D RECT ONS N DEVELOPMENT D II R E C T II O N S II N D E V E L O P M E N T 57489 Repositioning Nutrition as Central to Development A Strategy for Large-Scale Action O V E RV I E W DIRECTIONS IN DEVELOPMENT Repositioning Nutrition as Central to Development A Strategy for Large-Scale Action OVERVIEW THE WORLD BANK © 2006 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 USA Telephone 202-473-1000 Internet www.worldbank.org E-mail feedback@worldbank.org All rights reserved First printing 1 2 3 4 09 08 07 06 The findings, interpretations, and conclusions expressed here are those of the authors and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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Cover design by Fletcher Design Cover photos by World Bank Contents Foreword Acknowledgments Acronyms and Abbreviations Glossary Overview Three Reasons for Intervening to Reduce Malnutrition What Causes Malnutrition and How Should Governments Intervene? Next Steps Notes 1 Why Invest in Nutrition? Nutrition and Economics Nutrition and the Millenium Development Goals Nutrition and Human Rights The Know-How for Improving Nutrition Notes 2 How Serious Is Malnutrition and Why Does It Happen? Undernutrition Low Birthweight Obesity and Diet-Related Noncommunicable Diseases Micronutrient Malnutrition What Causes Malnutrition, and Who Is Worst Affected? Notes 3 Routes to Better Nutrition Long and Short Routes to Better Nutrition Community-Based Growth Promotion Programs Low-Birthweight Prevention Programs iii iv CONTENTS Micronutrient Programs Food and Social Protection Programs Malnutrition and HIV/AIDS Programs Programs to Tackle Overweight and Diet-Related Noncommunicable Diseases The Role of Policy Intentional and Unintentional Nutrition Policies Notes 4 Getting to Scale Managing Nutrition Programs Organizing Services Channeling Finance and Coordinating Financiers Strengthening Commitment and Capacity Notes 5 Accelerating Progress in Nutrition: Next Steps Uniting Development Partners around a Common Nutrition Agenda Three Key Operational Challenges to Scaling Up Where to Focus Actions against Malnutrition Supporting a Focused Action Research Agenda in Nutrition The Gaps between Identified Needs and Development Partners' Focus Next Steps Notes Annex 1 : Country Experience with Short Routes to Improving Nutrition Annex 2: Long Routes to Improving Nutrition Annex 3: Key Priorities for Action Research in Nutrition: A Proposal Technical Annexes References Index Tables 1.1 The benefit-cost ratios for nutrition programs 1.2 Annual unit costs of nutrition programs 1.3 Cost of nutrition interventions ($) 1.4 Reduction of the fraction of children underweight in Tanzania under different income growth and nutrition intervention coverage scenarios (%) CONTENTS v 1.5 Prevalence of underweight and anemia in Indian children by income quintiles 1.6 How investing in nutrition is critical to achieving the MDGs 1.7 The Copenhagen Consensus ranks the provision of micronutrients as a top investment 1.8 Coverage of nutrition interventions in some large-scale programs 3.1 Routes to better nutrition 3.2 The range of interventions for obesity programs 3.3 Examples of unintentional nutrition policies 5.1 Suggested priorities for action research in nutrition Figures 1.1 The vicious cycle of poverty and malnutrition 1.2 The income­malnutrition relationship 1.3 Estimated reduction of underweight prevalence at different economic growth and income-nutrition elasticity scenarios 1.4 Progress toward the nonincome poverty target 1.5 Progress toward the nonincome poverty target (nutrition MDG) 2.1 Prevalence of and trends in malnutrition among children under age five, 1980­2005 2.2 Projected trends in numbers of underweight children under age five, 1990­2015 2.3 Prevalence and number of low-birthweight infants 2.4 Trends in obesity among children under age five 2.5 Maternal and child overweight 2.6 Maternal overweight versus maternal and child undernutrition 2.7 Coexistence of energy deficiency and obesity in low- and middle-income countries 2.8 Prevalence of subclinical vitamin A deficiency in children age 0­72 months, by region, 1990­2000 2.9 Prevalence of iron deficiency in preschool children, by region, 1990­2000 2.10 Prevalence of underweight children by per capita dietary energy supply, by region, 1970­96 2.11 Prevalence of overweight among children under age five, by age group 2.12Underweight prevalence and rates of decline in World Bank regions and countries 3.1 How malnutrition and HIV/AIDS interact 5.1 Principal development partners supporting nutrition 5.2 Typology and magnitude of malnutrition in World Bank regions and countries vi CONTENTS Boxes 1.1 Off track on the Millennium Development Goals 2.1 Undernutrition prevalence in South Asian countries is much higher than in Africa 2.2 The window of opportunity for addressing undernutrition 2.3 Three myths about nutrition 3.1 Why malnutrition persists in many food-secure households 3.2 Food security versus nutrition security? 3.3 Ensuring that new behavioral practices make sense for poor people 3.4 Food subsidies versus targeted social safety net programs 3.5 Evidence that conditional transfer programs can work 3.6 Summary findings of scientific review on nutrition and HIV /AIDS 3.7 The role of public policy 3.8 Impact of agricultural and food policies on nutrition and health 4.1 How Thailand managed its National Nutrition Program 4.2 Assessment, analysis, and action: The "Triple A" process 4.3 Institutionalizing nutrition in Bangladesh: From project to program 4.4 Five steps toward integrating nutrition in country PRSPs 4.5 Ten reasons for weak commitment to nutrition programs 4.6 PROFILES 5.1 Lessons for nutrition from HIV/AIDS 5.2 What to do when Maps 1.1 Global prevalence of underweight among children under age five 1.2 Global prevalence of stunting among children under age five 1.3 Global prevalence of vitamin A deficiency and supplementation