die die social protection and child malnutrition pakistan SUMMARY THE CONTEXT

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1 social protection and child malnutrition pakistan A challenging context SUMMARY Pakistan faces immense challenges when it comes to tackling malnutrition. Although the proportion of underweight children has remained constant over the past ten years or so, the proportion of stunted children has worsened. Levels of malnutrition among under-fives and pregnant women remain high. In addition to high levels of poverty and food insecurity, social and political factors, and floods, converge to create an inherently challenging context. Social protection programmes are now included in the government s poverty reduction strategy, along with social welfare programmes and human resources development, which include a focus on health and nutrition. For example, the flagship Benazir Income Support Programme (BISP) is an unconditional cash transfer programme. It delivers Rs1,000 (US$11) to female beneficiaries in households with a monthly income below Rs6,000 (US$64), and coverage is steadily expanding. The benefits of other cash assistance and employment programmes may include increased household expenditure on food. It is imperative that social protection programmes are linked to existing activities aimed at addressing malnutrition. For example, an explicit nutritional focus should be added to the BISP and other social transfer programmes. The coverage and size of cash transfer programmes should be increased, programmes should target mothers and babies to ensure nutritional benefits, and coverage of the Lady Health Workers (LHW) programme should be expanded to provide nutrition education in more communities. It is also important that social protection programmes aimed at addressing malnutrition are regionally appropriate. THE CONTEXT Social protection, and particularly social transfers, offers a way of addressing malnutrition by tackling the critical underlying cause of poverty. Stus have shown that additional income tends to be spent on food, especially when women are the recipients of the transfer, and that this increased spending can lead to a reduction in levels of malnutrition within the household. Additional income that is predictable and that households can rely on in the long term can also boost local food markets and economic activity, leading to sustained nutrition benefits and investment in human capital. 1 Along with micronutrient supplements and complementary activities to promote optimal nutrition practices, such as nutrition education workshops and the promotion of exclusive breastfeeding, social transfers are essential in ensuring that more households can afford a nutritious t. This is particularly the case in Pakistan, which faces immense challenges when it comes to malnutrition in the broader population and which is currently not on track to achieve the Millennium Development Goals on poverty, hunger and child mortality. Levels of malnutrition among under-fives and pregnant women in particular have remained high for years. About 43% of children have moderate to severe stunting and about 31% are moderately to severely underweight. Although the proportion of underweight children has remained constant over the past ten years or so, the proportion of stunted children has worsened. 2 Micronutrient deficiencies in iron, iodine, zinc and vitamin A are widespread, particularly among preschool children and pregnant women. 3 This situation has profound implications for these children in the present and for the future. Inadequate nutrition in young children has been linked to negative outcomes later in life: poor health, poor performance in school and reduced adult earnings. 4 Tackling malnutrition now is essential for the future achievement and life chances of these children. NO CHILD

2 The persistent prevalence of malnutrition occurs against a backdrop of a complex interplay of factors. Levels of poverty certainly play a key role, with about 22% of people in Pakistan living below the poverty line. 5 Food security in the wider country was also greatly affected by the floods, leaving many in particular regions unable to obtain enough food on a daily basis. In addition to high levels of poverty and food insecurity, social and political factors converge to create an inherently challenging context. Despite improvements in recent years, approximately a third of Pakistani mothers do not breastfeed exclusively for the first six months, and complementary feeding practices are not always adequate to ensure a healthy t. 6 Another important factor is that many mothers have missed out on education. Women with lower education levels tend to have larger families, with shorter periods between children, 7 and this reduces their ability to meet the nutritional needs of each child. A STEP FORWARD The government has been taking steps to improve understanding of nutrition, as well as to address the problem of malnutrition. Over the last decade, nutrition has been institutionalised in the government. It is included as a focus in planning documents such as the Economic Framework for and the National Health Policy, and in 2011 a comprehensive report on the current nutrition status of mothers and children was released. There remains considerable room for improvement. One positive policy development in recent years has been the increased commitment to social protection at both provincial and federal levels. Social protection programmes are now included in the government s poverty reduction strategy, along with social welfare programmes and human resources development, which include a focus on health and nutrition. 8 The first National Social Protection Strategy was adopted in 2007 and amounts allocated by the government for cash transfer programmes have been increasing since then. The objectives of social protection according to the strategy were to mitigate risk, reduce social inequity, build up assets and other redistributive interventions, and counter social exclusion and marginalisation, although in practice the emphasis has been on risk mitigation. 9 The government then launched the flagship Benazir Income Support Programme (BISP) in 2008 against the backdrop of the economic crisis and rising food prices. The BISP is an unconditional cash transfer programme that delivers Rs1,000 (US$11)to female beneficiaries in households with a monthly income below Rs6,000. Coverage has been steadily expanded since its launch. The ultimate aim is to reach 40% of the population living below the poverty line, which would be about 15% of the total population, and the programme in general is aimed at alleviating poverty and empowering women. 10 In 2010, about 7% of the population was benefiting from the transfers. 11 The BISP now also includes microcredit financial assistance, while health and life insurance coverage and vocational skills training are being piloted. Improvements have been made to the way in which recipients are identified. In addition to the BISP, other smaller social assistance schemes are in place at national level. The Zakat Programme was launched in 1980 and was originally funded through mandatory levies on Muslims. 12 This has since been changed, and contributions are now voluntary, which has led to a decline in funds available. 13 Beneficiaries are also Muslims, and the different programmes target widows, orphans, the disabled and the unemployed. Coverage is extremely limited, with only about 3% of households receiving some form of benefit. 14 The Pakistan Bait-ul-Mal provides financial assistance in the form of a wide range of schemes for specific groups, namely destitute widows, orphans, and disabled, needy and poor people. 15 These schemes do not have explicit nutritional objectives, although a pilot conditional cash transfer programme to families aimed at improving primary school attendance could have nutritional outcomes should the additional income be spent on food

