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A PRESSING DEVELOPMENT CHALLENGE

SUMMARY

Tanzania has sustained high rates of economic growth in recent years, but it has had limited direct impact on the majority of Tanzanians’ lives. Despite attempts at policy level to create a national social protection agenda, little concrete progress has been made. Child poverty rates are alarming, suggesting an acute need for comprehensive, well-articulated and well-targeted social protection measures.

Over one-third of child deaths in Tanzania are due to undernutrition. There have been aggregate improvements over the past two decades but progress has been mixed at best. The underlying causes of malnutrition are complex and need to take into account a range of economic and social risks that govern access to food, eg, unstable rural livelihoods, commodity price fluctuations and low uptake of healthcare. Many rural households dependent on subsistence agriculture are both cash and asset poor and thus not resilient to economic and climatic shocks. Both rural and urban poor are highly vulnerable to commodity price fluctuations.

Child malnutrition represents a pressing development challenge in Tanzania, but evidence suggests that social protection programming is far from fulfilling its potential to bring about genuine transformation in children’s lives. The groups most vulnerable to malnutrition (infants, young children, pregnant women and lactating mothers) have not been covered sufficiently or targeted adequately in current social protection programmes. Therefore, caregivers and infants must be at the centre of future initiatives, and this could be achieved without significant additional budget outlay. In order to tackle these problems, there are five key areas that should be prioritised:

• expand coverage of social protection programmes• strengthen programme targeting• improve inter-sector coordination and policy coherence• integrate nutrition monitoring into social protection monitoring and evaluation systems• invest in maternal and infant health and wellbeing.

INTRODUCTION

Social protection is increasingly acknowledged as a core component of efforts to reduce poverty and vulner ability to economic, social, natural and other shocks and stresses. A considerable body of evidence shows it plays an important role in strengthening demand for and access to basic and social welfare services by the poorest throughout childhood and beyond.1 If designed well, social protection can also facilitate a better balance between caregiving and productive work responsibilities. This is critical, both for fulfilling children’s fundamental right to survival2 as well as for achieving the Millennium Development Goals (MDGs), especially the child-focused targets, including Goal 1 of halving child malnutrition (underweight rates) by 2015 (Jones and Holmes, 2010).

The 2007 global food, fuel and financial crises underscored the scale and depth of children’s vulnerability to hunger and malnutrition as a complex but urgent development challenge. Recent analysis by Save the Children based on World Bank projections and using data for 98

social protection and child malnutritiontanzania

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developing countries shows that an escalation of the eurozone crisis could push an extra 33 million people into hunger by 2013. Child-sensitive social protection programming can help address this problem more systematically. This briefing paper focuses on the links between child nutritional vulnerabilities and social protection in Tanzania. We begin by reviewing the poverty and vulnerability context and the patterns and underlying causes of child malnutrition in the country, before discussing the strengths and weaknesses of the social protection infrastructure and the extent to which it addresses child malnutrition.

CONCEPTUALISING CHILD-SENSITIVE SOCIAL PROTECTION AND LINKS TO CHILD SURVIVAL

Social protection refers to both public and private interventions that support communities, households and individuals to prevent, manage and overcome risks and vulnerabilities. A child-sensitive approach to social protection necessitates a comprehensive understanding of the multiple and often intersecting vulnerabilities and risks facing children and their caregivers (Jones and Holmes, 2010).

Social protection can be conceptualised as not only protective (of a household’s level of income and/or consumption), but also preventive (of households from resorting to negative coping strategies such as pulling children out of school and involving them in labour) and promotional (of children’s development through investments in their schooling, health and general care and protection) (Guhan, 1994). Social protection can also be transformative, tackling power imbalances that create and sustain vulnerabilities and supporting equity and empowerment, including that of children and young people (Devereux and Sabates-Wheeler, 2004).

Many interconnected risks and vulnerabilities contribute to malnutrition (see Figure 1). Child malnutrition can result from inadequate availability of food, but also inadequate access to food as a consequence of the way supplies are utilised within the household (Holmes and Jones, 2010). Moreover, malnutrition is often linked to childcare practices, health, sanitation and hygiene. Depending on the type of assistance provided (food, cash, productive inputs, etc), social protection can help address these causes at macro and micro levels (see Table 1 for examples). Indeed, when informal coping mechanisms are close to reaching their limits (eg, in times of crisis), formal social protection becomes increasingly important.

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Source: UNICEF framework, presented in Black et al (2008) ‘Maternal and child undernutrition: global and regional exposures and health consequences’, The Lancet, January 2008

Figure 1: Framework of the relations between poverty, food insecurity and other causes of maternal and child undernutrition and its short-term and long-term consequences

Householdfood insecurity

Inadequate dietry intake

Short-term consequencesMortality, morbidity, disability

Long-term consequencesAdult size, intellectual ability, economicproductivity, reproductive performance,metabolic and cardiovascular disease

Inadequate care

Maternal and child undernutrition

Unhealthy householdenvironment and lack

of health services

Disease

Underlying causes

Basic causes

Immediate causes

Income poverty: employment,self-employment, dwelling, assets,

remittances, pensions, transfers, etc

Lack of capital: financial, human,physical, social and natural

Social, economic andpolitical context

At macro level, safety net instruments such as cash transfers can play a key role in crisis response. During the food, fuel and financial crises of 2007, for example, Brazil’s Bolsa Família expanded coverage and increased funding; Senegal introduced the Social Cash Transfer and Nutritional Security to increase resilience; and Kenya accelerated the scaling-up of its vulnerable children cash transfer (Fiszbein et al, 2011).

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At micro level, social protection has a positive effect on household aggregate consumption: a large proportion of cash transfers is spent on food, which has a clear impact on child nutrition and can enable households to increase resilience through the purchase of assets (such as livestock or agricultural inputs), which helps increase productivity (Holmes and Jones, 2010).

However, it is important to also consider the most critical lifecycle stages for social protection interventions. There is growing consensus that the most cost-effective interventions focus on the 1,000 days from conception to when a child is two years of age. Cash transfers that condition mandatory attendance at preventive healthcare services and health and nutrition education sessions can have a positive role, for example Nicaragua’s Red de Protección Social, Ecuador’s Bono de Desarrollo Humano and Mexico’s Oportunidades, which aim to integrate early childhood development as core components (Engle et al, 2011). In general, though, very few instruments directly target this critical period, or include complementary nutrition components or articulation with services such as prenatal care, breastfeeding promotion, consultations for mild illnesses, parenting education and early intervention for at-risk children under three years of age (Engle et al, 2011).

