Malnutrition in Bangladesh

malnutrition in bangladesh

Harnessing social protection for the most vulnerable

Cover photo: Forija, 26, holds the youngest of her six children, many of whom suffer from malnutrition, Poilarkandi, Habiganj district, Bangladesh. Photo: Abir Abdullah/Save the Children

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Acknowledgements This report was written by Katherine Richards, with support from Save the Children colleagues Nicola Hypher, Julie Newton and Marie Rumsby. Particular recognition should be given to Grace Kite for her work on the data analysis; to James Manley and Vanya Slavchevska for their work on the literature review; and to Karda Rolland-Berge for her work on governance. Many individuals from a wide range of organisations in Bangladesh and internationally gave valuable time to tell us about their plans and experiences with nutrition-sensitive social protection. Many people contributed to this report by reviewing the research, sharing insights on the contextual analysis, and providing practical advice on tangible solutions to shape our recommendations. We are extremely grateful for all of these contributions. Particular thanks go to the Civil Society Alliance for Scaling Up Nutrition Bangladesh Secretariat and Executive Committee, to Edwyn Shiell and Mary Manandha of UN REACH, Bangladesh, and to Patrizia Fracassi at the SUN Secretariat for providing material and contacts as well as reviewing the report. This report has also been greatly enriched by comments from Nick Nesbit of Transform Nutrition and Richard Morgan and Jose Manuel Roche of Save the Children.

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First published 2015

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Typeset by Grasshopper Design Company Printed by Page Bros Ltd contents

Abbreviations and acronyms vi

Key terms vii

Executive summary viii

1 Introduction 1 An opportunity 2 Overview of the report 3

PART 1 5

2 The underlying causes of malnutrition in Bangladesh 6 1 Household food security 6 2 Caring practices for women and children 6 3 Health environment and services 7

3 Social protection and nutrition 8 Definitions 8 How social protection helps tackle hunger and malnutrition 9 The critical first 1,000 days 10 A high return on investment 11 part 2 13 4 Nutrition impacts: the potential of social protection for nutrition in Bangladesh 14 Learning from existing social protection programmes in Bangladesh 14 Understanding the nutrition pathways: what matters for improving nutritional status? 16 Poverty, inequality and nutrition 19

4.1 Nutrition pathway: household food security 22 The key drivers of malnutrition in Bangladesh 22 The impact of social protection on household food security 26 Implications for nutrition-sensitive social protection in Bangladesh 27

4.2 Nutrition pathway: caring practices for women and children 28 The key drivers of malnutrition in Bangladesh 28 The impact of social protection on caring practices for women and children 32 Implications for nutrition-sensitive social protection in Bangladesh 35 iv malnutrition in bangladesh

8 7 6 part 5

Im Th In 5. Im Ba Divis We Po Im Go Im Th Th 4. Im Un Yo Hi Wh Ar Governance and politics – the driving force driving –the politics Governance and nee protection social does what inBangladesh: Malnutrition Design implications for nutrition-sensitive social protection social for nutrition-sensitive implications Design inBangladesh protection social Nutrition-sensitive So In Nu Ex Le So 4.2.1 Wh B Is Im Nu Th ternational designternational principles for social nutrition-sensitive protection tegrating a nutrition focus within social protection social within focus anutrition tegrating 1 3 gh levels of stunting at birth at birth levels stunting of gh ssons on governance ngladesh’s progress on malnutrition compared to other countries other to compared ngladesh’s malnutrition on progress cial protection systems protection cial me key debates: use of transfers, economic gains, dependency dependency gains, economic transfers, of use keyme debates: plications for nutrition-sensitive social protection in Bangladesh in protection social for nutrition-sensitive plications istence of complementary services complementary of istence plications for nutrition-sensitive social protection in Bangladesh Bangladesh in protection social for nutrition-sensitive plications plications for nutrition-sensitive social protection in Bangladesh in protection social for nutrition-sensitive plications Bangladesh in protection social for nutrition-sensitive plications plications for nutrition-sensitive social protection in Bangladesh in protection social for nutrition-sensitive plications plications for nutrition-sensitive social protection in Bangladesh in protection social for nutrition-sensitive plications licy implications licy e inequalities widening or narrowing? or widening e inequalities ung mothers and child marriage child and mothers ung e impact of rapid urbanisation on malnutrition in Bangladesh Bangladesh in malnutrition on urbanisation rapid of e impact e impact of social protection on the health environment and services and environment health the on protection social of e impact Bangladesh in e key malnutrition of drivers e development of social protection in Bangladesh in protection social of e development dernutrition among pregnantdernutrition women vernance in Bangladesh in vernance trition-related services in Bangladesh Bangladesh in services trition-related

trition and the National Social Security Strategy Security Social National the and trition

alth inequalities inequalities alth angladesh on target to halve stunting by 2030? by 2030? stunting halve to target on angladesh y 1,000 days and women’s empowerment are critical for nutrition in Bangladesh Bangladesh in for nutrition women’s daysand are critical y 1,000 empowerment ich groups are furthest behind? behind? are furthest groups ich Sp 3 Nu ional inequalities

d to address? d to Sp ecial focus: urbanisation focus: ecial

trition pathway: health environment and services and environment health pathway: trition ecial focus: child marriage, young mothers and stunting at birth at stunting and mothers young marriage, child focus: ecial

64 40 48 48 77 68 68 46 38 45 50 73 56 36 56 36 42 78 75 75 55 43 43 70 70 70 53 62 62 59 37 47 47 81 74 74 61 51 contents v 93 97 87 83 92 82 82 82 82 85 86 84 84 84 88

clusions Bangladesh for development of nutrition-sensitive social protection internationally protection nutrition-sensitive social of development rld Health Assembly Global Targets SCN Social Protection and Food Security recommendations velopment agendavelopment commendations policy-makersfor and programme implementers in Bangladesh commendations thefor National Social Security Strategy of Bangladesh commendations specificfor groups st-2015 – Developing the Sustainablest-2015 Development Goals O Recommendation 202: Social protection floors Wo Po IL UN Overall conclusions and recommendations Social protection and nutrition on the global de The Con Re Re Re

Notes Appendix C: references Literature review Appendix B: Programmes included in literature review Appendix A: Nutrition-sensitive social protection checklist 10 9

h Abbreviations and

anglades acronyms b

n i n io t i BCC Behaviour change communication BDT Bangladeshi taka

malnutr BMI Body mass index CCT Conditional cash transfer CLP Chars Livelihoods Programme CSA Civil Society Alliance DHS Demographic and Health Surveys EGP Employment Generation Programme FSNSP Food Security Nutritional Surveillance Project GDP Gross domestic product GoB Government of Bangladesh GR Gratuitous Relief GRID Groups and Inequality Database HIES Household Income and Expenditure Survey ICDS Integrated Child Development Services IFPRI International Food Policy Research Institute ILO International Labour Organization JoJ Jibon-O-Jibika MDG Millennium Development Goal MDG/F Millennium Development Goal/Fund MUAC Mid-upper arm circumference NGO Non-governmental organisation NIPORT National Institute of Population Research and Training NNS National Nutrition Services NSSS National Social Security Strategy OMS Open Market Sale SDGs Sustainable Development Goals SPRING Strengthening Partnerships, Results, and Innovations in Nutrition Globally SUN Scaling Up Nutrition TR Test Relief TUP Targeting the Ultra Poor UN United Nations UNICEF United Nations Children’s Fund VGD Vulnerable Group Development VGF Vulnerable Group Feeding WASH Water, sanitation and hygiene WHO World Health Organization vi Key terms

1,000-day window Nutrition-sensitive interventions The 1,000-day period between a woman’s pregnancy Nutrition-sensitive interventions target the and her child’s second birthday. The right nutrition underlying determinants of nutrition, affecting the during this critical period can have a profound broader context of life and health, and enhancing impact on a child’s ability to grow, learn and rise out the coverage and effectiveness of nutrition-specific of poverty. It can also shape a society’s long-term interventions.4 Nutrition-sensitive interventions that health, stability and prosperity.1 have significant potential include social protection, agriculture and women’s empowerment (including Hunger girls’ education). Hunger is the body’s way of signalling that it is Nutrition-specific interventions running short of food and needs to eat something. It can lead to undernutrition, although it is only one Nutrition-specific interventions target the immediate of many causes, which include diarrhoea, malaria causes of undernutrition, for example, inadequate and HIV and AIDS.2 dietary intake and ill-health.5

Malnutrition Undernutrition Malnutrition is a broad term commonly used as an Undernutrition is defined as the outcome of alternative to undernutrition but technically it also insufficient food intake and repeated infectious refers to overnutrition. People are malnourished if diseases. It includes being underweight for one’s age, their diet does not provide adequate calories and too short for one’s age (stunted), dangerously thin protein for growth and maintenance or they are for one’s height (wasted), and deficient in vitamins unable to fully utilise the food they eat due to illness and minerals (micronutrient malnutrition).6 (undernutrition). They are also malnourished if they consume too many calories (overnutrition).3

vii Executive summary

Rates of malnutrition in Bangladesh are Many countries have improved nutrition through among the highest in the world, with six social protection. Malawi’s Mchinji Social Cash million children estimated to be chronically Transfer scheme pilot achieved impressive reductions undernourished.7 The decline in chronic in stunting, which fell from 55% to 46% in one year.15 malnutrition8 seen previously – from 60% Similarly, Bangladesh’s SHOUHADO programme in 1997 to 41% in 2011 – now appears to saw stunting rates among 6–24-month-old children fall from 56.1% to 40.4% in beneficiary households.16 be slowing down. Policies and practice in Achievements in wasting are also notable, as Bangladesh need to have a greater focus on Colombia’s Familias en Acción conditional cash 9 nutrition, at large scale and across different transfer programme illustrates, with an average sectors, in order to accelerate progress on increase of 0.58kg for newborn babies in urban areas tackling the country’s substantial malnutrition attributed to better nutrition during pregnancy.17 burden of 41% stunting and 16% wasting10 across a population of 156.5 million.11 Despite a growing international recognition of the impact of social protection, there is still some Social protection is a human right and a means for reluctance on the part of governments to invest states to protect their most vulnerable citizens.12 funds to develop social protection systems that will Bangladesh’s current social protection system is effectively tackle malnutrition. Governments must fragmented and ineffective – in 2010 reaching just recognise the value of social protection as a ‘hand 35% of those living below the poverty line.13 As the up, not a hand out’ for individual beneficiaries and Government of Bangladesh leads a significant reform national prosperity. There is also a growing appetite of its National Social Security Strategy, harnessing globally to understand the long-term human and the potential of social protection for nutrition is vital. economic gains which nutrition-sensitive social protection offers. This report contributes to the As set out in this report, a tangible opportunity is development of this knowledge base, as a crucial step presented for the development of social protection to encourage the investment of domestic resources to improve malnutrition in Bangladesh. for social protection to tackle malnutrition. Social protection and nutrition are prominent on Country-level advocacy must be undertaken because the international development agenda, supported of the local nature of social protection. This report by a series of high-level recommendations and focuses on Bangladesh, and is intended to be the first commitments. This report particularly complements in a series focusing on countries with high burdens the International Labour Organization-led Social of malnutrition. We hope it will make a substantial Protection Floor Recommendation,14 which contribution to the global ‘nutrition-sensitive’ expresses the commitment of member states for knowledge base. It forms part of Save the Children’s building comprehensive social security systems and malnutrition and child survival work, to progress the prioritising the establishment of national ‘floors’ role of nutrition-sensitive approaches and to provide accessible to all in need. Our conclusions highlight intellectual capacity at national levels for civil society the importance of an integrated nutrition-sensitive to advocate on specific legislative opportunities. social protection system. This gives weight to arguments to integrate nutrition, alongside a In this report we consider the major pathways stand-alone goal, across the international to nutrition outcomes and a range of evidence Post-2015 framework. on nutrition-sensitive social protection to make

viii Ex recommendations for policy development and Caring practices for women and children ecutive implementation in Bangladesh and for global learning. emerges as the most critical pathway in We affirm how developing social protection across Bangladesh. Despite progress illustrated by the lifecycle, with a greater focus on nutrition successful family planning and a drastic drop in

s behaviour change, adolescent girls, empowering fertility rates since 1971, women in Bangladesh still ummary women and the 1,000-day window of opportunity have a lower social status than men. This is deeply between a woman’s pregnancy and her child’s embedded in cultures and traditions that place second birthday, will help shape healthier and more greater value on men and boys and view girls and prosperous futures for everyone in Bangladesh. women as social and economic burdens. Women’s status remains low from one generation to the Social protection, as a nutrition-sensitive approach, next because of a preference for sons and because has been shown to have an impact on nutrition daughters have less access to food, health services outcomes by addressing the underlying causes and education. Women are a vital part of the solution through three main pathways, as illustrated in the of improving nutrition in Bangladesh. table below.18 Bangladesh has one of the highest rates of child The findings presented in this report are based on marriage below the age of 15 in the world, illustrating international and domestic evidence. They clearly how much more needs to be done to empower demonstrate the importance of an integrated women and adolescent girls in Bangladesh. Girls approach to tackling malnutrition in Bangladesh. who marry young typically give birth at younger Programmes that have effectively reduced stunting ages, increasing the risk of intra-uterine growth and wasting have also addressed many of the retardation (poor growth of a baby while in the underlying causes of malnutrition. mother’s womb) leading to stunting at birth. With We conclude that integrated nutrition-sensitive around 20% of babies in Bangladesh born stunted,19 social protection programmes in Bangladesh should half of all stunting in under-fives occurs before address priority focus areas for nutrition outcomes birth.20 Child marriage also leads to adolescent girls and across all three pathways, as set out in the table dropping out of education and restricts their social on pages xi and xii. development. It perpetuates an unequal society,

nutrition-sensitive social protection pathways

Pathway Importance How social protection helps

Household food security Assured access to and Improving income and consumption of enough increasing assets nutritious food for living an active healthy life

Caring practices for women Pregnancy and lactation are Targeting nutritionally vulnerable and children critical junctures for quality care populations through the and support 1,000-days approach

Health environment and Conditions children’s exposure Promoting improvement, access services to pathogens and the use and delivery of health and of preventive and curative sanitation services healthcare

ix x malnutrition in bangladesh income due to its long-term impact on productivity. on impact long-term its to due income national of loss 2–3% estimated an Bangladesh costs Malnutrition huge. is malnutrition of cost economic and human resulting The development. cognitive for achild’s and physical consequences lifelong complete their education. who children power than earning less 20% and outcomes education poor to may lead turn in which school, in enrolment late to may lead children for poor childhood during Chronic malnutrition of preventable child deaths child preventable of 45% of cause the is malnutrition child and Maternal economic returns. US$17.9–$18.4 in generates Bangladesh in stunting reduce to programmes in invested (US$) dollar every approach. nutrition-sensitive cost-effective sustainable, a is system protection social A well-designed priority. aclear is Bangladesh in protection social for nutrition-sensitive girls adolescent targeting and women Empowering lifecycle. acrossthe malnutrition for points are critical at birth stunting and pregnancy early marriage, Child vulnerability. female increasing Up Nutrition (SUN) costed nutrition plan nutrition costed (SUN) Nutrition Up Scaling national the investment, nutrition support 75 billion, (BDT) taka Bangladeshi than more or US$1 estimated an Bangladesh cost malnutrition, of rates high persistently alongside (approximately BDT 379 billion (approximately Bangladesh in interventions for nutrition years billion five over US$5 of gap afinancing estimates to be achieved. be to is development equitable and sustained if protection, social investments, such as nutrition-sensitive social and economic critical space for fiscal domestic find at 26.7% GDP.at 26.7% more significantly invests Europe western although GDP, of 8.6% is globally expenditure health and protection social Average Pacific. the and for Asia 5.3% of average the regional than lower significantly (2010–11) is GDP expenditure of health at 2.69% required. is funds domestic of investment Increased in economicproductivity. lost Bangladesh’s public social protection and It offers a high return on investment, as as investment, on return ahigh offers It 27 30 Despite economic evidence to to evidence economic Despite

21 24 22 These lifelong impacts, impacts, lifelong These and leads to irreversible, irreversible, to leads and 26

29 ). It is essential to to essential is It ).

b illion ayear,illion 28

The options for financing social protection include: protection forsocial The options financing specifically the top 10% by wealth. top the 10% specifically or 5, quintile until seen not is rates stunting in drop Asignificant over is it 1–3 40%. quintiles group for wealth and over 30% rates stunting have 1–4 quintiles group wealth research, our in shown As poverty. widespread linked to closely ‘bad and for is everyone’ Bangladesh in Stunting apriority. be must for nutrition system protection social existing this Strengthening possible. generating activities are as nutrition-sensitive as income- and awareness-raising communication, change behaviour that ensuring and criteria selection changing through made be can Gains expenditure. additional little requiring for nutrition, strengthened be to have potential the programmes protection social of number alarge Bangladesh, In pathways. nutrition the of anumber consider that programmes integrated and gains, long-term on focus a analysis, strong requires protection social sensitive nutrition- that is internationally implementers design and for policy-makers recommendation overall Our framework. macroeconomic accommodating amore adopting and/or reserves, exchange and foreign fiscal into tapping transfers, and aid increased drawing on flows, financial illicit curtailing debt, existing restructuring or borrowing contributions, security social extending revenues, tax increasing expenditure, public reallocating sensitive social protection in Bangladesh. nutrition- on action for time the is Now effort. collaborative a requires protection social nutrition-sensitive of The development requires improvement. Bangladesh environment is essential. Governance for nutrition in acrossamulti-sector nutrition of integration the and leadership and commitment political High-level should increased. be programmes protection social of coverage The malnutrition. chronic address sufficiently to going not is Strategy Protection Social National the in proposed currently as programme poverty targeted narrowly the 32 Therefore, Therefore, 31

Executive summary xi continued overleaf Policy and design implications for Bangladesh Review theReview National Social Security Strategy to identify priority programmes for nutrition. nutrition Strengthen objectives based on causal analysis. Develop programme design to target nutritionally vulnerable groups. Consider coverage for all socio-economic groups. Programmes should increase coverage of the critical window of the first1,000 days and adolescent girls. Integrate monitoring and evaluation systems to show impact on nutrition. for aim Programmes should universal coverage through progressively scaling-up in line with financing and administrative capacity. Consider use ofcash transfers to enable households to purchase a nutritious diet. Cash transfers should be large enough and adjusted to reflectregional and urban rural differences.and Impacts on productive activities and livelihoods can be enhanced through complementary income- generation activities or links to appropriate policies. household influence To household as such trends, sensitisation consumption, and behaviour change communication targeted towards men, as well as women, is recommended.

33 34 pathways

nutrition

Evidencefrom social protection Half of the 22 programmes in our review find reductions in stunting. Half of those were conditional cash transfer programmes, while the other half were transfer unconditional programmes. SHOUHARDO cut stunting percentage points. 16 by Cash transfers from social protection programmes to used predominantly are purchase food. Evidence shows social protection can improve household’s ability to shocks.absorb Social protection, including cash transfer programmes, can improve productive activities and livelihoods, thereby further improving income and food security. Jibon-O-Jibika Chars and Livelihoods programme also achieved significant stunting reduction. the

across

protection

Priority focus areas Stunting remains a considerable challenge in Bangladesh and levels are In other‘bad for everyone’. words, levels of stunting are above 30% for all but the top wealth quintile. Key challengeKey is affordability of adequate quality and quantity of food – the poorest spend large percentage of income on food (poorest 40% spend 60–70% on food), and are vulnerabletherefore to rising food prices. The cost of a nutritious diet varies and (region) division by urban/rural areas. between Food insecurity and dietary diversity particular are challenges in rural areas. social

Cross-cutting Nutrition outcomes Assured access to enough food of adequate quality for living an active healthy life Pathway: Household food security developing xii malnutrition in bangladesh developing healthcare curative and preventive of use the and pathogens to exposure children’s Conditions services and environment Health Pathway: and support care quality for critical junctures are lactation Pregnancy and children and women for practices Caring Pathway:

social Priority focus areas focus Priority eg, 5% drink surface water. surface drink 5% eg, challenges, experience still Sylhet, as such regions, Some stunting. in reduction observed the of some explain may Bangladesh in open-defecation and access water safe in Improvements system. healthcare a weak and healthcare on spending low has Bangladesh region. by vary Practices inadequate. are practices feeding child young and Mother, infant entire household benefits. the so families and children in earnings their invest consistently power making decision- Women with high. is motherhood young of rate The period. acrucial is Adolescence marriage. later positively associated with is Education nourished. under- be to likely less are significantly education more with women education: of Importance

protection

across

the most of existing services. the making Bangladesh, in healthcare to access encourage to potential has protection Social market. labour the in participation and making autonomy in decision- and power including empowerment, female on protection social of impacts positive on evidence Some attendance. education girls’ on transfers cash education of Impact impact. meaningful have a to low too is value transfer the and mothers lactating and pregnant currentlyBangladesh target in programmes protection social net safety two Only protection social from Evidence

nutrition

pathways continued healthcare systems. healthcare investmentincreased in awareness-raising, alongside insurance, referrals and/or health through example for schemes, protection social through promoted be should healthcare to Access education. to access promote to and girls for especially adolescence, toinclude programmes protection Target social in-law). members (eg, mothers- household influential other and women alongside men Involve activities. raising awareness- nutrition and change behaviour of inclusion Strengthen years. two under children and women lactating pregnant/ approach: 1,000-days Integrate protection towards women. activities alongside social enterprise and generating income- peer support, entrepreneurship training, basic tailored, to link or Incorporate Bangladesh for implications design and Policy

1 Introduction

Rates of malnutrition in Bangladesh remain Bangladesh’s malnutrition burden is significant, among the highest in the world, with an with 41% stunting, 16% wasting,38 22% with low estimated six million children chronically birthweight, and 2% overweight.39 Bangladesh’s undernourished.35 As Bangladesh’s National population at last count was 156.5 million, making 40 Social Security Strategy undergoes significant the number of people affected staggering. reform, harnessing the potential of social Despite a decline in the prevalence of chronic protection for nutrition is vital. malnutrition41 among children under five from 60% in 1997 to 41% in 2011 (see Figure 1), that trend is Social protection is a human right and a now slowing. Prevalence of chronic malnutrition means for states to protect their most remains well above World Health Organization vulnerable citizens. This is confirmed in the (WHO) ‘very high’ severity thresholds.42 Universal Declaration of Human Rights, the United Nations Convention on the Rights of the Child, the Undernutrition in Bangladesh is a national International Labour Organization’s constitution, multi-sector development problem. It is reducing and legal instruments on social security. However, Bangladesh’s chances of reaching its goal of achieving social protection is far from the norm for most of Middle Income Country status by 2021, and is the world’s population: 73% of the world’s population preventing millions of children from reaching are covered partially or not at all.36 In Bangladesh their potential. in 2010 the social protection system reached just 35% of those living below the poverty line.37

Figure 1 Progress on malnutrition in Bangladesh, 1997–2011 70

1997 60% 60 2000 2004 51% 51% 50 2007 43% 2011 41% 40

% of children under 5 2007 17% 2011 20 2004 16% 15%

10 Stunting

0 Wasting 1997 2000 2004 2007 2011

Source: Save the Children calculation based on the Demographic Health Survey from Bangladesh. Notes: To be classified as ‘stunted’ a child must have height less than two standard deviations below the median for that child’s age from the reference population. All stunting rates quoted in this document were estimated using most recent population of reference from WHO 2006.43

1 2 malnutrition in bangladesh health and family planning services, with infant and and infant with services, planning family and health into interventions nutrition progress by mainstreaming accelerate to aims initiative (NNS) Services Nutrition prosperous futures for everyone in Bangladesh. Bangladesh. in for everyone futures prosperous more and healthier shape help will birthday, second child’s awoman’s her and pregnancy between window 1,000-day the on and women empowering on focus agreater with lifecycle, acrossthe protection social stunting prevalence globally by just 20%. by just globally prevalence stunting reduce to are estimated population, the of cover 90% to if scaled-up even interventions, nutrition-specific Yet, recognised undernutrition. of causes immediate the address that interventions nutrition-specific on focused has attention decade past the Over Strategy, Security Social National draft the of PPORTUNITY words opening the in Bangladesh, of Government The A management of severemanagement malnutrition. as as well fortification, and supplementation food diversification, feeding, dietary complementary and for breastfeeding support including package, nutrition acomprehensive level through community at interventions nutrition-specific deliver to promise renewed its has Bangladesh of Government The underlying causes of child undernutrition. the of some address directly more to developed be can protection social as such programmes that ways identify to made have been Efforts to address the country’s high levels malnutrition. of high country’s the address to utilised and developed be must Bangladesh in protection Social reform. of need urgent in is It ineffective. and fragmented is system Yet protection social current the improving development and human reducing inequality. poverty, to reducing commitment strong its confirmed nutrition-sensitive developmentnutrition-sensitive programmes. large-scale, effective, of outcomes nutritional the in improvements requires nutrition in progress of n of society society of causes Basic levelscommunity Underlying causes Immediate causes undernutrition: of levels causes of three identifies framework conceptual UNICEF The T he

o UNICEF : around the structure and processes processes and structure the : around c onceptual : manifest at individual level at individual : manifest : manifest at household and and at household : manifest 48 The National 45 47

Acceleration Acceleration Developing f 44 ramework has 46 young child feeding as a top priority. atop as feeding young child to nutritious foods through the agriculture sector. agriculture the through foods nutritious to delivery, service health expanded to improving access –from acrosssectors objectives nutrition-sensitive shared out set that policies coordinate to made being nutrition-sensitive socialnutrition-sensitive protection in Bangladesh. on for action time the now is that confirms policy 2015 in national in issue Plan this embed to Five Year (7th) Government’s next the of drafting by the presented opportunity the Furthermore, protection. social nutrition-sensitive greater through improve to nutrition opportunity avital present Strategy, Security Social National the of reform the alongside NNS, the of commitments The health • c • household • three pathways: through nutrition of causes underlying the Nutrition-sensitive interventions impact on soc and actions. See Section 3for detail. more Section See actions. and goals nutrition specific and hygienic environment; asafe, and services health to access levels; community and household at maternal, resources care-giving and practices feeding adequate security; food includes: This development. and growth adolescent and young child foetal, of determinants underlying the address nutrition-focused interventions or programmes S systems, and policies protection social Within W the lifecycle. throughout risks major with cope to means the OCIAL provide and exclusion, and vulnerability poverty, S address that systems and programmes policies, public accountable of aset is protection Social W aring hat hat ial

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Spe sting and stunting, and it can diet improve 3 n contribute to reducing inequalities and

coh development and security. wa diversity and food security; this has been proven in a number of cases. ca empower the most vulnerable in society. rt ctionexplores 6 governance and the political a P Se Section 5 identifies the priority groupsfor Bangladesh in protection nutrition-sensitive social and highlights the places where the problems underlying poor nutrition outcomes worst. are 5.1 context. Section 7 looks the at development of nutrition- sensitive social protection in Bangladesh. Section 8 draws upon learning of our research to make specific designrecommendations. Section 9 considers the global priorities related to protection.nutrition-sensitive social Section presents 10 conclusions and recommendations the for development of nutrition- sensitive social protection in Bangladesh. The major pathways to nutrition outcomes nutrition- on demonstrated evidence are by sensitive social protection. This allows us to make knowledgeable recommendations policy for and programme development in Bangladesh and to inform global learning. • Social • Well-designed • For

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cial focus: Child marriage, motherhood young trition pathway: Health environment trition pathway: Household food security trition pathway: Caring practices for p nvestments in nutrition, health, education, ns. Social protection can address poverty

lnerability to global challenges such as Nu and services Nu Nu Spe and stunting at birth women and children 2 1 vu aggregate economic shocks, instability in the price of food or other essential commodities, and climate change. of i sanitation. water and and gai protectionand provide against vulnerability and exclusion. It can offer a means to cope with life’s risksmajor the throughout lifecycle.

rt rt verview ction 4 examines the results of our literature ctionsummarises 2 the issues driving Bangladesh’s • Social • Social • Investing T OTENTIAL a a 4.3 4.2 4.2.1 review on thereview impact of Bangladeshi andworldwide social protectionprogrammes on nutrition outcomes summarise and pathways. the We context in Bangladeshconsider each for pathway, the known impacts of social protection, and conclude with learning. 4.1 P Se Section 3 sets out social how protection helps tackle hunger and malnutrition, with reference factorsto key such as the ‘1,000-days’ approach, the intergenerational cycle of poverty, and the case. investment Se high of malnutrition. levels P This report examines the potentialof social protection nutrition for in Bangladesh, sets out the issues need we to consider (Part 2) and makes recommendations the for development of social protection programmes and systems to effectively nutritionimprove (Part 3). O ldren hi C he t ave /S rke la part 1 : CJ C CJ : hoto P

Nirob, 2, suffers from malnutrition and is his parents’ only surviving child. 2 The underlying causes of malnutrition in Bangladesh

A number of issues sit behind Bangladesh’s 2 Caring practices for high levels of malnutrition. As the population women and children of Bangladesh continues to increase, the number of people who are malnourished Women’s empowerment will rise unless the following critical areas, Despite progress since 1971 – illustrated by successful which we examine in detail in this report, family planning and a drastic drop in fertility rates55 – are addressed. women in Bangladesh still have a lower social status than men.56 This is deeply embedded in cultures and 52 Poverty and inequality are basic drivers of traditions that place greater value on men and boys malnutrition in Bangladesh. The gap between and that view girls and women as social and economic the poorest and the richest groups in relation to burdens. Women’s status remains low from one 53 malnutrition is significant at 28 percentage points generation to the next because of a preference for and must be addressed in order for Bangladesh to sons and because daughters have less access to food, truly address its malnutrition burden. Nutrition is health services and education. Women are a vital part closely linked to poverty in Bangladesh, which is of the solution of improving nutrition in Bangladesh, widespread and affects the bottom and middle and therefore more attention must be given to wealth quintiles. The ability to afford a nutritious empowering women. diet is limited to the wealthier sections of Bangladesh’s society. Stunting at birth The underlying causes of malnutrition in Bangladesh Around 20% of babies in Bangladesh are born manifest at household and community levels across stunted.57 Girls who marry young typically give three pathways: birth at younger ages. Giving birth at a young age increases the risk of intra-uterine growth retardation (poor growth of a baby while in the womb), leading 1 Household food security to stunting at birth. Child marriage leads to girls dropping out of education and restricts their social Aoccess t food, land and water development. It perpetuates an unequal society, In 2011, 69% of Bangladeshi households experienced enhancing female vulnerability. some food insecurity.54 Bangladesh is densely populated, with land and resources in limited supply. Child marriage, early pregnancy and stunting The intensity of the seasons increases vulnerability at birth are critical points for malnutrition across to limited food access for the poorest, particularly the lifecycle. in areas prone to flooding. Innovative approaches for resourcing poor areas are needed to allow them to leverage the natural and human resources available to them, increase access to food and achieve more sustainable livelihoods.

6 2 The uNDERLYING causes of malnutrition in Bangladesh 7 In the remainder of this 61 report will we probe into the ‘problems’ above and explore investing how in social protection to address malnutrition extremely could have positive social and economic returns for Bangladesh. A well-designed social protection systemhas the potentialto positively affect all of the issues outlined and above nutrition improve in Bangladesh. It issustainable, a cost-effective nutrition-sensitive approach. Every US dollar invested in programmes to reduce stunting in Bangladesh generates in US$17.9–18.4 returns.economic 60

The implications 59

nvironment e

a ervices

sation s

ealth

ross Bangladesh, there spending is low on en K : hoto P /S mann er H hi C he t e av ldren ealth rbani

for nutritionfor deeply are concerning. One-third of the urban population currently in slums, live where many factors affectenvironmental negatively health and the stuntingnutrition. rate was In 2013 50% in the worst-affected urban areas. By 2038, the majority of people in Bangladesh will in urban live areas. Amra, is 14, among thousands of children who live and work on the streets of the capital, Dhaka.By 2038, the majority of people in Bangladesh will live in urban areas. Bangladesh is experiencing rapid urbanisation. Urban populations expanded have rapidly and expected are to increase a further by 50% 2028. by Ac healthcare, weak a public health system and poverty. widespread Hccess 3 and U 3 Social protection And nutrition

In this section we first define social Social protection should be designed and protection then describe the ways in which implemented through a systems approach, where all social protection helps tackle hunger and actors coordinate in support of strategies, policies malnutrition, with effects on intergenerational and programmes underpinned by the national vision. cycles of poverty. We look at the importance The role of government in developing, implementing of the ‘1,000-days’ approach and how and financing social protection is critical in order to ensure long-term sustainability of policies, guided social protection provides a high return by national vision. National systems can comprise on investment. non-governmental social protection schemes alongside those that are government-led.

Definitions Nutrition-sensitive social protection Ws hat i sOCIAL protection? How does social protection positively impact Social protection is a set of accountable public on nutrition? policies, programmes and systems that address Within social protection policies and systems, poverty, vulnerability and exclusion and provide nutrition-focused interventions or programmes the means to cope with major risks throughout address the underlying determinants of foetal, the lifecycle. young child and adolescent growth and development, Social protection initiatives provide: which may include: food security; adequate feeding • social assistance to extremely poor, vulnerable practices and care-giving resources at maternal, and excluded individuals and households, including household and community levels; access to health transfers as part of social welfare, healthcare services and a safe, hygienic environment; and provision, child protection and predictable specific nutrition goals and actions. humanitarian responses Social protection interventions or programmes • social insurance to protect people against the can serve as delivery platforms for wider and more risks and consequences of livelihood shocks, comprehensive nutrition-specific interventions, including those related to unemployment, climate, potentially increasing their scale, coverage, and conflict, economy, and major health concerns effectiveness. • advocacy and support, as essential measures to address legal, social, cultural and economic Nutrition-sensitive social protection programmes barriers to social protection programmes and help tackle both the immediate and the underlying basic services. causes of malnutrition by reducing vulnerability, removing discrimination and exclusions, protecting To be effective, social protection should be productive assets, ensuring that basic needs can be complemented by wider policy reforms to address met, and securing access to a nutritious diet. the causes of poverty, improve the quality and scale of healthcare, education and other basic services, Nutrition-sensitive social protection is part of and promote social equity and inclusion. addressing the needs of children through the lifecycle.

