillment of the rights for those in major vulnerability situation. Some programmes also
contribute to the governance, encouraging the
peaceful resolution of conflicts (Figure 24).
Total
(n=110)
Figure 24
Positive collateral effects identified
In summary, although the information collected is not sufficient to make definitive statements, the analysis of it shows that social protection programmes have a high degree of
social sustainability. However, there is concern
about their financial sustainability, which is
closely linked to the source of public funding
and social investment (including nutrition) as
the States responsibility. For its part, environmental sustainability is practically nonexistent,
suggesting the urgent need for action to protect not only the present generations but also
the future ones.
90
91
Table 12
III
IV
II
STRENGHTS
•• More availabilty of funds for
social programmes (more to
the Conditional Cash Transfer
programmes).
•• Increased political support for
nutrition and other social programmes.
•• Existence of a favorable legal
framework, even included in
some countries political constitutions.
Additionally, some programmes can have a
negative impact on the women’s workload, especially if their activities and their timing are
not taken into consideration. For example,
compliance with the co-responsibilities (attending health centers, the training events, etc.)
in the conditional transfer programmes could
affect the amount of time that the woman has
for other activities, including the income generating activities79. In other cases, for women
to attend training events and/or meetings, this
means that they must extend their workdays to
fulfill all of their tasks 80. This and other possible negative collateral effects need further analysis to anticipate them when planning the programmes.
•• Conditional transfer programmes increase women’s
self esteem.
•• In emergency situations food
is crucial to avoid nutritional
deterioration.
•• Higher levels of schooling/education in the countries are influencing nutrition positively.
•• Mother and child health programmes with major achievements: reducing infant and
maternal mortality.
•• Population knows more about
their rights and can demand
their fulfillment.
Finally, the vast majority of the social protection programmes analyzed (89%) indicated
that they form part of strategies to reduce poverty in the country, and also there is a commitment and leadership of public institutions
in the reduction of undernutrition. By contrast,
HIV programmes are the ones with the highest proportion of negative responses on these
two aspects.
79
80
I. STRENGHTS, WEAKNESSES,
OPPORTUNITIES AND THREATS ANALYSIS
In order to collect different views on the design, implementation and evaluation of social
protection programmes from multiple perspectives, a Key Informant Interview was developed
and implemented in each of the countries participating in the Study. In total 35 interviews
were conducted in the eight countries, as it was
mentioned in the Methodology section of this
report. This qualitative information allowed
supplementing the comprehensive survey findings. The opinions of the informants were organized in a Strengths, Weaknesses, Opportunities and Threats (SWOT) matrix, described
as follows:
Ruel, 2007.
WFP (2009) b.
92
•• Organized community involvement with legal support in
some countries.
•• Increase in the populations
demand for social protection
programmes.
•• Presence of some NGOs that
help out with the human rights
approach and greater community participation within their
programmes.
•• Gradual increase in technical
personnel that speak native
languages and production of
educational/informational materials in these languages.
WEAKNESSES
OPPORTUNITIES
•• No programme sustainability
and continuity.
•• International agreements
(“pressures”) based on governments previous commitments. Example: MDG’s.
•• Programme dispersion and no
results.
•• Global food crisis raises the
importance of nutrition and
feeding issues.
•• Lack of coordination between
programmes, generates duplicities and family “fragmentation”.
•• Social issues and nutrition are
now trendy.
•• No links between programmes
and broader national strategies.
•• Solidarity among countries in
the Region: countries share experiences and resources.
•• Very low social investment
(public) in nutrition.
•• Increased trust and awareness
regarding breastfeeding (Lancet Series reiterates evidence).
•• Insufficient budget for breastfeeding promotion.
•• The increasingly stronger academia provides greater chances of programme success.
•• Policies and poverty reduction
programmes are only of containment, they do not overcome poverty.
•• Women development promotion expands possibilities for
children and families.
•• Inadequate targeting: the ones
in most need are not selected or the tools do not identify
them properly.
•• Recognition of the existence of
excluded groups.
•• Programmes do not prioritize
on young children.
•• Indigenous peoples and afro
descendants in government
positions (less discrimination).
•• Insufficient staff in quantity
and quality.
•• Programme decentralization
allows better implementation.
•• Field supervision is very weak.
•• Existence of access routes to
several rural communities.
•• Lack of evaluations, specially
impact ones.
•• Increased Attention to PLHIV.
•• Lack of human rights approach, programmes do not
have cultural relevance nor
gender perspective (in spite of
some advances).
•• Revaluation of ancestral cultures, their practices and
foods favorable to nutrition.
•• Statistical invisibility of indigenous peoples and afro descendants.
•• Weak community participation
(only in the execution stage).
•• Complementary foods do not
meet nutritional requirements.
•• HIV programmes do not prioritize support with food and nutrition.
93
THREATS
•• International crisis leads to
budget cuts in the public sector and donor community.
•• Dependency on external cooperation and “indebtedness”.
•• Tax collection is insufficient.
•• No laws to protect public investment in social programmes.
•• In general, no State or institutional policies on social protection.
•• Globalizing currents that seek
to apply same “recipe” in all
countries.
•• Politization and paternalistic
programmes.
•• Families depend on remittances to cover their basic needs.
•• Lack of technical information
for the decision makers.
•• Increase in the prices of inputs
increases services costs.
•• Deficient infrastructure.
•• Lack of information and nutritional education for the population.
•• Discrimination and stigmatization of excluded groups (indigenous peoples and afrodescendants, people with HIV).
•• Marketing (advertisement)
used to promote milk formula.
•• Non adoption of the Breast
Milk Substitutes Code.
An important element in the design of successful
programmes is the ability to timely anticipate
any negative effects and take measures to prevent their occurrence. Few programmes (n=18)
identified negative collateral effects. Among
these undesirable effects, it was mentioned the
generation of dependency, nonfood acceptance
for being different of local cultures and the deterioration of the delivered food. Also, two programmes mentioned that sometimes the food
and other products purchasing mechanisms affect the local market and economy.
In line with the findings and results of the Study,
the conclusions and recommendations presented below cover the following areas: i) Political commitment; ii) Institutional coordination
and safety nets conformation; iii) Nutritional
dimension specificities; iv)Targeting and priority groups; v) Coverage; vi) Human resources;
vii) Supplies and logistics; viii) Monitoring and
evaluation and nutritional surveillance; ix) Human rights approach, gender perspective, cultural relevance and community participation;
and, x) Sustainability-funding and programme
duration.
V CONCLUSIONS
94
III
IIV
CONCLUSIONS
Here are the key conclusions of the Study:
1
One of the most important advancements
reflected in the social programmes analyzed
is the gradual increase in political commitment
at the highest levels of government to position
the eradication of child and maternal undernutrition within national and regional agendas as
the core of human and economic development.
United Nations agencies as well as other institutions of technical and financial cooperation and
NGOs have contributed to this achievement.
2
In most countries a favorable legal framework and high-level intersectoral areas of
coordination have been formed, such as the National Food and Nutrition Security Secretari
ats and Councils in El Salvador, Guatemala
and Panama, concurred by sectors involved in
the improvement of nutrition and food security. Countries have national strategies and plans,
aimed to prevent and reduce child undernutrition and micronutrient deficiencies, approved
and implemented. However, coordination –both
intrasectoral and intersectoral– between the institutions that manage the programmes, is variable and ineffective, with the establishment of
articulated and coherent social safety nets, is a
challenge yet to be overcome in these countries.
Social protection programmes generally work
in isolation with different approaches and objectives.
But, given the evidence that the coverage of the
various social risks (both traditional and new)
is not universal, we must recognize that there is
not a real safety net. The countries of the Region have programmes, activities, rules, regulations and experiences from almost all the risks
and although the vision intends to be comprehensive, in practice unprotection and inequality
are present, because not all programmes work,
or because each one is not fully operational, so
that there is no universal coverage in any risk”.
3
Nutritional dimension, reflected through
the explicit incorporation of objectives, actions/ interventions and indicators of nutrition,
is low in most social protection programmes
analyzed, though the identification of major
nutritional problems occurs in about three
quarters of them. Half of the programmes analyzed have no nutritional objectives. At the
same time, a considerable portion is not implementing the interventions that have proven effective in reducing undernutrition at large scale.
For example, only half of the programmes include the promotion of breastfeeding and micronutrient supplementation. A third considers
the promotion of appropriate complementary
feeding. The scientific evidence emphasizes that
these interventions have an impact on the immediate causes of child undernutrition.
These factors, coupled with the weakness
of public policies and low continuity of programmes jeopardize the sustainable nutritional impact of the programmes. As Acosta and
Ramirez81 point out:
“A Social Safety Net should be a tool and a central concept in moving towards equity, and to
achieve it in specific and concrete circumstances.
81
Acosta and Ramírez, CEPAL (2004).
