Leveraging food systems for poverty and malnutrition reduction

Raza, Ahmed (Ed.); Soares, Fabio Veras (Ed.) Research Report Leveraging food systems for poverty and malnutrition reduction Policy in Focus, No. 46 Provided in Cooperation with: International Policy Centre for Inclusive Growth (IPC-IG) Suggested Citation: Raza, Ahmed (Ed.); Soares, Fabio Veras (Ed.) (2020) : Leveraging food systems for poverty and malnutrition reduction, Policy in Focus, No. 46, ISBN 978-92-5-133761-5, Food and Agriculture Organization of the United Nations (FAO) and the International Policy Centre for Inclusive Growth (IPC-IG), Brasilia, https://doi.org/10.4060/cb2498en This Version is available at: https://hdl.handle.net/10419/248829 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. Sie dürfen die Dokumente nicht für öffentliche oder kommerzielle Zwecke vervielfältigen, öffentlich ausstellen, öffentlich zugänglich machen, vertreiben oder anderweitig nutzen. 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DOI: https://doi.org/10.4060/cb2498en ISBN: 978-92-5-133761-5 [FAO] Summary 7 Exploring synergies between poverty and malnutrition reduction efforts within the food systems transformation agenda 10 Nutrition-sensitive value chain development and its role in improving nutrition and transforming food systems 14 Understanding the potential of territorial markets to reduce poverty and promote healthy diets 19 The role of smalland medium-sized enterprises in addressing the malnutrition challenge: reflections from project implementation in Ghana, Kenya and Viet Nam 22 Taxes as a policy measure to promote healthy diets 26 Building a food safety culture in Bangladesh 30 Ending malnutrition in all its forms: social protection and the growing prevalence of overweight, obesity and diet-related non-communicable diseases 35 Social protection responses to COVID-19 in the Middle East and North Africa: the case of Egypt 39 Enhancing maternal nutrition through cash transfers: what does the evidence say? 43 Empowering women for poverty alleviation and improved nutrition outcomes: from anecdotes to evidence 46 The potential of policy and programmatic synergies for impacting poverty and nutrition outcomes through schools 49 The Inter-Agency Social Protection Assessment Tool for food security and nutrition: what it is, and how it was applied in Cambodia, the State of Palestine, and Paraguay 52 The potential role of geographical indications in promoting healthy diets and reducing rural poverty 6 Ahmed Raza and Fábio Veras Soares Even though substantial progress has been achieved worldwide in reducing both poverty and malnutrition, much is yet to be done. There are signs that the progress made in both dimensions has stalled in recent years. Suboptimal diets have become a major driver for overweight and obesity and associated noncommunicable diseases such as diabetes, heart diseases and some types of cancers. Conflict and climate vulnerability have been identified as major obstacles to reaching Sustainable Development Goal targets related to malnutrition, in all its forms, by 2030. In 2019, economic downturns and slowdowns hindered efforts even further. More recently, the COVID-19 crisis has imposed even harsher conditions to countries. Poverty and malnutrition are inextricably linked, and therefore addressing one can help address the other. Given that most of the world’s extremely poor people and stunted children live primarily in rural areas and rely mostly on agriculture, an agriculture and food systems approach can offer opportunities to reduce both poverty and malnutrition. The food systems approach places equal emphasis on both the supply and demand dimensions that are critical for ensuring healthier diets and better nutrition for poor and vulnerable groups. This special issue of Policy in Focus is dedicated to answering a crucial question: How can a food systems approach be used to design and implement policies and investments that reach those most vulnerable to poverty, hunger, malnutrition and suboptimal diets? We hope that the contributions contained in this volume, by leading academics and development practitioners, exploring the linkages between nutrition, food systems and poverty, can help food systems stakeholders and policymakers make inroads towards the promotion of food security and nutrition and the reduction of rural poverty. Editorial Exploring synergies between poverty and malnutrition reduction efforts within the food systems transformation agenda Ahmed Raza1 and Fábio Veras Soares2 Poverty and malnutrition remain critical challenges for countries in their pursuit to achieve the Sustainable Development Goals (SDGs). Although considerable progress has been made in reducing both poverty and malnutrition, much remains to be done, as lower levels of poverty and malnutrition are actually much harder to bring down and require a broader and more coordinated set of policies and programmes to tackle them. In addition, there are signs that the progress made in both dimensions has stalled in recent years. The 2020 ‘State of Food Security and Nutrition’ (SOFI) has shown that an additional 60 million people have been affected by hunger since 2014. Extrapolating this trend, it means that by 2030, 840 million people will be undernourished. There are still about 144 million children under the age of 5 who suffer from stunting, and over 38 million children under the age of 5 and 337 million children and adolescents between the ages of 5 and 16 are overweight (UNICEF, WHO, and World Bank 2020; NCD-RisC 2017). In addition, suboptimal diets have become a major driver for overweight and obesity and associated non-communicable diseases such as diabetes, heart diseases and some types of cancers. The 2020 SOFI also shows that 3 billion people around the globe are unable to afford the cheapest forms of healthy diets and thus rely on suboptimal diets. Conflict and climate vulnerability have been identified since 2014 as major obstacles to reaching SDG targets related to malnutrition by 2030 (SDG 2). More recently, in 2019, economic slowdowns and downturns have further undermined the efforts to achieve these targets. In 2020, the COVID-19 crisis has emerged to make the situation even worse (FAO et al. 2020). Similarly, the World Bank (2020) points out that progress towards poverty reduction was slowing down even before the COVID-19 crisis after an unprecedent trend towards poverty reduction. The extreme poverty rate fell on average by 1 percentage point per year between 1990 and 2015, but that reduction slowed down to 0.5 percentage points between 2015 and 2017. At this pace, the SDG target 1.1 of bringing down extreme poverty to less than 3 per cent will not be reached by 2030. Overall, 689 million people lived in extreme poverty (9.2 per cent of the global population) in 2017— 52 million fewer than in 2015. However, this process has been uneven, and the rural population has become even more over-represented among those living in extreme poverty in this period so that, in 2017, 80 per cent of the people living in extreme poverty resided in rural areas. Finally, estimates of the impacts of COVID-19 on poverty using 2017 data as a baseline suggest that between 88 million and 115 million people have probably fallen into extreme poverty due to the COVID-19 crisis, raising global poverty rates to 9.4 per cent and basically cancelling out the progress made between 2015 and 2017 (World Bank 2020). In addition to the immense task of fighting poverty and malnutrition in a context of conflict, climate change and economic slowdown, now the COVID-19 crisis has added a layer of complexity that will require strong responses at policy and programme levels from national governments and the international community. From a policy and programme perspective, poverty and malnutrition are inextricably linked, meaning that addressing one can help address the other. Reducing malnutrition is vital to tackle the key determinants of poverty, and reducing poverty is a necessary condition for improving nutrition. In addition, given that most of the world’s extremely poor people and stunted children live primarily in rural areas and rely predominantly on agriculture (World Bank 2020; FAO et al. 2019), an agriculture and food systems approach offers an opportunity to reduce both poverty and malnutrition. The food systems approach places equal emphasis on both the supply and demand dimensions that are critical for ensuring healthier diets and better nutrition for poor and vulnerable groups. On the supply side, this entails working along the food supply chain—the production, processing, storage and transportation of food—and making efforts to diversify food production, enhance the availability and affordability of nutritious foods and improve post-harvest management. On the demand side, this entails shaping consumer behaviour by promoting nutrition education, raising consumer awareness and influencing food and nutrition labelling regulations, policies and programmes. The critical question, then, is how can a food systems approach be leveraged to design and implement coordinated and coherent policies, programmes and investments that reach those most vulnerable to poverty, hunger, malnutrition and suboptimal diets. The answer to this question will depend greatly on our ability to navigate the food system, as they are expansive and evolving rapidly. They comprise a range of activities, actors, institutions and enabling environment that are critical to the production, processing, marketing, consumption and disposal of food (FAO 2013). This Special Issue aims to answer this question by supporting policymakers and development practitioners to identify conceptual, policy and programmatic linkages between nutrition, food systems and poverty. It will enable these stakeholders to build a common narrative on the role of food systems in promoting nutrition and reducing rural poverty. The International Policy Centre for Inclusive Growth | Policy in Focus 7 “ Despite their popularity, social protection schemes overwhelmingly focus on one form of malnutrition— i.e. undernutrition. Food supply chains play a critical role in transforming agriculture and food systems towards better nutrition outcomes for nutritionally vulnerable groups (Raza et al. 2020). In their article, Garrett and De La Pena present the effectiveness of adopting a nutrition-sensitive value chains approach to navigate the complexity of food systems by selecting individual agricultural commodities with the potential to both improve nutrition and raise incomes for farmers. To make their case, they provide examples from largescale investment projects implemented by the International Fund for Agriculture Development (IFAD). Small-scale producers are an essential part of different kinds of food systems: local, regional and global. According to some estimates, smalland medium-scale farms contribute to over half of the world’s food production (Herrero et al. 2017); however, they often lack resources to compete in markets. In their article, Vicovaro, Puhac and Tartanac argue the need to consider the development of territorial markets and strong producer organisations to enable small-scale producers—who often tend to be women—to produce and market diverse foods which can meet the dual goals. In addition to small-scale farmers, the private sector is fundamental to ensuring the availability of and access to a diverse diet in lowand middle-income countries. The private sector in these contexts comprises small and mediumsized enterprises (SMEs), as argued by Santacoloma and Anta in their article. They propose that the potential of SMEs to increase the incomes of actors engaged in the food and agriculture sector and to reach vulnerable populations with healthy foods has been largely untapped. For most consumers, in both urban and rural areas, markets and retail outlets are the key sources of food. These markets and retail outlets form part of the physical, economic, political and socio-cultural context—or food environment—in which consumers interact with food systems (HLPE 2017). However, food environments in lowand middle-income countries tend not to support nutritious foods and need to be shaped so that they promote the desirability and affordability of healthy diets. Shu Wen and colleagues explain how, to meet this objective, fiscal policies such as taxes on food items have the potential of promoting healthier consumption patterns and reducing social inequities related to health and nutrition. Food environments in lowand middleincome countries are also characterised by poor food safety and quality standards, which are critical elements for achieving optimal nutrition. Effective food safety systems are also central to maintaining and adding value along the food value chain and reducing the incidence of food-borne diseases. Sridhar Dharmapuri provides an overview of the political commitment, institutional capacities and science-based processes needed to set up a food safety system in resource-poor and populous contexts. Consumers, citizens and households play a catalytic role in demanding healthy diets from food systems. In resourcepoor and vulnerable settings, however, consumers face considerable challenges in accessing and consuming better diets. Social protection schemes that integrate complementary activities in the agriculture, health, labour and sanitation sectors are innovative poverty reduction measures that can address malnutrition challenges. These schemes, which often include cash or in-kind transfers, have the potential to contribute to overcoming the challenge outlined by the SOFI 2020 report of making quality and diverse diets affordable. Despite their popularity, social protection schemes overwhelmingly focus on one form of malnutrition—i.e. undernutrition. Grinspun, Gyori and Rivera discuss the trends and determinants of the double burden of malnutrition and provide an overview of literature on the impact of cash transfers and other social protection programmes on overnutrition—i.e. overweight and obesity. Whereas ElEnbaby and Breisinger take a regional view by analysing how social protection programmes have been employed to tackle the effects of the COVID-19 pandemic in the Middle East and North Africa. Given that women’s empowerment and gender equality are critical to improving Photo: UNICEF Ethiopia/Ephrem Tamiru. Health extension worker assessing a child's nutritional status at Elala Health center, Fentale, Ethiopia 2020 <https://clck.ru/QyQvQ>. 8 because that can lead to simplistic solutions, such as ‘market integration’ as the one size-fits-all approach to poverty reduction. Markets are “collective devices that allow compromises to be reached, not only on the nature of goods to produce and distribute but also on the value to be given to them” (Callon and Muniesa 2005). In other words, there is a plurality of markets that operate on different market rules. Moreover, the power relations among stakeholders in these diverse markets also influence their functioning. Therefore, we have to consider the different types of markets and the conditions for smallholders’ participation in them to be able to capture their respective potential for poverty reduction. Since territorial markets are embedded in a territory, they have the potential to reduce distances, both geographic and socio-cultural, among supply chain actors. Furthermore, shorter distribution channels can enable smallholders to acquire information more easily, reducing information asymmetries, and to negotiate better terms of participation in territorial markets. Well-functioning territorial markets go beyond economic transactions and offer a wide spectrum of services that are crucial for ensuring smallholder inclusion in markets. Territorial markets are spaces for knowledge exchange and information access, social cohesion, business ‘matchmaking’ and even political organisation. Nevertheless, not all markets embedded in a territory are inclusive to all. Imbalances in power relations and access to productive resources can exist and hinder market inclusion, especially for the most vulnerable farmers. Therefore, the existence of wellorganised producers’ organisations and networks is as vital as the existence of the market infrastructure itself to ensure territorial development, economic growth and poverty reduction. Being a member of an organised group or network, such as a TABLE 1: The most frequented food retail outlets and their influence on healthy diets in developing countries 4 Consumers Pros in terms of healthy diets Cons in terms of healthy diets Supermarkets Preferred by high-income and well-educated households Exposure to several healthy food products, including non-traditional products that increase diet diversity Exposure to high-calorie and ultra-processed food items Territorial markets (e.g. open-air wet markets) Preferred by non-college-educated households and large households Mostly offer locally supplied foods, including in-season vegetables and fruits, live poultry and fish Food safety concerns due to poor infrastructure Hawkers Preferred by low-income and less-educated large households, especially those with small children Make foods widely available where the infrastructure is poor (including lack of storage facilities at home) and where consumers have variable income flows Low food quality, mostly ready-to-eat foods cooperative or a producers’ organisation, enables smallholder farmers greater opportunities for bargaining and advocacy, which can lead to enhanced prospects for fair market access (FAO 2018). Role of territorial markets in shaping healthy diets Lately, there has been a surge in diet-related health problems, such as obesity, diabetes and heart disease. These problems are linked to increased consumption of ultra-processed, energydense foods with low nutritional value, and insufficient consumption of nutrient-rich foods, such as fresh vegetables and fruits. Food retail outlets, including supermarkets, open-air wet markets (a type of territorial market) and hawkers