8 3 Social protection and nutrition 9 s alnutrition y the householdthe m of this income in in income this of

Improving income, income, Improving and hygiene education increasing assets and eg, pregnant women and critical 1,000-day window influencing the control Targeting nutritionally Targeting and sanitation services vulnerable populations, young children through the nutrition counselling, health Promoting improvement, eg, micronutrient supplements, access and delivery of health nd a

athwa p

These impacts can lead to impressive 64 63 unger 62 h

Programme examplesProgramme Old Age Allowance Widowed and Distressed Allowance Women Allowance Disabled Primary ProgrammeStipend Education Female Secondary for StudentsStipends Food-for-Work Development (VGD) Group Vulnerable Employment Generation Programme (EGP) Feeding Group Vulnerable (VGF) Gratuitous Relief (GR) Relief (TR)Test Open Market Sale (OMS) and services. gains stunting for and wasting. in which impacts Ways across the shown are in pathways the achieved are figure below. rotection p

healthy life ackle gladesh Assured access t adequate qualityadequate

to enough food of for living an active curative healthcare an Conditions children’s children’s Conditions Pregnancy and lactation are critical junctures for quality care and support B the use of preventive and ocial exposure to pathogens and s n

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N and services

Household food 2 s Caring practices for ypes women andwomen children Health environment environment Health

n igure ow F Type Cash transfersCash cash transfersConditional Public works or training-based cash or in-kind transfer Rural Maintenance Programme Emergency or seasonal relief ai M Nutrition-sensitive social protection tackles the underlying causes of malnutrition through three pathways: household food security; caring practices womenfor and children; and health environment H OCIAL 10 malnutrition in bangladesh in the number of children with stunted growth, stunted with children of number the in show reductions that Colombia and Malawi Mexico, in by programmes demonstrated as development, nutrition alsoBetter contributes physical to better food consumption during shocks or lean periods. lean or shocks during consumption food protect to well as as consumption, food of diversity the and quantity the improve to shown both have been transfers cash America, Latin and Asia Africa, In malnutrition. and hunger both on impacts positive of evidence strong are showing countries of acrossanumber initiatives protection Social L address. can systems protection social RITICAL well-designed that consequences Early malnutrition serious has long-term T were • were • scored • children: stunted children, non-stunted with compared showed that, countries, four in children followed 3,000 which Young fromthe study, Analysis Lives well established. are malnutrition child of consequences long-term The properly. develops brain the that ensuring play akey to rolein continues nutrition born, is child the Once performance. cognitive poor and development brain compromised have with children are to likely more nutrients right the access cannot who mothers breastfeeding or pregnant essential: is nutrition maternal Good world. the with engage and interact to ability their and learn children ways the affecting impact, indirect an has also It development. cognitive affecting directly brain, the of development functional and structural the affects malnutrition period, this During growth. cognitive and physical child’s a for time daysare critical a first The 1,000 than those in households without apension. without households in those than taller grow,a pension five centimetres average, on receiving households African South in children while of if he elong fo se to write a simple sentence asimple write to

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long-term health, stability andlong-term stability prosperity. health, asociety’s shape also can It poverty. of out rise and grow, to achild’s on learn ability impact profound have can a period critical this during nutrition right The futures. prosperous more and healthier shape to opportunity of window unique this maximise child’s her and helping birthday, second pregnancy awoman’s daysbetween 1,000 at the targeted when for nutrition useful particularly is protection Social outset. the children’s from consider needs systems protection social when likely are most for nutrition outcomes positive growth, inclusive towards distribution for income tool active an be and nutrition child Wi T less as adults than children who are well nourished. who children than adults as less 20% earn malnourished and are poor who Children national income growth by up to 2%. by to up growth income national 5–17% in adult increase productivity, the increasing a in results adults working in anaemia eliminate to enough nutrition improving World the to Bank, According growth. economic to barrier significant a as act therefore can Malnutrition inequality. entrench and poverty into children lock work can physical do to ability the and development cognitive stature, physical on malnutrition of effects The he See Sections 5.2 and 7for detail. more and 5.2 Sections See World fromthe Programme. Food support with exploring options to integrate nutrition-sensitivity, is Government the and area, this in potential its for recognised been has Programme Development Group Vulnerable The approach. 1,000-days the supporting mothers lactating and pregnant target low coverage, with both programmes, protection social two only Bangladesh, In th the ability to promote spending to improve to spending promote to ability the th

p otential

o f

s ocial

p rotection 72

3 Social protection and nutrition 11

79 estimates estimates 82 80 ). There is, therefore, a clear need 83 81 illion a year, or more than billion, 75 BDT illion a year, b

during childhood among poor children lead may to late enrolment in school, which in turn lead may to poor education outcomes and 20% less earning thanpower children who complete their education. a financing gap of US$5 years over billionfive for (approximately Bangladesh in interventions nutrition billion 379 BDT These lifelong impacts, alongside persistently high rates of malnutrition, cost Bangladesh an estimated US$1 for greaterfor nutrition investment from development Nutrition-sensitive Government. the and partners approaches, social including protection, for account 92.8% of the SUN costed plan. in losteconomic productivity. in Investing funds to end hunger and malnutrition can offer high economic returns. Every US$1 dollar invested in programmes to reduce stunting in Bangladesh in economic generates US$17.9–18.4 returns. Despite the economic evidence in support of nutrition investment, the national Scaling Up Nutrition (SUN) costed nutrition plan

The 75 and leads to 74 investment

which involves hundreds 76 Chronic malnutrition Chronic on

77 return

high obally conomics For Bangladesh Malnutrition costs Bangladesh an estimated 2–3% loss of national income due to its long-term impact productivity. on of economists evaluating the returns to investing in a variety of social goods, calls fighting malnutrition a ‘phenomenal’ investment, putting it in the top category of investments. irreversible, lifelong consequences a child’s for physical and cognitive development. The resulting human and economic cost of malnutrition is huge. With a long-term impact on productivity, hunger andundernutrition reduce global gross domestic product (GDP) 2–3% by and cost the world up to US$2.1 trillion in lost global GDP. Maternal and child malnutrition is the cause of 45% of preventable child deaths E Gl A Copenhagen Consensus, Copenhagen ldren hi C he t ave /S

dullah part 2 b A ir b : A : hoto P

Mothers attend a community meeting about the construction of a clinic in the village of Pukra, Habiganj district. 4 Nutrition impacts: the potential of social protection for nutrition in Bangladesh

So far, we have described the high rates Learning from existing social of malnutrition in Bangladesh and some protection programmes key policy areas. But before we can make recommendations for nutrition-sensitive This section explores the pathways by which social social protection, it is important to know protection interventions produce results and returns which programmes have been effective and by impacting on nutrition status and the underlying what features of those programmes might determinants of nutrition across the three pathways explain their success. identified in UNICEF’s conceptual framework (see Figure 3 on the next page). Based on our literature In the following section we explore the results of review, we summarise the main nutrition-related a comprehensive literature review, which shows impacts of 22 major social protection programmes,85 the impact of Bangladeshi and worldwide social eight of which are in Bangladesh.86 Indicators protection programmes on each nutrition pathway. covered nutrition-specific (stunting and wasting) and nutrition-sensitive (household food security, Subsequent sections contain a summary of the caring practices for women and children, health context in Bangladesh for each pathway, consider the environment and services) aspects. Programme known impacts of social protection, and conclude design features that may explain effectiveness, or with learning for Bangladesh. lack of effectiveness, are also discussed. This approach allows us to understand some of the potential gains for Bangladesh if social protection were to be scaled-up as a nutrition-sensitive approach.

T he pATHWAYS approach

UNICEF’s conceptual framework, which has Nutrition-sensitive interventions impact on been used by the nutrition community for the the underlying causes of nutrition through past 25 years, identifies three levels of causes of three pathways: 87 undernutrition: • household food security • caring practices for women and children Immediate causes: manifest at individual level • health environment and services. Underlying causes: manifest at household and community levels Basic causes: around the structure and processes of society

14 4 Nutrition impacts: the potential of social protection for nutrition in Bangladesh 15

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Poverty beliefs esources and d mental status atus autonomy autonomy an and st of r onceptual Caring practices for children and women Resources for care • Caregiver • Caregiver • Caregiver • Caregiver c Undernutrition ), 2008; Nutrition UNICEF, Child Improving 2013. ICEF The Lancet The

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Individual and national and Individual kind ash rsion ransfers in- e Inadequate dietary intake Household food security Resources for food security • Food • C • T v fied odi M

3 , IDS working paper: 10, based on Black et al ( around the structure and processes of societies Basic causes influencing influencing households and communities Underlying Underlying causes Immediate Immediate causes operating at the individual level igure F Fund: 6 http://www.unicef.org/publications/files/Nutrition_Report_final_lo_res_8_April.pdfFund: 6 2014] December 23 [Accessed Source: Modified by author with information from L. Smith and L. Haddad (2014), Reducing Child Undernutrition: Era Post-MDG Past Drivers and Priorities for the 16 malnutrition in bangladesh these priority areas.” priority these in investment increased require will future the in undernutrition in reductions accelerating policies, and nutrition-specific and nutrition-sensitive programmes to Complementary roles. facilitating played essential governance and growth Income stunting. in reductions key past of have drivers been countries in available food of quality and quantity the and empowerment, women’s and “…safe education sanitation, and water interventions. This leads to a lack of evidence. of alack to leads This interventions. nutrition-sensitive specific to gains attribute to difficult indicator. notoriously is It ashort-term as wasting) or weight-for-height (low malnutrition acute and indicator along-term as stunting) or age (low height-for- incidence of chronic malnutrition the alleviate to ability by their measured often is programmes nutrition-sensitive of success The Haddad and Smith As sanitation. of means developed and water clean to access as such health of determinants environmental of afunction part, in is, which status, health their linked to is nutrients absorb children’s to time, ability same At the children. to it provide to ability their and nutrition of awareness caregivers’ on and food to access household upon part in depends Nutrition it. absorb to ability achild’s upon and available being nutrition upon depends status level, nutritional basic most At the im pa U • • core components: three with for Action aFramework out sets series Nutrition Child and Maternal Lancet The F nderstanding thways proving ramework incorporate nutrition goals and actions into into actions and goals nutrition incorporate that interventions Nutrition-sensitive status health poor and intake dietary inadequate is, that undernutrition, child of causes immediate the address directly interventions Nutrition-specific :

w n utritional hat

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n ion utrition

s tatus

f that that 88 or explain: explain:

ch I • seen in any in case. seen be will effects that likely not is it implementation, after timeframe short arelatively in estimated be are to effects programme if and properly measure to survey-takers train to expensive is It stunting. on effects review our in evaluate not did included programmes the of many that note to important is It stunting. in reduction significant still but modest malnourished children). malnourished 31.5% 35.7 to (from moderately among stunting 40.4%). points in about three and a half years (from 56.1 (from years ahalf and three about in points by 16 stunting cut percentage which SHOUHARDO, achieved by was stunting in change largest The (CLP). Programme Livelihoods Chars extent, some to and, (JoJ), Jibon-O-Jibika SHOUHARDO, stunting: in reduction achieved significant reviewed programmes Bangladeshi the of Three programmes. transfer were unconditional half other the while programmes, on stunting were conditional transfer cash effect an had that interventions the of half about Interestingly, page). next the 4on Figure (see stunting in reductions find half that shows programmes A re mp shaping children’sshaping nutrition. environmental, social and context cultural political, broadeconomic, the to related factors distal more causes, basic the addresses environment enabling Building an children, and unhealthy living environments and for mothers practices caring of quality poor insecurity, food household are: which causes, interventions that address the underlying ronic acts view of the literature on the 14 international 14 the on international literature view the of 89 JoJ also achieved significant reduction is reduction achieved also significant JoJ

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Figure 4 Nutrition outcomes for 22 social protection programmes utrition 7

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Number of programmes of Number 2

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0 p Reduce both Reduce stunting Reduce wasting Nutrition not No effect on nutrition rotection not wasting not stunting evaluated (either or both)

Sources: Save the Children calculation based on literature review. See Appendix C for literature review references. Notes: Different programme evaluations used different measures for stunting and wasting. These have been interpreted liberally, with, eg, any

measured and significant increase in height-for-age counting as a reduction in stunting. Programmes that showed a measured effect, or lack of effect f for one nutrition outcome but the other was not evaluated, have been categorised according to the measured effect. This means that, eg, the or ‘reduce stunting not wasting’ group includes one programme where a reduction in stunting was measured but wasting was not evaluated.

n utrition

Impacts of social protection on None of the other ten programmes examined

i acute malnutrition (wasting) showed such gains, although some chose not to n examine the outcome at all. B In Bangladesh, more programmes report reductions an in wasting. This could be due to the fact that wasting, However, a positive nutrition outcome was not gladesh a short-term indicator of malnutrition, is often guaranteed. For two of the programmes included associated with severe food shortages and, once food in the review, both indicators of malnutrition were is introduced, rapid improvements can be achieved. tested and found not to have been affected: Bolsa Among the programmes that reduce wasting are Familia cash transfer programme in Brazil did not Millennium Development Goal/Fund (MDG/F), explicitly target nutrition, despite having a nutrition Jibon-O-Jibika, TUP (Targeting the Ultra Poor) and, education element; and the VGD programme in perhaps, SHOUHARDO (which does not specifically Bangladesh, where evaluations suggest that it was report wasting but reports that the percentage of not children under age five who ate more as a underweight children went down from 60 to 44%). result of the programme, but rather other MDG/F almost completely eliminates the most household members. severe form of malnutrition. By exploring the nutrition pathways in the Improvements in wasting are rarer as we look following sections of this report we will be able internationally. Unconditional cash transfer to understand more about the differences in programmes in Malawi, Zambia and Honduras impact (Sections 4 and 5) and the implications improved child weight-for-height and/or for design (Section 8). undernutrition. Peru also managed to make gains.

17 18 malnutrition in bangladesh for-age) scores among programme recipients. programme among scores for-age) (height- by stunting indicated as nutrition childhood bolstered also Africa South in Grant Support • • • • MDG/F • • • • • • • SHOUHARDO MPACT in T z-scores. weight-for-height girls’ young in deviations standard 0.6 of increase an in Africa South In by 22%. feeding young child and infant increased and five to years three aged children among z-scores in weight-for-height increase significant Zambia MPACT in T

he he nur A a 9% Moderate and 0.04%. 0.02% to age fell of five under years children pr From eliminated. p in young children among Wasting Access wa The Access care. antenatal di Women score. diversity dietary year, last household average the in the did as ‘t The months). 5.5 mo Households 16% by c 6–24-month-old among rates Stunting 1 ternationally B 4% to 54.6%. to 4% hildren in beneficiary households fell fell households beneficiary in hildren hree square meals’ a day rose significantly aday rose significantly meals’ square hree rogramme households was nearly nearly was households rogramme

ets, more rest during pregnancy and better better and pregnancy during rest more ets, evalence of severe acute malnutrition among among severe of malnutrition acute evalence r

an ter increased from57%72%. to increased ter nths per year (8.9 months compared to to compared months (8.9 year per nths eduction i i sing women was also reported. also was women sing

98 n n nd 11% 1%. to

’s Child Grant Programme brought a brought ’s Programme Grant Child umber umber i nitial

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J • • • • • • • • C • • • • • pregnancy. during nutrition better to attributed was which areas, urban in babies for newborn 0.58kg of increase sawaverage an programme transfer Colombia constant proportion at 55%. proportion constant a maintained non-recipients while 46%), to 55% (from growth stunted experiencing proportion the in areduction was there TransferCash scheme, Malawi in participants child Among o o ib

hars on n n Pregnancy sm Women wo programme on food. Access especially among girls. reported, t of Significant diversified diet. m Households Stunting cou Some s reported beneficiaries of 99% Over is A im The 33–40%. ho The Food s child in declines There were significant tunting and wasting. and tunting pending money earned from the the from earned money pending sues was achieved. was sues

eat and own produce, suggesting a more amore suggesting own produce, and eat

h proved. useholds fell from 44% at baseline to to at baseline from44% fell useholds m m all livestock and children’s and livestock all consumption. food men eating more and getting more rest. more getting and more eating men ubewells (67%) and latrines (80–90%) (80–90%) latrines and (67%) ubewells igher -O ld feed their families better. families their feed ld

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POVERTY, INEQUALITY that social protection systems can have on poor N AND NUTRITION and vulnerable people, countering deprivation and utrition reducing vulnerability to global challenges such as Monetary poverty, at household, local and national economic shocks, instability in the price of food or levels, is often linked to food security. As Figure 5 other essential commodities, and climate change.

i demonstrates, living below the poverty line is Social protection expenditure has a prominent role in mpacts associated with higher stunting. Bangladesh is no reducing and preventing poverty, promoting equality exception. However, we must recognise that the and addressing social exclusion. According to the : US$1.25 poverty line is likely to buy a very different International Labour Organization, there is a distinct t he amount of food in one country than it does in another. relationship between higher levels of public social

p As we look at Bangladesh’s divisions (regions), we see protection expenditure and lower levels of inequality. otential that a higher proportion of people living under the Social protection provides a channel through which poverty line is associated with a higher stunting rate governments can redistribute income and resources (see Figure 6 on the next page). Khulna and Rajshahi and share the benefits of growth. It promotes have low proportions of people living below the inclusive growth, allowing people to contribute to o f

102 poverty line and relatively low stunting. Barisal and and benefit from economic growth. s ocial Rangpur have higher proportions of the population Social protection has the ability to lift people out of living below the poverty line and higher stunting poverty for life and also reduce the depth of poverty:103 rates.101 As we will see later in this section, these p • in South Africa, non-contributory grants have rotection regions also experience high food insecurity. For reduced the poverty gap by more than one-third104 more detail on divisional differences for nutrition • Mexico’s Opportunities programme has reduced and across the pathways indicators, see Section 5. the number living in poverty by 10% and the poverty gap by 30%105

Social protection has emerged as a major focus in f efforts to reduce poverty worldwide. This is the • social transfers and taxation have reduced poverty or 106

by more than 50% in most European countries. result of growing recognition of the positive impact n utrition

Figure 5 Stunting rate vs. poverty headcount % across all countries

i and years in GRID n B 70 an gladesh

50 Bangladesh, 2011

20 Overall stunting rate, national (%)

0 0 10 20 30 40 50 60 70 80 90 100 Poverty headcount ratio – % living on $1.25 per day or less

Source: DHS, World Development Indicators Notes: Poverty headcount is % living under US$1.25 per day. GRID: Groups and Inequality Database

19 20 malnutrition in bangladesh on the next page illustrates this further. this illustrates page next the on 7 Figure childhood. early in for example, vulnerable, particularly may be people when phases sensitive during beneficial especially be can protection social capabilities, life of formation the and vulnerabilities lifecycle on focusing When cycle. poverty intergenerational the break help can that foundations Ef N cyc E line. are poverty food the non-food and than food on less or equal expenditures total Their poor’. ‘extreme as classed are line poverty lower the below living Those on a line. based is which poverty work, HIES national the in line poverty the uses figure The stunting. of levels different very that have can found we poverty expected, income is of level same the correlation While children. stunted of proportion the with poverty income of level the compares figure This Notes: 2010–11:35 Expenditure and (HIES) Income Survey Household the and Bangladesh from Survey Health 2011 the on Demographic based calculation Children the Save Source: ffects pathway indicators, its pregnant women are badly are badly women pregnant its indicators, pathway of range awhole on badly clear. performs Sylhet are stunting of indicators poor 52) page 5, Section in table (see indicators pathway the we examine When line. poverty the below living population the of share for its you would expect than division this in higher much is stunting because is This 6above. Figure in line above high is the Sylhet S fective social protection can build strong strong build can protection social fective F igure ylhet le Stunting rate (%)

o 40 45 50 30 55 35

o f 6 10

overty P

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Rajshahi % l iving below lower national poverty line poverty national lower below iving

Sylhet ercentage 20

transmission of poverty.transmission intergenerational perpetuates and adulthood in poverty of likelihood the increases it because awhole, as for society also but for children only not implications, long-term has age early froman children of wellbeing the in invest adequately to Failure Sylhet’s stunting rate is so high. is rate Sylhet’s stunting why explain help and line poverty the below compound the issues that arise from20% arise that issues the compound water.surface Together, are to likely these drinking are still 5% and system, healthcare a poor –suggesting at births professionals few health very are there well educated, not and undernourished vs . 25 s Barisal

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N utrition

i mpacts : t Nutritional status Nutritional status Nutritional he CCT

p School School feeding otential e rs rs cl y

o ouche c V f y

Food for work for Food Food transfers s ocial t er Education Education Healthcare Healthcare v nutritious food nutritious food Consumption of Consumption of Behaviour change communication o

p p rotection

f or

n utrition Income Income availability of availability of nutritious food nutritious food Production and and Production and Production ntergenerational Public works Public Cash for work i Cash transfers transfers Cash

he i n t

B n an o

gladesh Livelihood Livelihood rotection Input p transfers transfers

Public works Public ocial s f o mpact i he Human capital Human capital T

Next generation 7 igure Source: Cherrier, 2012. Social Transfers and Nutrition: Pathways and Emerging Evidence, Presentation made at the Lunchtime Conference at the External Cooperation Infopoint in Brussels, 20 March 2012, Brussels: European Commission. F

21 22 malnutrition in bangladesh FOOD SECURITY project, they often could not afford to buy enough food. enough buy to afford not could often they project, Improvements Household Resulting (Stimulating in Economicfrom the SHIREE Empowerment) agarage up set to agrant received parents her Until coconut. ahomegrown up holds Naima and diet diversity.security food pathway: access,under this food We lookkey at the drivers of malnutrition protection. social developmentthe of nutrition-sensitive pathway this on for implications and the of protection social impact known the in Bangladesh, of household food security we context section explore the this In turn. pathwaya closer nutrition lookin at each take to istime it in Bangladesh, nutrition for protection social of nutrition-sensitive weNow potential that are the on clearer 4.1 Photo: Patricia Kapolyo/Save the Children

N utrition

athway Bangladesh. of areas most in levels demand of current meet to sufficient is agriculture subsistence and systems barter from markets, available food that suggests Research life. healthy active an for living quality adequate of food enough to access through nutrition on impacts security food Household RIVERS DIVERSITY DIET AND SECURITY FOOD ACCESS, FOOD EY in T temporarily or permanently become too high. high. too become permanently or temporarily don’tthey money, have prices food enough when or when fail, owncrops households’ when occur can This affordable. not is it available, being food despite when, he B

ang k : HO 108

ladesh d Food insecurity therefore arises mainly mainly arises therefore insecurity Food USEHOLD USEHOLD

o f

107 m

alnutrition

Agriculture in Bangladesh utrition

Agriculture in Bangladesh is dominated by small produced pulses, oilseeds and fruit. For these and marginal farms and production for subsistence reasons, despite recent gains in food production,

rather than sale. A large proportion of cropped Bangladesh still relies heavily on imports. In the i mpacts land is given to rice farming. This means only a five years leading up to 2011, 70% of pulses and limited percentage of domestic crops circulate 66% of edible oil were imported and imports of through commercial channels. Therefore, many food grains fluctuated between two and three : people are unable to acquire domestically million tonnes.109 t he

p otential

Bangladeshi households are very vulnerable to such and resorting to unsustainable means such as loans changes (see Figure 8 below). The poorest 40% or selling assets to obtain food). In 2012, when prices

of households in Bangladesh spend 60–70% of had fallen, the rate of food-insecure households fell f

110 s their entire consumption budget on food. to 56% – still more than half of all households. ocial This compares to the poorest 20% of households in In both years, the rate was much lower in urban the UK, whose share of budget for food is only 17%.111

areas (48% in 2011, 41% in 2012), and much higher in p When rice prices were at a high in 2011, 69% of rural areas (72% in 2011, 59% in 2012). Rates were rotection Bangladeshi households experienced some also particularly high in the regions where stunting food insecurity112 (such as eating less preferred is highest, ie, Barisal (77% in 2011, 59% in 2012) and foods, eating less food than desired, skipping meals, Sylhet (79% in 2011, 64% in 2012).

f or

n utrition Figure 8 Household food insecurity by group, 2011 vs. 2012 National, 2012 National, 2011 Urban 56% 69%

i Dhaka n B an Rajshahi gladesh

National

Rural

Khulna

Barisal

Chittagong

Sylhet

2012 Rangpur 2011 0 10 20 30 40 50 60 70 80 90 % of households

Source: Food Security Nutritional Surveillance Project (FSNSP) 2011/2012113, 114 Notes: % of households having experienced food insecurity according to FSNSP’s Household Food Insecurity Access Scale

23 24 malnutrition in bangladesh By • Poor ROTECTION • security: food and protection social between Th S (64%). areas rural in (41%) than areas urban lower in much was It (70%). (71%) Rangpur and Barisal in higher considerably was women among groups fewer or food four of consisting diet diverse inadequately an consuming were women 2011, In 9above). Figure (see women among 61% diversity for dietary are visible patterns Similar 2011 FSNSP Source: ocial Chittagong F ere is a great deal of evidence supporting the link link the supporting evidence of deal agreat is ere the 2008 food price crisis. crisis. price food 2008 the during Bangladesh in experienced those as such im food. fro igure National Rangpur Rajshahi Khulna proves households’ ability to absorb shocks, shocks, absorb to ability proves households’ Barisal m social protection programmes to purchase purchase to programmes protection m social Dhaka Urban Sylhet i ncreasing Rural

. The prevalence of inadequately diverse diets diets diverse inadequately of prevalence . The

117

h p ouseholds

9 0

I nad 115

f ood

e u

q se s ecurity, 10 ua

m a

nd ost te

f s di f ocial ood

t he etar 20

c p

ash rotection s % o ecurity y

f women consuming 4 or fewer food groups food fewer 4or consuming f women t ransfers di 116 30 v

rsit o

f y Social • social transfers. and security security, food nutrition between relationship the outlines page 10Figure next the on Food • 40 am en attainment. educational increasing school attendance, children’s and development cognitive support practices nutrition and feeding child adequate and security fromfood resulting gains nutritional labour. physical Indirectly, demanding endure to workers enables intake caloric Directly, proper productivity. labour to contributions indirect and direct both make security food increased to have been implemented. programmes protection social where areas in food for demand market in stability increased of result lo

ng-term productivity. courage food production, food courage ong

s t ecurity ransfers,

w 50 120

omen

i s

w a n hether

i mportant , 2 60 119 011

61%

Gains in nutrition due due nutrition in Gains i n

118 c ash

thought to be the the be to thought p rerequisite

70 o r

i n

k ind,

o c 80 an

utrition National, National,

Individual level Individual i Household level mpacts sub-national and community level Living environment Living : t he

p ✕ otential Health status Health

o f

s ocial Healthcare y

p rotection ecurit s

Food qualityFood ood f

f or Food utilisationFood Nutritional status Nutritional nd

n Nutrition security a

utrition Care and feeding practices

Food acceptabilityFood i utrition n n B ✕

an Social-economic, political, institutional, cultural natural and environment gladesh Food securityFood Food consumption Food Household income Food supply chains supply Food etween Food and agricultural system agricultural and Food Household livelihood strategyHousehold livelihood b

Food affordabilityFood nks li he Household food consumption food Household t

Food availabilityFood erstanding nd U

1 igure Source: Cherrier, 2012. and Transfers Social Nutrition: Pathways Evidence, Emerging and Presentation made at the at Conference Lunchtime External Cooperation the Infopoint in Brussels on 20 March 2012, Brussels: Commission. European Nutrition security of outcome an is good health, a healthy environment, good caring practices and household-level food security. Food security exists when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life. F 0

25 26 malnutrition in bangladesh transfer programmes, Fiszbein and Schady and Fiszbein programmes, transfer cash review conditional of comprehensive their In improving. measures security food three of out 0.5 only of average an had nutrition on effect no found but looked the evaluations where programmes the figure, the of end other improving. At the security food of aspects three of out 2.3 of average an with increases, of number highest the had wasting and stunting both in improvement an was there where Programmes effects. nutrition different reporting programmes were improved in average on three) of maximum a 11Figure (to aspects showshowthese of many review literature our in programmes the of all Almost on the Source: Save the Children calculation based on literature review. See Appendix C for literature review references. review literature Cfor Appendix See review. literature on based calculation Children the Save Source: programmes included in this review, this in for also included but programmes transfer cash for conditional only not case the is This countries.” some in amount –by asubstantial have poverty reduced levels and “Transfers… consumption have raised consumed or consumption expenditure. calories and fromstaples, food of percentage diversity, dietary programmes: 22 acrossthe security food of aspects three in forlooked improvements review The insecurity. food reduce therefore and 1 F

Average aspects of food security improved (maximum is 3) igure

2.5 2.0 0.5 1.5 1.0

h 121 impact 0 ousehold enable households to purchase more food food more purchase to households enable 1

euebt Reduce stunting Reduce both e ffects

2.3 of

social

o ood f

f ood

not wasting

protection s ecurity 2.2

s 122 ecurit 123

write: write: y Reduce wasting o not stunting

n same amounts. amounts. same the by about consumption increasing results, similar have vouchers food and transfers cash transfers, food little: matters review, they countries modality well. and Yohannes Hoddinott as diversity dietary cases, most in but, increased is that calories of number absolute the only not is It aid. food of review. our in true is included same The programmes Bangladeshi various the in applied approaches other and the programmes unconditional micronutrient adequacy. adequacy. micronutrient higher necessarily security, not food higher to only linked been level has at household diversity Dietary adequacy. micronutrient higher linked to have been level at individual measures diversity dietary only that mind in keep to important also is It foods. more consuming may be people even though quality diet in improvements no may find consumed foods the of value nutritional score the that why studies explain may This consumed. food each of amount the account into taking not consumed, foods different of number the of counting simple on based measures diversity dietary most with diversity, dietary in improvements Yet note insecurity. food also programmes many of identifier an as usefulness its out point and availability, caloric and consumption household to

2.0 n 124 utrition Gilligan and colleagues and Gilligan Nutrition not not Nutrition evaluated 1.8 125 126 find that in the three three the in that find link dietary diversity diversity dietary link No effect on nutrition nutrition on effect No (either or both) or (either 0.5 4

Implications for nutrition- this report, although it is a vital part of nutrition- N sensitive social protection sensitive social protection, targeting food utrition security alone is not sufficient to address the in Bangladesh underlying causes of nutrition. • Policy-makers must consider the modality

• The analysis presented in this section i demonstrates that, in general, more income of transfer and how it impacts on food mpacts does lead to increased food security. There security (see Section 8 for more detail on is also evidence that increased income is a major the design implications of social protection

programmes). A recent study on modality : contributing factor to reduced stunting rates, t he both in different countries and in different regions undertaken by the International Food Policy

127 Research Institute (IFPRI) shows that different p within South Asia. In some cases this translates otential into increased dietary diversity. combinations of support impact differently on the • However, the nature of this relationship and types of nutritious food consumed. For example, the challenge that social protection must programmes with both transfer and behaviour

change communication (BCC) components saw tackle are more complicated. Even when it is o

greater consumption of diverse food groups f

measured very carefully using household surveys, s 128 increasing household income may not provide compared to ‘food’ alone and cash alone. ocial enough appropriate assistance. This is because IFPRI also found the size of the transfer relative to household income to be tremendously

in different geographical locations the lowest p income needed to eat nutritious food is different. important in achieving sustainable food security rotection 129 Also, importantly, as we see in other areas of or livelihood improvements.

f or ldren

n hi C utrition he t

ave /S tcher

le i n F B ren an ar : D : gladesh hoto P

Children at a nutrition class in the village of Baroikhali, south-west Bangladesh.

27 28 malnutrition in bangladesh Children at a school in Pukra, Habiganj district. Women’s education is correlated with better nutrition outcomes. nutrition better with correlated is education Women’s district. Habiganj Pukra, in aschool at Children behaviour. and young child feedingand health-seeking women’s pathway: under this infant status, We lookkey at the drivers of malnutrition protection. social nutrition-sensitive for developmentimplications the of pathway, this on protection and the of social impact known the in Bangladesh, for women and practices childrencaring of we context section explore the this In CHILDREN WOMENFOR AND 4.2 Photo: Abir Abdullah/Save the Children

N utrition

p athway children and caring for them on a daily basis. adaily on for them caring and children breastfeeding and birth giving rolein their of because women on is pathway this within focus the of Much section. throughout this explored as education, and services health food, to access poor their to due generations the RIVERS Wo W EY in T during illnesses. during healthcare seeking to breastfeeding of duration –from children give their they care of quality the on and post-partum and pregnancy during receive themselves they care of quality the on effects positive Women’s innumerable has attainment educational he omen B men’s low status in Bangladesh passes through through passes men’s Bangladesh in low status : CA

ang k ’ s

ladesh d tatus

RING PRACTICES PRACTICES RING 131

i n

ociety o f

m alnutrition 130

Education Bangladesh has seen huge increases in primary N

Better education status for women is correlated school enrolments among girls, with the rate more utrition with better nutrition outcomes in a wide range than doubling between 2000 and 2005 and reaching 136 of developing countries.132 This is certainly true in 90% by the end of that period. Yet this has not Bangladesh, where Zayed and colleagues133 found yet filtered through to an improved status for adult

i the extent of a mothers’ primary and secondary women. Analysis shows that women go without mpacts education had a negative effect on the probability of food considerably more often than men at her child being stunted. Secondary education was times of food insecurity. : the more important of the two. They concluded Women’s education is also positively t he that meeting Millennium Development Goal targets associated with later marriage. This is partly

p on stunting would require continued effort by the to do with girls and women dropping out of school otential Government in offering incentives to get girls into when they get married and partly to do with more- secondary education. educated girls being less likely to enter into child 137 Women’s education is also related to the two risk marriage. Among women aged 20–24 (in 2012),

Plan138 found that 86% with no education were o

factors related to stunting at birth, which is a major f

married by the age of 18, lowering slightly to 79% s

concern for Bangladesh. ocial for those who had completed primary education, Bangladeshi women with more education are and dropping significantly to 26% for those who significantly less likely to be undernourished completed secondary education or higher. This is p rotection (Figure 12). In fact, the chances of a pregnant woman important for nutrition due to the links between being so thin that her baby is at risk of intra-uterine young marriage and young motherhood, and resulting growth restriction (mid-upper arm circumference consequences for stunting at birth. (MUAC) <230mm) falls from 38% for a woman with

no education to just 4% for women educated to f post-Secondary School Certificate level.134 or

n utrition

F2igure 1 Percent of pregnant and non-pregnant women undernourished, by education, 2011

i 40 n

38% B an

35 gladesh

31% 30 29%

29% 25% 25 26% 24% 21% 20 21% % of women 15 12%

10 12%

Non-pregnant 5 women underweight 4% Pregnant women 0 (MUAC <230mm) None 1–4 years 5 years 6–9 years 10 years Post SSC

Source: FNSNP 2011135

29 30 malnutrition in bangladesh households with pre-school children pre-school with households twenty in one than less in decision-makers principal were the Bangladesh 2001,In rural in women visiting (see Figure 13). 13). Figure (see visiting family and women’s purchases, healthcare household on decisions of control sole retain men households, of situation does not appear to have changed. have to changed. appear not does situation Source: Save the Children calculation based on the 2011 Demographic Health Survey from Bangladesh and the CIA World Factbook 2011. Factbook World CIA the and Bangladesh from Survey Health 2011 the on Demographic based calculation Children the Save Source: decision-maker amale with households have even than they alower if income status, nutritional abetter enjoy and food, of choices better make care, medical and food on householdsmore spend decision-makers, principal the are women when that shows family. Research for their care to able are better they decisions household in participate women When Decision-making society outside the extended family. extended the outside society with interactions of majority for the are responsible men general, In men. than decisions over household have control they and less men than less earn they men, than educated less remain Women Bangladesh in 3 F

% of women or men igure 40 20 50 60 30 70 10 0 1

G 53% Literate en der 62%

i mbalances women’s health of spending on on spending of 141 Sole control 140 In around 30% 30% around In 7% and the the and 30%

i n . 139 B

an gladesh of large household In Ecuador, a programme that targeted transfers to to transfers targeted Ecuador,In that aprogramme by women, children are more likely to benefit. are to likely more children by women, are controlled resources when show that also Studies away being fromhome. or work, with preoccupied being man the and home the to close very being amarket as such important, be to seem conditions certain instances these in but purchases, making women of are examples There place. his in market the go to to spouse for his rare is it responsibility; that on take will family the in man go, another cannot household the of head male the family. for any reason If for their market at food the buy to income household use who men is it that found Kulna district in men among motivation purchase market into study A recent buy can wage daily aman’s that food of amount the half only buy can wage awoman’s average, daily on Bangladesh, In contribute. they resources the linked to closely is households in ability Women’s decision-making daily food basket is 5.2 compared to 2.6 for women. for women. 2.6 to compared 5.2 is basket food daily atypical of cost men’sdaily of to ratio wage daily Sole control purchases 13% 31% , 20 11 . In 2011,. In FSNSP of decisions on on decisions of visiting family Sole control 10% 29% 142 found the the found Men Women 144

143 4

poor rural mothers led to substantial improvements I nfant aND young child feeding N in child outcomes, particularly among the poorest As widely recognised, and not at all surprisingly, utrition 145 children. Social protection transfers put in the infant and child feeding is important for hands of women lead to greater nutritional gains nutrition among young children. Across for the household; the same trend applies to wages. Bangladesh improvement is needed in this area.

i This is due to their increased ability to make mpacts decisions to obtain better healthcare and food for Figure 15 on the next page compares stunting among their children. children in Bangladesh receiving different types of

feeding, with the ideal or desirable feeding practice : t

Health-seeking behaviour in purple and the less desirable practice in blue. For he

these four different aspects of feeding, getting it right p

Education has a positive impact on health-seeking otential reduces stunting. behaviour. Zayed and colleagues146 found that, in addition to directly affecting stunting, mothers’ Looking more closely at 6–23-month-old babies secondary education increased the effectiveness receiving a minimum adequate diet and being breastfed,

of healthcare provision in Bangladesh. As Figure 14 and at two- to four-year-old children eating a diverse o f demonstrates, primary and secondary education diet consisting of four food groups or more, the first s is associated with improved antenatal care, thing to notice is that there is room for improvement ocial births supported by skilled attendants, health- on both measures. Nationally, only 35% of babies

seeking behaviour when children are ill (acute age 6–23 months get the minimum adequate p respiratory infection and diarrhoea), and early breastfed diet,147 which feels far away from the World rotection initiation of breastfeeding (gains linked to primary Health Assembly target of exclusive breastfeeding rates education only). in the first six months of at least 50% by 2025.148 For

f or

F4igure 1 Health-seeking and early initiation of breastfeeding utrition by women’s education, 2011 90

80 i n B

70 an gladesh 60

20 None Primary 10 Secondary % of women or births or children at appropriate age 0 or higher Antenatal Births Children aged Children aged Early Children aged care coverage attended by 6–59 months <5 years with initiation of <5 years with – at least one skilled birth that received ARI symptoms breastfeeding diarrhoea visit (in the attendant (in vitamin A taken to (in the receiving oral three years the three supplementation facility (%) three years rehydration preceding the years prior to preceding the therapy and survey) (%) the survey) survey) continued feeding (%)

Source: Save the Children calculation based on the 2011 Demographic Health Survey from Bangladesh and WHO 2014150

31 32 malnutrition in bangladesh 69% in Dhaka, the best region. region. best the Dhaka, in 69% 61% to and compared nationally 47%, scores Sylhet children, older in diversity diet On region. best the Chittagong, in 39% and nationally 35% to compared diet, breastfed adequate an get region that in babies not good enough. are practices feeding where aregion as out stands Sylhet average. national the than worse considerably doing regions some with measures, both in acrossregions variation of alot is There is diet diverse 61%. asufficiently getting proportion the old), years four to (two children older 2011 FSNSP Source: child malnutrition between 1970 between 1995. and malnutrition child in reduction total the of for 43% accounted education, female of aresult as farming, productive more that revealed Institute Research Policy Food International by the 63 countries on child nutrition outcomes. nutrition child on OTECTION impacts positive have can extremely programmes protection social in gender Prioritising and S 5 pr F igure ocial % of children 40 20 actice 50 60 30 10 0

ge 1

food diversity, diversity, food

pr nder 6–23 months 6–23 P 151 Adequate 40% , 2 , re 011 v Only 21% of 6–23-month-old 21% Only 6–23-month-old of 34% al ence 152

o A study across Astudy

f Minimum diet 6–23 months 6–23 (breastfed), (breastfed),

s 39% 149 tunting 34% 153

b y i Meal frequency, frequency, Meal nfant in the country.in the rates birth in decline significant the to contributed have to are recognised trends These methods. contraceptive of use the in and market labour the in participation clothing, and medicine goods, durable of purchase decisions, powerand family in autonomy acquire greater to noted have been women These programme. the of ‘cardholders’ the majority, large the in are, beneficiaries women where Brazil, in clearer is picture The recognition of women’s roles. Some also describe women’s describe of also recognition Some roles. agreater including programme, transfer cash acrisis &Atención, Social Red Protección de the of aresult as recognised been has empowerment women’s increased Nicaragua, in Similarly although this is not as clear in quantitative analyses. quantitative in clear as not is this although have effects, to positive this found has programmes women. of hands power the in other or transfers by putting empowerment female facilitate to were designed review our in included programmes 22 the of Many wo on the 24–59 months 24–59 3 or more, more, 3 or 44%

men c impact 42% aring

a Q nd

a ua 155 nd litative research on cash transfer transfer cash on research litative

of hild pr

c 24–59 months 24–59 actices Food groups,

hildren social 4 or more, more, 4 or 50%

f eeding 38%

protection f or

Y No e s 154

more equality between men and women as a result economic and social empowerment by enabling N of the transfer programme.156 some women (specifically those in female-headed utrition households) to take more control of the household Many of the programmes in Bangladesh, including budget and increase their potential for undertaking SHOUHARDO and Jibon-O-Jibika, have also been income-generating activities. However, there is associated with greater female empowerment. i also evidence, particularly from the qualitative mpacts Care157 argues that the impressive achievements research, that for individuals this has the unintended of SHOUHARDO in terms of reduction in consequence of creating tensions within households, chronic malnutrition could not have been especially between female Hunger Safety Net : achieved without the remarkable achievements in t Programme recipients and their husbands.160 he women’s empowerment. IFPRI’s research on the

p most beneficial form of transfer showed that for Drawing upon the results of our literature review,161 otential participants in the south of Bangladesh, two-thirds the results are counter-intuitive. Programmes162 where reported participating more in making decisions there was no measured effect on these indicators about spending and 70% felt their status within the of women’s empowerment, in the bottom panel of household had improved as a result of the transfer.158 Figure 16, were more likely to see a measured impact o f

on nutrition. On the other hand, the bars in the top s However, impacts vary across programmes. Soares ocial half show that in programmes where there was a and Silva159 agree that programmes do some good measured improvement in the women empowerment things for women, particularly in freeing them to be

indicators, the likelihood of seeing an improvement p better mothers, but note that this focus can also rotection in nutrition was much nearer to 50–50. However, we entrench traditional roles. In Kenya, the Hunger remain assured of the relationship between women’s Safety Net Programme is noted to benefit women’s empowerment indicators and nutrition.

f or

F6igure 1 Women’s empowerment and effect on nutrition utrition

Primary enrolment for girls improved

i n B

Improvement in an women’s decision-making gladesh

Money delivered to women

No enrolments improvement reported

No decision-making improvement reported

No nutrition Money not specifically effect measured targeted at women Some nutrition effect measured 0 2 4 6 8 10 12 Number of programmes

Source: Save the Children calculation based on literature review. See Appendix C for literature review references. Notes: The measures here on whether or not money was delivered to women and whether or not there was an improvement in women’s decision-making were constructed according to whether or not these things were mentioned in the review tables or summaries. The review did not look for them specifically.