97
III
IIV
It is important to recognize that there are serious structural problems in the countries which
–despite political commitment, the existence of
programmes with proper design, clarity about
what is required and must be done and technical capacity as well– hinder progress towards
eradicating child undernutrition (Guatemala is
one of these countries).
the nutritional dimension explicitly. They aim
that the improved nutritional status would occur by way of compliance with the co-responsibilities (health care center attendance to child
growth monitoring and/or pre-natal control,
school attendance, among others) within the intervention of other sectors (i.e. health and education). Through conditionality, the demand for
health care increases, but there is no guaranteed
impact on health and nutrition if health servic
es in turn do not improve their coverage and
quality of care, same within the education outcomes.
The nutritional dimension is limited to the stage
of the design and implementation in some cases, even in programmes directly related to the
health sector. Programmes such as conditional cash transfers and childhood adolescence attention programme have great potential that
is not being properly used to improve nutrition for infant and young children and other
priority groups. The explicit non inclusion of
the nutritional dimension in all stages of social protection programmes reduce the chances
of achieving nutritional impact and therefore
mean the loss of opportunities for survival and
child development82,83,84.
5
In regards to HIV specific programmes,
countries do not systematically integrate
nutritional counseling and/or food assistance
to HIV treatment. The few voluntary food assistance initiatives to help people with HIV
tend to be ad hoc, small scale and often with
a short term duration. The involvement of PLHIV in programmes to control HIV is limited.
There is still a knowledge gap about HIV, contributing to discrimination and stigmatization
towards PLHIV, in both the general population
and within the human resources of the different institutions.
4
The Conditional cash transfer programmes,
which currently have high priority for
govern
ments, since their inception have had
goals related to poverty reduction and investment in human capital, but did not incorporate
Leroy et al (2009).
Ruel et al (2009).
84
Garret et al (2009).
82
83
98
levels of staff become lower. In addition, there is
no evidence that trainings are effective. One of
the exceptions is the breastfeeding programme
existent in Nicaragua that offers in depth, structured and comprehensive training.
The programmes focus on pregnant women, children under five years, lactating
mothers and families in extreme poverty. However, in general they do not prioritize nor highlight children under two years, despite the evidence related to the “Window of Opportunity”
(from pregnancy to two years of age). As positive examples, several programmes in El Salvador and Nicaragua highlighted targeting this
age group without neglecting specific interventions to children between two and five years.
Indigenous peoples are not given priority, even
though they have the worst socio-economic indicators. In general, with the exception of HIV
specific programmes, people living with HIV
are not included in other public social protection programmes. However, countries such as
Honduras incorporate this group on a priority basis in various programmes of their health
sector.
9
Availability of food and supplies (supplements, educational materials, and others) is enough in two-thirds (65%) of the programmes throughout the year. In a third of the
programmes, the avail ability of food and supplies is insufficient or it is only present at certain
times of the year. There are limitations observed
in the feeding quality –mainly in fortified complementary foods- and logistics (procurement,
distribution and storage), which impede adequate utilization and timely delivery of products to the target population, especially in the
local and community levels.
7
The programme coverage is low or unknown; less than 20% of the programmes
analyzed have adequate information on their
coverage (lack of specific data and/or they assume as coverage the number of people, communities or municipalities benefited). On the
other hand, there are geographic areas with
higher concentration of programmes, suggesting possible overlap, and in turn, there are priority areas with problems of child and maternal
undernutrition that do not have programmes
with extensive sub-national coverage.
10
The lack of monitoring and evaluation
systems as well as nutrition surveillance
with their own funding is a weakness that ham
pers progress, since it prevents the undertaking
of timely corrective measures or the strengthening of what is working properly. A little more
than half of the programmes reported having
made a nutritional diagnosis or baseline, but
less than a third cited to have specific documents in this regard. Furthermore, although in
the grand majority (76%) of programmes it is
indicated that they have made evaluations (design, process and/or impact), only half of them
refer to be impact evaluations. In turn, only
6% of all the programmes analyzed have rigorous evaluations of nutritional impact, documented and circulated; similar percentage can
be seen in food security evaluations, and 2%
on the ones over poverty. A positive example
is Panama, which has evaluated the nutritional impact of three of its programmes: Complementary feeding, Fortification of salt with
iodine and the Net of Opportunities (Red de
Oportunidades) Programme (conditional cash
8
In the area of human resources, there is insufficient number of trained/ qualified personnel in nutrition and programme management
in relation to needs. This limits the achievement
of programme objectives, particularly in local
and community levels. While there are opportunities for training on various subjects, they are
mostly short-term, isolated trainings and they
decrease in quantity and quality as the services
become more decentralized or the hierarchical
99
CONCLUSIONS
6
Similarly, the Study also identified the lack of
long-term approach that affects other determinants of undernutrition, such as maternal education, water and sanitation and improvement
of income. The proper balance between measures that impact the short and long term nutrition, focusing on a comprehensive approach
that simultaneously addresses the different levels of maternal and child undernutrition´s causality is still a challenge in social protection
programmes.
12
Most part of the programmes refers to
have social sustainability, followed by
institutional and legal sustainability. Financial
sustainability is weak, which is directly linked
to public funding sources and social investments (including the ones for nutrition) which
are core State responsibilities. Public social investment, particularly in nutrition, is very low.
The major source of funding for social protection programmes is external cooperation (donations and loans). Countries such as Costa Rica,
with greater social investment programmes that
have increased public budget and with longer
duration are the ones that show lower undernutrition prevalence. The environmental sustainability almost does not exist in all the programmes.
11
Many of the programmes refer to use
the human rights approach (related to
the principles of universality, indivisibility, interdependence, non-discrimination, participation and accountability) and take into account
the gender perspective, the cultural relevance
as well as the community participation. Almost all countries have Food and Nutrition Security Laws and Policies framed within these
approaches, including some countries such as
Guatemala that incorporates them into their
State Political Constitution. However, there are
still large knowledge gaps about them, both
at the institutions offering the services as well
as the target population who demands them.
Failures are detected in the implementation of
these approaches, as it can be observed in the
case of human rights approach results showed
in the Study.
© PAHO, Chessa Lutter, 2010
transfers) enabling the carry out of necessary
adjustments to the programmes. On the other hand, although some programmes gather information on nutritional indicators, there is no
evidence that the information is used to redirect interventions, strategies and programme
approaches in search of ensuring that they are
efficient and effective in improving nutritional
status.
Many of the programmes indicate that they
have links to national development and poverty reduction strategies, which is related to all
the types of sustainability (social, financial, institutional, legal and environmental) presented
in this report, but mainly to the institutional
sustainability. However, contrary to what programmes declared regarding the institutional
sustainability, all the analyzed data suggests
that it is weak.
Although the information analyzed is not sufficient to draw final conclusions about social
protection programmes sustainability and current financial situation, it reflects that there is
still a long way to go in order to have sustainable social public policies and programmes in
favor of priority groups social protection not
only for present generations, but also for future ones.
For gender perspective, it was evidenced that
the criterion persists of considering that the
programmes have this approach when they incorporate actions directed at women or there is
a greater involvement from them in the implementation of interventions. There is a tendency
to consider the improvement of nutritional status and socio-economic status of women primarily as a means to achieve progress in other
family members, especially children, ignoring
the needs and interests of women themselves.
Community participation is confined to the
programme implementa
tion stage. Nonetheless, further analysis is required before drawing
conclusions regarding how all these approaches
are applied on a daily basis.
VI RECOMMENDATIONS
100
III
VI
II
To incorporate objectives, interventions/
actions and nutritional indicators (nutritional dimension) in the different stages of social protection programmes: design, implementation, monitoring and evaluation. In parallel
the programmes have to be based in scientifically evidenced proven cost-effective interventions to prevent and treat undernutrition. In
fact, some countries are already in the process of
strengthening this dimension in their social programmes, especially those who are conditional
cash transfers such as the Solidarity Programme
in the Dominican Republic. On the social programmes that do not depend on the health sector,
it is required to establish effective coordination
with this sector in order to obtain a preventive
approach, adequate coverage and provision of
quality services to achieve impact and improve
the nutritional status of priority groups.
1
To strengthen the political commitment of
governments in favor of the nutri
tion of
their population, particularly the priority groups.
To take advantage of various international, regional and national instances to reiterate this, by
making use of scientific and empirical evidence,
means and instruments of advocacy and aware
ness, as this present Study, to mobilize commitments and resources to this cause.
2
To gradually move forward in the formation of genuine social safety systems that
encourages intersectoral concurrence and coordination in social programmes. Provide integrated and participatory social services that
address the various determinants of undernutrition and food insecurity to reduce inequity
and social, economic and ethnic and cultural inequality gaps. Also, to encourage greater
and better knowledge of legal and regulatory frameworks conducive to nutrition in each
country. And strengthen links within and between sectors belonging to other areas or institutions responsible for the strategies of poverty
reduction and national development.
