R E P O R T Improving Nutrition Through Multisectoral Approaches © 2013 International Bank for Reconstruction and Development/ International Development Association or 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. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this work is subject to copyright. 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TABlE Of CONTENTS | Improving Nutrition Through Multisectoral Approaches Table of Contents Acronyms .............................................................................................................................................................9 Glossary of Key Terms..........................................................................................................................................11 Acknowledgements ............................................................................................................................................20 Executive Summary .............................................................................................................................................21 CHAPTER A. Introduction....................................................................................................25 I. Rationale and strategic context ......................................................................................................................26 Interest in the “forgotten MDG” re-emerges...............................................................................................26 Economic growth, poverty, and malnutrition ..............................................................................................27 Scaling Up Nutrition (SUN): A new global framework and a roadmap for action ............................................28 II. Nutrition is a multisectoral problem with multisectoral solutions ....................................................................30 Determinants of malnutrition....................................................................................................................30 Key sectors for maximizing nutrition impacts.............................................................................................32 Think multisectorally, act sectorally ..........................................................................................................33 Rationale for World Bank involvement .......................................................................................................33 III. Nutrition basics..............................................................................................................................................37 What is malnutrition? ...............................................................................................................................37 What are the consequences of malnutrition? .............................................................................................38 Who is most vulnerable to malnutrition?....................................................................................................39 Why is intervening in nutrition important?.................................................................................................40 Where is malnutrition most prevalent? ......................................................................................................41 How can countries improve the nutrition status of their population? ............................................................41 How does the World Bank cost its investments in nutrition? ........................................................................43 CHAPTER B. Economic Growth, Poverty, and Nutrition .........................................................45 I. Objectives ...................................................................................................................................................46 II. Background ...................................................................................................................................................46 III. What is the cross-sectional relationship between poverty and malnutrition? ...................................................48 TABlE Of CONTENTS | Improving Nutrition Through Multisectoral Approaches IV. How far can economic growth take us? ............................................................................................................51 V. How equitable are nutritional outcomes? ........................................................................................................53 VI. Why is progress on improving nutritional outcomes lagging in South Asia? ....................................................54 VII. What are the implications for policy? ............................................................................................................55 VIII. Emerging operational research and knowledge gaps ....................................................................................57 CHAPTER C. Improving Nutrition through Agriculture ..........................................................59 I. Objectives ...................................................................................................................................................60 II. Rationale ...................................................................................................................................................60 III. Why is agriculture important for nutrition? .....................................................................................................61 IV. Why is nutrition important for agriculture? .....................................................................................................63 V. Pathways from agriculture to nutrition and available evidence .........................................................................65 Pathway 1. National macroeconomic growth ..............................................................................................65 Pathway 2. Higher food production, lower food prices................................................................................66 Pathway 3. Increased income....................................................................................................................67 Pathway 4. Home consumption ................................................................................................................68 Pathway 5. Women’s empowerment ..........................................................................................................70 VI. Systematic review results and knowledge gaps ...............................................................................................71 Cost effectiveness .......................................................................................................................................71 VII. Principles for nutrition-sensitive agriculture projects ....................................................................................72 VIII. The World Bank’s agriculture program .........................................................................................................73 IX. Challenges for nutrition-sensitive agriculture at The World Bank .....................................................................74 X. Addressing Nutrition through agriculture Projects at The World Bank ...............................................................76 Current status: Mainly through unintentional effects ..................................................................................76 Taking it further: Addressing nutrition explicitl ..........................................................................................78 Key Questions to consider in designing nutrition-sensitive agriculture projects ...........................................88 Measuring nutritional outcomes through agricultural projects ....................................................................89 “Do no harm” considerations....................................................................................................................91 TABlE Of CONTENTS | Improving Nutrition Through Multisectoral Approaches XI. Summary ...................................................................................................................................................92 Annex C-1. Guidance matrix of agricultural interventions explicitly targeting nutrition .........................................................142 Annex C-2. List of all gender disaggregated indicators included in World Bank agriculture (AES) projects approved in FY10 and FY11........................................................................152 Annex C-3. Food consumption indicators ............................................................................................................................154 Annex C-4. Suggested nutrition resources ..........................................................................................................................158 Annex C-5. Recent reviews and strategies to mainstream nutrition into agriculture ..............................................................160 CHAPTER D. Improving Nutrition through Social Protection .................................................95 I. Background ...................................................................................................................................................96 II. Objectives ....................................................................................................................................................97 III. How can we maximize the impact of income on nutrition? ..............................................................................98 Enhancing the role of income in transfer programs.....................................................................................99 Nature of transfers: Cash versus in-kind transfers .....................................................................................101 Including nutrition counseling or micronutrient supplementation components...........................................102 Enhancing the role of income in other social protection programs: Public works, insurance, and microfinance ...........................................................................................102 IV. How can social protection programs promote the link with other services to increase their nutritional impact? .............................................................................................................104 Conditioning transfers to access to services.............................................................................................106 firm versus soft conditions .....................................................................................................................108 Conditional versus unconditional transfers...............................................................................................110 Conditional “in-kind” transfers: School feeding and school health and nutrition programs..........................110 Promoting access to services: Community-based growth promotion programs ............................................111 V. Is there a role for targeting transfers to the nutritionally vulnerable? ..............................................................113 Targeting by demographic group .............................................................................................................113 Targeting by nutritional status or risk ......................................................................................................114 TABlE Of CONTENTS | Improving Nutrition Through Multisectoral Approaches VI. Concluding remarks .....................................................................................................................................114 VII. Emerging operational research and knowledge gaps ....................................................................................116 Annex D-1. ANNEX Additional Resources .............................................................................................................................162 CHAPTER E. Improving Nutrition through Health ...............................................................119 I. Objectives ..................................................................................................................................................120 II. Rationale ..................................................................................................................................................120 Poor nutrition affects health outcomes ....................................................................................................123 Poor health affects nutrition outcomes ....................................................................................................123 III. What are the key health sector interventions to improve nutrition, and what will they cost? ..........................123 IV. Which nutrition objectives can be achieved through the health sector, and how? ..........................................126 Reduce micronutrient deficiencies among the most vulnerable groups.......................................................126 Reduce the prevalence of anemia in pregnant and lactating women and children 0-24 months ....................127 Promote good feeding and nutritional care practices for the most vulnerable populations...........................129 Treat and prevent illness.........................................................................................................................132 Reduce low birth weight .........................................................................................................................133 Improve reproductive health and family planning .....................................................................................134 Treat moderate and severe acute undernutrition in children ......................................................................135 V. What are the challenges and lessons learned for delivering improved nutrition through the health sector?......136 VI. Conclusion .................................................................................................................................................138 Annex E-1. Guidance matrix: Health sector and nutrition linkages and programming ..........................................................163 Annex E-2. Menu of actions to address undernutrition by delivery mechanism ...................................................................169 Annex E-3. WHO’s health systems strengthening framework and nutrition .........................................................................172 Annex E-4. Contribution to mortality of nutrition interventions ...........................................................................................175 TABlE Of CONTENTS | Improving Nutrition Through Multisectoral Approaches Annex E-5. Links to other key resources ..............................................................................................................................175 Annex E-6. Suggested nutrition resources ..........................................................................................................................177 List of Figures Figure A-1. Higher than expected child stunting and underweight rates in many countries given GDP levels, particularly in South Asia ..........................................................................................27 Figure A-2. The emergence of the Scaling up Nutrition (SUN) movemen ................................................................28 Figure A-3. Determinants of child nutrition and interventions to address them .....................................................30 Figure A-4. Women’s status and reductions in child undernutrition (contributions in reductions 1970-95) ..............31 Figure A-5. Malnutrition, by type .........................................................................................................................37 Figure A-6. Undernutrition and the window of opportunity: A child’s first 1,000 days ............................................39 Figure A-7. Progression of malnutrition in developing countries from 1990-2010 ...................................................41 Figure B-1. Trends in poverty, hunger and malnutrition.........................................................................................46 Figure B-2. Malnutrition prevalence over time (stunting=height-for-age)..............................................................48 Figure B-3. Cross-country correlation between poverty rates and measures of malnutrition...................................49 Figure B-4. Episodes of changes in poverty and malnutrition ...............................................................................50 Figure B-5. Estimates for the change in stunting incidence in 2015 ......................................................................52 Figure B-6. Trends in chronic malnutrition (stunting), by wealth quintiles ............................................................53 Figure B-7. Dietary diversity is low in South Asia ..................................................................................................54 Figure B-8. Other proximate factors related to child malnutrition..........................................................................55 Figure C-1. Cross-country link between agricultural GDP and child underweight ...................................................66 Figure C-2. Ethiopia: Prevalence of stunting among children under 5 (by income quintile) ....................................68 Figure C-3. Five focal areas of AES projects ...........................................................................................................73 Figure C-4. Disbursement focus of agriculture and related sectors ........................................................................74 Figure C-5. Pipeline of biofortification crops for release in Africa and Asia ............................................................83 Figure C-6. Measuring nutrition-sensitive agricultural projects ............................................................................89 Figure D-1. Potential pathways of social protection programs to impact nutrition .................................................97 Figure D-2. Elements of social protection programs relevant for nutrition outcomes .............................................98 TABlE Of CONTENTS | Improving Nutrition Through Multisectoral Approaches Figure D-3. Income transfers in select countries as a percentage of per capita spending ......................................100 Figure E-1. Health sector-specific framework for child nutrition ...........................................................................121 Figure E2. The malnutrition-infection cycle ........................................................................................................122 List of Tables Figure A-1. Nutrition and poverty: Prevalence of child stunting by income quintile indicates that malnutrition rates are high even among those who are not poor.....................................................28 Figure B-1. Statistical relationship between malnutrition and income....................................................................51 Figure C-1. Determinants of child nutrition and interventions to address them ......................................................64 Figure C-2. Determinants of child nutrition and interventions to address them......................................................92 Figure E-1. Determinants of child nutrition and interventions to address them.....................................................129 List of Boxes Figure A-1. The SUN framework: Three key elements ............................................................................................29 Figure A-2. The South Asia Regional Assistance Strategy for nutrition, 2010-2015 ................................................36 Figure A-3. What activities are included under Code 68? ......................................................................................43 Figure C-1. Selected gender disaggregated indicators in AES projects (approved in FY10 and FY11) ........................79 Figure C-2. Commonly used food consumption indicators .....................................................................................91 Figure D-1. Assessing the relative impacts of cash and food transfers on nutrition in Nepal .................................102 Figure D-2. Djibouti social safety net project that combines workfare with a nutrition intervention ......................103 Figure D-3. Variations on the theme: Nutrition co-responsibilities in CCTs in Latin America ..................................105 Figure D-4. Strengthening the nutrition impact of the Peru CCT program ............................................................109 Figure D-5. Targeting the needs of acutely malnourished children ......................................................................114 Figure D-6. What should be monitored in SP programs to keep nutrition as a focus? ............................................115 Figure D-7. Priority objectives of nutrition-sensitive social protection .................................................................116 Figure E-1. Success in reducing maternal anemia in Nepal ..................................................................................124 Figure E-2. Growth monitoring and promotion: A useful delivery platform ...........................................................131 Figure E-3. Increasing exclusive breastfeeding rates in Sri Lanka ........................................................................131 Figure E-4. Tools that can guide prioritization of nutrition investments ...............................................................139 ACRONYMS | Improving Nutrition Through Multisectoral Approaches GAP Gender Action Plan Acronyms GDP Gross Domestic Product AAA Analytical and Advisory Work GHI Global Health Initiative AES Agriculture and Environmental Services GFRP Global food Price Response Program AFASS Acceptable, feasible, Affordable, Safe, Sustainable GNP Gross National Product AIN-C Atención Integral a la Niñez con Base GMP Growth Monitoring and Promotion Comunitaria (Community-Based Growth HACCP Hazard Analysis and Critical Control Points Promotion Programs in latin America) HHS Household Hunger Scale ANC Ante-Natal Care HIV/AIDS Human Immunodeficiency Virus/Acquired ARD Agriculture and Rural Development Immune Deficiency Syndrome ARV Anti-Retroviral HKI Helen Keller International BMGF The Bill & Melinda Gates foundation HLTF High-level Task force BMJ British Medical Journal HMIS Health Management Information System CAADP Comprehensive Africa Agriculture HNP Health, Nutrition, and Population Development Programme ICT Information and Communication Technology CAS Country Assistance Strategy IDD Iodine Deficiency Disorder CCT Conditional Cash Transfer IEG Independent Evaluation Group CDD Community Driven Development IFA Iron-folic Acid CIP Country Investment Plan IFPRI International food Policy Research Institute CGIAR Consultative Group for International IIP Iron Intensification Project (Nepal) Agricultural Research IMCI Integrated Management of Childhood Illness CGAP Consultative Group to Assist the Poor IPT Intermittent Preventive Treatment CMAM Community Management of Acute Malnutrition ITN Insecticide-Treated Nets CSFP Civil Society fund Program IUGR Intrauterine Growth Restriction CSO Civil Society Organization IYCF Infant and Young Child feeding DALY Disability-Adjusted life Years IYCN Infant and Young Child Nutrition DDS Dietary Diversity Score LIC lower Income Country DfID Department for International Development MAHP Months of Adequate Household food Provisioning DPL Development Policy loan MDG Millennium Development Goals EG Enterprise Groups M&E Monitoring and Evaluation FANTA food And Nutrition Technical Assistance MNP Micronutrient Powders FCS food Consumption Score MPI Multi-dimensional Poverty Index FY fiscal Year MSG Monosodium Glutamate GAFSP Global Agriculture and food Security Program MUAC Middle-Upper Arm Circumference ACRONYMS | Improving Nutrition Through Multisectoral Approaches OFSP Orange-fleshed Sweet Potato TAHEA Tanzania Home Economics Association ORS Oral Rehydration Salts TB Tuberculosis PAD Project Appraisal Document TTL Task Team leader PAL Programa de Apoyo Alimentario UCT Unconditional Cash Transfer (Mexico in-kind transfer program) PER Public Expenditure Review PDO Project Development Objective PNC Post-Natal Care PRAF Programa de Asignación familiar (Honduras conditional cash transfer program) PRN Programme de Renforcement de la Nutrition (Senegal Nutrition Reinforcement Programme) PSNP Productive Safety Net Programme (Ethiopia) RAS Regional Assistance Strategy RDA Recommended Dietary Allowance RESEPAG Relaunching Agriculture: Strengthening Agriculture Public Services Project (Haiti) RH Reproductive Health RMT Regional Management Team RSR Rapid Social Response RUCF Ready-to-Use Complementary foods RUSF Ready-to-Use Supplementary foods RUTF Ready-to-Use Therapeutic foods SAFANSI South Asia food and Nutrition Security Initiative SAM Severe Acute Malnutrition SAR South Asia Region SD Standard Deviations SDN Sustainable Development Network SME Small and Medium Enterprises SP Social Protection SSA Sub Saharan Africa SSN Social Safety Net STI Sexually Transmitted Infection SUN Scaling Up Nutrition GlOSSARY Of KEY TERMS | Improving Nutrition Through Multisectoral Approaches Glossary of Key Terms Active Labor Market Program (ALMP): Social protection programs that have economic and social objectives of in- creasing the probability of the unemployed finding jobs, productivity and earnings, and improving social inclusion and participation associated with productive employment. These programs are considered “active” as they include activities to stimulate employment and productivity, rather than “passively” providing insurance schemes and/or transfers. Acute malnutrition (wasting): low weight-for-height defined as more than 2 standard deviations (SD) below the mean of the sex-specific reference data. Wasting is usually the result of a recent shock such as lack of calories and nutrients and/or illness, and is strongly linked to mortality. Adequate Intake (AI): Recommendations for nutrient intake when insufficient information is available to establish a recommended dietary allowance (RDA). AIs are based on observed or experimentally determined estimates of the av- erage nutrient intake that appears to maintain a defined nutritional state in a specific population. Adequately iodized salt: Salt containing 15-40 parts per million of iodine. At the population level, household access to iodized salt should be greater than 90 percent, constituting universal salt iodization. Agricultural GDP: The returns to land, labor, and capital used in agriculture. Agricultural gross domestic product (GDP) constitutes a good indicator of farm income trends, assuming farmers own most of the land and capital and supply most of the labor used in the sector. Agricultural GDP of the agricultural population (or Agricultural GDP/worker): The ratio of total GDP for the agriculture sector divided by the estimated number of economically active workers claiming agriculture as their main source of income (the agricultural population). Agricultural population: The agricultural population comprises all persons depending for their livelihood on agricul- ture, hunting, fishing, or forestry, and includes all persons actively engaged in agriculture and their non-working de- pendents. Anemia: The condition of having a hemoglobin concentration below a specified cut-off point, which can change ac- cording to age, gender, physiological status, smoking habits, and altitude at which the population being assessed lives. The World Health Organization (WHO) defines anemia in children under five years of age and pregnant women as a hemoglobin concentration <110g/l at sea level. Although the primary cause of anemia worldwide is iron defi- ciency, it often coexists with a number of other anemia causes, including malaria and other parasitic infections; acute and chronic infections that result in inflammation and hemorrhages; deficiencies in other vitamins and miner- als, especially folate, vitamin B12 and vitamin A; and genetically inherited traits, such as thalassemia. Bioavailability: The degree to which the amount of ingested nutrient is absorbed and is available for use in the body. Biofortification: The development of micronutrient-dense staple crop varieties using traditional breeding practices or biotechnology. Body Mass Index (BMI): A measure of body fatness, calculated as weight (kg) divided by the square of height (m2). A BMI of <18.5 is considered underweight, ≥25 signifies overweight, and ≥30 signifies obesity. Although BMI is a good measure for determining a range of acceptable weights, it does not take into consideration some important factors, such as body build, i.e., relative contributions of fat, muscle, and bone to weight. GlOSSARY Of KEY TERMS | Improving Nutrition Through Multisectoral Approaches Breastmilk substitute: Any food marketed or otherwise represented as a partial or total replacement for breastmilk, whether or not suitable for that purpose. Childhood obesity: Weight-for-height that is >2 SD (see Overnutrition). Childhood obesity is associated with a higher probability of obesity in adulthood, which can lead to a variety of disabilities and diseases, such as diabetes and car- diovascular diseases. Chronic malnutrition (stunting): low height-for-age, defined as more than 2 SD below the mean of the sex-specific reference data. Stunting is the cumulative effect of long-term deficits in food intake, poor caring practices, and ill- ness. Colostrum: The first fluid secreted by the breast during late pregnancy and the first few days after birth. This thick fluid is rich in immune factors and protein. Community-Based Management of Acute Malnutrition (CMAM): The management of acute malnutrition through (a) inpatient care for children with severe acute malnutrition with medical complications and infants under six-months of age with visible signs of severe acute malnutrition; (b) outpatient care for children with severe acute malnutrition; and (c) community outreach. Community nutrition program: A community-based program intended to prevent growth faltering, control morbidity, and improve survival of children by promoting breastfeeding, providing education and counseling on optimal feeding practices, preventing diarrheal disease, and monitoring and promoting growth. Complementary feeding practices: A set of 10 practices recommended for caregivers to implement from 6 to 24 months, at which point breastmilk and/or breastmilk substitutes alone are no longer sufficient to meet the nutri- tional needs of growing infants. Poor breastfeeding and complementary feeding practices, coupled with high rates of infectious disease, are the principal proximate causes of malnutrition during the first two years of life. Complementary food: Any food, whether manufactured or locally prepared, suitable as a complement to breastmilk or to infant formula, when either becomes insufficient to satisfy the nutritional requirements of the infant (at about 6 months of age). Conditional Cash Transfer (CCT): A social safety net program aimed at reducing both present and future poverty by linking a targeted transfer of cash to compliance with a pre-specified investment, usually in child education or health. Cretinism: The stunting of body growth and poor mental development in the offspring that results from inadequate maternal intake of iodine during pregnancy. Demographic targeting: A targeting method in which eligibility is based on age. Diarrhea: The passage of three or more loose or liquid stools per day or more frequently than is normal for the indi- vidual. Diarrhea is usually a symptom of gastrointestinal infection, which can be caused by a variety of viral and para- sitic organisms. Severe diarrhea leads to fluid loss and plays a particularly important role in nutrition and growth faltering, perhaps because of its association with malabsorption of nutrients and appetite suppression. The adjusted odds of stunting at 24 months of age increases by 5 percent with each episode of diarrhea in the first 24 months of life. GlOSSARY Of KEY TERMS | Improving Nutrition Through Multisectoral Approaches Dietary Diversity: The number of food groups consumed over a given period of time. Household-level dietary diversity can be used as an indicator of household food security, and individual-level dietary diversity is an indicator of diet quality for an individual (typically measured for women or young children). Early initiation of breastfeeding: Initiation of breastfeeding within one hour of birth. As a public health statistic, it is measured as the proportion of children born in the past 24 months who were put to the breast within one hour of birth. Exclusive Breastfeeding (EBF): The feeding of an infant only with breastmilk from his/her mother or a wet nurse, or expressed breastmilk, and no other liquids or solids except vitamins, mineral supplements, or medicines in drop or syrup form. Food-based transfer/food-based safety net program: A food-based safety net program intended to support food con- sumption. It differs from other safety net programs in that it is tied to food either directly or through cash-like instru- ments (food stamps, coupons) that may be used to purchase food. Food fortification: The addition of one or more micronutrients (vitamins and minerals) to a food during processing. Ideally, food fortification provides a public health benefit with minimal risks to health in the population. Food-For-Work Programs (FFW): This type of program provides food rations in exchange for a given amount of work done or a stipulated wage rate. ffW programs have long been used to protect households against the decline in pur- chasing power that often accompanies seasonal unemployment, climate-induced famine, or other periodic disrup- tions by providing them with employment. Food security: According to the UN, food security exists when all people, at all times, have physical and economic ac- cess to sufficient, safe and nutritional food to meet their dietary needs and food preferences for an active and healthy life. The concept of food security includes the pillars of food availability, access, utilization, and stability/vulnerabil- ity. Food stamp, voucher, or coupon program: A type of safety net program that uses food-related mechanisms to deliver an income transfer to a target population. The specific instruments used to buy food (stamps, voucher, coupon) may restrict beneficiaries to buying only a few specific foods or allow them to purchase any food in the market. Fortified Blended Foods (FBF): Blends of partially precooked and milled cereals, soya, beans, or pulses, fortified with micronutrients. Special formulations may contain vegetable oil or milk powder. Corn Soya Blend (CSB) and Wheat Soya Blend (WSB) are often used in emergency food distributions. Global acute malnutrition is weight-for-height of -2 z-scores or more below the median, according to the WHO’s child growth standards (moderate and severe wasting). Global Hunger Index (GHI): An index that ranks 84 developing and transitional countries using the following three equally weighted indicators to describe the state of countries’ hunger situation: (i) the proportion of people who are undernourished; (ii) the prevalence of underweight children under the age of five; and (iii) the under-five mortality rate. By using these three indicators, the GHI captures various aspects of hunger and undernutrition, and takes into account the special vulnerability of children to nutritional deprivation (IfPRI). GlOSSARY Of KEY TERMS | Improving Nutrition Through Multisectoral Approaches Hidden hunger: Micronutrient malnutrition or vitamin and mineral deficiencies, which can compromise growth, im- mune function, cognitive development, and reproductive and work capacity. HIV/AIDS: Human immunodeficiency virus (HIV) is a retrovirus that affects cells of the immune system, destroying or impairing their function. As the disease progresses, the immune system becomes weaker, and the person becomes more susceptible to infection. The most advanced stage of HIV infection is acquired immunodeficiency syndrome (AIDS). Home garden / homestead food production: A small plot or plots around the home, managed by household mem- bers, where a variety of crops including vegetables, fruits, legumes, tubers, non-food plants, e.g., medicinal herbs, spices, fuel material are grown throughout the year and often livestock and fish are raised, primarily for household consumption. They typically use low-cost inputs and indigenous varieties, as well as local knowledge and practices and community participation. Home gardens have multiple uses, including improving diets within the household, provide inputs for other farm activities, e.g., fodder for animals, provide shade or natural fencing, raise income from the sale of garden produce, and empower women, who most typically manage home gardens. Nutritional impact of home gardening is increased when combined with nutrition education and linked with other health and development activities in the community. Human Development Index (HDI): A summary composite measure of a country’s average achievements in three basic aspects of human development: (i) health, as measured by life expectancy at birth; (ii) knowledge, as measured by the adult literacy rate and the combined primary, secondary, and tertiary gross enrollment ratio; and (iii) a decent standard of living, as measured by GDP per capita in purchasing power parity in terms of US$. Hunger: A feeling of discomfort, illness, weakness, or pain due to prolonged involuntary lack of food that goes be- yond the usual uneasy sensation of temporary absence of food in the stomach (Panel to Review the USDA’s Measure- ment of food Insecurity and Hunger, 2006). The sensation of hunger that results from a lack of food in the stomach is universal, but there are different manifestations and consequences of hunger, including undernourishment, malnu- trition, and wasting. Infant and Young Child Feeding (IYCF): Refers to specific recommendations and guiding principles for optimal nutri- tion, health, and development of children. A set of eight population-level IYCf indicators have been developed to: (i) assess IYCf trends over time; (ii) improve targeting of interventions; and (iii) monitor progress in achieving goals and evaluate the impact of interventions (WHO, 2008). Infant and Young Child Nutrition (IYCN): A term that encompasses all aspects that relate to the nutrition of infants and young children (0 to 24 months). In-kind transfers: The transfer of ownership of a good or asset other than cash, or the provision of a service without any counterpart. International Code on Marketing of Breastmilk Substitutes: A set of recommendations to regulate the marketing of breastmilk substitutes, feeding bottles, and teats. This code aims to contribute “to the provision of safe and ade- quate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution” (Article 1). GlOSSARY Of KEY TERMS | Improving Nutrition Through Multisectoral Approaches Intrauterine Growth Retardation (IUGR): The poor growth of a baby while in the womb, which results in birth weight below a given percentile cut-off (typically the 10th percentile) for gestational age. Iodine: An essential component of at least two thyroid hormones that are necessary for skeletal growth and neuro- logical development. Iodine deficiency: The condition resulting when iodine intake falls below recommended levels, tested through me- dian urinary iodine concentration (normal range 100-199 +a/l). Iodine Deficiency Disorders (IDD): All of the consequences of iodine deficiency in a population that can be prevented by ensuring that the population has an adequate intake of iodine. IDD can affect children at any stage of rapid growth, with the greatest negative impacts on cognitive development occurring during pregnancy. Symptoms range from mild impairment of brain development and subtle degrees of brain damage, goiter, hypothyroidism, reproduc- tive disorders (spontaneous abortion, stillbirth, congenital abnormalities, perinatal mortality) to its most severe form, cretinism. Iodine deficiency is the primary cause of preventable mental retardation and brain damage in the world. Iron: A key building block of hemoglobin, which plays a central role in oxygen transport throughout the body. Iron deficiency: The most common nutritional deficiency in the world, resulting from insufficient iron in the body due to inadequate consumption of bioavailable iron, blood loss, or unmet increased iron requirements due to infection, pregnancy, rapid growth, dietary habits, or any combination of these. Iron Deficiency Anemia (IDA): The condition in which the body does not have enough healthy red blood cells due to a deficiency in iron. Iron deficiency (above) and iron deficiency anemia are associated with fetal and child growth fail- ure, compromised cognitive development in young children, lowered physical activity and labor productivity in adults, and increased maternal morbidity and mortality. Women and young children are the most vulnerable to IDA, which increases the risk of hemorrhage and sepsis during childbirth, and is implicated in 20 percent of maternal deaths. furthermore, children with IDA suffer from infections, weakened immunity, learning disabilities, impaired physical development, and in severe cases, death. Large for Gestational Age (LGA): Birth weight above a given high percentile cut-off (typically the 90th percentile) for gestational age. Lipid-Based Nutrient Supplements (LNS): Refers generically to a range of fortified, lipid-based products (including RUTf, and other highly concentrated supplements used for “point-of-use” fortification) used for the prevention and treatment of acute malnutrition. lNS typically contain milk powder, high-quality vegetable oil, peanut paste, sugar, and micronutrients, and provide 120 to 250 kcal/day. Low Birth Weight (LBW): A birth weight of less than 2,500g. At the population level, the proportion of infants with a low birth weight often serves as an indicator of a multifaceted public health problem that includes long-term mater- nal malnutrition, ill health, hard work, and poor health care in pregnancy. Malaria: A disease caused by the Plasmodium parasite that is transmitted via the bites of infected Anopheles mos- quitoes; symptoms include fever, headache, vomiting, and anemia, and the disease can be fatal. Malnutrition: Poor nutritional status caused by nutritional deficiency or excess (undernutrition or overnutrition). GlOSSARY Of KEY TERMS | Improving Nutrition Through Multisectoral Approaches Measles: A highly contagious viral disease that mostly affects children and can be prevented through routine immu- nization. Measles infection substantially increases vitamin A utilization and therefore causes vitamin A deficiency in children whose body stores are marginal prior to infection. Mid-Upper Arm Circumference (MUAC): The circumference of the upper arm measured at the mid-point between the tip of the acromial process (shoulder) and the tip of the olecranon process (elbow). Micronutrient(s): Vitamins and minerals that are needed in small amounts by the body to produce enzymes, hor- mones, and other substances essential for proper growth and development. Iodine, vitamin A, iron, and zinc are the most important in terms of prevalence and severity; deficiencies are a major threat to the health and development of populations worldwide, particularly children and pregnant women in low-income countries. Micronutrient deficiency(ies): Deficiencies in one or more essential vitamin or mineral, often caused by disease and/or lack of access and/or consumption of micronutrient-rich foods such as fruit, vegetables, animal products, and fortified foods. Micronutrient deficiencies increase the severity and risk of dying from infectious disease such as diar- rhea, measles, malaria, and pneumonia. More than two billion people in the world are estimated to be deficient in io- dine, vitamin A, iron, or zinc. Microfinance: The provision of small-scale financial services to people who lack access to traditional banking serv- ices; usually implying very small loans to low-income clients for self-employment or entrepreneurial activity, often with the simultaneous collection of small amounts of savings. Simple application processes, provision of services in underserved communities, targeting poor and female clients, and group lending are traditional features of microfi- nance (Karlan, D. and N. Goldberg. 2007. Impact Evaluation for Microfinance. Washington, DC: The World Bank.). Multiple micronutrient powder: A tasteless powder that comes in the form of individual sachets, containing the rec- ommended daily intake of 16 vitamins and minerals for one person. They can be sprinkled into home-prepared food after cooking or just before eating. Moderate malnutrition: Weight-for-age between -2 and -3 z-scores below the mean of sex-specific reference data (moderate underweight). Moderate Acute Malnutrition (MAM): Weight-for-height between -2 and -3 standard deviations below the mean of sex-specific reference data (moderate wasting). Non-Agricultural GDP/worker: The difference between the total national and agricultural GDP divided by the differ- ence between total national and agricultural employment. Nutrition security: The ongoing access to the basic elements of good nutrition, i.e., a balanced diet, safe environ- ment, clean water, and adequate health care (preventive and curative) for all people, and the knowledge needed to care for and ensure a healthy and active life for all household members. Obesity: A condition characterized by excess body fat, defined as a BMI of 30 or more. Oral Rehydration Solution/Salts (ORS): A liquid electrolyte solution that is used for the management of diarrhea among children. ORS is typically distributed in ready-to-use sachets that are added to one liter of clean water. GlOSSARY Of KEY TERMS | Improving Nutrition Through Multisectoral Approaches Overnutrition: A state in which nutritional intake greatly exceeds nutritional need. Overnutrition manifests itself as overweight (BMI≥25) and obesity (BMI≥30). In children, overnutrition is defined as weight-for-height >2 SD (>2 SD is overweight and >3 SD is obese). Overweight: A condition characterized by excess body fat, defined as a BMI between 25 and 30 kg/m2. Pension: Non-contributory cash income given to older persons (usually by the government and/or other social pro- grams). Pneumonia: A serious bacterial lung infection that is transmitted by direct contact with infected people and is the leading cause of death in children worldwide. Malnutrition is considered a key risk factor for pneumonia; maintaining good nutritional status is thus important to prevent infection. Protein-Energy Malnutrition (PEM): A condition resulting from insufficient consumption of energy and protein, result- ing in wasting. Public works: Social protection programs where income support for the poor is given in the form of wages (in either cash or food) in exchange for work effort. These programs typically provide short-term employment at low wages for unskilled and semiskilled workers on labor-intensive projects such as road construction and maintenance, irrigation infrastructure, reforestation, and soil conservation. They are generally seen as a means of providing income support to the poor in critical times rather than as a way of getting the unemployed back into the labor market. Ready-to-use Supplementary Food (RUSF): A high-energy nutrition supplement that is particularly suited as a nutri- tional support in emergency situations or in the context of nutritional programs for the prevention or treatment of moderate malnutrition and deficiency-related illnesses. Ready-to-use Therapeutic Food (RUTF): A high energy and protein ready-to-eat food with added electrolytes, vitamins and minerals, specifically designed to treat SAM in the rehabilitation phase. RUTf is typically oil- and/or peanut- based; it does not have to be mixed with water so is microbiologically safe and enables outpatient treatment. Replacement food: Replacement foods are food products given to an infant whose mother is HIV/AIDS positive, to re- place breastmilk. Replacement foods are recommended over exclusive breastfeeding only when they are acceptable, feasible, affordable, sustainable, and safe (AfASS). Respiratory tract infections: Infections that affect the air passages, including the nasal passages, and the bronchi and lungs. Acute Respiratory Tract Infections (ARI), including pneumonia, have been implicated in nutrition through growth faltering, likely due to the contributing factors that define the disease and include anorexia, fever, pain, vom- iting, and associated diarrhea. School feeding programs: A form of supplementary feeding that encourages children’s school enrollment and im- proves their ability to pay attention in class. These programs vary and may include the provision of breakfast, lunch, a midmorning snack, or a combination of these. Sometimes, school feeding programs are integrated with health and nutrition education, parasite treatment, health screening, and provision of water and sanitation. Severe Acute Malnutrition (SAM): Weight-for-height more than 3 standard deviations below the mean of sex-specific reference data (severe wasting). GlOSSARY Of KEY TERMS | Improving Nutrition Through Multisectoral Approaches Small for Gestation Age (SGA): Birth weight below a given low percentile cut-off (typically the 10th percentile) for ges- tational age. SGA and IUGR are not synonymous; some SGA infants (e.g., those born to short mothers) may represent merely the lower extreme of the “normal” fetal growth distribution, while other normal weight infants may actually have been exposed to one or more growth-inhibiting factors. In individual cases, it is usually difficult to ascertain whether the observed birth weight is the result of restricted in utero growth. Therefore, classifying an infant as IUGR is based de facto on the established cut-off for SGA. Smallholder farmer: Marginal and sub-marginal farm households that own and/or cultivate typically less than two hectares of land. Smallholder farmer households constitute a large proportion of the population in the developing world and of households living in poverty and hunger. Social protection: The set of public interventions aimed at supporting the poorer and more vulnerable members of society, as well as helping individuals, families, and communities manage risk. Social protection includes safety nets (social assistance), social insurance, labor market policies, social funds, and social services. Social Safety Net (SSN): Noncontributory transfer programs targeted in some manner to the poor and those vulnera- ble to poverty and shocks—analogous to the U.S. term “welfare” and the European term “social assistance.” Stunting (chronic malnutrition): low height-for-age, defined as more than 2 SD below the mean of the sex-specific reference data. Stunting is the cumulative effect of long-term deficits in food intake, poor caring practices, and/or ill- ness. Supplementary feeding programs: A direct transfer of food to target households or individuals, most commonly ma- ternal and child feeding and school feeding. The food may be prepared and eaten on- site or given as a dry ration to take home. Supplementary feeding is often provided as an incentive for participation in public services such as pri- mary health care and education. Unconditional Cash Transfer (UCT): A social safety net program aimed at reducing both present and future poverty through a transfer of cash to vulnerable and specifically targeted populations. Undernourished: A person whose usual food consumption, expressed in terms of dietary energy (kcal), is below the energy requirement norm. The prevalence of undernourishment in a specified population is sometimes used as a measure of food deprivation. This term is not to be confused with undernutrition. Undernutrition: Poor nutritional status due to nutritional deficiencies. The main three indicators of undernutrition are stunting, wasting, and underweight. Underweight: low weight-for-age defined as more than 2 SD below the mean of the sex-specific reference data. Vitamin A: An essential micronutrient that plays an essential role in vision and immune response. Vitamin A Deficiency (VAD): The condition resulting when vitamin A intake falls below recommended levels. Vitamin A deficiency may be exacerbated by high rates of infection, and greatly increases the risk that a child may die from dis- eases such as measles, diarrhea, and acute respiratory infections, and is the leading cause of childhood blindness. Vitamin A deficiency compromises the immune systems of approximately 40 percent of the developing world’s chil- dren under five and leads to the deaths of as many as one million young children each year. GlOSSARY Of KEY TERMS | Improving Nutrition Through Multisectoral Approaches Wasting (acute malnutrition): low weight-for-height defined as more than 2 SD below the mean of the sex-specific reference data. Wasting is the result of a recent shock such as lack of calories and nutrients and/or illness, and is linked strongly to mortality. Weather-index insurance: A product designed to provide compensation to farmers when specific weather events are insufficient (rainfall) or destructive (cyclones, floods) for farmers to grow and optimize their yields. Weather index in- surance does not measure changes in yields; rather it measures changes in weather, assuming that if the weather is poor, the farmers’ yields will be too. Window of opportunity: The period between conception and age two when irreversible damage caused by malnutri- tion can and should be prevented. Zinc: An essential micronutrient that plays a critical role in the structure of cell membranes and in the function of im- mune cells. Zinc deficiency: The condition resulting when zinc intake falls below recommended levels. Zinc deficiency is associ- ated with growth retardation, malabsorption syndromes, fetal loss, neonatal death, and congenital abnormalities. Zinc supplementation reduces the duration and intensity of diarrheal illness and reduces clinical disease caused by acute respiratory infections and malaria. ACKNOWlEDGEMENTS | Improving Nutrition Through Multisectoral Approaches Acknowledgements This document was produced by a team led by Meera Shekar (AfTHW) and leslie Elder (HDNHE). Authors include Harold Alderman (HDNSP), leslie Elder (HDNHE), Aparajita Goyal (AES), Anna Herforth (HDNHE), Yurie Tanimichi Hoberg (AES), Alessandra Marini (lCSHS), Julie Ruel-Bergeron (HDNHE), Jaime Saavedra (PRMPR), Meera Shekar (AfTHW), Sailesh Tiwari (PRMPR), and Hassan Zaman (PRMPR). first round peer reviewers were liz Drake (DfID), Ariel fiszbein (HDNCE), Margaret Grosh (lCSHD), and Julie Mclaugh- lin (SASHN). In the second round, peer reviewers were Bénédicte de la Brière (HDNCE), Margaret Grosh, (lCSHD), Steven Jaffee (EASVS), Claudia Rokx (ECSH1), Shelly Sundberg (The Bill & Melinda Gates foundation), and Anna Taylor (DfID). This document benefitted greatly from consultations with the following Task Team leaders (TTls) and development partner colleagues: Erick Abiassi (AfTAR), Diego Arias Carballo (lCSAR), Katie Bigmore (AfTHE), luc laviolette (SASHN), Gayle Martin (AfTHD), Rasit Pertev (AfTAR), Animesh Shrivastava (SASDA), Joana Silva (MNSSP), Eileen Sullivan (EASHH), Shelly Sundberg (The Bill & Melinda Gates foundation), Ajay Tandon (EASHH), Anna Taylor (DfID), laketch Imru (AfTAR), Oluwole Odutolu (AfTHE), and Boubou Cisse (AfTED). The team gratefully acknowledges inputs and support received by both peer reviewers and participants of the TTl and partner consultations, as well as the funding support for this study from DfID, the Japan Trust fund for Scaling Up Nutrition, and the Rapid Social Response Trust fund. ExECUTIVE SUMMARY | Improving Nutrition Through Multisectoral Approaches Executive Summary This report responds to the The guidance notes are designed to contextual examples, the note is global development community’s assist World Bank staff, donor part- meant as generic guidance. These request for operational guidance ners, and country-level implementers recommendations will need to be to maximize the impact of invest- with adjusting the design of existing adapted to each country and opera- ments on nutrition outcomes for or future operations in their respec- tional context. women and young children. The tive sector to be more nutrition- importance of nutrition guidance has sensitive. When relevant, some of the Rationale and Strategic Context been expressed by the World Bank’s notes are accompanied by a succinct, (Module A). Recent assessments of regional teams, especially South Asia operational matrix that highlights the the Millennium Development Goals and Africa, the World Bank’s Advisory objectives, tracking indicators, op- (MDGs) show slower progress than Council of foundation leaders meet- portunities, trade-offs, and issues of expected. The global development ings, as well as the wider Scaling Up policy coherence. Where nutritional community recently has recognized Nutrition (SUN) donor partners evidence is weak, it is noted. Where it that one reason for slow gains in the group. This report is a first step to- is strong, the notes provide program- MDGs is the lack of investment in nu- wards operationalizing a multisec- matic guidance that will help these trition, the virtually “forgotten MDG.” toral approach to improve nutrition sectors to adopt a “nutrition lens” as Research confirms that investing in worldwide. they develop new programs and proj- nutrition significantly multiplies posi- ects. Each self-contained note can be tive outcomes in maternal and child The recommendations in this docu- applied to each sector or used to- health, cognitive function and educa- ment build on the extensive nutrition gether as one coherent cross-sectoral bility, human capital, and economic research and evidence to-date on is- approach. The document is divided growth and poverty reduction. How- sues of malnutrition. The authors’ into five modules, some of which in- ever, despite the proven high returns, aim is to mainstream nutrition activi- clude a list of additional resources. 36 countries carry about 90 percent ties into multisectoral action in World of the global burden of undernutri- Bank operations through a series of Module A provides the intellectual tion, and nutrition investments are guidance notes that are focused ini- and theoretical rationale for a multi- inadequate in many of these coun- tially on the three sectors of agricul- sectoral response to malnutrition. tries. To finance the scale up of effec- ture, social protection, and health, This module is targeted at a wider de- tive nutrition solutions globally, an including an overview of the link be- velopment policy audience. estimated $10.3 billion per year is re- tween nutrition and poverty reduc- quired, but current donor invest- tion. “Malnutrition” refers only to Modules B through E are targeted ments fall far below this amount.1 In undernutrition and micronutrient de- specifically at World Bank and other many developing economies, nutri- ficiencies in this document, and not agencies’ staff and country clients tion improvement is further ham- overnutrition. The overweight/obe- that design and support projects and pered by an emerging problem of sity aspects of malnutrition are not programs in poverty reduction, agri- overweight and obesity in addition to addressed. culture, and rural development, so- pre-existing undernutrition, which cial protection, and health. While leads to the “double burden” of un- every effort has been made to make dernutrition coexisting with over- the information as specific as possi- weight and obesity. ble, and to give concrete country and 1 BMGf. 2011. ExECUTIVE SUMMARY | Improving Nutrition Through Multisectoral Approaches Poverty, Economic Growth, and gether so that investments in one will Priority objectives to Nutrition (Module B). Global poverty have positive impacts on the other. enhance nutrition in has declined significantly in the last While nutrition investments are de- agriculture programs two decades, but this has not been signed to improve human capital and accompanied by commensurate re- to have a positive impact on physical 1. Invest in women: safeguard and ductions in global hunger nor im- well-being and work capacity, includ- strengthen the capacity of provements in nutritional outcomes. ing agricultural productivity, the po- women to provide for the food tential benefits of agriculture security, health, and nutrition of Since hunger and malnutrition are their families. linked intricately to poverty, the di- investments on nutrition have yet to vergence in the trends of these indi- be maximized. This module explains 2. Increase access to year-round cators is puzzling. We investigate why agriculture is important for nutri- availability of high-nutrient con- why nutritional status generally has tion, and vice versa. The available ev- tent food. remained poor despite widespread idence indicates four strong reduction in income poverty, and dis- principles for action in areas where 3. Improve nutrition knowledge cuss policy implications. An emerg- the World Bank’s agricultural pro- among rural households to en- grams can contribute Priority objec- hance dietary diversity. ing clear message is that even though economic development is re- tives. 4. Incorporate explicit nutrition lated significantly to malnutrition, objectives and indicators into economic growth alone often is insuf- Although the World Bank’s agricul- agriculture investments. ficient to improve malnutrition rates. ture projects have, to date, only ad- furthermore, there are considerable dressed nutrition implicitly or inequities in nutritional outcomes unintentionally, there is growing across socioeconomic groups; the awareness inside and outside of the rate of progress in nutritional out- World Bank of the importance of comes varies over time; and in sev- leveraging agriculture to improve nu- eral countries, the gaps between the trition. Of the 21 countries that have rich and poor have widened. for ex- met the goal of halving the propor- ample, South Asia and Africa’s com- tion of the population below the min- parative malnutrition rates are imum level of dietary energy striking. Relative to the “predicted” consumption, only six are on track to levels of malnutrition (stunting and meet the underweight goal.2 This is underweight) given poverty rates, an example of the limits of improving South Asian countries are lagging be- nutrition implicitly through agricul- hind, while many African countries ture. Simply increasing household in- are doing better than their poverty come or raising agricultural levels would predict. productivity is insufficient to improve undernutrition. Improving Nutrition through Agri- culture (Module C). Global momen- This module provides practical guid- tum, including that catalyzed by the ance for maximizing the nutrition im- global Scaling Up Nutrition (SUN) pacts of agriculture investments by movement framework and roadmap, action on the following fronts: (i) in- is bringing the agriculture, food secu- corporate nutrition-sensitive analysis rity, and nutrition agendas closer to- and activities into agriculture project 2 Armenia, Georgia, Ghana, Jamaica, Nicaragua, and Vietnam have met the hunger goal and are on track to meet the underweight goal. ExECUTIVE SUMMARY | Improving Nutrition Through Multisectoral Approaches design and food security policy dia- Improving Nutrition through Health Priority objectives of logue; (ii) measure the progress of (Module E). This guidance note aims nutrition-sensitive social activities affecting nutrition periodi- to assist World Bank and other pro- protection cally through relevant output indica- gram staff in maximizing the nutrition tors; and through outcome indicators impacts of health investments and 1. Target activities to the most such as food consumption indicators policies, with a special focus on un- nutritionally vulnerable popula- at least at baseline/mid-term/project tions such as pregnant women dernutrition among women and chil- and children under 24 months. completion; (iii) ensure that agricul- dren under two years of age in ture projects and policies do not developing economies. The strong 2. Include nutrition education and cause unintended harm to nutrition. synergies between health and nutri- counseling activities within tion are highlighted and key evi- social protection interventions to Improving Nutrition through Social dence-based nutrition interventions increase household awareness Protection (Module D). While most of care giving and health seeking that can be delivered through the behaviors. safety net programs include an in- health sector are presented. Imple- come transfer component—and many menting such interventions is cost- 3. Integrate nutrition services into vulnerable households lack adequate effective and can achieve large SP interventions, e.g. growth income to purchase key inputs to reductions in morbidity, mortality, monitoring and promotion, and/or maintain notable nutrition out- and undernutrition, furthering health activities for improved growth and comes—the evidence shows that in- sector goals. The main nutrition- diet quality. creased income alone is often related objectives that fall within the 4. Reduce the acute and long-term insufficient to have a major impact on health sector are outlined in the box negative financial impacts of nutrition. Thus, other components, below. Evidence-based interventions external financial, price, and such as directing transfers to women, to address each objective, along with weather shocks by scaling up targeting the most vulnerable and implementation considerations, are programs in times of crises and by the correct age group (-9 to 24 presented as options to integrate nu- targeting shock-affected areas. months), and adding a nutrition edu- trition interventions in health invest- cation or a micronutrient supplemen- ments and policies. tation component to social protection Priority objectives to improve programs can play an essential role nutrition through the health in generating impact. Alternative op- sector tions to improve nutrition for the most vulnerable populations are re- 1. Reduce micronutrient deficiencies. viewed to strengthen the design of existing or future interventions in so- 2. Reduce anemia in pregnant and cial protection. We discuss the path- lactating women and children 0-24 ways through which these programs months. can influence nutritional outcomes 3. Promote good feeding and nutri- and the different policy choices that tional care practices. can derive from each of them by ask- ing three broad questions: (i) How 4. Treat and prevent illness. can we maximize the impact of in- come transfers on nutrition? (ii) With 5. Reduce low birth weight. what services might the social pro- tection programs be linked? (iii) Who 6. Improve reproductive health and family planning. should be targeted? 