A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 LEARNING FROM WORLD BANK HISTORY Agriculture and Food-Based Approaches for Addressing Malnutrition WORLD BANK REPORT NUMBER 88740-GLB JUNE 2014 A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 LEARNING FROM WORLD BANK HISTORY Agriculture and Food-Based Approaches for Addressing Malnutrition WORLD BANK REPORT NUMBER 88740-GLB © 2014 The International Bank for Reconstruction and Development/The World Bank 1818 H Street NW Washington, DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org Email: feedback@worldbank.org All rights reserved This volume is a product of the staff of the International Bank for Reconstruction and Development/The World Bank. 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CONTENTS iii CONTENTS Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Chapter 2: Addressing Malnutrition over Time: The Relationship of Nutrition to Food and Agriculture . . . . . . . . . . . .3 Chapter 3: Emergence of Nutrition as a Science and Its Initial Approach (1900–60s) . . . . . . . . . . . . . . . . . . . . . . . .5 3.1 General Trend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 3.2 Nutrition at the Bank up to the 1960s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 3.3 Agriculture at the Bank up to the 1960s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 Chapter 4: The Food Shortage Era (1960s–70s) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 4.1 General Trend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 4.2 Nutrition at the Bank 1960s–70s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 4.3 Agriculture at the Bank 1960s–70s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Chapter 5: Multisectoral Nutrition Planning and Integrated Rural Development (1970s–80s) . . . . . . . . . . . . . . . . . 11 5.1 General Trend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 5.2 Nutrition at the Bank 1970s–80s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 5.3 Agriculture at the Bank 1970s–80s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Chapter 6: Nutrition Isolationism and Era of Low Global Food Prices (1980s–2008) . . . . . . . . . . . . . . . . . . . . . . . . 15 6.1 General Trend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 6.2 Nutrition at the Bank 1980s–2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 6.3 Agriculture at the Bank 1980s–2008. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Chapter 7: Twin-Track Agenda: Nutrition-Specific Interventions and Nutrition-Sensitive Development Amid High Investment in Agriculture (2008–Present) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 7.1 General Trend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 7.2 Nutrition at the Bank 2008–Present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 7.3 Agriculture at the Bank 2008–Present . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 iv CONTENTS Chapter 8: Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 8.1 What Has Been Tried? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 8.2 Missing Factors: What Was Lacking to Develop Sustained Action and Ownership? . . . . . . . . . . . . . . 30 8.3 Need for a New Paradigm for Agriculture’s Role in Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 8.4 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 8.5 Concluding Thoughts Based on the History of Addressing Malnutrition . . . . . . . . . . . . . . . . . . . . . 39 Appendix A: The Role of the WBG Archives in the Review of Nutrition-Sensitive Agriculture Knowledge Product. . . . 41 Appendix B: Projects That Have Addressed Nutrition through Agriculture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Appendix C: Samples of World Bank Guidelines on Addressing Nutrition though Agriculture . . . . . . . . . . . . . . . . . 53 Appendix D: Evolution of Nutrition Placement at the World Bank . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 References from the World Bank Group Archives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Other References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 BOXES Box 2.1: What Is Nutrition? How Has the Notion of Adequate Food Changed over Time? . . . . . . . . . . . . . . . . . . . . . . . . .3 Box 6.1: The Bank’s Nutrition Advisory Service: An Attempt to Facilitate Nutrition-Sensitive Action . . . . . . . . . . . . . . . . . 18 Box 7.1: The Quality Protein Maize Story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Box 7.2: Nepal Agriculture and Food Security Project NAFSP: Funded by the Global Agriculture and Food Security Program, GAFSP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 FIGURES Figure 6.1: Causes of Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Figure 6.2: World Bank Agriculture Lending Volume (in Nominal Million US$) and Share of Agriculture in Total World Bank Lending (IDA and IBRD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Figure 8.1: Food System Interventions for Better Nutrition (from FAO SOFA 2013) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 TABLES Table 2.1: Time Periods Used in This Paper to Represent Main Trends Related to Food and Nutrition . . . . . . . . . . . . . . . . .4 Table B.1: Examples of 17 Area Development (or Integrated Rural Development) Projects That Addressed Nutrition. . . . . . 45 Table B.2: Examples of Nine AGSECALs Projects That Addressed Food Security (and in Some Cases Nutrition) . . . . . . . . . . 47 Table B.3: Examples of Other Projects That Addressed Nutrition through Agriculture or Rural Development Managed by Population, Human Resources, Urban, and Water Operations Departments. . . . . . . . . . . . . . . . . 48 L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N P R E FA C E v PREFACE Today, more than ever before, there is unprecedented awareness in the international development community that we need to tackle all forms of malnutrition: hunger, hidden hunger, and overweight and obesity. The latest data expose the challenges we face: 840 million people are hungry; more than 2 billion are micronutrient-deficient; and 1.4 billion are overweight or obese. Overcoming these staggering numbers demands a multisectoral and collaborative approach from households, communities, countries, and development organizations across the sectors that affect the lives of children and their families. More than 100 organizations and more than 50 countries have signed on to the Scaling Up Nutrition (SUN) movement in support of this approach. The World Bank Group is a proud SUN partner and our commit- ment to this agenda is evident in our increasing support to nutrition-sensitive and agricultural activities. In 2011, three World Bank departments—Health, Nutrition, and Population; Agriculture and Environmental Services; and Poverty Reduction and Equity—launched the SecureNutrition Knowledge Platform to exchange experiences, to disseminate information, and ultimately to increase coordination, collaboration, and co-generation of knowledge on nutrition issues and interventions. The platform’s goal is to bridge some of the critical operational knowledge gaps that the development community faces in improving the nutrition of vulnerable popula- tions through nutrition-sensitive agriculture and food security investments. A distinguishing aspect of the SecureNutrition Knowledge Platform is its collaboration with the World Bank Library and Archives of Development team, which has resulted in this report: Learning from World Bank History: Agriculture and Food-Based Approaches for Addressing Malnutrition. This summary of how the nutrition and agriculture sectors of the World Bank have addressed agricultural and food-based approaches to nutrition from the 1960s to the present showcases the trove of resources available in the World Bank, and demonstrates how this deep well of information can inform the mainstreaming of nutrition in the World Bank’s agriculture operations. The report makes four main recommendations that call for a new common global vision for enhancing agriculture’s role in improving nutrition, with measurable outcomes and targets; a level playing field in public agriculture support for nutritious foods; actions to create demand for nutritious and sustainable food; and more capacity for addressing nutrition through agricultural interventions. These actions will enhance agriculture’s contribution to eliminate malnutrition globally. We believe that nutritional goals must be explicitly incorporated into the design and implementation of agricultural and rural development projects and policies. To do so, we need to close knowledge gaps and carefully plan sustainable solutions that address the challenges of macro- and micronutrient sufficiency and adequacy. The SecureNutrition Knowledge Platform and research like this are an important step in the right direction. Juergen Voegele Timothy Evans Denis Robitaille Senior Director Senior Director Director, Chief Information Officer Agriculture Global Practice Health, Nutrition, and Population Global Operations and Knowledge World Bank Practice Information and Technology Solutions World Bank World Bank Group A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 ACKNOWLEDGMENTS v ii ACKNOWLEDGMENTS This project was carried out in collaboration with staff of the World Bank Archives. (See appendix A describing the World Bank Group Archives and the collaboration efforts for this project.) Alan Berg, former Senior Nutrition Adviser of the World Bank from 1973 to 1995, advised on this project and gave the authors access to his personal historical documents. Yurie Tanimichi Hoberg was the Task Team Leader, and the team included Anna Herforth, Monika Gutestam, Jeanne Kramer-Smyth, Aira Htenas, and Srilatha Shankar. This paper benefited from interviews with Harold Alderman, Jock Anderson, Alan Berg, Lynn Brown, Christopher Delgado, Eileen Kennedy, Jim Levinson, Katherine Marshall, Nkosinathi Mbuya, Milla McLachlan, Judy McGuire, Iftikhar Mostafa, Per Pinstrup-Andersen, Bea Rogers, Meera Shekar, Paul Sommers, Robert Townsend, and Jeff Waage. Technical comments were provided by Jock Anderson, Diego Arias, Alan Berg, Leslie Elder, Madhur Gautam, Jim Levinson, Jorge Muñoz, Per Pinstrup-Andersen, Andrea Spray, Robert Townsend, and Bert Voetberg. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 A B B R E V I AT I O N S A N D A C R O N Y M S ix ABBREVIATIONS AND ACRONYMS AGR Agriculture and Rural Development Department AGRNU Rural Development and Nutrition Division within the AGR AGSECAL Agricultural Sector Adjustment Loans AVRDC The World Vegetable Center CAADP Comprehensive Africa Agriculture Development Programme CGIAR Consultative Group on International Agricultural Research CGP Child Growth Promotion CIAT International Center for Tropical Agriculture CIMMYT International Maize and Wheat Improvement Center CONASUPO Mexico National Company for Popular Subsistence CRP CGIAR Research Program CSA Mauritania Agency for Food Security CSB corn-soy blend CSM corn soy milk DfID United Kingdom Department for International Development FANTA Food and Nutrition Technical Assistance Project FAO Food and Agriculture Organization FY Fiscal year GFRP Global Food Price Crisis Response Program GAFSP Global Agriculture and Food Security Program HCO Human Capital Development and Operations Policy HDD Human Development Department HDDS Household Dietary Diversity Score HDNHE Health, Nutrition, and Population Team HFIAS Household Food Insecurity Access Scale HH Household HHS Household Hunger Scale HNP Health, nutrition, and population HRO Human Resources Development and Operations Policy IBRD International Bank for Reconstruction and Development ICN2 Second International Conference on Nutrition ICR Implementation Completion Report IDA International Development Association IEC Information, Education, and Communication IEG Independent Evaluation Group A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 x A B B R E V I AT I O N S A N D A C R O N Y M S IFAD International Fund for Agricultural Development IFC International Finance Corporation IFPRI International Food Policy Research Institute IHME Institute for Health Metrics and Evaluation IITA International Institute of Tropical Agriculture IRIS Integrated Records and Information System ITSKI Knowledge and Information Services JCTC Jamaica Commodity Trading Corporation LAD Library & Archives Development Team LCIRAH Leverhulme Centre for Integrative Research on Agriculture and Health LSMS Living Standards Measurement Study M&E Monitoring and Evaluation MDGs Millennium Development Goals MTR Mid-term Reviews NAFSP Nepal Agriculture and Food Security Project NARS National Agricultural Research System NGO Nongovernmental Organization OED Operations Evaluation Department PHN Population, Health, and Nutrition Department PHRHN Population, Health, and Nutrition Division PIDER Mexico Integrated Rural Development Project PMU Project Management Unit PNP Population Projects Department QBPRP China Qinba Mountains Poverty Reduction Project QPM Quality Protein Maize REACH Renewed Efforts Against Child Hunger and Undernutrition SAFANSI South Asia Food and Nutrition Security Initiative SARAS South Asia Regional Assistance Strategy SDA Social Dimensions of Adjustment Program SNKP SecureNutrition Knowledge Platform SNNPR Ethiopia Southern Nations, Nationalities, and People’s Region SOFA State of Food and Agriculture SUDENE Brazil Superintendency for the Development of the Northeast SUN Scaling Up Nutrition T&V Training and Visit TINP Tamil Nadu Integrated Nutrition Project TTL Task Team Leader TVE Town & Village Enterprise UNICEF United Nations Children’s Fund USAID U.S. Agency for International Development WBG World Bank Group WDR World Development Report WFP World Food Programme L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N EXECUTIVE SUMMARY xi EXECUTIVE SUMMARY Increasing the positive impact on nutrition from agriculture investments is a major area of interest in the international development com- munity, including within the World Bank. This is not the first time, however, that the agenda of linking agriculture and nutrition has arisen. In 1973, World Bank President McNamara sought to change the World Bank’s mission toward poverty reduction. As an integral part of the vision of poverty reduction, a nutrition department was initiated for the first time at the World Bank, concurrent with the addition of “rural development” to the existing agriculture department in the same year, 1973. This review uses the World Bank Group Archives to present a summary on how agricultural and food-based approaches to nutrition have been addressed by the nutrition and agriculture sectors of the World Bank. The review is set within the larger political and intellectual context of the development community that influenced those decisions. The period covered is roughly from the 1960s to the present with more detailed analysis from the post-1973 period. From the historical review and lessons learned the paper presents concrete recommenda- tions to contribute to the success of the current nutrition sensitive development approach in agriculture undertaken by the Bank and other development organizations including the Food and Agriculture Organization (FAO) and the International Fund for Agricultural Development (IFAD). Recommendations are identified for the World Bank and for the development community in general. In the 1970s, both nutrition and rural development were just getting started at the Bank, as central to World Bank President McNamara’s new poverty reduction agenda. Against the backdrop of the Green Revolution’s success, rural development focused mainly on agriculture, and primarily on income generation and staple grain production of smallholder farmers to allay a global food shortage. Nutrition, meanwhile, was a new area for the Bank, under close supervision as it began with large multisectoral programs in a few countries. From the start, the fields of agriculture and nutrition differed in the degree to which they focused on food requirements for nutrition. Arguably, the difference was less pronounced in the 1970s, when the main food requirement was perceived to be dietary energy. Before anthropometric data were collected at national scales, malnutrition prevalence was estimated from food shortage, and therefore, agriculture’s main mission to tackle food shortages would tautologically bring down estimated malnutrition rates. Even so, nutritionists remained unsettled about the lack of attention to distributional issues of increased food supply (Berg 1980). In the 1980s, agriculture and nutrition parted ways significantly. With better nutrition monitoring and a more sophisticated understanding of causes of malnutrition, it became clear that while famines were likely averted, increased staple grain production was not solving the malnutrition problem. Attempts at multisectoral coordination had also been fraught with problems. Large multisectoral projects, such as integrated rural development projects, went out of favor at the Bank due to poor performance, and multisectoral nutrition planning units set up in developing countries were established but quickly abandoned after failing to generate political will for focusing on nutrition. In the 1990s–2000s, the nutrition community moved toward a focus on direct nutrition interventions while agricultural investments became increasingly and almost singularly focused on productivity enhancement and market-led growth. Attention and funding to agriculture fell dramatically, amid high food stocks and low food prices, which led to lower rates of return on agricultural investment projects. Despite much rhetoric about food security, few food security operations took place. Agricultural projects in the Bank were under pressure to be simple A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 xii EXECUTIVE SUMMARY and focused (primarily on productivity), and the global nutrition community’s attention was on specific interventions that would improve nutritional status directly, such as micronutrient supplementation, deworming, and breastfeeding. Now, more than 5 years after the food price crisis in 2008, due to lingering concerns of a “new normal” in terms of higher food price volatil- ity, food security remains high on the development agenda. Concomitantly, there is unprecedented political attention to nutrition amid strongly presented evidence and the SUN movement. Putting the two recent priorities together, there are many high-level discussions and commitments to “nutrition-sensitive agriculture” that present an opportunity for tangible policy actions. Within the World Bank, attempts to link agriculture and nutrition since 1973 have not been altogether insignificant. There was no lack of guidelines, analytical work, and even staff support to advise on improving nutrition through agriculture projects. This review identified over 40 agriculture projects since 1973 that have explicitly included nutrition components, but lessons learned are scarce because nutrition was not a main project development objective of these projects; hence effects on dietary consumption or other aspects of nutrition were not measured. There was also, at times, high-level support from senior World Bank management. Nutrition was included in World Bank agricul- ture department strategies from 1997 to 2004, but these were not effectively translated into the establishment of an adequately budgeted “business line” or a new way of doing business within the agriculture department. This review identifies key missing factors that have prevented consistent and core ownership of and action to address nutrition within agri- culture. First and foremost is the lack of clarity in vision. There has been no well-articulated vision about what, operationally, agriculture can and should be accountable for regarding nutrition, and how such action is integral to agriculture’s goals. This is strongly related to an absence of targets for success and accountability that make sense for agriculture. Nutritional status of young children has been the main preoccupa- tion of the nutrition community, but indicators such as child stunting are affected by many factors outside of agriculture. The food security targets measured to date are primarily access to adequate calories and income. Agriculture has improved performance in these areas, but they are not sufficient indicators of access to adequate nutritious food. If agriculture is to respond to a problem different from lack of calories and income, then there is a need to collect and report data on the problem that needs to be solved. Poor monitoring and evaluation is one reason for another missing factor in this history. Virtually none of the World Bank projects that have partially attempted to address nutrition through agriculture actually monitored or measured nutritional or food security outcomes. They only measured supply side outcomes such as increase in production or yields. While the overall agriculture investment portfolio could have had significant aggregate effects on food security, dietary quality, nutritional status, and noncommunicable diseases, the effects have not been estimated. Producer support at the crop-food group level is determined primarily by supply-side considerations with little regard to the role of agriculture in providing required dietary consumption needs to sustain a healthy and active life. These missing factors form the basis for recommendations to improve ownership of nutrition within agriculture going forward. Recommendation 1: Establish a New Common Vision Globally for Agriculture’s Role in Improving Nutrition, with Measurable Outcomes and Targets. The proposed vision is that agriculture’s primary role in improving nutrition is to improve access to adequate diverse, nutritious food for healthy and active lives—that is, to improve efforts to meet the full concept of food security (FAO 1996). We do not recommend that agri- culture necessarily attempt to address all the determinants of nutritional status. Activities to improve health status and caregiving practices (also key determinants of nutrition) are mostly within the health, water, and sanitation sectors, and agriculture and agribusiness activities should explicitly avoid causing harm to health and caregiving practices. The focus of agriculture should be on ensuring access to adequate nutritious food for all people—that is, the “food” determinants of malnutrition—which will not be achieved by any other sector. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N EXECUTIVE SUMMARY x iii There is a need for this focus in agriculture because the food system has changed significantly since the 1970s, as has the prevalence of various forms of malnutrition, which is now understood as a “triple burden of malnutrition”: undernutrition, micronutrient deficiencies, and obesity and diet-related chronic diseases. Poor diets affect half the world’s population, including 2 billion with vitamin and mineral deficiencies, and 1.5 billion overweight or obese. Diabetes is rising fastest in Africa (International Diabetes Federation 2013). Poor diets are widespread among all wealth categories, meaning that higher income does not necessarily ensure access to affordable nutritious diets. Diets low in fruits, legumes, vegetables and whole grains are the top cause of years of life lost in developing countries and worldwide (IHME 2013). The food shortage paradigm, appropriate in the 1970s, no longer fits today’s data, which show stronger evidence of a nutritious food shortage. Additionally, food processing and marketing practices have increased access to ultra-processed “junk” foods at the same time nutritious food availability is constrained. PROPOSED KEY ACTIONS Global Development Community 1. Ensure that the new post-2015 framework moves beyond hunger as defined only by inadequate calories, toward a more holistic goal, targets, and indicators for “access to adequate food”—meaning consistent access to diverse, nutritious diets. 2. Further develop appropriate metrics of access to and consumption of adequate nutritious food, and monitor them.* 3. The Scaling Up Nutrition movement, the Global Panel on Agriculture and Food Systems for Nutrition, the Second International Conference on Nutrition (ICN2) accountability framework, the Renewed Efforts at Child Hunger and Undernutrition (REACH), and other partners need to develop a harmonized and aligned vision, targets, and indicators for interactions with stakeholders. 4. Build a community focused on nutrition within agricultural technical agencies (FAO, IFAD, WFP, and so on) to strengthen ownership. World Bank Group 1. Conduct analytical work and collaborate with other technical agencies on indicator* development through the research department (for example, in the Living Standards Measurement Study (LSMS), the South Asia Food and Nutrition Security Initiative (SAFANSI), or SecureNutrition). 2. Monitor access to adequate nutritious diets in food security projects. 3. In agriculture projects, systematically include health impact assessments that can identify health hazards and risks (for ex- ample, water quality, vector-borne disease risks), and develop cost-effective mitigation methods. 4. In International Finance Corporation (IFC) loans, explore the development of appropriate standards based on public health risks of food products that are supported through IFC financing. 5. Explore “food systems strengthening” through results-based financing based on targets for the indicators developed.* Learn from experience of the health sector in health systems strengthening. 6. Include a nutrition lens in standard agriculture sector policy review and dialogue and expenditure reviews to clarify nutrition consequences of large-scale production or consumption subsidy programs. 7. Support requests by regional or national initiatives such as the Comprehensive Africa Agriculture Development Programme (CAADP) in Africa in developing an operational planning for nutrition sensitive agriculture. Note: *Examples of indicator types include the following: (1) Availability and affordability of nutritious food, indicated by relative prices of dietary food groups at national and local market levels; (2) Dietary quality; (3) Sustainability of diets; (4) Household food insecurity experience measures; (5) For some projects, “nutrient yield” (for example, target micronutrient per ha). Some indicators of food access have already been developed, such as the Household Food Insecurity Access Scale (HFIAS) (Coates et al. 2007), Household Hunger Scale (HHS) (Ballard et al. 2011), Food Consumption Score (WFP 2008), and Household Dietary Diversity Score (Swindale and Billinsky 2006). These have shown correlation with nutritional status to varying degrees (Tiwari et al. 2013) and are valid proxies of food quantity (Leroy et al. forthcoming). For individual dietary quality, the Women’s Dietary Diversity Score (FAO 2011 and Swindale and Bilinsky 2006) has been validated for overall nutrient adequacy (Leroy et al. forthcoming). A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 xiv EXECUTIVE SUMMARY Recommendation 2: Level the Playing Field in Public Agriculture Support. Another missing factor has been lack of attention to leveling the playing field for investing in more diverse, nutritious foods. Evidence shows that the food supply has become more homogenous globally over the last decades, partially due to agricultural investment in research and development for a small portfolio of commodity crops (Khoury et al. 2014). Investments have favored cereal crops for food security, partly because this has reflected the common understanding of “food security” that arose in the 1970s, but also partly because of the higher risk nature of noncereal crop production due to various unique constraints in producing them. Constraints include, for example, perishability, lack of access to improved seeds, and limited knowledge of effective production practices, particularly with regards to using available water resources efficiently, given that most vegetables are more susceptible to dry conditions than cereal crops. Attention to diversification in agriculture may be increasingly important not only for nutritional reasons, but also for supporting resilience among farmers in the face of climate change. It would be difficult to recommend actions in agriculture that would imply trade-offs between income and nutritious food production for smallholders and other vulnerable groups employed in agriculture. Yet the structure of research, development, and public support for agricultural crop and livestock improvement has not focused on making nutritious crops less risky and more profitable to produce. The success of the Green Revolution was limited to basic cereals and was less successful in the case of other crops such as sorghum, millet, cassava, and tropical legumes. Part of the reason for the limited success is that unlike the case of wheat and maize, these crops have had no research from developed countries to draw upon (Pingali 2010). Thanks to the Green Revolution, real cereal prices have fallen over time despite the doubling of developing country population from 1965 to 1999. For noncereal crops such as legumes and vegetables, produc- tion did increase but did not keep pace with growth in demand. There was no commensurate technological change in the nonstaple sector. Consequently, inflation-adjusted prices of many nonstaple foods have increased over time (Graham et al. 2007) and the price of staples decreased relative to nonstaples such as legumes and vegetables (Bouis 2000), and led to more calorie-rich but less nutrient-dense diets PROPOSED KEY ACTIONS Global Development Community 1. Increase research and development on fruits, vegetables, and legumes,* including through public investment (Consultative Group on International Agricultural Research [CGIAR], the world vegetable center [AVRDC], and National Agricultural Research System [NARS], and public-private partnerships. 2. Invest in developing within-country capacity to do R&D and seed system development for nutritious crops and livestock of local importance, including underutilized crops. 3. Invest in reducing risks associated with horticultural and small-scale livestock/dairy/fish production. 4. Develop innovative ways to ensure equal access of risk management tools for all crops (not just for basic grains). 5. Invest in analysis of agricultural policy to estimate producer support at crop/food group or at cropping system level. World Bank Group 1. Conduct sector reviews and policy impact assessment to estimate producer support at crop/food group or cropping system level, including agriculture and IFC support. 2. Invest in analysis on risk reduction strategies for producers of noncereal crops. 3. Analyze the effect of climate-related diversification on availability of diverse foods and on diets. * About 5 percent of CGIAR’s research funding goes toward legumes (through CGIAR Research Program (CRP) 1.1 on drylands and CRP 3.5 on grain legumes) (Iftikhar Mostafa, personal communication). CGIAR does not have a research program specifically on fruits and vegetables. The budget of AVRDC, an international nonprofit research and development institute, was $13 million (AVRDC 2013), roughly 1 percent the size of CGIAR research funding in 2013. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N EXECUTIVE SUMMARY xv (Gómez et al. 2013). The vision of increasing access to nutritious foods among vulnerable populations would include support to overcoming technical challenges that limit production (perishability, food safety, crop/animal disease, and seed quality issues, for example). Agricultural policy, including research and development, is needed to incentivize nutritious food production, and to end the incentives toward less- healthy, less-sustainable diets.1 Recommendation 3: Create Demand for Nutritious and Sustainable Food. In the past, agriculture tackled the issues of consumer policies such as food subsidies. These activities have mainly been absorbed into the social protection agenda and today’s agriculture is almost solely focused on supply issues—raising productivity and increasing resilience to shocks such as climate change and price volatility. Opportunities for improving nutrition outcomes requires change in the supply side, but also on the postharvest value chain and the demand side, that is, people need to be informed of the nutritional quality of foods, and social marketing and incentives are needed to maintain, or in some cases shift, social norms that support healthy eating. This requires a shift in mindset that looks not just at the production phase, but the entire food system including the postharvest value chain, as well as consumer policy including behavioral change. It is unclear how the World Bank agriculture global practice will engage in these levels, given that its activities focus primarily on the supply side. In the World Bank Group, IFC engages on the postharvest side, through financing of private sector agribusiness. The kinds of foods produced and consumed have impacts on both public health and environmental sustainability2 (Foresight 2011), and integrating these outcomes into policy dialogue and financing decisions across the World Bank Group could help countries reduce health and environmental problems associated with unhealthy diets. PROPOSED KEY ACTIONS Global Development Community 1. Develop social marketing strategies based on nutrient or health attributes of nutritious foods (for example, “nutrition-focused marketing”), learn from social marketing of biofortified crop varieties. 