can play a significant role in influencing the diets and nutrition of consumers, through the quality and price of foods they sell. Although there has been a surge in the growth of supermarkets in developing countries over the past few decades, driven by rapid urbanisation and the expansion of the middle class, open-air wet markets and hawkers are still fundamental to the food retail system (Abrahams 2009; Del Pozo-Vergnes and Vorley 2015; Hawkes et al. 2017; Reardon et al. 2014). For instance, in Ghana, open-air markets continue to dominate the food retail system, with 70 per cent of households reporting buying food from them ‘once a week’ or ‘more than once a week’ (Meng et al. 2014). In Nairobi, Kenya, only 10 per cent of urban households’ income is spent at supermarkets (Abrahams 2009). Similarly, the Zambian Central Statistics Office recognises that open-air wet markets are the preferred retail outlets of urban Photo: UN Women/Ryan Brown. Woman selling bananas, Seychelles, 2017 <https://bit.ly/3ll6kk5>. The International Policy Centre for Inclusive Growth | Policy in Focus 15 residents (ibid.). Thus, in many developing countries territorial markets, both formal and informal, and hawkers continue to be the main choice of urban consumers for purchasing and procuring food. Additionally, a large proportion of these consumers have low disposable incomes, and their shopping patterns are tied to low-value-added goods, with minimal processing and packaging (ibid.). Territorial markets remain essential food retail outlets where households can access most locally produced foods, including in-season and nutritious foods, such as fresh vegetables and fruits (as shown in Table 1). Evidence from Bolivia In a study conducted by FAO and the National Institute of Agricultural Research (INRA) in 2016, four organic farmers’ markets5 (a type of territorial market) were analysed to understand their functioning mechanisms as well as products and consumer characteristics. Results of the study show that short supply chains linked to the four markets were dominated by family farmers, particularly women. Figure 1 shows that 84 per cent of market operators were women, with the majority of them having received only primary education. Concerning access to productive resources, 87 per cent of the producers have farmland of up to 2 hectares, and 75 per cent mainly use family labour. A total of 72 different products are sold at these farmers’ markets, especially potatoes, vegetables and cereals. In terms of food groups (Figure 2), the most typical product groups sold at these farmers’ markets are vegetables, tubers and cereals. This figure is very relevant for Bolivia because the country is experiencing an increase in adult overweight and obesity, while both availability and consumption of fruits and vegetables are below recommended quantities (Development Initiatives 2018). Concerning consumers, women make up 85 per cent of all buyers. An analysis into the monthly income of consumers’ households6 revealed that 1 per cent of households belong to the income bracket with less than BOB1,000 (USD145) per Source: FAO and INRA (2016). Source: FAO and INRA (2016). FIGURE 1: Characteristics of producers operating in four organic farmers’ markets in Bolivia Primary Upper secondary Lower secondary University Family Both Hired Men Women Less than 1.99 Between 2 and 4.99 Between 5 and 19.99 Between 20 and 100 Retailers Land Labour Formal educaon 16% 84% 87% 75% 23% 9% 2% 2% 2% 70% 14% 8% 8% FIGURE 2: Food groups sold in four organic farmers’ markets in Bolivia Other products Flowers Honey and honey products Processed produtcts Dairy products Smulants Cereals Spices Fruits Forage Roots and tubers Vegetables 0.6% 0.6% 1.1% 1.5% 3.5% 0.2% 13.9% 0.9% 3.2% 17.6% 54.0% 3.0% 16 “ Smallholder agriculture is the main source of income for the majority of the world’s poor people who live in rural areas. month, 25 per cent to the income bracket BOB1,000–3,000 (USD145–435), 48 per cent to the income bracket BOB3,000–5,000 (USD435–725), 19 per cent to the income bracket BOB5,000–10,000 (USD725–1,450), and 5 per cent to the income bracket with more than BOB10,000 (USD1,450) (see Figure 3). Approximately 27 per cent of consumers and households in the FAO study are living below or very close to the poverty line7,8— i.e. households with a monthly income of less than BOB3,000. Evidence from these four organic farmers’ markets in Bolivia shows that not only do these markets make healthy and nutritious foods available, such as organic and agroecological fresh fruits and vegetables— foods that are usually under-consumed in national diets—but also that these markets are important retail outlets for households belonging to different income brackets, including those living below the poverty line. Conclusion Smallholder agriculture is the main source of income for the majority of the world’s poor people who live in rural areas. Yet territorial markets where the majority of these smallholders operate are neglected and do not receive adequate support, limiting their contribution to food security and promotion of healthy diets. Since poverty and malnutrition are multidimensional phenomena (FAO 2019b), interventions for reducing poverty, improving nutrition and promoting healthy diets need inclusive and systemic approaches based on reliable data that incorporate territorial markets, as they are physical and social spaces at the core of territorial food systems where production and consumption meet. Territorial markets can play an important role in ensuring inclusive and sustainable food systems, and if policymakers want to transition to these systems, they should pay more attention to these markets. Abrahams, C. 2009. “Transforming the region: Supermarkets and the local food economy.” African Affairs 109(434): 115–134. Ayieko, M., D. Tschirley, and M. Mathenge. 2005. “Fresh Fruit and Vegetable Consumption Patterns and Supply Chain Systems in Urban Kenya: Implications for Policy and Investment Priorities.” Working Paper, No. 16. Nairobi: Tegemeo Institute of Agricultural Policy and Development, Egerton University. Callon, M., and F. Muniesa. 2005. “Peripheral Vision: Economic Markets as Calculative Collective Devices.” Organization Studies 26(8): 1229–1250. CFS. 2016. Connecting smallholders to markets. Rome: Committee on Food Security. Crush, J., N. Nickanor, and L. Kazembe. 2019. “Informal food deserts and household food insecurity in Windhoek, Namibia.”Sustainability11(1): 37. Development Initiatives. 2018. Global Nutrition Report: Shining a light to spur action on nutrition. Bristol, UK: Development Initiatives. EAT-Lancet Commission. 2019. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems 393(10170): 447–492. Source: FAO and INRA (2016). No fixed income Less than 1,000 1,000 - 3,000 3,000 - 5,000 5,000 - 1,0000 More than 10,000 FIGURE 3: Income bracket of consumer households buying at four organic farmers’ markets in Bolivia (expressed in bolivianos—BOB) 48% 19% 5% 25% 1% 2% The International Policy Centre for Inclusive Growth | Policy in Focus 17 FAO. 2015. Food outlook 2015. Rome: Food and Agriculture Organization of the United Nations. FAO. 2017a. The state of food and agriculture. Rome: Food and Agriculture Organization of the United Nations. FAO. 2017b. Supporting Family Farmers to reduce rural poverty. Rome: Food and Agriculture Organization of the United Nations. FAO. 2018. Empowering People and Strengthening Rural Organizations. Rome: Food and Agriculture Organization of the United Nations. FAO. 2019a. Sustainable Healthy Diets: Guiding Principles. Rome: Food and Agriculture Organization of the United Nations. FAO. 2019b. The State of Food Security and Nutrition in the World 2019: Safeguarding Against economic slowdowns and downturns. Rome: Food and Agriculture Organization of the United Nations. FAO. forthcoming. Mapping of territorial markets: a manual for data collection. Rome: Food and Agriculture Organization of the United Nations. FAO and INRA. 2016. Innovative Markets for Sustainable Agriculture. Rome: Food and Agriculture Organization of the United Nations. Hawkes, C., J. Harris, and S. Gillespie. 2017. “Changing diets: Urbanization and the nutrition transition.” 2017 Global Food Policy Report, 34–41. Washington, DC: International Food Policy Research Institute. IFAD. 2011. Viewpoint: Smallholders can feed the world. Rome: International Fund for Agricultural Development. Meng, T., W. Florkowski, D. Sarpong, M. Chinnan, and A.V.A. Resurreccion. 2014. “Consumer’s Food Shopping Choice in Ghana: Supermarket or Traditional Outlets?” International Food and Agribusiness Management Review 17: 107–129. Murphy, S. 2010. Changing perspectives: Smallscale farmers, markets and globalisation. London and The Hague: International Institute for Environment and Development and Hivos. Del Pozo-Vergnes, E., and W. Vorley. 2015. Global or local food chains? Uncovering the dilemmas in Senegal and Peru. London: International Institute for Environment and Development. Reardon, T., D. Tschirley, M. Dolislager, J. Snyder, C. Hu, and S. White. 2014. Urbanization, Diet Change, and Transformation of Food Supply Chains in Asia. Ann Arbor, MI: Global Center for Food Systems Transformation, Michigan State University. Roesel, K., and D. Grace (eds). 2015.Food safety and informal markets: animal products in subSaharan Africa. London: Routledge. WHO. 2016. Global Report on Diabetes. Geneva: World Health Organization. World Bank. 2018. Poverty and Shared Prosperity 2018: Piecing Together the Poverty Puzzle. Washington, DC: World Bank. “ Territorial markets can play an important role in ensuring inclusive and sustainable food systems. Photo: Dominic Chavez/World Bank. Members of an agriculture cooperative nurturing their fields of vegetables, Kieryaghin village, Burkina Faso, 2013 <https://clck.ru/QyQvQ>. 18 1. Food and Agriculture Organization of the United Nations (FAO). 2. Based on the CFS criteria, the main typologies of territorial markets are wet markets, neighbourhood food markets and farmers’ markets. Many other typologies can exist though, depending on the context. 3. Conseil National de Concertation et de Coopération des Ruraux (CNCR) in Senegal; Confédération Paysanne du Faso (CPF) in Burkina Faso; and Asociación Nacional de Productores Ecologicos (ANPE) and Terra Nuova in Peru. 4. Table 1 summarises results from different studies conducted in several developing countries (Meng et al. 2014; IDS 2015; Del Pozo-Vergnes and Vorley 2015). 5. Bio-Achocalla in La Paz, Bio-Tiqui and ECO Feria in Cochabamba, and Bio Tarija in Tarija. 6. Considering a four-member household. 7. According to the World Bank (2018), living on less than USD3.20 per day reflects the poverty line in lower-middle-income countries. 8. Given that the average household size is four members, USD3.20 per person per day means USD12.80 per household per day, and USD384 per household per month. The role of smalland medium-sized enterprises in addressing the malnutrition challenge: reflections from project implementation in Ghana, Kenya and Viet Nam Pilar Santacoloma and Manuel Anta1 The immense malnutrition challenge of today calls for a transformation of the food system, and a critical understanding of the driving forces and actors that can play a role in promoting better diets and optimal nutrition. Among the various forces and actors which comprise food systems, the private sector is one of the most important. It is critical to enhancing access to and the availability and affordability of safe, diverse and nutritious foods. A major proportion of private-sector entities in many countries are small and medium-sized enterprises (SMEs). Although they are a major vehicle for nutrition within food systems, they face many challenges to survive as a subsector, not least due to being erroneously considered missing and broke (AGRA 2019). This paper discusses the relevance of SMEs in addressing the malnutrition challenge, with illustrations from a field project on the development of SMEs led by the Food and Agriculture Organization of the United Nations (FAO). What are SMEs? SMEs participate in all stages of food supply chains, including production (input providers, technical, research and financial institutions), processing, transportation, branding and packaging, and retailing, as key actors such as wholesalers, vendors, restaurants and traders (Demmler 2020). However, there is no international standard for defining SMEs, as the criteria for definition vary according to country contexts and sectors. Most commonly though, SMEs are defined according to the number of employees, capital assets, turnover in the post-production stages, or the size of plots used during production. For instance, in the European Union, the upper limit designating SMEs is 250 employees (European Commission 2003). For lowand middle-income countries, the United Nations Industrial Development Organization (UNIDO) defines SMEs as those that have 5–99 employees, with small firms defined as those with 5–19 employees, and medium-sized firms as those with 20–99 employees. At the production stage, and depending on the context, SMEs are characterised as those with landholdings of 2–100 ha, 5–100 ha or 5–20 ha (Lowder, Skoet, and Raney 2016). While there are many definitions of SMEs, what is commonly agreed is that entrepreneurship is a driving force behind them. The European Commission defines it as follows: “Entrepreneurship is the mindset and process to create and develop economic activity by building risk-taking, creativity and/or innovation with sound management, within a new or an existing organization” (OECD 2006). Driven by entrepreneurship, the contribution of SMEs to employment, growth and sustainable development is now widely acknowledged. Their development can deepen the manufacturing sector and foster competitiveness, and can help achieve a more equitable distribution of the benefits of economic growth, thereby helping alleviate problems associated with uneven income distribution (Boto and La Peccerella 2009). In lowand middle-income countries, the available evidence suggests that SMEs have played a major role in the growth and development of all leading economies in “ The immense malnutrition challenge of today calls for a transformation of the food system. Photo: Cristina Aldehuela. A woman prepares green peppers to sell at this small stand in Agbogbloshie market. Ghana, 2016. The International Policy Centre for Inclusive Growth | Policy in Focus 19 Asia and is the key sector in the agricultural transformation in Africa (AGRA 2019). For example, we know that post-farm SMEs are the primary buyers of produce from small-scale farmers and are also suppliers of food for poor and vulnerable consumers (Demmler 2020). The role of SMEs in nutrition A rapid transformation is taking place in food systems worldwide, driven by rapid urbanisation, higher incomes, changing technology, increasing women’s participation in wage employment, and trade liberalisation (FAO 2019). This transformation has placed heavy pressure on food systems to deliver safe, diverse and nutritious foods (ibid.). For instance, in African countries there has been a rapid rise in the consumption of processed foods, which now represent 40–65 per cent of total urban and rural food purchases (Tschirley et al. 2015). Similarly, it is important to note the rise in consumption of non-staple foods (meat, fish, milk, fruits, vegetables, lipids and roots/tubers, the latter mainly in West Africa), which form 50–70 per cent of urban and rural diets in Africa (AGRA 2019). These developments have immense relevance for the SME sector, as they produce between 30 per cent and 65 per cent of all the food consumed globally, and even more—between 75 per cent and 90 per cent—in sub-Saharan Africa (Demmler 2020). It is at this stage of food systems where the availability, affordability, diversity and safety of food are shaped. Further, it is estimated that almost 95 per cent of small-scale farmers in Africa supply the SMEs involved in processing directly or via small-scale wholesalers (AGRA 2019). The processing stage—also mainly composed of SMEs in lowand middle-income countries— is fundamental to increasing food quality and safety and reducing the probability of contamination and losses of nutrient content of fresh products. It is estimated that nearly a third of total food production is lost in production and postproduction (HLPE 2014). Furthermore, processing helps to enhance shelf life, increase palatability and convenience of food and increase nutrient content (Demmler 2020). It is estimated that nearly 40 per cent of all agricultural output is generated in the processing stage (AGRA 2019). Therefore, to support an inclusive agricultural transformation, the linkages between small-scale farmers and SMEs engaged in processing need to be fostered and strengthened through investment. Similarly, the food retail stage—also composed mostly of SMEs—is highly relevant for food security and nutrition, as it not only links food with consumers but also because it is the transmitter of demand from consumers upstream to farmers. In sub-Saharan Africa, food retailing is believed to generate about 20 per cent of the total value of the agri-food sector (ibid.). A critical question then is how SMEs, which produce, process and market shelf-stable and nutrient-rich products, can make use of wholesale and retail networks to outsource their raw materials from smallscale producers, market their products effectively, make a profit and, at the same time, reach low-income consumers. SMEs face serious challenges in this endeavour in terms of access to finance, quality of supply, a skilled labour force, compliance with food quality and safety standards and infrastructural conditions (see Box 1). Maestre et al. (2017) note that another key challenge in the marketing of nutrient-rich foods is their credence characteristic—that is, their nutrient value is not observable by consumers. Demand for these foods, therefore, depends on distinctive labelling of food