Investing in early years: The importance of protecting children through comprehensive social protection during the critical first 1,000 days of life

Abstract

Introduction

With up to 70% of stunting taking place before a child’s second birthday, addressing child malnutrition during the First 1,000 Days of life will be crucial in determining a child’s future development outcomes and human capital potential. If not addressed, undernutrition can lead to irreversible negative physical, cognitive, economic and social consequences, which also have major economic consequences (Black et al., 2013; Dewey and Begum, 2011; Hoddinott et al., 2013).

Despite improvements over the last two decades, child malnutrition remains a serious social and economic issue with approximately 151 million children under five globally suffering from stunting (when a child is too short for their age) (United Nations Children’s Fund et al., 2018). These recent estimates reveal insufficient progress to reach the World Health Assembly stunting and wasting targets set for 2025, which are incorporated into the Sustainable Development Goals set for 2030 (Goal 2).

A growing body of evidence shows that in order to accelerate progress in reducing undernutrition, nutrition-specific approaches may be more effective in preventing undernutrition when complemented with cash transfers to address the multiple drivers of malnutrition (Bastagli et al., 2016). Save the Children is implementing a number of First 1,000 Day Maternal and Child Grant pilots that are combined with nutrition-specific interventions in various contexts to gather evidence on the potential for these progammes to prevent stunting, and to inform policy on if and how they should be scaled up.

Piloting first 1,000 day maternal and child grants in Myanmar and Nigeria

In Myanmar and Nigeria, Save the Children recently implemented two First 1,000 Day Maternal and Child ‘Cash Plus’ pilots aimed at improving nutrition outcomes for mothers and children through the delivery of nutrition-sensitive cash transfers to pregnant women during the First 1,000 Days of life (Table 1). Both programmes covered all pregnant women within the implementation areas, who received a monthly cash transfer until their child reached 2 years of age. The cash transfer was intended to support women to purchase nutritious food for themselves and their children. Both programmes also had complementary activities to improve knowledge and change key behaviours on nutrition and hygiene, through regular Social and Behaviour Change Communication (SBCC) sessions with pregnant women, their families, and influential stakeholders.

Table 1.

Overview of First 1,000 Day Cash Plus Pilots (Myanmar and Nigeria).

Pilot	Monthly Cash transfer value	Primary SBCC activities	Recipients
Myanmar Maternal and Child Cash Transfer (MCCT)^a	10,000 MMK^b (US$ 6.71)	• Mother groups (covering topics on infant and young child feeding; promoting uptake of maternal and child health care services etc.) • Influential caregiver groups to deliver behavioural change aimed at husbands/mother-in-law etc. • Individual counselling services for mothers struggling with breastfeeding and complementary feeding.	11,588
Nigeria Child Development Grant Programme (CDGP)^c	3,500 NGN^d (US$ 9.75)	• Social behaviour change covering recommended infant and young child feeding practices and use of health care services. Designed to be delivered through either: • a ‘low-intensity’ approach: posters, radio messaging, text messaging, health talks, and food demonstrations; • or a ‘high-intensity’ approach, that also included support groups and one-to-one counselling.^e	93,772

SBCC: Social and Behaviour Change Communication.

Implemented in partnership with Myanmar Nurses and Midwives Association (MNMA) and funded by the Livelihoods and Food Security Fund (LIFT) from January 2016 to April 2019.

Exchange rate of $1 =MMK 1,490 as of August 2019 from Oanda.com. The transfer value was revised upwards in October 2017 from 10,000 MMK to align with the government led MCCT.

Implemented in partnership with Action Against Hunger and funded by the United Kingdom’s Department for International Development (DFID) from 2013–2019.

Exchange rate of $1 = NGN 359 as of August 2019 from Oanda.com. The transfer value was revised upwards in January 2017 from 3,500 NGN following food price increases.

The original design intended to compare the ‘high-intensity’ SBCC model with a ‘low-intensity’ one, though during implementation the models were implemented more or less equally in all areas and so aggregate results are reported here.

Both pilots employed a cluster randomised controlled trial to measure the causal impact of the approaches on the health/ nutrition outcomes of recipients (Table 2).

Table 2.

Randomised Control Trial treatment groups.

Myanmar – MCCT^a	Nigeria – CDGP^b
• Control group: no programme activity took place • Treatment group 1 (Cash + SBCC): cash transfers and SBCC activities provided jointly • Treatment group 2 (Cash-only): only cash transfers provided^c	• Control group: no programme activity took place^d • High-intensity treatment group (Cash + SBCC): cash transfers and high-intensity SBCC activities provided jointly • Low-intensity treatment group (Cash + SBCC): cash transfers and low-intensity SBCC activities provided jointly

MCCT: Maternal and Child Cash Transfer; CDGP: Child Development Grant Programme; SBCC: Social and Behaviour Change Communication.

Research designed by Innovations for Poverty Action (IPA).

Research designed by e-Pact consortium, led by Oxford Policy Management (OPM).

Minimal information on the main purpose of the cash transfers was communicated via pamphlet or large posters.

A small share of households in control group communities reported receiving cash and being exposed to SBCC, which may have resulted in marginal underestimates of the true impact. See e-Pact evaluation for further details at: https://www.opml.co.uk/projects/evaluation-child-development-grant-programme-cdgp.