102
4
In regards to Conditional Transfer Programmes (cash, in kind, vouchers and others): to review or change the design and operation of these programmes to increase their
nutritional impact, including specific purposes
from the start in order to improve household
nutrition, especially of infant, young children
and of women. The following topics are fundamental and should be considered in the review
103
RECOMMENDATIONS
3
The following recommendations are based on
the findings and conclusions of the Study:
III
VI
II
RECOMMENDATIONS
systems, treatment and nutritional attention; v)
To conduct advocacy efforts for programmes
to include policies of non-discrimination, raise
awareness and educate employers and service
personnel; and, vi) To educate PLHIV about
their rights and available services.
of programmes, which can increase or inhibit
the effects of income or conditionality: targeting criteria and mechanisms; time or number
of hours that have to devote the people benefited; the amount and type or composition of the
transfer or input; the delivery mechanisms for
the transfers or other services; the quality of
supplies and services delivered; and, intersectoral coordination and integration. In parallel,
while the offer and demand of services are being strengthened, it is also important to move
forward in the discussions about the use of
conditionality, since in some way it is in counter position to the human rights approach: the
access to food, health and education is provisional or temporary, since it lasts the timeframe
on which the individuals or families are participating in the programmes.
6
To check the guidelines or targeting criteria with the intent to focus the interventions on priority groups, specially children under 2 years, pregnant women, indigenous and
afrodescendants, and, that people with HIV
have better access to social protection of the
public sector. To achieve this goal statistics
should be disaggregated by age group, especially for children under 6 months, after 6 to
12 months and 12 to 24 months. Also include
a breakdown of the data by sex, ethnic-cultural
and special conditions.
The recommendations made are mostly coincident with other recommendations generated by assessments made by various experts
and agencies on Conditional Cash Transfer
Programmes85,86,87,88,89.
7
5
For programmes that assist people with
HIV: i) To review the programmes and plans
to reduce the HIV epidemic through an intersectoral approach to ensure the incorporation of
food and nutrition components; to include diagnosis and nutritional counseling integrated
to the counseling for treatment adherence, ii)
To involve PLHIV in the design, implementation and evaluation of HIV control programmes
with nutritional dimension; iii) To decentralize
comprehensive attention services to improve access of PLHIV; iv) To ensure access of PLHIV
to other social programmes and link them together to ensure appropriate targeting, referral
To expand the coverage of programmes,
emphasizing the preventive approach and
the quality of health and nutrition services.
In parallel, a review must be done of the geographical location of programmes in order to
identify potential duplication of interventions
or areas that may have multiple programmes
for the same target population. Ensure that the
populations covered correspond to the pre-established targeting criteria.
To organize and maintain an adequate system of procurement, storage and distribution of inputs and food (donated, imported or
locally produced) ensuring their quality –especially of the fortified complementary foodsand the continuous and timely delivery to the
target population and the proper functioning
of the programmes.
8
10
To strengthen human resources capacity in
nutrition and health topics that are up to
date and relevant (based on evidence) and also
in social programmes management. To develop
a comprehensive plan for training human resources, including the monitoring and evaluation of training results, with a short, medium
and long term vision. Particularly crucial is the
increase of these capabilities at local and community level.
Leroy et al (2009).
Garret et al (2008).
87
Grosh et al (2008).
88
Hoddinott et al (2009).
89
Ruel (2009).
85
86
104
9
11
To incorporate the human rights approach as the larger framework for all
social protection activities from the design to
the evaluation of the programmes, ensuring
that gender perspective, cultural relevance and
community participation are explicitly considered in the programmes. Among other aspects, this means: to inform and train human
resources at different levels and sectors, and
the general population about the human rights
approach, including interculturality and gender perspective; to develop explicit actions or
interventions on health and education that directly benefit girls and women in regards to
their own condition (aside from their families);
to incorporate male participation in child care;
to rescue ancestral practices of health and food
favorable to nutrition ; and, to evolve from
passive or utilitarian participation of community members towards the vision of fundamental social actors in the improvement of nutrition and their own development.
To resolve technical and financial constraints in monitoring and evaluation as
well as in nutritional surveillance, and incorporate these aspects into the design of programmes.
The establishment of a baseline should be the
start to the definition of nutritional indicators
to measure progress on an ongoing basis and
evaluate the impact in the medium and long
term, to allow the necessary adjustments and
establish accountabilities.
105
12
To consider the programmes sustainability from its initial design stage with
the intent to gradually move forward looking
to achieve it. Special attention is deserved by
the financial and environmental sustainability;
without them, it would be impossible to obtain and maintain the nutritional impact for
the present and future priority groups. To gradually increase the allocation of public budget
in nutrition for social programmes in a framework of State policies –that exceed government
periods– looking to ensure sustainability of interventions and their impact in the population,
gradually decreasing external economic dependence. In this line, States must progressively assume the funding of conditional cash transfer
programmes.
VII LESSONS LEARNED
106
VII
III
II
LESSONS LEARNED
Some lessons learned during the process implementation of the Study are presented as follows:
1
The Study allowed to reflect on the actions
needed to reduce undernutrition and recognized the urgent need to mainstream nutritional dimension at the different stages of social programmes studied, and the feasibility of
applying this dimension to similar programmes
in different contexts.
2
The same process of elaboration of the
study was a forum for discussion on the
value of these issues and allowed the programme managers to identify by themselves
the strengths, weaknesses and some proposals
for solutions.
3
The Study highlights the importance of
political decisions and public budget allocation for the success of programmes in terms
of nutritional impact. The need for these programmes is framed within public policies and
State commitments to ensure sustainability.
108
109
4
Aspects related to the coverage scaling-up,
prevention, quality of services, monitoring
and evaluation, and training of human resources are crucial to achieve efficiency and effectiveness of programmes and consequently nutritional impact on the target population. They
should be housed within the larger framework
of human rights by ensuring gender perspective,
interculturalism and community participation.
5
It is recognized the need to review the programmes and improve cross-sectoral coordination to ensure that the actions cover the
different levels of causality of undernutrition
and take a comprehensive approach. Take into
account the scientific evidence generated by the
Lancet Series on Maternal and Child Undernutrition (2008) and the Copenhagen Consensus
(2008) whose cost-effective solutions and interventions allow to solve much of the problem. At the same time, improve quality and efficiency of programmes or interventions that
directly affect other determinants of undernutrition, such as maternal education, water
and sanitation and income improvements to
achieve a maximum nutritional impact.
VIII STUDY DISSEMINATION
AND NEXT STEPS
110
VIII
III
II
The Study –in its final version- was presented on the Third Meeting of the Interamerican
Commission for Social Development (ICSD)
of the Organization of American States (OAS)
held in early April, 2010. The report was elaborated under the agreement between OAS and
WFP, and is part of a series of activities accomplished within the Interamerican Social Protection Network, of recent creation, and answers
to the mandate emanated from the First Meeting of Ministers and High Level Authorities of
Social Development held in the City of Reñaca,
Chile in 2008. The report will also be considered and officially distributed during the upcoming Meeting of Ministers and High Level
Authorities of Social Development to be held
in July 2010.
WFP has planned to share the final reports
(subregional and for the eight countries) of the
Study with the active participation of key actors and stakeholders (governments, NGOs,
communities and agencies) for which a dissemination plan will be devised with the countries
involved. Similarly, forums, events as well as international, regional and national instances will
be used to share findings and recommendations
of the Study. In the short term, it is expected a
preparation of a manual or guide on the design
of social programmes with nutritional dimension and also to publish articles on the Study in
scientific magazines and peer-reviewed journals.
It is particularly important to use the results
of the Study and strengthen coordination with
other regional initiatives such as the Mesoamerican Public Health Initiative-Nutrition
Component (led by the INSP of Mexico) and
the Pan American Alliance for Nutrition and
Development (Regional initiative of the United
Nations agencies, led by PAHO), to optimize
cooperation to the countries.
There will be coordination to support countries in the context of the overall collaborative
multipartner proposal “Scaling Up Nutrition:
A framework for Action, 2009”90 whom the
Study is totally articulated with as it emphasizes the importance of mainstreaming nutrition in
multiple sectors, including evidence based main
cost effective interventions. It also gives high
priority to children under two years of age and
pregnant women, and proposes to “substantially increase” the internal and external support to
governments in the area of nutrition, within the
framework of the principles of effective international aid expressed in the Paris Declaration
Scaling up Nutrition: A framework for Action. Policy
Brief prepared with the support of the Bill and Melinda
Gates Foundation, the Government of Japan, UNICEF
and The World Bank. 2009. Based on a series of consultations with other agencies and institutions.
The World Bank. Scaling up Nutrition. What will it
cost? Washington DC, 2010.
90
112
STUDY DISSEMINATION AND NEXT STEPS
Preliminary results of the Study have been
shared in several regional and international
meetings, including the WFP Executive Board
in November 2009, in which the Study was
supported by governments and other authorities involved in the meeting; and, the “Global
South-South Development Expo 2009” where
the Study won an award as an innovative solution to support the MDGs achievements.
and the Accra Agenda for Action (AAA)91. As
this global collaborative effort states, it is crucial to mobilize buy-in from country national
stakeholders and development partners on an
inclusive approach to country ownership and
action for scaling up nutrition investments for
sustainable human and economic development.
“Successful national nutrition and food security strategies require ownership by governments, civil society, the private sector and communities as well as from external agencies”.
