D I R E C T I O N S I N D E V E L O P M E N T D I R E C T I O N S I N D E V E L O P M E N T 34775 Repositioning Nutrition as Central to Development A Strategy for Large-Scale Action D I R E C T I O N S I N D E V E L O P M E N T Repositioning Nutrition as Central to Development A Strategy for Large-Scale Action THE WORLD BANK © 2006 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 USA Telephone 202-473-1000 Internet www.worldbank.org E-mail feedback@worldbank.org All rights reserved First printing 1 2 3 4 09 08 07 06 The findings, interpretations, and conclusions expressed here are those of the authors and do not necessarily reflect the views of the Board of Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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Cover design by Fletcher Design Cover photos by World Bank ISBN-10: 0-8213-6399-9 ISBN-13: 978-0-8213-6399-7 eISBN-10: 0-8213-6400-6 eISBN-13: 978-0-8213-6400-0 DOI: 10.1596-978-0-8213-6399-7 Library of Congress Cataloging-in-Publication Data has been applied for. For additional information, contact Meera Shekar, HDNHE, World Bank Contents Foreword ix Acknowledgments xii Acronyms and Abbreviations xiv Glossary xvii Overview 1 Three Reasons for Intervening to Reduce Malnutrition 1 What Causes Malnutrition and How Should Governments Intervene? 10 Next Steps 17 Notes 19 1 Why Invest in Nutrition? 21 Nutrition and Economics 21 Nutrition and the Millenium Development Goals 34 Nutrition and Human Rights 37 The Know-How for Improving Nutrition 37 Notes 40 2 How Serious Is Malnutrition and Why Does It Happen? 42 Undernutrition 43 Low Birthweight 46 Obesity and Diet-Related Noncommunicable Diseases 49 Micronutrient Malnutrition 52 What Causes Malnutrition, and Who Is Worst Affected? 53 Notes 61 3 Routes to Better Nutrition 62 Long and Short Routes to Better Nutrition 63 Community-Based Growth Promotion Programs 65 Low-Birthweight Prevention Programs 69 iii iv REPOSITIONING NUTRITION Micronutrient Programs 71 Food and Social Protection Programs 74 Malnutrition and HIV/AIDS Programs 77 Programs to Tackle Overweight and Diet-Related Noncommunicable Diseases 82 The Role of Policy 85 Intentional and Unintentional Nutrition Policies 90 Notes 93 4 Getting to Scale 95 Managing Nutrition Programs 95 Organizing Services 98 Channeling Finance and Coordinating Financiers 101 Strengthening Commitment and Capacity 107 Notes 111 5 Accelerating Progress in Nutrition: Next Steps 113 Uniting Development Partners around a Common Nutrition Agenda 114 Three Key Operational Challenges to Scaling Up 117 Where to Focus Actions against Malnutrition 122 Supporting a Focused Action Research Agenda in Nutrition 126 The Gaps between Identified Needs and Development Partners' Focus 128 Next Steps 129 Notes 131 Annex 1 : Country Experience with Short Routes to Improving Nutrition 132 Annex 2: Long Routes to Improving Nutrition 136 Annex 3: Key Priorities for Action Research in Nutrition: A Proposal 140 Technical Annexes 145 References 219 Index 239 Tables 1.1 The benefit-cost ratios for nutrition programs 27 1.2 Annual unit costs of nutrition programs 28 1.3 Cost of nutrition interventions ($) 29 1.4 Reduction of the fraction of children underweight in Tanzania under different income growth and nutrition intervention coverage scenarios (%) 31 CONTENTS v 1.5 Prevalence of underweight and anemia in Indian children by income quintiles 33 1.6 How investing in nutrition is critical to achieving the MDGs 38 1.7 The Copenhagen Consensus ranks the provision of micronutrients as a top investment 39 1.8 Coverage of nutrition interventions in some large-scale programs 39 3.1 Routes to better nutrition 64 3.2 The range of interventions for obesity programs 84 3.3 Examples of unintentional nutrition policies 91 5.1 Suggested priorities for action research in nutrition 127 Figures 1.1 The vicious cycle of poverty and malnutrition 23 1.2 The income­malnutrition relationship 29 1.3 Estimated reduction of underweight prevalence at different economic growth and income-nutrition elasticity scenarios 30 1.4 Progress toward the nonincome poverty target 35 1.5 Progress toward the nonincome poverty target (nutrition MDG) 36 2.1 Prevalence of and trends in malnutrition among children under age five, 1980­2005 45 2.2 Projected trends in numbers of underweight children under age five, 1990­2015 46 2.3 Prevalence and number of low-birthweight infants 47 2.4 Trends in obesity among children under age five 50 2.5 Maternal and child overweight 50 2.6 Maternal overweight versus maternal and child undernutrition 51 2.7 Coexistence of energy deficiency and obesity in low- and middle-income countries 51 2.8 Prevalence of subclinical vitamin A deficiency in children age 0­72 months, by region, 1990­2000 52 2.9 Prevalence of iron deficiency in preschool children, by region, 1990­2000 53 2.10Prevalence of underweight children by per capita dietary energy supply, by region, 1970­96 54 2.11 Prevalence of overweight among children under age five, by age group 56 2.12Underweight prevalence and rates of decline in World Bank regions and countries 58 3.1 How malnutrition and HIV/AIDS interact 78 5.1 Principal development partners supporting nutrition 114 5.2 Typology and magnitude of malnutrition in World Bank regions and countries 125 vi REPOSITIONING NUTRITION Boxes 1.1 Off track on the Millennium Development Goals 34 2.1 Undernutrition prevalence in South Asian countries is much higher than in Africa 44 2.2 The window of opportunity for addressing undernutrition 55 2.3 Three myths about nutrition 57 3.1 Why malnutrition persists in many food-secure households 65 3.2 Food security versus nutrition security? 66 3.3 Ensuring that new behavioral practices make sense for poor people 68 3.4 Food subsidies versus targeted social safety net programs 74 3.5 Evidence that conditional transfer programs can work 76 3.6 Summary findings of scientific review on nutrition and HIV/AIDS 79 3.7 The role of public policy 86 3.8 Impact of agricultural and food policies on nutrition and health 90 4.1 How Thailand managed its National Nutrition Program 97 4.2 Assessment, analysis, and action: The "Triple A" process 100 4.3 Institutionalizing nutrition in Bangladesh: From project to program 103 4.4 Five steps toward integrating nutrition in country PRSPs 106 4.5 Ten reasons for weak commitment to nutrition programs 108 4.6 PROFILES 109 5.1 Lessons for nutrition from HIV/AIDS 116 5.2 What to do when 119 Maps 1.1 Global prevalence of underweight among children under age five 1.2 Global prevalence of stunting among children under age five 1.3 Global prevalence of vitamin A deficiency and supplementation coverage rates 1.4 Global prevalence of iodine deficiency disorders and iodized salt coverage rates "Nearly 4 million people die prematurely in India every year from malnutrition and related problems. That's more than the number who perished during the entire Bengal famine." --Amartya Sen and Jean Dreze, Hunger and Public Action, 1989 "The portion of the global burden of disease (mortality and morbidity, 1990 figures) in developing countries that would be removed by elimi- nating malnutrition is estimated as 32 percent. This includes the effects of malnutrition on the most vulnerable groups' burden of mor- tality and morbidity from infectious diseases only. This is therefore a conservative figure..." --John Mason, Philip Musgrove, and Jean-Pierre Habicht, 2003 "... investments in micronutrients have higher returns than those from investments in trade liberalization, in malaria, or in water and sanita- tion.... No other technology offers as large an opportunity to improve lives at such low cost and in such a short time." --Copenhagen Consensus, 2004 "Micronutrient deficiencies alone may cost India US$2.5 billion annu- ally and the productivity losses (manual work only) from stunting, iodine deficiency, and iron deficiency together are responsible for a total loss of 2.95 percent of GDP." --S. Horton, 1999 "Noncommunicable diseases account for almost 60 percent of the 56 million deaths annually and 47 percent of the global burden of dis- ease...the burden of mortality, morbidity, and disability attributable to noncommunicable diseases is currently greatest and continuing to grow in the developing countries, where 66 percent of these deaths occur... the most important risks included high blood pressure, high concentrations of cholesterol in the blood, inadequate intake of fruits and vegetables, overweight or obesity, and physical inactivity that are closely related to diet and physical activity." --WHO, 2004 vii "By 2002, only East Asia and Pacific and Latin America and the Caribbean had fewer undernourished people than 10 years earlier." --World Bank, 2005a "Sub-Saharan Africa is not on track to achieve a single MDG. ... it is off track on the hunger goal--and is the only region where child mal- nutrition is not declining.... And while malnutrition in the (South Asia) region is dropping sufficiently to achieve the MDG target reduc- tion, it remains at very high absolute levels: almost half of children under five are underweight." --World Bank, 2005b "A hungry person is an angry and dangerous person. It is in all our interests to take away the cause of this anger." --President Olusegun Obasanjo of Nigeria, The Guardian, June 23, 2005 (UK) viii Foreword Malnutrition remains the world's most serious health problem and the single biggest contributor to child mortality. Nearly one-third of children in the developing world are either underweight or stunted, and more than 30 percent of the developing world's population suffers from micronutri- ent deficiencies. Unless policies and priorities are changed, the scale of the problem will prevent many countries from achieving the Millennium Development Goals (MDGs)--especially in Sub-Saharan Africa, where mal- nutrition is increasing, and in South Asia, where malnutrition is widespread and improving only slowly. There are also new dimensions to the malnutrition problem. The epi- demic of obesity and diet-related noncommunicable diseases (NCDs) in developed countries is spreading to the developing world. Many poorer countries are now beginning to suffer from a double burden of undernu- trition and obesity. This phenomenon, which some have termed the "nutri- tion transition," means that those national health systems now have to cope with the high cost of treating diet-related NCDs at the same time they are fighting undernutrition and the traditional, communicable diseases. Malnutrition is also linked to the growing HIV/AIDS pandemic; malnu- trition makes adults more susceptible to the virus, inadequate infant feed- ing aggravates its transmission from mother to child; and evidence suggests that malnutrition makes antiretroviral drugs less effective. Two developments, one negative and one positive, have led to this report at this juncture. The first is the growing international awareness that many MDGs will not be reached unless malnutrition is tackled, and that this con- tinued failure of the development community to tackle malnutrition may derail other international efforts in health and in poverty reduction. The second development is the now unequivocal evidence that there are work- able solutions to the malnutrition problem and that they are excellent eco- nomic investments. The May 2004 Copenhagen Consensus of eminent economists (including several Nobel laureates) concluded that the returns of investing in micronutrient programs are second only to the returns of ix x REPOSITIONING NUTRITION fighting HIV/AIDS among a lengthy list of ways to meet the world's devel- opment challenges. Other nutrition-related interventions placed within the top dozen proposals. There is also clear evidence that the major damage caused by malnutri- tion takes place in the womb and during the first two years of life; that this damage is irreversible; that it causes lower intelligence and reduced phys- ical capacity, which in turn reduce productivity, slow economic growth, and perpetuate poverty; and that malnutrition passes from generation to generation because stunted mothers are more likely to have underweight children. This report sends the message that, to break this cycle, the focus must be on preventing and treating malnutrition among pregnant women and children aged zero to two years. School feeding programs--often sold as nutrition interventions--may help get children into school and keep them there, but such programs do not attack the malnutrition problem at its roots. This report argues that there are long and short routes to improving nutrition. Higher incomes and better food security improve nutrition over the longer term, but malnutrition is not simply the result of food insecu- rity: many children in food-secure environments are underweight or stunted because of inappropriate infant feeding and care practices, poor access to health services, or poor sanitation. Much more attention therefore needs to be given to shorter routes to better nutrition--providing health and nutri- tion education and micronutrient fortification and supplementation. In addition, more attention needs to be directed to gender issues such as pregnant women's care of themselves and their children. Conditional cash transfers, when coupled with improvements in service quality and access, are a good way to get poor people to use nutrition services. This report provides a framework to help countries decide what nutrition actions are appropriate under different circumstances. It also presents epidemio- logical data in a user-friendly way to help development partners prioritize countries for support, though it emphasizes that country commitment and capacity--as well as need--should determine investment priorities. Improving nutrition is not just about investing more. Equally important are conducting sound policy analysis, ensuring that nutrition policies are linked to nutrition action, and developing the appropriate capacity and institutional arrangements to manage nutrition programs. Strengthening commitment to tackling malnutrition and forging new partnerships to do so are critical to making progress--partnerships between governments, communities, and nongovernmental organizations; between governments and the development partner community; and between governments and the corporate sector, whose role in fortifying food and in taking responsi- bility for the nutritional content of snacks and fast food will be central. FOREWORD xi Putting an end to extreme malnutrition will lay the foundation for improving the health and well-being of the present generation and lead to benefits for future generations over the 21st century. Nutrition is the true foundation of sustainable poverty reduction, yet it is still neglected. It is time to spread a broader awareness of the worldwide challenges of nutri- tion--and its links with health and sustainable development--and of the new opportunities for making global progress. This report is written primarily for the community of international devel- opment partners, as well as those in government and civil society con- cerned with action to improve nutrition. It provides a global framework for action and complements similar analyses undertaken by the World Bank's regional units for Africa and South Asia. It is hoped that the report will reinvigorate dialogue regarding what to do about malnutrition; that it will encourage the development community to reevaluate the priority it gives nutrition; and that it will result in agreement on new ways for stake- holders to work together and in a new global commitment to scaling up proven interventions for tackling malnutrition. As the Bank gears up to move nutrition higher on the development agenda, this report allows us to underline the importance of investing in nutrition. Jacques Baudouy Jean-Louis Sarbib Director, Health, Nutrition, and Senior Vice President Population Human Development Network Human Development Network Acknowledgments This document was produced by a team led by Meera Shekar, with Richard Heaver and Yi-Kyoung Lee. Milla McLachlan led the concept review process. Substantive inputs were provided by Judith McGuire and Savitha Subramanian. Kei Kawabata (sector manager of Health, Nutrition, and Population) provided valuable guidance and support throughout the devel- opment of the report. The authors are grateful to Jean-Louis Sarbib, senior vice president of the World Bank's Human Development Network, and Jacques Baudouy, director of Health, Nutrition, and Population for their strategic support in repositioning the nutrition agenda in the World Bank. Detailed peer review comments were provided on various versions of the report by Jere Behrman (University of Pennsylvania), Alan Berg, Venkatesh Mannar (Micronutrient Initiative), David Pelletier (Cornell University), Ellen Piwoz (Academy for Educational Development/Linkages), and Richard Skolnik (U.S. President's Emergency Fund for AIDS Relief), as well as Harold Alderman, Shanta Devarajan, John Fiedler, Paul Gertler, Michele Gragnolati, Keith Hansen, Kees Kostermans, Kathy Lindert, Claudia Rokx, Richard Seifman, and Susan Stout from the World Bank. Several other colleagues attended review meetings and provided addi- tional input and feedback during development of the report: Catherine Le Galès Camus (World Health Organization), Denise Coitinho (WHO), Frances Davidson (USAID), Stuart Gillespie (IFPRI), Marcia Griffiths (The Manoff Group), Rainer Gross (UNICEF), Jean-Pierre Habicht (Cornell University), Lawrence Haddad (Institute for Development Studies), Carol Marshall (Micronutrient Initiative), Roger Shrimpton (UN Standing Committee on Nutrition), and Lisa Studdert (Asian Development Bank), as well as Anabela Abreu, Jock Anderson, Lynn Brown, Barbara Bruns, Derek Byerlee, Mariam Claeson, Carlo Del Ninno, Jed Friedman, Rae Galloway, Charles Griffin, Pablo Gottret, Sabrina Huffman, Emmanuel Jimenez, Lucia Kossarova, Antonio Lim, Akiko Maeda, Tawhid Nawaz, Willyanne Del Cormier Plosby, Meera Priyadarshi, Julian Schweitzer, xii ACKNOWLEDGMENTS xiii Suneeta Singh, Kimberly Switlick, Chris Walker, and Evangeline Javier from the World Bank. The report was edited by Bruce Ross-Larsen and his team at Communications Development, Inc. Consultations with development partners provided guidance for the report. Additional consultations are planned in 2006. The work was supported in part by a generous contribution from the Government of the Netherlands through the Bank-Netherlands Partnership Program grant to the World Bank. Acronyms and Abbreviations ADB Asian Development Bank AED Academy for Educational Development AFR Africa Region AIN-C Atención Integral a la Niñez-Comunitaria BASICS Basic Support for Institutionalizing Child Survival BINP Bangladesh Integrated Nutrition Project BMI body mass index BRAC Bangladesh Rural Advancement Committee CDD community-driven development CGIAR Consultative Group on International Agricultural Research CIDA Canadian International Development Agency DALY disability-adjusted life years DANIDA Danish International Development Agency DFID U.K. Department for International Development DGF Development Grant Facility (World Bank) DMC developing member country EAP East Asia and the Pacific EBF exclusive breastfeeding EC European Commission ECA Eastern Europe and Central Asia ECD early childhood development ENA Essential Nutrition Actions ESHE Ethiopia Child Survival and Systems Strengthening Project EU European Union FAD Food Aid for Development FANTA Food and Nutrition Technical Assistance Project (USAID) FAO Food and Agricultural Organization (of the UN) FFI Fresh Food Initiative GAIN Global Alliance for Improving Nutrition GDP gross domestic product GMP Growth, Monitoring, and Promotion GNI gross national income xiv ACRONYMS AND ABBREVIATIONS xv GNP gross national product GTZ German Agency for Technical Assistance HKI Hellen Keller International HNP Health, Nutrition, and Population (World Bank) HNPSP Health, Nutrition, and Population Sector Program HSD Health systems development ICDDR,B International Centre for Diarrhoeal Disease Research, Bangladesh ICDS Integrated Child Development Services Program (India) ICN International Conference on Nutrition IDA iron deficiency anemia IDD iodine deficiency disorders IEC Information, Education, and Communication IFAD International Fund for Agricultural Development IFPRI International Food Policy Research Institute IMCI Integrated Management of Childhood Illnesses JICA Japanese International Co-operation Agency KfW German Development Bank LAC Latin America and the Caribbean LDC less developed country MAP Multicountry AIDS project M&E monitoring and evaluation MDG Millennium Development Goal MENA Middle East and North Africa MI Micronutrient Initiative NCDs noncommunicable diseases NEPAD New Partnership for Africa's Development NESDB National Economic and Social Development Board (Thailand) NFA National Food Authority NGO nongovernmental organizations NHD Nutrition for Health and Development NID National Immunization Day OECD Organisation for Economic Co-operation and Development PEM protein-energy malnutrition PEPFAR President's Emergency Plan for AIDS Relief PRSCs Poverty Reduction Strategy Credits PRSPs Poverty Reduction Strategy Papers PSIA Poverty and Social Impact Analysis RENEWAL Regional Network on HIV/AIDS, Rural Livelihoods, and Food Security SAR South Asia Region SARA Support for Analysis and Research in Africa xvi REPOSITIONING NUTRITION SCN Standing Committee on Nutrition SIDA Swedish International Development Agency SWAP sectorwide approach TINP Tamil Nadu Integrated Nutrition Project TIPs trials of improved practices (USAID) UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund USAID United States Agency for International Development VAD vitamin A deficiency WABA World Alliance for Breastfeeding Action WFP World Food Program WFS World Food Summit WHO World Health Organization All dollar amounts are U.S. dollars unless otherwise indicated. Glossary Anemia Low level of hemoglobin in the blood, as evidenced by a reduced quality or quantity of red blood cells; 50 percent of anemia worldwide is caused by iron deficiency. Body mass index Body weight in kilograms divided by height in (BMI) meters squared (kg/m2). This is used as an index of "fatness." Both high BMI (overweight, BMI greater than 25) and low BMI (thinness, BMI less than 18.5) are considered inadequate. Iodine deficiency All of the ill effects of iodine deficiency in a pop- disorders (IDDs) ulation that can be prevented by ensuring that the population has an adequate intake of iodine. The spectrum of IDD includes goiter, hypothyroidism, impaired mental function, stillbirths, abortions, congenital anomalies, and neurological cretinism. Low birthweight Birthweight less than 2,500 grams. Malnutrition Various forms of poor nutrition caused by a com- plex array of factors including dietary inadequacy, infections, and sociocultural factors. Underweight or stunting and overweight, as well as micro- nutrient deficiencies, are forms of malnutrition. Obesity Excessive body fat content; commonly measured by BMI. The international reference for classifying an individual as obese is a BMI greater than 30. xvii xviii REPOSITIONING NUTRITION Overweight Excess weight relative to height; commonly mea- sured by BMI among adults (see above). The inter- national reference for adults is as follows: · 25­29.99 for grade I (overweight). · 30­39.99 for grade II (obese). · > 40 for grade III. For children, overweight is measured as weight- for-height two z-scores above the international reference. Stunting Failure to reach linear growth potential because (measured as of inadequate nutrition or poor health. It implies height-for-age ) long-term undernutrition and poor health, mea- sured as height-for-age two z-scores below the international reference. Usually a good indicator of long-term undernutrition among young chil- dren. For children under 12 months, recumbent length is used instead of height. Undernutrition Poor nutrition: It may occur in association with infection. Three most commonly used indexes for child undernutrition are height-for-age, weight- for-age, and weight-for-height. For adults, under- nutrition is measured by a BMI less than 18.5. Underweight Low weight-for-age; that is, two z-scores below the international reference for weight-for-age. It implies stunting or wasting and is an indicator of undernutrition. Vitamin A deficiency Tissue concentrations of vitamin A low enough to have adverse health consequences such as increased morbidity and mortality, poor repro- ductive health, and slowed growth and develop- ment, even if there is no clinical deficiency. GLOSSARY xix Wasting Weight (in kilograms) divided by height (in meters (measured by squared) that is two z-scores below the inter- weight-for-height) national reference. It describes a recent or current severe process leading to significant weight loss, usually a consequence of acute starvation or severe disease. Commonly used as an indicator of under- nutrition among children; especially useful in emergency situations such as famine. z-score The deviation of an individual's value from the median value of a reference population, divided by the standard deviation of the reference population. Overview It has long been known that malnutrition undermines economic growth and perpetuates poverty. Yet the international community and most gov- ernments in developing countries have failed to tackle malnutrition over the past decades, even though well-tested approaches for doing so exist. The consequences of this failure to act are now evident in the world's inade- quate progress toward the Millennium Development Goals (MDGs) and toward poverty reduction more generally. Persistent malnutrition is con- tributing not only to widespread failure to meet the first MDG--to halve poverty and hunger--but to meet other goals in maternal and child health, HIV/AIDS, education, and gender equity. The unequivocal choice now is between continuing to fail, as the global community did with HIV/AIDS for more than a decade, or to finally make nutrition central to development so that a wide range of economic and social improvements that depend on nutrition can be realized. Three Reasons for Intervening to Reduce Malnutrition High economic returns; high impact on economic growth and poverty reduction The returns to investing in nutrition are very high. The Copenhagen Consensus concluded that nutrition interventions generate returns among the highest of 17 potential development investments (table 1). Investments in micronutrients were rated above those in trade liberalization, malaria, and water and sanitation. Community-based programs targeted to children under two years of age are also cost-effective in preventing undernutrition. Overall, the benefit-cost ratios for nutrition interventions range between 5 and 200 (table 2). Malnutrition slows economic growth and perpetuates poverty through three routes--direct losses in productivity from poor physical status; indi- rect losses from poor cognitive function and deficits in schooling; and losses 1 2 REPOSITIONING NUTRITION Table 1 The Copenhagen Consensus ranks the provision of micronutrients as a top investment Rating Challenge Opportunity Very good 1. Diseases Controlling HIV/AIDS 2. Malnutrition and hunger Providing micronutrients 3. Subsidies and trade Liberalizing trade 4. Diseases Controlling malaria Good 5. Malnutrition and hunger Developing new agricultural technologies 6. Sanitation and water Developing small-scale water technologies 7. Sanitation and water Implementing community- managed systems 8. Sanitation and water Conducting research on water in agriculture 9. Government Lowering costs of new business Fair 10. Migration Lowering barriers to migration 11. Malnutrition and hunger Improving infant and child malnutrition 12. Diseases Scaling up basic health services 13. Malnutrition and hunger Reducing the prevalence of low birthweight Poor 14­17. Climate/migration Various Source: Bhagwati and others (2004). owing to increased health care costs. Malnutrition's economic costs are sub- stantial: productivity losses to individuals are estimated at more than 10 percent of lifetime earnings, and gross domestic product (GDP) lost to mal- nutrition runs as high as 2 to 3 percent. Improving nutrition is therefore as much--or more--of an issue of economics as one of welfare, social pro- tection, and human rights. Reducing undernutrition and micronutrient malnutrition directly reduces poverty, in the broad definition that includes human development and human capital formation. But undernutrition is also strongly linked to income poverty. The prevalence of malnutrition is often two or three times-- sometimes many times--higher among the poorest income quintile than among the highest quintile. This means that improving nutrition is a pro- poor strategy, disproportionately increasing the income-earning potential of the poor. OVERVIEW 3 Table 2 The benefit-cost ratios for nutrition programs Intervention programs Benefit-cost Breastfeeding promotion in hospitals 5­67 Integrated child care programs 9­16 Iodine supplementation (women) 15­520 Vitamin A supplementation (children < 6 years) 4­43 Iron fortification (per capita) 176­200 Iron supplementation (per pregnant women) 6­14 Source: Behrman, Alderman, and Hoddinott (2004). Improving nutrition is essential to reduce extreme poverty. Recognition of this requirement is evident in the definition of the first MDG, which aims to eradicate extreme poverty and hunger. The two targets are to halve, between 1990 and 2015: · The proportion of people whose income is less than $1 a day. · The proportion of people who suffer from hunger (as measured by the percentage of children under five who are underweight). The first target refers to income poverty; the second addresses nonincome poverty. The key indicator used for measuring progress on the nonincome poverty goal is the prevalence of underweight children (under age five).Therefore, improving nutrition is in itself an MDG target. Yet most assessments of progress toward the MDGs have focused primarily on the income poverty target, and the prognosis in general is that most countries are on track for achieving the poverty goal. But of 143 countries, only 34 (24 percent) are on track to achieve the nonincome target (nutrition MDG) (figure 1). No country in South Asia, where undernutrition is the highest, will achieve the MDG--though Bangladesh will come close to achieving it, and Asia as a whole will achieve it. More alarmingly still, nutrition status is actually deteriorating in 26 countries, many of them in Africa, where the nexus between HIV and undernutrition is particularly strong and mutually rein- forcing. And in 57 countries, no trend data are available to tell whether progress is being made. A renewed focus on this nonincome poverty target is clearly central to any poverty reduction efforts. The alarming shape and scale of the malnutrition problem Malnutrition is now a problem in both poor and rich countries, with the poorest people in both sets of countries affected most. In developed coun- tries, obesity is rapidly becoming more widespread, especially among 4 REPOSITIONING NUTRITION Figure 1 Progress toward the nonincome poverty target On track (24%) Deteriorating status (18%) AFR (7) LAC (10) AFR (13) ECA (4) Angola Bolivia Niger Albania Benin Chile Burkina Faso Azerbaijan Botswana Colombia Cameroon Russian Federation Chad Dominican Rep. Comoros Serbia and Montenegro Gambia, The Guyana Ethiopia Mauritania Haiti Guinea LAC (3) Zimbabwe Jamaica Lesotho Argentina Mexico Mali Costa Rica EAP (5) Peru Senegal* Panama China Venezuela, R.B. de Sudan Indonesia Tanzania* MENA (2) Malaysia MENA (6) Togo Iraq Thailand Algeria Zambia Yemen, Rep. of Vietnam Egypt, Arab Rep. of Iran, Islamic EAP (2) SAR (2) ECA (6) Rep. of Jordan Mongolia Maldives Armenia Syrian Arab Rep. Myanmar Nepal Croatia Tunisia Kazakhstan Kyrgyz Rep. SAR (0) No trend data available (40%) Romania Turkey AFR (13) Georgia Burundi Hungary Cape Verde Latvia Some improvement, but not on track Congo, Rep. of Lithuania Equatorial Guinea Macedonia, FYR AFR (14) Guinea Moldova Central African Rep. ECA (0) Guinea-Bissau Poland Congo, DR Liberia Slovak Republic Côte d'Ivoire LAC (4) Mauritius Tajikistan Eritrea El Salvador Namibia Turkmenistan Gabon Guatemala Sâo Tomé and Principe Ukraine Ghana Honduras Seychelles Uzbekistan Kenya Nicaragua Somalia Madagascar South Africa LAC (12) Malawi MENA (1) Swaziland Belize Mozambique Morocco Brazil Nigeria EAP (11) Dominica Rwanda SAR (4) Fiji Ecuador Sierra Leone Bangladesh* Kiribati Grenada Uganda India Marshall Is. Paraguay Pakistan Micronesia, Federated St. Kitts and Nevis EAP (5) Sri Lanka States of St. Lucia Cambodia Palau St. Vincent Lao PDR Papua New Guinea Suriname Phillippines Samoa Trinidad and Tobago Solomon Islands Uruguay Timor-Leste Source: Author's calculations. See also Tonga MENA (2) technical annex 5.6. Vanuatu Djibouti Note: All calculations are based on Lebanon ECA (17) 1990­2002 trend data from the WHO Global Belarus SAR (2) Database on Child Growth and Malnutri- Bosnia and Afghanistan tion (as of April 2005). Countries indicated Herzegovina Bhutan by an asterisk subsequently released prelim- Bulgaria Czech Republic inary DHS data that suggest improvement Estonia and therefore may be reclassified when their data are officially released. OVERVIEW 5 Figure 2 Prevalence of and trends in malnutrition among children under age five, 1980­2005 75 Bangladesh 200 India China (%) 60 (million) 160 45 120 children Africa underweight Asia of 30 80 LAC Developing Developed 15 underweight 40 of Prevalence No. 0 0 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 60 250 Africa Asia LAC 50 Developing 200 (%) Developed (million) 40 150 stunting Africa of children 30 100 Asia LAC Developing stunted Developed 20 50 of Prevalence No. 0 0 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 Source: De Onis (2004a); SCN (2004). Note: Estimates are based on WHO regions. Prevalence and numbers also appear in technical annex 2.1. poorer people, bringing with it an epidemic of diet-related noncommuni- cable diseases (NCDs) such as diabetes and heart disease, which increase health care costs and reduce productivity. In developing countries, while widespread undernutrition and micronutrient deficiencies persist, obesity is also fast emerging as a problem. Underweight children and overweight adults are now often found in the same households in both developing and developed countries. Nearly one-third of children in the developing world remain under- weight or stunted, and 30 percent of the developing world's population 6 REPOSITIONING NUTRITION Figure 3 Projected trends in numbers of underweight children under age five, 1990­2015 180 (millions) 1990 150 1995 2000 120 2005 children 2010 90 2015 60 30 underweight 0 of Africa Asia Latin America & Developing Developed the Caribbean countries countries No. Source: De Onis and others (2004a, 2004b). Note: Estimates are based on WHO regions. continues to suffer from micronutrient deficiencies. But the picture is chang- ing (figure 2): · In Sub-Saharan Africa malnutrition is on the rise. Malnutrition and HIV/AIDS reinforce each other, so the success of HIV/AIDS programs in Africa depends in part on paying more attention to nutrition. · In Asia malnutrition is decreasing, but South Asia still has both the high- est rates and the largest numbers of malnourished children. Contrary to common perceptions, undernutrition prevalence rates in the popu- lous South Asian countries--India, Bangladesh, Afghanistan, Pakistan-- are much higher (38 to 51 percent) than those in Sub-Saharan Africa (26 percent). · Even in East Asia, Latin America, and Eastern Europe, many countries have a serious problem of undernutrition or micronutrient malnutri- tion. Examples include Cambodia, Indonesia, Lao PDR, the Philippines, and Vietnam; Guatemala, Haiti, and Honduras; and Uzbekistan. In a recent WHO study (De Onis and others 2004b), underweight preva- lence in developing countries was forecast to decline by 36 percent (from 30 percent in 1990 to 19 percent in 2015)--significantly below the 50 per- cent required to meet the MDG over the same time frame (figure 3).1 These OVERVIEW 7 global data mask interregional differences that are widening disturbingly. Much of the forecast global improvement derives from a projected preva- lence decline from 35 to 18 percent in Asia--driven primarily by the improvements in China. By contrast, in Africa, the prevalence is projected to increase from 24 to 27 percent. And the situation in Eastern Africa--a region blighted by HIV/AIDS, which has major interactions with malnu- trition--is critical. Here underweight prevalences are forecast to be 25 per- cent higher in 2015 than they were in 1990. Many countries (excluding several in Sub-Saharan Africa) will achieve the MDG income poverty target (percentage of people living on less than $1 a day), but less than 25 percent will achieve the nonincome poverty target of halving underweight (figure 3). Even if Asia as a whole achieves that target, large countries there including Afghanistan, Bangladesh, India, and Pakistan will still have unacceptably high rates of undernutrition in 2015, widening existing inequities between the rich and the poor in these countries. Deficiencies of key vitamins and minerals continue to be pervasive, and they overlap considerably with problems of general undernutrition (under- weight and stunting). A recent global progress report states that 35 percent of people in the world lack adequate iodine, 40 percent of people in the developing world suffer from iron deficiency, and more than 40 percent of children are vitamin A deficient. Trends in overweight among children under five, though based on data from a limited number of countries, are alarming (figure 4)--for all devel- oping countries and particularly for those in Africa, where rates seem to be increasing at a far greater rate (58 percent increase) than in the devel- oping world as a whole (17 percent increase). The lack of data does not allow us to give definitive answers for why Africa is experiencing this exag- gerated trend; however, the correlation between maternal overweight and child overweight suggests that one of the answers may lie therein. Comparable data for overweight and obesity rates among mothers show similar alarming trends. Countries in the Middle East and North Africa have the highest maternal overweight rates, followed by those in Latin America and the Caribbean. However, several African countries have more than 20 percent maternal overweight rates. Also evident is that overweight coexists in the same countries where both child and maternal undernutrition are very widespread and in many countries with low per capita GNP (figure 5). In Mauritania, more than 40 percent of mothers are overweight, while at the same time more than 30 percent children are under- weight. Furthermore, as many as 60 percent of households with an under- weight person also had an overweight person, demonstrating that underweight and overweight coexist not only in the same countries but also in the same households. In Guatemala, stunted children and over- 8 REPOSITIONING NUTRITION weight mothers coexist. Again, these data support the premise that, except under famine conditions, access to and availability of food at the house- hold level are not the major causes of undernutrition. Figure 4 Trends in obesity among children under age five 6 20 Africa Africa Asia Asia 5 LAC 16 LAC (%) Developing Developing (million) 4 12 overweight children 3 of 8 2 overweight Prevalence of 4 1 No. 0 0 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 Source: SCN (2004). Note: Estimates are based on WHO regions. Figure 5 Maternal overweight rates across regions 80 80 AFR AFR Egypt EAP Egypt EAP Jordan ECA Jordan ECA 60 LAC 60 LAC MNA (BMI>=25) MNA SAR (BMI>=25) Guatemala SAR Mauritania 40 40 Mauritania overweight Gabon overweight Zimbabwe 20 20 Yemen maternal India maternal Yemen % % Bangladesh 0 0 0 10 20 30 40 h 50 0 15 30 45 60 % maternal undernutrition (BMI<18.5) % child (<3y) underweight (WAZ<2) Source: Author's calculations using data from measuredhs.com. OVERVIEW 9 Markets are failing Markets are failing to address the malnutrition problem wherever families do not have the money to buy adequate food or health care. Human rights and equity arguments, as well as economic return arguments, can be made for governments to intervene to help such families. But malnutrition occurs also in many families that are not poor--because people do not always know what food or feeding practices are best for their children or them- selves, and because people cannot easily tell when their children are becom- ing malnourished, since faltering growth rates and micronutrient deficiencies are not usually visible to the untrained eye. The need to correct these "infor- mational asymmetries" is another argument for government intervention (box 1). And governments should intervene because improved nutrition is a public good, benefiting everybody; for example, better nutrition can reduce the spread of contagious diseases and increase national economic pro- ductivity. Box 1 Why malnutrition persists in many food-secure households · Pregnant and nursing women eat too few calories and too little protein, have untreated infections, such as sexually transmitted diseases that lead to low birthweight, or do not get enough rest. · Mothers have too little time to take care of their young children or themselves during pregnancy. · Mothers of newborns discard colostrum, the first milk, which strengthens the child's immune system. · Mothers often feed children under age 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. · Caregivers start introducing complementary solid foods too late. · Caregivers feed children under age two years too little food, or foods that are not energy dense. · Though food is available, because of inappropriate household food allocation, women and young children's needs are not met and their diets often do not contain enough of the right micronutrients or protein. · Caregivers do not know how to feed children during and following diarrhea or fever. · Caregivers' poor hygiene contaminates food with bacteria or parasites. 