33 34 malnutrition in bangladesh in the review tables or summaries. The review did not look for them specifically. them for look not did review The summaries. or mentioned were tables things review the these in not or whether to according constructed was impacts or design in feeding infant on here measure The Notes: references. review literature Cfor Appendix See review. literature on based calculation Children the Save Source: window Targeting 1,000-day the vital. is nutrition household rolein their men’s and addressing that perceptions mean roles transfer stops. Bangladesh’s entrenched gender the when ends women’son often empowerment progress that suggests fromBangladesh Experience change. for long-term important particularly is alongside women’s empowerment This activities. considered be should activities awareness-raising nutrition and change behaviour in involving men protection, social nutrition-sensitive to relation yet in as this on evidence little is there Although effect. an up pick cannot evaluations so the outcomes, nutrition to through filter to time along women’s takes empowerment that may be It bad. quite already was women of plight the where women’s in places in made empowerment were investments greater that be could It operation. its during else or two), or a year just (after finished has programme the after soon quite out carried are evaluations programme most that observation the on rests results for the explanation A plausible improve breastfeeding and infant feeding practices practices feeding infant and improve breastfeeding to order in two age under children and women 7 F Breastfeeding methods methods Breastfeeding methods Breastfeeding breastfeeding methods methods breastfeeding igure Measured increase increase Measured design or impacts impacts or design Infant feeding in in feeding Infant in breastfeeding breastfeeding in 1 Breastfeeding Infant feeding feeding Infant breastfeeding not evaluated evaluated not evaluated not not evaluated infant feeding feeding infant No effect on on effect No No effect on on effect No on effect No

c improve improve aring

p ractices 1

163 for pregnant for pregnant 2

f 3 or

umber of programmes c 4 hildren

was experienced more often than not. However, not. than as often more experienced was effect 17 Figure of nutrition apositive panel below), bottom the (see practices caring in improvement was there where programmes In difficult. comparison making therefore for children, practices caring on programme of majority the unfortunately, that, we find Exploring the results of our literature review, literature our of results the Exploring engaging mothers-in-law in addition to mothers. in mothers. addition to mothers-in-law engaging from any improvements report interventions few Asia, South of context the in especially recognised, been long has caretakers other of role the Although husbands. and mothers-in-law as such family the in caregivers other among sanitation hygiene and nutrition, about awareness improved on reports that programme only the is Jibon-O-Jibika care). prenatal of rates higher well as as pregnancy during rest and food (more women and pregnant breastfeeding) children (including young for both practices caring in improvements significant report programmes Both programmes. Jibon-O-Jibika and SHOUHARDO for the prevalence improvement significant stunting in the may explain life in early practices caring Better growth. linear in improvements significant to lead also to likely is

a 6

165 7 e

ffect evaluations did not include measures measures include not did evaluations 8

o n 9

n utrition 10 effect Some nutrition effect nutrition No 164

the number of programmes included is small, the 1,000 days N figure is not conclusive. The impact of caring practices • The incorporation of the 1,000-days utrition on nutrition is not debated, however; the issue here approach into social protection is in relation to effective monitoring and evaluation of programmes is critical for nutrition. nutrition-sensitive social protection programmes. • Policy-makers should incorporate BCC activity

i on caring practices for pregnant women and mpacts their children during this window. For some Implications for nutrition- activity, such as income generating and enterprise, : sensitive social protection expectations of women during pregnancy and the t in Bangladesh period after birth must be treated sensitively as he

their availability will be limited. otential Women’s empowerment • Currently, only two safety net social protection • It is essential that nutrition-sensitive social programmes in Bangladesh target pregnant and protection programmes in Bangladesh lactating mothers, with a total coverage of less

tackle the issue of women’s empowerment than 165,000 women, representing 0.13% of all o f

households in Bangladesh receiving safety net

alongside other underlying determinants s of malnutrition. transfers. In most of the schemes, the transfer ocial • Policy-makers should take note of IFPRI’s study value is too low (eg, BDT 350/month) to have a

on women’s empowerment in agriculture, which meaningful impact. Apart from school stipends, p concluded that, in general, for Bangladeshi no programme addresses the needs of young rotection women, policies and programmes people, particularly adolescent girls at risk of early must address the three domains that marriage and undernutrition.168 Increasing the contribute most to disempowerment: coverage and scale of programmes in this area

should be a priority.

weak leadership in the community, lack of f control over resources, and lack of control or

166 over income. Specifically, social protection Behaviour change communication n utrition programmes, as well as wider nutrition initiatives, Including behaviour change communication must give more attention to empowering women (BCC) in nutrition-sensitive social to make decisions that promote the nutrition and protection measures, to tackle both

health of their families. women’s empowerment and the ‘1,000 days’, i • Income-generating and enterprise activities n is important. IFPRI’s modality research in B

should be tailored towards women, providing Bangladesh confirmed that if the policy objective is an

additional training where needed, to allow to improve the nutritional status of poor children, gladesh women to gain the business skills and the transfers alone are inadequate.169 confidence to succeed. Women are shown to The BCC training that accompanies IFPRI’s study consistently invest their earnings in their children covers basic nutrition, control and prevention of and families, so the entire household benefits. Basic micronutrient deficiencies, infant and young child entrepreneurship training, small-scale livelihood feeding practices, healthcare, maternal nutrition, and inputs, and peer support all help women gain hygiene. Women receiving the transfer attend the confidence, independence and lifelong livelihood training. Family group meetings share BCC messages skills.167 The approach must be sensitive to the with mothers-in law, pregnant and lactating mothers, diversity among women and acknowledge the fathers, and other influential family members.170 implications of the different stages of their lives. However, it is recognised that more research is • Recognising different gender roles is important. needed to explore exactly how this BCC should Although not as evident in the data presented be delivered and to whom, and what the resulting here, entrenched cultural roles in Bangladesh impact might be. are unlikely to change any time soon. Therefore, involving men in behaviour change communication (BCC) and nutrition awareness-raising activities is essential and should be programmed alongside women’s empowerment activities.

35 36 malnutrition in bangladesh Panna, 25, had suffered two miscarriages before her daughter, Sriti, was born at the rehabilitated clinic clinic Habiganj district. in Shibpasa, rehabilitated the at born was Sriti, daughter, her before miscarriages two suffered had 25, Panna, ,000 nu W young and stunting motherhood marriage, Trends analysis. in-depth in childwarrant and children highlightedthat some areas reviewOur of women practices caring of the y 4.2.1 In • Stunting • Half • H ou hy eadlines trition growth retardation. growth th of the birth. the of h is bir child marriage. child

in that their foetuses faced a moderate risk of of risk amoderate faced foetuses their that in 1 2 th, igher if the mother was under 18 under time at was the mother the if igher 011,

ng of

171

all a likely consequence of high levels of high of consequence alikely

SPECIAL Ch FOCUS:

o and

ne stunting d

173

i m i wasting n ays n

172 f our B ot

an in

a 174 p

among regnant under-fives nd h gladesh

er w

children

w omen omen

s occurs

under w ere ’

s before

s five mpowerment o

s il tunting Pregnant • Adult • sensitive social protection in Bangladesh. sensitive in Bangladesh. protection social forconsider implications their nutrition- in order to understood be to need at birth d women. their consumption. wi to b to

thout food when households need to reduce reduce to need households when food thout m e undernourished than non-pregnant non-pregnant than e undernourished

women 176 arriage

women

re are

are a almost c 175 t ritical

more b

always

, ir than t

the twice f h or

first

to likely

hi C t ave /S med h A r anvi T : photo ldren he 4

Bangladesh has achieved considerable progress in Hevelsigh l of stunting at birth N reducing maternal and child mortality. It has also utrition increased the rate of girl’s enrolment in universal Stunting rate of newborn babies primary education. However, the high rate of child by age, 2011 marriage (below the age of 15) is one of the highest

i in the world and shows that much more needs to be Stunting rate (%) Sample size mpacts done to empower women and adolescent girls.177 Month 0 20 51 The major underlying causes of the high rate of : child marriage emanates from the traditional Month 0–1 19 192 t he patriarchal and rigid social structure. Poverty,

p dowry and increasing sexual harassment in society Month 1–2 17 318 otential are some other major causes behind the increase Source: Save the Children calculation based on the Demographic Health 178 in early marriage. Survey (2011) from Bangladesh Note: This table shows stunting rates of newborn babies in Bangladesh

As 64% of women aged 20–24 are married by age o 179 before the age of 18, pregnancy among very f

s young women continues to be a serious problem Around 20% of babies in Bangladesh are ocial in Bangladesh. When girls marry young they often born stunted (see table above). As mentioned become pregnant before their minds and bodies previously, this is half of all stunting in

p are fully developed for childbirth.180 Pregnancy under-fives. rotection is the number one cause of death among young Due to the small sample, it is important to treat women aged 15–19 worldwide. Child marriage the stunting rate for ‘month 0’ with some care. disproportionately affects many more girls than boys However, the stunting (or ‘small for gestational age’) and reinforces the gendered nature of poverty, with

rates for months 0–1 and months 0–2 help verify f limited education and skills lowering the potential of or the figure. A detailed survey on food availability the girl, her family, her community and her country. and nutrition, carried out by the Food Security n These impacts extend throughout adult life and into utrition Nutritional Surveillance Project (FSNSP) in 2011 the next generation.181 (see Figure 18), revealed the same pattern. Young motherhood increases the risk of intra-uterine For babies aged 0–2 months, data showed 182 growth retardation (poor growth of a baby while in that 24% were stunted. Therefore, of the i n

the mother’s womb), leading to stunting at birth. 3.15 million babies born in Bangladesh in 2011, B an gladesh

F8igure 1 Stunting Rate of children under 5 by Age, 2011 50 46% 47% 47% 45 40% 41% 40 38%

35 32% 30 24% 25% 25 21% 20 Stunting rate (%) 15

0 0–2 3–5 6–8 9–11 12–17 18–23 24–29 30–35 36–47 48–59 Age in months

Source: FSNSP 2011183

37 38 malnutrition in bangladesh stunting in under-fives occurs before birth. before occurs under-fives in stunting Source: FSNSP 2011 FSNSP Source: anyWe draw information to unable have been undernourished. being born babies of chance the reduce to are taken measures that imperative is It born. have they been after only children target cannot undernutrition on action Bangladesh, in that clear is It age. of years three around 47% of at amaximum to for 0–2-month-olds 24% from increasing proportion the with stunted, be to are likely more they grow older children as that see we childhood, in rates stunting we explore When stunted. born havewill been babies 757,000 and (24%) (20%) 622,000 between babies experience intrauterine growth retardation. retardation. growth intrauterine experience babies their aresult, as and, themselves undernutrition of rates from high suffer women pregnant that is second The pregnant. becoming and married getting girls adolescent or young of women prevalence ahigh has Bangladesh that The iscommon first explanations. However, stunted. are born who are two there babies of 20–24% the of characteristics reveal the and further examine confidently to us allows that 9 at F igure

b irth 1

Undernutrition rate (%) U 40 20 25 45 50 30 35 10 15 188 0 5 nd

ernutrition 184 46% S However, all of half tunting 39%

o f 185

c hildren 186

15% Wa 1992 2007. and 18 between 15-year 19 to the period in old, years year, one by only increased from 20–24 aged women by reported birth first of age median The babies. having begin women at age which the in change little very been has there malnutrition, addressing in made has Bangladesh progress the all For action. society civil and for policy area overall stunting and birth at stunting both in areduction be might there over were they 18 children, having before until waited women if that suggests This 41%. of average national the than higher considerably was 18 of age the 2011 under in women to stunted born children of 46% The 19). Figure (see baby’sher birth OTHERS 18 of under time at was the mother the if higher is five under children among wasting and Stunting chil Y sting

oung u 11% nder d

m a arriage ge 187

5 b Mother older than 18 than older Mother 18 than younger Mother y m

aternal a nd . This is an important important an is . This

a ge

Part of the problem is that Bangladesh has had solvent grooms decrease, as girls get older. This puts N a consistently high rate of child marriage for poor families under a lot of financial pressure to utrition some time. Despite the legal minimum age for arrange marriages early.192 Plan’s survey also asked marriage being set at 18, in 2011 around 50% of about the consequences of child marriage. Around adolescent girls189 surveyed who were under 18 were 44% cited early pregnancy as a consequence and

190 193 i already married. Additionally, in 2012, when Plan 49% said this was bad for the health of the woman. mpacts Bangladesh asked 5,400 women of different ages There has been some improvement in the rates of how old they were when they got married, 1.6% marriage at very young ages. In Plan’s survey, the reported being married before age 11, and a further : older women were much more likely (around 40%) t 30.6% were married between the ages of 12 and 14.191 he to have been married before the age of 15 than were

Focus groups revealed some of the reasons for child p the younger women (closer to 25%) (see Figure 20). otential marriage. The belief was expressed that dowries But the prevalence of marriage below the legal generally increase, and the number of financially

o f

s C hild mARRIAGE and children’s rights in Bangladesh ocial

Child marriage is a serious violation of human In September 2014, the Government of Bangladesh

194 p

rights. A 2013 report by Plan Bangladesh proposed amendments to the Child Marriage rotection examining child marriage found that despite Restraint Act 1929, primarily that the minimum widespread awareness in rural areas about the legal age of marriage for girls be lowered from legal age of marriage and the adverse consequences 18 to 16 years and for boys from 21 to 18 years. of child marriage, there is limited awareness of In response to public outcry and appeals by

child rights. Reports suggest that authorities human rights organisations, in mid-October the or seldom intervene to stop child marriages and Government announced that the legal age of

parents continue to marry off their daughters marriage would remain at 18 for girls. Plans for a utrition in secrecy.195 mobile court were also shared for the ‘visible and speedy’ trial for the crime of child marriage.196

i n B an

F0igure 2 Child marriage by women’s age in 2012 and by age at marriage gladesh 90 80% 78% 77% 80 75% 75% 70% 70

50 42% 43% 40% 41% 40

% of women 31% 30 25% 23%

20 Married before age 15 10 Married before 0 age 18 15–19 20–24 25–29 30–34 35–39 40–44 45–49 Current age

Source: Plan 2013197

39 40 malnutrition in bangladesh Figure 21).Figure FSNSP (see east the in Sylhet in higher much and country the of north-west the in lower Rajshahi/Rangpur in is considerably marriage first of age average The country the of parts different in different very is marriage child of prevalence The 18. before married were women of 70–80% period, that Throughout 2012. in forties were their in who women the of over lifetime much the 18 of age changed not has 2011 DHS Source: becomes pregnant. In 2011, In pregnant. becomes FSNSP a woman when overcome to hard quickly very is which general, in age child-bearing of women in undernutrition is problem the part, In retardation. growth intra-uterine of cause amajor be to known well is This women. pregnant among undernutrition is at birth rates stunting for high explanation Another pre U extent of undernutrition among 27,000 nationally 27,000 nationally among undernutrition of extent 15–19 married. currently aged girls adolescent of proportion the on data their in 2010 of study patterns similar found indicators and healthcare district-level socio-demographic by 15. were married Bangladesh The 30% almost by 17, age were married region that in girls and adolescent of 60% around that found It detail. more 1 F ndernutrition Rajshahi/Rangpur igure gnant Chittagong 2 Khulna Barisal Dhaka Sylhet

13.5 edi w 198 investigated Rajshahi/Rangpur in in Rajshahi/Rangpur investigated

omen an

ge am 14

a ong t 199

f explored the the explored irst 14

mar riage 14.9 1 5

15.1 suggests that in a large proportion of cases the the cases of proportion alarge in that suggests evidence the Bangladesh in Unfortunately, conceived. was baby the when undernourished were already they if particularly are pregnant, they when food of variety and quantity alarger eat Women to need women pregnant many for required diversity diet and consumption Increased woman. adult an householdBangladeshi individual that is almost always a in consumption reduce to required is person 43% • According to FSNSP research, FSNSP to According food. of types all or some without going of consist generally which to strategies,’ adopt ‘coping first are the women adult times difficult in that shows evidence The limited. is supply when at times households within distributed is way food the is women in undernutrition of levels high the to led has that factors the of One household in the food ‘go to without’ likely Women more are almost • that: found It Bangladesh. in children have that age the of women and girls representative Age (years) Age

am ag or wasted). or malnourished 12 15 15.4 ed 19–49 were underweight 19–49 ed % .5 ong

o o 15.6 f the women aged 19–49 were chronically were chronically 19–49 aged women f the f

a g

irls t 25 hird

a –49-y 16 ged 200

(stunted) f

t 1 he 0–18 e

ar g 16.3 irls 16

a -

.5 nd ol a

ged 202

2 ds when only one one only when 2%

201 1 0–18 (malnourished (malnourished

o f 17

t he

a nd

w 17.2

omen 17 .5

F2igure 2 Amount of food consumed in pregnancy compared utrition to before (%)

i mpacts

1st trimester 32% 45% 23% : t he

2nd trimester 41% 42% 17% p otential

Less

3rd trimester 61% 31% 9% Same o f

More s ocial 0 10 20 30 40 50 60 70 80 90 100

p rotection Source: FSNSP 2011203 additional resources are not available or are not The pattern of eating by trimester (shown in

allocated to the pregnant woman. In FSNSP’s survey Figure 22) may partly explain why wasting at birth f of pregnant women, the majority actually reported is not as high as stunting at birth. Newborn babies or

eating less in the first trimester than they did before may be suffering from chronic undernutrition due n they were pregnant (Figure 22). As the pregnancy to their mothers not eating enough throughout utrition proceeds, a higher proportion of women reported the pregnancy. eating more, but there was still an alarmingly high The news on dietary diversity is also troubling as proportion of women eating less than they did

research has shown there is hardly any difference i before pregnancy. n B an gladesh F3igure 2 Undernutrition in pregnant women 45 43%

35 33% 31% 30% 30 28% 27%

25 23% 22%

Percent of pregnant undernourished of women Percent 5

0 Sylhet Barisal Rajshahi Khulna Rangpur National Dhaka Chittagong

Source: FSNSP 2011204

41 42 malnutrition in bangladesh re programmes. feeding should in included be emergency mothers from rural areas, are anaemic, areas, from rural those particularly Bangladesh, in mothers pregnant Sphere Project The 230mm. below mother’s MUAC falls pregnant a when ‘moderate’ to increases restriction growth intra-uterine of risk The variable. very naturally is women’s pregnant weight because (BMI) index mass body of instead used is which –ameasure status nutritional establish to (MUAC) circumference arm mid-upper at the by looking examined is This status. nutritional their of measures in clearly up shows women for pregnant diets Inadequate women pregnant in levels malnutrition of High women.and non-pregnant women for pregnant diets of diversity the between more than one in three. in one than more was rate the population, the of poorest 40% bottom the in and Barisal, and Sylhet In retardation. growth of risk amoderate faced foetuses their that so thin were nationally women pregnant (27%) four in one from2011 research Alarmingly, than more shows in Bangladesh. 7.9% to product domestic gross of contributes alone anaemia dueto economic productivity loss that suggest Estimates immunity. reduces children, of development brain and growth the impairs low birthweight, to contributes also Anaemia levels anaemia of High 12%. at only standing women non-pregnant for figure the with women, non-pregnant as measure by this undernourished be to likely as twice are than more women Pregnant are alarming. results the women, for non-pregnant undernutrition of measure same the to compared is women pregnant for figure 27%national the When to be undernourished likely as twice than more are women Pregnant mothers take iron tablets during pregnancy. during iron tablets take mothers productive age and more than one-third of of one-third than more and age productive 207 210 206 Forty-four percent of women of percent Forty-four recommends that at this point point at this that recommends 209 208 205 211, 212 yet only 55% of of 55% yet only 213

n of of ( a GDP) GDP) nd (particularly men). men). (particularly family pregnancy,BCC and for whole delaying pregnancy, during practices eating practices, eating gender-based transforming include Key elements mothers future as perspective a nutrition from girls adolescent target should activity BCC section, previous the in recommendations the on Building transfers. BCCof alongside importance the note again should Policy-makers groups. vulnerable key nutritionally girls women adolescent and lactating and pregnant targeting address malnutrition, effectively to programmes protection social into integrated be must empowerment women’s and window 1,000-days the impact positively that Initiatives nutrition. with concerned those only not policies, all to applies this – and capabilities and aspirations their fulfil and shape to them enable to investgirls in to crucial is it rights, protection programmes social in adolescents include to need makers policy- poverty, of cycles intergenerational and nutrition on impact positively to order in that mean young pregnancy and marriage child of rates high The generations. future and communities their families, their girls, of potential future the influence to period critical aparticularly is Adolescence Bangladesh. in protection social nutrition-sensitive of development the for priorities clear present motherhood and marriage of age the and pregnancy in levels malnourishment of The in se implications nsitive B ang ladesh

s ocial

f or

. In terms of human human of terms . In n otection utrition as as -

. 4

4.3 Nutrition pathway: HEALTH utrition ENVIRONMENT AND SERVICES

i mpacts

In this section we explore the context of Teyrivershe k d of malnutrition caring practices for women and children in Bangladesh : t in Bangladesh, the known impact of social he

W ater, sANITATION and hygiene protection on this pathway, and the p otential implications for the development of It is widely acknowledged that poor water and nutrition-sensitive social protection. sanitation, in particular open defecation combined with drinking surface water, breeds diseases We look at the key drivers of malnutrition

that affect malnutrition. Of particular concern is under this pathway: water, sanitation o a disorder of the small intestine called tropical f

s and hygiene, health and nutrition, and enteropathy, which is experienced in childhood. It ocial health services. thrives wherever there is open defecation, as faecal matter travels from children’s hands into their

mouths or drinking water. Tropical enteropathy rotection P hoto

f or : CJ C

n la utrition rke /S ave

t he C hi

i ldren n B an gladesh

Rohima, who is five months pregnant, receives her first antenatal check-up from Sita, a paramedic at the Poilarkandi health clinic in Habiganj district.

43 44 malnutrition in bangladesh are diarrhoea and parasitic infections (worms). infections parasitic and are diarrhoea children in growth affect that problems transmitted enable proper growth and development. can diet agood which upon foundation the is This are sick. they when treated being well as as hygiene, good and water clean by vaccinations, from disease and retain nutrients in food. in nutrients retain and children’s of absorb to bodies ability the impedes from the Rice Institute Rice from the another. one with Research are compared rates stunting different with countries when visible clearly is stunting and defecation open between link The nutritional status. achild’s undermines malaria, and measles pneumonia, ND diarrhoea, or persistent frequent particularly from malnutrition. children protect A go H 51% 43%. to from stunting, in saw a fall Bangladesh when 2007 and 2004 between aperiod with coincides sanitation on campaign national the of timing the Interestingly, consuming other people’s other faeces’.consuming we be will defecate, ‘if we openly that understand to were they helped and action, and planning of involved stages all approach’. in was community The sanitation a‘community-led called was what mount to together Government the and agencies international governmental organisations(NGOs), non- brought which 2003 in launched campaign anational with associated be can gains impressive 3% only to dropped had practice the of prevalence the but defecation, in three people open nationally practised 1990, In one defecation. open eradicating towards strides massive made has Bangladesh children. of height average lower the the defecation, open practising population of proportion adequate water source. now an use (85%) majority vast the but done, be to so workremains unimproved source, well other or ‘unimproved’ froman water drink still households of percent Fifteen Bangladesh. in eradicated virtually was water surface drinking of practice the dramatically, dropped defecation open which in period same the during story: success Another change. this about bring to helped sanitation ealth od diet is not enough on its own to to own its on enough not is diet od

a 218 It may be that the improvement in in improvement the that may be It

n 220 utrition Children need to be protected protected be to need Children 216 219 confirmed the higher the the higher the confirmed

b 214 y 2012. These Other similarly similarly Other 217 Infection, 215 creatively address future health challenges. challenges. health future address creatively and achievements health impressive country’s the underlie that innovations of generation first the of experience the on draw should agenda this out, sets universal health coverage. health universal towards strives it as innovations’ system health- of generation a‘second undergo to system Bangladesh’s for have called Experts malnutrition. and poverty deep including problems, acute faces still Bangladesh report, this in financial hardship. financial undue without them, receive care) palliative and rehabilitation prevention,(promotion, treatment, services health need who people all where performance system health of outcome desired the as defined been has coverage health Universal system, and widespread poverty. widespread and system, health aweak healthcare, on low spending despite achieved been has This story. success the of part all are control tuberculosis and coverage, immunisation expectancy, life age, of five under years children and infants of survival the in Improvements health. in progress for its commended been has Bangladesh protection • the • population: entire the benefit should that components interrelated two has coverage health Universal malnutrition include: malnutrition conditionsMedical contributeto can that for wellbeing. crucial is needed, is it when healthcare to He persistent • persistent • a • a • those • H persistent • ea po ser payments for health services. services. for health payments to d to or f alth coverage, and particularly access access particularly and coverage, alth or self-care or

lth m h liver disease liver ssible impoverishment due to out-of-pocket out-of-pocket to due impoverishment ssible ealth vices according to need to according vices

ental full igest food or absorb nutrients absorb or food igest

t s

hat spectrum ervices

224

c h ondition

ealth v d p

c fr omiting. ain iarrhoea ause 222 om 223

o c

r fi

a ondition 221 of

nancial

n t l ack hat ausea

good-quality

d o isrupts f

h a t ardship, hat 226 ppetite, As The Lancet As 225

But, as addressed addressed as But, ffects t

he essential

su ncluding b ody’s

ch a bility

a s

health a c 227

bility ancer

Central to the reform process will be the development T he iMPACT of social protection N of a multi-pronged strategic approach that: on the health environment utrition • responds to existing demands in a way that ensures affordable, equitable, high-quality and services

healthcare from a pluralistic health system 232

An important finding from our literature review i • anticipates healthcare needs in a period of rapid is that programmes that have achieved significant mpacts health improvements and social transition reductions in stunting have also addressed the health • addresses underlying structural issues that environment, resulting in infrastructure improvements.

otherwise might hamper progress. : Programmes from Bangladesh that have seen successes t he A pragmatic reform agenda for achieving universal include SHOUHARDO, Jibon-O-Jibika (although

p health coverage in Bangladesh should include: there were some issues with broken latrines) and otential • development of a long-term national human the Chars Livelihood Programme. resources policy and action plan Unfortunately, the information from our literature • establishment of a national insurance system review233 is very limited for programmes that saw

• the building of an interoperable electronic health o

a measured improvement in access to safe water f

information and monitoring system s

versus those that did not. This pathway indicator ocial • investment to strengthen the capacity of the was not evaluated for a majority of programmes. Ministry of Health and Family Welfare Therefore, it is hard to make strong conclusions in

• creation of a supraministerial council on health. p relation to these specific programmes. What we rotection Greater political, financial and technical investment to do know is, of the four programmes where access implement this reform agenda offers the prospect of to safe water was evaluated and there was an a stronger, more resilient, sustainable and equitable improvement, three measured some nutrition effect. health system.228 In the six where it was evaluated and there was no

effect, the chances of seeing impacts on nutrition, or or not, were even. This implies that if access to safe

Health protection schemes water is successfully achieved, impact on nutrition utrition is likely. Social protection impacts on health in many ways. A particularly important element is in relation to The disease environment also matters a great deal for wasting. While severe wasting may be reduced health protection schemes. i by simply improving food intake and nutrition as a n A health protection system or scheme provides B whole, tackling chronic malnutrition requires a more an legal health coverage to individuals, eg, through

integrated approach, including making improvements gladesh entitlements to benefits prescribed by national to the overall health environment in order to reduce law. Health coverage should be rights-based incidences of infectious disease. Providing nutrition and protected through national health services counselling without addressing access and use of safe and/or national, social or private health water and sanitation may prove ineffective, as almost insurance schemes.229 all programmes provide nutrition counselling but only Health protection schemes and systems that are a few achieve significant reductions in stunting. well designed and implemented, and which are embedded in appropriate economic and labour Information on access to healthcare is much market policies, are extremely cost effective and more conclusive (see Figure 24 on the next page). have the potential to recover a large part of their The majority of programmes were evaluated costs at national level.230 on this pathway and in most cases access to healthcare improved. Of all the elements of social protection, healthcare is arguably the most essential to the economy as a Of the 13 programmes that impacted on health whole and to economic recovery in particular. In access, 11 saw some measured nutrition effect. developing countries, the economic returns This demonstrates social protection as an effective on investing in health are estimated at 24% mechanism to improve health access and confirms of the economic growth between 2000 and the strong relationship between health and nutrition, 2011, taking into account increases in both highlighting the importance of this pathway for national income and life year’s gains.231 nutrition-sensitive social protection.

45 46 malnutrition in bangladesh This theory is supported by Humphrey supported is theory This highlighted. been has (stunting) chronic malnutrition tackle to approach integrated an of part as hygiene) and WASH of (water, sanitation importance The environment disease the and water safe on impacts protection social when greater often are gains nutrition shown, review our has As in se I references. review literature Cfor Appendix See review. literature on based calculation Children the Save Source: decrease in the practice of open defecation defecation open of practice the in decrease a and water safe to access in Improvements stunting. to lead sanitation and water poor which way in major the is this that and disease breeds water surface contaminated drinking and defecation open that argue who others mplications 4 F Access to healthcare healthcare to Access healthcare to Access healthcare to Access nsitive B igure ang didn’t improve improve didn’t not evaluated 2 improved improved ladesh

A s

ocial cc ess

0 f

t pr o

otection h utrition 2 ealthcare

234 and and 4

N umber of programmes

a . nd 6

e health reform agenda. reform health much-needed the support and encourage can Strategy Protection Social National how the consider also should Policy-makers design. programme and for strategy akey is question girls, adolescent on focus aparticular with Bangladesh, in services health public to access promote can protection Howsocial problem. asignificant is healthcare affordable and quality to Access at birth. stunting addressing women’s as and such empowerment priorities, are now important more there Bangladesh of parts many in that and are limited, water and sanitation in improvement fromfurther possible gains stunting the in Bangladesh. observed stunting in reduction the of some may explain ffect 8

o n

n utrition 10

It may also imply that that imply may also It 12 effect measured effect Some nutrition measured effect nutrition No 5 Malnutrition in BaAngladesh: what does social protection need to address?

Clear priorities have emerged from our stunting rate in 2030 would be 25% – four percentage pathways analysis, but before we can draw points higher than the target. conclusions we need to understand the wider Only the top 10% richest by wealth will meet nutrition context. In this section, we identify the target of halving stunting. The top two the priority groups for nutrition-sensitive quintiles by wealth and Khulna division are also likely social protection in Bangladesh, and highlight to get close. the places where the problems underlying Sylhet division, the poorest quintile, and poor nutrition outcomes are worst. In order urban areas of Bangladesh would remain to do this, we explore nutrition progress some distance from the target if current through an equalities lens, compared with trends continue. other Asian countries. Figure 25 shows a 2030 target based on halving 2010 levels of stunting, and a forecast for 2030, based Is Bangladesh on target to on trends between 1997 and 2011. The groups are halve stunting by 2030? ordered by how far from the target they would be in 2030 under this scenario, with those that will be In 2010 Bangladesh’s overall stunting rate was furthest away at the top. The targets for each group estimated at 42%.235 Halving this figure means differ due to the difference in stunting prevalence at reaching a target of 21% by 2030.236 If the trend the baseline for each. from 1997 to 2011237 continued238 to 2030, the

GRID

The data in this section is drawn from the Groups GRID is based on direct processing of raw data and Inequality Database (GRID). GRID was from Demographic and Health Surveys (DHS), developed by Save the Children and is designed to and it contains results from 257 nationally monitor group-based inequality across developing representative household surveys. GRID currently countries in key dimensions of child rights and includes over 90 developing countries (for up to wellbeing, including child mortality, malnutrition seven points in time). and WASH. Country data is disaggregated to measure and GRID allows the identification of children that monitor disparities across the following groups: are ‘hardest to reach’ or those who have been girls/boys; urban/rural; sub-national regions; ‘left behind’. ethno-linguistic groups; wealth groups (measured with the wealth index).

