PROTECTING HUMAN CAPITAL FROM THE IMPACT OF EARLY LIFE SHOCKS KEY INTERVENTIONS FOR LOWER–MIDDLE–INCOME COUNTRIES By Nakawala Lufumpa, Anne Hilger, Odyssia Ng, and Bénédicte Leroy De La Brière Additional input from Emanuela Galasso, Joana Silva, and Ritika Dsouza SASPP Policy Note Series NOTE 7 | MARCH 2023 SASPP Policy Note Series 2 NOTE 7 | MARCH 2023 KEY RECOMMENDATIONS This policy note presents strong evidence of the impacts of early childhood exposure to shocks on later life human capital outcomes in lower–middle–income countries, particularly in the Sahel region. It recommends key, evidence–based social protection interventions to mitigate these impacts and protect human capital as follows : • Cash transfers to improve child nutritional outcomes, particularly when combined with behavior change communication on water, sanitation and hygiene and hygiene practices. • Conditional cash transfers to increase educational outcomes, especially when monitored and reinforced. • Contributory schemes to mitigate the impact of shocks on asset loss and household expenditure, particularly health, livestock, and climate insurance schemes. • Food distribution interventions to mitigate the impact of shocks on nutritional and educational outcomes, particularly for children under–five, which is a critical period for growth and development. • Behavioral interventions to positively influence health and educational behavior and spending, especially nutrition education, academic nudges, and maternal psychotherapy interventions. • The success of these interventions requires context– and population–appropriate program design and implementation to maximize their effects on protecting human capital. 1 Introduction To ensure sustained economic growth in lower–middle– Box 1 : Indicators of Human Capital income countries (LMICs), it is essential to accumulate and protect human capital. Human capital is “the knowledge, Childhood nutritional status is routinely assessed skills, and health that people accumulate over their lives.” with anthropometric measures — measures of the Exposure to shocks in LMICs has resulted in significant body. These indicators include stunting (low height– economic costs, including through the loss of human for–age) and wasting (low weight–for–height). Stunting capital. Shocks are unanticipated events that result in major is considered an indicator of chronic undernutrition, disruptions at the household or national level, and include whereas wasting is considered an indicator of acute conflict, climate events, or sudden loss of income2. The undernutrition. impact of shocks is especially damaging when they occur in early childhood — the first five years of life3. Disruptions Nutritional status, in both childhood and adulthood, experienced during this critical period of cognitive and is assessed indirectly through feeding practices. The physical development have been shown to have long– World Health Organization and UNICEF recommend lasting effects on potential productivity and earnings4,5,6. that children under six months of age be exclusively Box 1 summarizes key indicators of human capital that can breastfed. Once complementary feedings begins, a help track human capital outcomes. child should be fed an adequate number of high–quality, diverse meals, which is primarily assessed by the number of different food groups from which one eats daily. BOX 1 CONTINUES ON THE FOLLOWING PAGE CONTINUE SASPP Policy Note Series 3 NOTE 7 | MARCH 2023 Among LMICs, the Sahel region is highly exposed to Box 1 continued shocks and vulnerable to their impacts on human capital formation and accumulation. The six countries of the Educational status, in childhood or adulthood, is Sahel — Burkina Faso, Chad, Mali, Mauritania, Niger, and assessed through measures of school attendance Senegal — experience increasingly frequent climate– and and performance. Indicators measured during childhood conflict–related shocks. The United Nations estimates that include current school enrollment, school attendance, the temperature increase in Sahel countries is almost 1.5 and test scores. Indicators assessing educational status times higher than the projected global average7, resulting in adulthood or late childhood include grades completed in numerous droughts. This is compounded by high levels or years of schooling. of poverty and inequality, which increase household vulnerability to the effects of shocks on human capital Health status is assessed directly through measures formation8. Persistent poor human capital outcomes mean of morbidity or mortality. In