2. Increase consumers’ nutrition knowledge, particularly where this is a limiting factor to demand for nutritious food. 3. Support, as appropriate, other possible actions outside of the agriculture sector that affect food consumption norms, such as incentives for nutritious food purchase, restrictions on food advertising to children, nutrition in school curricula, and healthy school meals programs to instill healthy eating norms, menu labeling, food vouchers, and so on. 4. Invest in analyses of environmental and distributional impacts of likely food demand changes. World Bank Group 1. For climate-smart agricultural strategy, incorporate evidence of the sustainability/climate impacts of likely food demand changes. 2. Invest in sector review/policy analysis to ensure that current producer supports are not incentivizing unhealthy food con- sumption patterns or unsustainable production. 1 See Graham et al. 2007 for a careful discussion on ways to stimulate growth in the nonstaple food sector for the major cropping systems around the world. 2 Current food demand trends pose significant sustainability and distributional risks, as they are a dominant driver of resource use and environmental outcomes including climate change (Kastner et al. 2012; Marlow et al. 2009). Recent research suggests that dietary changes (specifically, reduced meat and dairy consumption) are necessary to achieve the 2ºC climate change target (Hedenus et al. 2014). A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 xvi EXECUTIVE SUMMARY Recommendation 4: Build and Sustain Capacity for Addressing Nutrition through Agriculture and Monitoring Progress. Adequate capacity is needed to (1) monitor indicators of nutritious food access, as described in Recommendation 1, (2) adequately design and implement nutrition-sensitive agriculture policies and programs that respond to the food and nutrition situation, and (3) support coordination between agriculture and food sector actors along value chains. This entails capacity building in client country governments (national and local), civil society organizations, development partner organizations, and consultants. One reason capacity is low is that the intersection between agriculture, nutrition, and sustainability is not usually part of postgraduate training in agriculture. In the short term, agricultural technical agencies may need to team up to develop common core training for agriculture-nutrition consultants and food policy analysts, who could work with development agencies and country governments. PROPOSED KEY ACTIONS Global Development Community 1. Partner with other agriculture organizations to develop a basic training for agriculture-nutrition staff, consultants, and graduate students. 2. Fund university research and training programs on food systems that treat nutrition and sustainability as integral to agricultural development. 3. Provide ongoing support to country governments to support capacity in monitoring systems. 4. Provide ongoing support to country governments to support coordination between the agriculture and food sector actors along value chains (including production, transport, processing, retail, food safety, and so on). World Bank Group 1. Invest in capacity and adequate resources for rigorous monitoring and evaluation (M&E) (including household surveys where needed) in agriculture projects. 2. Increase number of nutrition and/or food and nutrition security staff in the relevant global practice groups. 3. Formally establish community of practice on food by including members of all the relevant global practices. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N CHAPTER 1 — INTRODUC TION 1 Chapter 1 INTRODUCTION Interest in linking agriculture and nutrition within international development to be solely the improvement of human health, but development is not new. In 1943, in Hot Springs, Virginia, 44 govern- rather a broader agenda recognizing the important role that agri- ments convened for a conference on food and resolved to establish culture plays as a major livelihood and income source for the rural 3 a permanent organization for food and agriculture, which became poor. Apart from attention to hunger issues peaking in the 1960s– the Food and Agriculture Organization (FAO) 2 years later: the first 70s, both the fields of agriculture and nutrition have lacked unified specialized agency of the newly formed United Nations. The Hot zeal for addressing nutrition problems explicitly through food over Springs Food Conference declaration states, “Poverty almost invari- the past several decades. ably means a poor and insufficient diet, and the latter is the main The history of nutrition science, and priorities over time within the cause of the disadvantage of the poor in respect of health, so clearly international nutrition community, indicate a much more tenuous shown by statistics of disease and mortality.” The importance of pov- and, at times, distant relationship with food than might be assumed.4 erty reduction and of good nutrition, as a foundational rationale for As the field of global nutrition has struggled to find its way, there international collaboration and assistance, is reflected in World Bank has been no time until the present when priorities in global nutri- President McNamara’s vision for the role of the World Bank almost tion have been as clearly and strongly stated. Even now, clarity of 30 years later. thought, evidence, and advocacy regarding the role of agriculture Given that the genesis of international agricultural development for nutrition is a work in progress. was to provide food “adequate for the health and strength of all Agriculture has had a strong relationship with food mainly through people,” it seems reasonable to expect that one of the top priori- the supply side or production side (whereby increased supply leads ties within international agriculture would be to feed people well. to increased access to food through lower prices), but not necessar- Likewise, it would seem that the field of nutrition should be closely ily with the direct consumption issues surrounding food, such as the connected, if not synonymous, with food consumption. Yet most actual dietary consumption changes due to increased production practitioners in both the nutrition and agricultural communities or income, or targeting of who is eating what. Consumption issues would consider those characterizations a poor representation of usually enter into agricultural discussions in association with “food their work. According to the nutritionists, nutrition is about much security” in terms of overall food stocks at household, national, and more than food; food has often been a distraction from vital issues global levels, typically measured by volume or calories. such as infant feeding and women and children’s health. And most agriculturalists do not consider the main goal of agricultural Amid high global attention to linking agriculture and nutrition cur- rently (since about 2008), the World Bank has committed to review- 3 The governments declared: “The goal of freedom from want of food, ing its agriculture pipeline as a step toward ramping up activities suitable and adequate for the health and strength of all people can be  achieved . . . The primary responsibility lies with each nation for seeing that its own people have the food needed for life and health; . . . but each nation can fully achieve its goal only if all work together” 4 For example, the term “food-based solutions” to malnutrition is generally (Boudreau 1943). accepted as nonredundant. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 2 CHAPTER 1 — INTRODUC TION that improve nutrition outcomes (Government of UK 2013). In addi- world. The initial motivation was to showcase the depth of his- tion, the World Bank’s Agriculture Action Plan FY13–15 (World Bank torical resources available in the World Bank Group Archives, and 2013a) includes nutrition as an area to increase emphasis and spe- to demonstrate how they can be used to inform current practice cifically includes a commitment to increase the share of agriculture (see appendix A). Several lessons learned primarily from the World projects that explicitly focus on nutrition. Bank experience are applicable to the Bank’s current commitment to nutrition-sensitive agriculture, as well as to the development The purpose of this paper is to provide forward-looking recommen- community at large, that is tackling the same agenda. dations for linking agriculture and nutrition by looking back over the 40 years since both nutrition and rural development began This paper is not a comprehensive review of international agricultural at the Bank in 1973 (see appendix D for evolution of nutrition development or agricultural lending supported by the World Bank, 5 within  the World Bank’s structure ). This paper sets out to explore nor of nutrition operations supported by the World Bank. Rather it is whether what is currently being suggested has been attempted in a review of how thinking and priorities evolved within the develop- the past; in what circumstances, with what sort of support or com- ment community around how to address malnutrition, highlighting mitment, by what actors, and with what results. Throughout, the times when that has involved agriculture. For each identified “era,” the World Bank is a case study set within the larger development aid paper describes the general trends at the time, as well as nutrition architecture due to its role as one of the largest actors in agriculture and agriculture work at the World Bank as they pertain to the topic of and nutrition investments in developing countries around the addressing nutrition through agricultural and food-based approaches. 5 Nutrition initially was housed in the Population department (1972–75), and then moved to Agriculture and Rural Development (1975–79). Since 1979 it has been housed with health and other human develop- ment sectors. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 2 — A D D R E S S I N G M A L N U T R I T I O N O V E R T I M E : T H E R E L AT I O N S H I P O F N U T R I T I O N TO F O O D A N D A G R I C U LT U R E 3 Chapter 2 ADDRESSING MALNUTRITION OVER TIME: THE RELATIONSHIP OF NUTRITION TO FOOD AND AGRICULTURE The historical progression of nutrition has been examined previ- BOX 2.1: What Is Nutrition? How Has the Notion of Adequate ously in Jonsson (2009)6 and Levinson and McLachlan (1999). The Food Changed over Time? problems that were considered most significant to the malnutrition The World Health Organization defines nutrition as: “the intake problem, and likewise the priorities within the field of international of food, considered in relation to the body’s dietary needs. nutrition, have evolved over time. Food has not always been a focus. Good nutrition—an adequate, well balanced diet combined Box 2.1 summarizes how the priorities with regard to dietary intake with regular physical activity—is a cornerstone of good health. have changed significantly over time, even though the concept of Poor nutrition can lead to reduced immunity, increased sus- ceptibility to disease, impaired physical and mental develop- an optimal diet, captured in dietary guidelines, has been quite con- ment, and reduced productivity” (WHO 2014). sistent for many decades. The nutrients in food include carbohydrates, proteins, and For the purpose of examining the field of nutrition’s relationship to fats (the “macronutrients”—which contain dietary energy); food, this paper utilizes the following five broad eras as presented and vitamins and minerals (the “micronutrients”—which do not contain dietary energy). Other components of in table 2.1: the emergence of nutrition as a science and its initial food that are not technically “nutrients” also contribute to approach (1900–60s), the food shortage era (1960s–70s), the era of nutrition and health, such as fiber, probiotic bacteria, and multisectoral nutrition planning (1970s–80s), the era of nutrition phytonutrients. isolationism (1980s–2000s), and the current twin-track agenda era7 As this paper details, the focus of the international nutrition (2008–present). community regarding dietary intake has shifted from proteins (in the 1960s) to dietary energy (1970s–80s)1 to micronutrients The same time periods can also be described for agriculture as: the (primarily provided via nutrient supplements) (1990s–2000s). emergence of agricultural economics as a discipline (1900–60s), the Now (2010s), the focus is moving toward dietary diversity and dietary quality more broadly.2 The ideal goal is to ensure that food shortage era (1960s–70s), the era of integrated rural devel- opment programs (1970s–80s), the era of low global food prices 1 (1980s–2000s), and the current food price crisis-spurred era of For example, the World Bank’s 1986 “Guidelines for Work in Nutrition” states, “The primary objective of the nutrition aspect in agricultural sector work is increased investment (2008–present). to improve the calorie (and protein) intake of the malnourished . . . In some countries in parts of Africa and Latin America where the diet of the poor consists mostly of cassava, bananas or plantains, which lack protein content, the diet goal should also include pulses, oilseeds, groundnuts or other protein- rich foods” (Berg et al. 1986). 6 Jonsson’s analysis includes: The period before 1950; The Protein 2 A key message of the Call the Action: Nutrition in the Post-2015 Development Deficiency Paradigm (1950–74); The Multisectoral Nutrition Planning Agenda: “Access to a range of diverse foods, reflected in dietary quality, is core Paradigm (1974–80); The National Nutrition Policy Paradigm (1980–90); to adequate food for all. Producing more diverse, nutritious foods is aligned The Community-Based Nutrition Paradigm (1985–95); The Micronutrient with and supports the broader objectives of sustainability and resilience.” Malnutrition Paradigm (1995–2005); A period of Paradigm Crisis (2005– (http://thousanddays.org/wp-content/uploads/2013/09/Nutrition-in-the present). -Post-2015-Agenda-Key-Messages.pdf ) See also FAO 2013a, FAO 2013c, World Bank 2013b, Bill and Melinda Gates Foundation 2014. 7 Twin-track agenda refers to a dual approach espoused by the Scaling Up Nutrition movement to promote nutrition-specific direct interventions as well as nutrition-sensitive interventions in sectors that affect underly- ing factors of malnutrition. (continued) A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 4 C H A P T E R 2 — A D D R E S S I N G M A L N U T R I T I O N O V E R T I M E : T H E R E L AT I O N S H I P O F N U T R I T I O N TO F O O D A N D A G R I C U LT U R E BOX 2.1: (continued) TABLE 2.1: Time Periods Used in This Paper to Represent Main Trends Related to Food and Nutrition diets provide adequate nutrients and promote good health, as PRIORITIES reflected in food-based dietary guidelines. Dietary guidelines OF NUTRITION ERA AGRICULTURE NUTRITION COMMUNITY themselves have remained remarkably consistent over the last 1900–60s The emergence of The emergence of nutrition Vitamins century (Davis and Saltos 1999). agricultural economics as a science and its initial as a discipline approach The primary basis for the current shift in emphasis is evidence 1960s–70s The food shortage era The food shortage era Calories and proteins of a “triple burden” of malnutrition—including undernutrition, micronutrient deficiencies, and obesity and diet-related chronic 1970s–80s The era of integrated The era of multisectoral Calories rural development nutrition planning disease—in all regions. For example, Africa has high rates of programs undernutrition as well as the fastest increases in diabetes and 1980s–2000s The era of low global The era of nutrition Micronutrients child obesity. Therefore, it has become clear that the past idea food prices isolationism of dealing with hunger first, before worrying about nutritious 2008–present The current food price The current twin-track Diverse diet with crisis-spurred era of agenda era attention to both diets, may lead to improvements in only one form of malnutri- increased investment undernutrition and tion while neglecting (or perhaps worsening) the others. obesity L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 3 — E M E R G E N C E O F N U T R I T I O N A S A S C I E N C E A N D I T S I N I T I A L A P P R O A C H ( 1900 – 60s ) 5 Chapter 3 EMERGENCE OF NUTRITION AS A SCIENCE AND ITS INITIAL APPROACH (1900–60s) 3.1 GENERAL TREND The “vitamin deficiency paradigm” shifted to the “protein deficiency The field of nutrition science can be said to have arisen around the paradigm” around the 1950s, after kwashiorkor was described beginning of the 20th century, with the identification of vitamins as (Jonsson 2009; Williams 1935; Trowell 1950). Here was a nutritional the cause of certain diseases. Nutrition science emerged from the deficiency that was not treatable with vitamins, but was success- medical paradigm discovering the cause of a disease, and finding fully treated with skim milk. Triggered by the kwashiorkor images that it could be cured with a missing vitamin or with a food that of bloated bellies and stick limbs, protein provision became the provided the missing vitamin.8 As all the essential vitamins were primary preoccupation of the nutrition community. A number of isolated by the 1940s, providing supplements and fortified foods9 conferences were held and a number of books published zeroing became easier than using foods as vehicles of nutrients (such as in on protein deficiency as the culprit of malnutrition. What is now brown rice to prevent beriberi, or citrus fruits that were carried known as the Standing Committee on Nutrition was then the UN’s onboard British Navy ships in the 1700s to prevent scurvy) as an Protein Advisory Group, a joint FAO/UNICEF/WHO program that expedient, life-saving treatment of deficiency. issued a report titled “International Action to Avert the Impending Protein Crisis” (UN 1968). Inadequate diets were recognized as a cause of deficiencies, so attention was also given to diet, mainly in the form of nutrition At around the same time in the 1950s, the first operational inter- education and personal responsibility for dietary choice. Apart from national nutrition programs were starting, born out of post-WWII discovery and isolation of vitamins, education on consumption international efforts to reduce poverty and malnutrition. Much of behavior could be called the other major part of nutrition science that the focus was on treatment of severe malnutrition in medical wards emerged during the first part of the 20th century. In the United States, (Chafkin et al. 1972), but there were early attempts at population- the first dietary guidelines intended for the public came out in 1917, based programs as well. These included interventions such as milk How to Select Foods (Hunt and Atwater 1917). The emerging science powder distribution and other forms of food aid in the 1950s, and of vitamins was incorporated into consumption guidance with the food technology interventions in the 1960s (such as efforts to release in 1941 of the first Recommended Dietary Allowances, which develop protein supplements, for example from fish protein con- provided a guide to nutrient needs and consumption. Treatment and centrate and single-cell organisms). The initial attention in fortifying prevention of deficiencies, and nutrition education (often nutrient- bread in India was to add lysine, the limiting amino acid in wheat based), remain core to the field of nutrition today. flour. The focus was heavily supply-oriented, and scientifically informed, in an age where industrialization, science, and technology were held as the keys to a better future.10 8 Christiaan Eijkman and Frederick Hopkins were awarded the Nobel Prize in Medicine in 1929 for identifying vitamin deficiency as the cause of a disease (beriberi). (Cashmir Funk first called the “anti-beriberi factor”“Vitamine” in 1912) (http://www.nobelprize.org/educational /medicine/vitamin_b1/eijkman.html) 10 Of note, the growing popularity of infant formula was an archetypal rep- 9 In the US, white flour and rice were fortified with B vitamins starting in resentation of faith in science-based replacements for natural foods, as the 1940s. it was widely—and falsely—advertised as superior to breast milk. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 6 C H A P T E R 3 — E M E R G E N C E O F N U T R I T I O N A S A S C I E N C E A N D I T S I N I T I A L A P P R O A C H ( 1900 – 60s ) The first attempts at integrated community-level nutrition took 3.2 NUTRITION AT THE BANK UP TO THE 1960s place in the 1960s. Applied Nutrition Programs were UNICEF- and Nutrition was not yet a department within the Bank. FAO-supported programs that provided food supplements, small- scale food production, and nutrition education. Born out of a history of highly supply-side interventions, these programs lacked targeting 3.3 AGRICULTURE AT THE BANK UP TO THE 1960s and analysis of the local relevant determinants of malnutrition, and In the 1950s, the Bank’s agriculture lending started off as a minor did not have a cost-effective impact on malnutrition (Levinson and sector within the World Bank, which was focused overwhelmingly McLachlan 1999). Several of the program elements, however, would on investments in public utilities such as power and transport be refined and better applied in the 1980s–90s, and now make up a infrastructure, and to a lesser degree industry and telecommunica- significant part of direct nutrition interventions. tions. Agriculture was widely regarded as a “backward sector,” and On the agricultural side, this overall time period saw the beginning the prevailing wisdom of the time prescribed investments in sup- of agricultural economics and agriculture as a development issue. port of more modern, dynamic sectors as a far more effective use Between 1913 and 1919, agricultural economics became a new of development finance (Cooke et al. 2011). In 1961 a total of 12 discipline, evolving out of farm management and farm survey data professionals covered the Bank’s agricultural program worldwide, collection (Stanton 2001). The new field was mainly concerned with and most of them were engaged in irrigation and drainage work agriculture as a viable business, examining cost accounting, and (Kapur et al. 1997). The establishment in 1960 of the International the reasons for changes in prices, yield, quality, sustainability, and Development Association (IDA) (to reach poorer countries) greatly profits. It complemented other applied areas such as crop and ani- expanded the demand for agricultural lending, since most of the mal breeding, agronomy (agricultural practices and soil and climate countries that qualified for IDA support were heavily dependent on information), and agricultural extension. Before the formation of the agriculture, far more so than middle-income International Bank for FAO in 1945, agriculture was not considered a development issue. Reconstruction and Development (IBRD) countries. Thus, the assis- In 1949, Lord Boyd-Orr (Director General of FAO) received the Nobel tance they sought from IDA was often for agriculture, and in most Peace Prize for developing thought and action around world hun- of these countries, agriculture was rainfed, not irrigated, which ger. Producing enough food to feed the world became paramount meant that IDA-supported operations also significantly diversified in development by the 1960s. the Bank’s agriculture portfolio beyond irrigation (Cooke et al. 2011). L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 4 — T H E F O O D S H O R TA G E E R A ( 1960s – 7 0s ) 7 Chapter 4 THE FOOD SHORTAGE ERA (1960s–70s) 4.1 GENERAL TREND were formed during the 1960s, and provided international food aid, The 1960s marked a time when both agriculture and nutrition com- directly and via nongovernmental organizations (NGOs). Another munities focused significant efforts on world hunger. Population approach that the agriculture sector utilized to address the food was becoming a major concern reaching its height in the 1960s, shortage was through its contribution to food aid and food distribu- with Malthusian fears that the human race could not feed itself tion programs in schools and health clinics. These programs were (Erlich 1968). Famine unfolded in India; the Sahel drought in seen as crucial safety nets for the poor who lacked adequate food. In 1968–72 resulted in a million deaths in Africa, and the early 1970s some countries these would later transform into food voucher pro- saw famines in Ethiopia and Bangladesh. grams and other social protection programs, in addition to school feeding as a transfer mechanism for food safety nets. Agriculture was responding to the strongly felt need to produce more food through the Green Revolution (for which Norman Borlaug won The priorities of the nutrition community also shifted toward basic the Nobel Prize in 1970) from the late 1960s to the 70s. These efforts food during this period, representing a significant broadening resulted in new high-yielding wheat and rice varieties developed beyond the medical supply-side approach. Emerging data at the time at international agricultural research institutes (The International indicated that inadequate consumption of calories was widespread, Center for Maize and Wheat Improvement and the International Rice and the available data were used to define the nutrition problem. No Research Institute, respectively). These centers, together with two other data on deficiencies were yet available, and even anthropomet- 11 other international agricultural research centers also founded under ric data were not available at a national scale in most countries. The the auspices of the Rockefeller and Ford Foundations, formed the priorities of the era are well-summarized by the statement, “Although Consultative Group on International Agricultural Research (CGIAR) in deficiency of vitamins and minerals may cause serious health prob- 1971, whose Secretariat was housed in the Bank, which has remained lems, especially among children, the therapy is now well known one of the major donors from its inception. The CGIAR research centers and relatively easy to apply so that the magnitude of this problem had an almost single-track mission: to raise food productivity in devel- is almost negligible in relation to the one created by lack of calories oping countries. The goals broadened later on to include issues such and proteins” (Chafkin et al. 1972). In this period, food was the main as sustainability, and more recently nutritional concerns. The Green intervention directed to child malnutrition. Most NGO nutrition pro- Revolution focused on basic food staples, such as rice, wheat, maize, grams were solely focused on food provision, which continued well and cassava, because of their importance in the diets of the poor. into the 1970s when corn soy milk and corn-soy blend dominated project budgets with a child nutrition objective. The bilateral aid agencies U.S. Agency for International Devel- opment (USAID)12 and Department for International Development In the 1960s, the overwhelming priority of the nutrition community was protein supply; in 1964, the Food and Agriculture Organization 11 International Center for Tropical Agriculture and International Institute of Tropical Agriculture. (FAO) had defined protein as “the heart of the world food problem,” 12 Then called AID. Although the newly named agency AID was formed and the nutrition community had addressed the situation with during the 1960s, the United States already had foreign aid agencies un- der different names for a dozen years before that. food technology approaches in the previous era. In the early 1970s, A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 8 C H A P T E R 4 — T H E F O O D S H O R TA G E E R A ( 1960s – 70s ) concern about protein rapidly fell and was subsumed by concern economic development paved the way for the initiation of focused 13 about calories. The death knell of the “protein deficiency paradigm” attention to nutrition at the World Bank. was sounded in an article in the Lancet entitled “The great protein fiasco” (McLaren 1974), the same year as the World Food Conference 4.2 NUTRITION AT THE BANK 1960s–70s in Rome first used the term “food security”14 and attention turned to In November 1973, the World Bank Board approved the Policy calories as a more urgent priority.15 Guidelines for Bank Nutrition Activities. Preceding this, a nutri- If inadequate supply of calories was the main problem, then nutri- tion unit was established in the Bank, in the Population Projects tion certainly needed agriculture as an ally. Arguably, this is the Department, which was renamed as the Population and Nutrition first and last time that agriculture and nutrition have been fairly Projects Department (see appendix D for more details on the 16 closely aligned on top priorities. The food shortage paradigm evolution of nutrition work at the Bank).17 In the midst of an era continues to this day to be the dominant narrative of agriculture’s where hunger was a highly visible problem, it was an important primary role regarding nutrition and child survival, where the pri- part of President McNamara’s vision to reshape the World Bank as mary goal is producing more calories, particularly in the form of an institution with the primary mission of reducing poverty. In his basic staple crops. September 27, 1971, Annual Address to the World Bank Board of Governors, President McNamara called malnutrition “a major barrier The stakes were also getting higher on the urgent necessity to human development.” He stated, “reducing the ravages of seri- of addressing malnutrition. At the pivotal 1964 International ous malnutrition will itself accelerate economic development and Conference on Childhood Malnutrition at the National Academy of thus contribute to the amelioration of poverty. And that there are Sciences, evidence of malnutrition affecting cognitive development a number of practical steps that can be taken . . . ” Continuing, he was formally introduced. This triggered the establishment of a 1965 emphasized that, “the central conclusion I wish to propose to you White House Report “Meeting Nutritional Needs” by an Interagency [the finance ministers of the world] is that the international develop- Task Force on Food and Agricultural Assistance to Less-Developed ment community and the individual governments of the countries Countries (Ellis and Berg 1965). In addition to the influential cogni- concerned must face up to the importance and implications of the tive and physical development evidence, a landmark paper (Berg nutrition problem.” 