47 48 malnutrition in bangladesh highest stunting rate are at the top of the figure. figure. the of top are at the rate stunting highest the with groups The available). data DHS latest (the by2011 in group rates 26Figure stunting shows wealth. by 10% richest the 5or quintile until seen not is quintiles wealth across rates stunting in drop Asignificant poverty. widespread reflect trends yet stunting stunting, of rates highest have the poorest The Bangladesh. in linked clearly are malnutrition Wealth and 50%. of rate stunting large asimilarly with group, worst third the is division Sylhet 41.3%. of figure national the than higher are significantly rates stunting These behind. furthest are and the stunting 50% ROUPS a with by wealth, 40% poorest the and rate, stunting a54% with by wealth, quintile lowest The fur W 2000 1997 and between rate growth annual compound on based Forecast Notes: Survey Health 2011 the on Demographic based calculation Children the Save Source: dropped by more than a third, to 6.0m. to athird, by than more dropped 2011, By were stunted. Bangladesh in had number that 1997, In undernutrition. chronic of out 9.9m children 1997 2011 and children of number a large brought has between rates stunting on Bangladesh’s performance 5 F Bottom 40% by wealth wealth by 40% Bottom hich igure

s thest To tunting rate, have the highest prevalence of of prevalence have highest the rate, tunting Chittagong region region Chittagong p 10% by wealth wealth by p 10% Rajshahi region region Rajshahi Khulna region region Khulna Barisal region region Barisal Dhaka region region Dhaka 2 Sylhet region Q

Q g 1 ( 5 (r

poorest) poorest)

F b ichest) ichest) or Urban Urban Rural Rural ehind Q Q Q All ecast 3 2 4

a re ?

tunting 10

239 Between Between G

r roup level stunting rate (%) rate stunting level roup ate 20

vs . 2030 . 2030 2007–11) slower. was progress and 2000–04 (eg, periods other In sanitation). on push national the to attributable partly at least been may have (which 2007 and 2004 between again and stunting, in drop fast afairly was there 1997 2000 and by wealth. (richest) 10% top the in child a than stunted be to likely more times 2.4 is by wealth (poorest) 40% bottom the in A child worse is getting for poor children The situation W second. the to compared is group first the in stunting higher how much measures This rates. stunting of ratio the reports It groups. between inequality summarises below table The NE or A examined the poorest versus richest quintiles. versus richest poorest the examined we when We pattern asimilar found Bangladesh. in children for poor situation a deteriorating meaning quintiles, richest versus poorest for the visible is from1.8 2007. in increased pattern ratio Asimilar re ea 30

t n lth

arget i arrowing

i ne q ua q ua 40 lities

lities ?

w idening 240 50 trends 1997–2011on based Forecast group for Target

This This 5 Malnutrition in Bangladesh: what does social protection need to address? 49

60 54% Increase 1997–2011 0.5 0.5 -0.2 0.1 0.3 50%

50% 50 46% 44% 2011 2.4 2.1 43% 43% 41% 41% 40%

40 38% 36% 997–2011 36% 2007 2.6 1 34%

sation roups 30 g

2004 2.3 ral versus urban inequality is narrowing 26% rbani The only type of inequality shown here that is narrowing is rural versus urban inequality. Between and 2004,1997 the ratio was dropping because rural areas faster saw reductions in stunting than urban areas did. These findings significantpose policyand design implications a closer so look is required. Next we will look the at trends in wealth inequality. U Ru roup level stunting rate (%) roup 21% G ifferent

g d 20

y 2000 2.5 2.0 2.0 2.0 b 011 011 2 etween n b i

10 1997 1.8 1.6 1.4 1.3 1.2 1.2 1.2 1.2 1.2 1.4 1.4 1.3 1.2 1.4 1.3 1.3 1.5 ates ates r

ifferences r

d ] ]

2 3 4

ional tunting All Q Q Q s

Rural Urban tunting ichest) n reg i s poorest)

[ 5 (r 1 ( 1 ulna region Q jshahi region Q Sylhet region region Sylhet 2 Dhaka region Barisal region Kh Ra Chittagong region uality Top 10% by wealthTop q igure Bottom 40% by wealth equality between the best and worst F6 Bottom 40% vs. top 10% ratio Poorest vs. richest quintile ratio Rural vs. urban ratio Barisal vs. Khulna ratio Sylhet vs. KhulnaSylhet ratio ivisional ne divisions is increasing is divisions Barisal and Sylhet divisions are the two worst for stunting rates and Khulna is the best. In 2004 and 2007 Barisal1997, was the worst, and in Sylhet was the worst.2000 Khulna is and the 2011 division with the The lowest stunting in each year. two bottom of the table rows above compare Barisal to Sylhet and Khulna. Khulna and Sylhet In particular, increasinglyare further apart on stunting. D In Source: Save the Children calculation based on the Demographic Health Survey of Bangladesh I Source: Save the Children calculationbased on the Demographic Health Survey of Bangladesh 50 malnutrition in bangladesh Source: Save the Children calculation based on the Demographic Health Survey of Bangladesh of Survey Health Demographic the on based calculation Children the Save Source: must efforts are developed, programmes nutrition future As for Bangladesh. concern amajor is This 27). Figure (see narrowing of sign significant no shows and time some for consistent been has poor NE and rich between gap large the we that see over time, children richest and poorest the between stunting in differences at the look acloser taking By W 5.1. Section in considered be will Urbanisation countries. Asian other with comparisons at the looking before analysis, pathway our on based others, than levels malnutrition of have higher divisions why some we explore Then 7 F ealth Group-level stunting rate (%) igure 40 20 50 60 30 70 10 0

19 66% 36% 2 97 97

S tu q nting ua lities 20 60% 24% 00 00

ates

f or

b ottom 20 60% 26% 04 04

4 is a viable cost-effective approach. approach. cost-effective aviable is coverage protection social universal that illustrating system, protection social Bangladesh’sof national development the for implications significant has This society. of majority vast the to refers actually ‘poorest’ The by wealth. top the 10% specifically or 5, quintile until not seen is rates stunting in drop A significant 28). Figure (see over is it 1–3 40% quintiles group for wealth and over 30% rates have stunting 1–4 quintiles Wealth group understand. to important also is quintiles acrosswealth stunting of prevalence The widespread poverty widespread reflect trends yet stunting stunting, of rates highest have the groups poorest The behind. left is one no that ensure and imbalance this address to made be 0% 0% a 20 nd 20% 52% 07

t op 1 0% 0% b y w 20 50% 21% ealth 11 1 997–2011 by wealth by Top 10% wealth by 40% Bottom

F8igure 2 Stunting rates in 2011 by wealth group quintile alnutrition 60

54%

50 46%

i n

40% B 40 an 36% gladesh

30 26% : w 20 hat Group stunting rate, (%) 2011

10 oes

s ocial

0 q1 (Poorest) Q2 Q3 Q4 Q5 (Richest)

p rotection Source: Save the Children calculation based on the Demographic Health Survey of Bangladesh

DIVISIONAL INEQUALITIES 15% wasting rate, are those which have good scores

on many of the pathway indicators. n In this report we have explored a range of nutrition eed Chittagong and Dhaka have a majority of pathway indicators that social protection affects in both t

indicators showing strong (green) scores, although o Bangladesh and elsewhere. The divisional (regional)

it is important not to be deceived. These are, by a

differences we have seen in Bangladesh are ddress far, the most populous divisions in Bangladesh, with significant. In the table on the next page, we explore 28.4m (19%), and 47.4m (32%) people respectively nutrition outcomes by division alongside ten of the in 2011. Because of their large share of the

‘pathway’ indicators identified to measure factors ? population, their nutrition outcomes are close that can contribute to nutrition outcomes. These to the national average, and so classified amber, indicators are grouped into five categories identified almost by definition.241 through our analysis to be particularly significant for nutrition-sensitive social protection in Bangladesh: Rajshahi and Rangpur are a little mysterious. They household financial status (money), factors associated both have better nutrition outcomes than their with stunting at birth (pre-birth), food security, pathway indicators would suggest. Most pathway caring practices for women and children, and water indicators in Rajshahi have been classified as amber and sanitation. or red, and yet the stunting rate in 2011 was a very low 34%. In Rangpur, six out of ten pathway Divisions with the highest levels of indicators were classified red, and yet stunting was undernutrition score poorly on a range of within 5% of the national average and wasting was pathway indicators. Sylhet, with a very high more than 5% below. One possible explanation is stunting rate of 50% and 18% wasting rate in 2011, the high rice price in 2010 and 2011. This may well has eight out of ten of the indicators coloured red. have benefitted households in Bangladesh’s ‘rice belt’ Barisal, which also has a poor stunting rate (44% in – located in Rajshahi and Rangpur. However, further 2011), has six out of ten red. At the other end of exploration is required before any conclusions can the scale, the divisions that do well on nutrition, like be drawn. Khulna with a relatively low 34% stunting rate and

51 52 malnutrition in bangladesh

Divisional scores on nutrition and pathway indicators, 2010–11

Nutrition outcome Money Pre-birth Food Caring practices for women and children Water and sanitation security Stunting (%) Wasting (%) % living MUAC Median Household Highest Feeding 4 Health Antenatal Surface No toilet under lower pregnant age at first food educational or more professional visits – any water (%) facility (%) poverty line women marriage insecurity level: food groups, at birth (%) <230mm (25–49- access scale secondary 24–59 (3 years (%) year-olds) (FSNSP) or higher months (%) before (years) (%) (%) survey) (%)

Sylhet 50 18 21 43 17.2 79 32 47 7 62 5 4

Barisal 44 15 27 33 15.4 77 46 51 9 60 4 2

Dhaka 43 16 16 23 15.6 63 42 69 7 74 0 4

Chittagong 41 16 13 22 16.3 64 48 63 9 86 0 2

Rangpur 43 13 30 28 14.7 76 38 48 11 87 0 14

Rajshahi 34 16 17 31 15.1 70 39 65 9 78 0 5

Khulna 34 15 15 30 15.1 74 47 59 18 82 5 2

Source DHS 2011 DHS 2011 HIES 2010 FSNSP DHS 2011 FSNSP DHS 2011 FSNSP DHS 2011 FSNSP DHS 2011 DHS 2011 2011:102 2011: 62 2011:132 2011: 96

Nat +5% 43 16 18 28 16.3 72 44 64 10 81 1 5

National 41 16 18 27 15.5 69 42 61 10 77 1 5

Nat -5% 39 15 17 26 14.7 66 40 58 9 73 1 4

Within 5% of national average Worse than that Better than that

Sources: Save the Children calculations based on DHS 2011, HIES 2010, FSNSP 2011 5

F9igure 2 Progress on malnutrition in Bangladesh compared to other alnutrition South Asian countries Bangladesh India Nepal Pakistan 14 years to 2011 14 years to 2006 15 years to 2011 21 years to 2012 0

-2

i n

-4 B an

-6 gladesh

-8

-10 -9 -10 : w -12 hat

-14 d oes -16 Percentage point change in stunting rate

-16 s -18 ocial

-19 -20

p rotection Source: Save the Children calculation based on the Demographic Health Survey of Bangladesh

Bangladesh’s progress on figure 30 Benchmarking malnutrition compared to n

countries by stunting and eed other countries disparities in stunting

t o

Bangladesh has reduced stunting quicker than a its neighbours in South Asia. It has seen a drop ddress of 19 percentage points in 14 years, while other ‘Unequal’ countries have only managed smaller drops (see

Figure 29). In order to understand this achievement ? in more detail, this section uses both the national stunting rate and inequality in stunting to benchmark ‘Good for ‘Bad for

Bangladesh, and to show how it is progressing Inequality stunting in everyone’ everyone’ relative to other countries.

Overall stunting rate Benchmarking countries by stunting and disparities in stunting Source: Save the Children Figure 30 shows possibilities for how stunting and measures of disparities might combine. Countries worst case scenario, but this is rarely seen in with high stunting rates across the whole population practice. This leaves the top left, which is where combined with little inequality appear in the bottom advantaged groups have lower stunting than right corner of the figure. Here, the situation is disadvantaged groups, presumably because the bad for everyone. The bottom left corner of the privileged have experienced progress not available figure is the opposite situation. Countries here have to the less fortunate. low overall stunting rates and low inequality. The Bangladesh’s position in Figure 31 on the next page, situation is good for everyone. The two uppermost alongside all the other countries in the GRID quadrants of the figure are where there is high database, gives some context to the findings outlined inequality. The top right hand corner with high above. It shows how the overall stunting rate and inequality and high overall stunting rates is the

53 54 malnutrition in bangladesh which we have data. Bangladesh’s score 41% of we havewhich data. in 31% for year was recent most rate the in stunting the included, countries 55 other the in average, On higher average than considerably are Bangladesh in rates Stunting figure. the of ‘bad quadrant for everyone’ the in is It groups. acrosswealth stunting in inequality low fairly but analysis, our according to countries, other to relative rate stunting ahigh has Bangladesh everyone’ for ‘bad and widespread remains 2011 in stunting progress, that all Even after countries? other to compare it how does but Bangladesh, in increasing is groups acrosswealth Inequality countries? worst levelsthe in the now it reaching is increasing, is inequality If groups? economic and social between inequalities widening of expense at the happening progress this is falling, is rate stunting overall the if So, Bangladesh’s progress. benchmark to us allows also This labelled. and are plotted for Bangladesh available years the all ‘high’ is ‘low’. or stunting in below, figures the In inequality and rate Bangladesh’s stunting whether and countries, other compare to in stunting inequality included. is database the in year recent most the only countries other for Bangladesh; for shown are years All total. in included countries 56 Notes: Bangladesh of Survey Health Demographic the on based calculation Children the Save Source: 1 F

Ratio of stunting rate bottom 40% vs. top 10% by wealth igure

10 12 0 2 4 6 8 0

B enchmarking 10

20 20

a N ational stunting rate (%) rate stunting ational gainst Bangladesh, 2011Bangladesh, 30 30

Nepal, 2011 2012Pakistan, 2006 India,

a ll 40 40

ountries across groups. wealth in inequality increases larger much experienced However, 1990s. early-mid the since have three all numbers by significant stunting national-level reduced have all Pakistan and India Nepal, well. very done has Bangladesh have experienced, nations Asian South other that trajectories Taken the of context the in low to levels inequality of due is nutrition in success comparative Bangladesh’s inequality. significant introducing without fall stunting see to is aim The progress. of kind right the is this with, off start to ‘bad quadrant for everyone’ the in acountry For groups. acrosswealth inequality in increase modest arelatively only of expense at the come has this and rate, stunting overall the in improvement a big 1997, since period the in been that, is has there stunting Bangladesh’s on of progress summary A fair slowly very improving is situation The average. above the ratio inequality Bangladesh’s push not did increase This 1.8 2.4. to 1997 2011, and Between from went Bangladesh 3.1. is 40% bottom and 10% top the between ratio 2011 is considerably higher. The average inequality 50 50

i n G 60 60 RID RID Bangladesh, 2007 Bangladesh, 2004 Bangladesh, 1997Bangladesh, 2000 Bangladesh,

f or 70

w ealth most recent year recent most countries, Other Bangladesh

g roup 5

F2igure 3 Progress in Bangladesh compared to other South Asian alnutrition Nations – wealth groups 3.5

3.0

i n B an

2.5 gladesh

2.0 : w hat

Bangladesh 1997–2011

1.5 d

Pakistan 1991–2012 oes India 1992–2006

s ocial Ratio of stunting rate bottom 40% vs. top 10% by wealth 1.0 Nepal 1996 –2011 35 40 45 50 55 60 65 National stunting rate (%)

p rotection Source: Save the Children calculation based on the Demographic Health Survey

Bangladesh has done well in reducing chronic Stunting in Bangladesh is ‘bad for everyone’, therefore n malnutrition relative to other countries, a narrow poverty-targeted programme (as is eed

but progress still needs to accelerate to proposed) is not going to sufficiently address stunting. t meet targets, and if you look below country Arguments for universal social protection coverage o level at particular groups there are still arise as a viable cost-effective approach due to the a ddress sizeable groups of children who need faster high stunting prevalence across wealth groups. progress. Poverty is widespread and this is Critical policy implications arising for the targeting of reflected in high stunting across all but the ? social protection programmes are: wealthiest groups. • progress to improve malnutrition in Bangladesh needs to increase for everyone Implications for nutrition- • the large divide between wealth groups needs addressing sensitive social protection • divisional trends need attention in Bangladesh • the trend of urban malnutrition rates moving closer to rural rates is an increasing Social protection carries the capacity to concern (see Section 5.1) improve nutrition for all while targeting the • well-designed social protection needs to most vulnerable groups. Poverty is very closely target a range of pathway indicators. linked with malnutrition. The risk of falling back into poverty is very high where effective social protection We present specific design recommendations for mechanisms do not exist. Bangladesh in Section 8 based on all of the evidence presented in this report.

55 56 malnutrition in bangladesh high levels of malnutrition. of levels high are there where Dhaka, of slums the in live 8 months, Shapna, daughter her and 18, Maushum, MPACT T implications policy for significant This has versus rural. isurban reducing in Bangladesh shown be to ofThe area inequality only 5.1 he Photo: Sebastian Rich/Save the Children The • Populations • Chronic • H eadlines ci country. urban apredominantly be will Bangladesh onwards, ex de

i ty corporation slums, had 50% had slums, corporation ty pand by a further 50% by 2028. From 2045 From 2045 by 2028. 50% by afurther pand creasing at a slower rate than in rural areas. areas. rural in than at aslower rate creasing SPECIAL U FOCUS:

w orst

malnutrition

ffected i o n

ur f

ban r

apid ur

(stunting) ban reas

u a reas re rbanisation

in f xpected

or s

tunting rate rate tunting urban

m alnutrition,

t areas o r

ani

o nutrition-sensitive social protection. protection. social nutrition-sensitive for trendand implications considerthe the into we section look deeper this In nutrition. Only • n

fro country.the in 2013. groups in worst the as bad as was This beneficiaries coming from urban areas. fromurban coming beneficiaries of 2% and 6% only with weak, particularly is women for vulnerable and age for old schemes m sation alnutrition m social protection. Coverage of key of Coverage protection. m social

9 .4%

o f

h ouseholds

i n

i n B

ur an ban gladesh

a reas

b enefit

5 Malnutrition in Bangladesh: what does social protection need to address? 57 Rural Urban 11 43% 36% 246 20

245 , and should be considered 997–2011 may be may theareas most 1 247 reas

07 07 tuntingrate, the poorest 40% a 50% rate, 45% 36% 20 s

ural r

Addressing undernutrition in slumsinvolve may targeting a range of pathways to better nutrition. Some pathway indicators – access to improved proximity of a healthwater, facility, contraceptive use, breastfeeding, exclusive and children with acute respiratory infection receiving antibiotics a show – good performance in urban slums. But, as Figure 34 shows, and as is the case elsewhere, a range of other issues important are nutrition for in urban areas. Urban slums remain behind other urban areas and in many cases behind Bangladesh as a whole. Each panel of the figure represents one of the major pathway areas have we focused on in this report: stunting birth, at women’s empowerment, caring practiceswomen for and health and environment. infant feeding, children, The pathway indicators that the show worst performance for urban areas are in women’s education, antenatal care from a medically trained and sanitation. provider, These, along with food security, in need of intervention thefor development of nutrition-sensitive social protection programmes in urban areas. It is also country. As we have seen, in 2011 the poorest quintile seen,country. As have in 2011 we had a 54% and Sylhet region, 50%also. nd

04 52% 44% 20 rban u

or f

ates r 00

53% 42% 20

242 nting tu S

97 3 62% 46% 19 This was as bad as the worst groups in the

3). masks considerable diversity (see Figure 34 on 3 244

10 70 30 60 50 20 40

243 igure (%) rate stunting Group-level F3 Source: Save the Children calculation based on the Demographic Health Survey Addressing nutrition in urban areas presents a complex challenge. The overall urban stunting rate, 36% at in 2011, As of 2011, the disparity in stunting ratesAs between of 2011, urban and rural was only nine percentage points and closing. the At same time, the location of populations is changing. Growth in rural populations has slowed and declines onwards. expected Urban are from 2016 populations, on the other hand, expanded have expected and are rapidly, to expand a further by 50% 2028.by 2045 From onwards, the urban population is expected to exceed the rural population, with the gap getting wider. ever Rural areas historically had much higher have stunting rates been and have home to approximately two- thirds of the totalpopulation. The improvements in nutrition likely to are be the result of well-targeted human development interventions. In the future, priorities look set to change. however, Rural versus urban inequality is decreasing andBetween 2004 1997 ruralareas saw faster decreases in stunting than urban areas (see Figure the next page). Urban Health The 2013 Survey showed that the stunting rate was 50% in city corporation slums – the worst affected urban areas. 58 malnutrition in bangladesh Bangladesh that FSNSP evaluated in 2012; in evaluated FSNSP that Bangladesh all than worse also is It figure. the in groups urban other the than rate worse aconsiderably is This page). next 35 the Figure on (see population reference the in median the below deviations standard three than more ‘height-for-age’ have five of age the under children of 25% slums, In Bangladesh. of rest the to even compared worse is slums urban in picture ‘severe’ the On stunting, disproportionately bad nutrition outcomes. experience they that likely therefore is it and slums in people poorest the are often these as migrants, newof needs specific the consider to important this mothers; nationally. already or available not pregnant was were who 15–19-year-olds of percentage the is bearing’ child ‘Early for used measure The indicators. other FSNSP all for from and provider’, trained medically by 2011 DHS ‘Delivery from for are figures National shown. not is which areas’, urban urban athird ‘other included category, publication 2013. That UHS from are non-slums’ corporation ‘city for and slums’ corporation ‘city for Figures Notes: 2013, (NIPORT) Training and Research Population of Institute National Source: where severe stunting was 17%. was severewhere stunting quintile, poorest the and at 21%, severehad stunting which region, weresurvey, Sylhet groups worst the and 4 F E primary education primary 6-month to 2-year- to 6-month shared) sanitation shared) olds get minimum medically trained trained medically igure arly child bearing bearing child arly number of meals meals of number from a medically amedically from trained provider provider trained Antenatal care care Antenatal 4+ food groups groups food 4+ 2-year-olds fed fed 2-year-olds Improved (not (not Improved Women with with Women 4+ antenatal antenatal 4+

6-month to to 6-month Delivery by by Delivery na care visits care (% 15–19) (% 3 provider provider tional

C om

paring the groups fromacross groups the 10

13%

p 20 athwa

21% 30 29% 251

y 32% 250 in its its in i ndicators 37% 40

% 45% 50 per year. per point by percentage one around declined only has 2013, and rate 2006 stunting the between seven years the in that means This slums. corporation 57% city in of rate astunting measured (UHS) Survey Health Urban the slow.Yet been 2006, so far In has progress to 24to home become to are predicted which slums, urban many as twice than more be will there By2030, rate. ten 2013, of growing. As are rapidly were about there and population urban total the of one-third to home are slums Urban help. for list priority the of top the at group the in be also therefore should and country the in groups malnourished most the among are dwellers slum Urban 50%

248

m DHS 2011, FSNSP 2012 2011, FSNSP DHS

illion slum dwellers experiencing a50% experiencing dwellers slum illion m i 60 n illion people. illion 253

s Accelerated effort is required. is effort Accelerated lums 70 68%

t 252 o 80 249

n on 90 - sl ums slum corporation City non-slum corporation City National

s tunting tunting 5

F5igure 3 Stunting rates for urban areas alnutrition 60

i n

40 B an 25% gladesh

22% 19% :

20 w hat Percent stunted/extremelyPercent stunted

25% 10 d oes 14% 15% % below -3 standard deviations

% below -2 standard deviations ocial 0 City corporation City corporation Other urban areas slum non-slum

p rotection Source: NIPORT 2013254 implications for nutrition- allowance’ and ‘widowed and distressed women

allowance’ reflect this bias, with 94% and 98% of sensitive social protection n

beneficiaries respectively coming from rural areas eed in Bangladesh (see table below).

t • Social protection coverage is substantially lower • As urban areas continue to grow in size and rates o

of malnutrition rise, a critical priority area for the a

in urban areas than rural areas in Bangladesh. ddress The historic rationale for this has been that targeting of nutrition-sensitive social protection more people live in rural areas, and that existing is emerging. Rural programmes need sustaining to address vulnerability to limited food access for programmes such as disaster relief and income- ? generation activities had an in-built rural focus. In the poorest in areas prone to flooding, but urban 2012, 20.1% of rural households benefited from a programmes must also be developed. social security programme, compared to 9.4% for • The coverage of social protection in urban areas.255 urban areas should be increased, with a • The number of beneficiaries of two of Bangladesh’s specific nutrition focus to address high unconditional cash transfer programmes, ‘old age levels of malnutrition, which are only set to increase. social protection coverage

Type of programme National Rural Urban

Old Age Allowance 24,75,000 23,27,247 1,47,753

100% 94.03% 5.97%

Widowed and Distressed Women Allowance 920,000 9,04,502 15,498

100% 98.32% 1.68%

Source: Government of Bangladesh (GoB) (2014)256

59 ldren hi C he t ave /S on ir K

m part 3 part 3 la A ul q hafi : S : hoto P

A mother and child in Gowainghat Upazila, Sylhet, where the MaMoni Integrated Safe Motherhood, Newborn Care and Family Planning project is supporting and complementing the government’s Health, Nutrition and Population Sector Programme. 6 Governance and politics – the driving force

We have learned a huge amount about the Central to the systems approach is a focus on potential of social protection for nutrition in coordination and harmonisation in order to address Bangladesh through our analysis so far. We the fragmentation that limits the effectiveness and have identified priority issues and groups. impact of social protection policies and programmes, It is now time to think about how to put as currently underway with Bangladesh’s National this learning into action. The remainder of Social Security Strategy reform process. National social protection systems are largely based on this report will focus on ways of developing the existing policy environment and the historical social protection programmes and systems in evolution of institutional arrangements developed Bangladesh that will effectively affect nutrition. within a country, as demonstrated in Bangladesh We start by exploring governance and the since 1971. To be successful and sustainable, social political context (this section), then look protection programmes should be institutionalised at the development of nutrition-sensitive as part of a system, within national social protection 258 social protection in Bangladesh (Section 7), strategy and domestic laws. making recommendations as we go. We The systems approach is advocated and endorsed then pause to reflect on everything we have by the World Bank, the UN and many other learned so far before making specific design development partners. However, it is important to recommendations (Section 8). note that there are many challenges, risks and costs involved, including: the challenges of the political economy and differing donor views and practice, the S ocial pROTECTION systems risks of excessive centralisation, and the potential costs of transactions and limited transparency.259 Social protection systems are a country’s set of The transition towards more integrated systems is a social protection programmes. Social protection gradual and contextual progress. In operationalising systems provide a coordinated portfolio of this agenda, it is useful to consider different levels interventions to address different dimensions of systems coordination: policy, programmatic of poverty and deprivation, aiming to reduce and administrative.260 vulnerability across the lifecycle and ensure cumulative benefits across generations.257

62 6 Governance and politics – the driving force 63 264 ? ake t

t i approach

overnance collaboration partnership and Takes a lifecycleTakes g Developed through

oes d

hat legislation w Enshrined in Enshrined in – vertical) Supported by (horizontal and ems 265 strong coordination strong Participatory oriented Consensus Accountable Transparent Responsive Effective and efficient Equitable and inclusive Conducted following the rule of law st nderstanding y U Governance refers to the of political exercise and administrative authority all to at levels manage a country’s affairs. Governance comprises the institutions through and mechanisms, processes which citizens and groups articulate their interests, their exercise legal rights, meet their differences. their mediate and obligations Good governance has eight major characteristics. It is: • • • • • • • • Good governance ensures that corruption is minimised, the views of communities are taken into account, and the of the voices most vulnerable in society heard are in decision- making processes. s

system Effective public supportpublic Underpinned by by Underpinned 263

social protection social protection 262 rotection Technical Technical p

261 commitment Driven by political ocial s ystems

Financed by s e

national budget v ecti ff E Tailored Tailored

to context to Inspired by overnance national vision g 3

rong governance system lays the igure F6 trong and scientific knowledge has established which interventions work to reduce undernutrition, and in this report seen thehave we potential that nutrition- in sensitive social protection However, has to offer. order to be successful, it must be delivered through effective governance systems. Furthermore, the influence of politics governance and is critical in the creation of a sustained political to maintain force productivity on the ground, where undernutrition continues to pose a threat to the population. Brazil been and Peru have widely hailed as two success stories, recognised as having made substantial progress in tackling nutrition through social protection systems. These examples can inform countries such as Bangladesh, which has very high of stuntinglevels but is making but slow steady progress in reducing hunger and undernutrition. In this section explain we the importance of building social protection systems, identify central policy and governance implications and present recommendations thefor development of governance systems to protection. social support nutrition-sensitive programmes to scale-up nutrition-specific and nutrition-sensitive interventions. S A st foundation for an enabling environment to maximise the impact ofpolicies and 64 malnutrition in bangladesh nutrition-sensitive socialnutrition-sensitive protection programmes. of monitoring and implementation design, the in actors diverse integrating successfully government to points strategy Peru’s nutrition national programme. the of nature depoliticised the to due undernutrition reducing in successful was programme, protection in order to be successful. be to order in funding sustainable and broadcoverage commitment, and nutrition interventions require long-term Nu • • • 3. R • • • engagement Multi-sector 2. • • • 1. Responsiveness protection social nutrition-sensitive support to systems governance developing when following factors three recommend governments the prioritise we countries, two these of experiences the from Learning population. insecure food the to municipalnational, and regional governments connect to amechanism as governance utilised multi-sector engagement. Both countries have framework institutional and commitment, political strong through outcomes health and nutrition in progress accelerated successfully have Peru and Brazil decades, past the Over L 1. R in the country.in the poverty reduce and hunger combat to commitment presidential the to connected is undernutrition of reduction the Brazil, in that recognised widely is It undernutrition. reducing in successes respective to central have Peru and been Brazil in agenda-setting and leadership executive Strong commitment level government of High

essons

International Effective Strong An Community A na Clearly Sustainable High trition-sensitive socialtrition-sensitive protection programmes e obust institutional framework institutional obust

sponsiveness tional priorities priorities tional v

ibrant a ctive

l evel

c d oordination

efined, m

c p on o onitoring ivil

rivate 267, 268 f f

unding

g su nd

overnment s

ociety pport

g c Juntos, Peru’s flagship social Peru’s social Juntos, flagship b

ontext- s eneficiary overnance ector

nd a

nd 266

nvestment

e a c valuation nd ommitment

ngagement t arget-specific

269

that means for their country. for their means that what and frameworks, policy broader within situated are programmes how these recognise initiatives, protection social of nature progressive the on focus that strategies consider should Governments priorities national target-specific and context- defined, Clearly approach to political economy. political to approach asound and dialogue social effective on based is selection level that and at national examined carefully is options of arange that requires country each and breastfeeding mothers. and breastfeeding women pregnant girls, adolescent age, of years two under children reach to designed be must policies protection social impact, To nutritional the maximise supportive. mutually linked and be must strategies nationalandprotection, nutrition social protection social nutrition-sensitive For protection. child and education, health, nutrition, as such returns, development higher support to areas relevant with aligned be should strategies protection Social to be achieved. be to is development equitable and sustained if essential is protection, social as such investments, social and economic critical for space fiscal domestic Finding government. national by the internally managed be must commitment sustained term, long the in However, funding. effective remain to strengthen can institutions financial international as such bodies nutrition requires a minimum level spend. of aminimum requires nutrition on success that suggests analysis our 8, Section in implementation. and coordination policy encourage to need funding mechanisms sustainable and Effective fundinginvestment and Sustainable – • • • • F • • • •

inancing Reallocating

t Adopting Tapping Drawing Curtailing Borrowing Extending Increasing ma res he croeconomic framework croeconomic erves

i ptions

nto

o a

271 i n s t

llicit o ocial ax m

As we explore design implications implications design we explore As

i public r ncreased fi ore

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ocial In the short term, external external term, short the In s

nancial a ecurity

a ccommodating expenditures 272 nd

275 ai f oreign

273 d fl

ows 274 a The uniqueness of of uniqueness The p ontributions nd

rotection

e xisting

t e ransfers xchange

d ebt

6 Governance and politics – the driving force 65 278 : requiring state bodies and individual : requiring citizens to act in a responsible Community and beneficiaryCommunity engagement societyCivil organisations community and groups uniquelyare placed to present the of the voice appropriate include to government drive and people nutrition goals into national plans. In Peru, the community initiative was successful in including nutritional goals within the national poverty reduction strategy. In Brazil, communities engaged with numerous political parties, government ministers and local governments to transform nutrition campaigns into national government policies. The experience of Brazil and Peru highlights the real impactindividuals community at can level on lobbyinghave government to consider nutrition as a national priority. An active role for the private sector Accountability is a two-way process: Downwards representatives of the state to act in a manner appropriate to their function Upwards and to demandmanner, that the state fulfils its properly. duties When considering the private sector role in nationalgovernance at it level, is important to distinguish between private sector organisations in the value chain and other actors that might include financial institutions that trade a huge and have impact on commodity markets and pricing. The privatesector is increasingly willing to contribute to sustainable development, particularly leading global and national corporates, but there remains Engaging the private sector is necessary to develop patternsnew of sustainable and inclusive production. The private sector has a central role in the production, distribution and marketing of food, as as well a strong influence on thecost and pricefood of products. Coupled with itsworkforces, influence over the private sector carries strong potential to accelerate the progress of nutrition-sensitive social protection and shape nutrition outcomes.

277 echanisms Given m 276

ngagement e

sector - ulti ocial Social accountability mechanisms are an important an Social accountability mechanisms are part of the governance process. Child-focused social accountability is a set of participatory activities designed and implemented children by and other citizens to hold public officials service and providers accountable, through dialogue, their for commitments to children. S CCOUNTABILITY n the past, nutrition has been identified as International and national civil society organisations civil national International and a greatalso deal have of experience to share in social of the development, evaluation delivery and should society civil International systems. protection society organisations to civil national alongside work build capacity in both civil society and government. opportunitiesSimilarly, to connect civil society- led social protection initiatives with national social protection systems should be encouraged. A vibrant civil society society civil vibrant A The active and strategic involvement of civil society implementation the formulation, and organisations in monitoring of social protection policies, programmes and systems is a critical governance component. It is widely recognisedto result in more sustainable and effective programmes responsive to local contexts and needs. Furthermore, the rights-based approach meaningful makes protection participation social to of relevant stakeholders, includingchildren and civil society organisations, a prerequisite to ensure effective and nutrition-sensitive relevant, inclusive social protection programmes. the multi-faceted and multi-dimensional causes of multi-sectorundernutrition, strong coordination across a number of ministries and stakeholders is critical to ensuring effective nutrition governance. everyone’s business, yet no one’s responsibility business, noeveryone’s one’s yet to nutrition is a development prioritychange. Today, recognised and prioritisedsectors. across National international financialinstitutions, governments, civil society and the private sector increasingly are working together to reduce the widespread prevalence of undernutrition in children. 2. M I 66 malnutrition in bangladesh Resulting in Economic Empowerment (SHIREE) project. Resulting in Economic Empowerment (SHIREE) Improvements Household Stimulating the from agrant with abusiness up set to able were husband her and She Bagerhat. Khulna, in home her at pots making Pal Rani Onju how consider to important also is It methods. banking innovative other and technology mobile through for example, level; at community transfers facilitate to development ofprominent the through technology most is This logistical. mainly albeit protection, social to contributes already sector private The building • leveraging • generating • mobilising • should focus on: partnerships sector sector. public the Private with partnerships in engage how and to do to what showing models of a lack ac challenges development complex to solutions scalable and sustainable develop to sectors al bu su ong with those of the public and not-for-profit not-for-profit and public the of those with ong countable for development results. for development countable stainable development stainable siness models

echanisms

t l m ong-term he ore

c apabilities

i nnovation

t p o rivate

h old

o f

t fi n t he he nance

t echnologies

p p rivate rivate

f or 279

s s ector ector

a nd

qualify to be part of their value chains. chains. value their of part be to qualify to communities poorer supporting or wage a living paying eg, inclusive, more be can sector private the and innovation. research or channels, distribution systems, infrastructure development, product agriculture, around efforts support to community business the for opportunities advance to works network The improve to nutrition. advantages comparative and strengths its apply and expertise harness to globally working network business (SUN) Nutrition Up Scaling the as such initiatives with developing, is nutrition in sector private the roleof Similarly, the create change in the levels undernutrition. of the in change create and awareness raise to sector private have the on can incentives financial and policy,public regulation of forms different impact the outline to required is research more progress, of evidence this Despite 280

281

hil C t av /S apol K ricia at P : hoto P dren he e yo 6 Governance and politics – the driving force 67

284 286 Civil society Civil Civil society often comes together to advance its common interests through collective action and bear the of voice communities. Civil society operate may organisations nationally or internationally. society:Civil organisations, networks, associations, groups and movements that are independent from government businessand prevent and respondprevent to environmental shocks and stresses. This is particularly important in areas prone to flooding, which increases the vulnerability of undernourished sectors of the population. Evidence of programme impact also plays an important role in reinforcing the political initiatives nutrition for needed commitment and increases accountability. support International provide International commitments initiatives and powerful support the for development of national nutrition-sensitive social protection systems. The ILO- and World Bank-ledThe ILO- and Social World Protection Floor initiative encourages national governments to develop support systems to protection provide to all citizens. This commitment will the aid prevention and reduction of poverty and social exclusion, and contribute environmental and economic the social, towards dimensions of sustainable development. The Scaling Up Nutrition (SUN) movement, which aims to eliminate all forms of malnutrition, is representative of a global push action for to improve conditions related to maternal and child nutrition. Utilising support from movements such as these can increase and ‘buy-in’ accelerate progress nationally. The Millennium Development Goals (MDGs) and the forthcoming Sustainable Goals Development (SDGs) a huge influencehave on international development Bothpolicy. social protection and nutrition feature prominently SDGs thein 2015–30. proposed for 285 Private sectorPrivate The private sector is where most people access most products and services to meet needs. their of most The private sector: local, small and medium-size enterprises multinational and regional and companies ramework f

282, 283 nstitutional i

obust e institutional that layout makes countries The public sector: government non-government and organisations operating at and national local, regional, levels international The public sector is responsible thefor targeted provision of supplements and services to the poorest of the poor. Public sector Public Strong coordination Sustainable change requires coordinated action and effort on the part of different line ministries and agencies national at and regional levels. Vertical decision- of different levels across coordination making andservice delivery is important.Cross- sector coordination is also required, particularly across areas of education, health, agriculture and nutrition. It is important to ensure that there are proper structures in place, and national and regional capacities technical proper the generate governments and incentives to transfer resources and remain accountable to each other. achieve more throughachieve collaboration is vital the for effective of nutrition-sensitive social development protection programmes. Th Up-to-date data should regularly be reviewed to enable identification coverageof gaps and help Effective and monitoring evaluation Effective monitoring and data collection is important usfor to understand what works and what does social in protection work not programming and understandingto improve of impact on nutrition outcomes. It is important to integrate nutrition nutritional monitor outcomes, and indicators including the nutrition pathways of household food caringsecurity, practices women for and children, services. and healthand environment 3. R 3. 68 malnutrition in bangladesh stakeholders nutrition of landscape by avibrant characterised agenda, Bangladesh’s of development Government Nu su F G Monitoring Committee Monitoring Policy Food Committee, Steering NNS Council, Nutrition level (eg, at achieve national to this Attempts response. multi-sector,coordinated strong a requires nutrition of nature multi-faceted The outcomes. nutrition on impact maximise to acrossministries collaborate how and to nutrition; monitor effectively more how to are; responsibilities and roles the what mandates; individual their to important is why nutrition on: across ministries and within built be to needs Understanding chronic absenteeism, and misuse of resources. of misuse and absenteeism, chronic capacity, poor in can result that financial) and human (both resources inadequate goals, shared of lack a levels, sub-national and at national departments ministries/ within acrossand targets inadequate directorates, and ministries across rivalries conflicting by characterised is Bangladesh in Governance and monitoring are not always present. present. always are not monitoring and for planning involving citizens information relevant on drawing processes participatory and absent, often is upwards) and downwards (both Accountability delivery. service of effectiveness the undermine can which decision-making, and communication of lines blurred and tenuous with challenging are commonly relationships These parishad). union and (upazila ground the on services and projects government all coordinating and implementing for planning, mandate the hold that institutions governance local the and ministries line transferred between coordination to related challenges highlighted also Research governance on sub-national mechanisms progress. hinder low and attendance agendas competing but ambitions into action. government of translation the hinder challenges paper. However, and operational political substantial ragmented overnance b trition has a prominent place within the the within place aprominent has trition - nat ional 287 and a number of strong plans on on plans strong of anumber and

an utrition

288 i d n 290

na B ) demonstrate commitment, commitment, ) demonstrate a tional ngladesh

g overnance

l evels

289

communication • Priorities include: for nutrition. resources for mobilising environment for enabling providing an block building fundamental a as recognised is parishad upazila and parishad union the both of accountability the well as as Improving capacity and functional the institutional Improved governance sub-nationally Bangladesh. in vulnerabilities that exacerbate undernutrition underlying and factors multi-faceted the address effectively and holistically to government’s ability the increase improvements couldSuch significantly partners. with collaboration in monitoring, and improved planning joint with ministries require stronger coordination mechanisms line These mandates. have nutrition Bangladesh Government of the within lineEight ministries Improved nationally coordination practice. into turned way frombeing are along commitments However, made. have been these commitments many and agenda Bangladesh’sof development Government the is prominent within Nutrition action into turned be to need Commitments how • h • w • why • building of: understanding encompass should It activities. nutrition in engaged currently not ministries government particularly all, for beneficial would be Capacity-building capacity and commitment increase to nutrition of understanding ashared Build in se I s • mplications nsitive im (u B tronger ow hat pwards and downwards). pact on nutrition outcomes. nutrition on pact ang

t t t o o utrition he

c m

ollaborate t r ladesh ore wo-way oles

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otection onitor m t utrition o inistries

i ndividual

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utrition a echanisms re

l t ines o

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andates - aximise

6 Governance and politics – the driving force 69

Photo: Shafiqul Alam Kiron/Save the Children Stronger multi-sector collaboration Utilise the commitment, existing skills, resources and access to beneficiariesavailable in Bangladesh’s civil society and the private sector to develop a robust national social protection system. This might include utilising domestic funds to scale-up successfulcivil society initiatives such as the Chars Livelihoods Programme.

