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social protection and child malnutrition
afghanistan

A NEED FOR GREATER FOCUS


AND SUSTAINED FUNDING
SUMMARY
Over the past decade Afghanistan has made tangible progress towards its social and
development objectives and meeting the Millennium Development Goals (MDGs). Infant and
under-five mortality have gone down from 111 and 161 per thousand live births in 2008 to
77 and 97 per thousand live births respectively.1 Key social protection initiatives have been
taken to address poverty and vulnerability, including a pilot safety net programme, a school
feeding programme and cash or assets for work initiatives. The country’s commitments to
social protection are captured in the National Social Protection strategy (2008-2013), which
falls under the Afghanistan National Development Strategy (ANDS)2 and the MDGs’ plan,
which serves as the country’s Poverty Reduction Strategy Paper.
Nonetheless, Afghanistan continues to face severe security challenges; weak governance
and corruption; limited fiscal resources that impede service delivery; a poor environment
for private sector investments; a large narcotics industry; and major human capacity
limitations. As a result, many people are actually getting poorer. Nearly a third of Afghans
are still food insecure, which means they cannot get enough nutritious food to support
an active, healthy lifestyle. Nearly 60% of children under the age of five are stunted, an
indicator of chronic malnutrition.3
To address these concerns, while building on the successes of the last decade, social
protection provision must be extended and the quality improved to ensure benefits reach
those who are most vulnerable, especially women and children. There is justified concern
that social protection will slip further off policy agendas as the country approaches transition
to national forces, given the increasing focus on security concerns and the likely dip in donor
spending from 2014.4
This briefing calls for an increased focus on social protection as a means of tackling hunger
and malnutrition. The Afghan government and donors can ensure a greater focus on nutrition
within social protection plans, which can go a long way towards addressing malnutrition and
the damaging effect it can have on children’s lives and their future potential.

THE CONTEXT
Afghanistan’s economy has grown strongly, if erratically, over the past six years, averaging
around 12% per annum. Average per-capita GDP has nearly doubled since 2002.5 Adult
mortality rates have also fallen substantially. Basic health services are available in districts
where 85% of the population lives, providing access to primary healthcare for 60% of the
country’s population.6
At the same time, achievements in some areas are below expectations and Afghanistan is
off-schedule for all of its MDG targets. Poverty remains high, particularly in the East and
West-Central regions, and a large share of the population is vulnerable to negative shocks.7
Low and often unreliable revenue flows, the unpredictability of the natural environment,
ongoing conflict and external factors such as fluctuating global food prices drive this
vulnerability.8 The re-establishment of the Office for the Coordination of Humanitarian
Affairs (OCHA) in 2009 reflects the rising humanitarian need in Afghanistan and the fact
that basic social protection remains limited.9

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Current statistics10

Population (million)11 31.412

Poverty (% of total population below


42
national poverty line)12

Regional poverty South-west poverty 23


(% of total population) East and Central 45

Male and female life expectancy at


48
birth (years)13

Maternal mortality ratio (2008)14 1: 11

Food insecurity (% households not


31
consuming sufficient caloric intake)15

Child malnutrition
33
(% children under 5)16

Maternal malnutrition
(% non-pregnant women of reproductive 20.9
age with BMI less than 18.5%)17

Poverty and severe food insecurity contribute to high levels of malnutrition (outlined in
the table) as households are forced to regularly trade-off quality for quantity as they move
towards staple foods and away from nutrient-rich foods such as meat and vegetables.
However, these are not the only underlying contributory factors. Inadequate healthcare, a lack
of knowledge regarding appropriate nutrition practices, low levels of education – particularly
among women – and scarcity of micronutrients are also important factors.18

