71669 ment in July 2012 lop So ve e ut lD South Asia Social Development Unit hA Socia sia Dissemination Note No. 3 Gender-Inclusive Nutrition Activities in South Asia* describes several pathways through which the impact occurs including preferential treatment of male children over female, I. Gender Matters for Undernutrition in expectations of marriage and childbirth at early, adolescent ages, and a woman’s capacity to care for herself and her chil- South Asia dren during pregnancy and after childbirth. As such, a broad- er conversation on gender is necessary even though nutrition As compared to biological differences, (usually termed programs already include pregnant women and mothers. “sex�), gender refers to the “socially constructed and learned female and male roles, behaviors, and expecta- tions� which translate biological differences between men tivities, rights, resources, and power.1 The literature draws in South Asian countries are the worst in the world. Un- and women into social norms that define appropriate ac- Both gender equity indicators and undernutrition rates empirical links between gender and nutritional outcomes and dernutrition rates in South Asia are roughly double those of worldwide averages and over 15% higher than the next worst region, Sub-Saharan Africa (Figure 1). Further, as shown by 1 (World Bank, 2011, p. 46). the Gender Inequality Index — a composite of five variables Figure 1. Undernutrition in South Asia Prevalence of Malnutrition in South Asia Prevalence of Malnutrition in South Asia (Weight for Age - Wasting) (Height for Age - Stunting) 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10% 0% 0% ) s ) s ia ev ld ica di a sh pa l an an ve a an ia ev ld ica di a sh pa l an an ve a an As (d or er de ni st st di nk hut As (d or er de ni st st di nk hut th a W Am In gl a Ne ki al La B h ca W Am In la Ne ki al La B ou ric an ha Pa M ri ou t ri an g ha Pa M ri S Af tin B Af g S S Af tin B Af g S h. La h. La - Sa - Sa S ub S ub Source: WDI, 2009 except AFG (2004), BGD (2007), BTN (2008), IND (2006), MLD(2001), NPL (2006), PAK (2001) Source: WDI, 2009 except AFG (2004), BGD (2007), BTN (2008), IND (2006), MLD(2001), NPL (2006), PAK (2001) * This Dissemination Note was prepared by Soham Sen, South Asia Social Development Unit (SASDS) with inputs from Mikael Hook, Consultant, SASDS. It draws from a longer work of the same title. The full report including country-specific annexes can be downloaded at http://documents.worldbank. org/curated/en/2012/06/16510193/gender-inclusive-nutrition-activities-south-asia-mapping-report or by emailing ssen2@worldbank.org. THE WORLD BANK 1818 H. St. NW, Washington DC 20433 The theoretical determinants of malnutrition provide in- tus affects nutrition outcomes.5 As described in the diagram Figure 2. Gender Inequality Index (2011)2 sight into the mechanisms through which low women’s sta- below (Figure 4), the immediate determinants of undernutri- tion are dietary intake and disease. These immediate determi- Gender Inequality Index (2011) nants are in turn affected by underlying — or intermediate — 0.8 determinants. For example, dietary intake is a function of (a) household food security and (b) the care that mother and child 0.7 receive. The other immediate determinant, disease, is a func- 0.6 tion of again (b) the care that mother and child receive and (c) 0.5 the health, environment, and other services available for care. 0.4 Gender affects each link since men and women have different 0.3 levels of access to resources and make different choices with 0.2 regard to resource allocation.6 Access to resources and these 0.1 choices are shaped by the social norms around gender that de- fine acceptable behavior, rights, access to resources, and the 0 ve s a an es h l an a an ld ia v) di nk ut pa ist di st or As de power to make decisions. al La Bh lad Ne k In ni W th a( M Sr i ng Pa ha u ric Ba Af g So Af h. Sa b- Su (labor force participation, maternal mortality, adolescent fer- tility, educational attainment at secondary level or above, and This report focuses on the linkages between women’s sta- parliamentary representation — SAR lags behind the rest of tus and nutrition operating through the care pathway since the world in gender parity (Figure 2).2 the this intermediate factor affects both dietary intake tion. A mother’s low status in the household generally ham- and disease, the immediate determinants of undernutri- tion is known to perpetuate poverty and have a signifi- 5 (UNICEF, 1998, p. 24) The implications of undernutrition are dire: the condi- cant impact on human development (Box 1 describes in 6 There is a significant body of research that refutes the idea that greater details the indicators used to describe undernutrition households have unified preferences (the unitary model) in favor of col- and the implications of various types). Malnourished children lective models that account for differences in preferences amongst the are more susceptible to disease and death; they have a harder members within a household. See for example (Alderman, Chiappori, time learning in school; and, as adults, they are less produc- Haddad, Hoddinott, & Kanbur, 1995). tive. Undernourished mothers 3 are more likely to give birth to underweight children or die in childbirth. The economic costs Figure 3. Drivers of Undernutrition in SAR of undernutrition are staggering for both individuals and societ- Drivers of Malnutrition in SAR ies. Individuals earn 10 percent Magnitude ofregression coe cients signi cat at 1% level less over a lifetime and the world economy loses 2-3% of Gross 0.5000 Domestic Product (GDP) due to Note the role of multiple sectors especially education and sanitation as undernutrition annually.4 0.4000 well at the various gender indicators (yellow and red barns). 0.3000 0.2000 There is empirical evidence to 0.1000 suggest that gender, operat- ing through women’s status, 0 is an important factor driving (Figure 3). Education, for both -0.1000 undernutrition in the region men and women, is also critical y ar ch ry ed ry ed e y or ge er e ge n m ar siz im w da da Po Ri tio a us us and is widely used an indicator a co im r po ’s n n :p ’s d ca ne ne an In pr co co an ol ng n lo tri tri e M eh io se se of women’s status. n: om dl at i n la la ak tio us n: n: ba id c W t sh m tio tio Ho du ca M Pi Ur u on du e ca ca Fl ’s isi du du e an ’s ec e e an om d ’s n’s an M ’s oa W en M Negative coe cients W 2 (UNDP 2011) om imply that these W 3 (Victoria, et al., 2008) factors increase malnutrition 4 (World Bank, 2006, p. 2) Source: International Food Policy Research Institute 2003,pg123 2 Box 1: What does Undernutrition Mean and How is it measured? Undernutrition is a broad term that refers to the outcome of inadequate intake of food (calories) or essential micro- nutrients that the body needs to grow, resist infection and disease, learn, perform physical work, and complete other essential bodily functions. Health and nutrition studies typically describe undernutrition in children under five years of age using the following indicators: Stunted describes children with height measurements that are two standard deviations below the mean of the WHO Child Growth Standards median. “Stunted� can be interpreted to be indicator of cumulative effects of un- • dernutrition and infection in utero and after birth. Stunting increases the likelihood of illness and poor health, reduces cognitive development, and lowers economic productivity. Women of small stature are more likely to give birth to babies with low birth weight. Wasted describes children with weight measurements that are two standard deviations below the