Nutritional dimension - Programa Mundial de Alimentos
Transcripción
Nutritional dimension - Programa Mundial de Alimentos
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 POVERTY, FOOD INSECURITY AND MALNUTRITION IN CENTRAL AMERICA AND THE DOMINICAN REPUBLIC – THE ROLE OF SOCIAL SAFETY NETS AND SOCIAL PROTECTION PROGRAMMES 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 POVERTY, FOOD INSECURITY AND MALNUTRITION IN CENTRAL AMERICA AND THE DOMINICAN REPUBLIC – THE ROLE OF SOCIAL SAFETY NETS AND SOCIAL PROTECTION PROGRAMMES 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 POVERTY, FOOD INSECURITY AND MALNUTRITION IN CENTRAL AMERICA AND THE DOMINICAN REPUBLIC – THE ROLE OF SOCIAL SAFETY NETS AND SOCIAL PROTECTION PROGRAMMES 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 POVERTY, FOOD INSECURITY AND MALNUTRITION IN CENTRAL AMERICA AND THE DOMINICAN REPUBLIC – THE ROLE OF SOCIAL SAFETY NETS AND SOCIAL PROTECTION PROGRAMMES 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 POVERTY, FOOD INSECURITY AND MALNUTRITION IN CENTRAL AMERICA AND THE DOMINICAN REPUBLIC – THE ROLE OF SOCIAL SAFETY NETS AND SOCIAL PROTECTION PROGRAMMES 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 POVERTY, FOOD INSECURITY AND MALNUTRITION IN CENTRAL AMERICA AND THE DOMINICAN REPUBLIC – THE ROLE OF SOCIAL SAFETY NETS AND SOCIAL PROTECTION PROGRAMMES 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 POVERTY, FOOD INSECURITY AND MALNUTRITION IN CENTRAL AMERICA AND THE DOMINICAN REPUBLIC – THE ROLE OF SOCIAL SAFETY NETS AND SOCIAL PROTECTION PROGRAMMES 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 METHODOLOGY, STAGES AND ORGANIZATION OF THE STUDY 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 METHODOLOGY, STAGES AND ORGANIZATION OF THE STUDY 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 Secretariat of the Presidency 2006 Country Plan for the Eradication of Chronic Child Undernutrition in Honduras Honduras Secretariat of Health 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). RESULTS AND ANALYSIS 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 RESULTS AND ANALYSIS 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 RESULTS AND ANALYSIS 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. Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. 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). RESULTS AND ANALYSIS 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) Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). Multiple answers. The sum of all percentages is more than 100%. Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). 38 39 RESULTS AND ANALYSIS 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 RESULTS AND ANALYSIS 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. Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). 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 RESULTS AND ANALYSIS 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). Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). Multiple answers. The sum of all percentages is more than 100%. 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 Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). 53 56 Multiple answers. The sum of all percentages is more than 100%. 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 RESULTS AND ANALYSIS 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 RESULTS AND ANALYSIS 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. Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. number of programmes (n). Multiple answers. The sum of all percentages is more than 100%. *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 in the programmes (n=110) 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). Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Given its nature, for food fortification programmes for massive consumption, the target group is the general population. Note: In parenthesis number of programmes (n). Tufts University/ Friedman School of Nutrition Sciences and Policies, WFP (2007). 60 48 Multiple answers. The sum of all percentages is more than 100%. 49 RESULTS AND ANALYSIS 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 RESULTS AND ANALYSIS 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 in the programmes (n=110) 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. Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. *Include all the programmes except HIV specific ones. Note: In parenthesis number of programmes (n). 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 Source: Study on the Nutritional Dimension in the Social Safety Nets of Central America and the Dominican Republic, 2009. 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 Source: Study on the Nutritional Dimension in the Social Safety Nets of Central America and the Dominican Republic, 2009. The World Bank (2006). 53 RESULTS AND ANALYSIS 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. Source: Study on the Nutritional Dimension in the Social Safety Nets of Central America and the Dominican Republic, 2009. 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 RESULTS AND ANALYSIS 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 RESULTS AND ANALYSIS 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. III IV 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 Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). 