Baxnaano: Integrating social protection, health, and nutrition in Somalia

What we know: Recurrent and protracted crises have affected Somalia for over 30 years and resulted in widespread poverty and food insecurity. Social protection programmes can reduce poverty and vulnerability to shocks and stresses. Integrating health and nutrition conditionalities is known to generate positive impacts on uptake of services and nutrition-related outcomes.

What this adds: This article describes the development of Somalia’s first national social protection platform, and discusses the challenges, lessons learned, and subsequent adaptations. To address the challenge of low uptake of services in particular, a pilot health and nutrition conditional cash transfer is to be provided in areas of well-supported integrated health and nutrition programmes.

Protracted conflict and cycles of droughts and floods have afflicted Somalia for over 30 years (Ullán de la Rosa & Arrey, 2021). This has triggered a humanitarian crisis and has led to widespread poverty and food insecurity (Pape & Karamba, 2019). Nearly 70% of Somalia’s population lives in poverty, with 4.3 million people in need of urgent humanitarian assistance in 2023 (IPC, 2023). An estimated 1.5 million children under five years of age are facing wasting, with 331,000 experiencing severe wasting. The combined impact of conflict, natural disasters, and limited availability of basic services is eroding household resilience to future shocks, reducing the chances of future generations breaking free from this cycle of poverty and vulnerability.

To alleviate poverty, push economic revival, and engender societal transformation, in 2019 the federal government collaborated with the World Bank, UN, and other development partners to launch its first national social protection platform – Baxnaano (which translates to “uplifting”).

Baxnaano, which is housed at the Ministry of Labor and Social Affairs (MoLSA), has enabled the federal government to provide safety net support to the country’s poorest people and respond to the impact of climate-related shocks. It operates with the full engagement of Federal Member States (FMS) authorities, in collaboration with humanitarian and development partners involved in social protection across the country. The national platform continues to evolve with the vision of empowering the poor and vulnerable beyond simple cash assistance. Baxnaano provides support through two current programmes (Regular and Shock Response) and will launch a third programme (Economic Inclusion) in November 2024. Baxnaano will also pilot an additional health and nutrition conditional cash transfer from July/August 2024.

The Baxnaano Regular Programme is a long-term, unconditional cash transfer programme. It aims to address chronic poverty and food insecurity, build resilience, and enhance the human capital of recipient households. As part of the programme, beneficiaries are provided with information on available health and nutrition services and encouraged to seek care as needed. The programme routinely covers 200,000 poor and vulnerable households with pregnant and breastfeeding women and/or children under five years in 25 districts across all FMS and Somaliland. A total of USD 20 per month is provided to each beneficiary household over a period of three years. After the standard three years, beneficiary households must undergo recertification regarding eligibility for continued support. 

The Baxnaano Shock Response Programme is a short-term, unconditional emergency cash transfer programme that aims to smooth food consumption and protect human life. The programme also aims to protect the physical assets of poor and vulnerable households in the aftermath of shocks, thus enabling recovery. The programme covers 668,000 households affected by shocks (338,000 drought-affected households, 260,000 locust-affected households, and 70,000 flood-affected households). A total of USD 60 per month is provided to shock-affected households for a period of six months.

The Baxnaano Economic Inclusion Programme will aim to enhance the economic inclusion of poor and vulnerable youth (including women) in urban and rural areas. Under this programme, the government will launch a pilot to test labour market interventions for 1,000 youth and women by November 2024. The interventions will focus on improving employability and supporting job creation by providing life skills training, technical skills training with a formal training provider or a master craftsman, business development services, labour intermediation, stipends, and grants.

MoLSA engaged the World Food Programme in 2019 to support the field implementation of the Regular and Shock Response programmes. As government social protection systems are becoming available, implementation arrangements are transitioning from UN assisted to direct government implementation modalities. The health and nutrition cash transfer pilot will be entirely government implemented in the Banadir region, which includes the capital city, Mogadishu.

