WATER GLOBAL PRACTICE GUIDANCE NOTE Nutrition-Sensitive Irrigation and Water Management AUGUST 2019 Elizabeth Bryan, Claire Chase, and Mik Schulte About the Water Global Practice Launched in 2014, the World Bank Group’s Water Global Practice brings together financing, knowledge, and implementation in one platform. By combining the Bank’s global knowledge with country investments, this model generates more firepower for transformational solutions to help countries grow sustainably. Please visit us at www.worldbank.org/water or follow us on Twitter at @WorldBankWater. About GWSP This publication received the support of the Global Water Security & Sanitation Partnership (GWSP). GWSP is a multidonor trust fund administered by the World Bank’s Water Global Practice and supported by Australia’s Department of Foreign Affairs and Trade; the Bill & Melinda Gates Foundation; The Netherlands’ Ministry of Foreign Trade and Development Cooperation; Norway’s Ministry of Foreign Affairs; the Rockefeller Foundation; the Swedish International Development Cooperation Agency; Switzerland’s State Secretariat for Economic Affairs; the Swiss Agency for Development and Cooperation; Irish Aid; and the U.K. Department for International Development. Please visit us at www.worldbank.org/gwsp or follow us on Twitter #gwsp. Nutrition-Sensitive Irrigation and Water Management Elizabeth Bryan, Claire Chase, and Mik Schulte © 2019 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Cover photos (left to right): John Hogg / World Bank, Dominic Chavez / The Global Financing Facility, Maria Fleischmann / World Bank. Cover design: Jean Franz, Franz and Company, Inc. Interior photos: p. iv, Curt Carnemark / World Bank; p. viii, Mitchell Maher / International Food Policy Institute; p. 2, Michael Foley / Flickr; p. 8, A’Melody Lee / World Bank. Contents Executive Summary v Abbreviations vii Chapter 1  The Business Case for Nutrition-Sensitive Water Management 1 Chapter 2  Pathways Linking Irrigation and Water Management with Nutritional Outcomes 3 Pathway 1: Enhanced Agricultural Production 3 Pathway 2: Increases in Household Income 4 Pathway 3: Improvements in Water Supply and Hygiene 4 Pathway 4: Strengthened Women’s Empowerment 5 Chapter 3  The Enabling Environment: Infrastructure, Institutions, and Information 7 Chapter 4  Entry Points for Improved Nutritional Outcomes 9 Incorporate Nutritional Considerations into Project Design at the Concept Stage 9 Maintain and Improve the Natural Resource Base 9 Equip Cooperatives, Agricultural Extension, and Water User Associations for Nutrition and Dietary Considerations 9 Leverage Community Platforms to Deliver Nutrition Messaging 12 Engage Women in Irrigation Interventions 12 Promote Nutrient-Dense Crops and Incorporate Home-Gardening Components in Irrigation Projects 12 Design Formal Multiple-Use Water Systems That Are Culturally Appropriate and Safe 13 Incorporate Irrigation into Community-Based Platforms for Rural Service Delivery 13 Chapter 5  Practical Guidance for Nutrition-Sensitive Monitoring and Evaluation 15 Production and Income Pathway Indicators 15 Water, Sanitation, and Hygiene Pathway Indicators 18 Women’s Empowerment Pathway Indicators 18 Enabling Environment Indicators 19 Measuring Health and Nutritional Outcomes 19 Notes 20 References 21 Nutrition-Sensitive Irrigation and Water Management iii Boxes 4.1. Strengthening Water Security and Resilience in Somalia 12 4.2. Linking Public Works Projects with Water Management and Irrigation 13 Figure ES.1. Pathways from Irrigation to Nutritional Outcomes v Table 5.1. Nutrition-Sensitive Indicators for Irrigation and Water Management Lending Operations 16 iv Nutrition-Sensitive Irrigation and Water Management Executive Summary T his document summarizes evidence and guid- De  Fraiture and Giordano 2014; Giordano and de ance on project design and results framework Fraiture 2014; Giordano et al. 2012; Xie et al. 2014; You indicators for nutrition-sensitive irrigation and et al. 2011), helps farm households to extend the grow- water management investments across water, agricul- ing season, and is increasingly important for farmer ture, rural development, and other sectors, in which resilience to climate shocks and stressors. Until recently, improving nutrition in vulnerable populations is a spe- there has been less attention to other benefits of irriga- cific objective of the project. It draws on existing guid- 1 tion, including improvements in household food secu- ance on nutrition-sensitive agriculture developed by the rity and nutrition, health, and women’s empowerment. Food and Agriculture Organization (FAO 2015) and the Irrigation affects nutritional outcomes along the same World Bank (2013), with an emphasis on water-related pathways as broader agricultural interventions, but it aspects of these guidelines. The recommended actions does so in specific ways (Domènech 2015; Passarelli at the project level depend on an enabling policy envi- et  al. 2018). These include a production pathway, an ronment that prioritizes water use efficiency, nutritious income pathway and a women’s empowerment path- diets, gender equality, and human capital development. way. In addition, irrigation presents a potential fourth Irrigation contributes to agricultural intensification and pathway to improvements in nutritional outcomes farm profitability (Burney, Naylor, and Postel 2013; through water, sanitation, and hygiene (figure ES.1). FIGURE ES.1. Pathways from Irrigation to Nutritional Outcomes Pathways Outcomes Impacts on nutrition Enhanced agriculture production Improved diet, including dietary diversity Improved child nutrition Increases in household Irrigation income and water Improved resource health management Improved maternal nutrition Improvements in water supply and hygiene Food security Strengthened women’s Key components of the enabling empowerment environment: - Access to markets - Natural resources - Infrastructure - Social, nutritional and health norms Source: Based on Passarelli et al. 2018. Nutrition-Sensitive Irrigation and Water Management v This note presents evidence for the effects of irriga- effects of irrigation and water management inter- tion on nutritional outcomes for each hypothesized ventions on these direct determinants of nutrition pathway. However, these pathways are only indi- and on nutritional outcomes. rectly related to nutritional outcomes, and few stud- ies assess the effects of irrigation on the more immediate determinants of nutrition, such as ade- Note 1. Project teams that intend for their lending operation or advisory ser- quate food and nutrient intake and infectious dis- vices and analytics activity to be coded under nutrition theme 671 ease, especially for children in the first 1,000 days of should review the Operations Policy and Country Services life. More evidence is needed to demonstrate the guidelines. vi Nutrition-Sensitive Irrigation and Water Management Abbreviations APL adaptable policy lending BCC behavior change communication BMI body mass index FIES Food Insecurity Experience Scale HAZ Height-for-age z-score HFIAS Household Food Insecurity Access Scale IWRM integrated water resource management IYCF infant and young child feeding IYCMAD infant and young child minimum acceptable diet LAZ length-for-age z-score LSMS Living Standards Measurement Study MDD-W Minimum Dietary Diversity for Women MLDD market-level dietary diversity MUS multiple-use water system PSNP Productive Safety Nets Project WASH water supply, sanitation, and hygiene WEAI Women’s Empowerment in Agriculture Index WHO World Health Organization Nutrition-Sensitive Irrigation and Water Management vii Chapter 1 The Business Case for Nutrition-Sensitive Water Management M eeting