In this regard, to implement the recommendations, there will be support and channeling
of direct technical assistance to countries according to their needs, capabilities, limitations,
challenges and priorities in order to strengthen the nutritional dimension of the social protection programmes studied, as well as other
similar programmes implemented in the same
countries or in different contexts.
The Study is intended to be used as an advocacy tool for greater public and private commitments in favor of priority groups social protection and in turn, these people can use it as a
tool to exercise their Right to food with a direct impact in the improvement of their nutritional situation.
Finally, in the last quarter of 2010 WFP is expected to replicate the Study in four priority
countries in the Andean Subregion: Bolivia,
Colombia, Ecuador and Peru. The Study will
be adapted to the socio-economic, ethnic, cultural and geographical-territorial particularities of these countries on the basis of lessons
learned from this Study.
Paris Declaration (2005) and Action Programme
(Agenda) of Accra (2008), focused in government ownership, alignment of donors with strategies and functioning
systems: including the search for sustainability of financial support, external assistance harmonization, analysis
and joint missions, fragmentation reduction, results managing and joint accountability.
91
ANNEXES
114
III
II
Main responsible persons for the Study
Direction and coordination:
Angela Céspedes, Regional nutrition advisor, WFP
Elaboration of the Study subregional report:
First draft by: Margarita Lovón, Consultant for the Study
Final report and summary by: Angela Céspedes
With the support of:
Aaron Lechtig, Senior consultant for the Study
Rachel Francischi, Programme officer-nutrition, WFP
Gabriela Hernández, Programme officer WFP Cuba
Specific contributions from:
Guillermo Fuenmayor, Micronutrient regional consultant, WFP
Fernando Sánchez, Conditional transfer programmes consultant
Alejandra Vásquez, Nutrition intern, INTA-University of Chile
Hugo Farías, HIV-subregional advisor, WFP
Review of the Study subregional report by:
High Level Technical Group, HLTG (see complete list as follows)
Representatives from national counterparts and key informants
(see complete list as follows)
Nutrition and HIV Officers and Focal points from country offices, WFP
(see complete list as follows)
Elaboration of the Study terms of reference:
Angela Céspedes
Review by:
High Level Technical Group, HLTG
Elaboration of the main survey:
Aaron Lechtig
Angela Céspedes
Rachel Francischi
With specific contributions from:
National counterpart’s representatives
Officials and nutrition and HIV focal points from local offices, WFP
Jayne Adams, HIV regional advisor, WFP
116
117
ANNEX i: STUDY COLLABORATORS
Annex i: Study collaborators
III
II
Elaboration of the interview for key informants:
Gabriela Hernández
Alessandra Marini
Lucy Bassett
Review by:
Angela Céspedes
Aaron Lechtig
Ricardo García
United Nations HIV/AIDS Joint Programme (UNAIDS)
The World Bank (WB)
Angela Céspedes
Jayne Adams
Raoul Balletto
Rodrigo Martínez
Information collection in the countries:
Nutrition and HIV Officers, Focal points and National consultants,
WFP country offices
Review and data validation by:
National counterparts’ representatives
Margarita Lovón
Economic Commission for Latin America and the
Caribbean (ECLAC)
World Food Programme (WFP)
Reynaldo Martorell
Hernán Delgado
Emory University
Food and Nutritional Security Regional Programme for
Central America (PRESANCA)
Eduardo Atalah
Data base elaboration:
Pedro Escobar, Statistician
Gumercindo Lorenzo, Statistician
Mercedes Díaz, Consultant for the Study
Data base review by:
Aaron Lechtig
Guillermo Fuenmayor
Rachel Francischi
Gabriela Hernández
University of Chile-Faculty of Medicine
Beatrice Rogers
Patrick Webb
Carmen Lahoz
Enrique De Loma-Osorio Friend
Tufts University
Hunger Studies Institute-Spain (IEH)
Marie Ruel
Alma Jenkins
Enrique Delamonica
Enrique Paz
International Food Policy Research Institute (IFPRI)
United Nations Children’s Fund (UNICEF)
Jesús Bulux
Central America and Panama Nutrition Institute (INCAP)
Juan A. Rivera
Data base cleaning and statistical analysis:
Margarita Lovón
National Institute of Public Health-Mexico (INSP)
Other collaborators:
Xinia Soto, Geographic information systems consultant, WFP
Deisy Cárdenas, Rose Nicholson and Anne-Cecile Gómez, Programme
assistants, WFP
Graphic design:
Jhoram Moya, Knowledge management consultant, WFP
Pablo Montes de Oca, Consultant
English translation:
Jairo Vásquez, Senior programme assistant, WFP
Ricardo Uauy
Institute of Nutrition and Food Technology/University
of Chile and London School of Hygiene and Tropical
Medicine, UK
Lynnette Neufeld
Micronutrient Initiative (MI)
Rosana Martinelli
Francisco Pilotti
Organization of American States (OAS)
Chessa Lutter
Cecilia Acuña
Panamerican Health Organization (PAHO)
118
119
Members of the High Level Technical Group (HLTG)
Review by:
High Level Technical Group, HLTG
III
II
José Pablo Valverde
Orlando Navarro
Dr. Clorito Picado Clinic
Costa Rican Social Security Fund
Home of Hope
Patricia Chinchilla
BELIZE
Rodel Beltran
José Rodolfo Cambronero
Study volunteer
Alliance against AIDS
Social Development Deputy Managers Office
Joint Social Welfare Institute
Randall Jiménez
COSTA RICA
Karol Madriz
Accreditation Department
National Foundation for Children
Department of Human Development
Ministry of Human Development and Social
Transformation
Bersy Silva
Generate Directorate of Strategic Planning and Health
Actions Evaluations. Ministry of Health
Ruth Linares
Margarita Claramunt
Hortence Augustine
Delia Miranda
Doroty Menzies Child Attention Center
Transformation
Social Development Deputy Manager Office
Abel Vargas
Hand in Hand Ministries
Ava Pennill
International Community of Women
Living with HIV/AIDS
(Key informant)
Generate Directorate of Strategic Planning and Health
Actions Evaluations
Ministry of Health
Sandra Cháves
Integral Attention Area for People
María Elena Montenegro
Emilce Ulate
Darling Ruíz
Sonia Camacho
University of Costa Rica, School of Nutrition
María Eugenia Villalobos
Study consultant
Esteban Rojas
Jorge Polanco
Regulation, Systematization, Diagnosis
and Treatment Area
Health Services General Direction Office
Ministry of Health
(Key informant)
Generate Directorate of Nutrition and Children
Development, Ministry of Health
(Key informant)
Generate Directorate of Nutrition and
Children Development
Ministry of Health
Sonia Villalobos
María Isabel Piedra
Judith Alpuche
Transformation
Francisco Sánchez
Study consultant
University of Costa Rica, School of Nutrition
(Key informant)
Marlen Montoya
EL SALVADOR
Agricultural and Rural Policy Area, Executive Secretariat
of Agricultural Sectoral Planning
Ministry of Agriculture
Martín Bonilla
Adrian Storbeck
Caritas Costa Rica
(Key informant)
Graciela Rojas
Melany Ascencio
HIV Patient Attention Programme
San Juan de Dios Hospital
Health Research Management Unit
National Micronutrients Commission
Ministry of Health
Hugo Chacón
Norma Aguilar
Ministry of Health
Integral Attention Programme for Patients
Pulcheria Teul
Jalila Meza
Norma Méndez
Senate of the Republic
(Key informant)
Social Development Deputy Manager Office
Franklin Charpantier
Leonie Herrera
King Children Center
Marvin Manzanero
Alma Yanira Quezada
HIV-AIDS and other STDs National Programme
Ministry of Health
Nadia Armstrong
STD/HIV/AIDS National Programme
Ministry of Public Health and Social Assistance
Alfredo Carvajal
Salvadorian Association of Health Promotion
Natalia Largaespada
120
Ana Josefa Blanco
Breastfeeding Support Center
(Key informant)
Ana María Delgado
AGAPE Association
121
Collaborators for the Study by country
III
II
Rafael Castellanos
Fernando Aldana
Liliana Aldana
Plan International
Entrepreneur
(Key informant)
Institute of Science and Agricultural Technology
Educational Community Strengthening
General Direction Office
Ministry of Education
(Key informant)
Carlos Escobar
Flor Idalia
Rocío Rivera
New Times Foundation
Links of Love Foundation
Department of Regulation and Food Control
Sonia Mena
Gabriela Mejicano
World Vision Foundation
Catholic Relief Services (CRS)
Mother and Child Health and Nutrition Project
Maija Laitinen
Luz Cabrera
Claudia Sandoval
Local Development Social Investment Fund
Daysi Márquez
