Report No. 41315-TZ United Republic of Tanzania Advancing Nutrition for Long-Term Equitable Growth December 2007 Poverty Reduction and Economic Management Unit (AFTP2) Africa Region Tanzania Food and Nutrition Centre UNICEF Tanzania Document of the World Bank TFNC Tanzania Food andNutritionCentre THIS Tanzania HIV/AIDS Indicator Survey TACAIDS Tanzania Commission for AIDS TASAF Tanzania Social Action Fund UN-DAF UN-DevelopmentAssistance Framework UNICEF UnitedNations Children's Fund WHO World Health Organization YSCD Youth and Child Survival andDevelopment Vice President: Obiageli Katryn Ezekwesili Country Director: John Murray McIntire Sector Director: Sudhir Shetty Sector Manager: Kathie Krumm Task Team Leader: Johannes Hoogeveen .... Ihave talked at length about this question offood because thefoundation of development ispeople. A hungry person cannot bringprogress. He is weak of body and also weak of mind. This must always be remembered; especially in relation to children. Whena child is not wellfed, he will not grow properly he will be deformed, and his intelligence will be affected - also; he will not reach hisfull potential. -Julius K.Nyerere i FOUR MYTHS ABOUT NUTRITION Poor nutrition is intimately linkedwith poor health, inadequate caring practices and poor environmental conditions. But planners, health specialists, politicians, and economists often fail to recognize these connections. Serious misunderstandings include the following myths: Myth 1: Malnutrition isprimarily a matter of insuflcient food intake. Not so. Food is o f course important and many in Tanzania have an inadequate diet and insufficient calorie intake. But most serious malnutrition occurs during the first two years o f life and is caused by disease (malaria, respiratory infections, worm infestations), poor sanitation leading to diarrhea, especially among young children, and a diet that is too uniform to provide all nutrients the body needs. Behavioral change plays a big part in improving nutrition. Myth 2: Improvednutrition is a by-product of other measures ofpoverty reduction and economic advance. It is not possible to jump-start the process. Again, untrue. Improving nutrition requires focused action by parents and communities and local and national action in health and public services, especially water, sanitation, malaria control and HIVIAIDS Thailand has shown that moderate and severe malnutrition can be reduced by 75% or more ina decade by such means. Inrural Tanzania, stunting was reduced by 7% and underweight by 8% between 1999 and 2004 through a combination o f increased household income and other factors including increased use o f bed nets, more rapid treatment o f malaria, improved access to safe water and improved sanitation. Myth 3: Givenscarce resources, broad-based action on nutrition is hardlyfeasible on a mass scale. Wrong again. In spite o f severe economic constraints, some impressive achievements have been attained. Over two-thirds o f Tanzanians now consume iodized salt. Over 80% o f children a year now receive vitamin A capsules, tackling the nutrient deficiency that causes blindness and increases child mortality. Mass immunization, malaria prevention and promotion o f oral rehydration to reduce deaths from diarrhea have also done muchto improve nutrition. Myth 4: Investing in nutrition improves the welfare of individuals but does not contribute to economic growth. Not correct. Improvements in nutrition have been shown to yield significant benefits contributing to increased labor productivity, directly through improved physical strength and indirectly through improved intelligence and school performance and reduced cost o f health care. Cost-benefit ratios for nutrition interventions indicate highrates o f return on nutrition investments. NUTRITIONAND THE MDGs Goal 1-Eradicate extreme povertyand hunger 0Malnutritionerodes human capital and reduces labor productivity. 0Malnutrition increases susceptibility to disease leading to high private and public cost for health care and reduced incomes. 0Malnutrition can disable. Vitamin A deficiency can cause blindness and iodine deficiency impairs mental development. Goal 2 -Achieve UniversalPrimary Education 0Malnutrition (iodine and iron deficiencies) reduces learning capacity. 0Malnourished children are less likely to enroll in school, enroll later in school than other children and complete fewer years o f education. 0Hunger reduces school performance. Goal 3 -Promote Gender Equalityand EmpowerWomen 0Bettermaternal educationreducesthe likelihood ofmalnourishedchildren. Goal 4 -Reducechild mortality 0Malnutrition is associated with more than 50% o f all child mortality. 0Vitamin and minerals (vitamin A, zinc) are key to child survival; vitamin A supplementation has the potential to reduce infant mortality by 23% among deficient populations. Goal 5 -Improve maternalhealth 0Stuntingincreases a mother's riskduringlabor. 0Deficiencies o f several micronutrients (iron, vitamin A, folate, calcium, iodine) are associated with pregnancy complications and maternal mortality. Goal6 -Combat HIV/AIDS, malaria and other diseases 0Malnutrition i s a major contributor to the overall burdeno f disease. 0Malnutritionhastens the onset of AIDS amongst HIV positive individuals. 0Malnutrition compromises the efficacy, efficiency and safety o f ARV treatment and weakens the resistance to opportunistic infections. 0Malnutritionreduces malaria survival rates. ... lll TABLE OF CONTENTS ... Acknowledgements .............................................................................................................. vu1 Executivesummary ................................................................................................................ ix 1 How seriousis malnutritionandwhy doesit matter?................................................. . 1 1.1 The prevalenceof malnutrition intanzania is high ........................................................... 1 1.2 Adult nutrition................................................................................................................... 1.3 Malnutrition has high economic and welfare costs........................................................... 5 1.4 Conclusion ...................................................................................................................... 7 12 2. Profile of malnutrition .................................................................................................. 13 2.1 Under-nutrition varies spatially ...................................................................................... 13 2.2 Householdwealth is not a good predictor for malnutrition ............................................ 17 2.3 Under-nutrition starts early ............................................................................................. 21 2.4 Conclusion ...................................................................................................................... 23 3. Causes of malnutrition ................................................................................................. 25 3.1 Food energy consumptionand dietary diversity are inadequate .......................................... ..................................... 25 3.2 Caring practices for young children and (pregnant) women 29 3.3 Healthy living conditions improve nutrition ................................................................... 32 3.4 Key factors contributing to under-nutrition.................................................................... 34 3.5 Conclusion ...................................................................................................................... 35 . ...................................................................................................... 4.1 Income growth alone cannot achievethe mkukuta or mdg targets................................. 4 Advancingnutrition 37 4.2 The economic rate of return i s high for many nutrition investments.............................. 37 40 4.3 The budget for nutritioninterventions is limited ............................................................ 43 4.4 Definingthe nutritionagenda ......................................................................................... 52 4.5 Conclusion ...................................................................................................................... 54 5 .................................................................................... 5.1 Focusingthe nutrition program....................................................................................... . Strengtheningimplementation 57 57 5.2 Improving the efficiency ofthe delivery ofthe nutrition program ................................. 58 5.3 To advance nutrition, coordination needs to be improved.............................................. 62 5.4 Enhanceddemand for and accountability of nutrition services ...................................... 63 5.5 Monitoringand evaluation .............................................................................................. 65 5.6 Conclusion ...................................................................................................................... 66 Annex A: CommissionedPapers ........................................................................................... 68 Annex B: ComparingNutrition OutcomesUsing Old andNew Reference Growth Tables ........................................................................................................ 69 Annex C: MalnutritioninTanzaniafrom an international perspective ................................. 71 Annex D: Under-nutrition and HIV/AIDS ............................................................................ 73 Annex E: Exclusive breast feeding? ...................................................................................... 74 Annex F: Objectives of the Youth and Child Development program .................................... 75 Annex G: On Pilots 77 REFERENCES ....................................................................................................................... ................................................................................................................ 78 1v LIST OF BOXES Box 1.1 Glossary ..................................................................................................................... 3 Box 1.2: Malnutritionaffects survival. productivity and intelligence indifferent ways ........8 Box 2.1: Mismatches intargeting ......................................................................................... 17 Box 3.1: Eleven reasonswhy child malnutrition persists infood-secure households ...........26 Box 3.2: The milk hypothesis ............................................................................................... 28 Box 4.1: Income growth is not sufficient to achieve the nutritionMDG .............................. Box 4.2: School feeding is an intervention that improves education. not nutrition 43 Box 4.3: Nutrition agenda ...................................................................................................... ...............39 53 Box 5.1: A not so focused pilot program .............................................................................. 58 Box 5.2: Actions for improved efficiency ............................................................................ 66 V LIST OF FIGURES Figure 1.1:Percent of undernourishedchildren since 1991 ..................................................... 2 Figure 1.2: Percent ofundernourishedchildren since 1991, by ruraland urban areas Figure 1.3: Body mass indices of adults ................................................................................... .............2 Figure 1.4: Stunted(YO.2004) and under 5 mortality (# per 1000 live births. 2002) ...............69 Figure 1.5: Height in2004 and childhood stunting 10 years earlier; Kagera ......................... Figure 1.6: Education inYears in2004 and childhood stunting 10 years earlier; Kagera .....10 11 Figure 2.1:Malnutrition in2004 for children under 5 years of age ....................................... 13 Figure 2.2: Prevalenceof stunting in 198 rural villages communities inTanzania Figure 2.3: Incidence curves of under-nutrition ..................................................................... ................16 18 Figure 2.4: Under-nutrition in 2004 for children under 5 years by rural areas and urban areas ......................................................................................................................... 19 Figure 2.5: Spatial patternsof malnutrition and income poverty .......................................... 21 Figure 2.6: Under-nutrition by age inmonths for urbanand rural areas ............................... 22 Figure 2.7: Incidence of small or very small babies .............................................................. 23 Figure 3.1: Non parametric estimateof stunting and milk consumption ............................... 28 Figure 3.2: Non parametric estimate of determinantsof stunting ......................................... 30 Figure 3.3: Non parametric estimates of determinant of stunning and months ..................... Figure 3.4: Non parametric estimate of determinantsof stunting and age inmonths ...........31 33 Figure 4.1: Projectedreduction inunder-nutrition inTanzania due to income growth.........38 Figure 4.2: Decomposition ofthe change inunder-nutrition inTanzania between 1999and 2004 ..................................................................................................................... Figure 4.3: Fiscal space for nutrition interventionsinthe short and the medium term ..........40 46 vi LISTOF TABLES Table 1.1 :Regressionof body mass index ofwomen on personalcharacteristics 6 Table 1.2: Early childhood mortality ratesby birthsize 7 Table 2.1: Spatialvariation inkey nutrition indicators ........................................................... 14 Table 2.2: Five worst and five best performing regions ......................................................... 15 Table 2.3: Decomposition of differences instunting within and betweenregions .................16 Table 2.4 Monthly householdconsumptionby wealth quintile (Tsh) ................................... 20 Table 3.1:Foodenergy availability ........................................................................................ 27 Table 3.2: Breastfeedingstatus by age ................................................................................... 29 Table 3.3: Prevalence of infectious diseases during the past 2 weeks amongst children under five ........................................................................................................................ 32 Table 3.4: Probit regression on stunting for children aged 0-60 months ................................ 36 Table 4.1: Estimates of benefit to cost ratios for nutrition interventions ................................ Table 4.2: Benefitto cost ratios ofcommunity based interventions inTanzania ...................41 42 Table 4.3: Annual cost of nutrition interventions ($ / Capita) 44 Table 4.4: Projectedpopulation for 2004 ............................................................................... ................................................ 44 Table 4.5: Budget for nutrition interventions Table 4.6: Overview of ongoing or planned interventions with potential nutrition benefits..45 ......................................................................... Table 4.7: Estimatedcost (usd) to the nutrition sector of investments innutrition ................47 56 Vii ACKNOWLEDGEMENTS This report is the fruit of collaboration between the World Bank, the Tanzania Food and Nutrition Centre (TFNC) and UNICEF Tanzania. It has benefited from the input and support of many individuals, in particular, James Garrett, Yi-Kyoung Lee, Mwanaisha Kassanga, Julie McLaughlin, Mary-Anne Mwakangale, Menno Mulder-Sibanda, Meera Shekar, Robert Utz and Paolo Zacchia (World Bank), Iqbal Kabir, Kerida McDonald and Felicite Tchibindat (UNICEF) and Godwin Ndossi (TFNC). The task manager and principal author of the report is Johannes Hoogeveen. The TFNC team was led by its Managing Director, Godwin Ndossi; the UNICEF team was led by its Nutrition Officer, Felicite Tchibindat. Substantive inputs and background papers were prepared by Godwin Ndossi and others at TFNC, Blandina Kilama, Wietze Lindeboom and Valerie Leach of REPOA, Adolf Mkdenda of the University of Dar es Salaam, Harold Alderman and Johannes Hoogeveen of the World Bank and Mariacristina Rossi of the University of Rome TOR Vergata. A complete list of background papers is provided in annex A, and can be obtained by sending an email to Mary-Anne Mwakangale at mwakangale@worldbank.org. Harold Alderman (World Bank) and Manisha Tharaney (Helen Keller International) peer reviewed this report. Financial support for this report was receivedfrom UNICEF, the Children and Youth Trust Fund and DflD's Social Protection Trust Fund. The report was prepared under the overall supervision of Ms. Kathie Krumm (Sector Manager, Poverty Reduction and Economic ManagementUnit for EastAfrica). The book Repositioning Nutrition as Central to Development.A Strategyfor Large- ScaleAction, World Bank, 2006 has beenan invaluable resourcefor this ESW as it brings together international evidence on the rationale to invest innutritionand provides a practical approachon how to accelerate progress innutrition. The box on page iiandthe maps on page iiihavebeenadaptedfromthisbook,whichcanbedownloadedfrom: http://siteresources.worldbank.org/NUTRITION/Resources/281846- 1131636806329/NutritionStrategy,pdf. Viii EXECUTIVESUMMARY 1. Nutrition indicators for Tanzania are troubling. Almost four out of every 10 childrenaged 0 to 59 months are chronically undernourished andthus too short for their age; about one out of every five children weighs too little given their height. Over 60% of all children and 50% of all women are anemic. 44% of Tanzanians are energy deficient and unableto simultaneouslysustaintheir bodyand carryout even light physicalactivity. 2. The prevalence of malnutrition differs little by wealth class. Poor households are only slightly more affected than non-poor households and differences in the prevalence of under-nutritionbetween households in the first two wealth quintiles (poor households) and those in the third and fourth wealth quintiles (non-poor households) are negligible. Only households inthe top wealth quintile are less affected, but even inthese households as many as one in five childrenare stunted (evidencingchronic malnutrition). FigureE.1 Malnutritionin2004 bywealth quintilefor childrenless5 years old -z.50 45 40 35 .$ 30 C `gg25 20 -0 c 15 10 5 0 Source: Author's calculations basedon DHS2004. 3. Malnutrition is associated with high maternal and infant and child mortality. Malnutrition is a major contributor to infant and childhood mortality. A small or very small newborn is almost four times as likely to die during the first month of life than a baby of average weight or more. A child that is severely underweight is more than eight times more likely to die from infectious disease than a well nourished child. All in all malnutrition is associated with over 50% of childhood mortality. Malnutrition also affects maternal mortality; women of small stature and anemic women, are more likely to die as a consequence ofchild birth. ix 4. Malnutrition is associated with high morbidity. Malnutrition increases the risk of illness and potentially leads to a vicious cycle with impaired immunity leading to infection with attendant loss o f appetite and increased use o f energy stores and, thus, an increased likelihood of additional malnutrition. Malnutrition i s a fundamental factor contributing to malaria-associated morbidity and the onset of AIDS for those infected by HIV. Low weight for height alone is heldresponsible for 9.5% of global burden o f disease. Iron, vitamin A, and zinc deficiencies add another 6.2%. 5. Malnutrition is bad for education outcomes. Well nourished children have higher IQs, go to school at an earlier age, are better able to concentrate when at school and are likely to complete more grades. Evidence from Kagera shows that eliminating malnutrition reduces the proportion of children who never attended school by up to 13%, reduces the years of delay in school enrollment by approximately one year, and increases the total years o f schooling by up to 1.5 years. 6. Malnutrition reduces labor productivity. Inadequate caloric intake and anemia have direct consequences for the ability to be productive. Depending on the nature o f the labor, eliminating anemia has been found to raise labor productivity by 5- 17%. Malnutrition also has indirect consequences for labor productivity. Evidence from Kagera shows that the combined effect o f lower education outcomes and smaller stature due to childhood malnutrition reduces lifetime income by as much as 12%. 7. Addressing malnutrition allows breaking the existing poverty-malnutrition cycle by improving the ability to be productive. Severe under-nutrition can trap people in a situation of low income and persistent under-nutrition. Malnourished children are more likely not to fulfill their full developmental potential and as adults are more likely to be poorly educated and of small stature both o f which are related to low incomes. Low household income, in turn, results in a greater likelihood o f their children being malnourished, thus contributing to the intergenerationaltransmission o f poverty. By addressing malnutrition this vicious cycle can be broken. 8. Investments in nutrition are investments in economic growth. Nobel Prize- winning economist Robert Fogel has estimated that about half the economic growth in Britain between 1780 and 1980 can be attributed to improved nutrition. In Tanzania, investments in nutrition equally have the ability to lay the foundation for future economic growth. Some benefits o f nutrition investments will be immediate, others will materialize once the beneficiaries o f nutrition interventions enter the labor market as healthier, more physically fit and better educated individuals. 9. Poor diets (quantity as well as quality), inadequate caring practices and unhealthy living environments are major factors contributing to malnutrition. The prevailing view in Tanzania stresses the importance o f improving caring practices for small children and of addressing unhealthy living conditions. This analysis supports this but also finds that inadequate calorie intake and an undiversified diet equally contribute to an undernourished population. X 10. Income growth is a necessary but not a sufficient condition to achieving the MDG and MKUKUTA goals for nutrition. Greater income allows families to spendmore on food, clean water, hygiene and preventive and curative health care. It allows them to have a more diversified diet and to obtain more effective childcare arrangements. At the community level greater income will eventually lead to better access to and higher quality health care, improved water and sanitation systems and greater access to information. However, the income elasticity for nutrition is low: between 0.25 and 0.5 implying that a 10% increase in income leads to a 2.5% to 5% reduction in malnutrition. As a consequence and despite the high GDP growth that Tanzania is currently experiencing, income growth alone will not be sufficient to reduce malnutrition by half by 2010 (MKUKUTA) or even 2015 (MDG). 11. Effective nutrition interventions exist. Breastfeeding promotion, integrated child care programs and pre-school programs aimed at young children have each proved to be effective in addressing malnutrition. Vitamin A deficiency amongst children under the age of 5 can be effectively addressed through a twice yearly vitamin A supplementation. Requiring all salt to be iodized helps prevent iodine deficiency. Iron supplementation for and intermittent presumptive treatment for malaria in pregnant women, the provision o f deworming tablets to children under five, sleeping under bed nets to prevent malaria, fortifying food with iron and cooking in iron pots are effective ways to reduce anemia. 12. A number of nationwide interventions have been successfully introduced since the year start of the millennium. Over 80% o f children under the age o f 5 receive twice a year vitamin A supplements and deworming tablets. At least three quarter o f all households utilize salt fortified with iodine. These are important successes that have significantly contributed to the reductionof infant and child mortality and preventable mental and physical impairment. 13. Nutrition interventions have attractive economic rates of return. Many (but not all) nutrition interventions are good economics and have attractive benefit to cost ratios. At a discount rate o f 3-5% the benefit cost ratios of most nutrition interventions exceed one, often by a factor 10 to 40. In other words, investments in nutrition yield benefits that are 10 to 40 times as much as the original investment. Spending on nutrition is an investment at par or better than investments in malaria control, trade liberalization or community managed water supply, programs that already receive considerable investments. Food fortification and the provision o f micro-nutrient supplements in particular have been demonstrated to yield highly attractive economic rates o f return. Table E.1 Estimates of benefitto cost ratios for Tanzanian nutrition programs Benefit-costratio Iodine fortification 38.6 Vitamin A supplementation (children<6y) 4.3 -43 (*) Iron supplementation (per pregnant women) 9.4 Breastfeeding promotion inhospitals 17.5 Integratedchild care programs 4.4 19.1 - Intensive pre-school program with considerable nutrition for poor 1.4-2.9 (*) fami1ies Note: Benefit to cost ratios are based on empirical studies of nutrition interventions and subject to a number o f assumptions. Calculations assume 3-5% discount rates and include both private and social costs. An asterix (*) indicates international evidence. All other evidence is from Tanzania xi 14. With the existing resources only the most crucial nutrition investments can be afforded. The budget available for direct investments in nutrition from UNICEF, HKI and TFNC is limited -less than $ 0.75 per beneficiary per annum. With such limited resources, nutrition interventions have to be confined to those with the highest rates of return, in particular those addressing vitamin and mineral deficiencies and activities addressing prenatal care and care and feeding practices for young children. Yet much can be achieved even with the existing resources. 