PLANNING, IMPLEMENTATION AND COORDINATION


Many households in Afghanistan have strong, longstanding social networks from which they
are able to borrow and villages are able to organise themselves to provide basic goods for
the public.19 However, these longstanding, informal sources of support have been weakened
by decades of conflict, and the need for social protection provided by the state and other
agencies remains strong.
The current strategic and planning framework is provided by the ANDS, which includes
the national Social Protection Strategy. The strategy reinforces commitments made in the
Afghanistan Compact20 and under the MDGs to promote social inclusion, reduce poverty
and prevent those who are poor from falling into deeper poverty through sustainable income
and transfer policies, pursued through pension reform and programmes focused on extremely
poor and vulnerable households. In theory, the Ministry of Labour, Social Affairs, Martyrs, and
Disabled (MoLSAMD) is the lead ministry responsible for managing and coordinating social
protection interventions. The Ministry of Rural Rehabilitation and Development (MRRD),
through its own social protection directorate, also helps to build local infrastructure and
provide temporary employment, which help disaster-affected rural communities recover
and returnees and internally displaced people reintegrate. Various other ministries operate
programmes with implications for social protection.

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In reality, public spending remains heavily dependent on donor funding and state-funded
social protection has long been restricted to a number of specific interventions targeting a
very limited number of people. Non-state actors, specifically international non-governmental
organisations or UN agencies, have therefore filled the gap, providing a range of social
services. This leads to off-budget spending on projects over which the government has little
influence and scant information on, reducing the effectiveness of its pro-poor planning and
performance budgeting.21
In the coming years, Afghanistan faces the combined challenge of a global economic crisis, high
food prices and an anticipated decline in some donor financial support. Government capacity
to broaden the scope of social services beyond existing interventions remains limited. This
scenario poses heavy implications for the sustainability of social protection programmes and
will likely exacerbate hunger and malnutrition. There is a clear need for international donors
to commit to backstop spending on social protection so that the government can invest in
long-term development and effective crisis response.

Addressing malnutrition
Children’s physical and cognitive development and potential could be irreversibly damaged
if food and nutrition needs are not met. Impacts on the economy are also likely, as healthier
workers are more productive and labour supply increases if morbidity and mortality rates
are lower. While there are sector strategies22 that specifically address the issue of nutrition,
growing evidence from other low-income countries demonstrates the effectiveness of social
protection programmes in enabling people to get more and better-quality food and become
better nourished.23
In theory, the link between social protection and nutrition is already recognised by policy-
makers in Afghanistan. Importantly, reductions in the number of underweight children and in
the number of individuals who suffer from hunger were included as indicator outcomes in
the Social Protection Strategy. The strategy also identified nutrition concerns such as food
insecurity and malnutrition during natural disasters and in the broader context of addressing
the needs of chronically vulnerable groups. However, support for nutrition within the relevant
line ministries is still weak, as indicated by the low positioning of nutrition-related departments
within organisational structures and the low funding priority given to nutrition programmes.24
Although ANDS offers a framework for developing the social protection system, it currently
highlights a broad menu of needs and fails to provide a coherent prioritisation of goals and
activities. Meanwhile, the failure to include social protection as a specific component of the
national priority programmes (designed to streamline ANDS as part of the ‘Kabul Process’)
is a worrying indication of the lack of attention awarded to social protection at policy
level. More political will and capacity will therefore be needed if social outcomes are to be
achieved, while the positive correlation between livelihood security and nutrition needs
further emphasis.

Existing programmes
Some examples of existing programmes, including those with a nutrition dimension, led by
either the government or donors, separately or jointly, are:
• Program for Martyrs and Disabled: This is the government’s largest national cash transfer
programme, accounting for about 0.2% of GDP. It provides cash benefits to the families of
martyrs from earlier wars and individuals with war and landmine-related disabilities.
• Safety Net Pilot: The programme is a MoLSAMD-operated and International Development
Association (IDA)-funded pilot unconditional cash transfer programme aimed at selected
high-risk categories defined in ANDS and the National Risk Vulnerability Assessment to
support their food consumption in the most difficult period of year, between end of winter
and first harvest. Transfer size is determined by the ‘food poverty line’.