10 REPOSITIONING NUTRITION What Causes Malnutrition and How Should Governments Intervene? Contrary to popular perceptions, undernutrition is not simply a result of food insecurity: many children in food-secure environments and from non- poor families are underweight or stunted because of inappropriate infant feeding and care practices, poor access to health services, or poor sanita- tion. In many countries where malnutrition is widespread, food production is not the limiting factor (box 2), except under famine conditions. The most important factors are, first, inadequate knowledge about the benefits of exclusive breastfeeding and complementary feeding practices and the role of micronutrients and second, the lack of time women have available for appropriate infant care practices and their own care during pregnancy. Undernutrition's most damaging effect occurs during pregnancy and in the first two years of life, and the effects of this early damage on health, brain development, intelligence, educability, and productivity are largely irreversible (box 3). Actions targeted to older children have little, if any effect. Initial evidence suggests that the origins of obesity and NCDs such as cardiovascular heart disease and diabetes may also lie in early child- hood. Governments with limited resources are therefore best advised to focus actions on this small window of opportunity, between conception and 24 months of age, although actions to control obesity may need to con- tinue later. In countries where mean overweight rates among children under age five are high, a large proportion of children are already overweight at birth-- suggesting again that the damage happens in pregnancy. These results are consistent with physiological evidence that the origins of obesity start very early in life, often in the womb, though interventions to prevent obesity must likely continue in later life. Income growth and food production, as well as birth spacing and women's education, are therefore important but long routes to improving nutrition. Shorter routes are providing health and nutrition education and services (such as promoting exclusive breastfeeding and appropriate com- plementary feeding, coupled with prenatal care and basic maternal and child health services) and micronutrient supplementation and fortification. Experience in Mexico shows that in middle-income countries conditional cash transfers, coupled with improved health and nutrition service deliv- ery on the supply side, have gotten poor people to use nutrition services. Other countries, such as Bangladesh, Honduras, and Madagascar, have successfully used government-nongovernment partnerships to mobilize communities to tackle malnutrition through community-based approaches. Experience in dealing with different forms of malnutrition is at differ- ent stages of development: OVERVIEW 11 Box 2 Three myths about nutrition Poor nutrition is implicated in more than half of all child deaths world- wide--a proportion unmatched by any infectious disease since the Black Death. It is intimately linked with poor health and environmental factors. But planners, politicians, and economists often fail to recognize these con- nections. Serious misapprehensions include the following myths: Myth 1: Malnutrition is primarily a matter of inadequate food intake. Not so. Food is of course important. But most serious malnutrition is caused by bad sanitation and disease, leading to diarrhea, especially among young children. Women's status and women's education play big parts in improving nutrition. Improving care of young children is vital. Myth 2: Improved nutrition is a by-product of other measures of poverty reduc- tion and economic advance. It is not possible to jump-start the process. Again, untrue. Improving nutrition requires focused action by parents and com- munities, backed by local and national action in health and public ser- vices, especially water and sanitation. Thailand has shown that moderate and severe malnutrition can be reduced by 75 percent or more in a decade by such means. Myth 3: Given scarce resources, broad-based action on nutrition is hardly feasible on a mass scale, especially in poor countries. Wrong again. In spite of severe economic setbacks, many developing countries have made impressive progress. More than two-thirds of the people in developing countries now eat iodized salt, combating the iodine deficiency and anemia that affect about 3.5 billion people, especially women and children in some 100 nations. About 450 million children a year now receive vitamin A capsules, tackling the deficiency that causes blindness and increases child mortality. New ways have been found to promote and support breastfeeding, and breastfeeding rates are being maintained in many countries and increased in some. Mass immunization and promotion of oral rehydration to reduce deaths from diarrhea have also done much to improve nutrition. Source: Extracted from Jolly (1996). · For undernutrition and micronutrient malnutrition, several large-scale programs have worked (in Bangladesh and Thailand, in Madagascar, and in Chile, Cuba, Honduras, and Mexico). The challenge is to apply their lessons at scale in more countries. The issue is less about what to do than about how to strengthen both countries' and development part- ners' commitment and capacity to scale up. 12 REPOSITIONING NUTRITION Box 3 The window of opportunity for addressing undernutrition The window of opportunity for improving nutrition is small--from before pregnancy through the first two years of life. There is consensus that the damage to physical growth, brain development, and human capital formation that occurs during this period is extensive and largely irreversible. Therefore interventions must focus on this window of opportunity. Any investments after this critical period are much less likely to improve nutrition. 0.50 0.25 Latin America and Caribbean 0.00 Africa (NCHS) Asia -0.25 Z-score -0.50 age -0.75 for -1.00 -1.25 Weight -1.50 -1.75 -2.00 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 Age (months) Source: Shrimpton and others (2001). Note: Estimates are based on WHO regions. · By contrast, for overweight and diet-related NCDs, low birthweight, and the complex interactions between malnutrition and HIV/AIDS, there are few tried and tested large-scale models. Action research and learning-by-doing are the priority here, but large-scale HIV or NCD con- trol efforts cannot be successful without addressing nutrition--so the challenge is to shorten the time lag between developing the science and scaling up action. OVERVIEW 13 Although some successful programs have been scaled up without com- prehensive nutrition policies, policy is important as well. Few countries have well-developed and well-resourced nutrition policies. More often, policies in other sectors (trade, foreign exchange, employment, gender, agriculture, social welfare, and health) have a haphazard, sometimes negative effect on nutrition and become unintentional but de facto nutrition policies. Poverty and Social Impact Analyses (PSIAs) should be more widely used to assess the intentional and unintentional effects of development policies on nutrition outcomes. And the capacity to advise policy makers about the nutrition implications of policy needs to be developed in a focal institution, such as a ministry of finance or a poverty monitoring office. Policy also has a potential role in diminishing the poor health and neg- ative economic outcomes associated with the increase in overweight and obesity in developing countries through both demand-side and supply- side interventions. If effective interventions exist, why have they not been scaled up in more countries? Nutrition programs have been low priority for both governments and devel- opment partners for three reasons (box 5). First, there is little demand for nutrition services from communities because malnutrition is often invisi- ble; families and communities are unaware that even moderate and mild malnutrition contributes substantially to death, disease, and low intelli- gence; and most malnourished families are poor and hence have little voice. Second, governments and development partners have been slow to rec- ognize how high malnutrition's economic costs are, that malnutrition is holding back progress not only toward the malnutrition MDG but also toward other MDGs, or that there is now substantial experience with how to implement cost-effective, affordable nutrition programs on a large scale. Third, there are multiple organizational stakeholders in nutrition, so mal- nutrition often falls between the cracks both in governments and in devel- opment assistance agencies--the partial responsibility of several sectoral ministries or agency departments, but the main responsibility of none. Country financing is usually allocated by sectors or ministries, so unless one sector takes the lead, no large-scale action can follow. How the international development community can help countries do more Countries need to take the lead in repositioning nutrition much higher in their development agenda. When countries request help in nutrition, devel- opment partners must respond first by helping countries develop a shared 14 REPOSITIONING NUTRITION Box 5 Ten reasons for weak commitment to nutrition programs · Malnutrition is usually invisible to malnourished families and communities. · Families and governments do not recognize the human and economic costs of malnutrition. · Governments may not know there are faster interventions for combat- ing malnutrition than economic growth and poverty reduction or that nutrition programs are affordable. · Because there are multiple organizational stakeholders in nutrition, it can fall between the cracks. · There is not always a consensus about how to intervene against malnutrition. · Adequate nutrition is seldom treated as a human right. · The malnourished have little voice. · Some politicians and managers do not care whether programs are well implemented. · Governments sometimes claim they are investing in improving nutrition when the programs they are financing have little effect on it (for example, school feeding). · A vicious circle: lack of commitment to nutrition leads to underinvest- ment in nutrition, which leads to weak impact, which reinforces lack of commitment since governments believe nutrition programs do not work. Source: Abridged from Heaver (2005b). vision and consensus on what needs to be done, how, and by whom, and then by providing financial and other assistance. This report argues that much of the failure to scale up action in nutrition results from a lack of sus- tained government commitment, leading to low demand for assistance in nutrition. In this situation, the role of development partners must extend beyond responding when requested to do so by governments. They must use their combined resources of analysis, advocacy, and capacity-building to encourage and influence governments to move nutrition higher on the agenda wherever it is holding back achievement of the MDGs (table 3). This role can be fulfilled only if the development partners share a common view of the malnutrition problem and broad strategies to address it, and if they speak with a common voice. The development partners therefore also need to reposition themselves. They need to convene around a common OVERVIEW 15 Table 3 How investing in nutrition is critical to achieving the MDGs Goal Nutrition effect Goal 1: Eradicate extreme Malnutrition erodes human capital through poverty and hunger. irreversible and intergenerational effects on cognitive and physical development. Goal 2: Achieve universal Malnutrition affects the chances that a child primary education. will go to school, stay in school, and perform well. Goal 3: Promote gender Antifemale biases in access to food, health, equality and empower women. and care resources may result in malnutri- tion, possibly reducing women's access to assets. Addressing malnutrition empowers women more than men. Goal 4: Reduce child mortality. Malnutrition is directly or indirectly associated with most child deaths, and it is the main contributor to the burden of disease in the developing world. Goal 5: Improve maternal health. Maternal health is compromised by malnutrition, which is associated with most major risk factors for maternal mortality. Maternal stunting and iron and iodine deficiencies particularly pose serious problems. Goal 6: Combat HIV/AIDS, Malnutrition may increase risk of HIV malaria, and other diseases. transmission, compromise antiretroviral therapy, and hasten the onset of full-blown AIDS and premature death. It increases the chances of tuberculosis infection, resulting in disease, and it also reduces malarial survival rates. Source: Adapted from Gillespie and Haddad (2003). 16 REPOSITIONING NUTRITION strategic agenda in nutrition, focusing on scaled-up and more effective action for undernutrition and micronutrients in priority countries and on action research or learning-by-doing for overweight, low birthweight, and HIV/AIDS and nutrition. This repositioning must involve reviewing and revising the current inadequate levels of funding for nutrition. For exam- ple, though the World Bank is the largest development partner investing in global nutrition, between 2000 and 2004 its investments in the short route interventions that improve nutrition fastest amounted to not more than 3.8 percent of its lending for human development--and less than 0.7 percent of total World Bank lending. Although we do not wish to propose a global "one size fits all" approach to addressing malnutrition, we do recommend that when developing strate- gies specific to a country or region, countries and their development part- ners pay special attention to the following: · Focusing strategies and actions on the poor so as to address the nonin- come aspects of poverty reduction that are closely linked to human devel- opment and human capital formation. · Focusing interventions on the window of opportunity--before pregnancy through the first two years of life--because this is when irreparable damage happens. · Improving maternal and child care practices to reduce the incidence of low birthweight and to improve infant-feeding practices, including exclu- sive breastfeeding and appropriate and timely complementary feeding, because many countries and development partners have neglected to invest in such programs. · Scaling up micronutrient programs because of their widespread preva- lence, their effect on productivity, their affordability, and their extraor- dinarily high benefit-cost ratios. · Building on country capacities developed through micronutrient pro- gramming to extend actions to community-based nutrition programs. · Working to improve nutrition not only through health but also through appropriate actions in agriculture, rural development, water supply and sanitation, social protection, education, gender, and community-driven development. · Strengthening investments in the short routes to improving nutrition, yet maintaining balance between the short and the long routes. · Integrating appropriately designed and balanced nutrition actions in country assistance strategies, sectorwide approaches (SWAps) in mul- tiple sectors, multicountry AIDS projects (MAPs), and Poverty Reduction Strategy Papers (PRSPs). OVERVIEW 17 In addition to these generic recommendations, practical suggestions are available for how countries might take some of these considerations into account as they position nutrition in their national development strategies. Next Steps Scaled-up and more effective action requires addressing key operational challenges: 1. Building global and national commitment and capacity to invest in nutrition. 2. Mainstreaming nutrition in country development strategies where it is not now given priority. 3. Reorienting ineffective, large-scale nutrition programs to maximize their effect. Action research and learning-by-doing need to focus on: 1. Documenting how best to strengthen commitment and capacity and to mainstream nutrition in the development agenda. 2. Strengthening and fine-tuning service delivery mechanisms for nutrition. 3. Further strengthening the evidence base for investing in nutrition. At the global level, the development community needs to unite in explic- itly rethinking and repositioning the role of malnutrition as an underlying cause of slow economic growth, mortality, and morbidity, and agree to: · Coordinate efforts to strengthen commitment and funding for nutrition within global and national partnerships. · Pursue a set of broad strategic priorities (such as the six outlined above) for the next decade, contributing wherever they have the most compar- ative advantage. · Focus on an agreed-on set of priority countries for investing in nutrition and for mainstreaming and scaling up nutrition programs. · Focus on an agreed-on set of priority countries for developing best prac- tices in building commitment and capacity, mainstreaming nutrition, and reducing overweight and obesity. · Make a collective effort to switch from financing small-scale projects to financing large-scale programs, except where small projects with strong monitoring and evaluation components are required to pilot-test inter- ventions and delivery systems, or to build capacity in nutrition. 18 REPOSITIONING NUTRITION At the country level, the development community needs to scale up its assistance by helping all countries that have micronutrient deficiencies develop a national strategy for micronutrients, finance it, and scale it up to nationwide coverage within five years--without crowding out the larger undernutrition agenda. The development community must also support countries with under- nutrition problems as follows: · Identify and support at least 5 to 10 countries with serious nutrition problems that have the commitment to work with development part- ners to mainstream nutrition into SWAps, MAPs, and Poverty Reduction Strategy Credits (PRSCs). In countries that have little experience in nutri- tion, nutrition projects may be the first step; in other cases, specific efforts to develop country capacity will be needed. · Identify and support three to five countries where large-scale invest- ments need to be reoriented to maximize their effect. In these countries, provide coordinated support to reorient program design and to strengthen implementation quality and monitoring and evaluation. · Identify and support at least three to five countries where nutrition issues loom large but appropriate action is not being taken. In these countries, focus on building commitment, analyzing policy, and developing inter- vention strategies that can be financed with assistance from develop- ment partners. To help achieve these goals, the development partners will need to cofi- nance a grant fund to catalyze action in commitment-building and action research, complementing the Bank's recent allocation of $3.6 million from the Development Grant Facility to help mainstream nutrition into mater- nal and child health programs. Large-scale funding for the national actions outlined above should come through normal financing channels, rather than through the creation of a special fund for nutrition. Initial estimates sug- gest that the costs of addressing the micronutrient agenda in Africa are approximately $235 million per year. Costs for other regions and for other aspects of the nutrition agenda have yet to be estimated. Other estimates are much larger ($750 million for global costs for two doses of Vitamin A sup- plementation per year; between $1 billion and $1.5 billion for global salt iodization, including $800 million to $1.2 billion leveraged from the pri- vate sector; and several billion dollars for community nutrition programs). A more detailed costing exercise is being undertaken by the World Bank to come up with more rigorous figures. OVERVIEW 19 The agenda proposed here needs to be debated, modified, agreed on, and acted on by development partners with developing countries. Without coordinated, focused, and increased action, no significant progress in nutri- tion or toward several other MDGs can be expected. Notes 1. De Onis and others (2004b). 2. Doak and others (2005). Map 1.1 Global prevalence of underweight among children under age five PREVALENCE OF UNDERWEIGHT IN CHILDREN SEVERITY OF MALNUTRITION: LESS THAN 5 YEARS OF AGE % UNDERWEIGHT CHILDREN <5 YEARS OF AGE VERY HIGH (30%) INTERNATIONAL BOUNDARIES HIGH (20­29%) This map was produced by the Map Design Unit of the World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the MEDIUM (10­19%) part of The World Bank Group, any judgment on the legal status of any territory, or any LOW (<10%) endorsement or acceptance of such boundaries. NO DATA Data source: WHO Global Database on Child Growth and Nutrition. Map 1.2 Prevalence of stunting in children less than five years of age PREVALENCE OF STUNTING IN CHILDREN SEVERITY OF MALNUTRITION: LESS THAN 5 YEARS OF AGE % STUNTED CHILDREN <5 YEARS OF AGE VERY HIGH (40%) INTERNATIONAL BOUNDARIES HIGH (30­39%) This map was produced by the Map Design Unit of the World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the MEDIUM (20­29%) part of The World Bank Group, any judgment on the legal status of any territory, or any LOW (<20%) endorsement or acceptance of such boundaries. NO DATA Data source: WHO Global Database on Child Growth and Nutrition. Map 1.3 Global prevalence of vitamin A deficiency and supplementation coverage rates VITAMIN A DEFICIENCY AND ESTIMATED PERCENTAGE OF CHILDREN UNDER 6 WITH SUB-CLINICAL VITAMIN A DEFICIENCY: 40%­50% >50 SUPPLEMENTATION COVERAGE 10%­19% 0­9% 30%­39% This map was produced by the Map Design Unit of the World Bank. The boundaries, NO DATA 20%­29% colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any Cutoff for moderate public health problem, when percentage of children under 6 with sub-clinical vitamin A deficiency >10% endorsement or acceptance of such boundaries. SUPPLEMENTATION COVERAGE RATE ABOVE 70% IN 1999 Data sources: UNICEF Global Database on Vitamin and Mineral Deficiency, UNICEF/MI, 2004. INTERNATIONAL BOUNDARIES Map 1.4 Global prevalence of iodine deficiency disorders and iodized salt coverage rates IODINE DEFICIENCY DISORDERS AND TOTAL GOITRE RATE 0%­9% 20%­29% >40 IODIZED SALT CONSUMPTION RATES NO DATA 10%­19% 30%­39% This map was produced by the Map Design Unit of the World Bank. The boundaries, Cutoff for moderate public health problem, when total goitre rate >20% PERCENTAGE OF HOUSEHOLDS CONSUMING IODIZED SALT (1998­2002): colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any 49% OR LESS endorsement or acceptance of such boundaries. 50%­89% Data sources: UNICEF Global Database on Iodized Salt Consumption, UNICEF/MI, 2004. INTERNATIONAL BOUNDARIES 1 Why Invest in Nutrition? Improving nutrition contributes to productivity, economic development, and poverty reduction by improving physical work capacity, cognitive development, school performance, and health by reducing disease and mortality. Poor nutrition perpetuates the cycle of poverty and malnutrition through three main routes-- direct losses in productivity from poor physical status and losses caused by dis- ease linked with malnutrition; indirect losses from poor cognitive development and losses in schooling; and losses caused by increased health care costs. The economic costs of malnutrition are very high--several billion dollars a year in terms of lost gross domestic product (GDP). Relying on markets and economic growth alone means it will take more than a generation to solve the problem. But specific invest- ments can accelerate improvement, especially programs for micronutrient fortifi- cation and supplementation and community-based growth promotion. The economic returns to investing in such programs are very high. Nutrition and Economics For many people, the ethical, human rights, and national security argu- ments for improving nutrition or the tenets of their religious faith are reason enough for action. But there are also strong economic arguments for invest- ing in nutrition: · Improving nutrition increases productivity and economic growth. · Not addressing malnutrition has high costs in terms of higher budget outlays as well as lost GDP. · Returns from programs for improving nutrition far outweigh their costs. 21 22 REPOSITIONING NUTRITION Improved nutrition increases productivity and economic growth Good nutrition is a basic building block of human capital and, as such, con- tributes to economic development. In turn, sustainable and equitable growth in developing countries will convert these countries to "developed" states.1 There is much evidence that nutrition and economic development have a two-way relationship. Improved economic development contributes to improved nutrition (albeit at a very modest pace), but more importantly, improved nutrition drives stronger economic growth. Furthermore, as quantified in the Copenhagen Consensus,2 productivity losses caused by malnutrition are linked to three kinds of losses--those due to: · Direct losses in physical productivity. · Indirect losses from poor cognitive losses and loss in schooling. · Losses in resources from increased health care costs (figure 1.1). Therefore, malnutrition hampers both the physical capacity to perform work as well as earning ability.3 Malnutrition leads to direct losses in physical productivity Malnutrition leads to death or disease that in turn reduces productivity. For example: · According to the World Health Organization (WHO), underweight is the single largest risk factor contributing to the global burden of disease in the developing world. It leads to nearly 15 percent of the total DALY (disability-adjusted life years) losses in countries with high child mortality. In the developed world, overweight is the seventh highest risk factor and it contributes 7.4 percent of DALY losses (technical annex 1.1).4 · Malnutrition is directly or indirectly associated with nearly 60 percent of all child mortality5 and even mildly underweight children have nearly double the risk of death of their well-nourished counterparts. · Infants with low birthweight (less than 2.5 kilograms)--reflecting, in part, malnutrition in the womb--are at 2 to 10 times the risk of death compared with normal-birthweight infants.6 These same low-birth- weight infants are at a higher risk of noncommunicable diseases (NCDs) such as diabetes and cardiovascular disease in adulthood. · Vitamin A deficiency compromises the immune systems of approx- imately 40 percent of the developing world's children under age five, leading to the deaths of approximately 1 million young children each year. WHY INVEST IN NUTRITION 23 · Severe iron deficiency anemia causes the deaths in pregnancy and child- birth of more than 60,000 young women a year. · Iodine deficiency in pregnancy causes almost 18 million babies a year to be born mentally impaired; even mildly or moderately iodine-defi- cient children have IQs that are 10 to 15 points lower than those not defi- cient. · Maternal folate deficiency leads to a quarter of a million severe birth defects every year.7 Figure 1.1 The vicious cycle of poverty and malnutrition Income poverty Hard Low food Frequent Frequent Large physical intake infections pregnancies families labor Malnutrition Direct loss in Indirect loss in Loss in resources productivity from productivity from from increased poor physical status poor cognitive health care ccosts development of ill health and schooling Source: Modified from World Bank (2002a); Bhagwati and others (2004). 24 REPOSITIONING NUTRITION The strongest and best documented productivity-nutrition relation- ships are those related to human capital development in early life. Height has unequivocally been shown to be related to productivity,8 and final height is determined in large part by nutrition from conception to age two. A 1% loss in adult height as a result of childhood stunting is associ- ated with a 1.4 percent loss in productivity.9 In addition, severe vitamin and mineral deficiencies in the womb and in early childhood can cause blindness, dwarfism, mental retardation, and neural tube defects--all severe handicaps in any society, but particularly limiting in developing countries. Anemia has a direct and immediate effect on productivity in adults, especially those in physically demanding occupations. Eliminating anemia results in a 5 to 17 percent increase in adult productivity, which adds up to 2 percent of GDP in the worst affected countries.10 Malnourished adults are also likely to have higher absenteeism because of illness. In addition to its effect on immune function, poor nutrition also increases susceptibility to chronic diseases in adulthood (see chapter 2). Diet-related NCDs include cardiovascular disease, high blood cholesterol, obesity, adult- onset diabetes, osteoporosis, high blood pressure, and some cancers. About 60 percent of all deaths around the world and 47 percent of the burden of disease can be attributed to diet-related chronic diseases. About two-thirds of deaths linked to these diseases occur in the developing world, where the major risk factors are poor diet, physical inactivity, and obesity.11 These diseases are increasing at such a rapid rate, even in poor countries, that the phenomenon has been dubbed "the nutrition transition."12 Like other types of malnutrition, diet-related chronic diseases have their origins in early childhood, often in the womb. They are strongly associated with both low birthweight and stunting in low-income countries. Strauss and Thomas (1998) have argued through the efficiency wage hypothesis that there is a relationship between calorie intake and work output. Although the hypothesis has yet to be proven, they have shown that calorie intake has an effect on farm output and piece rates of agri- cultural laborers. They have also shown that in Brazil and in the United States, height and weight of adults (measured as body mass index, or BMI) both affect wages, even after controlling for education. Among low- income men in Brazil, a 1 percent increase in height was associated with a 4 percent increase in wages. The relationship between BMI and pro- ductivity decreases as BMI drops below 18.5, showing that adults with extremely low weights (for their heights) have lower productivity. Adults with a high BMI of 24­26 (an indicator of overweight), also have lower productivity. Although the nutrition and productivity relationship is WHY INVEST IN NUTRITION 25 strongest for manual labor, it has also been found in the manufacturing sector and among white collar workers.13 Malnutrition leads to indirect losses in productivity from poor cogni- tive development and schooling. Low birthweight may reduce a person's IQ by 5 percentage points, stunting may reduce it by 5 to 11 points, and iodine deficiency by as much as 10 to 15 points.14 Iron deficiency anemia con- sistently reduces performance on tests of mental abilities (including IQ) by 8 points or 0.5 to 1.5 standard deviations in children.15 Growth failure before the age of two, anemia during the first two years of life, and iodine deficiency in the womb can have profound and irre- versible effects on a child's ability to learn.16 Malnutrition in Zimbabwe has been calculated to reduce lifetime earnings by 12 percent because of its effect on schooling.17 Height and weight affect the likelihood that children will be enrolled at the right time in school. Small and sickly children are often enrolled too late (or never), and they tend to stay in school for less time.18 Malnutrition also affects the ability to learn. Common sense tells us that a hungry child cannot learn properly. Although this is true and short-term hunger does affect cognitive function (particularly attention span),19 the effects of imme- diate hunger pale in comparison with the effects on school performance of malnutrition in early life, long before the child ever reaches the classroom. Children who were malnourished early in life score worse on tests of cog- nitive function, psychomotor function, and fine motor skills and they have reduced attention spans and lower activity levels.20 These cognitive skill deficits persist into adulthood and have a direct effect on earnings.21 Recent studies have shown that that the positive correlation between nutritional status and both cognitive development and educational attain- ment also applies to children in normal birthweight and height ranges.22 For example, as birthweight increased by 100 grams among sibling pairs, the mean IQ at age 7 increased 0.5 point for boys and 0.1 point for girls. Educational attainment at age 26 among cohorts with birthweights between 3 and 3.5 kilograms was 1.4 times higher compared with those with birth- weights between 2.5 and 3 kilograms. The odds of having attained higher education (beyond compulsory schooling) at age 26 were also 2.6 times higher among the tallest cohort compared with the shortest cohort. It is also worth noting here that the effect of improved nutrition often extends into the range of what is considered normal--so that improving birthweights has a positive effect even for children above the 2,500-gram cutoff for low-birthweight babies, reducing anemia has similar benefits beyond those for people afflicted with "severe or moderate" anemia, and levels of mortality are higher even among mildly underweight children. 26 REPOSITIONING NUTRITION Not addressing malnutrition has high costs in lost GDP and higher budget outlays Malnutrition costs low-income countries billions of dollars a year. A recent study, for example, showed that preventing one child from being born with a low birthweight is worth $580.23, 24 At the country level, it has been esti- mated that obesity and related NCDs cost China about 2 percent of GDP and in India productivity losses (manual work only) from stunting, iodine defi- ciency, and iron deficiency together are responsible for a loss of 2.95 percent of GDP.25, 26 Preventing micronutrient deficiencies alone in China will be worth between $2.5 and $5 billion annually in increased GDP, which represents 0.2 to 0.4 percent of annual GDP in China. Other studies have suggested that micronutrient deficiencies alone may cost India $2.5 billion annually, about 0.4 percent of India's annual GDP.27 One estimate suggests that the pro- ductivity losses in India associated with undernutrition, iron deficiency anemia, and iodine deficiency disorders (IDD), in the absence of appro- priate interventions, will amount to about $114 billion between 2003 and 2012 (India's annual GDP is about $601 billion).28 Another study, examining only the productivity losses associated with forgone wage employment resulting from child malnutrition, estimates the loss at $2.3 billion in India (0.4 percent of annual GDP). In Sierra Leone, lack of adequate policies and programs to address anemia among women will result in agricultural pro- ductivity losses among the female labor force exceeding $94.5 million over the next five years.29 Malnourished children require more health services and more expensive types of care than other children. Malnourished children have poorer school- ing outcomes and may repeat years more often,30 thus increasing education costs. Developing countries are also spending an average of 2 to 7 percent of their health care budgets on direct costs for treatment of obesity and asso- ciated chronic diseases--and the obesity problem is rapidly worsening (see chapter 2). All of these costs fall largely on governments, which provide extensive public sector financing for health and education for the poor. Returns from programs for improving nutrition far outweigh their costs Taking into account the reduced mortality, reduced medical costs, inter- generational benefits (reduced likelihood of giving birth to a low-birth- weight infant in the next generation), and increased productivity, Behrman, Alderman, and Hoddinott (2004) calculate that the returns from investing in nutrition are high (table 1.1). WHY INVEST IN NUTRITION 27 Table 1.1 The benefit-cost ratios for nutrition programs Intervention programs Benefit-cost Breastfeeding promotion in hospitals 5­67 Integrated child care programs 9­16 Iodine supplementation (women) 15­520 Vitamin A supplementation (children < 6 years) 4­43 Iron fortification (per capita) 176­200 Iron supplementation (per pregnant woman) 6­14 Source: Behrman, Alderman, and Hoddinott (2004). Costs are rarely evaluated rigorously in development programs, and nutrition programs are no exception. Where data have been collected (table 1.2 and annex 1), many nutrition programs are found to be not only effective, but also efficient. For example, eliminating Vitamin A deficiency alone will save 16 percent of the global burden of disease in children.31 Comparable estimates are available from other sources (table 1.3). Nutrition, economic growth, and markets The past 20 years have shown that in many developing countries where incomes have increased substantially, malnutrition has not declined cor- respondingly. This indicates that economic growth and markets alone are not enough to address malnutrition. How far can economic growth take us? The income­malnutrition relationship is modest. When gross national prod- uct (GNP) per capita in developing countries doubles, nutrition does improve but the changes in underweight rates are much more modest-- from 32 to 23 percent (figure 1.2). Nutrition has steadily improved in most regions of the developing world--for example, worldwide, stunting fell from 49 to 27 percent of chil- dren under age five between 1980 and 2005, and underweight rates declined from 38 to 23 percent between 1980 and 2005 (see chapter 2 and technical annex 1.2). Economic growth has played an important part in this improve- ment. But economic growth reduces malnutrition very slowly. On the basis of the past correlation between growth and nutrition, it is estimated that sustained per capita economic growth of 2.5 percent between the 1990s and 2015 would reduce malnutrition by 27 percent--only half of the MDG 28 REPOSITIONING NUTRITION target.32 Technical annex 1.3 outlines the number of years it would take for different countries to halve their underweight rates at different rates of economic growth. These estimations show that countries cannot depend on economic growth alone to reduce malnutrition within an acceptable timeframe, especially given the human and economic costs and the inter- national community's commitments to achieving the MDGs. Table 1.2 Annual unit costs of nutrition programs Intervention Unit cost per participant ($) Community-based growth promotiona 1.60­10.00 without supplementary food 11.00­18.00 with targeted supplementary feeding Food supplementationb 36.00­172.00 to provide 1,000 Kcal/day Early child development/child carec 250.00­412.00 with food (Bolivia) 2.00­3.00 without food (Uganda) Nutrition educationd 2.50 Breastfeeding promotion in hospitalse 0.30­0.40 if infant formula removed from maternity 2.00­3.00 if not Microcredit cum nutrition educationf 0.90­3.50 (cost of nutrition education only) Conditional cash transfersg 70.00­77.00 Vitamin A supplements to preschool 1.01­2.55 childrenh Vitamin A fortification of sugari 0.69­0.98 Iron supplementationj 0.55­3.17 Salt iodizationk 0.20­0.50 Sources: a. Fiedler (2003); Iannotti and Gillespie (2002); Gillespie, Mason, and Martorell (1996); Mason and others (2001). b. Horton (1993, 1999). c. World Bank (2002a); Alderman (personal communication). d. Ho (1985). e. Horton and others (1996). f. Vor der Bruegge, Dickey, and Dunford (1997; updated 1999). g. Caldes, Coady, and Maluccio (2004). h. Fiedler and others (2000); Hendricks, Saitowitz, and Fiedler (1998); Fiedler (2000); Gillespie, Mason, and Martorell (1996). i. Fiedler (2000); Horton (1999). j. Horton (1992); Mason and others (2001). k. Horton (1999); Mason and others (2001). WHY INVEST IN NUTRITION 29 In Tanzania and India, at realistic levels of sustained per capita GDP (2.1 percent and 3 percent, respectively) and using an elasticity figure (change in malnutrition rates relative to per capita income growth) of -0.5, economic growth alone would take until 2065 and 2035, respectively, to achieve the nutrition MDG (figure 1.3). Depending on income alone, both Table 1.3 Cost of nutrition interventions ($) Delivery method Intervention Fortification Supplementation Iodine 0.02­0.05 0.8­2.75a Vitamin A 0.17 0.9­1.25 Iron 0.09­1.00 3.17­5.30 Community-based growth promotion Less intensive More intensive 2.00­5.00 5.00­10.00b Source: Caulfield and others (2004b). a. For iodized oil injections. b. For example, with paid workers or food supplements. Figure 1.2 The income­malnutrition relationship 40 (%) five 1970s 30 under 1980s 1990s children 20 underweight 10 of Percent 0 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 9,000 10,000 GNP per capita Source: Haddad and others (2002). 