Djibouti is vulnerable to external shocks, such as surging food and fuel prices, and natural disasters. From 2007 to 2011, severe drought led to losses equivalent to 3.9 percent of Gross Domestic Product per year. The global financial crisis, subsequent drought, high urban density and unemployment, and limited access to basic services, have resulted in poor social and health indicators. High poverty levels persist.
In 2012, the rural food security situation was defined as “critical” with three-quarters of households found severely or moderately food insecure. The under-five mortality rate is still estimated at 68 deaths for 1,000 live births, with over 17.8 percent of children under five years found poorly nourished. The prevalence of moderate and severe stunting of children’s growth is 29.7 percent.
Djibouti’s government responded to the crisis by investing in infrastructure, private sector development, and human capital. As part of this, it piloted its first nutrition-based social safety net program with support from the World Bank. The pilot led to the formulation of a in 2012 that emphasized the importance of a long-term, development-oriented approach integrating different forms of social assistance through a national, nutrition-based program.
The government pursued a “first 1000 days approach” based on evidence that malnutrition starts during pregnancy, with early damage irreversible after a child reaches two years of age.
The pilot and its follow-up program are supported by the World Bank through a US$3.6 million Japan Social Development Fund (JSDF) grant and a US$5 million IDA grant. The program also partners with Djibouti’s Ministry of Health and the World Food Program (WFP).
Innovative aspect: nutrition-based intervention in a cash-for-work program
Under the program, eligible households receive nutrition services oriented towards pregnant women and children under two. Behavior change communication during monthly group sessions and individual home visits aims to effect change both at household and community level. Growth monitoring sessions for children under two are organized monthly. Children between 6 and 24 months are provided micronutrient powders and targeted supplements. The program also promotes healthy behavior and accompanies patients referred to health centers for free diagnoses of hemoglobin levels during prenatal care. This community-based nutrition complements activities by the Ministry of Health, which focuses on the treatment of acute malnutrition.
Cash-for–work includes community service and light labor. Each beneficiary can apply for 50 days of work, providing a small daily wage. This is only open to households who have attended the nutrition interventions, with the female caregiver having first right to decide whether she wants to take the work or delegate it to a household member.
Public works are becoming increasingly nutrition-based, with a focus on hygiene and access to water, and income-generating interventions for women, and options for household asset building.
Nutrition-based indicators are taken into consideration during targeting and transfers. Geographical targeting is based on poverty rates but within defined areas, households are eligible if they contain nutritionally vulnerable members such as pregnant women and children under the age of two.
The program aims to empower women within the household as priority beneficiaries, not only for the nutrition services but also for the cash-for-work interventions. Women are empowered through knowledge about optimal child care practices and financial transfers: the additional income they earn allows them to apply the recommended nutrition practices.
The project management information system has been designed to fully integrate the two components and conditionality. This ensures that individuals recruited for small works and services actually belong to the targeted households.
Investment in capacity building
The project is implemented by the with the Ministry of Health and local organizations. Cascade training is used to train health staff and local Non-Governmental Organizations and associations subcontracted to facilitate the delivery of nutrition services at the community level.
The program is using existing community structures as much as possible: nutrition services are provided by voluntary community workers and facilitators originating from the community itself. The trained volunteers provide monthly nutrition services to two groups of 20 households. They are supported by trained facilitators, who in turn support about 10 volunteers.
Public works are identified by a community-led development committee. The programs are reviewed and evaluated every three months at community level.
Gradual expansion guided by evidence on program implementation
During the first 18 months of implementation, the government focused on developing the tools for the program, building cross-sector collaboration between the health and social sectors, as well as increasing the capacity of the implementing agency and its partners. Since 2012, interventions at the community level have been rolled out geographically. By May 2014, over 5,400 beneficiaries have attended the nutrition services and more than 4,400 beneficiaries have benefited from the cash-for-work interventions.
During the program’s design phase, the emphasis was on setting up a good Monitoring & Evaluation system. During pilot and expansion phases, rigorous baseline and follow-up surveys were carried out. Additionally, a rigorous impact evaluation is ongoing of the added value of public works in preventing malnutrition, providing crucial information for the possible scaling-up of the program.
The Djibouti government has taken steps toward building a registry of poor and vulnerable households for better targeting in order to integrate different forms of assistance and coordinate support from different development partners.