childhood, morbidity is that children born in the Sahel are only one third to two– assessed through the incidence of illnesses such as fifths as productive as adults than they could have been diarrheal disease or respiratory infections. Additional if human capital had been optimally developed9. Figure 1 assessments of health status include measures of provides a framework that illustrates the potential impacts cognitive development. of unmitigated exposure to the impacts of shocks and the vital importance of investing in childhood human capital10. The World Bank Human Capital Index (HCI) brings some of these indicators together to capture the amount of human capital that a child born today could expect to attain by age 18. It calculates the human capital of the next generation, defined as the amount of human capital that a child born today can expect to achieve in view of the risks of poor health and poor education currently prevailing in the country where that child lives. The HCI is based on three components: survival, expected years of learning-adjusted school and health. Across Sub-Saharan Africa, a child born in 2020 will only be 40 percent as productive when she grows up as she could be if she had enjoyed complete education and full health. SASPP Policy Note Series 4 NOTE 7 | MARCH 2023 FIGURE 1. UNICEF Framework for Investing in Childhood Human Capital Source: Authors’ adaptation based on UNICEF (2017)11. Note: The black arrows illustrate the perpetual cycle of adverse long–term outcomes negatively affecting the macro environment and underlying causes. SASPP Policy Note Series 5 NOTE 7 | MARCH 2023 2 Impact of shocks on human capital in LMICs Impact of exposure during the 2.3 Impact of maternal exposure 2.1 early years on human capital to concurrent shocks on formation childhood human capital formation Childhood or in utero exposure to extreme weather events can have catastrophic impacts on human capital formation, A single extreme event can lead to concurrent and with long–lasting effects on adult outcomes. Global studies compounding shocks that impact maternal stress show that in utero or childhood exposure to famine, drought and subsequently child outcomes. Shocks increase or crop failure has variously resulted in a wide range of maternal stress, with measurable effects that range from adverse human capital outcomes in adulthood, such as complications during labor and birth29, developmental poorer health outcomes (higher likelihood of diseases, delays and behavioral abnormalities among their children, faster cognitive aging, adult body size, or diabetes).12,13,14,15,16,17,18 through to intergenerational impacts on the grandchildren Surviving a famine in early childhood affects not just health of those who experienced the stressor.30 Shocks can also but also long–term labor market outcomes, including lower increase violence against women, further magnifying levels of education and reduced working hours and income. maternal stress. 31,32 Children with one or more parents In utero exposure to health– or conflict–related shocks, exposed to war or intimate partner violence are at higher such as war or a pandemic, also has long–lasting impacts risk of experiencing child maltreatment,33 which increases on human capital outcomes in adulthood. Those in utero their risk of physical and mental illness.34 These examples during these events have experienced significant reductions highlight the need for interventions to mitigate the impacts in education, health, and economic outcomes.19,20,21,22,23,24 of exposure to shocks. 2.2 Impact of exposure during adolescence on human capital formation In Sub–Saharan Africa, exposure to droughts in adolescence can also increase the likelihood of child marriage. Households may use child marriage as a mechanism to manage a decrease in household income by reducing household size, and expenditure on food and education.25, 26 Girls who marry early are more likely to experience domestic violence, school dropout, and oppression, which further perpetuates poor short– and long–term human capital outcomes, including to the next generation.27, 28 The COVID–19 pandemic is likely to have long–lasting impacts on human capital. There is already evidence of pandemic–related impacts on income and consumption, increased intimate partner violence, reduced childhood human capital due to school closures, higher incidence of adolescents dropping out of school, increased teen pregnancies, and higher rates of child marriages. SASPP Policy Note Series 6 NOTE 7 | MARCH 2023 3 Impact of shocks on human capital in the Sahel Countries in the Sahel are highly vulnerable to shocks and their impact on human capital. Studies have revealed the extensive short and longterm human capital impacts of climate, conflict, and healthrelated shocks in this region. 