7. Treat moderate and severe under- nutrition in children. C H A P T E R - A Introduction Meera Shekar, Julie Ruel-Bergeron, Anna Herforth CHAPTER - A | Introduction I. Rationale and den of malnutrition,” with undernu- Nutrition-specific trition coexisting with overweight A term that refers to interventions strategic context and obesity. that directly address inadequate di- etary intake or disease—the immedi- Interest in the “forgotten ate causes of malnutrition. MDG” re-emerges The global community now concurs Nutrition-specific interventions are that increasing investment in nu- those identified in The Lancet series Recent assessments of the MDGs trition will accelerate progress on a on maternal and child undernutrition show that progress in nutrition has range of MDGs, especially MDGs 1 (2008), including micronutrient sup- (poverty), 2 (education), and 4 and 5 plementation, deworming, treatment been slower than expected. The (maternal and child health). Nutrition of severe acute malnutrition, and global development community re- breastfeeding promotion, which di- cently recognized that one reason for investments will support poverty re- rectly addresses dietary intake and slow gains in the Millennium Devel- duction efforts, and have the poten- disease for infants. opment Goals (MDGs) is the lack of tial to augment GDP in developing investment in nutrition, the virtually countries by at least 2-3 percent.3 Ac- _____________________________ “forgotten MDG.”1 Research shows celerating progress on the MDGs by that investing in nutrition signifi- 2015 therefore requires urgent invest- cantly multiplies the positive out- ments in nutrition. Translating the Nutrition-sensitive comes for maternal and child health, high level of national and interna- A term that refers to interventions or tional political consensus and com- development efforts that, within the cognitive function and educability, mitment and the available evidence context of sector-specific objectives, human capital, and economic growth also aim to improve the underlying and poverty reduction. However, de- into Nutrition-specific determinants of nutrition (adequate spite the proven high returns, 36 actions—delivered primarily through food access, healthy environments, countries carry about 90 percent of the health sector—and nutrition- adequate health services, and care the global burden of child undernutri- sensitive actions delivered through practices), or aim at least to avoid several other sectors is now the harm to the underlying or immediate tion,2 and nutrition investments are challenge. This report lays the causes, especially among the most inadequate in many of these coun- nutritionally vulnerable populations tries. This is partly due to the inade- groundwork for multisectoral action and individuals. Various actions that quacy of total global investments in by providing the overall rationale for would address the determinants of nutrition, which comprise only a such action and the programmatic malnutrition are possible in many small fraction of the estimated needs guidance on how to incorporate nu- sectors. In health, for example, re- trition actions into the World Bank’s productive health services can im- (about $10.3 billion), and a very small and its partners’ investments in prove birth spacing; in agriculture, proportion of the current spending in the investment and input-delivery sectors such as health or agriculture. poverty reduction, agriculture, social portfolio may be diversified to in- In many developing economies, nu- protection, clude more nutrient-dense foods; in trition improvement is hampered fur- social protection, cash transfers can ther by an emerging burden of have conditionalities for vaccina- tions and growth monitoring; in edu- obesity, leading to the “double bur- cation, efforts to keep girls in school can be strengthened; in water and sanitation, improved water provision can prioritize the most nutritionally vulnerable areas or populations; other actions exist in many other 1 MDG1 includes a target to halve, between 1990 and 2015, the proportion of children sectors. under age 5 who are underweight. 2 Child undernutrition is defined as low weight-for-age (underweight); low height-for-age (stunting or chronic malnutrition); low weight-for-height (wasting or acute malnutrition); and micronutrient deficiencies (minerals and vitamins). 3 SUN framework, http://siteresources.worldbank.org/NUTRITION/Resources/ 281846-1131636806329/PolicyBriefNutrition.pdf, Repositioning Nutrition, http:// siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/ NutritionStrategy.pdf. CHAPTER - A | Introduction Economic growth, poverty, reparable damage to human capital. table economic growth and pro-poor and malnutrition Even though poor children are more agricultural growth policies.4 How- likely to be malnourished, a surpris- ever, while economic growth, poverty Malnutrition rates remain surpris- ingly large percentage of those in the reduction, and agricultural productiv- ingly high in several countries with highest income quintiles—where ity all contribute to better nutrition, robust economic and agricultural food security is not a likely limiting in most countries, gains in economic growth. This paradoxical situation of factor—are also underweight or growth or agricultural productivity economic growth and malnutrition is stunted (Table A-1). In general, nutri- alone have been insufficient to im- starkly evident in India, as well as in tion outcomes have improved more prove child nutrition outcomes.5 many other countries (figure A-1). In quickly in countries with more equi- these countries, many children are born with low birth weights. for the 4 Webb, P. and Block, S. 2011. Support for agriculture during economic transformation: rest of their lives, these children con- Impacts on poverty and undernutrition. Proceedings of the National Academy of Sciences tinue to track at low heights and of the United States of America. www.pnas.org/cgi/doi/10.1073/pnas.0913334108 weights and to suffer from often ir- 5 See Module B on poverty and nutrition for more details and discussion on this issue. FIGuRE A-1. HIGHER THAN ExPECTED CHILD STuNTING AND uNDERwEIGHT PREvALENCE RATES IN MANy COuNTRIES GIvEN GDP LEvELS, PARTICuLARLy IN SOuTH ASIA HEIGHT FOR AGE WEIGHT FOR AGE Burundi Afghanistan Guatemala Nepal Angola India Bangladesh India Pakistan PCT MALNOURISHED WEIGHT FOR AGE Bangladesh Nepal Afghanistan Maldives Tajikistan Pakistan Botswana Maldives Mongolia Gabon Belize Sri Lanka Sri Lanka Namibia Thailand Mexico Suriname Ghana Jordan Moldora Algeria Botswana Saudi Arabia Gabon Brazil Trinidad and Tobago Saudi Arabia Jamaica Jordan Mexico Chile Czech Republic Kyrgyz Republic Czech Republic Belarus Chile K K K K K GDP PE R CAPITA PPP GDP PE R CAPITA PPP Source: World Bank. World Development Indicators as of 09/10/2010. Height-for-age and weight-for-age are for the latest year for which data are available. GDP per capita in constant 2005 PPP Int’l $ is for the year corresponding to the year in which the nutrition data was collected. All observations are between 2000 and 2008. Analysis by John Newman. CHAPTER - A | Introduction TABLE A-1. NuTRITION AND POvERTy: PREvALENCE OF CHILD STuNTING By INCOME quINTILE INDICATES THAT MALNuTRITION RATES ARE HIGH EvEN AMONG THOSE wHO ARE NOT POOR Regions Country Lowest 2nd 3rd 4th Highest South ASiA Bangladesh 59 53 45 43 30 India 61 54 49 39 26 Pakistan 54 47 43 37 26 AfricA Benin 50 48 48 40 29 Burkina Faso 50 47 46 41 26 Ethiopia 52 54 51 49 40 Mozambique 54 53 52 41 26 Rwanda 61 55 52 50 35 Tanzania 50 49 46 43 23 Uganda 43 38 44 37 25 Data Source: Bredenkamp, C., Health Equity and Financial Protection datasheets, World Bank 2012. Scaling up Nutrition (SuN): developing countries have committed lated initiatives in food security and A new global framework and a to scaling up nutrition. leaders of agriculture, health, and vulnerability roadmap for action these countries are prioritizing nutri- protection, such as the Comprehen- tion as an investment in their peo- sive Africa Agriculture Development The Scaling up Nutrition (SuN) ple’s growth, and recognizing Programme (CAADP), UN High level movement was launched in 2010 in nutrition as an investment in eco- Task force (HlTf) for the Global food response to the continuing high nomic and social development to Security Crisis, US Global Health Ini- rates of global malnutrition. A strengthen their nations. These coun- tiative (GHI), US Global Hunger and broad informal global partnership tries expect to see results within the food Security Initiative, the HlTf on was established through a collabora- next five years. The SUN’s success Innovative financing for Health, and tive process of consensus building on also depends on support from re- others. how to scale up nutrition interven- tions (see figure A-2). The fruits of this intensive work program between FIGuRE A-2. THE EMERGENCE OF THE SCALING uP NuTRITION (SuN) MOvEMENT developing countries, academic and research institutions, civil society or- ganizations, the private sector, bilat- PARTNERSHIP eral development agencies, United NuTRITIoN Nations agencies (fAO, UNICEf, WfP, Higher shared SCAlED-uP interests & AS CoRE PART and WHO), and the World Bank re- space for all of wIDER DEvEloPMENT AGENDA sulted in the SUN framework for Ac- tion and the SUN Roadmap. SoCIAl/PolITICAl SuPPoRT wide constituency, shared leadership, wider ownership To date, the Scaling Up Nutrition COMPENTITION How, wHERE, wHAT CoST, wHo framework has been endorsed by Evidence-based strategy for scale-up over 100 partners worldwide and 30 lower TECHNICAl STRATEGIES shared Prolific programs, populations, interventions interests CHAPTER - A | Introduction Translating the high level of national BOx A-1. THE SuN FRAMEwORk: THREE kEy ELEMENTS and international political commit- ment and evidence into Nutrition- 2. Scale up specific and nutrition-sensitive evidence-based cost- 1. Country-level effective interventions 3. A multisectoral actions to reduce malnutrition in the action is key action is key approach highest burden countries is the chal- lenge facing international develop- • Country ownership • For prevention • Accelerating action ment partners. and leadership and treatment on the determinants • Highest priority to the of malnutrition • Tailored to country- specific epidemiology window of opportunity SUN principles and partners from pregnancy to 24 • Tailored to country- months specific context The SuN is based on three key and capacities principles for improving nutrition outcomes: (i) the primacy of country- level action; (ii) the focus on evi- dence-based and cost-effective ac- leone, Tanzania, Uganda, Zambia, dow starts during pregnancy and tions; and (iii) a multisectoral and Zimbabwe. Involvement in the closes at about two years of age. approach (Box A-1). Many of the Nu- SUN movement as an early riser en- These first “1000 days” offer the best trition-specific interventions lie in tails political commitment building opportunity to lock-in future human the health sector. In addition, many within governments, establishing capital. If implemented at scale, in- other sectors have a key role to play multi- stakeholder platforms, pro- terventions during this period can in scaling up the indirect or nutrition- moting goals and targets for reducing potentially reduce undernutrition-re- sensitive interventions through these undernutrition, encouraging coher- lated mortality and morbidity by 25 sectors. for example, there is much ence and support of the movement percent. Many of the proposed inter- to be done to ensure that social through a global coalition of part- ventions are delivered primarily safety nets are designed to protect ners, and mobilizing support for ef- through the health sector and are those most nutritionally vulnerable, fective joint action at scale. summarized in Module E of this docu- i.e., women and young children ment. A similar body of evidence- under the age of two years, or that based recommendations does not agriculture investments do no harm Evidence for action exist for multisectoral actions to max- to these vulnerable groups. imize nutrition improvement across The evidence for action through the other sectors. This document at- health sector (Nutrition-specific in- tempts to fill this gap. It provides terventions) was presented in The The “early riser” countries Lancet Series on Maternal and Child guidance on scaling up interventions under the SUN across several sectors and draws Undernutrition (2008), the Copen- upon the recent reviews of evidence Thirty countries have expressed in- hagen Consensus (2008), and the specified in each respective module. terest in the SuN movement. These World Bank’s 2006 document Reposi- “early risers” include Bangladesh, tioning Nutrition as Central to Devel- Benin, Burkina faso, Burundi, opment. The findings show that there Ethiopia, The Gambia, Ghana, is a very small “window of opportu- Guatemala, Indonesia, Kenya, Kyrgyz nity” to improve nutrition outcomes Republic, lao PDR, Madagascar, and to prevent irreversible losses to Malawi, Mali, Mauritania, Mozam- human capital in countries. This win- bique, Namibia, Nepal, Niger, Nige- ria, Peru, Rwanda, Senegal, Sierra CHAPTER - A | Introduction II. Nutrition is a FIGuRE A-3. DETERMINANTS OF CHILD NuTRITION AND INTERvENTIONS TO ADDRESS THEM multisectoral problem with multisectoral solutions CHILD NUTRITION Determinants of malnutrition • Infant and INTERvENTIoNS NuTRITIoN SPECIfIC fooD/NuTRIENT HEAlTH young child INTAKE nutrition and The determinants of malnutrition treatment of severe are multisectoral. The immediate undernutrition causes are related to food and nutri- • Micronutrient ent intake and to health. The underly- supple- mentation & ing causes are embedded in the fortification household and community level con- • Hygiene Access Maternal & Water & text in which undernutrition occurs. practices to childcare sanitation, food practices health These underlying causes are further services impacted by issues such as agricul- • Agriculture & food security tural practices and climate change, • Health lack of access to and availability of Systems clean water and sanitation, health • Soc. protection/ services, girls’ education and gender safety nets INTERvENTIoNS NuTRITIoN SENSITIvE issues, social protection, and social • Water and INSTITuTIoNS sanitation safety nets. The basic causes of un- • Gender and dernutrition are rooted in institu- development PolITICAl & IDEoloGICAl fRAMEwoRK tional, political, and economic issues • Girls’ such as poverty reduction and eco- education nomic growth, governance and stew- • Climate ECoNoMIC STRuCTuRE change ardship capacities, environmental safeguards, and trade and patents is- • Poverty ENvIRoNMENT TECHNoloGY, PEoPlE sues, including the role of the private reduction & economic sector. Addressing the special condi- growth tions in fragile states and reducing programs conflict, are also key in fragile/con- • Governance, stewardship flict situations. A framework for the capacities & multisectoral causation of malnutri- management tion is shown in figure A-3. • Trade & patents (& role of private sector) • Conflict resolution • Environmental safeguards Source: Adapted from UNICEF 1990 and Ruel 2008. CHAPTER - A | Introduction Evidence shows that direct actions to address the immediate determi- nants of undernutrition can be fur- ther enhanced by action on some of the more distal or underlying de- terminants. for example, in addition to supporting improved infant and young child feeding practices, ad- dressing gender issues through health, agriculture or education pro- grams can have a powerful impact in preventing undernutrition by reduc- ing women’s workloads and allowing them more time for child care. Simi- larly, in addition to providing mi- cronutrient supplements to address vitamin and mineral deficiencies, im- proving food security, and enhancing hygiene and environmental issues have been shown to improve nutri- tion outcomes among children (fig- ure A-4). Multisectoral actions can supplements and deworming. The strengthen nutritional outcomes in gains from these direct interven- FIGuRE A-4. three main ways: (a) by accelerating tions can be further enhanced and wOMEN’S STATuS AND REDuCTIONS IN CHILD action on determinants of undernutri- sustained by improving water sup- uNDERNuTRITION tion; (b) by integrating nutrition con- ply and hygiene, and reducing re- siderations into programs in other infection. Improved hygiene and (contributions in reductions 1970-95) water supply not only helps to sectors which may be substantially larger in scale; and (c) by increasing break the cycle of disease and “policy coherence” through govern- malnutrition, it allows mothers to Women's Status ment-wide attention to policies or spend more time on the care of 12% strategies and trade-offs, which may their children, thereby improving Women's have positive or unintended negative children’s nutrition. The potential Health education Environment consequences on nutrition. impact of even the most effica- 43% cious interventions is very con- 19% a. Accelerating action on determi- text-specific. Therefore, nants of undernutrition. Nutri- interventions need to be selected National food Availability tion problems such as iron for each country and context 26% deficiency anemia require direct based on an assessment of the interventions like iron-folic acid epidemiology of the problem and Source: Smith and Haddad, 2000. CHAPTER - A | Introduction the context.6 for example, gender livelihoods programs, such as by streamed within other sectors. interventions are more likely to introducing biofortified crops into While capacity is clearly a binding have an impact in South Asia agricultural research and technol- constraint, ideally what is required where gender imbalances are ogy dissemination programs.7 So- is both better and timely reporting much greater than in Africa. While cial safety net programs can be of nutritional consequences of dif- anemia interventions are most designed to target women and ferent sectoral policies and pro- likely to have an impact in areas young children, and can include a grams, potentially similar to the and populations with a high stronger focus on nutrition, such Poverty and Social Impact Analy- prevalence of anemia. as using fortified foods (instead of ses (PSIA) used in Bank opera- non-fortified foods) for school tions. feeding programs, or by condition- ing cash-transfers on the use of preventive nutrition and health services. One powerful way to en- key sectors for maximizing courage more emphasis on nutri- nutrition impacts tion—and to hold those sectors accountable for nutrition results— The key sectors for maximizing is to include an appropriate nutri- nutrition impacts are indicated in tion related indicator (or a figure A-3. These include health, validated proxy indicator) to meas- agriculture and food security, social ure overall progress on nutrition in protection (especially social safety these sectoral projects and pro- nets), poverty reduction (although it grams. is not a traditional “sector”), educa- tion (especially girls’ education), c. Increasing “policy coherence” water and sanitation, environment b. Integrating nutritional consider- through government-wide atten- and climate change, private sector, ations in programs in other sec- tion to policies or strategies, and trade and intellectual property tors is critical to a multisectoral and analyzing trade-offs, which rights (especially in view of the grow- nutrition response to sustain the may have positive or unintended ing role of the private sector in food gains from direct Nutrition-spe- negative consequences on nutri- and health systems in developing cific interventions. for example, tion, is another critical means economies). Gender and governance while improving productivity and for mainstreaming nutrition into issues are crosscutting across sev- other agricultural goals will always other sectors. National develop- eral of these traditional sectors and remain the primary objective of ment strategies vary significantly need special consideration. the agriculture sector, there is a potential opportunity to incorpo- by the extent to which nutritional rate nutrition considerations into objectives are incorporated either smallholder agriculture and rural as a stand-alone issue or main- 6 IEG World Bank, 2010. 7 World Bank. 2006. Repositioning Nutrition as Central to Development; Spielman, D., and Pandya-lorch, R. 2009. Millions fed: Proven Successes in Agricultural Development. IfPRI: Washington, D.C. CHAPTER - A | Introduction Think multisectorally, Rationale for world Bank act sectorally involvement while there is a strong case for act- The world Bank’s primary mission ing across several sectors to im- is poverty reduction and promoting prove nutrition outcomes, little economic growth in the poorest evidence exists demonstrating the countries of the world, many of success of multisectoral projects which carry the highest burdens of improving nutrition outcomes. Ex- malnutrition. Through its invest- perience and evidence suggest that ments in multiple sectors, the while it is perfectly logical to think world Bank is well positioned to and plan multisectorally, actions support a multisectoral approach must follow sector by sector, tailored to reducing the underlying and im- to the specific context, objectives, mediate causes of undernutrition. and operating environment of each Moreover, the World Bank is one of sector.8 This approach is further bol- the few development organizations stered by the fact that budget alloca- that supports client countries acting dren and minimize harmful, often un- tions in institutions, as well as at across sectors and at scale, and intended consequences. An impor- country level, are made by sectors or strongly emphasizes governance and tant first step in this effort is to assist ministries, and governance and ac- gender issues. The World Bank has regional teams to move rapidly to a countability structures follow similar recently scaled up its investments in multisectoral approach to nutrition sectoral limitations with sectors several nutrition relevant sectors. by providing programmatic guidance holding themselves accountable for The more direct nutrition-specific in- and tools as they develop new pro- results within their own domains. terventions implemented primarily by grams. Adoption of this guidance Based on this experience and evi- the health sector will need to be com- would signal a move towards opera- dence base, the current guidance plemented by the indirect nutrition- tionalizing nutrition-specific develop- notes follow this mantra of thinking sensitive interventions implemented ment. Experience from countries such multisectorally but acting sector by through sectors such as agriculture as Senegal suggests that when this sector. The guidance notes are being and food security, social protection, approach is implemented well, with developed as modular sectoral inputs and water and sanitation. All sectors appropriate investments in capacity that can be applied to each sector, will need to plan and implement in- development and institutional but also pulled together into one co- vestments to maximize the nutrition arrangements, results can be herent cross-sectoral approach. benefits for women and young chil- achieved.9 8 The history of multisectoral projects is littered with non-performance. The 2007 World Bank Health Nutrition & Population (HNP) Strategy stated that actions in other sectors were necessary to reach outcomes in health. Since then, there has been a steady increase in multisectoral projects, with most of the increase being in AIDS projects. However, the performance of multisectoral AIDS projects in Africa has been less than satisfac- tory. A criticism of multisectoral projects has been that the increased number of sectors involved has resulted in reduced clarity and specificity of the role and responsibility of each sector. Also, lending in sectors outside of health, such as water and sanitation and education, has taken place independent of each other and the health sector. In the water and sanitation and transport sectors, projects with health objec- tives rarely collaborate with the Ministry of Health. (Ref: Improving Effectiveness and Outcomes for the Poor in Health, Nutrition and Popula- tion, IEG 2009). While PRSPs have helped policymakers link sector strategies with poverty reduction, progress has depended on the capacity of the country’s public sector, partner relationships with the government and relations among donors. There are also no intermediate indicators for measuring progress, which reduces clarity and accountability of what is expected to be achieved by the PRSP. (Ref: The Poverty Reduction Strategy Initiative: An Independent Evaluation of the World Bank’s Support Through 2003, 2004). 8 More detailed information about the case of Senegal is available from James Garrett and Marcela Natalicchio, eds. “Working Multisectorally in Nutrition: Principles, Practices, and Case Studies,” IfPRI, 2011. CHAPTER - A | Introduction In fY12, the World Bank’s agricultural nets. But the Rapid Social Response The three dimensions in the MPI are projects covered some 40 countries (RSR) trust fund, as well as the new education, health, and standard of and amounted to approximately $5.4 social protection strategy, offer real living. A person is identified as multi- billion in new IDA/IBRD assistance. opportunities to mainstream nutri- dimensionally poor if they experience The most common focus of these tion issues among the poorest and deprivation in at least 30 percent of projects is either to raise agricultural the most vulnerable populations into the weighted indicators. The two in- productivity and/or to link farmers to future social safety net designs to dicators for health are child mortality markets. Nutrition-specific interven- buffer the impact of future crises. The and nutrition. tions in these projects remain largely Bank’s new education strategy is de- absent, and nutrition sensitivity is signed to be nutrition-sensitive, with still weak. However, awareness, com- a focus on early childhood develop- mitments, and integration of nutri- ment, albeit the true test will lie in its tion activities are growing. In the implementation at country level. context of the global food price in- Within the health sector, commit- creases, initiatives such as the ments for nutrition accounted for Global food Price Response Program only 5 percent and 4 percent of over- (GfRP), had about 15 percent of the all health commitments in fY11 and $1.5 billion allocation going towards fY12, respectively.10 Nutrition is still a non-agricultural interventions, such marginal focus in the Results-Based as social protection and school feed- financing trust funds financed by the ing. Housed in the World Bank, the UK and Norway. Global Agriculture and food Security Program (GAfSP) was set up in April Nutrition must move to the center 2010, at the request of the G20, to of the discussion on poverty scale up support to country-led and reduction strategies and on developed agriculture and food secu- measuring progress on poverty Rice fields rity plans and to help promote invest- reduction. Despite recent global Photo: Thomas Sennett/World Bank ments in smallholder agriculture. dialogue on a composite poverty GAfSP recently allocated US$46.5 measurement index that includes nu- million to Nepal to enhance house- tritional considerations, poverty con- There are major opportunities to in- hold food security in the poorest and tinues to be measured and reported corporate small adjustments to IDA most food insecure regions through using income and consumption met- and IBRD investments across the increased agricultural productivity, rics alone. The measurement issue is sectors to make them more household incomes, and awareness relevant in that most national devel- x with a potentially impressive impact about health and nutrition in the mid- opment plans set core targets for on nutrition outcomes. Given the western and far-western develop- poverty reduction but do not report Bank’s country-level convening power, ment regions. on non-income metrics. However, re- its ability to advise on country poli- cent progress has been made in this cies, and current and upcoming invest- New strategies in social protection area under the Multi-Dimensional ments and strategies in key sectors, and education hold promise for nu- Poverty Index (MPI) developed by Ox- the impact of this effort will likely go trition. In the social protection sec- ford University. The MPI uses 10 indi- beyond the World Bank to other devel- tor, nutritional considerations are not cators that reflect the MDGs and opment partners, and most impor- yet central to the design of safety international standards of poverty. tantly, it will extend to country clients. 10 Business Warehouse, World Bank April 2012. Includes pipeline investments for 2012. CHAPTER - A | Introduction Five key lessons learned Potential solutions/incentives for tion; IfAD included nutrition as one cross-sectoral work. Several poten- of their core objectives in their new Based on experience to-date, five tial solutions can be explored. These Strategic framework; fAO has priori- steps are necessary for transforming include results agreements with in- tized nutrition as a corporate priority new operations across several sec- centives for cross-sectoral work. Ear- and is undergoing a process of main- tors to be more nutrition-sensitive: marked resources for cross-sectoral streaming nutrition within the institu- products/operations could also tion; and the Bill & Melinda Gates a. Explicitly incorporate nutritional prove catalytic. foundation (BMGf) has just approved considerations into initial design a new agriculture strategy that priori- of projects/policies. tizes a focus on nutrition through the The South Asia Regional quality of foods produced and con- b. Integrate nutritional considera- Assistance Strategy (RAS) sumed. The European Commission tions as elements of investments, has developed a “Reference Docu- not necessarily as the primary ob- on nutrition – a model ment” that provides guidance to their jective. for change? aid administrators working within Experience from the implementa- country teams to complement and ex- c. Modify the design/consider alter- tion of the SAR RAS strategy tend existing efforts by member natives to minimize unintended (Box A-2) over the first year suggests states to explore how nutrition com- negative consequences and maxi- that when management commitment ponents can be incorporated into mize positive impacts. is high, targets for cross-sectoral their projects and programs. Re- work are not just achieved, but can search and programmatic invest- d. Support nutritional objectives be surpassed. ments in agriculture-nutrition with technical capacity within linkages made by BMGf, DfID, USAID, countries. the UN, the Syngenta foundation, Translating knowledge and others are cited in the agriculture e. Monitor and evaluate nutrition im- into practice module.11 pacts with appropriate indicators. Although there is a body of literature demonstrating the Challenges and opportunities for The SuN donor partners group re- importance of linking nutrition and cross-sectoral work. Key challenges quested the Bank to develop guid- other sectors, the challenge facing to cross-sectoral work include lack of ance notes to translate current and partners is translating this knowl- knowledge about the impacts of agri- existing knowledge and research edge in to practice. The International culture and other sectors on nutri- into practice and to increase the food Policy Research Institute (IfPRI) tion, structural issues (such as nutrition sensitivity of agriculture organized a first international confer- institutional and sectoral administra- and social protection projects.12 ence, “linking Agriculture with Nutri- tive structures), staff time, budgets, Principals from the World Bank’s Ad- tion and Health” in New Delhi in related (dis)incentives, institutionally visory Council of foundation leaders february 2011. Many development or- mandated coding of nutrition invest- have agreed to work together to in- ganizations are starting to include ments (which often allows for owner- corporate nutrition interventions multisectoral linkages in their strate- ship of products by only one more seamlessly into future agricul- gies. for example the new DfID strat- sector/unit), and the political econ- ture and food security programs. egy on nutrition highlights the need omy of cross-sectoral work. for a multisectoral approach to nutri- 11 Information on guidance, statements, and strategies to link agriculture and nutrition, published by over 50 institutions, can be found in: fAO, 2012. Syn- thesis of Guiding Principles on Agriculture Programming for Nutrition. https://www.securenutritionplatform.org/Pages/ DisplayResources.aspx?RID=32 12 This group includes the Bill and Melinda Gates foundation (BMGf), Canada, European Commission, france, Germany, Ireland, Japan, US, UK, and the World Bank. CHAPTER - A | Introduction BOx A-2. THE SOuTH ASIA REGIONAL ASSISTANCE STRATEGy FOR NuTRITION, 2010-2015 To respond to the alarmingly high tages to support client countries im- more nutrition-sensitive. Three proj- rates of child malnutrition in South plementation of comprehensive pro- ects in India, three in Nepal, three in Asia, the potentially severe conse- grams that integrate critical Pakistan, one in Afghanistan, and quences of the problem, and the mul- nutrition-sensitive actions in multiple two projects in Bangladesh across tisectoral nature of its determinants, sectors. The overall objective of the the human development, agriculture the South Asia Regional Management RAS is to expand the scale, scope, and environmental services (AES), Team (RMT) adopted nutrition as a re- and impact of the region’s work pro- and social protection are now on gional priority. The RMT also identi- gram, while building SAR Bank staff’s their way to becoming nutrition- fied the need for a framework that and clients’ commitment to, and ca- sensitive. would ensure that the region main- pacity for a multisectoral response to tains and delivers on the results the nutrition crisis. The RAS is ex- In addition to the RAS, the South Asia focus, and hence a Results-Based pected to meet its objective through food and Nutrition Security Initiative RAS for Nutrition was developed with four key results: (SAfANSI) was formed by a World extensive consultations at the coun- Bank and DfID partnership in 2010. It try and regional levels with staff from • Improved awareness and commit- seeks to increase the commitment of different sectors. ment by Bank staff and clients to governments and development agen- addressing maternal and child nu- cies in South Asia to more effective The strategy outlines the region’s vi- trition; and integrated food and nutrition se- sion and approach to improving nu- curity policies and programs through trition. It draws upon collective • Increased World Bank lending for three broad program areas: knowledge, experience and thinking, operations aimed at improving and distills concrete actions that the maternal and child nutrition; • Analysis: improving evidence and region can take in the immediate to analysis on the most cost effective the medium term to translate com- • Increased World Bank ways to achieve food and nutrition mitment into results. Recognizing funding/management of analytical security in South Asia, that further development and refine- work to address knowledge gaps ment is possible, it is a “live” docu- in maternal and child nutrition; • Advocacy: improving awareness of ment meant to be updated food and nutrition security-related periodically. • Successful implementation of a challenges, and advocacy for ac- multisectoral convergence model tion amongst relevant stakehold- The RAS envisions that “Malnutrition project aimed at improving child ers, will no longer be a public health nutrition indicators. problem in South Asia by 2016.” To • Capacity Building: strengthening achieve this vision, the strategy out- A June 2011 review of the RAS against regional and in-country policy and lines some key results and provides a these objectives suggests that all ob- programming capacity to achieve road map to scale up South Asia Re- jectives have been surpassed, and it food and nutrition security out- gion’s work program on nutrition. It is time now to raise the targets even comes. proposes some strategic approaches further. As of June 2011, awareness to guide the scale up of this work pro- and commitment in the region is at SAfANSI currently has programs in gram, with an emphasis on working record high, several new analytic Afghanistan, Bangladesh, Bhutan, intersectorally, focusing on the pieces have been developed, and op- India, Nepal, Pakistan, and Sri lanka. Bank’s areas of comparative advan- erations are becoming more and CHAPTER - A | Introduction The Bank’s regional teams, espe- ence. It aims to bridge operational Nutrition Beam has done this cially South Asia and Africa where knowledge gaps between the three through the development of a net- the burden of malnutrition is the sectors, offering a space to exchange work of development practitioners highest, have also requested this experiences, disseminating informa- that share knowledge and catalyze guidance. In the South Asia Region tion and increasing coordination, col- synergies of interventions across (SAR), the SAR Regional Management laboration, and cogeneration of sectors. Team (as described earlier) is now ac- knowledge. The platform is working countable for supporting a multisec- towards building a community of toral response to malnutrition.13 The practice by interacting with units other regions are also exploring a within the Bank as well as a compre- III. Nutrition basics multisectoral approach to improving hensive external partner base that nutrition results. Thus, this report is will actively contribute to the knowl- what is malnutrition? a first step towards operationalizing edge sharing and cogeneration activ- this multisectoral approach. It has ities. The term malnutrition encompasses evolved in response to the urgent de- all categories of poor nutrition mands of the development commu- A similar initiative also has been caused by insufficiency/deficiency or nity, and builds on existing research undertaken in the latin America excess. Malnutrition is internation- to facilitate translating knowledge in and Caribbean region, known as ally categorized as one or more of the to action. Where evidence is weak, it the lAC Nutrition Beam, which has following types shown in figure A-5, calls for more evidence; where it is been created to maximize the im- and one or more types of malnutri- strong, it provides programmatic pact on nutrition outcomes of tion can coexist not only in one guidance that will help these sectors cross- sector investments and ini- household, but also in one single in- to adopt a “nutrition lens” as they tiatives within the lAC region. The dividual. develop new programs and projects with client country counterparts. In this first phase, the focus is on FIGuRE A-5. MALNuTRITION By TyPE poverty reduction, agriculture and food security, social protection, and MALNUTRITION health. These notes are accompanied uNDERNuTRITIoN ovERNuTRITIoN by a succinct, operational matrix that highlights the objectives, tracking in- dicators, opportunities and trade- STuNTING wASTING uNDERwEIGHT MICRoNuTRIENT ovERwEIGHT offs, and issues of policy coherence DEfICIENCIES AND oBESITY where relevant. Also known as acute low weight- as chronic malnutrition, for age, Also known A condition malnutrition, wasting is defined as as “hidden characterized The Bank has also received funding stunting is low weight- more than 2 hunger,” a by excess a low height- for- height, SD below the consequence body fat, from the Knowledge and learning of inadequate typically for-age, defined as mean of the Council to fund a Knowledge Plat- defined as more than 2 sex-specific intake of defined for form, known as “SecureNutrition” more than 2 SD below the reference essential children as a SD below the mean of the data. micronutri- weight-for- to link agriculture, food security, ents. Key height ™2 SD, mean of the sex-specific and nutrition. SecureNutrition has sex-specific reference micronutrients or for adults, both an internal and external audi- reference data. include: iron, a Body Mass data. vitamin A, zinc, Index (BMI) ™ and iodine. 25. 13 SAR Regional Assistance Strategy on Nutrition, Box A-2. CHAPTER - A | Introduction what are the consequences have reduced physiological capac- o vitamin A deficiency (vAD) is of malnutrition? ity and work output, reduced the result of inadequate di- physical growth, and poor educa- etary intake of vitamin A. Vita- At least 35 percent of child deaths are tional achievement, all of which min A deficiency is the largest attributable to undernutrition.14 The hold negative consequences for a cause of preventable blindness majority is due to the synergistic ef- child’s future. Adults who were (irreversible) and night blind- fect of undernutrition and disease. stunted in childhood have been ness. Healthy functioning of An undernourished child who falls ill shown to have lower earning po- the immune system depends is much more likely to die than a tential when compared to those on vitamin A, and VAD is a risk well-nourished child. Undernutrition who reached their full growth po- factor for increased severity of is also responsible for 11 percent of tential. infectious disease and mortal- all disability- adjusted life years ity. (DAlYs) lost globally, and up to a • wasting, or acute malnutrition, quarter of DAlYs in countries with is the result of a recent shock such o Iron deficiency is the most high mortality.15 as lack of calories and nutrients widespread preventable nutri- from famine, and/or severe and tional deficiency in the world Because of their higher prevalences, sudden illness. Wasting is often and affects both developing mild and moderate undernutrition used to assess the severity of and developed nations, across are responsible globally for a greater emergencies during crisis situa- all income groups. The conse- proportion of child death and burden tions. A child who is severely quences of anemia for chil- of disease than severe undernutri- wasted (z-score ) -3) is nine times dren—approximately half of tion. Undernutrition results in losses more likely to die than a child who which is due to iron defi- in brain development, physical is not wasted.17 ciency—include increased mor- growth, and human capital develop- bidity and mortality, stunting, ment, costing undernourished indi- • underweight reflects inadequate lower performance in school, viduals to lose about 10 percent of weight status and serves as a cognitive delays, and apathy. lifetime earnings, and high-burden composite measure that captures In adults, anemia is associated nations to lose approximately 2-3 both stunting and wasting. with weakness and fatigue, percent of GDP.16 Some of the specific lower productivity, and in- consequences of different forms of • Micronutrient deficiencies, also creased risk of maternal mor- malnutrition are listed below. known as “hidden hunger,” are tality from postpartum associated with adverse health hemorrhage. • Stunting, or chronic malnutri- outcomes, including heightened tion, reflects a long-term failure to disease prevalence and severity, o Iodine deficiency is caused by grow, and is the cumulative effect poor cognitive function, and in- lack of iodine in the diet, and of chronic deficits in food intake, creased risk of mortality. Globally, can cause irreversible mental poor caring practices, and illness. approximately two billion people retardation (cretinism), goiter, Children who are stunted are at are deficient in one or more mi- reproductive failure, and in- higher risk of death. They also cronutrients.18 14 The Lancet Series on Child and Maternal Undernutrition, 2008. 15 Ibid. 16 World Bank. 2006. Repositioning Nutrition as Central to Development. 17 The Lancet Series on Child and Maternal Undernutrition, 2008. 18 UNICEf website, Micronutrients- Iodine, iron and vitamin A. Accessed february 21, 2012. < http://www.unicef.org/nutrition/index_iodine.html> CHAPTER - A | Introduction creased child mortality. Salt premature death, and disability. In given the rapid growth and develop- iodization is an extremely ef- addition to future risks, obese ment that takes place. As shown in fective means of ensuring ade- children experience breathing dif- figure A-6, stunting and underweight quate iodine consumption at ficulties, increased risk of frac- can begin in utero, where children the population level. tures, hypertension, early markers who have not received adequate nu- of cardiovascular disease, insulin trition during gestation are born with o Zinc deficiency is estimated to resistance, and psychological ef- a negative z-score for either weight- be widespread in countries fects. for-age or height-for-age. Growth fal- with inadequate levels of zinc tering occurs mainly before a child’s in the food supply. Zinc defi- second birthday, when children are ciency is associated with stunt- particularly vulnerable to poor caring ing and increased incidence of who is most vulnerable to behaviors, inadequate access to diarrhea and pneumonia. malnutrition? health services, and inappropriate feeding practices, all of which can • overweight and obesity are a The damage that occurs from under- have detrimental consequences for major risk for non-communicable nutrition in a child’s first 1,000 days, their health and survival. diseases in adults, including car- from pregnancy to 24 months of age, diovascular diseases, diabetes, is largely irreversible. During this pe- Therefore, this critical period or “win- musculoskeletal disorders, and riod, nutritional requirements are dow of opportunity” between preg- certain types of cancers. Child- substantial, in terms of caloric and nancy and 24 months is when hood obesity is associated with a micronutrient needs for both preg- undernutrition can and should be higher chance of adult obesity, nant women and young children prevented. FIGuRE A-6. uNDERNuTRITION AND THE wINDOw OF OPPORTuNITy: A CHILD’S FIRST 1,000 DAyS . Weight-for-age (WAZ) Weight-for-length (WHZ) . Weight-for-age (HAZ) . . Z SCORES WHO . . . . . AGE MONTHS Source: Victora C.G., de Onis M., Hallal P.C., Blössner M., Shrimpton R. 2010. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health Organization growth standards. Pediatrics. CHAPTER - A | Introduction why is intervening in o less than 25 percent of coun- Productivity losses from nutrition important? tries will achieve the non-in- malnutrition are estimated come poverty MDG target of at more than 10% of • High economic returns, high halving underweight. lifetime earnings, and impact on economic growth, and • Malnutrition has irreversible up to 2%-3% of GDP. poverty reduction consequences that last o Overall, the benefit:cost ratios a lifetime for nutrition interventions range between 5 and 200.19 o Undernutrition’s most damag- ing effect occurs during preg- o Malnutrition slows economic nancy and in the first two years growth and perpetuates of life. The effects of undernu- poverty through direct losses trition during this critical win- in productivity from poor phys- dow on health, brain ical status; indirect losses from development, intelligence, ed- poor cognitive function and ucational attainment, and pro- deficits in schooling; and ductivity are largely losses owing to increased irreversible. health care costs. o Improving nutrition is essential to achieving MDGs 1, 4, and 5. • Malnutrition is an alarming problem worldwide o Malnutrition is a problem in both rich and poor countries, with the poorest people in both sets of countries affected the most. o Nearly a third of children in the developing world remain un- derweight or stunted, and 30 percent of the developing world’s population suffers from deficiencies in micronutrients such as iron, vitamin A, zinc, and iodine. 19 Horton, S., Shekar, M., McDonald, C., Mahal, A., J.K. Brooks. 2010. Scaling Up Nutrition: What Will it Cost? Washington D.C.: The World Bank. CHAPTER - A | Introduction where is malnutrition FIGuRE A-7. PROGRESSION OF MALNuTRITION IN most prevalent? DEvELOPING COuNTRIES FROM 1990-2010 • Globally, undernutrition has Wasting decreased since 1990, albeit very 50 44.4 Stunting slowly. However, overnutrition has Overweight been on the rise at an increased 40 36.1 rate over the last ten years (figure A-7). 29.2 30 • In Sub-Saharan Africa, malnutri- 20 tion is on the rise. Both over- weight and underweight 10 9.8 10 9.6 prevalence rates have increased 4.5 6.1 over the last twenty years, and 3.7 stunting has been reduced by 0 1990 2000 2010 only two percentage points in this same time period. Source: UNICEF, 2011. • In Asia, malnutrition is decreas- ing, but South Asia still has both • Malnutrition rates vary by in- How can countries improve the highest rates and the largest come quintile, with the poorest the nutrition status of their numbers of malnourished chil- being the most heavily affected. population? dren. The prevalence of malnutrition is often two or three times—some- • In East Asia and the Pacific, times many times—higher among The Scaling Up Nutrition Move- latin America, and Eastern Eu- the poorest income quintile than ment rope, many countries have a se- among the highest quintile. How- rious problem of chronic As discussed earlier, the Scaling Up ever, in many countries, undernu- undernutrition and micronutri- Nutrition (SUN) movement is advanc- trition is surprisingly high even in ent malnutrition coexisting with ing globally. Its purpose is to encour- upper income quintiles, making it high and rising rates of over- age increased political commitment clear that income alone does not weight and obesity. and programmatic alignment to ac- solve the problem. celerate reductions in global hunger • Deficiencies of key vitamins and undernutrition. and minerals continue to be per- vasive. In the developing world, 35 percent of people lack ade- quate iodine, 40 percent of people suffer from iron deficiency, and more than 40 percent of children are vitamin A deficient.20 20 World Bank. 2006. Repositioning Nutrition as Central to Development. CHAPTER - A | Introduction Main elements of the SUN • Provide substantially scaled up o Therapeutic zinc supplements Framework domestic and external assis- for diarrhea management • Start from the principle that tance for country-owned nutri- what ultimately matters is what tion programs and capacity. To o Multiple micronutrient that end, ensure that nutrition is powders happens at the country level. In- explicitly supported in global as dividual country nutrition strate- well as national initiatives for food o Deworming for children (to gies and programs, while drawing security, social protection, and reduce loss of nutrients) on international evidence of good health, and that external assis- practice, must be country tance follows internationally o Iron-folic acid supplements for “owned” and built on the coun- agreed upon principles of aid ef- pregnant women to prevent try’s specific needs and capaci- fectiveness. Support major efforts and treat anemia ties. at national and global levels to strengthen the evidence base, o Iodized oil capsules when • Sharply scale up evidence-based which is important for advocacy. iodized salt is unavailable cost-effective interventions to prevent and treat undernutri- • Provision of micronutrients tion, giving highest priority to the -9 to 24 month window of Priority Interventions for through fortification for all opportunity, which has the high- Scaling Up Nutrition o Salt iodization est returns on investments. A To curb child death and disability in conservative global estimate of fi- the short term, the immediate prior- o Iron fortification of staple nancing needs for these interven- ity interventions for Scaling Up Nutri- foods tions is US$ 10+ billion per year. tion are the evidence-based direct interventions to prevent and treat • Therapeutic feeding for malnour- • use a multisectoral approach to undernutrition presented in the 2008 ished children with special foods target nutrition in related sec- lancet Series on Maternal and Child tors and include indicators of Undernutrition. These Nutrition- undernutrition as one of the key o Prevention or treatment of specific interventions include: measures of overall progress in moderate undernutrition these sectors. The closest action- • Promoting good nutritional o Treatment of severe undernu- able links are to food security (in- practices cluding agriculture), social trition (severe acute malnutri- protection (including emergency tion) with ready-to-use o Includes optimal breastfeeding relief), and health (including ma- therapeutic foods (RUTf) and complementary feeding ternal and child health care, im- (after 6 months), and improved munization, and family planning). hygiene practices (including The Scaling up Nutrition There are also important links to handwashing) movement also recognizes the education, water supply and sani- urgent need for multisectoral tation, as well as to cross-cutting • Increasing intake of vitamins action, but efficacy evidence is less issues like gender equality, gover- and minerals through provision clear-cut for indirect nutrition- nance (including accountability of micronutrients for young sensitive interventions. This and corruption), and state children and their mothers document aims to address fragility. this gap. o Periodic vitamin A supplements CHAPTER - A | Introduction BOx A-3. wHAT ACTIvITIES ARE INCLuDED uNDER CODE 68? How does the Bank cost its • Promoting adequate infant and • Using food-based safety nets, investments in nutrition? young child growth including food stamps, food subsidies, and food for work with In 2002, the Bank released an up- • Improving breastfeeding practices nutrition objectives dated theme and sector coding sys- tem that provides the basis for • Ensuring the adequate and timely • Including nutrition components analyzing and reporting on the con- introduction of complementary in early childhood development, tent of Bank activities, including foods school health, reproductive Bank budget allocations to strategic health, and other programs goals and priority sectors. Theme and • Implementing programs to reduce sector codes are assigned to all lend- micronutrient malnutrition such • Ensuring that food security ing operations, economic and sector as fortification, supplementation interventions, including income work, technical assistance (non-lend- or food-based strategies, generation, labor-saving ing), research services, client train- and disease and parasite technologies, improved marketing ing, and other activities that directly prevention and control, e.g., systems, and food distribution serve the Bank’s external clients. Ac- helminths, tuberculosis, malaria, networks, have explicit objectives tivities that serve the Bank’s internal HIV/AIDS, etc. to improve household food needs, such as quality assurance, security, food intake and/or country assistance strategies, sector • Improving adolescent and nutrition outcomes strategy papers, knowledge prod- maternal nutrition and reducing ucts, and training of Bank staff, are low birth weight • Increasing crop/livestock not coded for sectors and themes. production to benefit the most • Developing capacity in nutrition malnourished and food insecure Although nutrition investments in the planning and policy development, World Bank only represent a small including consumption effects of • Targeting emergency food aid to fraction of total investments, nutri- food policy the most vulnerable, including tion activities are often not captured famine relief programs properly due to a lack of awareness • Improving institutional and/or use of code 68, the Nutrition development and capacity to • Developing and implementing and food Security code. Code 68 ap- design, implement, and monitor nutrition monitoring and plies to projects with objectives and nutrition interventions surveillance to improve specific activities related to improv- nutrition interventions and ing nutritional status or food security • Developing and integrating affect policy change at the household level. It also is used nutrition education and behavior when the actions described in Box A- change communication (BCC) • Developing policies and 3 are included in external, client-fo- into nutrition interventions programs concerning diet-related cused activities. noncommunicable disease • Targeting food supplementation prevention and control to malnourished women and children C H A P T E R - B Economic Growth, Poverty, and Nutrition Sailesh Tiwari, Hassan Zaman, Jaime Saavedra CHAPTER - B | Economic Growth, Poverty, and Nutrition I. Objectives II. Background global population still increasing, there is an increase in the actual Global poverty has declined signifi- Halving the proportion of people numbers of malnourished people. cantly in the last two decades but living in extreme poverty and fAO estimates that a total of 925 without commensurate declines in hunger by 2015 is one of the MDGs. million people were undernourished global hunger or improvements in Most recent estimates in 2010, compared with 1.023 billion nutritional outcomes. Since hunger indicate that the poverty target will in 2009. That is higher than before and malnutrition are linked intri- be met given the rate of recent the food and economic crises of cately to poverty, the divergence in progress.1 The number of people 2007-2008 and higher than the the trends of these indicators is living in extreme poverty decreased number in 1996, the year that puzzling. from 42 to 25 percent (see figure leaders at the World food Summit B-1), and the prevalence of hunger set a goal of reducing the number In this module, we investigate why declined from 20 percent of under- of hungry people by half. nutritional status generally has nourished2,3 in 1990–92 to 16 remained poor despite widespread percent in 2010. However, with the reduction in income poverty, and discuss the policy implications of the situation. This section is tar- FIGuRE B-1. TRENDS IN POvERTy, HuNGER, AND MALNuTRITION geted primarily at PREM economists working both on poverty reduction strategies and economic policy is- sues that feed into a variety of lend- 50 ing and non-lending outputs, ranging 42 from the Bank’s Country Assistance 40 Strategies (CAS) to the Development 34 31 Policy loans (DPl), and Public Expen- 30 27 diture Reviews (PER). 24 25 22 21 20 16 14 14 13 10 0 1990-92 1995-97 2000-02 2005-07 1 “Global Monitoring Report: The MDGs after the Crisis,” World Bank, 2010. living below $1.25/day, 2005 PPP 2 The fAO defines undernourishment in Undernourished a country as the proportion of the Underweight population below the minimum level of dietary energy consumption deemed necessary for basic human Source: WDI. Note: The plotted sample consists only of country-year pairs for which data on functioning in that particular country. poverty and the nutritional indicator were both available. This implies that the match may not It is essentially a measure of food always happen for the most recent year in the data. We did pick the most recent year for coun- deprivation and is based on the calcu- tries for which both data existed for more than one year. lation of three key parameters for each country: the average amount of food available for human consump- tion per person, the level of inequality in access to that food, and the mini- mum number of calories required by an average person. 3 “State of food Insecurity in the World,” fAO, 2009 CHAPTER - B | Economic Growth, Poverty, and Nutrition Nutritional status is an important tion in their early childhood years depending on the nature of the component of human welfare and have poorer test scores on cognitive work.8 Similarly, the median loss in economic development and slow assessments, activity level, and at- reduced work capacity associated progress on improving nutritional tention span.5 They also tend to start with anemia in adults has been esti- indicators is worrying in its own school later and are at a greater risk mated to be equivalent to 0.6 percent right. But undernourishment also di- of dropping out before completing a of GDP. The number goes up by an ad- rectly impinges on adult productivity, full primary school cycle. In ditional 3.4 percent when the sec- particularly in rural, agricultural set- Guatemala, a recent study found that ondary effects of retarded cognitive tings by lowering stature and physi- being stunted at age six is tanta- development in children is factored cal strength, and indirectly by mount to losing four grades of in.9 Overall, these studies reinforce increasing the burden of disease and schooling in terms of test perform- that poor nutritional status is a con- morbidity. In addition, it retards cog- ance.6 The accumulated evidence on sequence of low income and also one nitive development in children, un- child malnutrition suggests that chil- of its causes over a longer term. dermining the development of dren’s learning potential in school human capital, which is critical for and their productivity in later life is to In figure B-2, we present all ob- economic growth in the longer term. a large extent predetermined by their served measurements of chronic In addition, there is growing recogni- health and nutritional status before malnutrition (stunting) in the tion both within and outside the the age of two years. world Bank’s world Development Bank that nutritional deprivation is Indicators database between 1990 an important complementary meas- Even in settings in which sufficient and 2009. Every dot represents a ure to the standard income- related calories are consumed, the lack of country and the horizontal bar de- poverty measures. As a result, many diversity in the dietary composition notes the mean value of the observa- multi-dimensional poverty measures of the poor deprives them of the tions for the given year, while the being developed take into account optimal consumption of essential shaded area represents the range of nutritional status as one of the com- micronutrients such as iron, values that are +1 and -1 standard de- ponents of overall welfare. iodine, phosphorous, vitamin A, viation from the mean of that year. A and vitamin C. This issue becomes number of interesting patterns There is a growing body of evidence particularly important in the context emerge from this picture. first, look- that nutritional deprivation in the of rising food prices as households ing at the +1 and -1 standard error early years of life (including in use substitution away from micronu- bands around the mean, it is evident utero) has persistent long-term ef- trient-rich food items such as meat, that the overall decline in stunting fects into adulthood. The primary fish, eggs, milk, fruits, and vegeta- rates has been sluggish over the channel is through potential educa- bles as a coping strategy to maintain years. The aggregate, however, tional attainment, which is lower for their level of calories.7 Iron deficiency masks significant heterogeneity undernourished children.4 Children in adults has been estimated to de- within countries. Countries like who experience periods of malnutri- crease productivity by 5-17 percent, Bangladesh, Vietnam, and Uzbek- 4 Glewwe, P., Jacoby, H., and E. King. 2001. “Early childhood nutrition and academic achievement: A longitudinal analysis,” Journal of Public Economics, 81(3): 345-368. 5 Alderman, H. Hoddinott, J. and B. Kinsey. 2006. “long term consequences of early childhood malnutrition,” Oxford Economic Papers, 58(3): 450-474. 6 Maluccio, J. A., Hoddinott, J., Behrman, J. R., Martorell, R. Quisumbing, A. R. and A. D. Stein. 2009. “The impact of improving nutrition during early childhood on education among Guatemalan adults,” Economic Journal, 119 (537): 734-763. 7 Skoufias, E., Tiwari, S. and H. Zaman. 2011. “Can Cash Transfers Protect Dietary Diversity During Economic Crises? Some Evidence from Indonesia,” World Bank Policy Research Working Paper. 8 Horton, S. 1999. Opportunities for investment in nutrition in low-income Asia, Asian Development Review, 17: 246-273. 