Teresa de Jesús Tario
Nutrition and Soy Programme
Gladys Arreola
Maritza M. de Oliva
Plan International
Verónica Avalos
Department of Regulation and Food Control
Eduardo Montes
STD/HIV-AIDS National Programme
Hugo Valladares
Manuel Mendoza
William Pleitez
New People Foundation
(Key informant)
My Family Progresses Programme
Social Cohesion Council
Débora Aguilar
Salvadorian Institute of Children and Adolescence
Elvis Soriano
Human Development Unit
United Nations Development Programme (UNDP)
(Key informant)
Jessica Escobar
Irma Chavarría de Maza
(Key informant)
Mayte Ayau
Irma Esperanza Palma
Oscar López
Social Sciences Latin American Faculty (FLACSO)
(Key informant)
Plan International
Xinia Castro
World Vision
José Armando Velasco
Evangelical University, School of Nutrition
(Key informant)
GUATEMALA
Iván Mendoza
Ana Cristel Rojas
Mother and Child Health and Nutrition Project
Ofelia Arriaza
José Ernesto Navarro
Former Health Deputy Minister
(Key informant)
Plan International
Jaime Gómez
Pamela Orellana
Former Deputy Minister of Health
(Key informant)
Study consultant
Andrés Ramírez
Ludin Caballero de Chávez
Solidarian Feeding Center Presidential Programme
Social Welfare Secretariat
Save the Children
Margarita Sánchez
Secretariat of Food and Nutritional Security
Ramiro Quezada
Joan Pennington
United Nations Children’s Fund (UNICEF)
Roosevelt Hospital
Study consultant
Billy Estrada
María Teresa de Morán
Marta Aurelia Martínez
Coralia Tzul
World Vision
(Key informant)
Maya Vision
(Key informant)
Otoniel Ramírez
Eva de Méndez
I Live Positive Atlacatl Association and REDCA
(Key informant)
World Vision Foundation
122
Rodolfo Valdez
Jorge Pineda
Plan Internacional
Solidarity Bag Programme
Secretariat of Social Welfare
Sandra López
José Daniel Villela
Sara Cordón de Zamora
Solidarian Feeding Centers Presidential Programme
Secretariat of the President’s Wife Social Services
123
Anabell Amaya
III
II
Mayte Paredes
Anielka López
Martha McCoy
CHF International
Former Health Minister
(Key informant)
Miriam Chang
Antonio Largaespada
CHF International
Former Government official
Study consultant
Nancy Cano
Bárbara Mejía
Human Rights National Commissioner Office
Blanca Ramírez
World Vision
Ninoska Bulnes
Solidarity Net
Office of the First Lady
(Key informant)
Aurora Soto
Norman Herrera
Gladys Mejía
HIV-AIDS-STD Programme
Ministry of Health
Odalys García
Bernarda Oporta
Integral Attention Programme for Pregnant Women
for the Prevention of Vertical Transmission from Mother
to Child
Health Secretariat
Save The Children
Matagalpa Nutritional Recovery Center (Religious
Movement)
Edgardo Pérez
Ofilio Mayorga
Food Regulation Direction
Ministry of Health
Save The Children
Solidarity Net
Nubia Estrada
Gloria Elvir
National Programme of Food and Nutritional Security
Héctor Galindo
Patricia Carrillo
Orlando Rivera
Integral Attention Programme for Pregnant Women for
the Prevention of Vertical Transmission from Mother to
Child
National Programme of Food and Nutritional Security
Health Secretariat
Pedro Aguilar
Enrique Picado
Tropical Agriculture International Center
Community Leader
Communal Movement
(Key informant)
Ramón Noguera
Food and Nutritional Security Programme
Ministry of Agriculture and Forestry
Héctor Irías
Christian Children’s Fund
Family Assignment Programme
Presidency of the Republic
Rosa Gonzáles
CARE Central America in Nicaragua
Inge Jacobs
Keys Foundation
(Key informant)
Francisco Luna
Food Productive Programme
Agriculture and Forestry Programme
Samuel Reyes
Sandra Núñez
HIV/AIDS Adult Patient Clinical Attention Programme
Ivette Arauz
Silvia Mendoza
Nica Health Net Federation
Rainbow Network
Ezequiel Provedor
CHF International
Irma Mendoza
Sabrina Quezada
Rainbow Network
Iván Espinoza
Tomasa Sierra
Health Secretariat
Integral Attention Programme for Pregnant Women
for the Prevention of Vertical Transmission from Mother
to Child
Jeaneth Chavarría
Victoria Mendieta
General Direction Office for Extension
and Quality of Attention
Ministry of Health
Ministry of Family, Adolescence and Childhood
Wendy Alvarado
Jeremiah Eppler
Adventist Agency for Development and Assistance
Resources
Aychell Samaniego
José Alfredo Betanco
Azael Torres
Plan International
(Key informant)
Jackeline Rosales
Solidarity Net
Office or the First Lady
PANAMA
José Mauricio Ramirez
Christian Children’s Fund
NICARAGUA
Lilian Carcamo
World Vision
Aid for AIDS
Anielka Cajina
Martha Suazo
Ministry of Health General Secretariat
Ministry of Health
124
Leticia Romero
People Living with HIV and AIDS Association
(Key informant)
125
HONDURAS
III
II
Max Ramírez
Altagracia Suriel
Sócrates Barinas
In Pro of Welfare and Dignity of People Affected by HIV/
AIDS Foundation
(Key informant)
National Commission for Breastfeeding Promotion,
Ministry of Health
(Key informant)
Progressing Programme
Vamo´ Arriba Programme
Social Policies Cabinet
Vice Presidency of the Republic
Amarilis Then Paulino
Eira Vergara de Caballero
Mery Alfaro de Villageliú
National Nutrition Direction Office
(Key informant)
Sonia Aquino
Programme of Food Fortification with Micronutrients
State Secretariat of Public Health and Social Assistance
General Directorate for Mother and child
and Adolescent
Digna de la Cruz
Esther KwaiBen
Niurka Palacio
Archdiocesan Caritas
National Secretariat for the Food and Nutritional
Security Plan
Mother and Child Pastoral
Episcopal Conference Organization
(Religious Organization)
Odalis Sinisterra
Elizabeth Fadul
Ysidora Zabala
Fernando Ferreira
Nutrition Department
Ministry of Health
Fanny Algarrobo
General Direction Office for Control of Sexually
Transmitted Diseases and AIDS
Teresa Narvaez
Project HOPE
Order of Malta Association
Eyra de Torres
National Secretariat for the Food and Nutritional
Security Plan
Rebeca Bieberach de Melgar
Nutre Hogar
First Childhood Integral Attention Programme
Childhood and Adolescence National Council
Children’s Hospital
(Key informant)
Sor Lourdes Reiss
Julio Nin
Saint Joseph of Malambo Home
Ismael Camargo
Tayra Pinzón
Dominican Institute of Agricultural and Forestry
Research
State Secretariat of Agriculture
Institute of Agricultural Research of Panama (IDIAP)
José Bernardo González
Teresita Yaniz de Arias
Study consultant
(Key informant)
(Key informant)
María Virtudes Berroa
Juan Espinoza
Yarabín De Icaza
Nutrition Foundation
Maribel Contreras
Juventina de Hernández
Yariela Gallegos
Arts Reporters Association (Acroarte)
(Key informant)
In Pro of the Children of Darien Foundation
Nutrition Foundation
Lisbeth Escala
Yira Ibarra
HIV and AIDS National Programme
Ministry of Health
Francisco Lagrutta
Zaida Guerrero
General Direction for Control Office for Control
of Sexually Transmitted Diseases and AIDS
Kendra Mieses
Batey Relief Alliance, BRA
Martha Nina
National Breastfeeding Programme
María Mercedes Díaz
Neftali Soler
Study consultant
Solidarity Programme
Social Policies Cabinet
Vice Presidency of the Republic
DOMINICAN REPUBLIC
Maritza Villalaz
Altagracia Fulcar
Net of Opportunities Conditional Cash Transfers
Programme
Ministry of Social Development
Ramón Portes
Dominican Association of Planned Parenthood
(Key informant)
126
127
Edith Tristán
III
II
No
NAME
1
Social Assistance Programme
2
3
4
Mother and Child Programme
King Children Center Programme
Dorothy Menzies Children Attention Programme
COUNTRY
MAIN EXECUTING INSTITUTION
No
Ministry of Human Development
Belize
Ministry of Health, Health Services
Direction Office, Mother and Child
Unit
MOTHER AND CHILD NUTRITION
King Children Center with the
support of the Ministry of Human
Development
CHILDHOOD AND ADOLESCENCE
ATTENTION PROGRAMME
Belize
Belize
Ministry of Human Development
CONDITIONAL TRANSFERS
ATTENTION PROGRAMME
5
Programme Alliance Against AIDS
Belize
Alliance Against AIDS
HIV SPECIFIC PROGRAMME
6
Hand in Hand Ministries Programme: HIV Positive
Kids Attention Programme
Belize
7
National Programme for Tuberculosis HIV/AIDS
and other STD
Belize
Ministry of Health
8
Programme of Attention and Special Protection for
Childhood and Adolescence in its Solidarity Homes
Modality
Costa Rica
9
Food Security Programme (to tackle the economic
crisis)
Costa Rica
Joint Institute of Social Help,
Deputy Management Office of
Social Development
10
Mother and Child Nutrition Programme, First Level
of Attention
11
Children Development Programme-Intervention
Strategy
12
Children Health Programme. Second Level of
Attention