WHO Stan- dards median and. Since weight can change more quickly than height, wasting can be an indicator of both acute • short-term reduction of food intake or stunting. Underweight describes children below two standard deviations of the WHO Standards median. This is a dif- ficult indicator to interpret since it can reflect both wasting and stunting. • Low birth weight describes babies that are less than 2500 grams (5.5 pounds) and indicates premature birth or restricted growth in the womb usually due to malnutrition, ill health, hard work or overall poor care of the • mother during pregnancy. Undernutrition in Adults: Underweight or Thinness describes adults who have body mass index (weight divided by height squared) less than 18.5. Mothers who are excessively thin are more likely to give birth to babies with low birth weight or suf- • fer other complications during pregnancy and child birth. Micronutrient deficiencies for both children and adults can refer to inadequate levels of a number of critical vita- mins and minerals. The following are commonly-observed deficiencies: Anemia describes a condition in which mothers or children below age five have hemoglobin concentrations in their blood below 110 grams/liter at sea level. Anemia indicates an iron deficiency but can also imply insuf- • ficient levels of folate, Vitamin B12 and Vitamin A. Anemia increases the risk of maternal and child mortality, reduces work capacity, and reduces physical and cognitive development. Vitamin A deficiency refers to blood concentration of Vitamin A of less than .7 micro-mols per liter in adults and children. The deficiency causes night-blindness (blindness in low light conditions) or, in severe forms, com- • plete blindness. It can also reduce the ability to resist infections. Iodine deficiency refers to the condition of having an iodine concentration of 100 micrograms of iodine per liter in urine. This deficiency has significant implications for a child’s mental development and survival. • Source: (WHO, 2010) pers her capacity to carry out critical infant and young child make decisions and control resources; and (6) mental health. care practices such as breastfeeding, complementary feeding, These factors affect child nutrition through a mother’s capacity or health services utilization. As the diagram describes (Figure to take care of herself. This in turn also affects her health and 5),7 women’s status describes: the mother’s (1) knowledge and nutritional status, which then directly affects the birth weight and nutritional status of the newborn and the quality of care skills; (2) physical health; (3) support from other household the children receive. members; (4) support from the community; (5) autonomy to 7 The framework is drawn from (Smith, Usha, Ndiaye, Haddad, & Mar- Adolescent girls have especially low status in South Asia, torell, 2003) and adapted from (Engle, Menon, & Haddad, 1999). and child birth by undernourished mothers in adoles- cence transmits undernutrition to the next generation 3 Figure 4. Determinants of Undernutrition Outcome Malnutrition and Death Immediate Gender, a basic Determinants determinant, Inadequate dietary intake Disease a ects nutrition outcomes though all of the underlying and Insu cients immediate Inadequate access Inadequate care for health services and determinants. Underlying to food mothers and children unhealthy Determinants environment However it is through the Care Determinant that Inadequate eductaion Gender most directly in uences nutrition outcomes. Formal and non-formal institutions Political and ideological Basic superstructure Determinants Economic structure Potential Resources Source: UNICEF 1990 when babies are born with low birth weight or do not receive adolescent girls experience a substantial amount of change at adequate nutrition while in the womb. As the gender statistics a time when they typically have little control over reproduc- presented above for South Asia suggest, women face a lifetime tive decisions or agency in dividing household chores. In ad- of deprivation and inequality. Indeed, the preference for male dition, they often face domestic violence.9 Without sufficient children is so significant in the region that large numbers of status to take adequate care of themselves, they experience women are “missing� due to sex selective abortions.8 Yet, such poor health, which in turn affects the health of their children.10 male bias not only has negative health consequences for wom- Thinness of adolescent girls can lead to complications during en but also impacts their children be they boys or girls. The pregnancy and birth, higher rates of maternal mortality as well data show that an alarming number of South Asian children as low birth weight for babies.11 In the region, 30 percent of are born undernourished, and that the gap in nutritional sta- girls aged 15-19 are married – the highest rate in the world tus between male and female children begins to widen around – and just over 20% of women have children before the age age 4 (Figure 6). Higher quality of food and care that boys re- of 18. Indeed, 45% of adolescent girls in the region are thin, ceive compared to girls in the region results in differential nu- and 25 percent of babies are born with low birth weight, the tritional outcomes. worst rates worldwide. Such babies are more likely to die, suf- fer from undernutrition, and have cognitive impairments that Such differential treatment in childhood continues into affect their ability to learn and be productive. for them and their children. Social attitudes lead women to As such, gendered expectations around marriage and child adolescence for girls, leading to poor nutritional status eat last and least, and adolescent girls are often pressured to marry and give birth at an early age (Table 1). Newly-married 9 (Kapadia-Kundu, Khale, Upadhaye, & Chavan, 2007) 10 (Smith, Usha, Ndiaye, Haddad, & Martorell, 2003) 8 (Sen, 2001) 11 (SCN 1998) 4 Figure 5. Implication of Women’s Status on Care Care and Feeding Practices Women’s Status for Newborn Nutrition Indicators for Child Self Care for Women Status of Nutrition and • Physical Health Health for Women • Breastfeeding • Knowledge and Skills • Food Consumption • Low Birth Weight • Complementary Feeding • Agency & Control over • Health Care • Stunting • Nutrition Status • Micronutrients Resources • Birth spacing • Wasting • Physical Health • Vaccinations • Household Support • Prenatal Care • Underweight • Mental Health • Food Preparation and Storage • Community Support • Leisure and rest • Micronutrients Deficiencies • Self Esteem • Hygiene and Environment • Mental Health, Esteem and • Free from Abuse • Thinness or Low Body Mass • Health Sevices Utilization Gender Based of Violence • Psychosocial Care Source: Adapted from Smith, Usha, Ndiaye, Haddad, and Martorelli, 2003 Figure 6. Gender Gap in Undernutrition: India and Nepal India - Undernutrition by Sex, 2006 Nepal - Undernutrition by Sex, 2006 60 50 45 % 25 D Below Expected Weight for Age % 25 D Below Expected Weight for Age 50 40 35 40 30 30 25 20 20 15 10 10 5 0 0 s 1 2 2 3 4 5 s 1 3 4 5 th th on on m m 6 6 Males Females Males Females Source: World Health Organization, 2010 birth combined with the undernutrition of female children that persists through adolescence can transmit undernutrition into II. Nutrition Programs Address Gender the next generation of both boys and girls with consequences for their health, learning and economic status (Figure 7). Too Narrowly The following discussion addresses several questions: Thus, adequately addressing gender requires nutrition pro- grams to focus not only on mothers but also on adolescent 1. What are the major nutrition programs and who are their mothers. It requires programs to focus not only on health ser- major stakeholders? vices for the mother, but also on the support she receives from the household and community, her autonomy, and her mental 2. Do government nutrition policies reflect an awareness of health and self-esteem. the importance of gender in nutrition? 