the United Nations’ Sustainable average (Wiebe et al. 2015). Lower yield growth could Development Goals requires new policies, lead to higher food prices and therefore less affordabil- interventions, and research that consider the ity of food, lower calorie availability, concomitant synergies and trade-offs among development objec- changes in diets, and increases in childhood malnutri- tives and apply cross-sector solutions to meet complex tion in Sub-Saharan Africa (Fanzo et al. 2018; Ringler challenges (UN 2018). Interventions in one sector can et al. 2010; Springmann et al. 2016). Furthermore, the potentially reinforce and enhance outcomes in another. nutritional value of key staple crops is expected to be Water management and irrigation interventions pro- affected by climate change (Beach et al. 2019; Smith and vide farmers with a more reliable source of water for Myers 2017). Both trends pose a challenge for liveli- growing food, thereby increasing agricultural yield hoods, food security, and nutrition. and profits and contributing to food availability and Irrigation is a key strategy to mitigate these risks. access, which ultimately affect household health and Supplemental irrigation can stabilize yields under nutrition. However, evidence from the agriculture sec- climate change (Nangia and Oweis 2016), thereby ­ tor shows that interventions are more likely to directly potentially reducing the need for emergency relief and affect nutritional outcomes when they intentionally insurance payouts following climate shocks. When address factors that are important for nutrition, such as combined with seed varieties designed to meet local those that incorporate health and water, sanitation, and climate challenges and nutritional needs (for example, hygiene practices or promote adoption of biofortified through biofortification), irrigation interventions crops to address particular micronutrient deficiencies could also reduce the negative effects of climate (Ruel, Quisumbing, and Balagamwala 2018). change on nutritional outcomes. Small-scale irrigation Effective integrated approaches must also consider the has been found to be profitable in Sub-Saharan Africa challenges and opportunities that cut across sectors, under both a drier and a wetter climate future such as those related to climate change. Climate change (using  the most extreme climate scenarios available largely affects agricultural producers through changes at  the  time), as well as under alternative crop price in water availability because of changing rainfall pat- and irrigation cost trajectories (Xie et al. 2014). By terns; more frequent and extreme droughts, floods, the same token, policies and investments in sustain- and storms; and higher rates of evapotranspiration, able water management can mitigate the effects of which will increase the water demand of crops and the climate change by improving the quality of natural ­ need for alternatives to rainfed irrigation in many parts capital (for example, soils, water, and forests) and of the world (Jiménez Cisneros et al. 2014). increasing the resilience of ecosystems that support agricultural production to withstand climate shocks Globally, key staple crops are expected to experience and stressors (Tompkins and Adger 2004). significant yield declines because of climate change, on Nutrition-Sensitive Irrigation and Water Management 1 Chapter 2 Pathways Linking Irrigation and Water Management with Nutritional Outcomes Pathway 1: Enhanced Agricultural has been linked to decreased risk of low birth weight Production households regardless of household wealth, for farm ­ birth season, or country of residence (Grace et al. 2015). Production and nutritional outcomes depend on the type of irrigation intervention. For instance, studies of irrigated home garden production in Burkina Faso have found that irrigation programs increased produc- tion of fruits and vegetables, increased food security, and improved nutrition (Olney et al. 2015). Similarly, Kabunga, Ghosh, and Griffiths (2014) have found that in Uganda, women in farm households producing fruits and vegetables have higher intake of these foods and better health and nutritional outcomes. Although irrigation appears to increase production diversity and consumption of home-produced, micronutrient-rich foods (Alaofe et al. 2016; Passarelli ­ et al. 2018), there is less evidence for the link between increased production diversity and enhanced dietary Irrigation affects agricultural production in several diversity. In general, studies show mixed results: in ways. It increases crop productivity and broadens the some cases, increased production diversity leads to range of crops that farmers can cultivate, including improved diet quality, but in other cases, it does not crops that are more sensitive to drought stress, such as (Sibhatu, Krishna, and Qaim 2015). many vegetables, or those that have higher water There is also little evidence for the link between irriga- requirements, such as some fruit trees. Many of these tion and resilience to climate shocks and stressors. also have higher nutritional value (Alaofè et al. 2016; Still, some studies show that irrigation interventions Burney et al. 2013; De Fraiture and Giordano 2014; affect the availability and stability of food supply by Passarelli et al. 2018). enabling more cropping seasons, including during dry Increased production of nutritious crops because of periods (Aseyehegn, Yirga, and Rajan 2012), and by irrigation has also been shown to increase the reducing the risks of rainfed production (Fox and availability of and access to nutritious foods for ­ Rockström 2003; Oweis and Hachum 2006). A study in home  consumption and through market purchases South Africa found that irrigating farmers were less (Burney et al. 2010; De Fraiture and Giordano 2014; likely to perceive climate change, as irrigation buffered Namara et al. 2011; Namara, Upadhyay, and Nagar droughts and heat stress (Gbetibouo, Hassan, and 2005). Increased water access may directly benefit Ringler 2010), and a study in Kenya found that irriga- women and their children, given that increased rainfall tion was the most preferred climate change adaptation Nutrition-Sensitive Irrigation and Water Management 3 strategy of farmers, identified by almost half of all health care, and education (Alaofè et al. 2016; Burney farmers interviewed (Bryan et al. 2013). and Naylor 2012). Evidence from Ethiopia and Tanzania also shows higher income among irrigating households, In theory, combining irrigated production with which led to higher dietary diversity in the case of improved processing and storage practices would offer Ethiopia (Passarelli et al. 2018). Several studies also point even greater potential for improved stability of food to employment benefits created by irrigation that expand supply. More evidence is needed to determine the the economic benefits and potential nutritional out- extent to which these value chain improvements comes beyond the farm household (Namara et al. 2011). would increase the benefits of irrigation. Ex ante analyses on the regional scale also show con- siderable potential for further economic gains through Pathway 2: Increases in Household Income the expansion of irrigation in Sub-Saharan Africa (Xie et al. 2014; You et al. 2011). Income gains can be used to purchase foods that improve the nutritional status of household members, such as animal-source foods like meat and eggs, or can be used to purchase health services or pay school fees. ­ Pathway 3: Improvements in Water Supply and Hygiene Irrigation influences nutritional outcomes through a second pathway: the income pathway. Irrigation facili- tates the production and increases the yields of