3 In terms of social insurance, the Employees Old Age Benefits Institution (EOBI) ensures that workers receive cash benefits once retired, which has potentially important impacts for households as a whole. The amount allocated to this programme annually has been increasing and the number of beneficiaries has been rising, but pension schemes continue to benefit only a small portion of the population in the formal sector and cover less than 3% of the total employed labour force. 16 Peoples Works Programmes are aimed at providing employment and improving the quality of life in rural areas through the construction of roads, educational and health facilities, and sanitation, for example. In general, the effectiveness of social protection programmes in Pakistan has been compromised by small benefit amounts, irregular payments, weak governance and poor monitoring. 17 Specific problems entail a lack of synergy between different agencies and programmes, targeting flaws and leakages of funds, and lack of uniformity in terms of geographic coverage. 18 LIMITED NUTRITIONAL IMPACT The launch of the BISP was an important step towards the alleviation of poverty. Cash transfers that increase household incomes can lead to a reduction in the prevalence of malnutrition if they improve households ability to access more nutritious food. Stus have shown that purchasing food is one of the chief uses of the cash grant, and that women are also more likely to be the sole decision maker on the use of the cash. 19 Allocating cash to women in cash transfer schemes in other countries has been shown to have a greater likelihood of improving nutritional outcomes for the family as a whole. 20 In this sense, some nutritional impact can be expected, although this is severely limited by the size of the transfers. It is feasible that the EOBI could be improving nutrition within the household if the income is put towards the household food budget. Likewise, employment in Peoples Works Programmes and income from conditional cash transfers could have positive impacts by raising household income. In the light of the enormity of nutrition challenges, it is imperative that efforts be made to improve the nutritional impacts of social protection schemes. MOVING FORWARD: CHALLENGES AND OPPORTUNITIES Improving the nutritional impact of the BISP and other social transfer programmes While the BISP represents an important step forward in the attempt to alleviate poverty at national level, there is considerable room for achieving greater nutritional outcomes. This is especially the case as coverage of the programme continues to be scaled up. Two vital aspects here are transfer size and coverage. At minimum, it is vital that the size of the cash transfer is sufficient for households to meet their basic nutritional needs, especially in a context where food prices are rising. Stus have shown that even in regions where sufficient food is available, many households lack the income needed to buy sufficient food for a diverse nutritious t. In some regions, this income shortfall is particularly acute in certain seasons. 21 It is also important that the programme reaches those who are most in need large numbers of households continue to be excluded. Reaching all who are eligible is essential to maximise nutritional impacts

