1 PROGRAM BRIEF Towards a Child Benefit Scheme Bangladesh Capitalizing on the early years is one of the most critical investments a country can make to break the cycle of poverty, address inequality and boost productivity in later life. However, millions of children in Bangladesh are not reaching their full potential because of inadequate nutrition, lack of early stimulation and learning, and exposure to stress. Investments in the physical, mental and emotional development of children – from before birth until they enter primary school – are vital for the future productivity of individuals and for the country’s economic prosperity. 1 The Program Brief series discusses major safety net programs that the Government of Bangladesh implements. The series includes notes on the Old Age Allowance; Allowances for the Widow, Deserted and Destitute Women; and Allowances for the Financially Insolvent Disabled by the Ministry of Social Welfare; Employment Generation Program for the Poorest; Food for Work; Work for Money; Test Relief; and Vulnerable Group Feeding by the Ministry of Disaster Management and Relief; and the Child Benefit Scheme. Many of these programs are supported by the World Bank. 1 Towards a Child Benefit Scheme PROGRAM BRIEF BACKGROUND Investing in children’s human capital is one of the most The Government of Bangladesh has been implementing important policy objectives to reduce poverty and boost a number of programs dedicated to improved infant and shared growth. It will determine the productivity and maternal health. Major programs in this area began only in competitiveness of the future workforce and thus affect the 2006 while Bangladesh has had a very young population with growth trajectory of the country. However, many children in high fertility rates since the 1970s. Currently, these programs Bangladesh, especially those who live in poverty, have limited constitute approximately 3.7 percent of the social protection access to adequate opportunities for physical, cognitive, budget (figure 1). Though the proportion has grown over the and non-cognitive development. For instance, in 2017, 31 last decade, the increase has been much slower compared percent children under five years of age were stunted, which, to allocations to programs targeted towards the elderly, i.e. though significantly lower than 51 percent in 2004, is still high. civil service pensions and Old Age Allowance.v Support for Wasting in 2017 was 8 percent which has taken a slower pace older, school going children through stipends has also been of decrease from 15 percent in 2001.i More than a fifth of all significant and has increased over the years.vi children under five continued being underweight in 2017. The problem is particularly acute in rural areas. Recognizing the wholly inadequate allocation towards very young children’s social protection, in 2018 the Government Poor health and nutrition outcomes as well as limited established a Policy Guidance Unit for Child-focused Social childhood development leave a dent on children’s future Protection (PGU-CSP) under the Cabinet Division to accelerate productivity from as early as their life in the womb. Therefore, design and implementation of a Child Benefit Scheme, building a large body of global literature greatly emphasizes the upon the success and learnings from existing programs. importance of investing early from the prenatal stage to at least 1,000 days of the child’s life. Providing adequate nutrition and stimulation for early childhood development during this critical period can minimize the risk of permanent detrimental impacts on children’s intelligence and brain developmentii. In addition, improved nutrition also reduces the risk of 4.00% morbidity and health shocks that have devastating effects on 3.68% Share of annual social protection 3.50% households, depleting savings and stifling earning capacity. 3.00% Programs to promote neonatal and infant nutrition and 3.00% 2.71% 2.54% cognitive development have revealed evidence globally that 2.50% expenditure as a result of the interventions, the earning capacity of those 2.30% 2.00% 2.12% children increased significantly when they grew upiii. 1.50% The poverty rates in Bangladesh are much higher for 1.00% 0.86% 0.66% households with young children than the national average. 0.83% 0.50% 0.63% Nearly half the households with a child aged 0 to 5 years are 0.33% poor. This indicates that households with young children have 0.00% FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 unique challenges. This may be because these households are headed by young parents whose labor market career is still at an early stage yielding insufficient incomes. That working women have to give up paid employment outside the house following child birth likely contributes to poverty of these Figure 1: Expenditure on programs related to maternal, neonatal and infant nutrition and health as a percentage of the households. Young children from female headed households social protection annual expenditures containing elderly grandparents needing financial support Source: Analysis is based on budget archives, Finance