9 Ibid. CHAPTER - B | Economic Growth, Poverty, and Nutrition FIGuRE B-2. MALNuTRITION PREvALENCE OvER TIME (STuNTING = HEIGHT-FOR-AGE) YEAR Bangladesh Vietnam Yemen INCIDENCE OF CHRONIC MALNUTRITION HEIGHT FOR AGE Guatemala Uzbekistan Benin Source: WDI. Note: The red bar denotes mean malnutrition for each year. The shaded area signifies +1/-1 standard deviation of the incidence for each year. Sample composition varies from year to year and the frequency of observations for each country. istan have made remarkable progress the evolution of nutritional indica- III. What is the cross- in reducing stunting rates, while tors. Were the fastest growing coun- sectional relationship progress has been much slower in tries that were able to reduce poverty between poverty and countries such as Guatemala and also the countries that saw the malnutrition? Yemen. On the other hand, countries largest declines in malnutrition inci- like Benin have actually seen stunt- dence? Or, is there no correspon- Poverty and malnutrition are intri- ing rates increase over the years. This dence between poverty reduction cately linked. figure B-3 shows the cross-country heterogeneity in mal- and the improvements in nutritional positive correlation between the nu- nutrition trends raises important indicators? We explore this question tritional indicators stunting and un- questions about the role played by more systematically in the subse- derweight and poverty in a cross the prevailing economic context in quent sections. section of countries. CHAPTER - B | Economic Growth, Poverty, and Nutrition The data show that high rates of FIGuRE B-3. CROSS-COuNTRy CORRELATION BETwEEN POvERTy RATES malnutrition are generally accom- AND MEASuRES OF MALNuTRITION panied by high rates of poverty in many countries. Nepal, for instance, Bangladesh - 1992 REGION had roughly 68 percent of the popu- East Asia and Paci c Europe and Central Asia lation living below $1.25 a day in Latin America and Caribbean Yemen - 1997 Middle East and North Africa 1996, and 56 percent of children Yemen - 2003 Guatemala - 1995 South Asia Sub-Saharan Africa under the age of five were stunted. On the other hand, countries like STUNTING INCIIDENCE % Guatemala - 2002 Guatemala and Yemen stand out Bangladesh - 2005 against countries of similar income, for the surprisingly high incidence of malnutrition as measured by stunt- ing, despite relatively low national Gambin - 2000 poverty rates.10,11 Also remarkable are differences in child nutritional out- Dominican Republic - 2001 comes among countries with very POVERTY RATE . /DAY similar poverty rates, e.g., the differ- ence in stunting incidence between Bangladesh in 1992 and Gambia in Bangladesh - 1992 REGION 2000 (figure B-3). Contrasting malnu- East Asia and Paci c Europe and Central Asia trition indicators between Sub-Saha- Latin America and Caribbean Yemen - 1997 Middle East and North Africa ran Africa (SSA) and South Asia, one Yemen - 2003 Guatemala - 1995 South Asia can make the following general ob- Sub-Saharan Africa servation: countries in SSA appear to STUNTING INCIIDENCE % Guatemala - 2002 have better malnutrition indicators Bangladesh - 2005 on average than one would predict based on their poverty rates. Whereas it is the opposite case for countries in South Asia. Gambin - 2000 Dominican Republic - 2001 POVERTY RATE . /DAY Source: WDI. Note: The plotted sample consists of country-year pairs for which data on poverty and the nutritional indicator were both available. Whenever a poverty statistic was not available for any country-year, for which we had data on malnutrition, we matched it with the closest poverty figure within a five-year window on either side. This implies that a stunting number for a particular country for 2002 could be matched with the closest poverty number available for the country from 1997 to 2007. The dotted line represents a linear fit. 10 The case of Guatemala is interesting because the stunting incidence is much higher than its level of poverty would predict, and there are severe inequalities within the country. Stunting rates in rural Guatemala, and particularly among the Mayan population, exceeds 80 percent and is perhaps a reflection of the overall inequality of wealth distribution in the country. 11 IEG, 2010, What can we learn from Nutrition Impact Evaluations? lessons from a Review of Interventions to Reduce Child Malnutrition in Developing Countries, World Bank. CHAPTER - B | Economic Growth, Poverty, and Nutrition using the data we have assembled, FIGuRE B-4. EPISODES OF CHANGES IN POvERTy AND MALNuTRITION we can create a typology of coun- tries based on the changes in poverty and nutrition indicators. Buru00 We present this in figure B-4. Each Zamb99 quadrant represents a combination Nige06 of an increase or decrease of the % POINT CHANGE IN STUNTING INCIDENCE Guin06 Cent00 poverty rate and malnutrition indica- Gamb06 Mong06 tors. The third quadrant, for example, Ugan01 represents a decrease in poverty and Peru00 Tanz00 Gua99 Ugan05 a decrease in malnutrition incidence. Camb00 Although most country-year pairs are Camb00 Ugan06 Mong04 concentrated in this quadrant, the Viet06 Bang96 Hond01 Bang06 Bang00 key message here is that there are observations in the other quadrants. Pak01 Sri 00 Uzbe02 That is, there are countries that have witnessed episodes of decline in Viet00 poverty accompanied by a worsening % POINT CHANGE IN POVERTY INCIDENCE Buru00 % POINT CHANGE IN UNDERWEIGHT Ugan06 Guin06 of nutritional indicators, an increase Gamb06 Mong06 Zamb99 Tanz00 in poverty and improvements in nutri- Peru00 tional indicators, and so on. In com- paring the figures for stunting and underweight, it is noteworthy that Nige06 Mong04 the mass of country-year pairs in the Viet06 Hond01 Sri 00 third quadrant for underweight Pak01 Bang96 Uzbe02 Bang06 seems to be larger than that for Viet00 stunting. Since underweight is a measure of short-run malnutrition, this could potentially reflect a greater % POINT CHANGE IN POVERTY INCIDENCE responsiveness of the underweight C indicator to income poverty. Overall, these plots reveal that poverty reduc- Source: WDI. Note: The plotted sample consists only of country-year pairs for which data on tion is neither necessary nor suffi- poverty and the nutritional indicator were both available. This implies that the match may cient for improvements in nutritional not always happen for the most recent year in the data. We did pick the most recent year for countries for which both data existed for more than one year. status. CHAPTER - B | Economic Growth, Poverty, and Nutrition IV. How far can for both stunting and underweight, To make the implications of the es- log per capita GDP appears with a timated coefficients explicit, we economic growth negative coefficient, which is what perform the following hypothetical take us? we anticipated. The magnitude of analysis. from the base year (which while a reduction in income the coefficients implies that a dou- is different for each country and is poverty is neither necessary nor bling of per capita income would re- determined by the year for which we sufficient for improvements in mal- duce stunting by 14.8 percentage have the most recent nutrition data) nutrition, many countries have points and underweight incidence by to 2015, we allow the per capita in- seen progress in both indicators. 11.4 percentage points. The initial come growth rate in each country in As such, it is worth assessing the level of inequality appears with a our sample to be the highest growth growth-malnutrition elasticity. We positive sign, indicating that malnu- the country has registered in the last run a cross-country fixed effect trition is higher in countries with decade. Using the elasticities implied regression of the incidence of high levels of inequality. The interac- by our estimated coefficients, we can stunting and underweight on log of tion between initial inequality and retrieve what the implied malnutri- per capita GDP, controlling for the ini- the per capita GDP measure is in- tion rates would be in 2015. We re- tial level of inequality, human devel- tended to capture any inequality in- port the change in malnutrition opment, and public expenditure in duced heterogeneity in the incidence between the base year and health. Since the availability of the relationship between income levels the predicted incidence in 2015 in nutrition indicators are determined and the malnutrition indicators. The figure B-5. To incorporate the effect by the periodicity of the surveys, we positive and significant estimates for of inequality, we consider predictions limit our sample to country-year pairs this interaction confirm the exacer- under three scenarios in 2015: (a) for which the nutrition indicators we bating effect of inequality on malnu- distribution neutral growth; (b) require are available. Between 1981 trition indicators. The female literacy growth accompanied by a 5 percent and 2007, we end up with 255 coun- rate and public expenditure on health reduction in inequality, and (c) try-year pairs for 78 countries. The re- are positively associated with im- growth accompanied by a 5 percent sults of the regressions are reported provements in malnutrition rates. worsening of inequality. in Table B-1. TABLE B-1. STATISTICAL RELATIONSHIP BETwEEN MALNuTRITION AND INCOME VARIABLES Stunting incidence Underweight incidence Log per capita GDP -14.77*** -11.36*** (-4.74) (-5.20) Initial inequality (GINI) 0.09** 0.11** (2.32) (2.17) Initial inequality x Log per capita GNP 0.13*** 0.10** (3.09) (2.09) Female literacy rate -0.02** -0.00 (-2.03) (-0.34) Public expenditure on health (% of GDP) -0.39* -0.40*** (-1.93) (-2.90) Country fixed effect Yes Yes Number of countries 78 78 Observations 255 255 Note: All the data used are from WDI. Robust t-statistics in parentheses. Significance level of *** is 1%; ** is 5%; and * is 10%. CHAPTER - B | Economic Growth, Poverty, and Nutrition figure B-5 shows that the reduction FIGuRE B-5. ESTIMATES FOR THE CHANGE IN in malnutrition incidence would STuNTING INCIDENCE IN 2015 be small if one relied entirely on economic growth—even if this growth were accompanied by 3 reductions in inequality. for instance, consider the case of 2 Uganda. If the country grew by 7.2 percent from 2006 to 2015, and this 1 was accompanied by no change in inequality, the reduction in the inci- dence of severe malnutrition would 0 only be 7 percent, or roughly 0.8 percent per year. Based on this, the -1 implied growth elasticity of stunting for Uganda is –0.11.12 Notice also -2 that for countries like Nepal and Guatemala, where growth has been -3 relatively low, malnutrition may increase in 2015, unless nutrition -4 specific measures are put in place to address it. On the other hand, fast -5 growing countries like Rwanda and Bangladesh Guatemala Malawi Nepal Niger Rwanda Tanzania uganda vietnam Vietnam at best also will see a reduction in malnutrition incidence of roughly 4 percentage points. The overall take- away finding from this analysis is that growth has in and of itself little 2015-a impact on reducing chronic malnutri- 2015-b tion. Another finding is that equity 2015-c dimensions are important as illus- trated by the importance of both NOTE: 2015-a corresponds to the scenario in which the growth is distribu- tion neutral. 2015-b is the initial inequality and simulations of scenario in which the growth is accompanied by a 5 percent decline in inequality, and 2015-c corre- the impact of reduced inequality. In sponds to the scenario in which growth is accompanied by a 5 percent increase in inequality. the following section, we highlight differences in malnutrition trends between the richest and the poorest quintiles in a selection of countries. 12 The average growth elasticity of stunt- ing for all the countries in the sample was closer to -0.3 which is slightly lower than what has been found for underweight in Haddad et al (2004), “Reducing Child Malnutrition: How far Does Income Growth Take Us?” World Bank Economic Review. CHAPTER - B | Economic Growth, Poverty, and Nutrition V. How equitable are for most countries, the aggregate ened in recent years. The distribu- indicators show overall improve- tional breakdown of these aggregate nutritional outcomes? ments in the malnutrition indicator indicators reveals that it is the poor- Demographic and Health Surveys, over the years, but the pattern of est quintile that may be driving this the source of most malnutrition in- the decline is different for different since malnutrition has declined for dicators, do not collect information wealth groups. In Bangladesh, at the richest. A somewhat similar story on household income and expendi- least in the most recent period, there emerges for Nigeria and Bolivia ture, but do collect information on has been quicker progress among where improvements at the national assets. Using assets as a measure of the lowest quintile compared to the level have been accompanied by household wealth, malnutrition richer. This is exactly the opposite of gains at the top of the distribution trends can be analyzed for the richest what we see in Tanzania, where there (with some reversal in 2008 in Nige- and the poorest quintiles of the have been larger gains in nutritional ria), but a worsening or relatively wealth distribution for any given outcomes at the top of the distribu- slower progress at the bottom. Over- country. In figure B-6, we present tion, and to a lesser extent in all, these differential patterns across distributions for a selection of coun- Ethiopia as well. Ethiopia is also in- wealth groups in the evolution of tries that typify the different direc- teresting in how similar the levels of malnutrition trends highlight the im- tions in which trends can move. malnutrition are for the lowest quin- portance of taking into account the tile and the country as a whole. Burk- equity dimension when assessing ina faso, on the other hand, shows malnutrition indicators (also see that severe malnutrition has deep- Ergo, Shekar, and Gwatkin, 2008). FIGuRE B-6. TRENDS IN CHRONIC MALNuTRITION (STuNTING), By wEALTH quINTILES 70 BANGLADESH 70 ETHIOPIA 70 TANzANIA 60 60 60 50 50 50 40 40 40 30 30 30 20 20 20 10 10 10 0 1996/97 1999/00 2004 2007 0 0 2005 2005 1996 1999 2004-05 70 70 NIGERIA 70 BOLIvIA 60 BuRkINA FASO 60 60 50 50 50 40 40 40 30 30 30 20 20 20 10 10 10 0 0 0 2005 2005 1990 2003 2008 1998 2003 2008 NOTE: Increase of chronic malnutrition as measured by percentage of children below five years of age that Bottom Top Total are two standard deviations below the median of the reference population. CHAPTER - B | Economic Growth, Poverty, and Nutrition VI. Why is progress on ple ratio,” which is defined as the have been minimal: the starchy sta- share of total calories in the local diet ple ratio for most South Asian coun- improving nutritional that is derived from starchy staples tries is larger than what one would outcomes lagging in such as rice, wheat, sorghum, etc. predict from their level of incomes South Asia? According to Bennett’s law, starchy (see figure B-7). As a result, even Countries in Africa and South Asia staple ratio declines with income, when nutrition is adequate in terms dominate the list of countries with which basically means that as house- of calorie sufficiency, there is a the worst malnutrition indicators. holds become better off they switch chronic deficiency in terms of key The comparison of malnutrition rates away from cereal dominated diets to micro and macronutrients. In India conditional on poverty or level of in- diets that have a larger share of vari- for example, the ratio of average in- come between these regions, how- ous kinds of meat, fruits and vegeta- take to the recommended daily al- ever, reveals a striking contrast bles, dairy products, and so on. lowance among children aged 4-6 is between the two regions. All South However, for countries in South Asia, only 16 percent for vitamin A, 30 per- Asian countries (with the exception of the shift from cereal-dominated diets cent for fat, 35 percent for iron, and Sri lanka) are performing worse than to a more diversified diet appears to 45 percent for calcium.14 the “predicted” level of chronic mal- nutrition given their poverty rates, while a majority of African countries are doing better than what their FIGuRE B-7. DIETARy DIvERSITy IS LOw IN SOuTH ASIA poverty levels would predict (figure B-3). This raises interesting ques- . tions about non-income determi- nants of nutritional outcomes and Bangladesh highlights the possible importance of dietary diversity, gender relations, . STARCHY STAPLE RATIO India and hygiene in improving child nutri- Nepal Pakistan tion. There is evidence from interna- Sri Lanka tional data on the fact that well . diversified diets are associated with better child nutrition.13 One way to measure dietary diversity is to con- . sider what is called the “starchy sta- 13 Arimond, M., and M.T. Ruel. 2004. “Dietary diversity is association with LOG PER CAPITA GDP child nutritional status: evidence from 11 demographic and health surveys,” Journal of Nutrition, 134(10). The starchy staple ratio is the ratio of total calories derived from staple cereals such as rice and wheat. These are calculated for each country in the sample using data on calorie share obtained 14 Deaton, A. and J. Dreze. 2008. from the FAO for a wide variety of food sources. “food and Nutrition in India: facts and Interpretations,” Economic and Political Weekly, 44(7): 42-65; Ergo, A., Shekar, M. and D. Gwatkin. Inequalities in Malnutrition in low- and Middle-Income Countries, January 2008, mimeo, World Bank; Haddad, l., Al- derman, H., Appleton, S., Song, l., Y. Yohannes. 2004. “Reducing child malnutrition: How far does income growth take us?” World Bank Economic Review, 17(1). CHAPTER - B | Economic Growth, Poverty, and Nutrition In figure B-8 we present a compari- FIGuRE B-8. OTHER PROxIMATE FACTORS RELATED son of South Asia and Sub-Saharan TO CHILD MALNuTRITION Africa for the following indicators that are related to child malnutri- tion: proportion of children aged 0-6 100 months that are exclusively breast- Sub-Saharan Africa fed; (b) proportion of children that South Asia 80 are born with low birth weights; and (c) the proportion of children that are 60 covered by existing vitamin A supple- % mentation programs. It becomes ap- parent that while South Asia scores 40 better on the breastfeeding indicator, it is behind Sub-Saharan Africa on 20 the low birth weight indicator and vi- tamin A supplementation. 0 2000 2009 2000 2009 2000 2009 This discussion serves to highlight Exclusive breastfeeding low Birth vitamin a the multidimensional nature of (0-6 months) weight Supplementation child malnutrition and the need for a coordinated strategy that in- volves interventions not only to raise income but also health, edu- cation, agriculture, and empower- ment outcomes. In addition, there is VII. What are the trition is higher than expected rela- also a growing need to understand tive to poverty levels. More analytical empirically the dynamics that govern implications for work is necessary to identify which the allocation of resources within the policy? part of the causal chain determining household and how these change nutritional outcomes requires more during times of crisis. The dynamics The following four policy implications policy attention in these countries. of resource allocation are also impor- emerge from this analysis: tant to understand and incorporate There are considerable inequities into the design of policy because oth- while economic development on in nutritional outcomes across so- erwise, aggregate household level in- average is related to malnutrition, cioeconomic groups and the rate of terventions (such as cash transfers) promoting economic growth does progress in nutritional outcomes run the risk of perpetuating and even not necessarily lead to an improve- varies over time. In several coun- worsening inequities within house- ment in malnutrition rates. In addi- tries, the gaps between the rich and holds. tion, while poverty and nutritional poor have widened. Our results show trends on average are closely corre- the importance of a country’s initial lated, in many countries they are not. inequality in determining nutritional In these countries, e.g., Guatemala, outcomes. Hence, policies focusing India, Philippines, Egypt, Tunisia, it is on improving equity are essential. important to understand why malnu- CHAPTER - B | Economic Growth, Poverty, and Nutrition The comparison between malnutri- The relatively poor nutritional out- distributed through poverty reduc- tion rates in South Asia and Africa comes in the Middle East and in tion and social protection programs. are striking. The results clearly show South Asia illustrate the risks and Considerable progress has been that relative to the “predicted” level inefficiencies of subsidizing or free made in this area and new technol- of chronic malnutrition i.e., stunting distribution of starchy food staples ogy implies that the price premium and underweight, given poverty to improve nutrition outcomes. for fortified products is relatively low, rates, South Asian countries are lag- While the political economy of these e.g., 3-4% for fortified rice, and could ging behind, while many African measures are such that they may re- possibly be subsidized to ensure ac- countries are doing better than what main in place for many years to come, cess by the poor. In addition, other their poverty levels would predict. improvements can be made that will direct nutritional interventions such Gender relations, dietary diversity, ensure greater nutritional gains. One as promotion of breastfeeding, nutri- and hygiene are possible factors ex- such effort is fortifying food products tion education, deworming, and im- plaining this and illustrate the impor- with essential micronutrients, such proved hygiene practices remain tance of multisectoral interventions. as rice and wheat flour, which are crucial in reducing malnutrition. CHAPTER - B | Economic Growth, Poverty, and Nutrition VIII. Emerging opera- There is a growing need to under- finally, country economists work- stand the dynamics that govern the ing on a variety of Bank outputs tional research and allocation of resources within the such as the CAS, PER and DPls are knowledge gaps household and how these change uniquely positioned to elevate the A better measurement tool that during times of crisis. The dynamics importance of nutrition in the na- captures the food insecurity at are important to understand and in- tional policy agenda and to do so in household levels is becoming in- corporate into the design of policy. a manner that recognizes the mul- creasingly necessary. Unlike income Otherwise, aggregate household tisectoral nature of the inputs that poverty and nutritional outcomes level interventions, such as cash go into improving nutritional out- such as stunting and underweight, transfers, risk perpetuating and even comes. These inputs span trade poli- there is lower consensus around an worsening inequities within house- cies that define tariff rates on appropriate measure of food security holds. Existing survey instruments agricultural products, fiscal policies at the household and individual have limited information on food con- that guide subsidies for agricultural level. fAO publishes aggregate un- sumption at the individual level. As a inputs such as fertilizers and electric- dernourishment or hunger numbers result, most analyses of food security ity, regulatory issues that determine as a proxy for food insecurity. WfP that originate from these datasets in- the marketplace organization for produces a food consumption score evitably are based on food availabil- food, transportation and logistics, and a vulnerability map. IfPRI pro- ity as opposed to actual intake. and the efficiency of government pro- duces a global hunger index, which is Innovative and cost-effective ways of grams, such as cash transfers, that measured as a weighted average of incorporating modules that can elicit may aim to improve or protect nutri- fAO’s hunger measure, underweight information on actual intakes at the tional status directly. incidence, and mortality of children individual level have to be explored under five within each country. All of because there are important differ- these measures are varied in their ences in individual food security, par- methodology and often show contra- ticularly between gender groups, and dictory results. Moreover, there is even within the same household. very limited distinction between na- tional and household/individual food security measures. A unified ap- proach to measuring and tracking food security at the household level has become increasingly necessary to identify and monitor the effects of various kinds of shocks on vulnerable households and target interventions accordingly. C H A P T E R - C Improving Nutrition through Agriculture Yurie Tanimichi Hoberg, Anna Herforth, Meera Shekar, Aparajita Goyal CHAPTER - C | Improving Nutrition through Agriculture Agriculture has a strong influence on level of dietary energy consumption, food consumption and nutritional only six are on track to meet the un- status. Agriculture’s influence is max- derweight goal.1 Among those coun- imized when nutrition is explicitly tries showing insufficient progress considered and progress is meas- toward reducing underweight, Mali ured. has shown no progress on under- weight.2 The specific objectives of this guid- I. Objectives ance note are to support world The overall objective of this module Bank staff, partner agencies, and is to offer practical guidance to country clients efforts to make support world Bank staff, develop- agriculture investments more ment partners, and country imple- nutrition-sensitive in the following II. Rationale ways: menters in maximizing the positive nutrition impacts of agricultural in- The message that agriculture plays vestments, and minimizing the un- (1) enhance the design of agriculture a major role in nutrition (and vice intended negative consequences investments and policies to maximize versa) is gaining traction within on nutrition. The World Bank’s sup- the impact on nutrition outcomes for and outside of the world Bank. port to agriculture aims to contribute the poor; (2) measure the progress of There is considerable global momen- to meeting the MDG1 of halving activities affecting nutrition periodi- tum to bring the agriculture, food se- poverty and hunger by 2015, and the cally through relevant output and curity, and nutrition agendas closer indicators for the hunger goal deal- outcome indicators, such as food together so that investments in one ing directly with nutrition, i.e., preva- consumption indicators; (3) minimize will have positive impacts on the oth- lence of underweight among children the unintended negative nutritional ers. The new global SUN framework under five years of age, and the pro- consequences of agricultural inter- and Roadmap3 have identified nutri- portion of the population below the ventions and policies on the lives of tion-sensitive development in key minimum level of dietary energy con- the poor, especially women and sectors as one of the two most urgent sumption. These indicators do not young children; and (4) support gov- priorities for addressing malnutri- necessarily decline in tandem. Of the ernments and partners in designing tion, Agriculture is at the top of the 21 countries that have already met sustainable and coherent policies to list of key sectors.4 leaders from 27 the goal of halving the proportion of improve nutrition outcomes for the client countries are ready to scale up the population below the minimum poor. nutrition investments through multi- sectoral approaches and are known 1 Armenia, Georgia, Ghana, Jamaica, Nicaragua, and Vietnam have met the hunger goal and are on track to meet the underweight goal. 2 The 10 countries showing insufficient progress in reducing underweight are Azerbaijan, Congo, Guyana, Mali, Morocco, Myanmar, Nigeria, Sao Tome and Principe, Solomon Islands, and Uruguay. Morocco and Uruguay have limited data but progress appears insufficient based on average annual rates of reduction of 1.2% and 0.8%, respectively. five countries have no data on underweight progress: Chile, Cuba, Gabon, Kuwait, and St. Vincent and the Grenadines, http://www.childinfo.org/undernutrition_tables.php. 3 The SUN responds to the continuing high levels of undernutrition and the uneven progress towards the MDGs to halve poverty and hunger by the year 2015. The SUN framework was developed by specialists from governments, academia, research institutions, civil society, private companies, development agencies, and UN organizations, including the World Bank. It is endorsed by more than 100 organizations and was launched in Washington in April 2010, www.scalingupnutrition.org. 4 Malnutrition is defined as a condition resulting from ingesting an unbalanced diet lacking in certain nutrients i.e., undernutrition or excess intake i.e., overnutrition, or a misproportioned diet. As stated in Section A of the report, this document focuses primarily on undernutrition. CHAPTER - C | Improving Nutrition through Agriculture as the “SUN early riser countries.” ence groups of SecureNutrition is the farmers, who are the primary target (See Section A for more details on World Bank’s staff. There has been population of World Bank agriculture the SUN.) increasing demand within the World projects. When farmers are under- Bank for knowledge on how to link nourished, they are less productive. A series of briefs and papers also re- agriculture and nutrition, especially furthermore, undernourished chil- sulted from an international confer- from the South Asia region, where dren are less likely to attend school. ence hosted by IfPRI in february 2011 the South Asia food and Nutrition Se- These children in smallholder fami- on “leveraging Agriculture for Im- curity Initiative (SAfANSI) provides lies are less likely to transition out of proving Nutrition and Health.” these resources. The most basic ra- small-scale farming, and thereby fail Achieving nutrition results through tionale for Bank engagement in this to get out of the poverty trap. Poverty agriculture has been the subject of linkage is the critical importance of reduction and improvement in well- several recent reviews and strategy nutrition to human capital develop- being among the world’s vulnerable notes prepared by major develop- ment and ultimately to the reduction farmers will be more meaningful and ment partners, such as fAO, IfAD, the of poverty. sustainable if addressing undernutri- European Commission, USAID’s feed tion is part of the package for the the future Program, USAID’s Infant The next sections discuss the unique broad rural population which will ulti- and Young Child Nutrition Project contributions of agriculture to nutri- mately benefit the population in the (IYCN), DfID, as well as major interna- tion and why nutrition action cannot most vulnerable first 1,000 days from tional CSOs such as World Vision, be left to other sectors outside of pregnancy to 24 months.6 Save the Children UK, and Action agriculture; explain how improved Against Hunger (ACf). (See Annex C-5 nutrition contributes to core agricul- why should agriculture staff be for a list of recent reviews and strate- tural objectives; review briefly the concerned with nutrition? Don’t the gies.) pathways from agriculture to nutri- health and social protection sectors tion; and recommend practical inter- adequately cover nutrition? Agricul- The world Bank has also increased ventions to consider. ture has a unique and critical role in attention to the need for linking improving nutrition outcomes, and agriculture and nutrition. for exam- the following five reasons explain ple, SecureNutrition, a new know- why. ledge platform financed by the Bank, was established in fY12 to link agri- III. Why is agriculture a. Agriculture is the sector best culture, food security and nutrition.5 important for placed to affect food produc- SecureNutrition is led by a team from tion and consumption of nutri- Health, Nutrition and Population nutrition? tious foods needed for healthy (HNP), Agriculture and Environmental In support of its mission to fight and active lives. Physical and Services (AES), and Poverty Reduc- poverty, the world Bank works to economic access to adequate tion and Equity (PRMPR). Its goal is to reduce poverty through sustainable and affordable nutritious food is engage a community of practice to agriculture and rural development. primarily a function of the agri- exchange knowledge, awareness, Undernutrition is intimately linked culture sector through support to and capacity to support food security with both poverty and smallholder increased production and im- interventions to improve nutrition farmer well-being and is a major con- proved post-harvest storage and outcomes. One of the key target audi- straint to rural development among processing. Agriculture’s unique 5 The Knowledge Platform is cohosted by HNP, AES, and PRMPR and has received funding for fY12-14 from the Knowledge and learning Council. for more information, see http://www.securenutritionplatform.org. 6 World Bank. 2006. Repositioning Nutrition as Central to Development, http://siteresources.worldbank.org/NUTRITION/Resources/ 281846-1131636806329/NutritionStrategy.pdf. CHAPTER - C | Improving Nutrition through Agriculture role in food production and con- capital and well- being, of which led to faster (though still insuffi- sumption makes it indispensable nutrition is an essential part. for cient) declines in undernutrition for enabling people to have con- example, agriculture extension than non-agricultural growth.8 sistent access to nutritious diets workers have direct and ongoing (food security). contact with smallholder farm- d. A large percentage of rural ers, and therefore have a unique women are employed in the b. Agriculture has the most direct opportunity to strengthen mes- formal or informal agriculture influence and contact with the sages regarding consumption of sector. Women contribute over majority of households in the nutritious foods. 50 percent of the agriculture world where undernourished labor force in many developing individuals reside. Beneficiaries c. Agricultural-led growth is more countries. AES investments will of typical agriculture projects pro-poor than non-agricultural- have a large direct impact on nu- overlap with those most affected led growth; thereby increasing trition outcomes for the entire by undernutrition: the rural poor. agriculture’s potential to im- household through increased Seventy-five percent of the prove nutrition. Agricultural discretionary income and re- world’s poor are rural, and most growth is at least twice as effec- duced workloads for women. of those are smallholder farmers. tive in reducing poverty as GDP Any development activity reach- growth originating outside agri- e. Some agriculture projects could ing this population has enor- culture and is therefore pro- cause unintended nutritional mous potential to impact on poor.7 Agriculture-led growth has harm. Nutritional status of factors that constrain human household members is strongly influenced by clean water, dis- ease occurrence, food quality, and child care practices. Several unintended but related conse- quences, such as reducing- women’s available time for child care, have been documented as arising from some agricultural in- terventions. Possible harms and mitigation strategies are in- cluded at the end of this module (see Table C-2). 7 World Bank. 2008. World Development Report 2008: Agriculture for Development. 8 Webb P. and S. Block. 2011. Support for agriculture during economic transformation: Impacts on poverty and undernutrition. PNAS, www.pnas.org/cgi/doi/10.1073/pnas.0913334108. CHAPTER - C | Improving Nutrition through Agriculture IV. Why is nutrition im- reach the goal of improving the mined that every one percent in- well-being of farmers and poor crease in height is associated portant for agriculture? people living in rural areas. with a four percent increase in agricultural wages.11 Iron defi- The linkage between agriculture b. Nutrition investments improve ciency anemia results in lower and nutrition has reciprocal bene- human capital and have a posi- work capacity.12 In an agricultural fits. Improving nutrition can benefit tive impact on agricultural pro- context, anemia has been shown agricultural sector performance at ductivity. Smallholder farmers to reduce productivity by 17 per- least in the following four ways. are often among the populations cent.13 Overall, malnutrition di- most likely to be malnourished. minishes lifetime earnings by 10 a. Improved nutrition means im- percent or more, and reduces Women smallholder farmers, proved smallholder well-being. GDP by 2-3 percent in the worst who form a majority of the agri- Reducing malnutrition among cultural labor force in many affected countries.14 Investments the world’s most vulnerable peo- cases, are disproportionately in human capital, including nutri- ple is core to the World Bank’s likely to be malnourished. Under- tion, consistently have been mission of poverty reduction and nutrition accounts for 11 percent shown to increase productivity.15 core to agriculture’s role of re- of all DAlYs lost globally, and up ducing poverty and improving to a quarter of DAlYs in countries c. Nutrition knowledge may be an well-being of vulnerable farmers with high mortality.9 This is nat- added incentive to transition to in the “three worlds of agricul- urally reflected in lost agricul- a diversified production model. ture,” presented in the WDR tural productivity. Evidence Transition of households to di- 2008, i.e., agriculture-based, shows that when farmers are versified production is an oft- transforming, and urbanized. malnourished, they are less pro- cited goal for the agricultural When agriculture projects im- ductive.10 One analysis deter- sector to raise household in- prove nutrition, they more fully come, minimize risk exposure, 9 Black, R.E., Allen, l.H., Bhutta, Z.A., Caulfield l.E., de Onis, M., Ezzati, M., Mathers, C. J. Rivera et al. 2008. Maternal and child undernutrition: global and regional exposures and health consequences. lancet 371:243-60; World Health Organization. 2002. World Health Report 2002: Re- ducing Risks, Promoting Healthy life. Geneva: WHO. 10 D.E. Sahn. “The impact of poor health and nutrition on labor productivity, poverty, and economic growth in Sub-Saharan Africa,” in The African Food System and Its Interaction with Human Health and Nutrition, P. Pinstrup-Andersen, ed. (Ithaca, NY: Cornell University Press/UNU Press); McNamara, P.E., Ulimwengu, J.M., and K.l. leonard. 2010. Do Health Investments Improve Agricultural Productivity? International food Policy Research Institute Discussion Paper. 11 Haddad, l.J., H.E. Bouis. 1991. The impact of nutritional status on agricultural productivity: wage evidence from the Philippines. Oxford Bulletin of Economics and Statistics 53(1): 45-68. 12 Haas J.D, Brownlie, T. 2001. Iron deficiency and reduced work capacity: A critical review of the research to determine a causal relationship. J Nutrition 131: 676S-690S. 13 Basta, S.S., Soekirman, Karyadi, D., and N.S. Scrimshaw. 1979. Iron deficiency and productivity of adult males in Indonesia. American Journal of Clinical Nutrition 32, 916-925. 14 Harold Alderman. 2005. “linkages between Poverty Reduction Strategies and Child Nutrition: An Asian Perspective.” Economic and Political Weekly 40 (46):4837–42; World Bank. 2006. Repositioning Nutrition as Central to Development, http://siteresources.worldbank.org/NUTRI- TION/ Resources/281846-1131636806329/NutritionStrategy.pdf. 15 World Bank, 2008. World Development Report 2008: Agriculture for Development. 16 for example, a Kenyan CSO (farm Concern International) won a World Bank CGAP award for its approach of nutrition-focused marketing of Afri- can leafy vegetables, driving up the value of these horticultural products 213 percent in five years and substantially increasing incomes and inter- est among farmers interested in growing them. C. Irungu. 2007. “Analysis of markets for African leafy vegetables within Nairobi and its environs,” Global facilitation Unit for Underutilized Species (GfU); Ewbank, R., Nyang, M., Webo, C., and R. Roothaert. 2007. “Socio-Economic Assessment of four MATf-funded Projects,” fARM-Africa Working Paper No. 8, http://www.farmafrica.org.uk/smartweb/news-views/re- sources/4. 17 International food Policy Research Institute. 2011. Agriculture, Nutrition, Health: Exploiting the links. Washington, D.C.: IfPRI. CHAPTER - C | Improving Nutrition through Agriculture and promote ecosystem re- Most Bank agriculture projects productive resources as men, silience. Nutrition education and measure women’s participation they could increase yields on information can be leveraged to in projects as an indicator of gen- their farms by 20-30 percent, improve both supply and de- der equity. Retaining female par- raising total agricultural output mand for high-value vegetables, ticipation may improve if in developing countries by 2.5-4 fruits, legumes, fish, and live- agriculture projects adopt a nu- percent, and reducing the global stock products. Nutrition knowl- trition lens. Apart from their number of hungry people by 12- edge among farmers could be an livelihoods, women farmers’ 17 percent.19 By implementing additional incentive for farmers main time demands come from programs so women can fulfill to diversify their production infant and child care and feed- their multiple roles, agriculture model to include nutritious, ing. Agricultural projects that do projects can achieve a triple win: high-value crops, beyond the not account for women’s major they can become more nutrition- widely recognized incentives to role in child care are likely to see sensitive (to the feeding and care reduce risk exposure to weather, female participation in projects needs of children and mothers), biotic stress, or price shocks. Ad- flag. Structuring programs so while improving gender equity ditionally, nutrition knowledge women with small children can and concomitantly agriculture among consumers can increase meet care needs for their in- projects’ core productivity objec- demand for high-value nutritious fants/young children can in- tives. products substantially, and in- crease female participation and crease income for farmers who improve project outcomes. If In summary, evidence shows that grow them.16 women had the same access to when agriculture investments have explicit nutrition objectives that d. Adopting a nutrition lens is likely to improve women’s participa- tion and empowerment, with im- TABLE C-1. FIvE PATHwAyS LINkING AGRICuLTuRE TO NuTRITION portant effects on income and productivity, in addition to nutri- Pathway Strength of pathway tion and gender equity. Approxi- 1) Increasing overall macroeconomic growth modest effect mately half the world’s farmers 2) Increasing access to food by higher production are women. In some countries, and decreased food prices modest effect the ratio is much higher. In 3) Increasing household income through the sale Southeast Asia, women supply of agricultural products variable effects up to 90 percent of the labor re- 4) Increasing nutrient dense food production for quired for rice cultivation.17 household consumption some evidence Women account for 70 percent of 5) Empowering women through targeted farm labor and perform 80 per- agricultural interventions strong evidence cent of food processing in Africa.18 Gender equity is a corpo- Source: Adapted from World Bank 2007. rate priority of the World Bank 18 Cramer l.K., S.K. Wandira. 2010. Strengthening the Role of Women in the food Systems of Sub-Saharan Africa to Achieve Nutrition and Health Goals. In: The African food System and Its Interaction with Human Health and Nutrition, P. Pinstrup-Andersen, ed. (Ithaca, NY: Cornell University Press/UNU Press). 19 fAO 2011. The State of food and Agriculture 2010-11, Rome, as quoted in WDR 2012. CHAPTER - C | Improving Nutrition through Agriculture are tracked and measured over the A. Pathway 1. National relation between child underweight project’s lifetime, positive impacts macroeconomic growth with agricultural GDP (adjusted for can be expected for both nutrition the size of the agricultural popula- and agriculture outcomes. Economic growth from agriculture tion).25 Some longitudinal analyses has a modest effect on undernutri- report no significant correlation be- tion.21 tween annual economic growth and V. Pathways from reductions in stunting.26 In India, states with rapid agricultural growth agriculture to nutrition A recent longitudinal analysis found between 1992 and 2005 showed in- that agricultural per capita income and available was more strongly associated with consistent changes in undernutrition evidence stunting reductions than non-agricul- during the same period; while over- Agriculture can impact nutrition tural income presumably, because all, the correlation appeared positive. outcomes to varying degrees growth from agriculture benefits the Some states showed no improve- through several pathways,20 some poor more than growth from other ments in stunting or underweight, of which are stronger than others sectors.22,23 Absolute reductions in and in one state, there was an (see Table C-1). Evidence to date has stunting were nonetheless modest; a increase in underweight in women.27 shown that among the five main doubling of per capita agricultural in- Overall, the effect of GDP growth pathways, household consumption come was associated with approxi- on undernutrition appears stronger and women’s empowerment (includ- mately a 21 percent decline in from agriculture rather than non- ing control of economic resources) stunting.24 A World Bank analysis agriculture growth, but the effect is are the closest links to nutritional shows a similar magnitude of effect, quite modest regardless. further status and yield the greatest results. with a 15 percent reduction in stunt- information on the relationship ing and an 11 percent reduction in un- between economic growth and derweight from a doubling of total undernutrition can be found in GDP (see Module B). figure C-1 below Module B of this guidance note. shows the lack of cross-sectional cor- 20 There are various ways of categorizing the agriculture-nutrition pathways depending on the level of detail. World Bank (2007) uses five path- ways, while IfPRI identifies four pathways (excluding macroeconomic growth). TANDI (2010) spells out seven pathways, which are essentially the same as those listed here (excluding macroeconomic growth), but disaggregated in greater detail. Pathway 3, listed here, is split into two separate path- ways (one pathway linking household income, food expenditures, and nutrition outcome, and another pathway linking house- hold income, non- food expenditures, health status, and nutrition outcome), and Pathway 5 is split into three functions of women’s empower- ment. 21 Stunting (short height-for-age) and underweight (low weight-for-age) are two different indicators of undernutrition; estimates of the effect of GDP change have been made for both indicators. 22 At the same time, obesity prevalence increased at a greater rate with agricultural than non-agricultural growth. 23 Webb, P. and S. Block. 2011. Support for agriculture during economic transformation: Impacts on poverty and undernutrition. PNAS, www.pnas. org/cgi/doi/10.1073/pnas.0913334108. 24 This estimate was lower (about 15 percent reduction from a doubling of agricultural GDP in the range of low-middle-income countries) when con- trolling for overall income per capita 25 In India, which accounts for about one-third of the global population of malnourished children, strong agricultural growth has resulted in reduc- tions in malnutrition. Despite great increases in food production, due to the Green Revolution from 1965 to the early 1980s, child malnu- trition rates did not drop concomitantly. In fact, malnutrition rates in India continue to stagnate at unacceptably high levels today (nearly half of all children are stunted, 48 percent). In contrast, most African countries—despite continuing challenges in food security and agriculture— have lower rates of child malnutrition compared with most South Asian countries (albeit the absolute rates are still high). 26 As reported in “A life free from Hunger,” Save the Children UK, 2012. 27 Gillespie, S. and S. Kadiyala. 2012. “Exploring the Agriculture-Nutrition Disconnect in India,” in S. fan and R. Pangya-lorch, eds. Reshaping Agricul- ture for Nutrition and Health. Washington, DC: International food Policy Research Institute. CHAPTER - C | Improving Nutrition through Agriculture FIGuRE C-1. CROSS-COuNTRy LINk BETwEEN AGRICuLTuRAL GDP AND CHILD uNDERwEIGHT 50 45 Yemen India 40 Madagascar Burundi Ethiopia Eritrea % underweight (children < age 5) 35 Somalia Pakistan Lao PDR Cambodia Myanmar 30 Central African Republic DR Congo 25 Sri Lanka Togo Mauritania Guinea Papua New Guinea Guatemala Philippines Haiti 20 Namibia Tanzania, United Indonesia Repblic of Uganda Equatorial Guinea Guinea-Bissau 15 Bhotan Congo Morocco Suriname Botswana Gahon Dominican Republic 10 Panama El SalvadorEcuador Egypt Honduras Columbia Peru Uzbekistan JordanUruguay Kazakhstan Mexico Mongolia 5 Kyrgyzstan Paraguay 0 500 1000 1500 2000 2500 3000 Agricultural GDP of the agricultural population ($ constant 2000 prices) Source: State of the World’s Children, UNICEF 2009; FAO Statistical Yearbook 2009. B. Pathway prices due to increased production, foods needed for healthy and active 2. Higher food production, increased efficiency in marketing lives.28 When food is interpreted as lower food prices channels, or a reduction of distortive equivalent to calories, the connec- policy measures, including trade tion to nutrition is weak.29 Increasing food calorie availability policies, etc. Reduced food prices is a blunt tool to address food raise relative household income for National calorie supply is corre- security and nutrition. net-consumer households, which in lated with reduced undernutrition theory would better economic access but is not deterministic. A multi- various agricultural technology in- to food or health care, as discussed country descriptive analysis shows terventions, if effectively imple- in Pathway 3. It is important, how- that per capita calorie supply (includ- mented, will result in reduced food ever, that “food” is understood as all ing imports) is correlated with re- 28 It is important, however, that “food” is understood as all foods needed for healthy and active lives.[footnote] When food is interpreted as equivalent to calories, the connection to nutrition is weak. 29 fAO defines “food security” as “a situation that exists when all people, at all times, have physical and economic access to sufficient, safe and nutri- tious food that meets their dietary needs and food preferences for an active and healthy life, fAO 1996: World food Summit Declaration and Plan of Action. Rome. CHAPTER - C | Improving Nutrition through Agriculture duced undernutrition, especially at those with the highest child stunting C. Pathway 3. Increased the lowest daily per capita energy rates.31 Some provinces leading the income supplies (below 2,300 kcal/ per- rice export expansion had a lower re- son).30 While the trend is significant, duction in malnutrition than Increasing household income has the variance is striking: at that level provinces where rice production de- variable effects on nutrition. of calories, underweight rates span a clined as land was shifted into horti- range from approximately 10 percent culture and aquaculture. on average, poverty and undernu- to 70 percent. The correlation be- trition are correlated, and move- tween calorie supply and undernutri- one factor in the disconnect ment out of poverty is important tion within Sub-Saharan Africa between food production and for improved nutrition. In fact, the appears weaker than in other re- nutritional outcomes may be the ultimate higher-level objective of gions. As noted above, of the coun- persistent practice of defining and most agricultural projects is to tries meeting the MDG1 target to measuring food as calories, in- improve the beneficiaries’ overall halve hunger, fewer than 1/3 are on stead of focusing on the diversity well-being, especially their house- track to meet the MDG1 target to of foods needed for a healthy and hold income. Higher household halve undernutrition, showing the active life.32 for low-income coun- incomes have the potential to limited translation of national-level tries, most research to date on price improve nutrition outcomes, mainly calorie availability to nutritional im- elasticities of demand has focused by increasing the households’ ability provements. on calories, and therefore has not to purchase and consume foods that provided information on the effects are more nutritious and/or to pay limited associations between sta- of relative price changes of nutrient- for more and better health care to ple crop production and nutritional dense foods or other factors, such as improve the household members’ status have been observed within disease patterns. One recent study health. countries. for example, in Vietnam, a shows that prices of non-staples in- major rice exporting country, 36 per- creased substantially more than The evidence, however, shows that cent of children are stunted, and 19 starchy staples in Central Java during household income does not neces- percent are underweight. A World the food price crisis in 1999. These sarily lead to improved nutritional Bank-funded analysis from the price increases were accompanied by status of its most vulnerable mem- Mekong Delta in Vietnam showed strong reductions in the consumption bers.34 In a particularly striking ex- that the provinces with the highest of meat, fish, vegetables, fruit, eggs, ample, 40 percent of children in rice production levels were precisely and milk.33 Ethiopia are stunted, even in the wealthiest quintile (see figure C-2).35 In India, similarly high stunting rates 30 Smith, l.C. and l. Haddad. 2000. Explaining child malnutrition in developing countries: among the highest income quintile A Cross-Country Analysis, International food Policy Research Institute, Washington, D.C. have declined only marginally and 31 World Bank 2011. Unpublished draft report. Vietnam’s Mekong Delta Region: Malnutrition Amongst Plenty. Can Tho University. remain at about 25 percent, despite 32 Other factors in this disconnect may be the gap between production, consumption, and rapid economic growth.36 Module B utilization of food by the body, e.g., due to non-food factors such as disease. of this guidance note shows many 33 Skoufias, E., Tiwari, S., H. Zaman . 2011. Can we rely on cash transfers to protect dietary country examples where poverty diversity during food crises? Policy research working paper 5548. World Bank. reduction is not accompanied by a re- 34 World Bank. 2006. Repositioning Nutrition as Central to Development, http://siteresources.worldbank.org/NUTRITION/Resourc- es/281846-1131636806329/ duction in malnutrition. NutritionStrategy.pdf. 35 Reproduced from the World Bank Nutrition Country Profile for Ethiopia, www.worldbank.org/nutrition/profiles. 36 India National family Health Survey (NfHS-3), India, 2005-06. Mumbai: International Institute for Population Sciences; Calverton, Maryland, USA: ICf Macro. CHAPTER - C | Improving Nutrition through Agriculture sign of agricultural projects, includ- FIGuRE C-2. ETHIOPIA: PREvALENCE OF STuNTING AMONG CHILDREN ing which commodities are the focus uNDER 5 (By INCOME quINTILE) and who is able to sell those, can have a strong affect on women’s re- Richest source control.40,41,42 fourth D. Pathway Middle 4. Home consumption Second Increasing nutrient dense food production for home consumption Poorest shows some evidence of improving diets and micronutrient status. 0 10 20 30 40 50 60 Prevalence of Stunting Among Children under 5(%) In households that consume at least some of what they produce, Source: DHS 2005. Reproduced from the World Bank Nutrition Country Profile for Ethiopia.37 an increase in production can di- rectly affect the diet and nutri- tional status of household members. Evidence indicates that di- Empirical evidence shows limited crease, how much of the increased etary impacts differ based on the nutrition impact for households income was controlled by women, type of food the household produces. with increased incomes through and the changes in relative prices. That is, the effect of production on commercial agriculture. A World diet cannot be explained by the Bank review of the literature (2007) when evaluating the impact of in- foods’ monetary value alone. This concludes: “Overall, cash-cropping come on nutrition, available evi- pathway is particularly important in schemes (whether staple crops or dence shows that it is important to contexts where market access is lim- other) did not have a significant im- look not just at the household level ited and households routinely de- pact—negative or positive—on child but also at gender-disaggregated pend on self-production for some nutritional status.” However, house- data. Women’s access to income is components of their diets. The best hold incomes generally improved in strongly correlated with improved nu- evidence for nutritional effects of in- alignment with the primary goals of trition in many settings.38,39 It may creased production for home con- the cash crop projects. Consumption seem that intra-household resource sumption is found from increasing effects were variable and depended allocation is beyond the scope of small-scale production of nutrient- on the amount of the income in- project planning – but in fact, the de- dense foods. 37 www.worldbank.org/nutrition/profiles 38 Often, there are time-income trade-offs on nutritional status outcomes as well; both maternal time and maternal income are shown to be impor- tant for nutrition. 39 UNICEf 2011. Gender Influences on Child Survival, Health, and Nutrition: A Narrative Review. UNICEf and liverpool School of Tropical Medicine.; Smith, l.C., Ramakrishnan, U., Ndiaye, A., Haddad, l., R. Martorell. 2003. The Importance of Women’s Status for Child Nutrition in Developing Countries. IfPRI Research Report 131. Washington, D.C.: IfPRI. 40 One negative example comes from The Gambia, where a large-scale rice irrigation project resulted in higher total income for beneficiary house- holds, but in reduced equity of labor and resource control: women’s discretionary income decreased, while their labor commitment increased. Conversely, a dairy farming intervention in Kenya resulted in significant shares of income accruing to women. 41 J. Dey. 1981. “Gambian Women: Unequal Partners in Rice Development Projects,” Journal of Development Studies 17 (3). 42 Mullins, G., Wahome, l., Tsangari, P., and l. Maarse. 1996. “Impacts of Intensive Dairy Production on Smallholder farm Women in Coastal Kenya,” Human Ecology 24 (2): 231–53. CHAPTER - C | Improving Nutrition through Agriculture Increasing nutritious food produc- prove nutrition found that with very amount of death and disability.48 tion can be achieved in three dis- few exceptions, home garden pro- Seasonality of nutrient-dense food tinct ways: grams increased the consumption of production can be important, as they fruit and vegetables; aquaculture and are typically much more perishable a. Adding the production of specific small fisheries interventions in- than staple grains.49 low-stock sea- nutrient-dense foods, such as creased the consumption of fish; and sons affect child growth and cyclical fruits and vegetables, fish, and dairy development projects increased malnutrition rates through both livestock; the consumption of milk.44 In con- caloric and micronutrient depriva- texts where diets are heavily starch- tion. b. Increasing nutritional content of based, consumption of these the food produced, e.g., through nutritious foods is very likely to move Nutrition education enhances dietary crop biofortification, mineral fer- dietary patterns closer to those rec- consumption effects, as well as po- tilization, and industrial food for- ommended globally and by many tential for consumer demand. While tification;43 countries.45 There is some evidence increased production of nutritious that consumption of these foods in- foods may have some independent c. Improving the preservation of nu- creased micronutrient intakes and impact on dietary consumption and tritious food for year-round ac- status, especially vitamin A.46 Stud- micronutrient status, the evidence cess and to eliminate seasonal ies that have examined the connec- shows that nutrition education food shortages. tion between crop diversity and around those foods strongly en- dietary diversity among smallholders hances the effect.50 A review of food- Evidence supports the connection have found positive correlations.47 based approaches to reduce iron and between crop diversification, di- Biofortified crops have also been vitamin A deficiency found that only etary quality, and micronutrient demonstrated to improve vitamin A those food-based interventions with status. A recent DfID-funded review and iron intakes – alleviating two of education, social marketing, or mass of agricultural interventions to im- the deficiencies causing a large media demonstrated impact on nutri- tional outcomes.51,52 43 Biofortification is a method of breeding crops to increase their nutritional value. Biofortification differs from ordinary fortification (or industrial food fortification) because it focuses on making plant foods more nutritious as the plants are growing, rather than having nutrients added to the foods when they are being processed. Major organizations involved in biofortification include a CGIAR program called HarvestPlus (www.harvest- plus.org mainly focused on Africa and Asia), and AgroSalud (www.agrosalud.org focused on latin America). IRRI is also involved in the biofortifi- cation of rice. 44 Masset, E, Haddad, l., Cornelius, A., J. Isaza-Castro. 2012. “Effectiveness of agricultural interventions that aim to improve nutritional status of chil- dren: systematic review.” BMJ, v.344. Open access, available at http://www.bmj.com/content/344/bmj.d8222. 45 fAO repository of food-based Dietary Guidelines, http://www.fao.org/ag/humannutrition/nutritioneducation/fbdg/en/. 46 Masset, E., Haddad, l., Cornelius, A., J. Isaza-Castro. 2012. “Effectiveness of agricultural interventions that aim to improve nutritional status of children: systematic review. BMJ, v.344. Open access, available at http://www.bmj.com/content/344/bmj.d8222; leroy, J. and E.A. frongillo. 2007. “Can interventions to promote animal production ameliorate undernutrition? J Nutr 137: 2311-16. 47 Remans, R., flynn, D.f.B., DeClerck, f., Diru, W., J. fanzo et al. 2011. “Assessing Nutritional Diversity of Cropping Systems in African Villages.” PloS ONE 6(6): e21235. doi:10.1371/journal.pone.0021235; A. Herforth. “Promotion of Traditional African Vegetables in Kenya and Tanzania: A Case Study of an Intervention Representing Emerging Imperatives in Global Nutrition” (Ph.D. diss. Cornell University, 2010); Torheim, l.E., Ouattara, f., Diarra, M.M., Thiam, f., Barikmo, I., Hatloy, A. and A. Oshaug. 2004. “Nutrient adequacy and dietary diversity in rural Mali: Associ- ation and determinants,” European Journal of Clinical Nutrition 58, 594–604. doi:10.1038/sj.ejcn.1601853. 48 low, J., Arimond, M., Osman, N.,Cunguara, B., Zano, f. and D. Tschirley. 2007. “A food-Based Approach Introducing Orange-fleshed Sweet Po- tatoes Increased Vitamin A Intake and Serum Retinol Concentrations among Young Children in Rural Mozambique,” Journal of Nutrition 137; Haas, J.D., J.l. Beard, l.E. Murray-Kolb, A.M. del Mundo, A. felix, G.B. Gregorio. 2005. “Iron-biofortified rice improves the iron stores of non- anemic filipino women,” Journal of Nutrition, 135: 2823-2830. 49 World Bank. 2007. Pathways from agriculture to nutrition: Pathways, Synergies and Outcomes, http://siteresources.worldbank.org/ExTARD/Re- sources/final.pdf; M. Ruel. 2001. “Can food-Based Strategies Help Reduce Vitamin A and Iron Deficiencies? A Review of Recent Evidence,” food Policy Review 5. International food Policy Research Institute. 50 World Bank. 2007. Pathways from agriculture to nutrition: Pathways, Synergies and Outcomes, http://siteresources.worldbank.org/ExTARD/Re- sources/final.pdf; Berti, P.R, Krasevec, J. and S. fitzgerald. 2004. “A review of the effectiveness of agriculture interventions in improving nutri- tion,” Public Health Nutrition 7 (5): 599-609. 51 These studies have focused on household-level production and consumption; the effect of price changes on consumption of nutritious foods in the absence of education has not been well studied in low-income contexts. However, nutrition education also has been shown to affect allo- cation of household food budgets and to reduce price elasticity of demand for foods rich in micronutrients (Block 2003). 52 M. Ruel. 2001. “Can food-Based Strategies Help Reduce Vitamin A and Iron Deficiencies? A Review of Recent Evidence,” food Policy Review 5. International food Policy Research Institute. CHAPTER - C | Improving Nutrition through Agriculture E. Pathway 5. Women’s empowerment Empowering women shows strong evidence for improving nutrition. Strong evidence indicates that im- proving women’s status, particu- larly when combined with nutrition education, results in positive nutri- tion impact. A multi-country analysis found that improvements in women’s status and education were responsi- ble for over half of the reductions in women has a significantly greater bies may be relegated to child sib- child underweight from 1970-1995.53 positive effect on child nutrition and lings (usually older girls), children Women’s low status and decision- household food security than income may be breastfed less often, time for making power in South Asia is a large controlled by men.54 Projects that in- food preparation may be limited re- part of the explanation for the “Asian crease the likelihood that women are sulting in less nutritious diets, family enigma” of higher undernutrition able to control resources accruing members may be less likely to access rates, despite greater economic from their labor—through inclusion health services, other agricultural growth, than in Sub-Saharan Africa. of training and market opportunities production may suffer, and women Since gender, like nutrition, is not a for crops and animal products women may avoid off-farm income-earning sector, the chance of improving sell, for example—improve gender opportunities.55 Excessive maternal women’s status and gender equity equity and are likely to improve nutri- activity during pregnancy may also rests in practice with other sectors. tion as well. result in increased risk of poor birth Among all aspects of women empow- outcomes.56 Time- intensive projects erment, the most relevant for nutri- Reducing time and labor con- may also come at the expense of tion are (i) increasing women’s straints. A careful balance needs to other income-generating activities access to and control over re- be struck between nutritional gains that would result in women’s control sources—primarily incomes, and (ii) from improved incomes and potential of income, the importance of which is reducing time constraints. losses from increased time burden. addressed above. This points to a Agriculture projects that increase the need for timesaving and productivity- time or labor required from women enhancing technologies for gender- Increasing women’s discretionary can have unintended negative conse- specific tasks carried out by women incomes. A large body of evidence quences. When affordable child care (e.g., weeding and food processing). across many regions consistently finds that income controlled by services are unavailable, care of ba- 53 Smith, l.C. and l. Haddad. 