291 xpenditure e

economic

ealth the h

xpenditure:

nd a

ealth Despite h

nd a gap:

rotection p

funding ocial

rotection p

gladesh’s public social protection and health and protection social public gladesh’s idence in support of nutrition investment, the obally is 8.6%% although western GDP, Europe ev national SUN-costed nutrition plan estimates a funding gap of US$5years five billionfor over nutrition interventions in Bangladesh. There is, therefore, a clear need greater for nutrition investment from development partners and the government. gl invests significantly26.7%at more GDP Ban expenditure (2010–11) at 2.69% at ofexpenditure GDP is (2010–11) significantly lower than regionalthe average of 5.3% Asia for and the Pacific A mother and child who are being supported by the MaMoni project which aims to improve maternal and newborn health in the Sylhet and Habijang districts of Bangladesh. • nutrition Increased investment Increased Greater investment of domestic funds: • social • average 7 Nutrition-sensitive social protection in Bangladesh

Bangladesh’s existing social protection system emerging within society. The plan argues the need is not working well. It is fragmented and for “a holistic re-thinking on the direction, scope ineffective, reaching just 35% of those under and design of safety net policies in particular and the poverty line in 2010.292 The current social protection policy in general” in the context government reform of the national social of eroding informal safety nets, emerging newer security system is essential. In this section risks from rapid processes of urbanisation and global economic integration. we explore how the system has developed, future plans, and recommendations for development to support nutrition-sensitive NUTRITION AND THE NATIONAL social protection. SOCIAL SECURITY STRATEGY

The draft National Social Security Strategy (NSSS) T he dEVELOPMENT of social of Bangladesh297 advocates two core programmes protection in Bangladesh for children; in addition to continuing the school stipend for all primary and secondary school children The development of social protection in Bangladesh belonging to poor and vulnerable households, a child originates from independence in 1971. Since that grant for children of poor and vulnerable families time, there has been a gradual growth in the up to age four is proposed. The child grant will be proportion of transfers provided as cash instead limited to a maximum of two children per family to of food, although cash is mainly provided through ‘avoid any adverse implications for the population programmes targeting key moments across the management policy’. lifecycle. There has also been an increase in small schemes among both NGOs and government that The NSSS also sets out that eligible children will include elements of social protection.293 benefit from disability benefit, the school meals programme, the orphans programme and the legal Budgetary allocations from the Government of provision to ensure that abandoned children get Bangladesh to social security have grown in absolute financial support from the responsible parent. A terms, as well as a share of GDP. The allocation commitment is made to strengthen supply-side for social security programmes increased from interventions relating to immunisation, childcare, 294 1.3% GDP in 1998 to 2.5% of 2011. Since then, it health and nutrition, water supply and sanitation, and has stabilised at around 2%, with the latest available nutrition outreach. figure (2010–11) showing public social protection expenditure at 2.69% of GDP.295 The NSSS acknowledges the impact of social security programmes on hunger:298 “At the national level the In the Government’s Sixth Five Year Plan (2011– impact of the SSPs [social security programmes] 296 2015), social protection is defined to include safety spending is party reflected by the sharp reduction in nets, various forms of social insurance, labour market the incidence of hunger-based poverty.” However, policies as well as processes of self-help existing or the NSSS remains weak on malnutrition.

70 7

Bangladesh’s Social Security System N utrition Moment Response

1971 The main social security scheme was the government service pension, -

Independence complemented by a Provident Fund providing government and formal private se

sector employees with a lump sum on retirement.299 nsitive

1974 New schemes developed for poor families that were badly affected. These

Food shortage schemes were mainly public works and other food aid programmes, utilising s ocial foreign assistance.300 1980s

Floods p rotection 1990s The Government of Bangladesh began to introduce schemes intended to Vulnerable groups focus address risks across the lifecycle. In reality, more of a vulnerable groups focus was taken, such as through school stipends programmes and allowances for the elderly, people with disabilities, and widows.

i n

Significant investment by donors in programmes managed by non- B governmental organisations, providing a range of social services (including an

social transfers).301 gladesh

2000s Bangladesh’s safety net system contains a number of programmes (95 at the The current system last count) across a wide range of different types of interventions.302 Yet much improvement is needed. This fragmented system reached just 35% of those under the poverty line in 2010,303 and does not adequately address nutrition or the critical 1,000-day period.304 Only two schemes are targeted at pregnant women and lactating mothers, with very low coverage – less than 165,000 women, representing 0.13% of all households in Bangladesh receiving safety net transfers. In most schemes, the transfer value is too low (eg, BDT 350/month) to have a meaningful impact.305 Apart from school stipends, no existing programme addresses the needs of young people, particularly adolescent girls at risk of early marriage and undernutrition. Furthermore, there is no systematic linking of social protection beneficiaries to complementary schemes and services that could address undernutrition.306

Today The Government of Bangladesh has reiterated its strong commitment to social Reform protection by embarking on a National Social Protection Strategy reform process that seeks to strengthen and streamline social protection interventions. A new nutrition policy is also expected and is likely to have a social protection aspect. This follows a demonstrable a shift of recognition that nutrition focus needs to be better integrated into social protection reform.

71 72 malnutrition in bangladesh on nutrition. impact the increase could that services and schemes to complementary beneficiaries protection diet. anutritious of affordability the in improvement 5% a in women’s result only can allowance lactating and maternity existing the Sylhet in example, For impact. asustainable fromhaving nets prevent safety values transfer and Low investment area. this in for development considered be could stipend school secondary female The give birth. they before years the in undernutrition and marriage child of risk at may be who girls youngof women/adolescent needs the meet to designed specifically programmes P Bangladesh. for challenge a significant is deficiencies, micronutrient and wasting stunting, as such Malnutrition, causes. other to plan the in given is attention less and malnutrition, of causes all tackle However, not strategy. does security food improving the in recognised is and essential is measures security food through hunger Reducing vii). page ‘Key terms’, (see malnutrition and hunger of issues I H S t is very important to distinguish between the two two the between distinguish to important very t is pecifically, the strategy does not include include not does strategy the pecifically, ro unger 307 grammes There is also no systematic linking of social social of linking systematic no also is There

a nd

f m or alnutrition

a dolescent

a re

irls d ifferent

towards a lifecycle approach. system move away ‘poor relief’ a clear fromasimple 15 indicating over past the years, initiated have been Scheme, Generation Employment and MoWCA), (in Mothers for Lactating grants Child Grant, Disability Widows’ Allowance, Allowance, Age Old the as such schemes, Bangladesh’s of coreMany lifecycle age. old and age working youth, age, school childhood, early and pregnancy are: lifecycle the of Key poverty. of cycles stages for reducing intergenerational or eliminating effective also is It life. their in stages at particular individuals by experienced vulnerabilities addresses approach lifecycle The programming. protection social to Ba L ifecycle employment-based regulations. and insurance sector, social on private based the by financed is part other the financing; NSSS the of part one only is component Financed sector. Expenditure private Public The the and government the between arrangements sharing on cost- based is NSSS the of financing full The of S F ngladesh is moving towards a lifecycle approach approach alifecycle towards moving is ngladesh oc inancing B ial a ngladesh

a S pproach ec urity

t he N S at 309 tr ional 308 ategy

7 Nutrition-sensitive social protection in Bangladesh 73

hildren

tudent s

tipend s

cheme

S chemes

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tudent rogramme or econdary s f p

s eeding

oucher V

ipend ipend age tipend emale st ealth School School llowance Child benefits • Primary • F • School • S H a

rotection p poor lactating poor mothers

aternal for and early childhood Pregnancy Maternity • Maternal • M 310 e ocial s

cl y uth o Y ore fec c

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is f

x o

Old age e

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utrition age otection nd n a tages

evelopment evelopment

Working ghters d d s pr

eneration

g or

roup roup f g g rant

ork

llowance gladesh g

a w ension

reedom f P

mployment

or e an ocial f

reedom

gainst llowance F s rable women rable women B

intenance A

idows’

ladesh ulnerable ural mployment njured ervice or women ge f ma ulne S

3 A Disability • Disability • Vulnerable • W • V • I Unemployment Unemployment • Food • E • R V

hters ivil nsolvent Fig pped ang Pensions Pensions • Old • C • I igure B nsitive ma F7 mplications Recommendations the for National Social Security Strategy of Bangladesh can be found as part of our overall recommendations in Section 10. se in I 8 Design implications for nutrition-sensitive social protection

There are a number of steps that can be Existence of complementary taken to increase the positive impact that services social protection programmes can have on nutrition. In this section we apply our S ocial pROTECTION as part of an learning from the literature review,311 essential package of services contextual and policy analysis to understand Social protection can increase the effectiveness of the design implications. We look at the investments in health, education, shelter, water and importance of existing complementary sanitation as part of an essential package of services services, integrated versus simple approaches, for citizens.312 Social protection programmes can the target group, and the size of the transfer; serve as delivery platforms for wider and more we then explore some of the key debates. comprehensive nutrition interventions, potentially increasing their scale, coverage and effectiveness. We conclude with recommendations for the Yet in order for this to happen, there needs to be a design of nutrition-sensitive social protection foundation of basic and social services. in Bangladesh and offer international design principles.

F8igure 3 Social protection as part of a package of broader public service delivery313

Health

Housing Education

Family

Social care Water and services sanitation

Social Labour market protection policies

74 8

Nutrition-related services outcomes. Bolsa Familia did not explicitly include D in Bangladesh nutrition as an objective within its programme design, esign and the resulting programme did not affect nutrition. 317 Across the other programmes in the review, it A study commissioned by Save the Children in i mplications Bangladesh found that key nutrition-specific (Ministry was generally the case that programmes that saw of Health and Family Welfare) and nutrition-sensitive improvements in nutrition included nutrition ministries (Ministry of Agriculture, Ministry of explicitly in their objectives. All six programmes Fisheries and Livestock, Ministry of Finance, Ministry in our review that reduced both stunting and wasting of Social Welfare, Local Government Engineering explicitly targeted nutrition. This was also true for

Department, Ministry of Defence) did not have 10 of the 15 programmes that reduced either of the or

the technical capacity needed to deliver quality and two measures. n inclusive nutrition-related services. utrition Target group The study also revealed that inadequate staffing and vacant positions (in terms of coverage and quality) Nutrition and poverty in Bangladesh are widespread and closely linked. Therefore, were very common and widespread problems - se 314 Bangladesh should be striving towards a across the government service delivery system. nsitive Community clinics typically serve a population larger universal social protection system through than the intended capacity, which stretches both time progressively scaling-up in line with financing and administrative capacity.

and resources. s ocial This greatly limits the potential to reach poor and In the short term, inequalities in stunting should be vulnerable households through the provision of addressed by greater inclusion of the worst-affected

groups in social protection coverage: p important nutrition-specific and sensitive services, rotection including maternal and child health, WASH, • the first 1,000 days nutrition, agriculture, fisheries, livestock, and • women and adolescent girls. disaster risk management. Nutrition services cannot Our earlier analysis found limited inequality in be sustainable or resilient unless they are part of outcomes between groups; so, for example, wealth systems that can continue to prevent and treat quintiles 1 to 4 have stunting rates over 30% and undernutrition when shocks and stresses arise.315 1 to 3 over 40%. This should be taken into It is crucial that social protection is not seen as a account in programme design, and while some panacea for all problems but rather, in combination socio-economic groups or regions could be with good basic and social services, as a great prioritised in terms of coverage, programmes should resilience and graduation instrument for the poorest be broad based enough to make an impact on the and marginalised communities and their children. high stunting levels across the majority of the country. Urban areas are currently under-covered and, therefore, should be a focus for improving Integrating a nutrition focus nutrition-sensitive social protection. within social protection Size of transfer explicitly target nutrition The amount of money spent per household included Our review highlights the importance of incorporating also helps us understand the extent and variety ‘nutrition’ into the design of social protection schemes of help delivered to households through social in order to have an impact on reducing undernutrition. protection. The presence of an objective related to nutrition More money spent indicates more cash to recipients is likely to influence the design of programmes, in the cash transfer programmes,318 and in ‘in kind including how the programme is able to address needs packages’ means more of one type of transfer of specific groups as well as of messaging on the that is helpful to recipients, or a wider variety programme, which may influence behaviour. of benefits. As the Bolsa Familia case illustrates,316 nutrition As we explore the size of the transfer through the sensitivity in the design of programmes is important literature (average amount spent) per household for for their effectiveness at improving nutrition programmes with different nutrition outcomes (see

75 76 malnutrition in bangladesh used one specific year to provide a figure on transfer per household, and this year may not be representative of the whole programme. whole the of representative be not may year this and household, per transfer on figure a provide often to year evaluations specific one used Programme countries. other as well as Bangladesh from are which review, our in programmes 22 the covers Analysis Notes: references. review literature Cfor Appendix See review. literature on based calculation Children the Save Source: the by verified is This level spend. of a minimum requires nutrition on success that suggests This US$193. of average an had effect measured no was there where programmes whereas US$339, of household per transfer average an had stunting in saw areduction outcome abrings better spending more we that see 39 40), Figures and Poverty line of BDT 19,812 from HIES (2010) was converted to US$ using 2009 exchange rate from Bangladesh Bank; available at at http://www.bangladesh-bank.org/econdata/exchangerate.php available Bank; Bangladesh from rate exchange 2009 using US$ to converted was (2010) 19,812 BDT of HIES programme. line from whole the Poverty of representative be not may year this and household, per transfer on figure a provide to year specific one used evaluations often Programme countries. other as well as Bangladesh from are which review, our in programmes 22 the covers Analysis Notes: references. review literature Cfor Appendix See review. literature on based calculation Children the Save Source: 0 lin F IND 9 vs F igure igure . ‘ in e

k 3 4 Estimated cost per household as % of nd

Estimated cost per household (US$) N

poverty line expenditure E

400 200 300 250 350 100 150 n 50 100 140 120 ut st ’ 0 80 40 20 60 utrition p 0 ackages imated rition measured for for measured measured for for measured Reduction Reduction stunting Reduction Reduction stunting $339 . The programmes that that programmes . The 1 % 118

o c

e utcomes ost ffect

p Some nutrition effect Some effect nutrition er stunting or wasting) Some nutrition effect Some effect nutrition stunting or wasting) measured (either (either measured measured (either (either measured

f ousehold or $303 106%

c ash livelihood improvements. or security food sustainable achieving in important tremendously be to found was income household to relative transfer the size of the where Bangladesh, in research modality IFPRI’s from arises confirmation Further targeted. populations poor very the on effect have to anoticeable small were too transfers that Zambia and Kenya and Zambia Nepal, in programmes around findings qualitative

t ransfer

a programmes s Average all all Average programmes Average all all Average % $276 o 96% f B

p an rogrammes 319 – where our review suggests review our suggests –where gladesh 320 nutrition effect nutrition No measured measured No nutrition effect nutrition No measured measured No $193 67%

’

p o v er t y 8 Design implications for nutrition-sensitive social protection 77

339 The In Malawi, 338 334 describe mothers mothers describe Programme reviews 337 335 conclude that, “CCTs

341 340

and Nicaragua 336 pendency e nally, althoughnally, the evidence is not 100%, in Pantawad Pamilyang Pilipino Programme no saw reduction in work behaviour in the Philippines. over 70%over Progresa of the money Mexico’s from conditional cash transfer programme was used to increase consumption, with the rest investedin assetsproductive that increased permanent income a smallby amount. there In Kenya is some evidence (albeit, not fully conclusive) that programme participants able are to retain their livestock at higher rates,alongside more solid evidence that a small but significant proportion of beneficiaries started or expanded a business using Hunger Safety Net Programme cash as working capital. [conditional cash transfers] appear had at to have most modest disincentive effects on adult work. Research on Cambodia, and Mexico shows Ecuador, that adults in households that received transfers did not reduce their work effort.” The table on the next page summarises key aspects that or did not the work for worked programmes reviewed. intervention households amassed a range of assets, from household items to bicycles, productive farm assets and livestock during the one year that they received the cash transfer. Similarly, thereSimilarly, no negative were effects on adult labour supply resulting Nutrition from Honduras’s Socialand Project. almost no cases does transfer type of any lead to dependency. This is recognised to be due partially to careful programme design, such as keeping transfer amounts a small at enough level. engaging in entrepreneurial activity as a result of the transfers.receiving D Fi Fiszbein and Schady from Peru

and and In 325 322 331 no 327 326 332 In Malawi, show that show 324 333 Colombia E OF 330 note that, during 321 assets : US

and

In Zambia, ebates found that women’s body mass found that women’s 328, 329 d

323 gains

k t

w studies on international programmes have ogramme transfers used are remarkably by well se ome conomic indices rising were rates at matching their receipt of transfers. Recipients in Brazil found to were eat more biscuits, but also more of four kinds of fruit, six kinds of vegetables, meat, fishyogurt. and South Africa, programme participation reduced drug and alcohol use, sexual activity and the number of sexual partners. demonstrated the outsize returns that accrue to transfers. Gertler and colleagues E A fe On the other Juntos hand, programme Peru’s actually a 50%saw decline in alcohol consumption, Pr TRANSFERS = ECONOMIC GAINS, DEPENDENCY Ufransfers recipients,but it is important to recognise that dietary diversity bag’ is a ‘mixed and increases in consumption do not always take the most nutritious Fernandez Dasso forms. and Sey one in Mexico impacts on decreased adult work and no impacts on fertility. In the Philippines, there also were no increases in alcohol consumption or fertility. the week in which they gain access to their cash transfers, recipients in Peru much are more likely to home from eat and food to away eat more sweets and soft drinks. A study in Colombia on alcohol not are statistically different. Nicaragua, no impact was found on alcohol or tobacco spending. In Brazil, non-recipients consume statistically although per capitamore hard liquor, expenditures oil and sugar purchases climbed, along with roots and tubers, pulses, meat, fish, fruit and while dairy, vegetable consumption was already 100%. at 78 malnutrition in bangladesh developing nutrition-sensitive social protection response for response protection social nutrition-sensitive MPLICATIONS integrated An pathways. nutrition of analysis from our emerged that areas focus priority fromthe implications policy and we conclusions draw section, this In P social olicy Cross-cutting outcomes Nutrition Tracking • Conditional • Straightforward • Nutrition • worked? What and Peru’sand Juntos) Services Development Child Integrated (India’s a po project) Safety Social Honduran the and aCrisis Atencion and ne su nd Colombia) ch as vitamin and mineral supplementation supplementation mineral and vitamin as ch cessary (Nicaragua’s Red de Proteccion Social Social Proteccion Redde (Nicaragua’s cessary or (Malawi and South Africa) South and (Malawi or

protection

s hildren’s

pecifically

social c ash

t ash ransfer

h ealth

top wealth quintile. quintile. wealth top the but all for 30% above are stunting of levels words, everyone’. for ‘bad other In are levels and Bangladesh in challenge considerable a remains Stunting areas focus Priority

t t

protection and ransfers argeted

p a nd rogrammes

nutrition

342

t ntervening t hrough o

t he

xtremely across i ( nterventions Mexico

w here

the

stunting reduction. stunting significant achieved also programme Livelihoods and Chars Jibon-O-Jibika by 16 points. percentage stunting cut SHOUHARDO programmes. unconditional transfer were half other the while programmes, transfer cash conditional were those of Half stunting. in reductions find review our in programmes 22 the of Half protection social from Evidence

nutrition the pathways. the acrossall areas, outcome for nutrition areas focus priority following the consider should Bangladesh What didn’t work? didn’t What Too • Relatively • re results different have seen to likely (N stricting access (Philippine programme) access (Philippine stricting epal, Zambia, and Kenya) – higher transfer levels levels transfer –higher Kenya) and Zambia, epal,

m any

s pathways c mall onditions 344

c ash 343

a ransfers nd IN BANGLADESH IN administrative capacity. administrative and financing with line in scaling-up progressively through coverage universal shouldProgrammes aim for nutrition. on impact show to systems evaluation and monitoring Integrate girls. adolescent and days 1,000 first the of window critical the of coverage shouldProgrammes increase groups. socio-economic all for coverage Consider groups. vulnerable nutritionally target to design programme Develop analysis. causal on based objectives Strengthen nutrition nutrition. for programmes priority identify to Strategy Security Social National Review the Bangladesh for implications design and Policy

b ureaucratic

continued on the next page next the on continued t o

t he

xtremely p rocesses

oor

8 Design implications for nutrition-sensitive social protection 79

continued on the next page Policy and design implications for Bangladesh Consider use of cash transfers to enable households to purchase a nutritiousdiet. Cash transfers should be large enough and adjusted to reflectregional and urban rural differences.and Impacts on productive activities and livelihoods can be enhanced through complementary income- generation activities or links to appropriate policies. household influence To household as such trends, sensitisation consumption, and behaviour change communication targeted towards men, as well as women, is recommended. Incorporate or link to tailored, basic training, entrepreneurship support,peer income- generating and enterprise social alongside activities women. towards protection Integrate1,000-days approach: pregnant/ lactating women and children under two years. Strengthen inclusion of behaviour change and nutrition awareness- raising activities. Involve men alongside women and other influential household mothers- (eg, members in-law). socialTarget protection programmes to include adolescence, especially for girls and to promote access to education. continued pathways

nutrition

Evidencefrom social protection Cash transfers from social protection programmes to used predominantly are purchase food. Evidence shows social protection canimprove household’s ability to shocks.absorb Social protection, including cashtransfer programmes, can improve productive activities and livelihoods, thereby further improving income and food security. Only two safety net social protection programmes in target Bangladesh currently pregnantand lactating mothers and the transfer value is too low to a have meaningful impact. Impact of education cash transfers on girls’ education attendance. Some evidenceon positive impacts of social protection on female empowerment, includingpower and decision- in autonomy making and participation in the labour market. the

across

protection

Priority focus areas challengeKey is affordability ofadequate quality and quantity of food – the poorest spend large percentage of income on food (poorest 40% spend 60–70% on food), and are vulnerabletherefore to rising food prices. The cost of a nutritious diet varies and (region) division by urban/rural areas. between Food insecurity and dietary diversity particular are challenges in rural areas. Importance of education: women with more education significantly are less likely to be undernourished. Education is with associated positively later marriage. Adolescence is a crucial period. The rate of young motherhood is high. withWomen decision- making power consistently invest their earnings in children and families so the benefits. household entire infantMother, and young child feeding practices are inadequate. Practices vary by region. social

Assured access to enough food of adequate quality for living an active healthy life and Pregnancy lactation are junctures critical for quality care supportand Pathway: Household food security Pathway: Caring practices for women and children developing 80 malnutrition in bangladesh Mothers and children attend a cooking and nutrition class in Baroikhali. in class nutrition and acooking attend children and Mothers developing

Photo: Darren Fletcher/Save the Children healthcare curative and preventive of use the and pathogens to exposure children’s Conditions services and environment Health Pathway:

protection

across

the most of existing services. the making Bangladesh, in healthcare to access encourage to potential has protection Social protection social from Evidence

nutrition

pathways continued healthcare systems. healthcare investmentincreased in awareness-raising, alongside insurance, referrals and/or health through example for schemes, protection social through promoted be should healthcare to Access Bangladesh for implications design and Policy 8 Design implications for nutrition-sensitive social protection 81 to ld o orm)

f o

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the s od supplements, nutritional training, deworming nimising time spent (and cost) for beneficiaries receiveto the transfer, eg, using mobile phones

Fo Mi ial nderstanding

– – ernational to identify priorities • Having Health environment and services and environment Health • Food • Adapting

• Reaching • Exempting Caring practices for women and children • Having • U Cross-cutting • Integrating • Choice • Clarifying • Preventing Household security food • Providing • Adjusting • Reaching nternational nt • assess I The development of nutrition-sensitive social nutrition-sensitive social of development The protection internationally the include should following stepskey and be informed our international by design principles (see table below): In the short term, food securityand wasting can be addressed quite effectively through food transfers. to address chronic malnutrition andreduce However, programmes integrated rates, long-term stunting that consider a number of the nutrition pathways are required. I soc 9 Social protection and nutrition on the global development agenda

Social protection and nutrition currently sit World Health Assembly high on the development agenda, supported Global Targets by a series of high-level recommendations and commitments that have created a strong In 2012 the World Health Assembly set six global momentum to be utilised in the development targets designed to reduce the unacceptably high of nutrition-sensitive social protection burdens of disease and death caused by poor programmes within national systems. Before nutrition by 2025. we conclude and make our recommendations The World Health Assembly Global Targets347 to for nutrition-sensitive social protection in improve maternal, infant and young child nutrition Bangladesh, we consider the global priorities. by 2025 including: a 40% reduction in the number of children under five who are stunted; a 30% reduction in low birthweight; and a reduction and maintenance UNSCN Social Protection of childhood wasting to less than 5%. and Food Security recommendations Post-2015 – Developing the In October 2012 the United Nations Standing Sustainable Development Goals Committee on Nutrition endorsed recommendations regarding Social Protection for Food Security and The nutrition goal and social protection target Nutrition,346 notably: (under the poverty goal) are both thought be in • member states to design and put in place, or strong positions to make the final cut for the much- strengthen, comprehensive, nationally owned, anticipated post-2015 sustainable development goals. context-sensitive social protection systems for In the latest version of the proposed goals released food security and nutrition by the Open Working Group,348 social protection • member states, international organisations and sits under proposed goal 1: “End poverty in all its other stakeholders to improve the design and forms everywhere”, articulated by the target 1.3: use of social protection interventions to address “by 2030, fully implement nationally appropriate vulnerability to chronic and acute food insecurity social protection measures including floors, with a • member states, international organisations focus on coverage of the poor, the most marginalized and other stakeholders to ensure that social and people in vulnerable situations”. protection systems embrace a ‘twin-track’ strategy to maximise impact on resilience and The Open Working Group has received strong food security and nutrition. support from nutrition specialists for the proposed stand-alone food and nutrition security goal, with its emphasis on ending hunger and malnutrition as a universal goal. Proposed goal 2: “End hunger, achieve food security and improved nutrition for all, and promote sustainable agriculture” has 11 targets in its latest form, on areas including stunting and wasting for children under five, food access and sustainable food productions.

82 9 Social protection and nutrition on the global development agenda 83

N U

350 genda a 352 015 015 -2 ost p

he t

nd a

cial security throughout their lives. ls related to social The security. Recommendation provides guidance to member states to ensure that all membersof society least enjoy at a basic of level so The MDGs were set for 15 years, yet after 2015 years,The MDGs after yet set 15 for were 2015 efforts ofa world prosperity, equity, to achieve freedom, dignity and peace will continue. The The Social Protection Floor envisages that countries establish a set of tax-financedsocial security guarantees directed towards tackling lifecycle risks. Priority is given to schemes that income provide security for: children; those of working age to protect them against the risks of sickness, disability, maternity and unemployment; and the elderly. A Social meant to Protection Floor is, however, a minimumprovide and not a maximum. Countries can choose to a much provide higher of support level to their citizens, including establishing contributory schemes that enable people to in invest their own social protection that,so if a shock occurs, they can access a higher of benefit. level is working with governments, civil society and other partners to build on the momentum generated the by MDGs and carry on with an agenda. development post-2015 ambitious oa G 02: 2 elopment loors f

ev D 349 otection was adopted the by International Labour pr illennium

351 M ecommendation eight Millennium Development Goals (MDGs) ial

ve beenve a milestone in global and national he development efforts. The MDGs framework, ranging halving from extreme poverty to halting the spread of HIV and AIDS universal and providing primary education, has helped to galvanise efforts national development global and guide and priorities. development The T ha oc Conference in June 2012. The RecommendationConference in June 2012. expresses the commitment of member states to towards buildingmove comprehensive social security systems and extending social security coverage prioritisingby the establishment of national floors of social protection accessible to all in need. It complements the existing International Labour recommendations and Organization (ILO) conventions The Social Protection Floors Recommendation, 2012 (No. 202) Social protection floors are nationally defined sets of basic social security guarantees that secure protection aimed at preventing or alleviating poverty, vulnerability and social exclusion. ILO R ILO S 10 Overall conclusions And recommendations

Social protection needs to be linked to the development of nutrition- specific complementary interventions to sensitive social protection maximise its impact on nutrition. Cash internationally transfers are not usually a silver bullet on their own. Nutrition-sensitive social protection requires strong analysis, a focus on long-term gains Developing social protection across the lifecycle and integrated programmes that consider a with a greater focus on empowering women and the number of the nutrition pathways: 1,000-day window between a woman’s pregnancy and • Assess the context and evidence across nutrition her child’s second birthday will help shape healthier pathways to identify priorities and analyse policy and more prosperous futures. options (as we have done through this report The inclusion of behaviour change communication for Bangladesh). is important for sustainable gains. Access to • Ensure programme lifespan is long enough for water and maternal education are essential, as change to occur. Handa and colleagues353 note: “There is significant • Include and evaluate a range of pathway indicators heterogeneity in treatment effects among children to assess success against malnutrition and to living in households with a protected water source, inform multi-sector development plans. and whose mother had more years of schooling, • Consider the integration of empowerment, suggesting these are complementary inputs to behaviour change communication and cash in determining child height.” income-generating activities to encourage sustainable outcomes. Programmes that are too narrowly focused on achieving short-term gains in nutritional status may miss the larger picture. If transfers are burdened with Conclusions for Bangladesh too many conditionalities or kept too small, then important opportunities may be missed. Larger, more A well-designed social protection system sustainable impacts for individual and household has great potential to improve malnutrition welfare could be gained through synergies with in Bangladesh. productive household activities and opportunities to participate in household livelihood strategies and The international and domestic evidence presented community economic activity.354 in this report clearly demonstrates the importance of an integrated approach to tackling malnutrition in Bangladesh. Severe wasting may be reduced by simply improving food intake but tackling chronic malnutrition requires integrated social protection programmes. Programmes that have effectively reduced stunting and wasting have also addressed many of the underlying causes of malnutrition, including improving household food security and the health environment. Effects are greater when efforts are accompanied by infrastructural improvements that enable participants to access safe water and use sanitary latrines. Bangladesh has made great progress in this area.

84 10 Overall conclusions and recommendations 85

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he mp – informed the by common results framework being developed the by UN Food and Agriculture Organization (FAO), Food Programme the World and others to inform the Government of plan. nextBangladesh’s (7th) Year Five is e all ministries, not just those responsible for health and nutrition. A useful first stepwould be to integrate SMART aw pr – pr ad teenage pregnancies and child marriage or ev approach to impact show on nutrition future for learning development. and lnutrition and poverty widespread, are and • the The development of the Vulnerable Group Development (VGD) programme provides a good starting point. 3: I • H • ur Specifically,social protection programmes should be developed to impact nutrition through the following: • integrate • incorporate • widen • t • assess • strengthen 2:Ex pro Ma therefore the ultimate aim Bangladesh for should be coverage. universal In the short term, inequalities in chronic malnutrition (stunting) should be addressed greater by inclusion of worst-affected groups in social protection eg: coverage, • adolescent - utrition olicy

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kers trengthen plementers otection ngladesh has a large number of social protection ecommendations 1: S ma im R Policy- and decision-makers and Bangladesh in Policy- should recognise the value of integrating nutrition into social protection. Immediate opportunities available are with the vulnerable group development (VGD) programmes. Strengthening the ‘hand up, not a hand out’ the intergenerational approach can help prevent inequality undernutrition. and transmission poverty, of Stunting in Bangladesh everyone’ is for and ‘bad closely tolinked widespread poverty. Therefore, a narrowly targeted poverty programme, as is currently proposed in the National Social Protection Strategy, is not going to sufficientlyaddress chronic malnutrition. The pathways approach taken in this report demonstrates the potential of social protection for nutrition, issues yet on a number arose of occasionsin relation to limited data. This is a result of ineffective nutrition-sensitive social of evaluation and monitoring protection programmes. Well-designed programmes with clear indicators required. are eating practices during to pregnancy, delaying pregnancy andto the for BCC whole family (particularly men). The stark underlying causes of malnutritionin Bangladesh related to undernourished pregnant women, child marriage and stunting birth at highlight the importance and of BCC education as part of an social nutrition-sensitive for approach integrated protection. Specificfocus should be given to changing Demonstrating the importance of caring practices womenfor and children, behaviour change communication (BCC) and the education of caretakers (male and female) about proper child feeding practices, nutrition and has hygiene also been tolinked substantial improvements in child nutrition. programmes that the potential have to be strengthened nutrition, for with little additional expenditure. Gains can be made through changing selection criteria and ensuring that awareness-raising and income-generating activities as are nutrition- sensitive as possible. The design principles set out in this report inSection 8 should be incorporated. Ba pr 86 malnutrition in bangladesh of child poverty are equally pronounced in urban urban in pronounced are equally poverty child of dimensions the of many move, as awelcome is This poverty Urban welcome. is poverty to vulnerability their of recognition and poor’ ‘near the on focus The V Lif W by Children. Save the analysis on are based recommendations following The S R Five Year (7th) next 2015. in Plan Bangladesh’s of Government the of drafting the in and Bangladesh, of Strategy Security Social National the and Services Nutrition Bangladesh’sof National development the in considered be to need report this in raised implications and recommendations The To • There • very welcome. very also is poor the of numbers greater reach to way effective most the is core of schemes coverage extending significantly that acknowledgement The Coverage assessment. alongside poverty the poverty of measures non-consumption the of consideration further with applied consistently more be could approach lifecycle The grant. disability child and grant ofa child introduction the particularly children, on focus increased the is as welcome, is strategy for the framework guiding the as used approach lifecycle overarching The N tr ul ecommendations at e ecycle mu Scaling Up Nutrition (SUN) movement. (SUN) Nutrition Up Scaling for the important particularly is This specialists. protection social include to extended be to national forums nutrition and need mechanisms embe for nutrition. protection social of expansion and strengthening the support to provide to assistance technical effective nerability lcome ategy

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he evidence base nutrition-sensitive for ough the SUN movement to develop tential role of the private sector in supporting mmitments made on nutrition into practice, vernment and civil society to support the th a focus on empoweringwomen and targeting commendations in this report in relation to evelop eep acilitate vate Bangladesh’s commitmentBangladesh’s to ‘nutrition growth’ for through. followed is re po go wi co thr nutrition-sensitive social protectionand to utilise the experience of civil society in this area. of t social protection, the including of development indicators. and evaluation monitoring, resource implications. Bangladesh. in protection nutrition-sensitive social implementation of social protection programmes (see Section 6 of this report ideas). for Engagement should be sought through the Scaling Up Nutrition movement. adolescent girls. specificallyfollowingby through on the Nutrition Growthfor commitment national to review safety net programmes to ensure they are improved deliver nutrition-sensitive and outcomes. nutrition cademics ri eaders Now is the time for action on nutrition- Bangladesh. in protection social sensitive • D • K A • F • Support • Facilitate P L • Demonstrate • Facilitate

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mmunication and education activities in social otection programmes among communities. r the implementation of the recommendations evelop set out in this report. As part of this, assess the feasibility of the recommendations in relation to resource implications. Nu protection programmes. pr co fo ecific vil ecommendations i • Support • Play • Promote C The development of nutrition-sensitive social nutrition-sensitive social of development The protection requires a collaborative effort. • D R sp Outline the role of social protection for social long-termand economic development It be would particularly useful to outline the links to sectors. other Strengthen the role of NGOs The strategy has limited information on the anticipated role of NGOs in supporting government with implementation. This is a missed opportunity given that the strategy acknowledges that multiple- complementary elements required, are beyond income transfers, significant to achieve improvements in many aspects of child welfare (eg, nutrition, child education).labour, Elaborate the link between social care services and the National Social Security Strategy present,At a range of social care services are implemented government across under different policies – including some within the current safety nets budget framework. A coherent system social for care services is an essential complement to social protection interventions. Appendix A: Nutrition- sensitive social protection checklist362

Pathway Impact of programme Design principle incorporated (positive impact, no impact, negative (incorporated, partially incorporated, impact) not incorporated) Note: Broad indicator underlined, followed by examples of what might be measured under that indicator. The review should focus on the indicators and not be limited by the measures.