quality and marketing. Up to now, most of the efforts to leverage the private sector to deliver better diets have focused on incentivising large national and multinational companies. The role of SMEs in nutrition has been less discussed, despite their importance in linking smallholder producers, markets and consumers in both rural and urban areas (HLPE 2017). BOX 1: Main constraints for SMEs delivering nutritious foods in Ghana Under the project GLO/GCP/712/JPN, FAO undertook a ‘Net-Map’ workshop to identify bottlenecks and opportunities for supporting SMEs in delivering more nutritious products. The respondents interviewed are engaged in activities such as production, processing, and supply of raw materials. Commodities produced by the respondents included mushrooms, peppers, tomatoes, maize, cassava, table eggs, poultry, including chicken and guinea fowl, sheep and goats. Most of the respondents sell their commodities to urban dwellers, with a few also selling to rural residents, suggesting a lack of service to rural consumers and, consequently, limited food environments. According to the respondents, financing from banks is their most significant challenge. The reasons for this include: higher interest rates from banks; difficulty in accessing loans or high collateral requirements; banks requiring immediate repayment and perceiving agriculture-related businesses as risky; and the unwillingness of banks to lend money to SMEs due to poor repayment histories of some of their counterparts. The second major challenge is the expensive and inconsistent supply of inputs, particularly the small capacity of locally manufactured machines used in production and the high duty costs of imported ones. The third major challenge is a lack of workers with the required skills, implying costly training and supervision costs to accomplish given tasks. Lastly, marketing of their products also appeared to be a particular weakness. Some respondents mentioned that they do not provide any information about the quality of their products to potential consumers, and only a few advertise using public media outlets. The project collaborates with the University of Ghana, the Association of Ghana Industries (AGI) and the National Board for Small Scale Industries (NBSSI) to generate a capacity-building strategy for selected SMEs and raise awareness at the government level on the need to support SMEs with specific incentives and policies. Similar activities are also being implemented in Viet Nam and Kenya in partnerships with local universities. To reinforce these activities, an e-learning course designed for policymakers, SME associations and development partners on leveraging the potential of SMEs to support nutritionsensitive food systems is under development. Source: FAO and IFPRI (2020 forthcoming). 20 Policy recommendations SMEs along the food supply chain have considerable potential to supply safe, diverse and nutritious food to most populations but particularly to the most vulnerable. However, several restrictions need to be overcome for them to be able to reach their potential. The following policy recommendations are based on good practices from the FAO-led field programmes; they can support a vibrant SME sector and their contribution to better diets: yEase the barriers to doing business for SMEs along the food supply chain through infrastructure development, such as building and improving roads, electrification and wholesale markets, to enhance linkages between input suppliers, farmers, processors and retailers via reduced transaction costs and improved productivity. yPromote collaboration among stakeholders, including the participation of stakeholders and actors from the public and private sectors, to create business-friendly conditions and encourage the development of joint strategies to better address the multiple challenges faced by SMEs. yEnhance the capacities of SMEs to invest in equipment by establishing incentives through grants, credits, subsidies or tax breaks or by facilitating imports of processing equipment with low tariffs. yEstablish public nutrition awareness and education programmes on the importance of healthy diets for SMEs. yProvide training and mentoring campaigns to SMEs on food safety regulations and standards, and designate specific credit lines to support the upgrading of infrastructure and equipment. AGRA. 2019. “The Hidden Middle: A Quiet Revolution in the Private Sector Driving Agricultural Transformation.” Africa Agriculture Status Report, Issue 7. Nairobi, Kenya: Alliance for a Green Revolution in Africa. Boto, I., and C. La Peccerella, 2012. “SMEs: Resources on the opportunities and challenges for SMEs in the agricultural sector of ACP countries.” Brussels Rural Development Briefings: a Series of Meetings on ACP–EU Development Issues, No. 13. Brussels: CTA. <https://brusselsbriefings.files.wordpress. com/2012/10/reader-br-9-smes-eng.pdf>. Accessed 30 October 2020. Demmler, K. 2020. “The Role of Small and Medium-sized Enterprises in Nutritious Food Supply Chains in Africa.” GAIN Working Papers Series, No. 2. Geneva: Global Alliance for Improved Nutrition. <https://www.gainhealth. org/sites/default/files/publications/documents/ gain-working-paper-series-2-the-role-of-smalland-medium-sized-enterprises-in-nutritiousfood-supply-chains-in-africa.pdf>. Accessed 30 October 2020. European Commission. 2003. Recommendation concerning the definition of micro, small and medium-sized enterprises, 6 May 2003. Doc. 2003/361/EC. Brussels: European Commission. <http://europa.eu/eur-lex/pri/en/oj/ dat/2003/ l_124/l_12420030520en00360041.pdf>. Accessed 30 October 2020. FAO and IFPRI. 2020 (forthcoming). Approaches for Leveraging Small and Medium Enterprises to Improve Nutrition. Net-Map assessment of actors and activities in Ghana. Rome: Food and Agriculture Organization of the United Nations. Herrero, M. et al. 2017. “Farming and the geography of nutrient production for human use: a transdisciplinary analysis.” Lancet Planet Health 1(1): e33–e42. HLPE. 2014. Food losses and waste in the context of sustainable food systems. Rome: Food and Agriculture Organization of the United Nations, 117. Lowder, S.K., J. Skoet, and T. Raney. 2016. “The number, size, and distribution of farms, smallholder farms, and family farms worldwide.” World Development 1(87): 16–29. Maestre, M., N. Poole, and S. Henson. 2017. “Assessing food value chain pathways, linkages and impacts for better nutrition of vulnerable groups.” Food Policy 68: 31–39. OECD. 2006. The SME financing gap. Vol. 1: Theory and Evidence. Paris: OECD Publishing. <https:// www.oecd-ilibrary.org/finance-and-investment/ the-sme-financing-gap-vol-i_9789264029415en>. Accessed 30 October 2020. Tschirley, D., T. Reardon, M. Dolislager, and J. Snyder. 2015. “The rise of a middle class in urban and rural East and Southern Africa: Implications for food system transformation.” Journal of International Development 27(5): 628–646. UN DESA. 2018. “World Urbanization Prospects.” United Nations Department of Economic and Social Affairs website. <https://population.un.org/wup/Download/>. Accessed 30 October 2020. 1. Food and Agriculture Organization of the United Nations (FAO). “ A rapid transformation is taking place in food systems worldwide, driven by rapid urbanisation, higher incomes, changing technology, increasing women’s participation in wage employment, and trade liberalisation. Photo: Giulio Napolitano. Women filling jars with diverse and nutrient-rich foods. Swaziland, 2016. The International Policy Centre for Inclusive Growth | Policy in Focus 21 Taxes as a policy measure to promote healthy diets Shu Wen Ng, M. Arantxa Colchero, Juan Rivera and Barry Popkin1 Setting the scene: Malnutrition and the affordability of healthy food Addressing malnutrition involves increasing financial and physical access to health-promoting, nutrient-rich and culturally appropriate foods, in addition to educational efforts. This can be a challenge in under-resourced locations and among those experiencing poverty and food insecurity. Under the current global threat of COVID-19 and its associated immediate and long-term economic, health and social impacts, we are faced, more than ever, with the dire need to reform the food system. One illustration of the troubled food system is the imbalance between the affordability of unhealthy foods and of healthy options. From 1990 to 2016 the affordability of sugar-sweetened beverages (SSBs) increased in most low-, middleand high-income countries. This happened more rapidly in lowand middle-income countries (LMICs) than in high-income countries, largely due to the higher rate of income growth in those countries rather than a decline in the real price of SSBs (Blecher et al. 2017). Additionally, food price data from 176 countries in 2011 show that healthy foods, especially most animal-sourced foods and fortified infant cereals, were generally expensive in low-income countries, while most non-cereal foods, including sugarand fat-rich foods, were relatively cheap in high-income countries (Headey and Alderman 2019). It was also very telling that milk prices were found to be positively associated with stunting prevalence, while SSB prices are negatively associated with overweight prevalence. Thus, the food systems transformation agenda needs to include policies aimed at addressing affordability in the short term by creating incentives to promote healthy diets and changing norms around the desirability of unhealthy foods compared to healthy options, in addition to complementary efforts regarding physical access to healthy foods and education over time. Taxation could help support these efforts because it can serve three functions. A well-designed policy can: 1) create financial disincentives for consumers and producers regarding unhealthy items; 2) generate tax revenue to support healthy food production and diets among poor households; and 3) send consistent messages to the population on the importance of healthy foods and diets. These effects are likely to be larger in LMICs than in high-income countries, as well as among low-income populations within countries (Cornelsen et al. 2015). To date, over 45 countries, cities or regions within countries worldwide have instituted taxes on SSBs, with a few also imposing taxes on ultra-processed foods (UPFs) that exceed certain nutrient thresholds. Excise taxes have been adopted more quickly on SSBs than on UPFs because SSBs clearly do not provide nutrients of value, do not provide a feeling of satiation (thus resulting in excess consumption) and are associated with many diseases (WHO 2016). More recent research provides strong support for the extremely detrimental health effects of UPFs (Lawrence and Baker 2019; Vandevijvere et al. 2019). Meanwhile, UPF sales and consumption are increasing very rapidly across most LMICs, forming a growing share of the diets of very poor people and now reaching infants and pre-schoolers (Pries, Filteau, and Ferguson 2019; Pries 2016). While SSBs represent about 2–7 per cent of food purchases and 4–10 per cent of kcal/day, UPFs (which includes SSBs), represent between 17 per cent and over 25 per cent of purchases (15–60 per cent of kcal/day) depending on age group, gender and country. Therefore, it is also critical to adjust the prices of unhealthy UPFs relative to healthy foods. In this article we provide examples of places where such taxes have been implemented, to illustrate how they can help with this goal and how they might be further improved. We then discuss future options that recent research suggests are needed in fiscal policy to truly improve diets and, subsequently, all nutrition-related non-communicable diseases (NCDs). Mexico’s SSB and junk food taxes: A pioneer, but further action needed With some of the world’s highest prevalence of obesity and NCDs, Mexico introduced an excise tax of MXN1 per litre (a price increase of about 9–10 per cent if fully approved) on SSBs, as well as an 8 Photo: Bart Verweij / World Bank. Nutritious meals, Laos, 2012 <https://bit.ly/2GMNNOC>. 22 per cent ad valorem tax on non-essential foods with over 275 kcals per 100g (termed a non-essential food tax) in 2014. This was one way to begin addressing the growing imbalance between the prices of unhealthy foods and of healthy foods in the country, particularly for lower-income households (Colchero et al. 2019). Evaluations of Mexico’s taxes have shown that they have helped reduce the purchase, manufacturing and sales of the taxed items, particularly among low-income Mexicans and those who were previously high consumers of these unhealthy products. This was the case for the taxes on both SSBs and non-essential foods (Colchero et al. 2016; Ng et al. 2018; Batis et al. 2016). Meanwhile, purchases of untaxed beverages (such as water) increased, and shifts in demand meant that employment in the beverage and non-essential food sectors were not adversely impacted, as their production portfolios appeared to have shifted. This was also the case among retailers (Guerrero-López, Molina, and Colchero 2017). Based on the findings on SSB reductions alone, the predicted 10year reductions in poor health outcomes include: 189,300 fewer cases of type 2 diabetes, 20,400 fewer incidents of strokes and myocardial infarctions, 18,900 fewer deaths, global savings of around USD983 million (Sánchez-Romero et al. 2016), and a 2.54 per cent reduction in obesity prevalence, with the largest reductions found in populations with the lowest income (Barrientos-Gutierrez et al. 2017). Thus, these taxes (particularly as part of a larger package of interventions) have the potential to prevent many new cases of NCDs, especially among those least able to access treatment. One major missed opportunity in Mexico was the use of the tax revenue generated by the scheme. Early in the implementation phase, there were discussions and pushes by public health advocates for some of the revenue to be used to build potable water stations in rural schools (especially where water quality is poor) and to promote the local production of healthier foods (economic development). This did not occur, however, and the revenue was instead directed towards the general budget, with no specific earmarking. Although the use of revenues to cover general government expenses helps to correct some negative externalities of unhealthy diets, it would be better to earmark those expenses to obesity prevention efforts and to provide potable water to marginalised communities. Educating the public about the purpose of such taxes can help keep them relevant and enhance their health effect. Chile’s SSB tax restructuring and food labelling and marketing regulations: Early promise and opportunities for policy integration and enhancement As part of a concerted obesity and NCD prevention effort, in October 2014, Chile shifted its beverage tax structure from a 13 per cent ad valorem tax to: no taxes on plain water and plain dairy-based drinks; “ Evaluations of Mexico’s taxes have shown that they have helped reduce the purchase, manufacturing and sales of the taxed items, particularly among low-income Mexicans and those who were previously high consumers of these unhealthy products. Photo: Shu Wen Ng. Drinks stand in Mexico City, 2014. The International Policy Centre for Inclusive Growth | Policy in Focus 23 10 per cent on all non-alcoholic beverages with sweeteners and under 6.25 g of sugar; and 18 per cent on all non-alcoholic beverages with sweeteners and 6.25 g or more of sugar. Due to the relatively small increase (plus 5 percentage points) and decrease (minus 3 percentage points) in prices, evaluations of this tax restructuring have shown that the price changes were muted (i.e. partially absorbed by suppliers), and purchase changes were consequently small (Caro et al. 2018). In June 2016, Chile began implementing ground-breaking food labelling and marketing regulations, including mandatory warnings when products are ‘high’ in sugar, saturated fats, sodium or energy (products can have up to four warning logos). Additionally, products with at least one warning logo were not allowed to be marketed to children through any media (including digital) or in schools. This provides a good opportunity to further policy integration efforts. Simulations of expanding the tax to include UPFs show that if Chile were to implement an unhealthy UPF tax, in line with its food labelling and marketing regulations, household purchases of these items would fall dramatically. These substitutions could result in reductions in nutrients of concern such as sugar (-5 g/ capita/day) and sodium (-23 mg/capita/ day), and calories (-42 kcals/capita/day), which are linked with the most common NCDs (Caro et al. 2017). Moreover, simulations show that such an unhealthy UPF tax, in addition to the removal of Chile’s current 19 per cent value-added tax on fruits and vegetables, would result in a net welfare gain and subsidy transfer for the average household, with low-income households gaining more than high-income households (Caro et al. 2020). Therefore, if Chile were to integrate its tax policy with its labelling and marketing policy, and further adjust the relative prices of healthy foods by removing an existing tax, these measures could lead to important equityand health-promoting outcomes. The way forward: Fiscal policies to support healthy diets The current COVID-19 pandemic has created considerable shocks around the world, with those in the informal sectors of the economy most immediately impacted and thus facing enormous, long-lasting and potentially generational consequences for their overall well-being, including food and nutrition insecurity, educational attainment, and future earnings and upward economic mobility. The health crisis also presents opportunities for change and to reassess how different types of food and those who produce them should be valued, as well as our engagement with food. Fiscal policies can help nudge this re-framing of our relationship with food by adjusting the prices of healthy foods relative to unhealthy foods, and they can be used as an income transfer approach to redistribute resources and address existing economic and health inequities. “ The current COVID-19 pandemic has created considerable shocks around the world, with those in the informal sectors of the economy most immediately impacted. Photo: Oxfam International. Children in Mexico, 2012 <https://clck.ru/QyQvQ>. 