Table 1: Social protection to improve child nutrition

TYPE Of SOCIAL

PROTECTION MEASURES THAT MAY SUPPORT IMPROVED CHILD NUTRITION

SoCIAl TrANSFErS

• Cash transfers with specific conditionalities (eg, to increase utilisation of health and nutrition services)

• Unconditional cash transfers to enhance household consumption in general • Gender- and child-sensitive food for work, public works and employment

guarantee programmes (provided children do not complete work quotas; there are exemptions for pregnant and lactating mothers; crèche facilitates are provided; and wages compensate for calories spent on physical labour)

• Food subsidies to households during drought, flooding or financial crises• Vouchers or grants to purchase seeds, fertilisers and other agricultural inputs• Child support grants for parents or caregivers from deprived households • Social pensions for the elderly poor• Health voucher schemes for reproductive health and family planning services,

including training on safe hygiene practices• Health vouchers for people living with HIV and AIDS • Feeding programmes for people living with HIV and AIDS• Food rations and supplies for orphans and vulnerable children • School feeding programmes• Paid maternity leave

SoCIAl INSUrANCE

• Social health insurance with universal coverage• Exemptions to contributory health insurance for households deemed poor

and/or with children under five years of age • Insurance schemes against climate-induced shocks and natural disasters• Paid maternity leave

SoCIAl wElFArE SErvICES For MArgINAlISED groUpS oF CHIlDrEN

• Protective services for orphans and most vulnerable children • Foster care grants to support reintegration into family care of children in

institutions • Children with disabilities

SoCIAl EqUITy

• Legislation to protect the rights of orphans and vulnerable children • Legislation to protect the rights of people living with HIV and AIDS• Legislative measures to promote gender equality• Laws to protect children from trafficking, early marriage and harmful

traditional practices, and to ensure special treatment and rehabilitation services for young offenders

• Affirmative action measures such as scholarships for minority ethnic children or indigenous communities

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OVERVIEW Of POVERTY AND VULNERABILITY

Tanzania has sustained high rates of economic growth in recent years, but it has been concentrated in the extractive industries and in low employment-generating sectors (eg, finance), and thus has had limited direct impact on the majority of Tanzanians’ lives. The 2007 Household Budget Survey showed that monetary poverty incidence has declined only slightly on the mainland, from 35.7% in 2001 to 33.6% in 2007. In the same survey, the proportion of the population below the national food poverty line (the extremely poor) stood at16.5%. The Multidimensional Poverty Index, which seeks to capture the non-monetary dimensions of poverty (years of schooling, school attendance, child mortality, nutrition and six standard of living indicators),3 ranks Tanzania among the lowest in the world. Indeed, growth incidence analysis by the World Bank between 2000 and 2007 shows the poorest 10% of the population is benefiting least from growth and actually became worse off over the period. Child poverty rates are even more alarming. Using an analysis of severe deprivations of basic human needs, absolute poverty incidence among Tanzanian children is as high as 71%, and three times higher for rural children than for urban children (REPOA et al, 2009).4 This suggests an acute need for comprehensive, well-articulated and well-targeted social protection measures.5

CHILD NUTRITIONAL DEfICITS AND VULNERABILITIES

Over one-third of child deaths in Tanzania are due to undernutrition, making it the principal cause of child mortality. There have been aggregate improvements over the past two decades but progress has been mixed at best, as Table 2 highlights.

Table 2: Key nutritional indicators for children under five (%)

1996 1999 2004/05 2009/10

STUNTINg 49.7 48.3 44.4 42.5

UNDErwEIgHT 26.9 25.3 16.7 16.2

wASTINg 8.5 5.6 3.5 4.9

Source: world Health organization (2011)

Stunting has experienced a slow but steady decline, from around 50% in 1996 to 42% in 2009/10. Underweight rates have seen a more significant decline, from around 27% to 16% over the same period. However, wasting levels increased between 2004/05 and 2009/10. Moreover, there is significant variation between regions on various indicators. For example, stunting in 2010 exceeded 50% in Dodoma, Lindi, Iringa and Rukwa but was around 20% in both Dar es Salaam and Mjimi Magharibi in Zanzibar. What is very clear is that Tanzania will not meet MDG 1c (halving 1990 rates of child underweight by 2015) unless it goes beyond ‘business as usual’ (World Bank, 2010). In 2009, Tanzania was ranked tenth worst in the developing world in terms of the number of stunted children (UNICEF, 2009, 2010).6 The country’s Global Hunger Index rating is also concerning: although it has gradually improved, from a high of 27.4 in 1996 to 20.5 in 2011, Tanzania is still classified as ‘alarming’. Similarly, child mortality accounts for 32% of Tanzania’s Multidimensional Poverty Index 2011 (Oxford Poverty and Human Development Initiative (OPHI), 2011).

That said, there are some areas of encouraging progress. While rates of anaemia remain high, they fell from 72% to 59% between health surveys in 2004/05 and 2010. In particular, prevalence of moderate anaemia dropped sharply to 29% in 2010 from 43% in 2004/05.

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Tanzania also has a highly successful vitamin A supplementation programme among children aged six months to two years: coverage in 2004 was at 85% (HKI et al, 2004, quoted in UNICEF, 2010) and government service data consistently record coverage rates in excess of 95%.

UNDERLYING CAUSES Of CHILD MALNUTRITION IN TANZANIAAs our conceptual framework highlights, the underlying causes of malnutrition are complex and need to take into account a range of economic and social risks, as well as policy factors.

Unstable rural livelihoods

Tanzania is an overwhelmingly rural country in which approximately 80% of households depend on agriculture as their primary economic activity. In 2007, some 83% of individuals below the basic needs poverty line lived in rural areas, and overall this characterises 38% of the rural population on the mainland (National Bureau of Statistics (NBS), 2007). Many rural households dependent on subsistence agriculture are both cash and asset poor and thus not resilient to climatic shocks and commodity price fluctuations. These factors govern access to food and are compounded by a higher prevalence of illness resulting from limited access to safe water and adequate sanitation facilities.

Perplexingly, statistics suggest nutrition security in Tanzania is not strongly correlated with levels of food security (as measured by cereal crop production). Some parts of the country have cereal surpluses (generally in the south and west) and yet high levels of malnutrition (UNICEF, 2010). Equally, the World Bank (2011a) suggests the relationship between malnutrition and poverty status is perhaps not as strong as might be assumed, with malnutrition levels roughly equal among the bottom 60% of the population. Income elasticity is also low (in the range of 0.25–0.5): a 10% increase in incomes leads to only a 2.5–5% decline in malnutrition. On the other hand, poor food consumption is associated strongly with ownership of productive assets and vulnerability to climatic shocks (World Food Programme (WFP), 2010), and the highest stunting levels are found among the poorest quintile (United Republic of Tanzania (URT), 2010). This means both income and food security are important, but neither income growth nor increased food security alone will solve Tanzania’s malnutrition problem; as such, other drivers of malnutrition need to be considered, as we explore below.

Vulnerability to food crises

Tanzania’s poor, particularly those living in urban areas, are highly vulnerable to commodity price fluctuations. Most households spend the majority of their income on food (averaging 64%) (NBS, 2007).7 Even the very poor, who are generally more dependent on their own production, purchase close to a third of their food from the market (World Bank, 2011a). This makes cash- and asset-poor households particularly vulnerable to shocks. The rural economy has grown slowly over the past few years, given declining world market prices for certain commodities, rising fuel prices, inadequate infrastructure and poor access to markets and credit, and thus many households are unable to adjust to food price inflation. Meanwhile, increases in the prices of basic foodstuffs have been dramatic in recent years and were particularly acute between 2007 and 2009 as a result of the food and financial crises: maize flour, for example, increased 56% in rural areas and as much as 73% in Dar es Salaam (World Bank, 2011a). Increases can thus have a significant effect on Tanzania’s growing urban poor also, even though they spend a lower proportion of their income on food (NBS, 2007).

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Households that depend on subsistence agriculture run out of grain for between five and eight months after the harvest each year, and have to pick up casual work to help increase their resilience (World Bank, 2011a). When grain reserves run out, prices are typically 50% higher, which means cash-poor households often have to make trade-offs to survive, such as compromising on food intake or dietary diversity: around 44% of Tanzanians consume too few calories to sustain even light work (FAO, 2006, in UNICEF, 2010). Around 2 million Tanzanians are food insecure each year, and another 6 million tend to be at risk if harvests are inadequate, often as a result of drought (World Bank, 2011a). The insufficiently diverse diet consumed by much of the population aggravates nutritional insecurity. The predominant diet in Tanzania is cereal based with low energy and nutrient density:8 71% of all energy in Tanzania is obtained from staples (Smith et al, 2006, in UNICEF, 2010), and this represents a ‘hidden hunger’.