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• The National Skills Development Program aims to provide training in different marketable
vocational skills to a range of vulnerable groups; 35% of beneficiaries are required to be
women from chronically poor, female-headed households with small children. Nutrition
promotion modules are included in training programmes.25
• Horticulture and Livestock Project (HLP): A key component of this is the Backyard
Poultry Project (2009), which trains those involved in poultry production, largely women
in rural villages, to increase poultry and egg productivity to improve nutrition while
reducing poverty.
• HLP Integrated Dairy Schemes Project. The Ministry of Agriculture, Irrigation and
Livestock (MAIL) works with GRM International to implement the dairy component of the
World Bank-funded HLP. The programme targets women and is designed around local dairy
cooperatives to improve household food security and income.
• Food for education programme: The World Food Programme (WFP) runs a school
feeding project in food deficit areas affected by drought. In 2010, WFP provided a daily
snack of micronutrient-enriched biscuits or a hot meal to more than a million children.
• Public works programmes: Food-for-work and food-for-assets programmes are a means
of transferring resources through temporary employment generation, often targeted
at workers from poor households, while at the same time building or repairing local
infrastructure and community assets.

Effective implementation
Despite these positive initiatives, lack of awareness about nutrition at policy level, coupled
with ineffective coverage, inefficient targeting and poor administration and design of social
protection programmes are obstacles to progress in addressing malnutrition.
Broad coverage is critical to reducing national rates of malnutrition. In Afghanistan, the
coverage of social protection policies is inadequate, especially considering the high number
of at-risk households. Donor-funded programmes are generally small-scale and of limited
coverage with a tendency to focus on rural areas. In contrast, existing informal social
protection mechanisms are on the whole much weaker in urban settings.26 Increasing
coverage requires long-term domestic financing strategies that are complemented where
necessary by multiyear funding commitments from donors. However, the heavy dependence
on donor support in Afghanistan makes longer-term planning difficult, since strategies must be
constantly realigned with changing donor engagement.27 The situation is compounded by the
lack of coordination between the numerous stakeholders, leading to overlap and gaps
in coverage.
To be as effective as possible, programmes should be targeted at those who are most
vulnerable. However, the poor coverage of social protection programmes is exacerbated by
inefficient targeting. Programmes use categorical or geographic targeting or combinations of
the two (although community targeting and means-testing mechanisms are applied in certain
donor schemes). While geographic targeting allows provinces that have the highest burden of
food poverty and malnutrition to be selected, this can miss malnourished children in
other regions.
Given the high levels of malnutrition among women and children, categorical targeting that
focuses on these and other vulnerable groups is appropriate. However, targeting of safety net
programmes is also inefficient, with a relatively large number of ineligible households receiving
benefits while eligible households are left out. This is because only a few programmes have
been specifically targeted at poor households. The martyrs’ and disabled programme, which
dominates spending on safety nets, for example, is not poverty-targeted. Meanwhile, even
poverty-focused donor programmes show high levels of leakage to better-off households.
Some good initiatives have, however, been introduced, including the mapping of pro-poor
expenditures in the budget. The pilot safety net programme also specifically focuses on poor
households and could go some way towards redressing this imbalance.28