24 Food systems play an essential role in delivering affordable, safe and sustainable diets that, combined with other factors (living conditions, basic infrastructure and water and sanitation facilities, food preferences and feeding practices, access to health services), ultimately determine nutrition outcomes. Over the past decades, however, food systems have undergone radical transformations that have changed the way we access and consume food. There has been an exponential growth in the availability of retail food, supermarket penetration and the market power of agribusinesses and food retailers, manufacturers and food service companies (Popkin et al. 2020). This, accompanied and sustained by aggressive branding and marketing, has made cheap, ultra-processed food widely available around the world. Growth in per capita income and variations in relative prices have also transformed food patterns. Both healthier and unhealthier foods become more affordable as countries develop (Headey and Alderman 2019). This partly explains differences in food patterns between countries with varying levels of development. Access to nutritious foods such as milk, eggs, fruits and vegetables is usually more limited in low-income countries, whereas access to cheap, energy-dense but nutrient-poor foods is more frequent in middleand high-income countries. Food prices are also critical to explain diet quality. FAO, IFAD, UNICEF, WFP and WHO (2020) estimate that 3 billion people in the world could not afford a healthy diet in 2017, as it cost almost five times as much as a diet that would meet minimum energy needs. Inequality in food access contributes to the disparities in overweight rates observed between poor and wealthier households. Recent evidence suggests that the prevalence of overweight and obesity progressively shifts from affecting families at the top of the income distribution to those at the bottom as the economy develops (Popkin et al. 2020;). Data from lowand lower-middle-income countries, mainly in sub-Saharan Africa and South Asia, show that overweight is predominantly linked to high-income households. By contrast, in upper-middleincome economies such as China, Brazil and Mexico, overweight affects lowincome households more frequently. Overweight and obesity impose substantial costs on societies, families and individuals. They are a major determinant for the development of non-communicable diseases, including heart failure, type 2 diabetes and several types of cancer, which altogether are responsible for approximately 70 per cent of all deaths globally (WHO 2020b). The odds of developing non-communicable disease vary across population groups. The risk of cardiovascular disease and cancer is higher among low-income households, especially “ A rapid shift in our diets has reconfigured the global nutrition profile in just one generation. in lowand lower-middle-income countries (Williams et al. 2018). In the USA, being black, female, young or having low income or educational attainment increases the risk of obesity, and racial and class differences have been associated with the risk of premature death (Lincoln et al. 2014). The potential role of social protection in tackling the obesity epidemic While a large number of studies have shown that cash transfers can reduce undernutrition,4 we know surprisingly little about their impact on overweight and obesity. This could be because many social assistance programmes prioritise lifting households out of extreme poverty and protecting them from food insecurity and hunger, rather than addressing overnutrition. Brazil’s Bolsa Família, for instance, was at the core of the government’s Zero Hunger strategy. Overnutrition, however, is no longer a concern merely for rich people, but increasingly affects poor and vulnerable populations. Since social assistance programmes have been expanding in many countries to cover larger numbers of poor and vulnerable households beyond those living in extreme poverty, the proportion of social assistance recipients who are, or are at risk of being, overweight or obese will almost inevitably increase. Even at the outset of Bolsa Família in 2005, overweight and obesity were already as prevalent as undernutrition among programme beneficiaries. Source: Author's elaboration based on WHO and WB data. FIGURE 2: Prevalence of overweight among adults (18+ years), by per-capita income and income group, 2012-2016 GDP per capita, PPP (2017=100 internaonal US$) [Log scale], 2012-2016 1,0002,500 5,00010,00020,00040,00080,000150,000 Prevalence of overweight among adults (%), 2012-2016 20 40 60 80 Americas East Asia & Pacific Europe & Central Asia Middle East & North Africa South Asia Sub-Saharan Africa The International Policy Centre for Inclusive Growth | Policy in Focus 31 Dispensing cash to poor households increases their purchasing power, which will lead to both income effects5 and substitution effects.6 The former predicts that households will consume more of what they were already consuming before, while the latter implies that households will substitute the consumption of cheaper goods for more expensive ones. The income effect can be expected to lead to an increase in the daily amount of calories consumed. Indeed, there is ample evidence showing that food consumption accounts for the largest share of expenditures that households around the world incur from the cash transfers they receive (Fiszbein and Schady 2009). The substitution effect could incentivise households to switch from healthy to unhealthy food (e.g. increasing consumption of fast food or ultra-processed foods), help them afford a more balanced and healthy diet (e.g. switching from simple carbohydrates to more protein sources, vegetables and fruit) or even increase expenditures on non-food items. This will depend on a host of factors: dietary habits and preferences, the household’s initial income level, time poverty, food prices, public health education. Apart from direct consumption effects, there are a number of ways in which social protection programmes, in particular cash transfers, can help address overnutrition (see Figure 3). Evidence shows that the income boost provided by cash transfer programmes lowers the financial barriers that prevent households from accessing social services, most notably health care and education. More frequent contact with health professionals and use of health services can help in the early diagnosis and treatment of nutrition-related conditions. At the same time, expanding access to education might help caregivers and children of beneficiary households make more informed dietary choices, although there is limited evidence that it does. The potential positive effects of greater access to health services and education could be reinforced if a cash transfer programme incorporates conditionalities or strong messaging around health and education. Few studies have explicitly examined these links empirically. Fernald, Hou and Gertler (2008a; 2008b) show that participants of Mexico’s Oportunidades had a significantly lower BMI and prevalence of obesity than non-participants, but the programme’s cash component led to higher BMI, higher prevalence of overweight and obesity, and higher levels of blood pressure. Likewise, two studies on Colombia’s Familias en Acción (Attanasio et al. 2005; Forde et al. 2012) found that this programme also increased both BMI and the odds of being obese. A number of observational studies have reached similar conclusions, but they need to be interpreted with caution, as they are not showing any causal effects of cash transfers. These include a crosssectional study of Bolsa Família that found children in beneficiary households three times more likely to consume junk food (Saldiva, Silva, and Saldiva 2010), studies of Egypt’s Tamween food subsidy scheme (Ecker et al. 2016) and the US Supplemental Nutrition Assistance Program (Leung et al. 2013). There is little evidence, however, that cash transfers or other anti-poverty programmes have managed to address overnutrition among their participants. A recent study by Levasseur (2019) found an overall decrease in obesity related to Oportunidades, although it suggests that this decrease was caused not by the cash transfer but by the programme conditionalities, which included training sessions (pláticas) focusing on healthy nutrition and young child feeding practices. By contrast, Leroy et al. (2013)’s study of Mexico’s Programa de Apoyo Alimentario, launched in 2003 to assist very poor and vulnerable rural households who could not be reached by Oportunidades,7 found that both the food basket and cash transferred by the programme led to an increase in BMI even when accompanied by nutritional training. This effect was higher among women who were already obese at baseline. This limited evidence about the impacts of social protection on overweight and obesity suggests that policymakers, programme designers and evaluators have been slow to recognise the extent Source: Authors’ elaboration based on the literature cited in this article. FIGURE 3: Cash transfers and obesity—conceptual framework Cash transfer Condions Cash + Dedicated trainings on nutrion Access to health and educaon Substuon effect Income effect Shi to healthier / less caloric food Shi to processed food/meals out Consume more of the same Increase in overweight / obesity Decrease in overweight / obesity 32 to which overnutrition is affecting rising numbers of poor people. Consequently, programmes around the world have seldom made overnutrition a priority. The studies by Leroy et al. (2013) and Levasseur (2019) point to the need for more research to identify other contributing factors and how complementary nutrition sessions can effectively induce changes in dietary habits, food use and feeding practices among beneficiaries of cash transfers. It is possible—and a matter for further research—that cash transfers are helping poor households gain greater access to food but falling short of providing them with choices and the ability to afford healthy diets. We also need to know more about the long-term impacts of these programmes, particularly the generational impacts of investing in children’s health and education: the few existing studies do not examine their effects on overweight and obesity (Molina Millan et al. 2019). Countries have been experimenting with the provision of complementary interventions alongside cash—commonly referred to as ‘cash+’—ranging from social and behavioural change interventions aimed at improving knowledge and practices around health and nutrition to the distribution of vegetable seeds and training in home gardening, food storage and preparation to promote more diverse, nutritionally rich diets. Linking social protection with nutrition-sensitive agricultural interventions also offers the prospect of increasing the productive capacity of smallholder farmers, which can help them diversify and enrich their diets by either consuming what they harvest or procuring healthy foods in the market with the proceeds from the crops they sell. However, there is no empirical evidence yet on their impact on overweight and obesity. Social protection can clearly contribute to create an environment that enables and promotes healthy diets by improving physical and economic access to food. These schemes have already been shown to be a useful tool to reduce child and maternal undernutrition, but they may not be sufficiently well suited to address the rising prevalence of overweight and obesity that is increasingly affecting not just rich people but growing numbers of poor households around the world. The design and implementation of existing programmes could be revisited so that they can simultaneously address the nutritional deficiencies for which they were originally intended, but also emerging problems such as obesity and diet-related non-communicable diseases (Hawkes et al. 2020). Addressing the growing prevalence of overnutrition will be difficult for the social protection sector to tackle on its own, given current economic and demographic trends (urbanisation, rising incomes), changes in dietary habits (search for convenience food) and food system transformations globally (supermarket penetration, disruptions in local food systems and the increasing ubiquity of cheap, ultra-processed food and obesogenic food environments) While we need to learn more about how social protection can promote better dietary and nutritional outcomes, broader changes in public policy and consumer awareness and behaviour will be needed too, if progress towards addressing overweight and ending all forms of malnutrition is to materialise in the near future. Attanasio, O., E. Battistin, E. Fitzsimons, and M. Vera-Hernandez. 2005. “How effective are conditional cash transfers? Evidence from Colombia.” Institute for Fiscal Studies Briefing Note, No. 54. 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Gertler, and X. Hou. 2008a. “Cash component of conditional cash transfer program is associated with higher body mass index and blood pressure in adults.” The Journal of Nutrition 138(11): 2250–2257. Fernald, L.C., X. Hou, and P.J. Gertler. 2008b. “Oportunidades program participation and body mass index, blood pressure, and self-reported health in Mexican adults.” Preventable Chronic Diseases 5(3): A81. Fiszbein, A., and N. Schady. 2009. “Conditional Cash Transfers. Reducing Present and Future Poverty.” Washington, DC: World Bank. <https:// doi.org/10.1596/978-0-8213-7352-1>. Accessed 5 November 2020. Forde, I., T. Chandola, S. Garcia, M.G. Marmot, and O. Attanasio. 2012. “The impact of cash transfers to poor women in Colombia on BMI and obesity: prospective cohort study.” International Journal of Obesity 36(9): 1209–1214. GBD 2017 Diet Collaborators. 2019. “Health effects of dietar y risks in 195 countries, 19902017: a systematic analysis for the Global Burden of Disease Study 2017.” Lancet 393(10184): 1958–1972. <https://doi.org/10.1016/S01406736(19)30041-8>. Accessed 5 November 2020. Photo: Juan Carlos Huayllapuma/CIFOR. Children from La Roya community, Peru, 2015 <https://bit.ly/3koicQW>. The International Policy Centre for Inclusive Growth | Policy in Focus 33 Gertler, P. 2004. “Do conditional cash transfers improve child health? Evidence from PROGRESA’s control randomized experiment.” The American Economic Review 94(2): 336–341. Gitter, S.R., and N. Caldés. 2010. “Crisis, food security, and conditional cash transfers in Nicaragua.” Working Paper, No. 2010-07. Towson, MD: Towson University, Department of Economics. Hawkes, C., M.T. Ruel, L. Salm, B. Sinclair, and F. Branca. 2019. “Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms.” Lancet 395 (10218): 142-155. <https:// doi.org/10.1016/S0140-6736(19)32506-1> Accessed 5 November 2020. Headey, D., and H. Alderman. 2019. “The Relative Caloric Prices of Healthy and Unhealthy Foods Differ Systematically across Income Levels and Continents.” The Journal of Nutrition 149(11): 2020–2033. <https://doi.org/10.1093/jn/ nxz158>. Accessed 5 November 2020. HLPE. 2017. Nutrition and food systems. A report by the High-Level Panel of Experts on Food Security and Nutrition of the Committee on World Food Security. Rome: Food and Agriculture Organization of the United Nations. Jaacks, L., S. Vandevijvere, A. Pan, C. McGowan, C. Wallace, F. Imamura, D. Mozaffarian, B. Swinburn, and M. Ezzati. 2019. “The obesity transition: stages of the global epidemic.” Lancet Diabetes & Endocrinology 7(3). <https:// clck.ru/RyCgu>. Accessed 5 November 2020. Lagarde, M., A. Haines, and N. Palmer. 2009. “The impact of conditional cash transfers on health outcomes and use of health services in lowand middle-income countries.” Cochrane Database of Systematic Reviews, Issue 4, No. CD008137. <https://doi.org/10.1002/14651858.CD008137>. Accessed 5 November 2020. Leroy, J.L., P. Gadsden, T.G. de Cossío, and P. Gertler. 2013. “Cash and in-kind transfers lead to excess weight gain in a population of women with a high prevalence of overweight in rural Mexico.” The Journal of Nutrition 143(3): 378–383. Leung, C.W., S.J. Blumenthal, E.E. Hoffnagle et al. 2013. “Associations of food stamp participation with dietary quality and obesity in children.” Pediatrics 131: 463–472. Levasseur, P. 2019. “Can social programs break the vicious cycle between poverty and obesity? Evidence from urban Mexico.” World Development 113: 143–156. Lincoln, K., C. Abdou, and C. Lloyd. 2014. “Race and Socioeconomic Differences in Obesity and Depression among Black and Non-Hispanic White Americans.” Journal of Health Care for the Poor and Underserved 25(1) February: 257–275. <https:// clck.ru/RrmeK>. Accessed 5 November 2020. Macours, K., N. Schady, and R. Vakis. 2012. “Cash transfers, behavioral changes, and cognitive development in early childhood.” American Economic Journal: Applied Economics 4(2): 247–273. Maluccio, J., and R. Flores. 2005. Impact evaluation of a conditional cash transfer program: The Nicaraguan Red de Protección Social. Washington, DC: International Food Policy Research Institute. Molina Millan, T., T. Barham, K. Macours, J. Maluccio, and M. Stampini. 2019. “Long-Term Impacts of Conditional Cash Transfers: Review of the Evidence.” The World Bank Research Observer 34(1) February: 119–159. <https:// doi.org/10.1093/wbro/lky005>. Accessed 5 November 2020. NCD Risk Factor Collaboration. 2019. “Rising rural body-mass index is the main driver of the global obesity epidemic in adults.” Nature 569(7755): 260–264. <https://www. nature.com/articles/s41586-019-1171-x.pdf>. Accessed 5 November 2020. Popkin, B., C. Corvalan, and L. Grummer-Strawn, L. 2020. “Dynamics of the double burden of malnutrition and the changing nutrition reality.” Lancet 395(10217): 65–74. <https://clck.ru/ RrmdJ>. Accessed 5 November 2020. Popkin, B., S. Du, W. Green, M. Beck, T. Algaith, C. Herbst, R. Alsukait, M. Alluhidan, N. Alazemi, and M. Shekar. 