coverage rates 1.4 Global prevalence of iodine deficiency disorders and iodized salt coverage rates Overview It has long been known that malnutrition undermines economic growth and perpetuates poverty. Yet the international community and most gov- ernments in developing countries have failed to tackle malnutrition over the past decades, even though well-tested approaches for doing so exist. The consequences of this failure to act are now evident in the world's inade- quate progress toward the Millennium Development Goals (MDGs) and toward poverty reduction more generally. Persistent malnutrition is con- tributing not only to widespread failure to meet the first MDG--to halve poverty and hunger--but to meet other goals in maternal and child health, HIV/AIDS, education, and gender equity. The unequivocal choice now is between continuing to fail, as the global community did with HIV/AIDS for more than a decade, or to finally make nutrition central to development so that a wide range of economic and social improvements that depend on nutrition can be realized. Three Reasons for Intervening to Reduce Malnutrition High economic returns; high impact on economic growth and poverty reduction The returns to investing in nutrition are very high. The Copenhagen Consensus concluded that nutrition interventions generate returns among the highest of 17 potential development investments (table 1). Investments in micronutrients were rated above those in trade liberalization, malaria, and water and sanitation. Community-based programs targeted to children under two years of age are also cost-effective in preventing undernutrition. Overall, the benefit-cost ratios for nutrition interventions range between 5 and 200 (table 2). Malnutrition slows economic growth and perpetuates poverty through three routes--direct losses in productivity from poor physical status; indi- rect losses from poor cognitive function and deficits in schooling; and losses 1 2 REPOSITIONING NUTRITION Table 1 The Copenhagen Consensus ranks the provision of micronutrients as a top investment Rating Challenge Opportunity Very good 1. Diseases Controlling HIV/AIDS 2. Malnutrition and hunger Providing micronutrients 3. Subsidies and trade Liberalizing trade 4. Diseases Controlling malaria Good 5. Malnutrition and hunger Developing new agricultural technologies 6. Sanitation and water Developing small-scale water technologies 7. Sanitation and water Implementing community- managed systems 8. Sanitation and water Conducting research on water in agriculture 9. Government Lowering costs of new business Fair 10. Migration Lowering barriers to migration 11. Malnutrition and hunger Improving infant and child malnutrition 12. Diseases Scaling up basic health services 13. Malnutrition and hunger Reducing the prevalence of low birthweight Poor 14­17. Climate/migration Various Source: Bhagwati and others (2004). owing to increased health care costs. Malnutrition's economic costs are sub- stantial: productivity losses to individuals are estimated at more than 10 percent of lifetime earnings, and gross domestic product (GDP) lost to mal- nutrition runs as high as 2 to 3 percent. Improving nutrition is therefore as much--or more--of an issue of economics as one of welfare, social pro- tection, and human rights. Reducing undernutrition and micronutrient malnutrition directly reduces poverty, in the broad definition that includes human development and human capital formation. But undernutrition is also strongly linked to income poverty. The prevalence of malnutrition is often two or three times-- sometimes many times--higher among the poorest income quintile than among the highest quintile. This means that improving nutrition is a pro- poor strategy, disproportionately increasing the income-earning potential of the poor. OVERVIEW 3 Table 2 The benefit-cost ratios for nutrition programs Intervention programs Benefit-cost Breastfeeding promotion in hospitals 5­67 Integrated child care programs 9­16 Iodine supplementation (women) 15­520 Vitamin A supplementation (children < 6 years) 4­43 Iron fortification (per capita) 176­200 Iron supplementation (per pregnant women) 6­14 Source: Behrman, Alderman, and Hoddinott (2004). Improving nutrition is essential to reduce extreme poverty. Recognition of this requirement is evident in the definition of the first MDG, which aims to eradicate extreme poverty and hunger. The two targets are to halve, between 1990 and 2015: · The proportion of people whose income is less than $1 a day. · The proportion of people who suffer from hunger (as measured by the percentage of children under five who are underweight). The first target refers to income poverty; the second addresses nonincome poverty. The key indicator used for measuring progress on the nonincome poverty goal is the prevalence of underweight children (under age five).Therefore, improving nutrition is in itself an MDG target. Yet most assessments of progress toward the MDGs have focused primarily on the income poverty target, and the prognosis in general is that most countries are on track for achieving the poverty goal. But of 143 countries, only 34 (24 percent) are on track to achieve the nonincome target (nutrition MDG) (figure 1). No country in South Asia, where undernutrition is the highest, will achieve the MDG--though Bangladesh will come close to achieving it, and Asia as a whole will achieve it. More alarmingly still, nutrition status is actually deteriorating in 26 countries, many of them in Africa, where the nexus between HIV and undernutrition is particularly strong and mutually rein- forcing. And in 57 countries, no trend data are available to tell whether progress is being made. A renewed focus on this nonincome poverty target is clearly central to any poverty reduction efforts. The alarming shape and scale of the malnutrition problem Malnutrition is now a problem in both poor and rich countries, with the poorest people in