30 REPOSITIONING NUTRITION Figure 1.3 Estimated reduction of underweight prevalence at different economic growth and income-nutrition elasticity scenarios Tanzania 35 MDG will 30 be met in (%) 2109 25 2065 20 2026 underweight 15 of 10 2.1% p.c. growth/-0.3 elasticity 2.1% p.c. growth/-0.5 elasticity 5 5.0% p.c. growth/-0.5 elasticity Prevalence MDG 0 1998 2004 2010 2016 India 50 MDG will be met in 2059 (%) 40 2035 30 2020 underweight of 20 3.0% p.c. growth/-0.3 elasticity 10 3.0% p.c. growth/-0.5 elasticity 5.0% p.c. growth/-0.5 elasticity Prevalence MDG 0 1998 2004 2010 2016 Source: Underweight prevalence in 1999 from www.measuredhs.com. The projections are authors' calculations using different assumptions. WHY INVEST IN NUTRITION 31 Table 1.4 Reduction of the fraction of children underweight in Tanzania under different income growth and nutrition inter- vention coverage scenarios (%) Reduction in underweight (%) Per Farm capita income income Reduction Inter- Inter- maximum Additional Ratio of growth in No ventions ventions Inter- of 75% year of children (%) income more in 10% in 50% ventions of total education vaccinated since poverty inter- more com- more com- in all com- household for the increased 1993 (%) ventions munities munities munities income father to 95% 0.0 0.0 0.0 11.0 31.7 53.4 1.8 3.6 9.9 0.5 24.7 3.4 14.1 34.4 55.5 5.2 7.0 12.9 1.0 44.1 6.8 17.2 37.0 57.6 8.5 10.3 15.9 1.5 55.7 10.1 20.2 39.5 59.6 11.8 13.5 18.8 2.0 66.6 13.3 23.2 42.0 61.5 15.0 16.7 21.7 2.5 79.0 16.5 26.0 44.4 63.4 18.1 19.7 24.5 3.0 84.1 19.5 28.8 46.7 65.1 21.1 22.7 27.2 Source: Alderman, Hoogeveen, and Rossi (2005). Note: Based on data from Kagera district. Simulations are based on the random effect regres- sion model, which is the preferred estimation strategy. Base year is 1993. Because the per capita income growth rate between 1993 and 2003 in Tanzania is known (0.7 percent per year), the effective growth rates required to attain the 1993­2015 mean growth rates of 0, 1, 2, and 3 percent for the 2003­15 period are respectively: -0.5, 1.3, 3.1, and 5.0 percent. Figures in bold show attainment of the MDG. countries would need an unrealistic sustained rate of per capita income growth of 5.5 percent to achieve the MDG by 2015--unachievable under any circumstances (see technical annex 1.3). One small study applying data from the Kagera district in Tanzania shows that the income poverty target could be reached with a potentially achievable rate of per capita income growth of 1.5 percent. However, with- out any nutrition interventions, the corresponding improvement in the nonincome poverty target (nutrition) will be only 10 percent. Even with a per capita income growth of 3 percent, without nutrition interventions, the nutrition MDG cannot be achieved (table 1.4). Near-complete nutrition pro- gram coverage is required to achieve the nutrition MDG. 32 REPOSITIONING NUTRITION Market forces do not suffice to improve nutrition; public investment is necessary Although the private returns of improved nutrition are considerable, mal- nutrition persists. In part this is due to simple resource constraints that inhibit poor families from investing more resources (which they often do not have and cannot borrow) in children--investments that will not pay off for 10 or 20 years. A critical reason for market failure in addressing malnutrition has to do with informational asymmetries of two kinds: · People cannot tell when their children are becoming malnourished because healthy growth rates, arguably the best indicator of good nutri- tion, cannot be detected with the naked eye. And until micronutrient deficiencies are severe, they are impossible to detect without clinical tests. Thus families do not know there is a nutrition problem until it is too late. · Good nutrition is not intuitive: people do not always know what food or what feeding practices are best for their children or for themselves. Sometimes, too, food marketing and advertising change preferences in unhealthy ways, as is especially evident in the emerging epidemic of obesity and diet-related NCDs in developing countries, driven by the increased availability of inexpensive, calorie-dense foods. Because of such information gaps, even when families gain additional cash resources--for example through cash cropping33 or conditional cash transfers34--children's nutrition does not automatically improve. Given the productive and redistributive benefits of investing in nutrition, there is thus an argument for public intervention to ensure that parents get the information they need and to institute policies and programs (such as mandatory salt iodization) that bridge the information gaps. Yet another reason for justifying public investment is that improved nutrition is often a public good (as opposed to a private good), yielding benefits for everybody in society--for example, better nutrition can reduce the spread of contagious diseases and it increases national economic pro- ductivity. Furthermore, the infrastructure and institutions for delivering nutrition services as well as the authority to implement public interven- tions lie primarily in the public sector, though some interventions (such as food fortification) require much stronger private sector intervention. WHY INVEST IN NUTRITION 33 Table 1.5 Prevalence of underweight and anemia in Indian children by income quintiles Percentage of children with Percentage of children weight-for-age lower than 2 standard age 6­59 months with deviations below the mean iron levels less than g/dl Income quintiles Male Female Both Both 1992­93 National Family and Health Survey (children 0­3 years) Lowest 61.5 60.3 61.0 -- Second 62.5 58.9 60.6 -- Middle 57.1 56.9 57.0 -- Fourth 47.5 49.6 48.5 -- Highest 36.0 35.1 35.6 -- 1998­99 National Family and Health Survey (children 0­2 years) Lowest 59.7 61.5 60.7 78.8 Second 51.7 56.5 54.0 79.0 Middle 47.2 51.3 49.2 75.1 Fourth 37.6 40.3 38.9 72.3 Highest 25.2 27.6 26.4 63.9 Source: Gwatkin and others (2003). -- = not available. Nutrition and income poverty Undernutrition and micronutrient malnutrition are themselves direct indi- cators of poverty, in the broader definition of the term that includes human development. But undernutrition is also strongly linked to income poverty, although by no means synonymous with it. The prevalence of malnutri- tion is often two or three times--and sometimes many times--higher among the poorest income quintile than among the highest quintile.35 (Table 1.5 illustrates the situation in India, which has almost 40 percent of the world's malnourished children.36) This means that improving nutrition is pro-poor and increases the income-earning potential of the poor. In countries where girls' nutrition lags behind, improving the nutrition of young girls adds an extra equity-enhancing dimension to any such investment. Poverty and malnutrition reinforce each other through a vicious cycle (see figure 1.1). Poverty is associated with poor diets, unhealthy environ- ments, physically demanding labor, and high fertility, which increase mal- nutrition (chapter 2). Malnutrition in turn reduces health, education, and immediate and future income, thus perpetuating poverty. Even worse, poor 34 REPOSITIONING NUTRITION malnourished women are likely to give birth to low-birthweight babies, thus perpetuating poverty in the subsequent generation. Addressing mal- nutrition helps break this vicious cycle and stop the intergenerational trans- mission of poverty and malnutrition. Nutrition and the Millenium Development Goals Malnutrition is one of the most important constraints to achieving the MDGs. Improving nutrition is essential to reduce extreme poverty. Recognition of this requirement is evident in the definition of the first MDG, which aims to eradicate extreme poverty and hunger. The two targets are to be halved between 1990 and 2015: · The proportion of people whose income is less than $1 a day. · The proportion of people who suffer from hunger (as measured by the percentage of children under age five who are underweight). The first target refers to income poverty; the second addresses nonin- come poverty. The two indicators used for measuring progress on the non- income poverty goal are: Box 1.1 Off track on the Millennium Development Goals Recently the World Bank issued a Global Monitoring Report painting a pessimistic picture for achieving the MDGs on hunger: five years after the global commitment was made, progress has been inadequate to ensure their attainment. Sub-Saharan Africa is not on track to achieve a single MDG. In addition to other goals, it is off track on the hunger goal--and it is the only region where child malnutrition is not declining. South Asia is off track on six goals: gender equity, universal primary school completion, child mortality, maternal mortality, communicable diseases, and sanita- tion. And while malnutrition in that region is dropping sufficiently to achieve the MDG target, it remains at very high absolute levels: almost half of children under age five are underweight. The Middle East and North Africa is also off track on six goals: gender equity, universal prima- ry completion, child mortality, communicable diseases, water, and sanita- tion. Europe and Central Asia is off track on child mortality, maternal mortality, communicable diseases, and sanitation. And both Latin America and the Caribbean and East Asia and the Pacific are off track on child mortality, maternal mortality, and communicable diseases. Source: Excerpted from World Bank (2005b). WHY INVEST IN NUTRITION 35 Figure 1.4 Progress toward the nonincome poverty target On track (24%) Deteriorating status (18%) AFR (7) LAC (10) AFR (13) ECA (4) Angola Bolivia Niger Albania Benin Chile Burkina Faso Azerbaijan Botswana Colombia Cameroon Russian Federation Chad Dominican Rep. Comoros Serbia and Montenegro Gambia, The Guyana Ethiopia Mauritania Haiti Guinea LAC (3) Zimbabwe Jamaica Lesotho Argentina Mexico Mali Costa Rica EAP (5) Peru Senegal* Panama China Venezuela, R.B. de Sudan Indonesia Tanzania* MENA (2) Malaysia MENA (6) Togo Iraq Thailand Algeria Zambia Yemen, Rep. of Vietnam Egypt, Arab Rep. of Iran, Islamic EAP (2) SAR (2) ECA (6) Rep. of Jordan Mongolia Maldives Armenia Syrian Arab Rep. Myanmar Nepal Croatia Tunisia Kazakhstan Kyrgyz Rep. SAR (0) No trend data available (40%) Romania Turkey AFR (13) Georgia Burundi Hungary Cape Verde Latvia Some improvement, but not on track Congo, Rep. of Lithuania Equatorial Guinea Macedonia, FYR AFR (14) Guinea Moldova Central African Rep. ECA (0) Guinea-Bissau Poland Congo, DR Liberia Slovak Republic Côte d'Ivoire LAC (4) Mauritius Tajikistan Eritrea El Salvador Namibia Turkmenistan Gabon Guatemala Sâo Tomé and Principe Ukraine Ghana Honduras Seychelles Uzbekistan Kenya Nicaragua Somalia Madagascar South Africa LAC (12) Malawi MENA (1) Swaziland Belize Mozambique Morocco Brazil Nigeria EAP (11) Dominica Rwanda SAR (4) Fiji Ecuador Sierra Leone Bangladesh* Kiribati Grenada Uganda India Marshall Is. Paraguay Pakistan Micronesia, Federated St. Kitts and Nevis EAP (5) Sri Lanka States of St. Lucia Cambodia Palau St. Vincent Lao PDR Papua New Guinea Suriname Phillippines Samoa Trinidad and Tobago Solomon Islands Uruguay Timor-Leste Source: Author's calculations. See also Tonga MENA (2) technical annex 5.6. Vanuatu Djibouti Note: All calculations are based on Lebanon ECA (17) 1990­2002 trend data from the WHO Global Belarus SAR (2) Database on Child Growth and Malnutri- Bosnia and Afghanistan tion (as of April 2005). Countries indicated Herzegovina Bhutan by an asterisk subsequently released prelim- Bulgaria Czech Republic inary DHS data that suggest improvement Estonia and therefore may be reclassified when their data are officially released. 36 REPOSITIONING NUTRITION Figure 1.5 Progress toward the nonincome poverty target (nutri- tion MDG) 100% 80% 60% 40% 20% 0% AFR (47) EAP (21) ECA (27) LAC (29) MNA (11) SAR (8) On track Some improvement, but not on track Deteriorating status Trend data not available Source: Author's calculations. See also technical annex 5.6. · The prevalence of underweight children (under age five) · The proportion of the population consuming less than the minimum level of dietary energy. Therefore, improving nutrition is in itself an MDG target. Yet most assess- ments of progress toward the MDGs have focused primarily on the income poverty target, and the prognosis in general is that most countries are on track for achieving the poverty goal. Yet many regions are off track for achieving the nonincome poverty target (box 1.1). Of 143 countries, only 34 (24 percent) are on track to achieve the nonin- come target (nutrition MDG) (figures 1.4 and 1.5). It is particularly notable that no country in South Asia, where undernutrition is the highest, will achieve the MDG--though Bangladesh will come close to achieving it, and Asia as a whole will achieve it. Another alarming note is struck by the many countries where the nutrition status is deteriorating. Many are in Africa, where the nexus between HIV and undernutrition is particularly strong and mutually reinforcing. And in 57 countries, no data are available to tell whether progress is being made. WHY INVEST IN NUTRITION 37 Improving nutrition is not only intrinsic to achieving the first MDG, but also fundamental to progress toward five other goals (table 1.6). Nutrition and Human Rights The 1948 Universal Declaration of Human Rights established adequate health, including adequate food, as a basic human right. The right to health and nutrition was reiterated in the 1989 Convention on the Rights of the Child, adopted by all but two United Nations (UN) member countries. The right to adequate nutrition is also enshrined in the constitutions of many countries--for example, those of Ethiopia, Guatemala, India, Peru, and South Africa. Governments are entrusted to ensure that these rights are fulfilled, especially among children, the elderly, the vulnerable, and the infirm. The rights-based approach to development has also been firmly endorsed by the development community in recent years. Nutrition interventions also often act as social safety nets against shocks (see box 3.2). This is also true in countries undergoing reforms; access to safety nets such as nutrition interventions can increase the tolerance for shocks from public sector reforms, thereby increasing the potential for the success of reforms while also protecting basic human rights. The Know-How for Improving Nutrition As documented by the Copenhagen Consensus, we know what to do to improve nutrition and the expected rates of returns from investing in nutri- tion are high. Compared with many possible development investments, including trade reform and private sector deregulation, malaria eradica- tion, and water and sanitation, the provision of micronutrients was iden- tified as the second best opportunity for meeting the world's development challenges. Other nutrition investments also ranked high (table 1.7). Direct actions to improve nutrition are therefore desirable and have high poten- tial for returns. The final argument for investing in nutrition is that there are tried and tested models and experiences for reducing most forms of malnutrition-- models and experience that have not been adequately exploited and scaled up (see chapter 4). In some exceptional countries, nutrition programs have virtually universal coverage (Chile, Costa Rica, Cuba, and Thailand) and malnutrition has declined rapidly (see figure 2.12). But other countries with large nutrition programs still have significant gaps in coverage and quality. The reason undernutrition and micronutrient malnutrition per- sist at high levels is not that we do not know how to reduce them, nor that countries have applied best practice, yet failed to succeed. It is that most 38 REPOSITIONING NUTRITION countries have not invested at a scale large enough to get these tested tech- nologies to those who will benefit from them most. In addition, many countries that have invested have either used less effective and less strate- gic interventions (such as school feeding), or have not paid attention to implementation quality. Table 1.6 How investing in nutrition is critical to achieving the MDGs Goal Nutrition effect Goal 1: Eradicate extreme Malnutrition erodes human capital through poverty and hunger. irreversible and intergenerational effects on cognitive and physical development. Goal 2: Achieve universal Malnutrition affects the chances that a child primary education. will go to school, stay in school, and perform well. Goal 3: Promote gender Antifemale biases in access to food, health, equality and empower women. and care resources may result in malnutri- tion, possibly reducing women's access to assets. Addressing malnutrition empowers women more than men. Goal 4: Reduce child mortality. Malnutrition is directly or indirectly associated with most child deaths, and it is the main contributor to the burden of disease in the developing world. Goal 5: Improve maternal health. Maternal health is compromised by malnutrition, which is associated with most major risk factors for maternal mortality. Maternal stunting and iron and iodine deficiencies particularly pose serious problems. Goal 6: Combat HIV/AIDS, Malnutrition may increase risk of HIV malaria, and other diseases. transmission, compromise antiretroviral therapy, and hasten the onset of full-blown AIDS and premature death. It increases the chances of tuberculosis infection, resulting in disease, and it also reduces malarial survival rates. Source: Adapted from Gillespie and Haddad (2003). WHY INVEST IN NUTRITION 39 Table 1.7 The Copenhagen Consensus ranks the provision of micronutrients as a top investment Rating Challenge Opportunity Very good 1. Diseases Controlling HIV/AIDS 2. Malnutrition and hunger Providing micronutrients 3. Subsidies and trade Liberalizing trade 4. Diseases Controlling malaria Good 5. Malnutrition and hunger Developing new agricultural technologies 6. Sanitation and water Developing small-scale water technologies 7. Sanitation and water Implementing community- managed systems 8. Sanitation and water Conducting research on water in agriculture 9. Government Lowering costs of new business Fair 10. Migration Lowering barriers to migration 11. Malnutrition and hunger Improving infant and child malutrition 12. Diseases Scaling up basic health services 13. Malnutrition and hunger Reducing the prevalence of low birthweight Poor 14­17. Climate/migration Various Source: Bhagwati and others (2004). Table 1.8 Coverage of nutrition interventions in some large-scale programs Program/country Coverage rates ICDS/India Purported to cover 90% of development blocks, but only half the villages from the lowest two wealth deciles have access to the program, and the individuals not reached seem to be the poorer and younger childrena NNP/Bangladesh Aims to cover 105 of the 464 upazilas (< 25% coverage) AIN/Honduras Reaches only 24 of 47 health areas SEECALINE/Madagascar Reaches only 62 of 111 districts Source: Various unpublished World Bank reports. a. Gragnolati and others (forthcoming). 40 REPOSITIONING NUTRITION Some program coverage data can be illustrative as a proxy measure of underinvestment compared with the severity of undernutrition (table 1.8 and maps 1.1 and 1.2). While coverage for micronutrients is somewhat higher, similar discrepancies between needs and investments exist (vita- min A and iodine, maps 1.3 and 1.4). The conclusion: there is a significant gap between the size of the nutri- tion problem (chapter 2) and the coverage of current investments. Coverage of micronutrient programs is wider than for underweight programs. Nonetheless, investments in both are much smaller than warranted, although many models for and successful experiences in addressing mal- nutrition exist (chapters 3 and 4). Notes 1. Hunt (2005). 2. Behrman, Alderman, and Hoddinott (2004). 3. Hunt (2005). 4. Ezzati and others (2002). 5. Pelletier, Frongillo, and Habicht (1994); Caulfield and others (2004a); Caulfield, Richard, and Black (2004); Bryce and others (2005). 6. Behrman, Alderman, and Hoddinott (2004). 7. UNICEF and MI (2004a). 8. Behrman and Rosenzweig (2001). 9. Hunt (2005) 10. Strauss and Thomas (1998); Horton and Ross (2003). 11. IASO (2004). 12. Popkin, Horton, and Kim (2001). 13. Strauss and Thomas (1998). 14. Grantham-McGregor, Fernald, and Sethurahman (1999) 15. Horton and Ross (2003). 16. Behrman, Alderman, and Hoddinott (2004). 17. Behrman, Alderman, and Hoddinott (2004). 18. Behrman, Alderman, and Hoddinott (2004). 19. Pollitt (1990). 20. Behrman, Alderman, and Hoddinott (2004); Pollitt (1990). 21. Behrman, Alderman, and Hoddinott (2004). 22. Richards and others (2001); Richards and others (2002), Matte and others (2001). 23. It was calculated under the assumption that all non-low-birthweight children would survive to adulthood and become laborers. When corrected for age-specific mortality, the benefit becomes $510 (personal communication, Alderman). 24. Alderman and Behrman (2004). 25. IFPRI (2003). WHY INVEST IN NUTRITION 41 26. Horton (1999). 27. Gragnolati (forthcoming). 28. AED (2003). 29. Darnton-Hill (2005). 30. Behrman, Alderman, and Hoddinott (2004). 31. Darnton-Hill (2005) 32. Haddad (2003). 33. Von Braun (1995). 34. Behrman and Hoddinott (2001); Morris and others (2004). 35. Wagstaff and Watanabe (2001); Gwatkin and others (2003). 36. See Gwatkin and others (2003) for other countries. 2 How Serious Is Malnutrition and Why Does It Happen? Chapter 1 outlined the economic and other reasons for investing in nutrition. This chapter details the enormous size and scope of the nutrition problem (both under- weight and overweight) at global, regional, and country levels to further strengthen the case for investing in nutrition. Nearly one-third of the world's children are either underweight or stunted, and micronutrient deficiencies affect more than 30 percent of the developing world's population. The poor are the most affected. The malnutrition divide between the developed and the developing world is very wide, and inequities are increasing. Asia continues to have both the highest rates and the largest numbers of mal- nourished children in the world. Africa is the only continent seeing an increasing rate of undernutrition. The epidemic of obesity and diet-related noncommunicable diseases (NCDs) is emerging in the same countries and often in the same house- holds where undernutrition is already a serious problem. Evidence shows that malnutrition is not simply a result of household food inse- curity: many children in food-secure households are still underweight or stunted because of inappropriate infant feeding and care practices, poor access to health services, or poor sanitation, except under famine conditions. Malnutrition is often linked to gender issues such as women's lack of time. Though malnutrition is higher among the income poor, it also affects the better off--suggesting that behavior is often an underlying cause of malnutrition. The worst damage from malnutrition takes place from conception through the first two years of life, and most of this early damage is irreversible. Initial evidence suggests that the origins of obesity and diet-related NCDs may also lie in early childhood. Therefore, the best window of opportunity for addressing malnutrition is very small, from before conception through the first two years of age. Later invest- ments and actions are unlikely to be able to reverse the damage from early years. 42 HOW SERIOUS IS MALNUTRITION? AND WHY DOES IT HAPPEN? 43 Over one-fourth of all children in developing countries are either under- weight or stunted. One-third of the world's population (almost 2 billion people) suffers from various forms of iodine deficiency disorders (IDD). The same numbers have iron deficiency, which leads to anemia. About a quar- ter of the children under age five (127 million) suffer from vitamin A defi- ciency, which increases the risk of early death.1 Simultaneously, the proportion of people who are overweight or obese is growing, often in the same coun- tries where undernutrition and micronutrient malnutrition are concentrated, leading to what is often referred to as the "double burden of malnutrition." Some 1.1 billion adults are overweight, and 300 million are obese.2 Undernutrition The "malnutrition divide" between the developed and the developing coun- tries is huge. Twenty-seven percent (more than 147 million) of children under age five are stunted and 23 percent (more than 126 million) are underweight in developing countries. Comparable figures for the developed world are 2.6 percent for stunting and 1.1 percent for underweight. In Africa, about 24 percent of children are underweight and 35 percent are stunted; between 35 million and 50 million children under age five are affected. Less well known is that in Asia, average underweight rates are somewhat higher than in Africa (26 percent), and in several large South Asian countries, both under- weight and stunting rates are nearly double those in Africa (38 to 51 percent). Undernutrition is therefore worst in Asia, which has 92 million stunted and 89 million underweight children (box 2.1).3 In a recent World Health Organization (WHO) study, underweight preva- lence in developing countries was forecast to decline by 36 percent (from 30 percent in 1990 to 19 percent in 2015)--significantly below the 50 per- cent required to meet the MDG over the same time frame.4 These global data mask interregional differences that are widening disturbingly. Much of the forecast global improvement derives from a projected prevalence decline from 35 to 18 percent in Asia--driven primarily by the improve- ments in China. By contrast, in Africa, the prevalence is projected to increase from 24 to 27 percent. And the situation in Eastern Africa--a region blighted by HIV/AIDS, which has major interactions with malnutrition--is criti- cal. Here underweight prevalences are forecast to be 25 percent higher in 2015 than they were in 1990. Even in East Asia, Latin America, and Eastern Europe, many countries continue to carry heavy burdens of undernutrition and micronutrient mal- nutrition (Cambodia, Indonesia, Lao PDR, the Philippines, and Vietnam; Guatemala, Haiti, and Honduras; and Uzbekistan, to name only a few). In many, such as Guatemala and the Republic of Yemen, the undernutrition 44 REPOSITIONING NUTRITION Box 2.1 Undernutrition prevalence in South Asian countries is much higher than in Africa Africa* Stunted Asia* Underweight Pakistan Nepal India Bangladesh Afghanistan 0 10 20 30 40 50 60 Prevalence of undernutrition (% children) Source: De Onis and others (2004a); SCN (2004). *Estimates are based on WHO regions. Note: India, Bangladesh, Nepal, and Afghanistan have underweight rates that are similar to that of Ethiopia (see figure 2.12). · The numbers as well as the rates of underweight and stunted children are extremely high, especially in South Asia. · Underweight rates in several large countries in South Asia are nearly double those in Africa as a whole. · While numbers are projected to drop everywhere except in Africa, Asia will continue to have the majority of the malnourished even in 2015. Contrary to common perception, undernutrition is at much higher rates (and numbers) in Asia than in Africa. Yet most development partners con- tinue to invest in Africa and much less in Asia. rates are well above those in that region as a whole. Chances are that these high undernutrition rates will escape the attention of the international development partners unless special efforts are made to highlight this issue within regions that are doing well at an aggregate level (figure 2.1). HOW SERIOUS IS MALNUTRITION? AND WHY DOES IT HAPPEN? 45 Figure 2.1 Prevalence of and trends in malnutrition among children under age five, 1980­2005 75 Bangladesh 200 India China (%) 60 (million) 160 45 120 children Africa underweight Asia of 30 80 LAC Developing Developed 15 underweight 40 of Prevalence No. 0 0 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 60 250 Africa Asia LAC 50 Developing 200 (%) Developed (million) 40 150 stunting Africa of children 30 100 Asia LAC Developing stunted Developed 20 50 of Prevalence No. 0 0 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 Source: De Onis (2004a); SCN (2004). Note: Estimates are based on WHO regions. Prevalence and numbers also appear in technical annex 2.1. Regional and subregional data also mask other inequalities, as evident from the very high rates of underweight in Bangladesh and India (see box 2.1) and the very high rates of undernutrition in countries in Latin America (such as Guatemala), the Middle East and North Africa (such as the Republic of Yemen), and Eastern Europe and Central Asia (such as Uzbekistan) (figure 2.12). Although current trends suggest that Asia may approach the MDG target, wide disparities are likely to remain among Asian countries, with some of the largest countries lagging behind. Inequities are likely to be much larger within these countries--with rural areas, the poorest, and in 46 REPOSITIONING NUTRITION some cases girls, lagging furthest behind. In absolute numbers, the global total of underweight children is projected to decline by nearly one-third, from 164 million in 1990 to 113 million in 2015.5 Although numbers are pro- jected to drop everywhere except in Africa, Asia will continue to house the majority of the malnourished in 2015 (figure 2.2). Inequities in nutrition, including urban-rural differences and income and gender inequities, not only will persist, but often will become larger. Data from India illustrate these inequities across income quintiles for both underweight and anemia rates (see table 1.5). Underweight rates are much higher among the poorest quintile and the rate of decline is much lower, so that over time these inequities between the rich and the poor are widen- ing. Regional and country-specific data on child underweight and stunt- ing prevalence show wide disparities, even across countries in the same regions (figure 2.12 and technical annex 5.6). Low Birthweight South Asia has the highest rate of babies born with low birthweight (28 percent), followed by the Middle East and North Africa and the rest of the Africa region. Low birthweight is much less of a problem in Latin America and the Caribbean, East Asia and the Pacific, and Europe and Figure 2.2 Projected trends in numbers of underweight children under age five, 1990­2015 180 (millions) 1990 150 1995 2000 120 2005 children 2010 90 2015 60 30 underweight 0 of Africa Asia Latin America & Developing Developed the Caribbean countries countries No. Source: De Onis and others (2004a, 2004b). Note: Estimates are based on WHO regions. HOW SERIOUS IS MALNUTRITION? AND WHY DOES IT HAPPEN? 47 Central Asia. High rates of low birthweight contribute to the high rates of underweight and stunting, especially in South Asia. The large population in South Asia means that this rate is multiplied several times over--so that South Asia has the highest number of babies born with low weights, setting the stage for having the largest numbers of undernourished children. Birthweight is an issue in Africa as well, but on a smaller scale. Figure 2.3 Prevalence and number of low-birthweight infants 30 25 20 weight 15 birth low 10 % 5 0 SAR MNA AFR LAC EAP ECA Millions of children born with low birthweight 4 AFR 1 LAC 1 MNA 3 EAP 0.5 ECA 0.8 Developed 11 Source: UNICEF and WHO (2004). Note: Estimates are based on UNICEF regions. 48 REPOSITIONING NUTRITION Low-birthweight children are disadvantaged even before they are born, and evidence suggests that these children rarely catch up in growth.6 Furthermore, data suggest that the major causes of low birthweight are poor maternal nutrition, anemia, malaria, diarrhea, sexually transmitted diseases, and diseases, such as schistosomiasis, where they are endemic. In more industrial countries, cigarette smoking during pregnancy is the leading cause of low birthweight.7 Recent research has shown that babies born with low birthweight are much more prone to abdominal obesity and noncommunicable diseases in adult life. This phenomenon, referred to as the "Barker hypothesis" or "the fetal origins of adult disease," is still being debated, primarily because most evidence supporting the hypothesis comes from observational rather than experimental settings.8 We do not aim to review the entire literature here, simply to note that evidence to support this hypothesis has been docu- mented in varied observational settings in the developed and developing world (the Netherlands, Sweden, India, China, and several other coun- tries).9 In Japan, results from one study suggest that lower birthweight and lower rate of height increase during childhood are independently associated with increases in blood pressure and serum cholesterol in adult life.10 In Finland, low birthweights for height have been shown to be associated with increased risk of coronary heart disease, and low height and weight at age one year also increased the risk.11 Data from longitudinal studies on 300,000 19-year-old conscripts exposed to the Dutch famine of 1944­45 show that maternal malnutrition during early pregnancy was associated with higher body mass index (BMI, weight for height) and waist circumference in 50-year-old women, but not in men. The analyses also showed that the rate of obesity was higher in women who had been exposed to famine in early pregnancy, as compared with those exposed to famine in the last trimester.12 The timing of the food depri- vation (early or later in pregnancy) also determined susceptibility to diabetes and high blood pressure.13 Many of these observational studies conclude that improvements in fetal, infant, and child growth could substantially reduce the incidence of NCDs in adulthood. This link could explain why the same developing countries that have high numbers of low-birthweight and underweight children are now experiencing the double burden of increasing numbers of adults who are overweight or have NCDs, as documented in the fol- lowing sections. HOW SERIOUS IS MALNUTRITION? AND WHY DOES IT HAPPEN? 49 Obesity and Diet-Related Noncommunicable Diseases The International Obesity Task Force estimates that about 1.1 billion adults are overweight, including more than 300 million who are obese.14 Childhood overweight affects about 155 million school-age children, including about 40 million who are obese. Overweight and NCDs account for about 46 per- cent of the global burden of disease and about 60 percent of total global deaths, 79 percent of which occur in developing countries.15 The attribut- able mortality and burden of disease are expected to grow to 73 percent and 60 percent by 2020. Trends in overnutrition rates--observed as obesity or as an excess of added sugar and saturated or trans-fatty acids in the diet--are alarming. Take three examples from three continents: In Mexico, rates of adult male obesity have tripled since 1988; in China, more than 200 million adults are affected--a 2002 survey revealed national adult overweight at 23 percent, obesity at 7 percent, and childhood obesity at more than 8 percent; in South Africa in 1998, 29 percent of men and 56 percent of women were overweight or obese.16 High rates of overweight increasingly coexist with high rates of underweight--a 1999 national survey in China found one in five overweight children under age 9 had suffered from stunting because of chronic undernutrition early in life. Trends in overweight among children under age five, though based on data from a limited number of countries, are alarming (figure 2.4)--for all developing countries and particularly for those in Africa, where rates seem to be increasing at a far greater rate (58 percent increase) than in the devel- oping world as a whole (17 percent increase). The lack of data prevents definitive answers for why Africa is experiencing this exaggerated trend; however, the correlation between maternal overweight and child over- weight suggests that one of the answers may lie therein (figure 2.5). Comparable data for overweight and obesity rates among mothers show similar alarming trends. Countries in the Middle East and North Africa have the highest maternal overweight rates, followed by those in Latin America and the Caribbean. However, several African countries have more than 20 percent maternal overweight rates--in Mauritania, more than 40 per- cent of mothers are overweight. Also evident is that overweight coexists in the same countries where both child and maternal undernutrition are very widespread and in many countries with low per capita GNP (figures 2.6 and 2.7). Furthermore, as many as 60 percent of households with an underweight person also had an overweight person, demonstrating that underweight and overweight coexist not only in the same countries, but also in the same households.17 Again, these data support the premise that access to and availability of food at the household level are not the major causes of undernutrition. 