Cross-cutting Impact on World Health Assembly Integrating within broader food and 2025 global nutrition targets: nutrition security strategies Reduction in the number of Understanding the local causes of children under five who are malnutrition (supply, access, care, stunted363 environment) Reduce and maintain childhood Clarifying the pathways through wasting* which the programme is intended to impact nutrition No increase in childhood overweight* Preventing any negative side effects on the causes of both undernutrition Reduction in low birthweight* and overweight Reduction of anaemia in women of reproductive age* Increase the rate of exclusive breastfeeding in the first six months* Intra-uterine growth retardation (poor growth of a baby while in the mother’s womb during pregnancy) The amount of food available at the national level • Measured using countries’ daily per-capita dietary energy supplies, an indicator of the average amount of food available per person in a country.

* WHO and UNICEF provide the UN system’s joint monitoring programme definition: http://www.who.int/water_sanitation_health/mdg1/en/ [Accessed 4 December 2014] ** UNICEF: http://www.unicef.org/wcaro/overview_2570.html [Accessed 4 December 2014] *** http://www.wssinfo.org/definitions-methods/ [Accessed 4 December 2014]

88 Appendix A: Nutrition-sensitive social protection checklist 89

: pregnant/ (examples of consideration of Choice of impact indicators (as a dietaryminimum, diversity) Reaching the 1,000 days lactating women and children under two years of age Providing transfers in an appropriate form nutrition in development of form) level cash/voucher benefit Adjusting to the cost of a healthy diet Design principle incorporated (incorporated, partially incorporated, incorporated)not The The ntity of

ua Whether a Q 364 ntities of foods acquired ntity of food available ua household acquires insufficient acquires household food the over reference period to meet the energy requirements of all of its members for basal metabolic function and light activity. energy-deficiency (An individual’s situation is defined as that of her or household.)his expenditures of Percentage on food. The percentage of total household expenditures devoted to food the over reference period. Q daily per capita. Household daily energy food availability per capita. The energy in the food acquired a householdby the over survey reference period divided the by and members household of number the number of days in the period. Whether a household is food energy-deficient. Household diet diversity. diet Household number of foods or nutritionally significant food groups acquired a householdby the over reference period. Percentage of food energy staples. from available percentage of the energy acquired a householdby the over reference period that is derived from staple foods (cereals, roots, and tubers). specific foods acquiredover the reference period divided the by and members household of number the number of days in the period. ua Q vulnerabilityEconomic • • • • • • • (positive impact, no impact, negative impact) Diet quality Impact of programme Impact of Household security food Assured access to enough food of adequate quality for living an active healthy life Pathway * WHO and UNICEF provide the UN system’s joint monitoring programme definition: http://www.who.int/water_sanitation_health/mdg1/en/[Accessed December 4 2014] ** UNICEF: http://www.unicef.org/wcaro/overview_2570.html [Accessed 4 December 2014] *** http://www.wssinfo.org/definitions-methods/ 2014] December 4 [Accessed 90 malnutrition in bangladesh *** http://www.wssinfo.org/definitions-methods/ [Accessed 4 December2014] http://www.wssinfo.org/definitions-methods/ *** 2014] 4December [Accessed http://www.unicef.org/wcaro/overview_2570.html UNICEF: ** 2014] 4 December [Accessed http://www.who.int/water_sanitation_health/mdg1/en/ definition: programme monitoring joint system’s UN the provide UNICEF and * WHO care and support and care quality for junctures critical are lactation and Pregnancy women children and for practices Caring Pathway curative healthcare and preventive of use the and pathogens to exposure children’sConditions services and environment Health Improved • E • Female • Women’s education impact) negative impact, no impact, (positive Impact of programme Infant and young child feeding child young and Infant Age • The • men) to relative power Empowerment Acc U • Access • water safe of use and to Access Skilled • services health good-quality of use and to Access Place • shelter to Access Seeking • Timely • Utilisation • Utilisation • behaviours Health-seeking Minimum • Introduction • Continued • Early • Provision • waste human of for disposing facilitates en ex and faeces and fo we hea mi sof yea mont xclusive ess to and use of sanitation sanitation of use and to ess se r the safe disposal of human urine urine human of disposal safe r the rolment ratio rolment nimum acceptable diet acceptable nimum pectancy at birth atbirth pectancy ather or danger or ather t food r lthcare system lthcare

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Appendix A: Nutrition-sensitive social protection checklist 91 Water used for domestic purposes, drinking, cooking and personal hygiene. Access to drinking water means that the source is less than one kilometre away from its place ofuse and that it is possible to reliably obtain at least 20 litres per day.* per member household Water with microbial, chemical and physical characteristicsthat meet WHO guidelines or national standards on drinking water quality.* The proportion of people using improved drinking water sources, eg, household connection, public standpipe, borehole, protected dugwell, protected spring, rainwater.* Defined as one that,by nature of its construction or through active intervention, is protected from outside contamination, in particular from contamination with faecal It comprises matter.* piped water on premises suchas piped household water connection located inside the dwelling, user’s plot or yard. Other improved drinking water sources include public taps or standpipes, tubewells or rainwater.* springs, protected wells, dug protected boreholes, Defecation in fields, forests, bushes, bodies of water or other open spaces, or disposal of human faeces with solid waste.** The lowest-cost technology ensuring hygienic excreta and sullage disposal and a clean and healthful living environment both at home and in the neighbourhood of users. Access to basic sanitation includes safety and privacy in the use of these services. Coverage is the proportion of people using improved sanitation facilities, eg, public sewer connection, septic system connection, pour-flush latrine, simple pit latrine, ventilated improved pit latrine.* Defined as one thathygienically separates human excreta from human contact.*** Facilities that do not ensure hygienic separation of human excreta from human contact. Unimproved facilities include pit latrines without a slab or platform, hanging latrines and bucket latrines.** Sanitation facilities of an otherwise acceptable type shared between two or more households. Shared facilities include public toilets.** finitions de

Access to Safe water Safe Use of safe drinking water drinking water Improved Open defecation Basic sanitation sanitationImproved sanitationUnimproved Shared sanitation upporting * WHO and UNICEF provide the UN system’s joint monitoring programme definition: http://www.who.int/water_sanitation_health/mdg1/en/[Accessed December 4 2014] ** UNICEF: http://www.unicef.org/wcaro/overview_2570.html [Accessed 4 December 2014] *** http://www.wssinfo.org/definitions-methods/ 2014] December 4 [Accessed S Appendix B: Programmes included in literature review

Programme Country

1 Bolsa Familia Brazil

2 Familias en Acción/CCT Colombia

3 Child Support Grant South Africa

4 Child Grant Programme Zambia

5 Hunger Safety Net Programme Kenya

6 Progressa / Oportunidades Mexico

7 Social Safety Net Honduras

8 Juntos Peru

9 Pantawid Pamilyang Pilipino Program Philippines

10 Child Grant Nepal

11 Integrated Child Development Services (ICDS) India

12 Bono de Desarrollo Humano Ecuador

13 Red de Proteccion Social and Atencion a Crisis Nicaragua

14 Social Cash Transfer Malawi

15 Vulnerable Group Development Programme – national vulnerable Bangladesh group development programme

16 MDG-F – Protecting and Promoting Food Security and Nutrition for Bangladesh Children and Families in Bangladesh

17 Chars Livelihood Programme/Cash-for-work Bangladesh

18 CARE SHOUHARDO Bangladesh

19 Targeting the Ultra Poor (TUP) Bangladesh

20 Kishoree Kontha (KK) Bangladesh

21 SHIREE Bangladesh

22 Jibon O Jibika (now Nobo Jibon) Bangladesh

92 Appendix C: Literature review references

Abdul Latif Jameel Poverty Action Lab, 2013. Empowering Bailey, S., 2013. The Impact of Cash Transfers on Food Adolescent Girls in Bangladesh Midline Report on the Consumption in Humanitarian Settings: A review of evidence. Kishoree Kontha, Abdul Latif Jameel Poverty Action Lab. Study for the Canadian Foodgrains Bank, May: 32. http://old. alnap.org/pool/files/cfgb-impact-of-cash-transfers-on-food- Agüero, J. M., Carter, M. R., and Woolard, I., 2006. The consumption-may-2013.pdf [Accessed 3 December 2014] Impact of Unconditional Cash Transfers on Nutrition: The South African Child Support Grant. Southern Africa Labour and Bandiera, O., Burgess, R., Das, N., Gulesci, S., Rasul, I., and Development Research Unit Working Paper Number 06/08. Cape Sulaiman, M., 2013. Can Basic Entrepreneurship Transform the Town: SALDRU, University of Cape Town. Economic Lives of the Poor? IZA DP No. 7386. Ahmed, A. U., Quisumbing, A. R., Nasreen, M., Hoddinott, J. Barber, S. L., and Gertler, P. J., 2010. Empowering women: F., and Bryan, E., 2009. Comparing Food and Cash Transfers how Mexico’s conditional cash transfer programme raised to the Ultra Poor in Bangladesh. Research monograph 163. prenatal care quality and birth weight. Journal of development International Food Policy Research Institute. effectiveness, 2(1): 51–73. Ahmed, S. M., and Rana, A. M., 2005. Customized Development Barham, T., and Maluccio, J. A., 2009. Eradicating diseases: The Interventions for the Ultra Poor: Preliminary Change Assessments of effect of conditional cash transfers on vaccination coverage in Health and Health-seeking Behaviour (CFPR/TUP 2002 to 2004). rural Nicaragua. Journal of Health Economics, 28(3), 611–621. CFPR/TUP Working Paper Series No. 7. Barham, T., Macours, K., and Maluccio, J. A., 2013. Boys’ Ahmed, S. M., Petzold, M., Kabird, Z. N., and Tomson, G., Cognitive Skill Formation and Physical Growth: Long-Term 2006. Targeted intervention for the ultra poor in rural Experimental Evidence on Critical Ages for Early Childhood Bangladesh: Does it make any difference in their health-seeking Interventions. The American Economic Review, 103(3): 467–471. behaviour? Social Science & Medicine, 63: 2899–2911. Bhutta, Z. A., Das, J. K., Rizvi, A., Gaffey, M. F., Walker, American Institutes for Research, 2013. Zambia’s Child Grant N., Horton, S., and Black, R. E., 2013. Evidence-based Program: 24-month impact report. Washington, DC: Author. interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet, 382(9890): Attah, R., Farhat, M., and Kardan, A., 2013. Kenya Hunger 452– 477. Safety Net Programme Monitoring and Evaluation Component. Qualitative Impact Evaluation Report: 2011–2012: 47. Bradshaw, S., 2008. From Structural Adjustment to Social http://www.opml.co.uk/sites/default/files/HSNP%20 Adjustment: A Gendered Analysis of Conditional Cash impact%20evaluation%20qualitaive%20report_0.pdf Transfer Programmes in Mexico and Nicaragua. Global Social [Accessed 3 December 2014] Policy, 8(2): 188–207. Attanasio, O., Battistin, E., Fitzsimons, E., and Vera- Campello, Teresa, and Marcelo Côrtes Neri, 2014. Bolsa Hernandez, M. “AttBat”, 2005. How effective are conditional Família Program: A Decade of Social Inclusion. Executive cash transfers? Evidence from Colombia. http://eprints.ucl. Summary. http://socialprotectionet.org/resources/bolsa- ac.uk/14766/1/14766.pdf [Accessed 3 December 2014] familia-program-decade-social-inclusion-brazil [Accessed 3 December 2014] Attanasio, O., Gomez, L. C., Heredia, P., and Vera-Hernandez, M. “AttGom”, 2005. The short-term impact of a conditional cash CARE, 2012. Reaching New Heights: The Case for Measuring subsidy on child health and nutrition in Colombia: 15. Women’s Empowerment. http://www.care.org/sites/default/ files/documents/CARE_IWD_2012.pdf [Accessed 3 December Awofeso, N., and Rammohan, A., 2011. Three decades of the 2014] Integrated Child Development Services Program in India: progress and problems. Health Management-Different Approaches and Chaudhury, N., and Okamura, Y., 2012. Conditional Cash Solutions, Dr Krzysztof Smigorski (Ed.), ISBN: 978-953. Transfers and School Enrollment. http://www-wds.worldbank. org/servlet/WDSContentServer/WDSP/IB/2012/08/20/00038 Ayala, F., 2006. Inter-Regional Inequality Facility Policy Brief 2: 6194_20120820023407/Rendered/PDF/719040BRI0P1180m0in Familias en Acción, Colombia. Overseas Development Institute, 0the0Philippines.pdf [Accessed 3 December 2014] London. February: 4. Chaudhury, N., Friedman, J., and Onishi, J., 2013. Philippines Baez, Javier E., Camacho, Adriana, 2011. Assessing the long-term conditional cash transfer program: impact evaluation 2012. The effects of conditional cash transfers on human capital: Evidence World Bank. from Colombia, Discussion paper series // Forschungsinstitut zur Zukunft der Arbeit, No. 5751, http://nbn-resolving.de/ urn:nbn:de:101:1-201106202041 [Accessed 3 December 2014]

93 94 malnutrition in bangladesh The impact of of Roy, 2012. impact The S., V., and Moreira, J., D., Hoddinott, Gilligan, A., Brauw, de [Accessed files/fernandez_y_dasso.pdf 3 December 2014] http://www.cedlas-er.org/sites/default/files/cer_ien_activity_ Peru in Transfers Cash Conditional and F., 2013. Goods Temptation Fernandez, and R., Dasso, B from Evidence Women? to Transferred Are Assets When Change Dynamics Q P., Davis, M., Kamruzzaman, J., Ara, R., Yasmin, N., Das, Effectiveness Development of Journal scheme. transfer cash social Malawi the of impacts productive production: to protection P., 2012. From Winters, and B., Davis, K., Covarrubias, York: Earthscan. New and London Development and Livelihoods Rural Seasonality, (Eds), Longhurst R. and Sabates-Wheeler R. Devereux, S. In Bangladesh. in (2004–2010) Programme Livelihoods Chars the from Lessons Poverty: Extreme Reduce Can 2011. Seasonality for C., Vignon, Planning and How Conroy, K., Science Africa. South in health child boosts 2014. cash J., Hard Cohen, S389–S397. AIDS Africa. South in adolescents among behaviour risk HIV- mitigates cumulatively protection social care: plus Cash 2014. Sherr, L., and E., M. F. Boyes, M., D., Orkin, Cluver, L. 2014] publications-opinion-files/5753.pdf[Accessed 3 December http://www.odi.org/sites/odi.org.uk/files/odi-assets/ Malawi in Transfers Cash of Economy Political The 2009. B., Chinsinga, cash transfer program ( program transfer cash 2011. Ecuador’s of M., Hidrobo, and Effect C., L. Fernald, DOI:10.1016/S0140-6736(09)61676-7. Lancet The study. follow-up alongitudinal behaviour: and language, cognition, growth, child on programme, transfer cash conditional Mexico’s Oportunidades, of effect 10-year 2009. M., L. P. Neufeld, and Gertler, J., H., C. L. Fernald, 2014] 3 December [Accessed 21.Germany: http://mpra.ub.uni-muenchen.de/56480/ Munich, of Library University 56480). (No. Peru] in children for JUNTOS programme Transfer Cash Conditional the of BR>[Impacts Milenio< del Niños estudio el en basada Evidencia niños: los de bienestar el en JUNTOS programa del impactos 2012. Algunos a), (Esc S. Benites, and J., Escobal, Africa. andadolescents theirhouseholds children, of asurvey from Evidence Assessment: Impact Grant Support Child African 2012. South The UNICEF, and SASSA DSD, World Development Power. Women’s on Decision-Making Família Bolsa of Impact The Roy, 2014. and S., J., D. Hoddinott, O., Gilligan, A., Brauw, de International Food Policy Research Institute. welfare household and effectiveness trial. Social science & medicine Arandomized toddlers: and infants in development child an ui gladesh sumbing, A., and Roy, S., 2013. How Do Intrahousehold Roy, 2013. and Intrahousehold S., Do How A., sumbing, . A report prepared for ODI. Chancellor College: Chancellor ODI. for prepared . Areport , 345(6202): 1264–1264. 345(6202): , . GAAP NOTE. . GAAP , 4(1): 50–77. , 4(1): B RA C’s “Targeting the Ultra Poor” Program in in Program Poor” Ultra the C’s “Targeting . Working Paper. Washington DC: DC: Paper. Washington . Working B on , 59: 487–504. , 59: o de Desarrollo Desarrollo o de B ol sa Familia on child, maternal, maternal, child, on Familia sa . Pretoria: UNICEF South South UNICEF . Pretoria: . Washington, DC: 23. 23. DC: . Washington, H , 72(9): 1437–1446. 72(9): , um : 237–252). 237–252). : ano ) on ) on , 28: , 28: :

3 4. 4. Malawi Social Cash Transfer Program Program Transfer Cash Social 2014. M., Malawi Tsoka, P., and Mvula, S., Abdoulayi, G., Angeles, S., Handa, review Development policy Caribbean. the and America Latin in transfers cash conditional of experience The 2006. B., Davis, and S., Handa, [AccessedHDNFoodandFuel_Final.pdf 3 December 2014] org/SAFETYNETSANDTRANSFERS/Resources/ Prices Fuel and Schwab, Roy, and J., S., Hoddinott, M., D., Hidrobo, Gilligan, Economics Applied Journal: Economic American standards. living long-term raise to transfers cash Investing One the of Proceedings and Papers Review Economic American The Randomized Experiment. PROGRESA’s Control from Evidence Health? Child Improve Transfers Cash Conditional Do P.,Gertler, 2004. 85–96. of conditional transfers. cash impact P. 2013. J., heterogeneous The McEwan, and S., Galiani, Obesity of Journal International study. cohort prospective obesity: and BMI on Colombia in women poor to transfers cash of impact 2012. O., The Attanasio, and G., M. Marmot, S., T., Garcia, Chandola, I., Forde, Publications. poverty future and present reducing transfers: cash Conditional F. 2009. H., Ferreira, and R., N. Schady, A., Fiszbein, Paper Working CEDLAS Peru, from Evidence Supply: Labor and Dates Payment Transfers, F.Fernandez, V., and Saldarriaga, 2013. Conditional Cash Lancet The Oportunidades. Mexico’s of analysis an development: and growth, health, child for programmes transfer cash conditional in cash of Role 2008. L., P., Gertler, Neufeld, and L., Fernald, P. Hou, and Gertler, J., C., L. Fernald, Difference? a Making Programme CFPR/TUP the Is Poor: Ultra the Among Consumption Nutrient and Food in Change F., 2006. Haseen, Florence. Research, of Office UNICEF No.2014-08, Paper Working Innocenti Grant, Child Zambian the from Evidence Bullet? a Silver Team,Transfers 2014. Cash Are Evaluation Transfer Cash Zambia the and Tembo G. B., D., Davis, Seidenfeld, S., Handa, 3 December 2014] MalawiSCTPBaselineReportrev2014July8.pdf [Accessed edu/projects/transfer/countries/malawi/copy_of_ W., Rubio-Codina, S. and P. Martinez, Gertler, J., 336–341. 94(2): 2004, Association Economic American the Journal of Nutrition The adults. in pressure blood and index mass body higher with associated is program transfer cash conditional of component from the the from Responses for Guidance 2008. E., Tesliuc, and M., Grosh, 2014] 3December [Accessed pdf modalities%20and%20consumption%205%2029%2014--AAEA. http://ageconsearch.umn.edu/bitstream/171159/2/Transfer%20 patterns consumption on transfers food and cash of effects the on experiments Multicountry modalities: about ado Much 2013. B as eline Evaluation Report Evaluation eline , 371: 828–837. , 371: 828–837. H um CFPR/TUP Working Paper Series No. 11. No. Series Paper Working CFPR/TUP an Development Sector to Rising Food Food Rising to Sector Development an : http://siteresources.worldbank. 46. ,

1 38(11): 2250–2257. 38(11): , 24(5): 513–536. 24(5): , : 125. http://www.cpc.unc. H un , N. 140. , N.

J ournal of Public Economics Public of ournal dred Sixteenth Annual Meeting of of Meeting Annual Sixteenth dred San Diego, CA, January 3–5, 3–5, January CA, Diego, San , 36(9): 1209–1214. 36(9): , X ., 2 ., 008. Cash Cash 008. , 4(1): 164–192. , 4(1): . World Bank . World Bank

M ., 2012.., ,

1 03: 03: : 45. : 45.

B ., ., Appendix C: Literature review references 95 ., ., lth R

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re H , 36(4): B , 134(9): . MDG . letin of the World ul B : 154. http://www.opml.co. 154. : , International Policy , 4(2): 247–273. sa Família Program: implementing ol B gladesh Final Evaluation an zil’s B ra B . Research report written for the Socio- : 6. http://www.ifpri.org/publication/: , International Food Policy Research Institute. , 88(11): 854–860. . C., 2004. Conditional cash transfers are associated , 36(2): 230–238. A

. http://www.unicef.org/malawi/MLW_resources_ the Cycle ofPoverty [Accessed nicaragua-red-de-protecci-n-social-mi-familia 2014] December 3 Maluccio, J., and Flores, R., 2005. Impact evaluation of a conditional cash transfer program: The Nicaraguan Red de Social Protección C. G.Mascie-Taylor, N., Marks, M. K., Goto, R., and Islam, Impact2010. of a cash-for-work programme on food facing children and women among nutrition and consumption food insecurity in rural Bangladesh. Achievement Fund. Lindert, K., A., Linder, Hobbs, J., and De la Brière, B., 2007. The nuts and bolts of Levinson, J., and F. Hussain, MDG Fund – 2010–2013 2013. D., Protecting and Promoting Food Security and Nutrition among Families and Children in conditional cash transfers in a decentralized context Lokshin, M., Dasgupta, M., Gragnolati, M., and Ivashenko, 2005. Improving child nutrition? The integrated child development services in India. Change and Development 613–640. Macours, K., Schady, N., and Vakis, R., Cash 2012. transfers, behavioral changes, and cognitive development in early childhood: Evidence from a randomized experiment. American Economic Journal: AppliedEconomics Maluccio, J. A., Adato, M., Flores, R., and Roopnaraine, T., 2005. Nicaragua: Red de Protección Social Mi Familia. impactsocialcashtrf.pdf [Accessed 3 December 2014] Mirugi-Mukundi, Realising G., 2009. the Social Security Rights of Children in South Africa, with Particular Reference to the Child Support Grant Economic Rights Project of the Community Law Centre. http://www.communitylawcentre.org.za/projects/socio- economic-rights/Research%20and%20Publications/research/ Social%20Security%20Rights/realising-the-social-security- rights-of-children-in-south-africa-with-particular-reference-to- the-child-support-grant.pdf [Accessed 3 December 2014] Moore, C., 2009. Nicaragua’s Red de Protección Social: cash transfer short-lived exemplary conditional but an programme (No. 17). Country Study Centre for Inclusive Growth. Morris, S. S., Flores, Olinto, R., P., Nilson, E. A., and Figueiro, with a small reduction in the rate of weight gain of preschool northeastchildren in Brazil. The Journal of Nutrition 2336–2341. Organization Merttens, Hurrell, F., A., Marzi, M., Attah, R., Farhat, M., Kardan, A., and MacAuslan, Kenya Hunger I., 2013. Safety Net Component. Evaluation and Impact Monitoring Programme Evaluation Final Report: 2009 to 2012 uk/insights/publications/kenya-hsnp-monitoring-and- evaluation-component-impact-evaluation-final-report [Accessed December 3 2014] C.Miller, M., Tsoka, M., and Reichert, The impact of K., 2011. the Social Cash Transfer Scheme on food security in Malawi. policy Food C.,Miller, Tsoka, M., and Reichert, K., 2008. Impact Evaluation Report External Evaluation of the Mchinji Social Cash Transfer Pilot . . . gladesh . CPRC an B . , 2001. Son, 2001. gladesh (S2): 69–82. , 39(8): 9 . L. an

, B Q . Tucson: TANGO , International Food o Solidario en el Ecuador . International Food on B C’s ‘TargetingC’s the Ultra Poor’ RA B to, Ecuador. ui aternal & child nutrition child & aternal Q M , 48(2): 254–267. , 43 ( 6 ) : 1126 –1143.

, 53: 37–61. , 2004–2009. Bulletin No 1. . BWPI Working Paper University 1. of Manchester. . A report prepared for Overseas Development Insitute. gladesh: Learning from an Unpublished manuscript, Sistema Integrado de Indicadores Sociales del Ecuador, efectivos los programas de transferencias monetarias para combatir la pobreza? Evaluación de impacto del GRADE. http://disde.minedu.gob.pe/xmlui/bitstream/ handle/123456789/748/422.%20Impacto%20del%20 Programa%20Juntos%20sobre%20nutrici%C3%B3n%20 temprana.pdf?sequence=1 [Accessed December 3 2014] Kandpal, Beyond Average Treatment E., Effects: 2011. Distribution of Child Nutrition Outcomes and Program Placement in ICDS. India’s Development World 1410–1421. Krishna, A., Poghosyan, M., and Das, N., How Much 2012. Can Asset Transfers Help the Poorest? Evaluating the Results of BRAC’s Ultra-Poor Programme (2002–2008). Journal of Studies Development Langworthy, M., and Caldwell, R., 2009. Save the Children: Jibon o Jibika Program: End-line Survey Report International. Lee, M. H., 2009. Political Economy of Cash Transfers In Zambia. Overseas Development Institute Working Paper: 21. http://www.odi.org/sites/odi.org.uk/files/odi-assets/ December 3 [Accessed publications-opinion-files/5751.pdf 2014] León, S. Transfer payments, M., 2007. D., and Younger, mothers’ income and child health in The Ecuador. Journal of Studies Development León, M., R., Vos, Brborich, and Haya, W., Programme Ikiara, G. K., 2009. The Political Economy of Cash Transfers in Kenya University Nairobi. of Jaramillo Baanante, M., and Sánchez, A., 2011. Impacto del programa Juntos sobre nutrición temprana HTSPE, 2011. Bangladesh: Impact Independent Assessment HTSPE, 2011. of the Chars Livelihood Programme – Phase Final 1. Report Department for International Development: 194. Hulme, and D., Moore, K., Assisting 2007. the poorest in B Working Paper 92 Chronic Poverty Research Centre. Hossain, N., and Zahra, [not dated] Poverty Reduction and MDG Localization: a case study of the IGVGD Programme in Hoddinott, J., Skoufias, E., Washburn,and R., 2000. The impact of PROGRESA on consumption: a final report Institute. Research Policy Hossain, N., The politics 2007. of what works: the case ofthe in Programme Development Group Vulnerable Policy Research Institute (IFPRI). Hoddinott, J., and Skoufias, E., 2004. The Impact of Economic Consumption. Food on PROGRESA development and culturalchange Hoddinott, J., Alderman, H., Behrman, J. R., Haddad, L., and Horton, The S., economic 2013. rationale for investing in stunting reduction. Trend Analysis Trend of the 2010. JibonInternational, O Keller Helen ProjectJibika Hoddinott, J., and 2002. Yohannes, Y., Dietary diversity as a food security indicator. FCND briefs 136 96 malnutrition in bangladesh 101(3): 246–248. 101(3): Letters Economics income?. of sources other like spent women to made transfers cash Are 2008. J., Rosero, and N., Schady, 53–66. 23(1): Revista Estudios Económicos temprana. nutrición la sobre Juntos programa del 201. M., Impacto Jaramillo, and A., Sánchez, Press. Town: EPRI Designing and Implementing Social Transfer Programmes Mac and I., Niekerk, van M., Samson, India Forces Medical Journal Armed scheme. (ICDS) services development child 2001. Integrated J., Y., Dasgupta, Sachdev, and Study,Randomized Effectiveness JAMA A Young and Children Infants in Anemia and Growth of Rates on (Progresa) Nutrition and Health, Education, for Program Mexican the of Impact 2004. S., Villalpando, and T., J.-P., Shamah, D., Habicht, Sotres-Alvarez, A., J. Rivera, 2011. Conroy, D., K., and Panetta, America of Association Population the of Meeting Annual 2009 the of Annals In outcomes. labor and education Expenditures, Brazil: in Program Familia Bolsa the of evaluation An 2009. A., Oliveira, Economists. Agricultural of Association International the of meetings the of impact The 2003. A., Viega, and S., Morris, P., R., Olinto, Flores, 3 [Accessed webportal/CDN/PUBLICATIONS/pidsdps1433.pdf http://dirp4.pids.gov.ph/ Studies. Development for Institute Philippine 2014-33). DP (No. Philippines the in Poverty D., 2014. B. Child M. Mondez, D., and R. Asis, C., Reyes, Wellness and Nutrition of Journal Internet India. north in worker health and anganwadi between in of delivery and services nutritional functionalintegration program ICDS of Role 2008. S., Lal, and R., Verma, S., Prinja, 35(69): 53–82. Economía impacts. long-term and short program’s the on evidence New Juntos: in 2012. 5years R., Vakis, and E., Perova, 1–59. World Bank: evaluation anon-experimental from Evidence Peru: in Program “Juntos” the of impacts Welfare 2009. R., Vakis, and E., Perova, Change Cultural and Development Economic Ecuador. rural in development child on transfers cash of effects The matter? money 2010. Does N., Schady, and C., Paxson, Development 361–384. Programme: Nations Organisation/United Labor York: International Experiences Floor Social Successful Experiences: Innovative Sharing In Africa. South in Grants 2011. L., Support Patel, Child Foundation Khan Aga

D ecember 2014] B ol sa Alimentação Program on food consumption food on Program Alimentação sa . , 57(2): 139–143. , 57(2): , 5(2). , 5(2). B ey Q ond Services Financial , 291(21). ue , 59(1): 187-229. 59(1): , ne, K., 2006. 2006. K., ne, . In annual annual . In . Cape . Cape . New . New , . The . The . , , South Africa. South in Blacks among Teenage Pregnancy and Grant, Support Child Status, Socioeconomic and 2013. O., E. Demographic Udjo, Children. the Save 2010.Titus, S., Assessment Qualitative Kontha Project Kishoree Report Evaluation Final USAID of program ii atitle livelihoods): and (life oJibika Jibon 2009. Inc., TANGO International 39. Growth: Inclusive for Centre Peña, C., M. Araujo, N., Schady, World Bank, 2013. World Bank, 2014] 3 December [Accessed uploads/2011/03/rp39.pdf http://epri.org.za/wp-content/ 86. #39: Paper Working Grant Support Child Africa’s South of Impacts Economic and 2007. Social The J., M. Williams, Food Programme. activity development group vulnerable on report outcome Programme programme, net safety a social through Bangladesh in women poor extreme the to difference a Making (VGD): development group WFP, 2007. Vulnerable (Vol. review evidence an nutrition: and Women’s empowerment and Colombia 3 December 2014] [Accessed financing-nutrition-social-protection-project curated/en/2013/12/18765459/honduras-credit-additional- DC World Group. http://documents.worldbank.org/ Bank Project Protection Social and M., Bold, Van den of studies case vulnerabilities: gender and programmes 2010. E., F. V., Silva, Soares, and 3 December 2014] [Accessed handle/123456789/3816/Wp441R.pdf?sequence=4 47.MDG Era: http://opendocs.ids.ac.uk/opendocs/bitstream/ Post- the for Priorities and Drivers Past Undernutrition: Child 2014. Reducing L., Haddad, and L., Smith, World Development Bangladesh. in Stunting Child on Project SHOUHARDO CARE’s of Impact The Evaluation? Development of Court the in Evidence 2013. Admissible A., Wadud, and T. F., R., Frankenberger, Khan, C., L. Smith, Conference. Centre Research Poverty Chronic Thinking Wishful or Pragmatism Africa: Sub-Saharan in Countries Income Low in Reduction Poverty and Transfers 2010. Cash A., McCord, and R., Holmes, R., Slater, Institute. Report Final Enrollments: School on Progresa of Impact The P., 2000. Schultz, Economía Comments]. [with Ecuador in Enrollment School and Conditions, Transfers, Cash 2008. “SandA”,

1 294). International Food Policy Research Institute. Research Policy Food International 294). . Washington: International Food Policy Research Research Policy Food International . Washington:

( Po No. 69). Working Paper, International Policy Policy Paper, International Working 69). No. litics & Policy & litics Q H ui on sumbing, A. R., and Gillespie, S., Gillespie, and R., A. sumbing, duras – Additional Financing for Nutrition Nutrition for Financing –Additional duras . Economic Policy Research Institute Institute Research Policy . Economic . Report No: ICR2896 Washington Washington ICR2896 No: . Report ,

4 1(6): 833–851. 1(6):

C X onditional cash transfer transfer cash onditional ., a ., . Dhaka, Bangladesh: World Bangladesh: . Dhaka, . Draft paper prepared for for prepared paper . Draft nd López-Calva, L. López-Calva, nd , 41: 196–216. : 43–77. : B ra

zil, Chile Chile zil, 2

013. F . . . notes

Kermsey t 18 The World Bank, 2013. Improving Nutrition Through Multisector Approach: Social Protection briefing, The World Bank, Rapid Social 1 1000 Days Partnership, 2014. 1000 days. http://www.thousanddays. Response, DFID, Government of Japan. This brief is part of the World org/about/ [Accessed online 4 December 2014] Bank’s report on multisectoral approach for improving nutrition. 2 UNICEF, 2006. Progress for Children – Hunger definition. 19 Save the Children calculation based on the Demographic Health http://www.unicef.org/progressforchildren/2006n4/hungerdefinition. Survey (2011) from Bangladesh. html [Accessed online 4 December 2014] 20 Based on ‘20% stunting at 0 month’ statistic as half of the 41% national 3 UNICEF, 2006. Progress for Children – Malnutrition definition. stunting rate in children under 5 (DHS, 2011). http://www.unicef.org/progressforchildren/2006n4/ 21 malnutritiondefinition.html [Accessed online 4 December 2014] Hoddinott J. et al., 2013. The economic rationale for investing in stunting reduction. Maternal & Child Nutrition 9 (Suppl. 2), 69–82. 4 Ruel et al., 2013, Nutrition-sensitive interventions and programmes: 22 how can they help to accelerate progress in improving maternal and Note: Figure is for 2011. Source: Black et al, 2013. Maternal and child nutrition? The Lancet, Volume 382, Issue 9891: 536–551 child undernutrition and overweight in low-income and middle-income countries, Maternal & Child Nutrition, The Lancet. 5 Transform Nutrition, 2014. Nutrition-specific interventions, Transform 23 Nutrition. http://www.transformnutrition.org/research/direct- Save the Children, 2014. Suchana: Ending the Cycle of Malnutrition in interventions/ [Accessed online 4 December 2014] Bangladesh, Proposal for DfID. 24 6 UNICEF, 2006. Progress for Children – Undernutrition definition. Grantham-McGregor, S. et al., 2007. Development potential in the http://www.unicef.org/progressforchildren/2006n4/ first five years for children in developing countries. The Lancet, 369: undernutritiondefinition.html [Accessed online 4 December 2014] 60–70) 25 Based on exchange rate of US$1 being equal to Taka75.8, current on Executive summary 5th December 2012 http://www.oanda.com/currency/converter/ 26 FAO, 2012. State of Food Insecurity in the World, Food and Agriculture 7 DHS, 2011. UN population project, Save the Children calculation. Organisation of the United Nations. www.fao.org/docrep/016/i3027e/ Estimated for 2011. i3027e03.pdf [Last assessed 3 December 2014] 8 Measured by stunting, defined as height for age below international 27 ILO (2014) Work Social Protection Report: Building Economic growth standards recovery, inclusive development and social justice 2014/15, International 9 Ruel, M. T., Alderman, H., and the Maternal and Child Nutrition Labour Organization: 306 Study Group. Nutrition-sensitive interventions and programmes: how 28 Scaling Up Nutrition, 2014. Planning and costing for the acceleration of can they help to accelerate progress in improving maternal and child actions for nutrition: experiences of countries in the Movement for Scaling Up nutrition. The Lancet, 2013. Published online June 6. http://dx.doi. Nutrition org/10.1016/S0140- 6736(13)60843-0 29 Based on exchange rate of US$1 being equal to Taka75.8, current on 10 DHS, 2011. Demographic and Health Survey, Bangladesh DHS 5th December 2012 http://www.oanda.com/currency/converter/ 11 UN, 2013. World Population Prospects: The 2012 Revision, Highlights and 30 ILO (2014), World Social Protection Report 2014/15. Advance Tables, United Nations Department of Economic and Social Affairs/Population Division: 51 31 Hujo, K. and McClanahan, S. (eds). 2009. Financing social policy: Mobilizing resources for social development (Basingstoke, UN Research 12 This is confirmed in the Universal Declaration of Human Rights, the Institute for Social development and Palgrave Macmillan; Duran- UN Convention on the Rights of the Child, the International Labour Valverde, F. Pacheco, J.F. 2012. Fiscal space and the extension of social Organization’s constitution and legal instruments on social security. protection: Lessons learnt from developing countries. Extension of 13 Kidd, S., Khondker, B., 2013. Scoping Report on Poverty and Social Social Security ESS Paper no. 33 (Geneva, ILO); Ortiz, I.; Cummins, M Protection in Bangladesh (eds) 2012. A recovery for all: Rethinking social-economic policies for children and poor households (New York, UNICEF, Division of Policy 14 ILO (2012) R202 – Social Protection Floors Recommendation and Practice; and Cummins, 2012. (No.202), International Labour Organization, available online: http://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO: 32 Save the Children calculation based on the Demographic Health 12100:P12100_INSTRUMENT_ID:3065524:NO Survey of Bangladesh 15 ODI, 2013. Social protection and resilient food system, Overseas 33 CARE. (8 March 2012). Reaching New Heights: The Case for Development Agency. http://www.odi.org/sites/odi.org.uk/files/odi- Measuring Women’s Empowerment. assets/publications-opinion-files/8601.pdf [Last accessed 9 December Smith, L. C., Khan, F., Frankenberger, T. R., and Wadud, A. (2013). 2014] Admissible Evidence in the Court of Development Evaluation? The 16 CARE, 2012. Reaching New Heights: The Case for Measuring Impact of CARE’s SHOUHARDO Project on Child Stunting in Women’s Empowerment; Smith, L. C., Khan, F., Frankenberger, T. R.; Bangladesh. World Development, 41(196–216). Wadud, A.,2013. Admissible Evidence in the Court of Development 34 Helen Keller International. (January 2010). Trend Analysis of the Evaluation? The Impact of CARE’s SHOUHARDO Project on Child Jibon-O-Jibika Project, 2004–2009. Bulletin No1; Langworthy, M., and Stunting in Bangladesh. World Development, 41: 196–216. Caldwell, R. (2009). Save the Children: Jibon-O-Jibika Programme: 17 Attanasio, et al., 2005. The Short-term Impact, op. cit. http://www.ifs. End-line Survey Report. Tucson: TANGO International org.uk/edepo/rs_fam03.pdf [Last accessed 3 December 2014]