Healthcare utilisation

Healthcare utilisation in Tanzania is slightly higher than the regional average (World Health Organization (WHO), 2008) but remains low. Poor households are less likely to consult someone when sick, and consultation is slightly lower for women than for men, having declined from 69.7% to 68.9% between 2000/01 and 2007 on the mainland (NBS, 2007). Overall, healthcare utilisation was unchanged between 2000/01 and 2007, which suggests efforts to stimulate greater demand for services have been inadequate. The introduction of user fees has been criticised widely as a regressive measure that reduces demand, especially among poor people. Evidence suggests that user fee exemptions are partly implemented and waivers effectively non-existent (Mubyazi, 2004; UNICEF, 2010). This points to a significant equity problem.

However, the fact that utilisation did not decline over the period means that perhaps its negative impact is overstated. In fact, the use of government facilities increased from 54% in 2000/01 to 63% in 2007 (NBS, 2007), and the greatest increase was in rural areas, which suggests increasing reach among disadvantaged populations. This improvement should be viewed with caution, however, as long waiting times owing to chronic understaffing (particularly of highly skilled staff) and lack of key medicines are frequently reported, and thus the quality of services remains a serious problem (UNICEF, 2010).

Maternal health and wellbeing deficits

Women’s empowerment is correlated positively with improved child nutritional outcomes (International Food Policy Research Institute (IFPRI), 2002). However, Tanzania comes bottom of the ranking for the region on the 2011 Gender-related Inequality Index, with 0.627, followed by Kenya with 0.590 and Uganda with 0.577.9 A key factor relates to time poverty: Tanzanian women overwhelmingly bear the responsibility for caring for young children as well as being heavily occupied in domestic and agricultural tasks. This constrains their ability to ensure adequate food intake for their children and themselves (UNICEF, 2010).10

Decision-making power within the household is significantly biased away from women (URT, 2010). Only three in five women have sole or joint decision-making power about their own (and thus their children’s) healthcare, and only 39% participate in decisions on major household purchases. Rural women also tend to be more vulnerable to malnutrition, with men eating first given a belief that their labour is hardest (Holmes and Jones, 2010).

Meanwhile, children of mothers with at least some secondary education have the lowest stunting levels (22%), whereas those whose mothers have no education or only an incomplete primary education have the highest levels (40–49%) (URT, 2010). In addition, only 58.8% of mothers with no education use soap to wash their hands after using the toilet; this is as high as 84.6% for women with complete primary or higher education (WFP, 2010).

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Pregnant and lactating women are particularly at risk of malnutrition, with important implications for child survival. Low calorie intake among childbearing women leads to low birth weights and high neonatal mortality. Around 11% of women of reproductive age are thin or undernourished, with women in the lowest wealth quintile more likely to be thin. Mothers who are thin have children with the highest stunting levels (50%) (URT, 2010). Mothers’ wealth status is also positively correlated with their children’s nutrition status. Children born to mothers in the lowest wealth quintile are twice as likely (22%) to be underweight as children born to mothers in the highest wealth quintile (9%). Meanwhile, pregnant women are more likely to be anaemic (53%) than women who are breastfeeding and women who are neither pregnant nor breastfeeding (39%). In total, 40% of women aged 15–49 are anaemic, with 1% severely anaemic. However, anaemia declined 17% between 2004/05 and 2010.

Another significant determinant of children’s nutritional status relates to feeding practices. Only 50% of infants under six months are exclusively breastfed (an improvement from 41% in 2004/05), and this is especially the case among mothers with lower education levels (URT, 2010). Only 21% of children aged 6–23 months have a minimum acceptable diet containing breast milk or milk products, adequate meal frequency and sufficient dietary diversity. Less than half of non-breastfed children aged 6–23 months (41%) are given milk or milk products, 32% are given food from at least four food groups and 11% are fed four or more times a day. As such, only 6% of non-breastfeeding children are fed in accordance with all three infant and young child feeding practices. The likelihood increases slightly with an increase in the mother’s education and wealth quintile (URT, 2010).

Poor water, sanitation and hygiene

Access to safe water, sanitation and good hygiene practices is another key driver of nutritional outcomes. The majority (54.5%) of the Tanzanian population have access to an improved water source (URT, 2010), which suggests the country may be on course to meet its MDG target of 64% by 2015. Improvements are said to be attributable to effective government reforms in its water supply and sanitation institutions (USAID, 2007). Nevertheless, access to piped water sources on the mainland appeared to decline between 2000/01 and 2007 (NBS, 2007),11 and in 2010 it was estimated that only 39% of the population and 28% of the rural population were able to collect water from a protected source and return home within 30 minutes (URT, 2010). Water collection takes more than an hour in one-quarter of rural households, which is a significant time burden, particularly for women, who are usually charged with water provision (URT, 2010). Furthermore, only 13.3% of the population use improved toilet facilities not shared with other households, with as little as 9% in rural areas (URT, 2010).

Sanitation and hygiene have been accorded low priority by the government (UNICEF, 2010). A Sanitation and Hygiene Policy was developed only in 2010, and sanitation investment is less than 0.1% of gross domestic product (GDP). Inadequate attention has resulted in significant economic losses: poor sanitation is estimated to cost Tanzania US$206 million each year in terms of healthcare costs, productivity losses, premature death and lost time related to open defecation (WSP, 2012). This situation is reinforced by inadequate hygiene practices that put children at risk: nine out of ten children and caregivers do not wash their hands with soap after using the latrine or cleaning a baby or before preparing and eating food (UNICEF, 2010),12 and in 2010 a quarter of children’s stools were not contained, which shows no meaningful improvement on the previous survey in 2004/05 (URT, 2010).

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HIV and AIDS impacts on child nutrition

An estimated 5.7% of adults aged 15–49 in Tanzania are infected with HIV (TACAIDS, 2009, in UNICEF, 2010). Increased vulnerability to infections as a result of HIV and AIDS can lead to a loss of vital nutrients and then to malnutrition. Equally, malnutrition leads to immune impairment, which speeds up the progression of HIV to AIDS (Ministry of Health and Social Welfare and Tanzania Food and Nutrition Centre, 2009). Urassa et al (2001), cited in Gillespie and Kadiyala (2005), found that the mortality rate among children under two years of age born to HIV-positive mothers was 2.5 times higher than that among children of HIV-negative mothers. Adult mortality as a result of HIV also affects children’s nutritional status: children whose parents have died are more likely to be stunted.13

The HIV and AIDS pandemic has also contributed to a growth in the number of orphans in Tanzania, estimated at 2.4 million, many of whom are especially vulnerable to nutritional insecurity.14 In 2010, the projected number of most vulnerable children was around 1 million (World Bank, 2011a). According to a review of most vulnerable children in 2004, caregivers and community leaders mentioned food as the second-greatest problem faced, after education; children themselves often mentioned their need for food before education (URT, 2008).

