UNICEF - Building synergies between child nutrition and social protection to address malnutrition and poverty

UNICEF PROGRAMMING GUIDANCE Building synergies between child nutrition and social protection to address malnutrition and povertyAcknowledgements This guidance was developed in collaboration with the UNICEF Global Technical Teams for Child Nutrition and Development and Social Policy and Social Protection. It was informed by learning and practice in settings where UNICEF is already working to strengthen synergies between child nutrition and social protection. The guidance also reflects the learning from humanitarian and fragile contexts.

Lead Authors: Annalies Borrel, Chloe Angood and Tomoo Okubo Strategic Direction: Victor M. Aguayo and Natalia Winder-Rossi Technical research: Matthew Gibbs, Nikita White and Sarah Zahr.

Technical review: Aashima Garg, Andrea Rossi, Anuradha Narayan, Christiane Rudert, Claire Mariani, Cosma Giovanni Ezio Gabaglio, David Stewart, Deepika Sharma, Gabriele Erba, Jessica Owens, Jennifer Yablonski, Lauren Whitehead, Linda Shaker, Louisa Lippi, Megan Gayford, Nupur Kukrety, Paul Quarles Van Ufford, Rowena

Katherine Merritt, Tayllor Renee Spadafora, Zehra Rizvi and Zivai Murira. We would also like to thank the colleagues from headquarters and regional offices, particularly the Eastern and Southern Africa Regional Office (ESARO), Middle East and North Africa Regional Office (MENARO), West and Central Africa Regional Office (WCARO) and other UNICEF colleagues who provided strategic contributions toward the development of this guidance: Sara Rose Abdoulayi, Jennifer Asman, Ann Defraye, Enrique Delamónica, Minh Tram Le, Louisa Lippe, Wigdan Madani, Grainne Mairead Moloney, Louise Mwirigi, Simeon Nanama and Samman Thapa. Contributions were also gathered from interactions with colleagues from partner organizations, including Richard Chirchir and Sara Anderson (Development Pathways) and Shez Farooq (independent consultant).

Design: Nona Reuter (UNICEF); Editing: Julia D’Aloisio (UNICEF)

Thapa. Contributions were also gathered from interactions with colleagues from partner organizations, including Richard Chirchir and Sara Anderson (Development Pathways) and Shez Farooq (independent consultant).

Design: Nona Reuter (UNICEF); Editing: Julia D’Aloisio (UNICEF) Citation: United Nations Children’s Fund (UNICEF). Building synergies between child nutrition and social protection to address malnutrition and poverty. UNICEF Programme Guidance. UNICEF, New York, 2023.

© United Nations Children’s Fund (UNICEF) January 2024 Permission is required to reproduce any part of this publication. Permissions will be fully granted to educational or non-profit organizations.

Published by: UNICEF Nutrition and Child Development Section and Social Policy and Social Protection Section

Programme Group 3 United Nations Plaza New York, NY 10017, USA Email: nutrition@unicef.org www.unicef.org/nutrition; www.unicef.org/social-policy Photo credits: cover: © UNICEF/UN0841712/Dejongh; page 6: © UNICEF/UN0742468; page 8: © UNICEF/ UNI424556/Yegen; page 10: © UNICEF/UN0716667/Bidel; page: 14: © UNICEF/UN0791790/Mojtba Moawia Mahmoud; page 16: © UNICEF/UNI422598/Roisri; page 27: © UNICEF/UNI388994/Mussapp; page 32: UNICEF/ UN0832210/Quintero; page 36: © UNICEF/UNI423269/Mohamed; page © UNICEF/UNI273562/Hiller; page 43: © UNICEF/UN072426/Rfaat; backcover: © UNICEF/UN0844297/Izquierdo.UNICEF PROGRAMMING GUIDANCE Building synergies between child nutrition and social protection to address malnutrition and poverty4 CHILD NUTRITION AND SOCIAL PROTECTION Acronyms DHS Demographic and Health Survey

