a theoretical approach for increased cct effectiveness and sustainability

7/29/2019 A Theoretical Approach for Increased CCT Effectiveness and Sustainability

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Directed Study

7/29/2011

Ghida Krisht

[A THEORETICAL APPROACH FORINCREASED CCT EFFECTIVENESS

AND SUSTAINABILITY]


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A THEORETICAL APPROACH FOR INCREASED CCT EFFECTIVENESS AND SUSTAINABILITY

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Table of Contents

1.Introduction ......................................................................................................................................... 2

2.Background Information.................................................................................................................... 3

Development Intervention : CCT .......................................................................................................... 3Theoretical Approach to Development... .......................................................... 5

3.Review of the Current State of CCTs ................................................................................................ 6

4. Evidence for Potential Improvement ................................................................................................ 8

5. Recommended Practices and Possible Impacts .............................................................................. 10

6. References ........................................................................................................................................... 11

7.Appendices ......................................................................................................................................... 131. Nutrition-focused CCT : Conceptual Framework ........................................................................... 13

2. UNICEF FRAMEWORK ............................................................................................................... 15


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1. IntroductionIn reviewing the literature on CCT impacts and effectiveness, it appears that although theseprograms improve health and education outcomes, uncertainties remain about the underlying

social processes by which the recommended behavior is to be sustained.

Social processes are best highlighted through qualitative data collection that draws on keyinformant interviews, focus groups with and observation of the participants, program personnel

and other involved stakeholders (Adato, 2008).

This paper will show that there are no sufficient qualitative assessments from which to drawconclusive evidence for the reasons behind just moderate health and education outcomes so far.

In an extensive review of similar programs that condition extrinsic rewards on a desired

behavior, social-cognitive psychologists at the University of Rochester present a significant and

potentially foretelling finding regarding the chances of such a programs sustainability (Deciand Ryan, 1999).

Similarly, British psychologists have also investigated the same question and found that

financial incentives do improve health outcomes but leave unanswered questions that relate to

intrinsic motivation, informed choices and the nature of the subject-program relationship(Marteau et al, 2009). This raises questions about the sustainability and effectiveness of CCT

programs in their current design and operation.

To explore this point, the paper uses Sens development to freedom as a theoretical approachthat facilitates a discussion of the available CCT qualitative evaluations in Brazil, Mexico,

Nicaragua, and Peru (Lindert et al, 2007; Adato, 2008; Maluccio et al, 2005; Jones et al, 2006).

The paper demonstrates that it is justified to collect further qualitative data with a focus on

Sens category of transparency guarantee.


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2. Background InformationDevelopment Intervention: Conditional Cash Transfer

Recently, after the financial crisis of 2008, Conditional Cash Transfers (CCTs) are encouraged

as social safety-net programs that can stabilize compounded economic shocks worst felt by poorpopulations (Fajth et al, 2010). Examples of economic falls include unpredictable changes in

food prices and strong climate change effects, such as floods and droughts to which the poor are

most vulnerable. During such economically variable times, the conditional cash transfer canhelp the poorest from reverting to unsustainable coping measures and instead promote

instrumental behaviors such as child inoculation, preventative healthcare and child education

that strengthen their resilience.

CCTs are a relatively new type of social assistance program that transfer income to the poor,

usually female-headed households, conditional on the parents investment in their children's

health and education. Examples of health-related conditionality are perinatal care for pregnant

mothers, growth monitoring for the first 6-9 months, periodic checkups, vaccinations forchildren under 5 years, and attendance at health education sessions. Examples of education

conditions are school enrollment and 80% attendance of school days, and less common arerandom measures of performance. The key players in this program include the participant

parents, beneficiary children, program administrators or responsible government officials and

often participant-elected community representatives. CCTs vary a great deal in scope, rangingfrom nationwide to small-scale pilot efforts with a narrow target population (Fiszbein et al,

2010). In contrast, the following program components are shared among most CCTs:

determining eligibility through a combination of geographic and household proxy means

testing, amount and frequency of transfer (large sum, less often, or lower sum, more often),health and education conditions, and mandatory information or health/nutrition education

sessions (Fiszbein et al, 2010).