Policy factors

Nutrition is sometimes referred to as the ‘forgotten MDG’, and this is certainly true in Tanzania (UNICEF, 2010; World Bank, 2012). Since the World Bank’s 2008 assessment that there have been few effective interventions and donor support has been ‘uncoordinated, limited, haphazard, and mostly unproductive’ (World Bank, 2008), there have been strong calls for better coordination through the Development Partners’ Group for Nutrition, the National Multisectoral Technical Working Group for Nutrition and the High Level National Nutrition Steering Committee. Malnutrition in Tanzania incurs significant economic costs. Each year iron, vitamin A and folic acid deficiencies cost Tanzania over $518 million (around 2.65% of GDP) and anaemia is associated with a 2.5% drop in adult wages (Vester et al, 2010, in World Bank, 2011a). Improved nutrition could raise long-term productivity (by 5–17%) and lifetime earnings (by an estimated 12%) (World Bank, 2009, in World Bank, 2011a).

Limited policy attention to nutrition strategies and programming has been compounded by low investment and coverage and poor articulation with social protection mechanisms. Recognising the importance of these challenges over the past half decade, the government has recently designed a series of policies and frameworks to impel change, including the National Social Protection Framework (NSPF) 2008, the National Costed Plan of Action for Most Vulnerable Children 2007–10 and the National Nutrition Strategy (NNS) and implementation plan 2011–16. These advances have been complemented by the establishment of a multi-sector High-level Steering Committee on Nutrition.15

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SOCIAL PROTECTION INfRASTRUCTURE

Traditional coping mechanisms

Traditional coping mechanisms and informal safety nets in Tanzania, which include support from churches and mosques, are quite limited (World Bank, 2011a). In economic terms, remittances are the main source of informal transfers, but these payments are often erratic (eg, seasonal, temporary employment), and also are often directed towards non-poor households and not very significant in the incomes of the poor. Remittances represent around 13.9% of the incomes of the non-poor, 11.0% for the poor and 12.8% for the ultra-poor (World Bank, 2011a).

Recent research on coping strategies (Kessy, 2010; WFP, 2010) shows households adjust primarily by reducing their food intake, either cutting down the number of meals or substituting lower-valued foods, and dropping items like meat and milk from their diets. Moreover, poor people take longer to recover from the economic losses they incur.

Informal safety nets have their limits, especially when there are large shocks such as droughts, floods or food price increases, as these tend to affect all members of the community at the same time. This is when formal safety net mechanisms are vital.

formal social protection

Until recently, social protection programmes in Tanzania were viewed largely as residual or peripheral to pro-poor economic development (World Bank, 2008). However, in 2008, the government took a more proactive stance on the issue and, with the support of development partners, drafted the NSPF. This framework, which has not yet been approved, has been designed to support and advance the aspirations of the country’s Vision 2025 and the goals of the National Strategy for Growth and Reduction of Poverty (MKUKUTA I and II). The consultation process underpinning the development of the NSPF identified the following groups as those requiring support: street children; widows; people living with HIV and AIDS; young people whose mental health is affected by drug use; orphans; girl mothers; people living with disabilities; and elders above 60 years, including retired employees (Ministry of Finance and Economic Affairs Poverty Eradication and Empowerment Division, 2008: 3). The main goal proposed is to ensure greater coordination and collaboration among different social protection actors and programmes (as shown in Table 3), as the consultation process revealed limited coverage of existing interventions owing to resource constraints, poor coordination and weak institutional and governance capacity. The NSPF also aims to tackle data limitations and targeting errors, especially those relating to gender inequities and low levels of community participation.

In practice, current spending on all transfer programmes is roughly US$175 million per annum. This represents about 2.5% of public expenditure, or 0.3% of GDP (World Bank, 2011a). This is low in comparison with other countries in the region (2.8% for sub-Saharan Africa) and far below the world average of 5.7% (ACPF, 2011). This suggests Tanzania should be able to afford to spend more than it currently does. As with other countries (eg, Kenya), donors finance a substantial proportion (about 75%) of transfer expenditures. Many of Tanzania’s current programmes (the Tanzania Social Action Fund (TASAF), the Most Vulnerable Children (MVC) Programme and those of the WFP) are under revision and being scaled up.

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Table 3: Current social protection programmes

TypE oF INSTrUMENT

ExAMplES DETAIlS

SoCIAl ASSISTANCE To poor CHIlDrEN AND HoUSEHolDS

TASAF II

Type of assistance: Public works programme; grants to vulnerable groups; pilot conditional cash transferTarget population: Poor and vulnerable householdsAgencies involved: World BankAim: To empower communities to access opportunities so they can request, implement and monitor subprojects that contribute to improved livelihoods linked to MDG indicators targets in MKUKUTA Beneficiaries: 395,061 (World Bank, 2011b)

MVC Programme

Type of assistance: School assistance: school uniforms and/or scholastic supplies, Community Health Fund (CHF) cards (which provide a family with health coverage for a year and cost about Tsh 10,000 ($6.70)), mattresses, housing and/or bedding, food rations and supplementary feedingTarget population: MVCs in 85 districts; soon to be expanded to the whole countryAgencies involved: USAID/PEPFAR, Global Fund, Department of Social Welfare, PACT and Family Health International and local NGOsAim: To provide support to Tanzania’s MVCsBeneficiaries: 586,000 – the largest transfer programme aimed at poor people (World Bank, 2011a)

Food for Education

Type of assistance: School feeding programme (two cooked meals per day)Target population: Population of the 16 most drought-prone and food-insecure districts (Arusha, Dodoma, Manyara, Shinyanga and Singidaregions)Agencies involved: WFP Aim: To boost attendance and improve students’ concentration levelsBeneficiaries: 540,000 primary schoolchildren in 1,167 schools (UN, 2010; WFP, 2012)

National Food Reserve Agency (NFRA)

Type of assistance: Food subsidy/distributionTarget population: 72 food-insecure districtsAgencies involved: Government of TanzaniaAim: To reduce food insecurity and malnutrition Beneficiaries: 1.2 million (annually) (World Bank, 2011a)

Food for Asset Creation

Type of assistance: Food provision for public works Target population: Population of the 16 most drought-prone and food-insecure districtsAgencies involved: WFP (covers 84% of the costs)Aim: To encourage low-income, food-insecure households to participate in activities that contribute to their long-term food security. Employed a disaster risk reduction lens from 2011 onwards to strengthen community resilienceBeneficiaries: 110,000 in 2010 (WFP 2010, 2012; World Bank 2011)*

National Agricultural Input Voucher Scheme (NAIVS)

Type of assistance: Vouchers for seed (maize and rice) and fertiliserTarget population: Smallholding farmers (less than 1 hectare) in 72 food-insecure districts, but also reaches a significant number of non-poor farmersAgencies involved: Government of Tanzania and World Bank Aim: To provide input subsidies to poor farmers to increase productivityBeneficiaries: 1.5 million at the cost of about US$69 million annually – the largest single transfer programme in the country (World Bank, 2011a)

* Based on the rural daily labour wage rate and average market prices, the daily ration for activities is equivalent to approximately 90% of household expenditure on food (UN, 2010).