PROGRAMMING GUIDANCE Building synergies between child nutrition and social protection to address malnutrition and poverty4 CHILD NUTRITION AND SOCIAL PROTECTION Acronyms DHS Demographic and Health Survey FAO Food and Agriculture Organization of the United Nations GDP Gross domestic product HCT Humanitarian cash transfer CHNW Community Health and Nutrition Worker HSNP Hunger Safety Net Programme IASC Inter-agency Standing Committee IPC Integrated Phase Classification ISPA Inter-Agency Social Protection Assessment MEB Minimum expenditure basket MENARO Middle East and North Africa Regional Office MICS Multiple Indicator Cluster Survey NICHE Nutrition Improvements through Cash and Health Education NuVAC Nutrition Vulnerability Assessment in Fragile and Conflict Settings SBC Social and behaviour change SDGs Sustainable Development Goals SUN Scaling up Nutrition UNICEF United Nations Children’s Fund UNOCHA United Nations Office for the Coordination of Humanitarian Affairs WASH Water, sanitation and hygiene WFP World Food Programme WHO World Health OrganizationCHILD NUTRITION AND SOCIAL PROTECTION 5 Contents Section 1: Introduction 7

BACKGROUND 7

RATIONALE 8

PURPOSE, SCOPE AND STRUCTURE OF THIS GUIDANCE 9

Section 2: Framing the Guidance 11

DEFINING CHILD NUTRITION AND SOCIAL PROTECTION PROGRAMMES 11

PROGRAMME FRAMEWORK 12

PROGRAMMING PRINCIPLES 13

Section 3: Making it work in practice 15

EVIDENCE AND THE RELATIONSHIP BETWEEN POVERTY AND MALNUTRITION 16

Action 1: Collate and analyse data and evidence of the drivers of poverty and malnutrition and understand the relationship between them 16 Action 2: Map and analyse child nutrition and social protection policies, systems and programmes to identify opportunities for synergies. 18

POLICIES, GOVERNANCE, COORDINATION AND FINANCNG 19

Action 3: Support and advocate for mutually reinforcing commitments in policies and strengthen multisector stakeholder platforms that facilitate coordination 19 Action 4: Support governments to leverage public finance to ensure adequate,

and programmes to identify opportunities for synergies. 18

POLICIES, GOVERNANCE, COORDINATION AND FINANCNG 19

Action 3: Support and advocate for mutually reinforcing commitments in policies and strengthen multisector stakeholder platforms that facilitate coordination 19 Action 4: Support governments to leverage public finance to ensure adequate, efficient, and secure resources for child nutrition, social protection and the synergies between them 22

DESIGN AND SCOPE OF PROGRAMMING 23

Action 5: Design social transfers (cash, food, vouchers, school meals) to be nutrition-responsive 24 Action 7: Link to wider systems efforts for sustained food, nutrition and income security 32 Action 8: Make child nutrition and social protection programmes shock-responsive to mitigate increased poverty, vulnerability and prevent malnutrition 35

IMPLEMENTATION AND DELIVERY 37

Action 9: Strengthen local implementation capacities, including nutrition and social protection workforces and information systems 37

MONITORING, EVALUATION AND LEARNING 39

Action 10: Monitor, track, understand impact and learn, including for the purposes of scale-up 39 Annexes 43 Annex 1: Social protection and nutrition impact pathway 44 Annex 2: Country case studies 45 Annex 3: Resources 46

Endnotes 476 CHILD NUTRITION AND SOCIAL PROTECTIONCHILD NUTRITION AND SOCIAL PROTECTION 7

SECTION 1

Introduction BACKGROUND Important progress has been made to improve the situation of children globally. Over the last two decades, the proportion of children under 5 years of age suffering from stunted growth and development has fallen by one third (60 million).1 Poverty rates are also declining: the global poverty rate declined by 70 per cent between 2000 and 2019 and the proportion of children living in extreme poverty fell from 21 per cent to 16 per cent between 2013 and 2022.2,3 Despite these gains, the world remains off track to meet the ambitious Sustainable Development Goals (SDGs), specifically SDG 1 and SDG 2 to end