15. The positive impact improving nutrition has on health and education outcomes supports leveraging resources from these sectors for nutrition. Cost sharing with others will have to be an important element of a strategy aimed at improving nutrition outcomes. There are many opportunities to do so. For instance, behavioral change aimed at improving the quality of people's diets could be supportedby TACAIDS andthe Ministry of Healthand Social Welfare as good nutrition is of great importance in delaying the outbreak of AIDS for those infected with HIV and for ensuring that ARVs work effectively for those affected by AIDS. Similar opportunities exist with the Ministry of Health and Social Welfare as improved nutrition reducesthe burdenof diseases and reducesmortality, with the Ministry of Education and Vocational Training as good nutrition enhances school readiness and improvesattention. 16. Coordination with others could provide additional leverage for nutrition. Districts will need to play a more central role in implementing nutrition activities, a role that will have to be facilitated by nutrition focal persons and field officers of the Ministries for Agriculture and Livestock Development and for Community Development, Gender and Children. A closer collaboration with ongoing interventions is possible, being it the promotion of hygiene and good sanitation (Water Sector and Sanitation Program), community based nutrition interventions (TASAF), or the promotion of home gardens and livestock keeping (Agricultural Sector DevelopmentProgram). Collaboration with the private sector could go a long way in promoting food fortification (e.g. by fortifying maize flour, sugar or soft drinks with iron) and in marketing nutrition messages. 17. Enhancing the efficiency of delivery and coordination mechanisms is another way to free resources for essential nutrition services. Currently administrative costs absorb approximately one third of the budget available for nutrition interventions. By integrating nutrition interventions with ongoing activities, the cost of interventions would be reduced as only additional expenses would have to be covered. Other efficiency enhancing measures should also be considered. Enhancing efficiency requires reform which can only come about if the major actors in nutrition are committed to it: TFNC as the national institution charged with nutrition will have to provide leadership to ensure a coordinated, effective and efficient approachto tackling malnutrition. 18. Strengthening TFNC is important for future interventions to be implemented successfully. Vitamin A supplementationand salt fortification could be largely implemented from Dar es Salaam but decentralization and a greater reliance on (sector) budget support require a much greater focus on coordination and providing guidance and less on implementation. TFNC will needto be enabledto make this transition. xii i. To advance nutritionthe focus needsto beonaset ofobjectivesthat canbe achieved within the available resources, while enhancing demand for nutrition services, strengthening the institutions key to delivering such services (TFNC and LGAs) and improving accountability. A number ofconcrete steps are proposedfor consideration. ii. Focusnutritionservicesontheactivitieswiththehighestbenefit-costratios,in particular (i)vitamin and mineral provisionand (ii)improvedprenatal care and care and feeding practices for young children. The National Nutrition Strategic Plan should clearly prioritize these cost-effective interventions. Work programs of all nutrition partners (TFNC, LGAs, MoHSW as well as development partners) should then prioritize these actions and eliminate other strategies from their work programs. iii. TheMinistryofHealthandSocialWelfarehastotakefullresponsibilityfor nutrition outcomes. The Ministryof Healthand Social Welfare is responsible for many of the most effective nutrition interventions and as the parent ministry for TFNC bears final responsibility for achieving nutrition outcomes. Nutrition milestones could be identified in the Annual Joint Health Sector Review and the Health Sector Strategic Plan and should have clear targets for the delivery of vitamin A, salt iodization, anemia reduction and exclusive breastfeeding. A nutrition desk officer in the Ministry could provide in-house expertise and oversight and strengthen coordination with TFNC and could help to ensure that nutrition remainsan integral part ofthe Ministry'sdisease prevention strategy. iv. Enhance domestic accountability and transparency by initiating an Annual Nutrition Review. An Annual Nutrition Review which is accessible to all domestic stakeholders would provide an opportunity to report (and receive feedback) on progress in combating malnutrition, to discuss performance, to identify new demands and to agree on key priorities andmilestonesfor the futurework program. v. Establish a nutrition Sector Working Group to improve coordination and enhance efficiency. By bringing together development partners in a nutrition Sector Working Group (SWG), nutrition will have a clearer `home' inthe work of Cluster I1and in MKUKUTA monitoring, PER cluster work and the GBS annual review. A nutrition SWG will provide opportunities for dialogue and coordination and encourage development partners and NGOs to abide by the JAST principles and to align work programs, financing and technical assistance with the national nutrition agenda reducing the scope for inefficiencies and spendingon non-priority areas. vi. Improve service delivery by identifyingand training nutrition focal points in all districts and holding them accountable for making progress. Decentralization is an important aspect of making nutrition service delivery more effective and efficient as it brings implementation closer to the beneficiaries and creates demand for nutrition services from TFNC. With guidance from TFNC, nutrition focal points would be responsible for identifying the districts' key nutrition problems and hotspots, could be charged with assisting health, education and agriculture staff in designing nutrition interventions and integrating these in district plans and budgets. The focal person would have to report to TFNC to account for progressmade inthe delivery of nutrition services. vii. Enable TFNC to lead the nationalresponseto nutrition.TACAIDS may serve as a model for a TFNC that provides strategic leadership and coordinates the implementation of a national multi-sectoral response to malnutrition. A strengthened TFNC would focus most of its attention to monitoring progress and providing guidance, training and technical support to various implementing agencies (MDAs and LGAs), and would reduce its role in implementation. Enabling TFNC to more effectively lead the national response to nutrition requires staffing in accordance with TFNC's tasks and functions. The Public Service Reform Program I1could facilitate this. viii. Create a department in TFNC, responsible for leveraging resources for nutritionthrough strategic leadershipand coordination.Addressing malnutrition requires a multi-sectoral effort. To ensure effective implementation TFNC has to collaborate intensively with various Ministries (Health and Social Welfare, Education and Vocational Training, Agriculture, Food Security and Cooperatives or Livestock Development, Ministry for Community Development, Gender and Children). TFNC will also have to provide strategic leadership on nutrition for various programs and project (TACAIDS, Malaria Initiative; TASAF, Water Supply and Sanitation program, Water Sector Development Program, Agricultural Sector Development Program) to share costs and to ensure the alignment of these programs with nutrition objectives. ix. Establish public-private partnerships and collaborate with NGOs to deliver nutrition services. The availability of iodized of salt throughout Tanzania shows that it is possible to collaborate successfully with the private sector. Other opportunities for public- private partnerships exist for instance through social marketing of nutrition messages or by fortifying products like maize, sugar and cooking oil. Likewise volunteers or NGOs could be used to reach target population with nutrition messages and to implement nutrition related activities. x. Enhance demand for nutrition services, and instigate behavioural change through nutrition education.Nutrition education is keyto behavioural change, but will also increase the demand for nutrition services from service providers at local level (e.g. when pregnant women ask for advice at the clinic) or central level (when district nutrition officers request guidance from TFNC). Thailand which trained 1% of its population as volunteers to spread information about good nutrition has shown that remarkable results on a nationwide scale can be achievedthrough nutrition educationalone. xi. Co-opt the HIV/AIDS program into a nutrition education campaign. Good nutrition is particularly important for everyone, including those affected by HIV and AIDS. Most people are unaware of their HIV status so a nutrition education program will have to reach all Tanzanians. With its extensive resources and a program that is already supporting communication and behavioural change, the HIV/AIDS program is well suited to lead the implementation of the nutrition education agenda supported by TFNC will the necessary technical knowledge. Other programs such as the Water and Sanitation who are preparingto launchacampaign on the importanceofhandwashing with soap could also be approached. XiV xii. Strengthen monitoring and evaluation. Priorities for nutrition interventions, targeting mechanisms and progress against objectives can only be reliably assessed in the presence o f information. Monitoring and evaluation systems for nutrition services need to be strengthened in particular to provide information at the local level, to assess the performance o f micro-nutrient programs and to better understandbehavioural patterns. 19. For nutrition to be successfully advanced high levelsupport is needed. Efforts to advance nutrition inTanzania have made before, with the earliest attempts dating back to the late 1970s. Most have not been very successful. To enhance the likelihood o f success this time, commitment from all stakeholders is needed. A social `contract' that is announced at a public event by a high level policy maker may be one way to commit the actors to change. Such a social contract would have to set clear objectives and a timeline, it would have to define roles and responsibilities o f the various stakeholders and provide an accountability framework. 1. HOW SERIOUSI S MALNUTRITIONAND WHY DOESIT MATTER? 1. Malnutrition remains one of the most serious health problems and the single biggest contributor to child mortality. It is a main inhibitor to educational performance and a key impedimentto economic growth. Nobel Prize-winning economist Robert Fogel has estimated that improved nutrition, by bringing the ultra poor into the labor force, by raising the energy available for work, and by increasing the efficiency of the human body to transform dietary energy into work output, contributed to approximately 50% of the British growth in per capita income over the past 2 centuries (Fogel 2004). In other words about half of the remarkable rise of Britishper capita income from $205 in 1780to $2544 in 1980 should be attributedto nutrition!' 2. This chapter explores the importance of nutrition for Tanzania. It demonstrates that the prevalence of malnutrition is very high. In fact, Tanzania appears to be affected by a double burden of malnutrition, with a very high incidence of undernourished children, but with a high prevalence of overweight and obese adults as well, particularly in urban areas. The chapter highlights the high (economic and welfare) costs associatedto such high rates of malnutrition by discussing the consequence of malnutrition for infant mortality, education outcomes, the health system and labor productivity. 1.1 The prevalenceof malnutrition in Tanzania is high 3. Good nutrition is pivotal for national development and the reduction of income poverty. This is recognized by the Millennium Development Goals (MDGs) and the MKUKUTA which pay considerable attentionto the needto reduce the prevalence of under- nutrition. Improving nutrition outcomes is not only a desirable goal in itself, it is a pro-poor policy as poor households are disproportionately affected. Reducing malnutrition is equity enhancing as it helps to avoid the reduction to opportunities to life as a result of reduced cognitive, mental and physical development. Addressing malnutrition is also good economics as inadequatenutrition affects educationalattainment and leadsto reducedlabor productivity and lower incomes. Under-nutrition makes the human body susceptible to disease and addressingnutrition is an effective way to preventing illness and to reducing the private and public cost of health care. Improving nutrition is also an important way to reducing child mortality. 4. The goal set by the MDGs is to reduce to 15% (from 29% in 1992) the fraction of under five children that are underweight (see Box 1.1 for definitions). MKUKUTA sets itself an even more ambitious target of reducing to 20% by 2010 (from 44% in 1992) the proportion of stunted children (URT 2005). Much needs to be done to attain the MDG and MKUKUTA goals. In 2004, the year when the latest nation wide survey with a nutrition component was fielded, 38% o fthe children aged 0 to 59 months were stunted and 22% were underweight. IReal domestic product at factor cost per capita in 1965 US$(Maddison1983). 1 Figure 1.1 Percent of undernourished childrensince 1991 1. 1991 0 1996 61 1999 0 20041I Stunting Underwight Wasting Source: DHS surveys for 1991,1996, 1999 and2004 5. The incidence o f under-nutrition may be high but considerable improvements have beenreported recently. Between 1999 and 2004 the percent o f stunted children dropped from 44% to 38%. Better progress was recorded for underweight which fell from 29% to 22%. Of interest, but hard to explain, is the differential pattern in the reduction o f malnutrition that has occurred between rural and urban areas. Inurban areas nutrition outcomes improved over the 1990s (a reduction in stunting from 38% in 1991 to 25% in 1999), but stalled between 1999 and 2004. In rural areas the reverse has occurred. The prevalence o f under-nutrition remained high and unchanged throughout the 1990sand dropped between 1999 and 2004. Figure 1.2 Percentof undernourishedchildrensince 1991, by rural and urban areas Urban Rural 45 I 1999 02004 45 I 0 1999 1991 2004 1996 I 40 40 35 35 30- 33 31 30 30 25 25 20 20 15 15 10 10 5 5 0 n Stunting Underweight Wasting Stunting Underweight Wasting Source: DHS surveys for 1991, 1996, 1999 and 2004 6. The MDGs and MKUKUTA focus on anthropometric malnutrition (stunting and underweight). But Tanzanians are also affected by vitamin and mineral deficiencies such as iodine deficiency, iron deficiency or vitamin A deficiency. Over 40 different nutrients are essential to health and a diversified diet is important to ensure that a person consumes all nutrientsin sufficient quantities. Fat soluble vitamins and nutrients, such as vitamin A, iron or iodine can be stored inthe body and are usedwhen needed. Other, water soluble, vitamins and nutrients like zinc can not be stored in the body and have to be consumed regularly. Vitamin and mineral deficiencies may result from inadequate intake o f vitamin and mineral rich foods but could also come about because of an inadequate utilization o f the available 2 vitamins and mineralsby the humanbody because of infections or parasitic infestations. Ifa person is deficient in any one nutrient, health will be compromised. Vitamin and mineral deficienciesmay manifest themselves through diseases such as beri-beri or kwashiorkor, can contribute to growth failure (stunting) and waste loss (wasting) and lead to childhood morbidity and mortality, a reduced ability to process information and lower labor productivity. Box 1.1 Glossary Under-nutrition refers to three internationally accepted indicators of malnutrition: stunting, underweight and wasting. These are anthropometric indicators of overall malnutrition. The indicators are normalized with respect to a WHO/NCHS reference population (see annex B). When the indices are less than one, two, and three standard deviations below the reference median, they are referred to as mild, moderate, and severe under-nutrition. Unless otherwise stated, all indices in this report are moderate stunting, underweight and wasting among children aged 0-59 months. Stunting is an indicator for chronic under-nutrition, measuring the past growth failure of inadequate nutritional status due to many reasons including inadequate nutritional intake and poor health. Stunting is measured as height in relation to age and is referredto as height for age. Wasting is an indicator for currentor acute under-nutrition reflecting inadequate nutrition in the recent past due to, for example, seasonal food insecurity or acute infectious diseases such as diarrhea. Wasting is a measure of weight in relation to height and is referred to as weight for height. Underweightis a composite measure of long- and short-term under-nutrition. It is measuredas weight inrelation to age and referred to as weight for age. Body mass index (BMI) is measuredas the body's weight inkilograms divided by height in meters squared (kg/m2). It is used for adults only and is an index of "fatness." Both high BMI (overweight, BMI greater than 25-29.9; obese, BMI of 30 and above and low BMI (thinness, BMI less than 18.5) are considered inadequate or undesirable. Malnutrition refers to various forms of poor nutrition caused by a complex array of factors including dietary inadequacy, infections, and socio-cultural factors. Under-nutrition, as well as a BMI that is too high, as well as micro-nutrient deficienciesare forms of malnutrition. Source: Adapted from Repositioning Nutrition, World Bank 2006. 7. Vitamin A is a good illustration of an essential nutrientthat is often not available in sufficient quantities inthe diet of Tanzanians. Vitamin A is important for the immune system and plays a role in maintaining the epithelial tissue in the body. Vitamin A deficiency is closely associatedto infant mortality. A meta-analysiso feight mortality trials held across the globe found for instance that improving the vitamin A status of children aged six months to five years reduced mortality rates by about 23% in populations with at least low prevalence of clinical signs of vitamin A deficiency (Beaton et al. 1993). Severe vitamin A deficiency can cause eye damage and is a leading cause ofchildhood blindness. It also increasesseverity of infections such as measles and diarrhea and slows recovery from illness. Vitamin A deficiency is common in environments where fresh fruits and vegetables are not readily 3 available. Vitamin A can be stored in the liver and periodic dosing (every six months) with vitamin A supplements is a rapid, low cost method of avoiding the risk of Vitamin A deficiency (DHS2005). 8. According to the 2005 DHS report only half the children in rural areas (52%) consumed fruits and vegetables rich in vitamin A in the previous day. In urban areas this is 61%. Since the year 2000, twice annual yearly campaigns aim to provide vitamin A supplementsand deworming tables to all children aged 6 months to five years. In2004, about half the children (46%, DHS 2005) did receive a vitamin A supplement in the previous 6 months. Other data from TFNC and HKI suggest that the coverage of vitamin A supplementation is around 80%-90%. Vitamin A is also given to women after delivery, to replenishtheir body stores and to assure sufficient amounts of vitamin A in breast milk. But only one in five women received the recommended single postpartum dose of vitamin A according to the 2004 DHS. Others estimate that the coverage was higher, 29% (TFNC 2004a), but low none the less. 9. Iodine is another nutrient that has serious effects on normal body growth and intellectual development ifthe body is deficient in it. Iodine deficiency is the most common cause of preventable mentalretardation and brain damage. It decreases child survival, causes goiters, and impairs physical growth. Deficiency o f iodine during pregnancy causes abortions, stillbirths, low birth weight infants, premature births, and congenital abnormalities such as cretinism, an irreversible form of mental impairment. Goiter, an enlargement of the thyroid gland, is a visible manifestation of severe iodine deficiency. The national prevalence of goiter was estimated at 7% among school children in 2004 (TFNC 2004b) but the aggregated prevalence masks a geographical pattern, as the prevalenceof goiter inthe Iringa and Rukwa regions exceeds 20%. Nevertheless, the current national prevalence reflects large improvements since the 1980s, when the national goiter prevalence was estimated at 25% (Kavishe 1993). I O . The principalcause of iodine deficiency is inadequate iodine in food and water. Since iodine cannot be stored by the body for long periods, small amounts are needed regularly. Where crops and grazing animals do not provide sufficient dietary iodine, food fortification and supplementation have proven to be highly successful and sustainable solutions. The fortification of salt with iodine is the most common method of preventing iodine deficiency. It is practiced inTanzania. According to the 2004 DHS survey about 74% of all households use salt that i s fortified with iodine.* 11. Anemia is another nutrient related deficiency. It is characterized by a low level of hemoglobin in the blood and is an underlying cause for maternal mortality, spontaneous abortions, premature births and low birth weight. Inadequate iron status impairs brain development and decreases the ability of children to learn by adversely affecting language, cognitive and motor development. It also reduces labor productivity among adults. The most common cause o f anemia is nutritional anemia resulting from inadequate dietary intake of nutrientssuch as iron, folate and vitamin B12. Anemia also results from sickle cell disease, malaria or parasitic infections. Anemia can be addressed through food fortification and iron 2 An iodinedeficiencydisorders evaluation survey conductedby the TanzaniaFood andNutrition Center (TFNC2004b) estimated a comparableprevalenceof iodizedsalt inhouseholds: 84%. 4 supplementation . Other interventions such as the use o f insecticide treated bed nets, deworming every six months or the use o f iron pots and pans have also been found to reduce anemia (DHS 2005; Adish et al. 1999; Borigato and Martinez 1998; Rue12001; Geerligs, Brabin and Omari 2003). 12. Anemia is a major health problem and is associated with 20% o f the maternal deaths (Profiles 2006). In 2004 69% o f rural children and 59% o f children who live in urban areas were anemic. 48% o f women aged 15-49 are anemic. Anemia is even higher among pregnant women (58% o f pregnant women are anemic). 61% o f all pregnant women received iron tablets or syrup, but only 10% takes it for the recommended 90+ days (DHS 2005). 13. Little is known about the prevalence o f other micro-nutrient deficiencies in Tanzania, but the nature o f most diets -undiversified, low in animal products and high in plant sources that are rich in anti-nutrients, makes it likely that zinc and vitamin B 1 and B 2 deficiency are a public health problem. According to estimates by the International Zinc Consultative Group, 37.5% o f the Tanzanian population i s at risk o f inadequate zinc intake. This prevalence places Tanzania into the `high' risk category for zinc deficiency. Lack o f zinc i s known to impair the immune system and especially children with marginal nutritional status are at significant risk o f developing zinc depletion. Zinc in treatment o f acute diarrhea i s known to reduce its duration and severity, which is why in Tanzania zinc is currently being included in ORS packages. 1.2 Adult nutrition 14. For adults nutritional status i s typically expressed by the Body Mass Index (BMI). Figure 1.3 presents the BMI for women in urban and rural areas for 1992 and 2004. It demonstrates that in urban areas approximately 8% o f women are underweight and almost 34% are overweight, o f which as many as 12% are obese. Inrural areas beingunderweightis more of an issue as 10% o f women are too thin and 13% overweight. Less than 2% o f rural women are obese. National BMI data for adult men are not available, but information from Kagera suggests that thinness affects men and women equally, while overweight i s mostly a female feature. 