97 98 malnutrition in bangladesh The Lancet Estimated for 2011. for Estimated growth standards growth Protection in Protection 2014] accessed 3 [Last December bangladesh_bangladesh_statistics.html bangladesh 3 December 2014] accessed [Last nutgrowthdb/about/introduction/en/index5.html and Malnutrition Social Security Strategy (NSSS) of Bangladesh, 4th draft 4th Bangladesh, of (NSSS) Strategy Security Social GlobalFamilyPlanningRevolution.pdf [Last accessed 23 December 2014] December 23 accessed [Last GlobalFamilyPlanningRevolution.pdf h 55 54 NDERLYING 53 52 ma 2 51 50 49 48 47 46 45 44 43 42 41 40 39 38 37 36 35 1 statement_10.16.09.pdf [Last accessed 3 December 2014] 3 December accessed [Last statement_10.16.09.pdf protection social Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 52 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health in &Nutrition Security Food of 6736(13)60843-0 org/10.1016/S0140- Lancet child nutrition. and maternal improving in progress accelerate to help they can how programmes: and interventions Nutrition-sensitive Group. Study section 5 ‘Malnutrition in Bangladesh’ for more detail. detail. more for Bangladesh’ in 5‘Malnutrition section Studies: 9 Studies: Development of Institute Nutrition, Transform 2014 44, Volume No Paper Working IDS Era, Post-MDG the for Priorities and Drivers Past May%202012_0.pdf National%20Nutrition%20Services%20Mainstreaming%20Approach%20 http://www.aliveandthrive.org/sites/default/files/file-attachments/ Malnutrition Addressing for Approach Integrated and A Mainstreamed Child Nutrition?’, The Lancet Nutrition?’, Child And Maternal Improving In Progress To Help Accelerate They Can How Programmes: And Interventions 2013. ‘Nutrition-sensitive Group, en/index.html [Last accessed 3 December 2014] 3December accessed [Last en/index.html http://www.who.int/childgrowth/publications/technical_report_pub/ and development methods for-age: weight-for-age, weight-for-length, weight-for-height and body mass index- Affairs/Population Division: 51 Division: Affairs/Population Advance Tables ttp://siteresources.worldbank.org/INTPRH/Resources/ Advancing child-sensitive Advancing child-sensitive 2009. al, et International, Age Help DFID, Measured by stunting, defined as height for age below international international below age for height as defined stunting, by Measured Ruel, M. T., Alderman, H., and the Maternal and Child Nutrition Study Study Nutrition Child and Maternal the and H., T., Alderman, M. Ruel, Scoping Report on Poverty and Social Social and Poverty on Report 2013. Scoping B., Khondker, and S., Kidd, Note: Note: Note: Save the Children wealth quintile analysis using DHS data. See See data. DHS using analysis quintile wealth Children the Save Note: WHO, 2006. W 2006. WHO, UNICEF, 2014. Statistics UNICEF, The Global Family Planning Revolution Planning Family Global The 2007, Bank, World Institute of Public Health Nutrition, 2011. National Nutrition Services: Services: Nutrition 2011. National Nutrition, Health Public of Institute DHS, 2011. UN population project, Save the Children calculation. calculation. Children the Save project, 2011. population DHS, UN Global Database on Child Growth Growth Child on Database Global standards, 2014, Growth WHO, World Social Protection Report 2014/15 Report Protection Social 2014. ILO, World Smith, L., and Haddad, L., 2014. Reducing Child Undernutrition: Undernutrition: Child 2014. Reducing L., Haddad, and L., Smith, The Lancet DHS, 2011. DHS, and Demographic Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food Nutrition Child and Maternal the and H., T., Alderman, M. Ruel, SUN Bangladesh, 2014. Bangladesh, SUN http://scalingupnutrition.org/sun-countries/ World Population Prospects: The 2012 Revision, 2012 The Revision, Prospects: 2013. Population World UN, Government of the People’s Republic of Bangladesh, 2014. National 2014. National Bangladesh, of Republic People’s the of Government

T I ntroduction lnutrition he Basic causes are around the structure and processes of societies of processes and structure the around are causes Basic

Maternal and Child Nutrition Series, p6/7 Series, Nutrition Child and Maternal u B , 2013. Maternal and Child Nutrition, Executive Summary of of Summary Executive Nutrition, Child and , 2013. Maternal an , United Nations Department of Economic and Social Social and Economic of Department Nations , United , http://www.unicef.org/aids/files/CSSP_joint_ . World Organisation. http://www.who.int/ Health gladesh H O Ch , 2013. Published online June 6. http://dx.doi. 6. June online , 2013. Published

ild Growth Standards: Length/height-for-age, Length/height-for-age, Standards: Growth ild i . http://www.unicef.org/infobycountry/ n , June 6 , June B B an

H ang c . World Health Organisation. Organisation. Health . World gladesh ea auses lth Survey lth ladesh , James P Grant School of Public Public of School PGrant , James

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stunting reduction. Maternalstunting reduction. & Child Nutrition transfers in tackling child mortality child tackling in transfers http://www.thousanddays.org/about/ [Last assessed 5 December 2014] 5December assessed [Last http://www.thousanddays.org/about/ 14–2111 2104 Organisation. evidence of Areview agriculture: and protection National Bureau of Economic Research. Economic of Bureau National African pensions 2014 No 44, Transform Nutrition, Institute of Development Studies: 9. Studies: Development of Institute Nutrition, Transform 2014 44, No Era Post-MDG the for Priorities and Drivers see http://www.younglives.org.uk http://www.younglives.org.uk see details more For lives. their throughout countries four across children B unlock potential and book prosperity book and potential unlock Bank’s World the of part is brief This Japan. of Government DFID, Response, Social Rapid Bank, The World briefing, Protection Social Approach: 64 63 62 3 61 60 59 58 (2011) Bangladesh, from Survey 57 56 77 76 75 74 73 72 71 70 69 68 67 66 65 12th Session OWG Goals OWG 12th Session Training (NIPORT), Measure evaluation: 1 evaluation: Measure (NIPORT), Training Results – Preliminary Training (NIPORT), Measure evaluation: 1 evaluation: Measure (NIPORT), Training Results – Preliminary Agriculture Organisation of the United Nations. of Nations. the United Organisation Agriculture 165 EconomicsGeneral Division, Planning Commission, of Ministry Planning: Y Volume 382, No. 9890: 427–451, August 2013 August 427–451, 9890: No. 382, Volume countries, Series Paper Maternal and Child Nutrition, The Lancet middle-income and low-income in overweight and undernutrition child children in developing countries, The Lancet countries, developing in children Organization. Recovery McGregor Grantham earnings. on education of impact the on 51from countries evidence and education, on malnutrition of impact the of studies longitudinal available on based counterparts, non-stunted their than 11-03-50-20?layout=blog [Last accessed 23 December 2014] December 23 accessed [Last 11-03-50-20?layout=blog B ea an an Note: It has been estimated that stunted children earn 22% less less 22% earn children stunted that estimated been has It Note: Hoddinott, J. et al., 2013. The economic rationale for investing in in investing for rationale 2013. economic The al., et J. Hoddinott, Note: Figure is for 2011. Source: Black et al, 2013. Maternal and and 2013. Maternal al, et Black 2011. for is Figure Source: Note: The interaction between social social between 2013. interaction The B., Davis, M., Knowles, N., Tirivayi, Preliminary Copenhagen Consensus, 2014., Preliminary NIPORT et al, 2013. al, et NIPORT Save the Children calculation based on the Demographic Health Health Demographic the on based calculation Children the Save Food for Thought – Tackling child malnutrition to to malnutrition child –Tackling Thought for 2013. Food Children, the Save Sixth Five 2011. Five Sixth Bangladesh, of Republic People’s the of Government Note: Young Lives is a longitudinal survey which follows 12,000 12,000 follows which survey alongitudinal is Young Lives Note: The State of Food and Agriculture 2013 Agriculture and Food of FAO, 2013. State The Perspectives on Women’s Rights: Feminist Voices from from Voices Feminist Women’s Rights: on 2014. Perspectives BRAC, Reducing Child Undernutrition: Past Past Undernutrition: Child 2014. Reducing L., Haddad, and L., Smith, 1000 Days Partnership, 2014, About 1000 days. days. 1000 2014, About Partnership, Days 1000 The Lancet World Social Protection Report 2014/15: Report Protection Social 2014. ILO, World Lasting benefits: The role of cash cash of role The benefits: Lasting 2009. M., O’Donnell, J., Yablonski, Repositioning Nutrition as Central to Development to Central as Nutrition Repositioning Bank, World NIPORT et al, 2013. al, et NIPORT Does money protect health status? Evidence from South South from Evidence status? health protect money Does 2001. A., Case, Suchana: Ending the Cycle of Malnutrition in in Malnutrition of Cycle the Ending 2014. Suchana: Children, the Save Improving Nutrition Through Multisector Multisector Through Nutrition 2013. Improving Bank, World The

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r eport on multisectoral approach for improving nutrition. improving for approach multisectoral on eport , Inclusive Development and Social Justice, International Labour Labour International Justice, Social and Development , Inclusive

Y , Proposal for DfID DfID for , Proposal , Public http://gender.brac.net/news-a-media/2013-03- Event. S 2 , 2007. Development potential in the first 5 years for for 5years first the in potential , 2007. Development , 2013. 011–F

, NBER – Working Paper No. 8495, Cambridge, MA, MA, Cambridge, 8495, No. Paper –Working , NBER p rotection

Y V , National Institute of Population Research and and Research Population of Institute , National , National Institute of Population Research and and Research Population of Institute , National 20 olume 382, Issue 9910, 21 December 2013: 2013: 9910, 21 December Issue 382, olume 15: Accelerating Growth and Reducing Poverty Reducing and Growth 15: Accelerating B B , Copenhagen Centre an an gladesh Urban Urban gladesh gladesh Urban Urban gladesh , London, Save the Children. the Save , London, : iv–v

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, 41: 196–216. , 41: kground Paper to the European 010;88:854–860. doi: 10.2471/ , IDS working paper: 12 9, 2 , James P Grant School of Public , James P Grant School of Public , James P Grant School of Public , James P Grant School of Public ac

B gladesh: Independent ImpactAssessment ghts: The Case forMeasuring Women’s gladesh gladesh gladesh gladesh an ei B an an an an H B B B B , Florence Robert Schumann Centre for : 19. https://www.gov.uk/government/uploads/: 19. lth Organization ea H . Bulletin No 1; Langworthy, M., and Caldwell, R. gladesh household income and expenditure survey , FCND Discussion Paper No. Washington 123, DC, an B ; Smith, L. C., Khan, Frankenberger, F., R., T. and .,2013. Admissible Evidence in the Court of Development , Vol. 2, No. 2, 2005: 103–132 A

, Tucson: TANGO International TANGO Tucson: , ash-for-work programme on food consumption and nutrition 005., Food Security and Nutrition in Bangladesh: Progress gladesh Final Evaluation Final gladesh letin of the World Mascie-Taylor, CGN., Marks, MK., Goto, Food Security Nutritional Surveillance Project (FSNSP), State of 2011. Woolard, I., Harttgen, K., and Kalsen, S., The 2010. evolution and od Statistics Pocketbook ILO, 2014. World ILO, 2014. Social Protection, International Report 2014/15 Labour Skoufias, E., and Parker, S., 2001. Conditional cash transfers and FPMU, 2011. National FPMU, 2011. Food Policy: Plan of Action World Bank, 2009. GrowthInclusive Defining ILO, 2014. World ILO, 2014. Social Protection Report 2014/15 Smith, L., and Haddad, L., Reducing 2014. Child Undernutrition: Past Save the Children calculation based on the Demographic Health HIES, 2010. ., 2 Food Security Nutritional Surveillance Project (FSNSP), State of 2011. Food Security Nutritional Surveillance Project (FSNSP), State of 2011. Department for Environment, Food and Rural Affairs (DEFRA), Levinson, J., F. and Hussain, Protecting MDG D., 2013. Fund – 2010-2013 Helen Keller International., 2010. Trend Analysis 2010. International., of the Keller Jibon-O-Jibika Helen CARE, 2012. Reaching New an ul ttp://documents.worldbank.org/curated/en/2011/06/16494498/ Project, 2004–2009 (2009). Save the Children: Jibon-O-Jibika Programme: End-line SurveyReport Drivers and Priorities for the Post-MDG Era h bangladesh-household-income-expenditure-survey-key-findings- results-2010 [Accessed 3 December 2014] of a c system/uploads/attachment_data/file/315418/foodpocketbook- [Accessed December 3 2014] 2013update-29may14.pdf 105 106 107 108 98 99 100 101 102 103 104 97 112 113 109 110 111 Survey from Bangladesh. (2011) impact of social security in South Africa, Report 2010 Development Advanced Studies in World ILO, 2014. Social Protection, Report 2014/15 Labour Organization:155 International Food Security and Nutrition in Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 52 worldbank.org/INTDEBTDEPT/Resources/468980-1218567884549/ WhatIsInclusiveGrowth20081230.pdf [Last accessed 3 December 2014] Food Security and Nutrition in Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 36–37 Empowerment Wadud, Evaluation? The Impact of CARE’s SHOUHARDO Project on Child Stunting in Bangladesh. Development World Food Security and Nutrition in Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 52;Food Security Nutritional Surveillance Project (FSNSP), 2012. State of Food Security and Nutrition in Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 62 among women and children facing food insecurity in rural Bangladesh, B Fo their impact on child work and schooling: Evidence from PROGRESA program in Mexica International Food Policy Research Institute in World ILO, Social 2014. Protection Report 2014/15:155 Organization:155 and Promoting Food Security and Nutrition among Families and Children in B Monitoring Unit (FPMU) Ministry of Food and Disaster Management Dhaka, Bangladesh: 17/18; Hosain, M., and Naher, F., Shahabuddin, Q Determinants,and Electronic Journal of Agricultural and Development Economics Organization:155 of the Chars Livelihood Programme – Phase Final 1. Report Development:International 194 BLT.10.080994; HTSPE., 2011. ,

, 369:

, op. cit. utrition , Food and Agriculture n otential

9 (Suppl. 2), 69–82 p , Save the Children.

DO Project on Child Stunting , Research Report 11-741, or : 47. http://opendocs.ids.ac.uk/ 47. : AR he f H

t : OU H , IDS Working Paper Volume 2014 ghts: The Case for Measuring Women’s ei H gaining with Grandma: The impact of the South ar mpacts B i

rotection , Bulletin Langworthy, No1; M., and Caldwell, R., p

; Smith, L. C., Khan, Frankenberger, F., R., T. and ladesh . World Development, 196–216 41: ., 2013. Admissible., 2013. Evidence in the Court of Development A , The University of Cape http://www.cgdev.org/doc/ Town.

ocial ang utrition gladesh s

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Smith, L., and Haddad, L., Reducing 2014. Child Undernutrition: Past FAO, 2012. State FAO, of Food Insecurity in the World Save the Children, 2012. A Chance to Grow Helen Keller International, 2010. Trend Analysis 2010. of the International, Jibon-O-Jibika Keller Helen Note: See Appendix A and B for the pathways indicators, design Note: Programmes were selected following consultation with social CARE, 2012. Reaching New Attanasio, O., et al., 2005. The Short-term Impact Scaling Up Nutrition, Planning 2014. and costing for the acceleration of Ambler, Kate, 2011. Based on exchange rate of US$1 being equal to Taka75.8, current on Note: This data was collected as part of the literature review Based on exchange rate of US$1being equalto Taka75.8, current on ODI, Social 2013. protection and resilient food system, Overseas Smith, L. and Haddad, Reducing 2014. Child Undernutrition: Past Drivers Grantham-McGregor, S., et al., Development2007. potential in the Aguero, J., et al., 2006. The impact of Unconditional Cash Transfers on Hoddinott, J., et al., The economic 2013. rationale for investing in American Institute for Program: Research, Grant Child Zambia’s 2013. in in first five years for children in developing countries. Lancet The 60–70) http://www.ifs.org.uk/edepo/rs_fam03.pdf [Last accessed December 3 2014] principles and list of programmes included in the review. actions for nutrition: experiences of countries in the Movement for Scaling Up Nutrition Development Agency. http://www.odi.org/sites/odi.org.uk/files/odi- Agency. Development assets/publications-opinion-files/8601.pdf [Last accessed9 December 2014] 2009. Save the Children: Jibon-O-Jibika Programme: End-line Survey Report Project, 2004–2009 International. TANGO Tucson: 24-Month Impact Report 5th December http://www.oanda.com/currency/converter/ 2012 [Last assessed 5 December 2014] Nutrition [Last events/11.07.06/unconditional%20cash%20transfers.pdf accessed 2014] December 3 86 87 85 4 of in 84 83 82 80 81 79 78 96 94 95 92 93 91 90 89 88 Organisation of the United Nations. www.fao.org/docrep/016/i3027e/ i3027e03.pdf [Last assessed 3 December 2014] and Prioritiesfor the Post-MDG Era No 44, Transform Nutrition, Institute of Development Studies: 9 Evaluation? The Impact of CARE’s S Wadud, Empowerment 5th December http://www.oanda.com/currency/converter/ 2012 [Last assessed5 December 2014] protection advisors across Save the Children movement, especially Bangladesh. All programmes included in the review have either a nutrition or food security objective. African pension on household decision making Population Studies Centre, University of Michigan. Drivers and Priorities for the Post-MDG Era undertaken for this report. See appendix A for details of the pathways indicators, appendix B for details of the 22 programmes included and appendix C for references. Maternal & Child Nutrition Child & reduction.stunting Maternal opendocs/bitstream/handle/123456789/3816/Wp441R.pdf?sequence=4 opendocs/bitstream/handle/123456789/3816/Wp441R.pdf?sequence=4 [Accessed online 3 December 2014] 100 malnutrition in bangladesh ei 01375, International Food Policy Research Institute. Research Policy Food 01375, International Era, IDS working paper: 14 paper: working IDS Era, Post-MDG the for Priorities and Drivers Past Undernutrition: Child were evaluated; India, ICDS, neither were evaluated. were neither ICDS, India, evaluated; were neither net, Safety Social Honduras, evaluated; not was expenditures Institute (IFPRI). Institute (IFPRI). 136 briefs FCND indicator. security 77 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health in Nutrition and Security Food 3 December 2014] [Accessed Resources/281846-1131636806329/NutritionStrategy.pdf Development in in 2014] [Accessed 3 December consumption%205%2029%2014--AAEA.pdf umn.edu/bitstream/171159/2/Transfer%20modalities%20and%20 cash and food on transfers consumption patterns of effects the on experiments Multicountry modalities: about ado Much 119 118 117 116 115 114 121 120 132 131 130 129 128 127 126 125 124 123 references. Cfor appendix and included programmes 22 the of details 122 Transfers locations and Friends, Young Lives Student Paper Student Young Lives Friends, and Neighbours Family, of Role The Vietnam: and India in Nutrition Child and Education Adult 2005. H., Moestue, 2008; 57, No. August papers, working DHS Africa, Sub-Saharan from Evidence Transitions: Fertility and Schooling Across Stunting Child 2008. S, Giroux, Manchester; of University EDP-1409, Series, Paper Discussion Economics India, Rural in Children Underweight and Stunted of Prevalence and Empowerment transfers: reducing present and future poverty future and present reducing transfers: Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 52 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health in Nutrition and Security Food Drivers and Priorities for the Post-MDG Era, IDS working paper: 14 paper: working IDS Era, Post-MDG the for Priorities and Drivers Economic Policy Research Institute, Sept 2013. Sept Institute, Research Policy Economic paper working draft –preliminary protection’ social of imperative economic with WFP and Data Analysis and Technical Assistance Limited: 3 Limited: Assistance Technical and Analysis Data and WFP with Initiative Research Modality the of Transfer Performance Operational beneficial? on the pathways from 2011 or a very near year wherever possible. wherever year 2011 near from avery or pathways the on data use to tried we consistently effects with causes compare we that So date. stunting strong with Bangladesh, for available data DHS is there Transfers Guidance for Responses from the the from Responses for Guidance 2008. E., Tesliuc, and M., Grosh, 32.; May: Bank, Foodgrains pdf [Accessed 3 December 2014] 3December [Accessed pdf SAFETYNETSANDTRANSFERS/Resources/HDNFoodandFuel_Final. Prices Fuel and Food Rising ther; Nepal child grant, no impact on calories/consumption, and % of %of and calories/consumption, on impact no grant, child Nepal ther; The Social and Economic Impact of Cash Cash of Impact Economic and Social 2007. The al., et Michael Samson, Note: 2011 FSNSP data is used as 2011 is the latest year for which which for year 2011 as latest used the is is data 2011 FSNSP Note: Repositioning Nutrition as Central to to Central as Nutrition Repositioning 2006., Bank, World Food Security Nutritional Surveillance Project (FSNSP), 2011. of State (FSNSP), Project Surveillance Nutritional Security Food Food Security Nutritional Surveillance Project (FSNSP), 2011, of State (FSNSP), Project Surveillance Nutritional Security Food The Social and Economic Impact of Cash Cash of Impact Economic and Social The (2007). al. et Michael Samson, Ruel and Alderman, 2013. in L. Smith and L. Haddad, 2014. Reducing 2014. Reducing Haddad, L. and Smith 2013. L. in Alderman, and Ruel Note: The Note: The Impact of Cash Transfers on Food Consumption Consumption Food on Transfers Cash of 2013. Impact The S., Bailey, Imai, K., Annim, S., Kulkarni, V., and Gaiha, R., 2014. Women’s R., V., Gaiha, and Kulkarni, S., Annim, K., Imai, Costing Alternative Transfer Modalities Transfer Alternative 2014. Costing IFPRI, Safety Nets in in Nets 2014. Safety IFPRI, Dietary diversity as a food afood as diversity Dietary 2002. Y. and Yohannes, J., Hoddinott, Conditional cash Conditional 2009, F. H., Ferreira, and R., N. Schady, A., Fiszbein, Smith, L., and Haddad, L., 2014. Reducing Child Undernutrition: Past Past Undernutrition: Child 2014. Reducing L., Haddad, and L., Smith, Gilligan, D., Hidrobo, M., Hoddinott, J., Roy, S., and Schwab, B., 2013. B., Schwab, and Roy, S., J., Hoddinott, M., Hidrobo, D., Gilligan, Note: in this study that IFPRI were comparing different geographical geographical different comparing were IFPRI that study this in Note: Strengthening the the 2014. Strengthening A., Murphy, and M., Yang, M., Samson, See Appendix A for details of the pathways indicators, appendix B for Bfor appendix indicators, pathways the of details Afor Appendix See H um anitarian Settings: A review of evidence of Areview Settings: anitarian , International Food Policy Research Initiative in collaboration collaboration in Initiative Research Policy Food , International . Economic Policy Research Institute. Research Policy . Economic . Economic Policy Research Institute. Institute. Research Policy . Economic . http://siteresources.worldbank.org/NUTRITION/

exceptions were: Philippines, Pantawid, no impact on on impact no Pantawid, Philippines, were: exceptions : 46. http://siteresources.worldbank.org/ : 46. B B B an an an H gladesh gladesh . International Food Policy Research Research Policy Food . International gladesh: Which form of transfer if most most if transfer of form Which gladesh: um an Development Sector to to Sector Development an , James P Grant School of Public Public of School PGrant , James , James P Grant School of Public Public of School PGrant , James . World Bank Publications. Bank . World . Study for the Canadian Canadian the for . Study : 45 http://ageconsearch. : 45 , Discussion Paper Paper , Discussion , GirlsSecondaryEd.pdf [Accessed 3 December 2014] Resources/280558-1138289492561/2158434-1153492751565/Khan_ http://siteresources.worldbank.org/SOCIALPROTECTION/ Bank, World The Malnutrition, and Fertility on – Impact Bangladesh in Education Secondary Girl’s of benefits the Reaping Y., Khan, and Stopnitzky, S., Zayed, survey. DHS H Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 129 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health in Nutrition and Security Food has-been-surprisingly [Accessed 3 December 2014] bangladesh-has-dysfunctional-politics-and-stunted-private-sector-yet-it- http://www.economist.com/news/briefing/21565617- the fields, bangladesh-and-icddr-b/ [Accessed 3 Decemberbangladesh-and-icddr-b/ 2014] about/publications/national-survey-on-child-marriage-by-plan- Survey [Accessed 3 December 2014] 3 December [Accessed spring_bangladesh_report_qualitative_mens_purchase_motivations.pdf http://www.spring-nutrition.org/sites/default/files/publications/reports/ of district khulna the in men rural among motivations purchase 2014. Market (SPRING), Globally Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 88. 102 88. BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health in Nutrition and Security Food [Accessed 3 December 2014] 3 December [Accessed spring_bangladesh_report_qualitative_mens_purchase_motivations.pdf http://www.spring-nutrition.org/sites/default/files/publications/reports/ 9. study: Aqualitative Bangladesh, of district khulna the in Surveillance Project Project Surveillance Nutrition and IPHN Worldwide, 2011, Keller November Helen No. Bulletin Project Surveillance Nutritional children? and mothers of status nutritional the for adifference make is does awoman: is maker [Accessed 3 December 2014] 3 December [Accessed http://www.who.int/nutrition/topics/nutrition_globaltargets2025/en/ Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 42 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Food Security and Nutrition in in Nutrition and Security Food Research Institute, Sept 2013 Sept Institute, Research paper working draft –preliminary protection’ social of 135 134 133 148 143 139 138 137 136 147 146 145 144 142 141 140 Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 88. 102 88. BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health in Nutrition and Security Food plan-bangladesh-and-icddr-b/ [Accessed 3 December 2014]plan-bangladesh-and-icddr-b/ bangladesh/about/publications/national-survey-on-child-marriage-by- Survey GirlsSecondaryEd.pdf [Accessed 3 December 2014] Resources/280558-1138289492561/2158434-1153492751565/Khan_ http://siteresources.worldbank.org/SOCIALPROTECTION/ andFertility Malnutrition in Education Secondary Girl’s of benefits Surveillance Project Surveillance Nutrition and IPHN Worldwide, 2011, Keller November Helen No. Bulletin Project Surveillance Nutritional children? and mothers of status nutritional the for adifference make is does awoman: is maker ea SPRING, 2014. Market purchase motivations among rural men men rural among motivations purchase 2014. Market SPRING, Child Marriage: Findings from a National aNational from Findings Marriage: 2013. Child Bangladesh, Plan Note. Based on 10,500 households included in the 2004 2004 the in included households 10,500 on Based Note. Food Security Nutritional Surveillance Project (FSNSP), 2011. of State (FSNSP), Project Surveillance Nutritional Security Food Nutrition Surveillance Project, 2001. 2001. Project, Surveillance Nutrition Strengthening Partnerships, Results, and Innovations in Nutrition Nutrition in Innovations and Results, Partnerships, Strengthening Food Security Nutritional Surveillance Project (FSNSP), 2011. of State (FSNSP), Project Surveillance Nutritional Security Food The Economist Food Security Nutritional Surveillance Project (FSNSP), 2011. of State (FSNSP), Project Surveillance Nutritional Security Food Food Security Nutritional Surveillance Project (FSNSP), 2011. of State (FSNSP), Project Surveillance Nutritional Security Food Does Money Matter? The Effects of Cash Transfers on Child Child on Transfers Cash of Effects The Matter? Money 2007. Does Paxon, Child Marriage: Findings from a National aNational from Findings Marriage: 2013. Child Bangladesh, Plan Zayed, S, Stopnitzky, Y, and Khan, Y, Khan, and Stopnitzky, S, Zayed, WHO, 2014. Global Targets 2025, World Health Organisation. Organisation. Health World 2025, Targets 2014. Global WHO, Nutrition Surveillance Project, 2001. 2001. Project, Surveillance Nutrition Strengthening the economic imperative imperative economic the 2014. Strengthening Murphy, Yang and Samson, lth and Development in Rural Ecuador Rural in Development and lth : :

6 30, . http://plan-international.org/where-we-work/asia/bangladesh/ 31. http://plan-international.org/where-we-work/asia/ , 2012. Bangladesh and development: The path through through path The development: and Bangladesh , 2012. , World Bank: 26. 26. Bank: , World B an B B B B an an an an gladesh gladesh gladesh gladesh gladesh Q . A qualitative study: 10. study: . Aqualitative B , James P Grant School of Public Public of School PGrant , James , James P Grant School of Public Public of School PGrant , James , James P Grant School of Public Public of School PGrant , James , James P Grant School of Public Public of School PGrant , James an , 20 : 29 B B an an gladesh – Impact on on –Impact gladesh Reaping the the Reaping 05. gladesh, When the decision- the When gladesh, gladesh, When the decision- the When gladesh, Q , Economic Policy Policy , Economic ., 2 ., 005. 005.

8 8 , , nesot 101 t Practice in an Social es B ow C . H gladesh: Findings an , James P Grant School , James P Grant School , James P Grant School , James P Grant School , James P Grant School , James P Grant School B gladesh – Findings from a gladesh – Findings from a gladesh an an an B B B , PRI, SANEM, Development gladesh gladesh, 2011 gladesh, 2011 gladesh, 2011 gladesh, 2011 gladesh, 2011 gladesh, 2011 an gladesh: Which form of transfer if most gladesh: Which form of transfer if most . Save theChildren in Bangladesh and an an an an an an B B B B B B B an an B B ; FANTA. 2014. National; FANTA. 2014. Mapping of Nutrition gladesh’s Poorest gladesh’s : 01 http://plan-international.org/files/Asia/publications/ 01 : : 01 http://plan-international.org/files/Asia/publications/ 01 : an B , International Food Policy Research Initiative in collaboration , International Food Policy Research Initiative in collaboration The analysis of national level rural data obtained by HKI Bangladesh Food Security Nutritional Surveillance Project (FSNSP), State 2011. Kidd, S., Freeland, S., B. Khondker,International 2014. Food Security Nutritional Surveillance Project (FSNSP), State 2011. IFPRI, The Empowerment Women’s 2013. in Agriculture Index: Plan and Child icddr,b, 2013. Marriage in Save the Children calculation based on the Demographic Health IFPRI, Safety 2014. Nets in Food Security Nutritional Surveillance Project (FSNSP), State 2011. Plan, Asia 2014. Child Marriage Initiative: Summary of Research in ICDDRB and PLAN, Child 2014. marriage in Food Security Nutritional Surveillance Project (FSNSP), State 2011. Plan and Child icddr,b, 2013. Marriage in Save the Children, 2012. Growing the Future: Enhancing the Lives and IFPRI, Safety 2014. Nets in Food Security Nutritional Surveillance Project (FSNSP), State 2011. Food Security Nutritional Surveillance Project (FSNSP), State 2011. Based on ‘20% stunting at 0 month’ statistic as half of the 41% of Public Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 14 of Public Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 101 of Public Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 153 of Public Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 153 of Public Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 153, 159 beneficial? Operational Performance Transfer of the Modality Research Initiative with WFP and Data Analysis and Technical Assistance Limited. of Public Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 102 Results Bangladesh from the 2011–2012 Integrated Household Survey, International Food Policy Research Institute and Data Analysis and Assistance Limited: http://www.ifpri.org/sites/default/files/ 25 Technical publications/weaitr.pdf [Last accessed December 3 2014] of Food Security and Nutrition in Bangladesh, India and Nepal. Plan Asia Regional Office, International Centre for Research on Women: 5 of Food Security and Nutrition in Survey from Bangladesh (2011) 182 175 176 177 178 179 180 181 167 168 169 170 171 172 173 174 166 183 National Survey national-survey-on-child-marriage-by-plan-bangladesh-and-icddr-b from a National Survey Interventions and Projects in Bangladesh. Washington, DC: FHI 360/ FANTA of Food Security and Nutrition in beneficial? Operational Performance Transfer of the Modality Research Initiative with WFP and Data Analysis and Technical Assistance Limited: 5 of Food Security and Nutrition in of Food Security and Nutrition in in 2005 showed that the median age of marriage is and 16, median age at first delivery 19 yearswas in rural Bangladesh. dueHowever, to the nature of the study, this sample only included women with children. Therefore, age at marriage could be even lower among women in rural Bangladesh. National Survey national-survey-on-child-marriage-by-plan-bangladesh-and-icddr-b national stunting rate in children under 5 (DHS, 2011). Social Protection: implications for Pathways: 47/48; Save the Children/Rowe, G , 2014. Protection better Respond to Child Poverty in Livelihoods of of Livelihoods of Food Security and Nutrition in the PepsicoFoundation B