50 REPOSITIONING NUTRITION Figure 2.4 Trends in obesity among children under age five 6 20 Africa Africa Asia Asia 5 LAC 16 LAC (%) Developing Developing (million) 4 12 overweight children 3 of 8 2 overweight Prevalence of 4 1 No. 0 0 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 Source: SCN (2004). Note: Estimates are based on WHO regions. Figure 2.5 Maternal and child overweight 80 AFR Jordan Egypt EAP ECA 60 LAC Turkey (BMI>=25) Peru MNA SAR 40 overweight Armenia Comoros maternal 20 % Uzbekistan 0 0 5 10 15 20 % child (<5y) overweight (WHZ>2) Source: Author's calculations using data from measuredhs.com. HOW SERIOUS IS MALNUTRITION? AND WHY DOES IT HAPPEN? 51 Figure 2.6 Maternal overweight versus maternal and child undernutrition 80 80 AFR AFR Egypt EAP Egypt EAP Jordan ECA Jordan ECA 60 LAC 60 LAC MNA (BMI>=25) MNA SAR (BMI>=25) Guatemala SAR Mauritania 40 40 Mauritania overweight Gabon overweight Zimbabwe 20 20 Yemen maternal India maternal Yemen % % Bangladesh 0 0 0 10 20 30 40 h 50 0 15 30 45 60 % maternal undernutrition (BMI<18.5) % child (<3y) underweight (WAZ<2) Source: Author's calculations using data from measuredhs.com. Figure 2.7 Coexistence of energy deficiency and obesity in low- and middle-income countries 35 30 25 20 % 15 10 5 0 0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 GNP (US$ per capita) Chronic energy deficiency (BMI<18.5) Obesity (BMI>=30) Source: Monteiro and others (2004). 52 REPOSITIONING NUTRITION Micronutrient Malnutrition Deficiencies of key vitamins and minerals continue to be pervasive and they overlap considerably with problems of general undernutrition (under- weight and stunting). A recent global progress report states that 35 per- cent of people in the world lack adequate iodine, 40 percent of people in the developing world suffer from iron deficiency, and more than 40 per- cent of children are vitamin A deficient (figures 2.8 and 2.9).18 In sum- mary, the scale of the malnutrition problem is very large and, given its consequences for economic development, calls for immediate and large- scale action. Figure 2.8 Prevalence of subclinical vitamin A deficiency in children age 0­72 months, by region, 1990­2000 80 1990 70 1995 2000 estimated 60 deficient 50 years 6 A 40 under 30 vitamin be 20 to children 10 % 0 and Asia Africa Africa India) India Asia Asia China) China Total Europe East East America South Caribbean Sub-Saharan North Central (without South and Middle (without Central Eastern and Source: UNICEF and MI (2004b). Note: Estimates are based on UNICEF regions. HOW SERIOUS IS MALNUTRITION? AND WHY DOES IT HAPPEN? 53 Figure 2.9 Prevalence of iron deficiency in preschool children, by region, 1990­2000 80 1990 70 1995 2000 estimated 60 deficient 50 years 6 A 40 under 30 vitamin be 20 to children 10 % 0 and Asia Africa Africa India) India Asia Asia China) China Total Europe East East America South Caribbean Sub-Saharan North Central (without South and Middle (without Central Eastern and Source: UNICEF and MI (2004). Note: Estimates are based on UNICEF regions. What Causes Malnutrition, and Who Is Worst Affected? At an immediate level, an individual becomes malnourished because of inadequate or inappropriate dietary intake, ill health, or both. These two fac- tors often interact in a negative synergy. Illness reduces appetite and increases nutrient requirements, while inadequate intake of food (quantity or quality) makes the body more susceptible to illness. Underlying this vicious cycle are household or community deficits in food security, inade- quate access to health and environmental services, and household child- care behaviors and practices. These three underlying factors--often summarized as "food, health, and care"--also interact, and they too are underpinned by more basic causes relating to the amount, control, and use of resources and capacity in societies.19 Undernutrition is often assumed to result primarily from food insecurity, but data from many countries suggest that food is not the only and often not even the main cause of undernutrition, except under famine condi- tions. Data show that at any given level of food availability, underweight rates can range from as low as 2 to 10 percent to as high as 40 to 70 percent 54 REPOSITIONING NUTRITION Figure 2.10 Prevalence of underweight children by per capita dietary energy supply, by region, 1970­96 Percent of underweight children under age five 80 70 60 50 40 30 20 10 0 1,500 2,000 2,500 3,000 3,500 Per capita energy supply (kilocalories) Latin America and the Caribbean Near East and North Africa East Asia Sub-Saharan Africa South Asia Source: Haddad and Smith (1999). (figure 2.10). The conclusion, confirmed by many studies,20 is not that food supplies are irrelevant, but that other factors, such as maternal knowledge, caring practices for young children, access to health services, and water and sanitation, have important roles to play. Data from many countries show high undernutrition rates in regions and households where food is plentiful: examples are the Arsi region in Ethiopia and the Iringa region in Tanzania, both of which have high food production rates yet also very high stunting rates--62 percent in Arsi and 66 percent in Iringa.21 Other data also show that higher agricultural production and higher income do not guarantee improved nutrition. Although the nutritional HOW SERIOUS IS MALNUTRITION? AND WHY DOES IT HAPPEN? 55 status of children from the richest 20 percent of households is much better than that of children from the poorest 20 percent in many countries (for example, the Dominican Republic, Morocco, Nicaragua, Peru, and Turkey), the proportion of underweight children does not differ much by income level in many other countries (for example, Burkina Faso, Cambodia, Ethiopia, Kazakhstan, Madagascar, Niger, Tanzania, and Turkmenistan).22 In India (as in many other countries), even among the richest quintile, 26 percent of preschool children are underweight and 64 percent are anemic (see table 1.5), showing that food insecurity and poverty are not the only causes of undernutrition. Box 2.2 The window of opportunity for addressing undernutrition The window of opportunity for improving nutrition is small--from pre-pregnancy through the first two years of life. There is consensus that the damage to physical growth, brain development, and human capital formation that occurs during this period is extensive and largely irre- versible. Therefore interventions must focus on this window of opportu- nity. Any investments after this critical period are much less likely to improve nutrition. 0.50 0.25 Latin America and Caribbean 0.00 Africa (NCHS) Asia -0.25 Z-score -0.50 age -0.75 for -1.00 -1.25 Weight -1.50 -1.75 -2.00 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 Age (months) Source: Shrimpton and others (2001). Note: Estimates are based on WHO regions. 56 REPOSITIONING NUTRITION Undernutrition is not just a state, but a process whose consequences often extend not only into later life, but also into future generations. The process often starts in the womb (especially in South Asia), and continues through at least the first two years of life (box 2.2). The critical periods of pregnancy and lactation and the first two years of life pose special nutritional challenges because these are when nutrition requirements are greatest and when these population subgroups, in many parts of the world, are most vulnerable to inadequate caring behaviors, inadequate access to health ser- vices, and inappropriate feeding practices. Pregnancy and lactation substantially increase nutritional needs to sup- port adequate fetal growth and breastfeeding, and the additional energy and nutrient demands easily place pregnant and lactating women at great nutritional risk. When pregnancies occur during the teenage years, the risk is even higher because of the competition for nutritional requirements between the mother's needs and the babies' needs--that is, between the mother's preparation for lactation and the fetal growth and development.23 Children of adolescent mothers are also often at greater risk of poor nutri- tional care and feeding practices. Therefore women need access to appro- priate health care and nutrition information as well as appropriate foods during pregnancy and lactation more than during any other period. Very young children are the most susceptible to infections. They need the dietary inputs (through exclusive breastfeeding and timely comple- mentary feeding) to support the fast rate of growth that typically occurs in the first two years of life. They are the least able to make their needs known Figure 2.11 Prevalence of overweight among children under age five, by age group 25 25 Egypt Zimbabwe Peru Armenia Uzbekistan 20 20 15 15 overweight overweight 10 10 child child % % 5 5 0 0 5­0 11­6 17­ 23­ 29­ 35­ 41­ 47­ 53­ 59­ 5­0 12 18 24 30 36 42 48 54 11­6 17­ 23­ 29­ 35­ 41­ 47­ 53­ 59­ 12 18 24 30 36 42 48 54 Age (mo) Age (mo) Source: Data from measuredhs.com; authors' calculations. HOW SERIOUS IS MALNUTRITION? AND WHY DOES IT HAPPEN? 57 and the most vulnerable to the effects of poor care practices. In fact, the main causes of the often precipitous decline in nutritional status immedi- ately after birth (see box 2.2) are often inadequate feeding and caring prac- tices rather than a lack of food in the household. Data also show that the damage done by undernutrition very early in life, to both physical growth and brain development, is largely irreversible.24 Box 2.3 Three myths about nutrition Poor nutrition is implicated in more than half of all child deaths world- wide--a proportion unmatched by any infectious disease since the Black Death. It is intimately linked with poor health and environmental factors. But planners, politicians, and economists often fail to recognize these con- nections. Serious misapprehensions include the following myths: Myth 1: Malnutrition is primarily a matter of inadequate food intake. Not so. Food is of course important. But most serious malnutrition is caused by bad sanitation and disease, leading to diarrhea, especially among young children. Women's status and women's education play big parts in improving nutrition. Improving care of young children is vital. Myth 2: Improved nutrition is a by-product of other measures of poverty reduc- tion and economic advance. It is not possible to jump-start the process. Again, untrue. Improving nutrition requires focused action by parents and com- munities, backed by local and national action in health and public ser- vices, especially water and sanitation. Thailand has shown that moderate and severe malnutrition can be reduced by 75 percent or more in a decade by such means. Myth 3: Given scarce resources, broad-based action on nutrition is hardly feasible on a mass scale, especially in poor countries. Wrong again. In spite of severe economic setbacks, many developing countries have made impressive progress. More than two-thirds of the people in developing countries now eat iodized salt, combating the iodine deficiency and anemia that affect about 3.5 billion people, especially women and children in some 100 nations. About 450 million children a year now receive vitamin A capsules, tackling the deficiency that causes blindness and increases child mortality. New ways have been found to promote and support breastfeeding, and breastfeeding rates are being maintained in many countries and increased in some. Mass immunization and promotion of oral rehydration to reduce deaths from diarrhea have also done much to improve nutrition. Source: Extracted from Jolly (1996). 58 Figure 2.12 Underweight prevalence and rates of decline in World Bank regions and countries EAP FR Säo Tom Timor-Leste Phillippines Papua Burkina Madagascar Sierra Mozambique Gambia, é South Cambodia Mauritania Congo, Congo, Cape & Lao, Myanmar Indonesia Zimbabwe Swaziland Seychelles Vietnam Solomon Malaysia Thailand Mongolia Cameroon Côte Mauritius Kiribati Vanuatu Botswana Ethiopia Burundi Tanzania Comoros Guinea Angola Namibia Somalia Malawi Guinea Rwanda Uganda Senegal Lesotho Principe China Samoa Nigeria Zambia Sudan Leone Liberia Ghana Gabon PDR New Niger Eritrea Faso Mali Chad Kenya Togo Verde Africa Rep. CAR Benin d`Ivoire Fiji DR The Prevalence -30 0 Annual -15 10 0 of 20 underweight % change 15 30 30 45 40 U5MR>=50 U5MR<50 Annual % change (1990­2002) (%) 60 50 St Vincent Bosnia SAR MNA LAC BCA Serbia Trnidad REPOSITIONING & Turkmenistan &Herzegovina & Afghanistan Bangladesh Syrian Guatemala Grenadines El Montenegro Costa Dominican Venezuela Uzbekistan Azerbaijan Macedonia Kazakhstan Maldives Pakistan Sri Honduras Nicaragua Colombia & Argentina Djibouti Morocco Lebanon Algeria Tunisia Ecuador St. Suriname Paraguay Hungary Guyana Salvador Panama Uruguay Mexico Tobago Jamaica Albania Kyrgyz Ukraine Romania Georgia Armenia Croatia Nepal India Lanka Bhutan Yemen Jordan Bolivia Turkey Russia Iraq Iran Arab Egypt Haiti Lucia Belize Czech Peru Brazil Rica Chile Prevalence -30 0 Annual -15 10 0 of NUTRITION % 20 underweight change 15 30 30 45 40 U5MR>=50 U5MR<50 Annual % change (1990­2002) (%) 60 50 HOW Source: WHO global database on child growth and malnutrition. Note: U5MR = under age five mortality rate, per 1,000 live births. Prevalence of underweight is from the latest national survey available in each country. The coefficient of a regression that links the natural logarithm and underweight to the year of the survey serves as the average annual SERIOUS percentage change over the period for which data are available. All of the national data available between 1990 and 2002 were used for the estima- tion. Adjusted prevalence of underweight from national rural data (1990 and 1992) was used for India, as provided by WHO. No underweight data were available for these countries: AFR--Equatorial Guinea; EAP--Marshall Islands, Micronesia, Palau, Tonga; ECA--Belarus, Bulgaria, Estonia, IS Latvia, Lithuania, Moldova, Poland, the Slovak Republic, Tajikistan; LAC--Dominica, St. Kitts and Nevis; Industrial--Antigua and Barbuda, MALNUTRITION Republic of Korea, Slovenia. ? AND WHY DOES IT HAPPEN ? 59 60 REPOSITIONING NUTRITION Although data for the global or regional prevalence of overweight are much less readily available, we looked at data from five countries (figure 2.11) to track when obesity may have started to occur. In Egypt, Zimbabwe, and Peru, where mean overweight rates among children under age five are 12, 7, and 8 percent, respectively, a large proportion of children are already overweight at birth--suggesting again that the damage happens in preg- nancy. Weights decline in the first two years of life and then seem to show an upward trend again. Data from Armenia and Uzbekistan are less clear-- potentially because of the small sample sizes in the data we reviewed, as evi- denced by the very large standard deviations around the means in figure 2.11. These results are consistent with physiological evidence that the ori- gins of obesity start very early in life, often in the womb, though interven- tions to prevent obesity must likely continue in later life. Malnutrition is perpetuated across generations. Where undernutrition levels are high, malnourished women or adolescent girls often give birth to babies who are born stunted and small. These children's growth seldom catches up fully in subsequent years. They are more likely to get sick and enter school late, do not learn well, and are less productive as adults. As adults, they are also more likely to suffer from the diet-related diseases such as diabetes, coronary heart disease, and hypertension, formerly thought to be associated only with increasing affluence. Babies born to underweight or stunted women are themselves likely to be underweight or stunted.25 In this way, undernutrition passes from one generation to another as a grim inheritance. The key implications for policy are these: · The best window of opportunity for addressing malnutrition (both under- nutrition and, to a large extent, overweight) lies before conception until two years of age (though in the case of overweight, additional inter- ventions are needed in later years). Actions targeted to children older than age two, such as school feeding programs, are likely to have little effect on reversing the damage to brain development, the link with NCDs established in the early years, or on longer-term productivity and human capital formation. · Access to food is often not the key issue because the food needs of chil- dren age 0 to 18 months are relatively small and because undernutrition seems to persist in many households and communities that also suffer from problems of overweight. · Improving maternal knowledge, feeding, and time for care during preg- nancy (to address low birthweight, especially in South Asia) and lacta- tion and improving infant feeding and caring practices, such as exclusive HOW SERIOUS IS MALNUTRITION? AND WHY DOES IT HAPPEN? 61 breastfeeding and adequate and timely complementary feeding, are crit- ical to improving nutrition outcomes. These tasks are closely linked to issues of gender. All countries with underweight rates greater than 20 percent should get priority for action in nutrition (figure 2.12). Countries with high rates of mortality in children under age five may need somewhat different actions than those with lower rates. Similarly, countries with lower rates of decline (annual percentage change) should be of greater concern, while in those where declines are good, the focus should be on sustaining and scaling up actions. Notes 1. De Onis and others (2004a); SCN (2004). 2. WHO (2005b). 3. De Onis (2004a); SCN (2004). 4. De Onis and others (2004b). 5. De Onis and others (2004b). 6. Alderman and Behrman (2004). 7. UNICEF and WHO (2004). 8. Kimm (2004); Paneth and Susser (1995). 9. te Veldeand others (2003); Illiadou, Cnattingius, Lichtenstein (2004); Bhargava and others (2004); Zhao and others (2002). 10. Miura and others (2001). 11. Eriksson and others (2001). 12. Ravelli and others (1999); Ravelli, Steing, and Susser (1976). 13. Roseboom and others (2000). 14. IASO (2004). 15. WHO (2002, 2001). 16. IASO (2004). 17. Doak and others (2005). 18. UNICEF and MI (2004b). 19. UNICEF (1990). 20. Pelletier and others (1995); Smith, Alderman, and Aduayom (2005); Haddad and others (1995); Haddad and Smith (1999). 21. Pelletier and others (1995); Smith, Alderman, and Aduayom (2005). 22. Gillespie (2002); Gwatkin and others (2003). 23. Delisle, Chandra-Mouli, and de Benoist (2000). 24. Martorell, Kahn, and Schroeder (1994). 25. Allen and Gillespie (2001). 3 Routes to Better Nutrition This chapter summarizes what we know about the main interventions for improv- ing nutrition, on both the demand and the supply side, and identifies areas where we need to know more. It outlines two routes to improving nutrition--the long route via birth spacing, food policies, and women's education, and the shorter route via health and nutrition services, micronutrient supplementation, condi- tional cash transfers, and nutrition education. This chapter also draws two main conclusions about nutrition programs. When it comes to dealing with low birth- weight, overweight, and diet-related noncommunicable diseases (NCDs), and with the complex interactions between malnutrition and HIV/AIDS, there are no tried and tested models for effective large-scale programs; action research and learning-by-doing are the priority in these areas. Large-scale HIV initiatives must incorporate attention to nutrition if they are to succeed. By contrast, when it comes to tackling child undernutrition and micronutrient malnutrition, there are several examples of large-scale programs that have led to substantial improve- ments in nutrition and health behavior and outcomes; scaling up such programs in other countries is the obvious next step. This chapter emphasizes the impor- tance of policy as well as programs. The conclusions are that more attention needs to be paid to the policy process, to ensure that paper policies get translated into action, and that more attention needs to be focused on the unintended effects on nutrition of macroeconomic policies and sectoral policies outside nutrition because they often have haphazard or negative effects that work against the objectives of improving nutrition. 62 ROUTES TO BETTER NUTRITION 63 Long and Short Routes to Better Nutrition A wide variety of policies and programs can improve nutrition (table 3.1). Table 3.1 also illustrates that there are supply- and demand-side approaches to reducing undernutrition. Supply-side approaches include increasing the availability of appropriate foods at affordable prices, improving access to micronutrients, and improving basic health services--immunization, for example, prevents diseases that set back children's growth. There are two types of demand-side approaches. One consists of ways to increase the demand for food, or for health or nutrition services (column 2 of table 3.1). The other consists of changes to behavioral practices related to what is eaten and fed, and to workloads and exercise (column 3 of table 3.1). Most nutrition interventions require changing eating, feeding, or exercise behav- iors to have an effect. The fact that many poor children are adequately nour- ished and many nonpoor children are malnourished emphasizes the critical importance of child-care behavior. Each country needs to decide on the appropriate balance between the long route and the short route and between supply-side and demand-side approaches to improving nutrition, depending on their capacities, the epi- demiology of the problem, and political and institutional considerations. Although both long and short routes are important and should be part of national strategies, this report focuses on the short routes and emphasizes the importance of improving child feeding and caring practices in preg- nancy and infancy, for the following reasons: · Malnutrition's most serious and lasting damage is either during preg- nancy or to very young children (chapter 2). · Several short route interventions can improve child nutrition fast-- in two to five years, within the time frame in which politicians need to see results. · These interventions are affordable at scale by all but the very poorest countries. · Reducing income poverty or improving the food supply without chang- ing the way young children are cared for often does little to improve nutrition (box 3.1 and see table 1.4). · Most countries have invested more in food and health than in improving mothers' knowledge and practice of child care and feeding. Annex 1 lists more than 25 countries where different short route inter- ventions have been successful, while annex 2 discusses long routes to improving nutrition in more detail. The remainder of this chapter discusses some key lessons learned in four types of short route programs--growth 64 REPOSITIONING NUTRITION Table 3.1 Routes to better nutrition Demand-side Supply-side incentives Demand-side incentives behavior change Long routes · Primary health services · Economic develop- · Improving (such as family planning) ment (incomes of women's status and infectious disease the poor) · Reducing control · Participatory women's work- · Safe water and sanitation programs and policy load, especially · Policies on marketing development in pregnancy breast milk substitutes · Employment creation · Increasing · Food and agricultural · Fiscal and food women's policies to increase supply price policies to education of safe and healthy food, increase poor peo- or of healthier foods ples' purchasing · Food industry develop- power for the right ment and market incen- kind of foods tives (disincentives) for · Marketing regulation developing healthy of unhealthy foods (unhealthy) food · Fruit and vegetable production · Parks, bike paths, recreation centers Short routes · Community-based nutri- · Conditional cash · Maternal nutrition, tion and health services transfers knowledge, and (community growth · Microcredit cum care-seeking promotion programs, nutrition education during pregnancy community Integrated · Food supplemen- and lactation Management of tation · Infant and young Childhood Illnesses · Micronutrient child feeding [C-IMCI]) supplements · Weight control · Facility-based nutrition · Food stamps education and health services · Targeted food aid · Hygiene education (health and nutrition · Promoting healthy services, and antenatal life styles (increase care) physical activity; · Micronutrient supple- consume more ments fruits and vegeta- · Micronutrient fortification bles and less salt, · Targeted food aid sugar, and fat, and · Biofortification so on) ROUTES TO BETTER NUTRITION 65 promotion programs for young children, low birth-weight prevention programs, micronutrient programs, and food assistance and social protec- tion programs--before summarizing the less well-developed state-of-the- art with regard to tackling undernutrition associated with HIV/AIDS and issues of overweight and obesity. Community-Based Growth Promotion Programs These programs' main interventions are nutrition education or counseling (either with or without growth monitoring)--especially concerning mater- nal care and rest during pregnancy, exclusive breastfeeding and appropri- ate complementary feeding practices, birth spacing, and how to care for sick children--and links to essential health services. Some programs have also provided micronutrient supplements or food supplements for chil- dren and pregnant and lactating women. Throughout this report, we use the term "growth promotion" to refer to such community-based programs. Box 3.1 Why malnutrition persists in many food-secure households · Pregnant and nursing women eat too few calories and too little protein, have untreated infections, such as sexually transmitted diseases that lead to low birthweight, or do not get enough rest. · Mothers have too little time to take care of their young children or themselves during pregnancy. · Mothers of newborns discard colostrum, the first milk, which strengthens the child's immune system. · Mothers often feed children under age 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. · Caregivers start introducing complementary solid foods too late. · Caregivers feed children under age two years too little food, or foods that are not energy dense. · Though food is available, because of inappropriate household food allocation women and young children's needs are not met and their diets often do not contain enough of the right micronutrients or protein. · Caregivers do not know how to feed children during and following diarrhea or fever. · Caregivers' poor hygiene contaminates food with bacteria or parasites. 66 REPOSITIONING NUTRITION Box 3.2 Food security versus nutrition security? It is important to distinguish between food security and nutrition security, two quite different terms often used interchangeably in the literature. Food security, an important input for improved nutrition outcomes, is concerned with physical and economic access to food of sufficient quality and quantity in a socially and culturally acceptable manner. Nutrition security is an outcome of good health, a healthy environment, and good caring practices in addition to household-level food security. For example, a mother may have reliable access to the components of a healthy diet, but because of poor health or improper care, ignorance, gender, or personal preferences, she may not be able to or may choose not to use the food in a nutritionally sound manner, there- by becoming nutritionally insecure. Nutrition security is achieved for a household when secure access to food is coupled with a sanitary envi- ronment, adequate health services, and knowledgeable care to ensure a healthy life for all household members. A family (or country) may be food secure, yet have many individuals who are nutritionally insecure. Food security is therefore often a neces- sary but not sufficient condition for nutrition security. Program experience Successful, large-scale child growth promotion programs were established as long ago as the 1980s in India's Tamil Nadu state,1 Indonesia,2 and Thailand,3 and continue in Bangladesh,4 Honduras,5 Madagascar,6 and Senegal,7 among other countries. Such programs lead to a sharp decline in severe malnutrition in the first one to two years, with a slower rate of decline in moderate and mild malnutrition thereafter. A recent cross-country review of successful programs concludes that they led to an average fall in young child malnutrition of one to two percentage points a year--two to four times the 0.5 percent rate calculated as the average trend in the absence of such programs.8 Aside from the importance of targeting pregnant women and children under two years of age, those most vulnerable to malnutrition, key lessons about designing growth promotion programs include the following: · Female community workers are the best people to deliver services because they are less expensive than skilled health workers, on the spot, ROUTES TO BETTER NUTRITION 67 and able to communicate with mothers better than men. Low levels of formal education are not an impediment to workers' effectiveness so long as they are well trained. · Because moderate and mild malnutrition are not readily apparent, regular monitoring of children's weights on a growth chart is impor- tant, so mothers know whether their children are growing properly and can see the benefits of changes in practices; however, growth mon- itoring and promotion only work where programs can provide good training and effective supervision in weighing, recording, and coun- seling mothers, as well as other options for establishing regular contact with mothers. · Well-designed and consistent nutrition education, aimed at changing specific practices, is key. There are two ways to ensure that recommended child feeding and care practices make sense for poor people in their cul- tural and economic context (box 3.3). Breastfeeding promotion and appropriate complementary feeding for children are a central part of growth promotion programs listed as a short route to improving nutrition in table 3.1. But they deserve special men- tion, both because adequate breastfeeding and complementary feeding could prevent more than twice as many deaths of children under age five as any other intervention9 and because there are ways to improve these interventions besides growth promotion programs. An important policy intervention is enforcing the International Code on the Marketing of Breast Milk Substitutes, which prevents inappropriate promotion and market- ing of commercial infant formula products. A second way to improve breastfeeding is through the Baby-Friendly Hospital Initiative, which applies a 10-step process to improve practices in the labor and delivery wards of hospitals. The tenth step, focusing on follow-up at the commu- nity level, has been among the most challenging to implement. A third intervention, peer-to-peer counseling on breastfeeding (such as through La Leche League), has been used throughout the world to extend breast- feeding support to communities. Where we need to know more Key questions remain: · Inadequate training, support, and motivation for community workers are often the main reasons for unsuccessful implementation of growth promotion programs. What would be the most appropriate and sus- tainable human resource strategies for community health workers to 68 REPOSITIONING NUTRITION Box 3.3 Ensuring that new behavioral practices make sense for poor people Learning from "positive deviants" A good way to ensure new practices make sense is to see what positive deviants--poor women with well-nourished children--are doing right. Positive practices include everything from breastfeeding from both breasts in Indonesia, to building crude playpens in Bangladesh to keep children from contracting disease from dirty floors, to actively feeding fussy eaters in Mexico and Nicaragua, to adding locally scavenged pro- tein sources to complementary foods in Vietnam. Source: Marsh and Schroeder (2002); Zeitlin, Ghassemi, and Mansour (1990). Trials of improved practices (TIPs) TIPs is a consultative process to develop locally appropriate, culturally acceptable counseling messages that address resistance points and play to motivating factors. Formative researchers visit mothers to discuss child-feeding problems and possible solutions and negotiate changes in practice. They revisit when mothers have tried out the new practices and make modifications depending on what is found to be feasible. Experience with TIPs in more than 15 countries in Africa, Asia, and Latin America shows that trials with as few as 50 families, at a cost of $8,000 to $30,000 per country, can generate valid, programwide findings. For a how-to manual, see Dicken, Griffiths, and Piwoz (1997). Source: Costing information, personal communication with Marcia Griffiths. complement health care systems (for example, remuneration and incen- tives, pre- and in-service training methodologies, and good continuing education for community workers and supervisors) in resource-poor settings where capacity is weak? · Mothers and caregivers often face challenges in implementing advice on improving the care and feeding of young children. How best can we maximize family and community involvement to help them implement improved child-care and feeding practices at home? · Food supplementation is expensive, often taking up to 50 percent of the cost of a community-based nutrition program. Supplementing food for pregnant women and adolescent girls, which can improve birthweight and reduce maternal depletion, is especially expensive because they eat ROUTES TO BETTER NUTRITION 69 more than children. Under what circumstances is it cost-effective for countries to fund food supplementation for children (or mothers) as part of growth promotion or nutrition education programs, and how best can this food be targeted? Low-Birthweight Prevention Programs About 16 percent of infants globally have low birthweight, though these figures vary considerably from region to region.10 As noted in chapter 2, infants with low birthweights are more likely to die, more likely to become malnourished, and more vulnerable to adult-onset chronic diseases than children born at normal weight. Preventing low birthweight, however, requires attention to more than nutrition. Prematurity, short maternal stature, infections, cigarette smoking, alcohol and drug use, very young maternal age, indoor air pollution, domestic violence, closely spaced pregnancies, hypertension, stress, and malaria all contribute to low birthweight.11 Some strategies for preventing low birthweight are short route (malaria pro- phylaxis and treatment programs, iron and folate supplementation, food supplementation); others are longer route (smoking cessation, domestic violence, birth spacing). Some causes are easier to deal with; some can be dealt with through prenatal care; and others require intervention before pregnancy, even as early as childhood. The technical efficiency of some of the shorter route interventions is relatively well known: iron and folate supplementation, malaria pro- phylaxis, and food supplementation, when well targeted and imple- mented, have all been shown to have a positive effect on low birthweight or the health outcomes of the mother-child dyad during and after preg- nancy. Other relevant interventions--such as preventing unwanted preg- nancy, reaching women before and during pregnancy with appropriate services, overcoming social and cultural barriers to care seeking and behavior change (for instance, women in many regions of the world are thought to "eat down" during pregnancy to avoid having a large baby and a difficult birth), and convincing the woman and her family that her health is worthy of investment--may take longer. Furthermore, because many of the decisions or the circumstances happen either before marriage or soon after marriage, a focus on adolescent girls and newly married couples seems appropriate. Program experience Recent evaluation results from the large-scale Bangladesh Integrated Nutrition Project (BINP) project12 suggest that BINP improved selected knowledge and practices related to pregnancy by 20 to 40 percentage points. 