15. Underweight children and overweight adults are often found inthe same households, supporting the premise that access to and availability o f food at the household level are not the major causes for under-nutrition amongst children. For instance, 25% of the children of overweight or obese mothers are stunted. O f all stunted children 10% have a mother that i s overweight or obese. Even children that are acutely malnourished (wasted) often have mothers with a BMI that exceeds 25: this happens to 10% o f the wasted children. It is not necessarily surprisingto find stunted children with overweight or obese mothers. Overweight i s often due to high intakes o f carbohydrates and calorie rich foods such as cassava, rice; nutrientsthat are insufficient to support a child's gr~wth.~ 3 A trial inZanzibar (Sazawal et al. 2006) found that iron supplementation inmalaria endemic areas i s effective for reduction o f iron deficiency and anemia iniron deficient children, but also associated it with adverse increased risk of hospitalization (primarily due to malaria and infectious disease), and mortality. 4 There is also evidence that ties low birthweight to higher risks o f obesity and non-communicable diseases later in life (see Gluckman and Hanson 2006) 5 Figure 1.3: Body massindicesof adults Nutritional status of adult women aged 15-49 Density function of male and female years in 1992 and 2004 BMIs (aged 19-65 years) in Kagera 1991 2004 - F d e URBAN RURAL URBAN RURAL .2 2 - -I UNDER - WEIGHT 6% 10% 8% 10% I5 1 - 0VERWEIGHT 15% 9% 22% 11% 0 5 - OBESE 4% I% 12% 2% 0 - 15 25 I Source: Author's calculations usingDHS2004 and KHDS 1992-1994 16. Overweight and obesity cause health problems, reduce productivity and lead to economic costsjust as under-nutrition does. Yet the characteristics o f people affected by over nutrition are very different from those affected by under-nutrition. Overweight individuals are on average better educated, relatively wealthy and live in urban areas. This is demonstrated in Table 1. 1 presentinga weighted regression o f the BMI o f women with their personal characteristics as regressors. The regression indicates how, on average, the BMI for women from the wealthiest quintile i s two points higher than that for women from the poorest wealth quintile. Likewise, BMI in rural areas i s lower than that in urban areas (by 0.77), while the BMI first declines with the level o f education, but then increases when women attain more than 7 years o f education. 17. An aspect o fconcernis the rapid increase inoverweight between 1991and 2004. The fraction of urban women that are overweight or obese almost doubled from 19% in 1991to 34% in 2004 in part becausethe fraction o f obese urban women tripled from 4% in 1991to 12% in 2004. Inrural areas increases are also observed, but to a much lesser extent. The increase inobesity appears to be a reflection o f increasing wealth inTanzania, while the diverging patternbetweenrural and urban areas suggests that inequality is on the rise. 18. Inthe remainder ofthis study the focus will beonunder-nutrition andmineral and vitamin deficiencies as its economic and health consequencesare most pressing and because under-nutrition disproportionately affects those with low incomes, limited education and living in conditions with poor sanitation facilities, no access to safe water and a high prevalence of infectious disease. That said it is alarming that inurban areas more than a third o f urban women are overweight or obese. From a public health perspective it would be prudentto investigate its long-term implications. 6 Table 1. 1:Regressionof Body MassIndex of women on personalcharacteristics Coefficient T-statistic Constant 20.9 77.0 D-2"dwealth quintile 0.19 1.3 D-3rdwealthquintile 0.32 2.2 D-4'h wealth quintile 0.73 4.9 D-5thwealth quintile 2.05 11.7 D-rural (=1) -0.77 -5.4 Age 0.05 7.2 Education inyears -0.14 -4.8 Education squared 0.02 7.6 Note: Weighted OLS regression. The adjusted R2is 0.13. The number o f observations is 4940. Source: Author's calculationsusingDHS 2004. 1.3 Malnutrition has high economic and welfare costs 19. Malnutrition bears high economic and welfare costs that roughly fall into four categories. Inadequate nutrition (i)increases mortality, (ii)increases susceptibility to disease (iii)lowerslaborproductivity and(iv) reducesschool performance.Thissection addresses these four costs of malnutrition. 20. Malnutrition leads to high mortality. Malnutritionhas a direct bearing on mortality as demonstrated by the fact that infant mortality is significantly higher for low birth weight newborns than for others. This is illustrated in Table 1.2 which demonstrates how infant mortality for small newborns is more than twice as high as for children o f average birth weight or higherS5 Table 1.2: Early childhood mortality rates by birth size Neo-natal mortality Post-neonata1 Mortality Infant Mortality (1" month) (2nd-12* months) (1st year) Average for Tanzania 32 36 68 Small or very small at 86 44 13I birth Average or larger at birth 26 35 60 Source: DHS 2005. 21. Pelletier et al. (1995) estimate that 56% o f child deaths in developing countries are attributable to the effects o f malnutrition. Importantly, the relationship between malnutrition and mortality holds not just for the severely malnourished, it equally applies to the moderately and mildly malnourished. On average a child who is severely underweight is 8.4 5Birthweight is basedonrecallby mothers.There is a very high correlationbetweenbirth size as reported bymothersandbirthweight as reportedon the birth cards-for those with birthcards.Notehowever,that as birth size is basedonrecall, there is scope for selectionbiaswhereby motherswhose child has passed away are more likely to reportthat the child was smallor very small at birth. 7 times more likely to die from infectious diseases than a well nourished child. Children who are moderately underweight and mildly underweight are 4.6 and 2.5 times respectively more likely to die than well nourished children. Although the risk o f death is greater for severely underweight children, they make up only a small fraction o f the total number o f children suffering from malnutrition, so that to reduce the risk o f dying it is effective to address all malnourishedchildren. Box 1.2: Malnutrition affects survival, productivityand intelligencein differentways Under-nutrition affects health, survival, productivity and school performance in different ways. Below is a schematic overview o f how nutrition deficiencies affect the prospects o f young children. Deficiency Leads to Inadequate breastfeeding b Mortality and Vitamin A Disease Wasted, stunted, underweight I Labor Low birthweight Productivity T Iron School performance Iodine and intelligence Source: Adjusted from Profiles 2006. 22. The strong association between under-nutrition and mortality reported internationally is also found for Tanzania. There i s a strong association at the regional level, between the prevalence o f stunting and under five mortality (Figure 1.4). It is estimated that about 36% of all child deaths beyond early infancy are due to under-nutrition, making it the single greatest cause o f child mortality (Profiles 2006). 23. Vitamin and mineral deficiencies are a major cause o f mortality too. It has been demonstrated that distributing vitamin A on a semiannual basis can reduce overall child mortality by about 23% (Beaton et al. 1993). Based on this international evidence one expects that the provision o f vitamin A on a national scale which started in Tanzania in 1987 but whose coverage was increased from the year 2000, i s one o f the reasons behind the drop in infant mortality rates from 156 in the period 1995-1999 to 112 between 2000-2004. Amongst adults and pregnant women inparticular, iron deficiency is o f concern as the risk of maternal death i s substantially elevated for anemic women: over a fifth of all maternal deaths are associated with anemia (Brabin, Hakimi and Pelletier 2001). 8 Figure 1.4: Stunted (%, 2004) and under 5 mortality(# per 1000live births,2002) 60 T Ell Stunted T 250 c. 8 a 50 t 1 Underfivem 200 & 0 150 B 30 3 100 2 CI 20 10 50 4 0 Source: Author's calculationsusing DHS2004 and Populationand Housing Census 2002. 24. Malnutrition increases susceptibility to disease. Malnutrition increasesthe risk of illness and leads to a vicious cycle with impaired immunity leading to infection with attendant loss of appetite and increased catabolism and, thus, an increased likelihood of additional malnutrition (Behrman, Alderman and Hoddinott 2004). Malnutrition is a fundamental factor contributing to malaria-associatedmorbidity and anemia (Ehrhardt et al. 2006). Low birth weight, under-nutrition and vitamin and mineral deficiencies have been identified as the single largest risk factor contributing to the burden of disease in developing countries. Underweight alone is held responsible for 9.5% of global burden of disease. Iron, vitamin A, and zinc deficiencies add another 6.2% (Ezzati et al. 2002). And children with low birth weight have been found to stay longer in hospital in circumstances where births occur in such settings, have higher risks of subsequent hospitalization and make more frequent use of outpatient services (Victoria et al. 1999). 25, Increasedmorbidity has direct resourcecosts for the health care system and for those affected by disease through lost income or schooling. The costs of malnutrition related diseases to the healthsystem are high especially given the small available budget for public health care (of approximately $ 12 per capita per annum). Preventing disease through a reduction in malnutrition would not only free budgetary resources it would also ease the workload on the small contingent of trained medical staff that is available in Tanzania. The costs of illness to individuals and households are equally high. Using a cross section from Kilimanjaro, Christiaensen, Hofmann and Sarris (2004) find that serious adult illness reduces per capita consumption by 17%. Using panel data from Kagera it was demonstrated that chronic illness leads to a 6% decline inconsumptiongrowth (Hoogeveen 2005). 26. Malnutrition reduces labor productivity. The basis for productivity losses as an adult due to decreased body size, strength and endurance is laid in early childhood when malnutrition leads to retarded physical growth. Catching up is difficult as is illustrated in Figure 1.5. It presents anthropometric information that was collected from individuals in the Kagera region in 1994 and 2004. The figure demonstratesthat children who were stunted in 9 1994 are more likely to be short 10 years later. The older a child is when it i s stunted the greater the gap with non-stunted peers 10 years later. Figure 1.5: Height in 2004 and childhood stunting 10 years earlier; Kagera. 10 11 12 13 14 15 16 17 18 19 20 Age in 2034 I----Not stunted in 1994 -SNnted in 1W4 I Source: Alderman,HoogeveenandRossi 2006b. 27. Height has unequivocally been shown to be related to productivity (Behrman, Alderman and Hoddinott 2004). A number o f studies estimate the economic cost o f growth retardation. Thomas and Strauss (1997) estimate the direct impact o f adult height on wages for those in urban Brazil who work in the market sector and find that a 1% increase in height leads to a 2-2.4% increase in wages or earnings. Hunt (2005) reports that a 1% loss in adult heightas a result o fchildhood stuntingis associatedwith a 1.4% loss inproductivity. And an earnings regression for Kagera demonstrates that an additional I c m in height increases income by 1.8% (Alderman, Hoogeveenand Rossi 2006a). 28. Micronutrient status also has important productivity effects. Vitamin A deficiency can cause blindness with obvious consequences for productivity. Anemia is also associated with reduced productivity, though the magnitude depends on the nature of the task. Eliminating anemia was calculated to result in a 5 to 17% increase in adult productivity which adds up to 2% o f GDP in the worst affected countries (Strauss and Thomas 1998; Horton and Ross 2003). For many low-income Asian countries, productivity losses due to the high prevalence o f under-nutrition amounts to more than o f 2-3% of GDP per annum, even without considering the consequences o f long-term productivity losses due to developmental and cognitive impairment (Horton 1999). 29. Malnutrition decreaseseducationperformance.Malnutrition has a negative impact on schooling outcomes. There are at least two ways in which nutrition can affect education. First, malnourished children may receive less education. This may be because their caregivers seek to invest less in their education, because schools and parents use physical size as a rough indicator o f school readiness leading to later enrollment or because malnourished children may have higher rates o f morbidity and thus greater rates of absenteeismfrom school and learn less while in schooL6 6This sectionis basedon Behrman,AldermanandHoddinott,2004. 10 30. Another pathway from malnutrition to educational outcomes is via the capacity to learn, a direct consequence o f the impact of poor nutrition on cognitive development. Maternal iodine deficiency, for instance, has negative and irreversible effects on the cognitive functioning o f the developing fetus. Postnatal iodine deficiency i s also associated with cognitive deficits (Black 2003): iodine-deficient children have been shown to have IQs that are, on average, 13.5 points lower than iodine-sufficient children (Grantham-McGregor, Fernald and Sethuraman 1999) and iron deficiency anemia has been associated with half a standard deviation reduction inIQ (Horton and Ross 2003). 31. These three pathways interact. A child with reduced ability to learn is likely to spend less time in school and to learn less while in class. A hungry or anemic child i s less likely to pay attention in school. In combination these three pathways lead to significant costs. Glewwe and Jacoby (1995) demonstrate for Ghana that for each year o f delay in entry to primary school a child loses 3% of lifetime wealth. A study in Zimbabwe (Alderman, Hoddinott and Kinsey 2006) shows that by adolescence, malnourished children would be 4.6 centimeters smaller and completed 0.7 grades o f schooling less. As a consequence lifetime income earnings are reduced by 12-17%. 32. Alderman, Hoogeveen and Rossi (2006b) investigated for the Kagera region the impact of early childhood malnutrition on school achievement and earnings (Figure 1.5). They find that malnourished children enter school approximately 1 year later and lose up to two years o f education compared to their well-nourished peers. Severely malnourished children (80% o f the median) have a four times higher probability not to attend school than non-malnourished children. As a consequence o f the delayed school entry and lower educational attainment lifetime income earnings for children whose nutritional status is 85% o f the median reference child are reduced by 3% relative to a child whose nutritional status i s 95% o f the reference child. The loss in life time earnings increases to 12% if the impact o f heighton future earnings is taken into consideration. Figure 1.6: EducationinYears in 2004 and childhood stunting 10years earlier; Kagera. --I 10 11 12 13 14 15 16 17 18 19 20 1 _---Not Aee in vcan in 2004 stuntedm 1994- Sbntedin 1994 1 Source: Alderman, Hoogeveenand Rossi 2006b. 13 1.4 Conclusion 33. In this chapter the prevalence and types of malnutrition that affect Tanzania were discussed. Malnutrition comes in different guises. It can be observed from children that are too small for their age or too thin for their height and can result from inadequate intake o f calories, and essential vitamins and minerals. Malnutrition also comes in the form of being overweight and obese. It is found that the incidence o f the various types o f malnutrition is very high. Up to 40% o f children inrural areas are stunted, approximately halfthe population i s anemic and more than one in three urban women i s overweight or obese. 34. The economic and social costs o f these various types of malnutrition are high. Malnutrition leads to excess maternal, infant and child mortality, contributes considerably to the burdeno f disease and negatively affects the ability to learn and to work. 35. Malnutrition i s a scourge but its high incidence presents opportunities too. Malnutrition can be addressedthrough policy measures, oftentimes quite successfully so, and with limited means. The iodization of salt and the provision o f vitamin A and deworming tablets demonstrate this forcefully. The high incidence o f malnutrition thus presents an opportunity to enhance school performance, reduce maternal and infant and child mortality and to improve the ability o f the labor force to be productive. 36. The remainder o f this study will consider what can and needs to be done to bring the benefits o f addressing malnutrition within reach. To this end, chapter two will provide a profile of malnutrition. Chapter three will then consider the causes o f malnutrition, which helps determining the substance o f interventions. Chapter four discusses the budgetary implications o f interventions along with their rate o f return. Chapter five, finally, discusses how to enhance the effectiveness and efficiency o fthe actors operating inthe nutrition sector. 12 2. PROFILEOFMALNUTRITION 37. The prevalence o f malnutrition in Tanzania is alarming on average and is characterized by considerable variation between rural and urban areas, between regions and between socio-economic groups. Interventions that aim to address malnutrition will need to take these differences into account, in order to make efficient use o f resources. 38. This chapter considers various aspects of relevance to targeting. It considers spatial differences inthe incidence and types of malnutrition. It also discusses how the prevalence of malnutrition varies between households o f different wealth. And the chapter considers the timing when under-nutrition manifests itself, showing that most harm is done before a child is born or duringthe first two years o f life. 2.1 Under-nutrition varies spatially Figure2.1: Malnutrition in 2004 for children under 5 years of age 40 530 h 35 :$ 25 Y 20 35 15 3 10 5 0 Rural Urban Rural Urban Rural Urban Source; Author's calculations usingDHS2004 data 39. Nutrition outcomes differ considerably betweenrural and urban areas. The prevalence o f under-nutrition in rural areas exceeds urban prevalence rates by 40-50% (Figure 2.1). Out o f a hundred children, 40 in rural areas are stunted as opposed to 25 in urban areas. The fraction of underweight children is 23% in rural areas and 17% in urban areas. Nutrition outcomes also differ between regions. The percentage o f stunted children varies from 17% in Dar es Salaam and 23% in Kilimanjaro to more than three times as much in Lindi (54%). Comparable variations are found for underweight (13% in Mwanza, 32 % in Tanga) and wasting (0.4% inRuvuma, 6.8% inPwani). 13 Table 2.1: Spatial variation in key nutrition indicators Children Children Children Adequate1 Stunted Under Wasted aged 6-59 aged 6-59 under 3 y iodized childre weight childre months that did not eating salt not nunder childre nunder with any not get during available 5. nunder 5. anemia vit. A past day in 5. suppleme vit. A household nt inpast richfood. 6 months Percent Tanzania 71.8 54.5 46.3 56.6 37.7 21.8 3.0 Dodoma 66.4 33.0 48.3 76.8 44.4 30.4 3.9 Arusha 52.1 41.9 46.0 6.7 27.2 20.0 3.4 Kilimanjaro 51.3 40.6 53.7 19.7 23.4 19.4 5.2 Tanga 65.6 69.7 45.9 66.2 43.3 31.8 6.5 Morogoro 77.3 55.6 43.5 61.6 35.8 15.6 2.2 Pwani 76.6 40.6 31.3 62.2 36.8 26.8 6.8 Dar es Salaam 69.0 45.1 31.7 12.7 16.9 14.3 4.1 Lindi 88.2 61.8 40.3 89.7 54.0 23.7 2.6 Mtwara 79.3 58.5 28.7 95.4 52.7 29.1 1.8 Ruvuma 77.3 57.1 29.6 81.7 50.4 24.7 0.4 Iringa 46.6 45.9 43.2 85.8 50.5 25.9 1.4 Mbeya 66.9 71.5 38.7 44.3 37.6 15.1 1.5 Singida 71.9 40.6 35.2 87.3 39.2 26.3 5.2 Tabora 75.1 74.8 36.4 68.0 34.0 19.9 2.6 Rukwa 68.0 82.2 48.0 54.3 45.1 24.5 1.7 Kigoma 76.3 35.9 55.3 50.8 50.1 34.2 3.7 Shinyanga 79.5 38.1 54.7 61.7 37.4 19.3 1.9 Kagera 71.2 58.2 62.8 61.7 37.3 25.4 3.6 Mwanza 82.8 60.6 54.0 51.7 30.6 12.8 2.3 Mara 79.2 55.8 53.5 26.8 38.7 16.7 0.8 Manyara 55.6 57.1 47.0 54.4 39.6 30.6 4.6 Yource: DHS 2005. Note Zanzibar is omitteddue to the small number of observations. 40. What holds for anthropometric nutrient deficiencies also holds for vitamin A and mineral deficiencies. In Lindi, Mtwara, Iringa and Pemba North for instance, less than 10% of all householdsuse adequately iodized salt as opposedto more than 80% in Dar es Salaam and more than 90% inArusha. The consumptionof fruits and vegetables rich in vitamin A by children under 3 varies by region and ranges from 71% in Mtwara to 32% in Pemba South. Likewise, 67% of children in Dodoma receivedvitamin A supplementation, but only 18% in Rukwa. 41, Not only do prevalence rates differ between regions, there is substantial variation in the type of nutritional problem that affects regions. A region that performs well in one aspect may perform poorly in others. Dar es Salaam for instance, does well on iodization, stunting and underweight and belongs to the top five regions in Tanzania (Table 2.2). At the same time Dar es Salaam has a prevalence of wasting that is 30% above the national average. 14 Mwanzadoes poorly on anemia and the distribution of vitamin A supplements, but is one of the best performers in stunting and underweight. Similar divergences can be observed for Mtwara, Mara, Iringa or Kigoma. Table 2.2: Fiveworst and five best performing regions Children Childrenthat Childrenthat Households Stunted Underweight Wasted with any didnot didnot without children children children anemia receivea consume adequately (%) (%I (%> (%> vitamin A fruits or iodizedsalt. tablet in vegetables (%I previous6 richin months vitamin A. (%) (YO)Worst performing districts Lindi Rukwa Kagera Mtwara Lindi Kigoma Pwani Mwanza Tabora Kigoma Lindi Mtwara Tanga Tanga Shinyanga Mbeya Shinyanga Singida Iringa Manyara Kilimanjaro Mtwara Tanga Mwanza Iringa Ruvuma Dodoma Singida Mara Lindi Kilimanjaro Ruvuma Kigoma Mtwara Manyara Best performing districts Tanga Pwani Singida Mbeya Tabora Mara Rukwa Manyara Singida DSM Mara Mwanza Morogoro Mbeya Arusha Shinyanga Pwani Kilimanjaro Arusha Mbeya Iringa Kilimanjaro Kigoma Ruvuma DSM Kilimanjaro DSM Mara Iringa Dodoma Mtwara Arusha DSM Mwanza Ruvuma Source: Author's calculationsusing DHS 2004 42. Plannersand policy makers needto take into account the divergenceinthe prevalence and types o f malnutrition when preparing nutrition interventions. Planning in the face of large geographic differences requires good information about local conditions and a management information system that is able to capture it. It calls for caution in applying uniform, nationwide, approaches. A decentralizedapproachto nutrition interventions,backed up by national expertise, and guidance, coordination and knowledge sharing seems an appropriate way to address these issues. This is so in particular as regions are non- homogeneous as well. Differences between regions carry over to differences within regions. Of the differences inthe levels of stunting one finds betweenregions, 80% can be attributed to within regiondifferences (that is differences inthe incidence of stunting betweendistricts, villages and households) while 20% differences can be attributed to differences between regions. This is illustrated in Table 2.3 which presents a decompositionof the differencesin the incidence of stunting between regions whereby differences are expressed as inequality measures (measured as General Entropy (GE) and Atkinson (A)) with various degrees of sensitivityto inequalitiesbetweenthose with the highestand lowest levels of stunting. 15 Table 2.3: Decompositionof differences in stuntingwithin and between regions GE(-1) GE(0) GE(1) GE(2) A(0.5) A(l) 4 2 ) Within regions 83% 80% 78% 78% 78% 77% 73% Between regions 17% 20% 22% 22% 22% 23% 27% Source: Author's calculations usingDHS 2004 43. What holds for regions carries over to communities. Figure 2.2 presents the fraction of stunted children per village for 198 rural villages in which for at least 15 children anthropometric measures were taken. Moving from left to right the graph suggests that in about a quarter o f all communities less than 25% o f children are malnourished, that in about fifty percent of the communities between 25% and 50% o f children are malnourished and that in another 25% more than 50% of the children are undernourished. In other words the efficiency (and rate o f return) o f a community wide nutrition program would improve by more than a factor two if interventions in villages with relatively low incidence of malnutrition were shifted to villages with a high incidence o f malnutrition. Figure 2.2: Prevalenceofstunting in 198 ruralvillages communities in Tanzania 1 51 Village101 151 number Source:Author's calculations usingDHS2004. 44. Decentralization will allow addressing such divergences. It has long been on the agenda, and goes as far back as 1980 when there was an attempt to put nutritionists in every district. Recently the move towards decentralization in nutrition has received new impetus and there is an agreement between TFNC and PMO-RALG to identify nutrition focal points inall districts. These focal points will be responsible for planning andbudgeting for nutrition and implementing nutrition related activities, but will also need to account on progress achieved. 