2020. “Individuals with obesity and COVID‐19: A global perspective on the epidemiology and biological relationships.” Obesity Reviews 21(11): 1–17. <https://doi. org/10.1111/obr.13128>. Accessed 5 November 2020. Ruiz-Arranz, M., B. Davis, M. Stampini, P. Winters, and S. Handa. 2002. “More calories or more diversity? An econometric evaluation of the impact of the PROGRESA and PROCAMPO transfer programs on food security in rural Mexico.” ESA Working Paper, No. 02-09. Rome: Agricultural and Development Economics Division, Food and Agriculture Organization of the United Nations. <http://www.fao.org /3/ae028e/ae028e00.htm>. Accessed 5 November 2020. Saldiva, S.R.D.M., L.F.F. Silva, and P.H.N. Saldiva. 2010. “Avaliacao antropometrica e consumo alimentar em criancas menores de cinco anos residentes em um municipio da regiao do semiarido nordestino com cobertura parcial do programa bolsa familia.” Revista de Nutrição 23: 221–229. Shekar, M., and B. Popkin (eds). 2020. “Obesity: Health and Economic Consequences of an Impending Global Challenge.” Human Development Perspectives Series. Washington, DC: World Bank. <https://openknowledge. worldbank.org/handle/10986/32383>. Accessed 5 November 2020. UNICEF. 2019. The State of the World’s Children 2019. Children, Food and Nutrition: Growing well in a changing world. New York: United Nations Children’s Fund. WHO. 2020a. “Noncommunicable diseases. Key facts.” World Health Organization website. <https://www.who.int/news-room/factsheets/detail/noncommunicable-diseases>. Accessed 5 November 2020. Williams, J., L. Allen, K. Wickramasinghe, B. Mikkelsen, N. Roberts, and N. Townsend. 2018. “A systematic review of associations between non-communicable diseases and socioeconomic status within lowand lower-middle-income countries.” Journal of Global Health 8(2): 020409. <https://doi:10.7189/jogh.08.020409>. Accessed 5 November 2020. 1. Food and Agriculture Organization of the United Nations (FAO). 2. London School of Economics and Political Science. 3. FAO. 4. See, for example, Gertler (2004), (Macours et al. 2012), Maluccio and Flores (2005), Gitter and Caldes (2010), Attanasio et al. (2005), Ruiz-Arranz et al. (2002) and Lagarde et al. (2009). 5. We define the income effect as a proportional increase in the consumption of food or other goods when incomes rise. 6. We define the substitution effect as a change in the composition of a household’s consumption bundle in response to an income change. 7. In 2017 the Programa de Apoyo Alimentario was finally merged with Prospera, the successor to Oportunidades. Photo: World Food Programme. Food distribution to displaced children, Colombia, 2005 <https://bit.ly/3phsSVj>. 34 Social protection responses to COVID-19 in the Middle East and North Africa: the case of Egypt Hoda El-Enbaby 1 and Clemens Breisinger 2 Food subsidies and cash transfers in the Middle East and North Africa A social protection system is most effective if, in addition to protecting poor people, it can also respond to shocks and crises in an efficient and timely manner. In a world impacted by COVID-19, social protection has once again moved to the centre of attention as an important measure to shield the most vulnerable people from adverse impacts. Across all countries in the Middle East and North Africa (MENA) region, responses to the pandemic have included lockdowns, the closure of retail outlets and restaurants, the shutdown of airports and the halting of tourism and trade, among others. Governments have been fighting the pandemic while trying to balance health and economic considerations. As economic losses can severely impact the poorest households, social assistance is crucial to protect their livelihoods. Recent analysis estimated that an additional 140 million people could fall into extreme poverty worldwide (according to the World Bank’s USD1.90 per day poverty line) as a result of the pandemic if no relief actions are taken, such as fiscal stimulus or expansions of social safety nets (Laborde, Martin, and Vos 2020). Analysis from Egypt suggests that poor people living in rural areas may be hit especially hard by an expected reduction in remittances (Breisinger et al. 2020). Therefore, now is a good time to assess the current state of social protection in the region, to shed light on the potential role of existing social protection programmes as response mechanisms to COVID-19. In this article we focus on (food) subsidies and cash transfer programmes, as the majority of MENA countries have food subsidy systems and/or cash transfers currently in place. Nearly three quarters of all countries in the region allocated part of their budget to food and energy subsidies (Machado et al. 2018). Spending on social assistance is generally less than on subsidies in MENA, yet countries in the region also have a wide range of social assistance schemes, including cash transfers, contributory and noncontributory pensions, school feeding programmes and public works projects. Food subsidies are considered an important tool in ensuring access to food for poor people. For instance, they are essential for ensuring a minimum caloric intake, particularly during food price fluctuations (Rahman 2016). Yet food subsidies have considerable shortcomings: even though they are usually more progressive than energy subsidies, they are mostly badly targeted and suffer from leakages. This is particularly the case since many of the subsidies were first introduced as universal. In Jordan it is estimated that only 13 per cent of the subsidised bread is consumed by the poorest households, while 12 per cent is consumed by the wealthier segments, and 25 per cent of subsidised flour goes to the production of nonsubsidised bread or other bakery products (Duwayri 2016). In Egypt, the leakages were estimated at 28 per cent, when comparing the difference between quantities supplied by government agencies and quantities consumed by households (Sdralevich et al. 2014). These factors have prompted countries to consider reforming their food subsidy systems. National cash transfer programmes are not yet commonplace in MENA. Almost all countries have programmes that target specific groups of people (such as widows, people with disabilities, elderly people, orphans etc.), but in the aftermath of the Arab Spring, governments have been trying to reform their social assistance schemes. Following the successful examples of Latin America, some countries have introduced new cash transfers programmes, including Egypt, Tunisia and Morocco. However, most have made little progress, leading to continued inadequate support for the bottom quintile of the population, while a large number of better-off households keep benefiting from social protection programmes (Jawad 2016; Loewe 2017). Countries have taken several measures to respond to the pandemic. The most common response in the region has been to introduce a new emergency cash transfer (IBC-SP and IPC-IG 2020). Several countries have also expanded existing cash transfer programmes, while others have topped up payments or done both, among other measures (ibid.). In Jordan, for instance, it was announced that the government had started registering households for a Bread Subsidy Cash Compensation Programme using the existing cash transfer programme forms, and had launched a temporary emergency cash transfer programme to support poor households affected by COVID-19. In-kind support is also being provided to vulnerable families through food parcels, while the universal bread subsidy was increased (Gentilini et al. 2020). Iraq also launched an assistance package for the most vulnerable people, who have been affected by the curfew and lockdown measures imposed, and started distributing food baskets to some poor households (ibid.). Tunisia introduced a series of one-off cash transfers for households with family members in the informal sector and not covered by any social assistance programme, those covered in the social security system, those hosting elderly individuals or people with disabilities, and those fostering children without parental support. The country also made progress in launching a unified digital payment platform (ibid.). Apart from the cash and in-kind transfers, some countries introduced other mechanisms to support the incomes The International Policy Centre for Inclusive Growth | Policy in Focus 35 of households and businesses. In Tunisia, health insurance was maintained for all workers, pension payments were topped up, contributory unemployment benefits were announced, and businesses were allowed to waive their contributions to the social security scheme. In Bahrain, the government decided to cover utility bills for individuals and businesses, and exempted households from paying municipality fees on their first residence. The government is also paying the salaries of private-sector employees for 3 months from the unemployment fund, and paying 50 per cent of salaries of Bahrainis in the most affected sectors for a further 3 months (ibid.). All these measures are helping mitigate the effects of the pandemic on those most vulnerable and worst affected. In the next section we highlight Egypt’s experience as a successful example of introducing a national cash transfer programme and how it is used as a response to the pandemic. From food to cash transfers— The case of Egypt Egypt has a long history of providing social assistance programmes, covering both cash and in-kind transfers. Currently, the most important ones are Tamween (a food subsidy) and Takaful and Karama (TKP, a cash transfer). Tamween dates back to the Second World War (Ramadan and Thomas 2011), while TKP was introduced in 2015 as part of larger macroeconomic reforms. TKP was introduced to invest in human capital while mitigating the effects of the economic reforms that the Egyptian government was undertaking. It consists of two subprogrammes, as the name indicates; Takaful, which is a conditional cash transfer targeting poor households with children, and Karama, which is an unconditional cash transfer targeting poor elderly people, people with disabilities, and orphans. Tamween plays an important role in ensuring food security, and has benefited from restructuring. As Figure 1 shows, the food subsidy still represents a larger share of government spending in Egypt, covering more people than the cash transfer programme. Tamween has had almost universal coverage since its inception. In 2011, subsidised food accounted for nearly a fifth of poor households’ food expenditure, and subsidised Baladi bread accounted for 71 per cent of the bread they consumed. It has been estimated that a removal of food subsidies could have pushed national poverty estimates from 25.2 per cent to 34 per cent in 2010-2011 (Breisinger et al. 2013). Yet, in its previous structure—with the provision of only calorie-rich food— it was shown that the subsidy system has contributed to the prevalence of the so-called double burden of malnutrition (Ecker et al. 2016). This refers to the coexistence of underand over-nutrition within a population, a household or even the same individual (e.g. having a stunted child who is also obese). Ecker et al. (2016) estimated that 22 per cent of children are stunted with an overweight mother, and 21 per cent of children are both stunted and overweight. In 2019, nearly 73 million people benefited from the bread subsidy, and 64 million (with a total of 22.5 million cards) of Egypt’s 100 million citizens benefited from the food ration cards (Egypt MSIT 2020). The system has undergone several reforms and innovations. It now has two components: the Baladi bread and the ration cards. Prior to the most recent wave of reforms, the ration card system used to cover a specific list of food items, most of which are calorie-rich, such as cooking oil, sugar, rice and pasta. Households purchase their subsidised food using a smart card, loaded with EGP50 per registered individual in the household, which can be allocated to either food or non-food items. Meanwhile, each beneficiary of the bread subsidy also receives a bread allowance of five loaves of bread per day, at EGP0.05 per loaf (Ecker et al. 2016; Kassim et al. 2018; Al-Masry Al-Youm 2019). Currently, the two subsystems are interlinked, as beneficiaries are allowed to use their unspent Baladi bread allowance for the consumption of a range of other products. TKP has an increasingly important role within social protection in Egypt. With good targeting, Takaful has succeeded in improving household consumption and welfare. Targeting for TKP is conducted using proxy means testing, and through geographical targeting, as the programme was first launched in the poorest districts in the poorest governorates in Egypt. Beneficiary selection also includes other exclusion factors. TKP beneficiaries are also subject to recertification every 3 years, to ensure their continued eligibility. A recent study (Kurdi et al. 2018) that looked into Takaful’s targeting, as the largest of the two subprogrammes, revealed that more than half of the applicants in the lowest income quintile are rejected, while 13 per cent of applicants are in the highest quintile, which is considered efficient relative to other social programmes. Takaful’s impact on household spending is also comparable to other successful conditional cash transfer programmes Source: Authors’ elaboration based on Egypt Ministry of Finance’s Financial Monthly Bulletins. 0 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2 4 6 8 10 12 14 16 18 20 Government expenditure % Social security assistance (incl. T&K) Food Fuel FIGURE 1: Social spending as a share of government expenditure 36 worldwide (Figure 2), with beneficiaries spending 8.4 per cent more than nonbeneficiaries. Takaful beneficiaries consume more food—particularly meat, poultry and fruits. This indicates that the transfer has helped households diversify their diets, which may have a positive impact on their nutrition and on reducing the double burden of malnutrition. In addition, the probability of a beneficiary household living in poverty decreased by 11 per cent, for the group of beneficiary households with incomes near the poverty line (Breisinger et al. 2018a). The positive experiences from Takaful have likely encouraged the government to take further measures regarding the targeting of Tamween, such as re-certifying existing beneficiaries and introducing stronger exclusion criteria. There are also suggestions to remove 40 million beneficiaries from the system (Enterprise Press 2019), and to move households to cash transfers. In response to COVID-19, the Egyptian government made use of its existing social protection mechanism to protect those affected. The government added 160,000 new households to TKP (Gentilini et al. 2020). Their quick and efficient incorporation resulted from the automation of registration, as the Ministry of Social Solidarity has a database for all programme applicants—including those who were not accepted. Therefore, these additional households were able to be automatically integrated into the cash distribution system. In addition, the government is distributing a one-off payment of EGP1,500 (USD96) in three tranches to support seasonal workers who lost their income due to the pandemic (Ahram Online 2020; Gentilini et al. 2020). Those funds are expected to cover 1.9 million individuals, out of 4.4 million applicants. The Employees Emergency Fund was also activated to cover the salaries of individuals in businesses affected by the pandemic and the curfew, such as the tourism sector (Gentilini et al. 2020). Furthermore, EGP50 million has been allocated to seasonal workers, through a national fund supported by donations from Egyptian citizens (Moneim 2020). In addition, the government used its existing food subsidy network to make it obligatory for Tamween beneficiary households with four or fewer registered members to buy one mask per household, and to make it optional for households with three of fewer members. Having a large distribution network across the country under the management of the Ministry of Supply and Internal Trade (MSIT) made such an initiative possible (Al-Masry Al-Youm 2020). Conclusion The COVID-19 pandemic has served as a strong reminder of the importance of social assistance. Countries have employed a range of policies to respond to the pandemic and the resulting lockdowns. These included providing emergency payments to those affected by the pandemic, adding people to social assistance schemes, increasing the transfer amounts of existing programmes, distributing in-kind transfers and expanding unemployment benefits. Some of the key highlights of the response mechanisms were leveraging existing databases and infrastructure, and the increasing use of technology and digital systems (IBC-SP and IPC-IG 2020). The success in responding to such a crisis in a timely manner depends on the speed and efficiency of reaching the most vulnerable and those affected by the crisis. The pandemic should be taken as an opportunity for governments to continue to improve the targeting and design of their social assistance programmes, especially of food subsidy programmes, and to consider introducing more efficient cash transfers. Ahram Online. 2020. “Egypt to pay out the first of three grants totalling EGP 1,500 for seasonal workers on Monday.” Ahram Online, 11 April. <http://english.ahram.org.eg/News/367046. aspx>. Accessed 30 October 2020. Al-Masry Al-Youm. 2019. “Egypt’s cabinet implements automatic prices on oil products.” Egypt Independent, 7 July. <https:// egyptindependent.com/egypts-cabinetimplements-automatic-prices-on-oil-products/>. Accessed 30 October 2020. Al-Masry Al-Youm. 2020. “Selling one obligatory mask to Tamween beneficiaries due to incompliance with wearing masks.” Al-Masry Al-Youm, 1 September. <https://www. almasryalyoum.com/news/details/2025236>. Accessed 30 October 2020. Breisinger, C., A. Abdelatif, M. Raouf, and M. Wiebelt. 