70 REPOSITIONING NUTRITION There is some evidence that one of these practices (eating more during pregnancy) is associated with an 88-gram increment in birthweight among those reporting the practice. The evidence suggests little or no additional effect on pregnancy weight gain or birthweight for the population as a whole; however, consistent with theoretical expectations, subgroup analy- sis suggests sizable effects on birthweight among women who report that they eat more during pregnancy (an additional 88 grams), and an even greater impact among the destitute who report that they eat more during pregnancy (an additional 270 grams). Such large effects have not been demonstrated in effectiveness trials, primarily because few studies have looked at the mother-child dyad as a combination, instead focusing on the effect on either the mother or the child. Also, most evaluations have looked at a population as a whole, rather than at groups that have a potential to benefit. In the United States, the Women, Infants, and Children Program has successfully reduced low birth- weight through a combination of providing food coupons and linking preg- nant women to prenatal health care. This approach is akin to the conditional cash (food) transfers referred to in earlier sections, albeit not the same. Its applicability to less developed countries still needs to be tested. Results from the recent community trials of micronutrient supplementation in Nepal also demonstrated that iron and folic acid supplementation can reduce low birthweight by 16 percent, with mixed results on the added value of multiple micronutrient supplementation.13 Most mother-child food supplementation programs have documented more success with the child than with the mother. Until recently, the effect of food supplementation on birthweight has been demonstrated primar- ily in research settings (Narangwal in India, Four Village Study in Guatemala, Dunn Nutrition Centre studies in The Gambia, milk fortifi- cation in Chile).14 The size of this effect was 50 grams of birthweight for every 10,000 additional calories in pregnancy (in Guatemala and Indonesia). Programs have tried creative ways to overcome the cultural resistance to eating more during pregnancy or to resting during preg- nancy. The Tamil Nadu Integrated Nutrition Project (TINP) project in India provided a supplementary snack food to pregnant women, which was accepted largely because of its timing, convenience, and image as a snack, though there is little documented evidence of improvements in birthweight in TINP.15 Family planning, antismoking, malaria prevention, adolescent health, and reproductive health programs have all had some success, sometimes at large scale, but primarily as vertical efforts.16 The challenge in prevent- ing low birthweight at large scale is to combine forces, collaborate across departmental lines within and beyond ministries of health, and overcome ROUTES TO BETTER NUTRITION 71 the formidable problems of health service access, cultural barriers, and women's powerlessness and lack of self-confidence, while combining pre- ventive, therapeutic, and behavioral change approaches. Although this approach has not been demonstrated at scale yet, the potential for success through such integrated programming is there, especially as countries move from projects to programmatic and sectorwide approaches. Where we need to know more The evidence for large-scale programs that improve birthweight is much thinner than that for growth promotion or micronutrient programs. Intervention strategies for addressing low birthweight need to be tested at scale in more countries and in more integrated programmatic environments, rather than in vertical project approaches that are rarely sustainable. The scaled-up experience from Bangladesh needs to be reviewed carefully to see how strategies can be fine-tuned to maximize impact. Because food sup- plementation is a large part of the cost of such programs,17 the targeting and cost-effectiveness of food supplementation in pregnancy needs to be reviewed very carefully to maximize effects for the mother-child dyad (as opposed to effects on birthweight alone). Micronutrient Programs Fortifying foods and providing vitamin and mineral supplements are inex- pensive ways to address the widespread problem of micronutrient mal- nutrition. They can improve economic productivity and economic growth, enhance child and maternal survival, and improve mental development and intelligence in children (chapter 1). "No other technology offers as large an opportunity to improve lives at such low cost and in such a short time."18 Program experience Several countries have successfully iodized their salt supplies, thus reduc- ing goiter and cretinism, preventing mental retardation and subclinical iodine deficiency disorders (IDD), and contributing to improving national productivity. Iodized salt coverage rates of more than 75 percent have been achieved in 26 countries (Burundi, Cameroon, the Central African Republic, Eritrea, Kenya, Nigeria, Rwanda, Uganda, and Zimbabwe; Bolivia, El Salvador, Honduras, Nicaragua, Paraguay, Peru, and Venezuela; Armenia, Kazakhstan, and Turkmenistan; Bhutan, China, Lao PDR, and Vietnam; and Iran, Lebanon, and Syria; see map 1.4).19 Success with salt iodiza- tion, as with other forms of fortification, depends partly on how many 72 REPOSITIONING NUTRITION manufacturers there are, especially small-scale producers--the smaller the number, the easier it is to develop and regulate the program; how strong the legislative and regulatory system in the country is; and what proportion of the vulnerable have access to commercially fortified foods. Other suc- cess factors, more under the control of governments, include the need to: · Mount public awareness and advocacy campaigns so people know the benefits of using iodized salt. · Complement the carrot of awareness campaigns with the stick of legis- lation requiring iodization. · Back legislation with effective enforcement by ensuring that the amount of iodine in salt is monitored and that only iodized salt is sold in shops and markets. Developed countries have long fortified milk and breakfast cereals with vitamin A (and other vitamins and minerals), but in developing countries sugar has so far been the most successful vehicle. In Central America, Guatemala's sugar fortification program has virtually eliminated vitamin A deficiency; big reductions have also been seen in El Salvador and Honduras, where fortification was combined with supplementation.20 Sugar fortification and vitamin A supplementation were also combined in Zambia beginning in 1998, with demonstrated success so far in urban areas.21 But in much of Africa and Asia the poor do not consume as much sugar as they do in Latin America, so other countries are experimenting with fortifying wheat flour, cooking oil, and MSG (monosodium glutamate) with vitamin A. Research has shown that vitamin A supplementation can reduce young child mortality in deficient populations by an average of 23 percent.22 Vitamin A supplements lend themselves to distribution through a cam- paign approach because children require only two annual doses. Countries as different as Nicaragua,23 Niger,24 and Nepal25 have reached coverage levels of more than 80 percent (see map 1.3). Most campaigns were origi- nally attached to National Immunization Days, but as these are phased out in favor of immunization as a routine part of health services, countries have found other focuses for campaigns--for example, piggybacking on the Day of the African Child and World AIDS Day in Tanzania,26 or creating twice- yearly National Micronutrient Days, following the example of the Philippines and Niger. Iron programs to combat anemia have been less successful than iodized salt and vitamin A programs, yet models exist here too. Flour fortification with iron has substantially improved iron status across all population groups in Chile and Venezuela,27 and rice fortification with iron improved the iron status of school children in the Philippines.28 A promising large-scale ROUTES TO BETTER NUTRITION 73 trial of fortifying soy sauce in China also showed that it is a cost-effective way to reduce the prevalence of anemia ($0.0007 per person per year)29 among all population groups. Several small-scale community-based trials on home fortification with sprinkles for young children in Africa and in Asia have demonstrated that such innovations are feasible and as effective as commonly used ferrous sulphate drops in reducing the prevalence of anemia.30 The challenge of scaling up these programs remains. Where anemia is serious and widespread, as in much of South Asia, for- tification may not meet the iron needs of vulnerable groups such as preg- nant women, and supplementation is also required. Iron supplementation has proved more challenging than vitamin A supplementation because the supplement has to be taken daily and sometimes has perceived side effects. Consequently, there have been problems with the logistics of supply and sometimes with compliance. Indonesia and Thailand have made the most progress in reducing anemia. A practical publication called "What Works in Anemia Control"31 provides guidelines based on their experience and that of more than 20 other countries that have programs with aspects worth replicating. Last but not least, the Harvest Plus program is a promising initiative in which the international agricultural and research centers have begun to develop new breeds of staple foods that are rich in key vitamins and min- erals using a new approach to fortification termed biofortification (see www.harvestplus.org for details). Where we need to know more Key questions remain: · Under what circumstances is micronutrient supplementation more cost- effective than fortification? How can the two strategies best be combined to complement each other? · What is the scope for alleviating micronutrient malnutrition through breeding and consuming micronutrient-rich crop varieties and emerg- ing strategies such as biofortification? · How best can we maximize the opportunities for developing effective multisectoral partnerships (or National Fortification Alliances) with clear financial and operational commitments from all partners? 74 REPOSITIONING NUTRITION Food and Social Protection Programs Program experience Food assistance and social protection programs can be either long or short routes to improving nutrition. There are lessons about what does and what does not work. Two types of food assistance seldom work as nutrition interventions. General food subsidies can increase the food consumption of the poor, but they are a prohibitively expensive way to reduce malnutrition (box 3.4). School feeding programs can sometimes be justified in terms of providing an incentive for children to go to school and to perform better, but they are seldom a cost-effective nutrition intervention simply because undernutri- tion does its principal damage to preschoolers. Yet many governments try to justify school feeding for its nutritional benefits; if this means that school feeding comes out of the health and nutrition budget rather than the edu- cation budget, it can have big opportunity costs for programs that improve the nutrition of preschoolers. Nutrition education, iron supplements, and deworming are usually better school nutrition investments than school feeding. Iron supplements and deworming have been shown to improve schooling outcomes as well.32 Box 3.4 Food subsidies versus targeted social safety net programs Countries often resort to general food subsidies as a nutritional safety net program. Unfortunately, these programs are usually expensive and poorly targeted, and sometimes have perverse effects. Subsidies in the Republic of Yemen in the 1990s consumed more than 16 percent of the government budget and almost 5 percent of GDP, and yet only 7 percent of the bene- fits reached the poorest quintile of the population.33 In Morocco in the mid 1990s, the wheat flour "subsidy"--really a producer support pro- gram--was not only regressive and had a high opportunity cost (the 1.7 percent of GDP it cost could have been invested to generate substantial employment for the poor), but also had a negative environmental effect by encouraging farmers to expand wheat production onto more fragile lands.34 The good news, at least in the Middle East and North Africa, is that significant policy reforms have since taken place to replace food sub- sidies with more targeted and effective social safety nets. ROUTES TO BETTER NUTRITION 75 By contrast, food subsidies that are regular and significant, but tightly tar- geted to poor, malnourished populations, can be a cost-effective way to improve household food security--provided they are coupled with coun- seling services to help ensure that the additional food gets to the most vul- nerable household members.35 Targeting is often best achieved by subsidizing foods that are unattractive to nonpoor people. Furthermore, it has been found that subsidies in the form of food stamps do more to increase food consumption than the equivalent cash transfer. Yet improving house- hold food security is usually a long route to better nutrition, for the rea- sons given in box 3.1. When can food or cash transfers be short routes to improving nutrition? Experience suggests this happens mainly in three sit- uations: · When food assistance is made rapidly available to families who have suffered a serious food security shock, such as a crop failure. In such circumstances, it can safeguard children's as well as mothers' nutrition.36 But such aid needs to be well targeted and timely, so success depends on an effective early warning system, easily applicable targeting criteria, and a good storage and distribution network. · When food coupons or cash transfers to poor families are made conditional on beneficiaries using health and nutrition services. Conditional transfers were first tried in Honduras to protect the poor from the shock of structural adjustment, and then adopted by other Latin American countries as human development programs.37 Evaluations in Mexico,38 Colombia,39 and Nicaragua40 show that conditional transfers, though costly, work when there is political commitment and when they target the right pop- ulation with the right combination and quality of services (box 3.5). An important lesson is that these programs rapidly increase demand; hence, it is crucial to invest ahead of time in increasing service coverage for the poor, so supply can meet demand. In that context, conditional cash trans- fer programs can be an important component of both demand-side behav- ior change and supply-side interventions (see table 3.1). · When food supplements for children aged 6 to 24 months are used to educate mothers about the benefits of feeding small, affordable, additional amounts. As India's experience with food supplementation shows (see technical annex 4.1A), such programs need to be carefully designed if they are to improve home feeding practices and families' self-reliance, rather than becom- ing welfare entitlements that increase dependence on government. Conditional cash transfers may be an expensive option for effective nutri- tion interventions in poorer countries. An argument may be made that where governments may have decided for other reasons to make these transfers, adding a conditional element and linking it to enhanced supply 76 REPOSITIONING NUTRITION Box 3.5 Evidence that conditional transfer programs can work One of the best known programs, Mexico's PROGRESA (now called Oportunidades), aims to break the intergenerational transfer of poverty by encouraging poor families to use education, health, and nutrition services. Between 1997 and 2000, PROGRESA provided cash transfers to nearly 2.6 million rural families (40 percent of the rural total) in return for families participating in services that build human capital, such as schools, immunization services, and health and nutrition education for behavior change. Since 2001, it has also covered 2 million urban families. PROGRESA provides nutrition education, growth monitoring, and micronutrient-fortified foods to children aged 4 to 23 months, malnourished children aged 2 to 4 years, and pregnant and lactating women. Children who benefited from PROGRESA, compared with the control group that benefited one to two years later: · Had higher median food expenditure and higher intake of energy (7.1 percent). · Had a better quality diet because they ate more vegetables, fruits, and meat. · Were about 1 centimeter taller each year. · Had a more than 10 percent lower incidence of anemia. PROGRESA's effect was higher among younger children, girls, and children from poorer households. PROGRESA was also seen to have high distributional efficiency among the poorer populations for two reasons: more rural areas were targeted and larger families with more girls got larger transfers. Source: Gertler (2000); Behrman and Hoddinott (2001); Hoddinott and Skoufias (2003); Handa and Huerta (2004); Rivera and others (2004); Coady (2003). of services may make supply-side interventions more effective. Yet another variant of conditional cash transfers, a strategy that has not been tried at any large scale, is conditional transfers of food. Where we need to know more Most experience with conditional transfers has been in Latin American countries where relatively well-developed service delivery systems mean that supply was able to respond to increased demand. Key questions that remain: ROUTES TO BETTER NUTRITION 77 · What scope is there for conditional transfers to work in Africa or Asia, where budgets for transfers are often very limited and health and nutri- tion services and the capacity to strengthen them are often weak? · Where governments may have decided for other reasons to make trans- fers of food or other commodities, such as insecticide-treated bednets, would it be strategic to link these transfers with improved behaviors? Are conditional food transfers an option for improving nutrition? Malnutrition and HIV/AIDS Programs In the past several years, an increasing body of evidence has accumulated on the links between malnutrition and HIV/AIDS, and the effect of the two together on economic growth. There is little debate that nutrition plays an integral role in preventing, treating, mitigating, and caring for HIV-posi- tive individuals and affected households and communities (figure 3.1). Yet the strong and devastating interaction between malnutrition and HIV/AIDS--especially in Sub-Saharan Africa, where more than 60 percent of people with HIV/AIDS live and where malnutrition rates are increas- ing--has only recently been appreciated by policy makers. In a recent con- sultation on nutrition and HIV/AIDS in Sub-Saharan Africa, WHO and its partners41 emphasized two points: · Adequate nutrition cannot cure HIV infection, but is essential to main- tain a person's immune system, to sustain healthy levels of physical activity, and to support optimal quality of life. · Adequate nutrition is also necessary to ensure optimal benefits from the use of antiretroviral treatment, which is essential to prolong the lives of HIV-infected people and prevent transmission of HIV from mother to child. Two further points: · Exceptional measures are needed to ensure the health and well-being of all children affected and made vulnerable by HIV/AIDS, with young girls especially at risk. · Knowledge of HIV status is important to inform choices for reproduc- tive health and child feeding. Such measures will clearly need to include an increased focus on nutrition. An issue needing special attention is how to balance the well-known benefits of breastfeeding and the risk of HIV transmission through breast- feeding--a risk that is constant throughout the breastfeeding period.42 The 78 REPOSITIONING NUTRITION Figure 3.1 How malnutrition and HIV/AIDS interact Poor nutrition (Direct--weight loss, muscle wasting, weakness, micronutrient deficienty; Indirect--incapacitated breadwinner, children without adequate care, family budget diverted to health care) Increased nutrition needs (Due to Impaired malabsorption and immune system HIV decreased food intake (Poor ability and to address to fight HIV and infections and viral other infections) replication) Increased vulnerability to infections (Enteric infections--TB, diarrhea, respiratory infections--and thus faster progression to AIDS) Source: FANTA (2004); modified with information from Gillespie and Kadiyala (2005). dilemma is that switching to replacement feeding means children miss out on the immunity transmitted through breast milk and so are more susceptible to death or malnutrition from other diseases. The situation is further complicated by 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 feeding to mothers who are not HIV-positive). Furthermore, even women who know their status and choose alternative feeding often fall into the trap of mixed feeding (breastfeeding mixed with alternative ROUTES TO BETTER NUTRITION 79 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 continu- ous daily basis in hot, humid, resource-poor environments. Recent Box 3.6 Summary findings of scientific review on nutrition and HIV/AIDS · For uninfected mothers and mothers who do not know their HIV sta- tus, exclusive breastfeeding for six months is the ideal practice because of its benefits for improved growth, development, and reduced child- hood infections. Safe and appropriate complementary feeding and continued breastfeeding for 24 months and beyond is recommended. · HIV-infected mothers should avoid breastfeeding when replacement feeding is acceptable, feasible, affordable, sustainable, and safe. However these conditions are not easily met for the majority of moth- ers in resource-poor settings. If not feasible, early breastfeeding cessa- tion after exclusive breastfeeding (associated with less HIV transmis- sion than mixed feeding) is recommended for HIV-infected mothers and their infants. The age at which to stop breastfeeding depends on the circumstances of mothers and their infants. · Although there is no evidence to support a need for increased protein intake by people infected by HIV above that required in a balanced diet to satisfy energy need, energy needs do increase by 10 percent in asymptomatic HIV-infected adults and children and by 20 to 30 per- cent in adults with more advanced disease. For HIV-infected children experiencing weight loss, energy needs increase by 50 to 100 percent. · WHO's recommendations on vitamin A, zinc, iron, folate, and multiple micronutrient supplements remain the same. Micronutrient supple- ments are not an alternative to comprehensive HIV treatment, includ- ing therapy with antiretroviral agents. · Viral load, chronic diarrhea, and opportunistic infections impair growth in HIV-infected children, and poor growth is associated with increased risk of mortality. Improved dietary intake is essential to enable children to regain weight lost after opportunistic infection. · The lifesaving benefits of antiretroviral therapy are clearly recognized. To achieve the full benefits of such treatment, adequate dietary intake is essential. Dietary and nutritional assessment should be an integral part of comprehensive HIV care, both before and during antiretroviral treatment. Source: WHO (2005c). 80 REPOSITIONING NUTRITION findings on the lower risks of transmission through exclusive breastfeed- ing, compared with mixed feeding, warrant the promotion of exclusive breastfeeding until further evidence is available--especially in resource- poor environments.43 Program experience Uganda has led the way in incorporating nutrition considerations into counseling for people living with HIV/AIDS with an excellent set of guide- lines for service providers.44 A wide range of other nutrition­HIV/AIDS policy options including social protection and rural livelihood interventions are reviewed by Gillespie and Kadiyala (2005), but there is little or no evi- dence about the cost-effectiveness of the options or experience with their implementation at scale. However, there are inherent programmatic effi- ciencies in combining services because the vulnerable groups are similar and a common infrastructure will strengthen coordination, reduce frag- mentation of limited service delivery capacity, and increase the quality of program delivery. RENEWAL (Regional Network on HIV/AIDS, Rural Livelihoods, and Food Security), a recently launched international part- nership, aims to raise awareness, fill knowledge gaps, and help main- stream nutrition considerations into HIV/AIDS policy and HIV/AIDS considerations into nutrition policy (see www.ifpri.org/renewal). The U.S. Agency for International Development (USAID), through its Food and Nutrition Technical Assistance Project (FANTA) and Support for Analysis and Research in Africa (SARA) project, has been instrumental in keeping nutrition issues in the forefront of the development agenda for HIV research. The World Bank is starting an initiative to include nutrition inter- ventions in Multicountry AIDS Projects (MAPs), starting with two coun- tries, Mozambique and Kenya. The objective is to learn from this experience and to scale up to other countries in the region as well as to other non- MAP initiatives, such as President's Emergency Plan for AIDS Relief (PEPFAR). Although we are still learning how to combine HIV/AIDS and nutrition interventions, neither the virus nor programs to combat it wait for the sci- ence. Large-scale HIV programs are being implemented in many coun- tries, even as research is being carried out and policies developed. The challenges are to speed up research and to incorporate what we know about nutrition and HIV/AIDS as soon as possible into these large-scale programs. ROUTES TO BETTER NUTRITION 81 Where we need to know more Key questions: · What is the role of improved nutrition in offsetting and mitigating the economic effect of HIV/AIDS in affected households or communities? · WHO recommends early breastfeeding cessation after exclusive breast- feeding for HIV-positive mothers when alternative feeding is not accept- able, feasible, affordable, sustainable, and safe. What are the effects on growth and nutrition as well as HIV-free survival for children weaned early? · Under what circumstances is it cost-effective, feasible, acceptable, safe, and affordable to finance replacement feeding for HIV-positive mothers wishing not to breastfeed, and food supplements for people with HIV/AIDS? · What special nutrition and child care interventions may be needed for the children of parents with HIV/AIDS and single or double HIV/AIDS orphans? · Daily multivitamin supplements given to HIV-positive adults in the early stage of infection were found, in some studies, to slow HIV disease progression and are therefore suggested to prolong the time before antiretroviral drugs are needed.45 What is the most effective and efficient regimen for micronutrient supplementation for HIV- positive individuals? · Could eating more and a better diet, rather than supplements, also delay the onset of AIDS in HIV-positive people and the point at which anti- retroviral drugs are needed? What is the relative cost-effectiveness of nutrition interventions for potential cost savings on antiretroviral drug therapy? · The target group for HIV/AIDS-related nutrition programs is not just mothers and children--the main clients of other undernutrition programs--but a broader population. What does this mean for the design, management, and cost of nutrition and health services? Where the prevalence of HIV/AIDS is high, it affects not only indi- viduals and families, but also the development prospects of communi- ties and countries: for example, a labor force reduced by HIV/AIDS may compromise communities' capacity to produce food or to find volunteers for community programs. At the same time, lower productivity means governments have less tax revenue to fund development programs. A corresponding set of research questions at the national and global level includes these: 82 REPOSITIONING NUTRITION · When HIV/AIDS reduces financial and managerial capacity at the same time as it increases the need for government intervention, what does this mean for: ­ How governments should allocate investment between short routes to improving the nutrition of those with HIV/AIDS, and long routes such as livelihood creation? ­ How development partners allocate investment between develop- ment and social protection programs? · Most work on the interaction between nutrition and HIV/AIDS has been performed in Sub-Saharan Africa. In Asia, where the next phase of the HIV/AIDS pandemic will be concentrated, how will the interaction differ and how should interventions differ? · What are the opportunities for scaling up nutrition interventions through large scale AIDS programs/projects such as MAPs and PEPFAR? Programs to Tackle Overweight and Diet-Related Noncommunicable Diseases The problems of overweight and diet-related NCDs and ways to tackle them are much less well understood than the interventions for undernu- trition and micronutrient malnutrition (see technical annex 3.1 for what is known about the problem and potential solutions). Recent research sug- gests that obesity in school children and adults often has much earlier roots. Malnourished children are more likely to become obese later in life, and there is a growing body of evidence that suggests that maternal food depri- vation or low birthweight may program a child to be more prone to adult- hood obesity and NCDs.46 This--along with changes in eating habits and more sedentary lifestyles--helps explain why many developing countries that had high levels of low birthweight and early undernutrition are now experiencing an epidemic of NCDs. Program experience Because obesity is largely the result of changing eating habits, physical activity levels, and life styles, it is in principle largely preventable; and in practice, the high cost of treating obesity-related NCDs means that pre- venting excessive weight gain or promoting weight loss through a com- bination of nutrition and health education and food policy actions, which promote a healthier diet and lifestyle changes,47 are the only feasible way forward. However, if maternal deprivation, low birthweight, and early undernutrition predispose children to later obesity, then incorporating obesity prevention interventions into existing nutrition programs is not ROUTES TO BETTER NUTRITION 83 entirely incompatible, because undernutrition and micronutrient mal- nutrition programs mainly focusing on children under age two and preg- nant and lactating women will also have a positive effect on obesity. Other important entry points for tackling obesity are ages 4 to 7 years, adoles- cence, and early adulthood (see technical annex 3.1), so obesity programs inevitably involve a broader target group and hence higher cost and man- agerial complexity than traditional programs focused on undernutrition. There is a wide range of potential obesity interventions, ranging from education at the individual level to policy change at the national level (table 3.2). If obesity programs involve health, education, industry, the media, urban planning, transportation, and food and agriculture policy, they will require additional managerial capacity. Yet experience so far is that the seemingly more successful intervention programs, such as Finland's North Karelia project48 and Brazil's large-scale Agita program,49 have fol- lowed multiple approaches simultaneously. For example, the North Karelia project, launched in the early 1970s to prevent cardiovascular disease through lifestyle and risk factor changes, not only promotes healthy diets (that is, increased consumption of vegetables and fruits and reduced intake of salt), but also generates consumer market pressure for healthier food. Brazil's Agita program targeted school children, older adults, and work- ers with a combination of special events, informational materials, mass media, training for physical educators and physicians, worksite health promotion, and cooperative ventures with public agencies from several sectors. One lesson is that health services are not necessarily the main or the best vehicle for achieving behavioral change. Another lesson is that while demand-side interventions (nutrition education) seem the obvious strategy, supply-side interventions such as food policy and pricing of calorie-dense "junk foods" and fruits and vegetables may be equally important. Achieving an appropriate balance between the two may be complicated by conflicts of interest between public health goals (say, eating less energy-dense food) and commercial goals (say, selling more, often energy-dense, products). A key barrier to scaling up obesity programs is that very few have been well evaluated, partly because different outcome measures have been used and partly because many evaluations focus on changes in clients' awareness, rather than changes in behavior that actually affect obesity. Brazil's pro- gram, though better evaluated than most, illustrates this problem; it is clear that the program has led to behavioral change in terms of increased rates of physical activity, but it is not clear what the effects on obesity have been or which components have contributed to the effects. 84 REPOSITIONING NUTRITION Table 3.2 The range of interventions for obesity programs Intervention types Where implemented Communication Interpersonal Local clinic,50 school,51 about diet, workplace,52 community53 exercise, and life style Mass media54 Citywide, regionally, changes nationally Policy Provide parks, bike paths56 Locally change55 Promote fruit and vegetable Nationally growing and perishable food distribution systems57 Lower subsidies on sugar and dairy products58 Nationally Promote better-quality diet Nationally (low fat, low sugar) and market regulation59 Where we need to know more · Multitarget, multiagency programs such as Brazil's are relatively expen- sive as well as institutionally demanding. What is the relative cost-effec- tiveness of different approaches to controlling obesity and diet-related NCDs in different country circumstances? And, what is the appropriate balance between demand- and supply-side interventions? · In different country circumstances, how should obesity programs be tar- geted--on those with existing weight problems, on those at risk of obe- sity, or on the whole community? When in the life cycle are the best windows of opportunity for targeting programs to prevent obesity and diet-related NCDs? · There seems a clear link between agriculture and food policies and nutri- tion and health outcomes. What are the intentional or unintentional effects of policies in other sectors on nutrition? · Other barriers to progress include lack of awareness among politicians of the seriousness of the obesity problem; lack of awareness among econ- omists and financial planners of its costs; and cultural norms among the obese in some societies that weight is not a concern (there is some ROUTES TO BETTER NUTRITION 85 evidence that preference for smaller body sizes rises as countries mod- ernize). In such circumstances, how best can we increase commitment to obesity and diet-related NCD prevention programs, among both policy makers and the public, without crowding out the undernutrition agenda? · What combinations of integrated interventions can cost-effectively address both undernutrition and overweight in nutrition transition coun- tries? What effective policies that promote healthier foods and diets can also target undernutrition and overweight simultaneously? The Role of Policy Nutrition policy--the laws, regulations, and rules that govern public budget allocation and action to improve nutrition--is important, as are programs. For example, an appropriate policy framework is important for the suc- cess of programs to reduce obesity (box 3.7). In an ideal world, each coun- try would be committed to a nutrition policy outlining quantitative, time-bound nutrition goals; establishing an overarching strategy; priori- tizing specific practical and effective policy reforms and programs; and systematizing progress monitoring and reporting. The policy process However, experience with nutrition policy making and implementation has by and large been discouraging. Some countries lack explicit nutrition policies altogether. Others have policies that have not been implemented because they suffer from some or all of the following weaknesses: · They embrace broad goals without setting specific targets, what inter- ventions will be used to achieve them, and who will be responsible. · They are not based on analysis of what the different interventions will cost and how they will be financed and implemented. · They are not linked to investment plans and budgets, or to a monitoring and evaluation process that will inform policy makers on their progress. Beginning in 2000, the United Nations Children's Fund (UNICEF) and the World Bank jointly reviewed their work in nutrition over the preceding 20 years, with particular emphasis on what they had learned about the policy process.60 Key conclusions were that policy should be based on a more careful review of country commitment and capacity (both financial and managerial) and that strategies should focus on how they will be imple- mented61--unlike several National Plans of Action for Nutrition devel- oped after the 1992 International Conference on Nutrition, which contained no discussion of implementation. Policies and strategies work only if they 86 REPOSITIONING NUTRITION are the product of discussion and agreement among stakeholder institu- tions regarding what they are able and willing to do, and what will be financed and how. The central importance of the commitment to implement policy can be illustrated by some contrasting country experiences. India developed a national nutrition policy in 1993, a national plan of action for nutrition in 1995, and set up a national nutrition council to oversee implementation. But seven years later the council had not yet met.62 Thailand paid less atten- tion to formal nutrition policy but based its multisectoral nutrition pro- gram on an implementation-oriented investment plan and budget, to which sectoral ministries were committed.63 Vietnam iodized a substantial pro- portion of its salt by 1998, even before it formulated policy or legislation for salt iodization--in contrast to the Philippines, which enacted legisla- Box 3.7 The role of public policy Policy has a potential role in diminishing the poor health and negative economic outcomes associated with the increase in overweight and obesi- ty in developing countries through both demand-side and supply-side interventions. Demand-side · Change the relative prices of healthy and unhealthy foods. · Provide national diet guidelines and food labels to give clearer infor- mation about healthy diet and product contents. · Provide information campaigns to raise awareness of the consequences of poor diet and obesity. · Develop appropriate multisectoral approaches to address the market- ing of unhealthy food to children. Supply-side · Increase investment in agriculture to raise productivity and lower the price of fruits and vegetables. · Eliminate price incentives for high-fat foods and relax quantity restric- tions on healthier foods. · Regulate trade policies to reduce import tariffs on fruits and vegeta- bles. · Enforce tougher standards on the fat content of processed foods or food consumed away from home. Source: Excerpt from Haddad (2003); modified with information from WHO (2004). ROUTES TO BETTER NUTRITION 87 tion in 1994, but by 1998 had iodized less than 14 percent of its salt. As the UNICEF-Bank review concluded, "policy is what policy does."64 Policy choices Nutrition policy therefore needs to realistically reflect country commitment and capacity and be part of a process to turn policy statements into action. It also needs to address specific policy choices. Thailand was able to mount a successful multisectoral nutrition program because it was strongly com- mitted to nutrition; because it had the necessary management capacity; and because a cultural tradition of community self-help enabled it to expand its national growth promotion program cheaply, using village volunteers.65 Other countries may not be in this fortunate position: where commitment or financial and managerial capacity are limited, it may make sense to focus in the short run on limited, achievable nutrition goals within one or two sectors. This prioritization will need careful consideration of the trade-offs among the many actions necessary when malnutrition is widespread and holding back development, and the country's capacity to manage these events is limited. Some key priorities, trade-offs, and mismatches are dis- cussed in the next sections. Short routes versus long routes. One key policy choice is how much to invest in long route investments, as opposed to short route ones. Where finances are tight, short route interventions often offer more bang for the buck. They affect nutrition more directly, and most countries have invested less in micronutrient and growth promotion programs than they have in food and agriculture--despite the evidence from many countries showing that malnutrition exists even in food-surplus areas and among the non- poor (chapter 2). If this is the case, the most cost-effective course of action in the short run may be to concentrate additional funds for nutrition on short route interventions, while complementing these by reallocating exist- ing long route expenditures to have more effect on nutrition. For example, this could be accomplished by: · Focusing agricultural research and extension on crops grown by women because women's income is more likely to be spent on food-related expenditures for women and children. · Targeting water and sanitation programs to areas where diarrhea is a major contributor to malnutrition. · Using nutritional status as a criterion for targeting existing social pro- tection programs. · Optimizing the availability of certain kinds of foods (fruits and vegeta- bles, sugars and fats and oils, junk foods) and influencing the demand for these foods. 