16 Box 2.1: Mismatchesin targeting While most countries do not scale upnutrition programs to any reasonablelevel, many do scale up the wrong kindsof programs or interventions. Three mismatchesbetweenthe needor the cause ofmalnutrition and the design ofprogramswere identified inIndiaand are common across many other programs: The `tfoodJirst mismatch: Many nutrition programs focus on food security and food " supplementationin situationswhere unhealthy living conditions, poor child-care practicesare an undiversified diet are the main causes of malnutrition. The age-targeting mismatch: Most under-nutrition happensduring pregnancy and the first two years of life, and most ofthis early damage cannot be reversed(chapter 2). Yet many programs continue to expend large resourceson other age groups. Thepoverty-targeting mismatch: It is widely believed that under-nutrition is strongly concentratedwith income poverty. The analysis of chapters 1and 3 shows that this is not the case for Tanzania. Ratherthere are huge spatial differences inthe prevalence of under-nutrition. Programstherefore best target mal-performing geographic areas. For iodine interventions andthe post-partumvitamin A supplementationwould, I however, benefit from poverty targeting. 2.2 Householdwealth is not a good predictor for malnutrition 45. Household wealth and malnutrition are by no means synonymous. This is demonstrated inFigure 2.3 presentingincidencecurves for differenttypes of maln~trition.~ If malnutrition were equally distributed across the population, the incidence curve would coincide with the 45-degree line: i.e. the 10% poorest households are affected by 10% of stunting, the 20% poorest households have 20% of all stunted children etc. The curves for being stunted and being underweight lie slightly above the 45-degree line demonstratingthat under-nutrition affects children from poorer households disproportionately. The degree to which this happens is modest, however. The curves for having given birth to a child that is small or very small and for having received vitamin A supplementation are approximately the 45-degree line, suggesting that low birth weight and vitamin A supplementation affect households from different wealth classes equally. But in access to iodized salt and the provision of vitamin A within 2 months after birth poor households are disadvantaged relative to wealthier households. For instance 26% of households in the poorest quintile use adequately iodized salt, as opposedto 72% of those inthe wealthiest quintile. 46. The conclusion that can be inferred from these graphs is that malnutrition affects everybody and that household wealth is not a good predictor for nutritional status. Only in connection to purchased inputs (iodized salt) or inputs that need to be actively sought (postpartum follow up at health centers) are poor households disadvantaged relatively to wealthier ones. Positive is the fact that campaigntype interventions -such as the provision of vitamin A and deworming tablets reachchildren irrespectiveoftheir wealth background. 'An incidence curve presents on the horizontal axis the cumulative ranking o f all households by wealth. Onthe vertical axis it presents the cumulative rankingofthe incidence o f a certaintype ofmalnutrition. 17 Figure2.3: Incidencecurvesof under-nutrition I Incidenceof stunted children Incidenceof undenveightchildren ' 0 2 4 6 8 1 0 2 4 6 8 1 I Curnulmvedisuibuaonof papdauon (rankedbywdth) -45-degreeline - Curnulaavedtstribuuonof papulaaon (rankedbywdth) SNnted - 45.degree line - Undewaght Incidenceof babies small at birh Incidenceof adequately iodized salt ~ 0 2 4 6 8 1 0 2 4 6 8 1 Cumulaavedirtibuuan of papulaaon(rankedbywdth) -45-degree line - Curnulavedisaibuuonof papulauon(rankedbywdth) Small arbirrh -45-degree line Adequady to&& salt I C Incidenceof vitamin A supplementation ncidenceof vit.A supplemendonwithin 2 months after giving 0 2 4 6 8 1 -45-degreeline - Cumulmvedirt~buaonof populauan(rankedbywdth) KmmArupplaneneaon -45-degree line - Mother recaved"it A supplenmmon dta blrt 1 ~ Source: Author's calculationsusingDHS2004 47. Figure 2.4 delves deeper into the weak association o f wealth and malnutrition by illustrating under-nutrition rates by wealth quintile, separately for rural and urban areas. It demonstrates that inrural areas, where 80% o f all Tanzanians live and which dominates the national incidencecurves, the incidence o f stuntingand underweight does not vary by wealth class, with the exception for children living inhouseholds inthe top 20% wealthiest 18 households.8But evenamongst the wealthiest rural households, more than 30% ofall children are stuntedand 17% are underweight, Inurban areas there is a more explicit associationbetweenhouseholds.Buteven amongst 20% wealthiest urban householdsabout 12% of children are stunted. An implication that can be drawn from this is that poverty targeting (as opposedto spatialtargeting) is not a very effective way of rationalizing nutrition interventions inTanzania. Figure2.4: Under-nutrition in2004 for childrenunder 5 years by rural areas and urbanareas Fraction stunted 45 Rural Urban 40 g 35 30 :a 25 20 15 2 10 5 0 1 2 3 4 5 1 2 3 4 5 Wealth quintile Fraction underweight Rural Urban 1 2 3 4 5 1 2 3 4 5 Wealth quintile Source: Author's calculations using DHS2004 8Inruralsettings the livelihoodgroups (pastoralist, agro-pastoralists andagriculturalists) is often found to bemore important than income class. Pastoralists, because o fthe consumption o f animalprotein (especially milk) have more lean tissue and are therefore taller. 19 48. Household wealth may not be a good predictor for under-nutrition, this should not be taken as evidence of the absence o f a relation between income and nutritional status. In fact, there is solid evidence to support the contrary. Studies for Tanzania by Alderman, Hoogeveenand Rossi (2006a) and by Abdulai and Aubert (2004) find a significant negative relation between household income and the prevalence of malnutrition. The regression presented in chapter 3 demonstratesa significant relation between household wealth and the incidence of malnutrition. 49. Possibly the weak association between income and malnutrition in rural areas should be taken as evidence of the depth of poverty outside urban localities. Monthly income for a householdinthe fourth wealth quintile inrural areas is as high (low would be more accurate) as the monthly income of an urbanhousehold inthe secondwealth quintile (Table 2.4). That malnutrition only starts to drop in rural areas from the fifth quintile and in urban areas between the second and the third quintile suggests the existence of an income threshold below which additional income will not result inreducedmalnutrition. It is beyond the scope of this study to explore whether such a threshold exists and if it exists where is lies, but a comparison of Figure 2.4 with Table 2.4 is at least suggestive of the notion that up to Tsh 100,000 (or $ 100) per householdper month, malnutrition rates are unresponsive to income. When incomesrise above this threshold, nutrition outcomes appear to improve. Table 2.4 Monthly householdconsumption by wealth quintile (Tsh) Quintile Poorest 2 3 4 Wealthiest Dar es Salaam Monthly householdconsumption 40,763 69,704 96,9 18 143,643 293,489 Outside Dar es Salaam Monthly householdconsumption 21,295 36,3 17 50,704 72,14 1 142,116 Note: Assumed i s an inflation of 25.4% between2000 (when the HBS was collected) and 2005. In2005 the Tsh / $ exchangerate was approximately 1000/ 1. Average householdsize for households inDar es Salaam is 4.3. It is 5.0 for householdsoutside Dares Salaam. Source: Author's calculations usingHBS 2000/1. 50. Finally, another way to appreciate the weak associationbetween poverty and under- nutrition, and the large variation in under-nutrition betweenregions is by considering spatial patterns. This is done in Figure 2.5. It presents a clear geographic pattern, demonstratingthat stunting is worst in Southern and Western Tanzania. The pattern for income poverty is quite different and the highest incidences of poverty are found in the Central Region and around Lake Victoria. 20 Figure2.5: Spatial patterns of malnutrition and income poverty Percent o f stunted children (2004) Income poverty (2002) 2501 Source: PHDR2005. 2.3 Under-nutrition startsearly 51. Following birth the first two years o f life are critical for good nutrition and young children need to be provided with sufficient calories as well as a diverse diet to support the fast rate o f growth that occurs during this period o f life. Children under the age of two are especially vulnerable to under-nutrition, as they are less able to express their needs and becausethey are susceptible to disease. Many children end up with their needs only partially met and under-nutrition typicaIIy manifests itself during this period. This is illustrated in Figure 2.6, showing how during the first 20 months o f life the average z-score for children drops. This holds for all three anthropometric measures o f under-nutrition, and inboth urban and rural areas. 52. With the drop in z-scores following birth the fraction o f stunted (but the same holds for wasted and underweight) children increases rapidly to stabilize between 30% (urban areas) and 40% (rural areas) at the age o f two. The increase in malnutrition during this very early stage in life i s especially damaging as it i s duringthis critical period o f life that most of the (irreversible) damage to physical growth, brain development, and human capital formation occurs. The period starting with pregnancy and the first 20 months therefore presents itself as an excellent window o f opportunity to address under-nutrition and greatly facilitates to ability to target interventions. 21 Figure2.6: Under-nutrition by age in monthsfor urban and rural areas Smoothedz-scoresby age inmonths:urban --I 0 20 40 60 Age in months -Stunted __--_ Undenveight Wasted Smoothedz-scores by age inmonths:rural --I 0 20 40 60 Age m months __--- Stunted - Underwetght Wasted ource: Author's calculationsusingDHS2004 53. The process of under-nutrition starts early, sometimes even before a child is born. According to estimates from the early 1990s, which represent the most recent nationally- representative data, 16% of pregnancies in Tanzania give rise to a newborn with low birth weight (<2500 g). More recent data from seven districts indicate that the prevalence o f low birth weight ranged from 7.8% to 21% in those districts (TFNC 2002). The ramifications of low birth weight are manifold. During the neonatal period, newborns with birth weights between 2,000 and 2,500 grams have a four-fold increased risk of death compared to newborns weighing 2,500 to 3000 grams and a ten-fold increasedrisk o f death compared to newborns weighing 3,000 to 3,500 grams. And, these elevated mortality risks extend into infancy (Ashworth, 1998). Infants born with low birth weight who survive their early childhood are more prone to experience developmental delays and are hence more likely to be stunted or underweight. When these children reach adulthood, they may suffer an increase risk of various adult chronic diseases (Barker 1998). 22 Figure 2.7: Incidenceof small or very small babies I Incidence o f babies small at birth - 1 0 2 4 I 6 8 1 Cumdahvedistribuhonof m e a (rulkedby haght) -45-degreeLtne Small at birth I Source: Author's calculations using DHS 2004 54. Low birthweight is less a consequence of poverty (see section 2.2.) and is caused by poor maternal nutrition, anemia, malaria, diarrhea, sexually transmitted diseases and disease such as schistosomiasis(World Bank 2006). It is also associatedwith inadequate nutrition of the previous generation. Undernourished mothers are more likely to give birth to low birth weight infants. This is illustrated in Figure 2.7 which shows how the prevalence of small babies is higher (by about 50%) amongst the 10% shortest women than it is amongst the 10% tallest women. The 10% shortestwomen give birth to 14%of all small of very small children. The 10%tallest women give birth to 9% ofall small and very small children. An implication that can be drawn from this is that targeting pregnant mothers and children under the age of two is an effective way of implementing nutrition interventions inTanzania. 2.4 Conclusion 55. Inthis chapter aspects ofrelevanceto targeting nutrition interventions were discussed. There exists considerable spatial variability in the type and degree of malnutrition in Tanzania. This variability is found between ruraland urban areas, between regions, between districts and also within districts between communities. The analysis demonstrates that malnutrition has the potential to affect everybody. Poor households are somewhat more affected than non-poor households but wealth differences only account for relatively small differences in the incidence of malnutrition. Especially in rural areas, where the majority of Tanzanians live, are people affected irrespective of their wealth. It has also been noted that (irreversible) malnutrition starts early in life, typically during pregnancy or in the first 20 months after birth. 56. These findings send a clear message for the organization of nutrition interventions. Decentralized implementation that is able to do justice to the variability in type and spatial incidence of malnutrition is extremely important ifnutrition program are to be delivered in an effective and efficient manner. The findings also demonstrate that poverty targeting is not effective, especially in ruralareas. Spatialtargeting and age related targeting with a focus on children under the age o f two present good opportunities. Pregnant women should also be targeted. But as most women become pregnant at one point in life, targeting those reaching gestational age could be equally effective. 23 57. In the next section the analysis will turn towards the causes of malnutrition as this will provide insights inthe substance of nutrition interventions. 24 3. CAUSESOFMALNUTRITION 58. The conceptual framework that is often used to discuss the causes o f malnutrition (UNICEF 1990) considers malnutrition an outcome o f multiple factors: the most immediate causes are inadequate dietary intake and ill health. In turn, these immediate factors are determined by three underlyingdeterminants: food energy availability and dietary diversity, caring practices for children and (pregnant) women, and the quality o f living conditions. 59. This chapter considers empirically the importance o f the three underlying determinants, food energy availability, caring practices and living conditions. It does so by relying on data from the 2001 Household Budget Survey and the 2004 Demographic and Health Survey. None o f these surveys was designed specially for nutrition, yet in combination the two surveys provide sufficient material to get a reasonable sense o f the importance o f each o f the three factors. 3.1 Food energy consumption and dietary diversityare inadequate 60. Chapter two has shown how very young children are most susceptible to under- nutrition. A prevalence rate o f stunting(an indicator o f chronic malnutrition) o f almost 40%, demonstrates that many children do not consume the required amount o f calories. Whereas this seems to suggest that inadequate food availability is an important determinant for malnutrition, an undiversified diet, inadequate feeding and caring practices and unhealthy living conditions are considered the underlying causes for the decline in nutritional status immediately after birth. This view is informed by the observation that young children's caloric needs are much lower than those of adults ranging from 820 calories for children below the age o f 1to 1,550 for children aged 3-5, whereas adult men involved in moderate to heavy activity would need between 2,450 and 3,550 calories, depending on their age and the kindof activity (Smith,Alderman and Aduayon 2006). Other evidence insupport of the view that caloric intake i s only one o f the many causes o f malnutrition for children is that about 10% o f wasted and stunted children have overweight mothers. Similarly, the fact that underweight children are found in households o f all wealth groups suggests that there i s more to child malnutrition than food energy availability alone." 9 Of course intimes of critical food shortages, childrensuffer as others but as a matter of course, it is not acute food shortages which determine under-nutritioninyoung children as evidenced by the low percentageof children that are wasted (3%). 10The latter is confirmed by the geographic patternof under-nutrition which shows that areas characterizedby cereal surpluses, typically the south andwest of the country, are also areas with relatively highrates o funder-nutrition (Leach 2007). 25 Box 3.1: Eleven reasonswhy child malnutritionpersistsin food-secure households 1. Pregnant and nursing women eat too few calories and too little protein, have untreated infections such as sexually transmitted diseases that lead to low birth weight, work too hard and do not get enoughrest. 2. Mothers have too little time to take care of their young childrenor themselves during pregnancy and after birth. 3. Mothers of newborns discard colostrum, the first milk, which strengthens the child's immunesystem. 4. Mothers feed children under 6 months foods other than breast milk even though exclusive breastfeeding is the best source of nutrients and the best protection against many infectious and chronic diseases. 5. Caregivers introduce complementary solid foods too late. 6. Caregivers do not recognize that their children are undernourished as their stature is comparableto that of so many other childrenofthe same age. 7. Caregivers feed children under two too little food or with too low a frequency. Especially in households where only one meal a day is cooked, snack foods provides additional nutritional intake. 8. Caregivers provide food that is not energy dense. Though food is available and stomachs filled, young children's caloric needs are not met. 9. Caregivers provide an undiversified diet low in animal products and high in plant sources which provides too little interms of key vitamin and minerals and protein. 10. Caregivers do not know how to feed children during and following diarrhea thereby worsening its consequences for the body. About a quarter of all caretakers reduce, rather than increase, fluid intake of children during an episode of diarrhea. 11. Poor hygiene and inadequate access to safe water contaminates food with bacteriaor parasites. Source: Adaptedfrom RepositioningNutrition, World Bank 2006 61. Food energy availability is, however, an issue for many and 44% of all Tanzanians are energy deficient. Information about calorie intake can be obtained from the HBS (2000/01). This survey comprises detailed consumption information on 129 food items collected using a diary method for a set of approximately 22,000 households over the period of one month. Using this data Smith, Alderman and Aduayon (2006) estimate that the per capita food energy availability is 2,454 calories, with people in rural areas consuming slightly more calories (2,487) than those in urban areas (2,314). The latter is probably a reflection of the higher energy needs in rural areas due to the higher physical intensity of labor. Calorie intake differs by wealth quintile with people inthe poorest quintile consuming fewest calories (2,246) andthose inthe top quintile most (3,015). 26 62. Using the per capita energy availability it is possible to determine the fraction of people that is energy deficient, by comparing the per capita calorie availability with international reference data. Ifthe cut off point for energy deficiency i s put conservatively at the number of calories required for light activity 43.9% of Tanzanians is energy deficient. Amongst the poorest households almost 50% o f people are energy deficient; amongst the wealthiest households some 36% are energy deficient. The difficulty households have in meetingtheir core energy needs is also reflected in the highpercentage o f consumption that is spent on food: 65%." Table 3.1: Food energy availability Energy Percent o f Percent o f Percentage o f availability per people food energy from consumption on capita energy deficient staples food Tanzania 2,454 43.9 70.6 72.5 Rural 2,487 41.8 72.8 74.4 Urban 2,3 14 52.7 62.5 65.5 Firstquintile 2,246 49.3 76.4 75.7 Second quintile 2,562 39.5 71.9 74.5 Thirdquintile 2,6 13 39.4 68.6 71.6 Fourth quintile 2,543 43.2 64.1 67.6 Fifthquintile 3,015 35.9 59.3 64.4 Source: Smith, Alderman and Aduayom (2006) based on HBS2000/01 63. Not only are Tanzanian food energy deficient, diets are undiversified (71% o f all energy is obtained from staples - Table 3,1), low in animal products and high in plant sources that act as anti-nutrients contributing to an inadequate intake o f vitamin A, iron, zinc and leadingto vitamin B1 and B2 deficiencies. To investigate the impact o f enriching the diet with animal products, Lindeboom and Kilama (2004) combined data from various DHSes and the HBS 2000/01. They found a high correlation between the frequent consumption of meat and milk or milk products and a favorable under-five nutritional status. A comparable correlation is found usingexclusively DHS data. Figure 3.1 illustrates how the prevalence of stunting amongst children that drank milk during the past 24 hours is much lower than that for those who did not drink milk. 64. The correlation as depicted inthe graph may reflect the impact of milk consumption, but milk consumption could equally well be associated with other factors that positively affect nutrition such as income, or healthy living conditions. Unambiguous evidence towards the positive impact from milk consumption comes from Kagera. By including (imputed) expenses for milk consumption to the regression reported by Alderman, Hoogeveen and Rossi (2006a) one i s able to control for potentially confounding factors. The results show a 11Abdulai and Aubert (2004) c o n f m the above results. These authors investigate the degree to which increasedincome and reduced food prices would increase calorie intake using a panel data set from Dar es Salaam andMbeya. They report an average per capita daily calorie intake o f 2,270. 27 significant relation between milk consumptionand anthropometric outcomes (height z-score as well as BMI). Figure 3.1: Non parametricestimateof stunting and milk consumption p:- n E m - 5 .a -3"- P // l- Drank milk last 24 hours-----Didnotdrink milkI Source: Author's calculations using DHS2004 Box 3.2: The milk hypothesis The milk hypothesiswas first put forward by Bogin (1998). It states that greater consumptionofmilk duringinfancyandchildhoodcontributesto taller stature as an adult. The hypothesis suggests that it is not the energy supplied by milk that causes increased growth in height, but a type 2 nutrient or combination of nutrients in milk. It is currently speculated that bioactive peptides, milk IGF-I (insulin-like growth factors), amino acids or milk mineralsare involved. Among populations consuming nutrient-deficient diets, animal protein foods supply important nutrients such as high quality protein, calcium, zinc and other milk minerals which are important for linear growth (Hoppe, Molgaard and Michaelsen 2006). In populations with marginal or poor nutritional status, increased intake of animal foods has been shown to stimulate weight gain and linear growth in infancy, childhood and adolescence. Rue1and Menon (2002) and Allen et al. (1992) analyzedthe association betweenheight and the intakeofmilk, meat, eggs, fish and poultryproductsor maize tortillas in 8 countries in central and south America. They found that milk intakewas significantly associatedwith higherheight for age z-scores. 28 65. These findings demonstrate that improving calorie intake and increasing dietary diversity are important elements of a nutrition strategy. It suggests that substantial benefits are to be gained from raising agricultural productivity as it contributes to reduced food prices (for urban households) and increased income for farmers.12 Inadequatediets also need to be addressed. Providing information about what constitutes a balanced diet, how to best prepare food, promoting livestock keeping and home gardening are ways to do so. Social marketing strategies, such as putting nutrition information on the back cover of student's notebook, on the back of vaccination cards, or even on matchboxes are ways to bring such information to the attention of many. 3.2 Caring practices for young children and (pregnant) women 66. Food availability and diet are one aspect of nutrition. Caring practices determine whether the available food reachesthe child and whether it reaches the child inthe right form and frequency. Caring practices start during pregnancy. Pregnancy (and later lactation) substantially increases nutritional needs and inadequate feeding or rest place pregnant women and their babies at great nutritional risk.To reduce these riskspregnant women need access to appropriate health care, need to be informed about nutrition and have to eat appropriate foods during pregnancyand lactation. 67. Very young children are most susceptible to infections. To strengthen their immune systems and to avoid opportunistic infections, exclusive breastfeeding is recommended for the first six months of life. This recommendationis not widely followed (Table 3.2). In fact after a baby has reachedtwo months of age most babies are no longer exclusively breastfed and at 4 to 5 months only 13.5% of babies remain exclusively breastfed. The cost of such inadequate breast feeding is high. It is believed that 14% of all child deaths due to diarrhea and 5.5% of all child deaths due to acute respiratory infections can be attributed to sub- optimal breastfeeding practices. This amounts to over 20,000 infant deaths per annum (Profiles 2006). Table 3.2: Breastfeedingstatus by age Breastfeedingand consuming Age in breast Not Exclusively 'lainWaterbased Other Complementary .