higher-value crops, which can increase farm income ­ through the sale of these crops. The literature from several contexts demonstrates that irrigation contrib- Irrigation also has the potential to affect the water, utes to increased income from agricultural production sanitation, and hygiene (WASH) environment. This is (Burney and Naylor 2012; Passarelli et al. 2018). the third pathway through which irrigation can indi- rectly influence nutritional status, although there is An evaluation of a solar irrigation project in Benin shows less evidence for this pathway. Changes in the WASH that modern irrigation technologies increase consump- environment affect health risks, health status, and uti- tion expenditures and increase asset accumulation while lization of nutrients from food. reducing poverty. Households that engaged in solar-­ powered irrigation had higher expenditures, including The relationship between WASH and irrigation depends spending on total food purchases, nutritious foods, on the available services, water source, and system in 4 Nutrition-Sensitive Irrigation and Water Management place. Some systems are hybridized for both rainfed and which can affect water quality and human health (Mateo- irrigated supply, such as water catchments for rainfall. Sagasta et al. 2017). Irrigation with poorly treated waste- Vectors for the WASH pathway have different entry points water can increase exposure to pathogens resulting in in on-farm and off-farm irrigation systems. On-farm irri- schistosomiasis, diarrhea, or other ailments (Amoah et al. gation interventions (such as on-farm storage, pump irri- 2009). Poor water quality, because of agricultural runoff gation, or bucket irrigation) have relatively contained or poor WASH practices, increases the risk of infection and water sources, compared with larger off-farm irrigation disease and ultimately of undernutrition. In this weak- conveyance infrastructure that may be multipurpose, ened state, the body becomes more susceptible to infec- such as for recreation or drinking water. Attention has tion and disease, creating a vicious cycle of poor health. narrowed on wastewater reuse for irrigation, and as alter- native sources of irrigation water are considered, more Pathway 4: Strengthened Women’s evidence for this pathway will be uncovered. Empowerment The literature suggests that poor WASH conditions, such as fecal contamination of the household environ- ment (Curtis, Cairncross, and Yonli 2000; Marquis et al. 1990), soil contaminated with human and animal feces (Curtis et al. 2000; Pickering et al. 2012), and unsafe dis- posal of infant and child feces, contribute significantly to the diarrheal disease burden (Mara et al. 2010). Repeated episodes of diarrhea in young children con- tribute to growth stunting (Checkley et al. 2008). Evidence demonstrates an association between enteric infection and stunting independent of diarrheal disease or poor diet in The Gambia (Campbell, Elia, and Lunn 2003; Lunn, Northrop-Clewes, and Downes 1991). Irrigation can improve household access to water for hygienic and other domestic purposes. For example, van Several studies from various contexts have identified a der Hoek, Feenstra, and Konradsen (2002) showed in relationship between women’s empowerment and Pakistan that the use of irrigation water for domestic pur- improved development outcomes, such as nutritional poses can significantly reduce diarrhea, thereby improv- status, dietary quality, and education expenditures ing the nutritional status of children. However, in some (Malapit et al. 2015; Malapit and Quisumbing 2015; cases, the quality of irrigation water may not be appropri- Sraboni et al. 2014; Yimer and Tadesse 2015). Irrigation ate for human consumption. Moreover, irrigation may interventions have the potential to affect women’s increase health risks, if not properly managed, through an empowerment through changes in their control over increase in vector-borne diseases caused by standing or agricultural production decisions, income decisions, slow-moving water (Keiser et al. 2005). In addition, and time use. An increase in women’s decision-making Audibert, Mathonnat, and Henry (2003) showed that authority over production and income decisions could large-scale irrigation could increase the prevalence of lead to the adoption of irrigation systems that provide water-based parasites that reduce the potential for nutri- them with benefits, such as reduced labor burden, and tional uptake. Irrigation may also increase runoff of agri- may have implications for the health and nutritional cultural chemicals, such as fertilizers and pesticides, status of women and their children. Nutrition-Sensitive Irrigation and Water Management 5 Emerging evidence suggests that the link between nutritional outcomes in some contexts (Burney et al. ­ irrigation and women’s empowerment is context spe- 2010; Iannotti, Cunningham, and Ruel 2009; Olney cific. In some contexts, social norms and other barriers et al. 2009, 2015). Similarly, in terms of the income prevent women from benefiting directly from ­irrigation pathway, women also have different preferences interventions, given their limited control over the compared with men for how income is spent, and technology and income from the sale of irrigated pro- they tend to prioritize food and health care pur- duce (Theis et al. 2018). In other contexts, irrigation chases (Gillespie, Harris, and Kadiyala 2012; activities targeted toward women, such as through irri- Meinzen-Dick et al. 2012). Studies of irrigation proj- gated home gardens, have been shown to increase ects targeted to women’s groups have found that women’s control over irrigated produce and income. women often control income from the sale of irri- gated crops grown on their plots (Burney et al. 2010; Irrigation can also affect women’s time by either reliev- van den Bold, Quisumbing, and Gillespie 2013). ing their time burden or adding to it. This has implica- tions for women’s ability to care for their children and In terms of the water supply pathway, women tend to could result in negative nutritional outcomes. For prefer multiple-use water systems (MUS) close to the example, an increase in the agricultural workload of homestead that provide water for both productive and pregnant women is known to increase the risk of domestic purposes. Such systems can save time and preterm birth (Owens et al. 2015). The literature shows energy and can improve the WASH environment, that the extent to which irrigation affects women’s depending on the quality of water and the way it is labor varies, with some studies suggesting that an managed (Theis et al. 2018; van Koppen et al. 2009). In increased labor burden results in poor nutritional out- addition, reducing the time that caregivers spend comes (Riley and Krogman 1993; Steiner-Asiedu et al. fetching water lowers diarrhea and improves nutri- 2012) and others finding time savings or a shift in labor tional outcomes in children under age 5 (Pickering and allocation toward men (Bryan 2019). Davis 2012) through improved hygiene practices (Aiello et al. 2008; Motarjemi et al. 1993), more time available Changes in women’s empowerment are likely to for child care (Burger and Esrey 1995; Cairncross and intersect with the three previously described path- Cuff 1987; Diaz, Esrey, and Hurtado 1995; Miller and ways in important ways. In terms of the production Urdinola 2010), or income-generating activities pathway, women have different preferences com- (Koolwal and Van de Walle 2013). However, some stud- pared with men for the types of crops that are ies show that irrigation reduces the amount of time planted and how these crops are used (for example, that mothers spend on household activities like cook- sold in the market or consumed at home; Carr 2008). ing and caring for their children (Bénéfice and Because women often produce crops for home con- Simondon 1993; Brun, Reynaud, and Chevassus-Agnès sumption, interventions targeted to women around 1989; Vaughan and Moore 1988), with potential nega- irrigated home gardens have been shown to improve tive consequences for nutrition. 