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% Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: Multiple answers. The sum of all percentages is more than 100%. * In the programmes that include supplementation. Multiple answers. The sum of all percentages is more than 100%. 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. RESULTS AND ANALYSIS 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. III IV II 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. Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). 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. RESULTS AND ANALYSIS 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. III IV II Figure 15 Nutrition training of the different human resources (n=110) Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. 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 RESULTS AND ANALYSIS 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. III IV II RESULTS AND ANALYSIS 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. Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). 64 65 III IV II Table 5 Normative documents of analyzed programmes (n=97) Type of normative documents Number of programmes 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% Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. 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”). RESULTS AND ANALYSIS 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. III IV 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. Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. 3. Evaluation ii. 18% has staff or a technical team exclusively responsible for monitoring, even at regional or department level. Note: In parenthesis number of programmes (n). 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. RESULTS AND ANALYSIS Figure 17 III IV 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) Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. 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 Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. 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 RESULTS AND ANALYSIS 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). III IV II 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 RESULTS AND ANALYSIS 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. III IV II 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) Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). Multiple answers. The sum of all percentages is more than 100%. 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) RESULTS AND ANALYSIS 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. III IV II 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 Note: In parenthesis number of programmes (n). 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 RESULTS AND ANALYSIS 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%). III 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). RESULTS AND ANALYSIS 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. III IV II Figure 21 RESULTS AND ANALYSIS 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%). Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. iii. Development of educational materials and documents in local languages (14%). Note: In parenthesis number of programmes (n). 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. III IV II Table 7 Community participation in the programmes (n=110) Number of programmes 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 Number of programmes 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% Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. 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 Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: Answers about the total of programmes that have community participation (n=86). 83 RESULTS AND ANALYSIS 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, Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). 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. RESULTS AND ANALYSIS H. DURATION, SUSTAINABILITY, INVESTMENT, COLLATERAL EFFECTS AND DEGREE OF COMPLIANCE TOWARDS NATIONAL STRATEGIES FOR POVERTY REDUCTION III IV II III IV II Figure 23 Programmes duration according to country (n=110) 2. Sustainability and funding sources RESULTS AND ANALYSIS 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 Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). 86 87 III IV II 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 Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). Multiple answers. The sum of all percentages is more than 100%. 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) Public resources and 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 external cooperation - - 20% (3) - 6% (1) - - 4% (4) Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). Note: In parenthesis number of programmes (n). Multiple answers. The sum of all percentages is more than 100%. 