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SoCIAl INSUrANCE To proTECT CHIlDrEN AND THEIr FAMIlIES

National Health Insurance Fund

Type of assistance: Contributory insuranceTarget population: Predominantly public sector employeesAgencies involved: Government of TanzaniaAim: To provide insurance for access to medical benefits Beneficiaries: 2 million, with very limited coverage of the poor (World Bank, 2011a)

National Social Security Fund

Type of assistance: Pension schemeTarget population: Predominantly formal sector workers, but has been extended to the informal sectorAgencies involved: Government of TanzaniaAim: To provide pension insuranceBeneficiaries: About 6% of the population. This is the largest pension scheme in the country** (ILO, 2008; World Bank, 2011a)

Community Health Fund (CHF)

Type of assistance: Community funding as an alternative for the fee-for-service scheme. Each CHF card is worth around Tsh 10,000, which provides a family with free access to all health services in the district for a yearTarget population: Wider population not covered by health insurance (particularly poor people)Agencies involved: Ministry of Health and Social Welfare and district governmentsAim: To ensure health coverage for the poor with matching grants through the government’s Health Basket Fund Beneficiaries: 500,000 (ILO, 2008; World Bank, 2011a)

User fee exemptions and fee waivers

Type of assistance: Exemption from healthcare fees Target population: Vulnerable groups (pregnant mothers and children under the age of five years, citizens aged 60 years and above)Agencies involved: Ministry of Health and Social WelfareAim: To allow these groups to get free-of-charge medical services on essential reproductive and child health-related problemsBeneficiaries: Numbers are unclear ; evidence suggests exemptions are partly implemented and waivers effectively non-existent (Mubyazi, 2004; UNICEF, 2010)

SoCIAl wElFArE SErvICES For MArgINAlISED groUpS oF CHIlDrEN

Maternal and Child Health and Nutrition Programme

Type of assistance: Monthly take-home ration and behaviour change communication, demonstration feeding and training mothers in caring and feeding practices Target population: Pregnant and nursing women and moderately malnourished children aged 6–24 monthsAgencies involved: WFPAim: To improve the nutritional status of vulnerable women and children and address high stunting rates; designed to support the NNS 2009-–15Beneficiaries: 72,000 moderately malnourished children and 40,000 pregnant and lactating women (UN, 2010; WFP, 2006)

SoCIAl EqUITy MEASUrES To proTECT CHIlDrEN AND THEIr FAMIlIES

The Children’s Act (2009 and 2011)

The Children’s Act contains provisions relating to custody, guardianship, access and maintenance, foster care and adoption, children and health services and children in residential establishments. It also establishes clear procedures and outlines the roles and responsibilities of national institutions and professionals in providing child protection services and responding to cases of children in need of care and protection.

National strategy for Gender Development (2008)

In 2008, based on the government’s Gender Development Policy (2000) designed to mainstream gender in all policies, the Ministry of Community Development, Gender and Children provides guidance on interventions and suggests coordination mechanisms that will facilitate the participation of the various actors. It highlights a number of policy concerns including decision making and power, ownership of resources and food security and nutrition.

Women’s Development Fund (1993)

This was established in 1993 to facilitate access to commercial loans and to encourage women to participate in the economic sector.

CoMplEMENTAry polICIES rElATED To CHIlD NUTrITIoN

National Nutrition Strategy 2 011-–16

In September 2011, the NNS was launched as a cabinet paper, based on the National Food and Nutrition Policy of 1992 and the Food Security Policy of 2004. It focuses primarily on the prevention of malnutrition among under-fives, women of reproductive age and vulnerable groups.

** There are also other public sector pension schemes: (i) the Parastatal Pension Fund for parastatal and private enterprises, with coverage of 65,000; (ii) the Public Service Pension Fund for central government employees with coverage of 200,000; (iii) the Local Authorities Pension Fund for local government employees, with coverage of around 45,000; (iv) the Government Employees Provident Fund for non-pensionable civil servants with coverage of around 22,000; and (v) the Public Service Retirement Benefit Scheme for politicians, subject to the Political Service Retirement Benefits Act 1999. In 2008, it was estimated that social security coverage was less than 1% of the entire population, and about 6.5% of the formal working population (ILO, 2008).

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IMPACT Of SOCIAL PROTECTION ON CHILD NUTRITION

Evidence on the impact of safety net programmes in Tanzania is extremely limited, and there have been very few rigorous and independent evaluations of their impact. The information available suggests existing programmes have made only a limited contribution to children’s wellbeing and the impact on child malnutrition has been slight.

Tanzania Social Action fund (TASAf)

The overall coverage of TASAF is low: in March 2011, the World Bank estimated that 395,061 beneficiaries had received support in the second phase (World Bank, 2011b). The largest component, the Public Works Programme (PWP), covers around 25,000 people per year16 (less than three-tenths of 1% of the poor) and payments are a one-off of Tsh 90,600 (around US$74) each year (representing about 10% of the annual poverty line income for a family of six) (World Bank, 2011a). Meanwhile, the average payment per household for the Community-based Conditional Cash Transfer is around Tsh 15,000 (around US$9.50) per household every two months, with coverage as of 30 June 2011 at 11,792 (World Bank, 2011a). One study in 2010 found that about 90% of PWP beneficiaries were using their income from the programme subprojects to purchase food (Achrid (T) Ltd, 2010, in World Bank, 2011a). However, with current inflation rates close to 20%, much of the value of this transfer has eroded, with no increase in the size of the transfer – in part to dissuade the non-poor from enrolling in the programme. By way of comparison, in Kenya average transfers range between US$15 and $26 per month (Republic of Kenya, 2012), roughly equal to the food poverty line, and indeed the transfer amount increased to account for food price inflation.

The Most Vulnerable Groups (MVG) component contributes a more substantial amount, but coverage is also low. The size of the transfer for the MVG component is around US$1,000 per beneficiary (based on an average group of ten), yet it reaches only around 18,000 people per year.17 And indeed, expanding coverage at such a level would be prohibitively expensive. The World Bank (2011a) highlights anecdotal reports that suggest some households are saving out of this transfer to accumulate assets that may generate an income. Rapid qualitative surveys indicate improvements in the quality of life as beneficiary households report increases in the number of meals they now take, in the numbers and sizes of household enterprises and in production. Indeed, the Community-based Conditional Cash Transfer includes taking children aged 0–5 years to health facilities as a primary condition, which should have positive effects on child survival and nutrition. However, more in-depth and child-sensitive evaluations are urgently needed to demonstrate this (TASAF, 2010; 2011; World Bank, 2011a; 2011b).18

Most Vulnerable Children (MVC) Programme

The MVC Programme covers only a fraction of most vulnerable children and delivers ad hoc and very modest amounts of assistance.19 Its impact relative to the scale of the problem is therefore limited. Most children and caregivers think the MVC Programme is important but the support provided is unpredictable, inadequate and inconsistent (Mhamba et al, 2007, in Mamandi et al, 2009). An evaluation of the programme (Linebom et al, 2007), cited in World Bank, 2011) prior to scaling-up noted that benefits are sporadic and the cost of items being provided is extremely high, resulting in very inefficient use of tight resources. Costs remain high, around US$80 per beneficiary (or 75% of the poverty line income), of which only a small proportion represents the value of actual transfers to most vulnerable children. Moreover, the package of benefits does not usually include food20 – the largest share of identified needs of orphans and other most vulnerable children (World Bank, 2011a). It has been characterised as a ‘donor issue’ and thus relatively remote from public engagement (Mamdani et al, 2009) and includes no household-strengthening component that could

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empower caregivers. However, evaluations show that community-based targeting through village committees has been effective at reaching the most vulnerable (Mamdani et al, 2009; World Bank, 2011a). This will be a key challenge when the programme is expanded nationally.

food for Education

Studies show that Food for Education has had some positive impacts on learning and attendance. Unit costs are around US$31 per student per year, and the food transferred represents about half of the daily nutritional requirements of the child. This transfer represents a significant share of household income for the poorest. The programme is not targeted within schools; there are no data on beneficiaries, but inclusion errors are suspected to be large. Data from 2010 suggest that the benefits are concentrated in the second-lowest wealth quintile rather than among the poorest, which in terms of equity is clearly problematic (World Bank, 2011a).

food for Asset Creation

Food for Asset Creation employed around 54,500 people in 2010. At such a scale it has therefore had only limited impact as a poverty-reducing measure and, although it may be significant in the areas directly affected, data show that no more than 1% of rural households report receiving benefits from food for work in any district (World Bank, 2011a).