both sets of countries affected most. In developed coun- tries, obesity is rapidly becoming more widespread, especially among 4 REPOSITIONING NUTRITION Figure 1 Progress toward the nonincome poverty target On track (24%) Deteriorating status (18%) AFR (7) LAC (10) AFR (13) ECA (4) Angola Bolivia Niger Albania Benin Chile Burkina Faso Azerbaijan Botswana Colombia Cameroon Russian Federation Chad Dominican Rep. Comoros Serbia and Montenegro Gambia, The Guyana Ethiopia Mauritania Haiti Guinea LAC (3) Zimbabwe Jamaica Lesotho Argentina Mexico Mali Costa Rica EAP (5) Peru Senegal* Panama China Venezuela, R.B. de Sudan Indonesia Tanzania* MENA (2) Malaysia MENA (6) Togo Iraq Thailand Algeria Zambia Yemen, Rep. of Vietnam Egypt, Arab Rep. of Iran, Islamic EAP (2) SAR (2) ECA (6) Rep. of Jordan Mongolia Maldives Armenia Syrian Arab Rep. Myanmar Nepal Croatia Tunisia Kazakhstan Kyrgyz Rep. SAR (0) No trend data available (40%) Romania Turkey AFR (13) Georgia Burundi Hungary Cape Verde Latvia Some improvement, but not on track Congo, Rep. of Lithuania Equatorial Guinea Macedonia, FYR AFR (14) Guinea Moldova Central African Rep. ECA (0) Guinea-Bissau Poland Congo, DR Liberia Slovak Republic Côte d'Ivoire LAC (4) Mauritius Tajikistan Eritrea El Salvador Namibia Turkmenistan Gabon Guatemala Sâo Tomé and Principe Ukraine Ghana Honduras Seychelles Uzbekistan Kenya Nicaragua Somalia Madagascar South Africa LAC (12) Malawi MENA (1) Swaziland Belize Mozambique Morocco Brazil Nigeria EAP (11) Dominica Rwanda SAR (4) Fiji Ecuador Sierra Leone Bangladesh* Kiribati Grenada Uganda India Marshall Is. Paraguay Pakistan Micronesia, Federated St. Kitts and Nevis EAP (5) Sri Lanka States of St. Lucia Cambodia Palau St. Vincent Lao PDR Papua New Guinea Suriname Phillippines Samoa Trinidad and Tobago Solomon Islands Uruguay Timor-Leste Source: Author's calculations. See also Tonga MENA (2) technical annex 5.6. Vanuatu Djibouti Note: All calculations are based on Lebanon ECA (17) 1990­2002 trend data from the WHO Global Belarus SAR (2) Database on Child Growth and Malnutri- Bosnia and Afghanistan tion (as of April 2005). Countries indicated Herzegovina Bhutan by an asterisk subsequently released prelim- Bulgaria Czech Republic inary DHS data that suggest improvement Estonia and therefore may be reclassified when their data are officially released. OVERVIEW 5 Figure 2 Prevalence of and trends in malnutrition among children under age five, 1980­2005 75 Bangladesh 200 No. of underweight children (million) India China Prevalence of underweight (%) 60 160 45 120 Africa Asia 30 80 LAC Developing Developed 15 40 0 0 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 60 250 Africa Asia No. of stunted children (million) LAC 50 Developing 200 Prevalence of stunting (%) Developed 40 150 Africa 30 100 Asia LAC Developing Developed 20 50 0 0 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 Source: De Onis (2004a); SCN (2004). Note: Estimates are based on WHO regions. Prevalence and numbers also appear in technical annex 2.1. poorer people, bringing with it an epidemic of diet-related noncommuni- cable diseases (NCDs) such as diabetes and heart disease, which increase health care costs and reduce productivity. In developing countries, while widespread undernutrition and micronutrient deficiencies persist, obesity is also fast emerging as a problem. Underweight children and overweight adults are now often found in the same households in both developing and developed countries. Nearly one-third of children in the developing world remain under- weight or stunted, and 30 percent of the developing world's population 6 REPOSITIONING NUTRITION Figure 3 Projected trends in numbers of underweight children under age five, 1990­2015 No. of underweight children (millions) 180 1990 150 1995 2000 120 2005 2010 90 2015 60 30 0 Africa Asia Latin America & Developing Developed the Caribbean countries countries Source: De Onis and others (2004a, 2004b). Note: Estimates are based on WHO regions. continues to suffer from micronutrient deficiencies. But the picture is chang- ing (figure 2): · In Sub-Saharan Africa malnutrition is on the rise. Malnutrition and HIV/AIDS reinforce each other, so the success of HIV/AIDS programs in Africa depends in part on paying more attention to nutrition. · In Asia malnutrition is decreasing, but South Asia still has both the high- est rates and the largest numbers of malnourished children. Contrary to common perceptions, undernutrition prevalence rates in the popu- lous South Asian countries--India, Bangladesh, Afghanistan, Pakistan-- are much higher (38 to 51 percent) than those in Sub-Saharan Africa (26 percent). · Even in East Asia, Latin America, and Eastern Europe, many countries have a serious problem of undernutrition or micronutrient malnutri- tion. Examples include Cambodia, Indonesia, Lao PDR, the Philippines, and Vietnam; Guatemala, Haiti, and Honduras; and Uzbekistan. In a recent WHO study (De Onis and others 2004b), underweight preva- lence in developing countries was forecast to decline by 36 percent (from 30 percent in 1990 to 19 percent in 2015)--significantly below the 50 per- cent required to meet the MDG over the same time frame (figure 3).1 These OVERVIEW 7 global data mask interregional differences that are widening disturbingly. Much of the forecast global improvement derives from a projected preva- lence decline from 35 to 18 percent in Asia--driven primarily by the improvements in China. By contrast, in Africa, the prevalence is projected to increase from 24 to 27 percent. And the situation in Eastern Africa--a region blighted by HIV/AIDS, which has major interactions with malnu- trition--is critical. Here underweight prevalences are forecast to be 25 per- cent higher in 2015 than they were in 1990. Many countries (excluding several in Sub-Saharan Africa) will achieve the MDG income poverty target (percentage of people living on less than $1 a day), but less