---+L,. L..,..."+c-A water Total only liquiddjuice milk foods <2 2.4 70.0 18.4 0.5 1.5 7.2 100.0 2-3 0.3 42.4 19.9 2.2 3.1 32.1 100.0 4-5 3.8 13.5 16.4 3.O 5.4 57.9 100.0 6-7 2.0 1.7 4.6 2.4 0.8 88.5 100.0 Source: DHS 2005. l2 andAubert(2004) estimatethattheincomeelasticityofcalorieintakeisatleast0.4(suggestingthat Abdulai calorie intake would increase by 4% if incomes would raise by 10%) and a price elasticity of calorie intake of -0.1 (suggesting that a 10% decline in food prices would lead to an increase of calories intake by 1Yo) 29 68. As discussed in section 3.1 for children under the age of two years, the absolute amount of food inthe householdis unlikely to be the critical determinant for their food intake. It is rather the number of times each day they are able to eat and the energy and nutrient density o f their diets. Evidence that directly measures the adequacy o f care is not available, but the regressionof section 3.4 provides circumstantial evidence. It shows for instance how, controlling for wealth, the prevalence of stunting amongst children declines with the number of meals. Household size also has a positive impact on nutritional outcomes, possibly indicating that larger families have more time available to devote to caring for young children. 69. Other evidence supporting the importance of caring practices comes from a comparison of nutritional outcomes between own and other children (grand children and other relatives) living in the same household. Own children do better (Figure 3.2). One explanation for this is that own children receive preferential treatment. A competing explanation is that children who left their original household were already malnourished when they arrived intheir new household. The latter explanation does not hold for twins who are also more likely to be malnourished (Figure 3.2). Starting at birth twins are more likely to be and remain undernourished. The former is a reflection of competition for nutrients in the womb and between 0 and 20 months of age the gap betweentwins and other children grows gradually smaller.Yet the gap does not disappear completely supporting the notion that twins compete for care and end up short changed. (An alternative explanation would be that catch- up is not complete). 70. Lack of care may have many causes. Caregivers may simply not have the time to devote to their children or not recognize that there is a problem. Inan environment where up to 50% o f children are undernourished, parents may find it difficult to recognize that their child is not doing well. Parentsmay also be ill-informed as is suggested by the low adherence to exclusive breastfeedingduring the.first six months of life. Figure 3.2: Non ParametricEstimateof Determinants of Stunting Own child Twin -- -. ~.-..----- - - - --. --' J' I E ________ ----' B I 1 20 40 60 - ----- A& m months 0 la Agcvlmonrhi 40 60 Nofownchdd Own child - ----- N o r a t w m T W l " Source:Author's calculations using DHS2004. 30 71. Improved information and understanding can do much to help change ill-informed behavior. The relation between maternal education and child nutrition is well-documented and is confirmed inthe regression presented in section 3.4. Another indication that improved information matters can be distilled from Figure3. 3 which presents for rural and urban areas the fraction o f stunted children for mothers who do and do not listen to the radio. In rural areas there is a strong association between access to information and lower levels o f stunting, a relation that continues to hold in the multivariate regression presented in section 3.4. In urban areas no such association is found, possibly because information can be obtained from many different sources, making listeningto the radio less o f a distinct factor. Note, however, that listening to a radio does not have to imply better access to information. It could also indicate less work pressure (and more time for caring) or greater gender equality. 72. Apart from communication through the mass media, there exist many ways to provide information about healthy nutrition. Mothers o f young children, for instance, can be reached during antenatal visits - 88% of pregnant women visit a health facility for at least one antenatal check-up and almost all o f them for two or more - or at the time o f the first visit to the health facility after the birth of the baby - 91% of babies are immunized with BCG. Community health days offer other possibilities for communicating sound nutritionpractices. Throughout Tanzania, they are organized at least twice a year when children are provided vitamin A supplementation. Nutrition activities can also be organized around the Day of the African Child on June 16, and World AIDS Day in 1 December. Schools are other venues for communication, both for siblings o f young children who can share the information with their families, and for older pupils, especially adolescent girls, to gain greater understanding of nutrition. Figure3.3: Non parametric estimates of determinantof stunning and months Listensto radio, urban areas Listensto radio, rural areas I iI O 20 Apvl montha 40 63 - ----- Doe~norlirtentorndio Listrnrto radio ~ Source: Author's calculationsusingDHS 2004. 31 3.3 Healthy living conditions improve nutrition 73. Living conditions matter greatly for nutrition outcomes. Children of normal birth weight can become malnourished in infancy -even if their nutritional intake is adequate, if they suffer from poor food absorption caused by diarrhea, malaria, pneumonia, helminthic or other diseases. And as disease leads to loss of appetite, decreased food intake and declines in the bodies nutrient absorption capacity, at a time of increased nutrient requirements, the consequencesfor nutritional status of living inunhealthy conditions are considerable. 74. Living conditions for many householdsare not healthy. 53% o f all householdsdo not own at least one mosquito net, and only about one in four households owns an insecticide treated net. About half the population does not sleep under a mosquito net and only one in three households has access to piped water. About a third of the population relies on protected and unprotected wells for water and one in four households obtains its drinking water from springs, ponds, dams or rivers. About 80% of household in Tanzania uses a traditional pit toilet, regardless of the location of their residence. Modern toilet facilities are not common, even in urban areas (around 20% in 2004). Sixteen percent of households in rural areas and 32% of households in Zanzibar do not have any sanitation facilities. Improving living conditions is an important element of a nutrition strategy as unhealthy living conditions transpire in a high prevalence of childhood illnesses, such as malaria, diarrhea and acute respiratory infection (AM). The prevalence of both diarrhea and acute respiratory infection - estimated by cough with fast breathing - is around 8% and 12% respectively. The proportion of children under five with fever, a symptom that is often associatedwith malaria is much higher, 24%. 14% of children took antimalarial drugs in the preceding two weeks. Notably, children up to the age of 2, the time during which the likelihood of under-nutrition rises dramatically, are 50% to 100% more likely to be affected by these childhood illnesses. Table 3.3: Prevalenceofinfectiousdiseases duringthe past2 weeks amongst children under five ~ ~ ~ ~ ~ ~ ~ Symptoms of Took Age inmonths acute respiratory Diarrhea Fever antimalarial infection drugs <6 6.1 7.4 16.8 6.9 6-11 13.1 25.4 36.2 23.0 12-23 10.5 22.3 34.2 20.4 24-35 7.7 10.4 25.2 14.8 36-47 7.0 6.9 19.2 10.2 48-59 5.O 4.8 14.8 9.4 All children 8.1 12.6 24.4 14.2 under 5 Source: DHS 2005. 32 75. The high incidence o f infectious disease and the bidirectional interaction between under-nutrition and infection makes it necessary to break the vicious cycle. A healthy living environment with access to clean water, appropriate sanitation practices and malaria prevention allows doing so. The impact these environmental factors have on nutritional status i s illustrated in Figure 3. 4. Sleeping under a bed net, the absence o f diarrhea, access to safe water or the presence o f an improvedtoilet each contribute to improved nutritionoutcomes. Figure3.4: Non ParametricEstimateof determinantsof stunting and age in months Sleeps under bed net Had diarrhea in past2 weeks 1; 0 m 40 W 0 a0 40 a Age m months A p m months - ----- Bednctnornvdsblr Bcdnet svnilnble I- Haddmrrhhetm psitZwccka -----Dldnothcvzdhrrhra Access to safe water, rural areas Type of toilet, urban areas 1- B //------------/------ _.--/------- -________--- E - - ,< ,,.'._.^__,..-+.. .... , -....__ _._.-- i ..__ I .. .-.,-` 2z -,',/ ,y,d.,,.** N 7 - 0 m 40 W Age y1monrhs -Nororiet ........... -----Foartoclct G o o d f o k t Source: Author's calculations usingDHS 2004 76. In conclusion: the unhealthy conditions in which many Tanzanians live result in diseases which, in turn, negatively affect nutrition outcomes. Improving living conditions is therefore an important element o f a nutritionstrategy. 33 3.4 Key factorscontributingto under-nutrition 77. Inthis sectionwe bringtogether the various explanatory variables for under-nutrition, household wealth, food intake, caring practices, environmental quality and low birth weight into one regression. Using the 2004 DHS data, we explain in a probit regression whether children aged 0-5 years are stunted. 78. Apportioning the various variables to different categories is inevitably arbitrary. For instance, having an overweight mother or weighting less than 3000 grams at birth were included as indicator of access to food, but could equally well have been put under caring practices. The regression performs reasonably well. The results are stable and comparable across specifications. The (pseudo) R-squaredis acceptable (0.10 inrural areas; 0.12 inurban areas). 79. The regression, reported inTable 3.4 confirms the key finding reported earlier. They are summarizedbelow: Household wealth is correlated with under-nutrition. In urban areas the relation is significant for all quintiles and the coefficients are decreasing in wealth Le. greater wealth leads to better nutritional outcomes. Inrural areas a significant relationship is only found for householdso fthe fifth wealth quintile. The quality of living conditions matters. Children that sleep under a mosquito net or that live in a household with access to clean water are less likely to be stunted. The reverse holds for childrenthat were sick recently either because they had diarrheaor because they had an acute respiratory infection. Caring practices matter. Controlling for low birth weight, twins do less well than other children, possibly because they compete for attention. Likewise, children living in families where mothers listen to the radio regularly do better, because of the information received, but possibly also because being able to listen to the radio reflects availability of time (for caring), or a greater interest in information. Mother's education affects nutritional status as well. Food availability matters. Children living in households that eat meals more frequently, or where the mother is overweight are less likely to be stunted. Note that these variables are not a reflection of household wealth, as controls for this variable are included in the regression. Also note that the number of meals might also be considered an indicator of "caring practices" rather than of the availability of food. Caring for pregnant women matters. Low birth weight children are much more likely to be stunted. 80. The findings make clear the multiple causes of under-nutrition. Addressing under- nutrition will therefore require interventions across a range of sectors: in agriculture to enhance farm productivity and to increase diet diversity, in health to improve care for pregnant women, to early identify the signs of under-nutrition and to increase the use of bed nets, in water to increase access to and use of safe drinking water and in sanitationto spread the use of hygienic practices. The results also point to the need to improve the provision of 34 information about adequate diet and caring patterns, through the education system, extension services, healthand community services, or through the mass media. 3.5 Conclusion 81. The conceptual framework (UNICEF 1990) considers three underlying causes for malnutrition: food energy availability and dietary diversity, caring practices for childrenand (pregnant) women, and the quality of living conditions. The latter two (caring practices and the quality of living conditions) received most attention, yet the analysis in this chapter demonstratesthat all three matter. 82. Dietary quantity and diversity help ensure that all important nutrients and vitamins are consumed. An adequate diet i s intrinsically relatedto adequate care and behaviorsrelated to food handling and preparation. This is especially evident for young children whose nutritional status is arguably more affected by caring practices (hygiene, frequency of feeding, energy density of food served) than the absolute amounts of food they eat as the quantities involved are relatively small. But for older children, adolescents and adults food intake does matter and about 44% of all Tanzanian population eats too few calories to even sustain light work. 83. Caring practices and living conditions matter equally well. This makes addressing malnutrition truly multi-sectoral. After all addressing hygiene, food preparation, diet diversity, sleeping under bed nets, access to clean water, immunization etc. do not belong exclusively -and in some cases not at all, to the domain of nutritionists. In some instances, such as access to clean water or the provision of bed nets to pregnant women and children under five, progress is almost assured as championsexist outside the nutrition sector. Inother areas nutritionists will need to take the lead. Changing caring practices is such an area where it is important that change happens. Changing behaviors is difficult, but none the less possible. In neighboring Rwanda, for instance, (Annex C2) 71% of women exclusively breastfeeds for a period of at least 4-5 months. There i s no reason why this could not be achieved in Tanzania, where the comparator number is 14%. 84. Inthe next chapter the focus shifts from understandingmalnutrition to what can and needs to be done in practice. The chapter discusses the need for interventions and considers which interventions are most attractive from a costhenefit perspective. The chapter identifies a nutrition agenda that i s affordable given the existing resourceconstraints. 35 Table3.4: Probitregression on stunting for children aged 0-60 months Rural Urban Coef. T-stat Coef. T-stat Characteristicsof individual Age inmonths 0.0242 14.3 *** 0.0144 4.5 *** Age inmonths squared -0.0003 -11.0 *** -0.0002 -3.5 *** D-male 0.0249 1.7 * 0.0800 2.8 *** Characteristicsof household Age of father -0.0024 -2.1 ** -0.0022 -1.0 Age o fmother 0.0014 0.9 0.0025 0.7 Years of education o ffather 0.0036 1.5 -0.0041 -1.0 Year ofeducation ofmother -0.0081 -3.5 *** -0.0062 -1.4 D-2ndwealth quintile 0.0087 0.4 -0.0808 -2.1 ** D3rdwealthquintile -0.0128 -0.5 -0.1279 -3.1 *** D-4thwealth quintile -0.0155 -0.6 -0.1488 -3.3 *** D-5thwealthquintile -0.0900 -3.4 *** -0.1764 -3.5 *** Environmental characteristics D-haddiarrhea inpast 2 weeks 0.0758 3.4 *** -0.0306 -0.7 D-hadfever inpast 2 weeks 0.0317 1.8 * 0.0386 1.1 D-hadARI in past 2 weeks -0.0024 -0.1 -0.1303 -2.7 *** D-sleepsunder bednet -0.0908 -5.8 *** -0.1190 -3.3 *** D-hasflushtoiletor ventilatedpit latrine -0.1536 -2.7 ** 0.0368 0.5 D-haspit latrine 0.0203 1.1 -0.0170 -0.3 D-usesafe drinkingwater -0.0337 -2.1 ** 0.0182 0.5 Distanceto market 0.0008 0.8 -0.0010 -0.2 Caring variables D-twin 0.1515 4.9 *** -0.0016 0.0 Household size -0.0053 -2.9 *** -0.0132 -2.2 ** Dependencyratio -0.0064 -0.4 0.0273 0.9 D-listens to radioregularly -0.0368 -2.2 ** 0.0524 1.5 Foodsecurity Number of daily meals -0.0440 -3.1 *** 0.0027 0.1 Mother is overweight -0.0934 -4.3 *** -0.0198 -0.6 Caring for pregnantwomen D-childwas less 3000 grams at birth 0.1372 5.3 *** 0.0863 2.4 ** Observations 4806 898 PseudoR-squared 9.5 12.3 Note: ***, ** and * signals significanceat respectively99%, 95% and 90% levelsof confidence. Source: Author's calculations usingDHS2004. 36 4. ADVANCINGNUTRITION 85. Addressing malnutrition, it was argued inchapter 1brings considerable economic and social benefits as it reduces mortality, leads to resources savings in health, improved education outcomes and increases incomes. Evidence o f the reverse was also found. Higher incomes allow households to obtain diversified and adequate diets, to create healthy living conditions and to spend more time on child care. Higher income thus contributes to improved nutrition outcomes. 86. Tanzania i s going through a period of high GDP growth o f approximately 6% per annum. This chapter investigates whether this income growth is sufficient to achieve the MKUKUTAand MDGobjectives for nutrition. The answer is a resounding, no, andthe chapter continues to explore what interventions should complement income growth. It does so by exploring which interventions yield the highest benefits for every Shilling spent. Based on this analysis and starting from the premise that in the short term the existing budget constraint i s unlikelyto be changed, a nutrition agenda is formulated. 4.1 Income growth alone cannot achieve the MKUKUTA or MDGtargets 87. Ifhigher income is good for nutrition, does it imply that the MKUKUTA or MDG nutrition targets can be achieved with income growth alone? To investigate this two simulations are presented: (i) a MKUKUTA scenario aimingto reduce the level o f stunting to 20% by 2010 and (ii)a MDG scenario aiming to reduce the prevalence o f underweight to 15% by 2015. In both instances projected per capita income growth is 2.9%, which is the average rate o f income growth attained between 1999 and 2004 (Economic Survey 2006). The underweight elasticity o f real per capita income in the MKUKUTA scenario is set at - 0.50 in the optimistic scenario, and -0.25, inthe conservative scenario. In the MDG scenario, the stunting elasticity is set at -0.30 inthe conservative and -0.60 in the optimistic scenario. The elasticities for the conservative scenarios correspond to those that can be derived from Alderman, Hoogeveen and Rossi (2006a) and are in line with those reported by Mkenda (2005)13.Elasticities inthe optimistic scenarios are twice those o f the conservative scenario. 88. Figure4. 1 presents the results o f the scenario runs. It is evident that the MKUKUTA target of halving the prevalence o f stunting by 2010 will not be achieved if one relies on income growth alone. Even using an optimistic elasticity and despite the inclusion of the observed drop in stunting from 44% in 1999 to 38% in 2004 the prevalence o f stuntingwould only have dropped to 35% by 2010, far from the MKUKUTA target. And despite an even larger drop in underweight levels between 1999 and 2004 (from 29% to 22%) and despitethe fact that the MDG only has to be achieved 5 years after the MKUKUTA target, income growth alone will be insufficient to achieve the hunger MDG and to reduce underweight to 15% by 2015. 13Mkenda basis his estimate upon a review o f a cross country study carried out by Haddad et al. (2003) studies on the elasticities o f demand for calories in Tanzania by Abdulai and Aubert (2004a and 2004b). 37 Figure4. 1: Projected reduction in under-nutrition in Tanzania due to incomegrowth MKUKUTAtarget: MDGTarget: Stunting=20% by 2010 Underweight = 15% by 2015 _ _ . l l _ _ l l _ _ l l _ _ l l _ _ l I 15 - 10 - - Elastiaty -0.25 - ' Elastiaty -0.30 -Elasdaty -0.60 Elastiaty -0.50 lo!'- 5 5 - INote:The horizontal lines present the baseline for theMKUKUTA/MDGtargets respectively. I Source: Author's calculations usingAlderman, HoogeveenandRossi (2006a). 89. It is worthwhile to explore what could explain the observed drop inmalnutrition rates between 1999 and 2004 and how much income growth has contributed to it. The observed decline could be the result o f much higher income - nutrition elasticities than the ones used inthe simulations, but this seems unrealistic. Inchapters 1and 3 it was already observed that there is only a weak relation between household income and under-nutrition. And to assign the observed decline in nutrition to income growth alone, an elasticity in the order of magnitude o f 2.1 would be required. It i s more plausible that the decline i s the result o f a combination o f income growth and non-income factors such as a more effective management o f malaria, improved breast feeding and sanitation and increased access to iodized salt and vitamin A supplements. 90. Using the same assumptions as before - an average per capita GDP growth rate of 2.9% and an income - nutrition elasticity of 0.60, it is possible to demonstrate that about one third o f the decline in the prevalence of malnutrition (stunting and underweight) between 1999 and 2004 can be attributed to income growth. Two third o f the decline need to be explained by other factors. Likely candidates are mosquito nets, whose use increased from 21% to 36% between 1999 and 2004, the fraction o f children that are exclusively breastfed which increased from 58% to 70% and the fraction o f women that regularly listens to the radio which doubled from 31% to 61%.14 l4Other aspects that improvedsubstantiallybetween 1999 and 2004 are vitaminA supplementationand iodizedsalt. Unfortunatelyhouseholdlevel information for 1999 on these two aspects is not available. 38 Box 4.1: Income growth is not sufficient to achievethe nutrition MDG A study carried out using data from the Kagera region concludes that income growth in combination with nutrition interventions is needed to attain the Millennium Development Goals. In this study the impact o f income and o f the presence o f community based nutrition interventions are measured. It i s found that both significantly improve nutritional status of children (stuntingand underweight). Projections using the coefficients obtained from the regression analysis show that the nutrition MDG can't be achieved even under an optimistic income growth scenario. Only when nutrition interventions are available widespread will it be possible to achieve the nutrition MDG. The table below reflects the main results of the study. Dark shaded cells reflect that the MDGobjective i s attained (Le. at least a 50% reduction) Reduction inunder-nutrition inKagera (YO) Reduction inunder-nutrition (%) Per capita income No additional Interventions Interventions growth interventions in50% of inall communities communities Underweight 1.3% 6.8 37 3.1% 13.3 42 5.O% 19.5 46.7 Stunted 1.3% 5.3 44.4 3.1% 8.7 48.1 5.0% 13.9 Source: Alderman, Hoogeveenand Rossi (2006a) 91. One way to explore whether increases in these endowments explains the drop in malnutrition i s through a Blinder-Oaxaca decomposition. It i s a way to explain the difference in malnutrition rates between 1999 and 2004 by decomposing it in an explained portion due to differences inendowments (more bednets or good toilets) and an unexplained portion due to differences in the size of the coefficients (Le. the `technology' changes, for instance because o f a more effective treatment of malaria). Doing this decomposition using a regression comparable to that reported in Table 3. 4, but excluding the wealth quintile dummies, suggests that changes in coefficients were insignificant. Approximately half the change in under-nutrition can be explained by changes in endowments in particular bed nets, access to safe water, sanitation facilities and whether or not the household listens to the radio. Combining this result with the simulation's finding that approximately 30% o f the decline in malnutrition can be attributed to income growth, it seems likely that a combination o f income growth and improvements in endowments were the driving force behind the decline in malnutrition. 39 Figure 4.2: Decompositionof the change in under-nutritioninTanzania between1999and2004 1ooo//o 90% 80% Unexplained 70% 60% 0 Improvementsin 50% endowmnets su& as use of bednetsand B a s s to safe 40% water 30% Inamegrowth 20Yo 10% 0% Changeinundernutrition Source: Author's calculationsbasedon DIlS 92. Inconclusion, the nutrition MDGis attainable butonly when income growth is accompanied by interventions that directly or indirectly improve nutrition outcomes. These may be community based nutritioninterventions focusing on reducing low birthweight, improving child caring practices and exclusive breastfeeding, hygiene education or vegetable gardens but could equally well be improvements inaccess to safe water or the provision o f bed nets. 4.2 The economic rate of return is high for many nutrition investments 93. There have been substantial efforts to establish rates o f return for nutrition interventions (Horton 1999; Behrman, Alderman and Hoddinott 2004; Profiles 2006; Rossi 2006). Results are summarized inTable 4.1. It shows that at a 3-5% discount rate the benefits of reduced mortality, morbidity and increased productivity exceed the costs o f implementing nutrition programs 1.4 to 176 times. In other words it is good economics to invest innutrition interventions. Micro-nutrient interventions have the highest rate of return. Nutrition education programs focusing on macro-nutrient deficiencies have lower benefit-cost ratios but also inthese cases do the estimated benefitsexceed the costs. 