6 Nutrition-Sensitive Irrigation and Water Management Chapter 3 The Enabling Environment: Infrastructure, Institutions, and Information W hich pathways matter? Studies that look at management and monitoring, and information the link between irrigation and nutritional dissemination. Much literature exists on the role of ­ outcomes do not necessarily examine the institutions in ensuring adequate water quantity and causal pathways. For example, a study from Mali showed quality for agricultural production and other water increases in total consumption and calorie and pro- uses, whether through collective groundwater man- tein intake among irrigating households, although the agement in India (Meinzen-Dick et al. 2016), water pathway of these outcomes was not clear (Dillon 2008). transfers in China (Khan, Hanjra, and Mu 2009), river Passarelli et al. (2018) have examined changes in dietary basin management of transboundary hydrological sys- diversity because of the income and production pathway tems, water user associations to promote the effective and found that irrigation was associated with increased and equitable use of irrigation flows, or the promotion dietary diversity in Ethiopia as a result of increased of water-saving irrigation technologies. income from irrigation, rather than through an increase in production diversity; however, the results were not Integrated water resource management (IWRM) opera- significant in Tanzania. More evidence is needed to tions exert influence on the enabling environment for determine the pathways and conditions under which food security and nutrition through changes in the qual- production changes and income increases because of ity, quantity, and stability of the water supply and by irrigation improve diet quality and nutritional outcomes. influencing the distribution of infrastructural assets (for example, water harvesting structures), leveraging insti- In addition to household changes and dynamics, path- tutional platforms for social and behavioral change ways from irrigation to nutrition are also shaped by the communication around nutrition and social inclusion, enabling environment, including natural resource avail- and using information systems (for example, ground- ability and management, access to markets, infrastruc- water monitoring and hydrological and meteorological ture, institutions, and social norms. For example, more services) to provide water quality monitoring and early developed markets, transportation and logistics infra- warning indicators of water-related threats and disas- structure, and developed value chains can increase ters (for example, floods and flood-induced infectious farmers’ income from selling produce, as well as diseases). IWRM can play an important role in effective increase consumers’ access to nutritious foods. Norms flood management, which can be critical to increasing and knowledge around nutrition shape the extent to soil fertility and agricultural productivity while mitigat- which consumers spend their income on nutrition- and ing damage to agriculture, fisheries, and infrastructure. health-enhancing goods and services and provide Because these factors do not influence nutritional appropriate care to infants and young children. outcomes directly, there is no literature linking such ­ Institutions at multiple levels, from the state to com- institutional factors to nutritional outcomes. However, munity organizations, shape the enabling environ- increased understanding of irrigation-to-nutrition link- ment for irrigation, nutrition and health, by serving ages and the role of water management among policy as  platforms for governance (including laws and makers and other stakeholders can increase the likeli- regulations to protect natural resources, such as water, ­ hood that agricultural water is available and used in as  well as human health), agency strengthening, ways that enhance nutritional outcomes. Nutrition-Sensitive Irrigation and Water Management 7 Chapter 4 Entry Points for Improved Nutritional Outcomes T he body of evidence for the links among irriga- and  availability of land, soil, and water resources. tion, water management, and nutrition provides Conservation and restoration activities, including refor- important clues as to what nutrition-sensitive estation programs, wetland restoration, or buffer strips enhancements could achieve greater impacts on early to reduce nutrient and sediment runoff from agricultural child nutrition. The following approaches are recom- land into waterways, can affect downstream sedimenta- mended to improve the nutritional impact of irrigation tion, runoff, fisheries, and agricultural productivity. and water management investments. Transboundary water policies also need to consider the food security and nutritional implications of water avail- Incorporate Nutritional Considerations into ability, quality, and continuity of supply for all users. Project Design at the Concept Stage The concept stage of project design is an opportune Equip Cooperatives, Agricultural time to consider nutrition objectives of the project and Extension, and Water User Associations for incorporate these considerations. For example, one Nutrition and Dietary Considerations consideration may be to prioritize investments to an Nutrition-specific behavior change communication area of the country that is facing challenges of food or (BCC) is needed to bring about alterations in nutrition water insecurity. Another possibility could be to focus practices. Yet effective BCC demands substantial time on areas where large numbers of young children are and commitment from staff and beneficiaries (Ruel, undernourished. These are also likely to be areas Quisumbing, and Balagamwala 2018). Often, BCC is where other nutrition-related interventions are taking not intense enough in frequency or the quality of infor- place, providing the opportunity to converge geo- mation, is not culturally sensitive, and/or is insuffi- graphically and leverage common community-based cient to address barriers to improving nutrition platforms. practices. Using existing platforms to communicate Decisions around crop choice may also take place at messages related to household nutrition could be a the concept stage. Understanding the nutritional pro- cost-effective way to reach target populations. file of the beneficiary population, such as the preva- Information is shared with farmers through different lence and types of micronutrient deficiencies (for mediums and extension services. Better coordination example, lack of food sources rich in vitamin A or iron), linking agriculture and health extension workers and deficiencies in the consumption of certain food groups, information systems could ensure complementary and and dietary diversity, can inform which crops could coordinated messages are delivered at appropriate bring both income and nutritional benefits. times. Membership-based organizations that build social capital, such as river basin organizations, can also be used as a platform to disseminate nutrition and Maintain and Improve the Natural health training and education. Topics might include Resource Base healthy diets, resource planning and food storage Productive livelihoods and resilience that are essential practices to ensure food availability throughout the for food security and nutrition depend on the quality year, food safety, and hygiene. Identifying approaches Nutrition-Sensitive Irrigation and Water Management 9 Entry Points for Improved The current body of evidence on the links between irrigation, water management, and nutrition provides important clues as to what nutrition sensitive Nutritional Outcomes enhancements are needed to achieve greater impacts on early child nutrition. The following approaches are recommended to increase the nutritional impact of irrigation and water management investments. 