5 Table 1. Key Statistics on Adolescent Girls12 Adolescents aged Adolescent birth Women aged 20 – Adolescent girls Secondary school 15-19 currently Literacy rates rate per 1,000 fe- 24 who gave birth aged 15 – 19 with net enrollment ratio married or in union (%) males aged 15 - 19 before age 18 (%) a BMI <18.5 (%) (%) (%) 2005 - 2010 2000 - 2010 2000 - 2010 2006 - 2010 2007 -2010 2000 - 2010 Afghanistan 151 N/A N/A N/A 15 N/A Bangladesh 133 40 35 46 43 77 Bhutan 46 N/A N/A 15 49 68 India 45 22 47 30 N/A 74 Maldives 15 1 24 5 N/A 99 Nepal 106 23 26 32 N/A 77 Pakistan 16 10 N/A 16 29 61 Sri Lanka 23 4 N/A 9 N/A 99 3. Do nutrition interventions typically address gender and if so, how com- prehensively do they cover the spec- Figure 7. Nutrition Across the Lifecycle (Ransom & Elder, 2003) trum of relevant issues?12 4. Are important groups such as adoles- cent girls specially targeted? Baby with Low Birth Weight • Higher mortality 5. Do promising approaches exist that • Higher morbidity • Impaired mental development can be scaled-up or investigated fur- ther? Adult Malnourished/Pregnancy Child Stunted Low weight gain To answer these questions, a mapping • Reduced mental capacity • Men and women have lower exercise was conducted of nutrition economic productivity irreversible and impairs learning in school interventions and policies across the • Higher maternal mortality of desk research and interviews with • Lower resistance to disease • Baby with low birth weight South Asia region through a process key policy makers, program mangers, and researchers. A chain-referral sampling strategy was used to identify a network of stakeholders involved in nutrition and gender initiatives in the eight South Adolescent Stunted Asian countries13; examination of sec- • Reduced physical capacity and fat free mass lowers economic productivity 12 (UNICEF, 2012) 13 This technique is effective in identifying hidden or unknown stake- holders, and works by identifying initial (index) individuals who subse- quently recommend additional stakeholders from within their circle of WHO, USAID, DFID, and AusAid). Initial contact was made with index acquaintances (Schensul, Schensul, & LeCompte, 1999). For this study, stakeholders via email and phone in December 2011. Semi-structured index stakeholders included World Bank staff with expertise in nutrition interviews were conducted in person and over the phone from December and gender, authors of notable research papers on nutrition and gender, 2011 through January 2012 using a standard questionnaire developed for nutrition and gender focal points at key Ministries and country offices for this study. A total of 35 stakeholders were interviewed during this period development partner organizations (e.g., World Bank, UNICEF, FAO, WFP, (Appendix 3, p174). 6 ondary sources augmented the stakeholder interviews and vice versa. These initial Figure 8. Regional Distribution of Nutrition Interventions With Gender Components interviews led to the identi- fication of other stakehold- ers who were subsequently contacted and interviewed. 20 Interviews were used to gather background informa- tion on the both the gender 15 and nutrition issues in each country, identify relevant research and programs, and 10 map out other stakeholders to interview. Sources were identified through Google 5 Scholar searches using key words from the gender and nutrition framework de- 0 scribed above. Specifically, searches included specific Bangladesh India Sri Lanka Afghanistan Pakistan Nepal Bhutan Maldives program information as well Academic Bilateral Government Multilateral NGO as general searches for nutrition, country and combinations plan that will coordinate the planning and implementation of of other relevant keywords.14 A series of policy, program and nutrition activities across five ministries. This new plan calls literature summaries were produced for each country (see for inclusiveness and gender equity, and includes strategies Country Appendices). These program summaries were then to empower women and improve leadership skills, address post coded according to which gender issues they addressed, gender divisions of labor to reduce the workload on women, what approach was used, and which groups they targeted. The and improve adolescent girls’ education, life skills, and nutri- national-level policy documents on nutrition were also exam- tion. Other South Asian countries have policies and plans in ined for their references to gender place that typically include strategies to reach pregnant and lactating women, young children, and in some cases, adoles- 85 interventions with some type of gender component cent girls. However, few plans include specific strategies to ad- were identified which are currently being implemented dress the underlying gender-driven causes of undernutrition. or have recently been completed by governments, bi-lat- Bangladesh and India have nutrition policies and action plans erals, multi-laterals, NGOs, or academic groups (Map 1). developed in the mid-nineties that are outdated, whereas Af- Often the work of the bi-lateral and multilateral organizations ghanistan, Bhutan, and Sri Lanka have recently updated their are in support of government programs and are not separate policies. Pakistan devolved its Ministry of Health in 2011, and operations and these have not been included. Government is provincial governments are in the process of developing their the primary provider of nutrition services in India, Sri Lanka, own nutrition policies and action plans to secure funding di- and Afghanistan whereas NGOs are the major players in Ban- rectly from development partners. gladesh and Nepal. Save the Children and CARE are amongst the most active NGOs. Amongst the international donors, UNI- Finding 2: The lack of availability of nutrition data is also a CEF, WFP and World Bank along with USAID, a bilateral, have a basic constraint for some countries (Table 2). Even less data significant presence in the region on the issue. for adolescent girls exists since most nutrition surveys and studies focus on pregnant and lactating women and children up to the age of five. Recent Demographic Health Survey (DHS) data collected within the past six years is available for all South Finding 1: With a few exceptions, the national nutrition of gender. Nepal stands out among its South Asian peers and Asian countries, with the exception of Bhutan where no DHS policies of South Asian countries do not adopt broad view is currently developing an ambitious multi-sector nutrition data is available. Multiple Indicator Cluster Survey (MICS) data is available for most countries but is dated from 1995, with the exception of Bangladesh where a survey was completed in 14 These included: gender, education, access to and control over re- 2006 and Sri Lanka, which has no available data. A MICS for sources, autonomy, decision making and bargaining power, mothers time Bhutan appears to have been completed in 2010 and prelimi- and childcare, mothers participation in productive work, alternative child care, paternal roles, technology that reduces time poverty, gender bias in nary reports of that work are now available. Living Standard society (i.e. different treatment, care, resources), maternal and paternal Measurement Survey (LSMS) data is only available for India, norms, values, and identities, and domestic violence. Nepal and Pakistan, and much of this data is outdated. 