than 25 percent will achieve the nonincome poverty target of halving underweight (figure 3). Even if Asia as a whole achieves that target, large countries there including Afghanistan, Bangladesh, India, and Pakistan will still have unacceptably high rates of undernutrition in 2015, widening existing inequities between the rich and the poor in these countries. Deficiencies of key vitamins and minerals continue to be pervasive, and they overlap considerably with problems of general undernutrition (under- weight and stunting). A recent global progress report states that 35 percent of people in the world lack adequate iodine, 40 percent of people in the developing world suffer from iron deficiency, and more than 40 percent of children are vitamin A deficient. Trends in overweight among children under five, though based on data from a limited number of countries, are alarming (figure 4)--for all devel- oping countries and particularly for those in Africa, where rates seem to be increasing at a far greater rate (58 percent increase) than in the devel- oping world as a whole (17 percent increase). The lack of data does not allow us to give definitive answers for why Africa is experiencing this exag- gerated trend; however, the correlation between maternal overweight and child overweight suggests that one of the answers may lie therein. Comparable data for overweight and obesity rates among mothers show similar alarming trends. Countries in the Middle East and North Africa have the highest maternal overweight rates, followed by those in Latin America and the Caribbean. However, several African countries have more than 20 percent maternal overweight rates. Also evident is that overweight coexists in the same countries where both child and maternal undernutrition are very widespread and in many countries with low per capita GNP (figure 5). In Mauritania, more than 40 percent of mothers are overweight, while at the same time more than 30 percent children are under- weight. Furthermore, as many as 60 percent of households with an under- weight person also had an overweight person, demonstrating that underweight and overweight coexist not only in the same countries but also in the same households. In Guatemala, stunted children and over- 8 REPOSITIONING NUTRITION weight mothers coexist. Again, these data support the premise that, except under famine conditions, access to and availability of food at the house- hold level are not the major causes of undernutrition. Figure 4 Trends in obesity among children under age five 6 20 Africa Africa No. of overweight children (million) Asia Asia 5 LAC LAC Prevalence of overweight (%) 16 Developing Developing 4 12 3 8 2 4 1 0 0 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 Source: SCN (2004). Note: Estimates are based on WHO regions. Figure 5 Maternal overweight rates across regions 80 80 AFR AFR Egypt Egypt EAP EAP % maternal overweight (BMI>=25) % maternal overweight (BMI>=25) Jordan ECA Jordan ECA 60 LAC 60 LAC MNA MNA SAR Guatemala SAR Mauritania 40 40 Mauritania Gabon Zimbabwe 20 20 Yemen India Yemen Bangladesh 0 0 0 10 20 30 h 40 50 0 15 30 45 60 % maternal undernutrition (BMI<18.5) % child (<3y) underweight (WAZ<2) Source: Author's calculations using data from measuredhs.com. OVERVIEW 9 Markets are failing Markets are failing to address the malnutrition problem wherever families do not have the money to buy adequate food or health care. Human rights and equity arguments, as well as economic return arguments, can be made for governments to intervene to help such families. But malnutrition occurs also in many families that are not poor--because people do not always know what food or feeding practices are best for their children or them- selves, and because people cannot easily tell when their children are becom- ing malnourished, since faltering growth rates and micronutrient deficiencies are not usually visible to the untrained eye. The need to correct these "infor- mational asymmetries" is another argument for government intervention (box 1). And governments should intervene because improved nutrition is a public good, benefiting everybody; for example, better nutrition can reduce the spread of contagious diseases and increase national economic pro- ductivity. Box 1 Why malnutrition persists in many food-secure households · Pregnant and nursing women eat too few calories and too little protein, have untreated infections, such as sexually transmitted diseases that lead to low birthweight, or do not get enough rest. · Mothers have too little time to take care of their young children or themselves during pregnancy. · Mothers of newborns discard colostrum, the first milk, which strengthens the child's immune system. · Mothers often feed children under age 6 months foods other than breast milk even though exclusive breastfeeding is the best source of nutrients and the best protection against many infectious and chronic diseases. · Caregivers start introducing complementary solid foods too late. · Caregivers feed children under age two years too little food, or foods that are not energy dense. · Though food is available, because of inappropriate household food allocation, women and young children's needs are not met and their diets often do not contain enough of the right micronutrients or protein. · Caregivers do not know how to feed children during and following diarrhea or fever. · Caregivers' poor hygiene contaminates food with bacteria or parasites. 