die die social protection and child malnutrition afghanistan SUMMARY THE CONTEXT

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1 social protection and child malnutrition afghanistan A NEED FOR GREATER FOCUS AND SUSTAINED FUNDING SUMMARY Over the past decade Afghanistan has made tangible progress towards its social and development objectives and meeting the Millennium Development Goals (MDGs). Infant and under-five mortality have gone down from 111 and 161 per thousand live births in 2008 to 77 and 97 per thousand live births respectively. 1 Key social protection initiatives have been taken to address poverty and vulnerability, including a pilot safety net programme, a school feeding programme and cash or assets for work initiatives. The country s commitments to social protection are captured in the National Social Protection strategy ( ), which falls under the Afghanistan National Development Strategy (ANDS) 2 and the MDGs plan, which serves as the country s Poverty Reduction Strategy Paper. Nonetheless, Afghanistan continues to face severe security challenges; weak governance and corruption; limited fiscal resources that impede service delivery; a poor environment for private sector investments; a large narcotics industry; and major human capacity limitations. As a result, many people are actually getting poorer. Nearly a third of Afghans are still food insecure, which means they cannot get enough nutritious food to support an active, healthy lifestyle. Nearly 60% of children under the age of five are stunted, an indicator of chronic malnutrition. 3 To address these concerns, while building on the successes of the last decade, social protection provision must be extended and the quality improved to ensure benefits reach those who are most vulnerable, especially women and children. There is justified concern that social protection will slip further off policy agendas as the country approaches transition to national forces, given the increasing focus on security concerns and the likely dip in donor spending from This briefing calls for an increased focus on social protection as a means of tackling hunger and malnutrition. The Afghan government and donors can ensure a greater focus on nutrition within social protection plans, which can go a long way towards addressing malnutrition and the damaging effect it can have on children s lives and their future potential. THE CONTEXT Afghanistan s economy has grown strongly, if erratically, over the past six years, averaging around 12% per annum. Average per-capita GDP has nearly doubled since Adult mortality rates have also fallen substantially. Basic health services are available in districts where 85% of the population lives, providing access to primary healthcare for 60% of the country s population. 6 At the same time, achievements in some areas are below expectations and Afghanistan is off-schedule for all of its MDG targets. Poverty remains high, particularly in the East and West-Central regions, and a large share of the population is vulnerable to negative shocks. 7 Low and often unreliable revenue flows, the unpredictability of the natural environment, ongoing conflict and external factors such as fluctuating global food prices drive this vulnerability. 8 The re-establishment of the Office for the Coordination of Humanitarian Affairs (OCHA) in 2009 reflects the rising humanitarian need in Afghanistan and the fact that basic social protection remains limited. 9 NO CHILD - 1 -

2 Current statistics 10 Population (million) Poverty (% of total population below national poverty line) Regional poverty (% of total population) South-west poverty East and Central Male and female life expectancy at birth (years) Maternal mortality ratio (2008) 14 1: 11 Food insecurity (% households not consuming sufficient caloric intake) Child malnutrition (% children under 5) Maternal malnutrition (% non-pregnant women of reproductive age with BMI less than 18.5%) Poverty and severe food insecurity contribute to high levels of malnutrition (outlined in the table) as households are forced to regularly trade-off quality for quantity as they move towards staple foods and away from nutrient-rich foods such as meat and vegetables. However, these are not the only underlying contributory factors. Inadequate healthcare, a lack of knowledge regarding appropriate nutrition practices, low levels of education particularly among women and scarcity of micronutrients are also important factors. 18 PLANNING, IMPLEMENTATION AND COORDINATION Many households in Afghanistan have strong, longstanding social networks from which they are able to borrow and villages are able to organise themselves to provide basic goods for the public. 19 However, these longstanding, informal sources of support have been weakened by decades of conflict, and the need for social protection provided by the state and other agencies remains strong. The current strategic and planning framework is provided by the ANDS, which includes the national Social Protection Strategy. The strategy reinforces commitments made in the Afghanistan Compact 20 and under the MDGs to promote social inclusion, reduce poverty and prevent those who are poor from falling into deeper poverty through sustainable income and transfer policies, pursued through pension reform and programmes focused on extremely poor and vulnerable households. In theory, the Ministry of Labour, Social Affairs, Martyrs, and Disabled (MoLSAMD) is the lead ministry responsible for managing and coordinating social protection interventions. The Ministry of Rural Rehabilitation and Development (MRRD), through its own social protection directorate, also helps to build local infrastructure and provide temporary employment, which help disaster-affected rural communities recover and returnees and internally displaced people reintegrate. Various other ministries operate programmes with implications for social protection