40 Table 4.1: Estimatesof benefit to cost ratios for nutrition interventions Benefits/costs Interventionprograms International Tanzania Reducingmacronutrientdeficiencies Breastfeeding promotion inhospitals 5-67 17.5 Integratedchild care programs 9 - 16 4.4-19.1 Intensive pre-school program with considerable 1.4 - 2.9 nutrition for poor families Reducingmicro-nutrientdeficiencies Iodine supplementation (women) 15 - 520 38.6 (iodine fortification) Vitamin A supplementation (children<6y) 4.3 -43 Iron fortification (per capita) 176- 200 Iron supplementation (per pregnant women) 6.1 - 14 9.4 Note: Figures are based on empirical studies of nutrition interventions and subject to a number o f assumptions; calculations assume a 3-5% discount rate and includeboth private and social costs Source: Behrman, Alderman andHoddinott(2004); Profiles(2006) & Table 4.2 94. A potential obstacle to these economically attractive investmentsis that some returns are immediate (reduced mortality; reduced health care costs) while others only materialize in the medium term. A program reducing stuntingduring the first two years o f life, will only achieve many of its economic benefits when beneficiaries enter the labor force. The benefit - cost analysis takes this into account by discounting the stream o f future benefits at 3-5% per annum. A higher discount rate may be preferred to reflect the resource constraint (and high opportunity costs) the Government o f Tanzania faces. As a rule o f thumb -and assuming that all benefits occur after 15 years and last for 40 years, the benefit - cost ratios o f Table 4.1 would have to be reduced by a factor 3 to 4. Even at such high discount rates, most nutrition interventions remain economically attractive, further strengthening the case for investments innutrition. 95. For historical and other reasons there is considerable interest in community based approaches in Tanzania, in part because o f the Iringa program whose triple A approach (Assessment-Analysis-Action) has inspired community based efforts across the globe. For this reason we consider the costs and benefits of two Tanzanian community based approaches implemented in Iringa and Kagera. The Iringa program was run by UNICEF between 1983-1988. The program focused on nutrition rehabilitation and intervention in 168 villages with an emphasis on social mobilization and community animation (Dolan and Levinson 2000). The Iringa program reflectedthe view that nutritional status o f an individual "is the outcome o f a complicated process embedded in the fabric o f society" (JNSP evaluation report, 1988). As part of the Iringa program 46,000 children under the age of 5 were measured and weighted annually. 96. The Kagera program was (and still is) implemented by Partage a private NGO dedicated to children's welfare in rural areas. It focuses on social mobilization and reinforcing the ability o f families and communities to care for their children. Partage specializes in orphans and aims at sharing with needy households the responsibility o f educating and bringing up their children. Only children o f families below the poverty line 41 who commit themselves to actively participate in the program are eligible. Partage was created as a nutritional program buthas started to cover areas like education as well. 97. Rossi (2006) assesses in detail the costs of both programs and estimates the cost per beneficiary per year between $ 54 (Iringa)" and $ 60 (Partage). Ifthe Iringa program were to be scaled up to a nationwide program, the cost per beneficiary could drop to $ 14, but only under an optimistic scenario where no additional structures have to be built, start-up costs are zero and there are substantial economies of scale reducing the operating cost to 70%. The cost would be $ 60 under a scenario where there is no scope for economies o f scale and investments in physical infrastructure have to be made. Which scenario i s most realistic depends much on how a program was to be implemented. Ifthe intervention is a stand-alone operation then the higher cost estimate would be realistic. If, on the other hand, the intervention was integrated in an ongoing program and only marginal costs would have to be paid, the lower cost estimate may be more realistic. 98. On the benefit side three kinds of benefits are distinguished: height, which may be considered a proxy for health, educational attainment (in years) and (avoided) delays in school enrollment. Analysis using the KHDS data by Alderman, Hoogeveen and Rossi (2006b) suggest that the net present value of the total benefit i s $ 521 (at a 5% discount rate) and $ 144 at a 10% discount rate. Approximately 25% o f this benefit i s attributable to additional schooling and reduction in delayed enrolment while the remainder is due to increased height. These estimates are a lower bound o f the total benefits as they do not capture reduced mortality or lower health care costs. On the other hand, the coefficient for height inthe earnings regression is amongst the highest found in the literature and may well be overestimated.16 Table 4.2: Benefitto cost ratiosof community based interventions in Tanzania. Discount Net Net present Net present BenefitKOst Benefit/Costs rate present value o f $ 14 value o f $60 ratio at an ratio value o f intervention intervention intervention at an benefits for 2 years for 2 years cost o f $ 14 / intervention (40 Yrs) beneficiary for cost of $60 two years for two years 5% 521 27.3 117.1 19.1 4.4 10% I44 26.7 114.5 5.4 1.3 Source: Basedon Rossi 2006 andAlderman, Hoogeveenand Rossi, 2006a. 99. To derive the benefit-cost ratio for community based interventions Table 4.2 demonstrates the results for two different scenarios at a cost o f $ 14 and $ 60 per annum and at discount rates o f respectively 5% and 10%. It i s furthermore assumed that to achieve results an intervention would have to deal with a child for a period o f two years. The table demonstrates that community interventions are economically feasible. The costhenefit ratios are all greater than one, and within the range of ratios presented in Table 4.1. The ratio's are, however, substantially lower than those for micro-nutrient interventions. 15Or $41 in 1987prices. l6Inthe earningsregression, heightwas not instrumented.Studiesthatdo instrumentshow, however,that the heightcoefficient insuch regressions is likely to be biasedupwards. 42 100. Inconclusion, many nutrition interventions are economically attractive but ranked by their benefit-cost ratios, there is a clear hierarchy. Most attractive are micro-nutrient interventions, followed by interventions aiming at pregnant women and promoting exclusive breast feeding. Community based interventions are also economically attractive in that their benefit-cost ratios exceed one -even at high discount rates, but its benefit-cost ratios are substantially lower than those for micronutrient interventions or interventions aimed at pregnant or lactatingmothers. Box 4.2: School feeding is an intervention that improves education, not nutrition. Certain interventions have not been considered in this section, not because their benefit-cost ratios are not attractive but because their impact on nutrition outcomes i s limited. School feeding i s an example o f these. School feeding programs have limited to no impact on nutrition outcomes. This is unsurprisingas most under-nutrition is not fully reversible and occurs during pregnancy and the first two years o f life. Interventions targeting children over two years o f age are less likely to have an impact. Another reason for the limited impact o f school feeding on nutrition is that parents o f children who receive a school meal are likely to consider the school meal a replacement for a meal provided from home. Consequently, children will be sent to school without a provision for lunch (where they previously carried a lunch box) or receive less food at home. School feeding programs are still worth considering. School feeding can be very effective in motivating children to attend school and improves classroom behavior, by alleviating short term hunger, thus eventually improving school performance. Evidence shows that school feeding or take home rations improve school enrollment and attendance especially for girls. School feeding programs therefore may be considered as part o f the education program and their effectiveness should be assessed inrelation to other education interventions. iurce: Adapted from USAID (2000) and World Bank (2006). 4.3 The budget for nutrition interventionsis limited 101. The previous section demonstrated the economic rationale for nutrition interventions. Benefits exceed costs to a large degree, even at highdiscount rates, implyinga more than fair returnto nutrition investments. This is sufficient basis to argue for investmentsin nutrition. Next we consider what investments mightbe feasible given budget existingconstraints. 102. A first step to this end is to consider the cost of interventions. Here the full costs o f interventions are taken (as if interventions were stand-alone exercise), but note that for many there i s scope to integrate them in ongoing activities in which case the unit cost would be less as only the additional costs would have to be covered. International cost estimates vary from as low as $0.02 per beneficiary per year in the case o f salt fortification with iodine to as much as $2-10 per beneficiary per year for community based growth promotion (Caulfield et al. 2005, Horton 1999). Estimates carried out for Tanzania suggest that the cost o f implementing nutrition interventions in Tanzania are somewhat higher but otherwise 43 comparable to those done elsewhere: approximately $0.03 per capita for salt iodization, $0.71 for vitamin A supplementation, $3.4 per for iron supplementation per pregnancy and up to $14 - $60 for intensive targeted growth promotion per infant (MOST 2005; Profiles 2006; Rossi 2006). Table 4.3: Annual Cost of Nutrition Interventions($ / capita) Deliverv Method Forti- Supple- Intervention fication mentation Tanzania Iodine 0.02-0.05 0.8-2.75* 0.03 (fortification) 0.85 (supplementatiordtargetedmother) Vitamin A 0.17 0.9-1.25 0.22 - 0.71 (twice yearly / infant) Iron 0.09-1.00 3.17-5.30 3.3 (supplementatiordpregnancy) Less More Intensive Intensive Growth 2-5 5 - I O * * 1.9 (breastfeeding promotiordinfant) Promotion 14 (intensive community based/ infant) Note: For iodized oil injections; * ** For example, with paid workers/food supplements Source: Caulfieldet al. (2005); Tanzania Profiles Team (2006), MOST (2005). Table 4.4 presents the potential number o f beneficiaries based on population projections made out o f the 2002 Population and Housing Census. It shows that there are approximately 6 million children under the age o f 5 o f which about half, 3 million are under the age o f two. Taking the DHS estimates o f incidence o f stunting and underweight, it suggests that 2.3 million children are stunted and 1.3 million underweight. Micro-nutrient deficiencies affect equally large numbers o f children. Approximately 2 million children are anemic, some 10% of all children is vitamin A deficient and about I.6 million children below the age o f 2 live in a household consuming inadequately iodized salt. Table 4.4: Projected populationfor 2004 Age inmonths Total 0-11 1,501,614 12-23 1,407,109 24-35 1,360,282 36-47 950,23 3 48-59 824,010 Total 0-23 2,908,723 Total 0-59 6,043,248 Total population 35,73 1,93 8 Source: Author's calculations based on population projections (URT/NBS 2006). 44 103. Table 4.5 provides an overview of the budget that is available for investments in nutrition from three key actors (and funders): TFNC, UNICEF and HKI. It makes a distinction between administrative expenses and investmentexpenses. The budget TFNC has available for investmentsfluctuated in the past years but went down to about $ 500,000 with the budget guidelines for the year 2007/8. Buteven ifwe were to take an optimistic approach, it is hard to see how the budget for investments in nutrition could exceed $ 5 million per annum. 104. The population projections in combination with the available budget is sobering. A nutrition program targeting the most vulnerable only, that is children under the age of two and pregnant women would still have to reach approximately 3 million children and 1.5 million pregnant women per annum. And at an investment budget of less than $ 3.3 million, there is barely enough to spend $0.75 person per year. It would permit only a focus on vitamin A, deworming and iodine fortifications. Table 4.5: Budget for nutritioninterventions Age inmonths Year Currency Administrative Investment TFNC expenses Expenses TFNC 2007 / 2008 USD 800,000 500,000 UNICEF 20071 2008 USD Not Available 2,100,000 HKI 20051 2006 USD 330,000 670,000 Total USD 3,270,000 Note: In 2005/6 TFNC's budgetwas considerablyhigher:$2.5 million, o f which $ 800,000 was spent administratively. 105. Despite hard budget constraints, additional budget for nutrition exists. Four sources can be identified (i)larger aid from development partners (DPs); (ii)an increased budget allocation from Ministry of Health and Social Welfare (MoHSW); (iii)increasedefficiency in delivering nutrition interventions and (iv) collaboration with other sectors and programs. These four sources and their potential are captured in Figure 4.3, presenting a budget diamond. Inthe short run the scope for increasedbudget is limited. At a total health budget of $ 12 per capita it will be hard to obtain more resources from Ministryof Health and Social Welfare. Also development partners may be unable to provide additional resources. And if they were to provide additional resources, it is likely to be channeledthrough budget support or the health basket. In the long run more resources for nutrition may become available, not from development partners directly but channeled through MoHSW. This is reflected in Figure 4.3 by the outward shift of the upper, right corner of the budget diamond betweenthe short and the long run. 45 Short term Medium term Increased resources Increased resources fromDPs I fromDPs Increased Increased efficiency efficiency I Collaboraaon with other Collaboraaon w~th other sectors and programs sectors and programs Note: The point where the diamond touches the axis provides an indication of how much additional budget could be obtainedfrom the four sources. The grey surface reflectsthe total additional budgetthat could be 106. In the short run, the two areas with the greatest potential for additional budget are increasing the efficiency of nutrition interventions, through targeting or by no longer supporting ineffective interventions (see Box 4.2 or annex F for examples) and by tapping into resources available in other programs. The latter presents the greatest potential as there are numerous programs that could be tapped. TASAF for instance, the social fund, could include community based interventions in its list of eligible activities; TACAIDS could include the promotion of healthy diets in its information campaigns; Local Governments could be asked to include the cost of distributing vitamin A and deworming tablets in their budgets, while the cost of purchasingvitamin A and deworming tables could be included in the budget for drugs in the Ministry of Health. The malaria voucher program could be approachedto also include the distribution of iron pots (to prevent anemia) in its program, and should be convinced to include nutrition programs so as to enhance the effectiveness of their program (Ehrhardt et al. 2006). There are numerous other possibilities related to the Water Sector Development Program, the Water Supply and Sanitation Program, the Agricultural Sector Development Program (ASDP) or the sanitation and hygiene program. Table 4.6 identifies a number of policies and interventions that could be followed with possible beneficial impact on nutrition. 46 .-0d -.- Y 3 cd 4- .-e0 t? .I Y b 1 E! e E W > E I .-c d 0 cd 1 0 a ui a .-.t: Y 0 sm .-C .-C0a Y m d & 8 .-.-0 c U UL I c c 95 0 4.4 Definingthe nutrition agenda 107. Based on the previous analyses it is possible to arrive at a program of nutrition interventions.The program comprises four elements. 108. The first element deals with addressing vitamin and mineral deficiencies and is recognition of the high rates of return micro-nutrient interventions yield. Tanzania has already made much progress in this area, in particular vitamin A supplementation, deworming and control of iodine deficiency and the agenda aims to expand the coverage of these interventions. The vitamin A program will have to ensure that all children under 5 receive twice yearly vitamin A supplements and that the majority of women receive the recommended single postpartum dose of vitamin A, for instance by delivering it to mothers at the time of the first BCG vaccination for their children (more than 90% o f all children receive their BCG vaccination - DHS 2005). Also, children suffering from diseases that deplete the body's vitamin A status (diarrhea, measles, AM, TB and severe clinical PEM) should receive supplemental vitamin A (disease targeted vitamin A supplementation). Likewise the iodine program will needto be intensifiedto ensure that adequately iodized salt becomes available where this is currentnot the case. 17 109. Other micro-nutrient interventions deserve serious consideration, especially anemia reduction. Addressing anemia is attractive ifonly because it has immediate benefits for labor productivity and maternal survival. Pilot projects in Iringa, Handeni and Korogwe are ongoing and aim to demonstrate the feasibility of fortification of maize flour at hammer mill level. Fortification of centrally processed foods such as is tested by a company based in Arusha which is fortifying cereal flour is another possibilities. Both need to be carefully assessedas to whether they target the right population and for their feasibility to be scaled up. Especially reaching a large number of many hammer mills may be logistically difficult. Other opportunities exist. Sugar and soft drinks, which are produced inonly a limited number o f factories places and which are widely consumed in urban and rural areas can serve as vehicle for iron fortification (Layrisse et al. 1976). The introduction of iron pots or improving their use for the preparationof food hasbeenfound to be a promising innovative intervention for reducing iron deficiency and iron deficiency anemia (Adish et al. 1999; Borigato and Martinez 1998; Geerligs, Brabin and Omari 2003). A pilot trial in Ethiopia found, for instance, that the provision of iron pots (costing about $3 per pot) was a less costly alternative than the provision of iron supplements (Rue12001). To date the use of iron pots has not caught on and it needsto be assessedwhy this is the case. 110. The second element focuses on prenatalcare and feeding practicesfor young children, in recognition of the fact that many children are born with nutrition related deficiencies or become malnourished soon after birth and that recommendations on exclusive breastfeeding are largely not followed. Interventions seek to improve care for pregnant women (including the provision of micro-nutrients and deworming), the promotion of exclusively breastfeeding and adequate (complementary) feeding practices and care. Activities in this area will mostly have to be taken in collaboration with other sectors, the Ministry of Health and Social Welfare and TACAIDS in particular. l7 areabout4500smallscalesaltproducersinTanzaniaandtheyarelargelyresponsiblefortheun-iodated There salt in the market.. 52 Box 4.3: Nutritionagenda 1. Address vitamin and mineral deficiencies 0 Maintain and expandvitamin A provision and deworming (6-59 months). 0 Maintain and expand iodine fortification. 0 Maintain and expandvitamin A supplementationto post-partum women. 0 Maintain and expand iron supplementationto pregnantwomen and pursue iron fortification for the population at large. 2. Prenatalcare and care and feeding practices for young children 0 Maintain and expanddeworming, malaria prophylaxis, iron and folic acid supplementationto pregnantwomen. 0 Promoteexclusive breastfeedingfor the first six months of life. 0 Provide insecticide treatedbednets and iron pots for all pregnant women and children under 5. 0 Enhance complementaryfeeding and food fortification. 3. Improvethe efficiency of delivery and financingmechanisms through: i.Promotionofdecentralizedservicedeliverythroughdistricts 0 Appoint nutrition focal points inevery district and holdthem accountable. 0 Include nutrition service delivery in district budgets. ii. Coordinationwith andoutsourcingtoother sectorsandprograms: 0 TACAIDS: start an educationand information campaign stressingthe importance of a healthy diet. 0 Ministry of Health and Social Welfare: include the provision ofminerals and vitamins in healthbudget 0 Malaria Voucher Scheme: add provision of iron pots to the bednet scheme. 0 Ministry of Education and Vocational Training: consider nutritionan essential early childhood educationstrategy. 0 Ministry of Community Development, Gender and Children:promote at community level care and appropriatefeedingpracticesfor young children. 0 Private Sector and NGOs: EstablishPublic-Private Partnershipsfor food fortification, social marketing and implementation of activities iii.EnableTFNC 0 StrengthenTFNC, de-emphasizethe focus on implementation but focus on strategic planning, coordination, monitoring andthe preparationof guidelines; align staffing inaccordancewith these tasks. 0 Agree on time frame to completethe enabling ofTFNC. iv. Improved accountabilityand harmonization 0 Hold parent ministry (MoHSW), LGAs and TFNC responsiblefor results. 0 Create nutrition Sector Working Group. 0 Initiate annualNutrition Sector Review. v. Improve the ability to monitor and evaluate. 0 National Bureau of Statistics: include nutrition questionsroutinely inthe household survey program. 0 Ministry of Health and Social Welfare: include nutrition indicators inHMIS 4. Advocacy and preparationsfor additionalnationwide interventions 0 Improve profile ofnutrition amongst policy makers. 0 Identify effective communication strategiesaimed at behavioral change. 0 Identify a cost-effective, scalable package for community based nutritionservices. 53 111. The third element comprises various activities that would lead to an enhanced efficiency of delivery mechanisms. It stresses the importance of decentralized delivery o f nutrition services, a first step to which is the appointment o f nutrition focal persons in each district. It also recognizes that improved food intake and a balanced diet, caring practices and healthy living conditions are also addressed by other sectors and programs. Better coordination with (and outsourcing to) these sectors will allow activities undertaken by these sectors to benefit nutrition as well. Greatest potential appears to exist in a better collaboration with Ministry o f Health and Social Welfare, TACAIDS and the bed net voucher scheme, NBS, the Ministry of Agriculture, Food Security and Cooperatives and the Ministry of Community Development, Gender and Children. Other aspects will be discussed in greater detail in the next section. They revolve around the restructuring o f TFNC, improved monitoring, accountability and harmonization. 112. The fourth and final element considers actions needed to build a constituency for large scale interventions in the future. It requires building a political constituency to get a budget that would permit additional nation wide interventions. Meanwhile (a package of) interventions has to be identifiedthat is effective, affordable and scalable, including research into effective means to communicate the nutrition message. Information provision through the mass media and through health staff present opportunities. A systematic analysis of (i) how to best improve people's knowledge on healthy nutrition, (ii) which circumstances under improved knowledge leads to behavioral change and (iii)the costs and benefits o f various approaches would go a long way towards building a support base for larger nutrition interventions. Again, collaboration with other sectors and programs can help share costs, especially TACAIDS, WSSP and the Ministryo f Education and Vocational Training. 113. Table 4.7, finally, presents a first attempt at costing the nutrition agenda as proposed above, identifying interventions that need to be paid for by the nutrition sector (TFNC, HKI, UNICEF) and those that can be relegated to others. It i s clear from the table that even the very limited nutrition agenda as it is formulated her cannot be funded by the nutrition sector alone. Cost sharing and expanding the fiscal space for nutrition through collaboration, efficiency gains and tapping into additional resources are extremely important. 4.5 Conclusion 114. To achieve the MDG and MKUKUTA nutrition objectives high income growth will have to be combined with nutrition interventions. Interventions are not only desirable from an equity and social perspective, they are good economics. Even at a discount rate o f 10% the benefit cost ratios of most nutrition interventions exceeds one. In other words, the rate o f return to investments in nutrition is at least 10% per annum, and in most instances much more than that. Spending on nutrition is an investment at par or better than investments in malaria control, trade liberalization or community managed water supply, programs that each receive considerable funding (Lomborg 2004). 