Costa Rica
Costa Rica
Costa Rica
Costa Rican Social Security Fund –
Comprehensive Attention Area
13
Child Nutrition and Development Programme
Costa Rica
Ministry of Health, General
Directorate of Child Nutrition and
Development
14
Programme of Food Fortification with Micronutrients
Costa Rica
Ministry of Health
MICRONUTRIENT FORTIFICATION
15
Programme of Attention and Special Protection for
Childhood and Adolescence. Alternatives Residences
Modality
Costa Rica
and NGOs
ATTENTION PROGRAMME
128
FOOD BASED
TYPE OF MAIN PROGRAMME
/PLAN OR POLICY
Programme of Attention and Special Protection
for Childhood and Adolescence. Integral Diurnal
Attention Children Centers Modality
Costa Rica
and NGOs
ATTENTION PROGRAMME
17
Programme of Attention and Special Protection
for Childhood and Adolescence. Diurnal Feeding
Centers Modality
Costa Rica
and NGOs
ATTENTION PROGRAMME
18
Nutritional Attention Programme for People living with
HIV and AIDS
Costa Rica
19
Food National Programme
Costa Rica
Ministry of Agriculture, Agricultural
Sector
PLAN
20
National Plan Towards the Eradication of Child
Undernutrition 2008-2012
Costa Rica
Ministry of Health and the Costa
Rican Social Security Fund
PLAN
21
Solidarian Rural Communities Programme
El Salvador
Social Investment Fund for the Local
Development of El Salvador
22
Good Health and Nutrition Circles Operative
Mechanism
El Salvador
World Vision International
23
Health Services Nutrition Programme
El Salvador
Salvadorian Association of Health
Promotion
24
Nutrition Programme
El Salvador
Ministry of Public Health and Social
Assistance
25
Health and Food and Nutrition Security Programme
El Salvador
26
First Steps Towards Success and Health and School
Nutrition Programme
El Salvador
Save the Children
27
Pounds of Love Nutritional Food Safety Programme
El Salvador
Salvadorian Foundation for Health
and Human Development
28
El Salvador
Plan International
29
Nutritional Programme-Nutritional Component
Complement for Vulnerable Groups
El Salvador
Assistance
30
Initial Education Programme-Attention in Rural
Children Welfare Centers and Urban Marginal Children
Development Centers
El Salvador
Salvadorian Institute for Childhood
and Adolescence
FOOD BASED
31
Nutritional Recovery Center and Basket of Love
Programme
El Salvador
Links of Love Foundation
MCN–NUTRITIONAL RECOVERY
32
Nutritional Recovery Center
El Salvador
AGAPE Association of El Salvador
MCN–NUTRITIONAL RECOVERY
33
Promoting Agriculture Based in Basic Needs
Programme
El Salvador
Catholic Relief Services
PRODUCTIVE PROGRAMME
34
Soy and Nutrition Programme
El Salvador
Soy and Nutrition Programme
Foundation
35
STD/HIV-AIDS National Programme
El Salvador
Assistance
36
HIV Patients Nutritional Programme
El Salvador
New Times Foundation
37
National Plan Towards the Eradication of Child
Undernutrition (contents of this plan are being
implemented under the social policies of the new
Government)
El Salvador
Ministry of Health and Technical
Costa Rican Social Security Fund –
Comprehensive Attention Area
COUNTRY
16
/PLAN OR POLICY
Belize
NAME
129
PLAN
ANNEX ii:
i: STUDY
LIST OFCOLLABORATORS
PROGRAMMES AND PLANS OR POLICIES BY COUNTRY
Annex ii: List of programmes (n=110) and plans
or policies (n=10) by country
III
II
NAME
COUNTRY
/PLAN OR POLICY
38
Guatemala
CONDITIONAL TRANSFER
39
Guatemala
40
Complementary and Nutritional Feeding Programme
Guatemala
Basic Health Services Providers (San
Francisco and Vicariato)
41
Programme for the Production, Consumption and
Feeding for Families from the San Pedro Carchá
Municipality
Guatemala
Plan International
42
Chronic Undernutrition Reduction Programme, CURP
(currently National Strategy to Reduce Chronic
Undernutrition)
Guatemala
Secretariat of Food and Nutritional
Security
43
Mother and Child Health and Nutrition Programme
Component No. 2
44
45
46
47
No
NAME
COUNTRY
60
Mother and child Health Programme in Four
Municipalities of Southern Francisco Morazán
Honduras
Christian Children´s Fund (Child
Fund), Health Component
MOTHER AND CHILD HEALTH
61
Food Assistance Programme in the Francisco Morazán
Southern Zone
Honduras
Fund)
FOOD BASED
MICRONUTRIENT SUPPLEMENTATION
62
Micronutrient National Programme, 2007-2011
Honduras
Secretariat of Health National
Programme for Food and Nutritional
Security (coordinated with
the Micronutrients Consulting
Committee)
63
Clinical Attention of the Adult Patient with HIV/AIDS
Programme
Honduras
Secretariat of Health, Subsecretariat
of Population Risks, General
Direction Office for the Promotion
and Protection of Health
64
Programme for the Strengthening of a National Answer
for the Protection and Promotion of Health in the HIV/
AIDS Area
Honduras
CHF (Financial Habitat Community)
International in Honduras
65
Programme for the Attention of Vulnerable Groups –
Component No. 2 of the country programme
Honduras
Secretariat of Health, National
Nutrition Programme
66
The Attention of Pregnant Women for the Prevention
of the Transmission of HIV from Mother to Child
Programme
Honduras
Secretariat of Health, Subsecretariat
of Population Risks, General
Direction Office of Health
67
Programme for the Evaluation of the Role of Food and
Nutritional Security in the Promotion of Adherence to
Treatment with Antiretroviral Treatment in Persons
Over 18 years in Honduras
Honduras
Secretariat of Health, RAND
Corporation (Research and
Development) and WFP
Guatemala
Assistance
Guatemala
Guatemala World Vision
Health Services Strengthening Programme
Guatemala
Plan International
Guatemala
Secretariat of Food and Nutrition
Security (coordination), Ministry of
Public Health and Social Assistance
and WFP (execution)
FOOD BASED
Guatemala
Secretariat of Social Welfare of the
Presidency
FOOD BASED
FOOD BASED
68
The Prevention of HIV from Mother to Child Programme
Honduras
Fund)
Undernutrition Recovery and Prevention in Favor of
Vulnerable Groups Programme
Solidarian Feeding Centers Programme
/PLAN OR POLICY
48
Community Homes Programmes
Guatemala
Secretariat of the President’s Wife
Social Works
49
Fortified Foods Programmes
Guatemala
Ministry of Public Health and
Social Assistance, Department of
Regulation and Food Control
50
Beans Genetic Improvement Programme
Guatemala
Institute of Science and Agricultural
Technology
BIOFORTIFICATION
69
Strategic Plan for the Implementation of the Food and
Nutrition Security Plan 2006-2015
Honduras
Secretariat of the Presidency,
Technical Unit for Food and
Nutritional Security
51
HIV Adolescence Programme
Guatemala
Assistance and UNICEF
70
Mother and Child Health National Plan
Honduras
POLICY
52
HIV, Hepatitis B and Syphilis Vertical Transmission
Programme
Guatemala
Roosevelt Hospital
71
Food and Nutritional Security with Citizens
Participation Policy
Honduras
POLICY
53
Social Protection Integral Programme
Honduras
72
Honduras
54
Honduras
Secretariat of Health, National
Security
PLAN
Comprehensive Women Development Programme
(DI Mujer)
Country Plan for the Eradication of Child Chronic
Undernutrition
55
Solidarian Hand Bonus Programme
Honduras
73
Programme in Support of Rural Families in Zones
Affected by Droughts and Floodings
Nicaragua
Programme for Nutritional and Food
Security
56
Solidarian Net Programme
Honduras
First Lady Programme, Secretariat of
the Presidency
74
Model Programme of Nutritional Recuperation Heart in
the Family 2002-2009
Nicaragua
World Vision
57
Integral Attention Towards Vulnerable Groups
Programme
Honduras
National Programme for Food and
Nutritional Security, Dependency of
the Secretariat of Health and the
WFP
75
Health and Nutrition Community Programme
Nicaragua
Ministry of Health, General Direction
Office of Health Services, Normative/
Childhood Comprehensive Attention
58
Nutritional National Programme 2009-2015
Honduras
Secretariat of Health National
Security
76
Breastfeeding as part of the National Strategy
Nicaragua
59
Health, Nutrition and HIV National Programme (as part
of the Health, Nutrition and HIV National Strategy)
Honduras
World Vision Honduras
77
Axle Three Programme of the Love Programme
Nicaragua
Ministry of the Family, Adolescence
and Childhood
130
131
PLAN
ANNEX ii:
i: STUDY
No
III
II
78
NAME
Window of Opportunity Programme
/PLAN OR POLICY
COUNTRY
Nicaragua
Care Central America in Nicaragua
No
NAME
COUNTRY
/PLAN OR POLICY
101
National Salt Fortification Programme
Panama
Ministry of Health, Department of
Nutritional Health
102
Biofortification Programme