Division, Ministry of Finance and care are exposed to even greater risksiv. THE WORLD BANK 2 PROGRAM BRIEF Notable programs include the (i) Maternal Health Voucher in twenty-one districts. Currently the MHVS has expanded to fifty- Scheme which is now known as the Demand-Side Financing three upazilas. In FY16, the MHVS served more than hundred of Maternal Health Voucher Scheme; (ii) Maternity Allowance thousand pregnant women which represented about 3 percent Program for the Poor; (iii) Allowances for Urban Lactating of all pregnancies across the country. Mothers; and (iv) Income Support Program for the Poorest (ISPP)-Jawtno (figure 2). The program is now called Demand-Side Financing of Maternal Health Voucher Scheme (DSF-MHVS). To be eligible for DSF- MHVS, a pregnant woman (up to her second pregnancy) must belong to a household that is landless or owns less than 0.15 Program expenditure in BDT billion 25 acre of land; has irregular income of no more than BDT 3,100 20 (US$ 37) per month and owns no productive assets.vii Once enrolled in the program, a beneficiary is entitled to (i) three 15 ante-natal care (ANC) visits; (ii) facility-based child delivery; (iii) one post-natal care (PNC) visit within 6 weeks of delivery; 10 (iv) services for obstetric complications; (v) payment of BDT 5 500 (US$ 6) as transport cost to institutional obstetric services – each beneficiary is provided with a booklet of vouchers 0 which she can use each time she avails institutional ANC, FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 PNC or institutional delivery services; (vi) up to BDT 500 (US$ 6) for referral to district hospital; and (vii) cash grant of BDT Total allocation 2,000 (US$ 24) if the delivery is facilitated by a skilled birth attendant.vi The payments flow through the Line Director (LD) Maternal Health Voucher Scheme of Maternal, Neonatal, Child and Adolescent Health (MNCAH), Maternal, Neonatal, Child and Adolescent Ministry of Health and Family Welfare to upazila accounts of Health (Demand-side financing of Maternal MNCAH to beneficiary bank accounts. Health Voucher Scheme [DSF-MHVS] On the supply side, such health services are provided by Maternity Allowance Program for the Poor public, private and Non- Government Organizations (NGO) service providers. The program initially tried to create Allowances for Urban Lactating Mothers competition through performance incentives, but new service Income Support Progam for the Poorest providers did not respond and public health service providers (ISPP-Jawtno) remain the primary source.viii Service providers continue to be incentivized through a seed fund for health services for pregnant women including PNC. Figure 2: Expenditure on various programs related to maternal, Early pilot results revealed that the program was able to increase neonatal and infant nutrition and health the utilization of maternal health services by poor pregnant Source: Budget documents, Finance Division, Ministry of Finance women through incentives when compared with those pregnant women who were not incentivized.viv Women enrolled I) DEMAND-SIDE FINANCING OF MATERNAL in the program were more likely to seek ANC and PNC services; and more births were attended by skilled birth attendants, as a HEALTH VOUCHER SCHEME (DSF-MHVS) result of which the number of stillbirths and neonatal mortality was also found to be lower in DSF areas than in non-DSF areas. The primary goal of the Maternal Health Voucher Scheme (MHVS) Total out of pocket expenditure on ANC, PNC and child birth was was to reduce maternal mortality in line with the Millennium also found to be lower in DSF areas.x Development Goals. Designed by the Ministry of Health and Family Welfare with support from the World Health Organization, A diagnostic reportviii found a few challenges including limited the program since 2006 was piloted across twenty-one upazilas awareness of local authorities about the program’s policies To w a r d s a C h i l d B e n e f i t S c h e m e 3 Towards a Child Benefit Scheme PROGRAM BRIEF and procedures, delays in payments, targeting of noneligible Each beneficiary is enrolled in either program for a duration of beneficiaries etc. Increase in the incidence of caesarean three years and is entitled to receiving a monthly allowance of deliveries particularly in private health facilities was a key BDT 800xiii (US$ 9.5), paid through her bank account.xiv concern. Inadequate quality of services was also a challenge primarily due to overloaded service providers stemming from While beneficiaries are appreciative of having their individual insufficient human resources at the health facilities.viv accounts so that they can have better control over the allowances they receive, many find upazila-based bank branches inconvenient to reach because of the distance. Moreover, the accounts are of “short term” nature based on the tenure of II) MATERNITY ALLOWANCE PROGRAM FOR the entitlement. Many beneficiaries do not receive cheques to THE POOR (MAPP) & ALLOWANCES FOR withdraw their allowances – instead the banks draw the entire allowance amount each time so that account has no savings