poverty fell from 21 per cent to 16 per cent between 2013 and 2022.2,3 Despite these gains, the world remains off track to meet the ambitious Sustainable Development Goals (SDGs), specifically SDG 1 and SDG 2 to end poverty and hunger by 2030. Today, children are twice as likely as adults to live in extreme poverty. One billion children are experiencing multidimensional poverty and approximately 1.7 billion children below the age of 18 years have no access to social protection.4 Almost 3.1 billion people globally are unable to afford a healthy diet and 202 million children are living in severe food poverty.1 Poverty and poor diets jeopardize children’s ability to grow and develop to their full potential and contributes to child malnutrition. Currently, an estimated 37 million children globally are overweight, 45 million children under 5 years of age suffer from wasting, and 148 million have stunted growth and development. Global shocks, such as conflict, climate change, rising food prices and global pandemics, are worsening existing inequalities and pushing even more children into poverty and malnutrition. Tackling child poverty and malnutrition requires a synergized approach between multiple systems. This document provides guidance on building synergies between child nutrition and social protection policies, systems and programmes to help address this challenge. Undernourished girl Undernourished mother Household poverty Low adult work capacity Reduced cognitive and physical development and low school attainment Reduced access to quality food, care and services Low birthweight infant Undernourished child Undernourished child $ The outer cycle describes the mutually reinforcing, multigenerational relationship between poverty and undernutrition. The inner cycle describes how undernourished mothers give birth to undernourished infants, which reinforces the

child Undernourished child $ The outer cycle describes the mutually reinforcing, multigenerational relationship between poverty and undernutrition. The inner cycle describes how undernourished mothers give birth to undernourished infants, which reinforces the generational impact of both undernutrition and poverty. Figure 1: The intergenerational cycle of child malnutrition and poverty8 CHILD NUTRITION AND SOCIAL PROTECTION RATIONALE Child malnutrition and poverty are inextricably linked and should be tackled together. Malnutrition in early childhood is both a cause and manifestation of poverty, and poverty is both a cause and consequence of malnutrition. The debilitating physical effects of malnutrition lead to children having poorer cognitive skills, fewer years of schooling, lower school attainment and reduced wages in adulthood, leading to increased probability of living in poverty.5, 6 In turn, poverty increases the risk of children becoming and remaining malnourished and of relapsing into malnutrition even after they have recovered.7 When crises hit, children in the poorest households are often the most affected by malnutrition, with lasting impacts into adulthood. The intergenerational cycle of poverty and malnutrition can persist for generations, as undernourished mothers are more likely to give birth to undernourished children and children born into poor households are at greater risk of being poor in adulthood (Figure 1). This cycle exacerbates existing inequalities and undermines the health, development and human capital of entire countries. The World Bank estimates that undernutrition is causing productivity losses that cost low-income countries between 3 and 16 per cent of their GDP each year.8 Delivering child nutrition and social protection programmes together can address child malnutrition and poverty. In addition to addressing child poverty, there is evidence, including from the Transfer Project, that social protection can improve children’s diets by removing economic barriers to nutritious foods, increasing access to

Delivering child nutrition and social protection programmes together can address child malnutrition and poverty. In addition to addressing child poverty, there is evidence, including from the Transfer Project, that social protection can improve children’s diets by removing economic barriers to nutritious foods, increasing access to nutrition services, and preventing negative coping behaviours.9,10 Well-designed cash transfers can improve child growth, reduce wasting and stunting and improve birthweight.11,12 Impact on child nutrition is enhanced when cash transfers are combined with evidence-based nutrition interventions to improve access to safe and nutritious foods, positive nutrition and care practices and essential child services.13,14,15,16 There is evidence that school meals, another form of social protection, can improve nutrition outcomes for school-age children and adolescents.17,18,19 These outcomes are enhanced when school meals are nutritious and combined with a broader set of essential nutrition services, such as micronutrient supplementation, deworming prophylaxis, food and nutrition education, and healthy food environments in and around schools.CHILD NUTRITION AND SOCIAL PROTECTION 9 Potential pathways of impact of combined child nutrition and social protection programmes are described in Annex 1 and have also been described by the Technical Assistance for Strengthening Capacities project and Research on Food Assistance for Nutritional Impact project. Delivering child nutrition and social protection programmes together is critical in humanitarian and fragile contexts. Shocks often exacerbate and deepen existing poverty and reinforce deprivations, including child malnutrition. Populations experiencing multiple, compounding and protracted crises find it difficult to recover, compounding the risk of chronic child malnutrition. The early expansion of child nutrition and social protection programmes together can help populations withstand shocks and prevent malnutrition and worsening poverty.20 Linked child nutrition and social protection responses can also prevent children from relapsing into wasting following recovery from wasting treatment.21 UNICEF is well placed to make a unique contribution to child nutrition and social