2000. Explaining child malnutrition in developing countries: A Cross-Country Analysis, International food Policy Re- search Institute, Washington DC. 54 UNICEf 2011. Gender Influences on Child Survival, Health, and Nutrition: A Narrative Review. UNICEf and liverpool School of Tropical Medicine. 55 N. Ilahi. 2000. The Intra-household Allocation of Time and Tasks: What Have We learnt from the Empirical literature? Policy Research Report on Gender and Development, Working Paper Series No. 13. Washington, D.C., World Bank Development Research Group; Blackden, C.M., and Q. Wodon. 2006. “Gender, Time Use, and Poverty in Sub-Saharan Africa: Introduction,” in Gender, Time Use, and Poverty in Sub-Saharan Africa eds. C.M. Blackden and Q. Wodon. World Bank Working Paper No. 73 (Washington, D.C.: World Bank), 1-10. 56 Rao S., Kanade, A., Margetts, B.M., Yajnik, C.S., lubree, H., Rege, S., Desai, B., Jackson, A., C.H.D. fall. 2003. “Maternal activity in relation to birth size in rural India.” The Pune Maternal Nutrition Study. European Journal of Clinical Nutrition 57: 531–542; Pitchaya, T., Geater, A., Virasakdi, C., K. Ounjai. 1998. “The Effect of Heavy Maternal Workload on fetal Growth Retardation and Preterm Delivery: A Study among Southern Thai Women,” Journal of Occupational & Environmental Medicine 40 (11):1013-1021; Barnes, D.l., Adair, U.S., Popkin, B.M., 1991. Women’s Physical Activity and Pregnancy Outcome: A longitudinal Analysis from the Philippines. International Journal of Epidemiology 20 (1): 162-172. CHAPTER - C | Improving Nutrition through Agriculture VI. Systematic review only one documented an impact The review underscores important on stunting. The authors note gaps in the evidence and lessons results and knowledge that stunting rates are slower to for future studies. There is a strong gaps change and most studies likely need for more well-designed analy- Systematic reviews show few well- were not of sufficient duration to ses of the impact of agricultural inter- designed evaluations to measure observe a change. ventions on nutrition to inform the impact of agriculture on nutri- program decisions. The systematic tional status, but they do show • A meta-analysis of four studies review suggests that future studies some impact on intermediate out- that measured vitamin A status— should better measure intermediate comes, such as diet and incomes. based on interventions designed outcomes, such as dietary intake, di- One of the most thorough reviews of to increase vitamin A rich food in- etary diversity, and incomes, and the nutrition impact of agricultural take—found an overall significant only attempt to analyze agriculture’s projects, which explicitly target nutri- positive impact. effect on nutritional status when tion outputs, is the recent DfID- sample sizes and study designs per- funded systematic review.57 The • Most studies (19 of the 23) found mit adequate power. review found only a small set of stud- a positive impact on diet compo- ies from which to summarize the sition, based mostly on con- evidence, because too few well- sumption of the foods produced, designed studies exist to draw any although typically, the total diet Cost-effectiveness strong conclusions about agricul- was not assessed. Several stud- ture’s impact on nutritional status. ies also found positive effects on Cost-effectiveness data is highly The review however did find that agri- income, but income measure- desirable to inform decisions to in- culture had an impact on intermedi- ment and comparison suffered clude nutrition goals in agricultural ate outcomes, such as diet and from methodological weak- projects, but such information is incomes, which the studies were bet- nesses. currently minimal. Two kinds of ter powered to detect. A summary of cost-effectiveness information could the key results of the DfID review is The lack of a stronger demon- be collected. The most useful ap- as follows. strated impact on nutritional sta- proach would be to compare the cost- tus—despite some impact on effectiveness of a nutrition-sensitive • Of the 300+ studies screened,58 diet— is attributable mainly to intervention with a business-as-usual only 23 studies had enough in- methodological issues. first, de- intervention to reach the primary ternal validity to be included in spite ambitious goals, few studies agriculture sector goals of productiv- the review (studies without base- actually measured nutrition impacts, ity and income. To date, this evidence line measurement or a valid com- and measurement was inconsistent is non-existent. parison group were excluded). among those that did. Second, Most of these were evaluations among the studies looked for agricul- The second approach, somewhat of homestead gardening. tural impact, many had methodologi- available is data on the cost-effec- cal problems (such as power and tiveness of an agriculture interven- • Of nine studies that measured sample size) and analytical rigor. tion in reaching nutritional status anthropometry, four showed im- goals. The cost-effectiveness of bio- pact on underweight rates, and fortification has been the most stud- ied among all agricultural 57 Masset, E., Haddad, l., Cornelius, A., J. Isaza-Castro. 2012. “Effectiveness of agricultural interventions that aim to improve nutritional status of children: systematic review,” BMJ; v.344. Open access, available at http://www.bmj.com/content/344/bmj.d8222. 58 The 300+ reviewed studies were all peer-reviewed journal articles. Specific inclusion criteria required that the articles were written after 1990, in English, and that the reviewed intervention (i) took place in a low-income or middle-income country, (ii) aimed to improve child nutritional status through income or diet, and (iii) investigated the impact of an agricultural intervention on at least one of the following: nutritional sta- tus, micronu- trient intake, dietary diversity, income, or program participatio CHAPTER - C | throughAgriculture Improving Nutrition through Agricultureand Rural Development interventions. The 2008 Copenhagen responsibility of filling the gaps left 1. Invest in women: safeguard and Consensus concluded that biofortifi- by poor diets to other sectors. It also strengthen the capacity of cation was the fifth most cost-effec- misses opportunities to improve women to provide for the food tive intervention to advance global farmer well-being and female partici- security, health, and nutrition of their families. welfare. Estimates of cost-effective- pation, among other goals. ness of biofortification are between _________________________ $10-$120/DAlY saved, with The agriculture sector can address benefit:cost ratios of between 50:1 nutrition more fully, which will and 4:1, based on the assumption of likely result in additional gains in 2. Increase access to and the adoption of two biofortified crops productivity, demand for high- year-round availability of in low-income countries of Africa and value products, and household high-nutrient content food. South Asia.59,60 Another analysis esti- well-being. The available evidence mated the cost-effectiveness of bio- indicates four strong principles for _________________________ fortified beans in Nicaragua between action in areas in which agriculture $96-379/DAlY saved.61 has tremendous growth potential. 3. Improve nutrition knowledge among rural households to enhance dietary diversity. VII. Principles for VIII. The World Bank’s nutrition-sensitive agriculture program _________________________ agriculture projects Currently, there are very few agri- To be successful, efforts to maxi- culture projects supported by the 4. Incorporate explicit nutrition mize nutrition impact first need to world Bank that explicitly target objectives and indicators into incorporate nutrition goals explic- nutrition. That is not to say that the project and policy design. itly into the design and implemen- current portfolio of projects do not tation of agriculture projects and contribute to nutrition. They may well policies. The available evidence sug- be doing so. However, any nutrition gests that maintaining the business- effects are often unintentional and as-usual approach focus on consequently their scale, impact or agricultural productivity, economic exact pathway is often undocu- growth, and household-level income mented. has a limited scope for reducing un- dernutrition. The current approach The Bank’s agriculture strategy. misses opportunities that are unique The official strategic framework for to the agriculture sector to enhance the Bank’s agriculture sector is the nutrition, such as improving produc- 2008 World Development Report tion and consumption of foods to di- Agriculture for Development. The re- versify diets, leaving the port suggests a four- pronged ap- 59 The results are described in Horton, Alderman, and Rivera. 2008. Copenhagen Consensus Malnutrition and Hunger Challenge Paper. 60 J.V. Meenakshi et al. 2007. How cost-effective is biofortification in combating micronutrient malnutrition? An ex-ante assessment. HarvestPlus Working Paper No. 2, IfPRI, Washington D.C. 61 S. Perez Suarez. 2010. “DAlYs: a methodology for conduction economic studies of food-based interventions such as biofortification,” in eds. B. Thompson and l. Amoroso, Combating Micronutrient Deficiencies: food-Based Approaches (fAO and CABI International). CHAPTER - C | Improving Nutrition through Agriculture proach to agricultural development According to the world Bank The Bank ’s agriculture program is that should be differentiated across Group’s Agriculture Action Plan organized across five focal areas: the “three worlds of agriculture,” i.e., fY10-12, the world Bank Group has three thematic areas and two cross- agriculture-based countries, trans- committed to double the agricul- cutting across the thematic focal forming countries, and urbanized ture portfolio from an average of areas (see figure C-3). The three the- countries. $4.1 billion during the pre-food cri- matic focal areas are (i) raising agri- sis years of fY06-08 to $6.2-$8.3 cultural productivity, (ii) linking The four policy objectives of the billion in fY10-12. In the post-crisis farmers to market and strengthening World Development Report 2008 are years, the World Bank Group has value chains, and (iii) facilitating as follows: been averaging about $6 billion a agricultural entry, exit, and rural non- year on agriculture and rural develop- farm income. The two cross-cutting a. Improve market access; establish ment operations. This represents a focal areas are (i) reducing risk and efficient value chains, tremendous opportunity to main- vulnerability, and (ii) enhancing envi- stream nutrition-sensitive agricul- ronmental services and sustainabil- b. Enhance smallholder competi- ture, especially since nutrition is not ity. These focal areas will remain the tiveness; facilitate market entry, a sector per se, and the World Bank’s same in the updated Agriculture nutrition lending program is signifi- Action Plan being developed for c. Improve livelihoods in subsis- cantly smaller.62 fY13-15. tence agriculture and low-skill rural occupations, d. Increase employment in agricul- FIGuRE C-3. FIvE FOCAL AREAS OF ture and the rural non-farm econ- THE BANk’S AGRICuLTuRE PROjECTS omy; enhance skills. Raise Link farmers Facilitate Nutrition is mentioned specifically agricultural as an approach under the third pol- agricultural to market & productivity strengthen entry, exit & rural icy objective: “… improving the nutri- non-farm income tional value of foods produced for value chains home consumption.” This is only one of the possible ways that agriculture Reduce risk and vulnerability (cross-cutting) can improve nutrition, and even for this objective Bank projects have only addressed it indirectly. The Enhance environmental services and sustainability (cross-cutting) muted stance towards nutrition was mirrored in the follow-up action plan, Source: World Bank Group Agriculture Action Plan 2010-2012. the Agriculture Action Plan 2010- 2012, although the updated version 2013-2015 plan will likely include nu- trition as a cross-cutting “lens” alongside other topics such as cli- mate change, jobs, and gender. 62 IBRD/IDA lending coded to nutrition increased from an annual average of $97 million in fY06-08 to $150 million/year in fY09-11. CHAPTER - C | Improving Nutrition through Agriculture Raising agricultural productivity is FIGuRE C-4. DISBuRSEMENT FOCuS OF AGRICuLTuRE AND the largest focal area of The Bank’s RELATED SECTORS agriculture program. In terms of the relative importance in the portfolio, Agriculture productivity increased from 71 to 76 percent raising agricultural productivity com- Disbursements prises about three-quarters of the disbursement volume in fY10-11 (see fY06-08 fY10-11 figure C-4). Key activities in this the- $2.8 billion annual average $3.3 billion annual average matic area include agricultural tech- nology research and dissemination, water management, land administra- tion, and livestock management. Of this volume, about half was specifi- cally for investments in irrigation and drainage, which includes improving river basin management, strengthen- ing water rights, construction, reha- bilitation and modernization of irrigation and drainage systems, and Productivity Markets Non-Farm improving water use efficiency. A fur- Cross-cutting themes: Roughly 15% of lending (productivity, ther 15 percent of the disbursement markets, non-farm) had a focus on vulnerability and volume in fY10-11 was for the the- environmental sustainability, respectively matic focus area on linking farmers to Source: World Bank Agriculture and Environmental Services Department market. Key activities in this thematic area include expanding market infra- structure, strengthening producer or- Nutrition as a “lens” for IX. Challenges for ganizations, rural finance, and food agriculture. Given the cross-cutting safety. finally, the thematic area fa- nature, nutrition-sensitive agriculture nutrition-sensitive cilitating agricultural entry, exit, and can be incorporated into all of the agriculture at The rural non-farm income comprised World Bank five focal areas of the World Bank’s about 9 percent. Key areas include agriculture program. In this sense, why has nutrition not been improving the rural (non-farm) invest- nutrition is similar to the treatment mainstreamed into agriculture? ment climate, expanding rural (non- of cross-cutting relevant non- Despite the increased awareness of farm) infrastructure, and upgrading agricultural “lenses,” such as mainstreaming nutrition into agricul- skills to prepare rural residents to mi- gender, jobs, climate, smart agricul- tural operations for a more conscious grate out of rural areas. furthermore, ture, and landscape approaches. and direct impact on improving nutri- roughly 15 percent of the total dis- tional outcomes, there are currently bursement in the above three the- very few agriculture projects sup- matic areas had a dual objective of ported by the World Bank that explic- reducing risk and vulnerability and itly include objectives or targets for enhancing environmental services improving nutrition outcomes. The and sustainability, respectively. reasons are many and include the fol- lowing. CHAPTER - C | Improving Nutrition through Agriculture limited evidence base. As summa- lated singular project development low awareness of how food security rized above in the “Systematic Re- objective together with a results interventions can best improve the view Results” section, there are few framework that describes the tar- nutrition of the most vulnerable. The impact evaluations of agricultural in- geted objective of each separate World Bank, as a financial institution terventions explicitly targeting nutri- component leading to achieving the providing recipient executed loans tion.63 Among them, the majority (19) project development objective. Activ- and credits to developing country demonstrated impact on improved ities viewed as overly complex with governments, is especially sensitive consumption of specific nutrient-rich scant evidence of success have little to client demand. Because the major- foods. The few that measured change chance of surviving the layers of re- ity of World Bank operations are not in vitamin A status showed a signifi- view required for a typical project. grants- based, governments would cant positive impact. Only a few Bank staff have expressed concerns be reluctant to take out a loan for an demonstrated impact on child an- that proposing to include nutrition- agricultural activity that cannot thropometry, i.e., stunting, under- sensitive agriculture activities will re- demonstrate a certain level of techni- weight, wasting, mainly due to sult in the project being criticized as cal and financial feasibility. There- methodological weaknesses in most a “Christmas tree project,” a deroga- fore, despite strong evidence to the studies. Another significant gap in tory term for a project that is loaded contrary, nutrition still is considered evidence is the absence of cost- with seemingly novel but untested mainly the domain of the health sec- effectiveness information to meet and unrelated activities that are tor, and very few of the World Bank’s agricultural objectives using a bound to fail. clients have sought to include nutri- nutrition-sensitive approach as tion activities in non-health sector in- opposed to a business-as-usual ap- weak client demand. Insufficient terventions. Nevertheless, there may proach. With competing demands nutrition attention or awareness by be reason to expect some greater de- and a strong focus on results, pro- World Bank staff has been mirrored mand in coming years. Some South posing activities without a strong evi- by Ministries of Agriculture. Undernu- Asian64 and African countries, for ex- dence basis is challenging. trition is an invisible problem largely ample, have begun to treat nutrition because it is unobservable to the as a government-wide priority, espe- Strong accountability and focus on naked eye and not listed on death cially under the SUN movement.65 In- results. As part of its operational certificates as the cause of death. creasing the awareness of food policies, World Bank projects un- The major reasons for the lack of security measured by its quality and dergo a standard appraisal process client demand for nutrition interven- not simply by calories may also that appraises various aspects of tions—despite wreaking dire conse- prompt client requests for food secu- project design, such as fiduciary, quences on human capital and rity programs to achieve a greater technical, financial/economical, and development—are the invisibility of focus on nutrition, for example safeguards. Bank staff are expected stunting and micronutrient deficien- through country plans of the Compre- to demonstrate project linkages with cies (literally called “hidden hensive African Agriculture Develop- relevant country and Bank strategies. hunger”); very low technical nutri- ment Programme (CAADP).66 This is done through a clearly articu- tion capacity in most countries; and 63 Masset, E., Haddad, l., Cornelius, A., J. Isaza-Castro. 2012. “Effectiveness of agricultural interventions that aim to improve nutritional status of chil- dren: systematic review,” BMJ; v.344. Open access, available at http://www.bmj.com/content/344/bmj.d8222. 64 To respond to the prioritization on nutrition by many South Asia countries, the Bank’s South Asia region has developed a region-wide multi- sec- toral nutrition strategy. The South Asia AES unit also manages a trust fund specifically to link agriculture and nutrition called the South Asia food & Nutrition Security Initiative (SAfANSI). SAfANSI is a multi-donor trust fund supported by AusAID and DfID, which seeks to pro- mote coordi- nated efforts within and between countries to improve food and nutrition security in South Asia, www.worldbank.org/safansi. 65 “SUN early riser countries,” which have indicated their interest and commitment to reducing undernutrition, currently include Bangladesh, Benin, Burkina faso, Burundi, Ethiopia, The Gambia, Ghana, Guatemala, Haiti, Indonesia, Kenya, Kyrgyz Republic, laos PDR, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Nepal, Niger, Nigeria, Peru, Rwanda, Senegal, Sierra leone, Tanzania, Uganda, Zambia, and Zimbabwe. 66 Nutrition is covered in the Comprehensive African Agriculture Development Programme (CAADP) under Pillar 3: food Supply and Hunger. Nutri- tion is also the subject of recent and upcoming regional workshops to improve the mainstreaming of nutrition into CAADP plans, e.g., West Africa CAADP Regional Nutrition Programme Development Workshop, held November 9-12, 2011, Dakar, Senegal. CHAPTER - C | Improving Nutrition through Agriculture Inherent difficulties of multisec- their managers. Nutrition needs to be Economics Gender Action Plan toral activities. Given the World viewed by all parties as an integral (GAP) in 2007. Since then, the Bank’s sectoral organization, i.e., factor necessary to improving human Bank has been tracking gender agriculture and rural development in capital and well-being, and the im- mainstreaming across all the- the Sustainable Development Vice portant role played by agriculture in matic areas according to a com- Presidency and nutrition in the achieving this goal must be unam- mon approach established by the Human Development Vice Presidency, biguously understood. SDN, namely including gender and also due to client governments’ analysis and/or gender inclusive structures, it is inherently difficult to consultations, gender-respon- work on multisectoral activities sive design, and gender-respon- across vice presidencies or min- X. Addressing Nutrition sive M&E, or inclusion of at least istries. Therefore, responsible parties one gender-responsive indicator through Agriculture- in the project results framework. or their managers usually have little incentive to work beyond their “core Projects at the World In fY11, gender analysis was car- areas.” They also lack professional Bank ried out in 91 percent of agricul- contacts to easily solicit technical ture (AES) projects, up from 69 support in areas beyond their core percent in the baseline (fY07- mandate or mandatory safeguard re- A. Current status: Mainly 09). Gender-responsive design quirements covering certain environ- through unintentional effects was carried out in 74 percent of mental and social aspects. However, agriculture (AES) projects, up it is worth noting that the Bank’s nu- Some agriculture projects at the from 59 percent. And finally, gen- trition portfolio is much smaller than Bank already address nutrition, al- der-responsive M&E was in- that of AES. IBRD/IDA lending coded beit implicitly and without measur- cluded in 62 percent of to nutrition increased from an annual ing its effect on nutritional agriculture (AES) projects, up average of $97 million in fY06-08 to outcomes (since any nutritional out- from 28 percent. (See Box C-1 for $150 million/year in fY09-11.67 come would be unintentional). The a sample of gender disaggre- project activities affect the four nutri- gated indicators that were used Each of these challenges needs to tion-related goals in a significant in projects approved in fY10 and be addressed to mainstream nutri- way, i.e., invest in women, improve fY11. A full list of projects is tion-sensitive agriculture within nutrition knowledge among rural available in Annex C-2). world Bank operations. Introducing households for enhanced dietary di- nutrition-sensitive agriculture re- versity, and increase access to and These gender elements are all quires a behavioral change to work year around availability of high nutri- assessments at the project de- across silos. This requires sensitiza- ent content food. sign stage. Currently, there are tion or awareness building among all no assessments on gender inte- parties, including Bank clients, coun- a. Invest in women. As part of the gration done for the implementa- try directors, and the rest of the Bank’s commitment to improving tion stage.68 Also, with regards to country management team, Bank its performance on gender and the gender-responsive M&E, the agriculture staff, and development, the Bank adopted indicators currently collected by the Gender Equality as Smart agriculture (AES) projects do not 67 Typical nutrition activities funded by the Bank include the promotion of optimal infant and young child feeding practices (including breastfeeding and complementary feeding), distribution of micronutrient supplements (particularly vitamin A), community-based growth monitoring and pro- motion activities, and capacity building for the implementation of nutrition-specific and nutrition-sensitive interventions (both within and outside of the health sector). Nutrition-sensitive interventions within the health sector (through non-nutrition health projects) include prenatal care activi- ties, malaria prevention and treatment, and HIV prevention and treatment, for example. 68 The Gender in Agriculture Sourcebook, developed jointly by fAO, IfAD, and the World Bank presents good practice examples and considerations across all AES thematic areas. CHAPTER - C | Improving Nutrition through Agriculture fully cover the range of gender empowerment issues that are most critical for nutrition, i.e., (i) women’s access to land and other productive assets, (ii) women’s participation in income generating activities, and (iii) women’s control over cash from agricultural activities.69 Specifically, none of the gender- disaggregated indicators used in projects approved in fY10 and fY11 captured the intra- house- hold allocation of income be- tween men and women, or the dimension of women’s ability to make decisions about purchases. b. Increase access to and year- round availability of high nutri- ent content food. The Bank has were committed to support live- search Corporation (EMBRAPA) in agriculture projects that support stock and fishery related projects partnership with HarvestPlus and “nutritious foods” beyond basic in fY10 and fY11 respectively, its regional affiliate AgroSalud. cereals, e.g., livestock, fisheries, and not all of these projects were As HarvestPlus and other biofor- dairy, fruits and vegetables. targeted to increase access for tification efforts scale up their These projects are typically not smallholders; some were nar- dissemination, the Bank could justified based on their contribu- rowly focused on non-livelihood potentially support national agri- tion to dietary diversity, but aspects such as animal safety. cultural research systems in in- rather on grounds of income di- creasing their role in testing and versification, higher incomes, or However, the Bank has no experi- disseminating these biofortified safety nets (in the case of live- ence to date supporting crops crops. stock). Therefore, analyses of the that have been bred specifically self-consumption rate of sup- to have higher nutritional con- c. Improve nutrition knowledge ported producers (which is how tent, i.e., biofortified crops, such among rural households to en- production support to such sub- as the orange fleshed sweet po- hance dietary diversity. On im- sectors would affect dietary di- tato (OfSP) that has been devel- proving nutrition knowledge, a versity), and other related oped by HarvestPlus (a CGIAR review of approved Project Ap- nutrition indicators are typically program) and disseminated in praisal Documents does not re- absent. In terms of scale, sup- Uganda and Mozambique, or cas- veal how much, if any, is actually port to high nutrient content sava, maize, and other crops70 being financed. This is because foods is not large. for example, developed and disseminated by nutrition education is typically only $146 million and $61 million the Brazilian Agricultural Re- offered as part of a menu in a de- 69 IfPRI, USAID’s feed the future, and Oxford Poverty and Human Development Initiative developed a “Women’s Empowerment in Agriculture In- dex,” which is a composite index of various women empowerment indicators, including women’s control over use of income and access to assets, http://www.ifpri.org/sites/default/files/publications/weai_brochure.pdf. 70 EMBRAPA has developed a biofortification program called BiofORT, which is currently working on eight crops: pumpkin, rice, sweet potatoes, beans, cowpeas, cassava, maize, and wheat. CHAPTER - C | Improving Nutrition through Agriculture nerable households. It would also be important to promote the preserva- tion of some of the cultivated food for home consumption. This is particu- larly true for commercialization proj- ects that emphasize sales to improve incomes, where small amounts con- served for home consumption, partic- ularly by the most nutritionally vulnerable family members, can sig- nificantly improve nutrient intakes. Nutrition-sensitive agriculture for world Bank agriculture projects. Nutrition-sensitive agriculture aims to maximize impact on nutrition out- comes for the poor, while minimizing the unintended negative nutritional consequences of agricultural inter- ventions and policies on the lives of the poor, especially women and young children. As stated earlier, there are numerous guidance notes mand driven setting, such as in B. Taking it further: Addressing developed by other organizations, community driven development nutrition explicitly which attempt to list ways of ad- projects or women empowering The impact of agricultural projects dressing nutrition explicitly through livelihood projects and not as could be greatly scaled up if nutri- agriculture (see Annex E-5). This sec- large predefined investment cat- tion considerations are addressed tion attempts to distill interventions egories. more directly. for example, in an that are particularly relevant for aquaculture project, larger fish may World Bank supported agriculture d. Incorporate explicit nutrition be more profitable to sell at the mar- projects, which are large scale (often objectives and indicators. Be- ket and therefore promoted due to fi- national or covering a large part of a cause there are almost no proj- nancial reasons, but smaller fish are country), government executed, and ects that explicitly target often higher in vitamin A, iron, and on a credit or loan basis (i.e., not nutrition objectives, it is no sur- zinc, since they are consumed whole, grants). They therefore need to be prise that almost no projects in- including the head, organs, and justified on economic/financial clude explicit nutrition bone.71 Therefore, if the project in- grounds using standard economic indicators. To date, no projects tended to improve nutrition, it could and financial rates of return as per include direct nutrition indica- seek to include small fish together Bank appraisal guidelines. tors such as child anthropomet- with the more commercial large fish, rics or food consumption and it should intentionally seek to indicators. improve access among the most vul- 71 Roos, N., Islam, M.M., and S.H. Thilsted. 2003. “Small indigenous fish species in Bangladesh: Contributions to Vitamin A, Calcium, and Iron intakes,” Journal of Nutrition, 133: 11. CHAPTER - C | Improving Nutrition through Agriculture BOx C-1. SELECTED GENDER DISAGGREGATED INDICATORS IN wORLD BANk AGRICuLTuRE (AES) PROjECTS (APPROvED IN Fy10 AND Fy11) The list of suggested activities, which are expected to improve nu- Total number of beneficiaries (for entire project): Direct and indi- trition outcomes, are presented ac- rect project beneficiaries (number), of which female (percentage) in cording to the five focus areas of (Benin, CAR, Chad, Kenya, Mali, Nepal, Sierra Leone, West Africa Regional, Zambia). the world Bank Agriculture Action Plan together with some good prac- Overall household income: Percentage increase in agricultural tices. Given the fact that the Bank income of participating household (disaggregated by male and supports very few nutrition- female headed households*) (India, Uganda). sensitive agriculture projects to date, most of the examples are from a non- women’s access to land and other productive assets Bank context, which the Bank may be • Percent of women with use or ownership land rights registered supporting. The matrix in Annex C-1 (both joint and individual) (India). summarizes this list of suggested ac- • At least 40% of new land titles are provided directly to women tivities, together with suggested out- and/or jointly with their spouse/partner (Nicaragua). put and outcome indicators. To support these activities, nutrition • At least 70% of the modernized registries’ clients (and perspectives should be incorporated 70% of women) rate its services as satisfactory (third level on a four-level scale) (Honduras). into the Bank’s analytical and advi- sory (AAA) work, since these often • Number of water users provided with irrigation and drainage shape or influence project design or services, disaggregated by % female (Azerbaijan, Malawi). the thinking on particular topics. • Number of farmers benefitting from operational community assets, disaggregated by % female. women’s participation in income-generating activities i. Raise agricultural • Percent of women income-generating activities (Djibouti). productivity • Targeted vulnerable groups (women, young people, and land- less) develop related markets and sustainable income-generating Suggested nutrition-sensitive in- activities (AGRs) (Tunisia). terventions: • Percent of rural enterprise participants who are youth (<30yrs old) or women (Jamaica). Promotion of time saving technolo- gies72: Promotion of technologies • Women receive minimum 30% of all productive subprojects that improve productivity and time (Brazil). savings for productive and domestic • At least 30% participating small and medium enterprises (SME) tasks performed by women. WDR and enterprise groups (EG) will have increased direct and/or 2012 shows that for reasons that re- indirect employment by at least 30%. Of these, at least 35% will be women (Afghanistan). main unexplained, even when women contribute a substantial frac- women’s control over cash tion (or in some cases, all) of earned household income, they continue to None be largely responsible for housework and care work. Therefore, realizing * WDR 2012 notes that simply comparing female and male-headed households can exaggerate gender differences, women’s dominant role in this area, because such comparisons fail to account for the number of working-age adults in the household, and the number any technology that would save time of dependents. Not surprisingly, female-headed households with a male present often fare better than those with no male households fare, and in some cases, do as well as male-headed households. Therefore, WDR 2012 suggests the use of a more nuanced categorization of rural households for such indicators to be relevant. Source: World Bank Agriculture and Environmental Services Department. 72 This relates to the nutrition-related goal of “Invest in women,” CHAPTER - C | Improving Nutrition through Agriculture on tasks performed by women would treadle pumps to significantly livery of simple nutrition messages result in more time for women to ded- shorten time that women spend around specific crops via agricultural icate to domestic tasks or income on these activities. extension agents or other technical generating activities. experts.76 This approach can be effec- tive if messages are targeted to the farmers growing the crops, and pack- Potential trade-offs aged together with delivery of seeds Good practice examples 73 • focusing on women’s income or other pertinent information about • Easier to use and lighter farming generation could reduce time the crop. In many contexts, it is nor- tools for tasks typically carried available for domestic tasks in- mal for such a worker to talk to farm out by women, e.g. planting, cluding child care and health households about both food produc- weeding, grinding. care (see Table C-2 for mitigation tion and consumption decisions. considerations during the design Close coordination between agricul- • Plastic drum seeders for direct phase). ture and health sector staff can also seeding instead of broadcasting be effective. Challenges include the or transplanting rice seedlings, • labor-saving technologies could fact that globally, only 15 percent of allowing for mechanized weed- result in loss of employment for extension agents are women, and in ing as seeds are deposited in other workers who were previ- Africa, a mere seven percent.77 Given straight lines. ously performing the time con- the reality that food security and nu- suming task as a laborer. trition messages are most likely to be • Mechanized mills to replace delivered effectively by and to hand pounding or grating (e.g. in Incorporation of a food security women, this poses a challenge, espe- Botswana sorghum mills have re- and nutrition dimension into the cially in contexts where the social duced the time needed to national agricultural innovation norm prevents women from interact- process 20 kg of sorghum from 2- system.74 Depending on the country ing with non-family males. 4 hours to 2-4 minutes). context, this could imply incorporat- Including men in nutrition ing food security and nutrition mod- education, however, is also an • Water and fuel wood collection ules into extension system curricula, important practice. is a time consuming task prima- or increasing access to private tech- rily carried out by women and nical service providers specialized in children. As such, rainwater har- food security and nutrition.75 Several vesting, protected springs, guidance papers on linking agricul- wheelbarrows, donkey carts, ture and nutrition recommend the de- 73 See Module 7 Thematic Note 4 “labor-Saving Technologies and Practices” in the World Bank/fAO/IfAD, “Gender in Agriculture Sourcebook,” for a full discussion on labor saving technologies. 74 This relates to the nutrition-related goal of “Improve nutrition knowledge among rural households to enhance dietary diversity.” 75 In many African countries, home economics extension workers delivered nutrition education and training to rural women in the 1970s. But, many of these workers have disbanded in recent years during the transformation in the agricultural sector that demanded the integration of agricul- tural ex- tension services and required extension staff to deliver diverse services. These gaps typically are filled by NGOs. Given that most home economics extension workers are women, they are likely to be an effective channel to reach rural women. Even in cases where a home economics extension force exists, food security and nutrition modules need to be specifically incorporated and ideally coordinated with seeds and services available from agricultural extension or projects, since the breadth of home economics extension coverage is broad and encompasses all aspects of domestic livelihood. 76 Herforth, A., Jones, A., and P. Pinstrup-Andersen. 2012. “Prioritizing nutrition in agriculture and rural development projects: Guiding principles for operational investments.” World Bank HNP Discussion Paper. 77 World Bank 2012, World Development Report: Gender Equality and Development. CHAPTER - C | Improving Nutrition through Agriculture Good practice examples • The Haiti Re-launching Agricul- cronutrients that are difficult to ob- ture: Strengthening Agriculture tain in adequate quantities from • The success of the biofortified Public Services II Project (RE- plant source foods alone, and rela- OfSP project in Mozambique was SEPAG II) aims to integrate a nu- tively small amounts of these foods due in part to integrated exten- trition module in the training can substantially increase nutrient sion agent pairs of a male agri- curriculum of agricultural exten- adequacy.81 Increasing vegetable and cultural agent and a female sion agents and also to facilitate fruit consumption is important for nutrition agent embedded in vil- the production of nutrient dense providing micronutrients and for lages to conduct group education foods through the use of bioforti- maintaining or increasing healthful sessions on a variety of agricul- fied seeds already present in dietary patterns as obesity and tural and nutrition topics, includ- Haiti, and zinc based fertilizers. chronic disease rates are rising in ing production methods, most developing countries. food storage, marketing, infant and preservation technologies such as young child feeding and hygiene solar drying can reduce seasonality practices.78 Potential trade-offs of fruits and vegetables. • Adding food security and nutri- • A home gardening program in tion training could overload al- India showed consumption and ready overburdened extension nutrition impact when messages workers or technical service were communicated from multi- providers. ple kinds of extension workers, e.g., agricultural extensionists, health workers from India’s inte- Support to increase productivity of grated early childhood program, small-scale nutritious food produc- and village-level workers.79 tion, e.g., livestock, dairy, fish, legumes, fruits and vegetables.80 Most small-scale farmers with market • Kenya’s Ministry of Agriculture access still consume a portion of the maintains a cadre of home eco- food items they grow. Therefore, by nomics extension workers that encouraging farmers to grow nutri- has nationwide coverage. tious foods such as fruits and vegeta- bles, legumes, milk, eggs, fish and • The Tanzania Home Economics meat, the consumption pattern of Association (TAHEA) provides farmers can be affected positively training to farmers on nutrition (particularly if some nutrition educa- and preparation and promotion tion is also included). Animal source of OfSP through agricultural ex- foods can provide a variety of mi- tension services. 78 low, J.W., Arimond, M., Osman, N., Cunguara, B., Zano, f. and D. Tschirley. 2007. “A food-Based Approach Introducing Orange-fleshed Sweet Potatoes Increased Vitamin A Intake and Serum Retinol Concentrations among Young Children in Rural Mozambique.” Journal of Nutrition, 137. 79 I. Chakravarty. 2000. “food-Based Strategies to Control Vitamin A Deficiency.” food and Nutr Bulletin 21: 135-43. 80 This relates to the nutrition-related goal of “Increase year-round access to and availability of high nutrient content food.” 81 See Journal of Nutrition Supplement November 2003, “Animal Source foods to Improve Micronutrient Nutrition and Human function in Developing Countries” for a full discussion on nutritional benefits of animal source foods. CHAPTER - C | Improving Nutrition through Agriculture Good practice examples Potential trade-offs tional content. field-testing and dis- semination of many of these bioforti- • The Bangladesh Integrated Agri- • Subsidized, small-scale live- fied varieties could be included under cultural Productivity Project stock/fishery projects for house- Bank-supported AES projects. So far, funded by GAfSP Trust fund aims hold food security are seldom the OfSP is the only biofortified crop to improve the productivity of se- profitable at the enterprise level. to have been released in Africa or lected horticultural crops (fruits Asia, although a strong pipeline ex- and vegetables), fish and live- • livestock production can have ists for the next several years (see stock. The project will support high negative externality on the figure 5 for the pipeline of biofortifi- the development of backyard environment, particularly in cation crops in Africa and Asia). In poultry through building the ca- larger-scale production. latin America, EMBRAPA has devel- pacity of (women) breeders by oped a strong pipeline of biofortified imparting appropriate training • There is an increased risk of crops, such as cassava, maize, on routine vaccinations and de- zoonotic disease, particularly in beans, etc., in partnership with Har- worming, well-ventilated night larger-scale production (see vestPlus and its regional affiliate shelters, brood management, Table C-2 for mitigation consider- Agrosalud. and animal nutrition. ations during the design phase). Zinc and iodine fertilizers can in- • An agriculture project in South Enhancing capacity of national crease nutrient content of food in Africa provided nutrition educa- agricultural research institutions to areas where soils, and therefore the tion about consuming vitamin A promote the breeding for and dis- foods produced, are low in these im- rich foods, such as orange and semination of developed bioforti- portant human micronutrients. Ap- dark green vegetables, and found fied crop varieties and fortified plying zinc as a fertilizer to the soil that only the households with inputs.83 Biofortified crops use plant- can double or triple zinc content of gardens growing these crops breeding techniques to improve the cereal grains, depending on the crop increased consumption of vita- nutritional content of food with key species and variety.84The effect on min A and showed significantly micronutrients, such as iron, zinc, children’s zinc intakes or anthropom- improved vitamin A status.82 and vitamin A. Some of the bioforti- etry has not been specifically docu- The impact results suggest that fied crops use traditional plant mented. Zinc in fertilizers for AES access to a supply of vitamin breeding techniques, such as the projects is a potential win-win solu- A-rich vegetables was needed crops being developed by Harvest- tion since it can improve agricultural to act on education about nutri- Plus (a CGIAR program), while others productivity and increase zinc con- tious food consumption. use transgenic techniques such as tent of crops thus improving nutri- the Golden Rice being developed by tion, e.g., improving children’s the International Rice Research Insti- growth. fertilization with iodine- tute of the CGIAR. Typically, the most containing irrigation water has also profitable, highest yielding varieties met with great success where imple- are targeted to add micronutrient- mented.85 dense traits so that there are no trade-offs between yield and nutri- 82 faber, M., M.A.S. Phungula, S. Venter, M.A. Dhansay, A.J. Spinnler. 2002. “Homestead Gardens focusing on the Production of Yellow and Dark- Green leafy Vegetables Increase the Serum Retinol Concentrations of 2–5-Year-Old Children in South Africa.” American Journal of Clinical Nutrition 76: 1048–54. 83 This relates to the nutrition-related goal of “Increase year round access to and availability of high nutrient content food.” 84 Rengel, Z., Batten, G.D., and D.E. Crowley. 1999. “Agronomic Approaches for improving the micronutrient density in edible portions of field crops,” field Crops Research 60: 27-40. 85 x.Y. Cao x et al. 1994. “Iodination of irrigation water as a method of supplying iodine to a severely iodine-deficient population in xinjiang, China,” Lancet 344, 107-110. CHAPTER - C | Improving Nutrition through Agriculture FIGuRE C-5. PIPELINE OF BIOFORTIFICATION CROPS FOR RELEASE IN AFRICA AND ASIA CROP NUTRIENT TARGET ADDITIONAL RELEASE (Secondary nutrient) COUNTRY TRAITS YEAR Bean Iron (Zinc) DR Congo, Rwanda Virus resistant, heat & drought tolerant 2012 Cassava Vitamin A DR Congo, Nigeria Virus resistant 2011 Maize Vitamin A Nigeria, Zambia Disease resistant, drought tolerant 2012 Pearl Millet Iron (Zinc) India Mildew resistant, drought tolerant 2012 Sweet Potato Vitamin A Mozambique, Uganda Virus resistant, drought tolerant 2007 Rice Zinc (Iron) Bangladesh, India Disease & pest resistant 2013 Wheat Zinc (Iron) India, Pakistan Disease resistant 2013 Source: HarvestPlus, 2012. Good practice examples and semi-arid regions. The Inter- crops are unlikely to be adopted national Zinc Association (a non- even if they are high in nutritive • from 2007-09, HarvestPlus re- profit organization) and Harvest- value. leased vitamin A-rich OfSP in Uganda and Mozambique; Plus are leading a global zinc fer- 24,000 households were tilizer project with trials going on reached and the adoption was 68 in 20 countries.86 percent, increasing the OfSP ii. Link farmers to market share (among all sweet potatoes) and strengthen value to 47 percent, and increasing vi- Potential trade-offs chain tamin A intake by infants, chil- • fertilizers with micronutrients dren, and women by up to 100 Marketing projects to support may be unaffordable without sig- percent, resulting in improved vi- smallholders’ participation in the nificant subsidy. tamin A status. value chain of nutritious foods, • farmers growing biofortified e.g., vegetables, fruits, dairy, live- • Zinc fortified fertilizers have stock and fish.87 Support to crops may be less likely to mar- shown preliminary results in in- strengthen the marketing or post- ket them successfully without creasing crop yield and also the harvest aspects of nutritious foods significant consumer sensitiza- zinc content of the produced can increase the chance that farmers tion. crops upon human consumption. will grow and consume them, particu- Not only is zinc one of the most larly if combined with some nutrition common deficient micronutrients • Note that yield is typically not a education. Improving market access for humans, it is the most com- trade-off. Biofortified crop lines for nutritious foods provides farmers monly deficient micronutrient in are developed to have competi- additional incentive to produce the agricultural soils, mainly in arid tive yield traits, based on the un- foods, and may involve partnerships derstanding that low-yielding 86 Trials are ongoing in Argentina, Australia, Brazil, Canada, China, Ethiopia, Germany, Guatemala, India, Iran, Kazakhstan, laos, Mexico, Mozambique, Pakistan, South Africa, Thailand, Turkey, Zambia, and Zimbabwe. for more details, see www.harvestzinc.org. 87 This relates to the nutrition-related goal of “Increase year round access to and availability of high nutrient content food.” CHAPTER - C | Improving Nutrition through Agriculture with actors along the value chain • livestock production tends to other common leafy green veg- such as traders and supermarkets. have high negative externality on etables commonly consumed in These interventions can include re- the environment. Malawi. Based on this finding, moving bottlenecks along the value the government developed an in- chain such as reducing post-harvest • food safety standards to reduce digenous knowledge system for loss, improving auxiliary infrastruc- aflatoxin could compromise nutritional plant species, which ture such as roads, storage facilities, farmer profit margin if farmers includes a system of collecting, and wholesale markets, improving have to pay for compliance costs. documenting, and using indige- the availability of market information nous knowledge. or other risk management tools, and • There is an increased risk of strengthening the framework of food zoonotic disease, particularly in • A horticulture project in Kenya, safety standards, e.g., reducing afla- larger-scale production (see Tanzania, Malawi, and Rwanda, toxins. Table C-2 for mitigation consider- implemented by a Kenyan CSO ations during the design phase). (farm Concern International) and supported by BMGf, has sup- Promoting the production, market- ported smallholders’ participa- Good practice examples ing, and consumption of nutritious tion in the commercialization of • The World Bank-supported Haiti indigenous foods, e.g., develop- nutritious traditional African veg- RESEPAG II aims to develop ca- ment of an indigenous knowledge etables. farm Concern Interna- pacity building in food harvest- system.88 Conservation of indige- tional won a World Bank CGAP ing and storage techniques, e.g., nous food plants are often under- award for its nutrition-focused to reduce aflatoxin and improve taken for biodiversity reasons and marketing approach to African food processing techniques methodologies for collecting and an- leafy vegetables, driving up the through capacity building and alyzing them are developed. Among value of these horticultural prod- technical assistance such as for- these indigenous food plants, some ucts 213 percent in five years, tification and food quality con- are particularly rich in micronutrients and substantially increasing in- trol, including laboratory and/or can enhance the bioavailabil- comes and interest among farm- capacity to analyze micronutrient ity of micronutrients in other staple ers interested in growing them.89 contents. crops when consumed together. A “commercial village model” al- lows smallholder groups to mar- ket their vegetables to partnering supermarket chains and other Potential trade-offs Good practice examples urban markets, includes nutri- • Subsidized, small-scale live- • The Ministry of Agriculture in tion education for both farmers stock/fishery projects for house- Malawi identified the Moringa and consumers, and has suc- hold food security are seldom tree as a potential solution to the cessfully increased farmer in- profitable at the enterprise level. country’s vitamin A deficiency comes as well as consumption.90 problem, given its higher nutri- tious content compared to all 88 This relates to the nutrition-related goal of “Increase year round access to and availability of high nutrient content food.” 89 C. Irungu. 2007. “Analysis of markets for African leafy vegetables within Nairobi and its environs,” Global facilitation Unit for Underutilized Spe- cies (GfU); Ewbank, R., Nyang, M., Webo, C., and R. Roothaert. 2007. “Socio-Economic Assessment of four MATf-funded Projects,” fARM-Africa Working Paper No. 8, http://www.farmafrica.org.uk/smartweb/news-views/resources/4. 90 C. Irungu. 2007. “Analysis of markets for African leafy vegetables within Nairobi and its environs,” Global facilitation Unit for Underutilized Spe- cies (GfU); A. Herforth. 2010. “Promotion of Traditional African Vegetables in Kenya and Tanzania: A Case Study of an Intervention Representing Emerging Imperatives in Global Nutrition. Ph.D. diss. Cornell University. CHAPTER - C | Improving Nutrition through Agriculture • A small company in Botswana major cereals such as wheat and rice developing policy guidelines for has received international recog- through an activity to fortify them at both private sector and public nition for its approach to harvest- the national or regional level. sector involvement in fortifica- ing and drying wild fruits rich in tion activities. However, the proj- vitamin C and dietary fiber. It food fortification has a long history ect Implementation Completion processes the wild fruits accord- of use in industrialized countries Report shows that the actual for- ing to HACCP standards for retail, for the successful control of defi- tification process was delayed to buyers such as Air Botswana, ciencies in vitamins A and D, sev- due to disagreement between which provides income to local eral B vitamins, iodine, and iron. the government and the private farmers and pastoralists who fortification can take numerous sector on modalities of imple- harvest the fruit.91 forms from universal fortification mentation including the fortifica- mandated by the law, e.g., folic acid tion processes, type of fortification of wheat flour in Canada, fortificants to be allowed, mi- the US, and many latin American cronutrients premixes to be Potential trade-offs countries to lower birth defects, to used, and development of the • Markets for indigenous foods targeted fortification for vulnerable nutrition policy.94 may be small, therefore limiting groups, market-driven fortification, commercial potential. to household-based fortification, • Some examples of food fortifica- e.g., “sprinkles” and micronutrient- tion in developing countries be- Promotion of regional/national in- rich spreads. However, whatever yond iodized salt include vitamin dustrial food fortification.92 food form it takes, proper government reg- A enriched sugar in Central Amer- fortification refers to the addition of ulation is necessary as part of the na- ican countries and Zambia, iron micronutrients to processed foods, tional food safety and public health fortified fish sauce in Vietnam and is considered a valid technology policies to ensure that the benefits of and China, iron enriched curry for reducing malnutrition when peo- fortification are indeed ensured. powder in South Africa, vitamin A ple cannot consume a balanced diet enriched MSG powder in the adequate in every nutrient.93 In most Philippines, and folic acid en- countries, the Ministry of Health riched wheat flour in Chile. often leads industrial food fortifica- Good practice examples tion. However, fortification typically • The recently closed Second requires the cooperation of the Min- Health Sector Development Proj- istry of Agriculture or food Safety ect in Tanzania included a food Potential trade-offs Agencies, as it relates to the process- fortification component in its ad- • None identified. ing of food. Therefore, although no ditional financing at the specific industrial food fortification has been request of the Ministry of Health done to date, they could be included and Social Welfare. The project in AES projects that support the gov- supported the government’s Nu- ernment’s policy or production of trition and food Commission in 91 Wildfoods (Pty) ltd of Botswana won the 2008 PhytoTrade Africa Natural Product Award, http://www.phytotradeafrica.com/downloads/press/ PhytoTrade_Africa-NP-Awards-Press-Release.pdf. 92 This relates to the nutrition-related goal of “Increase year round access to and availability of high nutrient content food.” 93 for more details on food fortification, see “Guidelines on food fortification with micronutrients,” WHO and fAO, 2006. 94 World Bank. 2011. Implementation Completion Report of the Tanzania Health Sector Development Phase II, World Bank Report Number ICR00001511. CHAPTER - C | Improving Nutrition through Agriculture iii. Reduce risk and to address agriculture and food rooftops, and on roadsides. They are security issues comprehensively, generally close to home and man- vulnerability including nutritious food avail- aged by family members. Their prod- Broaden food security policy dia- ability, access, and utilization. ucts include fruits, vegetables, logue to include nutrition perspec- Building on this, it submitted an herbs, legumes, and sweet potatoes, tives.95 Country demand for projects investment proposal to the and most are grown for household to improve food security often base GAfSP and was competitively consumption. Studies have found discussion on a view equating food awarded a grant of US$46.5 mil- that complementary investments security with national-level grain lion in June 2011. Nepal has also such as nutrition education and tar- stocks. Abundant evidence has developed, again in consultation geting women increase the likelihood shown that this approach alone is un- with relevant development part- of household gardens showing posi- likely to address household food in- ners and stakeholders, a Multi- tive nutritional outcomes.97 Home- security among the most vulnerable. sectoral Nutrition Plan of Action. stead gardens also could be This disconnect is reflected in the These coordination efforts are promoted through rural CDD projects, MDG1 hunger target (which deals likely to attract more planned re- but in such a case, the selection of with national-level calories) and the source allocation from the gov- the actual investment is typically de- MDG1 undernutrition target, dis- ernment and development mand driven and therefore cannot be cussed above. The World Bank has a partners, e.g., the Asian Devel- preselected. role in engaging in food security dia- opment Bank, currently support- logues so that plans would better tar- ing the formulation of a get food insecure households, and twenty-year Agricultural Develop- would ensure that nutritional quality ment Strategy, is likely to follow Good practice examples of food is regarded as part of food se- up with a project on food secu- • The NGO Helen Keller Interna- curity policies. Addressing seasonal rity. USAID is in the process of tional (HKI) started the home- food shortages can serve as an entry launching its feed the future Ini- stead food production program point to achieving the goal of increas- tiative in the mid- and far-west in Bangladesh in 1990, targeting ing year-round production of nutri- regions and has an ongoing 1,000 households with a combi- tious food. Suaahara Program. nation of home gardening and nutrition education. It has since expanded to five countries (Bangladesh, Burkina faso, Cam- Good practice examples Potential trade-offs bodia, Nepal, and the Philip- • Nepal has developed a strong de- • None identified. pines). The original model velopment partnership in the focused on vitamin A rich vegeta- areas of food and nutrition secu- Promotion of nutritional home- bles and fruits such as sweet rity. In 2010, in consultation with stead garden plots with appropri- gourd, black arum leaves, and donors, civil society organiza- ate nutrition education.96 bottle gourd leaves. Because tions and other stakeholders, the Homestead gardens can be in back- given evidence shows lower than Government of Nepal developed yards, containers, small patches of expected bioavailability of a Country Investment Plan (CIP) available land, vacant lots, on pro-vitamin A, HKI has sought to 95 This relates to the nutrition goal of “Incorporate explicit nutrition objectives and indicators.” 96 This relates to the nutrition-related goal of “Increase year round access to and availability of high nutrient content food.” 97 Berti, P.R, Krasevec, J., and S. fitzgerald. 2004. “A review of the effectiveness of agriculture interventions in improving nutrition,” Public Health Nu- trition 7 (5): 599-609; M. Ruel. 2001. “Can food-Based Strategies Help Reduce Vitamin A and Iron Deficiencies? A Review of Recent Evidence.” food Policy Review 5. International food Policy Research Institute. CHAPTER - C | Improving Nutrition through Agriculture include animal husbandry into the broader homestead food pro- duction model. • The Bank’s Civil Society fund Program (CSfP) funded a project in Malawi to promote household gardens for balancing nutritional requirements while improving livelihoods.98 A CSO called lake Malawi Projects (Malawi) imple- mented the project, which demonstrated to the islanders how to make and sustain their own gardens year round, includ- ing training them on what veg- etables and fruits to cultivate, how to conserve soil, and make cal to ensure gender equity in the in which 24 percent of members compost and animal manure. planning, decision-making, and man- were women, despite the initial Other than for home consump- agement process or service provi- gender stereotype that women tion, most of the households on sion. Rural services to enhance non- were unfit for construction work. the islands grow fruits and veg- farm income encompass a wide range Another initiative was the “local etables to generate income to of services, including rural transport, development (financing) win- meet other daily needs. rural energy, ICT, water and sanita- dow” to assist communities in tion facilities, and employment insur- planning, skill development, and ance. seeking funding to support local Potential trade-offs development projects once road access was established. • Subsidized homestead garden schemes could pose a financial Good practice examples • The Asian Development Bank sustainability risk. • The second phase of the Peru supported the Community live- Rural Roads Project, supported stock Development project in by the World Bank and the Inter- Nepal, which recognized that American Development Bank, women contribute about 70 per- iv. Facilitate agricultural was highly recognized by cent of the work in livestock rear- entry, exit, and rural non- the NGO community for its ing. To increase female farm income participatory, inclusive design, participation in technology-re- and implementation with inter- lated training at district and re- Investments to improve opportuni- connected, complementary, gional centers far from their ties for off-farm laborers (espe- gender-informed initiatives. One home and village, the project cially women).99 Given the wide such initiative was the microen- provided child care facilities at range of women’s and men’s needs terprises for road rehabilitation, training sites. for rural non-farm services, it is criti- 98 World Bank website. Vegetable gardening improving livelihoods in Malawi, available from http://go.worldbank.org/W4AGQIYY20. 