10 REPOSITIONING NUTRITION What Causes Malnutrition and How Should Governments Intervene? Contrary to popular perceptions, undernutrition is not simply a result of food insecurity: many children in food-secure environments and from non- poor families are underweight or stunted because of inappropriate infant feeding and care practices, poor access to health services, or poor sanita- tion. In many countries where malnutrition is widespread, food production is not the limiting factor (box 2), except under famine conditions. The most important factors are, first, inadequate knowledge about the benefits of exclusive breastfeeding and complementary feeding practices and the role of micronutrients and second, the lack of time women have available for appropriate infant care practices and their own care during pregnancy. Undernutrition's most damaging effect occurs during pregnancy and in the first two years of life, and the effects of this early damage on health, brain development, intelligence, educability, and productivity are largely irreversible (box 3). Actions targeted to older children have little, if any effect. Initial evidence suggests that the origins of obesity and NCDs such as cardiovascular heart disease and diabetes may also lie in early child- hood. Governments with limited resources are therefore best advised to focus actions on this small window of opportunity, between conception and 24 months of age, although actions to control obesity may need to con- tinue later. In countries where mean overweight rates among children under age five are high, a large proportion of children are already overweight at birth-- suggesting again that the damage happens in pregnancy. These results are consistent with physiological evidence that the origins of obesity start very early in life, often in the womb, though interventions to prevent obesity must likely continue in later life. Income growth and food production, as well as birth spacing and women's education, are therefore important but long routes to improving nutrition. Shorter routes are providing health and nutrition education and services (such as promoting exclusive breastfeeding and appropriate com- plementary feeding, coupled with prenatal care and basic maternal and child health services) and micronutrient supplementation and fortification. Experience in Mexico shows that in middle-income countries conditional cash transfers, coupled with improved health and nutrition service deliv- ery on the supply side, have gotten poor people to use nutrition services. Other countries, such as Bangladesh, Honduras, and Madagascar, have successfully used government-nongovernment partnerships to mobilize communities to tackle malnutrition through community-based approaches. Experience in dealing with different forms of malnutrition is at differ- ent stages of development: OVERVIEW 11 Box 2 Three myths about nutrition Poor nutrition is implicated in more than half of all child deaths world- wide--a proportion unmatched by any infectious disease since the Black Death. It is intimately linked with poor health and environmental factors. But planners, politicians, and economists often fail to recognize these con- nections. Serious misapprehensions include the following myths: Myth 1: Malnutrition is primarily a matter of inadequate food intake. Not so. Food is of course important. But most serious malnutrition is caused by bad sanitation and disease, leading to diarrhea, especially among young children. Women's status and women's education play big parts in improving nutrition. Improving care of young children is vital. Myth 2: Improved nutrition is a by-product of other measures of poverty reduc- tion and economic advance. It is not possible to jump-start the process. Again, untrue. Improving nutrition requires focused action by parents and com- munities, backed by local and national action in health and public ser- vices, especially water and sanitation. Thailand has shown that moderate and severe malnutrition can be reduced by 75 percent or more in a decade by such means. Myth 3: Given scarce resources, broad-based action on nutrition is hardly feasible on a mass scale, especially in poor countries. Wrong again. In spite of severe economic setbacks, many developing countries have made impressive progress. More than two-thirds of the people in developing countries now eat iodized salt, combating the iodine deficiency and anemia that affect about 3.5 billion people, especially women and children in some 100 nations. About 450 million children a year now receive vitamin A capsules, tackling the deficiency that causes blindness and increases child mortality. New ways have been found to promote and support breastfeeding, and breastfeeding rates are being maintained in many countries and increased in some. Mass immunization and promotion of oral rehydration to reduce deaths from diarrhea have also done much to improve nutrition. Source: Extracted from Jolly (1996). · For undernutrition and micronutrient malnutrition, several large-scale programs have worked (in Bangladesh and Thailand, in Madagascar, and in Chile, Cuba, Honduras, and Mexico). The challenge is to apply their lessons at scale in more countries. The issue is less about what to do than about how to strengthen both countries' and development part- ners' commitment and capacity to scale up. 12 REPOSITIONING NUTRITION Box 3 The window of opportunity for addressing undernutrition The window of opportunity for improving nutrition is small--from before pregnancy through the first two years of life. There is consensus that the damage to physical growth, brain development, and human capital formation that occurs during this period is extensive and largely irreversible. Therefore interventions must focus on this window of opportunity. Any investments after this critical period are much less likely to improve nutrition. 