88 REPOSITIONING NUTRITION Food supplementation versus health care and micronutrient inter- ventions. There are also important policy choices in striking a balance between short route interventions. Many nutrition programs focus on food supplementation in situations where poor access to health services, poor child-care practices, or micronutrient deficiencies are the main causes of malnutrition. For example, a recent review of nutrition priorities in the Poverty Reduction Strategy Papers (PRSPs) of 40 countries where malnu- trition is serious showed that whereas vitamin A deficiency and anemia are public health problems in 35 and 34 countries, respectively, only 13 included activities to address these deficiencies. Micronutrient programs are an attractive policy choice because of their low cost per head. Where both micronutrient malnutrition and undernu- trition are problems, and where countries lack the commitment or the funds to go to scale with multiple short route nutrition programs at once, it can sometimes make sense to scale micronutrient interventions up first, while experimenting with how best to organize growth promotion. Although success with micronutrients is no substitute for investing in large-scale growth promotion programs, it can build the commitment to invest more in growth promotion. Putting more government money into micronutrient supplementation and budgeting for it within the governments' medium-term expenditure frameworks is particularly important if it is to be sustained: many coun- tries are now dangerously dependent on external grants for these efforts, just as they were dependent on grant finance in the early stages of the uni- versal immunization program. Nevertheless, investment in micronutri- ent programs must not crowd out attention to general undernutrition, as has been the case over the past decade in some countries. Instead, the capacity and confidence built in the process of implementing micronutri- ent programs could be used as a building block to implement large-scale community-based nutrition programs that require more complex man- agement skills. Coverage versus intensity. Experience from programs such as those in Bangladesh, Madagascar, and Mexico shows that the tensions between con- solidating the quality of program implementation and the political impe- tus to expand (or to close down) programs need to be managed very carefully. When political commitment is high, too rushed expansion can compromise program quality. Yet the opportunity and political commit- ment for expansion does not present too often. Balance is the key. Some countries have tried to increase the coverage of growth promotion programs--as is often politically expedient--at the expense of quality and the intensity of resource use, whether in the ratio of field workers to clients or the ratio of trainers and supervisors to field workers. This trade-off usually ROUTES TO BETTER NUTRITION 89 has big costs in terms of quality and effect. A recent review of community growth promotion programs suggests the need for worker-household ratios in the range of 1 to 10 or 20 for part-time volunteers and 1 to 500 for full-time paid workers, and supervisor-worker ratios of about 1 to 20.66 Younger children versus older children. Although most undernutri- tion happens during pregnancy and the first two years of life, and most of this early damage cannot be reversed, many programs. The poor versus the better off. Though data consistently show that mal- nutrition is concentrated among the poor, many programs (by design or through faulty implementation) fail to target either the poorest geographic areas, or the poorest people in mixed-income communities. Benefit-inci- dence analyses should therefore be part of program evaluations and feed into the design of policies and strategies. Mismatches between the malnutrition problem and the proposed solutions. While most countries do not scale up nutrition programs to any reasonable level (see table 1.8), many do scale up the wrong kinds of pro- grams or interventions. Three mismatches between the need or the cause of malnutrition and the design of programs were identified in India67 and are common across many other programs: · The "food first" mismatch: Many nutrition programs focus on food secu- rity and food supplementation in situations where poor access to health services or poor child-care practices are the main causes of malnutrition. · The age-targeting mismatch: Most undernutrition happens during preg- nancy and the first two years of life, and most of this early damage cannot be reversed (chapter 2). Yet many programs continue to expend large resources (especially food) on other age groups (for example, children aged 3 to 6 years, school children). The recent push in Africa for school feeding programs is yet another example of mistargeted resources and is particularly ironic in resource-scarce settings, where it has high oppor- tunity costs. · The poverty-targeting mismatch: Though data consistently show that mal- nutrition is concentrated among the poor, many programs (whether by design or through faulty implementation) fail to target either the poor- est geographic areas or the poorest people in mixed-income communi- ties. Benefit-incidence analyses should be part of all program evaluations. As mentioned earlier, a recent review of nutrition in the context of PRSPs shows that among 40 countries that have PRSPs, 38 had a micronutrient problem, yet only 23 had specific activities to address micronutrient mal- nutrition. However, more than 90 percent mentioned food security inter- ventions, even when food security may not have been the major problem. 90 REPOSITIONING NUTRITION Intentional and Unintentional Nutrition Policies Some intentional nutrition policy choices in certain sectors clearly relate to nutrition (box 3.8). In addition, policies in seemingly unrelated sectors can have a strong positive or negative effect on nutrition, in large part through price effects on food and other inputs to good nutrition. For instance, in the mid 1990s, the devaluation of the CFA franc had a large and immedi- ate effect on the Sahelian countries: the urban poor were particularly hard hit, as food prices rose sharply.68 Another dimension of nutrition policy making is therefore the analysis of the nutrition implications of macroeco- nomic and sectoral policies, and the development of ways to enhance their positive effects and mitigate their negative ones, for example, by develop- ing compensatory nutrition programs, as Senegal did when the CFA franc was devalued, to cushion the impact on the poor. A wide range of policies can have unintended effects on nutrition (table 3.3). Box 3.8 Impact of agricultural and food policies on nutrition and health Agricultural and food policies can affect nutrition and health outcomes both positively and negatively. For example, many Organisation for Economic Co-operation and Development (OECD) countries tend to sub- sidize grains (such as wheat and maize) more than fruits and vegetables, thereby directly increasing consumption of grains (and indirectly meats), while reducing consumption of fruit and vegetables. A recent review of the European Union (EU) Common Agricultural Policy noted that its sup- port for the cattle sector produced excess dairy products and aided con- sumption of saturated fats. As a result, diet-related disease, particularly cardiovascular disease, claims more than 7 million years of life annually and obesity-related costs are 7 percent of the EU health care budget. In Poland, the withdrawal of large consumer subsidies (especially for foods of animal origin) and subsequent substitution of unsaturated for saturated fats and an increased consumption of fresh fruits and vegeta- bles are believed to have decreased the prevalence of ischemic heart dis- ease and mortality from circulatory diseases since 1991. Source: Gastein Opinion Group (2002); Zilberman (2005); Zatonski, McMichael, and Powles (1998). ROUTES TO BETTER NUTRITION 91 Table 3.3 Examples of unintentional nutrition policies Policy Potential nutrition effects Foreign · Overvalued rates favor urban consumers of imported food exchange at the expense of rural food producers, who are at greater nutritional risk. Trade · Protecting local food producers by restricting imports raises consumer prices and net food purchasers (including most poor farmers) are taxed. · Customs and border controls on import of unfortified food where food fortification is mandatory (as with flour in Bolivia and salt in several countries) promotes nutrition. Environment · Preserving forests and parks promotes recreational exercise as part of reducing overweight; forests are a major source of foraged food. Energy · Taxation or subsidies on domestic fuels affect the type and amount of fuel used for cooking, which affects diet (for example, choosing to cook refined rice instead of sorghum or millet in the urban Sahel). Employment · Policies that require firms to offer breaks to lactating women during which they breastfeed their infants. Roads and · Safe bike paths and sidewalks in urban areas help promote public safety recreational exercise (as in the "healthy city" program in Bogotá, Colombia). Agriculture · Producer subsidies, publicly financed research, and public investments in infrastructure and markets can implicitly subsidize sugar, large animal livestock, oilseeds, and male- controlled cash crops instead of fruits and vegetables, coarse grains, or women-controlled crops, which affect the availability and price of foods and shift household decision-making power away from women. · Regulations or standards of identity of foods, permitted ingredients, purity, safety, nutritional content, labeling, and marketing can promote or inhibit food fortification (as with salt iodization in India), healthy consumer choices (as in Korea), and nutrition knowledge (as in Europe and the United States). Health · National health insurance and guaranteed basic health service packages that include (or exclude) growth promotion, micronutrients, and nutrition counseling can affect nutrition (as in Bolivia). · Regulations restricting marketing and distribution of breast milk substitutes, including through hospitals, can encourage breastfeeding. Education · Curricula requiring physical education, nutrition, and consumer education (as in Singapore). continued 92 REPOSITIONING NUTRITION Table 3.3 (continued) Policy Potential nutrition effects Social welfare · Social safety nets targeted to the poor ensure access to a minimum diet (income transfers, food stamps, institutional feeding). · Efforts to ensure the quality, availability, and affordability of early childhood development and parent education programs that include nutrition. Program experience Food policy analysis attempts to systematically analyze the effects of such disparate policies on the food consumption and nutrition of the poor.69 Macroeconomic and sectoral food policy analysis has been conducted in India,70 Tunisia,71 Mozambique,72 and Indonesia,73 to name a few, and valu- able lessons have been learned about how to effect policy transition in this highly politicized subject.74 Poverty and Social Impact Analyses (PSIAs) take food policy analysis further, by embedding it in poverty strategies, sectoral reform, and structural adjustment. Within countries, it is impor- tant to create the capacity to advise policy makers about the nutrition effects of policies in a focal institution, such as a ministry of finance or a poverty monitoring office. Where we need to know more Some basic data gaps make it hard to allocate resources sensibly: · More than 20 African countries lack adequate nutrition status or trend data.75 · Many more countries in all regions lack reliable data on the coverage and quality of existing nutrition projects and programs. Better cost, affordability, and financing analysis are needed almost every- where, on several subjects: · What national interventions cost in different country circumstances.76 · What financing can be raised by reallocating expenditures on inef- fective programs and which programs can be better redesigned and retargeted. ROUTES TO BETTER NUTRITION 93 · What additional public spending will be required, and how it can be financed and incorporated into regular government budgets. · How benefit-incidence analyses can be made a regular part of program evaluations. Notes 1. World Bank (1994a). 2. Berg (1987). 3. Tontsirin and Winichagoon (1999). 4. World Bank (2002b); Pelletier, Shekar, and Du (forthcoming). 5. Van Roekel and others (2002); Griffiths and McGuire (2005). 6. World Bank (1999b). 7. World Bank (2001b). 8. Mason and others (forthcoming). 9. Jones and others (2003). 10. ACC/SCN (2000). 11. ACC/SCN (2000). 12. Pelletier, Shekar, and Du (forthcoming). 13. Christian and others (2003); Orsin and others (2005). 14. ACC/SCN (2000). 15. World Bank (1994a). 16. Barros and Robinson (2000). 17. OED (2005c). 18. World Bank (1994b). 19. UNICEF and MI (2004a). 20. Mannar and Shankar (2004). 21. Serlemitsos and Fusco (2001). 22. Beaton and others (1993). 23. Mora and Bonilla (2002). 24. Aguayo and others (2005). 25. Fiedler (2000). 26. Masanja and others (forthcoming). 27. Mannar and Shankar (2004). 28. Mannar and Gallego (2002). 29. Chen and others (2005). 30. Zlotkin and others (2005); Sari and others (2001). 31. Galloway (2003). 32. World Bank (2002c). 33. World Bank (1999a). 34. World Bank (1999a). 35. Alderman (2002). 36. Quisumbing (2003); Yamano, Alderman, and Christiaensen (2005). 94 REPOSITIONING NUTRITION 37. Coady (2003); Rawlings (2004). 38. Behrman and Hoddinott (2000); Gertler (2000); Hoddinott and Skoufias (2003); Handa and Huerta (2004); Rivera and others (2004). 39. Attanasio and others (2005). 40. Maluccio and Flores (2004). 41. WHO (2005c). 42. Coutsoudis and others (2004); Iliff and others (2005). 43. Coutsoudis and others (1999); Iliff and others (2005); Ross and Labbok (2004). 44. Republic of Uganda (2004). 45. Fawzi and others (2004, 2005). 46. Barker and others (1992); Ravelli and others (1998); Barker and others (2002); Barker (2002); Prentice (2003); Barker (2004). 47. Zatonski, McMichael, and Powles (1998). 48. Puska and others (1998); Puska, Pietinen, and Uusitalo (2002). 49. Matsudo and others (2002); Ramsey and others (2002). 50. NICHM (2003); Sothern and others (2000); Sothern and others (2002). 51. NICHM (2003); Coleman and others (2005); Dowda and others (2005). 52. Coleman and Gonzalez (2001); Doak (2002). 53. Matsudo and others (2002); Kahn and others (2002); Puska and others (1998, 2002); Toh and others (2002); WHO (2000a). 54. Lee, Popkin, and Kim (2002); Doak (2002); Carroll, Craypo, and Samuels (2000). 55. Haddad (2003); Hawkes and others (2005). 56. Neiman and Jacoby (2003). 57. Nugent (2004); Lee, Popkin, and Kim (2002). 58. Nugent (2004). 59. Nugent (2004). 60. Gillespie, McLachlan, and Shrimpton (2003). 61. See especially Pelletier, D., "A Framework for Improved Strategies" in Gillespie, McLachlan, and Shrimpton (2003). 62. Gillespie, McLachlan, and Shrimpton (2003). 63. Heaver and Kachondam (2002). 64. Gillespie, McLachlan, and Shrimpton (2003). 65. Heaver and Kachondam (2002). 66. Mason and others (forthcoming). 67. Gragnolati and others (forthcoming). 68. Diagana and others (1999). 69. Timmer, Falcon, and Pearson (1983). 70. World Bank (2001c). 71. Tuck and Lindert (1996). 72. World Bank (1989). 73. Leith and others (2003). 74. World Bank (1999c). 75. Chhabra and Rokx (2004). 76. For a useful guide to nutrition program cost analysis, see Fiedler (2003). 4 Getting to Scale This chapter focuses on the challenge of scaling up programs for undernutrition and micronutrient malnutrition in more countries, whether on their own, or as is increasingly the case, as part of health, community development, or other sec- toral and cross-sectoral initiatives. There are different options in terms of policy choices, institutional arrangements, and financing approaches, and more analy- sis on which options are appropriate in which country circumstances will be useful. Several countries have already scaled up successfully, and lessons have emerged from their experiences in managing nutrition programs and organizing services, developing approaches for coordinating with development partners and obtaining financing, and finding ways to strengthen commitment and capacity. The key issue facing the international community is not so much how to scale up or what to scale up, but how to strengthen countries' commitment and capacity to do so. This chapter reviews lessons from the experience of countries that have tried and succeeded, and tried and failed, to scale up nutrition programs. It focuses on options for managing nutrition programs, organizing services, channeling finance and coordinating financiers, and strengthening com- mitment and capacity. Managing Nutrition Programs The international nutrition community has done less analytical work on these four areas mentioned above than on the efficacy and effectiveness of different nutrition interventions (chapters 1 and 3), reflecting a long-stand- ing bias in nutrition research.1 95 96 REPOSITIONING NUTRITION Managing nutrition programs in the field Of the four areas, there is substantial literature only on how large-scale community growth promotion programs are best designed and managed in the field.2 Two clear lessons emerge from this literature: · Involving and, as far as possible, empowering communities are key. This means not only consulting communities about the design of nutrition education and using community workers to deliver services (chapter 3), but also mobilizing communities through well-planned communication programs and giving them a role in designing, monitoring, and man- aging nutrition services. This was attempted in Senegal's first commu- nity nutrition project (technical annex 4.1B). · Successful programs also pay attention to the detailed micro-level design of management systems for targeting program clients; selecting, train- ing, and supervising staff; and monitoring progress. Monitoring processes that focus communities and implementing agencies on outcomes or results are particularly important. India's Tamil Nadu Integrated Nutrition Project (TINP) (see technical annex 4.1C) and Honduras' Atención Integral a la Ni_ez (AIN) (see technical annex 4.1D) programs are examples of paying special attention to the detailed design of man- agement systems. Managing nutrition programs at the national level The many sectors and agencies involved in improving nutrition make management difficult. Because nutrition does not naturally fall under a single line ministry, there has been long-standing debate and experiment (see Levinson 20023 for a review) about where its institutional home should be. Experience shows both what does not work (technical annex 4.1E) and what can work. In practice, successful nutrition programs have been managed by a variety of line agencies in different countries, with effective oversight from a variety of coordinating or managing bodies: for exam- ple, in Burkina Faso, from a National Food Policy Coordinating Committee; in Madagascar, from the Prime Minister's office; in Senegal, from the President's office; and in Honduras, from a ministerial-level body in charge of coordinating foreign-assisted projects. One set of emerging lessons: · There should be a clear division of responsibilities among implementing institutions. GETTING TO SCALE 97 · Although oversight agencies should not be given implementation respon- sibilities, they should be able to influence intersectoral resource alloca- tion so they have a way to give implementing agencies an incentive to perform. · Where the oversight institution is located is less important than that it is at a high level and that it is backed by strong political and bureaucratic commitment. Thailand managed its national nutrition program, perhaps the world's most successful, along these lines as detailed in box 4.1. Another clear lesson is that, although oversight and control are impor- tant, the best results are obtained when stakeholders cooperate as willing partners, whether in programs involving multiple government agencies, public-private partnerships such as those for food fortification, or programs bringing together multiple development partners or cofinanciers. Progress is being made with technologies for partnership building (see Tennyson 2003 for a recent how-to guide). Box 4.1 How Thailand managed its National Nutrition Program Thailand had no agency in charge of nutrition. The National Nutrition Program's overall direction was set by a National Nutrition Committee, chaired by the Deputy Prime Minister, on which the line agencies in the program were represented. The Committee was served by a small secre- tariat, headed by the Deputy Secretary-General of the National Economic and Social Development Board (NESDB, Thailand's planning ministry) and housed initially in the NESDB and later in the health ministry. The program was set out in an annual national food and nutrition plan, allocations to which were controlled by the NESDB, based on line agen- cies' performance. The Ministries of Health, Interior, Agriculture, and Education helped draw up their parts of the plan and control its imple- mentation, so they were motivated to perform. The Permanent Secretaries of the four ministries met once a month to coordinate their work. Thus in Thailand, it is less appropriate to speak of one multisectoral national nutrition program than of a set of nutrition programs in different sectors, run by different agencies. Source: Heaver and Kachondam (2002). 98 REPOSITIONING NUTRITION Where we need to know more Key areas for further work: · Best-practice case studies of how countries have organized multisec- toral nutrition program management and partnership building at cen- tral and field levels, and action research on how partnership approaches are best organized and managed in different country circumstances. · Best-practice case studies of monitoring processes that focus policy makers, implementers, and communities on outcomes and results. Organizing Services Because nutrition is not a sector, but contributes to the activities and out- comes in a variety of sectors, nutrition services need to be integrated into existing sectoral programs and build on existing institutional capacity. Using existing capacity is particularly important if nutrition programs are to scale up in Sub-Saharan Africa and other environments where financial and managerial resources are limited. Fostering public-private partnerships Countries are increasingly using institutional resources outside government. Food fortification programs harness the institutional capacity of the com- mercial private sector for production and marketing, while the government's role is usually to build awareness, monitor, and regulate. The Micronutrient Initiative (MI), the United Nations Children's Fund (UNICEF), and the World Bank have had successful experience in assisting governments in this area, especially with salt iodization. A new international nongovernmental orga- nization (NGO), the Global Alliance for Improving Nutrition, has been cre- ated to help foster partnerships for food fortification. Similarly, a new Network for Sustained Elimination of Iodine Deficiency is emerging from the Micronutrient Initiative--although questions remain about whether approaches that deal with single nutrients are the best way forward. Experience from these initiatives is still emerging, and the potential of such public-private partnerships is only beginning to be exploited. In each country, there is a need to identify ways in which the food industry can be involved in designing and supporting implementation of the national nutri- tion strategy. This means developing a multisectoral alliance in each coun- try between industry, the national government, international agencies, expert groups, and other players to work on specific issues relating to technology; food processing and marketing; standards; quality assurance; product GETTING TO SCALE 99 certification; social communications and demand creation; and monitoring and evaluation. As well as working with the commercial private sector, governments are increasingly working through partnerships that use the institutional capacity of NGOs for growth promotion as well as micronutrient pro- grams--as in 1993 in Madagascar, in 1995 in Senegal and Bangladesh, and more recently in Honduras and Uganda. Contracting with NGOs poses a management challenge for governments: NGOs have to be overseen, so developing adequate procurement, performance monitoring, and account- ing capacity in government is essential. But NGOs have proved flexible and many of them, especially locally based ones, are highly motivated and skilled at mobilizing local communities. And because they are employed on a contract basis, they can be phased out once malnutrition rates decline-- an exit strategy that is very difficult to implement in programs that rely on government field staff. Mainstreaming nutrition into sectoral programs and projects However, most countries lack a strong network of NGOs and need to orga- nize growth promotion services through government agencies. Integrating these services into existing health and child development programs is one logical option. The World Health Organization (WHO) and UNICEF recently commissioned an exhaustive review of more than 700 studies to determine what combination of interventions would have the most impact on child growth and development.4 Of the 12 interventions this review came up with (see technical annex 4.2A), 5 were in nutrition and 7 in health and hygiene, illustrating why it makes sense to build nutrition interventions into health services (the 12th was in cognitive and social development in early childhood). These 12 interventions now form the core of the Community-Integrated Management of Childhood Illnesses (IMCI) ini- tiative championed by UNICEF and WHO. Mainstreaming nutrition into health services. Progress is being made in integrating nutrition interventions into health services through several initiatives. One is the WHO and UNICEF­assisted IMCI program, which has made considerable progress in integrating nutrition interventions into health services at hospitals and clinics. The next step, applying IMCI to ser- vices at the community level, is at the pilot stage in several countries. Another initiative is Essential Nutrition Actions, developed by USAID and being implemented by governments and NGOs in several countries. It sets a framework for identifying entry points and tools for integrating essen- tial nutrition actions in policy, health, and community programs. In the Basic Support for Institutionalizing Child Survival (BASICS) projects, 100 REPOSITIONING NUTRITION nutrition activities are being incorporated into the routine work of health personnel (technical annex 4.2B). Micronutrient supplementation programs have also successfully mainstreamed nutrition through health. Mainstreaming nutrition into community development programs. But integrating nutrition into health services is not the only option. A comple- mentary opportunity, little exploited so far, is to integrate nutrition into the community-driven development (CDD) programs that are scaling up rapidly in Africa and elsewhere,5 rather than duplicate institutions for mobilizing and empowering communities in each sector. Integrating nutrition into CDD programs poses risks as well as opportunities,6 especially the risk that when empowered to choose their own development priorities, com- munities may opt for investments in infrastructure rather than nutrition. But incorporating nutrition into community development has three poten- tial advantages: · Growth monitoring data can help communities define their problems and monitor their progress, as in the World Bank­supported Sri Lanka Poverty Alleviation Project.7 In Thailand, growth monitoring data lead the list of community development indicators that are displayed in every village (technical annex 4.1F). · Growth monitoring data can help CDD programs target their interven- tions in different sectors to the families for which they will do most good. · CDD programs that finance investments in agriculture, income genera- tion, gender, and social protection can help integrate and balance short Box 4.2 Assessment, analysis, and action: The "Triple A" process The Triple A process was developed in Tanzania's Iringa district and then replicated in several other districts, with assistance from UNICEF. Community workers used child growth monitoring to assess the nutrition situation, identifying families in which there was actual malnutrition and families in which a child's growth was faltering and malnutrition needed to be prevented. They then worked with the family to analyze the possi- ble causes: ill health, poor child-care practices, food insecurity, or some combination. Working with the family and with local government organi- zations, they drew up a tailor-made plan of action to help the family. Depending on the cause of malnutrition, the intervention might be coun- seling, referral to the health service, or participation in a livelihood cre- ation, microcredit, or social protection program to improve food security. Source: UNICEF (1990). GETTING TO SCALE 101 route and long route approaches to improving nutrition at the local level. A practical process for achieving this was developed in the 1980s in Tanzania (box 4.2). Where we need to know more · Cultural traditions favoring community service vary, as do the amount of time and energy women have. Where are paid community workers likely to be more effective than volunteers? · What can be done to build and strengthen the trust of governments to give communities and NGOs more responsibility and accountability for identifying and addressing their development problems, with only selec- tive external help? · While the potential exists for early childhood development programs to improve nutrition, there has been mixed experience with delivering nutrition services through them.8 How could such programs be designed to make the most impact on nutrition? Channeling Finance and Coordinating Financiers Many countries with serious undernutrition problems need external assis- tance to help them scale up nutrition services. Whether nutrition actions are sustained and institutionalized depends critically on what vehicles and approaches are chosen for financing them. Projects Traditional projects are ideal vehicles for testing delivery strategies before scaling up and have also proved well suited to developing capacity--espe- cially, in the World Bank's experience, when improving nutrition is the pri- mary goal of a substantial project, as in Bank-financed projects in Bangladesh, Honduras, Madagascar, Senegal, and Tamil Nadu.9 Among their advantages: enough money was spent on nutrition to make an impact; enough technical resources could be put in for effective systems develop- ment and learning-by-doing; and managers had a strong incentive to focus on nutrition outcomes because they were the primary project goal. Large- scale projects with an emphasis on capacity building are therefore likely to continue to have a role to play. But many countries are implementing large numbers of small-scale pro- jects in nutrition, often following different intervention strategies, inade- quately evaluated, and overlapping geographically in some areas while leaving big gaps in coverage in others. They leave communities poorly 102 REPOSITIONING NUTRITION served and governments not knowing which project strategies are most effective. Scarce government management capacity is wasted administer- ing many small-scale efforts and dealing with different donor procurement and reporting requirements. And multiple small-scale projects, flying dif- ferent donor flags, encourage divided loyalties that make it difficult for government and civil society to build commitment to a national effort to control malnutrition. These major disadvantages suggest that small-scale project approaches are part of the problem rather than part of the solution and should give way to larger-scale approaches and financing. Sector-wide programmatic approaches Some countries have made progress toward national nutrition strategies through voluntary coordination efforts. Madagascar, for example, has a voluntary nutrition coordinating group that brings together more than 70 project agencies,10 reducing project overlaps and harmonizing the nutri- tion messages sent to communities. Other governments--India is an exam- ple--have taken stronger control, enforcing a single community nutrition program model. In the India model, however, the potential programmatic synergies between the reproductive and child health and micronutrient programs (managed by the Health Ministry) and the nutrition program (Integrated Child Development Services Scheme, ICDS, managed by the Social Welfare Ministry) have not been maximized. A third and increas- ingly widely used option is for traditional projects to give way to program financing, where governments and all development partners cofinance branches of a common national program or vision, rather than small-scale, time-bound projects. This kind of sectorwide approach (SWAp) is now being adopted in Bangladesh (box 4.3). This should make it easier to sustain and scale up the nutrition program--and to avoid the outcome in Tanzania, where the approach developed by the initially successful Iringa project (see box 0.2) has all but collapsed because the project had no line agency sponsor and its financing was never incorporated into the regular government budget.11 Sector-wide programs work best when governments have tested inter- vention strategies and have developed capacity in procurement, financial management, monitoring, and evaluation--one reason why traditional capacity-building projects still have a place in many countries. Sound mon- itoring is especially important to the success of sector-wide programs because many of them aim to disburse on the basis of whether output and outcome targets are reached. Linking disbursements to performance creates powerful incentives for managers and workers--but only if the GETTING TO SCALE 103 Box 4.3 Institutionalizing nutrition in Bangladesh: From project to program Bangladesh's first large-scale nutrition investment was the Bangladesh Integrated Nutrition Project (BINP), a traditional project financed by a $65 million World Bank credit, which expanded a community nutrition inter- vention piloted by the Bangladesh Rural Advancement Committee (BRAC), a major local NGO. The project focused on improving maternal knowledge and child-care and feeding practices, identified as key causes of undernutrition. The initial investment (1995­2000) was followed up with another investment of $92 million through the National Nutrition Program (2002­6). Financing for scaling up this community nutrition effort has recently been incorporated into Bangladesh's national Health, Nutrition, and Population Sector Program (HNPSP), which will support the government's Health Sector Investment Plan, which includes nutrition (2005­10). The HNPSP is financed by the Government of Bangladesh, with support from 13 development partners, 8 of which (the Canadian International Development Agency [CIDA], the U.K. Department for International Development [DFID], the European Commission [EC], the German Development Bank [KfW], The Netherlands, the Swedish International Development Agency [SIDA], the United Nations Fund for Population Activities [UNFPA], and the World Bank, collectively referred to as the "pooling development partners") will contribute $760 million to a common pool of resources to the government of Bangladesh provided through the World Bank. The SWAp will use common procurement and disbursement procedures and a common monitoring and evaluation sys- tem, thereby reducing transaction costs for the government. Other devel- opment partners in Bangladesh (including UNICEF, the U.S. Agency for International Development [USAID], WHO, the German Agency for Technical Assistance [GTZ], and the Japanese International Co-operation Agency [JICA], the "non-pooling development partners") will also finance the investment plan, albeit through parallel financing mechanisms. Thus, nutrition will now be financed and managed as part of an enduring gov- ernment program rather than as a time-bound project. There will be a stronger focus on results: disbursements will be linked to performance, and good performance will be rewarded with extra funds from the pooled financiers. In addition, nutrition is considered key among the six pillars of Bangladesh's Poverty Reduction Strategy Paper (PRSP), thereby further institutionalizing nutrition in the country's development agenda. Source: Pelletier, Shekar and Du (forthcoming), and World Bank staff. 104 REPOSITIONING NUTRITION monitoring system is trusted to reflect reality and if it provides results that feed into the planning and budget process in a timely way. Programs in multiple sectors Development financing is also moving away from traditional sectoral pro- jects to multisectoral program financing. More than 50 poor countries have now developed PRSPs, with priorities often financed through multisec- toral Poverty Reduction Strategy Credits (PRSCs). A recent review12 of PRSPs in 40 countries where malnutrition is serious concludes that although most PRSPs mention nutrition issues, they seldom effectively integrate nutrition into strategy. Malnutrition13 is frequently referred to in defini- tions of poverty, and nutrition is also often discussed as part of the poverty analyses. Twenty-eight countries used at least one nutrition indicator14 to measure nonincome poverty; indictors for macronutrient deficiencies such as underweight, stunting, and wasting are most commonly used (even though the technical terms used are not always clear). Six countries also used the United Nations Development Programme's human poverty index, which includes the proportion of underweight children as an indicator of deprivation in a decent standard of living. However, few of these countries follow up with appropriate actions. For example: · While more than 70 percent of the PRSPs identified malnutrition as a development problem, only 35 percent allocated budget resources for specific nutrition activities. This suggests that nutrition can potentially fit well in multisectoral policy initiatives such as PRSPs; however, because of limited commitment and limited capacity for planning and imple- menting nutrition actions in countries, it rarely gets funded. · Many PRSPs identified specific nutrition actions, but they often did not correspond to the type of malnutrition problem. As mentioned in chap- ter 3, 40 percent of the 38 countries had a micronutrient deficiency prob- lem, but their PRSPs mentioned no activities to address it. By contrast, most countries suggested additional actions to increase food produc- tion even when food was not necessarily the limiting factor in improv- ing nutrition in those countries. · Nutrition actions were rarely prioritized and sequenced on the basis of institutional and financial capacity analysis, or their importance com- pared with other development needs. Countries with limited develop- ment budgets have so far seldom used the PRSP process to face up to the trade-off that doing more in nutrition may mean doing less in other, lower-priority areas. GETTING TO SCALE 105 PRSCs, along with SWAps and CDD programs, are emerging as the dom- inant approaches to development in smaller, poorer countries, where lim- ited management capacity makes financing development through a smaller number of sectorwide or multisectoral efforts sensible. Integrating nutri- tion into these vehicles is a challenge now being addressed in countries such as Honduras, Madagascar, and Mauritania, which are scaling up suc- cessful nutrition efforts by moving from traditional project to financing through budget support or PRSCs. This experience is too new to have been evaluated; however, an evaluation process must be put in place now, so that lessons can be learned in the near future. Initial experience suggests that PRSCs may offer a very promising avenue for mainstreaming multisectoral nutrition actions in countries that have already invested substantially in nutrition, and where capacities have been developed through large-scale investment programs. They may be less useful where country commitment to and capacity in nutrition are weak. The dilemma is that while such countries do not have the capacity to implement large numbers of individual projects and need to explore multisectoral alter- natives, making nutrition a small part of a multisectoral program may be tantamount to sidelining it. In such cases, where commitment and capacity for nutrition are weak and yet it may have been included in the PRSPs/PRSCs, several options need to be systematically explored and documented: · Aphased approach, beginning with a standard investment project or pro- jects in nutrition to build capacity, followed by mainstreaming in a PRSC. · Ensuring that nutrition activities get appropriate attention in PRSCs by giving them clear objectives and progress indicators, and by incorpo- rating processes for progress monitoring by a variety of stakeholders-- politicians, government departments, program clients, and the media. · Complementing a nutrition component of such a PRSC with an addi- tional technical assistance project for nutrition capacity building. Where we need to know more More work is needed to document country experience with: · How to integrate nutrition better into health and other sectoral programs and into PRSPs, PRSCs, SWAps, and other new financing and coordi- nating approaches, while paying adequate attention to the details of behavioral change communication, management, and accountability that are critical for the success of nutrition activities. · How best to test and evaluate new strategies and develop management capacity in countries where development financing has moved from a project to a program approach. 