2020. “COVID-19 and the Egyptian “ Takaful’s impact on household spending is also comparable to other successful cash transfer programmes worldwide, with beneficiaries spending 8.4 per cent more than non-beneficiaries. Source: Breisinger et al. (2018b). 0 2 4 6 8 10 12 Egypt (Takaful)BrazilColombiaHonduras Mexico Impacts on household spending (percentage increase) FIGURE 2: Takaful’s impact on household spending compared to other conditional cash transfer programmes The International Policy Centre for Inclusive Growth | Policy in Focus 37 economy: Estimating the impacts of expected reductions in tourism, Suez Canal revenues, and remittances.” MENA Policy Note, No. 4. Washington, DC: International Food Policy Research Institute. <https://doi.org/10.2499/p15738coll2.133663>. Accessed 30 October 2020. Breisinger, C., D. Gilligan, N. Karachiwalla, S. Kurdi, H. El-Enbaby, A. Jilani, and G. Thai. 2018a. “Impact evaluation study for Egypt’s Takaful and Karama cash transfer program: Part 1: Quantitative report.” MENA RP Working Paper, No. 14. Washington, DC: International Food Policy Research Institute. <http://ebrary.ifpri.org/ cdm/ref/collection/p15738coll2/id/132719>. Accessed 30 October 2020. Breisinger, C., H. ElDidi, H. El-Enbaby, D. Gilligan, N. Karachiwalla, Y. Kassim, S. Kurdi, A.H. Jilani, and G. Thai. 2018b. “Egypt’s Takaful and Karama cash transfer program: Evaluation of program impacts and recommendations.” IFPRI Policy Brief, October. Washington, DC: International Food Policy Research Institute. <https://doi. org/10.2499/9780896295964>. Accessed 30 October 2020. Breisinger, C., P. Al-Riffai, O. Ecker, R. Abuismail, J. Waite, N. Abdelwahab, A. Zohery, H. El-Laithy, and D. Armanious. 2013. “Tackling Egypt’s rising food insecurity in a time of transition.” Country Policy Note. Washington, DC: International Food Policy Research Institute and World Food Programme. Duwayri, M. 2016. “Rethinking food subsidy in Jordan.” Arab Food and Nutrition Security Blog, IFPRI Egypt, 27 January. <https://clck.ru/Rrn77>. Accessed 30 October 2020. Ecker, O., P. Al-Riffai, C. Breisinger, and R. El-Batrawy. 2016. Nutrition and economic development: Exploring Egypt’s exceptionalism and the role of food subsidies. 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Santos. 2020. “Social Protection and Jobs Responses to COVID-19: A Real-Time Review of Country Measures (September 18, 2020) (Vol. 2): Global Database on Social Protection and Jobs Responses to COVID-19 (English).” Working Paper, No. 153102. Washington, DC: World Bank Group. <https://clck. ru/Rrn6G>. Accessed 30 October 2020. Jawad, R. 2016. Social Protection and Social Policy Systems in the MENA Region: Emerging Trends. New York: United Nations Department of Economic and Social Affairs. <https://clck.ru/ RrnAU>. Accessed 30 October 2020. Kassim, Y., M. Mahmoud, S. Kurdi, and C. Breisinger. 2018. “An agricultural policy review of Egypt: First steps towards a new strategy.” MENA RP Working Paper, No. 11. Washington, DC and Cairo: International Food Policy Research Institute. <http://ebrary.ifpri.org/cdm/ref/ collection/p15738coll2/id/132788>. Accessed 30 October 2020. Kurdi, S., C. Breisinger, H. ElDidi, H. El-Enbaby, D. Gilligan, and N. 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Overview of Non-contributory Social Protection Programmes in the Middle East and North Africa (MENA) Region through a Child and Equity Lens. Brasília and Amman: International Policy Centre for Inclusive Growth and UNICEF Middle East and North Africa Regional Office. Moneim, D.A. 2020. “How is Egypt supporting seasonal workers amid the coronavirus crisis?” Ahram Online, 25 March. <https://clck.ru/ Rrn5d>. Accessed 30 October 2020. Rahman, A. 2016. “Universal food security program and nutritional intake: evidence from the hunger prone KBK districts in Odisha.” Food Policy 63: 73–86. Ramadan, R., and A. Thomas. 2011. “Evaluating the impact of reforming the food subsidy program in Egypt: a mixed demand approach.” Food Policy 36: 638–646. Sdralevich, C., R. Sab, Y. Zouhar, and G. Albertin. 2014. Subsidy Reform in the Middle East and North Africa Recent Progress and Challenges Ahead. 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Maja Gavrilovic, Lusajo Kajula and Juliana Nyasha Tirivayi 1 Malnutrition remains a major health and developmental challenge. Globally, an estimated one in three children under 5 years old are malnourished, 144 million of whom suffer from stunting (UNICEF, WHO, and World Bank 2020). Growth deficits in utero and poor nutrition in the first 2 years of a child’s life are largely irreversible, although there is evidence that growth can catch up in childhood and adolescence2 (Black et al. 2013; Fink and Rockers 2014). Women’s health and nutritional status during pregnancy and lactation is a critical determinant of children’s survival and growth outcomes in later life (WHO 2013). Therefore, interventions that aim to improve children’s nutrition should also prioritise maternal health and nutrition.3 Cash transfers, particularly when designed as ‘cash plus’ interventions,4 are viewed as a promising tool for addressing children’s malnutrition (de Groot et al. 2017). Even though cash transfers can affect women’s nutritional status, maternal nutrition is often the least prioritised objective in these programmes, and maternal nutrition outcomes are overlooked in impact evaluations (Bhutta et al. 2013; WHO 2013). This article examines how maternal nutrition, and women’s nutrition more broadly, is considered in the design of cash transfer programmes, detailing the various mechanisms through which they can address key determinants of maternal malnutrition, and highlighting the evidence of impact. The links between maternal and child nutrition The link between maternal and child nutrition is well acknowledged in research (Van der Bold, Quisumbing, and Gillespie 2013; UNICEF 2013). Mothers influence their children’s growth directly in utero through their own nutritional and health status. Maternal undernutrition during pregnancy, signified by short stature, anaemia and low Body Mass Index (BMI), has been associated with adverse pregnancy outcomes, including premature delivery, low infant birthweight and increased risks of maternal and child mortality (Bhutta et al. 2013; WHO 2013). Caregivers can also affect children’s nutrition indirectly through childcare practices. Women may lack nutritional knowledge, sufficient time or decisionmaking power to care well for themselves and their children (WHO 2013; Debela et al. 2017). At the same time, women’s needs for energy, protein and micronutrients increase significantly during pregnancy and lactation. In many contexts, however, women consume less than their minimum requirements and enjoy poor nutritional intake, due to several reasons, including poverty, unequal intra-household food distribution and inadequate feeding and hygiene practices, resulting in micronutrient deficiencies and insufficient weight gain during pregnancy (Peterman et al. 2019). An estimated 469 million women worldwide are anaemic, and at least half of these cases are attributable to iron deficiencies, parasitic infections and inherited health disorders (WHO 2013). The potential role of cash transfers in tackling maternal nutrition Both unconditional and conditional cash transfer programmes have expanded rapidly in recent years as a key poverty reduction strategy across the developing world. Although they vary in coverage and design features, cash transfers generally aim to improve household poverty and food security, as well as the health, nutritional and educational status of children (Davis 2016). Some incorporate specific objectives to improve child nutrition outcomes. For example, child grant programmes typically cover the ‘window of opportunity’ for nutrition interventions—targeting pregnant and lactating mothers with a combination of health and nutrition services during the first 1,000 days in a child’s life for maximum impact (de Groot et al. 2017). While cash transfers often focus on children, they may include gendersensitive elements that are significant for women’s nutritional status and broader well-being (FAO 2018). Women, in their role as caregiver, are often designated recipients of cash, and this may increase their resources for personal expenditure, such as on food or health care. Cash transfers may also use specific behavioural features, such as conditionalities, messaging or educational nudges, to induce positive changes in women’s care practices. These ‘cash plus’ design elements aim to incentivise women’s uptake of health and nutrition services (e.g. antenatal check-ups, provision of supplements) and enhance their nutritional knowledge regarding diets and feeding practices, which ultimately contribute to the improvement of maternal and children’s health and nutritional status. Ways in which cash transfers may impact maternal nutrition Cash transfer programmes have the potential to address the multifaceted determinants of women’s nutrition in three core ways.5 First, such programmes directly increase household income, which can be spent to buy or produce a greater quantity and better quality of food to improve household food security (Davis 2016). Providing cash to women directly may increase their bargaining power and control over household budgets, allowing them to spend funds on their own food and health expenses, and improving nutritional intake (Armand et al. 2020; Owusu-Addo, Renzaho, and Smith 2018). Second, an increase in household purchasing power can reduce financial barriers and opportunity costs (loss of income due to health-seeking activities) that poor households face in accessing health services and improving their living conditions (WHO 2013). Cash, particularly when designed with soft conditionalities, can improve women’s demand for, and uptake of, essential antenatal and postnatal care, while complementary behavioural programming may expose them to health and nutrition education and dietary advice. Household The International Policy Centre for Inclusive Growth | Policy in Focus 39 essentially unchanged, cash is unlikely to generate sizeable improvements on women’s nutritional status and may lead to unitended effects, such as overweight and obesity in adult women (see Leroy et al. 2013). In terms of health, cross-country evidence shows that cash transfers can significantly increase the use of antenatal care by pregnant women, improving their access to critical nutritional information and treatment in case of maternal anaemia and malnutrition. An evaluation of Mexico’s Oportunidades programme found that women’s access to iron supplements, received during conditional antenatal visits, led to a reduction in maternal anaemia (Bhutta et al. 2008, cited in Glassman et al. 2013). General evidence of the uptake of postnatal check-ups and institutional birth delivery is less promising (Glassman et al. 2013; Lagarde, Haines, and Palmer 2009). The inadequate supply and quality of postnatal care, excessive work burdens, and discriminatory gender norms around women’s access to reproductive health and mobility are critical barriers to the uptake of these services. However, some design features—including information delivered through either phone text messages or behaviour change communication strategies in combination with cash top-ups—appear to be effective at addressing structural obstacles that women face in accessing health care. Such design features were found to enhance the effects of cash transfers on maternal practices related to institutional birth delivery, iron tablet consumption and handwashing practices (Maffioli and Field 2019). Finally, there is some indication that a combination of cash benefits with antenatal visits, nutritional supplements and information sessions on maternal nutrition reduced maternal mortality and morbidity rates in Bolivia, Mexico and The Philippines (de la O Campos 2015; Holmes and Jones 2013). Generally, further research and data are needed to understand the links between the effects of cash transfers on health care utilisation and changes in women’s health and nutrition status. Evidence is limited on how cash transfer programmes affect women’s care practices during pregnancy and lactation, and their relationship with maternal nutrition outcomes. The bulk of evidence exists on cash transfers and women’s empowerment, although results are generally mixed (Van der Bold et al. 2013).9 Data show that transferring cash directly to women can reduce their dependence on male income, resulting in increased access to resources and improved ability to make expenditure decisions with less interference (OwusuAddo et al. 2018). However, in some settings where discriminatory gender norms remain pervasive, giving benefits directly to women does not necessarily increase their ability to control the use of resources, particularly for their personal needs for food, health care and education (Armand et al. 2020; Peterman et al. 2019). improvements to water, sanitation and housing facilities may result in reduced labour burdens for pregnant and lactating women, improving their health and general quality of life. Finally, improved maternal nutrition can emerge through increased resources for maternal care.6 By reducing household poverty-related stress, cash transfers may positively impact the mental and emotional states of caregivers and improve their agency, autonomy and status in the household, resulting in a more positive outlook on life and investments in selfcare (e.g. food, health care, education, more time for leisure etc.) (Peterman et al. 2019). When a woman’s food and nutrient intake is improved in combination with investments in better maternal care and health, a positive effect on her nutritional status can be expected. Evidence of impacts of cash transfers on maternal nutrition Global evaluations of large-scale cash transfer programmes consistently show positive effects on household food security, including large gains in food consumption and improved food diversity (de Groot et al. 2017; Hidrobo et al. 2018). While gender-specific evidence is generally very limited, a recent review of social safety nets, including cash transfers in Africa, by Peterman et al. (2019) found promising impacts on women and girls’ dietary diversity and reduced stress related to food poverty. Evaluations in Ethiopia, Lesotho and Niger also confirm that cash transfers, particularly when combined with dietary advice, generally enable pregnant women to enhance their diets by diversifying food choices and eating more frequently (Carneiro et al. 2019; Owusu-Addo, Renzaho, and Smith 2018). Nevertheless, food security gains at the household level do not necessarily translate into improved food intake7 and changes in long-term nutritional status8 for women (Peterman et al. 2019). The available studies reveal that cash transfers do not have a significant impact on nutritional biomarkers (Maffioli and Field, 2019; Carneiro et al. 2019; Peterman et al. 2019). In contexts where disease burdens and inadequate access to health services and maternal knowledge as well as unequal food allocation remain Photo: Dominic Chavez/World Bank. Mother comforts baby, Sierra Leone, 2015 <https://clck.ru/QyQvQ>. 40 yAligning and complementing school procurement policies with agricultural development initiatives to strengthen smallholder farmers’ capacity to organise themselves into cooperatives or other forms of associations, produce and commercialise their products and meet required nutrition and food safety standards (drawing on support from concerned authorities to help ensure the safety and quality of school food along the supply chain, from production to preparation) (FAO 2018; FAO and WFP 2018). yAssessing the public procurement regulatory framework and identifying legal instruments that can be developed, used or adapted to support school food procurement from local smallholder farmers (see the example of Ethiopia in Box 2), focusing on nutritious products (FAO and WFP 2018; Swensson 2018; 2019). BOX 2: The example of Ethiopia Currently, there are two ongoing HGSF programmes in Ethiopia: a pilot initiative established in 2012 and an emergency programme established in 2015. The latter was set up to supply food to selected drought-affected areas to curb drought-induced school dropouts. It currently covers 10 regions, benefiting around 1.8 million children. Both programmes aim to support education outcomes, as well as agricultural development and income generation, through the procurement of food from local smallholder cooperatives. Various initiatives are being implemented by the government—with the support of FAO and other partners—to strengthen these programmes. For example, a multisectoral committee (with members from the Ministry of Education, the Ministry of Agriculture, the public procurement authority, FAO and WFP, among others) was established to support the development of a conducive public procurement regulatory framework and the revision of the related legislation and regional directives (see Swensson 2019). In the Southern Nations Nationalities and People’s Region an impact evaluation is being undertaken to assess the benefits of the HGSF pilot initiative for small-scale producers accessing school market outlets. Furthermore, complementary activities to enhance the nutrition quality and safety of school meals are being carried out, including the development of nutrition recommendations for the meal menus; the adaptation of the World Food Programme’s Food Quality, Hygiene and Safety Guide for the local context; and the training of school staff and health services. Although still at a preliminary stage, these are relevant efforts towards strengthening the nexus between nutrition, agriculture and social protection through school-based programmes, to improve poverty and nutrition outcomes. yDeveloping or revising nutrition guidelines and standards for school food through a multi-stakeholder