4 Adding an explicit nutritional focus to the BISP and other social transfer programmes There is no explicit nutrition objective in the BISP at present, a critical omission in the face of malnutrition levels. The government has raised the possibility of making BISP cash transfers conditional, and if this step is taken nutrition objectives could be considered as a function of this. Potential requirements are attendance at nutrition education sessions, growth and monitoring promotion with counselling, and the use of micronutrient supplementation. However, these need to be carefully considered in order to ensure that meeting requirements does not impose time costs on women, which could potentially lead to self-exclusion. It must also be acknowledged that mothers are not always the ones who make decisions about food, and that ways of reaching all members of the household need to be considered. Reaching mothers and babies to ensure maximum benefits The nine months of pregnancy and the first two years after birth are critical in terms of the growth and nutritional requirements of mothers and babies. One way to improve the nutritional impacts of cash transfers is to target pregnant women and children under two years. Considering supply-side factors and local provincial contexts Cash transfers that require women to use services or to attend nutrition education sessions are bound to be unsuccessful if these services are not available or are located too far away. Making cash transfers conditional in such circumstances can serve as a valuable impetus to improving the provision of primary health services, but can also make it impossible for some women to access the transfer. The provision of nutrition education can also be improved by increasing the number of trained LHWs and incorporating nutrition into their services. This is particularly relevant given higher levels of malnutrition in remote, rural areas. Maximising synergies with other nutrition interventions Success in tackling malnutrition is more likely when numerous interventions are simultaneously in place and the challenge is viewed holistically. 23 A sustained and multi-pronged approach is essential in the face of the challenge involved, and the inclusion of an explicit nutritional component in social protection measures cannot be regarded as a substitute for interventions in other areas. Increased incomes are less likely to lead to improved nutritional outcomes when there is food insecurity, for example. Nutrition interventions currently in place, such as the LHW programme and the fortification of food, should be expanded. Links to livelihood interventions, particularly for women, are also important. These can increase a household s income and therefore the ability to afford a nutritious t, and/or boost their production of nutritious foods that can be consumed at home. The possibility of exploiting synergistic links between these interventions and social protection measures needs to be prioritised. As responsibilities shift to the provinces following devolution it is also important that regionally appropriate social protection programmes aimed at addressing malnutrition are implemented. RECOMMENDATIONS IN BRIEF Increase coverage and transfer size of social transfer programmes Increase the explicit nutritional focus of social transfers where possible Maximise benefits by targeting mothers and children under two years of age Increase provision of complementary activities to improve understanding of nutrition - 4 -

5 Expand the coverage of Lady Health Workers, who can provide nutrition education in communities Link social protection programmes with existing activities aimed at addressing malnutrition NOTES 1 Save the Children(2012) A Chance to Grow: How social protection can tackle child malnutrition and promote economic opportunities 2 Aga Khan University (2011) National Nutrition Survey Pakistan 3 Government of Pakistan Planning Commission, Annual Plan , available at annualplan htm, accessed 4 May L Basset (2008) Can conditional cash transfer programs play a greater role in reducing child undernutrition?, SP Discussion Paper 0835, World Bank Aga Khan University (2011), see note 2 7 S Masood-us-Syed, S Muhammd and Z Butt (2011) Nutritional assessment of children under the age of sixty months in District Sialkot, Pakistan, The Journal of Pakistan Medical Students, 1, 1 8 Government of Pakistan Planning Commission, Annual Plan , available at annualplan htm, accessed 4 May H Gazdar (2011) Social Protection in Pakistan In the Midst of a Paradigm Shift?, CSP Research Report 13, Institute of Development Stus/Centre for Social Protection A Channa (2012) Background Paper Social Protection in Pakistan A Profile of Existing Programmes and an Assessment of Data Available for Analysis, Asia Research Centre, London School of Economics 12 N Kabeer, K Mumtaz and A Sayeed (2010) Beyond risk management: vulnerability, social protection and citizenship in Pakistan, Journal of International Development H Gazdar (2011) Social Protection in Pakistan In the Midst of a Paradigm Shift?, CSP Research Report 13, Institute of Development Stus/Centre for Social Protection 14 S Khan, and S Qutub (2010) The Benazir Income Support Programme and the Zakat Programme, London, ODI 15 UNICEF (2009) Social Protection in Asia A Review, Regional Office for South Asia (ROSA), July Ibid 17 C Mete, A Vermehren, I Malik and X Hou (2010) Building a Social Safety Net System in Pakistan, South Asia Sector for Human Development, World Bank 18 UNICEF (2009) Social Protection in Asia A Review, Regional Office for South Asia (ROSA) 19 USAID (2011) Final Monitoring Report Benazir Income Support Program (BISP), VTT Strategy and Management Consultants, L Basset (2008) Can conditional cash transfer programs play a greater role in reducing child undernutrition?, SP Discussion Paper 0835, World Bank 21 Save The Children (2011) Household Economy Approach: Livelihood Baseline Report and Assessing the cost of a nutritious t in Muzaffargarh, southern Punjab, Pakistan. Manuscripts available on request from 22 Save the Children (2012) A Chance to Grow: How social protection can tackle child malnutrition and promote economic opportunities 23 Ibid Written by: Tracy Swemmer and Deepta Chopra, Institute of Development Stus Photo: Jason Tanner/Save the Children Fazlam, who was widowed at 22, with one of her four children and the cow she bought with a cash grant. As well as improving the family s nutrition, she is hoping earn money by selling milk. 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

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