88 89 RESULTS AND ANALYSIS Table 9 III IV II 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) Public resources and external cooperation (loan and donation) 30% (16) 67% (10) 30% (3) 17% (1) - 15% (3) 30% (33) Public resources and 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 external cooperation 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 the programmes (n=110) Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). 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 Source: Study on the Nutritional Dimension of the Social Safety Nets in Central America and the Dominican Republic, 2009. Note: In parenthesis number of programmes (n). Multiple answers. The sum of all percentages is more than 100%. 91 RESULTS AND ANALYSIS 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. RESULTS AND ANALYSIS 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 ANNEX i: STUDY COLLABORATORS 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 Accreditation Department National Foundation for Children Margarita Claramunt Hortence Augustine Delia Miranda Doroty Menzies Child Attention Center Ministry of Human Development and Social Transformation Social Development Deputy Manager Office Joint Social Welfare Institute 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 Costa Rican Social Security Fund Integral Attention Area for People María Elena Montenegro Emilce Ulate Darling Ruíz World Food Programme (WFP) Sonia Camacho University of Costa Rica, School of Nutrition María Eugenia Villalobos Study consultant Esteban Rojas Jorge Polanco Regulation, Systematization, Diagnosis and Treatment Area Costa Rican Social Security Fund 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 Ministry of Human Development and Social Transformation Francisco Sánchez Study consultant University of Costa Rica, School of Nutrition (Key informant) Marlen Montoya Accreditation Department National Foundation for Children Costa Rican Social Security Fund 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) World Food Programme (WFP) Graciela Rojas Melany Ascencio HIV Patient Attention Programme San Juan de Dios Hospital Costa Rican Social Security Fund Health Research Management Unit National Micronutrients Commission Ministry of Health Hugo Chacón Norma Aguilar Ministry of Health Integral Attention Programme for Patients Costa Rican Social Security Fund Accreditation Department National Foundation for Children Pulcheria Teul Jalila Meza Norma Méndez Senate of the Republic (Key informant) Accreditation Department National Foundation for Children Social Development Deputy Manager Office Joint Social Welfare Institute 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 Hand in Hand Ministries Salvadorian Association of Health Promotion Natalia Largaespada 120 Ana Josefa Blanco Breastfeeding Support Center (Key informant) Ana María Delgado AGAPE Association 121 ANNEX i: STUDY COLLABORATORS 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 Ministry of Public Health and Social Assistance Sonia Mena Gabriela Mejicano World Vision Foundation Catholic Relief Services (CRS) Mother and Child Health and Nutrition Project Ministry of Public Health and Social Assistance Maija Laitinen Luz Cabrera Claudia Sandoval Local Development Social Investment Fund Daysi Márquez Teresa de Jesús Tario World Food Programme (WFP) World Food Programme (WFP) Nutrition and Soy Programme Gladys Arreola Maritza M. de Oliva Plan International Verónica Avalos Department of Regulation and Food Control Ministry of Public Health and Social Assistance Eduardo Montes STD/HIV-AIDS National Programme Ministry of Public Health and Social Assistance Hugo Valladares Manuel Mendoza William Pleitez New People Foundation (Key informant) My Family Progresses Programme Ministry of Education Social Cohesion Council Débora Aguilar Salvadorian Institute of Children and Adolescence Elvis Soriano Human Development Unit United Nations Development Programme (UNDP) (Key informant) Breastfeeding Support Center Jessica Escobar World Food Programme (WFP) Irma Chavarría de Maza Ministry of Public Health and Social Assistance (Key informant) Mayte Ayau Irma Esperanza Palma Oscar López World Food Programme (WFP) Social Sciences Latin American Faculty (FLACSO) (Key informant) Plan International Xinia Castro World Food Programme (WFP) 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 Ministry of Public Health and Social Assistance 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 Social Cohesion Council 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 My Family Progresses Programme Ministry of Education Social Cohesion Council Ministry of Public Health and Social Assistance 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 Social Cohesion Council Sandra López José Daniel Villela Sara Cordón de Zamora Solidarity Bag Programme Secretariat of Social Welfare Social Cohesion Council Solidarian Feeding Centers Presidential Programme Secretariat of Social Welfare Social Cohesion Council Secretariat of the President’s Wife Social Services 123 ANNEX i: STUDY COLLABORATORS Anabell Amaya III II Mayte Paredes Anielka López Martha McCoy CHF International World Food Programme (WFP) 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 World Food Programme (WFP) Ninoska Bulnes Solidarity Net Office of the First Lady (Key informant) Aurora Soto Norman Herrera Gladys Mejía HIV-AIDS-STD Programme Ministry of Health World Food Programme (WFP) 