0.50 0.25 Latin America and Caribbean Weight for age Z-score (NCHS) 0.00 Africa Asia -0.25 -0.50 -0.75 -1.00 -1.25 -1.50 -1.75 -2.00 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 Age (months) Source: Shrimpton and others (2001). Note: Estimates are based on WHO regions. · By contrast, for overweight and diet-related NCDs, low birthweight, and the complex interactions between malnutrition and HIV/AIDS, there are few tried and tested large-scale models. Action research and learning-by-doing are the priority here, but large-scale HIV or NCD con- trol efforts cannot be successful without addressing nutrition--so the challenge is to shorten the time lag between developing the science and scaling up action. OVERVIEW 13 Although some successful programs have been scaled up without com- prehensive nutrition policies, policy is important as well. Few countries have well-developed and well-resourced nutrition policies. More often, policies in other sectors (trade, foreign exchange, employment, gender, agriculture, social welfare, and health) have a haphazard, sometimes negative effect on nutrition and become unintentional but de facto nutrition policies. Poverty and Social Impact Analyses (PSIAs) should be more widely used to assess the intentional and unintentional effects of development policies on nutrition outcomes. And the capacity to advise policy makers about the nutrition implications of policy needs to be developed in a focal institution, such as a ministry of finance or a poverty monitoring office. Policy also has a potential role in diminishing the poor health and neg- ative economic outcomes associated with the increase in overweight and obesity in developing countries through both demand-side and supply- side interventions. If effective interventions exist, why have they not been scaled up in more countries? Nutrition programs have been low priority for both governments and devel- opment partners for three reasons (box 5). First, there is little demand for nutrition services from communities because malnutrition is often invisi- ble; families and communities are unaware that even moderate and mild malnutrition contributes substantially to death, disease, and low intelli- gence; and most malnourished families are poor and hence have little voice. Second, governments and development partners have been slow to rec- ognize how high malnutrition's economic costs are, that malnutrition is holding back progress not only toward the malnutrition MDG but also toward other MDGs, or that there is now substantial experience with how to implement cost-effective, affordable nutrition programs on a large scale. Third, there are multiple organizational stakeholders in nutrition, so mal- nutrition often falls between the cracks both in governments and in devel- opment assistance agencies--the partial responsibility of several sectoral ministries or agency departments, but the main responsibility of none. Country financing is usually allocated by sectors or ministries, so unless one sector takes the lead, no large-scale action can follow. How the international development community can help countries do more Countries need to take the lead in repositioning nutrition much higher in their development agenda. When countries request help in nutrition, devel- opment partners must respond first by helping countries develop a shared 14 REPOSITIONING NUTRITION Box 5 Ten reasons for weak commitment to nutrition programs · Malnutrition is usually invisible to malnourished families and communities. · Families and governments do not recognize the human and economic costs of malnutrition. · Governments may not know there are faster interventions for combat- ing malnutrition than economic growth and poverty reduction or that nutrition programs are affordable. · Because there are multiple organizational stakeholders in nutrition, it can fall between the cracks. · There is not always a consensus about how to intervene against malnutrition. · Adequate nutrition is seldom treated as a human right. · The malnourished have little voice. · Some politicians and managers do not care whether programs are well implemented. · Governments sometimes claim they are investing in improving nutrition when the programs they are financing have little effect on it (for example, school feeding). · A vicious circle: lack of commitment to nutrition leads to underinvest- ment in nutrition, which leads to weak impact, which reinforces lack of commitment since governments believe nutrition programs do not work. Source: Abridged from Heaver (2005b). vision and consensus on what needs to be done, how, and by whom, and then by providing financial and other assistance. This report argues that much of the failure to scale up action in nutrition results from a lack of sus- tained government commitment, leading to low demand for assistance in nutrition. In this situation, the role of development partners must extend beyond responding when requested to do so by governments. They must use their combined resources of analysis, advocacy, and capacity-building to encourage and influence governments to move nutrition higher on the agenda wherever it is holding back achievement of the MDGs (table 3). This role can be fulfilled only if the development partners share a common view of the malnutrition problem and broad strategies to address it, and if they speak with a common voice. The development partners therefore also need to reposition themselves. They need to convene around a common OVERVIEW 15 Table 3 How investing in nutrition is critical to achieving the MDGs Goal Nutrition effect Goal 1: Eradicate extreme Malnutrition erodes human capital through poverty and hunger. irreversible and intergenerational effects on cognitive and physical development. Goal 2: Achieve universal Malnutrition affects the chances that a child primary education. will go to school, stay in school, and perform well. Goal 3: Promote gender Antifemale biases in access to food, health, equality and empower women. and care resources may result in malnutri- tion, possibly reducing women's access to assets. Addressing malnutrition empowers women more than men. Goal 4: Reduce child mortality. Malnutrition is directly or indirectly associated with most child deaths, and it is the main contributor to the burden of disease in the developing world. Goal 5: Improve maternal health. Maternal health is compromised by malnutrition, which is associated with most major risk factors for maternal mortality. Maternal stunting and iron and iodine deficiencies particularly pose serious problems. Goal 6: Combat HIV/AIDS, Malnutrition may increase risk of HIV malaria, and other diseases. transmission, compromise antiretroviral therapy, and hasten the onset of full-blown AIDS and premature death. It increases the chances of tuberculosis infection, resulting in disease, and it also reduces malarial survival rates. Source: Adapted from Gillespie and Haddad (2003). 