A key challenge experienced during the design phase of Baxnaano was a lack of an existing government-led structure to bring together humanitarian partners involved in cash assistance programmes. For example, many partners maintain their own separate lists of beneficiaries, raising concerns surrounding effectiveness, duplication, and targeting. To this end, MoLSA is building capacity to consolidate social protection programmes by encouraging the use of Baxnaano’s new targeting and delivery systems including the Unified Social Registry (USR) and the government’s payment mechanism. The use of common systems will greatly improve coordination, transparency, and efficiency, while allowing different agencies the flexibility to respond to varying priorities.

Another challenge faced during implementation was the nascent government capacity and weak systems present in the country (particularly those still under Al-Shabaab control). Low uptake of available services and an extremely limited supply of nutrition and health services is an additional hurdle. Additionally, limited quality education, water, sanitation, and hygiene services, as well as limited employment and skill development opportunities, persist. To overcome these challenges within the social protection sector, MoLSA leveraged the UN to support an initial launch of life-saving social protection interventions, while simultaneously building key national social protection systems. This has led to a gradual transition to government implementation and the introduction of more complex social protection interventions, including conditional cash transfers and economic inclusion. To address the limited availability of basic services, the government is leveraging support provided by international development partners to implement health programmes through the UN and civil society.

In Somalia, where protracted conflict, recurrent shocks, and the provision of cash transfers for an extended duration are common, concerns regarding dependency and reduced labour market participation often emerge. In line with evidence (Bastagli et al., 2016), for Baxnaano these concerns are avoided through small, frequent, and reliable unconditional cash transfers provided over a longer time horizon, combined with conditional cash transfer top-ups for vulnerable households. These transfers are provided through digital payments to beneficiaries’ mobile wallets to ensure transparency and reliability. 

Limited data availability remains a persistent challenge for Baxnaano and other social protection programmes that target the poor. To address the data gap, MoLSA has developed key social protection information systems – such as the USR and the Baxnaano Management Information System. The USR collects socioeconomic data to enable dynamic data sharing among potential stakeholders and objective data-driven targeting of pro-poor programmes. Looking ahead, the government plans to launch a National Socio-Economic Survey to collect USR data from all accessible households in Somalia by November 2024. All 1.88 million accessible households in Somalia (excluding Somaliland) are expected to be covered in the survey. 

In Somalia, the importance of leveraging UN capacities and local non-governmental organisations to implement social protection interventions, under government leadership, was important. This is true of all fragile, conflict-affected, or violence-affected contexts. As these programmes are launched with support from development partners, it is also critical to concurrently build government systems and capacities to ensure sustainability. A transition from UN to government implementation is possible once key policy principles – such as ‘do no harm’, data protection and privacy, and inclusive systems – are adhered to. Despite this, it remains important to focus on the end goal of eventually transferring ownership to the government, ensuring that short-term interventions do not become a protracted situation.

Another lesson is the importance of starting with simple interventions and gradually moving towards more complex and diversified social protection programmes in fragile contexts. In the case of Baxnaano, a roadmap was used to develop a government-led social protection programme. The unconditional cash transfer was initially launched, followed by shock response emergency cash transfers, now leading to more complex interventions such as the health and nutrition conditional cash transfer described below. 

The first 1,000 days in a child’s life are critical for growth and development (Likhar & Patil 2022). A child’s ability to develop, grow, learn, and thrive are significantly impacted by the extent to which mother and child are appropriately fed and cared for throughout this period. This window of opportunity is affected by the pregnant mother’s health, diet, and stress levels. After birth, the child’s environment, health, diet, and care practices are key factors. To improve maternal and child health and nutrition outcomes, Baxnaano plans to implement a Health and Nutrition Co-Responsibility Cash Transfer (H&N CCT) targeted to the poorest 20% households in selected areas of Banadir.