1967) opened up the discussion of nutrition as a development issue. The links between malnutrition, mental development, and The nutrition policy guidelines emphasized the Bank’s potential role as “adding its voice in drawing attention to the problem, by assisting 13 One of the key factors was research showing that people who lacked in planning, by furthering the development of programming disci- protein usually lacked calories as well; and that additional protein in the absence of calories would be used by the body for energy rather pline in this new field through the project process, and by providing than protein synthesis. Major advocates for the broader food/calories approach rather than protein were G. Aroyave (see Aroyave 1975) and additional resources to finance nutrition intervention activities.” What C. Gopalan. to do about the nutrition problem from an operational sense was 14 Food security was first defined at the 1974 World Food Conference as “availability at all times of adequate world food supplies.” still quite undeveloped, and the Bank’s first four nutrition projects 15 According to a World Bank policy document, “The major nutrition prob- (Brazil, Indonesia, Colombia, India) would ultimately advance knowl- lem in the world today, according to most nutritionists, is insufficient intake of calories, or food energy” (World Bank 1980). edge considerably. But because of lack of experience and evidence 16 The fields of agriculture and nutrition differed, however, in their in international nutrition programs, the first World Bank nutrition emphasis on targeting consumption among the nutritionally vulnerable: “Considerable academic and, to a lesser extent, policy atten- projects had to have special Board oversight; a very unusual step, tion has been given of late to food security issues. Two quite different demonstrating the nervousness of the Bank to invest in this area. lines of work have emerged – one on supply issues, the other on con- sumption/nutrition issues. The production work generally ignores the nutrition effects and the nutrition studies rarely take into account the production implications” (Berg Dec 23, 1980). 17 The health sector was not established until 1979. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 4 — T H E F O O D S H O R TA G E E R A ( 1960s – 7 0s ) 9 Despite President McNamara’s personal enthusiasm for nutrition as that at the time of the speech the comparable rate was about 2.5 18 a major force in reducing poverty, “rural development” (or increas- percent per year for small farmers. To achieve this ambitious goal, ing the productivity of small-scale farmers) was selected as the main he stated the Bank would continue with its existing agricultural pro- vehicle. Topics such as population control, employment, and nutrition gram of mainly irrigation infrastructure and some support to rainfed were considered and deemed not “bankable” enough for the Bank to agriculture, but also to expand into new areas such as agricultural engage in a sufficiently significant way (Kapur et. al. 1997). The selec- credit, extension, “multi-purpose rural development projects,” and tion of rural development made sense in terms of the Bank’s posi- agricultural research. President McNamara concluded by stating tion as a still young institution which had to appease financiers from that 70 percent of the poor live in rural areas, and poverty is caused whom it raised capital. In other words, the financial institution side primarily by the low productivity of small-scale subsistence farmers. of the Bank, at this time, was significantly stronger than the develop- Thus, by tackling the productivity of small-scale farmers, countries ment agency side, with which it has since become more associated. should make a real dent in poverty alleviation. Although the importance of agriculture for poverty reduction was 4.3 AGRICULTURE AT THE BANK 1960s–70s clearly articulated, the operational link between agriculture and nutrition was not emphasized. From the start, it was assumed that In 1963, realizing the importance of the International Development the overall increase in the aggregate food supply and higher income Association (IDA) within the Bank, and the central nature of agricul- through agriculture (the dominant occupation of the poor) were ture for many IDA countries, President George Woods mandated a the main routes to better nutrition. This is in stark contrast to the quick doubling of the Bank’s agricultural program. Outside of the emphasis of the new nutrition unit developed the same year. The Bank, there was much optimism regarding the potential of modern nutrition unit recognized the complex nature of malnutrition, and agriculture to dramatically increase food production and contrib- laid out a broad menu of interventions which were deemed neces- ute to poverty alleviation. This was propelled by the success of the sary, including but not limited to increased aggregate food supply Green Revolution. and higher income. Within a range of actions called for, the nutrition President McNamara’s 1973 speech in Nairobi called for a transfor- Policy Guidelines (1973) clearly addressed the need to connect the mative change for the Bank to focus squarely on poverty alleviation, rural development initiative with nutrition. It sought to leverage the which represented a major shift in the World Bank’s mission. He efforts toward increased food production with improved targeting clearly identified “rural development” or increasing the productiv- of the poor: “Attention to food production, of itself, is insufficient to ity of small-scale farmers as the main vehicle for achieving this. In satisfy food needs. If investments in production by the Bank [for his speech, President McNamara laid out the goal of the support to FY74, $725 million] and others are to be of maximum benefit to small farmers to achieve a rate of 5 percent increase in yield per year those in need, attention should also be directed to the nutritive by 1985 (12 years from the time the speech was given). He noted quality, processing and distribution of what is produced.” It went on to recognize that food supplies “have a major positive effect on the problem of malnutrition (and could have much more if nutri- 18 From minutes of a 1972 meeting: “In a discussion today, Mr. McNamara . . . reaffirmed his interest in the field of nutrition and in the Bank’s role tion were given explicit consideration as one of the objectives in of making a contribution in this area. He pointed out that a contribu- tion can be made both through projects and nonproject interventions. the framing of agriculture policies.” At the heart of these recommen- On the latter, he mentioned his desire to see that nutrition elements be dations was a call for “more explicit attention in agriculture sector incorporated in economic reports, and agricultural sector reports . . . He said that it would be appropriate for the Bank to provide funds for neces- surveys to foodstuffs from the view of the consumer need, rather sary technical assistance [in countries not] equipped with nutrition plan- ners to do the kind of preparatory work necessary for a project . . . In sum, than concentrating primarily on agricultural production.” This theme Mr. McNamara’s interest in the activity was keen and his expectations would be repeated in subsequent analytic work, such as in Pinstrup- high—probably higher than the situation warrants, given the realities of staffing” (Berg 1972). Andersen (1981), Reutlinger and Selowsky (1976) and Knudsen and A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 10 C H A P T E R 4 — T H E F O O D S H O R TA G E E R A ( 1960s – 70s ) Scandizzo (1979), where increase in aggregate food availability reduction of infant mortality, and the raising of life-expectancy or household income were shown to be insufficient to solve the standards to those of the developed nations” (McNamara 1973). The “nutrition problem” (calorie deficiency) for society as a whole due to focus on health as the ultimate development outcome harkened income disparity and/or household expenditure decisions. back to the commitments of nations at the 1943 Food Conference at Hot Springs. McNamara’s holistic picture of poverty reduction Despite the disconnect between rural development and nutrition set the stage for integrated programming efforts at the Bank in the from the earliest days, McNamara equated poverty eradication to years that followed. mean, “in practice, the elimination of malnutrition, illiteracy, the L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 5 — M U LT I S E C TO R A L N U T R I T I O N P L A N N I N G A N D I N T E G R AT E D R U R A L D E V E LO P M E N T ( 1970s – 80s ) 11 Chapter 5 MULTISECTORAL NUTRITION PLANNING AND INTEGRATED RURAL DEVELOPMENT (1970s–80s) 5.1 GENERAL TREND programs at national level to improve nutrition. They typically The overall trend in the international development community included ministries of agriculture, food, health, social welfare, indus- in the 1970s emphasized centralized planning to attack social and try, and were usually within planning commissions or the office of economic inequalities that resulted in poverty (Thorbecke 2006). president or prime minister (Levinson and McLachlan 1999).19 Changing priorities in nutrition fit well within this trend. The growing Most of these planning units and many other efforts at multisec- perception in the 1960s that nutrition problems could not be solved toral nutrition planning did not accomplish lofty ideals of tackling without agriculture, vis -à- vis its role in increasing calorie production all causes of malnutrition because of two main downfalls: over- and targeting the vulnerable, contributed to a shift in the nutrition complexity and lack of ownership.20 Ultimately, the main hallmark paradigm from narrow technical fixes to what is now called the “mul- of the era was planning, rather than “multisectoral” as had been tisectoral nutrition planning era” by the 1970s. One of the main miss- the hope. Efforts to provide solid analysis of the determinants of ing pieces in the early programmatic attempts to address nutrition malnutrition, often provided by advisory services of research uni- at the community level was analysis of the context and  causes of versities, frequently led to elaborate models that were generally too malnutrition. The emphasis shifted to understanding the causes complex, and dependent on too much data, to be usable (Jonsson of malnutrition, targeting appropriate multisectoral responses, and 2009; Joy and Payne 1975). The complexity of plans and programs trying to involve all sectors relevant to the nutrition problem and not designed during this time also had implications for implementa- just rely on nutrition specialists. According to Levinson, Balarajan, and tion; they necessitated substantial collaboration between a large Marini (2013): “Interest [in multisectoral nutrition planning] emerged number of actors, and were not delivered effectively (World Bank initially from understandings of the diverse causality of malnutrition. 1987). Participants in one failed program concluded, “Complexity in . . . Interest arose also, in part, because international development intervention and the need for a high degree of intersectoral coordina- specialists, examining the “world food crisis” of those years and tion contradict the principles of successful implementation and require beginning to recognize the importance of combating malnutrition, a capacity beyond that of most implementing agencies” (Ross and distrusted the ability of nutritionists—and even health ministries—to Posanai 1988 as cited in Levinson 1995). address the problem adequately on their own. The slogan, “Nutrition is too important to be left to nutritionists”, was bantered widely. The collaboration required, and the lack of incentives for collabo- rating, relate to the second main problem: lack of ownership of During this era, a great deal of thinking in academic and develop- the nutrition issue among those expected to contribute to it. The ment circles investigated the causes of malnutrition and their rela- tive importance and interdependence. In 26 countries, multisectoral 19 In some of these units, however, planning ended up being limited to planning units were created with assistance from the U.S. Agency direct nutrition interventions; that is, they weren’t always actually multi- sectoral in reality (Levinson 1995; Field 1987). for International Development (USAID) and the Food and Agriculture 20 There were exceptions: Zimbabwe, for instance. See Tagwireyi and Organization (FAO), with the purpose of coordinating policies and Greiner 1994. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 12 C H A P T E R 5 — M U LT I S E C TO R A L N U T R I T I O N P L A N N I N G A N D I N T E G R AT E D R U R A L D E V E LO P M E N T ( 1970s – 80s ) creation of multisectoral planning units in 26 different countries 3. Consideration of nutrition consequences of projects in would seem to be a positive operational step, but in reality the other sectors22 4. Encouragement of nutrition awareness and analysis by structure could not substitute for true political priority for nutrition incorporating nutritional considerations in sector surveys (Jonsson 2009). What political support there was had to do with and economic reports and through other means. political priority for reducing food shortage, which was perceived to be mainly a problem for agriculture to solve independently. One To give a flavor of the agriculture side of these first three Bank nutri- by one, the country multisectoral planning units dissolved on an tion projects: the main goal of the agriculture components of the average of 6 years after they had started (Levinson 1995). Brazil project was to reach the nutritionally vulnerable, through the agricultural extension service, with access to improved inputs, Multisectoral nutrition planning “did not work because, in all like- and to produce and market low-cost fortified foods making them lihood, it could not work” (Field 1987). The operational reality was more accessible to the poor. This component was very successful prohibitive even where the theory was sound. It did, however, revo- and was replicated in all the Bank’s subsequent rural development lutionize how nutrition was thought about—most fundamentally projects in Brazil (Berg 1987a). In Indonesia, a home and village gar- by identifying the multiple causes of malnutrition, and attempting den program was implemented as part of the project, with appar- to find solutions to those causes that were most limiting to better ently successful consumption and marketing impacts, although it nutrition. “Nutrition has come a long way from the days of fish pro- was not integrated with nutrition education programs as hoped. tein concentrate and lysine fortification as miracle solutions. In the The Colombia project had a subsidized food coupon program, and process, the nutrition planning effort has created a new cadre of also a home gardening program designed to increase vegetable people working at country and regional levels, with a different view intake, including a package of seeds, credit, fertilizer, and agricul- of nutrition problems and how to solve them” (Berg 1987c). The last- tural extension that later expanded to include small-scale livestock ing impact of the multisectoral nutrition planning era is seen, for and fish ponds. The homestead food production component was example, in the UNICEF framework on the causes of malnutrition highly popular and reached over 35,000 households. It consumed (1990) (see figure 6.1). over 1⁄5 of the project budget, but its impact on nutrition was never evaluated (Berg 1987a). 5.2 NUTRITION AT THE BANK 1970s–80s The Tamil Nadu Integrated Nutrition Project (TINP), for many years The Bank’s work in nutrition was conceived in this multisectoral perceived as the Bank’s flagship accomplishment in innovative23 planning era, and was founded on the idea that the Bank had an (and widely since emulated) nutrition programming, initially was important, if not unique, role in delivering multisectoral work. In lay- designed to be “a broadly multi-sectoral project addressing selec- ing out possible types of involvement for the Bank, the 1973 World tive aspects of food production, processing, and storage as well as Bank nutrition policy paper revolved around nutrition as a multisec- the delivery of nutrition and health services” (Berg 1987a). However, toral issue. Three out of four of the strategic approaches focused on “a decision by IDA management to simplify the project” deleted the the Bank’s potential to incorporate nutrition into its overall strategy food track, with an intention of mounting a separate agriculture and the work of other sectors. The four approaches were: project to operate in parallel with the nutrition project—this then 1. Financing nutrition projects (with an initial emphasis on design of an overall nutrition strategy) 22 Agriculture was the field primarily highlighted. 23 “The innovative features of the nutrition delivery component of the TINP 2. Addition of nutrition components to projects in other include the following: Weight surveillance of children in the target age sectors21 group 7–36 months; selective supplementary feeding for a limited pe- riod of time for children identified as malnourished through the weight surveillance system; Service delivery centers around a village-based community nutrition worker (CNW) with well-defined responsibilities 21 The paper specified these other sectors to be “especially food process- and supported by intensive training and continuous close supervision; ing, rural development, population, certain types of agriculture and edu- Close collaboration between nutrition and health personnel at the level cation projects, and perhaps water supply.” of service delivery” (World Bank 1982). L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 5 — M U LT I S E C TO R A L N U T R I T I O N P L A N N I N G A N D I N T E G R AT E D R U R A L D E V E LO P M E N T ( 1970s – 80s ) 13 was to provide the same integrated effect as the original design.24 from other sectors, namely education and roads, met the definition, That agriculture project, however, never materialized. In Senegal they were also categorized as rural development. During FY68–74, there was a similar outcome from a decision to simplify operations. the Bank/International Development Association (IDA) lending for rural development totaled $1.1 billion (of which 92  percent was The push to simplify the design of the “second generation” nutrition for agriculture, 4.4 percent for roads and 3.4 percent for education) projects does not seem related to the success or value of agriculture (World Bank 1975, Annex 11). Therefore, almost all rural develop- components in the first three nutrition projects, as those had been ment projects were, in fact, agriculture projects. quite successful. Rather, TINP began around the same time when “integrated rural development projects” elsewhere in the Bank were The majority of the Bank’s agriculture projects (73 percent), however, failing. The resulting anathema to integrated or multisectoral projects did not claim to be rural development projects, or designed to have a extended to nutrition proposals by association. Similarly, when efforts targeted focus on the rural poor according to the definition that was were made for a more consequential nutrition role inside agriculture used at the time.26 In fact an independent evaluation report of the projects, the proposed nutrition components commonly became Bank’s rural development program (World Bank OED 1987) even calls casualties of the Bank’s aim to avoid potential “Christmas tree” proj- the agriculture projects that are not also rural development projects 25 ects. This concern about perceived complexity served as the main “nonpoverty (agriculture)” projects. One of the main conclusions of constraint for developing combined nutrition/agriculture projects. the independent evaluation of the Bank’s rural development program (FY65–86) was that despite the overall objective being poverty alle- viation, the Bank’s rural development program was not intended to 5.3 AGRICULTURE AT THE BANK 1970s–80s target the poorest of the rural poor, that is, the landless and laborers, To operationalize the President’s 1973 Nairobi speech that identi- since it was aimed primarily at smallholders with their own land. fied rural development as the main vehicle for poverty reduction, the Bank issued a Rural Development Sector Policy paper (World One of the key mechanisms for rural development was through Bank 1975). The goal of the Bank’s new policy was to reduce pov- integrated rural development projects (sometimes also referred to as erty through increased production and productivity. There was a area development projects). These projects tended to have an ambi- clear recognition that rural development should involve multiple tiously broad set of activities rolled into a single project in a rural sectors and thus should aim for improved productivity, increased area. The description of integrated rural development projects as employment, resulting in higher incomes for target groups, as well loosely defined in the Operations Evaluation Department (OED) as increased access to minimum acceptable levels of food, shelter, report (1987): an integrated rural development project would education, and health. To further emphasize the focus on rural involve two or more components, usually multisectoral, and these development for poverty alleviation, a definition of a rural develop- would include both social and productive activities. Prior to the late ment project was crafted as a project where 50 percent or more of 1990s, project documents were not required to explicitly identify primary (direct) benefits are intended to accrue to the rural poor. sector or thematic codes. Therefore, it is difficult to know the exact Therefore, some agriculture projects, if they met the definition, portfolio size or trend of integrated rural development projects. In would also be categorized as rural development projects. If projects at least 18 of these integrated rural development projects,27 nutri- tion was tackled in some form or other (see appendix B). In some 24 “The Region . . . supported the more focused approach [of TINP], in view 26 During FY68–74 lending for all agriculture (including those not labeled of the Bank’s own difficulties in staffing and coordinating the prepara- as rural development) was $3.7 billion, and total Bank/IDA lending tion and supervision of complex cross-sectoral projects, our relative lack was $18.2 billion. Therefore, agriculture was 20 percent of total Bank/ of experience in nutrition, and the Borrowers’ difficulties in coordinating IDA lending, and of total agriculture lending, agriculture projects that multi-sectoral projects, particularly in view of the general weakness of were also categorized as rural development comprised 27 percent of departments of health and social welfare” (Choksi 1984). total agriculture lending (5 percent of total Bank/IDA lending) (data from 25 This pejorative term implies that seemingly interesting components Annex 11 of 1975 Sector Policy Paper). are added on like ornaments, with little added value compared to the 27 The breakdown of the18 projects is as follows: Brazil [10], China, Mauri- increasing complexity. tius, Mexico [3], Papua New Guinea and the Philippines [2]. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 14 C H A P T E R 5 — M U LT I S E C TO R A L N U T R I T I O N P L A N N I N G A N D I N T E G R AT E D R U R A L D E V E LO P M E N T ( 1970s – 80s ) cases, it was through health interventions such as the Philippines and intended beneficiaries were achieved or reached, as well as Rainfed Agricultural Development Project—Iloilo (FY80) where salt timeliness of disbursement. The report suggested that a parallel iodization, iron/folate tablet distribution, and diarrhea management approach to relieving constraints through several projects over a measures were undertaken. In other cases it was through nutrition longer period is often preferable over complex integrated multi- sensitive agricultural interventions such as in the Mauritius Rural sectoral approaches. Development Project (FY73) where self-help groups, including Although the majority of integrated rural development projects kitchen gardening, construction of fish-ponds, duck, poultry, and were unsuccessful as a whole, there is no information regarding rabbit raising, were supported. nutrition results. None of the 18 integrated rural development proj- It is difficult to say precisely when integrated rural development ects that included aspects of nutrition explicitly measured any prog- projects began to fall out of favor at the Bank (due to the fact that ress toward nutritional outcomes for even intermediary outcomes historical project category coding information is unavailable in the such as level of increase in consumption of nutritious foods. This is current portfolio software), but the 1987 OED report clearly pre- despite the fact that most of these projects cited high malnutrition sented the poor performance of these projects, especially in Africa, rates among the target population as a major justification for the and this must have accelerated its decline. For the period studied project to begin with. In the Implementation Completion Report of (1965–86), integrated rural development projects comprised the Brazil Northeast Rural Development projects, one of the lessons 40  percent of all rural development projects and 55  percent of learned is to include in future operations “monitorable indicators on them were in Africa (hence 22 percent of the total rural develop- communities’ nutritional/health status.” Partly because of the weak ment portfolio consisted of integrated rural development proj- monitoring of these nutrition components, unfortunately—unlike ects in Africa). Half of the audits of integrated rural development the Bank’s self-standing nutrition projects (Berg 1987a)—there projects indicated a failure (and ⁄3 of the failures were in Africa), 2 is very little assessment of the performance of nutrition-related mainly owing to an ambitious and overly complex multisectoral activities. No significant lessons learned regarding nutrition from project design which precluded local participation and had to be these projects appear in the Implementation Completion Reports, 28 centrally managed. The assessment was based on standard meth- or in any reports produced by the Bank’s Agriculture and Rural odologies for project evaluation, namely examining the extent to Development department at that time, or by the Bank’s indepen- which intended objectives, expected economic rates of return, dent evaluation unit. 28 The complex nature of these projects meant that projects faced com- mon problems. The OED report summarized some of the challenges of integrated rural development projects in the following way: “formal coordination arrangements between what amount to competing, or at best indifferent government agencies almost never worked as planned; project research components produced very little of lasting value and, in any case, at a much later date than could make a serious contribution to project returns, internationally recruited staff have difficulty fulfilling intended training functions; and, contrary to assumptions, viable tech- nical packages were frequently either not available at all, not properly identified, or were of only modest potential. . . . Finally, the Bank never developed its own staff, expertise of an integrated structure to respond fully to the needs of these complex projects.” On the last point, the same OED report noted that “treating the development of rural areas as an off- shoot of agricultural (production) development, as has been customary in the Bank, tends to overlook the more complex multisectoral nature of the rural development task.” L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 6 — N U T R I T I O N I S O L AT I O N I S M A N D E R A O F LO W G LO B A L F O O D P R I C E S ( 1980s – 2008 ) 15 Chapter 6 NUTRITION ISOLATIONISM AND ERA OF LOW GLOBAL FOOD PRICES (1980s–2008) 6.1 GENERAL TREND causes and consequences of malnutrition. The 1990s–2000s were Despite the success of the small group of multisectoral nutrition pro- an important time period for building a strong evidence base in grams by the Bank and others, the difficulties of multisectoral plan- nutrition that could motivate political will and action, based on new ning and disenchantment with food as a focus for nutrition caused a data, research, evaluation, and analysis. shift in direction, toward a sector-specific approach, that is, the devel- Nationally representative data on child anthropometry were opment of nutrition as its own “sector.” The projected famines in India becoming available in a large number of countries.30 In the mid- had not materialized; yet rates of undernourishment there were not 1990s, new publications showed that undernutrition was the single declining substantially, either. Micronutrient supply data showed low largest cause of child death, responsible for over 50 percent of child increases if any in vitamin A and iron supply (Uvin 1994). The nutri- deaths because of the synergistic effect of undernutrition and infec- tion community’s lack of success convincing other sectors to tackle tious disease (Pelletier et al. 1995a). These epidemiologic analyses nutrition through complex coordination and planning led to a period showed conclusively that undernourished children who fell ill were sometimes referred to as “nutrition isolationism” which focused on much more likely to die than well-nourished children; and that the direct nutrition interventions (such as micronutrients, breastfeeding vast majority of child deaths were due to mild and moderate under- promotion, child feeding) that did not require multisectoral involve- nutrition, rather than severe.31 ment (Levinson, Balarajan, and Marini 2013). After struggling with what seemed to be an serious lack of political commitment and The term “hidden hunger” also arose in the 1990s—in particular at capacity to address nutrition, direct nutrition interventions were the 1991 Ending Hidden Hunger conference in Montreal cospon- much less politically difficult, as they did not require a substantial sored by WHO, UNICEF, and the World Bank—as the evidence grew change to food systems, or economic, social, and gender inequali- around the consequences of micronutrient deficiency, and its ties that are the basic causes of malnutrition. According to Reutlinger prevalence. Micronutrient deficiencies are harder to survey than body (1993), micronutrient programs could “reduce human suffering yet size, requiring either costly blood samples or imprecise estimates do not threaten the existing economic and political structures.” based on clinical signs; and national data were unavailable on the prevalence of iron, vitamin A, and iodine deficiency until around During this era, rife with internal struggles,29 nutrition came into its 1990.32 (They are still updated only infrequently.) Within the nutrition own and worked on getting the story straight with regard to the 30 Demographic and Health Surveys started in 1984. 29 As recently as 2008, the field of international nutrition was described as follows: “The international nutrition system—made up of international and 31 Earlier analyses of clinical observations had suggested a similarly large donor organisations, academia, civil society, and the private sector—is frag- role of undernutrition in child mortality (Scrimshaw 1968), but were mented and dysfunctional” (Morris et al. 2008). In a survey of international based on less reliable data, in the absence of population anthropom- nutrition professionals, “Infighting and the absence of consensus on pri- etry data.The malnutrition-mortality association was examined in many orities was cited (from among 13 options) as the main disappointment or subsequent studies, all finding large fractions of mortality due to under- negative factor” limiting progress in international nutrition (Berg, Levinson, nutrition, most notably nearly 30 years later in the new Lancet series on and Moorthy 2008). Ten years earlier, a survey of the nutrition community undernutrition (2013), where Black et al. reported 45 percent of deaths also found infighting to be the primary negative factor limiting progress. attributable to undernutrition. One respondent wrote: “Name me a country, and I’ll name you at least two 32 Before that, micronutrient deficiency prevalence was estimated from nutritionists who don’t talk to one another” (Levinson 1997, 2000). FAO food balance sheets (see UNSCN 1987). A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 16 C H A P T E R 6 — N U T R I T I O N I S O L AT I O N I S M A N D E R A O F LO W G LO B A L F O O D P R I C E S ( 1980s – 2008 ) community at this  time, the primary tools to address vitamin and A major conceptual advance, honed from the past multisectoral mineral deficiencies were supplementation and fortification, with planning era, was the UNICEF framework on the causes of malnu- comparatively little emphasis placed on food diversification. Focus on trition (figure 6.1), accompanied by the “triple A” cycle of assess- micronutrients alone became almost a single-minded focus in some ment, analysis, and action for nutrition (UNICEF 1990). This figure countries and agencies from the mid-90s to mid-2000s, sometimes communicates a complex phenomenon succinctly and effectively, to the exclusion of other work needed for addressing undernutrition to unprecedented agreement among nutrition experts (Pelletier 33,34 (Schuftan, Ramalingaswami, and Levinson 1998, World Bank 2006). 