115. This chapter shows that supplementation or fortification with vitamins and minerals (iodine, vitamin A, iron) yields the highest rates o f return. Interventions that focus on prenatal care, care and feeding practices for young children are also attractive though the rates or returnare somewhat less. In formulating the nutritionagenda, these two interventions are given priority, whereby it is noted that an affordable and effective program of (community based) interventions aimed at behavioral change still needs to be identified. 54 116. The budget available for nutrition investments is limited. Even a minimum program focusing on essential vitamins and minerals and care for pregnant women and young babies cannot be afforded. But as nutrition is multi-sectoral there exist opportunities to leverage the budget through collaboration with other sectors and programs. Anemia could be reduced by combining the bed net voucher scheme with the provision o f iron pots. The AIDS program is well placed to take forward the agenda on adequate and healthy diet as good nutrition is the first line drug against the onset o f HIV/AIDS. Other opportunities exist with respect to Health and Social Welfare, Water and Sanitation, Agriculture, Community Development, Education and even Statistics. 117. Enhancing the efficiency o f delivery and coordination mechanisms i s another way to free resources for essential nutrition services. It is included prominently in the nutrition agenda also because it enhances the credibility of the nutrition sector when it argues for more resources. The next chapter discusses reforms needed to enhance the performance o f the nutritionsector. 55 f 69 w o g o o o 6 9 w 6 9 .9I I r m .-e z LE! L B U 9 -0 8 0 c) s 5Q, .*B .- .-.- .- > > 5. STRENGTHENING IMPLEMENTATION 118. Enhancing the efficiency of implementation is not only a way to free resources for essential nutrition services it will enhance the credibility of the nutrition sector when it argues for additional resources. And despite achieving some remarkable results with respects to iodization, deworming and vitamin A supplementation performance in the nutrition sector is not optimal. Too often, implementation is done from Dar es Salaam. Pet projects are frequent, results are not monitored on a routine basis and coordination between development partners and TFNC, or between TFNC and other Ministries, Departments and Agencies is limited at best. 119. This chapter formulates an agenda to achieve more efficient implementation mechanisms.To this end reform is proposedin five areas: e Focusthe nutritionprogram on priority areas; 0 Improve the efficiency ofthe delivery of the nutrition program; Strengthencoordination betweenvarious actors innutrition; e Enhance demand for and accountability of nutrition services; e Strengthenmonitoring andevaluation. 5.1 Focus the nutrition program 120. A first priority to achieving efficient implementation is alignment of the work program with the nutrition agenda outlined in chapter 4. This agenda was prepared with a realistic resource constraint in mind and focuses on (i)addressing vitamin and mineral deficiencies, (ii)prenatal care and care and feeding practices for young children, (iii) improving the efficiency of delivery and financing mechanisms and (iv) building a constituency for more ambitious nutrition interventions inthe future. 121. Work is needed to align existing work programs of all partners in nutrition with the identified priorities. TFNC's new Strategic Plan which was developed according to the guidance of the Government's Public Service Management, has already done so and identified 3 "key results areas" and 16 objectives for the 5-year strategic plan period, but additional pruning may be needed. Other programs also require alignment. UNICEF's work program, for instance, focuses much of its activities (and budget) on a pilot to demonstrate models of interventions for scaling up in relation to three outcome areas: diseases prevention and healthpromotion, safe motherhoodandnewbornhealth and nutritionand early childhood development. However, the work plan (see Box 5.1 and Annex F) is so ambitious and the number o f (sub)-objectives so large (29) that it is seems highly unlikely that this approach will leadto scalable interventions. 57 Box 5.1: A not so focused pilot program An illustration of a less focused pilot is implementedas part of the Youth and Child Development program (YSCD). This program intends to demonstrate models of interventions for scaling up in relation to three outcome areas: diseases prevention and health promotion, safe motherhood and newborn health and nutrition and early childhood development. The pilot will spend approximately $ 3 million per annum in six districts: Temeke, Makete, Mtwara Rural, Morogoro Rural,Magu andHai with a total estimatednumber of 360,000 childrenunder the age of 5 (;.e. about $ 8 per child per annum). In addition to its 3 overarching outcomes, the pilot has 16 objectives and 13 sub-objectives, making it almost impossible to come up with tested results and a scalable package (see also Annex F). Source: UNICEF, Annual Work Plan2007. 5.2 Improve efficiencyin deliveringthe nutrition program 122. To advance nutrition given the existing budget, resources needto be spent efficiently. Currently, HKI and TFNC spend about one third of their resources on administration (including wages and salaries) and two thirds on investments (Table 4.5). In other words, of every $ 3 that is available for nutrition $ 1 is spent on activities with no direct impact on nutrition outcomes. If the announced reduction in TFNC's budget for the year 2007/2008 becomes a reality and administrative expenses are not reduced, TFNC may end up spending as much as 60% o f its resources on administration. The outlays for administration are such that it should be explored whether resource savings are feasible. At the very least the evolution of administrative expenses needs to be monitored over time and targets set to achieveefficiency gains. 123. The rapid changes in Tanzania's institutional landscapehave implications for the way a nutrition program is best delivered. These changes center around decentralization, public service reform and donor coordination. The Government of Tanzania is committed to decentralization by devolution and has put in place an administrative structure which provides for planning and management by local authorities in rural villages, urban mtaa and district and urban councils. The delivery of most of the public services is the responsibility of local government authorities, and the central ministry to which they report, the Prime Minister's Office -Regional Administration and Local Government (PMO-RALG). Local Government Authorities at district level receive the bulk of their financing through subventions from central government. A district development plan is prepared as part of the planning and budget process. Assessments of plans in several districts have revealed that nutrition is occasionally mentioned as a development problem and that there is only a limited understanding of how to deal with nutrition problems at local government levels (Leach 2007). As a consequence, nutrition does not feature in local government's plans. Ifnutrition is to be addressed more seriously it requires the identification, training and supervision of nutrition "champions" or focal points at the district level, the inclusion of nutrition in local government's plans and budgets and a TFNC that provides guidance and technical backstopping. 58 124. Within TFNC there i s a growing recognition that decentralization requires reform and an approach whereby implementation is the prime responsibility o f local government authorities (or other private entities and NGOs) while TFNC remains with the responsibilities o f capacity development, supervision and monitoring, resource mobilization and technical back stopping (TFNC 2004~). TACAIDS may serve as a model here. Like nutrition addressing HIV/AIDS i s associated with health interventions but requires, in practice, a multi-sectoral approach. TACAIDS delivers this by providing strategic leadership, by facilitating the pooling o f financial resources and by coordinating the implementation of HIV/AIDS interventions. To remain focused, TACAIDS refrains from implementation. Rather it delegates execution o f activities to local government authorities and private actors. This allows the agency to be effective with only a limited number o f professional staff. TFNC could learn lessons from this example for its own structure and staffing. It implies de- emphasizing implementation and greater attention to strategic planning, guideline development, backstopping, monitoring and evaluation, as reflected in the 1973 Act which established TFNC. This Act mandated TFNC with nutrition policy formulation, planning, harmonization, advocacy, research, training, facilitation, coordination, monitoring and evaluation of nutrition services inthe country. 59 Box 5.2: Functionsof TACAIDS do not include implementation FunctionsofTACAIDS are: b To formulate policy guidelines for the response of HIV/AIDSepidemic and management of its consequences in mainland Tanzania. e To develop Strategic Framework for planning of all HIV/AIDS control programs and activities within the overall national strategy. e To foster national and international linkages among all stake holders through proper co- ordination of all HIV/AIDScontrol programs and activities within the overall national strategy. b To mobilize, disburse and monitor resources and ensure equitable distribution e To disseminate and share information on the HIV/AIDS epidemic and its consequences in Tanzania and on the programs for its control e To promote research, information sharing and documentation on HIV/AIDS prevention and control b To promote high level advocacy and education on HIVIAIDS b To nionitor and evaluate all on-going HIV/AIDS activities b To-coordinate all activities relatedto the managementoftlie HIV/AIDS epidemic in Tanzania as per National Strategy 0 '1'0 facilitate efforts to find a cure, promote access to treatment and care, and develop vaccines e '1'0 protect human and communal rights of people infected and affected with HIV/AIDS b To promote positive living among people living with HIV/AIDS e To advicc the government on all matters relating to HIV/AIDS control inTanzania main1and. e To identify obstaclesto the implementation of HIVIAIDS, prevention and control policies, programs and ensure the implementation and attainment of programs, activities and targcts. e To promote all activities rclated to the prevention and control of HIV/AIDS epidemic in particular regarding the following: - (i)healthcareandcounselingofHIV/AIDSpatients (ii)thewelfare ofthebereavedoi-phansandsurvivors ofHIViAlDSvictims (iii) the handling of social, economic, cultural and legal issues related to the epidemic e To performsuchother activities and functions relatedto the prevention and control of HIV/AIDSepidemic inTanzania mainland as the commission may deemnecessary. Source: TACAIDS 125. Enabling TFNC requires a careful assessment of what should be implemented by TFNC itself and what not. TFNC staff is, at present, extensively engaged in the execution o f research, implementing surveys, and training, information and communication activities. Much of this could be left to others, local government authorities and private entities (NGOs, firms) alike. For instance one o f the activities regularly undertaken by TFNC are household surveys. Apart from ensuring that technical nutritional aspects are reflected in questionnaires and ensuring that enumerators are appropriately trained on nutrition, TFNC has no comparative advantage in survey implementation. Sampling, field work and data processing are best left to professionals who specialize in this kind of activity. TACAIDS could, again, serve as example. It sponsors, every four years, a nationally representative HIV/AIDS survey. This survey is executed by NBS and included in the National Survey Program which pays 60 70% of the survey cost. TFNC too should aim to work towards greater integration of nutrition in existing national surveys such as the Household Budget Survey (already collects detailed information on food items), Demographic and Health Survey (collects anthropometric information as well as information on micro-nutrients), HIV Indicator Survey, Agricultural Sample Census or the planned Income and Expenditure or National Panel Surveys. need for it. For instance, the 1987 joint TFNC/SIDA evaluation concludes that ... `It is 126. Strengthening TFNC will be not be easy, nor is this report the first to identify the important to decentralizeand to post nutrition officers at the regional offices, whereas TFNC provides back-up facilities in terms of advocacy, problem identification, training and project planning efforts' (Burgess et al. 1987, page 12). And the 1979 evaluation of TFNC, cited in the 1987 report, established that research on food science and technology can very well be left to the combination of the Bureau of Standards, Tanzania Food and Drug Agency, Food Quality Control Commission, the Food Science and Technology Department at Sokoine University and Industrial Development Institute.As both these reforms have not taken shape to date, it will be important to ensure that any proposals for reform are realistic and that an approach is found to implement them. 127. Public service reform is another aspect of the changing institutional landscape deserving attention. Public sector reform is implemented by PO-PSM. It is an ongoing process, aimed at improving the efficiency of the public service, amongst others through performance monitoring, improved planning and budgeting, and pay reform. Public service reform, if fully embraced, can be an important tool towards ensuring an increasedfocus on core deliverables, through annual reporting against outputs agreedupon inthe budget process, through a tri-annual reporting against outcomes and by implementing the Open Performance Review Appraisal System (OPRAS). TFNC's status as an autonomous agency provides it furthermore with some flexibility at reviewing salary scales. If implemented in conjunction with tightly monitored OPRAS, reviewed salary scales could reduce the extent to which allowances for field work and workshops act as salary top-ups and take away professional time from core deliverables. At the same time, it would create a dam against the outflow of experiencedprofessional staff in search of greener pasturesthat TFNC i s experiencing at the moment.The SecondPublic Service Reform Programwhich is currently being formulated by the Government of Tanzania with assistance from the World Bank comprises a component that deals with enabling (semi) autonomous Government Agencies. It provides a good opportunity to take forward the envisagedstrengtheningofTFNC. 128. Donor coordination, finally, is another significant change in the institutional landscape. With the Joint Assistance Strategy for Tanzania (JAST) there is a growing recognition of the necessity for government leadership and for coordination between development partners and government, national ministries and local authorities alike. As the national institution for nutrition, TFNC, will be the natural counterpartproviding guidance to developmentpartners. To this end, development partners will needto formalize their existing informal coordination arrangements and establish a nutrition Sector Working Group (SWG) under the DPG architecture. Such a group would ensure coordination amongst development partners, ensure agreement on a joint work program and streamline communication on nutrition in the work of Cluster 11, in MKUKUTA monitoring, the PER cluster work and the GBS annual review. And by reporting towards the Heads of Corporation on a regular basis, a nutrition Sector Working Group would contribute to assuringhigh level support for nutrition. 61 129. With the JAST there i s also a move away from project support towards pooling o f resources under Sector Wide Approaches (SWAp) or as General Budget Support (GBS). For instance, under its new country strategy, UNICEF will channel resources for micro-nutrient interventions through the Health SWAp. To assure that the money i s used for the intended purposes, it requires inclusion o f vitamin A supplementation and deworming in local government plans at budgets as well as those o f the Ministry o f Health and Social Welfare). It also requires that the formula used to determine the financial allocations for local authorities reflect district requirements to achieve nutrition outcomes. And, it requires that nutrition is brought to the attention o f central policy makers -in Ministry o f Finance, but also the development partners, so that nutrition activities are adequately resourced. This can only be achieved with clear advocacy, coordination and guidance from the center (TFNC and its partners). 5.3 To advance nutrition, coordinationneedsto be improved 130. Malnourished people have little political or economic influence -if at all they are aware o f their predicament, and are illpositioned to demand assistance or to compete for scarce resources. Nutrition is, at best, a minor concern to ministries and government agencies and, apart from TFNC, a major concern o f none. As the national institution for nutrition, TFNC will not only have to ensure that nutrition remains on the political agenda it will also needto facilitate a coordinatedapproach to tackling malnutrition. 131, Coordination between four types o f actors can be distinguished: between TFNC and other MDAs, between development partners, between TFNC and development partners and between TFNC and the private sector and NGOs. 132. Coordination between TFNC and other MDAs. Activities with positive outcomes for nutrition are implemented by various ministries, agencies and projects. TFNC has the challenging task to not only supervise, regulate, mobilize resources, and provide nutrition related policies and guidelines it also has to advocate for nutrition and make sure nutrition i s on the agenda o f all these MDAs. In addition TFNC has to provide oversight on the implementation o f nutrition related activities. Special attention should be given to coordination with local government authorities as with the ongoing decentralization most implementation activities will be initiated by local government. It underlines the importance o f identifying,guidingand supervising nutrition focal points in the districts so as to facilitate the integration of nutrition activities in budgets and actions plans and making sure that they are heldaccountable for advancing in the fight against malnutrition. 133. It has been suggested (e.g. Leach 2007) that for TFNC to truly advance the cause of nutrition, it should work with a central committee for nutrition, possibly established with the Ministry of Planning, Economy and Empowerment (MPEE) which also has responsibility for MKUKUTA and its monitoring process. As part of its responsibility for overall planning guidelines, MPEE the ministry also chairs the budget guidelines committee. A national committee for nutrition, established in this central ministry, could more easily attract the participation o f key planners and decision makers in multi-sectoral discussions than i s now usually the case. International experiences suggests that it matters less where nutrition coordination is situated in the administrative structure of government as long as the coordinating agency receives high level support, backed by strong political and bureaucratic commitment and is able to influence resource allocation between MDAs, so as to give implementing agencies an incentive to perform (World Bank 2006). 62 134. Coordination between development partners. Various agencies in Tanzania work on nutrition. Steps towards greater coordination have been taken and on a regular basis an informal nutrition partnership group comprising UNICEF, WHO, WFP, HKI, USAID and the World Bank meets. This group would benefit from formalization as it would increase its visibility, would make it accessible for those interested but not yet active in nutrition and would make it the natural interlocutor between development partners and government. The most likely place for such a group would be under the DGP-architecture. Within this structure, a nutrition group could coordinate nutrition activities, report to the Heads of Corporation, collaboratewith other Sector Working Groups in Cluster Iand Cluster I1(health, water, agriculture, education, private sector) and coordinate the development partners' efforts with government. 135. Coordination between TFNC and developmentpartners. With a nutrition SWG in place, and with TFNC coordinating the Government's response, coordination betweenTFNC and development partners should be straightforward. The collaboration should be used to discuss annual work programs, to align implementation activities (when development partners are involved in implementation), to exchange technical information as well as information on budgets and to agree on a common results framework that is monitored on a regular basis andthat forms the basis for next year's work program. 136. Coordination between TFNC and non-government actors. Nutrition is not only a public sector affair and it is important to harness resources that exist outside government. Fortification of foodstuffs like maize, sugar, oil or otherwise, is one area where there is scope for collaboration with the private sector. It requires building an alliance with industry on issues relating to research, technology, food processing and marketing, standards, quality assurance, product certification, social communications and demand creation. Likewise, public-private partnerships could be establishedfor social marketing for instance by putting nutrition messages on packaging. Collaboration with non-government entities need not be limited to the food industry. Partnerships could be built with other commercial entities or with NGOs and their capacities could be used for monitoring, advocacy and for activity implementation. Contracting private entities will pose a managementchallenge as it requires oversight, making it essential that adequate capacities exist in procurement, monitoring, and accounting. But private entities have proved flexible, highly motivated and skilled (World Bank 2006). This justifies greater collaboration with them, if only, initially, on a limited (pilot) basis. And because private entities are employed on a contract basis, they can be phased in when more resources for nutrition arrive and phased out once malnutrition rates decline-an exit strategy that is very difficult to implement in programs that rely on governmentfield staff. 5.4 Enhanceddemand for and accountabilityof nutrition services 137. Demand for nutrition services and accountability about actual deliveries are powerful mechanismsto improve performance.By identifying a set of indicators and targets priorities in the work program are clear and through a regular reporting against these targets accountability will help identify whether activities are on track, whether results are achieved and whether programmatic changes are desirable. 63 138. Various formal and informal accountability mechanisms are in place in the nutrition sector. TFNC, for instance, reports to its Board and to the Ministry of Health and Social Welfare. With the latter there exists a service agreement that specifies what TFNC will deliver in return for its core budget. TFNC also reports to the MKUKUTA secretariat on progressagainst the nutrition indicators included inthe MKUKUTA monitoring framework. Staff in TFNC are accountable towards management as specified in the performance agreements that are entered between supervisors and subordinates. Development partners have agreed with the JAST to provide aid on the basis of principles of national ownership, government leadership, harmonization and alignment 139. In practice the implementation of the accountability mechanisms are weak. Service agreements and performance agreements are not effectively used. Progress against pre- agreed targets is not assessed, and not meetingtargets does not have financial, disciplinary or other implications. There is only limited coordination between TFNC and development partners and work plans are aligned to a limiteddegree only. Partnershipmeetings take place infrequently and most DP-TFNC interaction takes place on an ad-hoc, bilateral, basis.18 140. Limited accountability is not unique to nutrition and with the 2007-2008 Budget Guidelines, Government seeks to improve the situation by demanding that MDAs prepare annual performance reports (APRs) and three-yearly outcome reports (URT 2007). Annual performance reports need to provide progress information on indicators by presentingtargets and demonstrating performanceagainst these targets. Outcome reports take a deeper look at a sector and assess the degree to which objectives are actually being met. With the APR and outcome reports the instruments needed for improved accountability within Government are largely in place. The challenge will be to use these tools such that they actually increase performance. 141. Whereas the tools for accountability within Government are largely in place, this does not hold for accountability amongst donors, between TFNC and donors and towards the public at large. The accountability between donors would be improved by the formation of a nutrition Sector Working Group, mentionedin section 5.2. By reporting directly to the Heads of Corporation and through peer pressure work a nutrition SWG would help aligning donor programswith the national strategy. 