2 Maintain and improve the 1 natural resource base Incorporate nutritional considerations at 4 concept stage Leverage community platforms to deliver nutrition messaging 3 Equip cooperatives, extension, and WUAs with nutrition and dietary considerations 5 Engage women in 6 irrigation interventions Promote nutrient-dense crops and incorporate home gardens 7 Design formal multiple-use water 8 systems that are culturally Integrate irrigation appropriate and safe investments into rural service delivery and social safety nets to target information to both men and women would time spent irrigating as a result of irrigation invest- increase the likelihood of uptake. ments could free time for women to spend on care- giving or productive activities, contributing to better outcomes at home. Finally, including women as ben- Leverage Community Platforms to Deliver eficiaries of irrigation investments may influence Nutrition Messaging women’s empowerment across several domains. Other community-based platforms that target pregnant This depends on many factors, including women’s women and households with young children could be control over decisions regarding which technologies equipped with information and messaging to promote are adopted and how they are used, who performs household nutrition and healthy diets  and reinforce the labor for irrigation, and who controls irrigated ­ rrigation-related platforms. the messaging through the i output and income from the sale of irrigated crops Schools, health centers, savings groups, and so on, are (Passarelli et al. 2018; Theis et al. 2018). Identifying present in most communities. interventions that reduce women’s time burden and support their authority over irrigated production could thus help accelerate nutritional gains and Engage Women in Irrigation Interventions increase benefits. Inclusion of women cuts across all pathways to influ- ence nutritional outcomes. Evidence shows that irri- gation interventions targeted to women can improve Promote Nutrient-Dense Crops and Incorporate Home-Gardening Components dietary quality and nutritional outcomes in some in Irrigation Projects contexts (Burney et al. 2010; Iannotti, Cunningham, and Ruel 2009; Olney et al. 2009). For example, Promotion of nutrient-dense crops could lead to women are more likely to make nutrition-related improvements in household nutrition, in which a por- decisions in the home, so they are more likely to set tion of that production is diverted to household con- aside nutrient-dense crops for home consumption or sumption or in which these crops make their way to be to spend additional income on health food and other sold in local markets, benefiting a wider population. inputs that lead to better nutritional outcomes. This includes promotion of biofortified crops to Improvements in the availability of water and less address micronutrient deficiencies. In some parts of BOX 4.1. Strengthening Water Security and Resilience in Somalia The Water for Agro-Pastoral Productivity and Resilience Project aims to tackle water for both crop and livestock productivity and community resilience. Somalia is subject to repeated cycles of devastating droughts, averaging one every 4 years, and has experienced five major flood events between 2006 and 2018, affecting hundreds of thousands of people. The last drought in 2016–17 led to 6.2 million Somalis requiring humanitarian assistance and close to 400,000 reported cases of acute child malnutrition. Livestock losses were estimated at US$2 billion, with people losing between 40 and 60 percent of their herd. The proposed project will provide access to multiple-use water resources (for human consumption, livestock, and small-scale irrigation) in dry lands of Somalia. The small-scale water infrastructure will be designed to deliver both improved human health outcomes and water for productive uses, including agricultural production as well as agroforestry services for landscape restoration. 12 Nutrition-Sensitive Irrigation and Water Management Africa, irrigation is used to produce fodder for live- seasonally limited or non-existent (Domènech 2015; stock (Frenken 2005). Irrigated fodder production can Ensink et al. 2002; Meinzen-Dick 1997; van Koppen increase livestock and dairy productivity, providing a et  al. 2009). Water systems designed for multiple greater supply of animal-source foods and protein purposes may reduce overall time spent collecting ­ intake for young children (Murphy and Allen 2003). water, freeing time for productive uses and caregiving, both  inputs to better nutritional outcomes. Promotion of home gardens alongside irrigation inter- However,  irrigation infrastructure is not typically ventions could be an explicit way to encourage con- designed to collect or distribute water for domestic sumption of a more diverse diet in the home. Several consumption, so this can lead to both positive and reviews have found a positive relationship between negative health effects (Domènech 2015). Formal ­ home gardens and consumption of fruit and vegeta- ­ multiple-use water systems (MUS) are designed to sup- bles (Berti, Krasevec, and FitzGerald 2004; Masset port both domestic and irrigation uses, and as such et al. 2012; Ruel, Quisumbing, and Balagamwala 2018). have the potential to increase health and nutritional Though these reviews do not assess the effects of irri- outcomes through multiple pathways (see box 4.1) gation on nutrition specifically, other studies have (van Koppen et al. 2009). found that the addition of irrigation and access to water year-round improve the uptake of home and small-scale gardens, as well as the outputs from these Incorporate Irrigation into Community- food sources (Bhagowalia, Headey, and Kadiyala 2012; Based Platforms for Rural Service Delivery Hirvonen and Headey 2018; Olney et al. 2013). Social protection and livelihood programs use ­community-based platforms for delivery of small-scale Design Formal Multiple-Use Water infrastructure, as well as financial safety nets that pro- Systems That Are Culturally Appropriate tect households from shocks and provide resources for and Safe recovery (see box 4.2). These programs often use tar- geting systems that enable both geographic and demo- Irrigation water is sometimes used for domestic pur- graphic (first 1,000 days of a child’s life) targeting of poses when access to other sources of domestic water is BOX 4.2. Linking Public Works Projects with Water Management and Irrigation The Ethiopia Productive Safety Nets Project (PSNP) is a core element of the government of Ethiopia’s pro-poor development agenda. The World Bank supports PSNP through an Adaptable Policy Lending (APL) instrument with the overall development objective to reduce household vulnerability, improve resilience to shocks, and promote sustainable community development in food-insecure areas of rural Ethiopia. The project targets chronically food-insecure households with safety net transfers based on completion of public works labor and/or soft conditions related to health and nutrition. Now in its fourth phase (PSNP IV), the project has continually harnessed evidence from ongoing impact evaluations and targeted studies to inform