106 REPOSITIONING NUTRITION Box 4.4 Five steps toward integrating nutrition in country PRSPs Step 1: Determine whether the country has a nutrition problem of public health significance (see annex 1 or technical annex 5.6 for a list of countries): · If yes, a strong rationale for including nutrition issues in the PRSP exists. · If yes, develop a case for prioritizing nutrition over other sectors in the country PRSP. · If not, prioritize other sectors and see if and how nutrition issues fit. Step 2: If nutrition issues are important: · Review the size and nature of the nutrition problem (see annex 1 for basic information). · Using levels of malnutrition estimated in annex 1, calculate estimated productivity losses attributable to malnutrition (both undernutrition and overweight), and analyze cost-benefit of addressing malnutrition.a Step 3: Identify the (possible) causes of malnutrition: · This information may be available in country. · If not, commission some analytical work--Demographic Household Survey data are usually a good source for these analyses; also check for other data sets such as Multiple Indicator Cluster Surveys and Living Standards Measurement Surveys.a Step 4: Set up working groups to: · Identify appropriate objectives for nutrition in the country.a · Select strategies and actions that will respond to the size and nature of the nutrition problem.a · Prioritize proposed actions so they match the epidemiology of the problem and the country capacity. · Lay out appropriate institutional arrangements for supporting the implementation of nutrition activities across sectors.a · Identify monitoring and evaluation arrangements and capacity development plans.a Step 5: Allocate reasonable funds and resource them through subsequent PRSCs: · Support implementation. · Strengthen capacity and implementation through a learning-by-doing approach. Source: Excerpts from Shekar and Lee (2005). a. These steps can be built into the PRSP/PRSC implementation process; however, consider laying out these steps in the PRSP. GETTING TO SCALE 107 · A related question (addressed in chapter 3) is to explore the opportuni- ties for scaling up nutrition actions/interventions through Multicountry AIDS Projects (MAPs) and other large-scale AIDS initiatives such as the President's Emergency Plan for AIDS Relief (PEPFAR). Strengthening Commitment and Capacity If short route nutrition interventions have high benefit-cost ratios and many of them are quite affordable (chapter 1), why have most countries failed to scale them up--and why have most development assistance agencies put few resources into them? The key constraints appear to be weak commit- ment and capacity. Of the two, commitment is the binding constraint, since the precondition for developing capacity is commitment to do so. Strengthening commitment Country commitment to combating malnutrition can be weak for a vari- ety of reasons (box 4.5). A recent report15 suggests ways to assess commit- ment and reviews how some countries with successful nutrition programs built the commitment to scale up. One or a few champions of nutrition-- people with the ear of policy makers and capable of carrying out evidence- based advocacy--built partnerships of individuals and institutions that can influence politicians and implementing agencies to press for increased budgets for nutrition programs. They did this by convincing others that improving nutrition was essential to achieving their own goals--whether political stability, national security, developing education, industry or agri- culture, or international competitiveness. Effective communication is the key to building commitment. In Bangladesh, a PROFILES analysis (Academy for Educational Development [AED] process for nutrition advocacy, box 4.6) helped convince financial decision makers of the importance of investing in nutrition. A film from a pilot project, showing children suffering from malnutrition and how vil- lage women could run an effective growth promotion program for them, helped bring key politicians on board. In Uganda, politicians promoted the Early Childhood Development and Nutrition project through a specially created Parliamentary Advocacy Committee, and were given on-camera training in how to communicate to the media about the project.16 These experiences show how important it is to use different communication strate- gies to win the support of different stakeholders. But there is more to strengthening commitment than good communica- tion, as shown by Thailand's experience developing its community nutri- tion program (technical annex 4.1G), and China's developing its salt fortification program (technical annex 4.1H). Also important in varying 108 REPOSITIONING NUTRITION Box 4.5 Ten reasons for weak commitment to nutrition programs · Malnutrition is usually invisible to malnourished families and communities. · Families and governments do not recognize the human and economic costs of malnutrition. · Governments may not know there are faster interventions for combat- ing malnutrition than economic growth and poverty reduction or that nutrition programs are affordable. · Because there are multiple organizational stakeholders in nutrition, it can fall between the cracks. · There is not always a consensus about how to intervene against malnutrition. · Adequate nutrition is seldom treated as a human right. · The malnourished have little voice. · Some politicians and managers do not care whether programs are well implemented. · Governments sometimes claim they are investing in improving nutrition when the programs they are financing have little effect on it (for example, school feeding). · A vicious circle: lack of commitment to nutrition leads to underinvest- ment in nutrition, which leads to weak impact, which reinforces lack of commitment since governments believe nutrition programs do not work. Source: Abridged from Heaver (2005b). degrees in different country circumstances are building informal con- stituencies in the civil service and in civil society, as well as with industry where appropriate; management arrangements that provide incentives for implementers; appropriate choices of financing vehicles; effective perfor- mance monitoring; policy environments conducive to reform; strong leg- islative and regulatory frameworks; and support from external development partners working together. Efforts to organize civil society in support of nutrition are particularly critical. Thailand's success in mobilizing civil society helps explain how it sustained commitment to its nutrition pro- gram for more than 25 years. By contrast, in Bangladesh, Tamil Nadu, and Tanzania, there has been little public pressure to keep initially successful pro- grams on track when government or development partner commitment has faltered. GETTING TO SCALE 109 Box 4.6 PROFILES PROFILES is a computer-based program for calculating the benefits from improving nutrition in terms of mortality and disease reduction, increased productivity and wages gained, and reductions in spending on social sector programs. Financial decision makers particularly appreciate the program's simulation facility, which allows them to instantly see the implications for the economy of different levels of achievement in improving nutrition. PROFILES estimates the far-reaching consequences of malnutrition, assess- ing the short- and long-range benefits of combating nutritional deficiencies, and helps in communicating these findings to decision makers. Over the past 10 years, PROFILES has been used in 25 countries (Bangladesh, Ethiopia, Ghana, Guatemala, India, Russia, and Gaza, to name a few) and a recent evaluation of PROFILES shows that it is an effective tool for: · Raising awareness about nutrition, promoting coalitions in support of nutrition, and building consensus that nutrition is a priority. · Building capacity and developing the leadership skills of nutrition advocates. · Promoting more comprehensive nutrition strategies, leveraging new resources for nutrition, and better targeting existing resources. In Ghana, for example, a team of nutrition and health professionals from various government ministries, universities, and NGOs used PROFILES to estimate that 5,500 infants were dying per year as a result of subopti- mal breastfeeding practices. The use of PROFILES with other initiatives helped nutrition advocates address poor infant feeding practices and helped mobilize the government to include breastfeeding and nutrition programs among its top five child survival priorities, as well as make it the top priority of the Ghana Vision 2020 health sector strategy. For further details, see www.aedprofiles.org. Source: Excerpt from AED (2003). Strengthening capacity The literature on strengthening management and implementation capacity in nutrition is limited.17 This section develops just two themes among many needing attention in this field--the usefulness of distinguishing between capacities that can be built during implementation and capacities that need to be developed before scaling up, and the need to pay greater attention to issues of governance as part of capacity building. 110 REPOSITIONING NUTRITION When and how to build capacity. Most countries that develop success- ful nutrition programs do not wait to build capacity before scaling up. After short pilot activities to develop effective strategies (a year in the case of Tamil Nadu and Bangladesh), they expand rapidly. Thailand mobilized half a million volunteers in just a few years. The nutrition champions knew they needed to move fast to take advantage of political commitment--a need that must be balanced against the risks of too rapid expansion, which can jeopardize funding and commitment if the program fails to deliver results. With this trade-off in mind, Matta, Ashkenas, and Rischard (2000) are developing an approach called "building capacity through results," in which systematic capacity building is built into the implementation process. Program implementation is broken down into steps; an analysis is made of what capacities, and whose, need to be developed to achieve the next step; and capacity development activities are limited to only those needed to achieve the next step. This approach means that capacity development automatically responds to operational needs, and managers have an incen- tive to focus on it because each capacity-building activity produces an immediate, tangible, improved outcome--unlike traditional institutional development activities, which are often disconnected from operations and given low priority.18 This approach can be systematically used to build capacities in com- munity mobilization, field-level training, and supervision during program implementation. However, a small number of key capacities are needed before programs expand. In addition to strengthening procurement and financial management capacity (now usually routinely included), up-front attention is required to the capacities for: · Communicating effectively, which is critical for strengthening the com- mitment of development partners, governments, and civil societies to nutrition, in turn a precondition for increasing investment. · Analyzing the relative cost-effectiveness of nutrition programs and ser- vice delivery approaches, key to ensuring the right investment decisions are made. · Carrying out quality baseline studies, so countries can evaluate down the line how well their investment has paid off. The need for more attention to issues of governance and corruption. A review of institutional development interventions in a sample of World Bank­assisted health and nutrition projects in Africa19 found that their focus was mainly on three or four of ten possible types of intervention: adding staff and physical and financial inputs; providing training and tech- nical assistance; introducing new technologies; and changing coordination mechanisms. The shortage of trained human resources, especially in GETTING TO SCALE 111 Sub-Saharan Africa, means that traditional, training-oriented, capacity development interventions will remain important. But equally salient in both Africa and South Asia, where malnutrition is concentrated, are prob- lems of weak governance and corruption.120 To address these issues, governments and development partners may need to focus more on six capacity development interventions that this study found to be less widely implemented: · Increasing particular stakeholders' voice in planning and imple- mentation. · Altering the balance between public and private sectors in service delivery. · Reforming specific organizational systems. · Changing or enforcing laws, rules, or regulations. · Changing attitudes, values, organizational cultures, or incentives and disincentives. · Providing information and increasing accountability. Recent work on education in Africa points to high returns from improve- ments in the governance of social services in countries where corruption is institutionalized.21 Where we need to know more The priority needs are for: · Practical methodologies for assessing and strengthening commitment and institutional capacity. · Case studies of successful attempts to assess and strengthen commit- ment and capacity, and to deal with problems of poor governance and corruption. Notes 1. Berg (1992). 2. Jennings and others (1991); Gillespie, Mason, and Martorell (1996); ACC/SCN (1997); Jonsson (1997); Hunt and Quibria (1999); Tontsirin and Gillespie (1999); Allen and Gillespie (2001); Heaver (2002). 3. A summary of this paper can be found in Gillespie, McLachlan, and Shrimpton (2003). 4. Hill, Kirkwood, and Edmond (2004). 5. Gillespie (2004). 6. Heaver (2003b). 7. World Bank (1998); Ranatunga (2000). 112 REPOSITIONING NUTRITION 8. Heaver (2005a). 9. Heaver (2005a). 10. Rokx (2000). 11. Dolan and Levinson (2000); a summary of this paper can be found in Gillespie, McLachlan, and Shrimpton (2003). 12. Shekar and Lee (2005). 13. Not only the explicit term "malnutrition" and its indicators stunting and underweight, but also implicit terms such as "food insecurity," "insufficient food," and "hunger" are used in definitions of poverty. 14. One of the most commonly used income poverty indicators, percentage of food-poor is the proportion of households whose annual per capita expenditure is not enough to buy a basket of food products that ensures the minimum energy requirement. 15. Heaver (2005b). 16. Elmendorf and others (2005). 17. For a tentative conceptual framework for assessing and strengthening capacity in nutrition, see Gillespie (2001); for a discussion of issues in nutrition management and capacity development, see Heaver (2002). 18. Johnston and Stout (1999). 19. Orbach and Nkojo (1999). 20. For example, at different times and in different places, World Bank­supported nutrition programs have suffered from attempts by program managers to use political influence to hire NGOs and community workers who do not meet program recruitment criteria; demand kickbacks for contracts, for recruitment, or for promptly processing expenditure claims; fix the bid prices of supplementary food and medicines; and supply low-quality weighing scales or food, permitting contractors to finance kickbacks from the excess profits. 21. Reinikka and Svensson (2004). 5 Accelerating Progress in Nutrition: Next Steps Chapter 1 outlined why we must invest in nutrition. Chapter 2 detailed the enor- mous size and the extensive scope of the nutrition problem (both underweight and overweight) at global, regional, and country levels to further strengthen the case for investing in nutrition. Chapter 3 outlined how best to tackle malnutrition. Chapter 4 focused on the challenge of scaling up programs for undernutrition and for micronutrient malnutrition in more countries, incorporating nutrition in rapidly expanding HIV/AIDS initiatives, while starting to address issues of over- weight and diet-related noncommunicable diseases (NCDs), where relevant. This chapter proposes that to accelerate progress in nutrition, development part- ners, in collaboration with developing countries, need to convene around a common agenda in nutrition and agree to support this agenda through a coordinated, focused set of actions in two areas: · Scaling up action in countries by addressing the three key operational chal- lenges: mainstreaming nutrition in country strategies and approaches; reori- enting existing large-scale programs to maximize their effects; and building global and national commitment and capacity for enhancing investments in nutrition. · Supporting a coordinated set of priorities for action research and learning-by- doing in mainstreaming nutrition in the development agenda, strengthening and fine-tuning delivery mechanisms, and strengthening the evidence base for investing in nutrition. Without this kind of coordinated and focused action by development partners and developing countries, no significant progress in nutrition can be expected and the Millennium Development Goals (MDGs) will continue to be compromised in the countries and among the people who need them the most. 113 114 REPOSITIONING NUTRITION Uniting Development Partners around a Common Nutrition Agenda Development partners supporting nutrition The principal development partners that support nutrition at the global or national levels are shown in figure 5.1. Most development partners sup- porting nutrition focus on food security, agriculture, and rural develop- ment, followed by HIV/AIDS and nutrition as part of maternal and child health services (technical annexes 5.1 and 5.2 outline partners' primary focus areas). Addressing micronutrient deficiencies, seizing the window of opportunity to address undernutrition among young children, and con- trolling overweight and obesity come lower in the current priorities of most partners. Few agencies are working toward mainstreaming nutrition into Poverty Reduction Strategy Credits (PRSCs), Poverty Reduction Strategy Papers (PRSPs), or sectorwide approaches (SWAps), or even across other intersectoral programs such as gender and community-driven develop- ment (CDD) programs. Figure 5.1 Principal development partners supporting nutrition Line ministries, agencies, etc. in SCN developing UNICEF countries UN WHO Ireland Dutch Agencies Government WFP IFAD Agencies DFID DANIDA FAO Bi-laterals CDC NORAD USAID WB ADB GTZ/KMF JICA SIDA Multilaterals CIDA IADB Partners in Nutrition ADB Harvest Plus IFPRI/CGIAR Public/Private Academia/ GAIN Partnerships Academic Research Universities Institute for Institutions AED MI HKI Development GATE Private SCF AKF UNU ICDDRB sector NGOs WABA CARE Manoff La Leche BRAC League ACCELERATING PROGRESS IN NUTRITION: NEXT STEPS 115 Most partners support capacity development activities in some form, but much of this effort goes into training nutritionists to be better nutri- tionists, rather than in orienting key government planning, finance, and economics staff toward nutrition and building commitment and support for nutrition in ministries of finance and planning. Though some agen- cies are actively building commitment, their efforts are mainly limited to narrow focus areas (such as breastfeeding for the World Alliance for Breastfeeding Action and La Leche League, and micronutrient fortifica- tion in selected countries for the Global Alliance for Improving Nutrition [GAIN]). The continuing low level of global interest in general nutrition is evidence that commitment building has been neglected; the fact that many of the agencies reviewed in technical annexes 5.1 and 5.2 have no specific nutrition policies or focus makes it even more evident that nutri- tion has been marginalized in the development agenda, even by devel- opment partners. Each country needs to drive its own investment agenda and hence should lead the repositioning of nutrition in the development agenda that is pro- posed in this report. When countries request help in nutrition, the role of development partners is to respond, first by helping countries develop a shared vision and consensus on what needs to be done, how, and by whom, and then by providing financial and other assistance. Nevertheless, in chap- ter 4 we argued that much of the failure to scale up action in nutrition results from a lack of sustained government commitment to action and hence low demand for assistance in nutrition. In this situation, the role of the devel- opment partners must extend beyond responding when requested to do so by governments, to using their combined resources for analysis, advo- cacy, and capacity building to encourage and influence governments to put nutrition higher on the agenda wherever it is holding back achievement of the MDGs, poverty reduction, and human capital formation. This role can be fulfilled only if the development partners share a common view of the malnutrition problem and broad strategies to address it and speak with a common voice (box 5.1). Building a shared vision and consensus on actions does not imply that there should be no discussion or dissenting voices or new research. Instead, we propose that the approach to cooperation and consensus should differ in the political and programmatic realms. In the political realm, key devel- opment partners must forge a consensus on the "big picture" issues that drive and sustain political commitment to investing in nutrition at global and national levels. In the programming realm, partners must institute a culture of inquiry that derives from action research, monitoring, and eval- uation--and that drives stakeholders at all levels to continuously reorient and fine-tune programs and investment strategies to maximize impact, within the framework of a broad strategic consensus.1 Although previous 116 REPOSITIONING NUTRITION efforts at uniting development partners have not always been successful, we hope that this distinction between the political and the programmatic realms will help lay the groundwork for successful consensus building as nutrition is repositioned at the center of the development agenda. Box 5.1 Lessons for nutrition from HIV/AIDS Some lack of focused interest and support for nutrition may derive from the disadvantages inherent in multisectoral problems and solutions, but successful examples from HIV/AIDS may offer lessons for scaling up nutrition efforts. The Multicountry HIV/AIDS Program (MAP) was jump- started by the World Bank committing $1 billion in little more than three years and creating an enabling environment for major inputs from other partners. This happened because Bank leaders spoke out forcefully and regularly so the issue became a "must" on national agendas, and dedicat- ed Bank funds and staff provided consistent support, and a mechanism supported by the Bank coordinated the relevant partners (primarily UN agencies through the Joint United Nations Programme on HIV/AIDS [UNAIDS]). Such a potential mechanism exists for nutrition through the United Nations' Standing Committee on Nutrition (SCN)--but for the SCN to play a coordination role would require major changes in its mandate. Other more operational mechanisms may need to be explored. Further lessons are embodied in the MAP interim review undertaken in 2004. It identified eight critical MAP elements that provide a simple framework--one that could apply to future efforts in nutrition: · Government commitment and governance, particularly the role of national leadership (in nutrition this is embodied in resolving institutional and commitment-building issues). · National HIV/AIDS strategies and frameworks linked to resource allocation (National Plans of Action for Nutrition have been largely theoretical, unlinked to national resources, and divorced from assessments of national capacities). · The multisectoral approach, including but not limited to the health sector. · Community engagement (may need to be considered in a review of human resources for nutrition at community levels, among other issues). · Strengthened monitoring and evaluation. · Donor collaboration and coordination. · Bank instruments--and the links from MAP projects to programmatic loans and health sector investments. · Implementation experience. ACCELERATING PROGRESS IN NUTRITION: NEXT STEPS 117 Three Key Operational Challenges to Scaling Up To more effectively address the malnutrition challenge, actions must be scaled up. To do so, three key operational issues must be addressed. They are to mainstream nutrition interventions into programs (rather than pro- jects) in health, agriculture, and other sectors; to reorient some existing large-scale nutrition investments that are not achieving the desired effect; and to build the commitment and capacity required to underpin the scal- ing-up and reorientation needed. Some tools to help development part- ners decide on priorities for scaled-up action follow this discussion. Mainstreaming nutrition in country strategies and program approaches As outlined in chapter 4, a new programming environment is emerging globally and nationally. The move from projects to programs, from financ- ing and implementing vertical disease-specific projects to SWAps and budget support, as well as a reinvigorated focus on multisectoral action, poverty reduction, and equity issues, are all part of this new environment. The roles of civil society and the private sector are becoming more important. The focus on results has never been higher on the agenda of both development partners and developing countries. These changes call for new approaches in taking the nutrition agenda forward, especially in the following areas. Repositioning nutrition appropriately in country development strategies. Countries need to recognize that nutrition is not a consumption issue; nor is it primarily a question of welfare. Strategic nutrition invest- ments can contribute to human capital formation and can thereby drive eco- nomic growth. Nutrition is an integral part of the first MDG, which aims to reduce poverty and hunger. While many countries are on track in reducing income poverty, most are not on track in improving nonincome poverty (malnutrition and hunger). Without direct investments in nutrition, they will continue to be off track not only on the first MDG, but also on the health, HIV/AIDS, education, and gender MDGs (chapters 1 and 2). This critical recognition is the most important issue in repositioning nutrition in country development strategies and within the agendas of development partners. Many evaluations have rightfully cautioned that intervention strategies must be context-specific,2 so we do not subscribe to a prescriptive approach. Each country's strategy and actions for improving nutrition will look dif- ferent. In particular, each country needs to find a balance of interventions in food, health, and caring practices that is appropriate to its situation--in terms of the type and seriousness of malnutrition, where past nutrition investments have gone, and the country's commitment and capacity to act. (See figure 5.2 for a practical tool for helping countries make policy choices 118 REPOSITIONING NUTRITION for investing in nutrition, and box 5.2 for some specific suggestions about priorities when commitment or capacity are weak.) We do not propose a global "one size fits all" approach to addressing malnutrition; however, we do recommend that when developing national or regional strategies, countries and their development partners pay special attention to the fol- lowing efforts: · Focusing strategies and actions on the poor to address the nonincome aspects of poverty reduction that are closely linked to human develop- ment and human capital formation. · Focusing interventions on the window of opportunity--conception through the first two years of life--because this is when irreparable damage occurs. · Improving mother- and child-caring practices to reduce the incidence of low birthweight, and to improve infant-feeding practices, including exclusive breastfeeding and appropriate and timely complementary feeding, because many countries and development partners have neglected to invest in such programs. · Scaling up micronutrient programs because of their widespread preva- lence, effect on productivity, affordability, and extraordinarily high ben- efit-cost ratios. · Building on the country capacities developed through micronutrient programming to extend actions to community-based nutrition programs. · Working to improve nutrition not only through health, but also through appropriate actions in agriculture, rural development, water supply and sanitation, gender, social protection, education, and CDD.3 · Strengthening investments in the short routes to improving nutrition, yet maintaining a balance between the short and the long routes. · Integrating appropriately designed and balanced nutrition actions in coun- try assistance strategies, SWAps in multiple sectors, MAPs, and PRSPs. Development partners can assist by: · Helping countries identify appropriate institutional arrangements for policy development, cost-effectiveness and affordability analysis, and investment planning. · Providing technical assistance and capacity-building support in these areas if needed. Accelerating the move from project to more coordinated program approaches. Multisectoral PRSPs, PRSCs, and SWAps offer an opportu- nity to mainstream and scale up nutrition. Development partners can help countries take advantage of this opportunity by moving from financing ACCELERATING PROGRESS IN NUTRITION: NEXT STEPS 119 Box 5.2 What to do when Financial capacity is weak: · Vitamin and mineral supplementation (vitamin A, iodine, iron). · Food fortification. · Immunization. · Oral rehydration therapy. · Deworming. · Community-Integration Management of Childhood Illnesses (IMCI), including nutrition. · Growth promotion, if it can be added to an existing outreach system. Managerial capacity is weak: · Immunization and oral rehydration therapy. · Vitamin A supplementation as an add-on to immunization. · Food fortification (provided there is a manageable number of food manufacturers). · Growth promotion, if it can be added to an existing outreach system. · Leverage scarce government capacity by: ­ Contracting services out to NGOs, if available ­ Using community organizations to deliver services. Commitment is weak: · Reduce risk by choosing just one or two interventions in one or two government departments where champions can be found. · Start with interventions that are relatively cheap and easy to manage, such as vitamin A and iodine supplementation. · Pilot interventions in a small area, where speedy, commitment-boost- ing results can be assured without government spending too much money. · Invest in analysis and evidence-based advocacy to strengthen country commitment rather than in donor-driven projects that will not be sus- tained without country ownership. Source: Excerpt from technical annex 5.4. small-scale, donor-driven projects to partnering in large-scale, country-driven programs; by agreeing on how each agency can best support developing country governments in terms of its comparative advantage in financing, technical expertise, or presence; and by reducing the government's aid man- agement burden through common procurement, accounting, and reporting 120 REPOSITIONING NUTRITION procedures. This is beginning to happen in some countries, showing that it can be done: · In Bangladesh through the recently approved Health, Nutrition, and Population Sector Program (HNPSP), 13 donors have agreed to pool their funds for a SWAp--of which a substantial proportion will go to nutrition. Nutrition is also a key element of the draft PRSP in Bangladesh. All this builds on experience gained through previous traditional pro- jects--the Bangladesh Integrated Nutrition Project (BINP) and the National Nutrition Project. · In Madagascar, nutrition is being mainstreamed and scaled up through the PRSC, building on experience from the SEECALINE project. · In Ethiopia, the government is developing a national nutrition strategy with coordinated support from several partners (The United Nations Children's Fund [UNICEF], the Canadian International Development Agency [CIDA], the U.S. Agency for International Development [USAID], the International Food Policy Research Institute, the World Bank, and others). The strategy, which was a condition to be met before the next PRSC, can provide a focus for coordinated donor support in the coun- try and could be resourced from the next PRSC as well as from coordi- nated donor resources for different elements. Reorienting existing large-scale investments to maximize impact While most countries have failed to mount large-scale programs to improve nutrition, some have made substantial investments whose effects are less than they could be. This usually happens because the quality of imple- mentation is poor, or because there is a mismatch between the causes of malnutrition and the priorities of the programs to address it, as outlined in chapter 4. In many cases, even where the need to change design and strategy is recognized, bureaucratic and political resistance to change often makes programs more inflexible than they need to be. Improving implementation quality. Poor implementation quality can have a variety of causes: implementation capacity in general may be weak; some specific aspects of program management such as worker training may be weak; or--a design problem--the intensity of resource use for train- ing and supervision, or the ratio of field staff to population, may not be enough to allow quality services; and monitoring and evaluation may not focus on this issue (chapter 4). In addition, program experience suggests that bureaucratic, professional, and political resistance to change has been underestimated. Development partners can help by: · Giving more attention to and financial and technical assistance for improving program design, monitoring, evaluation, and management. ACCELERATING PROGRESS IN NUTRITION: NEXT STEPS 121 · Providing technical support for cost-effectiveness analysis to identify issues of intensity of resource use and providing finance for resolving them. · Providing coordinated support and guidance on overcoming bureau- cratic and political resistance to change in program strategies and design. Addressing mismatches between causes and interventions. Three common mismatches between needs and design, outlined in chapter 3, are the "food- first" mismatch, wherein countries spend large resources on food or feed- ing programs when the problem lies elsewhere; the age-targeting mismatch, wherein countries invest in older children, when most malnutrition happens at younger ages; and the poverty-targeting mismatch, wherein programs fail to target malnutrition in the poorest areas, either by design or by faulty tar- geting. Such mismatches must be fixed if any effect is to be expected from several existing large-scale nutrition programs. Similarly, as PRSPs become important policy tools, attention must be paid to ensuring that the strategies and actions proposed in country PRSPs match the epidemiology of malnu- trition in that country. Development partners can help by supporting policy analysis that identifies mismatches (see, for example, Gragnolati and others forthcoming and Shekar and Lee 2005) and with technical support and financ- ing to help countries reorient their investments more productively. Building commitment and capacity Scaling up nutrition programs in countries that have underinvested and reorienting ineffective programs in countries that have invested requires strong commitment and specific institutional capacities. These two efforts also require a very specific investment in skills for building consensus among stakeholders at global and national levels. Building commitment. Commitment building takes place in a largely unsystematic way rather than being treated as a recognized field of pro- fessional practice as important to nutrition as epidemiologic or economic analysis. It needs to be professionalized, drawing on skills from the fields of strategic communication, political and policy analysis, and organiza- tional behavior.4 Well-informed nutrition champions need to work sys- tematically to: · Build local partnerships of individuals and institutions that can influ- ence politicians, implementing agencies, and development partners to press for increased budgets for the right kinds of nutrition investments because development partners can put more money into nutrition only if countries demand it. · Identify gaps in the country's capacity to build commitment to improv- ing nutrition and seek help to fill those gaps from local institutions, other 122 REPOSITIONING NUTRITION developing countries, or nongovernmental organizations (NGOs) and other development partners. Systematic commitment-building activities can cost several hundred thousand dollars per country,5 costs that are largely incurred before gov- ernment or donor finance is available for the resulting programs or reforms. Development partners could help countries cover these costs by raising a grant fund that countries can draw on to pay for technical assistance and the upstream costs of building commitment and stakeholder consensus. To advance the state-of-the-art, they could help develop best practices and document them in a toolkit. Building capacity. Evaluation shows that several aspects of institutional capacity building have received little attention (chapter 4). Countries need to focus more on increasing accountability to managers and clients, on improving governance, and on other measures that give implementers stronger incentives to perform. While many capacities can be strengthened during program implementation, countries need to focus also on devel- oping capacities required before major programs are scaled up or reori- ented, such as the capacities to: · Systematically strengthen commitment. · Analyze the relative cost-effectiveness of nutrition investments and ser- vice delivery approaches. · Identify appropriate institutional arrangements through careful analy- sis of the best implementation arrangements and their fiscal and politi- cal implications. · Develop evaluation plans and carry out quality baseline studies needed for evaluation. Development partners could support this agenda by developing guide- lines for assessing and strengthening institutional capacity, and by pro- viding funding and technical assistance in these areas where it is needed. Where to Focus Actions against Malnutrition Prioritizing countries for nutrition actions Many countries deserve priority action, given the scale of their malnutri- tion problems. But epidemiological considerations are only one of four key criteria for determining investment priorities across countries. The three remaining criteria are