Addressing malnutrition through nutrition-sensitive social protection


by Shamsul Alam 

December 19, 2017

The critical role of nutrition in cognitive development of the children highlights the importance of social protection measures. According to the World Bank, children between conception and age of 4, if undernourished, fall into the high risk zone of impaired cognitive development, and the likelihood of death of this group of children before the age of 5 is high. A child’s brain development in terms of vision, hearing, numeracy, language, emotional control and other cognitive factors are more sensitive in the early age of 0-4 followed by up to 4-7 years of age. As a result, productivity and growth is severely affected as children constitute the future human resource of the country. It is, therefore, of high importance to ensure proper level of nutrition in this age group. In Bangladesh, addressing malnutrition, especially for children, is being done by deepening both the schemes of poverty reduction and of social protection.

The very importance of nutrition intake of children has already been included in the policy-planning agenda of Bangladesh. The Perspective Plan (2010-2021) set the target of eliminating malnutrition by the year 2021. The 7th Five Plan also called for a number of actions to this end stating “proper attention will be given to the high rate of malnutrition among children and women”. The 7th Five Plan has sorted out some generic areas like awareness building, enhancement of food value, provision for food diversity etc. Major actions include: iron-folic acid supplementation among pregnant, lactating women; implementing national strategy for infant and young child feeding; continuation of half-yearly vitamin A capsules distribution for children; scaling up Post-partum Vitamin-A distribution to improve vitamin A status of neonates through breast milk; and reinforced monitoring of salt iodisation. Also, the 7th Plan recognises increasing efforts for nutrition-sensitive social protection in upcoming years. Social Protection has a very obvious role to play in achieving SDG 2, to “end hunger, achieve food security and improved nutrition”.

A major objective of the National Social Protection Strategy (NSSS) is to encourage the existing social protection programmes which usually allow protection against food price volatility and to balanced consumption when households face hardship and shocks. This is done by either food transfers or food purchase at subsidised prices on the one hand and by cash transfers that improve poor households’ access to food on the other hand.

It is well known that cash transfers increase income in beneficiary households, which, in turn, allows households to purchase more and better food items and increases food security and diet quality of all family members. Giving cash transfers to women may increase women’s control over resources, women’s empowerment, and their decision-making power relative to child nutrition and health.

Nutrition and health education, usually targeted at women, may change households’ preferences for nutrient-rich foods, shift the intra-household allocation of foods in favour of children, may lead to improved care-giving practices, and may improve household practices related to water and sanitation and improve child health. NSSS has proposed a ground-breaking scheme known as the Child Benefit providing a transfer to all children aged 0-4 years belonging to the poor and vulnerable group. The programme will provide a monthly transfer to each child that will be paid to the mother or female care-giver. To this end, the Ministry of Women & Children Affairs (MoWCA) has submitted a draft investment plan for their existing Social Security programmes proposing some reforms within those programmes.

Programmes that include micronutrient supplements directly improve the micronutrient status and overall nutritional status of children. Improved child diets are further reinforced by the additional household income and women’s empowerment. Cash transfers can contribute to increased and informed household demand for healthcare services. To be effective, such increased demand needs to be combined with improved quality and capacity of the health supply. Programme conditions to enrol school-age children in school can have long-term, intergenerational effects on nutrition through the well-documented pathway that links female education and positive child nutrition and health outcomes. In the current social protection portfolio programmes like National Nutrition Services and Support to the Urban Health and Nutrition to the Urban Bangladesh are playing critical role in addition to programmes directed to women empowerment e.g. Increase Productivity and Opportunity for Employment for Women (SWAPNO).

Malnutrition statistics of Bangladesh provide added importance to nutrition issue. Food and Agriculture Organisation (FAO) has placed Bangladesh’s malnutrition rates among the highest in the world despite the country’s success in continuously reducing the prevalence of underweight, stunting, and wasting children during the MDG period. With this end in view, the government has been continuing installation of nutrition sensitivity programmes in existing social protection schemes. Typically, nutrition sensitivity in social protection schemes requires three important aspects: foetal stage support, support for young children, and support for adolescents. Thus, it has the potential for solving intergenerational poverty in a country. The existing social protection schemes in Bangladesh are centred on access to food, food security, and diet diversity. Presently, a number of programmes are being implemented to ensure this such as Open Market Sales (OMS), Vulnerable Group Feeding (VGF), and Food friendly Program.

In order to ensure food security to the rural poor the government has initiated a programme of OMS of rice at BDT 10/Kg for rural people. The following Table reveals the changing undernourishment situation in Bangladesh.