3.1 Impact of climate–related Impact of the COVID–19 health 3.3 shocks in the Sahel shock in the Sahel Exposure to climate shocks in the Sahel can significantly Current studies on the COVID–19 health shock are revealing impact child nutritional, health, and educational the negative impacts of the pandemic on food security and outcomes. 35,36 This highlights the need to mitigate exposure poverty in the Sahel. In Burkina Faso, more than 70 percent to shocks in early childhood, to address both the direct of women in both urban regions rural regions reported partial impact on children and the indirect impact through parental or complete income loss due to the COVID–19 pandemic (particularly maternal) nutrition and stress. In numerous and associated restrictions.46 Additionally, the COVID–19 Sahel countries, droughts or flooding have frequently pandemic has increased food insecurity in Burkina Faso, resulted in sudden and dramatic increases in household including reduced meal frequency and meal size.47,48 food costs, with the negative impacts on food security continuing beyond the immediate shock.37,38 The Sahel region is highly vulnerable to droughts, and children living in the driest climates have an 80 percent higher likelihood of suffering from diarrheal disease than children in humid climates. Furthermore, birth month exposure to dust or sandstorms (harmattan) is associated with an increased likelihood of neonatal mortality. 39,40 In Mali, early childhood exposure to locust invasions reduced long–term school enrollment, particularly for children who were in utero and up to two years old during the locust invasion, and more so for boys. Similar negative impacts were seen on grade attainment among girls,41 while exposure to famine in Mali led to a decrease in male educational attainment.42 3.2 Impact of conflict–related shocks in the Sahel Increasing instability in the Sahel, and the associated conflict–related shocks, can negatively affect general and maternal health status. There is striking evidence of the mental and maternal health impacts of conflict– related shocks in this region. Among Malian refugees in Burkina Faso, 75 percent were found to be depressed or suffering from a mental illness, while 85 percent had post–traumatic stress disorder,43 particularly among women and older populations. In Burkina Faso, expectant mothers who were exposed to terrorist attacks made less use of maternal healthcare services. 44 In Chad, internally displaced populations experienced a higher prevalence of child and under–five mortality than their non–displaced counterparts.45 SASPP Policy Note Series 7 NOTE 7 | MARCH 2023 4 Interventions to limit the impacts of shocks on human capital Social protection interventions aim to mitigate the short– and long–term impacts of early–life shocks on key determinants of human capital in both childhood and adulthood. This section provides proven social protection interventions that can inform effective, evidence–based policy solutions in the Sahel. distribution of cash through mobile money may be 4.1 Cash transfer interventions the most cost–effective option for cash transfers and resulted in greater improvements in food purchases Cash transfer interventions in LMICs have been shown and consumption. to measurably impact child nutritional and educational outcomes. Cash transfers are most impactful on child Cash plus programs can improve the impact of cash nutritional status when combined with behavior change transfer programs in LMICs and ensure an enduring impact communication.49 WASH and hygiene behavior change on human capital. Cash plus programs are unconditional communication can have the greatest impact on both cash transfer programs implemented alongside child growth and undernutrition. Other priority areas for complementary programs or services that address the behavior change communication are on infant and young needs of the target population and facilitate household– child feeding and household nutrition. Effective cash level investments in human capital. These complementary transfer programs are dependent on program design, programs or services can include additional benefits or implementation, and target population.50 in–kind transfers, behavioral change communication, psychosocial support, facilitating access to services, or Cash transfer programs