November 6, 2003Social Policy Monitoring Network1 Evaluation of the pilot phase of the Social Safety Net (RPS) * in Nicaragua: Health and Nutrition Impacts

November 6, 2003 Social Policy Monitoring Network 1

Evaluation of the pilot phase of the Social Safety Net (RPS)* in

Nicaragua: Health and Nutrition Impacts

John Maluccio1 and Rafael Flores2

11International Food Policy Research Institute (IFPRI)International Food Policy Research Institute (IFPRI)

and and 22Emory UniversityEmory University

**Red de Protección SocialRed de Protección Social


Presentation

Project description Evaluation design and sample evolution Impacts on expenditures on food Impacts on service utilization and coverage of

preventive health interventions Impacts on nutrition


Red de Protección Social

(RPS)

Social Safety Net

IADB (US$ 9 million) GN (US$ 1 million)

Pilot Phase


The Social Safety Net pilot phase

Outputs Increase the demand for preventive health

care for children < 3 years of age Decrease school desertion during the first

four years of primary school Increase expenditures in food at the

household level


Demand and Supply-side Interventions: Food security, Health & Nutrition

Demand Bimonthly cash

transfer (food transfer) to all eligible households

US$ 224 per household per year

Conditional upon attendance at bimonthly educational workshops and on bringing their children < 5 for healthcare appointments

Supply Child growth

monitoring Monthly: 0-2 year olds Bimonthly: 2-5 year

olds Vaccination Provision of anti-

parasites, vitamins and iron supplements

Bimonthly health and nutrition education workshops


Demand and Supply-side Interventions: Education

Demand Bimonthly cash transfer

(school attendance transfer) to all eligible households

US$ 112 School supplies transfer

US$ 21 (per child/year) Conditional upon

enrollment and regular school attendance of children who have not completed 4th grade (ages 7-13)

Supply Teacher transfer

US$ 5 per child/year


Geographic Targeting

Stage 1: rural areas in all 17 departments were eligible. Madriz and Matagalpa were selected due to their needs and capacity to implement the project.

Stage 2: six out of 20 municipalities were selected because they had a participatory development program. 36-61% of the rural population extremely poor and 78-90 % extremely poor or poor.

Stage 3: 42 census “comarcas” out of the 59 were chosen based on a marginality index (highest scores). 50 % of the population extremely poor and 85% extremely poor or poor.


Base Line

Aug-Sep 2000

Measurement

Oct 2001

Measurement

Oct 2002

RPS Control RPS Control RPS Control

21a: 811b 21:771 21:766 21:724 21:722 21:712

Evaluation design: cluster-randomized trial

aCensus “comarcas”: administrative areas within municipalities that include between one and five small communities averaging 100 households each bHouseholds within 21 comarcas, planned sample size = 882 (42*21)


RPS average impact on per capita annual food expenditures (C$)

Measurement Intervention Control Difference

2002 3027 2246 781**

2001 3129 2141 988**

2000 2812 2598 214

Diff 2001-2000 316 -457** 774**

Diff 2002-2000 214 -352** 566**

**P<0.01


RPS average impact on the composition of food expenditures

Food Category

2000-2002 expenditures C$

2000-2002 food share %

Cereals 504 -3.2**

Beans -138 -3.1**

Meat 656** 1.9**

Milk 122 0.4

Fats and oils 663** 1.9**

Fruits and vegetables

494** 2.3**


Conclusions

Additional expenditures as a result of the transfers were spent predominantly on food

RPS prevented the deterioration of the food security situation in the intervention group offsetting the decline seen in the control group

The expenditure on almost every food group increased with the program

Three food groups associated with a better diet increased in absolute expenditures and as a percentage of total food expenditures


RPS average impact on percent of children age 0-3 taken to health control in past six months