National food Reserve Agency (NfRA)

There are no data on actual beneficiaries of the NFRA, and survey evidence suggests large inclusion errors. Anecdotal reports suggest that, while the poor and vulnerable tend to be targeted, there is a tendency for village committees to spread food more widely in order to maintain social cohesion, resulting in smaller benefits and greater coverage. Survey data also show that rural households receiving food distribution benefits are spread fairly evenly over wealth quintiles (World Bank, 2011a).21

GAPS AND CHALLENGES

Despite greater attempts at policy level to impel a social protection agenda nationally, little concrete progress has been made. The NSPF has not yet been approved, and as a result there remains significant disarticulation between programmes within the country. Many programmes remain dependent on donor interests, funding and capacities. With the launch of the third phase of TASAF, expanded coverage of the MVC Programme and continued commitment from the WFP, determination clearly exists, but, without strong leadership from the government and agreement of the role social protection should play in meeting national development challenges, social protection will continue to play a peripheral role. The lack of impact evaluations and documentation (eg, monitoring and evaluation reporting) means there are significant gaps in learning from past experience within and between programmes. Filling this gap will be vital to ensuring future initiatives are proposed based on evidence, and this evidence will be key to advocacy with government ministries to increase funding for social protection.

The evidence presented in this paper suggests that the groups most vulnerable to malnutrition (infants, young children, pregnant women and lactating mothers) have not been covered sufficiently or targeted adequately in current social protection programmes. This is reflected in a lack of clear maternal and child nutrition indicators in the monitoring and evaluation systems of the majority of programmes.

The policy framework for nutrition, with the adoption of NNS 2011–16 and the creation of the High-level Steering Committee on Nutrition, reflects a more positive picture. There have

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been significant efforts to document the nutrition situation of children and there appears to be a high level of consensus in the nutrition community. However, the role of social protection is not clearly defined in the NNS, and this would appear to be a missed opportunity.

POLICY RECOMMENDATIONS

In sum, child malnutrition represents a pressing development challenge in Tanzania, but existing evidence suggests social protection programming to date is far from fulfilling its potential to bring about genuine transformation in children’s lives. In particular, there needs to be a much stronger focus on the important lifecycle juncture from conception through the first 1,000 days if synergies between social protection and nutrition policy and programming are to be maximised. This approach could also be seen as an important opportunity to encourage more comprehensive and integrated social protection programming. Such an approach would require more a change of lens, putting caregivers and infants at the centre of future initiatives, rather than significant additional budget outlays. In order to tackle these problems our analysis suggests the following key areas need to be prioritised (see also Figure 2).

1. Expand and hone social protection coverage

Government investment in social protection accounts for less than half of all social protection spending in the country (see Table C in appendix) and overall investment as a proportion of GDP is significantly below the regional average. As the World Bank (2011a) suggests, it is therefore reasonable to argue that the government is capable of investing more and more effectively in social protection. A large proportion of existing coverage is through regressive (contributory) schemes, while various non-contributory schemes are not adequately targeted at the poorest or most vulnerable (eg, the NFRA). The largest programmes still have very limited coverage relative to need (given levels of poverty and malnutrition). Indeed, coverage in various programmes (eg, the MVC Programme) should be expanded to infants and mothers (see Recommendation 5). At the same time, a stronger case needs to be made for investing in both social protection and nutrition (as part of an integrated whole). Advocacy actions to increase spending should be evidence based (see Recommendation 4) to ensure government ministries appreciate the high returns possible from investing in child survival and human capital more generally.

2. Strengthen programme targeting

Given the significant fiscal constraints and considerable inclusion errors, promoting carefully targeted programmes towards most vulnerable children in the short to medium term seems to be the most politically and financially feasible approach. Community-based targeting is the most common method employed and has served to generate community support for various social protection initiatives. It is also worth evaluating the effectiveness of community-based targeting in different programmes (eg, MVC, Food for Asset Creation, TASAF, National Agricultural Input Voucher Scheme) to share lessons of best practice. There are, however, considerable problems of duplication, inclusion and exclusion errors. Greater efforts and strengthening of local administrative capacities will therefore be required to ensure transparent targeting. This is particularly critical now, as a number of programmes are currently being scaled up.22 The MVC Programme appears to be relatively successful in this regard, but the high costs of its targeting remain a concern. It is important to bear in mind that targeting is costly both financially and in terms of human resources,23 but if done well can bear dividends across a range of social policy interventions in the medium term and beyond. Targeting could also be improved by strengthening government agency oversight of social protection programmes, twinned with investing in the capacities of safety net programme implementers at all levels.

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3. Improve inter-sector coordination and policy coherence

Both nutrition and social protection are crosscutting issues, making efforts to strengthen inter-sector coordination and policy coherence particularly important. First, nutrition is often seen as ‘everybody’s business but nobody’s responsibility’. The Tanzania Food and Nutrition Centre (TFNC), acting on behalf of the Ministry of Health and Social Welfare, is charged with overall responsibility for oversight of nutrition programmes in terms of policy formulation, advocacy, coordination, monitoring and evaluation, and research. However, the semi-autonomous status of the centre and its limited financial resources means it has focused heavily on research and fieldwork rather than ensuring optimal coordination of programmes and acting as an advocate for change (UNICEF, 2010). This reflects the low policy profile that has historically been accorded to nutrition. The NNS of September 2011 did, however, provide some room for optimism in highlighting the government’s commitment to scaling up nutritional programming, including the establishment of the High-level Steering Committee on Nutrition, comprising senior representatives from the government, development partners, private sector and civil society to promote comprehensive and coordinated understanding and action in responding to nutrition challenges. As such, this is clearly a body to monitor closely as the strategy unfolds, including whether it provides opportunities for cross-agency coordination and synergistic programming opportunities for mainstreaming nutrition in both health and social protection interventions.

Second, coordination of social protection policy and programming is also complex and in need of streamlining. National oversight for social protection initiatives lies with the Poverty Eradication and Economic Empowerment Department in the Ministry of Finance and Economic Affairs, while the Social Protection Thematic Working Group serves as a focal point for broad discussion. The adoption and endorsement of the NSPF by key stakeholders is crucial if there is to be meaningful coordination between programmes. Furthermore, there is significant overlap between programmes and limited efforts to ensure coordination. Programmatic responsibility for social protection is spread among the Ministry of Agriculture and Food Security, the Prime Minister’s Office, the Ministry of Health and Social Welfare, the Ministry of Labour and TASAF, with substantial influence from individual donors in the design and operation of particular programmes (World Bank, 2011a).24

In order to address these coordination challenges, the MKUKUTA Technical Committee (and in relation to Zanzibar, MKUZA) would appear to be an appropriate forum in which the relevant stakeholders (principally the Ministry of Community Development, Gender and Children, the Ministry of Finance and Economic Affairs, the Ministry of Health and Social Welfare, the MVC Programme and TASAF) can debate ways in which nutrition can be mainstreamed more explicitly into social protection programmes and related sectoral policy frameworks, especially given that both the NNS and the NSPF highlight their contribution to MKUKUTA.25 Such an approach would avoid creating new structures and further complexity, and also provide an opportunity to develop specific nutritional indicators and monitoring systems.