2002). The UNICEF framework shows the three underlying causes of malnutrition as lack of access to adequate food, unclean environ- Given the increasing clarity around the alarming correlates of poor ments and lack of access to health care, and inadequate care and nutritional status, it was perhaps not surprising that the focus was feeding practices (“food, health, and care” in shorthand).36 on activities that directly affected health and nutritional status out- comes, such as micronutrient supplementation, supplementary The placement of health and care on par with food in the widely feeding, immunization, community-based treatment of infectious accepted framework was part of the process in the 1980s and 1990s disease such as diarrhea, and breastfeeding. Randomized controlled debunking the presumption that good nutrition depends only on trials of direct interventions showed striking results. A landmark meta- food.37 It was clear that food, at least as it was conceived and mea- analysis of vitamin A supplementation trials showed that twice-yearly sured in the preceding decade where a “food crisis” loomed, was doses reduced child mortality by 23 percent (Beaton et al. 1993). This not solving the problem of malnutrition, even as calorie availability was a major rationale to focus scarce nutrition resources on such an steadily grew as a result of the Green Revolution. Within the agricul- inexpensive and cost-effective intervention. ture sector, the most relevant contributions to reducing hunger and malnutrition were perceived to be increasing global food supply Emphasis on breastfeeding promotion was also based on new data and incomes, which nutritionists increasingly challenged as over- and trends. Breastfeeding rates had precipitously declined world- simplified (Berg 1970; World Bank 1981; Berg 1992). wide in the 1950s–70s, and were declared a “crisis” as early as 1973 (Berg 1973). Infant formula was being marketed in low-income Yet the field of nutrition was not offering an alternative to the over- countries by the 1960s, with profoundly harmful effects on child simplification of food security; it was not substantively challenging morbidity and mortality, in large part due to the infant formula the notion of “food” as a one-dimensional construct summarized as being mixed with contaminated water, watered down, or fed from “calories.” In the UN Standing Committee on Nutrition’s38 First Report unclean bottles.35 By 1981, the UN had released the International on the World Nutrition Situation in 1987, dietary energy supply per Code of Marketing of Breast-Milk Substitutes (UN 1981) based on capita was the only indicator reported with prevalence of under- strong and growing evidence of the importance of breastfeeding to weight. By the Second Report on the World Nutrition Situation in child nutrition and survival. 1992–93, many more indicators were added to reflect the “health” and “care” domains of the UNICEF framework but derivatives of 33 One viewpoint: “the attention of the nutrition community and the dietary energy supply remained the only indicator for “food.” While the resources of donors are more attracted by the glamour of micronu- trients, a largely technical and often top-down solution (as close to a nutrition community was focusing on developing knowledge and quick fix bullet as we are likely to get in this field), than by the politically sensitive business of poverty alleviation, people’s empowerment, and indicators for the “health” and “care” domains, and still stinging from equality, necessary to ensure that mothers and children have access to unsuccessful multisectoral collaboration attempts in the 1970s–80s, it health and educational services and adequate food to eat” (Schuftan et al. 1998 as quoted in Allen 2000). left the “food” domain alone, allowing “food” to be defined as access to 34 The authors of the World Bank report Repositioning Nutrition as Central to Development (2006) wrote, “While we strongly endorse the need to take the micronutrients agenda to completion, it must not crowd out 36 The identification of these as the major causes of undernutrition was the need for attention to general undernutrition, as has been the expe- not new (Berg 1973), but its pithy communication of them in a single rience in several countries and agencies over the past decade” (World graphic, and its wide acceptance, was important (World Bank and Bank 2006). UNICEF 2002). 35 The marketing of breast-milk substitutes has been the most profound 37 See, for example, Pelletier 2002. contribution to mistrust of the private sector in the nutrition community. 38 At the time, it was called the ACC Sub-Committee on Nutrition. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 6 — N U T R I T I O N I S O L AT I O N I S M A N D E R A O F LO W G LO B A L F O O D P R I C E S ( 1980s – 2008 ) 17 FIGURE 6.1: Causes of Malnutrition Malnutrition Manifestations and death Inadequate Immediate Disease dietary intake causes Insufficient Insufficient Inadequate Underlying health services & household maternal & child causes unhealthy environment food security care Formal and nonformal institutions Political and ideological superstructure Basic causes Economic structure Potential resources Source: UNICEF 1990. calories.39 Still today, remarkably, the percent lacking access to calories to invest in agriculture. The share of public spending on agriculture (undernourishment) is the only prominent indicator for food security in Asian countries halved from 14 to 7 percent between 1980 and used globally. This time period represents a critical and lengthy depar- 2004, and in Africa, it declined from about 7 to 4 percent. The share ture of the nutrition community, broadly, from dealing with access to of overseas development assistance to agriculture (by all donors nutritious food; although perhaps it was consistent with its earliest as reported by the Organisation for Economic Co-operation and roots, bypassing the food problem via isolated nutrients. Development (OECD)) halved from its peak of about 18 percent to 9 percent by the late 1980s and then again to about 4 percent by By 1977 real-world grain prices were half the 1974 levels, and by 2000 the early 2000s (Fardoust, Kim, and Sepulveda 2011). they were about one-quarter the 1974 levels. By the early 1980s, grain stocks had risen to burdensome levels. The significant decline in global food prices led to complacency about the continued need 6.2 NUTRITION AT THE BANK 1980s–2008 Almost all of the Bank’s work in nutrition had taken place during this 39 There were, in fact, developments on food security measurement and definition in the 1990s and into the 2000s (for example, in USAID’s FANTA era, except for the first four projects (described above). The size of Project), as well as operations (particularly in FAO). These efforts did not nutrition operations generated by Bank lending, from the establish- change the dominance of the dietary energy per capita indicator as the indicator used for food security. ment of the nutrition program in 1973 to 1998, was $2.1 billion, far A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 18 C H A P T E R 6 — N U T R I T I O N I S O L AT I O N I S M A N D E R A O F LO W G LO B A L F O O D P R I C E S ( 1980s – 2008 ) exceeding all other development agencies combined (Alan  Berg, BOX 6.1: The Bank’s Nutrition Advisory Service: An Attempt personal communication). 40 For most of this period, however, to Facilitate Nutrition-Sensitive Action nutrition at the Bank did not embrace “nutrition isolationism” The World Bank’s Health, Nutrition, and Population central unit per se—no doubt partly because it was led for many years by strong managed a Nutrition Advisory Service in the 1990s that was advocates for the strengths of multisectoral nutrition planning. essentially an internal consulting firm to meet the demand The nutrition unit tried to reach out to other sectors, particularly from Bank project task managers who were looking for consul- agriculture,41 while continuing to increase projects implementing tants on missions to help incorporate nutrition into projects. It was created because staff in other sectors did not have the the lower-hanging fruits: the nutrition-specific interventions such as knowledge, training, or capacity to be able to incorporate nu- micronutrients, infant feeding, and community-based nutrition. The trition effectively into their work; even if they understood its nutrition unit even offered a Nutrition Advisory Service with the aim importance. The activities of the NAS included writing terms of of providing nutrition expertise, free of charge, to help other sectors reference, locating and managing consultants, and reviewing their performance. It also served as a knowledge community incorporate nutrition into their activities (see box 6.1). Bank analytic that produced a nutrition toolkit (World Bank 1996), and held work consistently discussed the need for action in agriculture. seminars, trainings, and debriefings from task managers who had used the consultant service. The service was partially fund- Discussions about the Bank’s nutrition policy objectives and pri- ed by operations, and partly by trust funds provided by specific orities were held with senior management throughout the 1980s. countries, such as Japan and Norway. At its peak year, 138 staff Noteworthy from this history is that each reexamination concluded weeks were provided (Alan Berg, personal communication). with identical policy objectives and priorities regarding the link with According to Judith McGuire, who managed the Nutrition Advisory Service, “There was a big uptick in action on nutrition agriculture: primarily, to include nutrition and food consumption of because of the Nutrition Advisory Service. It made it easy for low-income groups as an explicit objective, and to ensure that their task managers to include nutrition.” That said, the majority of effects did not contribute to worsening nutritional status (including requests for help with nutrition came from the health sector. for those who were not direct program beneficiaries) (World Bank Those who managed the service recalled that it was difficult to 1980; Pinstrup-Andersen 1981; Koffsky 1982; Reutlinger 1983; Berg generate interest among agriculture task managers. Affiliated Nutrition Advisory Service consultants interviewed could not et al. 1986; Berg 1987a). In nearly all of the papers and related exten- recall any specific agriculture project that used the service. sive high-level deliberations held on nutrition, the significance of the nutrition/agriculture nexus was explicit.42 primarily engaged in honing direct interventions.43 Concurrently, the The nutrition issue was not high on political agendas in general. development community at large, including agriculture, saw no rea- There was no unified push from the nutrition community, which was son to prioritize nutrition when their main mission regarding “nutri- tion” was apparently being accomplished quite well: global food 40 At any given time, the nutrition budget and staffing was only a small supply was more than adequate to meet caloric needs of humanity fraction of the size of that in agriculture and rural development. from 1980–2008, with food prices steadily falling.44 This attitude pre- 41 In a correspondence with Agriculture and Rural Development Depart- ment (AGR) staff, the senior nutrition adviser wrote, “You are right that we ‘do not appear particularly comfortable’ with the way Bank agricul- 43 As of 1980, the evidence problems were laid out thus: “We have no clear tural sector work covers nutrition. I think it is fair to say that in most idea of what nutritional interventions work, under what conditions, at sector studies the consumption side of the food issue is neglected. In what costs in relation to what results. No international research mecha- short, to answer your question, ‘there is in my view a need to promote a nisms exist that are giving sustained and systematic attention to get- heightened awareness of nutrition questions in the minds of agricultural ting the answers.”(Chafkin 1980; These sentences were underlined in the project designer and sector analysts. ’ I . . . hope it is an issue we might personal copy of the report by the head of planning in the Population, discuss” (Berg 1984). Health, and Nutrition Department.) 42 The 1980 document, for example, said, “Agriculture and Rural Develop- 44 A sense of this complacency is implied in comments from the nutrition ment Department (AGR) will be responsible for ensuring that nutrition is unit on an early draft of an AGR food security policy paper (later revised adequately considered in agriculture sector work and that Bank agricul- to reflect these comments): “The [nutrition] situation is not under control ture and rural development projects are designed to have the maximum as the paper describes. It is a little glib in the assumption that adequate feasible beneficial impact on nutrition. A senior AGR officer should be aggregate availability takes care of the hunger problem. In the paper, ad- designated as being responsible for these concerns.” (Such a person was equate nutrition is largely used synonymously with adequate food sup- appointed on a part-time basis.) ply. This goes a long way—but is not enough, as we know” (Berg 1983). L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 6 — N U T R I T I O N I S O L AT I O N I S M A N D E R A O F LO W G LO B A L F O O D P R I C E S ( 1980s – 2008 ) 19 vailed both in donor agencies and country governments. So efforts evidence and practice being off the main development radar. The to link agriculture and nutrition on the part of a handful of Bank staff, document’s main recommendation was to position nutrition on the however strong their rationale, were working against the current. poverty and human development agenda. A 1994 Bank publication, Furthermore, internal norms at the Bank, strengthened after nega- “Enriching Lives,” showed that micronutrient interventions are among tive experiences with integrated rural development projects, were the most cost-effective for improving human capital and included an not supportive of multisectoral or cross-sectoral efforts. Although aim that the Bank would “include micronutrient intervention in every the narrative of multisectoral nutrition at the Bank has consistently appropriate Bank project where micronutrient malnutrition exists” been one of the Bank’s theoretical comparative advantages in multi- (and includes an annex listing all the countries with deficiencies in sectoriality, in reality most projects were confined to a single project iodine, vitamin A, and iron). development objective. The recommendation was telling, because it was a thinly veiled In the 10 years from FY97 to FY06, 21 projects with nutrition objec- statement of what was needed within the Bank, not just in coun- tives were approved which amounted to 10 percent of the Health, tries. Between 1999 and 2004, nutrition lending was $400 million, Nutrition, Population Department lending portfolio, plus six addi- amounting to only 2.3 percent of human development sector tional projects with nutrition in the title or nutrition components lending (Heaver 2006), and was very low in 2005. The publication of or subcomponents, for a total of 27 projects. Most of the projects Repositioning Nutrition as Central to Development (2006) was pivotal were general health/maternal and child health projects; only four to reviving interest in nutrition within the World Bank. It successfully were freestanding nutrition projects. The types of interventions presented malnutrition as a key barrier to poverty reduction, and supported by these operations included growth monitoring and ultimately gained senior management support as well as attention nutritional surveillance (100 percent), micronutrient supplements externally. At the decision meeting concluding the report’s peer (52 percent), behavior change (nutrition education, promotion of review, the Senior Vice President of Human Development Jean- growth monitoring, breastfeeding, specific dietary changes, and Louis Sarbib agreed to several significant high-level actions that hygiene [48 percent]), and feeding supplements or rehabilitation of placed nutrition back on the Bank’s agenda, and the Bank’s involve- malnourished children (41 percent). According to the Bank’s inde- ment in the current global agenda for nutrition.45 pendent evaluation group, “the overall performance of the nutrition projects was weak. Only two projects—Indonesia Iodine Deficiency 6.3 AGRICULTURE AT THE BANK 1980s–2008 Control and Senegal Nutrition—demonstrated substantial efficacy In terms of lending volume, in FY72 the amounts of the agriculture in meeting their objectives, with resulting changes in nutritional lending for the International Development Association (IDA) and the outcomes” (World Bank IEG 2009). However, for over half of the International Bank for Reconstruction and Development (IBRD) was nutrition projects the impact was unclear, “often due to the failure $463 million (15 percent of total IDA and IBRD lending) (see figure 6.2). to collect data or report on nutrition outcomes.” Although about half of the nutrition projects from FY97–06 were mul- 45 These actions included a briefing to President Wolfowitz to position nu- trition as a corporate priority within the Human Development frame- tisectoral in implementation (with involvement of the water and sani- work; meetings with regional and central vice presidents and country tation, health, social protection and transport sectors), agriculture was directors; development of a resource mobilization and a capacity devel- opment plan both within the Bank and with client countries to address notably missing. In the World Bank policy paper in 2003 “Combating this agenda; and upstream review by the nutrition team of all Country Assistance Strategies and Poverty Reduction Strategy Papers. Accord- Malnutrition: Time to Act,” agriculture only came up in reference to the ing to the decision meeting minutes: “The four key messages to the ongoing debate on the nutrition narrative and its institutional home. President will focus on: i) There is unequivocal evidence that nutrition is central to economic and social development, ii) most of the mille- Agriculture did not appear in recommendations around “proven best nium development goals (MDGs) will not be met without addressing nutrition issues, iii) we have the choice to act now or to continue to fail, practices”, consensus on “what it will take,” or capacity development. because economic growth and increased food availability are necessary Again, this is likely a consequence of two factors: agriculture and food but not sufficient to improve nutrition; and iv) if we do not act now, we will be repeating the same mistake we made with HIV/AIDS a decade production and the nutrition community’s main recent advances in ago” (World Bank 2005). A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 20 C H A P T E R 6 — N U T R I T I O N I S O L AT I O N I S M A N D E R A O F LO W G LO B A L F O O D P R I C E S ( 1980s – 2008 ) FIGURE 6.2: World Bank Agriculture Lending Volume (in FAO’s undernourishment indicator) declined from 18.9 percent in Nominal Million US$) and Share of Agriculture 1990–92 to 12.0 percent in 2011–13 (FAO 2013b). The food short- in Total World Bank Lending (IDA and IBRD) age that had so motivated intensive investment in agriculture in the 5,000 Ag share in total 45% 1960s–70s on the whole was no longer a crisis. Food aid and trade lending 4,500 Ag lending 40% were thought to be sufficient to address food security crises. 4,000 35% The Bank’s agriculture programming was also greatly influenced 3,500 30% by the Bank’s increasing emphasis in the late 80s to early 90s on 3,000 25% tackling the overall economic crisis in developing countries through 2,500 20% market-oriented approaches, best represented by structural adjust- 2,000 ment operations. Taxation, foreign exchange, and trade policies in 15% 1,500 developing countries were generally biased against agriculture and 10% 1,000 considered to be a key factor in the low performance of the sector 500 5% in most developing countries at the time (Schiff and Valdes 1992). 0 0% The 1986 World Development Report (World Bank 1986a) took up FY50 FY55 FY75 FY80 FY85 FY90 FY95 FY00 FY05 FY10 FY60 FY65 FY70 the issue of trade and pricing policies in the agricultural sector, and the agriculture sector strategy in 1993 (World Bank 1993) empha- This increased drastically after President McNamara’s 1973 speech sized getting prices right and getting the macro and sectoral envi- and its call for “rural development” as the main tool for the Bank’s new ronment right in order for the sector to function. An independent goal of poverty reduction. Agriculture lending peaked in FY86 at $4.4 evaluation report stated that “in agriculture, after 1991, the World billion (27 percent of total IDA and IBRD lending). Since then, Bank Bank truly goes to market.” lending to agriculture gradually decreased as developing countries The agricultural adjustment loans that arose during this time gener- and the development community’s overall interest shifted away from ally had little focus on consumption issues in general.47 An indepen- agriculture and more toward new competing concerns such as the dent evaluation report (Meerman 1997) found that most agricultural emerging health crisis (particularly HIV/AIDS), gender issues (espe- adjustment loans FY79–FY95 ignored food security entirely.48 In the cially girls’ education), the environment, infrastructure, and energy. few cases where agricultural adjustment loans addressed food secu- The decline in agricultural lending was a response to rising food sup- rity, it was through reform or elimination of costly food subsidies for ply that led to the growth of surplus stocks and lowered world grain consumers which were a drain on the country’s fiscal position, and/ prices, which led to lower preappraisal economic rates of return for or some “social components” that were intended to ease the pain some projects, enough to remove them from consideration for Bank for the poor due to reforms introduced by the project. The design of funding (Lipton and Paarlberg 1989). Another factor was the almost the Morocco Second Agriculture Sector Adjustment Project (FY87) across the board high project failure rates in the agriculture lending program, as seen in: subsidized credit that was found to be regres- 47 The strategy indicated that food security issues would be supported sive with weak cost recovery; the heavily promoted Training and through targeted assistance programs and through successful comple- tion of global trade talks. Visit (T&V) extension system with low sustainability (which was ulti- 48 Meerman (1997) reported that only 6 out of 50 Agriculture Sector mately abandoned); and the overly complex and failed integrated Adjustment Loans (AGSECALs) addressed food security issues (Jamaica, Kenya, Madagascar [1986], Mauritania, Mexico [1992], Morocco). Further rural development programs.46 The prevalence of hunger (using review by this paper’s authors indicated that three other AGSECALs (Burkina Faso, Mexico [1988], and Somalia) also dealt with issues of food security as loosely defined by OED as “the degree to which an individual 46 In 1987, the proportion of agriculture and rural development project or group has adequate nutrition at all times.” Therefore, we consider that with ex-post rates of return below 10 percent was 39 percent, compared out of 50 AGSECALs between 1979 and 1995, at least nine AGSECAL to 17–25 percent in other sectors (World Bank Operations Evaluation addressed food security in some way, and some also addressed nutri- Department 1987). tion explicitly (see appendix B.2). L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 6 — N U T R I T I O N I S O L AT I O N I S M A N D E R A O F LO W G LO B A L F O O D P R I C E S ( 1980s – 2008 ) 21 stood out among the agricultural adjustment loans that addressed President Kim Jaycox said the initiative would constitute “a major food security because it focused on nutrition through the selection shift in the way we are going to do business,” and Senior Vice 49 of a nutrient-rich kind of flour as the target of the subsidy. President of Operations Moeen Qureshi said the food security effort would be “center stage” in African operations. By 1990, SDA was Despite the backdrop of low overall agricultural lending, of which carried out in 29 countries but in practice, the SDA mostly limited very little was earmarked for food security, the rhetoric about food its work to statistical procedures and data collection, doing little to security was increasing globally and within the Bank as the world spark new lending approaches as had been intended (Kapur, Lewis, experienced periodic famine crises. During this era, agriculture’s and Webb 1997). As the studies were slow in being mounted and involvement in food security or nutrition was largely through then generally took far longer than anticipated to execute, the crisis nonproject knowledge activities. Perhaps the pinnacle of intel- by then had abated somewhat and only a handful of related opera- lectual enthusiasm by the Bank’s agriculture community was tions materialized.51 In short, the food security initiative petered out seen at the 1993 Bank-sponsored conference on “Overcoming and fell far short of expectations. Global Hunger.” This heralded event brought to Washington the likes of the UN Secretary-General  Boutros Boutros-Ghali, former During this period, there was also a disconnect between what was President Jimmy Carter, the President of Botswana who had just written in Agriculture and Rural Development strategies, and what won the World Food Prize, Nobel Laureates  Amartya  Sen and actions were actually taken. Two agriculture sector strategies (“From Mohammad  Yunus, the president and much of the Bank’s top Vision to Action” [1997] and “Reaching the Rural Poor” [2003]) were management and heads of several international development quite explicit in their stated goals for nutrition, as part of the Bank’s agencies and major nongovernmental organizations (NGOs). agriculture work. Bank Vice President Ismail Serageldin, the organizer and chair of The 1997 strategy (“From Vision to Action”) acknowledged food the conference, contended “food security is about access and consumption and nutrition policy as one of the “long-ignored nutrition as much as about production.” issues” (together with land reform) and called on itself to: The conference had been preceded in 1987 by the establishment 1. Better integrate its food and nutrition policy into rural sec- of a Task Force on Food Security in Africa headed by Africa Vice tor strategies and country assistance strategies President Kim Jaycox.50 This led to the creation of a small Food 2. Better incorporate food policy and nutrition into its lend- Security Unit within the Africa region but otherwise had relatively ing activities, specifically including them in pilots, adjust- ment operations, sector investment loans, and safety net little interaction with the Bank’s regular work program. The Task operations Force was accompanied by a separate initiative called the Social 3. Include in nonlending assistance to partner countries Dimensions of Adjustment program (SDA) cofunded by France policy advice that addresses consumption effects of agri- and United Nations Development Program to create data and cultural policies methodologies for developing targeted poverty programs in Africa The 2003 strategy (“Reaching the Rural Poor”) was even more ambi- by training government officials, and carrying out pilot projects tious in terms of its attempt to address a whole array of impacts that combined social welfare and income objectives. Africa Vice through agriculture and rural development, including nutrition. Specifically, a new area on social well-being included language on 49 In this Morocco AGSECAL, the project supported the government in reducing the core food subsidy program to a single commodity, that improving access to nutrition and health services and improving is, wheat flour, but of a less-refined high extraction rate flour, which is an “inferior good” as well as being nutritionally rich (high in bran content). 50 This was accompanied by a World Bank food security policy paper 51 Of the hundreds of investment operations for Sub-Saharan Africa (World Bank 1986b). Comments from the Population, Health, and Nu- approved by the Bank in the 8 years after food security was assigned trition department to an early draft of the policy emphasized that in- “center stage,” only six self-standing food security projects emerged and creased coordination and resources would be necessary for implement- it is not clear that any of those had their roots in the food security studies ing food security actions. (Schebeck 1983 and Berg 1983). (Alan Berg, personal communication). A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 22 C H A P T E R 6 — N U T R I T I O N I S O L AT I O N I S M A N D E R A O F LO W G LO B A L F O O D P R I C E S ( 1980s – 2008 ) food security for the rural poor. To improve health and nutrition Although the social well-being pillar was the second largest among outcomes, the stated actions were: the five pillars, a mid-term implementation review made no men- tion of nutrition.53 1. Advocate the interest of the rural poor to ensure that gov- ernment resources for health are not biased toward urban Despite the significant calls to action for food security in the constituents 1980s–90s (especially in Africa), it appears that low food prices and 2. Place greater emphasis on improving dietary quality and micronutrient status (fortification, supplementation, high food stocks, which encouraged developing countries to tax biofortification) the agriculture sector and thus lower its competitiveness ultimately 3. Promote community-driven multisectoral approaches to were the dominant factors resulting in only very modest invest- improving health and nutrition ments in agriculture as a whole, let alone food security or nutrition. 4. Promote the status of women in rural development The rhetoric around “a major shift in the way [the Bank was] going to There is very little evidence to assess progress on these nutrition do business,” and significant mention of nutrition within the Bank’s actions laid out in these comprehensive strategies. A two-phased agriculture strategies, was not aligned with the deliverables toward independent evaluation of the 1997 strategy was positive overall, which agriculture project task managers were held (and held them- but noted a disconnect between the vision and action (World Bank selves) accountable, particularly as there was no evaluation of how 52 OED 1999, 2000). The evaluation stated that “although the principles well the agriculture strategies had addressed food security or nutri- of the rural strategy are generally sound and widely accepted, they are tion. This is reflected in the extremely limited attention to nutrition not always reflected in project work. The challenge is to provide an effec- in the Independent Evaluation Group 2011 evaluation of agriculture tive framework for action, particularly at the country level.” Similarly, and agribusiness. In sum, there were no incentives for agriculture much was stated in the 2003 strategy but not all of it was achieved. projects to have and measure explicit nutrition objectives; and of Some attention was paid to promoting the status of women and the few food security projects there were, lack of M&E related to community-driven approaches in general within agriculture activi- food security and nutrition impact makes it difficult to draw out les- ties, but less on “improving dietary quality and micronutrient status.” sons learned. 52 The evaluation included two specific recommendations: (1) to fine-tune the vision, but emphasize action; and (2) to adopt a two-track recruit- ment strategy where sector specialists would be distinguished from rural development specialists, the latter to be charged with building bridges between the World Bank’s rural family and other families in the 53 Major areas of financing within the social well-being pillar were basic Bank (World Bank OED 2000). There is little evidence to suggest that health care services, education, and provision of clean water and these recommendations were taken up in a systematic way. sanitation. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C h apter 7 — T win - T rack A genda 23 Chapter 7  WIN-TRACK AGENDA: NUTRITION-SPECIFIC T INTERVENTIONS AND NUTRITION-SENSITIVE DEVELOPMENT AMID HIGH INVESTMENT IN AGRICULTURE (2008–PRESENT) 7.1  GENERAL TREND pregnancy and delivery, higher risk of chronic diseases such as dia- Two events in 2008 kick-started the present situation, where betes, and more than a third (revised in 2013 upward to 45 percent) increasingly, improving nutrition through agriculture is high on of all child deaths (Black et al. 2008; Black et al. 2013). Much of this the international development agenda. First, the food price crisis in knowledge was not new in principle; the lost human capital known 2008 rocketed food back onto the international agenda again, after “beyond reasonable doubt” when nutrition work first started at the it had lost priority as prices had fallen since the 1970s. At the same World Bank (Jeliffe 1971).54 But the rigorous review of evidence, the time, the publication of the first Lancet series on maternal and child concise list of prioritized core evidence-based interventions, and undernutrition in 2008 solidified evidence on the consequences of the timing of the series, all aided in widespread acceptance of and undernutrition, which were extraordinarily effectively leveraged by attention to the evidence base. the nutrition community for advocacy. The 2008 Lancet series identified 13 priority evidence-based direct Due to low investments in previous decades, the level of global food nutrition interventions to address maternal and child undernutri- stocks began to decline in 2000, and as a consequence, global food tion. These formed the initial basis for the Scaling Up Nutrition (SUN) markets became more vulnerable to shocks. Real prices reached all- movement, which started as fairly nutrition isolationist, focused on time lows in 2000 and then began a gradual recovery that eventually scaling up the direct interventions. Many stakeholders, however, accelerated and peaked in 2008 before declining again during a global strongly supported including attention to multisectoral efforts. recession. The increase in real food prices since 2000 was similar in A critical early step was drafting the SUN Framework for Action. magnitude to those in the 1970s, with real prices increasing 82 percent Launched at the World Bank/IMF Spring Meetings in April 2010, the from 1972 to 1974 compared with 98 percent from 2000 to 2008. The framework was endorsed by over 100 organizations (governments, price spikes in the 1970s occurred more quickly, however, and were civil society, UN agencies, donors, businesses, and research institu- driven by easily identifiable shocks (large imports by the Soviet Union tions) and marked the official start of the movement. The framework and drought), while the increase from 2000 to 2008 was more gradual laid out the key principles and priorities needed for taking action to and caused by a confluence of factors including weather, biofuels, and address undernutrition, including evidence-based nutrition specific speculation. Against this background, global attention began to shift interventions (such as including promotion of breastfeeding and back to agriculture (Fardoust, Kim, and Sepulveda 2011). 54 A peer review comment to the World Bank’s Repositioning Nutrition as Central to Development (2006), which presented evidence about the On the nutrition side, the 2008 Lancet series’ key conclusions were burden of malnutrition, noted: “The nutritionand human capital litera- that undernutrition experienced in the period of pregnancy and ture of the 60s and 70s says essentially all that this paper says about the burden of nutritional causes, the economic costs and consequences of the first 2 years of life (roughly the first 1,000 days) had typically that burden, and what can be done in cost-efficient ways to address those problems. Knowledge has not been a problem. The problem has irreversible consequences on cognitive development and physical been the failure of the Bank and others institutionally to keep up with growth and stature, and that these resulted in lower IQ, delayed knowledge and to act on it, and the mistaken approach of acting as if other goals could be met in the absence of nutritional improvements” and less schooling, lower income in adulthood, higher risks during (World Bank 2005). A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 24 CHAPTER 7 — T WIN-TRACK AGENDA micronutrient supplementation), along with investments in nutri- BOX 7.1: The Quality Protein Maize Story tion sensitive actions delivered through several sectors, including agriculture. Serious efforts to improve the nutritional quality of  maize endosperm protein began in the mid-1960s at the Inter- The SUN movement is the first time that a wide-ranging coalition national Maize and Wheat Improvement Center (CIMMYT) in Mexico, which would later become one of the founding cen- of stakeholders came together in a united front to elevate the ters of the Consultative Group on International Agricultural fundamental importance of the problem of undernutrition and Research (CGIAR). Research on developing a maize variety the feasibility of effectively addressing it. As of today, 50 countries with improved protein quality was a direct response to protein committed to scaling up nutrition have joined the SUN global deficiency, then considered the world’s most pressing nutri- tion problem. Unfortunately, initial efforts in developing what movement, there have been a spate of political advocacy events for later became known as Quality Protein Maize (QPM) produced nutrition, and rising commitments from donors. The 2013 Nutrition maize with up to 25 percent lower yield as well as increased for Growth G8 Summit event committed $4.2 billion for scaling susceptibility to fungal ear rots and storage pests. Its soft tex- up the nutrition-specific interventions, and another $19 billion for ture was also not acceptable in many parts of the world where nutrition-sensitive interventions (Government of UK 2013). consumers are accustomed to harder grain types (Vasal 2000). By the mid-1970s discouragement set in because of the lack While the SUN framework (2010) identified nutrition-specific actions of competitiveness of these varieties and most research proj- ects were either abandoned or drastically reduced. Interest clearly on the basis of the Lancet series, it did not explicitly identify even among the nutrition community had also vanished by what should be done on the nutrition-sensitive side. There is signifi- that time, replaced by concerns of overall food shortage and cant will to invest in nutrition-sensitive agriculture among donors broader causes of malnutrition. It took decades more of patient and SUN countries, but exactly what this should look like is a work plant breeding research at CIMMYT, the University of Natal in in progress—the subject of multiple international meetings and South Africa, and the Crow’s Hybrid Seed Company in Illinois to finally develop competitive traits in the mid-1990s. These mod- other forums, and many written documents (FAO 2013c). A com- ern QPM varieties are currently being actively disseminated, mon vision emerging through all of this conversation is represented particularly in Sub-Saharan Africa (Krivanek et al. 2007). in a consensus statement of Key Recommendations for Improving Nutrition through Agriculture55 (Herforth and Dufour 2013). from emphasizing proteins, then dietary energy, and now micronutri- An important development in agriculture for nutrition is the ents (Per Pinstrup-Andersen, personal communication).56 HarvestPlus initiative by the CGIAR, which develops crops biofortified Similarly, another opportunity where a nutrition problem requires with micronutrients, especially vitamin A, iron, and zinc in staple crops an agricultural solution is in the problem of aflatoxin. Aflatoxins (wheat, rice, maize, phaseolus beans, and cassava). This started in 1995 contaminate crops such as groundnuts and maize, and are highly as a Micronutrient Project within CGIAR to assemble the package of toxic, carcinogenic, fungal metabolites linked to liver disease, stunt- tools that plant breeders need to produce mineral- and vitamin-dense ing, immune system suppression, and death in both humans and cultivars. It differs from the Quality Protein Maize (QPM) initiative in domestic animals. Because of its toxicity, aflatoxin contamination is that this time it is micronutrient content that is being enhanced, and both a food safety and public health issue. Reduction in aflatoxin not protein, as it was earlier (see box 7.1). However, those involved content in crops through research and deployment of aflatoxin recall that at the inception of HarvestPlus, plant breeders were reluc- management practice including new methods for aflatoxin detec- tant to take up the HarvestPlus initiative, recalling their unfortunate tion, crop breeding, biological control, food storage and handling, experience with QPM and the nutrition community’s swift change and postharvest mitigation is one concrete area where agriculture is essential to improving a nutrition problem. 55 These include 10 recommendations for programming (such as empow- ering women, diversifying production, and targeting the vulnerable), and 5 for policy (such as increasing incentives/removing disincentives for nutritious food production, and monitoring access to adequate 56 Per Pinstrup-Andersen was Director General of the International Food nutritious food and dietary quality). Policy Institute (IFPRI) from 1992–2002. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N CHAPTER 7 — T WIN-TRACK AGENDA 25 7.2 NUTRITION AT THE BANK 2008–PRESENT the same time as the SUN Framework, providing cost estimates for The World Bank has been a major partner in developing the current scaling up the delivery of the nutrition-specific interventions. Similar twin-track agenda of nutrition-specific interventions and nutrition- costing analyses are being carried out in the Africa region. Since the sensitive development, and operational and analytic work within launch of the SUN movement, the Bank also developed a guidance nutrition at the Bank reflects it. The Health, Nutrition, and Population note, Improving Nutrition Through Multisectoral Approaches, and sector strategy (World Bank 2007) explicitly built on Repositioning programmatic guidance briefs for agriculture, social protection, and Nutrition as Central to Development (World Bank 2006), highlighting health (World Bank 2013b).59 The briefs were designed to meet the nutrition as an outcome in itself and malnutrition as a constraint to demands for practical, accessible operational guidance for client poverty alleviation and other development outcomes. It stated, “An countries as well as Bank and other development partner staff to ambitious agenda is being implemented for scaling up the nutrition support nutrition-sensitive activities across multiple sectors. portfolio and correcting the declining trend in the Bank’s invest- The SecureNutrition Knowledge Platform: Linking Agriculture, Food ments in nutrition.”57 Catalytic funds, complemented with trust fund Security and Nutrition began in early FY12 and is a cross-sectoral resources from Japan and other donors, were to be used primarily initiative with leadership from Health/Nutrition, Agriculture, and for “rebuilding the Bank’s own staffing capacity to respond to the Poverty Reduction units in the Bank. The goal of SecureNutrition is needs in high-malnutrition burden countries” and “to develop a to bring the agriculture, food security, and nutrition agendas closer shared global action plan for scaling up nutrition” (World Bank 2007). together by engaging with stakeholders both within the Bank and As laid out in the strategy, a batch hire of six full-time nutrition with external partners to address operational knowledge gaps; specialists in 2009 helped to reinvigorate nutrition activities within enable easy access to new information as it becomes available; the Bank across the regions. The SUN movement, which defines the encourage the development of networks between institutions, current twin-track agenda, was launched at the World Bank/IMF governments, program implementers, and individuals; and support Spring Meetings in April 2010. Funding for the Bank’s engagement innovation for improved nutrition outcomes through projects in reflected the twin-track agenda. For example, a trust fund from the agriculture and food security. government of Japan supported a combination of nutrition-specific The Bank is currently funding nutrition projects in 39 countries,60 a and nutrition-sensitive activities as well as pivotal financing of the major increase over FY00–06 when only 16 countries had any nutri- early work of the SUN movement including the development of tion-related activities in any sector (Garrett and El Hag El-Tahir 2008). the SUN Framework for Action which articulated the importance The focus in South Asia is strongly multisectoral; for example, the of both approaches. The internal environment was conducive to South Asia Regional Assistance Strategy (SARAS) for Nutrition (2010– a renewed emphasis on multisectoral work: The Health, Nutrition 2015) was adopted and has helped spearhead nutrition actions. and Population strategy for FY07-12 emphasized multisectoral The objective of SARAS is to expand the scale, scope, and impact approaches for health in general, specifying “strengthen Bank capac- of the region’s work program on nutrition, while building Bank staff ity to advise partner countries on a multisectoral approach to HNP as well as the clients’ commitment to and capacity for multisectoral results” as one of five new strategic directions58 (World Bank 2007). response to the nutrition crisis in the region. World Bank also sup- Analytic work and guidelines have also followed the twin-track ported the development of the Nepal Multi-Sector Nutrition Plan agenda. Scaling Up Nutrition: What will it cost? (2010) was prepared at (Government of Nepal 2012) and is supporting the nutrition and 57 Eighty percent was to be used for regional operations, and the rest for activities such as knowledge management, results monitoring, and 59 The agriculture brief was supported by a background paper (Herforth partnership building. et al. 2012). Previous work supported by the Bank also led to analyses 58 The strategy states, “Multisectorality is one of the most important pillars of working multisectorally in nutrition (Garrett and Natalicchio 2011; of the World Bank’s development work . . . The Bank will strengthen its Pelletier et al. 2012). multisectoral work to help countries and international partners achieve 60 Including 6 South Asia countries, 19 African countries, 8 in Latin America the best possible HNP results” (World Bank 2007). and the Caribbean, 4 in East Asia and the Pacific, and 2 in the Middle East. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 26 CHAPTER 7 — T WIN-TRACK AGENDA food security initiatives within it through the South Asia Food and support countries in producing more food to prevent more people Nutrition Security Initiative (SAFANSI), the 1,000 days project; and from being pushed back into poverty. The agriculture department Nepal Agriculture and Food Security Project (NAFSP). Afghanistan drew up a new “Agriculture Action Plan FY10–12” in 2009 based on is also developing a multisector nutrition plan. The Africa region the WDR to lay out its approach for the greatly increased lending pro- contains the highest number of SUN countries, and numerous new gram in agriculture. The five pillars of the Action Plan were as follows: projects and project components (including within agriculture in 1. Raise agricultural productivity. some countries) are focusing on nutrition in the region. The Latin 2. Link farmers to markets and strengthen value chains. America and Caribbean region has published a regional companion 3. Reduce risk and vulnerability. piece to the global multisectoral guidance note for agriculture, dem- 4. Facilitate agricultural entry and exit, and rural nonfarm onstrating strong interest in linking agriculture and nutrition (World income. Bank 2014). The East Asia and Pacific region is developing a regional 5. Enhance environmental services and sustainability. strategy for nutrition. Several countries in the region have projects Following the overall conceptual framework of the WDR, nutrition to address nutrition, and there are discussions in several countries is noticeably missing in the description of any of the pillars, which about addressing the double burden of undernutrition and obesity reflects the fact that despite two earlier ambitious rural strategies, (for example, Indonesia; see World Bank 2013c). which included concrete actions for nutrition (and many other issues), it had failed to enter into the mainstream of business line in agriculture. Nutrition was not included in the Agriculture Action 7.3 AGRICULTURE AT THE BANK 2008–PRESENT Plan FY10–12 (World Bank 2009). That plan was intentionally not After the food price crisis starting in 2008, the World Bank announced developed as a strategy that would require extensive and costly a “new deal in agriculture” where agriculture lending would double. consultation. It was developed as an action plan, which would be a Bank lending for agriculture reversed course after a bottoming out more pragmatic and operational document intended to guide the in FY00 at $872 million (6 percent of total International Development overall direction of the Bank’s programming for the agriculture sec- Association [IDA] and International Bank for Reconstruction and tor. In fact, the word “nutrition” appears only once in the Agriculture Development [IBRD] lending), and then jumped up after the first Action Plan: in the context of animal nutrition.61 There is no mention global food price hike in 2008, and in FY12 recorded a lending vol- of human nutrition in the document. ume of $5.1 billion (or 15 percent of total Bank lending). The Bank also There is a noticeable difference in the second Agriculture Action established a response mechanism to the food price crisis, the Global Plan FY13–15 (World Bank 2013a). By that time, the SUN movement Food Price Crisis Response Program (GFRP) from its own funds as well was launched and there was wider recognition that multisectoral as with external donor funds. The World Bank released the 2008 World actions, including those in agriculture, would be key to reducing Development Report: Agriculture for Development, setting the stage child undernutrition. The second Agriculture Action Plan main- for its return to agriculture (from a more broad rural development tained the same five pillars as in the first action plan, but also intro- approach). The report laid out a strong case for the power of agricul- duced seven areas62 to which the Bank would give more emphasis. ture for pro-poor economic growth, as a source of livelihood, and as a The second Action Plan recognizes that food production increases provider of environmental services. Despite the comprehensive cov- do not automatically translate into improved nutritional outcomes erage of issues in the sector, nutrition was dealt with only minimally as part of a two-page “focus” piece on the links between agricultural production and food security. The World Development Report (WDR) 61 “ . . . the World Bank Group will support improvements of nutrition and genetics of ruminant livestock, storage and capture technologies for was an influential piece for the Bank’s agriculture work to correct the manure, and conversions of emissions into biogas.” past neglect of agriculture in general, to address the sudden food 62 The seven areas are: climate-smart agriculture, private sector response, risk management, nutrition, gender, governance challenges, and land- price crisis, and the urgent need for the development community to scape approaches. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N CHAPTER 7 — T WIN-TRACK AGENDA 27 for vulnerable groups and thus calls for investments in areas such BOX 7.2: Nepal Agriculture and Food Security Project (NAFSP: as women-focused agriculture, adoption of biofortified crops, Funded by the Global Agriculture and Food Security Program, GAFSP) food fortification, crop diversification to food with high nutrient content, and increased nutrition education through extension and The objective of the project is to enhance food and nutritional livelihood projects. The Action Plan indicates the Bank’s agriculture security of vulnerable communities in selected locations of department’s intention to “increase the share of agriculture projects Nepal. The Project Appraisal Document (2012) states, “Food with an explicit focus on nutrition.” 63 Some agriculture projects with security will be realized through increased food availability, a strong nutrition focus are emerging such as the Nepal Agriculture made possible by increasing productivity of agriculture (both crop and livestock); and nutrition security through improved and Food Security Project supported by the Global Agriculture and nutrition, made possible by promotion of diversified diets and Food Security Program (see box 7.2). This project is one of the very improved feeding and caring practices for pregnant and nurs- few World Bank agriculture projects ever that includes nutrition as ing women and children up to 2 years of age.” an explicit project development objective. The project’s inclusion of The nutrition sensitive agriculture interventions include: tech- food security and nutrition goals and indicators is significant indeed nology development and adaptation of minor but nutritionally and constitutes a step toward aligning with global good intentions significant crops such as buckwheat, blackgram, soybean, olive, walnut, and lentil. Additional efforts include techno- and national-level country demand for agriculture investments to logical improvements for development of improved breeds improve nutrition of their beneficiaries. of poultry for backyard poultry in mountain areas; support to kitchen gardens as part of rural livelihood enhancement; Work on nutrition within agriculture is growing gradually within promotion of women-friendly labor-saving technologies such the country programs in an opportunistic manner responding to as treadle pumps to liberate time for self and care; integrat- emerging demand from clients and donors. In the Latin America and ing nutrition in the curriculum of district agricultural exten- Caribbean region, a nutrition beam was funded to encourage inter- sion teams; nutrition education to promote diet diversity; and strengthening government food lab capacity to enable analy- sectoral collaboration between the nutrition and agriculture units. sis of the nutrition value of locally available foods. In the Africa region, a nutrition focal point has been appointed in the Basic nutrition interventions that accompany the above agriculture department to develop a pipeline of agriculture projects include: nutrition education on nonfood aspects that affect that could incorporate various nutrition elements. Within the Bank’s nutrition (hygiene, sanitation, infant and young child feeding South Asia region, there has been significant cross-sectoral engage- and caring practices) as well as better utilization of iron folic ment on food and nutrition security issues through the South Asia acid and micronutrient powder supplements. The last two would be delivered through parallel World Bank-supported Food and Nutrition Security Initiative (SAFANSI), a multidonor trust operations in the health sector). fund created in March 2010. As part of the Nutrition for Growth Project targets include adding 57,000 to the number of farm- Summit commitments in 2013, the World Bank has committed to ers whose crop productivity had increased (of which 50 per- a review of all agriculture projects for their inclusion of nutrition, to cent will be women), increasing the proportion of pregnant increase the number of agriculture projects that explicitly address and lactating mothers with improved intake of nutritious nutrition (Government of UK 2013). foods by 20 percent, and increasing the proportion of children 6–24 months with appropriate complementary feeding by The rather sudden focus on nutrition within the Bank’s agriculture 30 percent. department is a welcome development. But how far we advance 63 A similar focus on nutrition has also taken place at FAO and the Interna- tional Fund for Agricultural Development (IFAD) around the same time. on this agenda still remains to be seen. Also, we should note that FAO’s Office of Evaluation carried out an evaluation of FAO’s role and work in nutrition in 2011 (FAO 2011). The findings generally found a low nutrition is not the only “new area” that agriculture will focus on. level of support to nutrition in an organization that is supposed to have There were six others, some that are directly linked to the corporate nutrition as one of its core mandates. Since the evaluation, FAO has instituted organizational changes to strengthen its work on nutrition. priority on climate change such as climate-smart agriculture. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 C H A P T E R 8 — C O N C LU S I O N 29 Chapter 8 CONCLUSION For an institution like the World Bank, the connection between its global research or other analytical work featuring nutrition (Alan agriculture projects and its objective of food security and nutrition Berg, personal communication). The World Bank even actively improvement would seem an obvious one. Improved food security, cosponsored with the International Food Policy Institute (IFPRI) and nutrition, and health, essential to poverty reduction writ large, were the U.S. Agency for International Development (USAID) an interna- central to McNamara’s vision for the World Bank in 1973, harkening tional conference on needs and priorities for international agricul- to world leaders’ vision for international collaboration after WWII. But tural research in the context of nutrition (Pinstrup-Andersen, Berg, this review of the 40 years since the World Bank began work in both and Forman 1984). Guidelines on linking agriculture and nutrition nutrition and rural development shows that despite conceptual were developed, going back to the initiation of nutrition activities at interest in linking the two, little sustained action of consequence the Bank, in many ways similar to those written now (see appendix has occurred. The persistent storyline in agriculture has been that C). These consistently have recommended focusing on vulnerable aggregate increase in food supply and improved income are the populations, building nutrition capacity in agriculture projects, and ways in which it can and should contribute to nutrition. To date, assessing the context to inform project design. Most strikingly, there ownership of nutrition issues has been limited in agriculture, and has been a consistent recommendation to invest in agriculture in emphasis on food has been low among nutritionists. We draw les- line with food requirements for nutrition and with a food consump- sons from this experience to inform and increase the likelihood of tion objective, ever since the first nutrition policy document in 1973. greater success of present day and future efforts. Including nutrition in agriculture strategies, along with Learning from History intermittent high-level support. There was also, at times, high- Has the World Bank, and the overall development community, tried level support from senior management. The most significant was to link agriculture and nutrition before? Our findings indicate the the major food security initiative led by the World Bank in the early answer is yes and no. It is clear that many things to encourage the 1990s. High-level statements were made in 1988–89 and 1993, but link between agriculture and nutrition have been tried since 1973. nutrition was not explicitly part of agriculture strategy until 1997. These have not resulted in sustained action or ownership—or a fun- The 1997 and 2003 agriculture strategies were the first to squarely damental change in the way agriculture does business—for reasons address nutrition as one of (many) goals within a broad rural devel- suggested in the next section on “missing factors.” opment approach. Unfortunately, these strategies were quite expan- sive, and the language on nutrition was not effectively translated 8.1 WHAT HAS BEEN TRIED? into the establishment of an adequately budgeted “business line” or Developing analytical work and guidelines. There was no lack of a new way of doing business within the agriculture department. The analytical work on improving nutrition through agriculture projects. most recent second Agriculture Action Plan FY13–15 (World Bank Identified for this review were at least 54 pieces of country-specific 2013a) is an improvement since it was developed with extensive food/agriculture sector-related or economic work and 29 pieces of internal discussions with regional agriculture teams and includes a A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 30 C H A P T E R 8 — C O N C LU S I O N commitment to increase the share of projects that explicitly include effect on objectives or priorities of its agriculture programs. Here, we nutrition, which is monitored annually. identify factors that appear to have been consistently missing. Providing technical assistance. Most notably, the Nutrition Advisory Clarity in vision. Despite analytical work that often came to simi- Service made available senior nutrition consultants who could pro- lar conclusions, there has been no clear, unified, easily articulated vide technical assistance for integrating nutrition into projects in any storyline about what, exactly, agriculture is supposed to do regard- sector in the Bank. This was promoted through free workshops offered ing nutrition; nor how such action is integral to agriculture’s goals. by the nutrition department that repeatedly targeted agriculture staff This would not imply a prescriptive program but would imply clear with the intent to have stronger participation from agriculture (Berg targets—in other words, clearly defined desired ends, but flex- 1990, 1991a, 1991b). While the service led to an increase in nutrition ible means. When the globally agreed definition of “food security” activities in health sector projects, the consultants involved cannot shifted from “availability of world food supplies” (1974) to “suffi- recall any agriculture project that used the service (Alan Berg, James cient, safe, nutritious food to meet dietary needs . . . for healthy Levinson, Judith McGuire, and Per Pinstrup-Andersen, personal com- and active lives,” no shift in operations reflected the updated vision. munication). Currently, technical assistance is being requested by agri- Nutritionists have long claimed that income generation and staple culture project leaders particularly in the Africa and South Asia regions, crop productivity are insufficient, but have not articulated a clear which may reflect growing interest in nutrition. alternative goal—partly because from about 1980 to 2008 (the era of “nutrition isolationism”) the field of nutrition in general was not Complex multisectorial projects. In the 1970s, the Bank focused on food or agriculture. The Bank led a high-level initiative attempted complex multisectoral projects including both agricul- on food security in the mid-1990s that was supposed to ensure ture and nutrition, through integrated rural development projects, that food security will be “center stage” in Africa region opera- most of which failed due to major management difficulties and tions. The crushing conclusion to this initiative was a total of six implementation challenges related to the extensive coordination projects that focused on food security: “The Bank pulled away required. Repeating this approach of complex multisectoral coordi- from food security in the ‘90s largely because there were so few nation in a context of limited ownership of nutrition within agricul- answers about what should be done” (Katherine Marshall, personal ture itself, is not a recommendation for today. The need for simplicity/ communication).64 feasibility of implementation, and tracking progress to clear targets, are the major lessons learned from these projects. To track progress, Targets for success and accountability that make sense for targets would need to be in the results-framework and logically agriculture. For the nutrition community, the goal for decades has linked to the overarching goal of the main project objective. been to convince decision makers that nutrition is central to devel- opment.65 Indicators of nutritional status—particularly stunting and underweight of young children, and micronutrient deficiencies 8.2 MISSING FACTORS: WHAT WAS LACKING (especially iron, iodine, and vitamin A)—have been essential to com- TO DEVELOP SUSTAINED ACTION AND municating the connection between nutrition and many human OWNERSHIP? and economic development outcomes. This agenda has been so Although the numbers of nutrition-related involvements in agricul- ture projects have not been altogether insignificant, in all likelihood 64 K. Marshall was agriculture division chief in east and central Africa from their ultimate nutrition impact has been limited. There is but scant 1979–1986 and country director in the Sahel from 1990–94. evidence that intermittent strong endorsements from senior man- 65 The World Bank has had a primary role in this agenda, starting with McNamara’s rationale for including nutrition in the Bank’s operations to agement, the extensive underlying analytical work and the support- fight poverty, influenced by Alan Berg’s 1973 book The Nutrition Factor, ive guidelines, seminars, workshops, and other training provided to and most recently by the major technical report “Repositioning Nutri- tion as Central to Development” and the World Bank’s support of the agriculture colleagues by others in the World Bank had any profound SUN movement. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 8 — C O N C LU S I O N 31 all-encompassing that global nutritionists frequently conflate the overall project objective.67 As such, any potential impacts or lessons word “nutrition” with “stunting” or other indicators of nutritional remain undocumented. Even in the 1990s at the height of high- 66 status. As a result, nutritionists’ and economists’ reviews of the evi- level fervor about food security, no World Bank project monitored dence base for agriculture and nutrition have focused on nutritional food security at the household level.68 Evaluations of self-standing status outcomes (Masset et al. 2011; Webb Girard et al. 2011; Ruel nutrition sector projects, on the other hand, focused on nutritional and Alderman 2013). Nutritional status, however, is not generally status impact and caregiving behaviors. Adding nutrition com- understood as relevant within the agriculture sector; nor is specifi- ponents might have had some impact on the diets, behaviors, or cally targeting the 1,000 days during pregnancy and the first 2 years nutrition of project beneficiaries, but were unlikely to have had any of a child’s life. Infant and child growth is too distant from its activi- effect on the availability and consumption of nutritious foods at ties and is affected strongly by factors outside agriculture’s scope (for scale. There may have been important technical lessons learned at example, health status, sanitation, knowledge, and care practices). the project level, but unfortunately the lessons, if any, have not been The understandable result has been that the agriculture community highlighted systematically. sees “nutrition” (thought of as young child nutritional status) as an Nutrition indicators relevant to agriculture. For decades, nutri- issue owned by the health sector. With good reason, few World Bank tionists have recommended that agriculture address nutrition by agriculture projects have ever adopted nutritional status outcomes. investing in line with consumer needs, meaning in line with dietary There has been relatively little advocacy for other outcomes, such as requirements. Yet, indicators of access to and consumption of ade- nutritious food access or consumption, that might be more closely quate nutritious food are not currently collected globally or made related to agriculture projects’ influence on nutrition. available to inform policy decisions. The indicators that have been Relevant monitoring and evaluation in projects. This reflects tracked on food security are indicators of grain stocks and calorie avail- the absence of any clear target related to food access or consump- ability; income has also been used as a proxy for food security. If food tion. From 1972 to 2000, 42 agriculture and rural development access is one of the three underlying causes of nutrition (UNICEF 1990); projects were identified that had nutrition activities—not an alto- and the available indicators of “food access” are income, grain stocks, gether insignificant number, although a small overall proportion and calorie availability—which agriculture has handily improved by of agriculture projects (Alan Berg, personal communication; see almost any measure since the 1970s; then it is understandable that appendix B). These were usually marginal community development the general perception, within agriculture professionals, is that their activities (such as home gardens, nutrition education), or adding work has benefited nutrition. If agriculture is to respond to a problem direct nutrition interventions (such as deworming) to an otherwise different from lack of calories and income, then there is a need to col- standard agriculture project. An important observation is that lect and report data on the problem that needs to be solved. almost none of the World Bank projects that attempted to address Level playing field for investments in more nutritious foods. nutrition through agriculture actually monitored or measured nutri- Added to the lack of vision, targets, and data, disincentives abound, tional or food security outcomes; nor have they included, in their related to investing in production and consumption of nutritious official project completion reports, even qualitative assessments of food. Projects to produce nutritious foods and diverse production are the specific nutrition activities. This is likely because most of these nutrition-related activities were minor and inconsequential to the 67 “Monitoring and evaluating nutrition components may have suffered because they seemed too small to merit much effort. Bank staff oversee- 66 Laypeople (including policy makers) often conflate “nutrition” with “food ing the parent projects have sometimes lacked the technical familiarity, consumption,” a concept that nutritionists have worked very hard to time, or interest” (Berg 1987b). reverse. The nutrition community largely rejected “food” because evi- 68 At the time, admittedly, household-level indicators of food security were dence became clear that the indicator of “food” (calorie availability) was not yet developed. Such indicators (such as Household Food Insecurity not a key factor limiting better nutritional status—and there was a need Access Scale (HFIAS) and Household Dietary Diversity Score (HDDS)) to convince policy makers to do something about nutrition other than started to appear in the 2000s from FANTA Project, and are still being growing more staple grains. further developed. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 32 C H A P T E R 8 — C O N C LU S I O N often operationally more difficult than projects primarily designed undernutrition (Smith and Haddad 2000). Food prices are volatile due for staple crop production given their heterogeneous nature. to reasons other than food shortage, including trade policies, futures Livestock and fish projects in the Sahel in the 1990s were designed markets, biofuels, and rising demand for grain-intensive livestock. with a nutrition rationale, but were the most difficult projects to In addition, since the 1970s some economies have experienced a manage, primarily because of food safety and value chain issues— transformation in the extent to which the food supply and demand they tended to be “problem projects” (Katherine Marshall, personal is affected by agrifood business. Overweight is now more prevalent communication). In the same era in Africa, research and seed proj- than underweight, globally and in some low- and middle-income ects (which had a nutritional justification and focused on legumes) countries (Black et al. 2013; Popkin 2009). Poor diets affect half the were unsuccessful due to lack of capacity and organizational dif- world’s population, including 2 billion with vitamin and mineral defi- ficulties within countries. In other instances, investment to promote ciencies, and 1.5 billion overweight or obese, with diabetes and child diversification to high-value crops was addressed not for nutrition’s obesity rising fastest in Africa (Black et al. 2013; International Diabetes sake, but for its income-enhancing potential. Such investments Federation 2013); Poor diets are widespread among all wealth cate- increase the supply of nutritious foods but there is no conclusive gories, so that increasing income does not necessarily ensure access evidence that shows its impact on nutrition, partly due to the fact to affordable nutritious diets. Diets low in fruits, legumes, vegetables, that actual investments almost never explicitly track the impact of and whole grains are the top cause of years of life lost worldwide in 69 increased supply on actual consumption. Consumer demand is developed and developing countries (IHME 2013). also a major factor that may incentivize or disincentivize production of nutritious food. Agriculture projects supported by the World Bank Based on food supply data compared with dietary recommenda- are almost always focused on supply-side issues, and typically deal tions, it is theoretically possible for everyone in the world to eat very little with consumption or demand creation activities. Some enough, but it is impossible for everyone in the world to eat nutri- community development projects have included nutrition behavior tious diets. There is a shortage of fruits and vegetables relative to change efforts, primarily led by the health or nutrition sector. population needs in most countries in the world (Siegel et al. forth- coming); in Sub-Saharan Africa, per capita legume availability is also very low, only enough to provide about one-quarter of protein 8.3 NEED FOR A NEW PARADIGM FOR AGRICULTURE’S ROLE IN NUTRITION needs (Herforth 2010). The food shortage paradigm, appropriate in The strongest impetus for a new vision and targets for agriculture the 1970s, no longer fits today’s data—which show stronger evi- is the transformation of the food environment since the 1970s, and dence of a nutritious food shortage.70 the increasing evidence of poor diets and chronic disease in nearly The main reason agriculture operations at the World Bank and other all countries. The prevalence of hunger (undernourishment) has international agriculture organizations have not taken nutrition declined by 37 percent since 1990, due to higher food availability onboard, despite well-reasoned and occasionally very high-level and lower food prices (FAO 2013b). However, its correlation with pushes to do so throughout the last four decades, has to do with a undernutrition is low; in general calorie availability explains less core lack of ownership of nutrition within agriculture. This is related than 30 percent of stunting reduction on average (FAO 2013b), to an absence of vision and incentives.71 The current situation, and above a threshold of per capita calorie availability of 2300 kcal, however, presents an opportunity perhaps greater than ever before further increases in calorie availability are poorly correlated with 69 For example, communication with a lead economist in the Bank’s South 70 Welch and Graham (1999) have also articulated the need for “A new Asia Agriculture and Rural Development Department indicated that at paradigm for world agriculture: meeting human needs.” least two current agriculture technology projects do have significant 71 The Lancet 2013 series on Maternal and Child Nutrition took up the issue emphasis on the diversification to fruits, vegetables, and other noncereal of nutrition sensitive interventions in agriculture and other sectors, and crops (India National Agricultural Innovation Project (P192735) and Ban- concluded that “nutrition-sensitive programmes hold great promise for sup- gladesh National Agricultural Technology Project (P084078). However, an porting nutrition improvements and boosting the scale, coverage, and benefits examination of these projects’ results framework shows that there are no of nutrition-specific actions. New incentives are needed to support innovations official indicators that track research output by crop type, consumption, or in nutrition-sensitive programmes and unleash their potential to tackle nutri- nutrition outcome indicators (Madhur Gautam, personal communication). tion while also achieving their own goals” (Ruel and Alderman 2013). L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 8 — C O N C LU S I O N 33 to overcome the identified gaps that have prevented ownership. Bank 2013b; FAO 2013b), and we lack global data to show how The current situation includes (1) strong global interest in nutrition well it correlates to access to nutritious food or consumption of (including nutrition-sensitive agriculture), especially among some healthy diets. The SUN movement, while underscoring the need donors; (2) an increasing recognition of food and dietary problems for both nutrition-specific and “nutrition-sensitive” actions, has apart from hunger; and (3) increasing concern for climate-smart and not yet strongly articulated what that means for agriculture— sustainable agriculture, which may be set back by current unhealthy although there is still plenty of potential.72 The new Global Panel food consumption trends. for Agriculture and Food Systems for Nutrition, and the Second International Conference on Nutrition (ICN2), also have the remit to foster a common vision for nutrition that makes sense for agri- 8.4 RECOMMENDATIONS culture. FAO can support country governments in agricultural The following points are key take-away lessons from a review of systems that support a common vision. the history of agriculture and food-based approaches to nutrition, The emerging core vision for agriculture’s role in improving nutrition through the lens of the World Bank experience. It is expected that is to increase access to adequate nutritious food73 in alignment with many of the proposed actions will be applicable to other develop- the current UN food security definition as “ . . . access to nutritious ment organizations as well. food to meet dietary needs.” The vision should also be considered in light of data on nutritious food shortage and the triple burden of Recommendation 1: Establish a new common vision globally for agriculture’s role in improving nutrition, with measurable malnutrition. At the same time, the vision is related to gender equity outcomes and targets. (providing gender equitable opportunities for income generation In the 1970s, there was a common vision shared among the agri- and reduction of time and labor burdens), and environmental sus- culture and nutrition communities: nutrition science at the time tainability. The vision need not require agriculture and rural devel- emphasized the importance of calories, the food shortage para- opment to address all of the limiting factors to improved nutritional digm was urgently compelling across the development community, status in rural communities—many of which fall in the health and and agriculture responded with successful efforts to increase grain water and sanitation sectors. If the agriculture sector were held productivity. However, subsequent developments included the accountable to targets for access to adequate nutritious food rather scientific knowledge that highlighted the importance of noncalorie than only dietary energy, these targets could provide an incentive issues such as micronutrients, as well as advances in food processing for ownership and action. technology and the emergence of global agrifood businesses that Beyond contributing to overall well-being, consumption of nutri- market convenient processed foods, including so-called “junk-foods.” tious food/demand patterns are important to agriculture’s main The Millennium Development Goals (MDGs) have provided a com- bottom lines: productivity, employment, and profitability.74 Current mon vision that has motivated substantial action and investment to achieve the goals. The Scaling Up Nutrition (SUN) movement 72 See Herforth and Dufour 2013. has also provided a common vision of what is needed to improve 73 A key message of the Call to Action: Nutrition in the Post-2015 Develop- ment Agenda: “Access to a range of diverse foods, reflected in dietary nutrition, around which many governments have coalesced. These quality, is core to adequate food for all. Producing more diverse, processes have demonstrated that a globally aligned vision is piv- nutritious foods is aligned with and supports the broader objectives of sustainability and resilience” (http://thousanddays.org/wp-content otal for commitment, targets, and actions to pursue. /uploads/2013/09/Nutrition-in-the-Post-2015-Agenda-Key-Messages. pdf ). See also FAO 2013a, FAO 2013c, World Bank 2013b, Bill and Melinda Gates Foundation 2014. These processes so far have not effectively created a vision for 74 Nutritional status per se is probably not central to agriculture’s success; nutrition that is relevant for agriculture or vice versa, but there while it can affect farmers’ productivity, there are many other more limiting factors to productivity advancements (seed access, soil qual- are opportunities to do so going forward. The vision for food ity, water availability, and so on). This contrasts to the education sector, security in the MDGs was limited to access to adequate calories. It as poor nutritional status has been shown strongly to limit both learn- ing capacity and school attendance, resulting in lower educational is clear that this is not well-correlated to nutritional status (World attainment—the key bottom line for education. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 34 C H A P T E R 8 — C O N C LU S I O N SUMMARY OF PROPOSED KEY ACTIONS Global Development Community 1. Ensure that the new post-2015 framework moves beyond hunger as defined only by inadequate calories, toward a more holistic goal, targets, and indicators for “access to adequate food”—meaning consistent access to diverse, nutritious diets. 2. Further develop appropriate metrics of access to and consumption of adequate nutritious food, and monitor them.* 3. The Scaling Up Nutrition movement, the Global Panel on Agriculture and Food Systems for Nutrition, the ICN2 accountability framework, Renewed Efforts Against Child Hunger and Undernutrition (REACH), and other partners need to develop a harmo- nized and aligned vision, targets, and indicators for interactions with stakeholders. 4. Build a community focused on nutrition within agriculture technical agencies (FAO, IFAD, WFP, and so on) to strengthen ownership. World Bank Group 1. Conduct analytical work and collaborate with other technical agencies on indicator* development through the research department (for example, in the Living Standards Measurement Study (LSMS), the South Asia Food and Nutrition Security Initiative (SAFANSI). 2. Monitor access to adequate nutritious diets in food security projects. 3. In agriculture projects, systematically include health impact assessments that can identify health hazards and risks (for example, water quality, vector-borne disease risks), and develop cost-effective mitigation methods. 4. In International Finance Corporation (IFC) loans, explore the development of appropriate standards based on public health risks of food products that are supported through IFC financing. 5. Explore “food systems strengthening” through results-based financing based on targets for the indicators developed.* Learn from experience of the health sector in health systems strengthening. 6. Include a nutrition lens in standard agriculture sector policy review and dialogue and expenditure reviews to clarify nutrition consequences of large-scale production or consumption subsidy programs. 7. Support requests by regional or national initiatives such as the Comprehensive Africa Agriculture Development Programme (CAADP) in Africa in developing an operational planning for nutrition sensitive agriculture. Note: *Examples of indicator types include the following: (1) Availability and affordability of nutritious food, indicated by relative prices of dietary food groups at national and local market levels; (2) Dietary quality; (3) Sustainability of diets; (4) Household food insecurity experience measures; (5) For some projects, “nutrient yield” (for example, target micronutrient per ha). Some indicators of food access have already been developed, such as the HFIAS (Coates et al. 2007), HHS (Ballard et al. 2011), Food Consumption Score (WFP 2008), and Household Dietary Diversity Score (Swindale and Billinsky 2006). These have shown correlation with nutritional status to varying degrees (Tiwari et al. 2013) and are valid proxies of food quantity (Leroy et al. forthcoming). For individual dietary quality, the Women’s Dietary Diversity Score (FAO 2011, Swindale and Bilinsky 2006) has been validated for overall nutrient adequacy (Leroy et al. forthcoming). food demand trends (such as rapidly rising demand for meat and an opportunity for increased farm profits, especially for women. ultra-processed foods) pose significant sustainability and distribu- There may be important alignment between diverse, nutritious tional risks, as they are a dominant driver of resource use and envi- diets for nutrition, poverty, gender, and sustainability goals. This will ronmental outcomes including climate change (Kastner et al. 2012; be increasingly important in the context of defining priorities for the Marlow et al. 2009). Recent research suggests that dietary changes post-2015 agenda. (specifically, reduced meat and dairy consumption) are necessary to achieve the 2°C climate change target set by the United Nations Establishing a new common vision, targets, and indicators is under- Framework Convention on Climate Change (Hedenus et al. 2014). way, but building commitment to it will require new evidence. The Thus it will be difficult for agriculture to be truly climate-smart if it recent experience in nutrition shows that evidence was essential supports current food demand trends. Moreover, if challenges and for generating political attention and commitments to improving risks to nutritious food production can be overcome, they present nutrition. Not only the quality and strength of evidence mattered, L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 8 — C O N C LU S I O N 35 but also what questions were being asked. For nutrition-specific nutrition interventions, although its effective delivery faces at interventions, the right questions were essentially the themes of least as many hurdles.76 the Lancet series on maternal and child undernutrition in 2008: “Where is malnutrition?” “What are the consequences of malnutri- Recommendation 2: Level the playing field in public tion?” “What works to reduce malnutrition?” For improving nutri- agriculture support. tion through agriculture, the main questions would be similar, but The structure of research, development, and public support for focused on food access and dietary intake:75 “Where (and for whom) agricultural crop and livestock improvement has not focused on are food access and diets inadequate?”“What are the consequences making nutritious crops less risky and more profitable to produce. of poor diets on health, productivity, and environmental sustainabil- The success of the Green Revolution was limited to basic cereals ity?” “What policies underpin access to nutritious food and dietary and had relatively lower success in the case of other crops such as quality of populations?” At present, generation of the needed evi- sorghum, millet, cassava, and tropical legumes. Part of the reason for dence is strongly limited by lack of data and indicators of the key the limited success is that unlike the case of wheat and maize, these outcomes: nutritious food access and dietary quality. Better data is a crops have had no research from developed countries to draw upon first step to better evidence. (Pingali 2010). Thanks to the Green Revolution, real cereal prices have fallen over time despite the doubling of developing country Unlike direct nutrition interventions, few of these kinds of ques- population from 1965–1999. For noncereal crops such as legumes tions can be answered by randomized controlled trials (Pinstrup- and vegetables, production did increase but did not keep pace Andersen 2013); many would require population-level analyses of with growth in demand. There was no commensurate investment food and dietary trends, related to food and agricultural policies or technological change in the nonstaple sector. Consequently, and investments. This requires a shift in mindset among nutri- inflation-adjusted prices of many nonstaple foods have increased tion advocates, who have made great headway for the nutrition over time (Graham et al. 2007) and the price of staples decreased cause through demonstrating efficacy of specific interventions. relative to nonstaples such as legumes and vegetables (Bouis 2000), Nutrition-sensitive development targets the underlying causes of and led to more calorie-rich but less nutrient-dense diets (Gómez et malnutrition, while nutrition-specific interventions target imme- al. 2013). The vision of increasing access to nutritious foods among diate causes of malnutrition (World Bank 2013b p25; Ruel and vulnerable populations would include support to overcoming tech- Alderman 2013). Therefore it is generally inappropriate to hold nical challenges that limit production all along value chains (perish- both to the same standard of short-term impact on nutritional ability, food safety, crop/animal disease, and seed quality issues, for status, which is much more amenable to change based on direct example). This could enable the rural poor to gain access to higher- nutrition-specific interventions. Interestingly, FAO differentiates value markets while producing nutritious foods.77 Agricultural between “nutrition-specific agriculture” (that enhances nutrient policy, including research and development, is needed to incentiv- content of food, such as biofortification or zinc fertilizers), and ize nutritious food production, and to end the incentives toward “nutrition-sensitive agriculture” (that increases access to nutri- tious food and ensures no negative effects on other causes of malnutrition) (FAO 2013a). Evidence for the efficacy of bioforti- 76 The website of the the Bill and Melinda Gates Foundation (BMGF) includes fication, then, can be generated in a similar way to other direct the following question: “How should impact indicators and ‘standards of credible evidence’ vary across the value chain for different interventions (for example, biofortification, improved food processing and storage methods, behavior change, policy change)” (BMGF webpage)? 75 These questions follow the core vision of increasing access to and con- 77 Although smallholder farmers engaged in horticulture often earn high- sumption of nutritious food. Other questions, however, will also be im- er incomes than cereal producers, the primary limitations to engaging portant, such as how agriculture policies and projects affect women’s in horticultural production is lack of market access and market infor- discretionary income, time, and labor; and how agriculture policies and mation, and biological/land constraints, as yield improvements in projects can improve health and sanitation environments and reduce fruits and vegetables have been lower than in cereals (Weinberger and disease risk. Lumpkin 2005). A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 36 C H A P T E R 8 — C O N C LU S I O N choice and, over time, “crowd out public investments that would do SUMMARY OF PROPOSED KEY ACTIONS more to boost nutrition” (Fan, Pandya-Lorch, and Fritschel 2012). Global Development Community In a similar way, the nutrition community should not be narrowly 1. Increase research and development on fruits, veg- focused on micronutrients when dealing with food, even though etables, and legumes,* including through public there is a role for micronutrient-based approaches. Biofortification investment (Consultative Group on International Agricultural Research [CGIAR], the world vegetable initiatives present themselves as an intermediate solution to center [AVRDC], and National Agricultural Research nutrient deficiencies, while the end goal is diverse diets (Bouis System [NARS]), and public-private partnerships. et al. 2011).79 It is important that this point is clear to agricul- 2. Invest in developing within-country capacity to do ture technical agencies, and that nutritionists do not limit their R&D and seed system development for nutritious advocacy to specific micronutrients through agriculture. There is crops and livestock of local importance, including underutilized crops. an important lesson in the efforts in the 1960s to breed Quality 3. Invest in reducing risks associated with horticultural Protein Maize, followed by evidence that lysine (and protein in and small-scale livestock/dairy/fish production. general) was not the main limiting factor to adequate nutrition 4. Develop innovative ways to ensure equal access of risk through food. While evidence is clear that iron, zinc, and vitamin management tools for all crops (not just for basic grains). A deficiencies are widespread and pose grave risks to health and 5. Invest in analysis of agriculture policy to estimate human development, it should be equally clear that food-based producer support at crop/food group or cropping system level. approaches should not be limited to targeting only a small num- ber of micronutrients, when adequate diverse, nutritious diets are World Bank Group the end goal. 1. Conduct sector reviews and policy impact assessment to estimate producer support at crop/food group or Recommendation 3: Create demand for nutritious and cropping system level, including agriculture and IFC sustainable food. support. 