3 In reality, public spending remains heavily dependent on donor funding and state-funded social protection has long been restricted to a number of specific interventions targeting a very limited number of people. Non-state actors, specifically international non-governmental organisations or UN agencies, have therefore filled the gap, providing a range of social services. This leads to off-budget spending on projects over which the government has little influence and scant information on, reducing the effectiveness of its pro-poor planning and performance budgeting. 21 In the coming years, Afghanistan faces the combined challenge of a global economic crisis, high food prices and an anticipated decline in some donor financial support. Government capacity to broaden the scope of social services beyond existing interventions remains limited. This scenario poses heavy implications for the sustainability of social protection programmes and will likely exacerbate hunger and malnutrition. There is a clear need for international donors to commit to backstop spending on social protection so that the government can invest in long-term development and effective crisis response. Addressing malnutrition Children s physical and cognitive development and potential could be irreversibly damaged if food and nutrition needs are not met. Impacts on the economy are also likely, as healthier workers are more productive and labour supply increases if morbidity and mortality rates are lower. While there are sector strategies 22 that specifically address the issue of nutrition, growing evidence from other low-income countries demonstrates the effectiveness of social protection programmes in enabling people to get more and better-quality food and become better nourished. 23 In theory, the link between social protection and nutrition is already recognised by policymakers in Afghanistan. Importantly, reductions in the number of underweight children and in the number of individuals who suffer from hunger were included as indicator outcomes in the Social Protection Strategy. The strategy also identified nutrition concerns such as food insecurity and malnutrition during natural disasters and in the broader context of addressing the needs of chronically vulnerable groups. However, support for nutrition within the relevant line ministries is still weak, as indicated by the low positioning of nutrition-related departments within organisational structures and the low funding priority given to nutrition programmes. 24 Although ANDS offers a framework for developing the social protection system, it currently highlights a broad menu of needs and fails to provide a coherent prioritisation of goals and activities. Meanwhile, the failure to include social protection as a specific component of the national priority programmes (designed to streamline ANDS as part of the Kabul Process ) is a worrying indication of the lack of attention awarded to social protection at policy level. More political will and capacity will therefore be needed if social outcomes are to be achieved, while the positive correlation between livelihood security and nutrition needs further emphasis. Existing programmes Some examples of existing programmes, including those with a nutrition dimension, led by either the government or donors, separately or jointly, are: Program for Martyrs and Disabled: This is the government s largest national cash transfer programme, accounting for about 0.2% of GDP. It provides cash benefits to the families of martyrs from earlier wars and individuals with war and landmine-related disabilities. Safety Net Pilot: The programme is a MoLSAMD-operated and International Development Association (IDA)-funded pilot unconditional cash transfer programme aimed at selected high-risk categories defined in ANDS and the National Risk Vulnerability Assessment to support their food consumption in the most difficult period of year, between end of winter and first harvest. Transfer size is determined by the food poverty line

4 The National Skills Development Program aims to provide training in different marketable vocational skills to a range of vulnerable groups; 35% of beneficiaries are required to be women from chronically poor, female-headed households with small children. Nutrition promotion modules are included in training programmes. 25 Horticulture and Livestock Project (HLP): A key component of this is the Backyard Poultry Project (2009), which trains those involved in poultry production, largely women in rural villages, to increase poultry and egg productivity to improve nutrition while reducing poverty. HLP Integrated Dairy Schemes Project. The Ministry of Agriculture, Irrigation and Livestock (MAIL) works with GRM International to implement the dairy component of the World Bank-funded HLP. The programme targets women and is designed around local dairy cooperatives to improve household food security and income. Food for education programme: The World Food Programme (WFP) runs a school feeding project in food deficit areas affected by drought. In 2010, WFP provided a daily snack of micronutrient-enriched biscuits or a hot meal to more than a million children. Public works programmes: Food-for-work and food-for-assets programmes are a means of transferring resources through temporary employment generation, often targeted at workers from poor households, while at the same time building or repairing local infrastructure and community assets. Effective implementation Despite these positive initiatives, lack of awareness about nutrition at policy level, coupled with ineffective coverage, inefficient targeting and poor administration and design of social protection programmes are obstacles to progress in addressing malnutrition. Broad coverage is critical to reducing national rates of malnutrition. In Afghanistan, the coverage of social protection policies is inadequate, especially considering the high number of at-risk households. Donor-funded programmes are generally small-scale and of limited coverage with a tendency to focus on rural areas. In contrast, existing informal social protection mechanisms are on the whole much weaker in urban settings. 26 Increasing coverage requires long-term domestic financing strategies that are complemented where necessary by multiyear funding commitments from donors. However, the heavy dependence on donor support in Afghanistan makes longer-term planning difficult, since strategies must be constantly realigned with changing donor engagement. 27 The situation is compounded by the lack of coordination between the numerous stakeholders, leading to overlap and gaps in coverage. To be as effective as possible, programmes should be targeted at those who are most vulnerable. However, the poor coverage of social protection programmes is exacerbated by inefficient targeting. Programmes use categorical or geographic targeting or combinations of the two (although community targeting and means-testing mechanisms are applied in certain donor schemes). While geographic targeting allows provinces that have the highest burden of food poverty and malnutrition to be selected, this can miss malnourished children in other regions. Given the high levels of malnutrition among women and children, categorical targeting that focuses on these and other vulnerable groups is appropriate. However, targeting of safety net programmes is also inefficient, with a relatively large number of ineligible households receiving benefits while eligible households are left out. This is because only a few programmes have been specifically targeted at poor households. The martyrs and disabled programme, which dominates spending on safety nets, for example, is not poverty-targeted. Meanwhile, even poverty-focused donor programmes show high levels of leakage to better-off households. Some good initiatives have, however, been introduced, including the mapping of pro-poor expenditures in the budget. The pilot safety net programme also specifically focuses on poor households and could go some way towards redressing this imbalance