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 Office of the First Lady Nubia Estrada Gloria Elvir National Programme of Food and Nutritional Security Secretariat of Health Héctor Galindo Patricia Carrillo Orlando Rivera Integral Attention Programme for Pregnant Women for the Prevention of Vertical Transmission from Mother to Child Secretariat of Health 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 Secretariat of Health Ivette Arauz Silvia Mendoza Nica Health Net Federation Rainbow Network Ezequiel Provedor CHF International Irma Mendoza World Food Programme (WFP) Sabrina Quezada World Food Programme (WFP) Rainbow Network Iván Espinoza Tomasa Sierra Health Secretariat Integral Attention Programme for Pregnant Women for the Prevention of Vertical Transmission from Mother to Child Secretariat of Health 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 World Food Programme (WFP) Adventist Agency for Development and Assistance Resources Aychell Samaniego José Alfredo Betanco Azael Torres Plan International Former Government official (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 World Food Programme (WFP) 124 Leticia Romero People Living with HIV and AIDS Association (Key informant) 125 ANNEX i: STUDY COLLABORATORS 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 Office of the First Lady 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 Ministry of Education Former Government official (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 State Secretariat of Public Health and Social Assistance 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) World Food Programme (WFP) Odalis Sinisterra Elizabeth Fadul World Food Programme (WFP) Ysidora Zabala Fernando Ferreira Nutrition Department Ministry of Health Fanny Algarrobo General Direction Office for Control of Sexually Transmitted Diseases and AIDS State Secretariat of Public Health and Social Assistance 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) World Food Programme (WFP) José Bernardo González Teresita Yaniz de Arias Study consultant Former Government official (Key informant) Former Government official (Key informant) María Virtudes Berroa Juan Espinoza Yarabín De Icaza Nutrition Foundation World Food Programme (WFP) 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 World Food Programme (WFP) 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 State Secretariat of Public Health and Social Assistance Kendra Mieses Batey Relief Alliance, BRA Martha Nina National Breastfeeding Programme State Secretariat of Public Health and Social Assistance 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 World Food Programme (WFP) Ramón Portes Dominican Association of Planned Parenthood (Key informant) 126 127 ANNEX i: STUDY COLLABORATORS 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 CHILDHOOD AND ADOLESCENCE 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 Hand in Hand Ministries HIV SPECIFIC PROGRAMME 7 National Programme for Tuberculosis HIV/AIDS and other STD Belize Ministry of Health HIV SPECIFIC PROGRAMME 8 Programme of Attention and Special Protection for Childhood and Adolescence in its Solidarity Homes Modality Costa Rica National Foundation for Children CONDITIONAL TRANSFERS 9 Food Security Programme (to tackle the economic crisis) Costa Rica Joint Institute of Social Help, Deputy Management Office of Social Development CONDITIONAL TRANSFERS 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 Rican Social Security Fund Costa Rica MOTHER AND CHILD NUTRITION Costa Rica Costa Rican Social Security Fund – Comprehensive Attention Area MOTHER AND CHILD NUTRITION 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 National Foundation for Children and NGOs CHILDHOOD AND ADOLESCENCE ATTENTION PROGRAMME 128 FOOD BASED MAIN EXECUTING INSTITUTION 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 National Foundation for Children and NGOs CHILDHOOD AND ADOLESCENCE ATTENTION PROGRAMME 17 Programme of Attention and Special Protection for Childhood and Adolescence. Diurnal Feeding Centers Modality Costa Rica National Foundation for Children and NGOs CHILDHOOD AND ADOLESCENCE ATTENTION PROGRAMME 18 Nutritional Attention Programme for People living with HIV and AIDS Costa Rica Costa Rican Social Security Fund HIV SPECIFIC PROGRAMME 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 MOTHER AND CHILD NUTRITION 23 Health Services Nutrition Programme El Salvador Salvadorian Association of Health Promotion MOTHER AND CHILD NUTRITION 24 Nutrition Programme El Salvador Ministry of Public Health and Social Assistance MOTHER AND CHILD NUTRITION 25 Health and Food and Nutrition Security Programme El Salvador Breastfeeding Support Center MOTHER AND CHILD NUTRITION 26 First Steps Towards Success and Health and School Nutrition Programme El Salvador Save the Children MOTHER AND CHILD NUTRITION 27 Pounds of Love Nutritional Food Safety Programme El Salvador Salvadorian Foundation for Health and Human Development MOTHER AND CHILD NUTRITION 28 Food and Nutritional Security Programme El Salvador Plan International MOTHER AND CHILD NUTRITION 29 Nutritional Programme-Nutritional Component Complement for Vulnerable Groups El Salvador Ministry of Public Health and Social Assistance MOTHER