In Bangladesh, the government is running social protection schemes to cover nutritional development of the children, and reducing their risk and vulnerabilities over time. Cash for Work and school stipend programme for females (6-16 years of age), which are conditional cash transfer programmes in nature, are destined for ensuring food security for children. Under School Feeding Programme for the primary level students has a coverage of 2.5 million. Cash has been transferred unconditionally under maternity allowance programme (coverage 6 hundred thousand) and support to lactating mothers (coverage: 2 hundred thousand) expecting that nutrients will be supplied to neo-natals and new-born for 1000 days between women’s pregnancy and their children’s second birthday. Vulnerable Group Development (VGD) bears the same potential for nutritional arrangement and dietary diversity for the children through their mothers by way of cash transfers. The government has already started introducing fortified rice distribution, a cash grant for vulnerable women and nutrition in its VGD programme. Another type of social protection programmes relates to providing services (visits to the incumbents) under broad-based livelihood programmes. Examples are Maternal, Neonatal, Child and Adolescent Health; National Nutrition Service etc. The Ministry of Agriculture provides extension services for different crops fortified with nutrition elements, newly developed by research institutes of Bangladesh. A new variety of rice namely, ‘Golden Rice’, fortified with beta carotene as Vitamin A supplement is a major achievement, which are being extended in suitable areas. All these schemes are designed in response to National Nutrition Policy 2015.

National Nutrition Policy 2015, with a vision that the people of Bangladesh will attain healthy and productive lives through gaining expected nutrition, has the following objectives: improve the nutrition status of all citizens, including children, adolescent girls, pregnant women and lactating mothers; ensure availability of adequate, diversified, and quality safe food and promote healthy feeding practices; strengthening nutrition-specific, or direct nutrition interventions; strengthening nutrition-sensitive, or indirect nutrition interventions; and Strengthen multi-sectoral programmes and increase coordination among sectors to ensure improved nutrition.

Apart from the social protection schemes mentioned above, the government is also considering bringing up new schemes for using nutrition sensitivity that would have an impact on reducing intergenerational poverty, risk and vulnerabilities. The NSSS proposes introduction of a new social protection programme, Child Benefit Scheme (CBS) that will target children of age group 0-4. The allowance will be disbursed to female parents preferentially. It is estimated that 50 per cent of children from 0 to 4 years of age will be brought under the new programme. Thus the number of beneficiary children is estimated to be around 7.5 million. The benefit per child of this age cohort is recommended to be Tk. 500 per month. According to the spirit of the NSSS, the Ministry of Women and Children Affairs is working on the preparation of a detailed implementation plan. In this process, cash transfer would be extended for the children of age 5 gradually.

Looking at the figures of over 2016-17 and 2017-18, the existing public investment on nutrition-sensitive social protection seems to be low-around 1.3 per cent of the total budget when the public investment on social protection schemes is around 13 per cent over the two financial years. As long as nutrition-sensitive social protection schemes reduce intergenerational poverty, investment on the related schemes should be increased. Another argument in favour of increased social protection for the children in Bangladesh lies in the fact that the event of breastfeeding of the children below age of six months is considerably low and between 6-23 months of their age they do not have the access to complementary diet.

Child nutrition is viewed as a fundamental human right according to the Constitution of Bangladesh. Encouraging the expansion of nutrition-sensitive social protection in Bangladesh needs more positive thinking. Malnutrition and poverty both are widespread, and therefore the ultimate aim for Bangladesh should be universal coverage. In the short term, inequalities in chronic malnutrition (stunting) should be addressed by greater inclusion of worst-affected groups in social protection coverage, for example, adolescent girls and pregnant and lactating women. Thus it requires incorporation of gender issues into social protection programmes for multiple gains. Critical areas are, women’s empowerment, and sensitisation on nutrition and the 1,000-days approach for men as well. A child’s health is intimately linked with the mother at the pregnancy stage. The government wants to build on the positive experiences of the Maternal Health Voucher Scheme (MHVS) and expand coverage to all women who need this service, undertaking it in a phased manner based on effectiveness of the scheme. Also, the government plans to integrate a mechanism for providing all new mothers with maternity insurance within a new National Social Insurance Scheme (NSIS). Another point to make is that complementary diet is required for the growth of children. Breastfeeding is not enough.

Nutrition must be integrated across activities of all ministries in Bangladesh. This is not just the responsibility of a single ministry. The role of the respective ministries ranges from allocation, disbursement, management, and monitoring and evaluation of the schemes. A better coordination may be done in the Social Allowance Cluster of the NSSS implementation.  Also, it is to continue the implementation of the National Nutrition Services (NNS) Operational Plan managed by the Ministry of Health and Family Welfare. This is also important to establish and fund national nutrition information systems to track and monitor impact and results of nutrition programmes as well as provide real time information to guide decision making, including budgetary supports.

Nutrition is not only a matter of food; largely it is a matter of health also.  Health & family welfare programmes on sanitation and primary healthcare are pertinent activities in this regard. Social Protection has a very obvious role to play in achieving SDG 2, to “end hunger, achieve food security and improved nutrition”. SDG action plan of the Ministry of Agriculture, Ministry of Food, and Ministry of Health & Family Welfare if properly implemented could also be instrumental in achieving nutrition targets of Bangladesh as they have proposed a number of projects that have nutrition implications. Finally, awareness building through education (school stipends as social protection) plays a vital role.

Dr. Shamsul Alam is Member (Senior Secretary), General Economics Division, Bangladesh Planning Commission. This is Keynote Speech at the inaugural session of Technical Symposium on Nutrition Sensitive Social Protection in Bangladesh, organised jointly  by Food and Agricultural Organisation (FAO), Save the Children Fund, Unicef, World Food Programme, IFRI, USAID and EU in Dhaka, December4-5, 2017. [email protected] 


The article appeared in The Financial Times on December 11, 2017