in LMICs can also improve the linking individuals to services.54 A combination or package likelihood of school enrollment and attendance.51,52 This of these interventions can be implemented concurrently impact is further improved when the program is conditional, or staggered to maximize their impact on human capital. and these conditions are monitored and reinforced. The most appropriate package and timing of interventions Conditional cash transfer programs can in particular counter depends on the needs of the population and the context the tendency to pull girls out of school, improving not just in which they are implemented. educational outcomes, but also reducing the likelihood of early marriage and teenage pregnancy. However, cash transfer programs do not impact on test scores, which points to policy opportunities for improving school and schooling 4.2 Public Work Programs quality, in addition to ensuring increased access to schools. Public work programs can mitigate the impact of shocks Box 2: Concern Worldwide Conditional Cash Transfer on human capital in LMICs.55 Public work programs are Program (Niger) 53 government interventions that provide individuals with employment opportunities for approximate market wage In 2012, Concern Worldwide introduced a conditional in–cash or in–kind (food items, vouchers, or subsidies) cash transfer program in rural Niger in response to payments. Public works programs in low–income and government predictions of an impending drought and lower–middle–income African countries have a varied famine. The program targeted the poorest households, impact on household expenditure, nutrition, and education which were particularly vulnerable to food insecurity. outcomes.56 Within this region, there is inconclusive evidence Households received approximately US$ 250 per of the impact of public works programs on consumption month for a 3–month period, and where possible, this and expenditure, the impact on food security and nutrition was provided directly to female beneficiaries. Prior outcomes is inconsistent, and the impact on education to receiving the monthly cash transfer, mothers were outcomes is largely statistically insignificant. However, required to attend nutrition education courses. available evidence is limited by a small number of rigorous studies outside of Ethiopia and considerable heterogeneity Children between 6 and 24 months whose households in the program design — including the duration of the were enrolled in this program observed increases across program, payment schemes and relative amounts, and the multiple weight measures. In Niger the electronic type of complementary packages. SASPP Policy Note Series 8 NOTE 7 | MARCH 2023 4.3 Contributory Schemes livestock insurance may also benefit household spending. Among rural households, selling livestock is often one of the first strategies to manage the financial effects of shocks. Health insurance Index–based livestock insurance schemes are interventions Health insurance schemes are the primary social insurance that could potentially eliminate or minimize this asset loss or schemes targeting the most vulnerable populations in changes in household expenditure. In Kenya and Ethiopia, LMICs and can also be provided as social health insurances coverage was associated with a 45 percent decrease in (non–contributory) to the poorest. Community–based health catastrophic losses following exposure to shocks. 62 insurance schemes can improve educational outcomes and reduce catastrophic health expenditures. The key Uptake of index–based insurance schemes remains low determinants of program effectiveness include participant in LMICs, despite their potential to mitigate the impact understanding of health insurance, trust in the insurer, of shocks on human capital. Demand and uptake of household size, community involvement, administrative these schemes is generally dependent on understanding, and management structure, the amount and timing of the perception, trust, cost, and available alternatives,63 in premium, and cost–sharing.57 addition to geographically specific determinants.64,65,66 At the individual level, demand also depends on the specific asset and the climatic event being insured against.67 This Box 3: Healthcare (Rwanda) 58 evidence highlights the importance of designing population– specific insurance schemes to ensure increased demand In Rwanda, a nationwide community-based mutual and uptake. health insurance scheme called Mutuelles de Santé was introduced in 2005, reaching 90 percent coverage by 2012. This scheme targets