the design of implementation and improve outcomes. box continues next page Nutrition-Sensitive Irrigation and Water Management 13 BOX 4.2. continued For example, impact assessments of PSNP in 2011 and 2012 demonstrated that linking public works, such as road and embankment construction, with livelihood investments, such as micro- and small-scale irrigation, water harvesting, and soil and water conservation, leads to greater impacts. Small-scale irrigation from water sources developed by PSNP helped to expand livestock for 4 to 12 percent of households and increased incomes by 4 to 25 percent. When compared with rainfed cultivation, small- and microscale irrigation projects were yielding an additional 3,652 Ethiopian birr per hectare per year (approximately US$ 125), contributing substantially to household livelihoods and food security. Based on these findings, a subsequent phase of PSNP intends to methodically link the design of public works with access to livelihood services. nutrition-related services without incurring additional Integration of irrigation infrastructure and services costs. Such services may include the following: into social protection and livelihood programs may face limitations if these programs are not equipped to • Construction and/or rehabilitation of small-scale address institutional capacity needs that are required irrigation infrastructure to sustain service delivery. For example, without ade- • Drought insurance products to enable households to quate operational and maintenance support to keep recover from unexpected weather shocks irrigation infrastructure functioning, they can break • Promotion of home gardens to diversify household diet down, resulting in households reverting to labor-­ • Nutrition-sensitive messaging around healthy diets, intensive irrigation approaches. resource planning and food storage practices, food safety, and hygiene 14 Nutrition-Sensitive Irrigation and Water Management Chapter 5 Practical Guidance for Nutrition-Sensitive Monitoring and Evaluation D espite growing evidence, the potential for Share of Beneficiary Area and/or Water Users ­ nutrition-sensitive irrigation and water man- Experiencing Food Insecurity at Baseline agement to affect nutritional outcomes has The first nutrition-sensitive indicators measure not been fully explored (Domènech 2015). Evidence coverage of the project for vulnerable populations expe- ­ is mostly observational, with only a few rigorous riencing food insecurity and are recommended for proj- impact evaluations of the links along the pathways ects that aim to target food-insecure communities with between irrigation interventions and nutritional out- irrigation services. Household food insecurity can be comes. Building this evidence base requires enhance- measured using the Household Food Insecurity Access ment of existing monitoring and evaluation efforts Scale (HFIAS) or the Food Insecurity Experience Scale to capture impacts along the key pathways to nutri- (FIES).1 Both can be generated using a short household tional outcomes. Table 5.1 presents a set of results survey module. The HFIAS captures households’ behav- framework indicators that link to each pathway to ioral and psychological manifestations of insecure food support nutrition-sensitive lending operations. These access, such as having to reduce the number of meals indicators can also be used for irrigation components consumed or cut back on the quality of the food because of agriculture projects and projects in other sectors. of a lack of resources. Similarly, the FIES captures the The selected indicators would need to be adapted range of food insecurity severity at either the individual to the project context, including data availability, or the household level. Both measures are useful inputs project components, and monitoring and evaluation for informing population-level targeting and monitor- capacity. ing and evaluating food access–related activities. Average Crop Production, Intensity, and Diversity Production and Income Pathway Indicators Irrigation has been shown to increase crop yields, the first step in the production pathway. Yields of irrigating As shown in the framework, one of the key pathways households can be used to measure the effects of irriga- to improved nutrition is through changes in food pro- tion on crop production, and disaggregating these duction. The nutrition-sensitive indicators proposed yields by crop type can explore how irrigation enables in table 5.1 adhere to traditional irrigation project indi- farmers to grow more nutrient-dense crops. Irrigation cators but focus the measurement of these indicators interventions may directly promote the adoption of on either (1) reach of the project among nutritionally micronutrient-rich foods, such as leafy green vegeta- vulnerable populations or (2) production of nutri- bles or orange-flesh sweet potatoes, but even where ent-dense crops. Additional nutrition-sensitive indica- these are not promoted, farmers may choose to plant tors measure whether increases in agricultural such crops for practical and economic reasons. production (the production pathway) and/or increases in agricultural income (the income pathway) have led Crop yield per unit of area is an indicator tradition- to changes in diet at the household level. ally used to determine cropland productivity. Nutrition-Sensitive Irrigation and Water Management 15 TABLE 5.1. Nutrition-Sensitive Indicators for Irrigation and Water Management Lending Operations Key results indicators for Additional key results indicators for Can be gender Data source and calculation irrigation operations nutrition-sensitive irrigation operations disaggregated Production pathway Area provided with new Share of area provided with new or improved Project-level data collected by or improved irrigation or irrigation or drainage services that was food implementing agencies; calculation drainage services (ha)a insecure at baseline (%) of HFIAS in project area at baseline (see below) Water users with improved Water users with improved irrigation and Project-level data collected by irrigation and drainage drainage services who were food insecure at implementing agencies; calculation services baseline (%) of HFIAS at baseline (see below) Average crop production Average crop production and diversity Project-level data collected by ¸ (disaggregated by type of nutrient-dense implementing agencies; LSMS crop crop) production modules in project area Average cropping intensity Average cropping intensity of nutrient-dense Project-level data collected by crops (%) implementing agencies None Months of crop production by nutrient-dense Project-level data collected by crop (number) implementing agencies Increase in agricultural Increase in nutrient-dense agricultural Project-level data collected by production sold (%) production sold (%) implementing agencies None Cumulative home gardens established Project-level data collected by (number) implementing agencies None Availability of nutrient-dense crops in local Baseline and follow-up market market assessment None Beneficiaries that report improved Baseline and follow-up household consumption of nutrient-rich food (%) surveys Income pathway None Targeted farmers that report increased Project-level data collected by ¸ agricultural income (%) implementing agencies WASH pathway People provided with access None Project-level data collected by ¸ to improved water sources implementing agencies People provided with access None Project-level data collected by ¸ to improved sanitation implementing agencies Reduction in time spent None Baseline and follow-up household ¸ obtaining water (hours) surveys Women’s empowerment pathway Farmers reached with Female farmers