The programs alleviate short-term poverty by addressing the financial and material determinants

ofunder-nutrition and can have an impact on the key underlying causes: increasing access tofood, dietary diversity, health care, and education. Over the long run, CCTs aim to secure the

investment in the next generation.As CCTs tackle several interrelated development

problems in a single policy, they are praised for promoting a multi-sector development

approach that capitalizes on the synergies among education, health, nutrition, andempowerment of women. To understand the pathways by which CCTs improve nutrition,consider the key determinants of nutrition: mothers knowledge and caring practices, household

food security and utilization of health services for regular and preventative care (See appendix

for more details).They encourage a collaborative agreementbetween governments andfamilies: a mutual agreementwhere both partners are required to show complimentary

efforts (Fajth et al, 2010). Governments are expected to invest insupply side measures to

ensure high coverage among the poorestpopulations and help meet the increased demand.

Through coordinated efforts between public and private social services, CCTs achieve

strong program administration and strict monitoring, possibly one of the most significantcomponents of the program (Fajth et al, 2010). For instance Mexicos best practice

Oportunidades spends one in 16 dollars on program administration while several smaller


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programs spend as much as one in five dollars (Fajth et al, 2010).

Brazil'sBolsa Escola is designed such that each municipality is responsible for one part of theprogram administration and requires that states and municipalities give participants priority in

the locally funded and available public welfare services (Lindert et al, 2007).Bolsa Escola,

Brazil's national CCT safety-net program is successful partly due to an alliance of committedpublic, private, and civil society partners. This synchronization between the program andparticipant centered stakeholders strengthens instrumental ties that organically help

beneficiaries achieve better health and education outcomes (Fiszbein et al, 2010). CCTs often

use a community representative who communicates information about cash provision, clearsany misconceptions about the program, and encourages participants to follow the conditions

with awareness of the long term health and education benefits.

An objective of all four CCTs discussed in this paper is to increase maternal knowledge aboutthe nutritional status of their children. In part, this is accomplished through attending regular

health education meetings, which may substantially increase the parent's awareness of health

problems before irreparable or incapacitating damage occurs (Bassett, 2008). In Mexico,

Oportunidadesparticipants attendplaticas (required education sessions), where best nutritionand health practices are discussed. Similarly, Nicaragua'sRed De Proteccion mothers attend

bimonthly meetings that cover lessons in household sanitation and hygiene, nutrition,

reproductive health, and breastfeeding. These behavior-change communication activities mayprogress child health and nutrition through improved maternal knowledge and practices.

However, this largely depends on the effectiveness of knowledge dissemination to and

communication with participants during the health education sessions (Adato, 2008). Tomaintain increased household food consumption and expenditure, participating mothers need to

believe in the importance of improved food for children as directly relevant to school

performance. The participatory nature of CCTs varies from country to country, but increasingly

many programs make use of a community representative (usually a local participant-electedfemale CCT recipient), who communicates the arrival of transfers, explains program conditions,

implementation of responses to non-compliance, and encourages compliance (Fiszbein et al,

2010).

As the economist Engel predicted that the poorest spend 80% of their income on food, it

remains the most pressing determinant of poverty reduction (Timmer et al, 1983). CCT

impacts are mediated by an improvement in the determinants of underlying nutrition

including feeding and care practices, household food security and diet diversity, and the

use of health and education services (See appendix for more details). The additional

income is hypothesized to increase purchasing power for more nutrient-dense foods that

will benefit household food security and diet quality. The cash also serves to increase the

mother's control over resources thereby empowering her to make meaningful decisions in

the best interest of her children's future (Bassett, 2008). By giving parents the tools and

opportunity to exert positive influence on their childrens future, CCTs are sure to increase

parents realm of possible actions of capabilities to achieve progress in development

(Sen, 1999).


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Theoretical Approach to Development: Sens Development as Freedom

Amartya Sens theory of development as freedom is a moral philosophy that explores the values

and underlying drivers of a development intervention. It perceives development interventions in

terms of the freedom they allow an individual agent to express. According to Sen, a deed thatfurthers the freedom of the involved individual is a good deed that advances development, as

freedom is both the manifestation of development as well as a medium for development (Sen,

1999).

There are five categories of freedom through which people are enabled to help themselves. To

communicate the exact meaning of these categories from Sens perspective, they are defined in

his words as follows:

1- Political freedomthe civil and political rights that enable an individual to participate inand criticize government.

2- Economicthe ability to engage in and participate in economic markets using availableresources.

3- Socialthe education and healthcare opportunities that enable a person to live a full life.4- Transparency guaranteeto assure agreements made under a system or by society will

be honored.