99 This relates to the nutrition-related goal of “Invest in women.” CHAPTER - C | Improving Nutrition through Agriculture Potential trade-offs supported by the International and protein deficiency, micronu- Development Research Center of trient deficiency or overweight • Reduction in women’s time could Canada and others aims to im- and obesity) in the country or re- reduce quality of care and feed- prove the health, food security, gion where the project or policy ing for infants and young chil- and soil fertility of resource poor will be operating? dren. (See Table C-2 for households in northern Malawi mitigation considerations during through participatory research • Which population groups suffer the design phase.) that tests legume systems.101 The most from these problems, e.g., project has demonstrated some smallholder farm families, land- nutritional outcomes such as less laborers, indigenous nearly tripling the frequency of groups, urban poor, women, chil- v. Enhance environmental legume consumption by young dren? Is it reasonable to expect services and sustainability children, which has led to im- that the project could reach one Rangeland management or soil car- provements in weight and height or more of these groups? bon sequestration projects that in- growth of the children. crease legume production for food • How is the project expected to in- or fodder.100 legumes are an impor- fluence gender-specific time de- tant source of nutrition for both hu- Potential trade-offs mands, e.g., weeding, watering, mans and livestock by providing • Increased land management with marketing, etc.? Are time de- protein, minerals, fiber, and vita- legumes may require more labor. mands for women likely to re- mins. By biologically fixing nitrogen Increases in women’s labor may duce time for child care? If so, in the soil, legumes also provide a reduce time spent on other im- can additional time demands be relatively low-cost method of replac- portant tasks. (See Table C-2 for offset with labor-saving tech- ing otherwise expensive inorganic ni- mitigation considerations during nologies for women? trogen in the soil. Moreover, legumes the design phase.) also improve other soil physical • Who in the household is most properties, provide ground cover and likely to control how the addi- reduce soil erosion, increase soil or- tional income is spent? Can proj- ganic matter, microbial activity, and ect design be adjusted to C. Key Questions to consider in lowers soil temperature, and sup- increase women’s discretionary designing nutrition-sensitive press weeds and pests. legumes are income? agriculture projects crops grown primarily by women in many settings, and women often pre- The questions below broadly cover • Do farmers reside close enough fer to grow edible species of legumes the basic set of questions that to markets that they would rea- to meet their combined goals of food the project team may want to sonably be expected to use in- security, fodder, and soil improve- consider as they design a come to purchase most of their ment. nutrition-sensitive agriculture dietary components? If not, is project. These questions may be there anything the project could useful in reviewing the agriculture do to improve access to diverse and nutrition linkage of a project’s diets, especially for women and Good practice examples design. young children, e.g., diversified • The Soils, food, and Healthy • What is the nature of the prevail- production, improved infrastruc- Communities Project in Malawi ing nutrition problems (energy ture? 100 This relates to the nutrition-related goal of “Increase year round access to and availability of high nutrient content food.” 101 See http://soilandfood.org/ for more information about the project, as well as published research results. CHAPTER - C | Improving Nutrition through Agriculture • Do farmers have access to mar- D. Measuring nutritional However, at the outcome level, meas- kets where they would be able to outcomes through agriculture urement of changes in food consump- sell perishable foods? Is it feasi- projects tion is an important step to ble to incorporate farm product determine if projects have positive preservation into project design? Explicit nutrition objectives and effects on diet and food security, interventions would need to be given that a major pathway of nutri- • Could the project design inte- accompanied by indicators to tion impact for agricultural projects is grate nutrition education/behav- measure progress at the output, through food consumption effects ior change strategies into outcome, or impact levels. The (either by household production or production- and income-related matrix in Annex C-1 includes output through market purchase, see figure goals, e.g., demand creation for and outcome level indicators for the C-6).102 Such outcome indicators nutrient-dense crops such as bio- listed interventions. Indicators at the could be measured at project mile- fortified crops? output level (collected every six stones such as baseline, mid-term, months for Bank projects) are project and project completion together with • Are there opportunities to in- specific, e.g., days of nutrition edu- other outcome and impact indicators. clude relevant nutrition informa- cation provided to beneficiaries etc. tion into the current training and activities of agriculture sector staff, e.g., training on nutritional FIGuRE C-6. MEASuRING NuTRITION-SENSITIvE AGRICuLTuRE PROjECTS attributes of biofortified crops and minor crops? Project level indicators for nutrition-sensitive activities • Is the AES project targeted in the Existing agriculture indicators Nutrition-sensitive same geographic area as other agriculture activity health, water and sanitation, and social protection programs, which are also important for re- Food expenditure indicators ducing malnutrition? If yes, is it • $ spent on food purchase (LSMS) feasible to encourage agricul- ture, health, and social protec- Food consumption indicators Productivity tion staff to consider joint • % of produced food consumed Household income supervision and monitoring vis- • # of days in the last week where any its? amount of X was consumed • % change in grams/day of X consumes • Is the project likely to affect the • Composite indiced: e.g. dietary diversity quantity and quality of water score, food consumption score available to the households in the community or risk of water- More or better borne disease? consumption Anthropometric indicators 102 Additionally, since improvements in • % increase in body mass index women’s access to economic resources • % reduction in proportion of is an important pathway to nutrition, underweight, stunted, wasted AES projects should also include indi- cators on women’s access to (i) land Nutritional and other productive assets, (ii) cash Biochemical indicators from agricultural sales, and (iii) ability status to make decisions about purchases for • Blood samples etc. daily needs, as discussed above. (See Box 1 earlier in the chapter.) CHAPTER - C | Improving Nutrition through Agriculture in grams/day of x consumed, estab- lished indices are commonly used by other international organizations, such as fAO and WfP, to measure progress at the outcome level. food consumption indicators could be employed by agricultural proj- ects to capture nutritional out- comes. Collecting data on food consumption does require some ad- ditional training of the enumerator or project M&E staff, but it requires no special medical equipment like the anthropometric or biochemical meas- ures. Therefore, for agricultural proj- ects, using such consumption indicators is a practical option to pro- vide relevant information about the nutrition-related impacts of projects. for example, dietary diversity scores Nutritional status is measured with take a first step towards measuring are simple to collect at the household anthropometric or biochemical in- nutrition outcomes by incorporating level (to indicate food access), or at dicators. If the intent is to improve food consumption indicators during the individual level (to indicate di- the nutritional status of project bene- assessments at project milestone etary quality). Other indicators, such ficiaries, the impact can most directly dates such as baseline, mid-term, as the Household Hunger Scale be measured by using anthropomet- and project completion (or more fre- (HHS), developed by the USAID food ric or biochemical indicators com- quently, if possible), as many of and Nutrition Technical Assistance monly used in nutrition or health these have been validated to be cor- (fANTA) project, are useful indicators projects.103 Collecting anthropometric related with nutrition status. of household food security. Another or biochemical indicators would re- fANTA-developed food security indi- quire additional training and re- food consumption indicators have cator, Months of Adequate House- sources, such as medical equipment, been developed to measure dietary hold food Provisioning (MAHfP), can for M&E staff that collect data for quality without having to conduct a also be useful to indicate year-round agricultural projects. Also, the sam- full food intake survey, which continuity of food security. (See Box ple size and project duration must be would be costly and cumbersome C-2 and Annex C-3 for more details on large enough to have power to ob- to administer. In addition to simple each index indicator and alternative serve a difference in these indicators. indicators that can be constructed derivations using these indicators). Therefore, attempts to measure ef- based on project interventions, e.g., Each of these indicators is relatively fects on anthropometry may not be percent of produced food consumed, straightforward to collect, and food appropriate in all circumstances, and number of days in the previous week consumption indicators most rele- power calculations should be done a where any amount of x (nutritious vant for the project’s expected im- priori to assure that time and effort food) was consumed, percent change pact on diets and food security can are not wasted. AES projects could be selected. 103 Commonly used anthropometric indicators are stunting (height-for-age: measures chronic malnutrition) and underweight (weight-for-age) among children under 5 years old, or body mass index (BMI) among women; the most common biochemical indicators are of vitamin A status (serum retinol), and iron status (hemoglobin or serum ferritin). CHAPTER - C | Improving Nutrition through Agriculture BOx C-2. COMMONLy uSED FOOD CONSuMPTION INDICATORS There are several food consumption The Food Consumption Score is a It captures changes in the house- indicators developed for different composite score based on dietary di- hold’s ability to address vulnerability purposes. The Dietary Diversity Score versity, food frequency, and relative in such a way as to ensure that food (DDS) and the Food Consumption nutritional importance of different is available above a minimum level Score (FCS) measure dietary quality, food groups consumed by the the year round. It has been incorpo- the MAHFP measures continuity of household, which can be used as a rated as a standard impact indicator food access, and the adapted HHS proxy measure of food security. In- in all Africare’s food security pro- measures the subjective experience formation about frequency of con- grams. of food insecurity. sumption (in days) by a household over a recall period of the past seven The Household Hunger Scale is a The Dietary Diversity Score consists days is collected from a country- spe- measure of the degree of food inse- of a simple count of the different cific list of food groups. The food curity (i.e., access) in the household food groups that a household or an consumption score has been vali- over a recall period of four weeks: individual has consumed over the dated against per capita calorie con- the higher the score, the more food preceding 24 hours.104,105 The sumption, and several alternative insecure the household. This indica- household dietary diversity score is indicators of household food secu- tor has demonstrated the potential meant to reflect household access to rity such as percentage expenditures for both internal and external valid- a variety of foods, while individual on food, asset, and wealth indices. ity, and has been shown to have a scores are meant to reflect nutri- The food consumption score is strong relationship with household tional quality of the diet. The dietary being used widely by WFP in their income and wealth scores. The diversity scores have been validated surveillance activities.107 Household Hunger Scale is being for several age and sex groups, e.g., used by FAO and USAID Feed the Fu- infants between 6-23 months, and Months of Adequate Household ture projects.109 women between 15-49 years old, as Food Provisioning measures house- a measure for micronutrient ade- hold food accessibility throughout For a more detailed description of quacy of the diet. These scores are the past year, and reflects the sea- each of the indicators, see being used by WHO, FAO and USAID sonality aspect of food security.108 Annex C-3. Feed the Future projects.106 E. “Do no harm” mitigation strategies appropriate for probability of negative externalities, considerations the circumstance. for example, alter- including zoonotic disease transmis- native child care arrangements may sion, in some situations than in oth- In considering the suggested list be more easily attained in one place ers. Monitoring of potential harmful of interventions, agriculture proj- than another, which has implications impact during the project implemen- ect teams needs to ensure that no for the strength of the potential tation also would provide information inadvertent harm is caused.110 Con- trade-off between increased labor important for triggering mitigation text assessment during the design and decreased child care quality. strategies. phase will allow project teams to as- livestock projects may have a higher sess potential harms and develop 104 Guidelines for measuring household and individual dietary diversity. fAO 2012. 105 fANTA. 2006. Household Dietary Diversity Score (HDDS) for Measurement of Household food Access: Indicator Guide. Version 2. 106 fANTA. 2006. Developing and Validating Simple Indicators of Dietary Quality and Energy Intake of Infants and Young Children in Developing Countries: Summary of findings from analysis of 10 data sets. Working Group on Infant and Young Child feeding Indicators. food and Nutrition Technical Assistance (fANTA) Project, Academy for Educational Development (AED), Washington, D.C. 107 World food Programme. 2008. Technical Guidance Sheet - food Consumption Analysis: Calculation and Use of the food Consumption Score in food Security Analysis. 108 Bilinsky P, A. Swindale. 2010. Months of Adequate Household food Provisioning (MAHfP) for Measurement of Household food Access: Indicator Guide. Version 4. fANTA-2. 109 Ballard, T., J Coates, A Swindale, M Deitchler. 2011. Household Hunger Scale: Indicator Definition and Measurement Guide. fANTA-2. 110 USAID’s Infant & Young Child Nutrition Project (IYCN) has recently developed a Nutritional Impact Assessment Tool that directly attempts to minimize these unintended negative consequences, http://www.iycn.org/resource/nutritional-impact-assessment-tool/. CHAPTER - C | Improving Nutrition through Agriculture TABLE C-2. COMMON NEGATIvE CONSEquENCES OF AGRICuLTuRAL INTERvENTIONS Observed negative impacts Possible mitigation measures Irrigation projects may cause an increase in hydrophilic vector-borne • Include analysis of hydrophilic vector-borne diseases in disease such as malaria, schistosomiasis, and Japanese encephalitis environmental safeguard analysis, and ensure mitigation measures are established Animal husbandry projects may cause an increased risk • Strengthen mitigation measures and risk management of zoonotic diseases framework of zoonotic infections in program design Reduction in women’s access to resources if projects shift production • In project social analysis or gender analysis, gather information toward male-dominated crops on who is benefiting from intervention activities, and develop strategies to ensure equitable intra-household access to resources Reduction in women’s time available for child care, impacting child • Include women’s time use analysis in project gender analysis to health and nutritional status determine labor time requirement by women • Introduce time saving technologies for tasks commonly performed by women Production increase/price reduction in calorie- dense foods may • Promote production and consumption of micronutrient rich crops unfavorably alter dietary quality and may contribute to obesity and` • In the project design phase, check levels of obesity as well chronic diseases. as undernutrition111 • In project Results Frameworks, include food consumption indicators to monitor consump- tion trends which could affect likelihood of obesity and chronic disease 1. Invest in women: safeguard Some common examples of unin- XI.Summary and strengthen the capacity of tended negative consequences of women to provide for the food This module has laid out the ra- agriculture projects are shown in security, health, and nutrition tionale for why agriculture is im- Table C-2 below, with suggested of their families. portant for nutrition, and vice approaches to avoiding or mitigat- versa. Agriculture is a key sector in _________________________ ing them. The mitigation measures reducing undernutrition, together for irrigation projects are important with health, social protection, educa- 2. Increase access to and year- because a large part of Bank agricul- tion, and other sectors. The available round availability of high- ture (AES) investments are for irriga- evidence supports four strong princi- nutrient content food. tion and drainage investments. ples for action in the agriculture sec- tor, and they are areas for _________________________ tremendous growth in programming. 3. Improve nutrition knowledge among rural households to enhance dietary diversity. _________________________ 4. Incorporate explicit nutrition objectives and indicators into 111 USAID’s Infant & Young Child Nutrition Project (IYCN) has recently developed a Nutri- tional Impact Assessment Tool that directly attempts to minimize these project and policy design. CHAPTER - C | Improving Nutrition through Agriculture Although to date the Bank’s agri- The annexes of this module aims culture and rural development to provide practical guidance to projects have only addressed nutri- agriculturists in maximizing the tion implicitly or unintentionally nutrition impacts of world Bank through other objectives, there is agricultural investments. This mod- growing awareness inside and out- ule calls on Bank staff to take action side of the Bank that leveraging on the following fronts: (i) incorpo- agriculture activities will boost nu- rate nutrition-sensitive analysis and trition outcomes. Of the 21 coun- activities into agriculture project de- tries that have already met the goal sign and food security policy dia- of halving the proportion of the pop- logue; (ii) measure the progress of ulation below the minimum level of activities affecting nutrition periodi- dietary energy consumption, only six cally through relevant output indica- are on track to meet the underweight tors; and through outcome indicators goal. While Mali has met the goal of such as food consumption indicators reducing hunger, it has shown no at least at baseline/mid-term/project progress on reducing underweight. completion; (iii) ensure that agricul- This case demonstrates the limit of ture projects and policies do not trying to achieve nutrition outcomes cause unintended harm to nutrition. implicitly through agriculture. Im- proving household income or raising agricultural productivity focused on staple grains and income alone is in- sufficient to reduce undernutrition. C H A P T E R - D Improving Nutrition through Social Protection Alessandra Marini, Harold Alderman, Meera Shekar CHAPTER - D | Improving Nutrition through Social Protection I. Background Nutrition is widely seen as a multi- improve people’s productivity and in- How can social protection inter- sectorial issue. This guidance note comes by preserving and building ventions affect nutritional out- builds on evidence to date regarding their human capital, and facilitating comes? Nutritional status reflects the links between social protection access to better jobs and income, the interplay of food consumption, (SP) and nutrition outcomes, and which can propel them out of access to health and sanitation, and aims to guide World Bank staff and poverty. nutrition knowledge and care prac- country level implementers in con- tices. Social protection programs typ- verting existing or future World Bank Investments in nutrition and early ically increase income (linked to food operations in the SP sector in to more child development are increasingly access), as well as influence the tim- nutrition-sensitive and nutrition- recognized as integral components ing, and to a degree, the control of specific programs (see Module A for of a coherent social protection sys- this income. Additionally, such pro- more details). tem to prevent the intergenera- grams may have greater impact on tional transmission of poverty. In nutrition by fostering linkages with The new world Bank Social Protec- addition, they are key determinants health services or with sanitation tion Strategy presents social pro- of long-term economic growth. When programs, and specifically through tection systems as aimed at child nutrition is improved the risk of activities that are related to nutrition building resilience by ensuring mortality is reduced, future human education or micronutrient supple- that individuals and families are capital is built, and productivity is in- mentation. Moreover, by taking into well-protected against the sudden creased. Thus, focusing on improving consideration the relatively narrow shocks that are likely to overwhelm nutrition furthers the objective of in- window of opportunity for investing them. These systems improve equity creasing opportunities, enhancing in nutrition, programs can be tar- at both national and global levels by both nutrition and social protection. geted to enhance their impact on nu- reducing poverty and destitution. trition. The critical window opens They also promote opportunities to during pregnancy and closes at about two years of age. These “1,000 days” offer the best opportunity to lock-in future human capital. Interventions during this period can potentially re- duce undernutrition- related mortal- ity and morbidity by 25 percent if implemented at scale.1 figure D-1 il- lustrates the key pathways through which a social protection program is expected to have an impact on nutri- tion, grouped under three categories: transfers, links with health services, and targeting the most vulnerable. 1 The Lancet Series on Maternal and Child Undernutrition (2008), available at www.thelancet.com; Copenhagen Consensus Results 2008; available from www.copenhagenconsensus.com; World Bank, 2006. Repositioning Nutrition as Central to Development, the World Bank, Washington D.C. CHAPTER - D | Improving Nutrition through Social Protection FIGuRE D-1. POTENTIAL PATHwAyS FOR SOCIAL PROTECTION PROGRAMS TO IMPACT ON NuTRITION 3 Improved 1 Income Nutritional Status vulunerable/the poor 2 Links with health/sanitation Target nutritionally Improved Diet Less Infectious Disease 3 Targeting the vulnerable To Food Improved Care Sanitation Services Source: Adapted from Neufeld, 2006. Income Supplements Counseling Education Services 1 2 Possible components of social protection programs This module will specifically discuss II. Objectives grams. This module analyzes the dif- these pathways under three broad ferent policy choices related to the el- questions and the different policy ements of SP programs that affect The specific objective of this choices that can derive from each of nutritional outcomes, namely: in- module is to support world Bank them: (i) How can we maximize the come, links with health and sanita- staff and country clients in impact of income on nutrition? (ii) tion services, and targeting the most strengthening the design of SP How might social protection pro- vulnerable. figure D-2 exemplifies interventions to maximize their grams be linked to nutrition, and with the key policy options arising when impact on nutrition by consider- what services? And, (iii) Who should designing typical SP programs. An ing alternative options for the most be targeted? important part of the discussion is vulnerable populations. Social pro- tection programs often aim at in- centered on transfer programs due to creasing household income or the key role they play in countries’ supporting the household’s con- social policies, and because of their sumption smoothing ability, and pro- demonstrated flexibility in adjusting moting access and links to services, their design to include nutrition-sen- such as health and education. Target- sitive considerations. ing considerations by either income or age are generally key elements of the design of social protection pro- CHAPTER - D | Improving Nutrition through Social Protection Evidence shows that economic FIGuRE D-2. ELEMENTS OF SP PROGRAMS RELEvANT FOR NuTRITION OuTCOMES growth will only reduce malnutri- tion slowly. However, transfer pro- grams often increase beneficiaries’ • Size expenditures by 10 percent, and oc- Income/ • Frequency casionally by more than 20 percent. Consumption • Control Transfers of this magnitude can con- • Nature (in kind/cash) siderably contribute to improving a population’s nutrition. In the design phase of a safety net project, the • Conditionalities expected impact on nutrition can be Link with (firm/soft) based on the planned size of the services • Promoting access to transfer and data from household services (supply side) surveys; in the absence of such sur- veys, global experience on the deter- minants of nutrition can assist in planning. for example, Haddad • By income (2003) confirms that income growth, Targeting • By nutritional status • By age group even when evenly distributed over a population, has a positive, albeit rel- atively modest, impact on undernu- trition rates. As a general rule, III. How can we A first sub-question under this country level rates of undernutrition, theme is what is the range of the measured as low weight-for-age, de- maximize the impact of expected impact of income on cline at roughly 50 percent of the rate income on nutrition? nutrition? If a fiscally sustainable that gross national product (GNP) per transfer program can increase a capita increases; household surveys Understanding how the relationship household’s access to food and its show comparable rates of improve- between income, consumption, and ability to obtain quality health and ment in nutrition as incomes rise. nutritional outcomes works, and sanitation services and/or increase likewise, anemia—measured as how to strengthen the relationship women’s control over incomes, then hemoglobin levels below 10.9 g/dl— is perhaps the most immediate the key programmatic consideration declines at roughly 25 percent of consideration. We pay special for nutritional outcomes is reaching the rate of income growth.3 from attention to transfer programs the vulnerable.2 If, on the other another perspective, malnutrition because of their increasing impor- hand, a transfer is not expected to rates among the richest 40 percent of tance among social protection address fully the most limiting the population in a country with high programs and because of their constraints, then additional design overall rates of malnutrition, such as design flexibility. features might be considered to India or Malawi, are only somewhat augment the impact of increased less than malnutrition rates for the household income. poorest 40 percent. To illustrate, based on the most recent nutrition 2 Two broad categories of income transfers are typically foreseen in social protection programs: (i) long-term transfers to alleviate the consequences of structural poverty, and (ii) short-term transfers to deal with the transitory income fluctuations for families that may not be poor enough to justify long-term transfers but still need consumption smoothing arrangements of some sort if hit by a shock. Depending on whether the shock is idiosyncratic or covariate, the government response could be an individual or community-level transfer. literature has generally focused on the impact of long-term transfer on nutrition (CCT or UCT, or feeding programs), although there is evidence that emergency relief transfers, such as food aid during crises, can deter the long-term effects of shocks on child growth (Alderman, Yamano, and Christiansen, 2005; Woldehanna, 2010). 3 Alderman, H. and Sebastian l. 2009. “Anemia In low Income Countries Is Unlikely to be Addressed by Economic Development without Additional Programs,” Food and Nutrition Bulletin, 30 (3): 265-270. CHAPTER - D | Improving Nutrition through Social Protection survey available for Pakistan, provid- A. Enhancing the quESTIONS TO CONSIDER wHEN ing transfers or income growth to the role of income in transfer DESIGNING TRANSFER PROGRAMS: poorest 40 percent of the population programs to attain the same wealth as the me- • How much of a transfer dian family would virtually eliminate i. Size of “payment” would make a difference? poverty in Pakistan. Nonetheless, or income transfers over 38 percent of the entire popula- • What is the role of payment tion of children would still be mal- The size of income payment and frequency? nourished.4 transfers matters. It is difficult to define what the best amount of trans- • Would providing the income Despite the low growth-nutrition fer ought to be, whether it is compen- to women make a difference? elasticity, for a subset of house- sating for expenses that relate to holds, cash remains a binding con- program participation or fulfillment • Do in-kind transfers have an straint for inputs needed for good of conditions, or whether it is an in- advantage over cash transfers? nutrition. There is evidence that centive to lift the household out of transfers, even when unconditional, poverty. It is also difficult to separate • Can the role of income be including food stamps, frequently the impact of the transfer from that of strengthened by additional have stronger impact on nutrition other program components. The ex- design features, including the than other sources of additional in- perience of PRAf, Honduras’ condi- degree to which conditional come. That is, when income transfers tional cash transfer program, where transfers improve upon the are part of SP programs, they seem to the relatively low impact of the pro- performance of unconditional change the budgeting process. This gram was linked to the limited size of transfers? has been documented in some con- the transfer, seems to suggest that texts, for example in the US food the actual size of the transfer can • Can the program design stamp program, and in cash transfers make a difference on the program im- accommodate social promotion in Ecuador or take home rations for pact.6 campaigns on improved female students in Burkina faso.5 nutritional practices or micronutrient supplementation? 4 If household surveys that contain both anthropometric data and expenditures are available, they can be used to make country specific estimates anywhere a transfer is being consid- ered. However, because demographic and health (DHS) or UNICEf multiple indicator cluster surveys (MICS) data can only provide the basis for an ordinal ranking of wealth, some inter- pretation is still needed to estimate the impact of a given cash transfer. This limitation, how- ever, is hardly insurmountable. If other data sets allow one to estimate income or expenditures by wealth quintiles, the two sources of complementary data allow an estimate of the impact of an income transfer on nutritional outcomes for the average household in a quintile. 5 Kazianga, H., de Walque, D. and H. Alderman. 2009. Educational and Health Impact of Two School feeding Schemes: Evidence from a Randomized Trial in Rural Burkina faso. World Bank Policy Research Working Paper #4976; Breunig, R. and I. Dasgupta. 2005. “Do Intra- household Effects Generate the food Stamp Cash-Out Puzzle? American Journal of Agricul- tural Economics. 87(3): 552-68; fraker, T., Martini, A. and J. Ohls. 1995. “The Effect of food Stamp Cashout on food Expenditures: An Assessment of the findings from four Demonstra- tions,” Journal of Human Resources 30(4): 633-49; Paxson, C. and N. Schady. 2007. Does Money Matter? The Effects of Cash Transfers on Child Health and Cognitive Development in Rural Ecuador. World Bank Policy Research Working Paper 4226. Washington, D.C.: World Bank, 2007; P. Kooreman. 2000. “The labeling Effect of a Child Benefit System,” American Economic Review 90(3): 571-583. 6 IfPRI, 2003, Proyecto PRAf/BID fase II: Impacto Intermedio, Sexto Informe, Washington D.C., International food Policy Research Institute. CHAPTER - D | Improving Nutrition through Social Protection The size of the transfer in the Hon- duras program was only one-third the FIGuRE D-3. INCOME TRANSFERS IN SELECT COuNTRIES AS A PERCENTAGE OF PER CAPITA SPENDING size of the transfer in programs con- sidered most successful in reducing chronic malnutrition, such as Mexico, 30 Colombia or Nicaragua. Compared Transfer, as a % of per capita spending with latin America, South Asia and 25 some Middle Eastern countries have significantly smaller transfers as a 20 percentage of per capita spending (see figure D-3).7 15 10 ii. Frequency of payment 5 frequency and reliability of payment 0 is an important feature of most ua ile bia re as a o h tan ey ia transfer and social pension pro- xic a ic es od do rk ur Ch rag l om kis lad Me Ja m Tu nd mb ua ca grams as well as public works pro- Pa ng Co Ec Ho Ca Ni Ba grams. When payments are frequent and reliable they directly support so- Source: Fiszbein and Schady, 2009. cial protection objectives. Payments of small amounts on a monthly or bi- monthly basis have the advantage of ensuring regular expenditures aimed at covering daily necessities, includ- ing the key nutritional inputs. How- iii. Control of income potential for increased friction within ever, we know of no studies that a household. However, cultural speci- have tested the relative impact of female control of income accompa- ficity should be taken into account, more regular payment’s conditions nying a transfer program has been as in some contexts the contrary may on the amount over time. Reduced associated with shifts in household be true.8 In general, there is evi- frequency, on the other hand, re- expenditure patterns towards chil- dence that women’s control of in- duces the administrative costs of pro- dren’s needs. female control of in- come increases expenditure more on grams. The introduction of new come regularly is incorporated into children than men do.9 However, payment technologies may help to the design of a transfer program with there is limited experimental evi- lower the costs of aligning payment modest but real costs in terms of the dence in the context of CCTs.10 frequency with beneficiary needs. woman’s time allocation, as well as a 7 fiszbein, A. and N. Schady, with francisco H.G. ferreira, f. H.G., Grosh, M., Kelleher, N., Olinto, P. and E. Skoufias. 2009. Conditional Cash Transfers for Attacking Present and Future Poverty. World Bank Policy Research Report. 8 In some countries in the Middle East and North Africa, giving transfers to men has been associated with resources spent on the family or children more than in the case of women (lebanon, for example, as described in IfES, IWPR, and CIDA Topic Brief, 2009). 9 Haddad, l. and Hoddinott, J., H. Alderman and DEC. 1994. “Intra-household resource allocation: an overview,” Policy Research Working Paper Series 1255, The World Bank. 10 Gitter S.R. and B. l. Barham, 2008, “Women and Targeted Cash Transfers in Nicaragua,” World Bank Economic Review, 22(2), 271-290. CHAPTER - D | Improving Nutrition through Social Protection B. Nature of transfers: In contrast, extra-marginal pro- CONSIDERATIONS wHEN Cash versus in-kind transfers grams—transfers for an amount DESIGNING IN-kIND TRANSFER greater than the household would PROGRAMS Despite its importance for devel- have consumed without the trans- opment assistance in low-income fer—tend to increase food con- • How do food markets work countries, there are few rigorous sumption. Studies in Bangladesh (availability, procurement, evaluations of the impact of food indicate that recipients of in-kind distribution, etc.)? versus cash aid on households. transfers show preference for that Until recently, in-kind assistance was modality, while recipients of cash • Is there a food emergency? common in low-income countries, programs prefer their means of sup- both to promote food consumption port. However, in times of price • Are food prices very volatile? and because financial services were volatility, preference is generally for limited. However, cash-based pro- in-kind transfers as their real value is • Carefully evaluate the nature of grams are being developed that take protected. This was noted in the Pro- the food distributed versus the advantage of information technology ductive Safety Net Program (PSNP) nutritional problem. innovations for beneficiary identifica- for Ethiopia in 2008. Overall, be- tion and for delivering cash transfers. cause the advantages of in-kind food • Carefully evaluate unexpected While transfer programs in lAC were programs are often small, in non- consequences on local markets. among the first to shift from in-kind emergency situations and especially assistance (including subsidized when markets are working, the lower food) to cash, new technology has al- cost of cash distribution may be the lowed cash to reach beneficiaries in deciding factor in choosing the form remote places such as pastoral com- of transfer. munities of northern Kenya. The Mexican Progresa (then opor- Both forms of assistance have ad- tunidades) Program evaluated the vantages and disadvantages. food- possibility of delivering its food based transfers may perform better support component in cash or in- when markets for food do not func- kind transfer from the beginning. tion well or in the aftermath of a dis- levy and Rodriguez (2005) concluded aster. On the other hand, with that considerations of efficiency and proper monitoring, often enhanced efficacy highlighted the convenience by improvements in IT and mobile of delivering cash transfers, de- phone transfers, cash entails lower linked from consumption patterns, average logistical costs (therefore rather than in-kind transfers. Sk- higher coverage), and gives benefici- oufias (2008), in a review of the food ary households greater freedom to distribution program PAl in Mexico, respond to their own priority needs. found that while transfers have a The impact of in-kind transfers on nu- large and positive impact on con- trition depends in part on whether sumption and poverty reduction, irre- the commodity is provided in spective of the nature of the transfer amounts smaller than would have (cash or in-kind), cash transfers had been otherwise purchased (infra- higher impact on height-for-age z- marginal), in which case the impact scores of children younger than two is similar to a cash transfer of similar years. Additionally, in-kind transfers value. CHAPTER - D | Improving Nutrition through Social Protection in the context of populations that are achieved through simple communica- BOx D-1. ASSESSING not energy deficient should be care- tion of the objectives of the transfer THE RELATIvE IMPACTS fully designed to ensure that they are or through a more concerted strategy OF CASH AND FOOD TRANSFERS not associated with an increase in of raising public awareness via ON NuTRITION IN NEPAL energy consumption, as was the case health/nutrition education programs for the in-kind transfer program PAl that may accompany such transfers. DfID and the World Bank are under- in Mexico.11 A final consideration Examples of this include group-based taking a two-stage research study to compare the relative impact of cash, demonstrates that in remote areas, a demonstration/education sessions, food transfers, and enhanced nutri- cash infusion may push up local individual counseling or nutrition tion counseling for women. The prices, as seen in an example from education, such as the one provided study will include an initial 2.5-year Mexico.12 While this implies a need through community-based growth randomized controlled trial in the for monitoring in general, markets promotion programs (see Module E). Terai region of Nepal to assess the tend to be fairly well integrated. relative impact of three interven- tions to reduce low birth weight and to improve maternal and neonatal Coupons and food stamps serve an D. Enhancing the role of health and nutrition compared to intermediary role. Relative to cash, income in other social protec- current approaches. If the efficacy coupons and food stamps have addi- tion programs: Public works, trial proves successful, the most ef- tional logistical costs related to their insurance, and microfinance fective approach will then be tested redemption system, but, as they use in an effectiveness study under nor- Some considerations discussed mal operating conditions, including existing market channels, they have previously for transfer programs, in challenging geographical environ- fewer direct costs than food distribu- ments in South Asia, with the objec- such as size and frequency of tion programs. In principle, tracking tive of developing scalable models. payment and control of income, coupon redemptions offers an inher- IFPRI and WFP are funding similar apply to the design of other social ent means of monitoring, although evaluations in other countries to as- protection programs. However, sess the difference in impact be- this advantage, relative to cash dis- some elements that are specific to tween food and cash. tribution, is declining with improved other programs’ design are worth technology for cash transfers. discussing separately. _______________________________ C. Including nutrition i. Accommodating time quESTIONS TO CONSIDER counseling or micronutrient demands for women in wHEN DESIGNING PuBLIC wORkS supplementation components public works programs PROGRAMS If improving nutritional status is a A well-designed public works key objective, an income or in-kind • Which payment would make program accommodates the time a difference? transfer alone may be insufficient. demands on women. The overlap Specific design features can aug- between public works and nutrition • What is the role of frequency ment impact, such as including a nu- is often considered slight and mainly of payments? trition counseling component, reflecting the increased calorie providing micronutrient supple- demands of labor intensive activities, • Would including a crèche ments, or deworming drugs. The link- as well as the indirect impact of make a difference and attract ing of a transfer with nutrition may be more women? • Can the program design 11 leroy, J.l., Gadsden, P., Rodríguez-Ramírez, S. and T. González de Cossío. 2010. accommodate counseling on “Cash and In-Kind Transfers in Poor Rural Communities in Mexico Increase Household improved nutritional practices or fruit, Vegetable, and Micronutrient Consumption but Also lead to Excess Energy micronutrient supplementation? Consumption,” J. Nutr, 140 (3): 612-617. 12 Cunha, J.M., G. De Giorgi, and S. Jayachandran, The Price Effects of Cash Versus In-Kind Transfers, NBER Working Paper No. 17456. CHAPTER - D | Improving Nutrition through Social Protection BOx D-2. DjIBOuTI SOCIAL SAFETy NET PROjECT THAT COMBINES these demands on the household, wORkFARE wITH A NuTRITION INTERvENTION and of course reflecting the role of income and women’s control. The participation of women in public basis for a (productive) safety net by Djibouti has high rates of childhood works programs can be enhanced malnutrition (affecting 33% of the (i) improving the design and effec- if the programs provide a crèche. children), unemployment (hovering tiveness of a public works program A well-designed crèche may also at 55%), and poverty (affecting 42% so it becomes an effective social provide early child development and of the population). In addition, over safety net, (ii) generating new short- the last four years the country has term job opportunities for the poor care. In India, for example, mobile been confronted with recurrent and vulnerable; and (iii) improving crèches for construction workers is nutrition practices among participat- droughts that negatively affected one such successful model. These poor and vulnerable households, and ing households through behavioral crèches are designed to travel with created emergency needs. In re- change interventions. The program the workers as they move from sponse, the government is imple- links creation of employment oppor- construction site to site. menting an innovative social safety tunities to improvement of nutri- net (SSN) program “Djibouti Crisis tional practices by adding a Response: Employment and Human nutrition and growth promotion com- As pregnant and lactating women Capital Social Safety Nets,” combin- ponent to the traditional cash-for- have high-energy demands for ing short-term employment with a work program to leverage the effect their child, a well-planned public nutrition intervention for the poor of the additional income on the fam- works program can offer produc- and vulnerable. The project supports ily’s nutritional status. tive tasks that are suited to this a crisis response that provides the constraint. Women can be involved in managing a crèche, providing similar services within the wider community, or attending childcare INTEGRATED APPROACH: “ALL [FAMILy MEMBERS] classes, as an alternative to more AGAINST MALNuTRITION” energy intensive tasks (See Box D-2 for an example from Djibouti). Argentina’s Jefes y Jefas program, a Common Goal: Prevent Malnutrition variation of a public works project, allowed beneficiaries to substitute 20 hours of training a week for man- Workfare: Increased Nutrition: Enhanced ual labor. While relatively few individ- household income. nutrition practices. uals selected this option, a degree of Offers short-term Targets vulnerable flexibility still existed. Public works employment in: non-working members projects can also offer flexible hours (young children and pregnant women) or piecework to accommodate moth- • Community works (for all) ers’ time constraints. chosen (and built) by the community from catalogue Focus on first 1,000 days of life (e.g. containment walls) • Monthly community • Services (for women only), meetings (e.g. sensitization mainly plastic bags on exclusive breastfeeding) collection, community- • Bi-weekly home visits by a level recycling and community worker transformation into blocks • Food supplements to pave footpaths distributed during the lean season CHAPTER - D | Improving Nutrition through Social Protection ii. Strengthening ance may also play a role in income ening the access to financial serv- the role of insurance smoothing—health shocks often are ices. To the degree that these efforts by promoting utilization a larger risk factor for impoverish- raise incomes or assist in consump- of services ment than are weather shocks. tion smoothing, they increase food Health insurance differs from weather and health security. financial deep- Insurance is one way to smooth insurance in many essential features. ening is often accompanied by finan- consumption over time and across for example, collective payouts or cial literacy enhancing programs. for households. Households hit by a collective indices do not seem appro- example, group-lending programs shock face the dilemma of either con- priate. More important, in addition to may hold regular educational meet- serving productive assets for future consumption smoothing, one objec- ings for participants. In a few cases, consumption or stabilizing consump- tive for public involvement is to en- communication on health and nutri- tion by drawing down assets. How- courage utilization of services, tion has been included in these ever, formal insurance plays a small especially preventative and primary meetings. These are similar to the role in the risk reduction strategy of health. Since children have a rela- training sessions that are part of low-income households. This in part tively low risk of incurring cata- some CCT programs (such as the plat- is because of the lack of insurance strophic health costs, the primary icas in Mexico’s Oportunidades). markets, which reflects real struc- role of health insurance for children However, it is difficult to separate the tural aspects of incentives for clients is promoting the use of health facili- role of access to credit and banking and the costs of monitoring their ties. Targeted subsidies for health in- from the role of information, and losses. While innovations such as surance and the linkage of insurance there are still few evaluations of such weather indexing have increased the with conditional transfers, as in programs. Transfer programs, how- range of instruments available, most Ghana or Mexico, are means to link ever, have a different objective than evidence indicates that individual in- social protection with health insur- financial deepening, and the balance surance for livelihoods that is actuar- ance. Conceptually, fee waivers for of adding wider social objectives to ially fair and therefore attractive to children’s primary health needs can the latter is largely unexplored. private providers without subsidies, also serve this function, though in remains beyond the budgets of low- practice, fee waivers have a tendency income households. If subsidies are to be under budgeted and thus starve considered, the issues of targeting health services of funds. are similar to those for transfer pro- grams in general. IV. How can social protection programs iii. Smoothing weather index insurance to miti- consumption by promote the link with gate damage by droughts, cy- promoting microfinance other services to in- clones, or floods may be viable at crease their nutritional the community or similar aggregate Microfinance–including savings level. Indeed, financial or self-insur- promotion, some forms of insur- impact? ance may be feasible at the national ance, and credit provision– can level. If so, the payout when there is assist low-income households in Access to services can be pro- a shock is also at the aggregate level, entrepreneurial opportunities, as moted through links with and a program or distribution rule is well as to smooth consumption. In transfer programs or directly needed to get the benefits to the some countries, as in Kenya, the pri- by promoting access to serv- wider population. The decisions vate sector has designed financial ices at local level. The same products to serve the needs of rural needed for this are similar to the pro- principles of social inclusion grammatic decisions needed for as- low- income households, facilitated that pervade most social pro- sistance following a disaster or by cell phone access. In others, tection programs underlie financial crisis. While health insur- NGOs have taken the lead in broad- some nutrition interventions. CHAPTER - D | Improving Nutrition through Social Protection BOx D-3. vARIATIONS ON THE THEME: NuTRITION CO-RESPONSIBILITIES IN CCTS IN LATIN AMERICA latin America has pioneered the use advantage of CCTs’ reach to vulnera- chart below summarizes the health of CCTs. Because of persistent stunt- ble groups to attach nutrition co- and nutrition co-responsibilities of ing rates, many countries have taken responsibilities (conditions). The CCT programs in several countries in latin America and the Caribbean. COuNTRy PROGRAM NuTRITION CO-RESPONSIBILITIES Brazil Bolsa Familia • Children <7 yrs: complete immunizations and attendance at growth monitoring 2x/year • Pregnant and lactating women: attendance at ANC and PNC checkups and health and nutrition education sessions Bolivia Bono Juana Azurduy • Children <2 yrs (with no other siblings <2 yrs): attendance at bimonthly checkups • Pregnant and lactating women (with no children <2 yrs): attendance at 4 prenatal checkups, institutional birth, and postnatal checkups Colombia Familias en Acción • Children < 7 yrs: attendance at regular health checkups (growth monitoring, nutritional status and development; hygiene and diet education; vaccinations) Dominican Solidaridad • Children <6 yrs: immunizations and attendance at regular health checkups Republic • Pregnant and lactating women: attendance at ANC and PNC visits • Adolescents and head-of-households: attendance at quarterly workshops Guatemala Mi Familia Progresa • Children <7 yrs: attendance at regular health checkups (immunizations, growth monitoring, deworming, vitamin A supplementation, supplementary feeding) • Children 6-15 yrs: iron folic acid and fluoride supplementation, deworming • Pregnant and lactating women: attendance at ANC and PNC visits, iron folic acid supplementation,education on complementary feeding and health Mexico Oportunidades • All family members: attendance at health checkups 2x/year • Pregnant women, children <2 yrs, malnourished children: attendance at monthly health education sessions Panama Red de Oportunidades • Children < 5 yrs: regular health checkups • Pregnant women: ANC visits every 2 months Peru Juntos • Children < 5 yrs: regular health check-ups (including growth monitoring, receipt of fortified complementary food and vitamin supplements, vaccinations, deworming) • Pregnant women and mothers: attendance at ANC and PNC appointments (including reproductive health education and food assistance), institutional birth Verification that co-responsibilities program where data are compiled. Brazil’s CCT program, which serves have been fulfilled prior to the cash Means of verification range from fill- 12 million households, decentralizes transfer requires a well- functioning ing out lists of beneficiaries on verification by municipality, while chain of information flow from the paper, to scanning beneficiary bar- most other countries have a centrally point of service delivery/utilization codes, and electronic filing of co-re- managed system. to a central clearinghouse for the CCT sponsibilities in an online system. Source: Ochoa, Marini, Silva, 2011. CHAPTER - D | Improving Nutrition through Social Protection A. Conditioning transfers The idea of conditioning transfers quESTIONS TO CONSIDER to access to services is not based on a paternalistic wHEN DESIGNING CONDITIONAL view that poor mothers do not PROGRAMS linking income transfers to compliance with a conditionality (or know how to spend their money adequately. Rather, conditionalities • What is the role of the co-responsibility) can function as a “condition”? Which objective powerful incentive for the use of are based on the expectations that is it trying to achieve? health and nutrition services. they will have an impact on prices and preference ordering: even when • What is the cost of monitoring Conditional Cash Transfers (CCT) people optimize their budget, lower conditions? Is it worth are a well-known type of program prices have a strong impact on de- monitoring conditions “firmly”? that aims at reducing both present mand, possibly even stronger than and future poverty. By linking a tar- the income effect itself. It is conceiv- • Does it make sense to “punish” able that these conditionalities (or households that do not comply geted transfer to health seeking be- co-responsibilities) may also allow with conditions? havior(s), or to participation in education through the “conditionali- poor mothers additional bargaining • What are the reasons ties” or “co-responsibilities,” CCTs power in the use of these additional behind non-compliance? can change the effective price of resources for the care of their young preventive health care and offset children. • Is it worth introducing liquidity constraints that reduce conditions at the investments in children. The The evidence indicates that most community level? co-responsibilities vary according to CCT programs achieve changes in context, responding to the salient service utilization. However, problems of each country, and taking changes in outcomes seem less fre- into consideration the availability of quent, and when observed, they services and the operational capacity are less uniform.13,14 There are to administer and manage the CCT many reasons for this, including (see Box D-3). Close links between measurement challenges and the du- the CCT administration and the ration of the evaluations, but another health sector are generally very im- concern is the quality of services. If a portant, since the health sector must health CCT is conditioned on a preg- provide adequate coverage and qual- nant woman receiving prenatal ity of the services required as co-re- check-ups or bringing an infant to sponsibilities. Health sector staff growth promotion sessions, the im- also often verify beneficiaries’ use of pact depends critically on whether services. anything happens at these visits other than simple measurement and whether the “promoted” services are accessible and available. Therefore, the design of these CCTs needs to 13 Because the first wave of CCTs was in latin America, more evaluations exist from this region. 14 fiszbein, A., and N. Schady, with ferreira, f.H.G., Grosh, M., Kelleher, N., Olinto, P. and E. Skoufias. 2009. Conditional Cash Transfers for Attacking Present and future Poverty. World Bank Policy Research Report. CHAPTER - D | Improving Nutrition through Social Protection balance the demand side (which is catalyzed by the CCTs) with the sup- ply side of health, nutrition, and pop- ulation (HNP) services and gender empowerment programs, ensuring that all the key pieces are in place and working well. A recent paper found that the Juntos CCT Program in Peru made a significant impact on nutritional status of the most mal- nourished children. It also found that conditional on being beneficiaries of the program, nutritional impact is correlated to the duration of expo- sure and to the education level of the In poor, rural areas, parents attend to farming early and often don’t have time to prepare meals for their children to take to school. Through a national school feeding program in mother.15 laos, students get at least a third of their daily energy and nutrition needs. In this photo, a student is enjoying her vegetables. Oudomxay province, lao PDR. There is some evidence from edu- Photo: Bart Verweij / World Bank cation that the presence of condi- tions affects service utilization care as both a right and an obliga- provided additional funds. The pro- better than the transfer amount. tion can address social exclusion. gram builds on the successful experi- That is, providing a large transfer in- ence of CDD programs, their existing Such empowerment may stimulate creases service utilization margin- effective machinery, and their social improved health care, as was noted ally, compared to a small transfer. At capital. The program constitutes an in a study of prenatal care in Mex- this time, however, such evidence is interesting example of results-based ico.17 In Peru, after technical assis- only available from education pro- financing, by promoting results at tance identified coverage gaps in grams and needs to be verified in the community level. While initial services to beneficiaries of Peru’s health care.16 evaluation results do not indicate ro- Juntos CCT, a subsequent project bust differences relative to the core aimed to rectify this imbalance by in- Some programs are experimenting creasing demand for nutrition serv- program, the innovation is not partic- with conditions or co-responsibili- ices by strengthening the ularly costly, and variations of the ties at the community level. The In- operational effectiveness of the Jun- theme are under consideration and donesia Generasi program, for tos CCT program and at the same evaluation. example, has introduced grants for time improving the coverage and communities to address health and quality of the supply of basic preven- Even when the enhancement of education needs. In one pilot, com- tive health and nutrition services in service quality is not directly in the munities that performed well in im- the targeted communities (see Box hands of a CCT program, the fact proving selected indicators were D-4 for more details).18 that a program presents health 15 Jaramillo, M. and A. Sanchez. 2011. Impacto del Programa Juntos sobre nutricion temprana, GRADE Documento de Investigacion 61, lima, Peru. 16 Baird, S., McIntosh, D. and B. Ozler. 2010. Cash or Conditions? Evidence from a Cash Transfer Experiment; filmer, D. and N. Schady. 2009. “Are there diminishing returns to transfer size in conditional cash transfers?” Policy Research Working Paper Series 4999, The World Bank. 17 Barber, S. and P. Gertler. 2010. “Empowering women: how Mexico’s conditional cash transfer programme raised prenatal care quality and birth weight. Journal of Development Effectiveness,” 2 (1): 51-73. 18 World Bank. 2012. Building Resilience and Opportunity, The World Bank’s Social Protection and labor Strategy 2012-2022. Washington DC. CHAPTER - D | Improving Nutrition through Social Protection However, even programs that ap- pear to combine all the essential ingredients seem to perform poorer than expected. Oportunidades in Mexico, for example, touches on nu- trition by including: (i) a substantial in size-cash transfer, (ii) parental ed- ucation, (iii) micronutrient supple- mentation, and (iv) linkage with health services in its program. How- ever, many still argue that the impact on nutrition outcomes, particularly anemia, is less than one would have expected. Why is that the case? first, impact on height is limited, given the amount of time needed to detect such a change, which typically tends to be longer than the study’s period and/or length of programs.19 Sec- ond, it is important for any SP pro- gram to ensure that the different components are articulated and that Children having a meal at school. Ghana. nutritional knowledge is incorporated Photo: © Arne Hoel/The World Bank and tailored to the needs of the spe- cific context. In Mexico, for example, the Oportunidades program is under- tion strategy that restructured the nu- B. Firm versus soft conditions going continuous modifications to re- trition education, emphasizing train- Even when they include only “soft” inforce its impact on nutritional ing and introducing culturally conditions, i.e., co-responsibilities outcomes, incorporating lessons adequate material, and replaced dis- that are advocated but not strictly learned from international best prac- tribution of food supplements with enforced, CCTs can enhance the tices and from local evaluations. To micronutrient sprinkles in urban potential nutritional impact of a increase acceptance and use of mi- areas. This comprises an important transfer program. These soft condi- cronutrient supplements, minimize example of how a program should tions may be considered a form of be- the costs, and decrease the unde- continuously evaluate itself and stay havior promotion—one that is fairly sired impact on overweight and obe- abreast of the latest innovations in explicit about the recommended ac- sity, the program recently the nutrition sector. tions.20 firmer conditions to pro- implemented a new health and nutri- mote health-seeking behaviors, which monitor and enforce compli- ance, have an additional impact. This is not based on a patronizing view that the poor do not know how to spend their money wisely, as occa- 19 World Bank Independent Evaluation Group. 