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: 9). Working Paper, International Policy Centre for Inclusive 6

d gender vulnerabilities: case studies of See appendix A for details of the pathways indicators, appendix B for Merttens, Hurrell, F., A., Marzi, M., Attah, R., Farhat, M., Kardan, Maluccio, J. A., Adato, M., Flores, R., and Roopnaraine, 2005. T., Note: Information is taken from our analysis of the pathways to WHO, 2014. IFPRI, Safety 2014. Nets in Bangladesh: Which form of transfer if Note: The 1,000 days between a woman’s pregnancy and her child’s Samson, and Yang Murphy, Strengthening 2014. the economic imperative CARE, 2012. Reaching New Heights: The Case for Measuring Food Security Nutritional Surveillance Project (FSNSP), State of 2011. Campello, Teresa, and Marcelo Côrtes Neri. “ 2014. Note: Information is taken from our analysis of the pathways to Van den Bold, M., Smith and Haddad, Developing in Malnutrition Child Explaining 1999. Soares, and Silva, V., F. E., 2010. See Appendix A for details of the pathways indicators, Appendix Food Security Nutritional Surveillance Project (FSNSP), State of 2011. r details of the 22 programmes included and Appendix C for (No. Growth: 39 http://apps.who.int/gho/data/node.main.HE-1540?lang=en [Accessed 2014] December 3 Poverty Nicaragua: Red de Protección Social Mi Familia. 2014 December 3 [Accessed n-social-mi-familia Food Securityand Nutrition in Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 132 references. an Food Security and Nutrition in Health (JPGSPH) and Helen Keller International (HKI), Dhaka, BD: 153 fo Countries: cross-country a analysis nutrition, comparing whether or not there was a measured impact on indicators of improvement along that pathway with whether or not the programme had a measured effect on nutrition. The results of this exercise should be used with care because by its very nature it involves looking at one aspect of programmes in isolation. recognise We it is vulnerable to the criticism that each programme may have other aspects which either offset or magnify the effect that this particular pathway might have on nutrition. nutrition, comparing whether or not there was a measured impact on indicators ofimprovement along that pathway with whether or not the programme had a measured effect on nutrition. The results of this exercise shouldbe used with care because by its very nature it involves looking at one aspect of programmes in isolation. recognise We it is vulnerable to the criticism that each programme may have other aspects which either offset or magnify the effect that this particular pathway might have on nutrition. Women’s Empowerment.Women’s 164 165 163 162 161 160 151 150 149 159 158 157 155 156 154 153 152 A., and MacAuslan, I., Kenya Hunger 2013. Safety Net Programme Monitoring and Evaluation Component. Impact Evaluation Final Report: 2009 to 2012: http://www.opml.co.uk/insights/publications/kenya- 154 hsnp-monitoring-and-evaluation-component-impact-evaluation-final- report [Accessed 3 December 2014] most beneficial? Operational PerformanceTransfer of the Modality Research Initiative, International Food Policy Research Initiative in collaboration with WFP and Data Analysis and Technical Assistance Limited: 32 details of the 22 programmes included and appendix C for references. Research Institute. Research of social protection – preliminary draft working paper second birthdaysecond empowerment and nutrition: an evidence review Policy Res Inst. Program: A Decade of Social Inclusion.” Executive Summary http://socialprotectionet.org/resources/bolsa-familia-program-decade- social-inclusion-brazil [Accessed 3 December 2014] 102 malnutrition in bangladesh adolescent/topics/adolescence/dev/en adolescent/topics/adolescence/dev/en age’. of http://www.who.int/maternal_child_ 19 10 and years between report [Last accessed online 5 December 2014] 5December online accessed [Last report international.org/files/Asia/bangladesh/child-marriage-in-bangladesh- of Food Security and Nutrition in in Nutrition and Security Food of of Food Security and Nutrition in in Nutrition and Security Food of of Food Security and Nutrition in in Nutrition and Security Food of [Last accessed online 5 December 2014] 5December online accessed [Last from 18 October 2014news/55228/Marriage-age-to-remain-as-before October plan-bangladesh-and-icddr-b/ [Last accessed online [Last 5 December 2014]plan-bangladesh-and-icddr-b/ bangladesh/about/publications/national-survey-on-child-marriage-by- http://plan-international.org/where-we-work/asia/ 23/24 Survey: 188 187 186 185 184 191 190 189 202 201 200 199 198 197 196 195 194 193 192 alone conclusive. plan-bangladesh-and-icddr-b/ [Last accessed online [Last 5 December 2014]plan-bangladesh-and-icddr-b/ bangladesh/about/publications/national-survey-on-child-marriage-by- 15Survey: http://plan-international.org/where-we-work/asia/ of less less of index BMI a deficient, energy chronically as defined is Thin” Mildly or Moderately “Severely, achild. of delivery normal during risk increased of Food Security and Nutrition in in Nutrition and Security Food of of Food Security and Nutrition in in Nutrition and Security Food of compared to a healthy reference population provided by WHO (2007) WHO by provided population reference ahealthy to compared are both -2SD, than less z-score BMI-for-age is Underweight -2SD. than plan-bangladesh-and-icddr-b/ [Last accessed online [Last 5 December 2014]plan-bangladesh-and-icddr-b/ bangladesh/about/publications/national-survey-on-child-marriage-by- http://plan-international.org/where-we-work/asia/ 24: Survey: plan-bangladesh-and-icddr-b/ [Last accessed online [Last 5 December 2014]plan-bangladesh-and-icddr-b/ bangladesh/about/publications/national-survey-on-child-marriage-by- 13Survey: http://plan-international.org/where-we-work/asia/ 17th September 2014, Daily Sun newspaper Dhaka. page 6 page Dhaka. newspaper Sun 2014, Daily 17th September of Food Security and Nutrition in in Nutrition and Security Food of of Food Security and Nutrition in in Nutrition and Security Food of national stunting rate in children under 5 (DHS, 2011). 5(DHS, under children in rate stunting national BD: 79–86 (93) (93) 79–86 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of BD: 93 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of BD: 93 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of BD: 14 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of BD: 153 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of BD: 93 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of BD: 153, 159 153, BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of Plan Bangladesh, 2013. Child Marriage: Findings from a National aNational from Findings Marriage: 2013. Child Bangladesh, Plan Plan Bangladesh, 2013. Child Marriage: Findings from a National aNational from Findings Marriage: 2013. Child Bangladesh, Plan Plan Bangladesh, 2013. Child Marriage: Findings from a National aNational from Findings Marriage: 2013. Child Bangladesh, Plan Daily Sun, 2014. Prevention of Child Marriage – editorial, Wednesday Wednesday –editorial, Marriage Child of 2014. Prevention Sun, Daily Prothom Alo, 2014. Child marriage to remain as before, before, as remain to marriage 2014. Child Alo, Prothom Plan Bangladesh, 2013. Child Marriage: Findings from a National aNational from Findings Marriage: 2013. Child Bangladesh, Plan Plan Bangladesh, 2013. Child Marriage In Bangladesh: http://plan- Bangladesh: In Marriage 2013. Child Bangladesh, Plan Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food Note: Inadequate height is defined as height-for-age z-score less less z-score height-for-age as defined is height Inadequate Note: Adolescence is defined by the World Health Organization as ‘people as ‘people Organization Health the World by defined is Adolescence Based on ‘20% stunting at 0 month’ statistic as half of the 41% the of half as statistic 0month’ at stunting ‘20% on Based The samples in available surveys are too small to be indicative let let indicative be to small too are surveys available in samples The Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food Food Security Nutritional Surveillance Project (FSNSP), 2011. S (FSNSP), Project Surveillance Nutritional Security Food Note: Inadequate height is defined as <145cm, women this short face face short this women <145cm, as defined is height Inadequate Note:

1 8th 2014.8th http://en.prothom-alo.com/bangladesh/ B B B B B B B an an an an an an an gladesh, 2011gladesh, gladesh, 2011gladesh, gladesh, 2011gladesh, gladesh, 2011gladesh, gladesh, 2011gladesh, gladesh, 2011gladesh, gladesh, 2011gladesh, , James P Grant School School PGrant , James , James P Grant School School PGrant , James , James P Grant School School PGrant , James , James P Grant School School PGrant , James , James P Grant School School PGrant , James , James P Grant School School PGrant , James , James P Grant School School PGrant , James tate tate H of Journal future, the for directions and trends Bangladesh: in women and children of Nutrition 2012, A., F. P., Cravioto, and Choudhury, Islam, H Islam, Journal of of Journal future, the for directions and trends Bangladesh: in women and children of Nutrition 2012, A., F. P., Cravioto, and Choudhury, programs. Health Care for Women International: 29(8-9). International: Women for Care Health programs. nutrition and health reproductive for Implications Bangladesh: rural and environmental underlying factors maternal malnutrition in maternal_child_adolescent/topics/child/malnutrition/en/ maternal_child_adolescent/topics/child/malnutrition/en/ of Food Security and Nutrition in in Nutrition and Security Food of more detail. more detail. of Food Security and Nutrition in in Nutrition and Security Food of no. bulletin Project Surveillance (Nutritional 4p. 2006. International, Keller Helen Dhaka: action. urgent for need the Bangladesh: rural in downloads/2013/04/rice-sanitation-stunting-brief.pdf http://riceinstitute.org/wordpress/wp-content/uploads/ sphere/ Response,Humanitarian http://www.spherehandbook.org/en/what-is- accessed online 4 December 2014] 4 December online accessed [Last http://www.nhs.uk/Conditions/Malnutrition/Pages/Causes.aspx 210 209 208 207 206 205 204 203 221 220 219 218 217 216 215 214 213 212 211 in Nutrition and Security Food of of Food Security and Nutrition in in Nutrition and Security Food of toilets, and handwashing.”toilets, The Lancet of Food Security and Nutrition in in Nutrition and Security Food of neighboring-india/ [Last accessed online 4 December 2014] 4December online accessed [Last neighboring-india/ bangladesh-had-such-success-in-improving-sanitation-but-not- http://blogs.bmj.com/bmj/2014/09/23/jocalyn-clark-why-has- Journal Medical British India? neighbouring not but sanitation, diarrhoea/en/ [Last accessed online 4 December 2014] 4December online accessed [Last diarrhoea/en/ , http://www.who.int/water_sanitation_health/diseases/ disease/en/ disease World Organisation. http://www.who.int/dracunculiasis/ Health http://www.wssinfo.org [Last accessed online 4 December 2014] 4December online accessed [Last http://www.wssinfo.org Bangladesh. facilities, sanitation and sources water of use the on BD: 99 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of BD: 101 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of BD: 100 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of BD: 102 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of BD: 102 BD: Dhaka, (HKI), International Keller Helen and (JPGSPH) Health Public of ea ea Stevens et al. 2013, 2011 al. et data. Stevens Clark, J, 2014. Why has Bangladesh had such success in improving improving in success such had Bangladesh has 2014. Why J, Clark, Ahmed, T., Mahfuz, M., Ireen, S., Ahmed, A.M. S., Rahman, S., S., Rahman, S., A.M. Ahmed, S., Ireen, M., T., Mahfuz, Ahmed, Ahmed, T., Mahfuz, M., Ireen, S., Ahmed, A.M. S., Rahman, S., S., Rahman, S., A.M. Ahmed, S., Ireen, M., T., Mahfuz, Ahmed, Humphrey, J, 2009. “Child undernutrition, tropical enteropathy, enteropathy, tropical undernutrition, “Child 2009. J, Humphrey, WHO and UNICEF Joint Monitoring Project (JMP), 2014. Estimates 2014. Estimates (JMP), Project Monitoring Joint UNICEF and WHO WHO, 2014. Water-related diseases, Diarrohea and Guinea-Worm Guinea-Worm and Diarrohea diseases, 2014. Water-related WHO, Rice Institute, 2014. Sanitation and Stunting, available available Stunting, and 2014. Sanitation Institute, Rice Save the Children drawing upon DHS data. See Figure 1 on page 1 for 1for page 1on Figure See data. DHS upon drawing Children the Save Helen Keller International (HKI) Bangladesh: the burden of anaemia anaemia of burden the Bangladesh: (HKI) International Keller Helen NHS, 2014. Malnutrition – causes. National Health Service UK. UK. Service Health National –causes. 2014. Malnutrition NHS, Shannon, K., Mahmud, Z., Asfiab, A., and Ali, M., 2008. The social social The 2008. M., Ali, and A., Asfiab, Z., Mahmud, K., Shannon, Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food WHO, 2014. http://www.who.int/ Available online: Malnutrition, Sphere, 2014. Humanitarian Charter and Minimum Standards in in Standards Minimum and Charter 2014. Humanitarian Sphere, Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food Food Security Nutritional Surveillance Project (FSNSP), 2011. State (FSNSP), Project Surveillance Nutritional Security Food

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overnance e G NIPORT et al., Bangladesh 2013. Urban Health Survey (UHS) 2013 NIPORT et al., Bangladesh 2013. Urban Health Survey (UHS) 2013 Carmona, M., 2009. report of the UN independent expert on Government of the People’s Republic of Bangladesh, National 2014. NIPORT et al., Bangladesh 2013. Urban Health Survey (UHS) 2013 Government of the People’s Republic of Bangladesh, National 2014. NIPORT et al., Bangladesh 2013. Urban Health Survey (UHS) 2013 NIPORT et al., Bangladesh 2013. Urban Health Survey (UHS) 2013 NIPORT et al., Bangladesh 2013. Urban Health Survey (UHS) 2013 NIPORT et al., Bangladesh 2013. Urban Health Survey (UHS) 2013 UNICEF and the World Bank (2013), Common Ground: UNICEF UNICEF and the World Bank, Common 2013. Ground: UNICEF Save the Children, GRID 2014. (Groups and Inequalities Database) NIPORT et al, Bangladesh 2013. Urban Health Survey (UHS) 2013 FSNSP, 2012. State of Food Security and Nutrition in Demographic and Health Survey (DHS), Bangladesh 2011. Food Security was not included in the Niport et al. Urban Health Food Security Nutritional Surveillance Project (FSNSP), State 2011. Bangladesh Bureau of Statistics, Results 2012. Census 2011

Helen Keller International (HKI) and BRAC Institute of Global Health (BIGH) of Public Health (JPGSPH) and Helen Keller International (HKI), BDDhaka, – Preliminary Results, National Institute of Population Research and Training (NIPORT), MEASURE EVALUATION: 60 – Preliminary Results, National Institute of Population Research and Training (NIPORT), MEASURE EVALUATION: 1 – Preliminary Results, National Institute of Population Research and Training (NIPORT), MEASURE 46, 35, 41, 48, EVALUATION: 60 17, 13, human rights and extreme poverty. Human Rights council. Available at: http://www.un.org/esa/socdev/csocd/2011/Magdalena.pdf http://www.geohive.com/cntry/bangladesh.aspx [Last accessed 2014] December 4 online Social Security Strategy (NSSS) ofBangladesh, 4th Draft, June 04, 2014, Planning Commission: 44 Demographic and Health Dhaka, Survey 2011, Bangladesh and Calverton, Maryland, USA: NIPORT, Mitra and Associates, and ICF International: 167 – Preliminary Results, National Institute of Population Research and Training (NIPORT), MEASURE EVALUATION: 4, 99 Survey analysis DHS based data. on 2011 258 259 251 252 253 254 255 256 6 th 257 242 243 244 245 246 247 248 249 250 241 and World Bank Approaches to Building Social Protection Systems. Available online: http://www.unicef.org/socialpolicy/files/UNICEF- WB_systems_note_formatted(1).pdf – Preliminary Results, National Institute of Population Research and Training (NIPORT), MEASURE EVALUATION: 21 – Preliminary Results, National Institute of Population Research and Training (NIPORT), MEASURE EVALUATION: 56 – Preliminary Results, National Institute of Population Research and Training (NIPORT), MEASURE EVALUATION: 60 of Food Security and Nutrition in and World Bank Approaches to Building Social Protection Systems. Available online: http://www.unicef.org/socialpolicy/files/UNICEF- WB_systems_note_formatted(1).pdf – Preliminary Results, National Institute of Population Research and Training (NIPORT), MEASURE EVALUATION: 55, 56 37, 12, 29, Social Security Strategy (NSSS) of Bangladesh, 4th Draft, June 04, 2014, Planning Commission: 43

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M ILO, 2014. World ILO, 2014. SocialProtection , International Report 2014/15 Adams, A. M.et al., Innovation 2013. for universal health coverage Adams, A. M. et al., Innovation 2013. for universal health coverage WHO, World Bank towards Group, progress Monitoring 2014. Adams, A. M. et al., Innovation 2013. for universal health coverage ILO, 2014. World ILO, 2014. Social Protection, International Report 2014/15 Labour Note: That is, if the average annual growth rate experienced Humphrey, J., 2009. “Child undernutrition, tropical enteropathy, ILO, 2014. World ILO, 2014. Social Protection, International Report 2014/15 Labour Adams, A. M. et al., Innovation 2013. for universal health coverage Source: DHS, Save the Children. See Figure 1 on page 1 for Note: Target is from Save the Children’s ‘Children 2030’ campaign Note: In the DHS survey in 2007 stunting was 43% and in 2011 WHO, World Bank towards Group, progress Monitoring 2014. Save the Children calculations using data and from UN DHS 2011 See Appendix A for the pathways indicators, Appendix B for details Information is taken from our analysis of the pathways to nutrition, Note: The earliest and latest DHS surveys available Lancet Commission ( Commission Lancet

wh to Labour Organization: 100 more detail.more The Lancet The toilets, handwashing.” and and coincides with the timescale for goals currently being agreed as part of the global process Post 2015 between was achieved and 1997 2011 every year to 2030 in Bangladesh: a call to action, Lancet The 2104 –2111 comparing whether or not there was a measured impact on indicators of improvement along that pathway with whether or not the programme had a measured effect on nutrition. The results of this exercise should be used with care because by its very nature it involves looking at one aspect of programmes in isolation. recognise We it is vulnerable to the criticism that each programme may have other aspects which either offset or magnify the effect that this particular pathway might have on nutrition. on Global Governance for Health. “Global 2013. health 2035: A world converging within a generation”, Lancet in The 1898–1955, IN World ILO, 2014. Social Protection, Report 2014/15 Labour Organization:International 100 universal health coverage at country and global levels: Framework, Measures and Targets Reconstruction and Development/The World Bank 2014: 1 240 239 237 238 236 235 5 234 233 232 230 231 229 228 226 227 225 224 222 223 in Bangladesh: a call to action, Lancet The 2104 –2111 Population Project (2012), World Population Prospects: The 2012 available:Revision, http://esa.un.org/wpp/unpp/panel_indicators.htm Organization: 100 Organization: 100 of the 22 programmes included in the review and Appendix C for full references. in Bangladesh: a call to action, Lancet The 2104 –2111 it was 41%. The figure of 42% for was2010 estimated using linear interpolation. universal health coverage at country and global levels: Framework, Measures and Targets Reconstruction and Development/The World Bank 2014: 1 2104 –2111 in Bangladesh: a call to action, Lancet The 104 malnutrition in bangladesh (E/C.16/2006/4) (New York, 2006) York, (New (E/C.16/2006/4) administration public and governance in terminologies and concepts security systems security all: for Security Bangladesh Intercooperation Swiss Helvetas Experience, Practical of – Lessons Organization WB_systems_note_formatted(1).pdf http://www.unicef.org/socialpolicy/files/UNICEF- online: Available Systems. Protection Social Building to Approaches Bank World and 552–69. building and commitment accelerating progress. The Lancet malnutrition: reducing of politics the 4: nutrition child and Maternal Operation and Development Development and Operation Participation in Policy-Making Institute of Development Studies: In Focus Policy Briefing 22. 22. Briefing Policy Focus In Studies: Development of Institute us? tell governance nutrition can what nutrition: under in reductions 274 273 272 271 270 269 268 267 266 265 264 263 262 261 260 278 277 276 275 Bangladesh, ProposalBangladesh, for DfID progress’, The Lancet progress’, accelerating and commitment building malnutrition: reducing of politics 2013. al. ‘The et S., Gillespie, governance. Multi-sectoral 4. resources; and Capacity 3. governance; and economy Political 2. evidence; and knowledge, 1. Narrative, environment: enabling an creating for and Practice; and Cummins, 2012. Cummins, and Practice; and Policy of Division UNICEF, York, (New households poor and children for policies social-economic Rethinking all: for Arecovery 2012. (eds) M Cummins, I.; Ortiz, ILO); 33 (Geneva, no. Paper ESS Security Social of Extension countries. developing from learnt Lessons protection: social of extension the and space F. J. Fiscal 2012. F., Pacheco, Valverde, Duran- Macmillan; Palgrave and development Social for Institute Research UN (Basingstoke, development social for resources Mobilizing Development Studies: In Focus Policy Briefing 22. 22. Briefing Policy Focus In Studies: Development of Institute us? tell governance nutrition can what nutrition: under in Lancet global andundernutrition: regional exposures and consequences. health child and Maternal 2008. J., Rivera, and C. Mathers, M., Ezzati, M., Institute of Development Studies: In Focus Policy Briefing 22. 22. Briefing Policy Focus In Studies: Development of Institute us? tell governance nutrition can what nutrition: under in reductions 552–69. building and commitment accelerating progress. The Lancet malnutrition: reducing of politics the 4: nutrition child and Maternal Peru The Lancet global andundernutrition: regional exposures and consequences. health Ez , International Labour Labour 2014/15 Report , International Protection Social 2014. ILO, World The Strategy of the International Labour Organization. Social Social Organization. Labour International the of Strategy The 2012. ILO, Gillespie, S., et al., 2013. identify 4 key issues that are important important are that issues 4key 2013. identify al., et S., Gillespie, Gillespie, S., Haddad, L., Mannar, V., Menon, P., and Nisbett, N., 2013. N., P., Nisbett, and V., Menon, Mannar, L., Haddad, S., Gillespie, Haddad, L. Acosta, A. M. and Fanzo, J. 2012. Accelerating reductions reductions Accelerating 2012. J. Fanzo, and M. A. Acosta, L. Haddad, Haddad, L., Acosta, A. M., and Fanzo, J., 2012. Accelerating Accelerating 2012. J., Fanzo, and M., A. Acosta, L., Haddad, Analysing success in the fight against malnutrition in malnutrition against fight the in success 2011. A., Analysing Acosta, Helvetas, 2012. Strengthening Local Governance in Bangladesh Bangladesh in Governance Local Strengthening 2012. Helvetas, Gillespie, S. Haddad, L, Mannar, V, Menon, P. and Nisbett, N. 2013. N. P. Nisbett, V, and Mannar, Menon, L, Haddad, S. Gillespie, Black, E. R., Allen, H. L., Bhutta, A. Z., Caulfield, E. L., De Onis, De L., E. Caulfield, Z., A. Bhutta, L., H. Allen, R., E. Black, A Chance to Grow to AChance 2012. Children, the Save Haddad, L., Acosta, A. M,. and Fanzo, J., 2012. Accelerating Accelerating 2012. J., Fanzo, and M,. A. Acosta, L., Haddad, Hujo, K., and McClanahan, S. (eds). 2009. Financing social policy: policy: social Financing 2009. (eds). S. McClanahan, and K., Hujo, Citizens as Partners – Information, Consultation and Public Public and Consultation –Information, Partners as Citizens 2001. OECD, Save the Children, 2014. Suchana: Ending the Cycle of Malnutrition in in Malnutrition of Cycle the Ending 2014. Suchana: Children, the Save A Chance to Grow to AChance 2012. Children, the Save UNICEF and the World Bank, 2013. Common Ground: UNICEF UNICEF Ground: 2013. Common Bank, World the and UNICEF Black, E. R., Allen, H., L., Bhutta, A. Z., Caulfield, E. L., De Onis, Onis, De L., E. Caulfield, Z., A. Bhutta, L., H., Allen, R., E. Black, Committee of Experts on Public Administration, Definition of basic basic of Definition Administration, Public on Experts of Committee zati, M., Mathers, C., and Rivera, J., 2008. Maternal and child child and Maternal 2008. J., Rivera, and C., Mathers, M., zati, . Institute of Development Studies working paper: 29 paper: working Studies Development of . Institute : 1–19. , pp. 1–19., pp. B , Geneva ui lding social protection floors and comprehensive social social comprehensive and floors protection social lding , 382: 552–69. , 382: , Organisation for Economic Cooperation, , Save the Children: 30 Children: the , Save , Save the Children: 30 Children: the , Save . 382: . 382: . 382: . 382:

M., M., Report-Bangladesh.pdf [Accessed online 4 December 2014] 4December online [Accessed Report-Bangladesh.pdf http://www.transformnutrition.org/files/2011/11/Stakeholder-Mapping- Development Studies: In Focus Policy Briefing 22. Briefing Policy Focus In Studies: Development of Institute us? tell governance nutrition can what nutrition: under in Development Studies: In Focus Policy Briefing 22. Briefing Policy Focus In Studies: Development of Institute us? tell governance nutrition can what nutrition: under in Planning Commission: xxi Commission: Planning of (NSSS) Strategy Security Social Review World Facilities.” Health Bangladeshi in Absenteeism Doctors: “Ghost 2003. Hammer. S. Jeffrey and Nazmul Chaudhury, Clinics; Community and NNS of evaluation from findings Preliminary 2014. ICDDR-B, Bangladesh; rural in workers health based community assessment level Upazila and network [Last accessed 4 December 2014] 4December accessed [Last network http://scalingupnutrition.org/the-sun-network/business- Nutrition. Study: a national and Upazila level assessment level Upazila and anational Study: 2014. Nutrition Governance Children, the Save (source: Welfare Family Planning: 163Planning: EconomicsGeneral Division, Planning Commission, of Ministry Five 287 286 285 284 283 282 281 280 279 297 296 295 294 293 292 in 7 291 290 289 288 policy%20briefs/kharas%20policy%20brief.pdf [Last accessed online online 4 december 2014] accessed [Last policy%20briefs/kharas%20policy%20brief.pdf media/Research/Files/Papers/2013/08/blum%20roundtable%20 http://www.brookings.edu/~/ Institution: Brookings Development, Protection in Protection network/business-network Accessed http://scalingupnutrition.org/the-sun- Nutrition, online at: The Lancet global andundernutrition: regional exposures and consequences. health Planning xvi Commission: Social Security Strategy (NSSS) of of (NSSS) Strategy Security Social Development Studies: In Focus Policy Briefing 22. Briefing Policy Focus In Studies: Development of Institute us? tell governance nutrition can what nutrition: under in http://www.who.int/trade/glossary/story006/en/ at: online Accessed Organisations. Health World Society. Planning Commission: xxi Commission: Planning of (NSSS) Strategy Security Social Organization: 306 306 Organization: FAO NFPCSP FAO NFPCSP the under supported is and 13 ministries involving mandate FPMU’s Organization Ez

, International Labour Labour 2014/15 Report , International Protection Social 2014. ILO, World Government of the People’s Republic of Bangladesh, 2014. National Bangladesh, of Republic People’s the of Government Haddad, L., Acosta, A. M., and Fanzo, J., 2012. Accelerating 2012. reductions J., Fanzo, and M., A. Acosta, L., Haddad, Government of the People’s Republic of Bangladesh, 2014. National Bangladesh, of Republic People’s the of Government Peevy, S., 2013. Reimagining the Role of the Private Sector in in Sector Private the of Role the 2013. Reimagining S., Peevy, , International Labour Labour 2014/15 Report , International Protection Social 2014. ILO, World Government of the People’s Republic of Bangladesh, 2011. Sixth Bangladesh, of Republic People’s the of Government Scoping Report on Poverty and Social Social and Poverty on Report 2013. Scoping B., Khondker, S., Kidd, Government of the People’s Republic of Bangladesh, 2014. National Bangladesh, of Republic People’s the of Government Transform Nutrition, 2011. Nutrition, Transform Black, E. R., Allen, H, L., Bhutta, A. Z., Caulfield, E. L., De Onis, De L., E. Caulfield, Z., A. Bhutta, L., H, Allen, R., E. Black, Note: Coordination at national level for FSN is in place through the the through place in is FSN for level national at Coordination Note: Haddad, L. Acosta, A. M. and Fanzo, J. 2012. Accelerating 2012. reductions J. Fanzo, and M. A. Acosta, L. Haddad, Note: For example, among the NNS under Ministry of Health and and Health of Ministry under NNS the among example, For Note: SUN Business Network, 2014. Business Network, Scaling Up Up Scaling Network, 2014. Business Network, Business SUN WHO, 2014. Trade, foreign policy, diplomacy and health: Civil Civil health: and diplomacy policy, foreign 2014. Trade, WHO, Haddad, L., Acosta, A. M., and Fanzo, J., 2012. Accelerating 2012. reductions J., Fanzo, and M., A. Acosta, L., Haddad, SUN Business Network, 2014. Business Network, Scaling Up Up Scaling Network, 2014. Business Network, Business SUN Nutrition Governance Study: a national anational Study: Governance 2014. Nutrition Children, the Save zati, M., Mathers, C., and Rivera, J., 2008. Maternal and child child and Maternal 2008. J., Rivera, and C., Mathers, M., zati, N B Y ea utrition ang 18(3): 423–441, doi: 10.1093/wber/lhh047. doi: 423–441, 18(3): r Plan F r Plan : 1–19. : B an ladesh Y 2 gladesh 011-F - se Y 20 nsitive 15: Accelerating Growth and Reducing Poverty Reducing and Growth 15: Accelerating ; Save the Children, 2011. The status of of 2011. status The Children, the ; Save B an B B B an an an gladesh Stakeholder Report gladesh Mapping gladesh gladesh gladesh

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, . Washington, DC. Impacts of the Conditional Cash Transfer programme , 4(2): 247–273. [ , 41(6), 833-851. R> B , Colombia. Overseas Development Institute, London. February: 4 : 154 http://www.opml.co.uk/insights/publications/kenya-hsnp- 154 : sa Alimentação Program on food consumption sa Alimentação Program on food consumption d MacAuslan, I., Kenya 2013. Forde, I., Chandola, Garcia, T., S., Marmot, M. G., and Attanasio, O., IFPRI, Safety 2014. Nets in Bangladesh: Which form of transferis Cluver, L. D., Orkin, M., F. Boyes, M. E., and Sherr, L., Cash 2014. plus Miller, C., Tsoka, M., and Reichert, K., 2008). Impact Evaluation American Institutes for Program: Research, Grant Child Zambia’s 2013. Fernald, L., Gertler, and Neufeld, P., L., 2008. Role of cashin Perova, E., and Vakis, R., 2009. Welfare impacts of the “Juntos” Program Merttens, Hurrell, F., A., Marzi, M., Attah, R., Farhat, M., Kardan, Udjo, E. Demographic O., 2013. and Socioeconomic Status, Child Escobal, J., and Benites, S. (Esc a), 2012. Algunos impactos del programa Miller, C., Tsoka, M., and Reichert, K., 2008. Impact Evaluation Chaudhury, N., Friedman, J., and Onishi, conditional J., Philippines 2013. Olinto, Flores, P., R., Morris, S., and Viega, A. 2003. The impact of the Olinto, Flores, P., R., Morris, S., and Viega, A., 2003. The impact of the Gertler, J., Martinez, P. S. and W., Rubio-Codina, M., 2012. Investing Macours, K., Schady, N., and Vakis, R., 2012. Cash transfers, Dasso, R., and Fernandez, Temptation 2013. F., Goods and Ayala, 2006. F., Inter-Regional Inequality Facility Policy See Appendix B for details of the programmes included in our review ol ol Acción Report External Evaluation of the Mchinji Social Cash Transfer Pilot http://www.unicef.org/malawi/MLW_resources_impactsocialcashtrf.pdf [Accessed online 4 December 2014] and Appendix C for full references. B behavioral changes, and cognitive development in early childhood: Evidence from a randomized experiment. Journal: Economic American Applied Economics 24-month impact report Conditional Cash Transfers in Peru. Washington, DC:23 http://www.cedlas-er.org/sites/default/files/cer_ien_activity_files/ 2014] December 4 online fernandez_y_dasso.pdf [Accessed in Peru: Evidence from a non-experimental evaluation 1–59 B Report External Evaluation of the Mchinji Social Cash Transfer Pilot http://www.unicef.org/malawi/MLW_resources_impactsocialcashtrf.pdf [Accessed online 4 December 2014] 336 337 327 328 329 330 331 332 333 334 335 320 321 322 323 324 325 326 319 Support Grant, and Teenage Pregnancy among Blacks in South Africa. Politics & Policy cash transfer program: impact evaluation 2012 most beneficial? Operational PerformanceTransfer of the Modality Research Initiative, International Food Policy Research Initiative in collaboration with WFP and Data Analysis and Technical Assistance Limited: 3 and Evaluation Component. Impact Evaluation Final Report: 2009 to 2012 monitoring-and-evaluation-component-impact-evaluation-final-report [Accessed online 4 December 2014] 828–837. 828–837. conditional cash transfer programmes for child health, growth, and development: an analysis of Mexico’s Oportunidades. Lancet The care: social protection cumulatively mitigates HIV-risk behaviour among adolescents in South Africa. AIDS, 28, S389–S397. JUNTOS for children in Peru] (No. 56480). University Library of Munich, Germany: http://mpra.ub.uni-muenchen.de/56480/ 21. [Accessed online 4 December 2014] JUNTOS en el bienestar de los niños: Evidencia basada en el estudio Niños del Milenio< 2012.The impact of cash transfers to poor women in Colombia on BMI and obesity: prospective cohort Obesity of Journal study. International 36(9): 1209–1214. an cash transfers to raise long-term living standards. American Economic Journal: Applied Economics International Association of Agricultural Economists. of Association International International Association of Agricultural Economists. of Association International t t t - t es es es . es B B B B , PRI, SANEM, , PRI, SANEM, , PRI, SANEM, , PRI, SANEM, utrition n gladesh gladesh gladesh gladesh

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an B esign D nsitive Government of the People’s Republic of Bangladesh, National 2014. Government of the People’s Republic of Bangladesh, National 2014. Save the Children, Social 2014. protection and child poverty study, Save the Children, Suchana: 2014. Ending the Cycle of Malnutrition in Kidd, S., Freeland, S., and Khondker, B., International 2014, Kidd, S., Freeland, S., and Khondker, B., International 2014. Save the Children, Social 2014. protection and child poverty study, Kidd, S., Khondker, B., Scoping 2013. Report on Poverty and Social Government ofthe People’s Republic of Bangladesh, National 2014. Government ofthe People’s Republic of Bangladesh, National 2014. Save the Children, Cost 2013. of Diet: Sylhet Agricultural Plain zone, Government of the People’s Republic of Bangladesh, National 2014. Kidd, S., Freeland, S., and Khondker, B. International 2014. Note: The figures, musthowever, be read with some caution. Olinto, Flores, P., R., Morris, S., and Viega, A., 2003, The impact ‘Building Nutrition Disaster Resilience’ Abigail Perry, DFID. – 2012 Save the Children, Resource 2013. mapping study in Sylhet and UNICEF et al., 2009. child-sensitive protection Advancing social Kidd, S., Freeland, S., and Khondker, B., International 2014. See Appendix B for details of the programmes included in our review The literature review considered 22 major social protection

Presentation at ACF ‘Hunger Talks’ event, October 2012. Social Security Strategy (NSSS) of Planning Commission: xxi and Appendix C for full references. Save the Children in Bangladesh Save the Children in Bangladesh Social Security Strategy (NSSS) of Planning Commission: xix Moulvibazar districts, Save the Children in Bangladesh. Social Security Strategy (NSSS) of Planning Commission: xxi 317 318 316 315 313 314 312 se 311 8 310 309 308 306 307 304 305 303 302 300 301 299 298 Practice in Social Protection: implications for Development Pathways, February 2014: 47/48; Save the Children / Rowe, G, How 2014. Can Social Protection better Respond to Child Poverty in Bangladesh Social Security Strategy (NSSS) of Commission: xviPlanning Bangladesh, Proposal for DFID for Bangladesh, Proposal of the Bolsa Alimentação Program on food consumption. In annual meetings International the of Association Agricultural of Economists. Practice in Social Protection: implications for Development Pathways: 47/48; Save the Children/Rowe,G (2014) How Can Social Protection better Respond to Child Poverty in Bangladesh. Development Pathways. Development Practice in Social Protection: implications for programmes across nutrition pathways. Eight of the programmes included were from Bangladesh. See section 5 for moredetail. Higher spending does not necessarily translate to households receiving more of the transfer. Higher costs could be because more is going to households, but higher costs could also bedue to higher administrative costs. Social Security Strategy (NSSS) of PlanningCommission: xxi Protection in Save the Children in Bangladesh http://www.unicef.org/aids/files/CSSP_joint_statement_10.16.09.pdf [Accessed online 4 December 2014] Development Pathways: 60 Practice in Social Protection: implications for 106 malnutrition in bangladesh Development Pathways, February 2014: 38 2014: February Pathways, Development for implications Protection: Social in Practice UNICEF conceptual framework (see section 5) section (see framework conceptual UNICEF 9, and Studies: Development of Institute Nutrition, Transform 44, No 2014 Volume Paper Working IDS Era, Post-MDG the for Priorities and Drivers Past Undernutrition: Child Reducing (2014), Haddad and L. Smith, from developed is approach ‘aspects’ and approach End-line Survey Report Survey End-line Programme: Jibon-O-Jibika Bangladesh: in USA Children the Save 2009. 2004–2009 Project, Poverty Research Centre Conference. Centre Research Poverty Pragmatism or Wishful Thinking Africa: Sub-Saharan in Countries Income Low in Reduction Poverty and social_protection.php [Accessed online 4 December 2014] 4December online [Accessed social_protection.php committee_world_food_security/committee_world_food_security_ http://www.unscn.org/en/ Nutrition: and Security Food For Protection online 4 December 2014] 4December online agenda 352 351 350 349 348 347 346 on 9 345 344 343 342 341 340 339 338 ID:3065524:NO [Accessed online 4 December 2014] 4December online [Accessed ID:3065524:NO en/f?p=NORMLE http://www.ilo.org/dyn/normlex/ International Organization/ Labour evaluations and experience experience and evaluations 4 December 2014] [Accessed online int/nutrition/topics/nutrition_globaltargets2025/en/ 4 December 2014] [Accessed online http://www.un.org/millenniumgoals/beyond2015.shtml cash transfer program: impact evaluation 2012 evaluation impact program: transfer cash Bangladesh. WorldBangladesh. Development in Stunting Child on Project SHOUHARDO CARE’s of Impact The Evaluation? Development of Court the in Evidence Admissible 2013. A., Wadud, and T. R., F., Frankenberger, Khan, C., L. Smith, Empowerment transfers: reducing present and future poverty future and present reducing transfers: conditional cash transfers. Group, 16th June 2014 June 16th Group, Agenda Post2015 Development the for Development

R202 – Social Protection Floors Recommendation (No.202) Recommendation Floors Protection –Social R202 2012. ILO, Conditional cash Conditional 2009. F. H., Ferreira, and R., N. Schady, A., Fiszbein, Chaudhury, N., Friedman, J., and Onishi, J., 2013. Philippines J., conditional Onishi, and J., Friedman, N., Chaudhury, International 2014. International B., Khondker, and S., Freeland, S., Kidd, WHO, 2014. World WHO, Cash Transfers Transfers 2010. Cash A., McCord, and R., Holmes, R., Slater, Reaching New New Reaching 2012. CARE, Millennium Development Goals and and Goals Development 2014. Millennium Nation. United Millennium Development Goals and post 2015 post and Goals Development 2014. Millennium Nations, United Note: Design principles developed by Save the Children. ‘Pathways ‘Pathways Children. the Save by developed principles Design Note: Note: Developed by Save the Children based on programme programme on based Children the Save by Developed Note: United Nations Standing Committee on Nutrition, 2012. Social Social 2012. Nutrition, on Committee Standing Nations United Introduction and Proposed Goals and Targets on Sustainable Sustainable on Targets and Goals Proposed and 2014. OWG, Introduction Galiani, S., and McEwan, P. J., 2013. The heterogeneous impact of of impact P. 2013. heterogeneous The J., McEwan, and S., Galiani, Trend Analysis of the Jibon-O-Jibika Helen Keller Jibon-O-Jibika International, the of 2010. Analysis Trend S ocial

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Progress with the Millennium Development Goals has shown children in the poorest 20% of households to be twice as likely to be stunted as children in the richest 20%. One thing is clear about the much anticipated Sustainable Development Goals – they must leave no child behind. With the ability to promote spending to improve child nutrition and be an active tool for income distribution towards inclusive growth, social protection provides a, currently underutilised, key policy solution. Malnutrition in Bangladesh: Harnessing social protection for the most vulnerable explores the impact of social protection on nutrition. It makes recommendations for policy development and implementation in Bangladesh and for global learning. The report guides the reader through a pathways approach to understand how developing social protection across the lifecycle – with a greater focus on nutrition behaviour change, adolescent girls, early marriage, empowering women and the 1,000-day window of opportunity between a woman’s pregnancy and her child’s second birthday – will help shape healthier and more prosperous futures for all. In doing so, essential lessons are shared on an integrated approach to tackling malnutrition through social protection internationally, the importance of national systems and contextual programme design.

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