5- Protective securitythe trust that societies will not be reduced to abject poverty andmisery.

Sens approach focuses on the capabilities that serve to increase an individuals opportunity,

sense of responsibility and agency. By capability, Sen is referring to the act of using available or

given capacity to create functional categories of freedom that later become entitlements.Forexample, Sen explains that in a market with choice of several products, one can only have fair

access if their economic entitlements are covered. Recognition and awareness of what a person

is entitled to or capable of receiving in a given system is important to achieve freedom of voiceand agency. The ability to express oneself and act, while building more inclusive societies, is

accomplished to an important extent by social accountability. Public resources are part of the

pool of resources to which citizens clearly will want to have access. In his approach, he

emphasizes agency, which can be explained through his definition of an agent as someone whoacts and brings about change, whose achievement can be evaluated in terms of his or her own

values and objectives (Sen, 1999).

Unquestionably, his approach emphasizes the agency necessary to enhance an individuals

decision making skills. Agency is felt and granted by the surrounding community and can

also be limited with a lack of trust and ambiguous communication styles. Also, providing a

society with tools implies a widening of its choice. In a Sen like approach, the social-

cognitive psychologist behind the theory of self-determination, Edward L. Deci, believes

when there is choice, it is essential that it be backed up with the information necessaryfor making a meaningful decision otherwise a choice will feel more like a burden than a

support for autonomy, as without adequate information, people are more likely to make a

mistake (Deci, 1996). The social system in a society plays the role of communicator todetermine how useful the imparted knowledge can be to an agent.


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3. Review of the Current State of CCTsCurrently CCTs are the world's most widely used national social protection system. In one decade,

1998 to 2008, CCTs spread from three countries to 23 countries, respectively, covering allcontinents. In 2009, the World Bank commissioned a comprehensive investigation of all CCTs

around the world presented in a published report titled, Conditional Cash Transfers: ReducingPresent and Future Poverty (Fiszbein et al, 2010). Data sources for the collected evaluationsinclude community and household surveys, school and clinic administrative data, interviews, and in

some cases school performance-based tests.

CCTs consistently showed an increase in food consumption, utilization of public health and

education services. For example, Mexico's 'best practice' CCT, Oportunidades, showed positive

steps towards the United Nation's Millennium Development Goals by reducing infant mortality,

improving childhood nutrition, and increasing school enrollment and attendance, particularlyamong girls (Fajth et al, 2010). More specifically, randomized control studies in Mexico, Columbia,

and Nicaragua confirm an improvement in child anthropometry measures. In comparison to control

groups, program participants exhibited higher average food consumption in Mexico by 13% and inColombia by 15%. CCTs in Nicaragua decreased the prevalence of stunting (low height for age) inchildren under age 5 by 5.3% (Leroy et al, 2009).

Although analysis of the compiled World Bank (mostly quantitative) evaluations demonstratesmodest impacts on health and education outcomes in almost all countries, school enrollment among

participants increased, and compared with non-participants, participants were more likely to seek

preventative healthcare services and inoculation. These are persistent favorable results among mostCCTs; however, going a step further in measuring performance-based outcomes at school and child

height for age as opposed to growth-monitoring attendance, the results are much more mixed

(Fiszbein et al, 2010).

To understand the reason for mixed results in the final outcomes of health and education, some

countries with larger established national scale programs authorized the World Bank and the

International Food Policy Research Institute to evaluate their programs using mixed quantitativeand qualitative means. Several countries achieved positive effects such as increased women's

income and control over resources, improved mothers knowledge about health and nutrition, and

improved household diet quality through increased consumption of micronutrient rich foods

(Adato, 2008). Also, in Mexico and Nicaragua, the only two countries that assessed women'scontrol of income and resources, positive effects were found. Mexico's program evaluation also

found that maternal health knowledge and practices increased among program participants.Red De

Proteccion (RPS) in Nicaragua increased women's awareness, self-confidence, and ability to

express and share experiences in casual social meetings outside of the house (Maluccio et al, 2010).

The CCT literature presents only five qualitative assessments of national programs:Bolsa Escola in

Brazil, Oportunidades in Mexico,Juntos in Peru,Red de Proteccion in Nicaragua and in Turkey.This section outlines some important anecdotal evidence from the qualitative assessments from the

first four countries. The participant viewpoints present some of the benefits and conflicts of the

implementation of a conditional income transfer.