2010. What can we learn from nutrition impact sionally depicted. Rather, this de- evaluations? Washington, D.C.: World Bank. rives from a simple expectation that 20 Another interesting example of soft condition comes from the Ecuador Bono de lowering a price increases demand Desarrollo Humano (BDH) CCT program which introduced a ran- domized verification of co- more than an equivalent income responsibilities in urban areas to reduce the cost of monitoring. transfer does. CHAPTER - D | Improving Nutrition through Social Protection BOx D-4. STRENGTHENING THE NuTRITION IMPACT OF THE PERu CCT PROGRAM Peru’s CCT program Juntos began in of 2008, they were far below the pro- ducing chronic malnutrition in chil- 2005 and serves more than half a gram’s potential. Poverty was re- dren under-5 by 9 percentage points million households. The program tar- duced, beneficiaries were spending in five years. Juntos is at the core of gets poor rural households with chil- more on nutritious food, and there the strategy to reduce undernutri- dren under 14 years. It transfers was a significant increase in the uti- tion, and since no nutrition impact approximately US$38 to the mother lization of health services (mainly in was observed, it needed to be of each beneficiary household per check-ups and vaccination). However, strengthened. As part of the GoP’s month, which represents 15% of total there was no impact in other key overarching commitment to improv- household consumption. The co-re- service utilization, such as prenatal ing nutrition, and assisted by World sponsibilities of receiving the pay- check-ups, and no impact on final Bank non-lending technical assis- ment include regular health visits for outcomes (malnutrition). Meanwhile, tance, an effort was made to identify pregnant women and children under- the rate of chronic malnutrition key bottlenecks in the program and 5 years, and school attendance of at (stunting) in Peru remained at 31%, create a plan to strengthen its func- least 85% for school-age children far higher than expected given per- tioning to reach better nutrition out- who have not yet completed elemen- capita income. In 2007, the govern- comes. Highlighted results of this tary education. While the program ment placed nutrition at the forefront analysis are summarized in the table had shown some positive results as of its social policy, committing to re- below. BOTTLENECk LINE OF READjuSTMENT Inadequate (low) coverage of target Improved targeting (priority for children aged 0-2yrs) population (<2yrs old) Transfer scheme inappropriate for Adjustment of incentive scheme, i.e., amount, co-responsibilities, frequency desired incentives of payment Cash transfers to households without New process of cash transfer delivery; Compliance verification through health and information about the compliance education sectors and/or without compliance of co- responsibilities Limited supply capacity of health and Guarantee the supply of health and education services through the standardization education services of basic packages, including nutrition such as distribution of micronutrient powders Lack of a managerial monitoring system Establish a monitoring system that tracks the supply of service i.e., are services dependably available and high quality Inadequate institutional Establish an adequate and professionalized structure, e.g., clarify operational implementation structure rules and staff, fill vacant director position An important and innovative aspect the program’s success. The group is with the objective to improve pro- to the modification of Juntos is the an important instrument for coordi- gram aspects related to the affiliation changes were pilot-tested in one dis- nation across the different sectors process and the process of verifica- trict of Peru (San Jerónimo, Apurimac (particularly between Juntos and Min- tion of co-responsibility. It is ex- Region) to validate the functioning of istry of Health). Its goal was to coor- pected that implementing the the revamped program and to fine- dinate the delivery of transfers and reforms will contribute to improving tune aspects for national scale up. demand incentives to targeted the impact of final outcomes and the This involved the establishment of a households by providing a basic program’s capacity to break the inter- multisectoral inter-agency working package of interventions in health generational cycle of poverty. group (known as the “Grupo Apuri- and nutrition. In 2010, the program mac”) that turned out to be critical to approved a new operational manual Source: Vargas, 2011. CHAPTER - D | Improving Nutrition through Social Protection Some programs have introduced crease participation and change in but as they are untargeted within a community-based conditionalities practices. While no experiments com- school, they are generally smaller to generate social pressure on pare health outcomes between a CCT than targeted UCTs or CCTs. School minimum utilization of services and a UCT, a related experiment on feeding programs are conditioned on and to promote inclusion of the school participation in Malawi found school attendance; thus, that is most vulnerable. In the case of In- that while unconditional transfers in- where their impact is most apparent, donesia, the community set the pro- creased schooling, the CCT had a particularly in regards to girls’ atten- gram conditionalities, offering much larger impact.21 A similar in- dance. School meal programs are not incentives to identify community ference was made in regards to designed to address the most critical problems, seeking solutions to im- Ecuador and Mexico’s transfer pro- nutritional constraints in low-income prove specific health and education grams based on whether the house- settings, simply because they are not indicators, and increasing both hold was informed about the targeted at the most vulnerable pe- usage and funding of community conditions or did not receive the riod in child development. Nonethe- services. forms to monitor the children’s atten- less, the indirect effects of girls dance.22 Still, unconditional trans- remaining in school can contribute to fers can play an important role in improved maternal and infant nutri- C. Conditional versus contexts where the cost of monitor- tion outcomes via delayed marriage unconditional transfers ing compliance with co-responsibili- and older age at first childbearing. ties is very high. Their impact can be when choosing between a condi- strengthened by ensuring a mini- from a nutrition perspective, the tional and an unconditional trans- mum set of conditions: e.g., by en- highest payoff comes from reach- fer, the key question to ask is, Are suring that the transfer is given to ing children before school age, but the expected gains worth the ap- mothers, taking advantage of the recent studies from Burkina faso and preciable costs of monitoring and 23 beneficiary registry to target the most Uganda have shown that school- reporting? Monitoring conditions vulnerable with a specific nutrition feeding programs may have a posi- can be complex and expensive. education campaign or micronutrient tive impact on younger siblings. Caldes (2006) estimates that the cost supplementation, depending on the What in the past was termed leakage of monitoring conditionalities can nature of the nutrition problem. from the targeted school- aged child range between 8 and 15 percent of may in fact be sharing with more vul- the total budget of a program. An un- nerable family members. However, conditional transfer assumes that preferred expenditures can be D. Conditional “in-kind” there is currently not enough evi- achieved simply by an increase in in- transfers: School feeding and dence or experience to assess school health and nutrition whether take-home rations or school come, rather than by accompanying programs meals have a higher potential to im- the income transfer with a lowered pact younger household members. price. for example, the existence of a School feeding programs—both This benefit is, nevertheless, indi- strong community-based growth pro- school meals and take-home ra- rect. motion program in Senegal has cre- tions—can be viewed as condi- ated enough demand for nutrition tional in-kind transfers. School meal programs can have a modest School feeding programs can also activities that an unconditional trans- impact on household expenditures, contribute directly to nutrition of fer was considered enough to in- school-age children if the meals are fortified, particularly with iron 21 Baird, S., McIntosh, D. and B. Ozler. 2010. Cash or Conditions? Evidence from a Cash Transfer Experiment. 22 Schady, N. and M.C. Araujo. 2008. “Cash Transfers, Conditions, and School Enrollment in Ecuador,” Economía 8 (2) 43–70; De Brauw, A. and J. Hod- dinott. 2008. Must conditional cash transfer programs be conditioned to be effective? The impact of conditioning transfers on school Enrollment in Mexico, IfPRI Discussion Paper 57, Washington, D.C., International food Policy Research Institute. 23 Alderman, H. and D. Bundy. “School feeding Programs and Development: are we framing the question correctly?” World Bank Research Observer, forthcoming. CHAPTER - D | Improving Nutrition through Social Protection and folic acid. While school feeding Alternatively, a school health finally, creating a partnership be- programs are not designed to im- program can provide deworming, tween health and school adminis- prove nutrition status during the and iron and folic acid supple- trations that would facilitate the most vulnerable “1,000 days window ments as part of a wider program provision of deworming medicines of opportunity” from pregnancy to of school health. The efficacy and can be forged around school age two, they can contribute to im- benefit-cost ratios for such school- meals. Although deworming of chil- proving nutrition status among based vitamin and mineral supple- dren is undertaken on a biannual school-age children. Individual mentation programs is clearly basis, which does not correspond to school programs and populations re- demonstrated (especially when school-meal programs or take- home quire close attention; however, as coupled with deworming), though rations. Partnerships have proven to emerging research suggests that the coverage and effectiveness of a be effective for preschool as well as rapid weight gain after the age of two full-scale program remains contin- primary school-age children. Such may predispose previously under- gent on capacity and cross-sectoral programs, however, are not currently nourished children to obesity and programming. Safety net programs included within safety nets or wider non-communicable diseases later in could help scale up these interven- social protection systems, despite life. tions with large potential benefits strong evidence of impact on child for nutrition at low marginal costs. growth in populations where worm further, while few school feeding However, some health ministries are infestations are endemic, a potential programs currently use fortified reluctant to entrust this responsibil- win-win situation. foods, the range of appropriate ity to educational staff, and some technology has broadened with re- teachers are reluctant to accept it. cent advances in extruder fortified rice, (which adds less than 5% to the School-based health and nutrition cost of this staple), and a range of programs can be vehicles for other fortification options, such as nutritional education. for example, wheat flour and maize meal, and meal programs can be linked to double fortified salt (salt fortified encouraging handwashing. Adding with iodine and iron). However, the such encouragement to a school potential for fortification is some- meal program costs little, while what problematic with the increased adding school feeding programs to a focus on local sourcing of foods. health promotion campaign may be local foods are less likely to be cen- costly and may make the benefits E. Promoting access to trally processed, and thus, less likely less persuasive. services: Community-based to be fortified at scale. growth promotion programs In some cases, school meals can Community-based growth promo- The use of premixed packages of promote diet diversity. In other con- tion programs are based on the micronutrients, such as a variant texts, particularly in latin America, same principles of social inclusion of micronutrient “sprinkles” that school meal programs have intro- that are applicable to most social are designed for school-aged chil- duced healthy diets to counter trends protection programs. Several coun- dren may enhance the nutritional in childhood obesity, but the long- tries use a strategy of community- value of the meals. These premixes term contribution of these re- based growth promotion, which in- can be added to school meals, al- designed programs to preventing corporates these key interventions though their efficacy or doses for obesity is not yet determined. and strengthens knowledge and ca- school settings is not yet determined pacity at the community level, as well since they originally were designed as creates demand for health and nu- for home use with young children. trition services by bringing services CHAPTER - D | Improving Nutrition through Social Protection closer to the communities. Such growth monitoring, linked to advice linked to supply-side interventions strategies have proven effective in on and access to maternal care serv- that improve access to health improving mothers’ knowledge, atti- ices during pregnancy, promotion of services. tudes, and practices related to child exclusive breastfeeding and appro- nutrition, boosting family demand for priate and timely complementary CDD projects and social funds can health care and reducing malnutri- feeding, and health and care prac- incorporate nutrition into basic tion. In addition to linkages through tices and referral to health centers. service provision. The first genera- CCTs, social protection projects have Some programs also have provided tion of Bank supported social funds fostered community nutrition as part micronutrient supplements for preg- focused on countries with low capac- of their social inclusion strategy, nant mothers and children, and im- ity and transition economies. The even in the absence of a transfer pro- munization and related services. main objective of such funds was to gram, like in the case of Honduras Program experiences have high- involve communities in prioritizing AIN-C. lighted the importance of: (i) female and constructing infrastructure. This community workers as service deliv- model is still applied to fragile states Successful, large-scale child- ery agents; (ii) regular child growth and in post-conflict environments. In growth promotion programs were monitoring (weight) paired with a many other places, however, this established in the 1980s in Ja- well-trained agent providing counsel- model has evolved. The new objec- maica, India (Tamil Nadu Inte- ing and communication to the tive is to strengthen local govern- grated Nutrition Project and mother, who benefits from effective ment in decentralized service others), and Tanzania (Iringa). fol- and regular supervision in weighing, delivery. local governments may be lowing these initial successes, com- recording, and counseling; (iii) well- the most practical place to achieve munity growth promotion has also designed, culturally appropriate, and multisectoral integration, an elusive been supported in Madagascar consistent nutrition education aimed goal of integrated nutrition planning. (Seecaline), Senegal (PRN), and Hon- at promoting specific nutrition prac- Nutrition projects, such as the com- duras (AIN-C), among others, achiev- tices. munity-based growth promotion pro- ing sharp declines in child grams in Senegal, Madagascar or malnutrition in the first five years, Although community-based growth Central America can use techniques with a more gradual rate of decline in promotion programs offer a prom- learned from social funds to enhance moderate and mild malnutrition ising approach to addressing un- community participation. thereafter. dernutrition, common problems related to agent training, support, The main characteristic of these and motivation, barriers faced by initiatives is their community beneficiary mothers in implementing basis, which has allowed them to recommended behavior changes, and address a wide variety of malnutri- the cost-benefit of expensive food tion’s causes, often with a focus on supplementation programs for moth- women and children under age two. ers and children, remain as overarch- Main interventions include nutrition ing challenges that merit further education or counseling, typically ac- attention.24 Overall, results have companying and based on child been better when community-based growth promotion programs are 24 World Bank. 2006. Repositioning Nutrition as Central to Development, the World Bank, Washington D.C.; Marini, A., Bassett, l., Bortman, M., flores, R., Griffiths, M. and M. Salazar. 2009. Promocion del Crecimiento para Prevenir la Desnutricion Cronica. Estrategias con Base Comunitaria en Centro America, the World Bank, Washington D.C. CHAPTER - D | Improving Nutrition through Social Protection V. Is there a role for Some programs have a fixed per Targeting unconditional transfers household transfer to avoid fertility to the elderly can be an important targeting transfers effects. However, Peru’s Juntos CCT poverty reduction policy; however, to the nutritionally programs found that this served as a they are difficult to justify on the vulnerable? disincentive to register children in grounds of their positive impact on Most social protection programs use the program since the burden of co- children. Some programs target un- some sort of poverty targeting. To responsibility increased with the conditional transfers to the elderly strengthen the impact on nutrition number of children, but payment did partially because they are labor poor, outcomes, social programs typically not. Other programs increase pay- and thus there are few disincentive have the choice of combining poverty ments in accord with the number of issues for labor. However, an addi- targeting with targeting by demo- children eligible, but capped them at tional justification commonly voiced graphic group, geographic area or by a maximum number of beneficiaries. is that they spend their income on at nutritional status. Targeting is a key This gives a family an incentive to risk children, which is based on a operational feature of most social register the child. Indeed, some pro- misinterpretation of the evidence. protection programs. grams make birth registration a co- While it is the case that pensioners responsibility. This can be aided by often do support children, as Duflo a monitoring system used to track (2003) recorded, this study referred A Targeting by demographic participants in maternal health pro- to an uncharacteristically large pro- group grams and in CCTs that include as- gram. Moreover, it only found that sisted births as a program activity. spending on children pertained to fe- Clearly, age-based or group target- male recipients. While an argument ing can direct transfers to the most A focus on this critical period may be made for prioritizing elderly at-risk age groups. for example, serves to promote future earnings. on equity grounds, justifying UCTs to most CCTs include children as a prior- Indeed, not only are prenatal services the elderly based on the trickle down ity. In Africa, children affected by often included in CCTs, pregnant impact on children is disingenuous. HIV/AIDS are often prioritized as a women can be particularly receptive This logic, in effect argues for ac- particular focus. Pregnant women are to nutritional education and guidance cepting large amounts of leakage also a likely target group. Targeting on issues such as breastfeeding and from the nominal target group of chil- young children and pregnant women provision of colostrum. Additionally, dren in part because targeting the is consistent with the global evidence a few CCTs have been targeted to- elderly is convenient. In the event indicating that the period between wards adolescent girls, but these that a social pension is a policy conception and the first two years of usually have schooling or prevention choice, and the program is targeted a child’s life is a critical window of of sexually transmitted infections due to a limited budget, skipping opportunity during which good nutri- (STIs) as the main objectives (as in generation households with direct re- tion is decisive for healthy human de- Malawi). To date, no nutritional out- sponsibility for children would be a velopment. After the age of two, most comes have been reported for ado- high priority due to the overlap of eq- losses to human capital and future lescents. Nevertheless, it is plausible uity and the economic returns to in- productivity attributable to undernu- to include education on child care, as vesting in children. Generally, trition during this period are irre- well as the distribution of micronutri- focusing on nutrition vulnerability versible. However, when defining the ents in the design of a program tar- will entail exclusion of some poor details of a program, it is important geted to adolescents, especially households with no children living in to take into account potential unex- since iron and folic acid for adoles- the household or with children who pected effects of the incentive. cent girls is important for their are outside the age associated with healthy development and the future the greatest risk of malnutrition. of their children. CHAPTER - D | Improving Nutrition through Social Protection B. Targeting by rainfall deviations in Ethiopia or on VI. Concluding remarks nutritional status or risk rollout of supplementary feeding pro- grams in response to Indonesia’s fi- while most safety net programs in- Targeting transfers to households clude an income transfer compo- nancial crisis, confirms that with malnourished children has nent, and many vulnerable large-scale programs can prevent in- the conceptual advantage of being households seem to lack adequate creases in malnutrition. responsive to transitory shocks, income to purchase key inputs for unlike most indicators used to con- nutrition outcomes, the evidence struct proxies for poverty, which shows that increased income alone are relatively static. This approach was used to prioritize nutrition pro- grams in Tamil Nadu’s community nu- trition program, but targeting malnourished children is not com- monly used in safety net programs. BOx D-5. TARGETING THE NEEDS OF ACuTELy MALNOuRISHED CHILDREN One purported disadvantage of this approach is it may create an incentive for a family to keep a child malnour- Ready to use therapeutic foods (RuTfs) ing RuTfs to children at heightened or ready to use supplementary foods risk of malnutrition, but who are not ished. While such abuse is possible, (RuSf) may be employed successfully yet malnourished, remains controver- verifying or disproving the extent of to mitigate the effects of such crises sial due in part to the costs of many of such behavior is difficult. This form and to deal with children that are al- the products designed for use in ther- of targeting also has the disadvan- apeutic settings. Concerns also exist ready malnourished. They function as a tage of only reaching children who that RuTfs and especially RuSfs, may sort of targeted unconditional in-kind are malnourished or on the thresh- transfer. RuTfs are less susceptible to replace breastfeeding, thereby under- old, rather than being preventative. spoilage than powdered milk-based mining one of the most cost-effective supplementary foods, do not require nutrition inputs. further, the feasibil- Heightened risk is another basis of mixing with water, and can be used by ity and the cost-effectiveness of RuSfs nutrition targeting. Many safety net community health workers to address is still being researched, albeit new strategies seek counter-cyclical pro- acute malnutrition, especially in emer- products such as lipid-based nutri- grams that can be scaled up in the gencies, or in situations when markets tional supplements show great prom- are failing. various studies have shown ise. wake of weather, price, or financial shocks. Employing the same strat- that RuTf can be used to reduce mortal- ity in a cost-effective manner for treat- Despite these concerns, distributing egy, it may be possible to target a ing severe malnutrition (about peanut or grain and soy-based RuTfs, safety net scale up to the increased $200/child/episode). However, distin- geographically and temporally tar- risk of malnutrition through preven- guishing the intrinsic advantage of geted to children in crises, may serve tive efforts in a population, leaving as a bridge between their well-estab- products promoted with RuTf from the more clinical nutritional interventions advantages of the community-based lished role in therapeutic feeding for to address observed cases of severe management of care may be difficult, the severely malnourished and their and acute forms of malnutrition. Even and in many situations it may be hard still controversial use to prevent mal- though the evidence on the conse- to provide such care at scale. Still, this nutrition among the chronically poor. quence of price, financial or climatic curative function is only one dimension Reformulating the RuTfs so they are shocks on nutrition is robust, assess- of their potential benefits of RuTf. Ar- less expensive and nutrient dense, ing the impact of programs designed guably, they can also be useful in pre- while retaining their convenience, to offset these shocks is difficult, for venting malnutrition within a safety net may make the preventative approach both ethical and logistic reasons. program. The practicality of distribut- more acceptable and feasible at scale. Nevertheless, evidence on changes of food aid allocation attributed to CHAPTER - D | Improving Nutrition through Social Protection BOx D-6. wHAT SHOuLD BE MONITORED IN SP PROGRAMS TO kEEP NuTRITION AS A FOCuS? The relevant outcomes most com- individuals in a target age group overweight are more commonly mon- monly tracked within SP programs rather than for a household as a unit. itored than are measures of micronu- are consumption (or expenditures) Diet diversity is usually measured trient status such as vitamin and and anthropometric measures of using a simple count of foods or food mineral deficiencies. (See nutritional status of young chil- groups over a given reference period glossary/definitions). Stunting is low dren, both acute and chronic. A and has been found to be strongly as- height-for-age because of prolonged case can be made that tracking con- sociated with direct measures of mal- inadequate nutrition or poor health. sumption is less important than mon- nutrition. It implies long-term undernutrition itoring the incidence of program and poor health. Underweight is participation. This implies that the It should be noted, however, that measured as low weight-for-age; it main focus remains on monitoring from the standpoint of nutrition, could imply stunting and/or wasting, the targeting efficiency in terms of consumption data reveal informa- and is one of the indicators used in the share of transfers that reach the tion about inputs into nutrition, al- tracking MDG1c. Wasting is low poor, as well as the amount of up- beit critical ones, and not weight-for-height and describes a re- stream leakage from the program, if outcomes. Nevertheless, food secu- cent or current severe process, usu- any. If transfers have a small impact rity measured by this and similar ally a consequence of acute food on labor or on private remittances, as data is an issue of household welfare deprivation or severe disease. All is generally the case, a dollar trans- that is closely aligned with the social these indicators are commonly col- ferred to the poor will lead to a dollar protection (SP) strategy and of intrin- lected to gauge undernutrition of savings and consumption com- sic interest. SP programs, particu- among children; wasting data is es- bined. It is difficult to argue that SP larly CCTs, also track inputs such as pecially useful in emergency situa- program objectives have a desired or participation in health activities in- tions and humanitarian crises. While target distribution for the share of cluding public awareness campaigns obesity is often thought of as a corre- savings or consumption out of this (for example, the platicas in Pro- late of affluence, the current profes- total. Arguably, welfare economics gresa) and attendance in clinics and sional opinion of the causes of and an adherence to consumer sover- vitamin A or deworming medicine obesity is that it often reflects early eignty also imply that the household distribution. Similarly, school feed- deprivation, including prenatal un- allocates its budget efficiently. To be ing programs track enrollment and dernutrition. sure, this point is debatable, but less attendance within monitoring sys- so when intra-household allocation tems, and less commonly, school is already considered and the pro- performance. The latter, however, is gram targets female recipients. This a key component of many impact said, tracking food expenditures evaluations, especially those that within a SP program is politic. Moni- have a multi-year panel. toring food consumption is, however, data intensive especially in rural Malnutrition indicators are often communities where self-production collected on a regular basis with and seasonal fluctuations add to the community health coverage, al- challenge of data collection. Data on though self-selection into public diet diversity or meal frequency often health programs will influence the serve as a source of relatively easy interpretation of these indicators. indicators to monitor with the advan- Anthropometric measures such as tage that these can be collected for underweight or stunting as well as Source: Vargas, 2011. CHAPTER - D | Improving Nutrition through Social Protection BOx D-7. PRIORITy OBjECTIvES is often insufficient to have a major VII. Emerging opera- OF NUTRITIoN-SENSITIvE impact on nutrition. Thus, other components, such as directing trans- tional research and SOCIAL PROTECTION fers to women, targeting the most knowledge gaps vulnerable and the correct age group, while all projects need their re- 1. Target activities to the most adding nutrition education or a mi- sults evaluated to a degree, given the resource costs for establishing nutritionally vulnerable cronutrient supplementation or a de- a means to determine the causal populations. worming component can play an essential role in generating impact of impacts of innovative programs at both transfers and other types of so- scale and the time frame neces- 2. Include education activities cial protection programs, such as sary for assessing cumulative im- within SP interventions to in- welfare, pension or insurance. The pacts, research needs to be crease household awareness priority objectives of SP interventions selective and prioritized. Some is- of care giving and health seek- are outlined in Box D-7 below. sues that might be considered as pri- ing behaviors. ority themes for the interaction of social protection and nutrition in- 3. Integrate nutrition services clude: into SP interventions, e.g. growth monitoring and promo- • Evaluating the cost effectiveness tion, and/or activities for im- of soft versus hard conditions in proved growth and diet CCTs in lICs. What basic country quality. systems are needed to be in place to implement conditionali- ties (or co- responsibilities) at 4. Reduce the acute and long- scale? What is the cost of moni- term negative financial im- toring, and how will outcomes be pacts of external financial, improved by these expendi- price, and weather shocks by tures? These modalities need to scaling up programs in times be compared in the same setting of crises. over the same time period and with the same amount of transfer offered. A woman holds an infant during a community meeting Heenabowa – community club gathering. Sri lanka. Photo: Simone D. McCourtie / World Bank CHAPTER - D | Improving Nutrition through Social Protection • Designing results-based incen- crises and developing and test- The general topic has been well tives or other means to increase ing alternative and more cost- ef- researched (especially in regards community participation in the fective products. to food aid), but under some cir- accountability of the supply of cumstances, fortification (or services linked to CCT programs. • Improving targeting mecha- home fortification pre-mixes) nisms/systems. may provide value added to lo- • for CCTs with nutrition condition- cally sourced in- kind assistance. alities, assessing the marginal • Assessing the impact of full- benefits of different size of in- scale programs for supplementa- • Also, for school feeding, the im- come transfers. Assessing the tion or fortification within home pact of programs aimed at pre- benefit-cost ratio for RUTf used grown (local sourcing) for school venting obesity or reducing its to prevent malnutrition in re- feeding. This is a subset of the prevalence need to be assessed. sponse to drought or financial more general issue of the circum- stances under which food based • Exploring the potential role of transfers may be appropriate. microfinance for improving nutri- tion outcomes for the poor. C H A P T E R - E Improving Nutrition through Health Julie Ruel-Bergeron, Leslie Elder, Anna Herforth CHAPTER - E | Improving Nutrition through Health I. Objectives II. Rationale A central tenet of the SuN frame- work is the multisectoral nature of The overall objective of this mod- undernutrition is the single largest malnutrition and the need to invest ule is to assist world Bank staff in cause of child death globally and in in actions that will address undernu- enhancing the nutrition impacts of most low-income and lower middle- trition through a variety of sectors. current and pipeline health invest- income countries. Responsible for The immediate causes of malnutri- ments and policies, with a special over 35 percent of all child deaths, tion are inadequate food and nutrient focus on undernutrition among undernutrition increases the mortal- intake, and disease. The underlying women and children under-two ity rate from infectious disease.1,2,3 causes stem from household food in- years of age in developing While severe wasting greatly in- security, poor maternal and child economies. This brief will inform creases the risk of death, starvation, care practices, inadequate access to World Bank staff and country-level and visible undernutrition as seen in health care, lack of clean water, poor implementers about the linkages famines, it is responsible for rela- sanitation and hygiene, gender in- between health and nutrition to tively few of all child deaths attribut- equities, and low levels of education encourage them to integrate able to undernutrition. A much for girls, among others. nutrition-specific interventions in greater proportion of child deaths are health investments and policies. due to moderate undernutrition be- The more direct, nutrition-specific in- This will contribute to the decline cause of its high prevalence. If chil- terventions (usually delivered of the global burden of hunger and dren have poor nutritional status through the health sector) address poverty, help achieve the nutrition coupled with malaria, pneumonia, the immediate causes of malnutrition MDG1, as well as the child and and other infectious diseases, they through actions such as promotion of maternal health-related MDGs 4 and are much more likely to die than exclusive breastfeeding and adminis- 5, build future human capital, and well-nourished children are. tration of vitamin A supplements to enhance economic and social young children. Nutrition-sensitive prospects at the global, regional, There is a global resurgence of interventions include actions deliv- and country levels. awareness and a concomitant in- ered through sectors such as health, crease in support for nutrition. The agriculture, and social protection, The specific objectives of this brief Scaling Up Nutrition movement, or which are expected to yield positive are to support Bank staff, partner SUN, is both a by-product and a results for nutrition (for example, re- agencies, and country clients in the major reason for this renewed inter- productive health services to enable following: (1) enhance the design of est and momentum. More than 100 adequate birth spacing), or to reduce health investments and policies to agencies and institutions have en- harmful impacts on nutritional status maximize impact on nutrition out- dorsed the SUN framework for Ac- (for example, combining health-sec- comes for the poor; and (2) support tion, and there is rapid progress tor delivered counseling on the need governments in designing sustain- toward operationalizing the frame- for increased rest during pregnancy able and coherent health policies and work at the national level in countries with agricultural projects that incor- programs that provide explicit atten- with some of the highest burdens of porate labor-saving devices for tion to nutrition issues in the context undernutrition in the world. women to reduce excessive energy of the national health strategy. expenditure). 1 Pelletier, D.l., frongillo, E.A. Jr., Schroeder, D. and J.P. Habicht. 1995. “The effects of malnutrition on child mortality in developing countries,” Bull World Health Org., 73: 443-48. 2 Caulfield l.E., de Onis M, Blossner M., and R.E. Black. 2004. “Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. AJCN, 80: 193-98. 3 Black, R.E., Allen, l.H., Bhutta, Z.A., Caulfield, l.E., de Onis, M., Ezzati, M., Mathers, C. and J. Rivera J. 2008. “Maternal and child undernutrition: global and regional exposures and health consequences,” lancet 371: 243-60. CHAPTER - E | Improving Nutrition through Health The highest priority target popula- tions are pregnant women and FIGuRE E-1. HEALTH SECTOR-SPECIFIC FRAMEwORk FOR CHILD NuTRITION children up to 24 months. This win- dow of opportunity represents the crucial period in any individual’s life Child malnutrition, health status and survival (MDGs 1 and 4) when poor nutrition can result in irre- versible deficits in cognitive develop- -Infant and young ment and linear growth leading to child nutrition and treatment of severe Nutrition-specific reduced productivity as adults. In ad- Inadequate Increased dition, there is some evidence that undernutrition food/ disease: undernutrition in the first two years -Prevention and Nutrient incidence, treatment of intake, severity, of life is related to adult conditions of childhood undernutrition duration obesity and non-communicable dis- illnesses: diarrhea, eases such as diabetes and heart dis- malaria, ARI ease. -Safe and effective The delivery of nutrition interven- delivery of health Access Caring Access and nutrition to and to tions through the health sector is a food feeding health services to familiar strategy, although the in- vulnerable groups practices services terventions are not always deliv- -Micronutrient ered effectively at scale, e.g., supplementation during contact points such as antena- and fortification tal and postnatal care, well and sick -Hygiene and child services, or community-based health practices HEAlTH woRKfoRCE Nutrition-sensitive that impact health outreach services.4 Health nutritional status systems strengthening programs and public insurance mechanisms can -Human resources HEAlTH INSuRANCE also have increased impacts on nutri- for health/ capacity tion. for example, nutrition-specific building in activities are particularly relevant in nutrition programs -Maternal and child HEAlTH INfoRMATIoN two of the six building blocks of the insurance schemed 2007 WHO Health Systems Strength- ening framework for Action: delivery -Regular nutrition data collection/ HEAlTH fINANCING of health services and medical prod- nutrition ucts, with the remaining four build- surveillance -Increased and results-based lEADERSHIP AND GovERNANCE 4 There is less known about the most financing schemes effective approaches to preventing and for nutrition, treating overweight and obesity. A focusing on growing number of low- and middle- vulnerable groups income countries are facing a double burden of malnutrition. A shift in diet to -Stewardship to overconsumption of energy-dense, enforce nutrition nutrient-poor foods, high in fat, salt, guidelines and and refined sugar, combined with lower regulations (e.g. levels of physical activity has resulted in overweight and obese adults and food fortification, children. Paradoxically, undernutrition nutrition policies) Source: Adapted from UNICEF 1990. persists in the same communities as overnutrition, and even in the same households. CHAPTER - E | Improving Nutrition through Health ing blocks providing opportunities to fined by inadequate dietary intake Nutrition interventions as affect nutrition and health outcomes that causes weight loss, which leads part of health programs help to indirectly through a high-performing to growth faltering, and eventually ei- prevent infection, and serve as an important feature of effective workforce, a good health financing ther to increased vulnerability to dis- disease management. In general, system, a well-functioning informa- ease, increased morbidity, and/or wherever nutrition is a problem — tion system, and adequate leader- severity of disease (figure E-2). Dis- as marked by growth faltering ship and governance of the health ease often leads to problems of al- in children and/or micronutrient system (figure E-1 and Annex E-3). tered metabolism, nutrient loss, and deficiencies — nutritional support malabsorption, and lack of appetite through health services can have significant impacts on both The relationship between nutrition causing weight loss, growth faltering, nutrition and health. and the health sector is the most and undernutrition. Because of this obvious and well understood vicious cycle, including nutrition in -Tomkins and Watson (1989) among the potential sectoral part- health sector activities is central to ners as conceived by the multisec- meeting the health sector goals, as toral approach to undernutrition. The well as MDGs 4 and 5, of reduced malnutrition-infection cycle is de- morbidity and mortality in women and children under- five years. FIGuRE E-2. THE MALNuTRITION-INFECTION CyCLE Inadequate dietary intake, undernutrition Appetite loss, Weight loss, nutrient loss, growth faltering, malabsorption, lowered immunity, altered mucosal damage metabolism Increased disease: Incidence Severity Duration Source: Adapted from Tomkins and Watson (1989). CHAPTER - E | Improving Nutrition through Health A. Poor nutrition affects changes affecting feeding prac- III. What are the key health outcomes tices. At a systems level, access to and quality of health care and health health sector interven- The pathway between poor nutri- tions to improve nutri- tion and health status operates insurance that covers basic services, largely through a compromised im- for example, directly influences a tion, and what will mune system due to micronutrient child’s health status and risk of they cost? deficiencies as well as growth fail- death, which in turn affects nutrition ure. through the pathways described In 2008, The lancet published the below. Examples of interactions Maternal and Child undernutri- • Vitamin A deficiency increases where poor health affects nutrition tion Series,5 which estimated that the incidence and risk of dying outcomes include the following: more than one-third of all child from measles, respiratory tract deaths (3.5 million) are attributa- infections, and diarrhea. • Malaria frequently causes iron ble to maternal and child undernu- deficiency and anemia. trition. • Other micronutrient deficiencies (zinc, iodine, and iron), also de- • Measles and diarrheal infections Paper #3 (What works? Interventions press the immune system. increase the body’s vitamin A re- for maternal and child undernutrition quirements and can precipitate and survival)6 lays out the results of • Poor maternal nutrition during severe forms of deficiency (e.g., an extensive review of interventions pregnancy can cause intrauterine blindness). to address undernutrition in preg- growth restriction (IUGR), leading nant women and children, and identi- to low birth weight (lBW), and • Parasitic infections (e.g., hook- fies the most efficacious actions for increased risk of infections, poor worm) cause iron deficiency and reducing undernutrition and nutri- growth, and greater risk of adult- anemia; both bacterial and para- tion-related mortality. Those results onset of chronic diseases in off- sitic infections can reduce ab- form the basis of the recommended spring. sorption of vitamin A from the interventions outlined in this report, gut. as well as the prioritization scheme • Undernutrition can accelerate outlined in Table E-1. The interven- the severity of infectious dis- • Infections often suppress ap- tions are included in the SUN frame- ease, and the progression of petite and decrease the amount work for Action (2010), which was HIV/AIDS. of food that is consumed, leading endorsed by over 100 international to lack of catch-up growth, agencies, CSOs, universities, and bi- weight loss, and micronutrient lateral organizations.7 deficiencies. B. Poor health affects nutrition The World Bank estimated the cost of outcomes • Maternal infections and poor delivering the 13 key interventions8 The reverse linkage from poor health (e.g., HIV/AIDS, depres- identified in The Lancet Paper #3. The health to poor nutrition operates sion) that limit the ability of interventions are grouped into three primarily through changes in me- women to care properly for their categories: behavior change, mi- tabolism, malabsorption, and ap- children. cronutrients and deworming, and petite loss, as well as behavioral 5 This series is available from http://www.thelancet.com/series/maternal-and-child-undernutrition. 6 Bhutta, Z.A., Ahmed, T., Black, R.E., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S.S., Sachdev, H.P.S. and M. Shekar. 2008. “What works? Interventions for maternal and child undernutrition and survival,” lancet, 371: 417-40. 7 Scaling Up Nutrition: A Framework for Action from http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/Policy- Brief- Nutrition.pdf. 8 Horton, S., Shekar, M., McDonald, C., Mahal, A. and J.K. Brooks. 2010. “Scaling Up Nutrition: What Will it Cost?” Washington D.C.: The World Bank. CHAPTER - E | Improving Nutrition through Health TABLE E-1. ESTIMATED COSTS, BENEFITS, PRIORITy, AND FEASIBILITy OF SCALING uP SELECTED NuTRITION INTERvENTIONS Intervention Estimated Unit Estimated Cost Contribution Implementation Cost (USD) Effectiveness or to mortality Feasibility Benefit: Cost reduction10 * = less feasible ratio (USD) ** = more feasible *** = most feasible 1. Breastfeeding promotion $7.50 per child $53-153 per hiGh * and support <5yrs11 DALY saved 2. Complementary feeding LoW * promotion (provision of food is outlined in intervention 12) 3. Handwashing with soap and LoW * promotion of hygiene behaviors 4. Vitamin A supplementation $1.20/child/yr12 $3-16 per DALY saved hiGh *** 5. Therapeutic zinc supplements $1/child/yr $73 per DALY saved hiGh ** 6. Multiple micronutrient $3.60/60-sachet $12.20 per DALY saved insufficient ** powders course/child (zinc) data 37:1 benefit:cost ratio (iron) 7. Deworming $0.25/round/Child13 6:1 benefit: cost ratio No data *** 8. Iron-folic acid supplements $2/pregnancy/yr 8:1 benefit: cost ratio hiGh ** for pregnant women 9. Iron fortification of staple foods $0.20/person/yr 8:1 benefit: cost ratio LoW ** 10. Salt iodization $0.05/person/yr 30:1 benefit: cost ratio LoW 14 ** 11. Supplementation with $2.16/person/yr 15:520 benefit:cost ratio hiGh *** Iodized oil capsules (for women) 12. Prevention and treatment $0.11/child/day15 $500-1,000 per MEDiuM * of moderate malnutrition DALY saved16 in children 6-23 months of age 13. Treatment of severe $200/child treated $41 per DALY saved hiGh ** acute malnutrition 10 A detailed table on public health priority categorization, data and references provided in Annex E-4. 11 for the combination of all three interventions by community volunteers to facilitate community organization; educate households about breastfeeding, complementary feeding, and handwashing; and to distribute micronutrient powders, iron-folic acid supplements, and refer cases of faltering growth. 12 This includes 2 rounds per child per year, at $0.60 per round per child. 13 Cost refers only to children 24-59 months. There are no cost estimates currently available for children 12-24 months, who would require syrups that are more costly to purchase and to deliver. 14 The public health priority of salt iodization has less to do with mortality, and more to do with its effect on cognitive development and lifelong learning and earning potential. 15 This cost estimate includes the provision of a small amount of complementary food for selected children 6-23 months of age. 16 These are rough estimates based on Caulfield et al.’s (1999) estimate that increased intake of 71-164 kcal per day for children younger than one year of age, as a result of complementary feeding, could decrease deaths due to malnutrition by 2-13%, depending on underlying presence of malnutrition in the community. CHAPTER - E | Improving Nutrition through Health Mortality reduction Legend Implementation Feasibility Legend High Mortality reduction *** high capacity setting Most feasible to implement, requires very little between 10-80% additional infrastructure and/or human resources to implement. Medium Mortality reduction ** medium capacity setting More difficult to implement, requires some existing between 5-10% infrastructure, has higher costs in most cases, and higher human resource investments. Low Mortality reduction * low capacity setting Most difficult to implement, requires existing between 0-5%; or no infrastructure, and significant human resource demonstrated/ direct investments. effect on mortality Sources: Horton et al. 2010. CORE Group Workbook April 2010 - Nutrition Program Design Assistant: A Tool for Program Planners; IZincG Technical Brief 1. 2007; Bhutta et al., 2008; Brown et al., 2009; Imdad et al., 2011; Lamberti et al., 2011; Yakoob et al., 2011. preventive and therapeutic feeding. The return on investment for these the health sector still has a steward- The total financing required to imple- activities would be over one million ship role to play in terms of policy de- ment the 13 interventions is esti- child deaths prevented; 30 million velopment and enforcement of mated at US$11.8 billion per year for disability adjusted life years (DAlYs) guidelines and regulations that are in 100 percent coverage of the target saved; 30 million fewer stunted chil- line with international standards. Al- groups. Of this sum, $1.5 billion is ex- dren under the age of five years (a ternatively, or in addition to tradi- pected to come from wealthier pri- 20% reduction from current rates); tional lending, other types of lending vate households to cover costs for and a remarkable halving of the such as Development Policy loans complementary and fortified foods, prevalence of severe acute malnutri- (DPls), present excellent opportuni- and the remaining $10.3 billion from tion.9 Table E-1 represents these ties to support the development and public resources worldwide. The costs and cost:benefit ratio by inter- enforcement of nutrition policies, in- Bank’s estimate includes education, vention at an individual level, com- cluding those related to food fortifi- capacity building, and delivery mech- bined with contribution to mortality, cation. The matrix in Annex E-1 anisms, in addition to the basic sup- and implementation feasibility. summarizes nutrition interventions plies needed for each intervention. for integration into routine and spe- The intervention costs are broken The majority of the interventions cialized service delivery down as follows: $2.9 billion for be- to scale up for improved nutrition strategies/approaches in the health havior change programs; $1.5 billion outcomes are most feasibly deliv- sector. A compilation of technical for micronutrients and deworming; ered through the health sector, guidelines by intervention (outlining and $6.2 billion for preventive and with the exception of the fortification dosages and age groups) is provided therapeutic feeding, with the remain- of foods with micronutrients (e.g., in Annex E-5. Contact points between der ($1.2 billion) for capacity devel- salt iodization and fortification of the health sector and individual opment and monitoring and staple foods with iron and other mi- households provide the settings for evaluation (M&E). cronutrients). In this case, integrated service delivery for many nutrition interventions. These are de- scribed in detail in Annex E-2. 9 Ibid. CHAPTER - E | Improving Nutrition through Health IV. Which nutrition hemoglobin)20 in young children, low- • Steward the food ered physical activity and labor pro- fortification process (salt, objectives can be ductivity in adults, and increased flours, etc.), including achieved through the maternal morbidity and mortality. legislation, marketing, health sector, and Zinc deficiency is associated with production, and quality how? stunting and increased incidence and assurance of fortified foods duration of diarrhea and pneumonia. • Promote use of iodized A. Reduce micronutrient Interventions in the health sector to salt if it is available deficiencies among the most address micronutrient deficiencies: vulnerable groups • Promote the use of other a) Promote and ensure routine fortified staple foods, such Micronutrient deficiencies, also micronutrient supplementation as oil and sugar, (vitamin A), known as “hidden hunger,” can flour (iron and folate), rice cause deficits in physical and • Provide routine vitamin A (zinc, iron and folate) mental development, which if ex- supplementation to children perienced in early life, are often ir- c) Promote dietary diversification reversible. The major deficiencies in • Provide multiple for children and pregnant/lactat- terms of prevalence and severity are micronutrient supplements ing women based on available vitamin A, iodine, iron, and zinc defi- or powders (MNP) to and nutritionally rich foods ciencies. Vitamin A deficiency is the young children through counseling at all routine leading cause of childhood blind- health service contacts ness, as well as a risk factor for in- • Provide iron-folate creased severity of infectious disease supplements to pregnant and mortality, leading to the deaths and lactating women. of as many as one million young chil- Provide routine iodized oil dren each year.17 Iodine deficiency capsules when iodized salt is disorders (IDD) affect cognitive devel- not available, focusing on opment and reduce IQ between 10 pregnant and lactating and 15 points;18 18 million children women and young children are mentally impaired as a result of IDD.19 b) Promote and provide steward- ship for population-level con- Iron deficiency is associated with sumption of locally available fetal and child growth failure, com- fortified staple foods promised cognitive development (1.7 lower IQ points per 10g/l decrease in 17 Micronutrient Initiative. 2011. Our Programs; Information on Vitamin A, Iodine, Iron, Zinc, and folic Acid, accessed on May 08 2011 from: 18 World Bank. 2006. Repositioning Nutrition as Central to Development: A Strategy for large-Scale Action. Washington, D.C.: The World Bank. 19 Micronutrient Initiative. 2011. Our Programs; Information on Vitamin A, Iodine, Iron, Zinc, and folic Acid accessed on May 08, 2011 from: 20 Black, R.E., Allen, l.H., Bhutta, Z.A., Caulfield, l.E., de Onis, M., Ezzati, M., Mathers, C. and J. Rivera. 2008. “Maternal and child undernutrition: global and regional exposures and health consequences,” lancet, 371: 243-60. CHAPTER - E | Improving Nutrition through Health Considerations when imple- d) Promote optimal infant and B. Reduce the prevalence of menting interventions to reduce young child feeding practices anemia in pregnant and lac- micronutrient deficiencies: through traditional and innova- tating women and children 0- • what is the prevalence of each defi- tive behavior change methods, 24 months ciency? Are deficiencies particularly including mass media marketing Iron deficiency is the most common common in certain population groups of optimal behaviors, peer-to- (i.e., the poorest, women, infants, or preventable nutritional deficiency. peer counseling, and extension children)? It affects all nations and is found to other influential audiences in all income groups. The wHo es- • If routine coverage with vitamin A sup- such as fathers, grandmothers, timates that two billion individuals plements is 80% or higher, vitamin A and mothers-in-law, among oth- are anemic and up to five billion supplements may not need to be in- ers: are iron deficient.22 The large ma- cluded with supplementary immuniza- jority of anemia is estimated to be tions. • Exclusive breastfeeding from caused by dietary deficiencies. 0-6 months, including early • what is needed to generate political fifty percent of anemia is a direct support and funding for multiple mi- initiation and use of result of iron deficiency (due to lack cronutrient supplementation? colostrum of sufficient consumption of high- iron containing foods, such as animal • Is there a possibility to engage with • Continued breastfeeding the private sector to create and market products and legumes), with the re- and optimal complementary fortified products (being cautious of mainder due to other dietary defi- feeding using age- creating perverse incentives)? ciencies such as vitamin A deficiency, appropriate nutrient- rich • If most vulnerable households already deficiencies of vitamin B12 and fo- foods with adequate consume iodized salt, then iodized oil late, and health conditions that inter- frequency, nutrient density, capsules would not be advised. act negatively with iron status, such food diversity, and as malaria, HIV, other infectious dis- • Are fortified foods accessible and con- consistency21 eases, sickle cell disease, and other sumed by the most vulnerable? inherited anemias.23 The conse- e) Integrate micronutrient • what is the current status of food for- quences of anemia for children in- supplementation activities, tification regulation and laws? Is there clude increased morbidity and such as vitamin A and iron an enforcement mechanism to ensure mortality, stunting, lower academic supplementation (through iron compliance with food fortification reg- performance, cognitive delays, and ulation and laws? supplements or MNPs) into a apathy.24 In adults, anemia is associ- basic package of free services • Do the typical diets of the most vulner- ated with weakness and fatigue, (through health insurance lower productivity, and increased risk able groups suggest particular mi- and/or government provision cronutrient gaps? of maternal mortality associated with mechanisms). postpartum hemorrhage. • what are the typical infant feeding practices related to micronutrient-rich foods in target locations? what al- ready works well, which practices could benefit from change to improve health, and what are the barriers to improving practices? 21 See PAHO/WHO. 2003. Guiding Principles of Complementary feeding of the Breastfed Child. (link provided in Annex E-3.) • which delivery channels already exist 22 M. Black. 2003. “Animal source foods to improve micronutrient nutrition and human func- and are functioning well enough to tion in developing countries: Micronutrient deficiencies and cognitive functioning.” J.Nutr, implement the suggested interven- 133: 3927S-3931S. tions? what are some of the barriers 23 Ibid. to implementation, and how can these 24 Children who suffer from anemia have an average of 1-2 lower IQ points per 10g/l decrease be surpassed? in hemoglobin levels, Black et al. 2008. CHAPTER - E | Improving Nutrition through Health Interventions in the health sector to • Steward the food Considerations when reduce the prevalence of anemia: fortification process (salt, implementing interventions flours, etc.), including to reduce anemia: a) Provide daily iron and folic acid legislation, marketing, supplements to pregnant and production, and quality lactating women assurance of fortified foods • What is the prevalence of anemia in reproductive-age women and b) Provide supplemental iron25 to f) Prevent and treat malaria in infants and children? Is anemia children to prevent and treat malaria-endemic areas in the setting mainly due to iron deficiency, to infection, malaria, iron deficiency anemia hookworm, or to other factors? • Provide insecticide-treated c) Provide multiple micronutrient nets (ITN) for pregnant and • What is the burden of malaria, supplements or powders (and lactating women and the existing coverage and use of guidance for use) to young children ITNs and IPT, and opportunities children for further scale up? • Provide intermittent d) Promote and provide deworming preventive treatment (IPT) • What would be the most effective channel through treatments for pregnant women (2 visits, which IFA supplements could be 3 for HIV+ women) delivered to pregnant women • Provide routine deworming (depending on capacity, supply treatments twice-yearly to • Identify and treat cases chains, and use by the most children in high worm of malaria vulnerable pregnant women)? burden communities g) Delay cord clamping at time of • What are the opportunities to increase iron intake among • Provide deworming delivery. Immediate cord clamp- the most vulnerable through treatments for pregnant ing has been shown to increase improved diets, in combination women (after the first the incidence of iron deficiency with supplementation programs? trimester) in hookworm and anemia during the first half endemic areas of infancy, with lower birth • Which facilities and staff need weight infants and infants born to be targeted to adopt delayed to iron deficient mothers being cord clamping as a standard e) Promote and provide steward- obstetric practice? ship for population-level at particular risk. Delayed cord consumption of locally- clamping (clamping done after available iron-fortified staple 2-3 minutes versus within ten foods such as wheat/soy/ seconds or less of birth) allows corn-based flours, and rice extra blood flow from the placenta to the fetus, thereby 25 Refer to the WHO statement on Iron supplementation of young children in regions where malaria transmission is intense and infectious disease highly prevalent at http://www. who.int/child_adolescent_health/documents/pdfs/who_statement_iron.pdf for specific guidance on prevention and treatment of iron deficiency anemia in children in specific disease-context settings. 26 PAHO. Essential Delivery Care Practices for Maternal and Newborn Health and Nutrition. 27 Andersson, O., Hellstrom-Westas, l., Andersson, D. and M. Domellof. 2011. “Effect of de- layed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomized control trial,” British Medical Journal, 343:d7157. CHAPTER - E | Improving Nutrition through Health BOx E-1. SuCCESS IN REDuCING MATERNAL ANEMIA IN NEPAL shoring up the infant’s iron stores from which it draws In 1998, a National Micronutrient and side effects of IFA. during the first six months of Survey found that 75% of Nepalese women were anemic. In response to Under this model, Nepal has been life.26 This effect was further this shocking statistic, the Govern- successfully implementing the IIP, confirmed by a recent study27 ment of Nepal intensified its mi- with results indicating increased ANC where cord clamping improved cronutrient program, the Iron attendance (almost double), con- the iron status of infants, and the Intensification Project (IIP) in five sumption of IFA (increased 3-4 risk of iron deficiency was lower districts, followed by a scale up in times), and deworming coverage of at four months of age compared subsequent years to achieve cover- 60% in 2009 (from zero in 2001) (See age rates of 70 out of Nepal’s 75 dis- figure below). National data on the to infants who did not receive tricts in 2011. prevalence of maternal anemia show the intervention. substantial decreases between 1998 The IIP is a program that aims to in- and 2006: from 68% h) Integrate routine iron supple- crease coverage of interventions in mentation, intermittent preven- pregnant women that are known to to 36% in women of reproductive tive treatment of malaria, and reduce maternal anemia. The IIP is age, and from 75% to 42% in preg- distribution of ITNs into a basic based upon delivery of a package of nant women. Indirect effects of re- interventions by female community ductions in anemia may have also package of free services for preg- health volunteers, encourage atten- contributed to reductions in maternal nant women and young children dance at antenatal visits, provide mortality, which decreased in Nepal (through health insurance IFAs and deworming medicine, and from 539 deaths per 100,000 in and/or government provision counsel women on the importance of 1996, to 281 per 100,000 in 2006. mechanisms). anemia reduction, and use, benefits, C. Promote good feeding ANTENATAL CARE COvERAGE AND INTERvENTIONS LIkELy TO BE ASSOCIATED wITH MATERNAL ANEMIA and nutritional care practices PREvALENCE REDuCTIONS IN NEPAL, 2001-2009 for the most vulnerable populations 100 ATTENDING ANC 100 RECEIvING ANy IRON worldwide, 20 percent of children 80 80 under five are underweight, and 32 percent of children under five 60 60 Percent Percent are stunted. In most countries, poor 40 40 children are more likely than richer children to suffer from stunting and 20 20 other forms of undernutrition due to 0 0 the strong influence of poverty on 2001 2006 2009 2001 2006 2009 access to and availability of food, Year of Survey Year of Survey education, health, and a hygienic environment.28 However, this is not 70 RECEIvING DEwORMER National always the case. Undernutrition may 60 Terai 50 Mtn/Hill Percent 40 30 SOURCE: Pokharel, R.K., Maharjan, M.R., 28 Black, R.E., Allen, l.H., Bhutta, Z.A., 20 Mathema, P. and P. Harvey. August 2011. Caulfield l.E., de Onis, M., Ezzati, M., Success in Delivering Interventions to Reduce 10 Maternal Anemia in Nepal: A Case Study of Mathers, C. and J. Rivera. 2008. “Maternal and child undernutrition: 0 the Intensification of Maternal and Neonatal global and regional exposures and 2001 2006 2009 Micronutrient Program. Government of health consequences,” Lancet, Nepal, USAID, MI, UNICEF, A2Z, FHI360. Year of Survey 371: 243-60. CHAPTER - E | Improving Nutrition through Health directly reflect poor dietary choices • Continue promotion/support Considerations when and/or feeding practices among of optimal breastfeeding implementing interventions vulnerable groups despite available through individual to improve feeding and nutritionally rich and diverse counseling of mothers; nutritional care of foods. The intergenerational ensure that health-system vulnerable populations: cycle of undernutrition begins when support strategies align their a child is born small. The child is messages with those of more likely to suffer from undernutri- community- based • What are the existing opportuni- tion in childhood and through ado- breastfeeding promotion ties to improve diets in the target lescence, leading to undernourished (e.g., mother-to-mother population? Can improved pregnant women giving birth to low peer support groups, etc.). knowledge be expected to overcome barriers to access? birth weight infants, perpetuating the cycle. Other basic and underlying • Support and implement the • What are the infant feeding causes of undernutrition, such as en- development of policies that practices in target locations? vironmental, economic, and sociopo- protect optimal Which positive existing practices litical contextual factors, are also breastfeeding at the could be promoted, and which important contributors to undernutri- population level, including practices could benefit from tion across all societal levels. legislation and enforcement change to improve health? regarding breastmilk Interventions in the health sector to substitutes and hospital care • What are the main factors limiting exclusive breastfeeding: promote good feeding and nutritional (Baby-friendly Hospital cultural norms, marketing of care practices: Initiative, for example). breastmilk substitutes, health staff, stigma, women’s work, a) Promote dietary diversification c) Provide counseling and support etc.? How can these be over- and adequate weight gain for for optimal complementary feed- come, and who would be the most ef- fective group to counsel pregnant women and children’s ing from six months (individual in addition to new mothers diets and group counseling), including (husbands, mothers-in-law, counseling on feeding during ill- health staff, etc.)