7 Figure 10. Target of Gender Components of Nutrition Activities Across SAR • MOPH Basic Package of Health Services • MAIL School Based Nutrition Program • MAIL Horticulture Livestock Program • MAIL Promoting Household Level Food Processing, Preservation and Storage Project • World Bank – Strengthening Health Activities for the Rural Poor (SHARP) • UN – Feeding the Children of Afghanistan Together Program • WFP – School Meal Program • USAID – Basic Support for Institutionalizing Child Survival (BASICS) • Save the Children – Child Survival (CS-19) Project • Care for Afghan Families – Baby Friendly Villages Project AFGHANISTAN • MOH – Lady Health Worker Program (*discontinued, devolved) • Tawana Pakistan Project (*discontinued, develoved) PAKISTAN • World Bank – Enhanced Nutrition for Mothers and Children Project (in Sindh, KPK, Balochistan) NEPAL • Joint UN Program on Health and Population • WFP – Country Program, Various • USAID Nutrition Assessment Project • Aga Khan University/Health and Nutrition Development Society – Community Based Intervention to Improve Growth in Children B • Save the Children – Saving New Born Lives Initiative • Mercy Corps – Positive Deviance Health Clinic Training • Greenstar – Behavior Change Communications (BCC) Program INDIA • Integrated Child Development Services Scheme (ICDS) • Rajiv Gandhi Scheme for Empowerment of Adolescent Girls (SABLA) • Swayamsidha Program (IWEP) • National Rural Livelihoods Mission (NRLM) • Mid-Day Meal Program (MDM) • Public Distribution System • National Rural Health Mission • UNICEF – Child Development and Nutrition Program (CDN) (supports NRHM, ICDS) • World Bank – Strengthening Health Activities for the Rural • World Bank – Reproductive and Child Health Project • WFP – ICDS Effectiveness • USAID – Support to ICDS • DFID – Support to ICDS • World Bank/USAID/DFID – Support to ICDS • Care – Reproductive and Child Health , Nutrition and HIV/AIDs (RACHNA) SRI Program LANKA • IntraHealth – VISTAAR Project • Lata Medical Research Foundation – Improve Exclusive Breastfeeding Project • UnivDelhi_Inst of Home Economics – Healthy and Positive Pregnancy Initiative • Aga Khan Health Services Social Capital to Improve feeding practices • Coalition for Sustainable Nutrition Security in India – Grameen Gyan Abhiyan • Interagency Working Group on Gender (IWGG) – Overall Program MALDIVES • Concern Worldwide – Male Health Worker Pilot • Center for Communications Programs – NRHM/ Strategic Behavioral Change Communication for Child Survival and Maternal Health 8 • Nepal Health Sector Program (MOH) • World Bank – Second HNP and HIV/AIDs Project • Health, Nutrition and Population Sector Program/National Nutrition Services • World Bank – Support to NHSP II • UNICEF – Decentralized Action for Children and Women (DACAW) • World Bank – Health Sector Development Program (SWaP) • WFP – Girls Incentive Programme (GIP) • UNICEF – Support to NNP's BCC component • USAID – Suaahara Program • World Bank – Area-based community nutrition, various • USAID/HKI – Action Against Malnutrition through Agriculture (AAMA) • UNICEF – NNP’s BCC Component • WFP – Country Program*Gender Assessments of Nutrition Program • Helen Keller Intl./USAID/JHU/Others – Suahaara Components • Helen Keller Intl – Action Against Malnutrition through Agriculture • WFP – Improving Maternal and Child Nutrition Program (AAMA) USAID supported • WFP – School Feeding Program • EAN – Nutrition through Knowledge • WFP – Enhancing Resilience to Disaster and Climate Change Program • International Nepal Fellowship – Community Nutrition Program • USAID – Country Program, Presidential Global Health Initiative, • PLAN International – Country Program Feed the Future • USAID – Food for Peace Multi Year Assistance Program (MYAP) • USAID – Food and Nutrition Technical Assistance 2 (FANTA 2) • USAID Strengthening Partnerships, Results and Innovations in Nutrition Globally (SPRING) • JSI, Helen Keller Intl., Save the Children, Manoff Group, IFPRI – Strengthening Partnerships, Resutls and Innovations in Nutrition Globally • DOPH Nutrition Program (SPRING, USAID supported) • FHI360 – Alive and Thrive Program (Gates Foundation) • UNICEF – Model Villages Program • Helen Keller International – Homestead Food Production Program BHUTAN • WFP – Improving Rural Children’s Access to Basic Education • CARE – Shouhardo Program • Save The Children – Nobo Jibon Program None discovered • Save The Children – Kishoree Kontha (KK) Project • Concern Worldwide – Community-Local Government Partnership to Combat Child Malnutrition • BRAC – Maternal, Neonatal and Child Health Care Program (MNCH) • BRAC – Employment and Livelihoods for Adolescents ELA Program • BRAC – Social and Financial Empowerment of Adolescents (SoFEA) BANGLADESH Program • MoH Integrated Maternal and Child Health and Nutrition (MCHN) Program • MoH/FHB Population Level Program to Promote Breastfeeding • Population –Level Nutrition Programs • Triposha Supplementary Feeding Program • Micronutrient Control Programs • School Feeding Programs • Poshana Malla Food Supplement Programs • World Bank/Japan Social Development Fund – Support to MoH Health Sector Program • UNICEF – Integrated Early Childhood Care and Development (ECCD) Program • WFP – Support to MCHN Program • Sri Lanka Green Friends Environmental Organization – Three Generation Communication for Improved Infant and Young Child Nutrition • Sarvodaya – Preschool Nutrition Program • Sarvodaya – Community Kitchen Program Map of Gender and Nutrition Activities Across South Asia • MoHF – Nutrition and Safe Motherhood Program Legend • World Bank – Integrated Human Development Project • UNICEF – Young Child Survival and Development Government Multilateral/Bilateral Donors/NGOs/Civil Society (YCSD) Program None discovered 9 Figure 10. Target of Gender Components of Nutrition Table 2. Gaps in Health and Nutrition Data Activities Across SAR DHS MICS LSMS Other Data 90% 80% Best Estimates of Social Indicators 70% Afghanistan 2010 1995 N/A for Children in 60% Afghanistan 2006 Gaps in 50% Targeting Bangladesh 2007 2006 N/A N/A 40% Multiple Indicator 30% Bhutan N/A N/A N/A Survey 2010 20% India 2005-6 1995 1997 N/A 10% Maldives 2009 1995 N/A N/A 0 Mothers and/or Children Men and/or Adolescent Girls 2010-11 LSMS, Grandmothers Nepal 2006 1995 2003 2010 MICS (Preliminary) Finding 4: Nutrition interventions rarely target adolescent ness (Figure 10). As noted above, most nutrition programs in- Pakistan 2006-7 1995 1991 N/A girls, fathers, or elderly women, reducing their effective- clude a BCC component to teach mothers childcare and feeding practices, but BCC can be ineffective if it is not targeted with an UNICEF Nutrition understanding of the cultural context and gender dynamics in Sri Lanka 2006-7 N/A N/A and Food Security the household. For example, an evaluation of the Government Survey 2010 of Bangladesh’s Integrated Nutrition Program (BINP) by UNI- gender comprehensively. With regard to gender, most nu- CEF and Save the Children in 2005 found that the BCC activities Finding 3: Existing nutrition interventions do not address trition programs are direct interventions that directly target did not achieve the desired behavior change since they did not pregnant women, lactating mothers, and young children. These engage mothers-in-law. Although women who entered into the interventions employ health services, food supplements and program improved their knowledge, a large number of women impart information