Equally, at local level, there is a need for greater coherence and coordination between programmes. Reports suggest TASAF beneficiaries are using cash to pay for health insurance even though they should be entitled to free healthcare according to the government’s waiver and exemption policy. Also, most vulnerable children have been reported to be paying school fees even though they should be entitled to free schooling. This suggests beneficiaries of one social protection programme need to be made aware of wider entitlements so that individual programmes will have the maximum impact. In this regard, in the medium to long term, the government could consider the development of a single registry system along the lines of those developed in Brazil and Chile in order to achieve a unified database of social protection beneficiaries and of their entitlements and impact.26

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4. Integrate nutrition monitoring into social protection monitoring and evaluation systems

The lack of data on both government- and donor-led programmes is a serious concern, as recently highlighted by the World Bank. First, nutrition indicators should be better integrated into existing national surveys and management information systems, and particularly nutrition indicators into social protection programming. Second, there would appear to be significant overlap in coverage between programmes (eg, Public Works Programme, Food for Asset Creation, school feeding, the MVC Programme, cash transfers, MVG and NFRA), but there has been no review of the sector. This is necessary to rationalise potential duplication of programmes and reduce gaps, as well as to review transfer amounts in relation to food price inflation. The World Bank (2011a) points out that the Nutrition Surveillance System is not fully functional and may need to be revitalised in order to provide timely and accurate data to be used to monitor nutrition and guide decisions. As local government authorities are responsible for the implementation of nutrition services, there need to be greater efforts and resources directed towards capacity building, not only in terms of data collection but also with regard to data analysis and use, to strengthen programme reform processes. It is also vital that agencies take advantage of inter-institutional spaces to share learning, such as in the newly established Community of Practice for cash transfers. 27

5. Invest in maternal and infant wellbeing and complementary actions

There is a strong evidence base on the positive links between maternal wellbeing and empowerment and children’s nutritional status. This is arguably particularly important in Tanzania, as the main drivers of child malnutrition are not solely income and food availability. Rather, the evidence points to the critical role of improved caring and feeding practices, which requires greater attention to women’s own education and nutritional wellbeing. Investment levels in maternal health are low and there would appear to be little coordination between this sector and social protection. Women’s access to healthcare services is low, and thus efforts could take advantage of antenatal care visits to provide information and skills on infant nutrition and feeding, as there is a very strong correlation between improved women’s education and nutrition outcomes. It is equally worth considering broader actions related to women’s empowerment such as on the gendered division of labour in the rural economy, which has an impact on women’s time poverty, and also helping to increase women’s decision-making power within the household, including over domestic budgets vital for increasing and diversifying food intake.

Equally, greater attention in social protection programming needs to be accorded to the health and wellbeing of infants, who are the most vulnerable to malnutrition. Despite highlighting nutrition in the National Costed Plan of Action for Most Vulnerable Children, the definition of ‘most vulnerable child’28 does not specifically include malnourished children. Modifying this definition may help to shift the current bias away from school-aged children (and the purchase of school inputs). Other key complementary actions that cannot be overlooked include nutrition education for mothers and fathers (such as that in the WFP’s Maternal and Child Health and Nutrition Programme) and behavioural change initiatives for safe hygiene practices through sensitisation and training activities.

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Integrate nutrition monitoring into social protection

M&E systems

Improve programme targeting so as to reach MVC more effectively

Promoting child-sensitive social protection to enhance

child survival

Focus on women’s wellbeing and strengthening links to

complementary interventions

Expand and hone social protection programme

coverage

Improve inter-sector and inter-agency coordination so that nutrition can be mainstreamed into

social protection programming

Figure 2: Key policy recommendations to strengthen social protection as a tool to reduce children’s nutritional deficits and vulnerabilities

APPENDIX

Table A: Distribution of malnutrition by zone

ToTA

l

wES

TEr

N

No

rTH

ErN

CEN

Tr

Al

SoU

TH

ErN

HIg

HlA

ND

S

lAK

E

EAST

ErN

SoU

TH

ErN

ZA

NZ

IBA

r

Children <5 years who are stunted (moderate or severe) (%)

42 42 43 50 51 38 31 47 30

Children <5 years who are wasted (moderate or severe) (%)

5 3 7 7 3 5 6 4 12

Children <5 years who are underweight (moderate or severe) (%)

16 12 22 24 13 13 13 19 20

Median duration of exclusive breastfeeding (months)

2.4 2.6 2.4 3.4 1.9 3.3 1 2.3 0.5

Prevalence of anaemia in children 6–59 months (%) 59 70 53 46 49 55 66 66 69

Prevalence of anaemia in women age 15–49 (%) 40 49 29 29 29 41 52 40 59

Source: UrT (2010)

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Table B: Estimated numbers of most vulnerable children, 2010

rUrAl UrBAN ToTAl

No. of children in child-headed households 140,656 59,527 200,091

No. of children in elderly-headed households 294,106 33,408 327,514

No. of double-orphaned children 162,213 68,043 230,256

No. of disabled children 185,177 33,237 218,413

Total no. of most vulnerable children 825,454 218,643 1,044,096

Source: NCpA (projected numbers) (2010), in world Bank (2011a)

Table C: Approximate current annual financing of transfer programmes

FINANCIEr/DoNor ApproxIMATE 2009/10 FINANCINg (ExClUDINg NAIvS)

World Bank $57 million $9 million

WFP $9 million $9 million

USAID/PEPFAR $24 million $24 million

Global Fund $20 million $20 million

Government of Tanzania $59 million $21 million

Total $169 million $83 million

Source: world Bank (2011a)

Details of nutrition indicators

Median of the NCHS/CDC/wHo Child growth Standards

Table D: Major nutrition indicators (%)

2010

STUNTINg 35.4

UNDErwEIgHT 20.6

wASTINg 4.0

Source: TDHS (2010)

WHO growth standards 2006

Table E: Key indicators for children under five (%)

1999 2004/05 2009/10

STUNTINg 48.3 44.4 42.5

UNDErwEIgHT 25.3 16.7 16.2

wASTINg 5.6 3.5 4.9

Source: wHo (2011a). Data available at: http://www.who.int/nutgrowthdb/database/countries/who_standards/tza.pdf

Stunting has experienced a slow but steady decline from around 50% per cent in 1999 to 42% for 2009/10. Stunting has had a more significant decline from around 27% to 16% over the same period. However, wasting levels between the 2004/05 and 2009/10 surveys, based on WHO Child Growth Standards, show that the figure has in fact increased (see Table E). Tanzania will not meet MDG 1c (halving 1990 rates of child underweight by 2015) unless it goes beyond ‘business as usual’ (World Bank, 2012).

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NOTES1 See Barrientos and Scott (2008); Fiszbein et al (2011); Sampson (2009)

2 See Articles 26 and 27 of the UN Convention on the rights of the Child and in the Universal Declaration of Human rights, and Article 9 of the International Covenant on Economic, Social and Cultural rights.

3 Cooking fuel, water, sanitation, electricity, floor and asset ownership.

4 Children up to 14 years of age represent 18.4% of the population below the poverty line and 36.3% of those below the basic needs poverty line (world Bank, 2011a).

5 The country’s Gini Coefficient is at 37.6 (2007). Gender inequality has improved over the past decade and a half, from 0.648 in 1995, but remained high at 0.590 in 2011 (UNDp, 2012).