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As stated before, CCTs are designed differently, to fit the needs of a given context and its capacity

to administer the intervention. Some programs employ social workers who, in the case ofnoncompliance, will reach out to the beneficiaries. In Brazil, if the beneficiary is non-compliant, the

program's social worker is sent for a home visit to see if the program can help with a non-cash

related problem (Fiszbein et al, 2010). Although nutrition education sessions are in place, the poorfrequency and/or quality of counseling in Brazil and overcrowded sessions in Nicaragua are

examples of overlooked implementation details that reduced the program's impact (Adato, 2008).

For example, inRPSduring informal conversations with participants, many expressed that the mainincentive to attend the information sessions was to comply with the requirement and receive the

cash (Maluccio et al, 2010).

John A. Maluccio et al in their detailed qualitative evaluation ofRPSin Nicaragua exploredbeneficiary perceptions surrounding the limitations and/or influence of their contribution to the

program. The anecdotal evidence emphasizes the importance of obedience and compliance because

of the threat of losing benefits or of the program leaving (Maluccio et al, 2010). In contrast to the

program beneficiaries, the community representatives note their flexibility to influence and enhancethe program as they see best for the participant.

InJuntos of Peru, Jones et al present a participant's positive account of the capability the extra cashprovides the household to acquire assets for future risk mitigation:

Some of us didnt have homes. The money is helpful for everything, we are buying buildingmaterials and now we are improving our houses Buying animals is like saving money in a

bank account; we buy piglets and when they grow, we have some capital for the future (Focus

group with women beneficiaries, Arizona) (Jones et al, 2006).

Others in theJuntos program recall particular life circumstances that the program could have

responded to with more sensitivity if it were in touch with the existing communication channels in

the society. In one such example:

Well, the woman was pregnant and she had no one to look after her cattle, so she sent her

young daughter to take care of them. Consequently, the girl did not go to school and was

marked absent. When the people from the Program went to verify her school attendance, theynoticed she had been missing school and so they penalized the womanthe Program has to be

more flexible with these families because life in the countryside is different than in the city, in

the country people depend on their cattle (Technician, Rosapata) (Jones et al, 2006).

As mentioned earlier, the program may cause feelings of exclusion towards the parents, or in this

case often make them feel less adequate.

Im not aware that the families are in opposition, its more a case of submission. Sometimes it

appears to be treating them like children but the advantage is the system is producing resultsI

believe the task is twofold and also involves talking to them about their rightsyour sons anddaughters have the right to be educated (Andres Solaria, Agenda Sur) (Jones et al, 2006).


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4. Evidence for Possible ImprovementsDeci and Ryans extensive research points to clear and consistent evidence that extrinsic rewards

undermine intrinsic motivation through two psychological processes: compromised sense of self-

esteem and self-determination.

As defined by Deci and Ryan, one is intrinsically motivated when one receives no apparent rewardexcept the activity itself (Deci and Ryan, 1999). Compromised self-esteem is when the intervener

does not recognize the participants or agents motivation, thus under valuing their efforts.

Similarly, a compromised feeling of self-determination stems from the perception that theparticipants intrinsic motivation is submissively competing with external inputs (Deci and Ryan,

1999).

For instance, in the last excerpt from aJuntos participant,he expresses that although the program is

effective in some way, he is frustrated with the programs passive treatment towards the participantparents. In his view, the program almost assumes that the parents are not a worthy investment or are

passive in their degree of involvement with the program, thereby undermining their autonomy as

seen in Deci and Ryans experimental meta-analyses findings. The participant recommends that

they be more involved in the cash entitlement of their child and its meaning , pointing to Sens ideaof building trust between the agent and the program to ensure transparency guarantee.

Also, an article that looked at whether monetary rewards achieved better health outcomes in Britain

showed that although there is some improvement, uncertainty remained concerning unintended

consequences related to intrinsic motivation, informed choices and the nature of the subject-program relationship (Marteau et al, 2009). As the CCT program follows a design similar to the

kind researched by Deci and Ryan and by Marteau et al, it serves to examine whether similar

unanswered questions and uncertainties arise in CCT implementation.

The qualitative data presented in the previous section mostly denote issues with the nature of theagreement between the participants and the implementing government as indicated by evidence of

weak communication channels and distrust. For example, RPS parents only attended information

sessions for fear of losing the cash benefit, which may point to the poor quality of instructionprovided in those sessions.