through behavioral change communica- did not put this knowledge into practice. Reasons for this lack tion (BCC) programs. There is less emphasis on addressing of implementation included resource constraints (women in other aspects of gender such as mental health, social support poorer households are less likely to eat more during pregnan- from the household or community, or control over resources cies and those in households owning land or that had an elder- (Figure 9). ly male relative were less likely to rest during pregnancy), and the role of mothers-in-law in enforcing traditional nutrition Figure 9. Gaps in Focus of Gender Components of Nutrition behaviors that contradict the BCC messages (White, 2009). Activities Across SAR 70% III. Promising Interventions to More Gaps in 60% Programmatic Comprehensively Address Gender 50% Focus 40% While most nutrition interventions focus on gender too ward to address gender more comprehensively. This sec- narrowly, several promising programs point to a way for- tion notes several such programs identified during the course 30% of the mapping exercise. Some primarily tackle a specific gen- 20% der issue such as improving household support or increas- 10% ing autonomy and control of resources, while others focus on 0 strengthening community support or on targeting adolescent girls. Most often, however, the categorization not mutually ex- fs es ld er r ity ve ie ho iv un rc i l eg eg Be clusive as an intervention focused on a particular gender is- ou se m ar ar ou om e/ es C C dg fR H sue can have an impact on a number of others. Only programs C of of le m lo m ow th th fro ro ro l l addressing mental health and self-esteem and gender-based ea ea Kn tf t t on or H H or pp C pp al al violence did not appear at all. Wherever possible, information y/ Su t ic Su en om ys M al Ph al on ci ci So t So Au 10 regarding effectiveness of programs is noted. Generally, how- ers working together could also travel more safely at night and ever, these interventions have been limited in implementation to more isolated places, extending the reach of their services and scale, and efforts to evaluate their effectiveness have been overall (Concern Worldwide, 2012). inconsistent. Similarly, the Grandmother Project, through their work on several projects mostly in Africa, recognizes the role grand- mothers play in maternal health and childcare by transmitting Household Support information between generations, influencing men and young- er women in the household, and providing guidance on preg- Efforts to improve household support for the mother household such as mothers-in-law or grandmothers. As nancy and child-rearing. The Project has designed programs often incorporate husbands and elderly women in the noted earlier, instruction in care and feeding practices is typi- to leverage the special role of grandmothers to act as nutri- cally delivered by female community health workers through tion educators and sources of influence to change behaviors behavioral change communications (BCC) programs focused and adopt new practices. In one instance, Indian daughters-in- on the pregnant woman or mother. law were found to learn better and adopt new practices more quickly when being taught by grandmothers or mothers-in- BCC programs may see better results by combining broad- law (Aubel, 2010). sively presenting information to women. For instance, Save er targeting and adult learning approaches instead of pas- Community Support Afghanistan has implemented a Positive Deviance approach15 the Children’s Child Survival 19 Project in Northwestern to promote household behaviors among mothers, mothers-in- Moving beyond framing community support for nutrition law and caregivers that can lead to good nutrition outcomes. A as involving only growth monitoring and promotion, a mid-term evaluation of the program found that 90% of children number of projects are trying to form community groups enrolled in the program demonstrated significant weight gain. or create mass awareness campaigns using various com- The evaluation team concluded that the Positive Deviance/ munications approaches and technologies. For example, Hearth model was effective at changing household behaviors, desh used a rights-based livelihoods approach and imple- the Shouhardo project implemented by CARE in Bangla- and could generate nutritional improvements for infants and mented a range of activities focused on mother and child health small children in Afghanistan (Save the Children, 2006). An- and nutrition, sanitation, women empowerment, poverty and other Save the Children’s program, Saving New Born Lives food insecurity alleviation, empowerment of the poor and di- Initiative in Pakistan, also implemented Positive Deviance saster mitigation and response. The women’s empowerment trainings to change behaviors in the community and house- component was comprised of three interventions: support for holds that included mothers, mothers-in-law, fathers, fathers- the formation of social groups for women and adolescent girls, in-law, and unmarried men and women. Results data showed pre-school for young girls, and formation of parent-teacher as- that there was a 45% decrease in the number of mothers who sociations. An impact evaluation of the Shouhardo project by gave pre-lacteal feeds to the newborns within 3 days of birth. the Institute for Development Studies (IDS) found that stunt- ing prevalence among project participants fell by nearly 16 percentage points over a three-and-a-half year period. The vidual responsible for delivering the information. For evaluation also found that the project’s women’s empower- Another promising approach might be to vary the indi- example, in addition to female health workers, in India, Con- ment interventions had the strongest independent impact on stunting (Smith, Khan, Frankenberger, & Wadud, 2011). CARE Accessible Health Care project. The project aims to provide is currently implementation a follow-on Shouhardo II program, cern Worldwide is piloting the Male Health Workers for maternal health and nutrition information to husbands using a and Save the Children is implementing a smaller scale program group of male community health workers. Currently, men make with similar objectives called Nobo Jibon. a number of decisions regarding food purchases and health care access which affect nutritional outcomes. However, they Similarly, The Government of Pakistan implemented the Tawa- often lack any training on maternal health or nutrition. The na Pakistan Project (TPP), a pilot project from 2002 to 2005 typical health volunteer is usually female and faces difficulties to address poor nutrition status and school enrolment of pri- reaching out to men to discuss family planning or nutrition mary school-age girls. TPP’s main intervention involved creat- issues. Male health workers, acting as peer counselors, may ing a safe environment for village women to make collective have greater success. A pair of male and female health work- decisions. Women were taught to plan balanced menus, pur- chase food, and prepare and serve a noon meal at school pre- pared using locally available foods at nominal costs (USD 0.12/ 15 Positive deviance approaches identify high performers from the community and facilitate peer to peer learning to spread good practices child). An evaluation of the project found that wasting among from these high performing “deviants� to others to improve their out- participating girls decreased by 45% (from 14.3% to 7.9%). comes. The number of underweight girls decreased from 23.2 % to 11 18%. Chronic under-nutrition and stunting only decreased by Bangladesh