5 Conditional cash transfer programmes (CCTs), such as cash/products for work, training or education programmes, have been used to link benefit award to some change in household behaviour. However, CCTs cannot be a complete safety net in the Afghan context where children have limited access to healthcare and education, and many households do not have family members free to participate in public works schemes. 29 Consequently, the impact of conditional CCTs is restricted to the people who are able to sign up. This suggests that conditionality should not be the default option when designing social transfer programmes. Moreover, while social protection structures can promote behaviour that supports good nutrition (at payment points, through programme communication and community committees), programmes often fail to capitalise on these opportunities. Even programmes that have stated nutrition goals, such as the Backyard Poultry Project, are not systematically accompanied by a component directly promoting nutrition. The size of transfer is critical in determining the impact on hunger and nutrition. Evidence shows that, by tackling the underlying poverty constraint, a larger cash transfer leads to young children eating more and better food, which is likely to have a positive impact on height-forage and stunting. 30 In Afghanistan there is a huge gap between the cost of a nutritious t and household income, particularly for very poor groups. Cash transfer schemes largely fail to take this gap into account and the transfer size of all benefits is generally too small to impact on nutrition standards. While the definition used to determine transfer size in the pilot safety nets project is food poverty line, this does not necessarily mean it is sufficient for nutritious food, given high and fluctuating food prices. In order to increase access to and affordability of a nutritious t, cash transfer schemes aiming to improve nutrition need to assess affordability and as far as possible bridge the gap. Finally, the lack of prioritisation in ANDS leads to stand-alone interventions by the government and donors. Lack of coordination means the system is failing to sufficiently exploit complementarities between programmes and may be generating sub-optimal outcomes. At a conceptual level there is considerable scope for strengthening the links between social protection, health and livelihood sectors, particularly in relation to nutrition. 31 Building strategic links between the MoLSAMD, the Ministry of Education, the Ministry of Rural Rehabilitation and Development, the Ministry of Public Health s Public Nutrition Department and MAIL s Home Economics Department could increase the reach and impact of social protection programmes, with accompanying benefits for food security and nutrition. 32 POLICY RECOMMENDATIONS Afghanistan s maternal, infant and child mortality rates are among the highest in the world. Improving the nutritional status of these groups is therefore imperative. Social protection strategies can reduce malnutrition. Taking into account the context of transition and the limited capacity of the Afghan government to deliver services, this paper makes the following key policy recommendations: 1. Renew commitments to the Social Protection Sector Strategy by ensuring that commitments outlined in ANDS are implemented. Social protection should be firmly embedded in national priority programme and nutrition outcomes as an indicator of success. 2. Improve poverty reduction outcomes by targeting beneficiaries in social protection policies using more nuanced criteria of vulnerable groups and ensuring social transfer programmes work for women and children. 3. Ensure social protection programmes are nutrition sensitive by considering the cost of a nutritious t in cash transfers and providing training for caregivers 33 on how to prepare culturally acceptable, nutritious food in transfer programmes