Low uptake and utilisation of nutrition and health services is an issue experienced across Somalia, including under Baxnaano’s regular programme. The regular programme prioritises targeting of poor households with pregnant women and mothers of children aged 0–5 years. Although beneficiaries are encouraged to visit health facilities and access health and nutrition services, programme monitoring data revealed few beneficiaries have actually done so. The H&N CCT seeks to overcome this challenge and encourage uptake of nutrition and health services by introducing co-responsibilities (conditions) before beneficiaries are eligible to receive cash transfers. To address supply-side challenges and create demand, the new H&N CCT will leverage existing health programmes financed by international development partners, such as Damal Caafimaad (World Bank supported) and Better Lives (UK aid supported). These programmes are improving access to health facilities, capacity of health staff, and availability of high-impact services – such as antenatal care, postnatal care, facility births, immunisation, supplementation, and treatment for acute respiratory and gastrointestinal infections. 

The H&N CCT – Wasiila Caafimaad, in Somali – will target 16,000 pregnant and breastfeeding mothers, and children aged under two years in District Daynile of the Banadir region. Beneficiaries will be the poorest 20% of households from District Daynile. Eligible women will be enrolled and participate in the programme during pregnancy, up to the point their child reaches two years of age. Health and nutrition interventions will include antenatal and postnatal care, maternal and child immunisations, health and nutrition awareness sessions, micronutrient supplementation, growth monitoring, and wasting treatment, where appropriate. All interventions will be carried out at Baxnaano facilitation centres, established in health facilities. These health facilities are supported by existing health and nutrition programmes. Figure 1 outlines the process flow and interventions for the H&N CCT.

A total of USD 30 will be provided to these women upon attending a health awareness session on a quarterly basis. The health awareness session acts as a key behaviour change communication instrument, encouraging beneficiaries to use available services. The payment is both an incentive for mothers to adhere to the programme and a vehicle for improving nutrition security – as mothers can utilise these funds to purchase food and other items. The payment is designed as a top-up to any other support being received by targeted households, including from social protection or humanitarian programmes.

MoLSA and the Ministry of Health are responsible for the coordination and implementation of the pilot. Continuous support and collaboration will be provided by the respective FMS and district health authorities, UN agencies, and other international development partners. 

Figure 1: Process flow for Baxnaano’s H&N CCT

The key outcome expected from the H&N CCT is an increased uptake of an essential package of health and nutrition services. The increased uptake may result in reduced risk of low birthweight, improved vaccination rates, reduced risk of anaemia and micronutrient deficiencies among pregnant and breastfeeding mothers and children, and reduced risk of maternal and child morbidities. Pilot outcomes will be assessed through an impact evaluation, consisting of a baseline and an endline survey. Data from the Baxnaano Management Information System, government and third-party spot checks, and process evaluations (questionnaires, focus group discussions, and key informant interviews) carried out by a third-party monitoring firm will be used to monitor the H&N CCT. Programmatic data on the H&N CCT will be available starting in November 2024.

Baxnaano has been able to reach 200,000 of the poorest and most vulnerable households, with 100% being female beneficiaries since its inception in 2019. Approximately US$ 500 million has been dispersed to beneficiaries across the country. Most recent estimates from the regular programme indicate that the cash transfers are being primarily used for purchasing food (99%), purchasing clothing and other household items (52%), accessing healthcare (49%), repaying debts (44%), and paying educational fees (38%). Moving forward, MoLSA and the World Bank will continue to invest in developing human capital through social protection interventions and systems that redistribute income to the poor, reduce poverty, build human capital, and improve labour market outcomes. 

The H&N CCT builds on lessons learned, increasing the nutrition sensitivity of the existing programme. If the pilot is successful, the government plans to expand the H&N CCT to all districts where supply-side interventions are being made available through Damal Caafimaad. MoLSA is therefore:

“Focused on the transition toward a longer-term development agenda, which builds the government’s capacity to implement its own social protection programmes. This is key to ensuring sustainability, inclusivity, efficiency, and transparency. Our new H&N CCT initiative is the first of its kind and will support the government’s vision to build the human capital of our citizens and bring sustainable economic growth in Somalia.” – Yussuf Hassan Isaak, Director General, MoLSA

For more information, please contact Fardosa Ahmed Abdullahi at fardosa@molsa.gov.so

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