populations withstand shocks and prevent malnutrition and worsening poverty.20 Linked child nutrition and social protection responses can also prevent children from relapsing into wasting following recovery from wasting treatment.21 UNICEF is well placed to make a unique contribution to child nutrition and social protection programming. UNICEF is a global leader in advancing child rights and has unparalleled experience supporting nutrition and social protection systems in more than 130 countries, including in humanitarian and fragile contexts. Moreover, the UNICEF Nutrition Strategy 2020–2030 and the UNICEF Global Social Protection Programme Framework (2019) promote a systems approach that calls for strengthening synergies across child nutrition and social protection policies and programmes to realize children’s right to nutrition and social protection. In many countries, interventions are not currently addressing the underlying drivers of child poverty and malnutrition, including the financial barriers that families experience in making positive changes for child nutrition and development. UNICEF’s commitment to addressing these gaps is described in UNICEF’s position paper, Leveraging nutrition and social protection programming to address malnutrition and poverty including in fragile and humanitarian contexts (see Box 1). These commitments are relevant in all contexts, including in countries most affected by the food and nutrition crisis, as described in the UNICEF No Time to Waste Acceleration Plan for the Early Prevention, Detection and Treatment of Child Wasting (2022–2023). Box 1 Five priorities in UNICEF’s position paper

1. Build and enhance synergies between child nutrition and social protection policies and programmes at multiple levels.

2. Design integrated maternal and child nutrition and social protection programmes that are agile, fit-forpurpose and impactful.

3. Anticipate, maintain and scale up capacity for risk-informed child nutrition and social protection programmes in fragile and humanitarian contexts.

4. Strengthen implementation capacity to make these changes happen in practice.

5. Invest in gender-transformative programmes to

purpose and impactful.

3. Anticipate, maintain and scale up capacity for risk-informed child nutrition and social protection programmes in fragile and humanitarian contexts.

4. Strengthen implementation capacity to make these changes happen in practice.

5. Invest in gender-transformative programmes to achieve sustainable results in child nutrition and social protection.

PURPOSE, SCOPE AND STRUCTURE OF THIS GUIDANCE The purpose of this guidance is to assist UNICEF leaders, managers and programme staff to support governments in intentionally developing synergies between child nutrition and social protection within the relevant policies, systems and programmes to effectively and sustainably address child malnutrition and poverty. Actions and approaches to building synergies between child nutrition and social protection are context specific. However, evidence and practice allow us to propose a set of principles and a programme framework based around five entry points, described in Section II, and 10 actions across these entry points, which are described in Section III. All actions are potentially relevant in any context where child malnutrition and poverty coexist, including in humanitarian fragile and humanitarian contexts. This includes contexts with high burdens of child overweight and obesity where this is closely associated with child poverty22 and contexts experiencing a triple burden of child malnutrition (where stunting and wasting, micronutrient deficiencies and overweight and obesity exist concurrently). Practical examples of country actions are included throughout the document. Additional considerations are outlined for humanitarian and fragile contexts where government systems may be weak, overwhelmed or disrupted and therefore different approaches are needed.10 CHILD NUTRITION AND SOCIAL PROTECTIONCHILD NUTRITION AND SOCIAL PROTECTION 11 DEFINING CHILD NUTRITION AND SOCIAL PROTECTION PROGRAMMES UNICEF Child Nutrition programmes aim to prevent child malnutrition in all its forms across the life cycle. When efforts to prevent malnutrition fall short, UNICEF aims to ensure early detection and treatment of children suffering from life-threatening malnutrition. To achieve this, UNICEF leverages the potential of