reached with agricultural Project-level data collected by ¸ agricultural assets or assets or services** implementing agencies services** Farmers adopting improved Female farmers adopting improved agricultural Project-level data collected by ¸ agricultural technology technology and/or equipment (%) implementing agencies Women providing extension or other Project-level data collected by ¸ agricultural cooperative services (%) implementing agencies table continues next page 16 Nutrition-Sensitive Irrigation and Water Management TABLE 5.1. continued Key results indicators for Additional key results indicators for Can be gender Data source and calculation irrigation operations nutrition-sensitive irrigation operations disaggregated Enabling environment Irrigation strategy or policy Irrigation strategy or policy developed and Project-level data developed and approved approved that incorporates food security and nutrition policy measures Basin plan established or Basin plan established or improved that Project-level data improved addresses food security and nutrition objectives Reduced erosion and None Project-level data or MIS improved water quality Households receiving behavioral messages on Project-level data collected by healthy diet and nutrition (number) implementing agencies Extension agents trained in healthy diet and Project-level data collected by ¸ nutrition (number) implementing agencies Note: HFIAS = Household Food Insecurity Access Scale; LSMS = Living Standards Measurement Study; MIS = Management Information System; WASH = water supply, sanitation, and hygiene. a. Core sector indicator. Although yield is a good indicator of land productiv- Market-Level Dietary Diversity ity for cropping systems with a systematic planting Poorly functioning markets in rural areas could form pattern, in more complex cropping systems with an important factor that influences access to and con- more than one crop planted in a plot, measures such sumption of diverse foods by local populations, but as value of crop production per unit area can be used this information is not captured by household-level to determine the productivity of the output. Because indicators of dietary diversity. The diversity of foods irrigation also extends the timeline for crop cultiva- available in local markets, called a market-level dietary tion into the dry season, crop counts over the course diversity (MLDD) score by Pingali et al. (2014), rep- of one production season or year can capture differ- resents the number of distinct foods or food groups ences between households producing irrigated crops available in a local market at a given point in time. during the dry season (in addition to rainfed produc- Although this indicator has not been fully developed tion) and those depending on rainfall. This can pro- or widely used, it presents an opportunity to fill a gap vide a measure of the stability of the food supply in the data on factors, such as availability and access to throughout the year. food, that influence household and individual diet Data for calculating crop production, diversity, and diversity.3 value of production can be collected using agricultural household surveys, such as those administered by the Household Dietary Diversity Living Standards Measurement Study (LSMS). These 2 Changes in agricultural production and increases in modules can also be used to measure the share of pro- income from agriculture can lead households to duction that is allocated to consumption, sale, seed, change their diet. Diet quality as measured by increase and so on. in intake of micronutrients such as vitamin A, iron, Nutrition-Sensitive Irrigation and Water Management 17 and zinc can demonstrate improvements in nutritional Agricultural Income and Farm Profits status associated with irrigation interventions. The Increased household income is one of the key pathways following indicators capture dietary diversity for dif- through which irrigation can improve nutritional out- ferent household members.4 Micronutrient intake can comes, especially if this income leads to greater spend- also be calculated for individual household members. ing on nutritious foods or other nutrition inputs. Data to Minimum Dietary Diversity for Women. The Minimum calculate net profits of agricultural production can be Dietary Diversity for Women (MDD-W) score is an indica- collected through production modules as part of farm tor of dietary diversity validated for women of reproduc- household surveys. Data on expenditures, such as total tive age (15 to 49 years). Women who have consumed at food expenditures; spending on animal-source foods, least 5 of the 10 possible food groups over a 24-hour recall vitamin A–rich foods, and iron-rich foods; and health period are classified as having minimally adequate diet expenditures, could be measured, as well as part of an diversity. Data are gathered from a questionnaire admin- expenditure module of a household survey. istered to female respondents in the specific age range. Water, Sanitation, and Hygiene Infant and Young Child Minimum Acceptable Diet. The Pathway Indicators Infant and Young Child Minimum Acceptable Diet (IYCMAD) indicator is one of eight core indicators for Irrigation interventions can provide unique opportu- assessing infant and young child feeding (IYCF) prac- nities to improve water, sanitation, and hygiene tices developed by the World Health Organization (WASH) conditions in the beneficiary population, but (WHO) This indicator is calculated for both breastfed they can also potentially introduce risks. For example, and nonbreastfed children. It is a composite indicator irrigation interventions provide a reliable source of based on two components: minimum dietary diversity water that can be used for practicing household and minimum meal frequency. This indicator be disag- hygiene and can substantially reduce the amount of gregated and reported for the following age groups: time spent fetching water, freeing that time for care- 6 to 11, 12 to 17, and 18 to 23 months of age. giving, education, or productive pursuits that are inputs to nutrition. As an underlying determinant of Micronutrient Intake (Vitamin A, Iron, and Zinc). nutritional outcomes, measurement of WASH indica- Micronutrient deficiency continues to be a widespread tors in n ­ utrition-sensitive irrigation interventions can problem in low-income economies, especially for iron, provide context as to how well food can be used by ­ vitamin A, and zinc. These nutrients are essential not just beneficiaries. Irrigation water may also introduce risks for infants and children, to ensure proper growth and if the water is consumed by the household, if it is development, but also for adults, to ensure productivity, untreated, or if improper management of irrigation healthy pregnancies, and overall cognitive and physical water increases the incidence of vector-borne dis- health. Individual micronutrient intake can be a useful eases, such as malaria and schistosomiasis. indicator in assessing the need for or effect of nutri- ent-specific interventions, including nutrition-sensitive irrigation projects, biofortification, and supplementa- Women’s Empowerment tion. In addition, if micronutrient intake data are avail- Pathway Indicators able for all members of a household, this indicator could Given that women’s empowerment can influence deci- shed light on the dynamics of intrahousehold allocation sion making over production and income, the extent to of food. To estimate individual daily intake of micronu- which women are empowered with access to agricul- trients, data from a quantitative 24-hour dietary recall tural services, assets, and inputs (including irrigation method or a weighed food record are