Panama
Agricultural Research Institute of
Panama
BIOFORTIFICATION
103
Universal Treatment Access Programme
Panama
Aid for Aids
104
People with HIV Education Programme
Panama
Aid for Aids
105
I Learn to Love and Take Care of Myself Programme
-Children’s Programme
Panama
Aid for Aids
79
Childhood Attention Programme, Attention of
Childhood Prevalent Illnesses
Nicaragua
80
Families United for their Health Programme
Nicaragua
Nica Health Net Federation
81
Children Feeding Center Programme 2009
Nicaragua
Rainbow Network
FOOD BASED
82
Nicaragua
FOOD BASED
83
Nutritional Recovery Center for Matagalpa Children
Programme
Nicaragua
Missionary Adventures for the Needy
Association
MCN-NUTRITIONAL RECOVERY
84
National Food Fortification Programme
Nicaragua
Ministry of Health, Food Regulation
Office
106
STD/HIV/AIDS National Programme
Panama
Ministry of Health–HIV/AIDS
National Programme
85
Agro Health Programme Project
Nicaragua
International Center for Tropical
Agriculture
BIOFORTIFICATION
107
National Plan for the Prevention and Control
of Micronutrient Deficiencies 2008-2015
Panama
Nutritional Health
PLAN
86
Food Security Programme
Nicaragua
Save the Children
108
National Plan for the Reduction of Child
Undernutrition 2008-2015
Panama
Ministry of the Presidency, National
Secretariat for the Food and
Nutritional Security Plan
PLAN
109
Solidarity Programme
Dominican
Republic
Social Policy Cabinet
Nicaragua
Adventist Agency for the
Development and Assistance
Resources, Nicaragua
Childhood in Sustainable Families Programme
Nicaragua
Plan International
89
Productive Food Programme
Nicaragua
Programme for Nutritional and Food
Security
110
Vamo’ Arriba Programme
Dominican
Republic
Social Policy Cabinet
90
STD, HIV and AIDS Programme
Nicaragua
Ministry of Health
111
Mother and Child and Adolescent Programme (Mother
and Child and Adolescent General Direction Office)
Dominican
Republic
State Secretariat for Public Health
and Social Assistance
91
National Plan Towards Eradication of Chronic Child
undernutrition 2006-2015
Nicaragua
General Secretariat of Health,
Ministry of Health
PLAN
112
Programme of Child Mother, Family and Community
Health Clinics
Dominican
Republic
Project HOPE and the Order of Malta
Dominican Association
92
Red de Oportunidades (Net of Opportunities)
Programme
Panama
Ministry of Social Development
Secretariat of the Social Protection
System
113
Breastfeeding National Programme
Dominican
Republic
93
Family Vouchers for Purchasing of Foods
Panama
Ministry of the Presidency, National
Secretariat for the Food and
Nutritional Security Plan
114
Education, Faith and Citizenship Programme
Dominican
Republic
Mother and Child Pastoral,
Organization of the Dominican
Episcopal Conference
94
Programme for the Training and Support of Poor
Families and Vulnerable Groups for their Integral
Development
Panama
Archdiocesan Caritas
115
First Childhood Integral Attention Programme
Dominican
Republic
National Council for Childhood and
Adolescence
FOOD BASED
95
Health and Feeding Programme
Panama
National Association for Childhood
Nutrition NUTRE HOGAR
116
Humanitarian Help Programme
Dominican
Republic
Batey Relief Alliance (BRA
Dominicana)
FOOD BASED
96
Complementary Feeding Programme
Panama
Nutritional Health
FOOD BASED
117
Undernutrition Prevention Programme-Multivitamins
for the Dominican Republic
Dominican
Republic
Batey Relief Alliance (BRA
Dominicana)
MICRONUTRIENT
SUPPLEMENTATION
97
Pre School, School Feeding and Community
Development Programme
Panama
In Pro of the Children of Darien
Foundation
FOOD BASED
118
Food Fortification with Micronutrient Programme
98
Vitamin A Supplementation Programme
Panama
Nutritional Health
Dominican
Republic
119
Programme for the Development of beans
germoplasm, Phaseolus vulgaris L biofortified in the
Dominican Republic
Dominican
Republic
Dominican Institute of Agricultural
and Forestry Research
BIOFORTIFICATION
120
Programme for the Control of Sexually Transmitted
Diseases and AIDS
Dominican
Republic
87
Programme for Food and Nutritional Security in the
North Atlantic Autonomous Region
88
99
Iron Supplementation Programme
Panama
Nutritional Health
100
National Wheat Flour Fortification Programme
Panama
Nutritional Health
132
133
ANNEX ii:
i: STUDY
No
III
II
Malnutrition is a broad concept which covers both undernutrition and overnutrition.
Annex iv: Political and technical support meetings for
the Eradication of Child Undernutrition, for the promotion
of Food and Nutritional Security and Social Protection
1. IV Meeting of Ministers of Health and Social Protection in South America. Chile, April 2005.
2. Regional Technical Consultation “Monitoring and Evaluation: Key Tools for Increasing the Effectiveness of Food Based Social Programmes”. Cartagena de Indias, Colombia, July 2005.
3. IV Summit of Heads of State and Governments of the Association of Caribbean States. Panama,
July 2005.
4. Annual Meeting of the Health Sector Network for Central America and Dominican Republic
(XXI RESSCAD). Belize, September 2005.
6. Regional Technical Consultation “Towards the eradication of child undernutrition in Central
America and the Dominican Republic”. Panama, June 2006.
7. Technical Meeting of Health Ministers of the Andean Group, “Towards the eradication of child
undernutrition by 2015”. Lima, Peru, November 2006.
8. Declaration of Panama in the XXVIII Regular Meeting of Heads of State and Government of
SICA. Panama, July 2006.
9. Annual Meeting of the Health Sector Network for Central America and Dominican Republic
(XXII RESSCAD). Guatemala, September 2006.
10.Meeting of Health Ministers of the Andean Area (XXVIII REMSAA). Bolivia, March 2007.
11.48th Annual Meeting of IADB Governors. Guatemala, March 2007.
12.Thirty-Seventh Regular Session of the General Assembly of the OAS. Panama, June 2007.
13.Meeting of the Intergovernmental Commission for Eradication of Child undernutrition in the
Andean Region. La Paz, Bolivia, July 2007.
* Nutritional indicator MDG 1, Target 1.C, 1.8.
** Commonly used as Acute Malnutrition, as in Severe Acute Malnutrition (SAM).
Subnutrition: is other indicator which reflects insufficient energy intake required to maintain body weight and a healthy life (percentage
of the population below the minimal level of food energy intake). FAO Hunger Indicator. MDG 1, Target 1.C, 1.9.
14.Annual Meeting of the Health Sector Network for Central America and Dominican Republic
(XXIII RESSCAD). El Salvador, September 2007.
15.XVII Iberoamerican Summit of Heads of State on Social Cohesion. Santiago de Chile, November 2007.
Elaboration: A.C. WFP Regional Office for LAC
134
135
ANNEX iv: POLITICAL AND TECHNICAL SUPPORT MEETINGS
5. Special Meeting of Central American Integration System (SICA). Panama, March 2006.
ANNEX iii:
i: STUDY
MALNUTRITION
COLLABORATORS
TERMINOLOGY
Annex iii: Malnutrition Terminology
III
II
Annex v: References
17.First Meeting of Ministers and High Level Authorities of Social Development. OAS. Reñaca,
Chile, June 2008.
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141. Santiago de Chile, 2004.
18.Seminar “Impact of the Food Crisis in Vulnerable Groups of Latin America and the Caribbean”.
Madrid, Spain, October 2008.
Allen L, Gillespie S. What works? A review of efficacy and effectiveness of nutrition interventions. Nutrition and
Developmet Series no. 5. Asian Development Bank, Manila, 2001.
19.Annual Meeting of the Health Sector Network for Central America and Dominican Republic
(XXIV RESSCAD). Tegucigalpa, Honduras, January 2009.
Asociación Demográfica Salvadoreña (ADS). Encuesta nacional de salud familiar - FESAL 2008. El Salvador, 2009.
20.Technical Consultation: The international Crisis and the Right to Food in the Most Vulnerable
Groups (Children under 2 years of age in Latin American and the Caribbean). Panama City, September 2009.
Attanasio O, Trias J, Vera-Hernandez M. The relative merits of a comparison of a conditional cash transfer program and
a childcare and food program on child nutrition. FAO, Roma, 2006.
Attanasio O, Gómez LC, Heredia P, Vera-Hernández M. The short-term impact of a conditional cash subsidy on child
health and nutrition in Colombia. Centre for the Evaluation of Development Policies, Institute for Fiscal Studies,
London, 2005.
Barrientos A, Santibañez C. New forms of social assistance and the evolution of social protection in Latin America.