low–income households Box 4: The Kenya Livestock Insurance Program or individuals who are employed in the informal (Kenya)68,69 sector. Every Rwandan is obliged by law to have some form of health insurance. This particular mandatory In 2015, the Kenyan government introduced a social scheme provides coverage for healthcare services and protection program to prevent the loss of livestock medication. While households enroll in the scheme and improve food insecurity in the most vulnerable jointly, payment is calculated per household member. drought–affected communities. Kenya purchases Payment for households with the lowest income levels insurance coverage for vulnerable households in arid are covered by the Rwandan government or donors. and semi–arid counties. Calculating agents monitor, Insurance payments among other members are based via satellite, the amount of vegetation available for on income level. livestock to consume and create an associated index of drought. Once a predetermined index threshold is This scheme has resulted in improved educational reached and communicated to relevant stakeholders, outcomes, better protection against parental health insurance companies provide payments directly to shocks, decreased catastrophic spending, and a reduced policyholders. Payments are proportional to the value poverty gap. 59,60,61 Insurance coverage also decreased thresholds reached. Households then use the payments the number of hours worked by boys. The effectiveness and sustainability of community–based health insurance schemes is dependent on local buy–in at all levels and the identification of reliable and sustainable financing 4.4 Food distribution interventions mechanisms. Index–based insurance schemes Food distribution interventions mitigate the impact of Index–based insurance schemes mitigate the impact shocks on food consumption, particularly for children of shocks, particularly climate and agricultural shocks, under–five, which is a critical period for growth and on household expenditure and poverty levels. These development. Food distribution interventions broadly schemes require a particular threshold to be met before target either school or non-school-age children. cash payments are automatically distributed to beneficiaries. The effectiveness of these interventions is dependent on Supplementary/complementary feeding adequate demand for the insurance scheme and appropriate Supplementary/complementary child feeding programs indexes to ensure that payments are adequately timed to target non–school–age children, especially during the mitigate the impact of shocks on households. Index–based critical growth period of the first 1,000 days of life. SASPP Policy Note Series 9 NOTE 7 | MARCH 2023 Complementary feeding programs in LMICs, with or without additional nutrition education, can result in marked 4.5 Behavioral interventions improvements in measures of growth in children.70,71 Nutrition Education Box 5: The Rainbow Project Supplementary Feeding Nutrition education can improve child feeding practices Program (Zambia) 72,73 and key measures of child growth.80,81,82 Nutrition education programs — commonly referred to as complementary In 2011, an NGO called the Rainbow Project, introduced a feeding education — educate parents and caregivers about supplementary feeding program in two Zambian districts. how to promote the overall well–being of their children and The program targeted the most undernourished children ensure that feeding practices are timely, adequate, and safe. under–five who did not suffer from any additional medical These programs are among the most widely implemented complications. Feeding centers provided weekly growth behavioral interventions across LMICs. monitoring, nutrition education, cooking demonstrations, onsite provision of a meal to the children, distribution Academic nudges of high energy protein supplements for the children Behavioral interventions can encourage improved school under–five and a basket of local foods for the whole attendance and academic outcomes.83,84 Decision–makers household, and home visitations. Home visits were can augment the promising outcomes of these interventions also conducted by community volunteers. by ensuring effective monitoring and improvement of schools and schooling quality. School feeding School feeding interventions can improve both nutrition Mental health interventions and education outcomes.74,75 School feeding programs Psychotherapy interventions that target women — provide children with nutritious meals and snacks during particularly for depression — can have significant long–term school hours, or take–home food items, and are regularly impacts on women’s empowerment and improve time– introduced alongside complementary programs such as and monetary–intensive parental investments.85 Mental deworming treatments or micronutrient supplementation. health interventions that foster women’s empowerment can School feeding programs in Africa have been shown result in improved maternal and child health.86 Mental health to increase school attendance, enrollment, and test interventions can also address the direct mental effects of scores.76 There is also evidence of long–lasting and exposure to shocks (e.g., post–traumatic stress disorder). multi–generational impacts of school feeding programs on nutritional outcomes.77 The impact of these programs is Box 7: The Thinking Healthy Program–Peer Delivered dependent on their context, design, and implementation. (Pakistan)87,88,89 Box 6: School Feeding Program (Ghana) 78,79 An evidence–based mental health intervention has been introduced by the World Health Organization The Ghana School Feeding Program is a nationwide in rural Pakistan to address high rates of perinatal government–led school feeding program that provides depression. The ‘Thinking Healthy Program’ uses a kindergarten and primary school children with one simplified version of cognitive behavioral therapy to nutritious hot meal every school day. Identification of address mental health issues in mothers, and costs US$ schools or communities is based on factors including 133 per participant. Trained peers facilitate individual poor educational outcomes, high rates of poverty or and group sessions with mothers who are diagnosed gender inequality, and the existence and willingness to with depression. Sessions focus on improving mothers’ introduce complementary nutrition or health education relationship with themselves, with their babies, and with interventions. their support systems. SASPP Policy Note Series 10 NOTE 7 | MARCH 2023 5 Conclusions Protecting children in the crucial first five years of life from the impacts of exposure to shocks is vital to long–term human capital outcomes and sustained economic growth in LMICs. Countries in the Sahel are particularly exposed to climate– and conflict–related shocks and are more vulnerable to their impacts due to their reduced ability to withstand this exposure in a way that minimizes the impact on human capital formation, especially in early childhood. This policy note has outlined proven social protection interventions that can mitigate or even eliminate this vulnerability and ensure the protection and accumulation of human capital. To be effective, the design of these interventions must be population– specific, and their implementation closely monitored. SASPP Policy Note Series 11 NOTE 7 | MARCH 2023 ENDNOTES 1 Buchsbaum, “HCP an Introduction”. 2 Brunelin, Ouedraogo et Tandon, “Five Facts about Shocks”. 3 Currie et Almond, “Human Capital Development”. 4 Knudsen, “Sensitive Periods”, 1412–25. 5 Knudsen, Heckman, Cameron et Shonkoff, “Economic, Neurobiological, and Behavioral”, 10155–62. 6 Victora, Adair, Fall, Hallal, Martorell, Richter, Sachdev et le Groupe d’étude sur la nutrition maternelle et infantile, « Santé maternelle et infantile et de la nutrition », 340–357. 7 Niang, Ruppel, Abdrabo, Essel, Lennard, Padgham et Urquhart, “Africa”, 1199–1265. See also: World Bank Group 2022b. G5 Sahel Region Country Climate and Development Report. 8 Groupe de la Banque mondiale, « Indicateurs de la Banque mondiale ». 9 Banque mondiale, « Indice du capital humain (ICH) de 2020 mis à jour ». 10 UNICEF, « Orientation des programmes de l’UNICEF relatifs au développement de la petite enfance ». 11 UNICEF, « Orientation des programmes de l’UNICEF relatifs au développement de la petite enfance ». 12 Stein, Susser, Saenger et Marolla, “Famine and Human Development”. 13 Roseboom, Van Der Meulen, Ravelli, Osmond, Barker et Bieker, “Effects of Prenatal Exposure”, 293–298. 14 Roseboom, de Rooij et Painter, “The Dutch Famine”, 485–491. 15 Banerjee, Duflo, Postel-Vinay et Watts, “Long–Run Health Impacts”, 714–728. 16 Kumar, Molitor et Vollmer, “Drought and Early Child Health”, 53–68. 17 Ampaabeng et Tan, “The Long–Term Cognitive Consequences”, 1013–1027. 18 Lumey, Stein et Susser, “Prenatal Famine and Adult Health”, 237–262. 19 Lee, “In Utero Exposure”, 76–93. 20 Almond, “Is the 1918 Influenza Pandemic”, 672–712. 21 Almond, Edlund et Palme, “Chernobyl’s Subclinical Legacy”, 1729–1772. 22 Dewi, Putu, and Dartanto, “Natural Disasters and Girls Vulnerability,” 24–35. 