What has been the impact on stunting?

Evaluation of both pilots found that pairing SBCC interventions with cash transfers can be an effective approach for preventing the development of chronic malnutrition (stunting). While impacts were observed on multiple interim outcomes, for brevity we will focus on the impact on stunting.

In Myanmar, after 2 years of programme delivery, there was a 4 percentage point reduction (a 13% reduction, p < 0.10) in the proportion of stunted children (6–29 months old) covered by the Cash + SBCC intervention, compared to the control group.¹ This result was primarily driven by a 4.4 percentage point reduction (an 18% reduction, p < 0.05) in the proportion of moderately stunted children among the Cash + SBCC intervention group. For children in the Cash-only intervention group, no significant effects were observed in stunting compared to the control group.

The reduction in the proportion of stunted children was more pronounced for children who received maximum exposure (aged 24–29 months) in the Cash + SBCC intervention group. There was a 5.4 percentage point reduction for children in this age cohort (p < 0.10), and for girls there was a reduction of approximately 10 percentage points (p < 0.01) compared to the control group.²

In Nigeria, after just 2 years, the incidence of stunting among children who had benefitted from the programme (aged 0–27 months) was reduced by 5.8 percentage points (an 8% reduction, p < 0.01).³ This preventive effect was maintained after children left the programme, with a 5.4 percentage point reduction by endline among children who were by then aged 21–49 months (also an 8% reduction, p < 0.05). By endline, the CDGP resulted in a 4.8 percentage point (p < 0.05) drop in the proportion of children who were severely stunted (aged 21–49 months). Endline reductions in moderate stunting were only found to be significant among boys (p < 0.05), though severe stunting only among girls (p < 0.10). Reductions in stunting were only observed among children who were directly exposed to both cash and SBCC.⁴ There was also a marginally significant reduction in the share of girls that were underweight (based on weight-for-age) by 6 percentage points (p < 0.10) with no such effect found among boys.

Conclusion

Global evidence on sustainably reducing chronic malnutrition shows it is a challenging task. Both pilots offer a promising solution for tackling stunting and demonstrate the importance of investing in the First 1,000 Days as part of comprehensive life-cycle social protection systems. In Myanmar, the government has adopted the approach and is rapidly expanding it nationally through a mixture of government and development partner financing. In Nigeria, the CDGP has led to a greater focus on the importance of scaling up Cash Plus approaches to cover the First 1,000 Days, with some states also developing their own similar programmes.

However, the pilots also showed that more could be done to further reduce the incidence of stunting, including

The importance of also strengthening the supply of quality health services, particularly around maternal and child health;

Ensuring the cash transfer value is based on a contextually grounded assessment of the cost of a minimum nutritious diet – for example, Cost of the Diet analysis;⁵

Ensuring that pregnant women receive support from early in their pregnancy, to maximise coverage throughout the First 1,000 Day window of opportunity;

The provision of quality SBCC is crucial for achieving impact. Both pilots struggled to fully address issues around the quality of SBCC delivered, which could have led to even greater behavioural changes, and therefore growth outcomes.

Footnotes

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Notes

Author biographies

Mathew Tasker is a Social Protection Advisor at Save the Children UK. Mathew has been working in the rural livelihoods and social protection sectors for over 11 years, with country level programmatic and policy experience mainly in Asia. He joined Save the Children in Myanmar in 2014 and is currently developing Save the Children’s global work on social protection, with a focus on nutrition-sensitive cash plus approaches. He also provides technical and policy support to specific programmes, including the Maternal and Child Cash Transfer (MCCT) Programme, which has been adopted, adapted and is being expanded by the Government of Myanmar to cover all pregnant women and children under 2 years of age.

Luke Harman is Senior Social Protection Advisor at Save the Children UK. Luke has been working on and researching international development for 11 years, with country level programmatic and policy experience mainly focusing across sub-Saharan Africa. Among his various publications, Luke was one of the key authors of the 2016 DFID-commissioned review on Cash Transfers: Cash transfers: what does the evidence say? A rigorous review of impacts and the role of design and implementation features. He joined Save the Children in 2016 and in his current role he co-leads the development of Save the Children’s global work on social protection, with a focus on child-sensitivity and promoting the case for expanding access among children and youth. He also provides technical and policy support to specific programmes, including the flagship Child Development Grant Programme in Nigeria.

References

Bastagli

Hagen-Zanker

Harman

, et al. (2016) Cash Transfers: What Does the Evidence Say? A Rigorous Review of Programme Impact and the Role of Design and Implementation Features. London: Overseas Development Institute.

Black

Victora

Walker

, et al. (2013) Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet 382(9890): 427–451.

Dewey

Begum

(2011) Long-term consequences of stunting in early life. Maternal and Child Nutrition 7(Suppl. 3): 5–18.

Hoddinott

Alderman

Behrman

, et al. (2013) The economic rationale for investing in stunting reduction. Maternal and Child Nutrition 9(Suppl. 2): 69–82.

United Nations Children’s Fund, World Health Organization and World Bank Group (2018) Levels and Trends in Child Malnutrition: Key Findings of the 2018 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization. Available at: https://www.who.int/nutgrowthdb/2018-jme-brochure.pdf?ua=1