URBAN LACTATING MOTHERS (AULM) functions. At the same time, long delays in the transfer of funds from the central level to upazilas lead to less frequent payments Maternity Allowance Program for the Poor (MAPP) and to beneficiaries (usually lumped into six monthly or yearly Allowances for Urban Lactating Mothers (AULM) both focus on payments instead of monthly payments). Such accumulated maternal and child health. The two key differences between payments represent windfall gains which are often used by the programs are: households for investment purposes e.g. to purchase livestock, - Geographic focus: MAPP focuses on rural areas while poultry and capital items. While that may translate into increased AULM focuses on urban areas; future income contributing to poverty reduction, it has limited immediate effect on food and nutritional intake of children which - Objectives: The two programs have similar objectives - the programs aim to improve. Moreover, due to delays, women reduced infant and maternal mortality; improved utilization often receive accumulated allowances after the pregnancy so of PNC and delivery services; and improved breastfeeding prenatal nutrition is unlikely to benefit from the payments.xii and family planning practices. However, while the MAPP emphasizes on improved immunization; reduction of dowry, Under both programs, Community Based Organizations (CBOs) child marriage and divorce; and increased registration of birth and NGOs arrange training for beneficiaries on pregnancy, and marriage; AULM emphasizes on increased utilization of child birth, neonatal care and other social and developmental ANC, improved standard of living and living conditions. aspects. According to an evaluation,xv MAPP beneficiaries were found to be more likely to utilize ANC and PNC services MAPP began in FY2008 under the Ministry of Women and than women who did not receive any intervention. The Children Affairs (MoWCA) and since then has expanded rapidly study also suggested that MAPP beneficiaries’ knowledge on to become a large national program, focused on rural areas. breastfeeding was slightly better than non-beneficiaries, but Each year, the number of new beneficiaries is determined that did not lead to better breastfeeding practices. Similarly, no centrally and at present the program reaches 700,000 women significant effect was noticed in the incidence of institutional around the country. On the other hand, AULM began in FY11, delivery among MAPP beneficiaries. A cause for such mixed also under MoWCA, and currently, the number of beneficiaries outcomes could potentially have been delayed training in this program reaches is around 250,000.xi many instances resulting in many beneficiaries not receiving any training during pregnancy. Moreover, in case of sessions In order to be eligible for MAPP, a woman must (i) be at least on neonatal care, it was found that mothers have difficulty twenty years old; (ii) be pregnant with her first or second child attending sessions with their new-born babies. Having to tend during the annual enrolment of the program during July; (iii) to the baby during the session constrained the mother’s ability have a household income of less than BDT 1,500 (US$ 18) to concentrate on training contents. At the same time, there per month; and (iv) not be a previous/existing beneficiary of were also concerns about the educational attainment and similar programs. Similarly, an AULM beneficiary has the same knowledge of the trainers on the training content.xii demographic criteria with the addition that she must be a working woman. The household income threshold is set at no MoWCA recognizes many of these challenges and, with support more than BDT 5,000 (US$ 60).xii from World Food Programme (WFP), has recently designed the 4 PROGRAM BRIEF Improved Maternity and Lactating Mother Allowance (IMLMA) 0 to 36 months and education outcomes for primary school Programme which aims to combine the two existing programs children, through bi-monthly cash transfers to nearly 16,000 and facilitate rolling enrolment, provide monthly Government poor households in two upazilas in Rangpur.xi The 13-month to Person (G2P) payments and improve behavioral change pilot significantly improved the knowledge of mothers about communication. of exclusive breastfeeding; increased dietary diversity; and reduced the incidence of wasting of children aged between 0-14 months at the time of enrollment.xvii III) INCOME SUPPORT PROGRAM FOR Based on the positive outcomes and findings from the pilot, the THE POOREST (ISPP-Jawtno) Government scaled up the CCT to 43 of the poorest upazilasxviii with a high likelihood of malnutrition, focused on improving Global evidence suggests that, if implemented well, nutrition and cognitive development of children from conception conditional cash transfers (CCT) can contribute to poverty to five years. The Income Support Program for the Poorest-Jawtno reduction and improved human development outcomes.xvi By (ISPP) aims to provide income support to poor households while making payments to households, conditional upon compliance increasing the mothers’ use of child nutrition and cognitive with co-responsibilities, CCTs can stimulate behavioral changes, development services and enhancing local level government contributing to improved household wellbeing and preventing capacity to deliver safety nets. A unique feature of the ISPP- intergenerational transmission of poverty in the long run. Jawtno program is its focus on the full spectrum of a child’s early years with a great emphasis on overall development, beyond The Government of Bangladesh was among the first to health and nutrition, up to the age of five. Through the child implement a CCT through the Female School Stipend Program nutrition and cognitive development (CNCD) sessions, caregivers in the 1990s which had a major contribution to increasing girls’ are counseled on various topics, including nutrition, hygiene and enrollment in secondary schools.xvii This paved the way for safety, and developing motor skills and cognitive awareness.xviv numerous other programs around the world which have shown impressive health and education outcomes. Human brain development is greatest at the very young age.xx Through the conditional cash transfer, Jawtno aims to In 2011, the Local Government Division, with the support enhance households’ ability to make the most of the timing of of the World Bank, implemented a pilot CCT initiative, brain development as presented in Figure 3. Shombhob, focusing on improving nutrition for children aged Sensory pathways Higher Cognitive Function Language -8 -7 -6 -5 -4 -3 -2 -1 1 2 3 4 5 6 7 8 9 10 11 1 5 10 15 19 Potentially Conception Birth Age in months Age in years healthier and more productive adults Jawtno Jawtno who can overcome ANC GMP poverty Information on Information on post-partum health, child health, pregnancy nutrition and cognitice development Cash Cash Figure 3: ISPP’s theory of change for improved cognitive development 5 Towards a Child Benefit Scheme PROGRAM BRIEF For a woman to be eligible for ISPP-Jawtno, she must (i) belong ISPP-Jawtno’s co-responsibilities require support from local to a poor household; and (ii) either be pregnant or have a child public health service providers, in particular community below the age of five years (only for the two eldest children). clinics managed by the Ministry of Health and Family Welfare. Beneficiaries must comply with specific co- responsibilities For the ANC and growth monitoring and promotion (GMP) co- based on her profile (Table 1). responsibilities, beneficiaries avail services from their closest health center and record their attendance by swiping their In line with the Government’s safety net strategy for objective Jawtno cash cards. Since community clinics have minimal targeting of the deserving poor, ISPP-Jawtno is designed to staffing capacity, ISPP has procured the services of an NGO, identify beneficiaries using the National Household Database BRAC, to support community clinics in providing ANC and GMP (NHD), which contains household poverty scores based on services and recording beneficiaries’ attendance. a proxy means test (PMT) formula. Until the NHD becomes operational for safety net programs, the program uses ANC, GMP and CNCD services are prudently scheduled and community-based targeting to identify beneficiaries. managed to make sure that each beneficiary receives the customized session that serves her and her child/ren’s needs. Applicants to the program must meet defined poverty criteria, which include land ownership, occupation of household ISPP-Jawtno’s beneficiaries receive quarterly payments head, asset ownership and average household income. through the Bangladesh Post Office (BPO) using the Jawtno The application is vetted by the community and following a cash cards. Payment camps are organized at the union, close verification visit, the final list of beneficiaries is prepared. to where beneficiaries live as opposed to upazila level bank branches common for other safety net programs. The program Once beneficiaries are identified, they are enrolled into is also exploring use of other payment providers to improve ISPP-Jawtno. The enrolment process includes collecting the beneficiaries’ ease of access to their funds. household’s basic demographic information - NIDs, birth certificates/immunization cards, and pregnancy test results ISPP-Jawtno receives grievances through its union-based – as well as the beneficiary mother’s fingerprints. All the data safety net cell (SNC), staffed by a safety net program assistant feeds into a management information system (MIS) that (SPA). The SNC’s vision is to become a one-stop-shop service has been developed by the Project for improved program center for safety nets in each ISPP-Jawtno union. For the administration. Each enrolled beneficiary receives a ‘Jawtno time being, the SPAs help implement ISPP-Jawtno and serve cash card’ which is biometrically-enabled to serve as her as the beneficiary interface of the Project, which includes beneficiary ID as well as her instrument for cash withdrawal. troubleshooting beneficiary problems with targeting, enrolment, services and payments. Table 1: ISPP-Jawtno’s coresponsibilities