23 Corna, Hildebrandt, and Voena, “Weather Shocks.” 24 UNICEF, “Child Marriage.” 25 Jensen, and Thornton “Early Female Marriage,” 9–19. 26 lesue, Casanova et Piquero, “Domestic Violence”, 589–614. 27 Zulaika, Bulbarelli et Nyotach, “Impact of COVID–19 Lockdowns”, e0076666. 28 Rahiem, “COVID–19 and the Surge”, 105168. 29 Currie et Rossin–Slater, “Weathering the Storm”, 487–503. 30 Lee, “Intergenerational Health Consequences”, 284–291. 31 Weitzman et Behrman, “Disaster, Disruption”, 167–189. 32 Rao, “A Natural Disaster”, 112804. 33 lstratii, “War and Domestic Violence”. 34 WHO, “Child Maltreatment.” 35 Lazzaroni et Wagner, “Misfortunes Never Come”, 246-262. 36 Dunn, “The Impact of Climate Variability”. 37 Nebie, Ba et Giannini, “Food Security and Climate”, 100513. 38 Yobom, “Climate Change, Agriculture”. 39 Karimi, Pouran, Majbouri, Moradi–Lakeh et Hakimian, “Saharan Sand and Dust”, 139053. 40 García–Pando, Stanton, Diggle, Trzaska, Miller, Perlwitz, Baldasano, Cuevas, Ceccato, Yaka et Thomson, “Soil Dust Aerosols”, 679–686. 41 De Vreyer, Guilbert, and Mesple–Somps, “Impact of Natural Disasters”, 57–100. 42 Latham, “The Long–Term Impacts”. 43 Carta, Oumar, Moro, Moro, Preti, Mereu et Bhugra, “Trauma– and Stressor Related”, 189–195. 44 Druetz, Browne, Bicaba, Mitchell et Bicaba, “Effects of Terrorist Attacks”. 45 Guerrier, Zounoun, Delarosa, Defourny, Lacharite, Brown et Pedalino, “Malnutrition and Mortality Patterns”. 46 Gummerson, Cardona, Anglewicz, Zachary, Guiella et Radloff, “The Wealth Gradient”. 47 Ouoba et Sawadogo, “Food Security, Poverty”, 100387. 48 Ozer, Dembele, Yameogo, Hut et de Longueville, “The Impact of COVID–19”, 100393. 49 Manley, Alderman et Gentilini, “More Evidence on Cash”. 50 Manley, Balarajan, Malm, Harman, Owens, Murthy, Steward, Winder–Rossi et Khurshid, “Cash Transfers and Child”. 51 Baird, Ferreira, Ozier et Woolcock, “Conditional, Unconditional and Everything”, 1–43. 52 García et Saavedra, “Educational Impacts and Cost–Effectiveness”, 921–965. 53 Bliss, Golden, Bourahla, Stoltzfus et Pelletier, “An Emergency Cash Transfer”. 54 Roelen, Devereux, Abdulai, Martorano, Palermo et Ragno, “How to Make ‘Cash Plus’ Work”. 55 Kalanidhi, del Ninno, Andrews et Rodriguez–Alas, “Public Works as a Safety”. 56 Beierl et Grimm, “Do Public Works Programmes Work ? ”. 57 Fadlallah, EI–Jardali, Hemadi, Morsi, Abou Samra, Ahmad et coll., “Barriers and Facilitators to Implementation”. 58 Rwanda Social Security Board, “CBHI Scheme”. 59 Woode, “Parental Health Shocks”, 35–47. 60 Strobl, “Does Health Insurance Reduce Child Labour and Education Gaps ”, 1376–1395. 61 Woldemichael, “The Impacts of Community–Based Health Insurance Schemes”. 62 Jensen, Barrett et Mude, “Cash Transfers and Index Insurance ”, 14–28. 63 Carter, De Janvry, Sadoulet et Sarris, “Index–Based Weather Insurance for Developing Countries”. 64 Fonta, Sanfo, Kedir et coll., “Estimating Farmers’ Willingness”. 65 Ali, Egbendewe, Abdoulaye et Sarpong, “Willingness to Pay”, 534–547. 66 Aina, Ayinde, Thiam et Miranda, “Willingness to Pay”. 67 Ali, Egbendewe, Abdoulaye, and Sarpong, “Willingness to Pay”, 534–547. 68 lmbali, “Tackling Drought in Kenya”. 69 Fava, Jensen, Sina, Mude et Maher, “Building Financial Resilience”. 70 lmdad, Yakoob et Bhutta, “Impact of Maternal Education”. 71 Lassi, Das, Zahid, lmdad et Bhutta, “Impact of Education”. 72 Moramarco, Amerio, Gozza Maradini et Garuti, “The Rainbow Project”. 73 Moramarco, “Enhancing the Effectiveness”, 78. 74 Alderman et Bundy, “School Feeding Programs”. 75 Bundy, Burbano, Grosh, Gelli, Jukes et Drake, “Rethinking School Feeding”. 76 Wall, Tolar–Peterson, Reeder, Roberts, Reynolds et Rico Mendez, “The Impact of School Meal”, 3666. 77 Chakrabarti, Scott, Alderman, Menon et Gilligan, “Intergenerational Nutrition Benefits”, 1–10. 78 Government of Ghana, “Ghana School Feeding”. 79 PAM, “Home–Grown School”. 80 Dewey et Adu–Afarwuah, “Systematic Review of the Efficacy”, 24–85. 81 lmdad, Yakoob et Bhutta, “Impact of Maternal Education”, S25–S25. 82 Lassi, Rind, lrfan, Hadi, Das et Bhutta, “Impact of Infant and Young”, 722. 83 Nguyen, “Information, Role Models”. 84 Jensen, “The Perceived Returns”. 85 Baranov, Bhalotra, Biroli et Maselko, “Maternal Depression, Women’s”, 824–59. 86 Garcia, Yim, “A Systematic Review”, 347. 87 OMS, « Penser sain ». 88 Rahman, “Challenges and Opportunities in Developing”, 211–219. 89 Sikander, Ahmad, Atif, Zaidi, Vanobberghen, Weiss, Nisar, Tabana, Ain, Bibi et Bilal, “Delivering the Thinking Healthy”, 128–139. 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