? b) Promote/protect early initiation ness and in support of catch-up and exclusive breastfeeding for growth during convalescence. • What training is needed to the first six months of life (indi- improve staff capacity to deliver vidual and group counseling) counseling messages? • What training is needed to build • Counsel pregnant women, nutrition capacity in country, partners, mothers-in-law and including nutritionist training other influential actors on curricula, sensitization of optimal breastfeeding high level policymakers and practices such as early academics? initiation, use of colostrum, and exclusive breastfeeding • How will the quality of for the first six months of counseling be monitored? the baby’s life CHAPTER - E | Improving Nutrition through Health BOx E-2. GROwTH BOx E-3. INCREASING ExCLuSIvE BREASTFEEDING RATES IN SRI LANkA MONITORING AND PROMOTION: A uSEFuL DELIvERy PLATFORM Sri Lanka, with its well-developed health system and good health infrastructure, has experienced impressive improvements in exclusive Growth monitoring and promotion breastfeeding (EBF) rates. (GMP) programs hold an enormous potential when used as a platform In 1995, only 17% of women were practicing EBF. Given that over or entry point for the delivery of a 95% of women receive antenatal care and deliver in health facilities, package of essential nutrition improvements in extensive lactation management training for nearly services, as well as a link to the all health workers in the field and in hospitals has made it possible to formal health system in the case provide skilled assistance to mothers across the country. High-level of a community-based center or political commitment at various points in time, a culture supportive gathering point that is separate of breast-feeding and parents, effective transmission of infant and young from a health post or clinic. Although child feeding (IYCF) messages through multiple communication channels, the results of GMP have been mixed, a high literacy rate among women, and good “health-seeking behaviors” in cases where the growth promotion of parents likely contributed to the increase of EBF over the ten-year component was carried out effec- period. In 2006/7, 76% of Sri Lankan women were practicing EBF. tively and linked to delivery of other essential nutrition services, Community outreach by public health midwives also played an important there is better evidence (such as role in these results: two home visits are made within the first 10 days from the AIN-C Program in Honduras of a normal delivery to provide added support to mothers. IYCF is also a – see Schaetzel et al. 2008, component of the country’s integrated health and nutrition package, World Bank 1996). providing a sustainable platform for continued support in this area. Essential services that would be delivered through GMP include weighing/measuring children at set intervals, determining the adequacy 80 of growth, engaging in dialogue with parents to determine reasons for 76 success or causes of problems, 60 0 - 5 months (%) referral to health services as needed, 53 and agreement with the caregivers 40 about actions that will support continued positive child growth or correct growth faltering. 20 17 Counseling messages include discussion of optimal young child 0 feeding practices such as exclusive 1995 2000 2006/7 breastfeeding 0-6 months, adequate complementary feeding, and feeding during and after illness, among others. Caregivers are encouraged to seek health care services for sick children (e.g., IMCI); ensure that children are immunized; use proper handwashing techniques; and ensure that children receive micronutrient supplements as needed (e.g., vitamin A). CHAPTER - E | Improving Nutrition through Health D. Treat and prevent illness services, malaria treatment Considerations when and prevention, etc. implementing interventions Illness is a direct cause of undernutrition. Increasing access to treat and prevent illness: to high-quality health care, either b) Encourage/deliver full course of through global-level health system childhood immunizations improvements, government • How often do parents use child c) Provide quality sick-child care health services when their provision, or universal insurance services, for example, IMCI29 children are sick, and what are mechanisms for vulnerable groups is the barriers to use? a high priority to reduce the burden of undernutrition. Moreover, actions d) Provide counseling and support • Based on capacity and client that directly target key infections that for improved hygiene practices, use, what are the most cause undernutrition in children, including handwashing promising channels to deliver and women in some cases, and that counseling on hygiene and often lead to mortality synergistically e) Provide intermittent preventive other information? with undernutrition, are diarrhea, treatment (IPT) and ITN to preg- nant and lactating women to pre- • What is the prevalence of respiratory tract infections (including vent malaria diarrhea, and through which pneumonia), measles, malaria, channels could therapeutic and HIV/AIDS, and TB. Therefore, zinc be delivered? addressing these illnesses should f) Promote/protect early initiation be a high priority of the health and exclusive breastfeeding for • How will an adequate supply of sector. Hygiene interventions also first six months of life, including zinc supplements be ensured? often fall under the health umbrella; cases where the mother is HIV+, poor hygiene is strongly linked with unless AfASS criteria can be met • What training is needed to for replacement feeding (Is re- improve staff capacity to nutrition through the pathway of placement feeding acceptable, deliver counseling messages? an unsanitary environment, poor handwashing, and food preparation feasible, affordable, sustainable, • How will the quality of practices that increase the risk of and safe?)30 counseling be monitored? parasitic infection and diarrhea. g) Treat malaria Interventions in the health sector to prevent and treat illness: h) Provide therapeutic zinc supple- ments with oral rehydration salts a) Provide coverage of a basic (ORS) for diarrheal disease man- package of essential health and agement nutrition services for pregnant women and children, e.g., i) Identify and treat women who are immunizations, sick-child HIV+ during pregnancy and en- sure that both their clinical and 29 IMCI is a strategy combining improved management of childhood illness with aspects of nutrition, immunization, and other important disease prevention and health promotion activities. The objectives of IMCI are to reduce deaths and the frequency and severity of illness and disability, and to contribute to improved growth and development. Developed by the WHO and UNICEf, the strategy includes three main components: (1) Improvements in the case-management skills of health staff through the provision of locally adapted guidelines on IMCI, and through activities to promote their use; (2) Improvements in the health system required for effective management of childhood illness; and, (3) Improve- ments in family and community practices. 30 Outlined in WHO’s Guidelines on HIV and Infant feeding, 2010. CHAPTER - E | Improving Nutrition through Health nutritional needs are met (e.g., Interventions in the health sector to Considerations when provision of ARVs, counseling on reduce low birth weight: implementing interventions proper feeding practices, food to reduce low birth weight: support) a) Ensure the provision of afford- able (free or low cost) health and • What is the prevalence of low nutrition services (such as those birth weight, and what are the E. Reduce low birth weight described below) through differ- main factors behind it in the ent mechanisms, including insur- setting, e.g., smoking, too low birth weight (< 2500g) often little food, excessive energy reflects the poor health and nutri- ance schemes, social safety net expenditure during pregnancy tion of mothers, and is associated programs, government provision, and maternal infections? with continued poor nutrition in in- etc. fancy and childhood. Poor maternal • Who are the key decision makers nutrition (e.g., low body mass b) Prevent/treat maternal infec- about nutrition and health care tions, e.g., malaria prophylaxis practices during pregnancy, e.g., index/being too thin), and infections, and treatment; testing and man- women themselves, husbands, including malaria,31 are associated mothers-in-law? with intrauterine growth restriction agement of syphilis and other (IUGR), leading to poor fetal growth STIs • Can counseling be delivered to and low birth weight, which is asso- all key decision makers? ciated with an increased risk of mor- c) Provide counseling and support bidity and mortality in the newborn for increased dietary intake • What training is needed to period.32,33 Being stunted in utero in- (quality and quantity) during improve staff capacity to pregnancy; reduced maternal deliver counseling messages? creases the risk of stunting in in- fancy and childhood, which in turn workload; prevention and treat- ment of anemia; decreased in- • How will the quality of increases the risk of short girls, who counseling be monitored? are more likely to give birth to chil- door air pollution; reduced dren with low birth weight, thus per- tobacco consumption; avoidance • What infrastructure and funding petuating the intergenerational cycle of gender violence; planning for is needed to provide access to of compromised growth. The conse- contraception after delivery health and nutrition services quences of being born undernour- such as prenatal care and d) In situations where food short- protein- energy supplementation ished are grave: IUGR infants suffer age for pregnant women is prob- to pregnant women? Is there a from impairment of most immune possibility of local sourcing of functions and face an increased risk able, provide maternal the food? of diarrhea and pneumonia, with a supplements of balanced energy neonatal risk of death that is 10 and protein times higher for infants weighing 2- 2.5kg than for those weighing 3- e) Provide iron folate supplementa- 3.5kg.34 tion for pregnant women 31 Black, R.E., Allen, l.H., Bhutta, Z.A., Caulfield, l.E., de Onis, M., Ezzati, M., Mathers, C. and J. Rivera. 2008. “Maternal and child undernutrition: global and regional exposures and health consequences,” Lancet, 371: 243-60. 32 Elder, l and l. Kiess. 2004 Nuts and Bolts. Washington D.C.: The Human Development Network at the World Bank. 33 Black, R.E., Allen, l.H., Bhutta, Z.A., Caulfield, l.E., de Onis, M., Ezzati, M., Mathers, C. and J. Rivera. 2008. “Maternal and child undernutrition: global and regional exposures and health consequences,” Lancet, 371: 243-60 34 Gillespie, S. and R. flores. 2000. The Life Cycle of Malnutrition. Washington D.C.: The International food Policy Research Institute. CHAPTER - E | Improving Nutrition through Health F. Improve reproductive health The time between pregnancies is Considerations when and family planning strongly associated with neonatal, implementing interventions infant and under-five mortality, to improve reproductive The nutritional status of women, low birth weight, and stunting health and family planning: particularly adolescents who are and underweight in children. The still growing and have higher nu- longer the interval between birth and • Is the use of contraceptives tritional requirements, age at first conception, the more time the socially acceptable to women pregnancy, birth spacing, and sex- mother has to recover nutritionally and to men? ually transmitted infections, affect from her previous birth, and thus the • What barriers exist to fetal growth and the nutritional better the nutritional and health out- contraceptive use (lack of status of infants. Reproductive comes for both mother and child. access, lack of supply, stigma)? Health (RH) is therefore an underly- Moreover, the proper timing of a sub- ing determinant of nutritional status, sequent birth helps to prevent dis- • What are the current norms and RH interventions are important to placement of a young child from around adolescent pregnancy reduce undernutrition of adoles- receiving breastmilk during his/ her and birth spacing? cents, women and children. critical early growth period (0-24 months), reducing their risk of un- • Is LAM viable given breastfeeding norms? The age of a woman’s first preg- dernutrition and mortality. Child nancy can have serious implica- feeding practices are in fact protec- • Who needs to be reached with tions for both the mother and tive against short birth intervals, as counseling messages about child’s health outcomes. Children exclusive breastfeeding extends the delaying age at first pregnancy, born to women aged 15-19 years period of lactational amenorrhea, adequate birth spacing and old are at highest risk of infant lengthening the period between birth contraceptive use (women, and child mortality, and there is a and the return to fertility. men, adolescents, religious leaders, etc.)? higher risk of morbidity and mor- tality for the young mother.35 Many Reproductive health and family • What training is needed to health problems are particularly as- planning interventions in the improve staff capacity to sociated with negative outcomes of health sector: deliver counseling messages? pregnancy during adolescence, in- cluding anemia, malaria, HIV and a) Include nutrition-sensitive fam- • How will the quality of other STIs, postpartum hemorrhage, ily-planning and reproductive counseling be monitored? obstetric fistula, and mental disor- health services as an affordable ders such as depression.36 Moreover, (free or low cost) and accessible stillbirths and death in the first week service as part of part of a basic and month of life are respectively 50 insurance package or govern- percent and 50-100 percent higher ment provision for adolescent among babies born to adolescent and pregnant women mothers in comparison those born to a mother who is over 20 years old.37 35 WHO. 2011. Making Pregnancy Safer: Adolescent Pregnancy. Geneva: WHO, accessed on february 9, 2012, http://www.who.int/maternal_child_adolescent/topics/maternal/ adolescent_pregnancy/en/index.html 36 Ibid. 37 Ibid. CHAPTER - E | Improving Nutrition through Health b) Provide integrated postpartum death or disability from childhood ill- Considerations when family planning: Counseling on nesses increases substantially with implementing interventions lactational amenorrhea method descending z-scores of weight for to treat moderate and/or (lAM); use of progestin- only height. for example, a child whose severe acute malnutrition: modern contraception after shift weight for height is -3 SD has a risk from lAM; healthy spacing of of death that is 9.4 times higher than • What is the prevalence of pregnancies that of a child with a weight for moderate and severe acute height in the normal range (-1 SD and undernutrition? c) Promote and counsel adolescent above), and 3 times higher for a child women on delayed age of first whose weight for height is between - o Note that routine screening for SAM is only necessary in pregnancy, birth spacing and 2 to -3 SD. for both moderate and se- certain contexts and modern contraceptive use vere acute malnutrition, the overall conditions, such as case fatality rate ranges from 5 to 60 emergencies, shocks, or percent.39 countries with chronically G. Treat moderate and high levels of wasting severe acute undernutrition for severe acute malnutrition (SAM) without complications, • What is the capacity to procure in children and deliver therapeutic feeding Interventions to prevent undernu- treatment in the community/ at the community level (funds, trition are well established and outside of health facilities is supply of therapeutic foods, ac- proven to be cost-effective; preven- preferred. Community-based cessible venues, and well- management of severe acute malnu- trained staff)? tion is preferable and more effec- trition (CMAM) was made possible by tive than a curative approach in the introduction of ready-to-use ther- • Where and how frequently is terms of both cost and recurrence children’s nu- tritional status apeutic foods (RUTf), which contain of disease.38 However, acute under- measured? Are there adequate all of the needed nutrients for chil- nutrition (moderate or severe wasting referral systems for treatment? dren to reverse growth failure and or low weight- for-height) affects as achieve catch-up growth, combined much as one-tenth of children under- with the use of simple color-coded five years globally, primarily in condi- measuring tapes for middle-upper tions of extreme poverty, in conflict arm circumference, which allows settings, and during natural emer- community-based workers to diag- gencies in developing countries. It is nose acute malnutrition. The lipid- categorized according to severity, rich food (often peanut-based) is where severe acute malnutrition ready to eat directly from the sachet refers to children whose weight/ or container, requires no water for height is a z-score below -3 standard preparation, is good for 24 months deviations (SD), and moderate acute after manufacture, and for up to 24 malnutrition refers to children whose hours after opening. z-score is below -2 SD. The risk of 38 Ruel, M., Menon, P., Habicth, J-P., loechl, C., Bergeron, G., Pelto, G., Arimond, M., Maluccio, J., Michaud, l. and B. Hankebo. 2008. “Age-based preventive targeting of food assistance and behavior change and communication for reduction of childhood undernutrition in Haiti: a cluster randomized trial, The Lancet, 371 (9612): 588-595. 39 Manary, M.J. and H.l. Sandige. 2008. “Management of acute moderate and severe childhood malnutrition, British Medical Journal, 337: 1227-1290. CHAPTER - E | Improving Nutrition through Health for moderate acute malnutrition, • In contexts with high rates of interventions, and in some cases, a children are treated with supple- moderate acute malnutrition, lack of distinction between the two. mental food that contains all the community-based rather for example, the growth monitoring recommended daily allowance of than health-sector based and promotion intervention platform micronutrients along with energy interventions comprise a may be interpreted as having low ef- and protein for catch-up growth. more effective means of ad ficacy, when in fact poor results are Typically, this is a fortified cereal and dressing the problem, due to suboptimal implementation. legume blended flour.40 fortified through distributions of The lack of clear evidence on how to lipid-based spreads are being stud- supplemental fortified or deliver interventions also reflects the ied to treat moderate acute malnutri- cereal/legume blends real variations in circumstances and tion in Africa, and there is ongoing capacity across country and local set- experimentation with use of ready-to- d) Ensure that referral procedures tings, which makes it difficult to rec- use supplemental foods (RUSf) for for complications of acute malnu- ommend any one mode of delivery to this purpose. trition are established and uti- be universally applied. Annex E-2 lized at community level gives brief definitions of important Moderate and severe undernutrition contact points in the health sector, treatment interventions in the health e) Monitor and maintain adequate and lists key nutrition interventions sector: stocks of drugs and medicines that could be delivered through each needed to treat severe acute mal- contact point, depending on local or a) Ensure that a national policy or nutrition national circumstances. protocol for CMAM is in place and up-to-date and that commu- f) Strengthen capacity-building of In addition to the general challenge nity mechanisms and facilities the health workforce to be ade- of defining the how to mainstream are equipped to implement it quately trained in the implemen- nutrition activities into the health tation of the CMAM model sector, a number of specific opera- b) Ensure routine community-based tional challenges have been identi- screening of acute malnutrition fied by TTls. These include: using simple measures such as middle-upper arm circumference • lack of technical nutrition (MUAC) measurements V. What are the chal- staff to support the integration, implementation, and supervision lenges and lessons c) Implement community-based of nutrition projects. Both within therapeutic feeding programs learned for delivering the Bank at the country level, nu- (ready-to-use therapeutic foods) improved nutrition trition capacity is extremely lim- for the treatment and case- through the health ited. The number of technical management of severe acute sector? nutrition experts that can be malnutrition (<-3WAZ) called upon to support project While a consensus is emerging on preparation and implementation what to do to address malnutrition, of health projects that include evidence is weaker on how to imple- nutrition components is largely ment key interventions, especially in insufficient. TTls and country light of a renewed focus on global counterparts have specifically health systems strengthening and 40 Bergeron, G. and T. Castleman. 2012. highlighted the lack of staff sup- “Program responses to acute and universal health coverage. Part of chronic malnutrition: divergences and port as a barrier to integrating this tentativeness reflects the pre- convergences,” Advances in Nutri- nutrition into their projects. tion, 3:1-8. dominant research focus on the effi- cacy rather than the effectiveness of CHAPTER - E | Improving Nutrition through Health • Although this is slowly changing, old. Moreover, given the diffi- • Identification of a core set of a lack of awareness of nutri- culty of measuring micronutrient maternal and child health and tion and its critical role for deficiencies, data on such indi- nutrition indicators for effec- human capital development, cators tends to be either out- tive nutrition outcomes, as ap- including in the health sector, dated (in some cases, up to 20 propriate for each context, is a limits the integration of nutrition years old), or based on output- challenge for TTls. Process indi- activities in other sectors. level indicators (number of vita- cators are particularly important min A capsules distributed, to monitor for assessment of im- • Nutrition is not a priority for rather than rate of vitamin A defi- plementation quality. While an- client governments; therefore, ciency, for example). thropometric indicators are client demand for nutrition useful for impact analysis, most activities is generally lacking. • Nutrition activities are largely are not fast changing enough for A number of regions have underfunded. Nutrition activi- use as monitoring indicators. increased demand for nutrition ties are mostly funded by trust activities through high-level funds, and comprise a minimal Given those challenges, there are advocacy efforts, but awareness portion of the Bank’s budget. some broad lessons learned on ef- building is largely dependent on Tracking exact disbursements for fectively integrating nutrition into the the presence of a “champion” nutrition is challenging because health sector to reduce undernutri- for nutrition working either in nutrition-sensitive activities are tion: that country or region (TTl, not always coded correctly, manager, etc.). which applies to projects that • Interventions should be priori- have objectives and specific ac- tized based on (1) what the pri- • In this context, the implementa- tivities related to improving nu- mary nutrition problems are tion of nutrition activities is tritional status or food security at within a country or local context, very often dependent on the the household level. Therefore, and (2) the existing human and presence of a “champion for funding for nutrition through institutional capacity to imple- nutrition” at the managerial trust funds is highly variable, and ment health and nutrition pro- level. Having the support for nu- tracking is inconsistent. grams. Refer to Box E-4 for a trition activities at a higher level quick reference to tools that can is essential for applying the nu- • Difficulty in prioritization of support the prioritization of nu- trition lens to Bank operations. interventions. Often, TTls are trition interventions based on faced with a long list of nutrition country context. • lack of recent data on nutrition interventions, without guidance limits the effect that nutrition or information on how to priori- • Existing health contacts (ANC, “champions” can have in terms tize them. This guidance note PNC, family planning, Child of advocacy to increase demand aims to address this challenge, Health Days/Weeks, c-IMCI, etc.) for nutrition activities. Although and encourages TTls to use are often effective entry points national-level basic nutrition available resources, such as the for integrating nutrition activities data (anthropometric indicators, Nutrition Country Profiles,41 as into the health system. for example) are generally avail- well as the priority-setting ma- able, it is often collected at 5+ trix provided at the beginning of • Capacity building and training is year intervals, which in many this note (based on effect of in- critical at the community, clinic, cases means that the only avail- terventions on mortality). educational (pre- and in-service) able data is as much as ten years 41 Nutrition Country Profiles were done for 68 countries around the world with the worst nutrition indicators. These profiles are brief, two-page doc- uments that contain a synopsis of the country’s nutrition situation based on relevant indicators. These also include key recommendations based on the country’s nutrition problems, as well as costing and cost-effectiveness calculations of scaling up core micronutrient interventions. See www.worldbank.org/nutrition/profile CHAPTER - E | Improving Nutrition through Health and national policy level. Capac- • Community health workers, es- contribute to achieving sustained ity includes knowledge and moti- pecially those who are paid and dietary diversity and increased vation of health care workers, trained, comprise an essential micronutrient intake. adequate staffing and physical avenue for the expansion and de- space to deliver services, and livery of nutrition services, par- • In the spirit of multisectoral supply chains for just-in-time de- ticularly in terms of reaching the planning and actions, the health livery of products, equipment most vulnerable and geographi- sector should exercise its stew- and maintenance. Programs that cally isolated populations. ardship role to improve health increase demand for a certain and nutrition outcomes through health or nutrition product (e.g., • What gets measured gets man- the implementation of nutrition- iron folic acid supplements for aged—or more accurately—only sensitive policies and programs pregnant women), must ensure what gets measured has a in other sectors, as well as the that the supply of commodities chance of being managed. Nutri- monitoring and quality assur- will meet increased demand. tion indicators, such as micronu- ance of these. for example, the trient program coverage health sector has the capacity to indicators and nutritional status legislate for food fortification, indicators, should be a part of and should work with the private HMIS systems and regularly com- sector to market, produce, and piled at levels where prompt ac- distribute such products to the tion can be taken to improve population, while maintaining delivery. Measuring nutrition can the role and responsibility of also generate political support product safety and quality. for addressing demonstrated problems. • Multisectoral planning, “thinking multisectorally” but acting sec- VI. Conclusion torally, using a shared model of • undernutrition is the largest program delivery can achieve contributor to child deaths, sustainability and synergies that which has direct implications improve nutrition outcomes. for for the health sector’s goal of example, micronutrient supple- reducing child mortality. mentation programs are often • Community acceptance at a mini- criticized for their reliance on • MDGs 1, 4, and 5 will not be mum, and ideally community par- long- term donor provision of reached if undernutrition is not ticipation in nutrition activities commodities. Ideally, these pro- addressed. The health sector is are important for effective uptake grams are coupled with promo- the best-placed sector to de- of interventions. Knowledgeable tion of dietary change, liver most of the nutrition in- local health staff and/or forma- fortification efforts, smallholder terventions that have been tive research can assess the cul- agriculture and home-gardening rigorously evaluated, recom- tural acceptability of programs, and deworming activi- mended, and costed, and interventions and how they can ties that are delivered through which would avert one million work within existing norms for other sectors, i.e., private sector, child deaths annually, and save maximum comprehension and agriculture, and education, that 30 million DAlYs annually. acceptability. CHAPTER - E | Improving Nutrition through Health BOx E-4. TOOLS FOR TTLS THAT CAN GuIDE PRIORITIzATION • The cost for basic nutrition financing system, a well-func- OF NuTRITION INvESTMENTS interventions is minimal in tioning information system, and both real terms and when adequate leadership and gover- • Table E-1. Estimated Costs, Bene- compared with returns on nance of the health system. Pri- fits, Priority, and Feasibility of investment. oritization of activities will Scaling Up Selected Nutrition In- depend on (1) what the source of terventions. This table lists nutritional problems are in the twelve evidence-based interven- • The health sector can and tions, which can be selected on should reduce undernutrition specific project/country setting, any of all of the following crite- through interventions that target and (2) the capacity to imple- ria: cost, cost:benefit ratio, pub- micronutrient deficiencies, opti- ment nutrition programs given lic health priority based on mal feeding and caring practices, the available and existing deliv- deaths averted, implementation treatment and prevention of ill- ery mechanisms/platforms for feasibility, and country status service delivery. A great number relative to public health cut-off ness, reduction of low birth points. Further information can weight, improvements in repro- of needed interventions are in- be found in “Scaling Up Nutri- ductive health and family plan- cluded in the guidance above tion: What will it cost?” (World ning, and treatment of moderate and organized in the following Bank 2010), available at and severe malnutrition in chil- annexes; refer back to Table E-1 www.worldbank.org/nutrition dren. to assist in choosing priority in- terventions. The World Bank nu- • Nutrition Country Profiles: short, trition country profiles show the two-page documents that sum- • Health system strengthening marize the nutrition situation can and should support nutri- main nutritional problems and and key interventions needed for tion through nutrition-sensitive top five priority interventions 68 of the highest nutrition bur- public insurance mechanisms, specific to each of the 68 highest dened countries worldwide. delivery of high quality services, burden of undernutrition coun- These are available from availability and access to med- tries, are a resource to assist www.worldbank.org/nutrition/pr TTls in prioritizing interventions ofiles. ical products (specifically, nutri- tional supplements and for the contexts in which they • Annex E-2: Menu of Actions to therapeutic foods), a high-per- work. Address Undernutrition by Deliv- forming workforce, a good health ery Mechanism. Interventions can be prioritized based on pres- ence of existing delivery plat- forms. • Annex E-6: Suggested Nutrition Resources, which include links to databases containing the most recent nutritional data worldwide, as well as docu- ments that take a global view of the nutrition situation. • A new HNP Knowledge Exchange provides information on nutri- tion staff in the Bank and useful internal and external publica- tions on nutrition. It is now available on HDN’s intranet site, or can be found by entering the friendly URL(FURL) HDKE. A N N E x Annex for Chapters C, D and E ANNEx C Annex C-1. Five Focus Areas of the world Bank Agriculture Action Plan Guidance matrix I. Raise Agricultural Productivity of agricultural interventions explicitly II. Link farmers to markets and strengthen value chains targeting nutrition III. Reduce risk and vulnerability This table summarizes World Bank agricultural (AES) interventions that IV. Facilitate agricultural entry, exit, and rural non-farm income (cross-cutting across focus explicitly target nutrition and are ex- areas I-III) pected to demonstrate impact on en- hancing nutrition outcomes. for each V. Enhance environmental services and sustainability identified intervention, sample indi- (cross-cutting across focus areas I-III) cators and any trade-offs or needed policy coherence are presented. The table also includes a rough approximation of the degree to which identified interventions already are implemented through World Bank Priority objectives to enhance nutrition operations. The table is organized in agriculture programs according to the five focus areas of the World Bank Agriculture Action 1. Invest in women: safeguard and strengthen the capacity Plan 2010-20121 and the four of women to provide for the food security, health and nutrition Principles for Nutrition-sensitive of their families Agriculture2 as identified in the 2. Increase year round access to, and availability of high main text. nutrient content food 3. Improve nutrition knowledge among rural households to enhance dietary diversity 4. Incorporate explicit nutrition objectives and indicators into project and policy design 1 An Agriculture Action Plan 2013-2015 is being prepared. This is expected to utilize the same five focus areas as the original Agricultural Action Plan. 2 Principle 4 is an over-arching goal, which could potentially be included in any AES project in any of the five focus areas of the World Bank Agriculture Action Plan. ANNEx C I. RAISE AGRICuLTuRAL PRODuCTIvITy Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Invest in women • Promotion of technologies • % change in labor - • Focusing on women’s • High at design stage that improve productivity productivity of agricultural income generation could (overall gender integration in and timesavings for pro- tasks by women reduce time available for AES project design is good) ductive and domestic domestic tasks including tasks performed by • Change in women’s time child care • Medium at implementation women used for domestic tasks stage (indicators for tracking including care of infants • Could result in loss of em- exist but should be followed and young children ployment for other female up more closely) workers who were previously performing the time consuming task as a laborer Improve nutrition • Expansion of the • # of days of home • May require large resource • Low knowledge among number of home economics extension outlay to adequately train rural households economics specialists service received by home economics extension to enhance dietary in extension force beneficiaries workers diversity • Dietary diversity score (for women and children) • Capacity training of home • # of days of training • Male extension workers • Low economics extension work- received by home econom- may not be receptive to ers and key extension work- ics extension workers and advising on nutrition ers (horticulture, livestock,3 key extension workers related interventions aquaculture, etc.) on nutri- tion related interventions • Dietary diversity score • Culturally, male extension (for women and children) workers may not be able to work with female farmers Increase year- • Support to increase • % change of (livestock, • Subsidized, small-scale • Low round access to productivity of small-scale milk, fish, fruits & livestock/fishery projects (livestock and aquaculture) and availability of nutritious food production vegetables) production for household food high nutrient (e.g., livestock, dairy, security are seldom profitable • Medium/High content food fish, fruits and vegetables) • # of days in the last at the enterprise level (horticulture) week where any amount of (animal meat, fish, • Livestock production milk, fruits & vegetables) tends to have high was consumed by negative externality on household members natural resources (disaggregated by gender and children) • % change in grams/day • Dietary diversity score of (animal meat, fish, milk, (for women and children) fruits & vegetables) consumed by household • Seasonal fluctuation of dietary diversity scores • # of months in the past 12 months the household did not have adequate food to meet its needs 3 Women are typically the main actors in poultry, small ruminant, and micro-livestock production, as well as dairying. ANNEx C I. RAISE AGRICuLTuRAL PRODuCTIvITy (CONTINuED) Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) • Support for (horticulture, • # of client days of (fruits & • Low livestock, and aquaculture) vegetables, livestock, aqua- culture) extension services provided to farmers (disaggregated by gender) • # of days in the last week where any amount of (animal meat, fish, milk, fruits & vegetables) was consumed by household members (disaggregated by gender and children) • % change in grams/day of (animal meat, fish, milk, fruits & vegetables) consumed by household • Dietary diversity score (for women and children) • Seasonal fluctuation of dietary diversity scores • # of months in the past 12 months the household did not have adequate food to meet its needs extension workers • Enhancing capacity of • # of biofortified varieties • Negligible (biofortified national agricultural research made available to farmers varieties are only now being institutions to promote made available) the breeding for and • # of farmers using dissemination of developed biofortified varieties biofortified varieties • Enhance capacity of • # of farmers using zinc • Fertilizers with • Low (fortified fertilizer) national agricultural and iodine containing micronutrients may be research institutions to fertilizers unaffordable without promote the dissemination significant subsidy of zinc and iodine containing fertilizers ANNEx C II. LINk FARMERS TO MARkET & STRENGTHEN vALuE CHAINS Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Increase year- • Marketing projects to • % change of net sales • Subsidized, small-scale • Low round access to support smallholders’ from (livestock, milk, fish, livestock/fishery projects (livestock and aquaculture) and availability of participation in the value fruits & vegetables) for household food security high nutrient chain of nutritious foods are seldom profitable at the • Medium/High (horticulture) content food (e.g., livestock, dairy, fish, • Volume of (dairy, livestock, enterprise level fruits & vegetables) fish, fruits & vegetables) marketed • Livestock production tends to have high negative • # of days in the last week externality on natural where any amount of resources (animal meat, fish, milk, fruits & vegetables) was consumed by household members (disaggregated by gender and children) • % change in grams/day of (animal meat, fish, milk, fruits & vegetables) consumed by household • Dietary diversity score (for women and children) • Seasonal fluctuation of dietary diversity scores • # of months in the past 12 months the household did not have adequate food to meet its needs • Promoting the production, • Volume of nutritious • Markets for indigenous • Low (indigenous foods) marketing and consumption indigenous foods produced, foods may be limited, of nutritious indigenous marketed, and/or therefore limiting consumed • Promotion of regional/ • Volume of industrially • Negligible (industrial national industrial food fortified food produced food fortification) fortification (flour, vegetable oils, etc.), which may • % change in share of include national/regional fortified food within its institution- al reform to total regional/national strengthen food safety production standards, legislations and enforcement ANNEx C III. REDuCE RISk AND vuLNERABILITy Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Incorporate • Broaden food security •# of sector AAAs that • None • Low explicit nutrition policy dialogue to include include analysis of nutrition objectives and nutrition perspectives indicators Increase year-round • Promotion of nutritional • # of households with • Homestead gardens could • Low access to and homestead garden plots nutritional homestead be promoted through rural availability of high (which may include crops, gardens established and CDD projects, but the nutrient content trees and animal maintained selection of the actual food husbandry) with appropriate investment is typically demand nutrition education • Household and child driven and cannot be dietary diversity score (for preselected women and children) • Subsidized homestead • % of households with garden schemes could basic nutrition knowledge pose a financial promoted by the project sustainability risk Iv. FACILITATE AGRICuLTuRAL ENTRy, ExIT & RuRAL NON-FARM INCOME (CROSS-CuTTING ACROSS I, II AND III) Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Invest in women • Investments to improve • Share of women actively • Low labor condition for off-farm participating in the laborers, e.g., transportation, planning and decision sanitary facilities, employ- making of new service ment insurance, ICT provision • Number of satisfactory women who have used the provided facilities/programs • Change in women’s time used for domestic tasks including care of infants and young children ANNEx C v. ENHANCE ENvIRONMENTAL SERvICES AND SuSTAINABILITy (CROSS-CuTTING ACROSS I, II AND III) Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Increase year- • Conservation of indigenous • # of ha of non-farm land • Financial incentives may • Low round access to food plants (development containing indigenous have to be provided to and availability of of an indigenous food plants conserved encourage conservation of high nutrient knowledge system) non-farm lands in order to content food • # of nutritious indigenous conserve indigenous food food plant germplasms plants collected, analyzed, and documented • Rangeland management • # of ha (rangeland/ • Low or soil carbon sequestration fallows) with edible projects that increase leguminous cover crops) legume production for food or fodder vI. RAISE AGRICuLTuRAL PRODuCTIvITy Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Invest in women • Promotion of technologies • % change in labor • Focusing on women’s • High at design stage that improve productivity and productivity of agricultural income generation could (overall gender integration in timesavings for productive tasks by women reduce time available for AES- project design and domestic tasks domestic tasks including is good) performed by women • Change in women’s time child care used for domestic tasks • Medium at implementation including care of infants • Could result in loss of stage (indicators for tracking and young children employment for other exist but should be followed female workers who were up more closely) previously performing the time consuming task as a laborer Improve nutrition • Expansion of the number • # of days of home • May require large resource • Low knowledge among of home economics economics extension outlay to adequately train rural households specialists in extension service received by home economics extension to enhance force beneficiaries workers dietary diversity • Dietary diversity score (for women and children) • Capacity training of home • # of days of training • Male extension workers • Low economics extension received by home may not be receptive to workers and key extension economics extension advising on nutrition workers (horticulture, workers and key extension related interventions livestock,4 aquaculture etc.) workers on nutrition related • Culturally male extension interventions • Dietary diversity score workers may not be able to (for women and children) work with female farmers 4 Women are typically the main actors in poultry, small ruminant, and micro-livestock production, as well as dairying. ANNEx C vI. RAISE AGRICuLTuRAL PRODuCTIvITyy (CONTINuED) Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Increase year-round • Support to increase • % change of (livestock, • Subsidized, small-scale • Low access to and productivity of small-scale milk, fish, fruits & livestock/fishery projects (livestock and aquaculture) availability of high nutritious food production vegetables) production for household food security nutrient content (e.g., livestock, dairy, fish, are seldom profitable at the • Medium/High food fruits and vegetables) • # of days in the last week enterprise level (horticulture) where any amount of (animal meat, fish, milk, fruits & • Livestock production tends vegetables) was consumed to have high negative by household members externality on natural (disaggregated by gender resources and children) • % change in grams/day of (animal meat, fish, milk, fruits & vegetables) was consumed by household • Dietary diversity score (for women and children) • Seasonal fluctuation of dietary diversity scores • # of months in the past 12 months the household did not have adequate food to meet its needs • Support for (horticulture, • # of client days of (fruits • Subsidized, small-scale • Low livestock, and aquaculture) & vegetables, livestock, livestock/fishery projects extension workers aquaculture) extension for household food services provided to farmers security are seldom profitable (disaggregated by gender) at the enterprise level • # of days in the last week • Livestock production tends where any amount of (animal to have high negative meat, fish, milk, fruits & externality on natural vegetables) was consumed resources by household members (disaggregated by gender and children) • % change in grams/day of (animal meat, fish, milk, fruits & vegetables) consumed by household • Dietary diversity score • Seasonal fluctuation of (for women and children) dietary diversity scores • # of months in the past 12 months the household did not have adequate food to meet its needs ANNEx C vI. RAISE AGRICuLTuRAL PRODuCTIvITyy (CONTINuED) Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) • Enhancing capacity of • # of biofortified varieties • Negligible (biofortified national agricultural made available to farmers varieties are only now research institutions to being made available) promote the breeding for • # of farmers using and dissemination of biofortified varieties developed biofortified varieties • Enhance capacity of • # of farmers using zinc • Fertilizers with • Low (fortified fertilizer) national agricultural research and iodine containing micronutrients may be institutions to promote the fertilizers unaffordable without dissemination of zinc and significant subsidy iodine containing fertilizers vII. LINk FARMERS TO MARkET & STRENGTHEN vALuE CHAINS Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Increase year-round • Marketing projects to • % change of net sales • Subsidized, small-scale • Low access to and support smallholders’ from (livestock, milk, fish, livestock/fishery projects (livestock and aquaculture) availability of high participation in the value fruits & vegetables) for household food security nutrient content chain of nutritious foods are seldom profitable at the • Medium/High food (e.g., livestock, dairy, fish, • Volume of (dairy, livestock, enterprise level (horticulture) fruits & vegetables) fish, fruits & vegetables) marketed • Livestock production tends to have high negative • # of days in the last week externality on natural where any amount of (animal resources meat, fish, milk, fruits & vegetables) was consumed by household members (disaggregated by gender and children) • % change in grams/day of (animal meat, fish, milk, fruits & vegetables) was consumed by household • Dietary diversity score (for women and children) ANNEx C vII. LINk FARMERS TO MARkET & STRENGTHEN vALuE CHAINS (CONTINuED) Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) • Seasonal fluctuation of • # of months in the past dietary diversity scores 12 months the household did not have adequate food to meet its needs • Promoting the production, • Volume of nutritious • Markets for indigenous • Low (indigenous foods) marketing and consump- indigenous foods produced, foods may be limited tion of nutritious indigenous marketed, and/or consumed therefore limiting foods, e.g., development of commercial potential an indigenous knowledge system • Promotion of regional/ • Volume of industrially • Negligible (industrial food national industrial food fortified food produced fortification) fortification (flour, vegetable oils, etc.) which may • % change in share of include national/regional fortified food within its total institutional reform to regional/national production strengthen food safety standards, legislations and enforcement vIII. REDuCE RISk AND vuLNERABILITy Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Increase year-round • Promotion of nutritional • # of households with • Homestead gardens could • Low access to and homestead garden plots nutritional homestead be promoted through rural availability of high (which may include crops, gardens established and CDD projects, but the nutrient content trees and animal husbandry) maintained selection of the actual food with appropriate nutrition investment is typically education • Household and child demand driven and cannot dietary diversity score (for be preselected women and children) • Subsidized homestead • % of households with garden schemes could pose basic nutrition knowledge a financial sustainability risk promoted by the project ANNEx C Ix. FACILITATE AGRICuLTuRAL ENTRy, ExIT & RuRAL NON-FARM INCOME (CROSS-CuTTING ACROSS I, II AND III) Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Invest in women • Investments to improve • Share of women actively • Financial incentives may • Low labor condition for off-farm participating in the have to be provided to laborers, e.g., transportation, planning and decision encourage conservation of sanitary facilities, making of new service non-farm lands in order to employment insurance, ICT provision conserve indigenous food plants • Number of satisfactory women who have used the provided facilities/programs • Change in women’s time used for domestic tasks including care of infants and young children x. ENHANCE ENvIRONMENTAL SERvICES AND SuSTAINABILITy (CROSS-CuTTING ACROSS I, II AND III) Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in measuring impact on existing AES projects nutrition outcomes (High/Medium/Low) Increase year- • Conservation of indigenous • # of ha of non-farm land • Financial incentives may • Low round access to food plants (development containing indigenous have to be provided to and availability of of an indigenous food plants conserved encourage conservation of high nutrient knowledge system) non-farm lands in order to content food • # of nutritious indigenous conserve indigenous food food plant germplasms plants collected, analyzed, and documented • Rangeland management • # of ha (rangeland/ • Low or soil carbon sequestra- fallows) with edible tion projects that increase leguminous cover crops) legume production for food or fodder ANNEx C Annex C-2. List of all gender disaggregated indicators included inWorld Bank agriculture (AES) projects approved in FY10 and FY11 Agricultural Technology • Direct and indirect project beneficiaries (number), of which female (percentage) (for entire project) (Central Africa Re- public, Nepal, Zambia, West Africa Regional) • Percentage of direct female beneficiaries of improved technologies for agricultural and animal production (Democratic Republic of Congo) • Percentage of women benefitting from investment sub-projects (Mali) • Percentage of participating farmers (male/ female) adopting new technology packages (for production, post-harvest, processing, etc.) (Burundi) • Percentage increase in agricultural income of participating households (by gender) (Uganda) • Proportion of target population below the minimum level of dietary energy consumption, disaggregated by gender and vulnerable group (Togo) • Proportion of farmers in project affected areas using improved methods (disaggregated by gender) (Rwanda) • Producers specialized in certified seed production - indigenous - women within project context (Nicaragua) • Number of project beneficiaries (of whom 40% are female) (for entire project) (West Africa regional) • Number of water users provided with irrigation and drainage services – disaggregated by % female) (Malawi) • Number of farmers benefiting from operational community assets – disaggregated by % female (Malawi) • Number of people trained, of which % female (Malawi) • Number of female and male water users provided with improved irrigation and drainage services (Azerbaijan) • Women account for at least 25% percent of people trained (Egypt) • Number of female project direct beneficiaries using package of improved inputs (Central Africa Republic) • Percentage of female project direct beneficiaries adopting improved animal husbandry practices (Central Africa Republic) • Percentage increase of agricultural output in the project area, disaggregated by male and female headed households (Ethiopia) Community Driven Development • Direct project beneficiaries, female (for entire project) (Chad, Mali) • Representation of women and young graduates managing income-generating activities (Tunisia) • Minimum of 70% of sampled women representatives in the community development councils (CDCs) take active part in decision-making related to community development (Afghanistan) • At least 50% of decision-making positions (chairperson or treasurer of various subcommittees) are occupied by women, at village level (Sri lanka) • Women as % of participants in village project management groups (China) • At least 60% of women and ethnic minorities satisfied with public representation and service delivery (Vietnam) • 30% of CBO/CADEC members are women (Haiti) • direct project beneficiaries (number) of which women (percentage) / indirect project beneficiaries (number) of which women (percentage) (Sri lanka) • Percent women self-help group (SHG) members (India) ANNEx C • At least 20% increase in incremental income against base year for 50% of the target households by end of project; disaggregated by gender and youth (India) • At least 70% of target households have increased their incomes; disaggregated by gender and youth ((India) • At least 80% of the community based organizations (CBOs) (Village Poverty Reduction Committees, Panchayat level federation) have accessed and managed project funds according to project rules and procedures; disaggregated by gender and youth ( India) • The number of women income-generating activities (Djibouti) • Percent of women, youth, and elderly participating in community based organizations (CBOs) and community repre- sentative committee (COPRODEPs) (as measured by the percent of members in CBOs who are participating; CBO at- tendance at COPRODEP prioritization meetings) (Haiti) • Percent of subprojects specifically targeting women, youth, and the elderly (subprojects proposed, managed, and/or benefiting these groups) (Haiti) • Project beneficiaries, of which female (for only community organization members) (Nepal) • Targeted vulnerable groups (women, young people, and landless) develop related markets and sustainable income generating activities (AGRs) (Tunisia) • Village rehabilitation and development direct project beneficiaries, of which female is over 50% (Sri lanka) Linking Farmers to Market • Number of project beneficiaries, direct/indirect (40% of which is female) (for entire project) (Sierra leone) • Direct project beneficiaries, of which female (40% ) (for entire project) (Benin) • Percent of rural enterprise participants who are youth (< 30 years old) or women (Jamaica) • Number of women in farming households reporting increased access to, and use of, information on improved farming practices, processing and marketing (Papua New Guinea) • Women receive minimum 30% of all productive subprojects (Brazil) Land Administration • Percent of women with use or ownership land rights registered (both joint and individual) (India) • At least 40% of new titles are provided directly to women and /or jointly with their spouse/partner (Nicaragua) • At least 70% of the modernized registries’ clients (and 70% of women) rate its services as satisfactory (third level on a four-level scale) (Honduras) others • Natural resource management, direct beneficiaries % of which are female (Kenya) • Emergency, number of mandals with 100% children immunization (below one year) and full ANC check-up for women (Sri lanka) • Integrated, 10% per annum increased in farmer based organization (fBO) capacity for production, post-harvest management and marketing of products (including by women members) over baselines (Ghana) • Non-farm, at least 30% of participating small & medium enterprises (SMEs) and enterprise groups (EGs) will have increased direct and/or indirect employment by at least 30%. Of these at least 35% will be women (Afghanistan) ANNEx C Annex C-3. validation. The dietary diversity scores program target values of the DDS. have been validated for several age Moreover, the calculation of percent- Food consumption and sex groups as proxy measures for age of individuals or households indicators macro and/or micronutrient ade- consuming certain food groups or quacy of the diet. Scores have been combinations of nutrient dense food positively correlated with adequate groups can be another important a. Dietary Diversity Score (DDS) micronutrient density of complemen- analytical tool. Description. The dietary diversity tary foods for infants and young chil- score, developed by the USAID- dren,2 and macronutrient and funded food and Nutrition Technical micronutrient adequacy of the diet b. Food Consumption Assistance (fANTA) project and by for non-breastfed children,3,4,5,6 ado- Scores (FCS) fAO,1 consists of a simple count of lescents7 and adults.8,9 Description. The food Consumption the different food groups that a Score (fCS) is a frequency-weighted household or an individual has con- use. Since the scores are used for dif- diet diversity score that was devel- sumed over the preceding 24 hours. ferent purposes, the calculations are oped by WfP as a proxy measure of The household dietary diversity score based upon different numbers of food security. Information about fre- is meant to reflect household access food groups. Twelve food groups are quency of consumption (in days) by a to a variety of foods, while individual commonly proposed for the house- household over a recall period of the scores are a proxy for nutrient ade- hold: nine for women and seven for past seven days is collected from a quacy of the diet of individuals. for infants.10 There are no established country specific list of food groups.11 example, the Women’s Dietary Diver- cut-off points in terms of number of The consumption frequency of each sity Score reflects the probability of food groups to indicate adequate or food group is multiplied by an micronutrient adequacy of the diet inadequate dietary diversity for the assigned weight that is based on its for women of reproductive age, and household or individual. Because of nutrient content; the values are the Infant Dietary Diversity Score this, the mean score or distribution summed to obtain the fCS. reflects the dietary quality of of scores is recommended for analyt- children aged 6–23 months. ical purposes and to set appropriate 1 Guidelines for measuring household and individual dietary diversity. fAO 2011; fANTA 2006. Household Dietary Diversity Score (HDDS) for Measurement of Household food Access: Indicator Guide. Version 2. 2 fANTA. 2006. Developing and Validating Simple Indicators of Dietary Quality and Energy Intake of Infants and Young Children in Developing Countries: Summary of findings from analysis of 10 data sets. Working Group on Infant and Young Child feeding Indicators. food and Nutrition Technical Assistance (fANTA) Project, Academy for Educational Development (AED), Washington, D.C. 3 Hatloy, A., Torheim, l. & Oshaug, A. 1998. food variety--a good indicator of nutritional adequacy of the diet? A case study from an urban area in Mali, West Africa. European Journal of Clinical Nutrition 52(12):891-8. 4 Ruel, M., Graham, J., Murphy, S. & Allen, l. 2004. Validating simple indicators of dietary diversity and animal source food intake that accurately reflect nutrient adequacy in developing countries. Report submitted to Gl-CRSP. 5 Steyn, NP, Nel, J.H., Nantel, G., Kennedy, G., labadarios, D. 2006. food variety and dietary diversity scores in children: are they good indicators of dietary adequacy? Public Health Nutrition 9(5): 644-650. 6 Kennedy, G., Pedro, M.R., Seghieri, C., Nantel, G. & Brouwer, I. 2007. Dietary diversity score is a useful indicator of micronutrient intake in non breast-feeding filipino children. Journal of Nutrition 137: 1-6. 7 Mirmiran, P., Azadbakht, l., Esmaillzadeh, A. & Azizi, f. 2004. Dietary diversity score in adolescents- a good indicator of the nutritional adequacy of diets: Tehran lipid and glucose study. Asia Pacific Journal of Clinical Nutrition 13(1): 56-60. 8 foote, J., Murphy, S., Wilkens, l., Basiotis, P. & Carlson, A. 2004. Dietary variety increases the probability of nutrient adequacy among adults. Jour- nal of Nutrition 134: 1779-1785. 9 Arimond, M., Wiesmann, D., Becquey E., Carriquiry, A., Daniels, M., Deitchler, M., fanou-fogny, N., Joseph, M., Kennedy, G., Martin-Prevel, Y. & Torheim, l.E. 2010 Simple food group diversity indicators predict micronutrient adequacy of women’s diets in 5 diverse, resource-poor settings. Journal of Nutrition 140(11): 2059S-2069S. 10 fAO. 2011. Guidelines for measuring household and individual dietary diversity. Rome: fAO. 11 World food Programme. 2008. Technical Guidance Sheet - food Consumption Analysis: Calculation and Use of the food Consumption Score in food Security Analysis. ANNEx C validation. International food Policy of days that different food groups in use. The MAHfP indicator captures Research Institute12 carried out vali- the food consumption clusters are changes in the household’s ability to dation of the fCS for three countries consumed, can also be calculated to address vulnerability in such a way – Burundi, Haiti, and Sri lanka.13 The interpret the composition of the diet. as to ensure that food is available study found that fCS is positively above a minimum level year round. correlated with calorie consumption Measuring the MAHfP has the advan- per capita and validated the fCS c. Months of Adequate tage of capturing the combined ef- against several alternative indicators Household Food Provisioning fects of a range of interventions such of household food security, such as (MAHFP) as improved agricultural production, the dietary diversity scores for differ- storage, and strategies to increase Description. MAHfP measures house- ent age and sex groups. Moreover, the household’s purchasing power. It hold food accessibility throughout strong and expected correlation has has been incorporated as a standard the past year, and reflects the been found between fCS and other impact indicator in all of Africare’s monthly and seasonality aspect of proxy indicators of food consump- food security programs. food security.15 To capture improve- tion, food access, and food security ments in household food access ac- (percentage expenditures on food, curately over time, data in MAHfP food procurement source, wealth should be collected during the period d. Household Food Insecurity index, asset index, number of meals Access Scale (HFIAS) of greatest food shortages (such as eaten per day, harvest and produc- immediately prior to the harvest). Description. HfIAS, developed by the tion indicators) by using the data This will increase the accuracy of re- USAID-funded food and Nutrition from Burundi and Mali.14 Similar re- call for the number of months when Technical Assistance (fANTA) project, sults were also found from the the household did not have sufficient consists of nine items and four fre- Cameroon Comprehensive food Se- food. Subsequent data collection quency responses.17 The HfIAS score curity and Vulnerability Analysis should be undertaken at the same is a continuous measure of the de- (CfSVA) project. time of year. gree of food insecurity (i.e., access) in the household in the past four use. The fCS has been in use by the weeks (30 days), with the minimum validation. The MAHfP score has not WfP as part of their community score 0 and the maximum score 27. been validated against other meas- household surveillance and other The higher the score, the more food ures of food security or dietary in- data collection efforts. The fCS can insecurity the household experi- take, but one research paper found be used to describe the general food enced. that MAHfP scores tracked with consumption pattern and the current HfIAS scores in three different coun- food security situation. In addition, tries in Africa.16 the mean fCS and the mean number 12 International food Policy Research Institute (IfPRI). 2009. Validation of the world food program’s food consumption score and alternative indicators of household food security. 13 International food Policy Research Institute (IfPRI). 2009. Validation of the world food program’s food consumption score and alternative indicators of household food security. 14 World food Programme. 2008. Technical Guidance Sheet - food Consumption Analysis: Calculation and Use of the food Consumption Score in food Security Analysis. 15 Bilinsky P, A. Swindale. 2010. Months of Adequate Household food Provisioning (MAHfP) for Measurement of Household food Access: Indicator Guide. Version 4. fANTA-2. 