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Conditional cash transfer programmes (CCTs), such as cash/products for work, training or
education programmes, have been used to link benefit award to some change in household
behaviour. However, CCTs cannot be a complete safety net in the Afghan context where
children have limited access to healthcare and education, and many households do not have
family members free to participate in public works schemes.29 Consequently, the impact
of conditional CCTs is restricted to the people who are able to sign up. This suggests that
conditionality should not be the default option when designing social transfer programmes.
Moreover, while social protection structures can promote behaviour that supports
good nutrition (at payment points, through programme communication and community
committees), programmes often fail to capitalise on these opportunities. Even programmes
that have stated nutrition goals, such as the Backyard Poultry Project, are not systematically
accompanied by a component directly promoting nutrition.
The size of transfer is critical in determining the impact on hunger and nutrition. Evidence
shows that, by tackling the underlying poverty constraint, a larger cash transfer leads to young
children eating more and better food, which is likely to have a positive impact on height-for-
age and stunting.30 In Afghanistan there is a huge gap between the cost of a nutritious diet
and household income, particularly for very poor groups. Cash transfer schemes largely fail to
take this gap into account and the transfer size of all benefits is generally too small to impact
on nutrition standards. While the definition used to determine transfer size in the pilot safety
nets project is ‘food poverty line’, this does not necessarily mean it is sufficient for nutritious
food, given high and fluctuating food prices. In order to increase access to and affordability of
a nutritious diet, cash transfer schemes aiming to improve nutrition need to assess affordability
and as far as possible bridge the gap.
Finally, the lack of prioritisation in ANDS leads to stand-alone interventions by the
government and donors. Lack of coordination means the system is failing to sufficiently exploit
complementarities between programmes and may be generating sub-optimal outcomes.
At a conceptual level there is considerable scope for strengthening the links between social
protection, health and livelihood sectors, particularly in relation to nutrition.31 Building strategic
links between the MoLSAMD, the Ministry of Education, the Ministry of Rural Rehabilitation
and Development, the Ministry of Public Health’s Public Nutrition Department and MAIL’s
Home Economics Department could increase the reach and impact of social protection
programmes, with accompanying benefits for food security and nutrition.32

POLICY RECOMMENDATIONS
Afghanistan’s maternal, infant and child mortality rates are among the highest in the world.
Improving the nutritional status of these groups is therefore imperative. Social protection
strategies can reduce malnutrition. Taking into account the context of transition and the
limited capacity of the Afghan government to deliver services, this paper makes the following
key policy recommendations:
1. Renew commitments to the Social Protection Sector Strategy by ensuring that
commitments outlined in ANDS are implemented. Social protection should be firmly
embedded in national priority programme and nutrition outcomes as an indicator of
success.
2. Improve poverty reduction outcomes by targeting beneficiaries in social protection
policies using more nuanced criteria of ‘vulnerable groups’ and ensuring social transfer
programmes work for women and children.
3. Ensure social protection programmes are nutrition sensitive by considering the cost of
a nutritious diet in cash transfers and providing training for caregivers33 on how to prepare
culturally acceptable, nutritious food in transfer programmes.

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4. Encourage coordination and harmonisation between departments and policies by


revitalising the Inter-Ministerial Council on Social Protection, strengthening MoLSAMD and
integrating social transfer programmes with wider nutrition packages. Conditionality should
not be the default option.
5. Ground forthcoming programmes in government capacity to ensure that they are
affordable and sustainable in the long term and incrementally increase the fiscal space for
social protection and coverage as GDP increases.
6. Donors should remain committed to social protection given the strong reliance of
Afghanistan on donor aid and the role of social transfer programmes as one of the most
effective policy tools to combat hunger and malnutrition.