2. Invest in analysis on risk reduction strategies for In the past, agriculture tackled the issues of consumer policies producers of noncereal crops. such as food subsidies. These activities have mainly been absorbed 3. Analyze the effect of climate-related diversification on into the social protection agenda. Thus, agriculture became solely availability of diverse foods and on diets. focused on supply issues—raising productivity to feed a growing * About 5 percent of CGIAR’s research funding goes toward legumes (through population while adapting to a changing climate. Opportunities for CRP 1.1 on drylands and CRP 3.5 on grain legumes) (Iftikhar Mostafa, personal communication). CGIAR does not have a research program specifically on fruits improving nutrition outcomes requires changes in the supply side, and vegetables. The budget of AVRDC, an international nonprofit research and development institute, was $13 million (AVRDC 2013), roughly 1 percent the but also on the demand side, that is, people need to be informed size of CGIAR research funding in 2013. of the nutritional quality of foods, and social marketing efforts are needed to maintain, or in some cases shift, social norms that sup- port healthy eating. The global “supermarket revolution” and the less-healthy, less-sustainable diets.78 “Plant  breeding and  distribu- lengthening of the food value chain in developing countries cannot tion of high-yielding major crops as a development strategy, and subsidies dedicated to a narrow range of crop commodities have contributed to the increasing global availability of a limited number 79 “To reiterate, the long-term task of public food policy is to stimulate of major crop plants, with lesser priority given to nutritional diver- growth in the nonstaple food sector (sometimes referred to as “high- value” agriculture) through any number of instruments—agricultural sity” (Khoury et al. 2014). Such investments can distort consumer research, education, building infrastructure, and improving markets for agricultural inputs and outputs, to name a few. However, this is a several-decades-long process. In the meantime, there are specific, cost- 78 See Graham et al. 2007 for a careful discussion on ways to stimulate effective steps (such as biofortification and adding zinc and selenium to growth in the nonstaple food sector for the major cropping systems fertilizers) that can be taken to utilize agriculture to improve mineral and around the world. vitamin intakes in the shorter term” (Bouis et al. 2011). L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 8 — C O N C LU S I O N 37 Postproduction interventions and demand creation may be SUMMARY OF PROPOSED KEY ACTIONS necessary to ensure profitability of, and demand for, nutritious Global Development Community and sustainably produced foods. It is unclear how the World Bank agriculture department will engage in these levels, given that its 1. Develop social marketing strategies based on nutrient or health attributes of nutritious foods (for example, activities focus almost exclusively on the supply side. There is need “nutrition-focused marketing”), learning from social for further research to highlight the importance of demand-side fac- marketing of biofortified crop varieties. tors, especially on effective policies and actions to affect consumer 2. Increase consumers’ nutrition knowledge, particu- preferences.80 Furthermore, as the part of the World Bank Group that larly where this is a limiting factor to demand for finances agribusiness, the IFC may have a role in engaging on the nutritious food. 3. Support, as appropriate, other possible actions outside postharvest side to ensure good nutrition practice (for example, of the agriculture sector that affect food consumption limits in trans-fats, sugar, sodium), or to safeguard against unhealthy norms, such as incentives for nutritious food purchase, food environments. There is not yet an established standard for restrictions on food advertising to children, nutrition good nutrition practice, but some examples of voluntary pledges in school curricula, and healthy school meals pro- grams to instill healthy eating norms, including menu and commitments exist, and the World Bank Group could engage labeling and food vouchers. with country governments on an accountability framework to pro- 4. Invest in analyses of environmental and distributional mote healthy food environments (Kraak et  al. 2014). The kinds of impacts of likely food demand changes. foods produced and consumed have impacts on both public health and environmental sustainability (Foresight 2011), and integrating World Bank Group these outcomes into policy dialogue and financing decisions across 1. For climate-smart agriculture strategy, incorporate the World Bank Group could help countries reduce health and envi- evidence of the sustainability/climate impacts of likely food demand changes. ronmental problems associated with unhealthy diets. 2. Invest in sector review/policy analysis to ensure that current producer supports are not incentivizing Recommendation 4: Build and sustain capacity for unhealthy food consumption patterns or unsustain- addressing nutrition through agriculture, and able production. monitoring progress. Adequate capacity is needed if the World Bank, and the develop- ment community as a whole, are to respond to political will to reduce child malnutrition through agriculture. This entails capacity building be ignored, and policy makers should engage with the private in client country governments (national and local), civil society orga- sector to create a viable market for nutritious, healthy foods, while nizations, development partner organizations, and consultants. promoting consumer education, product labeling, and appropriate Specifically, capacity is needed to (1) monitor indicators of nutritious marketing rules for junk food targeted at children. This requires a food access, as described in Recommendation 1, (2) adequately shift in mindset that looks not just at the production phase, but the design and implement nutrition-sensitive agriculture policies entire food system including postharvest value chain, as well as con- and programs that respond to the food and nutrition situation. sumer policy including behavioral change. FAO’s 2013 State of Food Monitoring nutritious food access is a key recommendation for and Agriculture (SOFA) report titled “Food systems for better nutri- informing options to improve it, as described in Recommendation 1. tion” sets forward a framework for this approach, highlighting the Country systems may have the capacity to collect some of the rel- food system view and presents basic principles that are advocated evant data (such as food prices of diverse foods at local or district in common by international development institutions and inter- level), but lack the capacity to analyze, interpret, and act on the data agency UN bodies (FAO 2013a). SOFA 2013 presents a framework for food system interventions for better nutrition (figure 8.1). 80 For a review see Hawkes et al. 2013. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 38 C H A P T E R 8 — C O N C LU S I O N FIGURE 8.1: Food System Interventions for Better Nutrition (from FAO SOFA 2013) Policy environment and development priorities FOOD SYSTEM ELEMENTS NUTRITION OPPORTUNITIES POLICY TOOLS Production “up to • Sustainable intensification of production • Food and agricultural the farm gate” (R&D, • Nutrition-promoting farming systems, policies to promote inputs, production, farm agronomic practices and crops availability, management) —Micronutrient fertilizers affordability, diversity —Biofortified crops and quality —Integrated farming systems, including • Nutrition-oriented fisheries and forestry agricultural research —Crop and livestock diversification on crops, livestock and Economic, social, cultural and physical environment • Stability for food security and nutrition production systems —Grain reserves and storage • Promotion of school and Gender roles and environmental sustainability —Crop and livestock insurance home gardens • Nutrition education —School and home gardens • Nutrient preserving on-farm storage Post-harvest supply chain • Nutrient-preserving processing, packaging, • Regulation and taxation “from the farm gate to transport and storage to promote efficiency, retailer” (marketing, • Reduced waste and increased technical safety, quality, diversity storage, trade, processing, and economic efficiency • Research and promotion retailing) • Food fortification of innovation in product • Reformulation for better nutririon (e.g. formulation, processing elimination of trans fats) and transport • Food safety Consumers (advertising, • Nutrition information and health claims • Food assistance labelling, education, safety • Product labelling programmes nets) • Consumer education • Food price incentives • Social protection for food security and • Nutrition regulations nutrition • Nutrition education and —General food assistance programmes information campaigns and subsidies —Targeted food assistance (prenatal, children, elderly, etc.) AVAILABLE, ACCESSIBLE, DIVERSE, NUTRITIOUS FOODS Health, food safety, education, sanitation and infrastructure Source: Reprinted from FAO The State of Food and Agriculture 2013 (FAO 2013a). that would be collected. For agricultural projects such as those sup- There is also a need to (3) support coordination between agricul- ported by the World Bank, there is a need for technical and financial ture and food sector actors along value chains (such as production, support for more informative monitoring and evaluation. In  addi- marketing, processing, food safety, and so on). Lack of coordina- tion, increases in nutrition technical staff may be helpful to support tion among these actors within country governments was a chal- design and implementation of nutrition-sensitive agriculture. lenge identified in past projects that aimed to increase production L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N C H A P T E R 8 — C O N C LU S I O N 39 of academic training needs, that is, the ability to analyze why an SUMMARY OF PROPOSED KEY ACTIONS intervention or policy does or does not work, based on how it is Global Development Community implemented. 1. Partner with other agriculture organizations to In the short term, agricultural technical agencies may need to team develop a basic training for agriculture-nutrition staff, up to develop a common core training for agriculture-nutrition consultants, and graduate students. consultants and food policy analysts, who could work with devel- 2. Fund university research and training programs on food systems that treat nutrition and sustainability as opment agencies and country governments. The International integral to agricultural development. Fund for Agricultural Development (IFAD), the Food and Agriculture 3. Provide ongoing support to country governments to Organization (FAO), and the Leverhulme Centre for Integrative support capacity in monitoring systems. Research on Agriculture and Health (LCIRAH) are developing a train- 4. Provide ongoing support to country governments to ing course along these lines. support coordination between the agriculture and food sector actors along value chains (including production, transport, processing, retail, food safety, and so on). 8.5 CONCLUDING THOUGHTS BASED ON THE HISTORY OF ADDRESSING MALNUTRITION World Bank Group Recurrent interest in the same topic does not necessarily mean repeat- 1. Invest in capacity and adequate resources for rigorous monitoring and evaluation (M&E) (including house- ing history. It is worth noting that many of the nutrition-specific hold surveys where needed) in agriculture projects. interventions now considered solidly evidence-based were tried 2. Increase number of nutrition and/or food and nutri- earlier and initially met with little success. In the 1950s–60s, the first tion security staff in the relevant global practice international applied nutrition programs focused on food supple- groups. ments, breastfeeding, community based nutrition, and malnutrition 3. Formally establish community of practice on food, including members of all the relevant global practices. rehabilitation. They did not work very well due to lack of targeting and analysis of the causes of undernutrition. The 1970s broadened into multisectoral solutions to nutrition with and marketing of nutritious foods (Katherine Marshall, personal a significant emphasis on agriculture and food-based solutions to communication). malnutrition. Thinking around the causes of malnutrition advanced greatly; but unwieldy multisectoral planning units, integrated rural One reason capacity is low is that the intersection between development projects, and unrealistic data needs led to disillusion- agriculture, nutrition, and sustainability is not usually part of post- ment with action for nutrition multisectorally, including through graduate training in agriculture. Even in the United States, very few agriculture. universities offer training in better integrated research and evalua- tion tools across agriculture and nutrition, such as mainstreaming From the 1980s–2008, the nutrition community gathered a strong the nutrition  dimension in farming system research (Fan, Pandya- evidence base on nutrition-specific actions, grounded in a unified Lorch, and Fritschel 2012).81 Delivery science is also a critical part understanding of the causes of malnutrition (that is, the UNICEF framework 1990). Interventions very similar to the 1950s worked 81 Some notable exceptions are Cornell University Division of Nutrition Sci- ences international nutrition program, Leverhulme Centre for Integra- much better with the lessons learned of causal analysis, targeting, tive Research on Agriculture and Health (LCIRAH), and Tufts Friedman and disaggregation of data in research and monitoring to under- School of Nutrition Sciences, as well as several new food centers and institutes, such as the Berkeley Food Institute. Some programs that had a stand who would benefit. The culmination of the improved evi- strong focus on the agriculture-nutrition linkage existed in the past but have since been discontinued, for example, at Brown, MIT, Stanford, and dence base for nutrition-specific actions was the 2008 Lancet series Meharry Medical College along with international nutrition thrusts at on maternal and child undernutrition. There was very little attention the University of California at Berkeley and the Harvard School of Public Health (Levinson 2000). to agriculture or food-based solutions. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 40 C H A P T E R 8 — C O N C LU S I O N After 2008, attention returned to agriculture and possible links to nutrition-specific side. Pieces are in place now that were not there in nutrition with the food price crisis. This is now the second time the the 1970s—including the triple burden of malnutrition highlighting development community has focused in earnest on agriculture and an apparent shortage of adequate nutritious food, higher advocacy food-based approaches to nutrition. A lesson learned in the history for “nutrition-sensitive agriculture” than ever, and the increasing of nutrition is that it may take some time to get alignment, to get the imperative of climate-smart agriculture. New research and action right data to answer the right questions, and to build the needed on nutrition-sensitive agriculture is taking place, and more called capacity. This is what has happened, to a large degree, on the for, to have a lasting impact. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N A P P E N D I X A — T H E R O L E O F T H E W B G A R C H I V E S I N T H E R E V I E W O F N U T R I T I O N - S E N S I T I V E A G R I C U LT U R E K N O W L E D G E P R O D U C T 41 Appendix A THE ROLE OF THE WBG ARCHIVES IN THE REVIEW OF NUTRITION-SENSITIVE AGRICULTURE KNOWLEDGE PRODUCT A.1 NUTRITION BACKGROUND/ORIGINS timeline to be hosted on the SNKP website.82 The timeline will have OF ENGAGEMENT links to documents in the archives and other resources that will be President Kim’s Science of Delivery Initiative and Information and of interest to the external SecureNutrition community. The intent Technology Services Vice President Stephanie von Friedeburg’s sup- is to inform current policy work undertaken by the Agriculture and port to the World Bank Group (WBG) Archives eArchives digitization Environmental Services and health, nutrition, and population (HNP) project inspired a partnership between the WBG Library & Archives departments of the World Bank. Development Team (LAD) with the SecureNutrition Knowledge Platform (SNKP). This partnership resulted in the Historical Review of A.2 NUTRITION AVAILABLE RESOURCES Nutrition Sensitive Agriculture Knowledge Product (P148433). The World Bank manages a number of different repositories of infor- The WBG LAD team collaborated with a team of subject matter mation. The WBG Archives contains the historical program-related and specialists on the topic of nutrition and food security. The objective administrative records produced by the World Bank Group institutions, was to develop a knowledge product that leveraged the informa- and offers a vast amount of original source material related to economic tion assets of the Bank’s archives and library in order to showcase development. The WBG Archives serves all five WBG organizations: the depth of resources available in the Bank, and to demonstrate the International Bank for Reconstruction and Development (IBRD), how they can be used to inform current attempts on mainstream- the International Development Association (IDA); the International ing nutrition in the Bank’s agriculture operations. Finance Corporation (IFC); Multilateral Investment Guarantee Agency and International Centre for Settlement of Investment Disputes (both The SNKP already featured a robust section of Resources, but these of the World Bank Group). The collection covers a broad perspective resources were only the most current from the past few years. The on the business activities of the Bank,  including records relating to SNKP team identified an opportunity to incorporate older reports lending operations, policy decision making, relations with donor and for use by the SNKP community. Historical reports discussing client countries, and administration. nutrition were identified in the World Bank Documents & Reports repository (http://documents.worldbank.org). In addition, archival A subset of archival documents is cataloged at the individual docu- records from the WBG Archives dating back to 1972 were identified ment level in a curated online repository internally referred to as for inclusion in the platform. ImageBank. A large subset of these materials is available to the gen- eral public in the Documents & Reports83 repository. This repository The final form of the Historical Review of Nutrition Sensitive contains final World Bank Documents, for instance: Project Appraisal Agriculture Knowledge Product was determined by LAD and Documents (PADs), Program Documents (PGDs), President’s Reports SNKP after analysis of the available archival records and identified and Memoranda, Economic and Sector Works, Evaluation Reports key knowledge gaps. The final product is derived from a historical analysis utilizing archive references and interviews of subject mat- 82 www.securenutritionplatform.org. ter experts to produce a research paper and interactive web-based 83 www.documents.worldbank.org. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 42 A P P E N D I X A — T H E R O L E O F T H E W B G A R C H I V E S I N T H E R E V I E W O F N U T R I T I O N - S E N S I T I V E A G R I C U LT U R E K N O W L E D G E P R O D U C T and Studies, Global Environment Facility & Montreal Protocol Project The two biggest challenges to this collaboration were refining the documents, and Oral Histories. The collection also contains working focus of the research topics and the standard challenge that archival papers, publications, briefs, and newspapers. materials present regarding time needed to review materials only described in aggregate. In 1994 the Integrated Records and Information System (IRIS) repository was launched for internal staff. A precursor to the current Given the broad range of available resources, it took a great deal of WBDocs repository, IRIS was originally launched as a part of a large- time to identify the most appropriate path of research and the best scale scanning project to replace microfiche. Over time this reposi- approach for presenting that research. The focus of the research tory grew to become the official system of record for storage of the shifted a number of times over the course of the collaboration. This Bank’s digital records. The Bank migrated to the WBDocs repository is part of the nature of archival research, which brings us to our sec- in phases beginning in 2011. WBDocs is now the official repository ond challenge. for all records of the Bank which are created on computers, also known as electronic or born digital records. Archival records are described at an aggregate level. This means that it is not possible to identify individually useful records without All of these repositories are overseen by the WBG Knowledge and a great deal of hands-on work with the records. In addition, pre- Information team (ITSKI). ITSKI provides global access to the current dicting where the records of interest might be is a collaborative and historical materials to both internal and external audiences process that requires both the expertise of the WBG archivists and to empower Bank Group staff and the global development com- subject matter experts. In an era in which many expect immedi- munity with business intelligence for project and analytical work. ate identification of and access to research materials, the more Information experts at the Integrated Reference Desk assist Bank organic and drawn-out process of finding archival records can be staff with finding and using research information, including both a major hurdle. archival materials from the WBG Archives and electronic documents found in the Bank’s official repositories. Without the institutional memory of staff members who understand the relative significance (or insignificance) of various records, it is dif- WBG staff can request records from the Archives at any time. ficult to correctly identify important materials. During the course of Requested records are sent to Washington each weeknight by this project, the project advisor, who had worked at the World Bank courier from the WBG’s off-site records repository, the Mine. Records during the 1970s–1990s, guided the team toward highly significant requested by 1:00 p.m. normally are available from the Archives by material (that is, major policy statements, analytical pieces, initia- 9:00 a.m. the following business day. Since 2010, a new Access to tives of senior management, and so on). Information Policy opens to the public a large amount of develop- ment information. A.4 SERVICES THAT ARCHIVES COULD OFFER TO BANK TEAMS TO SUPPORT THE BANK’S A.3 NUTRITION LESSONS LEARNED FROM THIS KNOWLEDGE AGENDA ENGAGEMENT (FROM ARCHIVE AND FROM SNKP TEAM) The records in the custody of the WBG Archives can provide a foun- The resources available in the WBG Archives are unique and can dation for the Bank’s knowledge agenda. The following proposed guide research in new directions. The collaboration of subject mat- services and programs could facilitate the usage of WBG Archives ter experts and archivists can dramatically improve the final product records by both Bank teams and external researchers: of research. This joint effort may uncover information that is rare and § Continued digitization of archival records disclosed for has rarely been seen by others. Materials which may not have made public access. it into the final versions of official reports of the past may illuminate § The creation of WBG Archives Holdings web platform. This the thinking of today and challenge current beliefs. website will make the search of archival holdings easier. It L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N A P P E N D I X A — T H E R O L E O F T H E W B G A R C H I V E S I N T H E R E V I E W O F N U T R I T I O N - S E N S I T I V E A G R I C U LT U R E K N O W L E D G E P R O D U C T 43 will also enable discovery of digitized materials, download- § Coordinate with Library staff in creation of Project Alerts able as PDFs. emails. These emails are sent to Task Team Leaders (TTLs) § Improve access to project related materials. Manifests of for new projects. They remind TTLs of the materials and re- folders in WBG Archives custody per project will be added to sources available to them through the library. After a critical the operational (OPS) portal Documents tab. mass of folder manifests for projects exist in the OPS portal, § Provide assistance for Bank staff to identify freelance Project Alert templates could be modified to draw TTLs’ researchers who can be hired to do hands-on first review of attention to this new resource for doing research into the materials in archives, perhaps a “white glove” type service. history of their project area. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 A P P E N D I X B — P R O J E C T S T H AT H AV E A D D R E S S E D N U T R I T I O N T H R O U G H A G R I C U LT U R E 45 Appendix B PROJECTS THAT HAVE ADDRESSED NUTRITION THROUGH AGRICULTURE TABLE B.1: Examples of 17 Area Development (or Integrated Rural Development) Projects That Addressed Nutrition NUTRITION ACTIVITY YEAR PROJECT NAME (FROM APPRAISAL REPORTS) OUTCOME (FROM COMPLETION REPORTS) FY73 Mauritius RD • A self-help program including the construction of • “Represented a bold departure from projects supported by the Bank in the past” kitchen gardening, fish ponds, duck and poultry (“innovative”) raising • Extension service provided for about 2,300 kitchen gardens and for over 1,700 rabbit • Establishing rural health centers that would provide hutches (due to cultural reasons the rabbit program was unsuccessful) nutrition and health education services • “Considerable benefits” were generated in terms of the cash income earned from the marketed surplus from kitchen gardens • Improvements of village infrastructure, especially construction of health centers, markets, village halls, roads, and water supplies were undertaken but on a reduced scale due to rising costs and insufficient demand. Only three of the projected five health centers were established. The completed health centers, public water taps, and village roads improved the quality of life of the villagers but also resulted in consider- able time savings, freeing up beneficiary time for productive economic activities, such as more intensive cultivation of kitchen gardens and handicraft industries. FY75, FY77, FY81 Mexico PIDER I, II, III • Support the National Company for Popular • Overall PIDER I and II economic benefits were well below those projected at appraisal. Subsistence (CONASUPO) to enhance rural marketing For PIDER III, the government indicated to the Bank that it would be difficult to (storage warehouse and retails stores)—fortified calculate a rate of return given the paucity of reliable and disaggregated economic tortilla flour was one of the items carried data by type of project. • Research on further fortification opportunities • Although one of the stated objectives of CONASUPO was to increase the availability of for products to be sold at CONASUPO stores (for lower cost and better quality food to the rural poor, the emphasis was on the former example, fortified hot sauces, fish protein concen- (a quote from a CONASUPO official in the ICR “we have to solve the quantity problem trate to be used as fortificant in various foods) first before we can worry about the quality”). • Supporting farmers in select micro-regions to • Little activity in the rural marketing and nutrition component supporting CONASUPO diversify beyond maize into beans, fruits, vegetables, since only 20% of project funds were spent because there was no agency (inside and small animals or outside of the Secretariat of Planning and Budget) that was prepared to take • Introducing an integrated package of supporting responsibility for approving the execution of this component. services including health care and home economics • CONASUPO has been somewhat hesitant to move aggressively forward in the nutri- extension tion area because this is presumably the realm of the National Nutrition Institute. The • Rural health offered as part of a minimum package Institute undoubtedly has the requisite nutritional technical expertise but CONASUPO of social services, which included nutrition education has the operational delivery system skills. An inter-institutional partnership was therefore pursued but the result was mixed. • Support to productive activities detailed and comprehensive information on the impact of specific project investments was lacking making it impossible to assess precisely project successes and failures, and their causes. • A high proportion of livestock investments (beef, dairy, pigs, and poultry) were uneconomical due to faulty design, producer inexperience, inadequate technical assistance, social conflict, and marketing difficulties; orchard investments are mixed. • Women’s home extension program was a success; other kinds of extension were not. The inclusion of home economists in the agricultural extension service began in 1964, with four teachers assigned to instruct rural women in such areas as nutrition, child care, sewing, sanitation, and home improvement. The program grew to 345 home economists in 1970 and reached 796 in 1975. PIDER financed approximately 50% of the Secretary of Agriculture’s home economics program. • School classrooms and health facilities under PIDER I offered much improved infra- structure, but their benefit depended heavily on their staffing. The access to health facilities (among other project benefits) provided a “much improved quality of life” (no specific outcome for nutrition education). (continued ) A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 46 A P P E N D I X B — P R O J E C T S T H AT H AV E A D D R E S S E D N U T R I T I O N T H R O U G H A G R I C U LT U R E TABLE B.1: (continued ) NUTRITION ACTIVITY YEAR PROJECT NAME (FROM APPRAISAL REPORTS) OUTCOME (FROM COMPLETION REPORTS) FY80 Philippines rainfed • A wide array of crops and livestock production were • The livestock component was generally successful from a production standpoint agricultural develop- supported mainly for local consumption purposes except for goats. The ICR made no mention of its consumption effect. ment (Iloilo) with the aim of reducing anemia • The multiple cropping component was successful. Average cropping intensity rose • Health interventions to reduce anemia such as to 200% and rice yields rose from 3.8 tons/ha/yr to 5.6 tons/ha/year (both exceed subsidies for the production and distribution of salt appraisal estimates). The ICR made no mention of its consumption effect. ironization in order to make it available at the same • The related health and nutrition program substantially reduced the incidence of price as unfortified salt; iron/folate tablets distribu- diarrhea through home-made oral rehydration therapy (salt-sugar solution), the tion; deparasitation drugs to rid the population of prevalence of anemia through iron supplementation, and the incidence of parasitism worms, including hookworm; equipment for the through improved sanitation (provision of water pumps) and curative medication. biochemical determination of Hb in blood • Other health interventions such as diarrhea management through the provision of supplies for oral rehydration; equipment for production and packaging of rehydration mixture FY81 Philippines agricultural • Strengthening the Ministry of Agriculture’s Central • The second and third national surveys were funded and pilot programs were imple- support services Office in project planning, preparation, implementa- mented to test new approaches to addressing nutrition problems. Staff were trained tion, management, and monitoring capability and vehicles and equipment provided. • Support the Food and Nutrition Research Institute in • Studies and workshops to implement the Food and Nutrition Plan were funded the preparation and implementation of the second with a focus on determining measures to enhance the nutrition of families in National Nutrition Survey to be used as the data base depressed areas. for the proposed Food and Nutrition Plan. FY85 Papua New Guinea • Support services to subsistence agriculture, cash • The project’s success in improving the productivity and production in agriculture is West Sepik provincial crops including tree crops and vegetables mixed. Incremental production of food crops has been far below appraisal targets, development • Construction of food farms at six high schools, primarily because of inadequacies in the support services, lack of technological including vegetable gardens, poultry and small recommendations (food crops) and marketing constraints (vegetables). However, the livestock to improve diets and reduce food procure- livestock development activities, particularly poultry, and tree crop development have ment expenditures. been reasonably satisfactory. It is possible that some of the incremental production of • Introducing the Community School Agriculture and vegetables and livestock products are consumed on farms and thereby contribute to Nutrition Program to 38 community schools where improved nutrition. school vegetable gardens (about 1 ha) would be • It is difficult to assess the impact of the agricultural development component on constructed, and instruction in good nutrition and farm income, employment, and nutrition because of a lack of relevant data. However, gardening practices would be provided. Vegetables given the reduced prices of cocoa and rubber since the mid-1980s, it appears that the from the school garden would be used for a school project’s tree crop interventions resulted in only minimal impact on farmer income. lunch program. • The nutrition activities (including the school farm programs) failed because they were not suitably detailed nor were the combined roles and responsibilities of the Health, Education, and Primary Industries’ Divisions clearly specified, or subsequently resolved. Most of these problems could have been overcome by a project launch workshop which would have meant that all parties had a clear idea of their role and responsibilities. • The Community School Agriculture and Nutrition Program was dropped altogether. • Five