and Nepal, which integrates nutrition, agricul- 6% during the duration of the project. The project increased ture and food production, maternal self-care, infant and young school enrollment by 40% by attracting un-enrolled girls who child feeding, gender awareness, and women’s empowerment came to attend the feeding program. The average number of interventions. An evaluation of the HFP model in Bangladesh, girls per school also increased from 64 to 89 by the end of the Cambodia, Nepal and the Philippines from 2003 to 2007 project (Badruddin, Agha, Peermohamed, Rafique, Khan, & showed that HFP participants increased production and con- Pappas, 2007). sumption of vegetables and animal food products, increased household earnings that were used to purchase additional The groups can include more than just women. In Afghani- foods, and reduced the incidence of anemia among mothers stan, Care for Afghan Families (CAF) implements the Baby and children compared to the control group. The evaluation Friendly Villages program in four districts of Takhar Prov- found that the HFP program empowered women, giving them ince. The program seeks to improve child-feeding practices more control over household resources from the income gen- by creating breastfeeding support groups with all key stake- erated from their homestead food production activities. Such holders– including mothers-in-law, husbands and other male control over HFP resources and income is likely a key factor members of the family, health workers, traditional healers, in how the program has enhanced women’s participation in birth attendants, and local religious leaders. The project com- household decision-making. The study also found that home- bined such groups with breastfeeding counseling centers and stead food production has a potential positive impact on over- enlisted the support of community health workers and profes- all household spending, food preparation, food choices and in- sionals health services. The objective focused on transforming tra-household food allocation as well as care-seeking behavior entire villages into baby-friendly locations where all individu- of women (HKI, 2010). als have the proper knowledge and skills to support a breast- feeding mother. Another project uses technology to ease mobility constraints. In India, Lata Medical Research Foundation is implementing an innovative project that seeks to use cell phone technology to improve breastfeeding and reduce infant mortality. The proj- Mass media campaigns can spread awareness about un- ect seeks to empower women to overcome barriers of leav- dernutrition identification and prevention practices using ing their home after delivery due to limited transportation by a variety of methods and technologies. Save the Children’s bines a communications program, mass media campaigns, and providing mothers with information, guidance and coaching Integrated Nutrition Program (or Suaahara) in Nepal com- a community mobilization strategy that uses music, theater, through mobile phones. links to religious festivals. Concern Worldwide is implement- ing the Local Government Partnership to Combat Child Undernutrition project in Bangladesh which engages men through awareness campaigns using a combination of tra- Targeting of Young and Adolescent Girls ditional tools and modern technologies such as cell phone messages, awards and subsidized services to promote behav- Schools offer the most promising means to target younger ior change. The program also encourages support from local provides schoolgirls with monthly rations of oil to take home as girls. The WFP’s Girls Incentive Programme (GIP) in Nepal government and women’s participation in leadership bodies. incentive for regular school attendance. Keeping girls in schools Equal Access Nepal (EAN) is implementing the Nutrition is critical for enhancing agency later in adolescence, and de- through Knowledge project in Nepal. The project uses radio laying marriage and childbirth. WFP implements the program programs to raise awareness among parents about infant and as part of its broader school feeding program in 11 Western young child nutrition to empower women to address various districts and independently in five Terai districts where girls’ socio-cultural determinants of undernutrition at the house- school attendance has been found to be particularly low. The hold level, and to engage men as key stakeholders, agents of WFP has reached more than 62,000 school girls through this change, and advocates within families. program, and rates of girls’ school attendance have increased by as much as 27% in areas where WFP has implemented GIP (WFP, 2012). Similarly, the WFP School Feeding Program in Bangladesh provides a daily micronutrient fortified biscuit Autonomy, Decision-Making and Control Over Assets to primary school students in participating schools that serve source access and autonomy. However, increasing women’s as an incentive for families to keep their children in school. Nutrition programs can do much to ease constraints of re- autonomy, decision-making and control over assets cannot be A midterm evaluation of the program found that attendance the work of nutrition programs alone. The contributions of rates increased between baseline and follow-up in all months programs focused on education, livelihoods, financial inclu- for both boys and girls in the treatment schools. These differ- sion sectors are vital. ences were highly significant (p<0.001). The evaluation also found that increases in attendance were consistently slightly For instance, Helen Keller International (HKI) is imple- higher for girls than boys, although these differences were not menting a Homestead Food Production (HFP) program in statistically significant (Rogers, Coates, & Osei, 2004). 12 While adolescent girls are much more difficult to reach, 1. Begin a dialogue with policymakers inside develop- one approach is to provide services and information rel- ment institutions and governments to expand the con- In India, the government has launched a adolescent girls pro- evant to adolescents and incentivize their participation. versation on gender and nutrition that goes beyond a gram termed SABLA16, which will be piloted in 200 districts narrow focus on mothers and children. This dialogue all across the country and aim to reach adolescent girls, aged • a focus on adolescent girls; should include: 11-18, with nutrition and job training interventions to be de- livered in conjunction with the Integrated Child Development • increased support for mothers and children from the Scheme at local health centers (anganwadi centers) by commu- household and community; nity health workers. The program focuses on those who have dropped out of school as well as those who have dropped out. • interventions to reduce resource constraints to pro- Through the bi-montly meetings, girls will receive a food sup- viding proper nutritional care for a mother and her plement, micronutrient supplements, health checkups, family child, and; planning and reproductive counseling, life skills education and • efforts to improve mental health and self-esteem of guidance on accessing government programs, and vocational caregivers. training for those above the age of 16 (ICDS, 2009). 