NOTES
1 Afghan Public Health Institute, Ministry of Public Health (APHI/MoPH) [Afghanistan], Central Statistics Organization
(CSO) [Afghanistan], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India] and World Health
Organization Regional Office for the Eastern Mediterranean (WHO/EMRO) [Egypt], Afghanistan Mortality Survey
2010 (Calverton, Maryland, USA: APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO, 2011) http://www.usaid.gov/
locations/afghanistanpakistan/documents/afghanistan/AMSKeyFindings.pdf.  Many of the current statistics available on
even Afghanistan’s most basic indicators, such as poverty or infant mortality, should be considered estimates.
2 Government of the Islamic Republic of Afghanistan, Afghanistan National Development Strategy (ANDS) (2008) Kabul:
GoA, 2008
3 Save the Children (2011) Afghanistan in Transition: Putting Children at the Heart of Development (Washington, D.C.: Save
the Children
4 Although donor governments are signing agreements to provide long-term financial support, experience suggests that
withdrawals of international troops reduce civilian aid.
5 World Bank (2011) Afghanistan Economic Update: Poverty Reduction, and Economic Management, South Asia Region. Note,
as with much of the data from Afghanistan considerable caution has to be exercised with respect to its reliability.
6 World Bank (2012) Quarterly Country Update: Afghanistan, Issue 411, January 2012, http://siteresources.worldbank.org/
INTAFGHANISTAN/Resources/CountryUpdateJAN2012English.pdf
7 World Bank (2011) Afghanistan Economic Update: Poverty Reduction, and Economic Management, South Asia Region
8 P Kantor and A Pain (2011) Rethinking Rural Poverty in Afghanistan, Afghanistan Research and Evaluation Unit (AREU),
Kabul
9 A Pain (forthcoming) Working Paper, Secure Livelihoods Research Consortium, London: ODI
10 These statistics were compiled from a number of sources to ensure information is as recent as possible but should be
considered estimates.
11 UNICEF, Afghanistan Country Information, http://www.unicef.org/infobycountry/afghanistan_statistics.html
12 Statistics are from Ministry of Economy and World Bank (2010) Poverty Status in Afghanistan, A Profile based on National
Risk Vulnerability Assessment (NRVA) 2007/08
13 UNICEF, Afghanistan Country Information
14 Ibid
15 World Food Programme (2010) Project Document on Protracted Relief and Recovery Operation (PRRO) –
Afghanistan 200063
16 UNICEF, Afghanistan Country Information
17 Ministry of Public Health, United Nations Children’s Fund, Centres for Disease Control and Prevention, National
Institute for Research on Food and Nutrition – Italy (2009) 2004 Afghanistan National Nutrition Survey, Atlanta: CDC
18 E Levitt, K Kostermans, L Laviolette and N Mbuya (2011) Malnutrition in Afghanistan: Scale, Scope, Causes and Potential
Response, Washington, D.C.: World Bank, pp 127–8
19 P Kantor and A Pain (2010) Poverty in Afghan Policy: Enhancing Solutions through Better Defining the Problem, AREU: Kabul
20 The Afghanistan Compact (Building on Success: 2006 The London Conference on Afghanistan, 31 January to
1 February 2009). Available at: http://www.ands.gov.af/admin/ands/ands_docs/upload/UploadFolder/The%20
Afghnistan%20Compact%20-%20Final%20English.pdf
21 World Bank (forthcoming 2012) Afghanistan Social Protection Review: Improving Targeting, Promoting Results Based Policies,
Strengthening Institutions in Afghanistan
22 Specifically the Health and Nutrition Sector Strategy and the Agriculture and Rural Development Sector Strategy
23 Save the Children (2012) A Chance to Grow: How social protection can tackle child malnutrition and promote economic
opportunities
24 E Levitt et al (2011) Malnutrition in Afghanistan

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25 This manual was developed jointly by MAIL, MoPH, UNICEF and the Food and Agriculture Organization of the United
Nations (FAO).
26 Recognising this gap the EU social protection programme has a strong urban focus. See European Union (2011)
The State of Play September 2011 http://eeas.europa.eu/delegations/afghanistan/documents/content/state_of_play_
september_2011_en.pdf
27 World Bank (forthcoming 2012), see note 21.
28 Ibid
29 Ibid
30 Save the Children (2012), see note 23.
31 Levitt et al (2011) Malnutrition in Afghanistan
32 Ibid
33 A training manual for this was developed jointly by MAIL, the MoPH, UNICEF and FAO.

Written by: Emily Winterbotham This briefing is part of a set of eight


country briefings produced to accompany
Photo: Mats Lignell/Save the Children
Save the Children’s report A Chance to Grow:
As part of a cash-for-work project, Fatima How social protection can tackle child malnutrition
works at a site making huge boxes used to and promote economic opportunities.
hold stones to prevent flooding in Bamyan
Thank you to all those who commented
province, Afghanistan.
on previous drafts.

savethechildren.org.uk
Save the Children, June 2012
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The Save the Children Fund is a charity registered in England and Wales (213890)
and Scotland (SC039570). Registered Company No. 178159

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