6 4. Encourage coordination and harmonisation between departments and policies by revitalising the Inter-Ministerial Council on Social Protection, strengthening MoLSAMD and integrating social transfer programmes with wider nutrition packages. Conditionality should not be the default option. 5. Ground forthcoming programmes in government capacity to ensure that they are affordable and sustainable in the long term and incrementally increase the fiscal space for social protection and coverage as GDP increases. 6. Donors should remain committed to social protection given the strong reliance of Afghanistan on donor aid and the role of social transfer programmes as one of the most effective policy tools to combat hunger and malnutrition. NOTES 1 Afghan Public Health Institute, Ministry of Public Health (APHI/MoPH) [Afghanistan], Central Statistics Organization (CSO) [Afghanistan], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India] and World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO) [Egypt], Afghanistan Mortality Survey 2010 (Calverton, Maryland, USA: APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO, 2011) locations/afghanistanpakistan/documents/afghanistan/amskeyfindings.pdf. Many of the current statistics available on even Afghanistan s most basic indicators, such as poverty or infant mortality, should be considered estimates. 2 Government of the Islamic Republic of Afghanistan, Afghanistan National Development Strategy (ANDS) (2008) Kabul: GoA, Save the Children (2011) Afghanistan in Transition: Putting Children at the Heart of Development (Washington, D.C.: Save the Children 4 Although donor governments are signing agreements to provide long-term financial support, experience suggests that withdrawals of international troops reduce civilian aid. 5 World Bank (2011) Afghanistan Economic Update: Poverty Reduction, and Economic Management, South Asia Region. Note, as with much of the data from Afghanistan considerable caution has to be exercised with respect to its reliability. 6 World Bank (2012) Quarterly Country Update: Afghanistan, Issue 411, January 2012, INTAFGHANISTAN/Resources/CountryUpdateJAN2012English.pdf 7 World Bank (2011) Afghanistan Economic Update: Poverty Reduction, and Economic Management, South Asia Region 8 P Kantor and A Pain (2011) Rethinking Rural Poverty in Afghanistan, Afghanistan Research and Evaluation Unit (AREU), Kabul 9 A Pain (forthcoming) Working Paper, Secure Livelihoods Research Consortium, London: ODI 10 These statistics were compiled from a number of sources to ensure information is as recent as possible but should be considered estimates. 11 UNICEF, Afghanistan Country Information, 12 Statistics are from Ministry of Economy and World Bank (2010) Poverty Status in Afghanistan, A Profile based on National Risk Vulnerability Assessment (NRVA) 2007/08 13 UNICEF, Afghanistan Country Information 14 Ibid 15 World Food Programme (2010) Project Document on Protracted Relief and Recovery Operation (PRRO) Afghanistan UNICEF, Afghanistan Country Information 17 Ministry of Public Health, United Nations Children s Fund, Centres for Disease Control and Prevention, National Institute for Research on Food and Nutrition Italy (2009) 2004 Afghanistan National Nutrition Survey, Atlanta: CDC 18 E Levitt, K Kostermans, L Laviolette and N Mbuya (2011) Malnutrition in Afghanistan: Scale, Scope, Causes and Potential Response, Washington, D.C.: World Bank, pp P Kantor and A Pain (2010) Poverty in Afghan Policy: Enhancing Solutions through Better Defining the Problem, AREU: Kabul 20 The Afghanistan Compact (Building on Success: 2006 The London Conference on Afghanistan, 31 January to 1 February 2009). Available at: Afghnistan%20Compact%20-%20Final%20English.pdf 21 World Bank (forthcoming 2012) Afghanistan Social Protection Review: Improving Targeting, Promoting Results Based Policies, Strengthening Institutions in Afghanistan 22 Specifically the Health and Nutrition Sector Strategy and the Agriculture and Rural Development Sector Strategy 23 Save the Children (2012) A Chance to Grow: How social protection can tackle child malnutrition and promote economic opportunities 24 E Levitt et al (2011) Malnutrition in Afghanistan - 6 -

7 25 This manual was developed jointly by MAIL, MoPH, UNICEF and the Food and Agriculture Organization of the United Nations (FAO). 26 Recognising this gap the EU social protection programme has a strong urban focus. See European Union (2011) The State of Play September september_2011_en.pdf 27 World Bank (forthcoming 2012), see note Ibid 29 Ibid 30 Save the Children (2012), see note Levitt et al (2011) Malnutrition in Afghanistan 32 Ibid 33 A training manual for this was developed jointly by MAIL, the MoPH, UNICEF and FAO. Written by: Emily Winterbotham Photo: Mats Lignell/Save the Children As part of a cash-for-work project, Fatima works at a site making huge boxes used to hold stones to prevent flooding in Bamyan province, Afghanistan. This briefing is part of a set of eight country briefings produced to accompany Save the Children s report A Chance to Grow: How social protection can tackle child malnutrition and promote economic opportunities. Thank you to all those who commented on previous drafts. savethechildren.org.uk Save the Children, June 2012 The Save the Children Fund is a charity registered in England and Wales (213890) and Scotland (SC039570). Registered Company No