National social assistance programmes to improve child nutrition

• Significant progress is being made by governments in Eastern and Southern Africa to implement large-scale social assistance programmes.
• Examples from Burundi, Ethiopia and Tanzania show that combining cash transfers with ‘plus’ elements - such as social and behaviour change, livelihoods support and links to services - can help address the underlying determinants of child undernutrition, leading to nutrition impact.
• For programmes to contribute to national nutrition goals, scale-up and enhanced engagement of multiple sectors is required. 

In Eastern and Southern Africa, national governments, with the support of UNICEF, are piloting ‘cash plus’ programmes that target nutritionally vulnerable households with cash and additional services. These programmes aim to address multiple underlying causes of undernutrition by increasing household resources, as well as access to nutritious foods, uptake of positive nutrition practices and access to nutrition and other services.

Burundi  

Merankabandi is the Government of Burundi’s national social safety net programme. It began as a pilot scheme (2018-2022) that was implemented across four provinces and that targeted 56,090 poor and vulnerable households with children under 12 years of age. The programme included the following elements: 

• Unconditional electronic payments (USD 24) every two months for 30 months. 
• Community-based social behaviour change communication (SBCC) for caregivers to support the uptake of optimal nutrition practices. 
• Tented spaces with a handwashing device, kitchen gardens, cooking areas, playgrounds for children and latrines in each village.
• Sessions conducted by Community Agents on kitchen gardening, hygiene practices and cooking demonstrations.
• ‘Solidarity groups’ set up part way through the pilot, which met weekly to receive financial education. 

After three years, the results showed the following: 

• Improved access to healthcare, exclusive breastfeeding rates, availability of food for children, handwashing practices, joint household decision-making, household savings and birth registration. 
• Reduced prevalence of stunting for children under five years of age among participating households compared to non-participating households (53% vs 70%).  

Based on these findings, the project is being extended to 250,000 households in 18 provinces over five years. A key implementation challenge during the pilot was weak integration between different programme components. The Community Agent model was also expensive and time-consuming. In this next phase, instead of Community Agents, mothers enrolled in Merankabandi who engage in positive nutrition practices will be recruited to provide peer support.  

Ethiopia  

The Government of Ethiopia’s Productive Safety Net Programme (PSNP) currently targets 8 million poor rural households with cash or food assistance, either in exchange for public works or unconditionally (‘direct support’) where the household has limited labour capacity. Despite the fact that the design of PSNP IV (2015-2020) included nutrition-sensitive provisions, the results of an endline review found limited or no change in nutrition outcomes. This was largely attributed to poor programme performance (late and irregular transfers and low transfer value), as well as to the irregular implementation of nutrition provisions.  

The Integrated Basic Social Services with Social Cash Transfer programme (2016-2018) was implemented in four woredas. A case management approach was used to link direct support PSNP clients with an integrated package of services, including SBCC, health and nutrition services, and agricultural extension and livelihoods support. An endline evaluation revealed successful linkages between clients and services, but little impact on child nutrition outcomes. In areas receiving additional agricultural extension and livelihoods support some improvements occurred: for example, in household dietary diversity, food security and breastfeeding practices.  

Building on the lessons learned from the Integrated Basic Social Services with Social Cash Transfer programme, a five-year Integrated Safety Net Pilot was launched in 2019 in four woredas using a similar case management approach. Social work staff were recruited to provide more consistent individual case management, supported by a new digital information management system and improved enrolment and referral systems. Furthermore, nutrition-sensitive design provisions were integrated into the wider PSNP V, including the selection of nutrition-sensitive assets for public works projects, embedded case management and referrals to health and nutrition services, enhanced nutrition SBCC, the transfer of women from public works to ‘direct support’ during pregnancy until their child’s first birthday, the mobilisation of female ‘nutrition champions’, improved shock responsiveness, and the provision of childcare at public works sites.  

Tanzania  

The Productive Social Safety Net (PSSN) II programme (2020-2023) is the Government of Tanzania’s social assistance programme, targeting 1.2 million participants in poor households. Households with no labour capacity receive ‘direct support’, and those with labour capacity participate in public works. Households with children under the age of 18 also receive a variable cash transfer, conditional on their uptake of health, nutrition and education services. Households receive bi-monthly cash transfers of USD 5.30 and USD 24.10 per day, depending on how they fitted the eligibility criteria. 

The Stawisha Maisha Cash Plus programme (2018-19) was piloted in two districts to test the impact of delivering additional SBCC sessions on infant and young child feeding. Peer-led SBCC sessions were delivered to 10,837 caregivers/other household members at PSSN payment sites. An endline review showed acceptance of the approach, the integration of activities into the social protection workforce, and increased knowledge regarding infant and young child feeding. A key limitation was the use of written materials among a largely illiterate audience. Programme performance was also poor, with several missed payments due to funding shortages. Low coverage of services in some target areas also meant that it was impossible to link PSSN with services.  

A second version of the programme has been designed which includes increased frequency of group meetings within the community, improved targeting, improved SBCC materials and channels, and a stronger monitoring and evaluation system.  

• Cash plus programmes have the greatest potential for impact when social protection and nutrition colleagues work together, cash transfers are of adequate value, are regular and predictable, and are paid on time, and when ‘plus’ elements are delivered to the same population in tandem. 
• Delivering SBCC alongside cash transfers can ‘nudge’ vulnerable populations towards optimal child feeding and care practices. This is more likely to be effective when the target population has access to quality nutrition services and diverse foods.  
• A referral system for referring cash transfer participants to multiple services can increase access to, and uptake of, services. This will be most effective when clear referral pathways exist and when information systems are integrated or shared. 
• Cash plus programmes must be robustly monitored and evaluated to provide quality evidence.  

The country examples show that, if they intentionally include nutrition provisions within their design, social assistance programmes have the potential to address multiple barriers to optimal child nutrition. For these programmes to contribute to national nutrition goals, scale-up and enhanced engagement of multiple sectors is required. National social assistance programmes can go further by including scale-up mechanisms in response to shocks, and by linking with food systems interventions to improve access to nutrient-dense foods at all times. 

For more information, please contact Chloe Angood at cangood@unicef.org.