As there is insufficient anecdotal evidence to draw upon, using Sen's development as freedom

approach and Deci and Ryan's experimental findings on the effects of extrinsic rewards on sense of

responsibility and self-determination, we predict an analogy supported by the existing qualitativeevidence, that just conditioning cash on the recommended behavior changes might not be enough to

sustain these best practices, and more importantly can have negative drawbacks in terms of

diminished autonomy, relatedness and self-esteem of the participant-parents.

CCTs provide families with extra income and education and health services for their children withconfirmed positive effects that help progress Sens first three categories of development as freedom.However, the programs uncertainties illustrated by some qualitative information shows that the

program mostly falls short on furthering development into Sens fourth category, transparency

guarantee, which operates at the level between household and institution, serving to enhancecommunication channels and trust. In Sens outlook, a development approach that partially fulfills

the categories of freedom is incomplete and will therefore only achieve some of its potential

impacts.


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In essence, strengthening the communication channels between the household and above household

levels will increase the participants' sensitivity to the conditions and bolster their resilience to asudden or planned change/stop to the program. In turn the program may have better chances at

achieving positive impacts and ensuring the sustainability of the recommended good practices of

protective healthcare and investment in education.


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5. Recommended Practices and Possible ImpactsAlthough the available qualitative assessment supports program assumptions of voluntary

commitment, trust and strong communication between the key players, it is not enough for a

conclusive speculation. Therefore, more research in this particular area of communications iswarranted with Sens idea of transparency guarantee at its nexus. By focusing the forthcoming

CCT data collection on qualitative means, we would be able to decipher the social relations

underpinning assumptions in the current CCTs and better inform future implementation and design.

We would gain access to important information that can identify problem areas as well asexemplary practice.

More specifically, qualitative assessments will examine participant constraints in complying with

conditions in their current design and see where the program can afford more flexibility in its

treatment of non-compliance. It may also help cast light on the participants understanding ofprogram operations and whether they correspond with the community representatives messages to

determine if and where a communication gap exists. Also, this kind of information will indicate

whether there is sufficient need for referral to existing social services thereby promoting increasedcoordination among functioning complimentary social organizations. Qualitative data is mostimportant in relaying the weaknesses and strengths of program communications. Participants

views regarding the nutrition education or in some cases mandatory information sessions will

reveal if messages are culturally appropriate and whether they are sensitively passed on.

This research would create a much needed qualitative account of CCTs as seen from the agentsviewpoint, which has the potential to map the beginnings of a fabric that connects the household

level to the institutional level. It would give the program administrators a chance to improve their

understanding of the ecosystems sensitivity and resilience in order to exert the right pressure pointsat the right time to improve their influence on the program chances for sustainability (Maxwell and

Smith, 1992). Furthermore, with qualitative data generated from various types of CCTs

(institutional nationwide, small narrow target and community or participatory programs) it would

give programmers a good inclination of design and implementation efforts that improveeffectiveness and those that inhibit it. Based on Sens theoretical approach to development and the

potentially extrapolative psychology experiments outlined in the paper, it is likely that future

qualitative data will point to assumptions and weaknesses in the communication channels of theprogram.


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6. ReferencesAdato, Michelle. Integrating Survey and Ethnographic Methods to Evaluate Conditional Cash

Transfer Programs. IFPRI Discussion Paper No. 00810, Food Consumption and Nutrition Division,

October 2008.http://www.ifpri.org/pubs/dp/IFPRIDP00810.pdf

Adato, Michelle, and John Hoddinott. "Conditional Cash Transfer Programs: A Magic Bullet forReducing Poverty?"2020 FOCUS BRIEF on the Worlds Poor and Hungry People. International Food

Policy Research Institute, Oct. 2007. Web.

Bassett, Lucy. "Can Conditional Cash Transfer Programs Play a Greater Role in Reducing Child

Undernutrition?" Social Protection, World Bank, Oct. 2008. Web..

Bastagli, Francesca. "Conditionality in Public Policy Targeted to the Poor: Promoting Resilience?"

Social Policy and Society9 (2008): 127-40. Web.

Deci, Edward L., Richard Koestner, and Richard M. Ryan. "A Meta-analytic Review of Experiments

Examining the Effects of Extrinsic Rewards on Intrinsic Motivation." American PsychologicalAssociation. 1999. Web.