UNICEF Child Nutrition programmes aim to prevent child malnutrition in all its forms across the life cycle. When efforts to prevent malnutrition fall short, UNICEF aims to ensure early detection and treatment of children suffering from life-threatening malnutrition. To achieve this, UNICEF leverages the potential of five systems – food, health, water and sanitation, education and social protection – to deliver nutritious diets, essential nutrition services and positive nutrition practices for children, adolescents and women everywhere. This is explained in the UNICEF Nutrition Strategy 2020–2030. UNICEF Social Protection supports policies and programmes that aim to prevent and protect all people against poverty, vulnerability and social exclusion throughout the life cycle, with a particular emphasis on the most vulnerable. Social protection programmes include social transfers (cash, food, other in-kind transfers and school meals), social insurance (such as health insurance), labour market policies (including family-friendly policies, such as paid parental leave and care services) and social welfare services and referrals provided by social service workforce. UNICEF promotes child-sensitive social protection systems, with an overall aim to address child poverty and promote child development, as outlined in the UNICEF 2019 Global Social Protection Programme Framework. Box 2 Terminology related to synergies Synergies refers to cooperative interaction between separate entities that creates an enhanced combined effect. Synergies is used as an overarching term in this guidance to describe both linkages and convergence Linkages refer to the general connections between systems, policies, programmes and services Convergence refers to the synergies that exist between programmes, interventions or services from multiple sectors when they are delivered to the same geographic area and/or the same households Both child nutrition and social protection programmes contribute to early childhood development. Early childhood development encompasses all of UNICEF’s programming for children in early life, bringing together multisectoral expertise to ensure that all children benefit from

geographic area and/or the same households Both child nutrition and social protection programmes contribute to early childhood development. Early childhood development encompasses all of UNICEF’s programming for children in early life, bringing together multisectoral expertise to ensure that all children benefit from policies, programmes and practices that protect, promote and support optimal nutrition, stimulation, learning, health, safety and security in early childhood, everywhere. This is described in Early Childhood Development: UNICEF’s vision for every child. An overview of the different terms and concepts used in this guidance to describe synergies between child nutrition and social protection are described in Box 2.

SECTION 2

Framing the Guidance12 CHILD NUTRITION AND SOCIAL PROTECTION Figure 2: Programme framework for building synergies between child nutrition and social protection programmes PROGRAMME FRAMEWORK UNICEF’s programme framework (Figure 2) describes how to intentionally build and strengthen synergies between child nutrition and social protection programmes to address child poverty and malnutrition. This guidance focuses primarily on social transfers, as this is the most common entry point for synergies between child nutrition and social protection. However, synergies within other parts of the social protection system are also promoted and explored, including social insurance (including health insurance), labour market policies (including family-friendly policies) and social welfare services workforce. Social transfers (cash, food, food vouchers and other inkind transfers) may be led and resourced by governments, partners, or both, and may exist at different levels of maturity, coverage and scale. In humanitarian contexts, cash is provided as a critical response for income support and stability. Humanitarian cash transfers (HCTs) may be delivered through national systems, or where systems are unavailable, ineffective or disrupted, HCTs may be delivered directly by UNICEF or partners, or delivered through a hybrid modality. Cash transfers combined with one or more complementary interventions are commonly referred to as ‘cash plus’

delivered through national systems, or where systems are unavailable, ineffective or disrupted, HCTs may be delivered directly by UNICEF or partners, or delivered through a hybrid modality. Cash transfers combined with one or more complementary interventions are commonly referred to as ‘cash plus’ programmes (Box 3). Cash plus programmes are often used as an entry point for delivering child nutrition and social protection programmes in synergy. This guidance builds on the concept of ‘cash plus’ and goes further to describe how synergies can be built between systems for sustained changes and impact at scale. This includes synergies between social protection and nutrition, including in the four systems of health, food, water and sanitation and education. Box 3 Definition of ‘cash plus’ programmes ’Cash plus’ interventions combine cash transfers with complementary interventions, including child nutrition interventions. 23 Complementary interventions can either be (i) provided as integral elements of the cash transfer intervention, such as additional benefits or in-kind transfers; information, counselling and support; and essential child services; or (ii) delivered externally to the cash transfer intervention by other sectors (including but not limited to child nutrition services) with explicit links with the cash transfer programme. All children reach their full potential Entry points for synergies

1. Evidence of poverty and malnutrition

2. Policy, governance, financing, coordination

3. Programme design

4. Implementation

5. Monitoring, evaluation and learning

1. Early childhood nutrition

2. Nutrition in middle childhood and adolescence

3. Maternal nutrition

4. Nutrition and care for children with wasting 5. maternal and child nutrition in humanitarian action

6. Partnerships and governance for nutrition

1. Expanding social protection coverage

2. Inclusive social protection

3. Shock-responsive social protection

4. Sustainable financing

SDG 1 & UNICEF Strategic Plan Goal Area 5 SDG 2 & UNICEF Strategic Plan Goal Area 1

nutrition

1. Expanding social protection coverage

2. Inclusive social protection

3. Shock-responsive social protection

4. Sustainable financing

SDG 1 & UNICEF Strategic Plan Goal Area 5 SDG 2 & UNICEF Strategic Plan Goal Area 1