16 REPOSITIONING NUTRITION strategic agenda in nutrition, focusing on scaled-up and more effective action for undernutrition and micronutrients in priority countries and on action research or learning-by-doing for overweight, low birthweight, and HIV/AIDS and nutrition. This repositioning must involve reviewing and revising the current inadequate levels of funding for nutrition. For exam- ple, though the World Bank is the largest development partner investing in global nutrition, between 2000 and 2004 its investments in the short route interventions that improve nutrition fastest amounted to not more than 1.5 percent of its lending for human development--and only 0.3 percent of total World Bank lending. Although we do not wish to propose a global "one size fits all" approach to addressing malnutrition, we do recommend that when developing strate- gies specific to a country or region, countries and their development part- ners pay special attention to the following: · Focusing strategies and actions on the poor so as to address the nonin- come aspects of poverty reduction that are closely linked to human devel- opment and human capital formation. · Focusing interventions on the window of opportunity--pregnancy through the first two years of life--because this is when irreparable damage happens. · Improving maternal and child care practices to reduce the incidence of low birthweight and to improve infant-feeding practices, including exclu- sive breastfeeding and appropriate and timely complementary feeding, because many countries and development partners have neglected to invest in such programs. · Scaling up micronutrient programs because of their widespread preva- lence, their effect on productivity, their affordability, and their extraor- dinarily high benefit-cost ratios. · Building on country capacities developed through micronutrient pro- gramming to extend actions to community-based nutrition programs. · Working to improve nutrition not only through health but also through appropriate actions in agriculture, rural development, water supply and sanitation, social protection, education, gender, and community-driven development. · Strengthening investments in the short routes to improving nutrition, yet maintaining balance between the short and the long routes. · Integrating appropriately designed and balanced nutrition actions in country assistance strategies, sectorwide approaches (SWAps) in mul- tiple sectors, multicountry AIDS projects (MAPs), and Poverty Reduction Strategy Papers (PRSPs). OVERVIEW 17 In addition to these generic recommendations, practical suggestions are available for how countries might take some of these considerations into account as they position nutrition in their national development strategies. Next Steps Scaled-up and more effective action requires addressing key operational challenges: 1. Building global and national commitment and capacity to invest in nutrition. 2. Mainstreaming nutrition in country development strategies where it is not now given priority. 3. Reorienting ineffective, large-scale nutrition programs to maximize their effect. Action research and learning-by-doing need to focus on: 1. Documenting how best to strengthen commitment and capacity and to mainstream nutrition in the development agenda. 2. Strengthening and fine-tuning service delivery mechanisms for nutrition. 3. Further strengthening the evidence base for investing in nutrition. At the global level, the development community needs to unite in explic- itly rethinking and repositioning the role of malnutrition as an underlying cause of slow economic growth, mortality, and morbidity, and agree to: · Coordinate efforts to strengthen commitment and funding for nutrition within global and national partnerships. · Pursue a set of broad strategic priorities (such as the six outlined above) for the next decade, contributing wherever they have the most compar- ative advantage. · Focus on an agreed-on set of priority countries for investing in nutrition and for mainstreaming and scaling up nutrition programs. · Focus on an agreed-on set of priority countries for developing best prac- tices in building commitment and capacity, mainstreaming nutrition, and reducing overweight and obesity. · Make a collective effort to switch from financing small-scale projects to financing large-scale programs, except where small projects with strong monitoring and evaluation components are required to pilot-test inter- ventions and delivery systems, or to build capacity in nutrition. 18 REPOSITIONING NUTRITION At the country level, the development community needs to scale up its assistance by helping all countries that have micronutrient deficiencies develop a national strategy for micronutrients, finance it, and scale it up to nationwide coverage within five years--without crowding out the larger undernutrition agenda. The development community must also support countries with under- nutrition problems as follows: · Identify and support at least 5 to 10 countries with serious nutrition problems that have the commitment to work with development part- ners to mainstream nutrition into SWAps, MAPs, and Poverty Reduction Strategy Credits (PRSCs). In countries that have little experience in nutri- tion, nutrition projects may be the first step; in other cases, specific efforts to develop country capacity will be needed. · Identify and support three to five countries where large-scale invest- ments need to be