Deci, Edward L., and Richard Flaste. Why We Do What We Do: Understanding Self-Motivation. New York: Penguins, 1996. Print.

Sen, Amartya.Development as Freedom. New York: Knopf, 1999. Print.

Fajth, G. and Vinay, C. Conditional Cash Transfers: A Global Perspective, MDG INSIGHTS Issue 01February 2010. Web.

Jones, Nicola, Rosana Vargas, and Eliana Villar. "Conditional Cash Transfers In Peru: Tackling theMulti-Dimensionality of Poverty and Vulnerability." Unicef, 2006. Web.

.

Leroy, Jef L., Marie Ruel, and Ellen Verhofstadt. "The Impact of Conditional Cash

Transfer Programmes on Child Nutrition: a Review of Evidence Using a Programme Theory

Framework."Journal of Development Effectiveness 1.2 (2009): 103-29.

Http://www.informaworld.com/smpp/title~content=t906200215. Routledge, June 2009. Web.

Lindert, Kathy, Anja Linder, Jason Hobbs, and Bndicte De La Brire. "The Nuts and Bolts of Brazils

Bolsa Familia Program: Implementing Conditional Cash Transfers in a Decentralized Context." SocialProtection, World Bank, May 2007. Web.

.

Maluccio, John A., Michelle Adato, Rafael Flores, and Terry Roopnaraine. "Red De Proteccion Social-

Mi Familia Breaking the Cycle of Poverty." Www.ifpri.org/sites/default/files/pubs/pubs/ib/ib34.pdf.

International Food Policy Research Institute. 2005. Web.
http://www.ifpri.org/pubs/dp/IFPRIDP00810.pdfhttp://www.ifpri.org/pubs/dp/IFPRIDP00810.pdfhttp://www.ifpri.org/pubs/dp/IFPRIDP00810.pdfhttp://www.ifpri.org/pubs/dp/IFPRIDP00810.pdf


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Marteau, Theresa M., Richard E. Ashcroft, and Adam Oliver. "Using Financial Incentives to AchieveHealthy Behaviour."BMJ 2009; 338:b1415 . Web. .

Maxwell, Simon, and Marisol Smith. "Household Food Security: A Conceptual Review." IFAD, 1992.Web. .

Timmer, C. P., Falcon, W. P. & Pearson, S. R. 1983. Food policy analysis. Baltimore, MD: The JohnHopkins University Press.

Appendix References:

Weiss, Carol H. Evaluation: Methods for Studying Programs and Policies. Upper Saddle River, NJ:

Prentice Hall, 1998. Print.

"The State of the World's Children: Focus on Children 1998." UNICEF. Web..
http://www.bmj.com/content/338/bmj.b1415.fullhttp://www.bmj.com/content/338/bmj.b1415.full


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7. Appendices1. Nutrition-focused CCT : Conceptual Framework

Inputs Input

Assumptions

Outputs Output

Assumptions

Outcomes Outcome

Assumptions

Impact

Eligibility

criteria for

poorest HH w/

children < 2

cash transfer in

mother's name

nutrition

education

campaign

(materials,

staff)

preventative

HC input ex:

deworming

agent

(mebendazole)

administered

once a yr by

school teacher

health

care/education

facilities andmaterials for

monitoring and

measurement of

nutrition

indicators

monitoring/

information

systems

Female

beneficiary

selected by

colleagues as a

community

representative

Implementing

partners at the

national and

regional level

as well as

Efficient

targeting to the

poorest HH, to

minimize

leakage to the

non-poor

good

governance and

political

commitment

and will

(financial +administrative)

no constraints

in access to

schools,

meetings, or

markets to

purchase food

(time +

distance)

motivated and

willing staffwith incentives

to improve the

supply side

inputs

no processing

delays in cash

transfer

cash transfer is

large enough to

offset the

opportunity cost

of sending girls

to school and

women's time in

attending

nutrition

education

meetings

Mothers receive

cash transfer

girls attend

school 85%

mothers attend

monthly

nutrition

education

meetings

social/community

workers

monthly

random spot

checks with

tailored

messages to

noncompliant

participants

mothers voice

their concerns,

questions tocommunity rep.

during monthly

meetings

data collection

on school

attendance/enro

llment recorded

by participating

schools,

submitted to

corresponding

municipalities

(education unit)