high schools established food farms. FY85–87 Brazil Program of • Rural extension services including social extension • The ICRs reported very little in terms of concrete outcomes. It relied heavily on a integrated areas of the workers cooperating in teams with agricultural Government report by the Superintendency for the Development of the Northeast Northeast (Sergipe, Rio extensionists to work with farm families to improve (SUDENE). The SUDENE report steers away from estimating income, production, and Grande, Bahia, Piaui, sanitation, child care, family nutrition, small animal job generation, citing methodological difficulties, and relies on interviews with asso- Pernambuco, Ceara, husbandry, and vegetable gardening ciation/community members concerning subproject benefits: of the most-frequently- Maranhao, Alagoas, • Community development funds to support cited is employment and income generation, followed by better family nutrition, Paraiba, Minas Gerais) agricultural and nonagricultural local development increased family production, and transportation of production and people. projects, such as building of fish ponds and small • The ICRs suggested that more monitorable indicators should have been used for animal production schemes communities’ nutritional/health status (among others). L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N A P P E N D I X B — P R O J E C T S T H AT H AV E A D D R E S S E D N U T R I T I O N T H R O U G H A G R I C U LT U R E 47 TABLE B.1: (continued ) NUTRITION ACTIVITY YEAR PROJECT NAME (FROM APPRAISAL REPORTS) OUTCOME (FROM COMPLETION REPORTS) FY95 China Southwest • The project has six components: • Achievement of the project objectives and outputs was highly satisfactory. First, poverty reduction (1) social services including an in-school supplemen- the project had a major positive impact on national poverty reduction policy by tary nutrition program and nutrition surveillance (a) demonstrating the effectiveness of a new multisectoral poverty reduction model monitoring system; (2) labor mobility; (3) rural infra- in China’s most severely affected areas, and (b) directly involving senior policy makers structure including the labor intensive construction in the design and implementation of this new model. The new integrated rural of rural roads, safe drinking water supply systems, development project approach to poverty reduction—which the government calls small-scale irrigation and drainage works, biogas di- the “Southwest Project” model—was first extended to the 26 counties of the ongoing gesters, and rural electrification; (4) land and farmer Qinba Mountains Poverty Reduction Project (QBPRP), and the Chinese government development, using menus of crop and livestock continues to extend the lessons of the “Southwest Project” approach to the poverty activities to increase upland agricultural productivity reduction program throughout China’s poor counties. and reverse the trend of environmental degradation; • The nutrition supplementation activity was ineffective because of the complicated (5) Town & Village Enterprise (TVE) development; nature of distributing the food and social constraints to anything but a fully equal and (6) institution building and poverty monitoring distribution, that is, targeting only the very poorest children for nutritional supple- mentation was not found to be an acceptable practice at the local level. • The ICR did not address other nutrition-related outcomes from any of the components. TABLE B.2: Examples of Nine AGSECALs Projects That Addressed Food Security (and in Some Cases Nutrition) NUTRITION CONSIDERATIONS YEAR PROJECT NAME FOOD SECURITY ACTIVITY (FROM APPRAISAL REPORTS) (FROM APPRAISAL REPORTS) FY86 Madagascar agriculture sector Reform of the rice market by eliminating the official distribution None adjustment loan system FY88 Mexico agriculture sector • Gradual shift from general to targeted food subsidies; and a A nutrition study was carried out to improve the monitoring of the adjustment loan gradual consolidation of food subsidies to one existing organiza- government’s food and nutrition programs. The study recommended tion (CONASUPO) (i) improving the capacity of the institutions involved; (ii) improving • Reform of the food coupon program to ensure that the nominal inter-institutional coordination; (iii) better targeting of assistance prices of the food coupons kept pace with tortilla prices to populations at risk; and (iv) the establishment of a food and nutrition monitoring program. FY91 Mexico agriculture sector Reform of food consumption policies to reduce poverty, provide • Piloting a food, nutrition, and health pilot project aimed at adjustment loan II income protection to the poor, and improve the nutritional status of providing food assistance to approximately 45,000 rural families the most vulnerable groups of the population in the states of Nuevo Leon, Tamaulipas, San Luis Potosi, and Mexico; and test different methods for operating a nutrition and health program. • Implementing a process and impact evaluation of the pilot proj- ect and other existing government food consumption programs FY88 Morocco second agricultural Mitigate the extent of the expected impact of higher food prices Restrict food subsidy to high extraction rate flour (which has a high sector adjustment loan from the planned liberalization of the cereals sector on the poor bran content and thus is more nutritious) generally consumed only by the poor. FY89 Somalia second agricultural Reform to liberalize agricultural marketing and other sectors of the A comprehensive plan was drawn to finance a number of actions to sector adjustment loan economy address the cost of adjustment to be borne by vulnerable groups. As part of this exercise, the Ministry of Health and UNICEF jointly carried out nutrition surveys in four areas of Mogadishu. FY90 Mauritania agriculture sector Reduce the role of the Agency for Food Security (CSA), a public None adjustment and investment agency that purchases and processes surplus cereals (rice, sorghum, project millet, and maize), sells commercial food aid, and distributes free food aid. FY90 Jamaica agricultural sector Reduce the role of the Jamaica Commodity Trading Corporation None adjustment loan (JCTC) which was a monopoly in basic food import, and sold them to consumers at subsidized prices. FY91 Kenya second agricultural Reform the agricultural sector to contribute to fiscal stabilization. The completed food security action plan included intended action sector adjustment credit Tranche triggers included completion of a food security action plan, for nutrition. adoption of a drought contingency and early warning plan, and monitoring the impact of adjustment on vulnerable groups and targeting assistance to them FY92 Burkina Faso agricultural Reform to liberalize domestic marketing and prices of traditional This AGSECAL intended for a separate project (the Food Security and sector adjustment loan cereals at producer and consumer levels and liberalizing (external) Nutrition project (FY92)— see table B.3) to support the implemen- trade in traditional cereals tation of a food security action plan to address issues of impact on living standards and nutrition status. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 48 A P P E N D I X B — P R O J E C T S T H AT H AV E A D D R E S S E D N U T R I T I O N T H R O U G H A G R I C U LT U R E TABLE B.3: Examples of Other Projects That Addressed Nutrition through Agriculture or Rural Development Managed by Population, Human Resources, Urban, and Water Operations Departments PROJECT RESPONSIBLE NUTRITION ACTIVITY YEAR NAME BANK SECTOR (FROM APPRAISAL REPORTS) OUTCOME (FROM COMPLETION REPORTS) FY90 India Tamil HNP Project supported the local procurement of therapeutic food supple- While performance of the service delivery of the supplements was Nadu nutrition ments to be produced by women’s working groups and local factories. noted, the ICR did not report on procurement source, or the intended project The former would provide employment as well as nutrition education, benefits that were supposed to accrue to the suppliers. and the latter would encourage development of food processing and marketing systems. FY91 Cameroon food ARD • Providing micro-credits to farmer groups to create employment • The micro-credit carried out by the project was able to generate security project opportunities and raise the purchasing power of rural groups, some profitable farming activities, but was not a success from a particularly women, improve feeding and dietary practices through micro-finance point of view since the recovery was low (73%), and a pilot nutrition education program for high risk groups (children also the intended transition of the micro-credit scheme for cash- under 5 and pregnant and lactating women), increase efficiency in generating activities to a commercial bank did not occur since there marketing and storage of foodstuffs was no interest from the commercial bank side. • Nutrition education to encourage changes in inappropriate child • 40% of the women in nutrition groups improved their nutritional feeding and maternal dietary practices by providing research and knowledge, and 20% of these women actually improved their analysis of child feeding and maternal dietary practices; formula- nutritional practices. tion of a national nutrition education strategy; development and testing of educational material; implementing a pilot program in several departments of the three provinces with the highest rates of malnutrition; evaluation of the pilot program and the development of guidelines for the expansion of nutrition education throughout the country. FY91 Malawi popula- HNP • Training and equipping of 5,500 community health volunteers. • It is difficult to precisely measure project effectiveness in terms of tion, health and • Carrying out and evaluating the three experimental models of health status improvements, nor to attribute these results to the nutrition sector community-based nutrition innovations: (1) provision of food project alone, but iodine deficiency nationally declined dramatically credit supplements through the WFP; (2) income generation activities and from 41.5% in 1990 to 27.0% in 1996. the introduction of labor-saving technologies for women to reduce • A number of the income generation activities for women were their caloric expenditure; and (3) area-based, integrated programs quite successful as pilot schemes. A final assessment of the maize including packages of agricultural inputs and food for lowest income mill component, for instance, indicated that sound market research women on the choice and finding locations for mills, good management • Finance a study to assess the feasibility of salt iodization procedures, and reliable back-stopping services have made these schemes viable undertakings that contribute to the socioeconomic uplifting of women and their families. Maize mills were also shown to significantly reduce the amount of time and labor women spend to process their food so that they could spend more time to do other activities. FY92 Sao Tome ARD • Support the diversification of agricultural production from cocoa • Diverisification of production has been limited and food crop produc- and Principe through privatizing the publicly owned agricultural sector and tion, which did increase, mainly banana and matabala and small agricultural promoting smallholder production, increased agricultural research animal products (chickens, pigs, and goats), primarily for the limited privatization on food crops such as vegetables, pulses, root crops and cereals, local market is now facing marketing outlet problems. and smallholder pineapple, tree fruits, and spices • A detailed socioeconomic survey was planned but never carried out. development • Support the reviving of beef production in coconut areas Thus, it is impossible to evaluate the full impact of the project on project beneficiary incomes and their living conditions. • Unintentionally, the natural resources were severely affected by the lack of technical support services when farmers cut cocoa shade trees to compensate for their falling income as cocoa prices fell in 1999. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N A P P E N D I X B — P R O J E C T S T H AT H AV E A D D R E S S E D N U T R I T I O N T H R O U G H A G R I C U LT U R E 49 TABLE B.3: (continued ) PROJECT RESPONSIBLE NUTRITION ACTIVITY YEAR NAME BANK SECTOR (FROM APPRAISAL REPORTS) OUTCOME (FROM COMPLETION REPORTS) FY91 Sri Lanka pov- HNP • A nutrition fund was supported to reduce the proportion of wasting • The achievement of project objectives was partial and unsatisfactory. erty alleviation and stunting in children and reducing the incidence of low birth The overall objectives, expansion of employment opportunities and project weight and the prevalence of maternal malnutrition. To this end, incomes among the poor, and the reduction of malnutrition among the project developed a set of innovative nutrition interventions mothers and young children, were achieved to a limited extent. including nutrition training and education in baby food preparation, • Child malnutrition fell from 38% in 1987 to 33% in 1995, and weaning practices, child weight measurement, and general nutrition unemployment declined from 14% in 1985–90 to 10% in 1997. and food preparation. Project activities are likely to have contributed to these improve- • The project also supported a multidimensional program which ments in malnutrition and unemployment. included: nutrition counseling and training, growth promotion • Among the reasons of failure was the absence of synergies among activities, and education on sanitation, home gardens, livestock the separate funds. Project interventions in one fund failed to lead rearing and early childhood development. smoothly to interventions in other funds. According to the design, social mobilization and nutrition activities under one fund were expected to prepare beneficiaries for participation in the credit and micro-enterprise development fund, the rural works fund, and nutrition activities. However, such progression of activities from one fund to another was limited due to weak understanding of the importance of promoting synergy between activities of the four funds and poor coordination of efforts. FY92 Ghana national ARD About half a million farm households would be directly reached by • Technology adoption rates were high for many cereals, legumes, agricultural improved agricultural extension services. Women farmers would be and horticultural crops. However, increase in production and farmer extension reached not only with improved production technology but also with incomes due to adoption of improved technologies were constrained project technologies for improving the home environment, for food processing by high input and marketing costs. and preservation, and for saving energy and labor in their daily tasks. • Achievement of people-level impacts, especially on nutrition, is uncertain. • The project made substantial gains in institutionalizing a unified professional extension service in Ghana. FY92 Burkina Faso ARD • Ran concurrently with the AGSECAL • 90% of all activities undertaken were profitable with average food security • Household Food Security Interventions to finance income- financial rates of return exceeding 40% per month. Women used and nutrition generating activities (directed primarily at women’s groups) such as their profits to supplement household expenditures on nutrition project home gardening, poultry raising, fattening of small ruminants, the and education (22 to 34% of their profits) and to accumulate cash making of handicrafts, flour mills, sheanut presses for oil extraction, savings. Overall, 70 % of the women, and 60% of the women’s local beer brewing, food processing, and petty trading. Grain groups, who benefited from project loans opened savings accounts marketing is excluded (even though it is potentially profitable) since, in decentralized financial institutions. in Burkina, it is predominantly a male activity. • The nutrition communication campaign appears to have met its • A nutrition communication campaign including a beneficiary stated objective of improving the nutritional status of children by assessment, a rapid assessment of training needs of NGOs and changing women’s behavior (in particular child feeding practices agricultural extension workers responsible for women’s activities in and spending habits). Nutritional impact indicators or targets were the provinces, nutrition education message development, training of not defined at appraisal. During the mid-term review, the Bank 150 agricultural extension workers and 64 NGO agents in nutrition recommended that the nutritional impact of project activities be education, and a multimedia nutrition education campaign. measured quantitatively. Although this was not done, village rep- resentatives and beneficiaries themselves regularly monitored the nutritional status of infants and children using a simple upper arm measurement technique developed in India (bandelekte Shakir). This information was used to assess the effectiveness of the training programs and messages but was never systematically collected by the PMU. FY92 Chile small ARD Technology transfer, involving both farm-oriented extension and • The overall outcome of the project is unsatisfactory and sustain- farmer services home-centered assistance (family kitchen gardens, water treatment, ability is unlikely. As a consequence of the government’s changing project improved diets and cooking methods, awareness of education, and focus on extension, most original project goals were only partially health service pursued. • There is no mention in the ICR on the home-centered assistance that was envisioned during the design of the project. (continued ) A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 50 A P P E N D I X B — P R O J E C T S T H AT H AV E A D D R E S S E D N U T R I T I O N T H R O U G H A G R I C U LT U R E TABLE B.3: (continued ) PROJECT RESPONSIBLE NUTRITION ACTIVITY YEAR NAME BANK SECTOR (FROM APPRAISAL REPORTS) OUTCOME (FROM COMPLETION REPORTS) FY93 Mozambique HNP • Policy development through strengthening capacity of monitoring • The government designed several strategic policy documents in food food security of poverty and household food security status and strategies security, population, and poverty, and has completed a number of capacity build- • Development of a poverty and food security database on poverty key pieces of analytical work orienting government policy. Principal ing project including information on food supply and nutrition surveillance among the latter is the first national Poverty Assessment, which • Support for two national food security conferences, a series of resulted from substantial field work, including the first national workshops and high-level policy seminars to create widespread household expenditure survey. awareness and debate of food security issues • Awareness among policy makers on the issues of food security and • Curriculum development for the inclusion of food security/nutrition- poverty has increased significantly. related courses at training institutes in health • A small cadre of local staff benefited from considerable technical training and experience; and a number of workshops and seminars took place. • The Intersectoral Food Security and Nutrition Group was established in 1997 and was involved in development of the Food Security and Nutrition Strategy and supporting documents. • Institutional cooperation in the country and in the region was established. The strengthened Faculty of Agronomy and Forestry Engineering and the Ministry of Planning and Finance engaged in a continuous collaboration on the following activities: – formulation of the food security and nutrition policies and strategies; – poverty analysis; – analysis of the district food security and nutrition profiles. FY95 Senegal HNP • A nutrition program, consisting of Information, Education, and • The project was successful in recuperating the malnourished children community Communication (IEC) interlocutors, supported by supplemen- who participated in the program. Almost 70% of the malnourished nutrition I tary feeding in urban areas and a small fund for research and children at the time of entry in the program recuperated or gained development sufficient weight to become above two standard deviations (weight • The food supplement will be produced locally, using only local per age). foodstuffs (pearl millet, roasted cowpeas, roasted peanuts), except • The food supplement, financed by WFP, turned out to be much more for sugar and a multivitamin/mineral mix which will be imported. expensive than estimated at appraisal, largely due to the high costs • A pilot rural household food security program to develop labor- of raw materials (maize and millet). In order to reduce the cost, intensive community micro-projects, such as wells, village health the formula of the food supplement was changed during the third posts, classrooms, school canteens, community gardens, food year of implementation. Instead of using high-priced local millet, storage facilities, and maintenance of communal roads which are of cheaper imported maize was used as the basis for the formula. principal benefit to the poorest households. The fluctuations in the price and availability of raw materials for the production of the food supplement caused problems for the weaning food production units and jeopardized the availability of the food supplement for the nutrition centers. The distribution of the food supplement was irregular at times, which had a negative impact on the participation in the growth monitoring program and the lEC sessions. • The pilot rural household food security program was added late in the project design phase and was less well prepared. The objective was complex and its focus very different from the other objectives. The detailed design of the activities began only after the MTR. The feasibility study and the proposal for pilot interventions were finalized during the last year of the project (component rating unsatisfactory). • The project demonstrated that production of the food locally has advantages, such as promotion of national production units, employment, and promotion of raw materials production. However, this is a process that requires sufficient start-up time, substantial technical assistance, and close monitoring. L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N A P P E N D I X B — P R O J E C T S T H AT H AV E A D D R E S S E D N U T R I T I O N T H R O U G H A G R I C U LT U R E 51 TABLE B.3: (continued ) PROJECT RESPONSIBLE NUTRITION ACTIVITY YEAR NAME BANK SECTOR (FROM APPRAISAL REPORTS) OUTCOME (FROM COMPLETION REPORTS) FY02 Ethiopia food ARD • Child Growth Promotion (CGP) activities—social mobilization, • CGP–CGP activities did not have a discernible effect on the likelihood security project weighing and measuring of children 2 years and younger, and of a child’s weight being recorded. However, there was a positive counseling for pregnant and lactating women and significant effect on behavior and on knowledge. Women in CGP • Food marketing initiatives—conduct studies to inform reforms kebeles were 7% more likely to exclusively breastfeed at least one and institution building for: (i) improved management of food aid child in the first 3 days of life and were 12% more likely to identify to secure a stable price environment for domestic producers and correctly the recommended age to introduce complementary foods. traders; (ii) establishment of a food market information system: (iii) • Indicator: Average increment in the number of months of food development of a warehouse receipt and inventory credit system consumption covered from own resources among vulnerable HHs in for traders; and (iv) the development of a competitive and efficient targeted communities (target: 3 months; baseline: n/a) market in warehousing services sufficient to support a warehouse • Outcome: Oromiya (all woredas) 4.3 months Amhara (25 woredas): receipt system 1.25 months SNNPR: 2004 entrants: 1.02 months 2005 entrants: 1.98 months 2006 entrants: 1.11 months Tigrai (5 woredas): 1 month • Indicator: % of children under 2 within project kebeles weighed each month (average for the year) (target: 70%; baseline: n/a) • Outcome: Amhara: 72% Oromiya: 49% Tigrai: 76% SNNPR: 84% • The food marketing initiatives were cancelled and implemented under a separate project. FY03 India food and HNP • Improve the quality and safety of foods and drugs by strengthen- • The project contributed significantly to the strengthening of policies drugs capacity ing the regulatory framework and incorporating components of and regulatory capacity in the food and drug sector. However, due building project consumer education and public-private partnerships. to the novel nature of the project for the Bank and for the client, • Training of about 2,000 food inspectors and 500 analysts in public disbursement remained stagnant and at the end of the project, more sector laboratories and recruitment of additional qualified staff ; new than half of the project amount was cancelled. construction and equipping of six central and nine state laboratories; • The lack of coordination between the food and drugs sector was one renovation and equipping of nine existing laboratories and public factor which led to a lack of interest and commitment in some states health offices at central and five laboratories at state levels. to a project mandated by the center. • Also, due to the project size ($54 million), the amount received per state was too little for the states to evoke much interest or owner- ship of the project, especially for the decision makers and as a result, they did not give high priority for the project implementation. • The ICR makes no explicit mention for nutrition. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 A ppendi x C — S amples of W orld B ank G uidelines on A ddressing N utrition t h roug h A griculture 53 Appendix C  AMPLES OF WORLD BANK GUIDELINES ON S ADDRESSING NUTRITION THROUGH AGRICULTURE 1. World Bank. 1973. Policy Guidelines for Bank Nutrition Scandizzo, P. 1981. “Analyzing Nutrition Effects of Agricultural Activities. Population and Nutrition Projects Department. Projects.” AGR Interim Guidance Note No. 7, World Bank. Background paper: 4. Berg A., S. Basta, N. Koffsky, F. J. Levinson, J. Pines, 1986. Chafkin, S., Pines, J., Berg, A., and Longhurst, R. “A Review “Guidelines for work in nutrition.” World Bank. of Possible World Bank Actions on Malnutrition Problems - American Technical Assistance Corporation” – January 1972, Background papers: Folder 347351, World Bank Group Archives, Washington, D.C., Martin, T. 1983. “Nutritional Consequences of Agricultural United States. Development Projects: A Survey of Experience.” AGR and PHN, World Bank. 2. World Bank. 1980. Nutrition, Basic Needs, and Growth. Reutlinger, S. 1983. “Nutritional Impact of Agricultural Population, Health, and Nutrition Department, World Bank. Projects.“ AGR/ARU 14, World Bank. 3. Koffsky, N. 1982. “Nutrition in Agriculture Sector Work 5. World Bank, 2013. Improving Nutrition through Multisectoral Guidelines.” PHN and AGR, World Bank. Approaches. Background papers: Background paper: Pinstrup-Andersen, P. 1981. “Nutritional Consequences Herforth, A, Jones, A., Pinstrup-Andersen, P. 2012. “Prioritizing of Agricultural Projects: Conceptual Relationships and Nutrition in Agriculture and Rural Development: Guiding Assessment Approaches.” World Bank Staff Working Paper No. Principles for Operational Investments.” HNP Discussion paper, 456, World Bank. World Bank. A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 A P P E N D I X D — E V O LU T I O N O F N U T R I T I O N P L A C E M E N T AT T H E W O R L D B A N K 55 Appendix D EVOLUTION OF NUTRITION PLACEMENT AT THE WORLD BANK For a full description, see the Records of Population, Nutrition, and functioned as a Central Operating Projects department, maintain- Health of the World Bank Group Archives: http://web.worldbank.org ing responsibility for policy formulation, research and operational /WBSITE/EXTERNAL/EXTABOUTUS/EXTARCHIVES/0,,contentMDK:23263 support, as well as the planning, direction, and supervision of proj- 805~pagePK:36726~piPK:36092~theSitePK:29506,00.html ect and sector work (PHN staff were not placed in the regional vice presidencies). 1968: Population is formally started by the creation of the Population 1987: Projects Department (PNP) under the Vice Presidency of Projects. A Bank-wide reorganization resulted in the termination of almost all organizational units. The Vice Presidency, Sector Policy and Research 1972: (PRE), was established in May 1987. PRE had five departments report- Within PNP, the Nutrition Unit (PNPD2) was created. PNP was ing to it including the new Population and Human Resources subsequently renamed the Population and Nutrition Projects Department (PHR). This department integrated the functions Department but retained its original acronym. of PHN and the Education and Training Department (EDT); it also assumed responsibility for activities related to ‘strengthening the role of women in development.’The PHR had four divisions: Education and 1975: Employment Division (PHREE); Population, Health and Nutrition The nutrition functions of PNP (PNPD2) were transferred to Division (PHRHN); Women in Development (PHRWD); and Welfare Agriculture and Rural Development Department (AGR). PNP and Human Resources Division (PHRWH). At this time, the opera- reverted to its previous title, the Population Projects Department tional functions conducted by the former PHN were passed to the (PNP). At that time, AGP consisted of three divisions: general agricul- regions (PHR units were now present in regional vice presidencies). ture, economics and resources, and rural development & nutri- tion (AGRNU). 1993: [Between 1975 and 1979, nutrition was housed in the Agriculture and Three new thematic vice presidencies were created: Human Rural Development department] Resources Development and Operations Policy (HRO); Finance and Private Sector Development (FPD); and Environmentally 1979: Sustainable Development (ESD). At this time, PHR was terminated The Population, Health, and Nutrition Department (PHN) was and its functions were split between a reconstituted Population, established reflecting the Bank’s expanded role in the health sec- Health, and Nutrition Department (PHN) and a new Education tor. Nutrition work carried out under AGRNU moved to PHN. PHN and Social Policy Department (ESP). Both of these departments A G R I C U LT U R E A N D E N V I R O N M E N TA L S E R V I C E S D I S C U S S I O N PA P E R 1 0 56 A P P E N D I X D — E V O LU T I O N O F N U T R I T I O N P L A C E M E N T AT T H E W O R L D B A N K were placed in the HRO vice presidency. The PHN had no divisions of the 1997 restructuring was four networks: the Environmentally but had task-specific teams including a Population Team, Health and Socially Sustainable Development Network (ESSD); the Finance, Team, and Nutrition Team. Private Sector Development, and Infrastructure Network (FPD); the Human Development Network (HDN); and the Poverty 1995: Reduction and Economic Management Network (PRM). HRO became Human Capital Development and Operations As part of this reorganization, the HDD was broken into three Policy (HCO). At this time education, health, nutrition, and popu- teams that were linked to HDN. The teams were: Education Team lations functions were again combined in a single department (HDNED); Health, Nutrition, and Population Team (HDNHE); named the new Human Development Department (HDD). The and the Social Protection Team (HDNSP). In 2003 an HIV/AIDS Global nutrition team continued under HDD. Program Team (HDNGA) was created and added to the HDN. 1997: [This structure remains in place till June 2014. As of July 2014, the four The thematic Vice Presidencies were reorganized to strike a better networks will be replaced by 14 Global Practices. Nutrition will be carried balance between “country focus” and “sectoral excellence.” The result out in the Health, Nutrition, and Population Global Practice.] L E A R N I N G F R O M W O R L D B A N K H I S TO R Y: A G R I C U LT U R E A N D F O O D - B A S E D A P P R O A C H E S F O R A D D R E S S I N G M A L N U T R I T I O N REFERENCES 57 REFERENCES Resources from the World Bank Group Archives Berg, A. 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