142. Accountability between TFNC and development partners and towards civil society would be strengthenedthrough a greater focus on creating demand for nutrition services and through an Annual Nutrition Review. Demandfor nutrition services from e.g. health facilities could be enhanced through social marketing campaigns or by using volunteers who have been trained in nutrition (as Thailand has very successfully done -World Bank 2006), whereas demand for nutritional services from the center would be enhanced by the appointment o f nutrition focal persons in the districts. An Annual Nutrition Review would bring together representativesfrom TFNC, MoHSW, civil society, development partnersand other actors involved nutrition (Local Government; other MDAs; private sector) and through analysisarrive at a common understandingabout last year's performance, would assess needs for change and would agree on a common plan of activities for the coming year with (revised) indicators and targets. An annual review would monitor the performance of TFNC but would equally assesswhether developmentpartners are meeting their JAST obligations. 18This is not to say that no accountingtakes place. TFNC has regular reporting to its Board andthe Ministry of Health and Social Welfare. TFNC also accountsto the public throughthe parliamentaryprocess. 64 143. An Annual Nutrition Review does not exist at the moment, but it would be worthwhile to set one up. The Health Sector Review may serve as a template, but sector reviews can be structured in different ways as long as they comprise the elements of analysis, performance monitoring, agreement on a common work program and accountability to the general public. One aspect that would have to be carefully considered would be timing such that the information can feed into government processes (budget guidelines) and other processes(e.g. Health Sector Review; PRBS annual review). To ensure relevance satisfactory performance on the NutritionReview would have to be incorporated inthe PAF o fthe PRBS. 5.5 Monitoring and Evaluation 144. Monitoring and evaluation (M&E) allows learning from past experience, improves service delivery, planning and allocating resources, and helps to demonstrate results as part of accountability to key stakeholders. A good monitoring and evaluation system is crucial to advance nutrition as it provides feedback on the progress o f program implementation. In the absence o f reliable, unbiased and timely data it will not be possible to assess whether nutrition interventions are effective, whether targets are met and what may have to be done to further improve performance. Accountability is not possible in the absence o f information. Without analysis it i s impossible to integrate lessons learned into future programming. 145. Monitoring encompass information about outcomes, outputs as well as inputs. For instance to reduce child mortality (outcome), it i s necessary to know who benefited from vitamin A distribution (output), which in turn depends on coordination activities implementedby TFNC and the districts (input). Information is needed on all these aspects, whether related to operational and administrative activities of TFNC and the districts, the implementation of activities or the outcomes o f these activities. Monitoring should not only focus on collecting information about input, output or outcome indictors, for a better understanding o f what works and what does not work, additional information may have to be collected. For instance ifa vitamin A campaign only reaches 80% o f the target population, it is useful to know whether this is related to household characteristics (e.g. the poor do not benefit) or relatedto spatial characteristics (e.g. households in isolated areas are underserved). Itrequires a robust system of data collection, and an ability to analyze these data. 146. Information for monitoring can be obtained from TFNC's Management Information System, other MIS systems, including the Health Management Information System (HMIS) and household surveys. At present none o f these systems functions optimally. TFNC's management information system is rudimentary and not computerized. The H M I S has its own problems, including the fact that information on anthropometric status is not collected systematically, even though this could be done, e.g. as part o f the measles vaccination. The HMIS could be used for monitoring in other ways as well. For instance there is a need to monitor the effect o f Vitamin A campaigns and documentation o f vitamin A supplementation campaign contacts on routine maternal and child health cards would be a simple step to facilitate this monitoring (Masanja et al. 2006). The ongoing household survey program as implemented by NBS could provide very valuable nutrition information, for instance by including anthropometric indicators in the HBS and through a closer coordination with the various DHS surveys. 65 Box 5.3: Actions for improved efficiency Focus nutritionactivities on those with the highest benefit-cost ratios and align the NationalNutrition Strategic Plan and donor work programs with the proposed nutrition agenda. Include responsibility for nutrition outcomes in work program o fMoHSW and strengthen oversight by the Ministry on TFNC inpart through the appointment of a nutrition desk officer. Implement and effectuate OPRAS (within TFNC) and service agreement between TFNC and MoHSW. Prepare annual performance reports and three yearly outcome reports Create a department (preferably inTFNC) charged with coordination nutrition activities with other Ministries, Local Government and programs and projects Identify and train nutrition focal persons inall districts, include nutritionactivities in district plans and budgets and hold focal persons accountable for progress in nutrition. Establish a nutrition SWG that reports to Heads o f Corporation Create greater demand for nutrition services and strengthen monitoringand evaluationthrough surveys and the HMIS. Establishan Annual Nutrition Review (ANR)that reviews performance against pre- agreed indicators and targets and that identifies priorities for next year. Reach agreement on objectives, approach and timingfor restructuring TFNC. Enter a social contract for reform innutrition with highlevel support. 147. Information for monitoring can be obtained from TFNC's Management Information System, other MIS systems, including the Health Management Information System and household surveys. At present none of these systems functions optimally. TFNC's management information system is rudimentary and not computerized. The H M I S has its own problems, including the fact that information on anthropometric status i s not collected systematically, even though this could be done, e.g. as part o f the measles vaccination. The HMIS could be used for monitoring in other ways as well. For instance there is a need to monitor the effect o f Vitamin A campaigns and documentation o f vitamin A supplementation campaign contacts on routine maternal and child health cards would be a simple step to facilitate this monitoring (Masanja et al. 2006). The ongoing household survey program as implemented by NBS could provide very valuable nutrition information, for instance by including anthropometric indicators in the HBS and through a closer coordination with the various DHS surveys. 5.6 Conclusion 148. Improving the performance of the nutrition sector is a key element towards more effective nutrition services in Tanzania. This chapter has proposed reforms affecting all major actors, the development partners, TFNC, the Ministry o f Health and Social Welfare and District Authorities. 66 149. Reform requires commitment, and a clear timeline within which it will be accomplished. Development partners should form a nutrition Sector Working Group over the next six months andpurge from their programs elements not in line with the nutrition agenda. Districts should identify nutrition focal points over the course of next year, and TFNC has to ensure they receive training and guidance and provide an accountability framework. The effectiveness o f TFNC should be enabled and the Center should return to its mandate and focus on coordination, training, monitoring and providing guidance. Doing so will involve substantial restructuring and an alignment of TFNC's staffing with it tasks and functions. Doing so will high level support that could be obtained by establishing a social contract in which the partners in nutrition, TFNC, TFNC's Boards, development partners, Ministry o f Health and Social Welfare commit to carrying out their share of the bargain. Other ways to ensure that reform will actually happenshouldalso be explored. 150. Enhanced demand for nutrition services and accountability for results achieved are key to ensuring that reforms are actually implemented. OPRAS, annual performancereports and three annual outcome reports are -in theory at least, important tools to enhance a focus on results within the public sector. The Ministry of Health and Social Welfare, as the parent ministry for TFNC, will have to include nutrition outcomes in its own performancereporting and hold TFNC accountable for delivering against it. Development partners involved in nutrition will need to abide by the JAST principles and will have to hold each other accountablethrough peer review and by reporting regularly to the Heads of Corporation. 151. Ad ultimo, good nutrition is a matter of all Tanzanians. An Annual Nutrition Review whereby in a forum accessible to all domestic stakeholders, progress in combating malnutrition is reviewed, performance is discussed and where the key elements for the future work program are agreed is an important element to enhancing accountability in the future. The National Nutrition Conference which TFNC organized in May 2007 is a first step towards such an annual review. 67 ANNEXA: COMMISSIONED PAPERS 1. Causesofmalnutrition andTanzania's nutritionprograms:pastandpresent. Tnzania Food and Nutrition Centre. 2. Trends in Malnutrition inTanzania Blandina Kilama and Wietze Lindeboom 3. The benefitsof malnutrition interventions:empiricalevidenceand lessons to Tanzania Adolf Mkenda 4. ReducingChild Malnutrition in Tanzania: CombinedEffectsof IncomeGrowth andProgramInterventions HaroldAlderman, Johannes Hoogeveenand Mariacristina Rossi 5. PreschoolNutrition and Subsequent SchoolingAttainment: Longitudinal Evidencefrom Tanzania HaroldAlderman, Johannes Hoogeveenand Mariacristina Rossi 6. Long-termBenefitAnalysis of NutritionProgrammeInterventionsinTanzania Mariacristina Rossi 7. InstitutionalAnalysis of Nutritionin Tanzania Valerie Leach 68 ANNEXB: COMPARING NUTRITION OUTCOMES USING OLDAND NEWREFERENCE GROWTHTABLES. In response to the WHO'S recommendations in 1993 to develop new standards for infant and young child growth, the Multicentre Growth Reference Study (MGRS) was undertaken between 1997 and 2003 to generate new growth standards for assessing the growthand development of infantsandyoung children.The MGRS i s basedon data from six distinct countries (Brazil, Ghana, India, Norway, Oman and the USA). In Africa, the study '' was conducted in Ghana. Compared to the former NCHS/WHO growth standards, the new growth standards describe how all children should growthwhen their needs are met.The new standards make breastfeedin the biological"norm" and establishthe breastfedinfant as the normative growth model. The new growth standards constitute an essential tool to accurately detect growthfaltering inchildrenandto measurethe prevalence of malnutrition. The updated WHONCHS reference growth tables have been released, leading to differences in prevalence rates. Using the old and new growth references tables, the prevalence of stunting and underweight is shown below for the years 1996, 1999 and 2004. The data suggests that using the latest series stunting is a more serious problem -with stuntingrates exceeding 40%, while underweightis less of a problem. Irrespectiveof which reference tables are used, nutrition trends are comparable: Le. no change between 1996 and 1999 and a significantdrop between 1999 and2004. The decline in stunting i s somewhat less ifoneusesthe newreference series. Figure B.l: The prevalenceof under-nutrition (YO)according to old and new growth referencetables Old reference table 50 49 45 22 10 0 T T T T- 1996 1999 2004 1996 1999 2004 Stunting Underweight Source: Author's calculations usingvarious DHSes A noteworthy difference between usingthe old and the new series is that at an early age more children are underweight.This is illustratedbelow for the fraction of childrenthat are stunted. The difference disappears with age and by the age of 5 there is no discernable differencein rates o f stuntingdependingon the measure used. l 9The new tables are published inActa Paediatrica,International Journalof Paediatrics-WHO Child Growth Standards, Volume 95, April 2006, Supplement 450 69 Inthe analysis presented in this report the old reference tables are used as this is the way in which the official numbers are currently calculated in Tanzania. Certain analyses in this report-such as the regression reported in chapter 3, were done using both old and new indicators, to verify whether the choice o f indicator matters for results. This was found not to be the case Figure B.2: Fractionof stunted childrenby age for new and old growth referencetables l o 20 40 60 Age in months Stunted, old measures -----Stunted,newmeasures Source: Author's calculations using DHS 2004 70 ANNEXc: MALNUTRITIONINTANZANIAFROMAN INTERNATIONAL PERSPECTIVE Malnutritionis not unique to Tanzania. The maps presentedat the beginning ofthis document demonstrate that the prevalence of underweight and stunting in Tanzania are not amongst the very highest in the world, they fall into the high category. Figure C.1 brings the comparison closer to Tanzania by presentingthe prevalence of under-nutrition in Tanzania along with that in neighboring countries. It suggests that compared to most countries in the region, Tanzania does relatively well in stunting, underweight and wasting. Prevalence rates are at par with those in Uganda, better than those in Rwanda but worse than those inKenya. Figure C.l: Percentageof undernourishedchildren under 5 years in Tanzania and it neighbors L2 e, B! Underweight Wasted 285 0 - 47 49 42 n n 38 39 -41 s 0 (ci 0 e 0 N 8 N N 0 8 N a 5 1- 0 N 0 .- a Y B a' 9.$ Source: DHS country reports. Figure C.2 presents some evidence on micro-nutrients and the prevalence of exclusive breastfeeding for Tanzania and its neighboring countries. In these respects Tanzania's performance is worse than that of its neighbors. For instance, the fraction of households using adequately iodized salt is amongst the lowest in East Africa. The same holds for the fraction of householdsthat practice exclusive breastfeeding. Rwanda is an interestingcase in point as it does well inmost respects. A lessonthat can be drawn from this regional comparison is that there is scope for improvement. Countries at comparable levels of development do considerably better than Tanzania. Muchcan be learnedfrom the effectiveness of iodine provision in Rwanda and Ugandaandthe high prevalenceof exclusive breastfeedingin Rwanda. 71 Figure C.2: Nutrition related factors for relevant for children aged five and less in East Africa Source: DHS country reports. 72 ANNEX D: UNDER-NUTRITION AND HIV/AIDS It is estimated that 7.7% of women and 6.3% of men aged 15-49 years are infected with HIV, yielding a nationalaverage of 7.0% (DHS 2004). An increasingbody o f evidence has accumulated over the past several years on the links between HIV/AIDS and under- nutrition. Both HIV and under-nutritionnegatively affect the immune system and increase the susceptibility to infections which often lower food intake as well as absorption. This, coupled with 10%-30% increased energy requirementof people living with HIVIAIDS (for HIV infectedchildrenexperiencingweight loss energy needs increase by 50-100%) results in further under-nutrition (WHO 2003). For the same reason, HIV infected pregnant women gain less weight and experience more frequent vitamin and mineral deficiencies. Good nutritionenables HIV infectedchildrento regainlost weight after opportunistic infectionand HIV infected mothers during pregnancy and lactation to improve birth outcomes. Furthermore, adequate nutrition is necessary to maximizethe benefitsof ARV, by increasing the responsiveness of treatment and reduce the side-effects that come with compromised immune system. An issue requiring attention is how to balance the well known benefits of breastfeeding and the risk ofHIV transmissionthrough breastfeeding-a risk that is highand constant throughout the breastfeeding period.The dilemma is that switchingto replacement feedingmeans childrenmiss out on the immunitytransmittedthroughbreast milk and so are more susceptible to death or malnutrition from other diseases. The situation is further complicatedby the fact that most women in resource-poor settings do not know their HIV status, and there is still uncertainty about the risks associated with different feeding alternatives (such as increased diarrheal disease, stigma associated with not breastfeeding, and spillover effects of formula feedingto mothers who are not HIV -positive). Furthermore, even women who know their status and choose alternative feeding often fall in the trap of mixed feeding (breastfeedingmixed with alternative milks), an option shown to carry the highest risk of transmission. This default to mixed feeding is usually driven by cultural factors, social stigma, or the unavailability of or infeasibility of using breast milk on a continuous daily basis in hot, humid, resource-poor environments. Recent findings on the lower risks of transmissionthrough exclusive breastfeeding, compared with mixed feeding, warrant the promotion of exclusive breastfeeding until further evidence is available (World Bank 2006, WHO 2006). 73 ANNEX E: EXCLUSIVE BREASTFEEDING? UNICEF and WHO recommendthat childrenbe exclusively breastfed (no other liquid, solid food, or plain water) during the first six months of life (World Health Assembly, 2001 cited in DHS 2005). Reasons for this include that introducing breast milk substitutes to infants before six months can contribute to breastfeedingfailure andthat substitutes are often watered down and provide too few calories. Possible contamination of these substitutes is another reason for the guideline. To establish the beneficial effect of exclusive breastfeeding on a child's development, weight of children up to 6 months of age was regressedon a number of control variables, age and an interaction term of age with and whether the child is exclusively breast fed. If exclusive breast feeding has a positive effect on nutritional status, this interaction term is expected to be positive. Weight was the preferred dependent variable as other nutritional measureswere consideredtoo inaccurate for childrenofthis age. The remarkable finding is that exclusive breastfeedingdoes not have a significant effect during the first two months of life and a significant negative impact during months 3 and 4. The impact for month 5 is insignificant-possibly due to the small number of observations.As only 2 children aged 6 months were exclusively breast fed, this variable was dropped from the regression. Various variants of the regression were tried, including using an indicator variable for underweight, and with different control variables including access to safe water, diarrhea or without the control for birth weight. The absence of a positive impact of exclusive breast feeding heldthroughout. Table E.l. OLS regression on weight for children aged 0-6 months Coefficient T-stat Household size -0.077 -1.0 Dependency ratio -0.662 -1.1 D-femalehead 2.745 2.5 ** Age of mother 0.057 1.o Years o feducation ofmother 0.142 1.3 D-male 3.594 4.8 *** D-twin -4.602 -2.4 ** D-aged 1month & exclusive breast feeding 2.026 1.1 D-aged2 months & exclusive breast feeding -1.661 -0.9 D-aged 3 months & exclusive breast feeding -4.733 -1.8 D-aged4 months & exclusive breast feeding -6.513 -2.1 *** D-aged 5 months & exclusive breast feeding -4.636 -1.1 D-aged 1month 5.415 3.0 *** *** D-aged2 months 18.085 12.4 D-aged3 months 26.538 18.8 *** D-aged4 months 31.472 21.9 *** D-aged 5 months 35.174 22.8 *** D-aged 6 months 37.365 26.1 *** *** Birthweight inkilograms 6.749 8.4 Constant 10.138 3.1 *** Source: Author's calculations using DHS2004. 74 ANNEXF:OBJECTIVESOF THE YOUTHAND CHILDDEVELOPMENT PROGRAM The Youth and Child Development Programhas 3 overarching outcomes, the pilot has 16 objectives and 13 sub-objectives. A. DiseasePrevention and HealthPromotionaims at developing: 1. more targeted and focused householdvisits for C-IMCI addressingmost vulnerable children under 5 years; 2. extension of householddialogue aroundchild care practicesto include group dialogue; 3. strengthenedEPI surveillance systems and 4. integration of birth registration. 5. Under the Water, Sanitation and Hygiene it will also support a. community managementand maintenanceof water supply and sanitation facilities, b. sanitation marketing and c. promotion of appropriatehand-washingand hygiene behaviors. B. Safe Motherhood and Newborn Health includes strengtheningcontinuum of care for mothers and infants by improving: 6. access to, quality of and linkages betweenfacility and community-based antenatal, delivery and post-natal services; 7. basic emergency obstetrical care, 8. promotion of health facility deliveries, 9. safe home deliveries, 10. Facility IMCIand post-natal outreach services , 11. Adaptation of Community IMCIto incorporatehome-basednewborn care. To this end Community PMTCT services will be integratedto promote d. early antenatalattendance and male involvement, e. increaseuptake of counselingand f. testing by mother and partner, g. improve tracking and follow-up, and h. utilize lay counselorsand community groups. 75 12.PaediatricAIDS by: i. testing,improvingaccesstopaediatricARVsandprophylaxisand j. improving linkagesbetweenPMTCTandMaternal andChildhealth services, k. PMTCT and Care andTreatment Centresand Care andTreatment serviceswith Home BasedCare and 1. provisions for orphans and vulnerable children. C. Nutrition and Early Child Developmentincludes: 13. strengthening district and community capacitiesfor delivery of comprehensive nutrition interventions integratedwith healthand early child development interventions, 14. strengtheningcapacities of service providers, communities and families to manage and implement community nutrition interventions as part of a minimum integrated package of services for scalingup. 15. combining parenting educationfor early stimulation and 16. developing affordable group childcare options that integrate early learning, nutrition and healthinterventions while freeing women to engage inwork. 76 ANNEXG: ONPILOTS Pilot interventions will be neededto identify, test and adapt new interventions. When designing pilots, they should be FIRST. Focused, International best practice, Realistic, Scalable and Tested. Focused. The ultimate objective o f pilots i s to show impact so that they can be scaled up. It requires (i)establishing "success" and (ii)an intervention package that can be brought to scale. Both requirements make it necessary not to overload a pilot. Christmas tree type approaches (see annex F.) are bound to be unsuccessful as testing can only be done on clearly defined interventions while complex design makes it hard to arrive at a package that can be replicated. International best practice. Nutrition is an active field. New results are published on a continuous basis and innovative approaches tested and documented. During its design, pilots should benefit from this pool o f global knowledge, identify interventions that have worked elsewhere and focus on adaptingthem to national circumstances. Realistic.With sufficient resources, human, financial or organizational, results are almost assured. In practice resources are scarce and a pilot needs to be aware o f this reality. The closer a pilot resembles true circumstances (limited financial resources, implementation through local authorities, partially informed or motivated staff) the more trustworthy will be its results. With the benefit o f hindsight the Iringa program is an illustration o f an unrealistic program. The program managed to achieve impressive results due to, in part, huge inflows of human and financial resources and organizational talent. Butthe program could never been brought to scale in a satisfactory manner and was too expensive to be sustained, even in Iringaalone. Scalable. Pilots typically will test approaches that, if successful, will be implemented nation wide. Scalability should be o f concern right from the design phase o f the pilot as what works in a small number o f sites may not work when all 12,000 communities in Tanzania need to be reached. The pilot to fortify maize through hammer mills in Iringa, Handeni and Korogwe presents an approach that is likely to achieve results but which cannot be scaled up. Already TFNC is facing serious challenges in reaching the 6,000 odd small salt producers for its iodine supplementation program. In the absence o f a solution to reach the small salt producers, it is unclear how an ever more ambitious program o f reaching all hammer mills can be successful. Tested. To establish whether results are achieved, pilots need to invest in monitoring and evaluation. The gold standard i s one where a baseline i s carried out before the pilot is implemented, where the pilot is executed in a randomly selected number o f communities, leaving other baseline communities as control group. To allow proper testing and comparisons across different approaches, the pilot needs to implement one intervention per (group of) communities. 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