Journal of Latin American Studies 2009; 41: 1-26.
Basset, L. Can conditional cash transfer programme play a greater role in reducing child undernutrition? SP Discussion
Paper no. 0835. The World Bank, Washington DC, 2008.
Bastagli F. From social safety net to social policy? The role of conditional cash transfers in welfare state development in
Latin America. International Policy Centre for Inclusive Growth, United Nations Development Programme. Brasilia
DF, 2009.
Bello A, Rangel M. La equidad y la exclusión de los pueblos indígenas y afrodescendientes en América Latina y el Caribe.
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Bhutta Z, Ahmed T, Black R, Cousen S, Dewey K, Giugliani E et al. What works? Interventions for maternal and child
undernutrition and survival. Maternal and Child Undernutrition Series. The Lancet 2008; 371: 417-40.
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Aug 20]. Oportunidades de Inversión en Nutrición Preventiva para Guatemala, Honduras, Nicaragua y El Salvador.
Proyecto ATN-EA 7924 RG. Available from: http://www.bvsde.ops-oms.org/dvdnutri/indice/titulo_pt/b.htm
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BID, Gesaworld. Borrador del plan de inversiones en nutrición preventiva para Guatemala. [cited 2009 Aug 20].
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21.Third Meeting of the Interamerican Commission on Social Development. OAS. Washington DC,
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ANNEX v:
i: STUDY
iii:
REFERENCES
MALNUTRITION
COLLABORATORS
TERMINOLOGY
16.Regional Ministerial Conference “Towards the Eradication of Child undernutrition in Latin
America and the Caribbean”. Santiago de Chile, May 2008.
III
II
Black R, Allen L, Bhutta Z, Caulf L, Onis M, Ezatti M et al. Maternal and child undernutrition: global and regional
exposures and health consequences. Maternal and Child Undernutrition Series. The Lancet 2008; 371: 243-60.
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Bryce J, Coitinho D, Darnton-Hill, Pelletie Dr, Pinstrup-Andersen P. Maternal and child undernutrition: effective action
at national level. Maternal and Child Undernutrition Series. The Lancet 2008; 371: 510-26.
FAO. Panorama de la seguridad alimentaria y nutricional en América Latina y el Caribe 2009. Una nueva agenda de
políticas públicas para superar la crisis alimentaria. Santiago de Chile, 2009b.
Centro de Estudios Sociales y Demográficos (CESDEM) y Macro International Inc. Encuesta demográfica y de salud,
2007. República Dominicana, 2008.
FAO. Transferencias condicionadas. Erradicación del hambre y la desnutrición crónica. Iniciativa América Latina y
Caribe sin Hambre. Volumes I y II. Roma, 2009.
CEPAL, PMA. El costo del hambre. Impacto social y económico de la desnutrición infantil en Centroamérica y la
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Garrett J, Bassett L, Marini A. Designing CCT Programme to improve nutrition impact: Principles, evidence, and
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CEPAL, PMA. Inseguridad alimentaria y nutricional en América Latina y el Caribe. Santiago de Chile, 2009.
Gentilini O. Social protection in the real world: issues, models and challenges. Development Policy Review 2009; 27 (2):
147-66.
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perspectivas para 2009. Evaluación preliminar. Santiago de Chile, 2009a.
FAO. The state of food insecurity in the world. Rome, 2009a.
Government of Belize, Statistical Institute of Belize and UNICEF. Multiple Indicator Cluster Survey (MICS). Key findings:
monitoring the situation of children and women. Belize, 2006.
CEPAL. Panorama Social de América Latina 2008. Santiago de Chile, 2009b.
Centro de Coordinación para la Prevención de Desastres Naturales en América Central (CEPREDENAC). Plan Regional
de Reducción de Desastres 2006-2015. Guatemala, 2006.
Creed H. Mejorando la nutrición infantil a través de una intervención educativa por los servicios de salud. In: OPS,
PMA, UNICEF. Alimentación y nutrición del niño pequeño: Memoria de la reunión subregional de los países de
Sudamérica, 2-4 diciembre 2008. Lima, Perú. Washington, DC, 2009. p 65-7.
Cunningham M. Dimensión cultural y comunitaria de la desnutrición infantil en Centroamérica. Informe preliminar.
Nicaragua, 2006.
Dary, O. Vigilancia de intervenciones en nutrición (Monitoreo y Evaluación). [Presentación] A2Z/El Proyecto de USAID
en Micronutrientes y Ceguera Infantil, Washington DC, 2006.
Declaración de París sobre la eficacia de la ayuda al desarrollo (2005). II Foro de Alto Nivel sobre la Eficacia de la Ayuda
al Desarrollo; 2005 Feb 28 - Mar 02; París, Francia.
de Onis M, Garza C, Victora C, Onyango A, Frongillo E, Martines J. The WHO Multicentre Growth Reference Study:
Planning, study design, and methodology. Food and Nutrition Bulletin 2004; 25 (1): 15-26.
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promotion. The World Bank, Washington DC, 2008.
Hall G, Patrinos H. Indigenous peoples, poverty and human development in Latin America. Palagrave Macmillan, New
York, 2006.
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Food and Nutrition Bulletin, 2009; 30 (Suppl 1): S5-11.
Hoddinott J and Bassett L. Conditional cash transfers and nutrition in Latin America: Assessment of impacts and
strategies for improvement. Iniciativa América Latina sin Hambre, FAO Working Papers 2009; no 9.
Hoddinott J, Maluccio J, Behrman J, Flores R, Martorell R. Effect of a nutrition intervention during early childhood on
economic productivity in Guatemalan adults. Maternal and Child Undernutrition. The Lancet 2008; 371: 411-16.
Horton S, Alderman H, Rivera J. Hunger and malnutrition. Copenhagen Consensus 2008. Malnutrition and hunger.
Executive summary. Copenhagen Consensus Center, Copenhagen, 2008.
Horton S, Shekar M, McDonald C, Mahal A, Brooks J. Scaling up nutrition: What will it cost? The World Bank,
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Departamento Nacional de Planeación y SINERGIA (Sistema Nacional de Evaluación de Resultados de la Gestión Pública).
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Departamento Nacional de Planeación y SINERGIA (Sistema Nacional de Evaluación de Resultados de la Gestión
Pública). Serie de evaluaciones externas del Centro Nacional de Consultoría. Evaluación del Programa Familias en
Acción para población desplazada. Informe final. Bogotá, 2008.
ANNEX v:
i: STUDY
iii:
REFERENCES
MALNUTRITION
COLLABORATORS
TERMINOLOGY
BID, Gesaworld. Borrador del plan de inversiones en nutrición preventiva para Honduras. [cited 2009 Aug 20].
Oportunidades de Inversión en Nutrición Preventiva para Guatemala, Honduras, Nicaragua y El Salvador. Proyecto
ATN-EA 7924 RG. Available from: http://www.bvsde.ops-oms.org/dvdnutri/indice/titulo_pt/b.htm
III
II
Instituto Nacional de Estadísticas y Censos. Situación en Costa Rica de lactancia materna, según Encuesta Nacional de
Hogares y Propósitos Múltiples - INEC-2006. San José, Costa Rica, 2006.
Instituto Nacional de Información de Desarrollo (INIDE), Ministerio de Salud (MINSA). Encuesta nicaragüense de
demografía y salud, 2006/2007. Nicaragua, 2008.
Lechtig A, Cornale G, Ugaz M, Arias L. Decreasing stunting, anemia, and vitamin A deficiency in Peru: results of the
Good Start in Life Program. Food and Nutrition Bulletin 2009; 30 (1): 37-48.
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evidence using a programme theory framework. Journal of Development Effectiveness 2009; 1 (2): 103-9.
Leroy J, Gutiérrez J, Denova E, Ventura C, Rivera J. Análisis del impacto de intervenciones nutricionales en el grupo
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PMA. Alza de precios, mercados e inseguridad alimentaria y nutricional en Centroamérica. [Informe]. El Salvador, 2008.
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PMA. Redes de protección social: Instrumento para el beneficio de los más vulnerables. Nota Conceptual propuesta a los
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PMA. Análisis de los medios de vida y vulnerabilidad de los hogares rurales e indígenas, desde una perspectiva de
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140
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ANNEX v:
i: STUDY
iii:
REFERENCES
MALNUTRITION
COLLABORATORS
TERMINOLOGY
INCAP. Diagnóstico de la situación nutricional y caracterización de programas alimentario-nutricionales dirigidos a
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III
II
Programa de Acción de Accra (2008). III Foro de Alto Nivel sobre la Eficacia de la Ayuda al Desarrollo; 2008 Sep 2-4;
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Ruel M, Menon P, Habicht JP, Loechl C, Bergeron G, Pelto G et al. Age-based preventive targeting of food assistance and
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ANNEX v:
i: STUDY
iii:
REFERENCES
MALNUTRITION
COLLABORATORS
TERMINOLOGY
PNUD. Integración del Enfoque de Género en los Proyectos del PNUD. El Salvador, 2004.

Nutritional dimension - Programa Mundial de Alimentos

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