2. Similarly, the Kishoree Kontha (KK) project in Bangladesh run by Save the Children with support from the Nike Founda- Collect low-hanging fruit. Existing development inter- a nutrition component. In particular, development part- tion. The KK program aimed to link savings schemes with other ventions that engage adolescent girls should include ners should expand school-based nutrition programs non-financial services, such as health and education, to allow that provide incentives to families for keeping their girls rural adolescent girls aged 10-19 to build human, social and in school. Generally, policy makers should be encouraged economic assets. Using a group mechanism, girls were empow- adopt multi-sectoral nutrition policies with gender-in- ered to make their own decisions in terms of savings and were clusive strategies. When governments and development then given access to credit to transition to income-generation partners begin to view the nutrition problem in a more ho- activity. The Abdul Latif Jameel Poverty Action Lab (JPAL) is listic way that addresses multiple sectors, gender-driven conducting a randomized control trial to evaluate the effective- causes of nutrition concerns become more visible as they ness of the KK project, and Save the Children is moving for- are themselves cross cutting issues. In this respect, multi- ward with the UK Department for International Development sectoral policies create an enabling environment for devel- (DFID) to implement a larger scale project using the KK model oping gender-inclusive nutrition approaches. Ministries in based on preliminary successes (IPA, 2011). charge of women and children’s affairs should be engaged, in addition to the ministries of health and agriculture, in the development of gender-inclusive, multi-sector policies IV. The Way Forward to tackle nutrition. The preceding sections have discussed the linkages between gender and nutrition outcomes in South Asia and presented evidence from a mapping exercise to suggest that policy mak- 3. ers conceive of gender too narrowly and nutrition interven- Support and facilitate the generation of new ideas to tions addressed inadequately address gender-based factors. ing. Consultations with experienced practitioners, policy address the programmatic gaps and improve target- Gaps were noted in the programmatic focus of existing pro- makers, community health workers, as wells as beneficia- grams; programs heavily emphasize providing information ries may generate new ideas. Grant competitions to iden- and health services and fail to adequately mobilize household tify or scale new approaches may also be beneficial. and community support or increase a mother’s agency and au- tonomy. Gaps were also noted in targeting. Most existing nutri- 4. Evaluate promising approaches for effectiveness. A tion services target mothers and young children and neglect lack of evidence on the effectiveness of interventions ham- the needs of adolescent girls and the important roles of men, pers their widespread adoption by governments and de- mothers-in-law, and grandmothers. Even basic nutrition data velopment partners. Pilot studies should test, for example, is unavailable in some countries. Various approaches to close whether nutrition outcomes can be improved by: these gaps that have been taken by implementing organiza- tions in the region were discussed. • targeting BCC to other household members such as men, grandmothers and/or mothers-in-laws • distributing behavioral change messages through male community health workers or elderly women in Five areas of follow-up to this discussion constitute one the household way forward: 16 Full name is The Rajiv Gandhi Scheme for Empowerment of Adoles- • the use of various types of social groups to generate cent Girls. community support 13 • generating mass awareness using various mecha- al. (2001). Strengthening Grandmother Networks to Improve nisms such as ICTs, television, radio, arts, media per- Community Nutrition: Experience from Senegal. Gender and sonalities Development, 62-73. • introducing a range of time saving technologies Badruddin, S. H., Agha, A., Peermohamed, H., Rafique, G., Khan, • providing additional homestead production activities K., & Pappas, G. (2007). Tawana project-school nutrition pro- and livelihood activities The Aga Khan University. gram in Pakistan: its success, bottlenecks and lessons learned. 5. Bhagowalia, P., Menon, P. Q., & Soundararajan, V. (2010). Un- Conduct additional research in gap areas and fill holes packing the Links Between Women’s Empowerment and Child Nutrition: Evidence Using Nationally Representative Data From in existing data, including the following: • Knowledge, attitudes and practices of men and elder women in the household related to the care of women Bangladesh. Selected Paper prepared for presentation at the Ag- and children. An understanding of family systems and cultural systems is also necessary. ricultural & Applied Economics Association 2010 AAEA,CAES, & Denver. WAEA Joint Annual Meeting, Denver, Colorado, July 25-27, 2010. • Targeting adolescent girls requires region-specific information on the lives of adolescent girls and the Bhattacharjee, A., & Das, N. C. (2011). Profile of Adolescent Girls: mapping of institutions that might be used to reach them. Stakeholders interviewed noted that there is powerment of Adolescents (SoFEA) Programme. BRAC. BRAC. Findings from the Baseline Survey for Social and Financial Em- little knowledge on the roles and expectations of ado- lescent girls in households between the ages of five Concern Worldwide. (2012). Male Health Workers for Acces- and pregnancy and how this influences nutrition out- sible Health Care. Retrieved May 15, 2012, from Innovations comes. for maternal, newborn, and child health: http://innovations- formnch.org/finding-what-works/male-health-workers-for- • Health and Nutrition Data should be disaggregated for accessible-health-care adolescent girls across the region. • General health and nutrition information availability De Silva, D. (2011, December 28). Nutrition Specialist, WFP/ is poor in Bhutan. Sri Lanka. (M. Hook, Interviewer) • Given the lack of programs on mental health and self- DiDio, D., Schumacher, B., & Choudhury, N. (2011, December esteem and on the incidence of gender-based violence 11). Gender and M&E Consultant and Nutrition and Food Se- experienced by caregivers, region-specific research curity Specialists, WFP Bangladesh & Nutrition Colleagues. (M. should draw out the linkages between mental health, Hook, Interviewer) care practices and ultimately nutrition outcomes. Possible interventions should be identified. Engle, P., Menon, P., & Haddad, L. (1999). Care and Nutrition: Concepts and Measurement. World Development, 27 (8), pp. 1309-1337. Garret, J., & Natalicchio, M. (. (2011). Working Multisectorally in V. References Alderman, H., Chiappori, P.