reoriented to maximize their effect. In these countries, provide coordinated support to reorient program design and to strengthen implementation quality and monitoring and evaluation. · Identify and support at least three to five countries where nutrition issues loom large but appropriate action is not being taken. In these countries, focus on building commitment, analyzing policy, and developing inter- vention strategies that can be financed with assistance from develop- ment partners. To help achieve these goals, the development partners will need to cofi- nance a grant fund to catalyze action in commitment-building and action research, complementing the Bank's recent allocation of $3.6 million from the Development Grant Facility to help mainstream nutrition into mater- nal and child health programs. Large-scale funding for the national actions outlined above should come through normal financing channels, rather than through the creation of a special fund for nutrition. Initial estimates sug- gest that the costs of addressing the micronutrient agenda in Africa are approximately $235 million per year. Costs for other regions and for other aspects of the nutrition agenda have yet to be estimated. Other estimates are much larger ($750 million for global costs for two doses of Vitamin A sup- plementation per year; between $1 billion and $1.5 billion for global salt iodization, including $800 million to $1.2 billion leveraged from the pri- vate sector; and several billion dollars for community nutrition programs). A more detailed costing exercise is being undertaken by the World Bank to come up with more rigorous figures. OVERVIEW 19 The agenda proposed here needs to be debated, modified, agreed on, and acted on by development partners with developing countries. Without coordinated, focused, and increased action, no significant progress in nutri- tion or toward several other MDGs can be expected. Notes 1. De Onis and others (2004b). 2. Doak and others (2005). 20 REPOSITIONING NUTRITION Prevalence of underweight (%) Prevalence of underweight (%) 10 20 30 40 50 10 20 30 40 50 0 0 Seychelles Croatia South Africa Czech Annual % change (1990­2002) Swaziland Serbia & Montenegro Gabon Hungary Annual % change (1990­2002) Botswana Armenia Säo Tomé & Principe Georgia Zimbabwe Romania Cape Verde Ukraine Mauritius Bosnia &Herzegovina Gambia, The Kazakhstan Lesotho Russia Underweight prevalence and rates of decline in World Bank regions and countries Côte d`Ivoire Kyrgyz BCA Kenya Macedonia U5MR<50 Cameroon Turkey Senegal Turkmenistan Uganda U5MR<50 Albania Benin Azerbaijan CAR Uzbekistan U5MR>=50 Congo, Rep. Chile Rwanda Paraguay Ghana Jamaica U5MR>=50 Guinea Venezuela Togo Uruguay FR Malawi Dominican Somalia Costa Rica Comoros Argentina Mozambique Brazil Namibia Trnidad & Tobago Liberia Belize Sierra Leone Colombia Chad Peru Zambia Mexico LAC Tanzania Bolivia Angola Panama Nigeria Nicaragua Congo, DR El Salvador Mauritania Guyana Guinea Suriname Madagascar St. Lucia Mali Ecuador Burkina Faso Honduras Eritrea Haiti Niger St Vincent & Grenadines Sudan Guatemala Burundi Lebanon Ethiopia Tunisia Samoa Egypt Fiji Jordan MNA China Algeria Vanuatu Syrian Arab Mongolia Morocco Kiribati Iran Thailand Iraq Malaysia Djibouti Solomon Yemen EAP Indonesia Bhutan Myanmar Sri Lanka Papua New Pakistan Phillippines Maldives SAR Vietnam India Lao, PDR Bangladesh Timor-Leste Nepal Cambodia Afghanistan -30 -15 0 15 30 45 60 -30 -15 0 15 30 45 60 Annual % change Annual % change Source: WHO global database on child growth and malnutrition. OVERVIEW Note: U5MR = under age five mortality rate, per 1,000 live births. Prevalence of underweight is from the latest national survey available in each country. The coefficient of a regression that links the natural logarithm of underweight to the year of the survey serves as the average annual percent- age change over the period for which data are available. All of the national data available between 1990 and 2002 were used for the estimation. Adjusted prevalence of underweight from national rural data (1990 and 1992) was used for India, as provided by WHO. No underweight data were available for these countries: AFR--Equatorial Guinea; EAP--Marshall Islands, Micronesia, Palau, Tonga; ECA--Belarus, Bulgaria, Estonia, Latvia, Lithuania, Moldova, Poland, the Slovak Republic, Tajikistan; LAC--Dominica, St. Kitts and Nevis; Industrial--Antigua and Barbuda, Republic of Korea, Slovenia. 21 Persistent malnutrition contributes not only to widespread failure to meet the first Millennium Development Goal--to halve poverty and hunger--but also to meet other goals related to maternal and child health, HIV/AIDS, education, and gender equity. Underweight prevalence among children is the key indicator for measuring progress on nonincome poverty, and malnutrition remains the world's most serious health problem--as well as the single largest contributor to child mortality. Nearly one-third of children in the developing world are underweight or stunted, and more than 30 percent of the developing world's population suffers from micronutrient deficiencies. Moreover, new malnutrition problems are emerging: the epidemic of obesity and diet-related noncommunicable diseases is spreading to the developing world, and malnutrition is linked to the HIV/AIDS pandemic. Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action makes the case that development partners and developing countries must increase investment in nutrition programs. This case is based on evidence that the scale of the problem is very large and that nutrition interventions are essential for speeding poverty reduction, have high benefit-cost ratios, and can improve nutrition much faster than reliance on economic growth alone. Moreover, improved nutrition can drive economic growth. The report proposes to the international development community and national governments a global strategy for accelerated action in nutrition.