process, considering production systems data, agricultural seasons, agroecological zones, local cultures, food habits and preferences, and criteria compatible with smallholder production (FAO 2019c). yPromoting complementary measures within social protection systems—for instance, linking social protection measures such as cash transfers, which can support access to education for children by removing financial barriers to school systems (uniforms, fees etc.), with school meals, which, in turn, can address other barriers, ensuring access to food and—when available— nutrition education (Alderman 2015; Spray 2015). yExtending effective school-based food and nutrition education to the most vulnerable communities in combination with school, home and community garden programmes (Tamiru et al. 2016; Marquis et al. 2018). yChannelling school food service employment opportunities to the most vulnerable community members, combined with regular and welldesigned nutrition and food safety training schemes (FAO and WFP 2018; FAO et al. 2019; Drake et al. 2016). Conclusion To capitalise on and consolidate the options outlined in this article, we recommend developing a theory of change that highlights the evidencebased pathways to enact changes in nutrition and poverty outcomes, and outline possible risks and mitigation mechanisms. Nevertheless, key programmatic gaps still remain regarding the right mix of components for the best possible outcomes and the best way to manage trade-offs. Evidence gaps also remain on differential impacts of the various programmatic components (e.g. farmers’ access to school markets with and without capacity development and provision of inputs, and home/ community/school gardens with and without nutrition education). Photo: Pep Bonet/NOOR for FAO. School cookers in Guatemala. The International Policy Centre for Inclusive Growth | Policy in Focus 47 From a policy and legal perspective, the adoption of a holistic approach is highly recommended to ensure policy coherence and to foster institutional coordination for effective action (Cruz 2020). Coherent legislative measures can target and protect those who are most vulnerable to food insecurity by defining clear legal entitlements for guaranteeing children’s access to food at school and providing poor people with effective grievance redressal mechanisms in case of violations. Furthermore, legislative obligations lay the foundations for the provision of adequate funding to support policy action to reduce poverty and malnutrition, while ensuring school-based programmatic continuity. In addition, policy and legislative frameworks should provide incentives for responsible private-sector engagement and foster multi-stakeholder mechanisms enabling the inclusive and participatory involvement of all sectors—particularly the poor, marginalised and most vulnerable people (FAO 2019d). Alderman, H. 2015. Leveraging social protection programs for improved nutrition. Summary of evidence prepared for the global forum on nutritionsensitive social protection programs. Washington, DC: International Bank for Reconstruction and Development and World Bank Group. Bundy, D.A.P., N. de Silva, S. Horton, D.T. Jamison, and G.C. Patton. 2017. “Child and Adolescent Health and Development.” Disease Control Priorities 3(8). Washington, DC: World Bank. Development Initiatives. 2017. Global Nutrition Report 2017: Nourishing the SDGs. Bristol, UK: Development Initiatives. Drake, L., A. Woolnough, C. Burbano, and D. Bundy. 2016. Global school feeding sourcebook; lessons from 14 countries. London: Imperial College Press. FAO. 2018. Evaluation of Zambia’s Home Grown School Feeding program and of its combination with the Conservation Agriculture Scale-Up project. Rome: Food and Agriculture Organization of the United Nations. FAO. 2019a. “Strengthening sector policies for better food security and nutrition results.” Education Policy Guidance Note, No. 13. Rome: Food and Agriculture Organization of the United Nations. FAO. 2019b. School Food and Nutrition Framework. Rome: Food and Agriculture Organization of the United Nations. FAO. 2019c. Nutrition guidelines and standards for school meals: a report from 33 low and middleincome countries. Rome: Food and Agriculture Organization of the United Nations. FAO. 2019d. “Legal measures to eradicate rural poverty.” Legal Brief for Parliamentarians in Africa, No. 7. Rome: Food and Agriculture Organization of the United Nations. <http:// www.fao.org/3/ca3524en/ca3524en.pdf>. Accessed 30 October 2020. FAO and WFP. 2018. “Home-Grown School Feeding. Resource Framework.” Technical Document. Rome: Food and Agriculture Organization of the United Nations. FAO, IFAD, UNICEF, WFP, and WHO. 2019. The State of Food Security and Nutrition in the World 2019. Safeguarding against economic slowdowns and downturns. Rome: Food and Agriculture Organization of the United Nations. HLPE. 2013. Investing in smallholder agriculture for food security. A report by the High Level Panel of Experts on Food Security and Nutrition of the Committee on World Food Security. Rome: Food and Agriculture Organization of the United Nations. Cruz, L. 2020. “Legal Guide on school food and nutrition—Legislating for a healthy school food environment.” FAO Legal Guide, No. 2. Rome: Food and Agriculture Organization of the United Nations. Marquis, G.S., E.K. Colecraft, R. Kanlisi, B.A. Aidam, A. Atuobi-Yeboah, C. Pinto, and R. Aryeetey. 2018. “An agriculture-nutrition intervention improved children’s diet and growth in a randomized trial in Ghana.” Maternal Child Nutrition 14 Suppl. 3. Spray, A. 2105. Leveraging social protection programs for improved nutrition. Report of the Global Forum on Nutrition-Sensitive Social Protection Programs. Washington, DC: International Bank for Reconstruction and Development and World Bank Group. Swensson, L.F.J. 2018. “Aligning policy and legal frameworks for supporting smallholder farming through public food procurement: The case of home-grown school feeding programmes.” IPC-IG Working Paper, No. 177. Rome and Brasília, International Policy Centre for Inclusive Growth and Food and Agriculture Organization of the United Nations. Swensson, L.F.J. 2019. “Aligning public procurement rules and practices to support the implementation of home-grown school feeding (HGSF) initiatives: The case of Ethiopia.” Rome: Food and Agriculture Organization of the United Nations. Swensson, L.F.J., and F. Tartanac. 2020. “Public food procurement for sustainable diets and food systems: The role of the regulatory framework.” Global Food Security 25: 10366. Tamiru, D., A. Argaw, M. Gerbaba, A. Nigussie, G. Ayana, and T. Belachew. 2016. “Improving dietary diversity of school adolescents through school based nutrition education and home gardening in Jimma Zone: Quasi-experimental design.” Eating Behaviours 23: 180–186. Walker, S.P., T.D. Wachs, J. Meeks Gardner, B. Lozoff, G.A. Wasserman, E. Pollitt, and J.A. Carter. 2007. “Child development: risk factors for adverse outcomes in developing countries.” Lancet 369(9556): 145–157. World Bank. 2006. Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action. Washington, DC: International Bank for Reconstruction and Development and World Bank Group. 1. Acknowledgements are extended to the FAO School Food and Nutrition Task Force members Cristina Scarpocchi, Luisa Cruz and Dirk Schulz, as well as to Ana Ocampo and Jessica Owens for their valuable inputs. 2. Food and Agriculture Organization of the United Nations (FAO). 3. For example, while there is evidence on the effects of HGSF on child-level education and food security outcomes, the evidence base for agriculture-related changes is thinner and, until more recently, has received less attention. Nevertheless, an increasing number of studies have also been showing positive impacts of HGSF on the livelihoods of smallholder farmers and local communities. FAO is currently supporting the development of methodology guidelines to assess the impact evaluation of HGSF programmes, and developing monitoring and evaluation guidance on school food and nutrition. Photo: Benedicte Kurzen/NOOR for FAO. Woman farmer in Senegal. 48 The Inter-Agency Social Protection Assessment Tool for food security and nutrition: what it is, and how it was applied in Cambodia, the State of Palestine, and Paraguay Iean Russell,1 Flavia Lorenzon,2 PirroTomaso Perri,3 Raja Khalidi 4 and Ana C. Louteiro 5 The main objective of the Inter-Agency Social Protection Assessment Tool for food security and nutrition (ISPA-FSN Tool)6 is to support national and subnational governments in assessing how social protection programmes can be harnessed to improve food security and nutrition (FSN) outcomes. The Tool aims to identify gaps and areas for further improvement based on the right-to-food and the right-to-social-protection approaches. It assesses social protection programmes against seven pre-established criteria: (1) explicit FSN objectives and indicators; (2) inclusiveness and accessibility; (3) adequacy of benefits, duration, timing and predictability; (4) responsiveness; (5) inter-sectoral coherence in o perational and governance structures; (6) sustainability; and (7) rights and dignity. After its development, the ISPA-FSN Tool was piloted in Paraguay, Cambodia and the State of Palestine. The pilots gathered stakeholders from across various sectors, in particular food security, nutrition and social protection, and identified design and implementation features that have the potential to enhance the impact of social protection programmes on FSN. In doing so, it also raised awareness of food security and nutrition within the social protection sector. Adapting the ISPA-FSN Tool for Cambodia Background The Council for Agricultural and Rural Development (CARD) of the Royal Government of Cambodia conducted the ISPA-FSN assessment in Cambodia jointly with the Food and Agriculture Organization of the United Nations (FAO and the German Cooperation Agency (GIZ). After examining the prospects for applying the Tool to various social protection programmes, the Home-Grown School Feeding Programme (HGSF), a social protection programme with demonstrated effects on FSN around the world (Vargas, Swensson, and Carter 2020—see page XX of this Special Issue), was selected for piloting the tool. This choice was also supported by the Ministry of Education, Youth and Sport and the World Food Programme. The HGSF provides children enrolled in school with food that is mostly produced and purchased locally. It links school feeding to rural development, stimulating local agricultural growth by purchasing food from local producers to supply school kitchens, thereby contributing broadly to positive FSN outcomes. In 2017 the HGSF was implemented in four provinces of Cambodia, covering 84 primary schools and 17,218 students, of whom 8,482 were girls. The timing of the pilot supported some critical decisions that were being made about HGSF in Cambodia during the assessment and contributed to an internal review process. The programme has expanded substantially since. Implementation The ISPA-FSN was directed by a formal inter-ministerial Task Force established by CARD. The Task Force initially spent 2 days reviewing the guidelines and discussing the pre-established criteria. This information was augmented by interviews with key informants, a desk review and information collected in the field. The field assessment involved 18 primary schools in three provinces. Interviews were conducted with representatives of provincial and local governments, school committees, school directors, teachers, cooks, parents, students and suppliers. The assessment criteria were addressed using semi-structured questionnaires during face-to-face interviews, focus group discussions and other formal discussions with the broad groupings of stakeholders. Formal meetings of the Technical Working Group for Social Protection and Food Security and Nutrition and the Task Force meetings served for both consultation and validation of results at the national level. The results of the assessment were brought directly to the attention of policymakers. The direct participation of government staff in the collection and analysis of information meant that the process had to conform to their thought processes, practices and limited availability. Recognising the trade-off between research quality and ownership and given that the Task Force was officially appointed by CARD, it was preferable to employ methods more akin to ‘action research’. Action research offers the advantages of developing insights into a situation particularly for the research team itself. For effective action research, the team is selected from those directly involved in programme delivery, problem-solving and decision-making. Participants understand the results and can incorporate the information directly in their work. Main findings Results showed that the HGSF programme was serving as an effective mechanism for linking social protection and FSN activities in Cambodia. Areas for improvement identified included strengthening measures to address shocks affecting FSN and improving the The International Policy Centre for Inclusive Growth | Policy in Focus 49 monitoring and evaluation mechanisms. Limited funding and capacity-building were identified as key challenges for scaling up. The sustainability of HGSF is limited by the commitment of the national budget, given the many competing needs for the education sector. However, the HGSF model is the government’s and the community’s preferred model for school feeding. Follow-up After the assessment, the government included HGSF in the framework for social assistance for Cambodia and recognised the programme as the preferred model for school feeding in the country. The government recognised the need to allocate resources to deal with shocks and scale up the programme. Greater investment in training was made possible by a grant from the US Department of Agriculture to support further development. Adapting the ISPA-FSN Tool for the State of Palestine Background Following a request from the Ministry of Agriculture (MoA), in agreement with the Ministry of Social Development (MoSD), and with support from the FAO Country Office and the FAO–European Union FIRST programme,7 the State of Palestine was selected to pilot the implementation of the ISPA-FSN Tool in the first half of 2018. Two programmes were analysed, which were primarily managed by the MoSD: yThe Cash Transfer Programme: The main poverty alleviation social protection programme in the State of Palestine, established as a part of the social protection strategy in 2010 and funded by the State of Palestine, as well as key donors such as the European Union and the World Bank. It provides cash assistance every 4 months to extremely poor and vulnerable households. yThe Deprived Families Economic Empowerment Programme (DEEP): A poverty alleviation scheme aimed at promoting livelihoods. It provides an inclusive approach for targeting vulnerable yet productive households and engages their members in sustainable income-generating activities, mainly through microand small enterprise development, to provide employment and bridge their consumption and income poverty gaps. Implementation The Palestine Economic Policy Research Institute (MAS) was selected to undertake the implementation of the ISPA-FSN Tool, in close cooperation with senior officials from the MoSD and the MoA. The Tool, which lies firmly at the centre of Sustainable Development Goal (SDG) 1 (“end poverty in all its forms everywhere”) and SDG 2 (“end hunger, achieve food security and improved nutrition and promote sustainable agriculture”), saw the engagement of the National Working Groups for SDG 1 and SDG 2, with the objective of bridging these interrelated goals by promoting food security and nutrition-sensitive social protection programmes. The implementation of the Tool in the State of Palestine was based on a consultative process, which began with a preparatory phase consisting of a desk review, familiarisation with the components of the tool by the National Working Groups, and forming the ISPA-FSN Tool Task Force. The desk review helped provide important background material that was then used in an inception workshop. This workshop proved to be an important opportunity for members of the Task Force to familiarise themselves with the methodology for the implementation of the Tool and fine-tune the related questionnaire. Through a comprehensive review of the questionnaire, the participants highlighted the need to refine some of the components. In the data collection phase, the tools used were agreed with the Task Force, and a total of nine interviews were conducted, in addition to focus groups discussions with local organisations belonging to the FSN sector as well as beneficiaries of the two programmes. The findings were validated during a multi-stakeholder workshop, which included local and international organisations, where participants discussed the way forward. Main findings The ISPA-FSN process resulted in a list of recommendations. Three main findings were deemed the most relevant: yPolicy coherence sphere: There was a lack of inter-sectoral coherence in operational and governance structures, partially due to the absence of a formal agreement to support different institutions working together. The formalisation of the cooperation between the MoSD and the MoA was recommended. yProgrammatic support to DEEP: This key programme proved to bear positive results when beneficiaries happened to be working in agriculture. One suggestion was to specifically target poor farmers and those in marginalised areas, in cooperation with the MoA. yProgrammatic interventions should be aligned with the National Investment Plan (NIP) for Food and Nutrition Security and Sustainable Agriculture (FNSSA) 2020–2022 and the National Food and Nutrition Security Policy (NFNSP) 2030. Follow-up The NFNSP 2030 and the NIP for FNSSA 2020–2022, submitted by the MoA, as the institution in charge of meeting SDG 2 commitments, to the