2002 92.7 84.9 7.9*

2001 95.5 79.0 16.5**

2000 69.8 72.9 -3.1

Diff 2001-2000 25.7** 6.2 19.5**

Diff 2002-2000 23.0** 12.0* 11.0

**P<0.01 *P<0.05


Impact on coverage of preventive health interventions

IndicatorDD

2001-2000

DD 2002-2000

Children age 0-3 weighed in past six months % (mother report)

28.9** 17.5*

Children age 12-23 months with updated vaccination % (health card)

14.2 6.1

** p<0.01 ** p<0.01 **p <0.05p <0.05


Conclusions

RPS had a large impact on the utilization of well baby check-ups between 2000 and 2001, however this impact decreased in 2002 due to a continued improvement in the control group

Growth monitoring was markedly increased in both 2001 and 2002. However, childhood immunization did not significantly improve in these years


Impact on percentage of children < 5 who are stunted*

41.9

37.140.9 41.5

21.818.6

0

5

10

15

20

25

30

35

40

45

RPS Control Nicaragua

2000

2002

**Estimated from ENDESA 1998 and 2001

*

*HAZ < -2.00

DD= -5.3

D= -3.1**


Impact on percentage of children < 5 who are wasted*

0.9

0.4 0.30.2

2

2.3

0

0.5

1

1.5

2

2.5

RPS Control NIC OMS

2000

2002

2001

Expected

*WHZ < -2.00


Impact on percentage of children < 5 who are underweight1

15.3

10.4

14.715.8

10.5

8.7

0

2

4

6

8

10

12

14

16


2000

2002

****Estimated from ENDESA 1998 and 2001

*

1WAZ < -2.00

DD= -6.0*

D= -1.7**

*P < 0.05


Conclusions

Improved household diet and improved health care services (bimonthly health and nutrition education workshops) for children have combined to improve nutritional status of beneficiary children < 5.

Net impact was a 5 percent point decline in the percentage of children who were stunted.

This decline is more than one and a half (1.7) times faster than the improvement see at the national level between 1998 and 2001.


Impact on percent of children age 0-3 given iron supplement in past 12 months


2002 75.4 41.4 34.0**

2001 69.0 40.9 28.1**

2000 39.1 36.3 2.8

Diff 2001-2000 29.9** 4.6 25.2**

Diff 2002-2000 36.3** 5.1 31.1**

**P<0.01


Impact on percentage of children 6-59 months of age with anemia*

33.7 32.8 31.5 30.933.5

0

5

10

15

20

25

30

35


2000

2002

*Hemoglobin < 11.0 g/dL

**

**ENM, 2000


Impact on average Hemoglobin (g/dL) for children 6-59 months of age


2002 11.2 11.4 -0.2

2000 11.4 11.5 -0.1

Diff 2002-2000 -0.2 -0.1 -0.1


Conclusions

RPS has been successful in distributing iron supplements to mothers of children 6-59 months of age during its two years of operation

One out of every three children shows anemia in the area where RPS is operating

Despite improved household diet, improved health care services and improvements in the distribution of iron supplements, RPS had not succeeded in improving the grave situation on anemia nor improving hemoglobin levels


Are conditional cash transfer programs capable of improving

the nutritional status of pre-school children?


Impacts (double differences 2002-2000)

Indicator RPS PRAFa % children age 0-3 taken to health control in past six months / 0-5 last 30 days

11.0 21.0***

% children age 0-3 weighed in past six months / 0-5 last 30 days (mother’s report)

17.5* 21.7***

% children age 12-23 months with updated vaccination / DTP1/pentavalent (health card)

6.1 6.9*

*** p<0.001 ** p<0.01 *** p<0.001 ** p<0.01 **p <0.05p <0.05aDemand


Impacts, changes and interventions

Indicator RPS PRAFa % children age 0-5 who are stunted -5.4 -0.3

% children age 0-5 who are stunted

country level estimation -3.1 -2.0

% of total annual household expenditures

13 4

Supply side interventions Yes No

aDemand

Documents

November 6, 2003Social Policy Monitoring Network1 Evaluation of the pilot phase of the Social Safety Net (RPS) * in Nicaragua: Health and Nutrition Impacts