AND CHILD NUTRITION 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 PRODUCTIVE PROGRAMME 35 STD/HIV-AIDS National Programme El Salvador Ministry of Public Health and Social Assistance HIV SPECIFIC PROGRAMME 36 HIV Patients Nutritional Programme El Salvador New Times Foundation HIV SPECIFIC PROGRAMME 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 Secretariat of the Presidency MOTHER AND CHILD NUTRITION Costa Rican Social Security Fund – Comprehensive Attention Area COUNTRY 16 TYPE OF MAIN PROGRAMME /PLAN OR POLICY Belize NAME 129 CONDITIONAL TRANSFERS 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 MAIN EXECUTING INSTITUTION TYPE OF MAIN PROGRAMME /PLAN OR POLICY 38 My Family Progresses Programme Guatemala Social Cohesion Council CONDITIONAL TRANSFER 39 Solidarity Bag Programme Guatemala Social Cohesion Council CONDITIONAL TRANSFER 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 MOTHER AND CHILD NUTRITION 42 Chronic Undernutrition Reduction Programme, CURP (currently National Strategy to Reduce Chronic Undernutrition) Guatemala Secretariat of Food and Nutritional Security MOTHER AND CHILD NUTRITION 43 Mother and Child Health and Nutrition Programme Component No. 2 44 45 46 47 MOTHER AND CHILD NUTRITION No NAME COUNTRY MAIN EXECUTING INSTITUTION 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 Christian Children´s Fund (Child 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 HIV SPECIFIC PROGRAMME 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 HIV SPECIFIC PROGRAMME 65 Programme for the Attention of Vulnerable Groups – Component No. 2 of the country programme Honduras Secretariat of Health, National Nutrition Programme HIV SPECIFIC 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 HIV SPECIFIC PROGRAMME 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 HIV SPECIFIC PROGRAMME HIV SPECIFIC PROGRAMME Guatemala Ministry of Public Health and Social Assistance MOTHER AND CHILD NUTRITION Food and Nutritional Security Programme Guatemala Guatemala World Vision MOTHER AND CHILD NUTRITION 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 MICRONUTRIENT FORTIFICATION 68 The Prevention of HIV from Mother to Child Programme Honduras Christian Children´s Fund (Child Fund) Undernutrition Recovery and Prevention in Favor of Vulnerable Groups Programme Solidarian Feeding Centers Programme TYPE OF MAIN PROGRAMME /PLAN OR POLICY MOTHER AND CHILD HEALTH 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 Ministry of Public Health and Social Assistance and UNICEF HIV SPECIFIC PROGRAMME 70 Mother and Child Health National Plan Honduras Secretariat of Health POLICY 52 HIV, Hepatitis B and Syphilis Vertical Transmission Programme Guatemala Roosevelt Hospital HIV SPECIFIC PROGRAMME 71 Food and Nutritional Security with Citizens Participation Policy Honduras Secretariat of the Presidency POLICY 53 Social Protection Integral Programme Honduras Family Assignment Programme CONDITIONAL TRANSFER 72 Honduras 54 Honduras Family Assignment Programme CONDITIONAL TRANSFER Secretariat of Health, National Programme for Food and Nutritional Security PLAN Comprehensive Women Development Programme (DI Mujer) Country Plan for the Eradication of Child Chronic Undernutrition 55 Solidarian Hand Bonus Programme Honduras Family Assignment Programme CONDITIONAL TRANSFER 73 Programme in Support of Rural Families in Zones Affected by Droughts and Floodings Nicaragua Ministry of Agriculture and Forestry Programme for Nutritional and Food Security CONDITIONAL TRANSFER 56 Solidarian Net Programme Honduras First Lady Programme, Secretariat of the Presidency CONDITIONAL TRANSFER 74 Model Programme of Nutritional Recuperation Heart in the Family 2002-2009 Nicaragua World Vision MOTHER AND CHILD NUTRITION 57 Integral Attention Towards Vulnerable Groups Programme Honduras National Programme for Food and Nutritional Security, Dependency of the Secretariat of Health and the WFP MOTHER AND CHILD NUTRITION 75 Health and Nutrition Community Programme Nicaragua Ministry of Health, General Direction Office of Health Services, Normative/ Childhood Comprehensive Attention MOTHER AND CHILD NUTRITION 58 Nutritional National Programme 2009-2015 Honduras Secretariat of Health National Programme for Food and Nutritional Security MOTHER AND CHILD NUTRITION 76 Breastfeeding as part of the National Strategy Nicaragua Ministry of Health, General Direction Office of Health Services, Normative/ Childhood Comprehensive Attention MOTHER AND CHILD NUTRITION 59 Health, Nutrition and HIV National Programme (as part of the Health, Nutrition and HIV National Strategy) Honduras World Vision Honduras MOTHER AND CHILD NUTRITION 77 Axle Three Programme of the Love Programme Nicaragua Ministry of the Family, Adolescence and Childhood MOTHER AND CHILD NUTRITION 130 131 PLAN ANNEX ii: i: STUDY LIST OFCOLLABORATORS PROGRAMMES AND PLANS OR POLICIES BY COUNTRY No III II 78 NAME Window of Opportunity Programme TYPE OF MAIN PROGRAMME /PLAN OR POLICY COUNTRY MAIN EXECUTING INSTITUTION Nicaragua Care Central America in Nicaragua MOTHER AND CHILD HEALTH MOTHER AND CHILD HEALTH MOTHER AND CHILD NUTRITION No NAME COUNTRY MAIN EXECUTING INSTITUTION TYPE OF MAIN PROGRAMME /PLAN OR POLICY 101 National Salt Fortification Programme