Council of Ministers in November 2019, were endorsed in October 2020. The endorsement of the NFNSP and the NIP is fully in line with the ISPA-FSN recommendations mentioned earlier. Further, the NFNSP and the NIP foresee the establishment of a National FSN Council at the inter-ministerial level to: (a) coordinate NFNSP/NIP interventions; (b) oversee NFNSP implementation and the achievement of results; and (c) provide services (for example, the elaboration of dossiers, supported by the SDG 2 Working Group as technical secretariat) for the higher-level political deliberative body. The NIP also includes dedicated priorities and investments for nutrition-sensitive programming and socio-economic inclusion of poor and vulnerable people. Adapting the ISPA-FSN Tool for Paraguay Following a request from Paraguay’s Ministry of Social Development (Ministerio de Desarollo Social—MDS), the ISPA-FSN 50 Tool was implemented as a pilot in 2017– 2018, with support from FAO. The goal was to carry out a qualitative assessment regarding the incorporation of the FSN theme into the Tekoporã8 programme, contribute to the implementation of public social policies and promote development for vulnerable families, who live primarily in rural areas. Tekoporã is the country’s largest social protection programme, covering all 17 departments and the capital, reaching 167,000 families in 248 districts, of which 28,173 families are indigenous. It is implemented by the MDS and seeks to improve the quality of life of the populations living in poverty and vulnerability through conditional cash transfers. The programme aims to fulfil the rights of these populations, especially the rights to health, education and food. In addition, the programme carries out follow-up visits to vulnerable families and communities, aiming to break the intergenerational cycle of poverty. During the implementation of the ISPA-FSN assessment, methodological adjustments were made to the Tool, adapting it to the country’s context for appropriate application at the local level, making it possible to analyse the Tekoporã programme’s performance regarding the FSN status of its beneficiaries. This process was carried out with the participation of key actors, such as policymakers, technicians and beneficiaries. Main findings The results obtained through the application of the Tool highlighted the need to incorporate indicators in the programme to demonstrate the benefits of linking the objectives of social protection with those of FSN. The use of the Tool revealed the need for a review and a redesign of the Tekoporã programme. Soon after it was adjusted, aspects linked to FSN and women’s participation were included, and although their incorporation increases budget costs, it is hoped that effective implementation will reach the entire population living in a vulnerable situation. According to the pilot project report, a large proportion of the MDS field team did not possess sufficient technical knowledge to tackle the themes of food and nutrition. Moreover, it identified a need to strengthen linkages with institutions working on women’s empowerment, as they were not envisaged during the planning, execution and evaluation stages of the Tekoporã programme. Follow-up The ISPA-FSN Tool has helped place FSN on the public agenda. Both the Social Protection System and the National Plan for the Reduction of Poverty, recently approved by the Government of Paraguay, envision FSN as one of their crucial aspects. In light of the problems facing the country, this limited but crucial progress is extremely important for vulnerable populations and to achieve the SDGs such that no one is left behind. Conclusion Social protection systems play a crucial role in helping countries achieve better FSN outcomes. However, these systems can be effective when greater efforts are made to integrate FSN considerations into social protection and agricultural interventions. In this regards, the ISPA-FSN Tool can enable countries, as illustrated by pilots in Cambodia, the State of Palestine and Paraguay, to: (i) improve coherence at the policy level between food security, nutrition and social protection policies so that they can jointly address the consumption and production needs of poor rural households; (ii) promote coordination between sectors to achieve better FSN outcomes; and (iii) develop programmatic approaches to bring together different interventions in support of improved nutrition. FAO and GIZ. 2018. Report on a pilot application of the ISPA-FSN tool for the Home-Grown School Feeding Programme in Cambodia. Phnom Penh, Cambodia: Food and Agriculture Organization of the United Nations and Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH. MAS. 2017. Strategic Review of Food and Nutrition Security in Palestine 2017. Ramallah: Palestine Economic Policy Research Institute. Vargas, M., L. Swensson, and D. Carter. 2020. “The potential of policy and programmatic synergies for impacting poverty and nutrition outcomes through schools.” Policy in Focus Special Issue. Brasília: Internnational Policy Centre for Inclusive Growth. 1. Food and Agriculture Organization of the United Nations (FAO), Cambodia. 2. FAO, Egypt. 3. FAO, the State of Palestine. 4. Palestine Economic Policy Research Institute (MAS), Ramallah, the State of Palestine. 5. FAO, Paraguay. 6. The Inter-Agency Social Protection Assessment (ISPA) Initiative, established by members of the Social Protection Inter-Agency Cooperation Board (SPIAC-B), aims to develop a set of practical tools that can assist countries in improving their social protection system. These tools can be useful in analysing the strengths and weaknesses of social protection systems, and can offer options for further action. FAO leads the working group on the development of a tool aimed at assessing the contribution of social protection programmes to food security and nutrition outcomes (FSN-ISPA). 7. See: <http://www.fao.org/europeanunion/euprojects/first/en/>. 8. In the Guarani language, Tekoporã means ‘good living’. Photo: Fani Llauradó/WorldFish Cambodia. Family having lunch, 2018 <https://clck.ru/QyQvQ>. The International Policy Centre for Inclusive Growth | Policy in Focus 51 The potential role of geographical indications in promoting healthy diets and reducing rural poverty Bin Liu 1 Nutrition has been put high on the development agenda through a series of high-level events and initiatives, including the Second International Conference on Nutrition (ICN2) in 2014, the Sustainable Development Goals adopted by the United Nations General Assembly in 2015, and the United Nations Decade of Action on Nutrition 2016–2025. Nutrition challenges faced worldwide are complex. Most countries are burdened by multiple forms of malnutrition: undernutrition, micronutrient deficiencies, overweight or obesity, which may co-exist within the same country, household or individual (CFS 2016). A population’s nutritional status is determined by many factors, but most critically by their diet, and there is unequivocal evidence that the global malnutrition pandemic is caused by poor diets. Current diets in many parts of the world are high in unhealthy foods such as ultra-processed food rich in sugar, salt and calories and low in nutritious foods such as nuts, fruits, vegetables and legumes. These trends are driven partly by rapid urbanisation, increasing incomes and inadequate accessibility of nutritious foods. In addition, food production for such diets is pushing the Earth’s environmental systems beyond safe boundaries (Willett et al. 2019). The role of traditional foods, diets and food systems is mentioned in some important documents, such as the ICN2 Framework for Action and Rome Declaration on Nutrition (FAO and WHO 2014b; 2014a). Moreover, the High Level Panel of Experts on Food Security and Nutrition (HLPE 2017) provided a good overview of the capacity challenges of current food systems to provide nutritious foods, with chapters specifically discussing traditional food systems and diets. Some products (mostly food products but also other types such as handicrafts, leather etc.) have a long history of production and are deeply linked to the culture, history and environment of their place of origin. They possess characteristic qualities that result from the interaction between the local people and the environment, thus becoming inseparable from many elements that belong only to that place. A number of measures have been developed to protect origin-linked, characteristic products. The most common modern-day practice is to associate the product with a geographical indication (GI), which is treated as collective intellectual proper rights (see Box 1). GI foods, being the best examples of traditional foods and successful products of traditional food systems, have great potential to contribute to improved nutrition and combat non-communicable diseases. However, nutrition has received limited attention in the GI literature. An upcoming report from the Food and Agriculture Organization of the United Nations (FAO), 'The Nutrition and Health Potential of Geographical Indication Foods', reviews the nutritional values of several GI foods from Europe, Asia and Africa—notably meats, fermented products and rice. The study finds that the contents of beneficial compounds such as polyunsaturated fatty acids, vitamins, minerals and flavonoids are higher in the GI foods examined than in their non-GI counterparts. This can be attributed to several factors linked to the unique materials and processes used for production and the natural environment of the geographical origins. Because of the great potential in value addition to local products, GI has been frequently suggested and applied as a tool for poverty alleviation, improving the economic well-being of producers and their communities. Among the many successful stories around the world (Box 2), recent research demonstrates that the adoption of GI has enhanced rice farmers’ livelihoods and reduced rural poverty in India and Thailand, using examples of basmati and jasmine rice (Jena et al. 2015). Similar conclusions were also drawn in Albania for chestnut farmers (Bardhi and Kapaj 2017). However, this impact should not be automatically assumed and should be approached and assessed carefully, because the GI process may contain inherent conditions that actually impede it (Bonanno, Sekine, and Feuer 2019). Among the successful factors of GI’s potential in rural development, some authors emphasise exogenous factors such as market access, marketing channels, the cultural and economic role of the product in the local context and the structure of the supply chain (Pacciani et al. 2001). BOX 1: Definition of geographical indication A GI is a symbol used on products that have a specific geographical origin and possess qualities or a reputation that are due to that origin. To function as a GI, a symbol must identify a product as originating in a given place. In addition, the qualities, characteristics or reputation of the product should be essentially due to the place of origin. Since the qualities depend on the geographical place of production, there is a clear link between the product and its original place of production. Source: WIPO (2020). 52 BOX 2: Examples of positive economic impacts of GI processes A study analyses nine GI processes and confirms the existence of positive economic impacts, including Colombian coffee, Darjeeling tea (India), Futog cabbage (Serbia), Kona coffee (United States), Manchego cheese (Spain), Penja pepper (Cameroon), Taliouine saffron (Morocco), Tête de Moine cheese (Switzerland) and Vale dos Vinhedos wine (Brazil). The introduction of GI leads to higher prices paid to growers and processors, improved product quality, an increase in the number of permanent jobs, and resilience against price fluctuations on the international market. The major elements contributing to these impacts are: yspecific characteristics linked to the geographical place of origin of the product; yeffective collective decision-making by a strong producers’ organisation; yan effective marketing strategy at both the individual and collective levels of the GI value chain; and ysupport from the public sector. Source: FAO (2018). Central to the effectiveness of GI development in contributing to poverty reduction is to guarantee that the increased profits of GI products flow to producers. A few studies argue that the distribution of benefits of GI products is linked to the ownership of production inputs. If some of the critical, specialised inputting factors (e.g. land, raw materials, key elements of the production technology) are owned by the producers, they may benefit more (Moschini, Menapace, and Pick 2008). As an opposite example, if it is impossible for farmers to share land ownership at all, all benefits may go to landowners (Kolady, Lesser, and Ye 2011). Researchers have suggested the following recommendations for better leveraging GI for rural development and poverty reduction: yCarefully choose the product to be developed. It should have domestic and/or market potential, be representative of local context and be produced sustainably. yPromote farmers’ organisations. yPay special attention to ensure that the benefits are distributed to producers. Choosing products that need farmers’ own production inputs may be one strategy. Nutritional advantages could be a potential appeal of some types of GI foods, thus enhancing the profits and eventually benefiting producers, but this aspect has not been thoroughly researched. The nutritional content of local products should be determined first, and their potential contribution to healthy diets could be assessed subsequently. Nutritional quality should also be an important factor when considering candidates for GI development. Bardhi, R., and I. Kapaj. 2017. “The Contribution of Geographical Indications in Sustainable Rural Development (Evidence from Northern Albania).” European Journal of Business, Economics and Accountancy 5(6): 71–79. <https:// clck.ru/Rrrtx>. Accessed 30 October 2020. Bonanno, A., K. Sekine, and H. Feuer. 2019. “Introduction [Geographical Indication and Global Agri-Food].” In Geographical Indication and Global Agri-Food: Development and Democratization, 1–19. London: Routledge. CFS. 2016. “Inclusive Value Chains for Sustainable Agriculture and Scaled Up Food Security and Nutrition Outcomes—Background Document.” Rome: Committee on World Food Security (CFS) 43rd Session. <http://www.fao.org/3/a-mr587e. pdf>. Accessed 30 October 2020. FAO. 2018. Strengthening Sustainable Food Systems through Geographical Indications: An Analysis of Economic Impacts. Rome: Food and Agriculture Organization of the United Nations. <www.fao.org/3/a-i8737en.pdf>. Accessed 30 October 2020. FAO and WHO. 2014a. Framework for Action. Conference Outcome Document. Rome: Food and Agriculture Organization of the United Nations. <www.fao.org/3/a-mm215e.pdf>. Accessed 30 October 2020. FAO and WHO. 2014b. Rome Declaration on Nutrition. Conference Outcome Document. Rome: Food and Agriculture Organization of the United Nations. <www.fao.org/3/ml542e/ML542E.pdf>. Accessed 30 October 2020. HLPE. 2017. “Nutrition and Food Systems. A Report by The High Level Panel of Experts on Food Security and Nutrition.” HLPE Report, No. 12. Rome: Food and Agriculture Organization of the United Nations. <www.fao.org/3/a-i7846e.pdf>. Accessed 30 October 2020. Jena, P.R., C. Ngokkuen, D.B. Rahut, and U. Grote. 2015. “Geographical Indication Protection and Rural Livelihoods: Insights from India and Thailand.” Asian-Pacific Economic Literature 29(1): 174–185. <https://doi.org/10/ghdwwq>. Accessed 30 October 2020. Kolady, D.E., W.H. Lesser, and C. Ye. 2011. “The Economic Effects of Geographical Indications on Developing Country Producers: A Comparison of Darjeeling and Oolong Teas.” The WIPO Journal 2(2): 157–172. <https://clck.ru/ Rrrt6>. Accessed 30 October 2020. Moschini, G., L. Menapace, and D. Pick. 2008. “Geographical Indications and the Competitive Provision of Quality in Agricultural Markets.” American Journal of Agricultural Economics 90(3): 794–812. <https://doi.org/10/d8k5s2>. Accessed 30 October 2020. Pacciani, A., G. Belletti, A. Marescotti, and S. Scaramuzzi. 2001. “The Role of Typical Products in Fostering Rural Development and the Effects of Regulation (EEC) 2081/92.” Paper presented at the 73rd Seminar of the European Association of Agricultural Economists, Ancona, Italy. Willett, W., J. Rockström, B. Loken, M. Springmann, T. Lang, S. Vermeulen, T. Garnett et al. 2019. “Food in the Anthropocene: The EAT–Lancet Commission on Healthy Diets from Sustainable Food Systems.” Lancet 393(10170): 447–492. <https://doi. org/10/gft25h>. Accessed 30 October 2020. WIPO. 2020. “Frequently Asked Questions: Geographical Indications.” World Intellectual Property Organization website. <https://clck.ru/ Rrrrp>. Accessed 30 October 2020. 1. Food and Nutrition Division, Food and Agriculture Organization of the United Nations (FAO). “ Central to the effectiveness of GI development in contributing to poverty reduction is to guarantee that the increased profits of GI products flow to producers. The International Policy Centre for Inclusive Growth | Policy in Focus 53 The immense malnutrition challenge of today calls for a transformation of the food system. Pilar Santacoloma and Manuel Anta The food systems approach places equal emphasis on both the supply and demand dimensions that are critical for ensuring healthier diets and better nutrition for poor and vulnerable groups. Fábio Veras Soares and Ahmed Raza Smallholder agriculture is the main source of income for the majority of the world’s poor people who live in rural areas. Marcello Vicovaro, Ana Puhac and Florence Tartanac International Policy Centre for Inclusive Growth (IPC-IG) SBS, Quadra 1, Bloco J, Ed. BNDES, 13º andar 70076-900 Brasília, DF - Brazil Telephone: +55 61 2105 5000 [email protected]g  www.ipcig.org © 2020 International Policy Centre for Inclusive Growth ISSN: 2318-8995 CB2498EN/1/12.20 ISBN 978-92-5-133761-5 9789251337615