Category of beneficiary Co-responsibility Benefit amount (BDT) Payment condition Maximum payment per quarter Pregnant women Up to four ANC visits during BDT 1,000 No visit, no payment BDT 1,000 – 2,000 pregnancy All beneficiary mothers Take child for height and BDT 700 per visit plus a bonus of BDT 700 if all Payment allowed if at BDT 2,800 with children aged 0-24 weight check every month three visits are completed in a quarter least two visits have been months completed in a quarter All beneficiary mothers Take child for height and BDT 1,500 No visit, no payment BDT 1,500 with children aged 25-60 weight check every 3 months months All beneficiary women Attend child nutrition and BDT 700 per visit (total of BDT 2,100 in one Payment allowed if at BDT 2,800 development counseling quarter, irrespective of the number of children least two visits have been sessions every month enrolled plus bonus BDT 700 if all three visits are completed in a quarter completed in a quarter) 6 PROGRAM BRIEF WAY TOWARDS THE CHILD BENEFIT SCHEME Building human capital is an essential step to ensure a The Government is planning to launch a comprehensive country’s productivity and strengthen household resilience. Child Benefit Scheme, the implementation plan for which This is particularly critical for Bangladesh at a time when the will be developed by MoWCA. According to the plan for the country needs to take advantage of its demographic dividend. Scheme, it is expected to support children’s socio-economic environment to fulfill long-term strategic needs of increasing Although Bangladesh has managed to significantly improve their earnings ability and lifting their households out of overall human development outcomes, under five stunting poverty. The scheme will build on the achievements and and wasting continue to be major problems. Preventing lessons of the existing maternal and child health programs early chronic malnutrition is the first step in creating and discussed in this note. protecting human capital – this can only be done through both providing adequate health and nutrition services and helping households utilize such services. i Bangladesh Demographic Health Survey, 2000-2017/18 ii Hawley, T. 2000. “Starting Smart: How Early Experiences Affect Brain Development.” Zero to three Press iii Gertler, P. et al. 2014. “Labor Market Returns to an Early Childhood Stimulation Intervention in Jamaica.” Science 30, vol 344 (6187): 998-1001 iv National Social Security Strategy, 2015 v At the same time, it should be noted that a well-functioning old age allowance or pensions system with wide coverage contributes to child care as financially better off elderly parents require less support from their grown-up children which enables those adults to provide more support for their own children. vi Osmani, Ahmed, Ahmed, Hossain, Huq and Shahan, Strategic Review of Food Security and Nutrition in Bangladesh vii Budget documents, Health Services, Ministry of Health & Family Welfare viii Ahmed, S; Khan MM; A maternal health voucher scheme: what have we learned from the demand-side financing scheme in Bangladesh? viv Khan, MM; Khan, MA Rahman; Report on the Diagnostic Study of DSF-MHVS Bangladesh, Maxwell Stamp, Strengthening Public Financial Management for Social Protection (SPFMSP) Project, 2016 x Economic Evaluation of Demand-Side Financing (DSF) For Maternal Health in Bangladesh, Ministry of Health and Family Welfare, supported by GIZ xi MoWCA/WFP, 2018 no more than BDT 8,000 in areas where enrolment is conducted by Bangladesh Garment Manufacturers and Exporters Association (BGMEA) and Bangladesh Knitwear Manufacturers and Exporters xii Association (BKMEA) xiii Increased from 2 years and BDT 500 per month (MoWCA) in the FY19 budget xiv A Diagnostic Study on Maternity Allowance (MA) and Lactating Mothers Allowance (LMA) Programmes of Ministry of Women and Children Affairs, Ministry of Finance, SPFMSP Project xv Jetha, 2011 xvi Fiszbein and Schady, 2009 xvii Ferre, Celine; Sharif, Iffath; 2014; World Bank; Can Conditional Cash Transfers Improve Education and Nutrition Outcomes for Poor Children in Bangladesh? xviii The 44 upazilas fall within Gaibandha, Jamalpur, Kurigram, Mymensingh, Nilphamari, Lalmonirhat and Sherpur districts. xviv The CNCD curriculum was developed by the Child Development Unit of icddr,b and based on research and findings of international and local best practice. xx C.A. Nelson in “From Neurons to Neighborhoods, 2000” For more information: Overview on Bangladesh’s safety net program: This Program Brief has been World Bank. 2016. Bangladesh Social Protection prepared by Rubaba Anwar and https://bit.ly/2B7FBSW and Labor Review: Towards Smart Social Protection Aneeka Rahman, Social Protection and Jobs for the Poor. Bangladesh Development & Jobs Global Practice, World Bank, Series,no. 33;. World Bank, Dhaka, Bangladesh. with kind support of the Korea-World © World Bank. Bank Partnership Facility (KWPF). https://bit.ly/2TWVVx9 World Bank Office Dhaka Plot- E-32, Agargaon, Sher-e-Bangla Nagar Dhaka-1207, Bangladesh Tel: 880-2-5566-7777, Fax: 880-2-5566-7778 www.worldbank.org/bangladesh 7