required.5 technologies) and with control over these resources 18 Nutrition-Sensitive Irrigation and Water Management can influence the effects of irrigation on household water management, can influence nutritional out- nutritional outcomes. Therefore, an understanding of comes, but it is important to include food security and women’s empowerment and engagement in project nutrition as specific objectives. activities is important for nutrition-sensitive irrigation projects. Watershed and Water Quality Improvements Understanding who has access to and who controls Water quality indicators can report on the establish- agricultural assets and equipment can provide ment of water quality monitoring stations and track insights into men’s and women’s bargaining power availability and access to data on groundwater and over irrigation decisions. Emerging evidence shows sedimentation by season. Changes in water quality can that when households own modern irrigation equip- be measured directly to demonstrate improvements ment, such as motorized pumps, men tend to control related to project interventions. Projects can also track and use these assets; in contrast, women tend to use the establishment of hydrometeorological water mon- traditional irrigation methods, such as buckets or itoring stations to monitor droughts and floods and watering cans, that are more labor intensive. In some incorporate surveillance and reporting of water-­related cases, irrigation equipment provided to women is still disease outbreaks. considered owned by men (Theis et al. 2018). Men and women often have different production prefer- Training and Communication of Behavior ences. Inclusion of women both as providers and Change Messages on Diet and Nutrition recipients of agricultural extension services can influ- The enabling environment for better household nutri- ence production decisions, such as what crops to tion is supported through complementary messaging plant, what animals to raise, and for what purposes on healthy diet and nutrition that can be integrated (sale or household consumption). into irrigation and water management investments The Women’s Empowerment in Agriculture Index using existing platforms or leveraging other communi- (WEAI) captures women’s empowerment across several ty-based platforms. domains, including decision making related to agricul- tural production, access to and control over productive resources, control over income, community leadership, Measuring Health and Nutritional and time allocation. A shorter, streamlined version of Outcomes the WEAI, the Abbreviated WEAI, was developed to Irrigation can potentially affect health and nutritional simplify the index and shorten the interview time while outcomes through changes in diet, changes in health maintaining cross-cultural applicability. care practices and risks, and the WASH environment. However, including health outcomes in the project results framework raises issues of attribution and cost. Enabling Environment Indicators These challenges are outlined here for various out- Protection and restoration of watersheds can help to come measures. It is uncommon even for health oper- ensure the availability of sustainable ecosystems, ations to measure these outcomes. For multisectoral reduce erosion and other risks to water quality, and projects that adopt a convergence approach, it may be increase overall water availability for livelihoods and appropriate to measure health and nutritional out- resilience. Key policy actions and conditions in the comes at the program or portfolio level so that projects enabling environment, such as institutional capacity, share accountability for health and nutritional out- infrastructure, strategy, and planning for sustainable comes and no single project claims attribution. Nutrition-Sensitive Irrigation and Water Management 19 Diarrheal Disease Body Mass Index of Women of a Prevalence of diarrhea is relatively easy to collect, Reproductive Age but it is highly variable and requires large sample Body mass index (BMI) is one measure often used sizes to estimate with precision. Self- or caregiver-re- to assess the nutritional status of women of childbear- ported diarrhea can be biased downward because of ing age. BMI is an individual’s weight in kilograms placebo effects, social desirability bias, and recall divided by the square of that person’s height in meters. attenuation bias; therefore, such reports may show BMI can be used to screen for weight categories that impact where there is none. Moreover, diarrhea is may lead to health problems. A high BMI can be an indi- caused by multiple factors, and without an appropri- cator of overweightness and obesity, and a low BMI can ate research design to attribute causality, data may indicate someone is underweight. not be sufficiently specific to demonstrate impact. Measures of diarrhea include incidence of diarrhea in Anemia previous 7 days (or 2  weeks) for children under Anemia, measured by levels of hemoglobin in the 5 years of age or for adults, symptom-based recall of blood, is an objective measure of nutrition, but it watery stools and three or more stools per day, or requires a finger prick, specialized equipment, and blood in stool. training, which may not be practical for most projects. Moreover, anemia has many causes that are not Anthropometrics affected by WASH. Child anthropometrics are objective measures of nutrition, but they are costly to measure because they Micronutrient Status (Vitamin A, Iron, and Zinc) require specialized equipment and well-trained staff. To determine actual micronutrient status (as opposed Moreover, they have low specificity, because growth to micronutrient intake) different biomarkers are can be influenced by many factors. Some growth needed (for example, blood or urine samples) depend- measures, such as height for age, are best measured ing on the nutrient being measured. For more informa- over the long term, which is not always practical for tion on how to collect and analyze micronutrient status typical project and evaluation time frames. Systematic through population-based surveys, see Gorstein et al. administrative data on height and weight are uncom- (2007). mon, and population-level data are typically only col- lected every 5 years. Measures include height and Notes length for age, weight for age, and head and arm 1. For further details on the HFIAS and the FIES, including household circumference. modules, translations, and calculation methods, see https://inddex​ .nutrition.tufts.edu/data4diets/indicators. Stunting worldbank​ 2. Further details on the LSMS can be found at http://surveys.­ .org/lsms/programs/integrated-surveys-agriculture-ISA. Stunting is defined as the share of the population of children under 5 years of age whose height-for-age 3. Further details on the MLDD are available at https://inddex.nutrition​ .tufts.edu/data4diets/indicators. z-score (HAZ) or length-for-age z-score (LAZ) is less than two standard deviations below the median of the 4. Further details on indicators of dietary diversity are available at https://inddex.nutrition.tufts.edu/data4diets/indicators. reference population. National-level statistics on prev- 5. For more information on how this indicator is constructed, alence of stunting are typically updated every 5 years. see  chapter 2, “Overview of the WHO Intake Monitoring, In some cases, figures are available at regional, provin- Assessment and Planning Program (IMAPP),” of the WHO (2010) cial, or district levels. report. 20 Nutrition-Sensitive Irrigation and Water Management References Aiello, A. E., R. M. Coulborn, V. Perez, and E. L. Larson. 2008. “Effect of Burney, J. A., and R. L. 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