Panama Ministry of Health, Department of Nutritional Health MICRONUTRIENT FORTIFICATION 102 Biofortification Programme Panama Agricultural Research Institute of Panama BIOFORTIFICATION 103 Universal Treatment Access Programme Panama Aid for Aids HIV SPECIFIC PROGRAMME 104 People with HIV Education Programme Panama Aid for Aids HIV SPECIFIC PROGRAMME 105 I Learn to Love and Take Care of Myself Programme -Children’s Programme Panama Aid for Aids HIV SPECIFIC PROGRAMME HIV SPECIFIC PROGRAMME 79 Childhood Attention Programme, Attention of Childhood Prevalent Illnesses Nicaragua Ministry of Health, General Direction Office of Health Services, Normative/ Childhood Comprehensive Attention 80 Families United for their Health Programme Nicaragua Nica Health Net Federation 81 Children Feeding Center Programme 2009 Nicaragua Rainbow Network FOOD BASED 82 Food and Nutritional Security Programme Nicaragua Ministry of Agriculture and Forestry 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 MICRONUTRIENT FORTIFICATION 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 Ministry of Health, Department of 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 CONDITIONAL TRANSFERS CONDITIONAL TRANSFERS PRODUCTIVE PROGRAMME Nicaragua Adventist Agency for the Development and Assistance Resources, Nicaragua PRODUCTIVE PROGRAMME Childhood in Sustainable Families Programme Nicaragua Plan International PRODUCTIVE PROGRAMME 89 Productive Food Programme Nicaragua Ministry of Agriculture and Forestry Programme for Nutritional and Food Security PRODUCTIVE PROGRAMME 110 Vamo’ Arriba Programme Dominican Republic Social Policy Cabinet 90 STD, HIV and AIDS Programme Nicaragua Ministry of Health HIV SPECIFIC PROGRAMME 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 MOTHER AND CHILD HEALTH 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 MOTHER AND CHILD HEALTH 92 Red de Oportunidades (Net of Opportunities) Programme Panama Ministry of Social Development Secretariat of the Social Protection System CONDITIONAL TRANSFERS 113 Breastfeeding National Programme Dominican Republic State Secretariat for Public Health and Social Assistance MOTHER AND CHILD NUTRITION 93 Family Vouchers for Purchasing of Foods Panama Ministry of the Presidency, National Secretariat for the Food and Nutritional Security Plan CONDITIONAL TRANSFERS 114 Education, Faith and Citizenship Programme Dominican Republic Mother and Child Pastoral, Organization of the Dominican Episcopal Conference MOTHER AND CHILD NUTRITION 94 Programme for the Training and Support of Poor Families and Vulnerable Groups for their Integral Development Panama Archdiocesan Caritas MOTHER AND CHILD NUTRITION 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 MOTHER AND CHILD NUTRITION 116 Humanitarian Help Programme Dominican Republic Batey Relief Alliance (BRA Dominicana) FOOD BASED 96 Complementary Feeding Programme Panama Ministry of Health, Department of 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 State Secretariat for Public Health and Social Assistance MICRONUTRIENT FORTIFICATION 98 Vitamin A Supplementation Programme Panama Ministry of Health, Department of Nutritional Health Dominican Republic MICRONUTRIENT SUPPLEMENTATION 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 MICRONUTRIENT FORTIFICATION 120 Programme for the Control of Sexually Transmitted Diseases and AIDS Dominican Republic State Secretariat for Public Health and Social Assistance HIV SPECIFIC PROGRAMME 87 Programme for Food and Nutritional Security in the North Atlantic Autonomous Region 88 99 Iron Supplementation Programme Panama Ministry of Health, Department of Nutritional Health 100 National Wheat Flour Fortification Programme Panama Ministry of Health, Department of Nutritional Health 132 MICRONUTRIENT SUPPLEMENTATION 133 ANNEX ii: i: STUDY LIST OFCOLLABORATORS PROGRAMMES AND PLANS OR POLICIES BY COUNTRY 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. Acosta O, Ramírez J. Las redes de protección social: modelo incompleto. Serie Financiamiento del Desarrollo. CEPAL no. 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. Revista de la CEPAL 2002; 76: 39-54. 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. BID, Gesaworld. Borrador del plan de inversiones en nutrición preventiva para Nicaragua (2007-2015). [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 BID, Gesaworld. Borrador del plan de inversiones en nutrición preventiva para El Salvador (2007-2009). [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 BID, Gesaworld. Borrador del plan de inversiones en nutrición preventiva para Guatemala. [cited 2009 Aug 20]. Oportunidades de Inversión en Nutrición Preventiva para Guatemala, Honduras, Nicaragua y El Salvador. Proyecto ATN-EA 7924 RG. 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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). 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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, Washington DC, 2010. Departamento Nacional de Planeación y SINERGIA (Sistema Nacional de Evaluación de Resultados de la Gestión Pública). Programa Familias en Acción - Resultados de impacto un año después de implementado el programa. 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