6 In total, 34% of the population suffers from malnutrition (FAO, 2010).

7 This includes the value of home-produced food. The share has declined slightly from 66% in 2000/01 (NBS, 2007).

8 Cereals are rich in energy (calories). They also supply some appreciable amounts of protein, vitamins and minerals. The problem is over refining during processing, leaving the final product as predominantly starch, and deprived of the other essential nutrients (proteins, minerals, vitamins and particularly fibres) that get lost during processing. When it comes to energy and other nutrients, the low-density phenomenon is more pronounced in young children below the age of two years, mainly because of their limited feeding capacities (handling solid food and gastric carrying capacities per feeding) in relation to their nutrient requirements per body weight. For adults, the problem is not so much the energy density of meals eaten, rather fewer meals – (normally) one (small) meal per day and sometimes none. For women of child-bearing age, this pattern can be a problem.

9 Tanzania’s gender-related Development Index was 0.527 in 2007 and the country ranked 53rd out of 102 countries on the organisation for Economic Co-operation and Development (oECD) Social Institutions and gender Index.

10 For instance, if a couple separates, it is customary for the children to remain with the mother until the age of seven (oECD, 2012).

11 The decline was said to be from 39.3% in 2000/01 to 33.9% in 2007, but the 2007 Household Budget Survey suggests this decline is likely overstated because of comparability of data issues (NBS, 2007).

12 No significant correlations can be found in the Tanzanian Demographic and Health Survey data between diarrhoea and source of drinking water, mother’s education or sex of child (UNICEF, 2010).

13 Ainsworth and Semali (2000), cited in gillespie and Kadiyala (2005), show that in Tanzania the death of a mother was associated with an average decline of one standard deviation in child height-for-age between 1991 and 1994, and a paternal death was associated with a decline of one-third of a standard deviation (lundberg and over, 2000, in gillespie and Kadiyala, 2005).

14 Not all orphans are poor, however, as traditional community-based safety nets have absorbed large numbers into non-poor households, and so Tanzania employs the term ‘most vulnerable children.’ See endnote 28 for definition.

15 It is also worth noting that, in the related field of child health, Tanzania’s progress has been quite impressive in a number of areas, suggesting that, with adequate attention and resources, significant advances are possible. Tanzania’s 2010 Demographic and Health Survey estimated that infant mortality had fallen from 71 deaths per 1,000 live births for the five- to nine-year period before the survey to 51 for the five-year period before the survey. Under-five mortality levels had decreased from 106 deaths per 1,000 live births to 81. gains in child survival have been said to be attributable to investment in effective, mostly low-cost interventions, in particular increased use of insecticide-treated mosquito nets, improved treatment of malaria, immunisation and expanded coverage of vitamin A supplementation (UNICEF, 2010).

16 The cumulative number of beneficiaries was 260,268 by 30 June 2011 (TASAF, 2011).

17 This was 395,061 cumulatively by the 30 June 2011 (TASAF, 2011).

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18 The most recent data from the world Bank (31 March 2011) suggest the programme has allowed 10,727,062 people better access to health facilities, 1,510,500 to safe drinking water and 879,583 to sanitation (TASAF, 2010). The TASAF II Impact Evaluation should have been available in December 2011 but has not yet been released.

19 For example, Community Health Fund cards are worth only around US$9 over the course of a year.

20 This is in around only 6% of cases. The figures are based on a sample of Global Fund beneficiaries, and the World Bank suggests there are no good data on benefits of the programme as a whole (World Bank, 2011a).

21 Save the Children piloted an unconditional cash transfer scheme for the extreme poor in linde district from 2007 to 2009. This provided assistance to 60 households, most of which were headed by a single mother or grandmother supporting vulnerable children. Each family received Tsh 6,000 (US$5) per month, plus 3,000 (US$2.50) for each vulnerable child. A qualitative evaluation found the funds were used primarily to purchase food and school materials, and concluded that the programme reached genuinely vulnerable households and materially improved their consumption during the pilot period – increasing from one to two meals a day to two to three. Several recipients reported longer-term gains (purchase of assets, income-generating activities), although more reported that their situation reverted to extreme poverty after the programme ended (watson and gibson, 2009; world Bank, 2011a). In 2003, HelpAge International piloted a pension in Kagera region of north-western Tanzania, which is severely affected by HIv and AIDS. Its aim was to provide poor and vulnerable people over the age of 60, including those caring for children without parents, with a regular cash income in the form of pensions and child benefits. By the end of 2007, nearly 600 older people were receiving a regular monthly pension of Tsh 6,000 (US$5). Additionally, main carers received child benefits of Tsh 3,000 (US$2.50) for each grandchild. Albeit a programme of limited scale, this had a meaningful impact. pensioners had to beg less and did not have to strip their assets; their health improved and children ate better, had better hygiene (owing to the purchase of soap) and were absent from school less often (HelpAge International, 2009).

22 TASAF Executive Director ladislaus Mwamanga declared that TASAF would introduce its Community-based Conditional Cash Transfer programme in all districts under TASAF phase III in July of this year under the name of productive Social Safety Net and that already US$220 million had been received for the phase (Tanzania Daily News, 2012). The programme includes cash transfers (a basic, unconditional component, plus a variable, conditional one), cash for seasonal work during lean seasons and targeted infrastructure development.

23 Mamdani et al (2009) argue that human resources are seriously lacking in the Department for Social welfare (which is in charge of the programme): in 2009 only a third of the 126 districts in mainland Tanzania were staffed with social welfare officers, and they were overwhelmed with the enormity of the task to provide direct services to populations of 300,000 or more people in each district.

24 The world Bank (2011a) recommends an integrated National productive Safety Net programme, including an expanded public works programme and a cash transfer programme consisting of conditional transfers linked to human capital investments and limited unconditional transfers for the most needy.

25 MKUKUTA includes nutrition goals.

26 pANITA (partnership for Nutrition), a coalition of over 100 civil society organisations across Tanzania launched in August 2011, could have a significant role in making sure that social protection mechanisms contribute to tackling malnutrition in Tanzania. pANITA’s aim is to contribute to attaining adequate nutrition for all Tanzanians. Its guiding principles include a cultural and contextual approach to reducing malnutrition and establishing long-lasting infrastructure for policy and advocacy across sectors, including (but not limited to) children’s rights, agriculture and livestock development, education, health and water and sanitation.

27 on 24 April 2012, the world Bank established a regional Community of practice of cash transfers and conditional cash transfers, and this constitutes a key opportunity to further develop the NSpF and integrate initiatives in the country (Tanzania Daily News, 2012).

28 The definition adopted in Tanzania for a ‘most vulnerable child’ is a child who experiences any of the following conditions: lives in extreme poverty; is affected by a chronic illness and lacks adequate care and support; lives without adequate adult support; lives outside of family care; is marginalised, stigmatised or discriminated against; has disabilities; or lacks adequate support (UrT, 2008).

Save the Children, June 2012 registered Charity No: 1076822

everyone.org

This briefing is part of a set of eight country briefings produced to accompany Save the Children’s report A Chance to Grow: How social protection can tackle child malnutrition and promote economic opportunities.

Thank you to all those who commented on previous drafts.

written by Tom Aston and Nicola Jones, overseas Development (oDI)

photo: Freyhiwot Nadew/Save the Children

Sharifa receives money to support her family as part of a cash transfer project aimed at reducing poverty and improving nutrition in lindi province, Tanzania