[data flow

aggregation for

monitoring]

data collection

on healthcare

visits submitted

to

Efficient and

effective

administration

and monitoring

culturally

sensitive

nutrition

education

messages that

encourage best

practice

methods asoutlined by

lancet and

(promote better

health, caring

practices and

food choices)

mothers use

cash to

purchase higher

quality foods

(more nutrient

dense)

girls actually

attending

school; staff not

marking absent

girls, present

community rep

understands the

operations of

the program

and motivated

to answer peers'

questions/conce

rns and has

time

no intraHH

allocation

disparity

size of nutrition

Improved

maternal

knowledge,

self-confidence,

awareness,

Mothers'

increased use of

best nutrition

practices and

health care

access

increased

women's

purchasing

power and

improved food

utility

social workers

and community

reps share

participant

concerns with

municipalityadministration

increased

school

attendance for

girls

Increased HH

food

consumption &

expenditure

increased

caloric diversity

increased use of

healthcare

services, GMP

& doctor visits

for

immunizations

Quality of

supply side

services (MOE,

MOH) are

continuously

revised and

enhanced

increased

synergy

between

participating

ministries

program

monitoring is

regular and

effective

multiplier

effect on cash

transfer and

local markets

social workers

successful inmediating

conflicts of

interest between

participants and

municipalities/

ministries

Decreased rate

of stunting in

children < 5

increased

female literacy

reduced illness

in children < 5

reduced LBW

rate

increased food

security

increased

women's

entitlement to

basic

HC/educational

services

(demand

services and

provider

accountability)

increased

economic

growth

increased

capacity of poor

HH to cope and

meet basic

needs

sustainably

integrated social

safety net as a

result of

increased

investment in

health, nutrition

& education

improved

female


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community orgs

and partner

NGOs

adequate

training for

social workers

and community

reps

no

overcrowding at

schools and

schools have

sufficient

resources to

deal with an

increased

demand

nutrition

education

messages are

culturally

sensitive andhighlight the

key messages to

improve

nutrition

(including

hygiene and

best nutrition

practices)

quantity and

quality of

complementary

servicesavailable,

particularly

health and

education

services

municipalities

(health unit)

[data flow

aggregation for

monitoring]

distribution of

deworming

agents at

nutrition

education

sessions

growth

monitoring &

regular HC

visits for

immunization

and

anthropometry

measurement

community rep

communicates

with participant

families about

the arrival of

transfers,

explains and

clarifies

conditions and

possible

sanctions for

noncompliance

education

classes are not

too large thus

compromising

the quality of

the session

beneficiaries

willing to

comply with

conditions

social worker is

able to decipher

whether

noncompliance

by a HH is

related to a non-

cash problem

dataaggregation on

beneficiaries'

compliance

with conditions

and other

related

information

addresses

problems in

data entry

social workers

and community

reps meet

monthly to

discuss

implementation

problems and/or

exceptional

cases, document

into a lessons

learned report

for future use

monitoring

systems at

MOH and MOE

are

continuously

strengthened

with the help of

thegovernment's

technical

capacity

effective

systems of

monitoring

compliance and

enforcing

conditions

representation

in social and

political spheres

of the economy

**Notes in italics are valid if the program offers mandatory nutrition education sessions and trains community

representatives in program operations and implementation

Acronyms:GMP- growth monitoring promotion

HC- healthcare

HH- household

LBW- low birth weight

MOE- ministry of education

MOH- ministry of health

NGO- non-profit organization


16/16


Page 15

2. UNICEF FRAMEWORKCCT nutrition-focused pathways

HC Services &

Environment

Ac

cess

topreven

tiveHC

service

s

(Immunizat

ion)

De

man

dfo

rservic

es

Adequate Dietary

Intake

Food Security

Wom

enspu

rchasingpower

Food

access

Malnutrition

Maternal/

Child Care

Disease

Social Factors

Political Factors

Economic

Factors

Potential

Resources

Womens marketinclusion

Womens social

inclusion

Self-confidence

Investment

in Health,

Nutrition

Education

Womens

rights and

entitlements

Female literacy

Maternal health

knowledgeImproved family planning

Improved food utility

Stunting rateImproved anthropometrics

Food consumption

Fruit/veg/meatCaloric diversity

Birth weightChildhood illness

Basic

Causes

Under

lying

Causes

Immediate

Causes

Manifestation

a theoretical approach for increased cct effectiveness and sustainability

Documents