-A., Haddad, L., Hoddinott, J., & Kan- Nutrition. Washington, DC: IFPRI. bur, R. (1995). Unitary versus collective models of the house- hold: is it time to shift the burden of proof? World Bank Re- Grace, J. (2004). Gender roles in agriculture: case studies in five search Observer, 1-19. villages in Northern Afghanistan. Afghanistan Research and Evaluation Unit. AREU. Ashrafi, H. (2009). Gender dimension of agriculture and rural HKI. (2010). Homestead Food Production Model Contributes to ariculture and rural development sector. FAO. FAO. development: special focus on Afghan rural women’s access to powerment: Experience From Scaling-Up Programs in Asia. HKI. Improved Household food Security, Nutrition and Female Em- Aubel, J. (2012). The role and influence of grandmothers on HKI, Nutrition Bulletin. child nutrition: culturally designated advisors and caregivers. Maternal & Child Nutrition, 19-35. ICDS. (2009). Sabla Scheme. Retrieved 10 2012, June, from In- tegrated Child Development Service: http://www.cdpo.eweb- Aubel, J. (2010). The roles and influence of grandmothers and site.com/articles/sabla-scheme.html men. Washington, DC: USAID. IPA. (2011). Empowering Girls in Rural Bangladesh. Retrieved Aubel, J., Touré, I., Diagne, M., Lazin, K., Sène, E. H., Faye, Y., et Jan 2012, from Innovations for Povery Action: http://poverty- 14 action.org/project/0121 Meinzen-Dick, R., Behrman, J., Menon, P., & Quisumbing, A. (2011). Gender: A Key Dimension Linking Agricultural Pro- Jain, M. (N/A). India’s struggle against malnutrition - is the grams To Improved Nutrition and Health. Washington, DC.: IF- ICDS program the answer? N/A. PRI - 2020 Conference. Kapadia-Kundu, N., Khale, M., Upadhaye, S., & Chavan, D. (2007, MOPH and others. (2009). Afghanistan National Nutrition Sur- Nov. 3). Whose Mistake? Gender Roles and Physical Violence vey. Ministry of Public Health, UNICEF, CDC, National Institure among Young Married Women. Economic and Political Weekly, for Research on Food and Nutrition, Tufts University. Atlanta: pp. 71-78. CDC. Kathuria, A. K. (2011, June). Nutrition in India. India Health MOPH. (2009). National Child and Adolescent Health Strategy. Beat, 5 (1). Ministry of Public Health. MOPH. Khan, F. (2012, January 30). Chief of Party, USAID Shouhard MOPH. (2009). National Public Nutrition Policy and Strategy. Project implemented by CARE. (M. Hook, Interviewer) Ministry of Public Health. MOPH. Koirala, H. (2011, December 29). Nutrition Cluster Lead at Nutrition Foundation of India. (2006). Report of Evaluation of USAID/Nepal. (M. Hook, Interviewer) of National Programme for Adolescent Girls. Nutrition Founda- tion of India. Krishnaraj, M. (2007, Nov. 3). Understanding Violence against Women. Economic and Political Weekly, 90-91. Pinstrup-Anderson, P., Pelletier, D., & Alderman, H. (1995). Child Growth and Nutrition in Developing Countries. Cornell Kurz, K., & Johnson-Welch, C. (2000). Enhancing Nutrition Re- University Press. sults: The Case for a Women’s Resources Approach. Washing- ton, DC: International Center for Research on Women. Ransom, E., & Elder, L. (2003, July). Nutrition of Women and Adolescent Girls: Why It Matters. Retrieved Dec. 10, 2011, Kusin, J., & Markell, V. (2006, June). Report on the Nutrition and from Population Reference Bureau: http://www.prb.org/Arti- Gender Initiative as Implemented by The International Center cles/2003/NutritionofWomenandAdolescentGirlsWhyItMat- for Research on Women September 2002-2005. Retrieved Dec ters.aspx 12, 2011, from The World Bank: Rogers, B. L., Coates, J., & Osei, A. K. (2004). WFP Bangladesh http://siteresources.worldbank.org/EXTGLOREGPARPROG/ School Feedig Program Midterm Evaluation Report. Tufts Uni- Resources/icrw.pdf versity. Tufts University. Levitt, E. J., Pelletier, D. L., & Pell, A. N. (2009). Revisiting the Save the Children. (2006). CS-19 Afghanistan Midterm Evalua- tion Report. Save the Children. UNICEF malnutrition framework to foster agriculture and son of stakeholder priorities for action. Food Policy. Schensul, S., Schensul, J., & LeCompte, M. (1999). “Ethnograph- health sector collaboration to reduce malnutrition: a compari- Levitt, E., Laviolette, L., Mbuya, N., & Kostermans, K. (2011). Malnutrition in Afghanistan. World Bank. World Bank. Interviews and Questionnaires. AltaMira Press. ic Sampling� In Essential Ethnograpic Methods: Observations, Levitt, E., Stoltzfus J., R., David, P. L., & Alice, P. N. (2009). A com- Seckel, L. (2011). Factors that constrain or prevent optimal in- from a formative research study in three districts. Nepal Family fant and young child feeding practices in rural Nepal: Findings Health Program II. USAID. munity food system analysis as formative research for a compre- hensive anemia control program in Northern Afghanistan. Food Sen, A. (2001, September 17). The Many Faces of Gender In- Security. Mashal, T., Takano, T., Nakamura, K., Kizuki, M., Hemat, S., Wa- tanabe, M., et al. (2008). Factors associated with the health and equality. The New Republic, pp. 35-40. nutritionl status of children under 5 years of age in Afghani- stan: family behavioir to women and past experience of war- Sethuraman, K., & Duvvury, N. (2007, Nov. 3). The Nexus of related hardhips. BMC Public Health, 8. Gender Discrimination with Malnutrition: An Introduction. Economic and Political Weekly, 49-53. Mashall, et all. (2008). Factors associated with the health and nutritional status of children under 5 years of age: family behav- Shahnaz, R., & Karim, R. (2008). Providing Microfinance and So- ship. BMC Public Health. BMC Public Health. ELA Centers. BRAC. BRAC. ior related to women and past experience of war related hard- cial Space to Empower Adolescent Girls: An Evaluation of BRAC’s 15 Smith, L. C., Khan, F., Frankenberger, T. R., & Wadud, A. (2011). munity Based Child Survival Interventions. BASICS. Victoria, C., Aldair, L., Fall, C., Hallal, P., Martorell, R., Richter, L., Admissible Evidence in the Court of Development Evaluation: Bangladesh. Institute for Development Studies, IDS Working et al. (2008). Maternal and child undernutrition: consequences The Impact of CARE’s Shouhardo Project on Child Stunting in Paper Volume 2011 Number 376. Institute for Development for adult health and human capital. The Lancet, 340-357. Studies. WFP. (2009). Learning from experience: good practices from 45 Smith, L., Usha, R., Ndiaye, A., Haddad, L., & Martorell, R. years of school feeding. WFP. (2003). The Importance of Women’s Status for Child Nutrition in Developming Countries. Washington, DC.: International Food WFP. (2012). WFP/Nepal. Retrieved February 13, 2012, from Policy Research Institute; Dept of International Health, Emory WFP Website: http://www.wfp.org/countries/nepal/opera- University. tions UN SCN. (1998). Challenges for the 21st Century: A Gender White, H. (2009). Theory based impact evaluation: principles Perspective on Nutrition Through the Life Cycle. ACC/SCN 25th and practice. International Initiative for Impact Evaluation . In- Session Symposium 30 March and 1 April, 1998. Olso: UN Stand- ternational Initiative for Impact Evaluation . ing Committe on Nutrition. WHO. (2010). Nutrition Landscape Information System (NLIS) UNICEF and others. (2002). Maternal Mortality in Afghanistan. country profile indicators: Interpretation guide. Geneva: World UNICEF, MOPH, CDC. UNICEF. Health Organization. UNICEF. (2011). Gender Influences on Child Survival, Health and World Bank. (2011). Gender Equality and Development - World Nutrition: A Narrative Review. UNICEF. Development Report 2012. Washington, DC: World Bank. UNICEF. (2012). Progress for Children. UNICEF. World Bank. (2006). Repositioning Nutrition as Central to De- velopment. Washington, DC.: World Bank. UNICEF. (1998). The State of the World’s Children: Focus on Nu- trition. New York: Oxford University Press. World Bank. (2010). Understanding the Dynamics of Gender USAID BASICS. (2009). BCC Strategic Plan in Support of Com- gramming. Washington, DC: World Bank. and Nutrition in Bangladesh: Implications for Policy and Pro- ment in lop So ve e ut lD hA Socia sia South Asia Social Development Unit (SASDS) The World Bank 1818 H Street N.W. Washington DC 20433 This volume was created by staff of the International Bank for Reconstruction and Development/The World Bank. The findings, interpretations, and conclusions expressed in this paper do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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. The authors gratefully acknowledge the support of the South Asia Food and Nutrition Security Initiative (SAFANSI) for this research. SAFANSI is supported by both AusAID and UKaid from the Department for International Development; however, the views expressed do not necessarily reflect these departments’ official policies. 16