16 Remans R, flynn DfB, DeClerck f, Diru W, fanzo J, et al. 2011. Assessing Nutritional Diversity of Cropping Systems in African Villages. PloS ONE 6(6): e21235. doi:10.1371/journal.pone.0021235 17 Coates, J, A Swindale, P Bilinsky. 2007. Household food Insecurity Access Scale (HfIAS) for Measurement of food Access: Indicator Guide. Version 3. fANTA. ANNEx C paring groups within the same or RECALL PERIOD: 4 wEEkS similar settings (such as two urban Household items: Frequency categories: villages in the same area). The indi- cator guidelines, however, clearly 1. Worry that the household would not have enough food Never, Rarely, Sometimes, Often mentions that it should only be em- 2. Not able to eat the kinds of food preferred Never, Rarely, Sometimes, Often ployed after a proper in- country 3. Eat a limited variety of foods Never, Rarely, Sometimes, Often qualitative assessment has been car- 4. Eat some foods that you really did not want to eat Never, Rarely, Sometimes, Often ried out and necessary refinement in the questions have been applied. 5. Eat a smaller meal than you felt you needed Never, Rarely, Sometimes, Often 6. Eat fewer meals in a day Never, Rarely, Sometimes, Often 7. No food to eat of any kind in your household Never, Rarely, Sometimes, Often e. Household Hunger Scale (HHS) 8. Go to sleep at night hungry Never, Rarely, Sometimes, Often Description. HHS21 is based on the 9. Go a whole day and night without eating Never, Rarely, Sometimes, Often HfIAS but has been modified to make it more applicable across cul- tures. HHS consists of three items validation. Studies found that the Zimbabwe and South Africa) and and three frequency responses: 0 for HfIAS measurement instrument using statistical modeling, the study never, 1 for rarely or sometimes, 2 for shows validity and reliability in determined that though the survey often. The household hunger status measuring household food insecurity has been shown to be internally valid is categorized as “little to no hunger in the contexts of rural Tanzania and in a number of settings (it measures in the household” if the score is 0 or in urban Iran.18,19 food security what it should be measuring in those 1, “moderate hunger in the house- through improved access, as meas- settings) the questions are not exter- hold” if the score is 2 or 3, and “Se- ured by HfIAS, was positively asso- nally valid (it does not measure the vere hunger in the household” if the ciated with household wealth status. same things in different settings, and score is 4, 5, or 6. HfIAS was negatively associated therefore cannot be compared across with maternal age and household cultures). size. An important recent study on the validity of the HfIAS determined use. The HfIAS is being used by fAO that despite a number of years of and USAID feed the future projects. work to develop a cross-culturally It is important to note that while the valid measure of the experience of scale does not allow for the compari- food insecurity, most of the ques- son of data across settings, it can tions in the scale may not be exter- achieve other intended goals, such nally valid.20 Drawing from seven as measuring change over time (in data sets (Mozambique, Malawi, one group and one setting), or com- West Bank/Gaza Strip, Kenya, 18 Knueppel D, Demment M, Kaiser l. 2010. Validation of the Household food Insecurity Access Scale in rural Tanzania. Public Health Nutr. 2010 Mar;13(3):360-7. 19 Mohammadi f, Omidvar N, Houshiar-Rad A, Khoshfetrat MR, Abdollahi M, Mehrabi Y. 2011. Validity of an adapted Household food Insecurity Access Scale in urban households in Iran. Public Health Nutr. 2011 Aug 2:1-9. 20 Deitchler, Megan, Terri Ballard, Anne Swindale and Jennifer Coates. Validation of a Measure of Household Hunger for Cross-Cultural Use. 2010. Washington, DC: food and Nutrition Technical Assistance II Project (fANTA-2), AED, 2010. 21 Ballard, T., J Coates, A Swindale, M Deitchler. Household Hunger Scale: Indicator Definition and Measurement Guide. fANTA-2, 2011. ANNEx C RECALL PERIOD: 4 wEEkS Household items: Frequency categories: 1. No food to eat of any kind in your household Never, Rarely, Sometimes, Often 2. Go to sleep at night hungry Never, Rarely, Sometimes, Often 3. Go a whole day and night without eating Never, Rarely, Sometimes, Often validation. The HfIAS study men- tioned before22 proposed the House- hold Hunger Scale. The HHS has demonstrated the potential for both external (cross-cultural) and internal validity, and has been shown to have a strong relationship with household income and wealth scores. use. The HHS is most appropriate when large proportions of house- holds and individuals experience food deprivation and actual hunger. It can be used to monitor the preva- lence of hunger over time across lo- cations and assess progress towards meeting development commitments. The Household Hunger Scale is being used by fAO and USAID feed the fu- ture projects. 22 Deitchler, Megan, Terri Ballard, Anne Swindale and Jennifer Coates. Validation of a Measure of Household Hunger for Cross-Cultural Use. 2010. Washington, DC: food and Nutrition Technical Assistance II Project (fANTA-2), AED, 2010. ANNEx C Annex C-4. Suggested uNICEf State of the world’s Children - world Bank world Development Indicators data tables (2011) nutrition resources WDI contains two indicators for mal- The data tables in UNICEf’s annual nutrition (stunting, underweight), as The Human Development Network is flagship report present major nutri- well as rural population and propor- currently establishing a Knowledge tion indicators, comparable across all tion of the population employed in Exchange for Nutrition, which will countries, in a highly user-friendly agriculture, which can help to esti- provide key information on nutrition format. It is updated annually. mate likely risk of malnutrition resources, including a list of nutrition http://www.unicef.org/sowc2011/pdf among farmers. specialists within the World Bank, s/SOWC-2011-Statistical- who could potentially assist in plan- tables_12082010.pdf http://data.worldbank.org/ ning nutrition-sensitive approaches in projects. uNICEf Tracking Progress on Child and To understand the basic nutrition sit- wHo nutrition databases Maternal undernutrition (2009) uation in countries, the following re- (http://www.who.int/nutrition/data- This publication provides profiles of bases/en/index.html) sources are useful: several high-burden-of-malnutrition countries, presenting information on WHO maintains several databases on nutrition indicators and what propor- nutrition, including: tion of child deaths are due to malnu- world Bank Nutrition trition and other diseases. • Nutrition landscape Information Country Profiles (2011) System (NlIS) – a web-based tool These are two-page profiles of the 68 http://www.unicef.org/publications/ which provides nutrition and nutri- highest-burden-of-malnutrition coun- files/Tracking_Progress_on_Child_an tion-related health and develop- tries. They contain information on d_Maternal_Nutrition_ ment data in the form of automated prevalence of malnutrition and its EN_110309.pdf country profiles and user-defined causes, how the country’s state of downloadable data nutrition compares to countries with similar GDP or geography, informa- • WHO Global Database on Body tion on current World Bank nutrition uNICEf ChildInfo Mass Index – contains updated projects in the country, cost for scal- This allows country-by-country track- data on underweight, overweight ing up core micronutrient interven- ing of the MDG1 indicator on child and obesity, and related indicators tions, and suggested actions. These underweight (Indicator 1.8: % of Chil- for all countries. profiles are useful for basic context assessment and for making the case dren under 5 moderately or severely to address nutrition through agricu underweight), underweight preva- lture in high-burden countries. lence by economic background, and underweight and stunting data (the http://www.worldbank.org/ same compiled in UNICEf State of nutrition/profiles the World’s Children reports). http://www.childinfo.org/undernutri- tion_mdgprogress.php ANNEx C • National nutrition policies and pro- grams - The Global Database on National Nutrition Policies and Pro- grams was established in 1995, initially to monitor and evaluate the progress in implementing the World Declaration and Plan of Ac- tion for Nutrition. It has been fur- ther developed to monitor country progress in developing, strength- ening and implementing national nutrition plans, policies, and pro- grams, including multisectoral ac- tions, development of dietary guidelines, undertaking of nutri- tion surveys, demographic, and epidemiological data. • WHO Global Database on Child Growth and Malnutrition - an A-Z list from which users can choose a country to view available child malnutrition data and reference tables (in pdf). Caution: these tables are not easy to interpret for non-nutritionists. UNICEF SOWC (see above) contains similar information. • Vitamin and Mineral Nutrition Information System (VMNIS) – contains most recent data for anemia, iodine deficiency disorders, and vitamin A defi- ciency. Caution: these tables are not easy to interpret for non- nutritionists. World Bank country nutrition profiles (see above) contain similar information for 68 countries. ANNEx C Annex C-5. Recent reviews and strategies to mainstream nutrition into agriculture • A Synthesis of Guiding Principles on Agriculture Programming for Nutrition, of recommenda- tions in common among many different institutions, was recently supported by fAO. https://www.securenutritionplatform.org/ Pages/DisplayRe- sources.aspx?RID=32 • The European Commission’s Reference document (September 2011) provides guidance to country teams on how to incor- porate nutrition components into existing projects and programs. http://capacity4dev.ec.europa.eu/ topic/fight- ing-hunger • The DfID commissioned systematic evidence review (Masset et al., 2011) summarizes existing evidence and programme theory of agricultural interventions, and identifies gaps in knowledge. This document is available from: http://www.dfid.gov.uk/R4D/PDf/Outputs/SystematicReviews/ Masset_etal_agriculture_and_nutrition.pdf. An abridged version is published in BMJ 2012, v. 344. Open access, available at: http://www.bmj.com/ content/344/bmj.d8222 • The Bill and Melinda Gates foundation published a statement of their approach to optimize nutrition impacts from agriculture, based on a review of evidence. http://www.gatesfoundation. org/agriculturaldevelopment/Pages/ optimizing-nutrition-outcomes-from-investment-agriculture. aspx • The world Bank’s From Agriculture to Nutrition (2007) document presents a review of evidence of agriculture interventions with a nutrition focus, and examines the changes in agriculture and nutrition that are affecting the operational contexts in which nutrition-focused agricultural interventions are carried out, and the institutional issues related to these. This document is available from: http://siteresources.worldbank.org/ExTARD/ Re- sources/final.pdf • DfiD’s Nutrition Strategy (2010) focuses on four strategic objectives of mobilizing and coordinating the international response, prioritizing countries and populations most vulnerable to malnutrition, investing in a multiple sectors to improve nutrition, and using evidence and demonstrating results. This document is available from: http://collections.europarchive.org/ tna/20100423085705/http:/dfid.gov.uk/Documents/publications/ nutrition-strategy.pdf • uSAID’s IYCN Nutrition and Food Security Impact of Agriculture Projects Review of Experiences (2011) showcases nutrition and food security impacts separately, and then integrates the two for a comprehensive look and recommendations on sensitizing agricultural projects to be more nutrition friendly. This document is available from: http://www.iycn.org/2011/09/resources-for- agriculture-project-designers/ • fAo has a new corporate priority to mainstream nutrition into agriculture, reflected in several documents including Assist- ing the food and agriculture sector in addressing malnutrition and Investing in Food Security: Linking Agriculture to Nutrition Security (2009) http://www.fao.org/fileadmin/user_upload/agn/pdf/food_and_Agr_sector_and_malnu- trition.pdf. http://www.fao.org/fileadmin/templates/ag_portal/docs/i1230e00.pdf • IfAD Strategic framework 2011-2015: Enabling poor rural people to improve their food security and nutrition, raise their incomes and strengthen their resilience. http://www.ifad.org/pub/strategy/index.htm ANNEx C • uSAID feed the future Guide 2010 is available at http://www.feedthefuture.gov/resource/ feed-future-guide, and the feed the future Indicator Handbook: Definition Sheets are also available online. http://www.feedthefuture.gov/ resource/feed-future-handbook-indicator- definitions • Action Against Hunger (ACf) operational document: “Maximizing the nutritional impact of food security and livelihoods interventions: a manual for field workers,” July 2011. http://www. actionagainsthunger.org/publication/ 2011/07/ maximising-nutritional-impact-food-security-and-livelihoods-interventions • Save the Children uK’s “A Life Free from Hunger” includes a substantial section on “harnessing the potential of agriculture to tackle malnutrition.” http://www.savethechildren.org.uk/resources/ online-library/life-free- hunger-tackling-child-malnutrition • IfPRI’s 2020 International Conference on leveraging Agriculture for Improving Nutrition and Health website (2011), which includes links to Conference Briefs on various aspects of the three main topics discussed: agriculture, health, and nutrition. The 2020 conference link is at http://2020conference.ifpri.info/publications/ • Highlights from the leveraging Agriculture for Improving Nutrition and Health International Conference (IfPRI, 2011) includes key themes that emerged from this conference, including videos that capture some exciting and thought-provoking moments of the event, as well as a mini-documentary on the importance of bringing together agriculture, health, and nutrition. Videos and the highlights interactive booklet are available from: http://2020conference.ifpri.info/ • Bioversity International produced “a manual on implementing food systems field projects to assess and improve dietary diversity, and nutrition and health outcomes” (Oct 2011). http:// www.bioversityinternational.org/fileadmin/bioversityDocs/ Research/Nutrition new_/Improving_ Nutrition_with_agricultural_biodiversity.pdf • The Lessons from the Mainstreaming Nutrition Initiative article (Pelletier et al., 2011), which presents the main findings from MNI’s country-level activities and provides concrete recommendations for nutrition agenda setting, policy formulation, and implementation. This article is available from: http://heapol.oxfordjournals.org/content/early/ 2011/02/03/heapol.czr011. full.pdf+html • The Value Chains for Nutrition Brief (Hawkes and Ruel 2011), which provides a summary of the food supply chain, and the role that the agriculture sector can and should play between the production and consumption phases through “value-chain” concepts, analyses, and approaches. This was presented during IfPRI’s 2020 International conference, and the brief is available from: http://www.ifpri.org/sites/default/files/publications/ 2020anhconfbr04.pdf • Zincworld’s Zinc Crops Improving Crop Production and Human Health website (2007), includes links to presentations and posters presented during this conference, focusing on zinc and human nutrition, soil and crop management, zinc fertilizers and crop nutrition, and plant physiology, genetics, and molecular biology. The Zinc Crops conference link is http://www.zinc-crops.org/ ZnCrops2007/page_session_1.htm. ANNEx D Annex D. Additional Resources • Caldes, N, Coady, D. and J. Maluccio, 2006. “The cost of poverty alleviation transfer programs: a Comparative Analysis of three programs in latin America, World Development 34 (5): 818-837. • E. Duflo. 2003. “Grandmothers and Granddaughters: Old-Age Pensions and Intrahousehold Allocation in South Africa,” World Bank Economic Review, 17 (1): 1-25. • Garrett, J., Bassett l. and A. Marini. 2009 “Designing CCT Programs to Improve Nutrition Impact: Principles, Evi- dence and Examples,” fAO Working Paper # 6. • Grosh, M., Del Ninno, C., Tesliuc, E., A. Ouerghi. 2008. “for Protection and Promotion: the Design and Implemen- tation of Effective Safety Nets.” World Bank. • Haddad, l., Alderman, H., Appleton, S., Song, l., and Y. Yohannes. 2003. “Reducing Child Malnutrition: How far Does Income Growth Take Us?” World Bank Economic Review, 17(1): 107-131. • R. Hermosillo. 2007. Más Oportunidades para la Nutrición, Experiencia del Programa Oportunidades de México en el mejoramiento del impacto nutricional, Note for Discussion, Mexico, Df. • Horton, S., Shekar, M., Ajay, M., McDonald, C. and J. Brooks. 2009. Scaling up Nutrition: what will it cost? World Bank. • levy S. and E. Rodríguez. 2005. Sin herencia de pobreza: el Programa Progresa - Oportunidades de México. Banco Interamericano de Desarrollo, Editorial Planeta Mexicana. • Neufeld, Nutrition in the Oportunidades conditional cash transfer program: Strengths and challenges, presentation at the Third International CCT Conference, Istanbul, 29 June 2006. • M. Ruel. 2003. “Operationalizing Dietary Diversity: A Review of Measurement Issues and Research Priorities,” Journal of Nutrition, 133 (11): 3911S-3926S. • Skoufias E, Unar, M., T. González de Cossio. 2008. The impacts of cash and in-kind transfers on consumption and labor supply: experimental evidence from rural Mexico. World Bank Policy Research Working Paper WPS4778. Washington, D.C.: World Bank. • Vakis, R. and E. Perova. 2011. The longer the Better: Duration and Program Impact of Juntos in Peru, mimeo, World Bank, 2011. • Vargas. 2011. Mejorando el diseño e implementación del Programa Juntos, 2008-2010. • T. Woldehanna. 2010. Do pre-natal and post-natal economic shocks have a long-lasting effect on the height of 5-year old children? Evidence from 20 sentinel sites of rural and urban Ethiopia, Working Paper 60, Young lives, Department of International Development, University of Oxford: Oxford. • World Bank. 2009. Promoción del Crecimiento para Prevenir la Desnutrición Crónica, Washington, D.C.: World Bank • World Bank. 2011. Juntos Results for Nutrition, Project Appraisal Document, Washington, D.C.: World Bank. • Yamano, T., Alderman, H. and l. Christiansen. 2005. “Child Growth, Shocks, and food Aid in Rural Ethiopia,” American Journal of Agricultural Economics, 87 (2): 273-88. ANNEx E ANNEx E-1. GuIDANCE MATRIx: HEALTH SECTOR AND NuTRITION LINkAGES AND PROGRAMMING Sample Indicators and mechanisms for Trade-offs/ interventions measuring impact on nutrition outcomes Policy coherence PROGRAM OBJECTIVE: Reduce micronutrient deficiencies among the most vulnerable populations • Provide routine vitamin A • Proportion of children ages 6-59 months • Effectiveness of dietary counseling supplementation to children who have received twice yearly vitamin A depends on its appropriateness to clients’ supplements circumstances; health and agriculture/ • Provide multiple micronutrient home economics workers should share supplements or powders (and guidance for • Proportion of children 6-23 months knowledge around optimal diets use) to young children receiving multiple micronutrient powders based on available foods • Provide iron-folate supplementation to • Proportion of women receiving iron-folate • The most effective mechanisms for pregnant and lactating women supplements during their pregnancy/ delivering interventions depend on local and postpartum national contexts and systems in place • Promote use of iodized salt through counseling, marketing, subsidies, and other • Number of MCH projects that include • The use of campaign days to address many in-novative approaches such as requiring iodized salt purchase/provision health issues at once (vitamin A, vaccination, proof of purchase of iodized salt as a as a conditionality other issues) may result in lower budgetary conditionality for receipt of MCH services resources for or use of routine health • Proportion of children age 6-59 services • Provide iodized oil capsules to mothers/ months provided with iodized oil capsules children in areas with high levels of iodine • Although social protection, government deficiency disorders when iodized salt is • Proportion of health care staff at (ANC, programs, and the private sector are in better not available at household level PNC, well-child, routine, etc.) contacts giving positions to provide iodized salt and other counseling on dietary quality fortified foods, the health sector can play an • Promote dietary diversification of pregnant important stewardship and monitoring and women’s and children’s diets • Qualitative assessment of quality of dietary evaluation role of food fortification programs counseling • Promote optimal infant and young child feeding practices through a mass media • Proportion of mothers who exclusively communications/behavior change campaign breastfed their youngest child for the first 6 months of life • Develop and enact legislation for the fortification of a staple food. For example, • Proportion of children receiving a minimum fortification of flour/rice with iron, folate, acceptable diet at 6-23 months of age zinc; salt with iodine; oil/sugar with vitamin A • Presence of food fortification legislation • Work with the Ministry of Commerce/ • Proportion of households consuming Finance to define and implement a commercially available fortified staple marketing and dissemination strategy foods (based on national legal of a fortified food requirements/guidelines for fortification) • Work with aid organizations and/or the • Proportion of children receiving Ministry of Trade to set guidelines for/ micronutrient supplementation (as per what monitor the quality of incoming fortified foods is included in their insurance package) during their health visits • Include micronutrient supplementation activities for children into the basic • Proportion of health centers that have package of interventions covered by adequate stock levels of micronutrients health insurance (as per micronutrients included in child/ maternal insurance package) ANNEx E ANNEx E-1. GuIDANCE MATRIx: HEALTH SECTOR AND NuTRITION LINkAGES AND PROGRAMMING (CONTINuED) Sample Indicators and mechanisms for Trade-offs/ interventions measuring impact on nutrition outcomes Policy coherence PROGRAM OBJECTIVE: Reduce prevalence of anemia in pregnant and lactating women and children 0-24 months • Deliver iron-folic acid supplements to • Proportion of pregnant women who • The use of iron-fortified staple foods pregnant/ lactating women with emphasis received IFA supplements during pregnancy depends on their availability a and price on problem solving to address side effects (or through ANC or PNC visits) for increased compliance • Effectiveness of dietary counseling • Proportion of children 6-23 months depends on its appropriateness to • Provide multiple micronutrient receiving multiple micronutrient powders clients’ circumstances; health and supplements or powders (and guidance for agriculture/home economics workers use) to young children • Proportion of children 24-59 months should share knowledge around optimal receiving supplemental iron diets based on available foods • Provide supplemental iron1 to children to prevent and treat iron deficiency anemia • Proportion of children age 12-59 months • The most effective mechanisms for receiving twice yearly deworming treatments delivering interventions depend on local • Provide twice yearly deworming of children and national contexts and systems in place in high worm burden communities • Proportion of pregnant women who received a deworming treatment after their • Social protection programs and the private • Provide deworming for pregnant women first trimester of pregnancy sector are in better positions to provide after the first trimester in areas with endemic fortified foods than the health sector hookworm and other helminth infections • Proportion of women who know that iron-fortified staple foods help to • Promote use of iron fortified staple foods prevent anemia through counseling and mass media communication strategies • Proportion of households who purchase iron-fortified staple foods • In malaria endemic areas, provide intermittent preventive treatment (IPT) for • Proportion of pregnant women in malaria malaria and insecticide-treated bednets endemic areas who received IPT (ITN) to pregnant women, and promote and support the use of ITNs by mothers • Proportion of pregnant women/ and children children sleeping under ITNs • Treat malaria • Proportion of live births in health care facilities where cord clamping (delayed • Delay cord clamping at time of delivery 3 minutes or more) is practiced • Develop and enact legislation for the • Proportion of children <59 months fortification of a staple food (flour, rice) who are anemic with iron and folate • Proportion of pregnant women who • Work with the Ministry of Commerce/ are anemic Finance to define and implement a marketing and dissemination strategy of an • Presence of food fortification legislation iron-fortified staple food • Proportion of households consuming • Work with aid organizations and/ commercially available iron-fortified staple or the Ministry foods (based on national legal requirements/guidelines for fortification) of Trade to set guidelines for/ monitor the quality of incoming iron-fortified foods • Proportion of pregnant women and children receiving iron folate supplementation, • Include iron supplementation, multiple micronutrient powders, and/or deworming, and malaria prevention and intermittent iron supplementation treatment activities for pregnant women and children into the basic package of • Proportion of health centers that have interventions covered by health insurance adequate stock levels of anemia-prevention supplies (iron folate supplements, multiple micronutrient powders, ITNs, IPT, malaria drugs, etc.) 1 Refer to the WHO Statement on iron supplementation of young children in regions where malaria transmission is intense and infectious disease highly prevalent at http://www.who.int/child_adolescent_health/documents/pdfs/who_statement_iron.pdf for specific guidance on prevention and treatment of iron deficiency anemia in specific disease-context settings. ANNEx E ANNEx E-1. GuIDANCE MATRIx: HEALTH SECTOR AND NuTRITION LINkAGES AND PROGRAMMING (CONTINuED) Sample Indicators and mechanisms for Trade-offs/ interventions measuring impact on nutrition outcomes Policy coherence PROGRAM OBJECTIVES: Promote good feeding and nutritional care practices for the most vulnerable populations • Promote dietary diversification of • Proportion of health care staff at (ANC, • The most effective mechanisms for pregnant women and children’s diets PNC, well-child, routine, etc.) contacts delivering interventions depend on local and giving counseling on dietary quality national contexts and systems in place • Promote weight gain among pregnant women through adequate diet and • Proportion of health care staff at (ANC, • Impact from growth monitoring and consumption of diverse foods PNC, well-child, routine, etc.) contacts promotion is variable based on the skill of the giving counseling on breastfeeding staff in conveying effective growth • Promote/protect early initiation and promotion counseling that addresses exclusive breastfeeding for first six months • Existence of a baby-friendly community addresses individuals’ specific obstacles to of life (individual and group counseling) initiative optimal growth • Counseling for optimal complementary • Proportion of women who know the feeding with continued breastfeeding from optimal length of exclusive breastfeeding 6 months (individual and group counseling), including counseling on feeding during • Proportion of health care staff at (ANC, illness and in support of catch-up growth PNC, well-child, routine, etc.) contacts giving counseling on optimal • Carry out growth monitoring and promotion complementary feeding • Develop and implement policies that • Proportion of children under 6 months of protect optimal breastfeeding practices, age who are exclusively breastfed such as legislation for breastmilk substitutes and hospital care (baby- • Proportion of children receiving a minimum friendly hospitals) acceptable diet at 6-23 months of age • Proportion of infants born to HIV- positive women receiving appropriate feeding • Child malnutrition rates (stunting, underweight) • Proportion of mothers who bring their child to attend monthly growth monitoring and promotion sessions • Proportion of hospitals providing maternity care designated as Baby-Friendly • Existence of a national code for breastmilk substitutes • Existence of a Baby-Friendly community initiative • Proportion of women who know the optimal length of exclusive breastfeeding ANNEx E ANNEx E-1. GuIDANCE MATRIx: HEALTH SECTOR AND NuTRITION LINkAGES AND PROGRAMMING (CONTINuED) Sample Indicators and mechanisms for Trade-offs/ interventions measuring impact on nutrition outcomes Policy coherence PROGRAM OBJECTIVES: Treat and prevent illness (with particular focus on diarrhea, acute respiratory infections, malaria, and HIV/AIDS) • Implement comprehensive, high quality • Proportion of pregnant women screened • HIV screening and PMTCT counseling PMTCT programs (maternal screening, for HIV/ AIDS and TB during pregnancy is most effective if public education/ ARV therapy, TB treatment, and counseling awareness is ongoing to reduce stigma, in IYC feeding choices) • Proportion of HIV/TB+ women receiving and if sufficient ARVs are available ARV therapy/TB treatment during • Encourage/deliver full course of (pregnancy, lactation) • For HIV+ mothers, choice of breastfeeding + childhood immunizations ARV or formula feeding depends on local • Proportion of HIV+ mothers counseled situations, sanitation, and economics • Provide quality sick-child care on PMTCT counseling and services • The use of sick-child services and • Proportion of health care providers who health care in general depends on many • Provide counseling for improved hygiene routinely counsel HIV+ women on PMTCT factors (distance, time available, financial practices including handwashing issues, stigma) in addition to quality of • Proportion of children age 0-59 months care offered • Provide intermittent preventive treatment who received full course of immunizations (IPT) for malaria and insecticide-treated bednets (ITN) to pregnant women • Proportion of one-year-olds who received at least one dose of measles • Promote/protect early initiation and vaccine in a given year exclusive breastfeeding for first six months of life • Proportion of households where children are taken to health care providers when ill • Advise on continued feeding during illness and catch-up feeding during • Proportion of households that have ITNs recuperative period • Proportion of clinics with sufficient supply • Treat malaria of anti-malarials to treat all confirmed and suspected cases of malaria • Provide therapeutic zinc supplements for diarrheal disease management • Proportion of health care staff at (ANC, PNC, well-child, routine, etc.) contacts giving • Provide coverage of a basic package counseling on handwashing of essential health and nutrition services (immunization, sick- child services, malaria • Proportion of health care staff at (ANC, treatment and prevention, PMTCT services, PNC, well-child, routine, etc.) contacts etc.) for pregnant and lactating women, giving counseling on breastfeeding and children • Proportion of hospitals nationwide that are Baby-Friendly • Existence of a Baby-Friendly community initiative • Proportion of health service points where zinc supplements are stocked regularly • Proportion of children who were given zinc as part of the treatment for acute diarrhea • % of children (0–59 months) with diarrhea who received ORT and continued feeding • Proportion of pregnant women and children enrolled in insurance program • Proportion of health clinics that have adequate stock levels of essential health and nutrition supplies (ITNs, IPT, malaria drugs, ARVs, TB drugs, zinc supplements, ORT, childhood immunizations, etc.) ANNEx E ANNEx E-1. GuIDANCE MATRIx: HEALTH SECTOR AND NuTRITION LINkAGES AND PROGRAMMING (CONTINuED) Sample Indicators and mechanisms for Trade-offs/ interventions measuring impact on nutrition outcomes Policy coherence PROGRAM OBJECTIVES: Reduce low birth weight • Provide counseling for increased • Proportion of ANC visits where patients are • The most effective mechanisms for dietary intake (quality and quantity) screened for malaria delivering interventions depend on local and national contexts and systems in place • Counsel pregnant women on reduced • Proportion of health care staff at (ANC, maternal workload; prevention and treatment PNC, etc.) contacts giving counseling on • Decreasing indoor air pollution depends on of anemia; decreased indoor air pollution; dietary quality, maternal workload, ability of households to access alternate reduced tobacco consumption; avoidance prevention and treatment of anemia; cooking fuel/setting of gender violence decreased indoor air pollution; reduced tobacco consumption; avoidance of gender • Decreasing smoking and gender violence • In situations where food shortage for violence (each on a separate indicator) depend on larger public awareness pregnant women is probable, provide campaigns, social support systems, maternal supplements of balanced energy • Proportion of women aged 15–49 years and taxes (for smoking) and protein with a live birth that received antenatal care: (1) at least 4 times by any provider, (2) at • Prevent/treat maternal infections least once by skilled personnel • Provide health insurance for pregnant • Proportion of last live births who were women that covers a basic package of weighed at birth health and nutrition services • Percent of infants born at a low birth weight • Proportion of pregnant women enrolled in insurance program ANNEx E ANNEx E-1. GuIDANCE MATRIx: HEALTH SECTOR AND NuTRITION LINkAGES AND PROGRAMMING (CONTINuED) Sample Indicators and mechanisms for Trade-offs/ interventions measuring impact on nutrition outcomes Policy coherence PROGRAM OBJECTIVES: Improve reproductive health and family planning • Provide iron-folate supplementation to • Proportion of women of reproductive age • Social marketing, public media and other women of reproductive age who received iron-folate supplements awareness-generating mechanisms are helpful to support counseling messages • Provide integrated postpartum FP: • Proportion of mothers counseled on LAM delivered at individual contact points Counseling on LAM; use of progestin-only modern contraception after shift from LAM; • Proportion of mothers counseled on • LAM is not a failsafe method of birth control healthy spacing of pregnancies progestin-only contraception within 6 weeks postpartum (or at each PNC visit) • Promote and counsel adolescent women at routine immunization and/or health • Proportion of mothers counseled on optimal check-ups on birth spacing and modern birth spacing contraceptive use • Proportion of fathers counseled on optimal • Involve men and community elders as birth spacing appropriate in education/outreach about benefits to families of lengthening time • Proportion of women of reproductive age between pregnancies enrolled in insurance program • Provide a basic insurance package for • Proportion of health clinics that have women of reproductive age that includes adequate stock levels of contraceptives family planning activities PROGRAM OBJECTIVES: Treat moderate and severe acute undernutrition in children • Ensure that all children attending health • Proportion of children attending health • Cutoffs for defining children eligible for services are screened for acute malnutrition services screened for acute malnutrition treatment may vary by context and therapeutic food supply • Implement therapeutic feeding (including • Proportion of children with severe acute ready- to-use therapeutic foods) for malnutrition having access to appropriate • The use of therapeutic foods for prevention moderate (<-2 to -3 WAZ) and severe treatment including therapeutic foods of malnutrition is controversial acute malnutrition (<-3WAZ) in children delivered through clinics and community • Proportion of children <-2 to -3WAZ outreach services receiving therapeutic feeding • Ensure that referral procedures are • Proportion of children <-3 WAZ receiving established and utilized at community therapeutic feeding level • Child undernutrition rates (underweight, • Ensure adequate stocks of drugs and wasting) medicines needed to treat severe acute malnutrition • Child mortality • Develop and implement a national policy • Proportion of health clinics with adequate for CMAM and nutrition surveillance, stock levels of therapeutic foods and drugs particularly in emergency situations needed to treat severe acute malnutrition with complications • Build/strengthen capacity at the community and health clinic level to implement the • Existence of a national, up-to-date CMAM model CMAM policy • Proportion of health clinic staff trained in CMAM • Proportion of health clinics implementing CMAM ANNEx E Annex E-2. Menu • Provide twice yearly deworming • Deliver quality counseling and of children in high worm burden family planning services for of actions to address communities optimal birth spacing and undernutrition by modern contraceptive use • Deliver full course of childhood delivery mechanism immunizations • Insure that health referral procedures are established Various health delivery channels may • Provide therapeutic zinc and utilized be used to deliver interventions to supplements for diarrheal disease improve nutrition and/or reduce un- management dernutrition. The effectiveness of any • Screen children for acute one mechanism depends heavily on context, such as priority/ need to ad- malnutrition Community outreach dress undernutrition based on dis- Community outreach often involves ease burden, national or regional community health workers, paid or policies and systems (health insur- volunteer, who make periodic home ance, for example) already in place, Routine health service contacts visits and can provide a wide range of staff capacity (coverage and quality), Routine contacts include visits to services, depending on their training support from multilateral institutions health care professionals, usually ini- and mission. It may also involve such as UNICEf, consistency in sup- tiated by clients, for routine physical health services delivered through plies, availability and emphasis on exams, evaluations for chronic prob- schools, fairs, mobile clinics, or community systems, and behavioral lems, diagnosis and treatment of ill- other venues easily accessible and norms. The interventions provided in nesses, or reproductive health geographically close to intended the matrix (Annex E-1) are organized needs. In many countries, the Inte- beneficiaries. here by the mechanisms through grated Management of Childhood Ill- • Encourage/deliver full course of which they could be delivered. nesses approach (IMCI) is the childhood immunizations primary approach for diagnosis and treatment of child infections and un- • Deliver vitamin A supplements to dernutrition. children Public health campaigns, such as • Promote dietary diversification • In malaria endemic areas, provide Child Health Days through counseling intermittent preventive treatment Child Health Days or Child Health (IPT) for malaria and insecticide- • Promote use of iron fortified Weeks are typically held twice yearly treated bednets (ITN) staple foods through counseling in six-month intervals, and involve • Deliver quality growth monitoring social and community mobilization • Treat malaria and other illness and promotion that promotes and provides health • Provide therapeutic zinc and nutrition services, such as vacci- • Ensure that children are screened supplements for diarrheal disease nations, vitamin and mineral supple- for acute malnutrition management mentations, and deworming, among • Promote early initiation and exclu- others, in geographic areas that have • Provide iodized oil capsules sive breastfeeding for first six restricted access to services. and/or promote use of iodized months of life salt through counseling • Provide twice-yearly vitamin A • Provide counseling on: supplementation to children 6-59 months42 42 The blue text indicates interventions identified as having sufficient evidence of efficacy and effectiveness to recommend for implementation, either in all high-burden countries or in specific, situational contexts, by The lancet (2008) Series on Maternal and Child Undernutrition. ANNEx E o Optimal complementary • Encourage/deliver full course of • Implement therapeutic feeding feeding from six months childhood immunizations (including ready-to-use therapeu- (individual and group tic foods) for moderate (<-2 to-3 • Treat malaria counseling) WAZ) and severe acute malnutri- • Provide deworming of children in tion (<-3 WAZ) in children o Infant and young child high worm burden communities feeding choices for PMTCT • Deliver vitamin A supplements to o Continued feeding during children illness and catch-up feeding Antenatal care contact (ANC) during recuperative period • Provide multiple micronutrient Pregnant women should receive at supplements or powders (and least four ANC visits, which may be at o Improved hygiene practices guidance for use) a clinic, hospital, birth center, or de- including handwashing • Provide iodized oil capsules livered by a nurse-midwife at home o Birth spacing and modern (as a form of community outreach). and/or promote use of iodized salt contraceptive use (to These visits serve to monitor mater- through counseling women, men, and nal weight gain and/or fetal size, adolescent girls) • Provide intermittent iron supple- screen and treat pregnancy complica- mentation (syrup, tablets) to chil- tions, provide supplements, and de- • Provide therapeutic zinc supple- dren to prevent and treat iron liver key information about ments for diarrheal disease man- deficiency anemia maintaining health in pregnancy and agement • Provide therapeutic zinc supple- lactation and preparing for birth. • Ensure that health referral proce- ments for diarrheal disease man- • Provide deworming for pregnant dures are established and utilized agement women after the first trimester in at community level • Ensure that all children attending areas with endemic hookworm health services are screened for • Deliver iron-folic acid supple- acute malnutrition ments to pregnant women Sick/well-child health contacts • Provide counseling to promote: • Provide iodized oil capsules Well-child health contacts usually o Dietary diversification and/or promote use of iodized salt occur on a regular schedule, often through counseling one that coincides with immunization o Use of iron fortified schedules, to measure the growth staple foods • In situations where food shortage and development of young children. for pregnant women is probable or Sick-child health contacts occur o Early initiation and exclusive where screening criteria are estab- when a caretaker takes an ill child to breastfeeding for first six lished/used, provide maternal a clinic, health post or hospital to re- months of life supplements of balanced energy ceive assessment and therapeutic o Optimal complementary and protein care. Community outreach may be feeding from six months • Provide counseling for increased used to refer and/or motivate care- (individual and group dietary intake (quality and quan- givers to attend well-child visits and counseling) tity) during pregnancy; reduced to seek care when children fall sick. o Continued feeding during maternal workload; prevention illness and catch-up feeding and treatment of anemia; de- during recuperative period creased indoor air pollution; re- duced tobacco consumption; o Improved hygiene practices substance abuse; avoidance of including handwashing gender violence ANNEx E • Promote use of iron fortified Postnatal care contact (PNC) Emergency health services staple foods through counseling Postnatal care visits in the six weeks Emergency services may be delivered • In malaria endemic areas, provide after delivery serve to monitor post- through existing health posts/clinics intermittent preventive treatment partum maternal and neonatal health or hospitals, or may require special (IPT) for malaria and insecticide- and nutrition, and to deliver counsel- setup of an expanded venue in the treated bednets (ITN) ing and support for optimal IYCN, ma- case of widespread famine or a natu- ternal nutrition, and prevention and ral disaster. They are often partner- • Treat malaria treatment of infection or other health ships between national governments, • Prevent/treat maternal infections problems. UN agencies and other multilateral organizations, and/or CSOs. • Screen women for HIV and TB • Deliver iron-folic acid supple- • Implement therapeutic feeding • for HIV/TB+ women, provide ARV ments to lactating women (including ready-to-use therapeu- and/or TB drugs and counseling • Provide iodized oil capsules tic foods) for moderate (<-2 to - on IYC feeding choices for PMTCT and/or promote use of iodized salt 3WAZ) and severe acute through counseling malnutrition (<-3 WAZ) in children • Provide counseling to promote: Intrapartum/Delivery care o Dietary diversification Delivery (childbirth) attended by a o Use of iron fortified skilled health professional may take staple foods place in a health facility or at home, and is an opportunity for timely inter- o Exclusive breastfeeding for ventions for maternal and neonatal first six months of life health and nutrition. o Optimal complementary • Delay cord clamping to improve feeding from six months and infants’ iron stores beyond (individual and group counseling) • Promote/protect early initiation and exclusive breastfeeding for o Continued feeding during first six months of life illness and catch-up feeding during recuperative period • Provide counseling on lAM, the use of progestin-only modern con- o Improved hygiene practices traception after shift from lAM including handwashing while lactating, and healthy spac- • Screen women for HIV and TB ing of pregnancies • for HIV/TB+ women, provide ARV • Provide contraceptives and/or TB drugs and counseling on IYC feeding choices for PMTCT • Provide counseling on lAM; use of progestin-only modern contracep- tion after shift from lAM while lac- tating, and healthy spacing of pregnancies • Provide contraceptives ANNEx E ANNEx E-3. wHO’S HEALTH SySTEMS STRENGTHENING FRAMEwORk AND NuTRITION In 2007, the World Health Organization articulated a framework for Action on Health Systems Strengthening (HSS) as a necessary action not only to improve health outcomes, but also to reach the Millennium Development Goals (MDGs). WHO’s Health Systems Strengthening framework is based on six building blocks, outlined in the table below. The relationship between health systems strengthening and nutrition is presented through these six building blocks with brief descriptions or examples of interventions that contribute to a stronger health system that is better prepared to address undernutrition. HSS Description of HSS Where nutrition falls Building Block Building Block in this building block Health Services Good health services deliver effective, safe, quality • Use of community systems to extend nutrition personal and non-personal health interventions to those services and messages to the most that need them, when and where needed, with minimum vulnerable populations waste of resources. Health Workforce A well-performing health workforce is one that works • Use of community systems to extend nutrition in ways that are responsive, fair and efficient to achieve services and messages to the most vulnerable the best health outcomes possible, given available populations resources and circumstances. In other words, there are sufficient staff, fairly distributed; they are competent, • Capacity building of health staff for the responsive, and productive. assessment of malnutrition, as well as understanding of key nutrition messages and issues Health Information A well-functioning health information system is one that • Nutrition surveillance activities (for acute ensures the production, analysis, dissemination and use of malnutrition in high burden countries) reliable and timely information on health determinants, health system performance, and health status. • Regular collection of anthropometric indicators to inform policy-making and resource allocation Medical products, A well-functioning health system ensures equitable • Ensure adequate procurement and stock of vaccines, technologies access to essential medical products, vaccines, and nutritional supplies and medicines across all types of technologies of assured quality, safety, efficacy and cost health structures effectiveness, and their scientifically sound and cost-effective use. Health Financing A good health financing system raises adequate funds • Insurance mechanisms that include basic and for health in ways that ensure people can use needed essential nutrition services services and are protected from financial catastrophe or impoverishment associated with having to pay for them. • Use of externalities to increase funding for It provides incentives for providers and users to be efficient. nutrition (for example, drought in the horn of Africa that leads to increased aid for nutrition activities) Leadership and Leadership and governance involves ensuring strategic • Development and implementation of nutrition governance policy frameworks exist and are combined with effective policies and guidelines (nutrition policy, oversight, coalition building, regulation, attention to system CMAM policy/guidelines, food fortification legislation) design and accountability. • Quality assurance/monitoring and evaluation of national-level nutrition specific guidelines and legislation (for example, salt iodization) ANNEx E ANNEx E-3. wHO’S HEALTH SySTEMS STRENGTHENING FRAMEwORk AND NuTRITION Intervention Relative Risk/ Reduction in Deaths Contribution to mortality reduction Support of Exclusive BF versus not BF = 14.40 RR all-cause mortality,1 Exclusive BF versus partial HIGH optimal BF: BF = 2.84 RR all-cause mortality (more realistic to developing country contexts)2, 0-6 months 9.9% reduction in deaths at 24 months of age with 99% coverage3 Support of optimal BF: Continued BF versus not BF = 3.69 RR4 MEDIUM 6-23 months Complementary 1.1% reduction in deaths by 24 months of age with 99% coverage5 LOW feeding promotion Hygiene interventions 0.1% reduction in deaths by 24 months of age with 99% coverage6 LOW Vitamin A 15% reduction in all-cause mortality7; HIGH supplementation in 7.1% reduction in deaths by 24 months with 99% coverage8 children 0-59 months Vitamin A 25% reduction of all-cause mortality9 HIGH supplementation in children 6-59 months Therapeutic zinc Reduction in mortality of children >12 months by ~18%,10 Reduce mortality risk by 9%,11 HIGH supplementation 2.8% reduction in deaths by 24 months with 99% coverage12 • High = Mortality reduction between 10-80% • Medium = Mortality reduction between 5-10% • Low = Mortality reduction between 0-5%; or no demonstrated/direct effect on mortality 1 lamberti, l., fischer Walker, C., Noiman, A., Victora, C. and R. Black. 2011. “Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health 2011, 11(Suppl 3): S15. 2 Ibid. 3 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008. “for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40 4 lamberti, l., fischer Walker, C., Noiman, A., Victora, C. and R. Black. 2011. “Breastfeeding and the risk for diarrhea morbidity and mortality,” BMC Public Health, 11(Suppl 3): S15. 5 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008. “for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371:417-40. 6 Ibid. 7 Imad, A., Yakoob, M., Sudfeld, C., Haider, B., Black, R., and Z. Bhutta. 2011. Impact of vitamin A supplementation on infant and childhood mortality,” BMC Public Health, 11(Suppl 3): S20. 8 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008. “for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40. 9 Imad, A., Yakoob, M., Sudfeld, C., Haider, B., Black, R., and Z. Bhutta. 2011. Impact of vitamin A supplementation on infant and childhood mortality,” BMC Public Health, 11(Suppl 3): S20 10 Ibid. 11 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008. “for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40. 12 Ibid. ANNEx E ANNEx E-3. wHO’S HEALTH SySTEMS STRENGTHENING FRAMEwORk AND NuTRITION (CONTINuED) Intervention Relative Risk/ Reduction in Deaths Contribution to mortality reduction Multiple micronutrient Data from one study in Indonesia shows that MNS associated with a 22% reduction in Insufficient data supplements infant mortality13 Deworming No data No Data Iron-folic acid 73% reduction of anemia at term14 estimated to reduce risk of maternal death by 23%15 HIGH supplements for pregnant women Iron fortification of No effect on mortality, but reduces odds of iron deficiency anemia in children by 28%16 LOW staple foods Salt iodization Reduced risk of iodine deficiency by 41% in children,17 reduction of infant mortality LOW decreased by 56.5% after iodization of water18 Supplementation with Reduced deaths during infancy and early childhood by 29%, (RR 0.71) and decreased risk HIGH iodized oil capsules of endemic congenital hypothyroidism at age 4 years (RR 0.27)19 (for women) Prevention and 3.1% reduction in deaths before 24 months of age (with 99% coverage with balanced MEDIUM treatment of MAM/ energy protein supplementation)20 GAM Treatment of SAM 55% reduction in case-fatality21 HIGH • High = Mortality reduction between 10-80% • Medium = Mortality reduction between 5-10% • Low = Mortality reduction between 0-5%; or no demonstrated/direct effect on mortality 13 Ibid. 14 lamberti, l., fischer Walker, C., Noiman, A., Victora, C. and R. Black. 2011. “Breastfeeding and the risk for diarrhea morbidity and mortality. BMC Public Health 2011, 11(Suppl 3): S15. 15 Ibid. 16 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008. “for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40 17 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008. “for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40. 18 Ibid. 19 Imad, A., Yakoob, M., Sudfeld, C., Haider, B., Black, R., and Z. Bhutta. 2011. Impact of vitamin A supplementation on infant and childhood mortality,” BMC Public Health, 11(Suppl 3): S20. 20 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008. “for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40. 21 Ibid. ANNEx E Annex E-5. Links to other key resources Additional resources that have been consulted in the preparation of this guidance note and that may be useful for fur- ther analysis on specific topics include the following: • What works? A Review of the Efficacy and Effectiveness of Nutrition Interventions (ACC/SCN, 2001), a series in- tended for countries, development partners, and scholars, stressing three central themes for targeting nutrition in- terventions, applying scientific evidence in program planning, and creating opportunities for and engaging public, private, and civil sector partnerships into programming and investments. This policy paper is available in seg- ments, from http://www.unsystem.org/SCN/archives/ npp19/begin.htm#Contents • The Lancet Series on Maternal and Child Undernutrition (The Lancet, 2008), which includes a five- paper series focusing on undernutrition, vulnerable groups, consequences, proven interventions that work, and challenges in addressing maternal and child undernutrition. http://www.thelancet.com/series/ maternal-and-child-undernutri- tion • Scaling Up Nutrition: What Will it Cost? (Horton, S., Shekar, M., McDonald, C., Mahal, A., Brooks, J.K., 2010), a report that estimated the cost of scaling up a minimal package of 13 proven nutrition interventions from current coverage levels to full coverage of target populations in the 36 countries with the highest burden of undernutrition. http://siteresources.worldbank.org/ HEAlTHNUTRITIONANDPOPUlATION/Resources/Peer-Reviewed- Publications/ScalingUpNutrition.pdf • Facts for Life (UNICEf, 2010) is a handbook that provides vital messages and information for changing behaviors and employing best practices in health, nutrition, sanitation, child protection, among others, which can save and protect the lives of children and help them grow and develop to their full potential. http://www.factsforlifeglobal.org/resources/factsforlife-en-full.pdf • The Global Strategy for Infant and Young Child Feeding (WHO and UNICEf, 2003) includes guidelines on appro- priate feeding of infants and young children, highlighting the need for all health services to protect, promote, and support exclusive breastfeeding and timely and adequate complementary feeding, as a means of saving lives. http://whqlibdoc.who.int/publications/2003/9241562218.pdf • Guiding Principles for Complementary Feeding of the Breastfed Child (PAHO, 2003), which can be used as the basis for developing recommendations on complementary feeding, and to set standards for practical dietary guide- lines. http://whqlibdoc.who.int/paho/2003/a85622.pdf • Iodine Requirements in Pregnancy and Infancy (ICCIDD, 2007), highlights the results of a consultation where con- sensus was reached on iodine requirements and monitoring in vulnerable age groups. This document includes success stories in iodine programming. http://www.iccidd.org/media/ IDD%20Newsletter/2007- present/feb2007.pdf • Reaching Optimal Iodine Nutrition in Pregnant and Lactating Women and Young Children (WHO and UNICEf, 2007), includes guidance on iodized salt evaluation at the country level, and the use of iodized oil as a means of reaching vulnerable groups, primarily women and children in areas of severe iodine deficiency where universal salt iodization cannot be or is not implemented. http://www.who.int/ nutrition/publications/WHOStatement IDD_pregnancy.pdf • Global Prevalence of Vitamin A Deficiency in Populations at Risk 1995-2005 (WHO, 2009), provides an overview, etiology, consequences, and control of vitamin A deficiency. http://whqlibdoc.who.int/ publica- tions/2009/9789241598019_eng.pdf ANNEx E • How to Add Deworming to Vitamin A Distribution (WHO and UNICEf, 2004), provides practical guidance for health planners to promote the deworming of preschool children where vitamin A distribution campaigns are conducted. This document includes general information on benefits and practical issues about deworming, dosages and costs, as well as country case studies. http://whqlibdoc. who.int/hq/2004/WHO_CDS_CPE_PVC_2004.11.pdf • Vitamin A in Child Health Weeks (Micronutrient Initiative) is a toolkit developed to assist district-level man- agers to plan, implement and monitor child health weeks or similar regular twice-yearly events to reach the greatest number of children to improve their health and survival. http://www.micronutrient.org/ CMfiles/What%20we%20do/Vitamin%20A/VASToolkit.pdf • The Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia (INACG, WHO, and UNICEf, 1998) provide recommendations for iron supplementation in anemia control programs at the local, district, or national levels. These guidelines also integrate recommendations for the use of antimalarial and an- thelminthic medications, where appropriate, along with iron supplements to prevent and treat anemia. http://www.who.int/nutrition/publications/micronutrients/guidelines_for_Iron_ supplementation.pdf • Worldwide Prevalence of Anemia 1993-2005 (WHO, 2008) provides an overview of anemia as a public health problem, its etiology, health consequences, method of assessment, and control of anemia. http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf • Micronutrient Sprinkles for Use in Infants and Young Children (Sprinkles Global Health Initiative, 2008), pro- vides a background on Sprinkles/multiple micronutrient powders, guidelines on recommendations for their use, and recommendations for program monitoring and evaluation. http:// www.sghi.org/resource_centre/GuidelinesGen2008.pdf • Implementing the New Recommendations on the Clinical Management of Diarrhea (WHO, 2006), presents re- vised recommendations for the use of ORS and zinc supplementation in the management of diarrheal disease, as well information on what is needed to introduce and/or scale up ORS and zinc supplementation in the clini- cal management of diarrheal diseases. http://whqlibdoc.who.int/publications/2006/9241594217_eng.pdf • Guidelines on HIV and Infant Feeding (WHO, 2010) are based on evidence and include systematic reviews, GRADE evidence profiles, risk-benefit tables, and discussion on the potential impact of the recommendations on HIV and infant feeding, human rights issues, and costs. http://whqlibdoc.who.int/ publica- tions/2010/9789241599535_eng.pdf • HIV/AIDS, Nutrition, and Food Security: What We Can Do (World Bank, 2007), is a synthesis of existing techni- cal and international guidance on HIV, AIDS, nutrition, and food security from a broad range of UN, bilateral, re- search, and nongovernmental entities, aiming to provide guidance on how to integrate efforts in each of these sectors into nutrition projects and programs for HIV and AIDS. http://siteresources.worldbank.org/NUTRI- TION/Resources/281846-1100008431337/ HIVAIDSNutritionfoodSecuritylowres.pdf. • The European Commission’s Draft Reference document (October 2010), provides guidance to country teams on how to incorporate nutrition components into existing projects and programs. A link to this document is not yet available. • Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for Ac- tion (2007) addresses the urgent need to improve the performance of health systems as a means to improving health outcomes. This framework lays out the basic concept and fundamental building blocks of health sys- tems for policy-makers within countries and in other agencies. http://www. who.int/healthsystems/strategy/everybodys_business.pdf ANNEx E Annex E-6. Suggested nutrition resources The Human Development Network has established a Knowledge Exchange for nutrition, which provides key informa- tion on nutrition resources, including a list of nutrition specialists within the Bank, who could potentially assist health TTls in planning nutrition-specific and nutrition-sensitive approaches in projects. for TTls to understand the basic nutrition situation in countries where they work, the following resources are useful: World Bank Nutrition Country Profiles (2011) These are two-page profiles of the 68 highest-burden-of-malnutrition countries. They contain information on preva- lence of malnutrition and its causes, how the country’s state of nutrition compares to countries with similar GDP or geography, information on current World Bank nutrition projects in the country, cost for scaling up core micronutrient interventions, and suggested actions. These profiles are useful for basic context assessment and for making the case to address nutrition through agriculture in high-burden countries. http://www.worldbank.org/nutrition/profiles UNICEF State of the World’s Children - data tables (2011) The data tables in UNICEf’s annual flagship report present major nutrition indicators, comparable across all coun- tries, in a highly user-friendly format. Updated annually. http://www.unicef.org/sowc2011/pdfs/SOWC-2011-Statisti- cal-tables_12082010.pdf UNICEF Tracking Progress on Child and Maternal Undernutrition (2009) This publication provides profiles of several high-burden-of-malnutrition countries, presenting information on nutrition indicators and what proportion of child deaths are due to malnutrition and other diseases. http://www.unicef.org/publications/files/Tracking_Progress_on_Child_and_Maternal_Nutrition_ EN_110309.pdf UNICEF ChildInfo This allows country-by-country tracking of the MDG1 indicator on child underweight (Indicator 1.8:% of Children under 5 moderately or severely underweight), underweight prevalence by economic background, and underweight and stunting data (the same compiled in UNICEf State of the World’s Children reports). http://www.childinfo.org/un- dernutrition_mdgprogress.php World Bank World Development Indicators WDI contains two indicators for malnutrition (stunting, underweight), as well as disease prevalence and health systems information, which can help to estimate likely risk of malnutrition among farmers. http://data.worldbank.org/ WHO nutrition databases (http://www.who.int/nutrition/databases/en/index.html) WHO maintains several data- bases on nutrition, including: • Nutrition landscape Information System (NlIS)—a web-based tool which provides nutrition and nutrition-related health and development data in the form of automated country profiles and user- defined downloadable data • WHO Global Database on Body Mass Index—contains updated data on underweight, overweight and obesity, and related indicators for all countries. ANNEx E • National nutrition policies and programs—The Global Database on National Nutrition Policies and Programs was established in 1995 initially to monitor and evaluate the progress in implementing the World Declaration and Plan of Action for Nutrition. It has been further developed to monitor country progress in developing, strengthening and implementing national nutrition plans, policies and programs, including multisectoral actions, development of dietary guidelines, undertaking of nutrition surveys, demographic, and epidemiological data. • WHO Global Database on Child Growth and Malnutrition—an A-Z list from where users can choose a country to view available child malnutrition data and reference tables (in pdf). Caution: these tables are not easy to inter- pret for non-nutritionists. UNICEf SOWC (see above) contains similar information. • Vitamin and Mineral Nutrition Information System (VMNIS)—contains most recent data for anemia, iodine defi- ciency disorders, and vitamin A deficiency. Caution: these tables are not easy to interpret for non-nutritionists. World Bank country nutrition profiles (see above) contain similar information for68 countries.