Actions to improve: Social transfers Social insurance Labour Market Policies Social service workforce Actions across the food, health, water and sanitation, education, social protection

systems to improve: Food Practices Services Social protection result areas Reduced child poverty and vulnerablility Maternal and child nutrition Nutrition result areas Diets

CareCHILD NUTRITION AND SOCIAL PROTECTION 13

As shown in Figure 2, there are five entry points for synergies between child nutrition and social protection programming:

1. Collation and analysis of evidence to understand the relationship between poverty and malnutrition

2. Development of policies, governance, coordination structures and financing mechanisms

3. Planning, design and coordination of programmes that address both child poverty and malnutrition

4. Implementation capacity to support programme delivery, including staff and data systems

5. Monitoring, evaluation and learning to inform the improvement and scale-up of programmes.

To prevent child malnutrition and worsening poverty for households following shocks, child nutrition and social protection programmes must be shockresponsive through the timely scale-up of financing and programme delivery. This requires preparedness to ensure that systems are ready to scale and adapt ahead of a crisis, informed by early warning and surveillance. Shock response mechanisms are ideally built into national systems; but in contexts where national systems do not yet exist or are weak, humanitarian responses will likely be needed. PROGRAMMING PRINCIPLES Programming principles that underpin and inform the work to build synergies across child nutrition and social protection include: ƽContext specificity: Programmes are designed based on an analysis of the situation in terms of child nutrition, poverty and vulnerability to shocks; they are aligned with national priorities and build

Programming principles that underpin and inform the work to build synergies across child nutrition and social protection include: ƽContext specificity: Programmes are designed based on an analysis of the situation in terms of child nutrition, poverty and vulnerability to shocks; they are aligned with national priorities and build on existing synergies, platforms, structures and programmes. ƽPrevention first: Preventing child malnutrition and increased vulnerability are primary objectives, including for crisis-affected populations; but when prevention fails, services for the early detection and treatment of malnutrition are available. ƽInclusivity: Policies and programmes are inclusive of and aim to reach the most vulnerable, including women, girls, children with disabilities and children who are displaced or migrants. ƽGender-transformative: Policies and programmes explicitly respond to the differentiated needs of girls and women to tackle the underlying, root causes of gender inequality and foster girls’ and women’s empowerment. ƽPrioritizing greatest risk: Programmes reach children and women and adolescent girls during the most nutritionally vulnerable stages of the life cycle, such as the first 1,000 days from pregnancy to the child’s second birthday and during adolescence for girls. In crisis situations, the most nutrition insecure populations should be reached first. ƽSystems-strengthening: The capacity of national social protection and nutrition systems are built at national and decentralized levels to deliver services to vulnerable populations. Where parallel HCTs are needed, actions are taken to integrate and strengthen national systems wherever possible. ƽAnticipating and responding to shocks: Child nutrition and social protection programmes are designed to anticipate, prepare for, withstand and bounce back from shocks through risk-informed programming. ƽSustainability: Approaches seek to strengthen the capacity of institutions at national and subnational levels, promote sustainable financing mechanisms and address structural determinants of child malnutrition and poverty, including in fragile and humanitarian contexts.

bounce back from shocks through risk-informed programming. ƽSustainability: Approaches seek to strengthen the capacity of institutions at national and subnational levels, promote sustainable financing mechanisms and address structural determinants of child malnutrition and poverty, including in fragile and humanitarian contexts. ƽCollaboration at all stages of the programme cycle: Child nutrition and social protection sectors, ministries and partners deliberately collaborate and work together from the outset of the programme and during all stages of the programme cycle.14 CHILD NUTRITION AND SOCIAL PROTECTIONSECTION 3 Making it work in practice Action 1: Collate and analyse data and evidence of the drivers of child malnutrition and poverty and understand the relationship between them. Action 2: Map and analyse child nutrition and social protection policies, systems and programmes to identify opportunities for synergies. Action 3: Support and advocate for mutually reinforcing commitments in