commitment, capacity, readiness for action, and to some extent, population size. ACCELERATING PROGRESS IN NUTRITION: NEXT STEPS 123 A matrix for prioritizing nutrition actions (figure 5.2) has two purposes: · First, the matrix uses available epidemiological data to make the case that the malnutrition problem is pervasive in many countries and should therefore be an impetus for action; countries with the highest malnutri- tion rates in each region should be prioritized for action, followed by those with lower rates. · Second, the matrix suggests that the response should be tailored to the magnitude and the nature of the problem. For example, where prob- lems of underweight or stunting are overwhelming, that should be the focus of action. Where the undernutrition problem is confined to micronutrient deficiencies, those should be the focus for action. Where undernutrition issues are large and the overweight problem is emerg- ing, actions must be targeted to both, without compromising invest- ments in either. For overweight it may be best to scale up slowly, starting with only a few countries, to allow fine-tuning of strategies and approaches. The detailed methods for identifying priority countries for support are outlined in technical annex 5.5. More details on regional and national epi- demiology are included in technical annex 5.6. Priority countries for nutrition actions Three categories of countries are identified in figure 5.2, based on this classification: · Category A: Countries that have either underweight or stunting rates greater than 20 percent. · Category B: Countries that have either vitamin Adeficiency greater than 10 percent or iron deficiency anemia prevalence greater than 20 percent. · Category C: Countries that have an emerging overweight problem. The matrix shows that undernutrition (both macro- and micronutrient deficiencies) and overweight are significant public health problems in most developing countries: 80 of 126 countries for which we had data fall in cat- egory A, and all 80 countries with micronutrient data fall in category B; 63 countries have both macro- and micronutrient deficiency problems (over- lap between categories A and B). In about half the countries with over- weight data, more than 3 percent of children are overweight (category C), and about 40 percent of these countries have both underweight and over- weight problems (overlap between categories A and C), suggesting that 124 REPOSITIONING NUTRITION both ends of the malnutrition spectrum (underweight and overweight) coexist in many developing countries. Almost all the countries in the Middle East and North Africa, as expected, have both macro- and micronutrient deficiency problems that require inter- ventions. It is also evident that overweight among children is fast becom- ing a public health problem even though absolute levels are still considerably low compared with the magnitude of the undernutrition problem. About one-third of the countries with overweight data have overweight preva- lence rates higher than 3 percent among preschool children. In East Asia and the Pacific, more than 70 percent of countries with data have underweight or stunting problems. Countries such as Indonesia and Mongolia carry the double burden of undernutrition and overweight prob- lems, and the overweight problem is emerging in China. Prevalence of undernutrition is much lower in Europe and Central Asia, but a quarter of the countries still have a stunting problem. Uzbekistan and Albania also show more than 10 percent wasting. Unsurprisingly, over- weight is common; two-thirds of countries with data have an overweight problem. Besides vitamin A deficiency and iron deficiency anemia, iodine deficiency disorders (IDD) of public health significance are found in two- thirds of countries with data. Countries in the Middle East and North Africa have a similar malnutri- tion profile to those in Latin America and the Caribbean. Although under- weight is very limited (primarily to the Republic of Yemen), about one-third of the countries have stunting, and Djibouti has a concurrent problem of wasting. Overweight is of particular concern in the Middle East and North Africa; in all seven countries with data, more than 3 percent of children are overweight. Prevalence of overweight is higher than 5 percent in Algeria, Egypt, Jordan, and Morocco. And the high prevalence of both macro- and micronutrient deficiency in Yemen calls for immediate attention. Although only one country in Latin America and the Caribbean region (Guatemala) shows an underweight prevalence of more then 20 percent, one-third of the countries have a problem with stunting. Vitamin A defi- ciency and iron deficiency anemia are also common, although the prevalence of IDD is relatively low. Overweight is pervasive in seven countries-- Argentina, Bolivia, Chile, Costa Rica, Jamaica, Peru, and Uruguay--with rates of more than 5 percent. Figure 2.12 and Maps 1.1­1.4 give additional regional and country information. Although in South Asia overweight is currently limited to two coun- tries, Afghanistan and Pakistan, undernutrition is incomparably high in all countries in the region; even Sri Lanka, with an under-five mortality rate of less than 20 per 1,000 live births, has about 30 percent underweight and 20 percent stunting. All countries in South Asia also have extremely high rates of vitamin A deficiency and iron deficiency anemia. ACCELERATING PROGRESS IN NUTRITION: NEXT STEPS 125 Figure 5.2 Typology and magnitude of malnutrition in World Bank regions and countries Category A Stunting (20% and/or Underweight (20%) VAD (10%) and/or IDA (20%) Category B AFR Côte d'Ivoire AFR Lesotho Myanmar AFR Sâo Tomé & Angola Liberia Papua New Gambia Principe Benin Madagascar Guinea EAP Somalia Botswana Mali Philippines Thailand Sudan Burkina Faso Mauritania Vietnam Burundi Mozambique ECA EAP Cameroon Niger ECA Georgia Malaysia CAR Rwanda Kyrgyz Rep Turkey Solomon Islands Chad Senegal Tajikistan Timor-Leste Congo, DR Sierra Leone Turkmenistan LAC Vanuatu Congo, Rep. Swaziland LAC Dominican Rep El Salvador ECA Eritrea Tanzania Haiti Albania Ethiopia Togo Honduras MNA Gabon Uganda Nicaragua Lebanon LAC Ghana Syrian Arab Rep Ecuador Guinea EAP SAR St. Vincent & Guinea-Bissau Cambodia Bangladesh Grenadines Lao, PDR Bhutan India MNA Nepal Djibouti Iraq SAR AFR AFR EAP MNA ECA Maldives Comoros Kenya Indonesia Morocco Armenia Sri Lanka Malawi Mongolia Yemen Azerbaijan EAP Namibia Kazakhstan Kiribati ECA Nigeria SAR South Africa Uzbekistan Afghanistan LAC Zambia Pakistan Brazil LAC Zimbabwe Chile Bolivia Paraguay Guatemala Venezuela Peru MNA Egypt Iran AFR ECA LAC Mexico MNA Mauritius Croatia Argentina Panama Algeria Seychelles Czech Rep Costa Rica Trinidad & Jordan Macedonia, FYR Jamaica Tobago Tunisia EAP Uruguay China Category C Overweight (3%) Source: WHO (2004); UNICEF and MI (2004b); De Onis and Blossner (2000). Note: IDA = iron deficiency anemia only; VAD = vitamin A deficiency only; S = stunting only; U = underweight only; (S) = stunting with no underweight data; (U) = underweight with no stunting data; = wasting; = total goiter rate greater than 20 percent. All countries with only macronutrient deficiency do not have micronutrient information. TM = no overweight data. AFR = Africa; EAP = East Asia and Pacific; ECA = Europe and Central Asia; LAC = Latin America and the Caribbean; MNA = Middle East and North Africa; SAR = South Asia. 126 REPOSITIONING NUTRITION Implications for action Decisions to prioritize nutrition actions in regions and countries must be based on two criteria: · The nature and magnitude of the nutrition problem in the region or country, as identified in the prioritization matrix. · Country capacity, commitment, and readiness for nutrition actions, including institutional arrangements for nutrition. Where the need is great, but capacity and commitment are low, invest- ing in building commitment and capacity and identifying an appropriate institutional home for nutrition may be the first priority, perhaps through the vehicle of a traditional project. Where the need is high and there is some experience, commitment, and capacity for implementing nutrition actions, efforts may be best directed at scaling up pilot interventions through newer approaches and instruments, such as SWAps and PRSCs. For countries that fall in the middle of this continuum, a carefully balanced approach may be called for. Supporting a Focused Action Research Agenda in Nutrition Though some technical challenges remain (especially in overweight and in links between nutrition and NCDs and nutrition and HIV), there is broad consensus in the international nutrition community on many technical approaches for improving nutrition.6 The emerging research challenges are therefore not so much technical or academic as operational, and so need to be pursued through learning-by-doing in the real world in three areas: · Mainstreaming nutrition in the development agenda. · Strengthening nutrition service delivery. · Continuing to build the evidence base for how to tackle some forms of malnutrition operationally. Research in the last area is needed to meet the rapidly growing chal- lenge of overweight and obesity and the links between nutrition and HIV, as well as low birthweight reduction where operational experience is insuf- ficient to scale up with confidence. Pulling together the knowledge gaps identified earlier in the report sug- gests a set of action research priorities for discussion (table 5.1). Ensuring a strategic link and a synergy between the global research agenda and the global programmatic agenda--so that each drives the other--is critical for ACCELERATING PROGRESS IN NUTRITION: NEXT STEPS 127 Table 5.1 Suggested priorities for action research in nutrition Theme Key action research issues Mainstreaming · Mainstreaming nutrition into sector programs and nutrition in the PRSPs/PRSCs--how this can best be operationalized in development different country circumstances. agenda · How best to strengthen commitment to nutrition, build stakeholder consensus, and overcome resistance to change in different country circumstances. · How best to assess and build institutional capacity for nutrition policy analysis and investment planning at the country level. · Costing, financing, and institutional options for nutrition service delivery, including human resource options for nutrition services. Strengthening · Exploring replicability of new service delivery mecha- and fine-tuning nisms in different resource-poor settings: conditional cash service delivery transfers, NGO service delivery, public-private partner- mechanisms ships for micronutrients, and so on. · Micronutrients: the complementary role for supplementa- tion, fortification, and food-based strategies (including the efficacy and effectiveness of emerging technologies for food-based approaches such as biofortification). · Targeting and cost-effectiveness of food supplementation linked to nutrition education and growth promotion to maximize the effect on the mother-child dyad. Further · Evidence-based strategies to prevent and reduce over- strengthening weight and diet-related NCDs. the evidence · Efficacy and effectiveness of nutrition interventions in base for what HIV programs, such as the role of exclusive breastfeeding works in preventing mother-to-child transmission in developing operationally countries; the role of food security in preventing HIV; and the role of nutrition in enhancing the effectiveness of antiretroviral therapy. · Linking nutrition data with larger global monitoring initiatives such as the Health Metrics Network and other MDG and poverty monitoring initiatives, such as the national sample surveys, Multiple-Indicator Cluster Surveys, Demographic and Health Surveys, and Living Standards Measurement Surveys. · Methodologies for evaluating nutrition in the context of programmatic approaches (SWAps and PRSCs); fine- tuning the indicators--are we setting higher standards for nutrition than for other sectors? Note: For details, see annex 3. 128 REPOSITIONING NUTRITION future investments in nutrition to succeed. Development partners could help countries pursue these priorities by providing funds and technical assistance for designing the action research and documenting, evaluating, and disseminating results. Further details on suggested action research pri- orities appear in annex 3. The Gaps between Identified Needs and Development Partners' Focus The development community, and the world as a whole, has consistently failed to address malnutrition over the past decades. The consequences of failure to act on what has been long known about how malnutrition under- mines economic growth and perpetuates poverty are now evident in the slow progress toward the MDGs. The unequivocal choice now is between acting on what has been known for so long or continuing to fail. Few development partners have clear nutrition policies or strategies. The main gaps between the operational needs for scaling up and the focus of development partners lie in four areas: · Mainstreaming undernutrition and micronutrient programs, as well as integrating nutrition into HIV/AIDS programs. · Identifying strategies for addressing the emerging epidemic of obesity and building the evidence base for the link between early undernutrition and later susceptibility to NCDs, as well as diet-related NCDs. · Building commitment. · Identifying workable institutional arrangements for, and developing institutional capacity in promoting, managing, monitoring, and evalu- ating large-scale nutrition actions. The World Bank is the largest investor in global nutrition, with many other investments in its portfolio that can improve nutrition more generally. However, it will take several decades for many of its investments to improve nutrition adequately. Given the magnitude of the problem (chapter 2), the Bank's investments in direct interventions (short route) are extremely small--not more than 3.8 percent of its lending for human development and less than 0.7 percent of Bank-wide lending in 2000­4. Currently, only 36 Bank-supported investments include some direct sup- port for nutrition. The Bank's total investment is $662 million, spread across Health, Nutrition, and Population (22 investments); Agriculture and Rural Development (5); Education (4); Social Protection (3); and Transport (2 emergency rehabilitation projects). Most of these investments are less than $10 million and only nine have somewhat more substantive (albeit modest) investments in Argentina, Bangladesh, Eritrea, India and its state of Andhra ACCELERATING PROGRESS IN NUTRITION: NEXT STEPS 129 Pradesh, Iran, Madagascar, Senegal, and Uganda. Yet undernutrition is serious in more than 80 developing countries. The gap between the need and the level of investment, paralleled in the efforts of other development part- ners, is indeed very large. Next Steps The next steps address the gaps between current focus and identified needs in scaling up nutrition actions at global and country levels. At the global level, the development community needs to unite in explic- itly recognizing the role of malnutrition as an underlying cause of mortal- ity, morbidity, and slow economic growth in countries, and to agree on five next steps: · Coordinating efforts to strengthen commitment, consensus, and funding for nutrition within global and country-level partnerships such as the Child Survival Partnership, the Partnership for Safe Motherhood and Neonatal Health, the New Partnership for Africa's Development (NEPAD), GAIN, SCN, the Micronutrient Initiative (MI), national and global alliances, and public-private partnerships. · Agreeing on broad strategic priorities for the next decade (such as the three operational priorities and three research themes proposed above) and applying their comparative advantage to each area. · Agreeing on priority countries for investing in nutrition and for main- streaming and scaling up nutrition programs (see figure 5.2, figure 2.2, and maps 1­4). · Agreeing on priority countries for testing systematic approaches to main- streaming nutrition, building commitment and capacity, and reducing overweight and obesity. · Making a collective effort to switch financing from small-scale projects to large-scale programs, except where small projects with strong moni- toring and evaluation components are required to pilot-test interven- tions and delivery systems. In addition, the grant development agencies and foundations need to work together to make funding available at global and national levels to promote and finance the country commitment and capacity-building activ- ities needed before large-scale investments or program reforms are made. Development partners should also encourage well-designed action research on large-scale nutrition programs and more systematic monitoring and evaluation so we can learn from this research and share the resulting knowl- edge internationally. The World Bank has recently committed to support the International Centre for Diarrhoeal Disease Research, Bangladesh 130 REPOSITIONING NUTRITION (ICDDR,B) through a small catalytic development grant ($3.6 million) that will allow ICDDR,B to undertake such activities. Development partners need to strategize together to see how this model can be a catalyst for addi- tional investments to empower other global and regional agencies to play a similar stepped-up role. At the country level, the development community needs to agree on four next steps: · In all countries with micronutrient deficiencies, develop a national strat- egy for micronutrients, finance it, and scale up micronutrient programs to nationwide coverage within five years. An important caveat: while we strongly endorse the need to take the micronutrients agenda to com- pletion, it must not crowd out the need for attention to general under- nutrition, as has been the experience in several countries and agencies over the past decade. · In all countries with undernutrition and overweight problems, in the medium or shorter term: ­ Identify and support at least five to ten countries with large nutrition problems where development partners collectively work toward main- streaming nutrition into SWAps, Multi-country AIDS Projects (MAPs), and PRSCs (as in Bangladesh and in Madagascar). Where countries have little experience with such investments, nutrition projects may be the first step toward building capacity. ­ Identify and support at least three to five countries where existing large-scale investments can be reoriented to maximize impact. In these countries, provide constructive and coordinated technical support to reorient program design and strengthen implementation quality. ­ Identify and support at least three to five countries where nutrition issues loom large, but where limited investment is available (as in Ethiopia). In these countries, invest in building commitment and pro- vide technical support to develop coordinated strategies that can then be financed through complementary resources from development partners.7 The challenge--especially in low-income developing countries--will be to take the unfinished micronutrient agenda to completion and slowly introduce attention and tested strategies to address the overweight agenda, without crowding out attention, capacity, and funding for the most impor- tant undernutrition agenda. Initial estimates suggest that the costs for addressing the micronutrient agenda in Africa will be approximately $235 million a year. Costs for other regions and for other aspects of the nutri- tion agenda have yet to be estimated. Other gross estimates are much larger, ACCELERATING PROGRESS IN NUTRITION: NEXT STEPS 131 ($750 million for global costs for two doses of Vitamin A supplementation per year; between $1 billion and $1.5 billion for global salt iodization, includ- ing $800 million to $1.2 billion leveraged from the private sector; and sev- eral billion dollars for community nutrition programs).8 A more detailed costing exercise is being conducted by the World Bank to come up with realistic figures. One way to prioritize the selection of these countries and actions is to use the tools outlined here and in technical annexes 5.4, 5.5, and 5.6, while considering country capacity, commitment, and readiness for action. The balance between long and short route interventions (identified in chapter 3) will be critical. The agenda proposed here needs to be debated, modi- fied, agreed on, funded, and acted on in concert by development partners through a process of consultation and dissemination. Notes 1. Pelletier, Shekar, and Du (forthcoming). 2. Pelletier, Shekar, and Du (forthcoming); Habicht, Victora, and Vaughan (1999). 3. Most development partners share the health sector bias. In UNICEF, USAID, and the World Bank, for example, nutrition is managed by the agencies' health bureaus. Of 36 current World Bank-supported projects that include nutrition, 22 are in the health sector, the other 14 in agriculture and rural development (5), education (4), social protection (3) and transport (2) (from April 2005 Portfolio review). 4. Heaver (2005b). 5. Heaver (2005b). 6. Lancet series on child survival (2004). 7. In doing this, several steps may be involved: · Helping countries identify the local causes of malnutrition, and malnutrition's importance compared with other development constraints. · Helping with practical tools for deciding how to invest (see technical annex 5.4). · Helping develop a national intervention strategy and a matching action research program. · Putting in place the public expenditure reorientation needed to finance the strategy. · Agreeing on a cofinancing strategy that makes best use of each development partner's comparative advantages (technical support, financing, monitoring and evaluation, and on-the ground presence). 8. Hunt (2005). Annex 1 Country Experience with Short Routes to Improving Nutrition Costs per Large-scale Effect on participant Intervention program experience nutrition* per yeara Best practices Community- Indonesia UPGK; + $1.60­$1 Target to children based Tamil Nadu Inte- 0.00 under age two. growth grated Nutrition recurrent Tailored, negotiated, promotion Program; BINP; addition- two-way counseling Madagascar al bud- with mother; mes- SEECALINE; getary sages based on Nicaragua cost; "trials of improved PROCOSAN $11­$18 practices"; can inte- (Health Sector if food grate preventive Reform Project; added health and rapid Honduras AIN-C response to danger (national); signals and mental Tanzania Iringa; stimulation. Medical Thailand National and nursing person- Nutrition nel need training and motivation to support. Vitamin A India, Indonesia, + $1.01­ Campaign approach supplements Bangladesh, $2.55 needs perennial moti- (to preschool Ghana, Nepal, vation and mobiliza- children) Pakistan, Niger, tion. Need to inte- Tanzania, Senegal grate into main- stream medical ser- vices. Medical and nursing personnel need training. Vitamin A Guatemala (sugar) + $.69­$.98 Special attention to fortification per high regulatory enforce- risk ment of fortification person laws to ensure indus- reached try compliance; con- sumer education may be needed; costs are usually small and can often be passed on to consumers, except when a targeted sub- sidy is warranted. 132 COUNTRY EXPERIENCE WITH SHORT ROUTES TO IMPROVING NUTRITION 133 Costs per Large-scale Effect on participant Intervention program experience nutrition* per yeara Best practices Iron supple- Indonesia _ + $.55­ Counseling to mentation Thailand _ $3.17 address resistance (daily to Cuba _, C points and motiva- pregnant Bolivia _, C tions needed; women, _, Honduras AIN-C C reminders enhance and children Zambia C adherence; medical under age Nicaragua PRO- and nursing staff two, C) COSAN C need to be educated and motivated; con- sider combining with community- based growth pro- motion. Iron Venezuela, United + $.12­$.22 Special attention to fortification States, Canada, regulatory enforce- United Kingdom, ment of fortification Sweden, Chile laws to ensure industry compliance; consumer education may be needed; costs are usually small and can often be passed on to con- sumers, except when a targeted subsidy is warranted. Salt China Salt + $.20­$.50 Special attention iodization Iodization Project; needed to regulato- Indonesia Iodine ry enforcement of Project fortification laws; Worldwide consumer education may be needed. Consolidation of alternative employ- ment for artisan producers. Costs are usually small and can often be passed on to consumers. Conditional Mexico PROGRESA +/- $70­$77 Pay attention to the cash transfers Honduras PRAF quality of nutrition Nicaragua Red de counseling in health Protección Social services. Consider (RPS) combining with community-based growth promotion. 134 REPOSITIONING NUTRITION Costs per Large-scale Effect on participant Intervention program experience nutrition* per yeara Best practices Maternal- Ethiopia, Gambia, +/- $42 per Tight targeting criti- child food Kenya, Benin, 1,000 cal. Important that supplementa- Madagascar, calories food not be disin- tion (listed Mozambique, per day centive to family or countries India, Bolivia, per local agriculture; have NGO Guatemala, Haiti, person nutrition education programs Peru, Honduras, critical; avoid for- evaluated for Nicaragua eign foods, use local impact) Virtually every foods if possible; country. targeting to mal- nourished risks rewarding failure. Early child Bolivia PIDI +/- $250­ develop- Colombia HBI $412 Involve parents in ment/Child Uganda ECD with food growth promotion care India ICDS (Colom- and child develop- Philippines ECD bia, ment through inter- Kenya ECD Bolivia); personal counseling $2­$3 and community without meetings. food (Uganda) Nutrition Most small nutri- +/- $2.50 Most common prob- education tion components lem is poorly (breastfeed- and information, designed messages, ing promo- education, and materials, and tion, comple- communication in media. Counseling mentary health-based nutri- messages should be feeding) tion projects. tailored, negotiated, and based on forma- tive research in the community. Generic information, educa- tion, and communi- cation and group talks ineffective. Breastfeeding Brazil, Honduras, + $.30­$.40 For hospital-based promotion in Mexico if infant births; education of hospitals Baby-friendly formula medical and nurs- hospitals in ward ing professional $2­$3 if critical, as is keep- no infant ing infant formula formula purveyors out of in ward hospitals. COUNTRY EXPERIENCE WITH SHORT ROUTES TO IMPROVING NUTRITION 135 Costs per Large-scale Effect on participant Intervention program experience nutrition* per yeara Best practices Microcredit Ghana + $.90­ Freedom from cum nutrition Bolivia $3.50 Hunger (NGO). education Uganda (marginal Pay attention to cost of quality of nutrition nutrition counseling. educa- tion) Facility-based Honduras AIN -- Educating medical integrated and nursing person- nutrition nel about breast- services feeding, infant feed- such as IMCI ing, growth, and (micro- micronutrients is nutrient essential. supplements, growth monitoring, nutrition education, prenatal nutrition; care of severely mal- nourished) -- = not available. a. Costing is a complex exercise, and the costs presented here, extracted from several sources, are not necessarily comparable. We include the information here simply to emphasize the point that costing is important in setting priorities. Annex 2 Long Routes to Improving Nutrition Economic growth Economic growth is perhaps the most important long route to improved nutrition. Although nutrition is correlated with income, both across coun- tries and over time in the same country, improvement takes a long time-- time during which many children suffer irreparable damage to human capital. Haddad and others (2002) estimate that countries with 2.5 percent GDP growth per capita could expect a reduction of 27 percent in under- weight in preschool children between 1990 and 2015. Macroeconomic policies Macroeconomic policies, particularly trade policies, can profoundly affect both the supply of and the demand for food. Policy reforms can have a rapid effect on the income of the poor, but their effect on nutrition is less direct, and pro-poor reforms have often proven to be politically difficult to implement. As was shown in the Sahel in 1996 when the CFA franc was devalued, foreign exchange rates have an immediate and large effect on food consumption of the rich and poor alike. Unfortunately, government controls on food markets (tariffs, subsidies, price controls, ration shops, public ownership of mills, and parastatal food marketing boards) often fail to benefit the poor, while draining the public coffers.1 Reforms of such pro- grams can improve poor people's nutrition or food consumption and reduce public expenditures (usually by reducing benefits to wealthy and politi- cally powerful populations, however). Careful food policy analysis on the effect of policy changes on food consumption of the poor can show which policy reforms make the most sense. A good example of this type of analy- sis is Romania's Agricultural Sector Adjustment Loan;2 it identified the regressiveness of food subsidies and tariffs, and at the same time built local capacity to undertake food policy analysis. 136 LONG ROUTES TO IMPROVING NUTRITION 137 Female education and enhanced women's status Female education and enhancing the status of women are important long routes to nutritional improvement.3 In a large cross-country study, women's education was found to have a greater influence on child nutrition than food availability, women's status, and access to safe water.4 Improving women's education and status is desirable for many reasons, of course, but the lag time between girls entering school and having their first child (hope- fully delayed by additional schooling) and the slow pace of improvement in women's status make these long-term approaches to improving nutrition. In Ethiopia, analysis showed that increased schooling, food security, and income growth would take too long to affect preschool malnutrition, but that community-based growth promotion could accelerate and potentiate their effect on nutrition.5 The nutritional effect of growth promotion among 25 percent of children is equivalent to primary schooling in one female adult per household. This had been shown previously in the Bank-supported Indonesian Nutrition Development Project, where growth promotion was shown to have the greatest effect on mothers with the least education.6 Women's workload Women's workload is also important for nutrition. Women are farmers and wage workers, and they carry out the bulk of family maintenance (cooking, washing, child care). Women's income can have an important positive effect on child nutrition, if child-care arrangements are adequate. Relieving this workload through labor-saving devices (food mills, wheelbarrows, improved stoves, water supply) can free both time and energy for attention to nutri- tion, both for the woman and her children. Many development programs expect women to "do more" for health when they have no time available. Attention to women's income, control of resources, energy expenditure, and time use is critical to improving the nutrition of women and children. Food production Food production is also a long route to nutrition improvement. Countries with higher food availability tend to have better nutrition. Nonetheless, nutrition does not track food availability within countries over time. This is undoubtedly because those who need the food the most are unlikely to be able to increase production or purchasing power in the short term, unless explicit efforts are made to increase their economic access to food. Also, as shown in studies of agricultural commercialization by the International 138 REPOSITIONING NUTRITION Food Policy Research Institute,7 the effect of income on nutrition is medi- ated by women's control of income and their time.8 Water supply and sanitation Diarrhea, a major cause of malnutrition, is strongly related to water access and quality,9 so it is not surprising that water supply and sanitation have been shown to have an effect on nutrition.10 Water supply programs not only reduce the waterborne transmission of disease, but also save women time and energy otherwise spent carrying water. This extra time can be devoted to child care and feeding or to income generation, and the extra energy benefits undernourished women. Water and sanitation programs might find that their cost-benefit increases if they measure their effect on improving nutrition. Family planning The relationship between nutrition and fertility is complex. On the one hand, exclusive breastfeeding (arguably the most important nutrition inter- vention) reduces fertility. On the other hand, high parity and short birth intervals are associated with worse child nutrition and maternal nutritional depletion. Family planning affects nutrition both by enhancing maternal resources available to each child and by enhancing women's health. Such programs rarely measure nutrition as an outcome, but a successful family planning program is likely to have a substantial positive effect on nutri- tion. Thus maternal health and family planning programs provide another long route to nutritional improvement. Notes 1. Alderman and Lindert (1998); Adams (1998); Tuck and Lindert (1996); World Bank (2001c). 2. Esanu and Lindert (1996). 3. Smith and others (2003); women's status is proxied by whether women work for cash, age at first marriage, age difference between partners, and education difference between partners. 4. Smith and Haddad (2000). 5. Christiaensen and Alderman (2004). 6. Manoff International, Inc. (1984). 7. Von Braun (1995). 8. Haddad and others (1996). 9. Cairncross and Valdimanis (2004). 10. Anderson (1981); Burger and Esrey (1995). LONG ROUTES TO IMPROVING NUTRITION 139 11. Heaver (2002). 12. Monteiro and others (2004). 13. Panneth and Susser (1995). 14. Caballero (2005). Annex 3 Key Priorities for Action Research in Nutrition: A Proposal Mainstreaming Nutrition in the Development Agenda A new programming environment is emerging at the global and country levels. The move from projects to programs, from vertical, disease-specific approaches to sectorwide approaches (SWAps), and budget support are all part of this changing picture. The roles of civil society and the private sector are becoming more important in global health and nutrition. The focus on results has never been higher on the agenda of development part- ners. These changes call for some adjustments in how the nutrition agenda is furthered. Four key areas of action research are critical in making these adjustments: · Mainstreaming nutrition into health, agriculture, rural development, educa- tion, and social protection programs. As outlined in chapter 1, evidence now shows that several of the health and other Millennium Development Goals (MDGs) will not be met without investments in improving nutri- tion. Some evidence suggests that nutrition education efforts and other demand-side interventions may be necessary but not sufficient to improve outcomes unless these efforts are linked to supply-side interventions such as improved access to health services and micronutrient supple- mentation and fortification, supplementary feeding, and increased access to cheaper fruits and vegetables for addressing overweight. Programs across many sectors have attempted to include nutrition interventions. Yet very little information is available on how best to do so or which approaches are successful. The Bank-supported development grant for the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) will look at opportunities to include nutrition in maternal 140 KEY PRIORITIES FOR ACTION RESEARCH IN NUTRITION: A PROPOSAL 141 and child health programs. There is a need to review and support similar experiences in other sectors. · Guidelines and instruments for assessing institutional capacity. As outlined in chapter 4, a key constraint on action in nutrition is the institutional arrangements and capacity for nutrition.11 Many programs are unsuc- cessful because not enough effort is invested in assessing capacities and in defining capacity needs. Developing guidelines and instruments for assessing institutional capacity and identifying best practices for insti- tutional arrangements in different country scenarios will be critical to helping countries make rational assessments for scaling up programs. Human resource options for nutrition service delivery under different institutional arrangements and their management and fiscal implica- tions need to be researched. · Building commitment for nutrition. How should these commitment-build- ing approaches vary in different country circumstances, and how can international and local stakeholders best partner to strengthen commit- ment? · Costing and financing interventions and service delivery approaches in varied country circumstances. The Copenhagen Consensus (Behrman, Alderman, and Hoddinott 2004) has shown that nutrition interventions rank very high among other interventions in terms of cost-benefit. While some information is available for costing individual interventions, very little is available on large-scale programs and the levels of investments needed to meet the nutrition MDGs. Strengthening and Fine-Tuning Delivery Mechanism · Exploring the replicability of new delivery mechanisms for nutrition services. Where government capacities for implementation are limited, countries have explored service delivery through nongovernmental organizations (NGOs), as in Bangladesh. Lessons suggest that this may warrant an alternative capacity for contracting and managing NGOs. In other coun- tries (such as Mexico and Honduras), conditional cash transfers have been used as an opportunity for strengthening the use of health and nutrition services. In the micronutrient sector, public-private partner- ships and alliances are being explored. Experience and learning from these innovations needs to be tested in other environments for future adaptation and scaling-up. · Research to support a clearer understanding of how far micronutrient supple- mentation can take us (and for which micronutrients), how long it should be continued under different conditions, and whether fortification or food-based 142 REPOSITIONING NUTRITION strategies are sufficient. The efficacy of biofortification and other emerg- ing food-based strategies for micronutrient deficiency control is being explored through initiatives such as the Harvest Plus program. These strategies have immense potential that must be maximized. · Cost-effectiveness of food supplementation (linked to nutrition education), and conditions under which costs may outweigh potential benefits. Food supple- mentation often consumes 50 percent or more of program budgets. Evidence suggests that to be effective, food supplementation must be linked to nutrition education through growth promotion or other strate- gies, especially for young children. Yet the evidence is unclear as to what the best targeting mechanisms are and when costs may outweigh benefits. · Devise methodologies for forging stakeholder consensus around results from operations research and monitoring and evaluation as well as the pro- grammatic vision and capacities to fine-tune strategies based on these inputs. Strengthening the Evidence Base: · Evidence-based strategies to prevent and reduce overweight and diet-related noncommunicable diseases (NCDs). This is a key challenge because it affects both rich and poor countries; these problems contribute substantially to chronic disease and mortality, as well as to economic growth; and revers- ing overweight offers huge public expenditure savings in both low- income and middle-income countries. The poor in low socioeconomic status countries (gross national product [GNP] less than $2,500 per capita) may be protected against obesity, but the poor in upper middle-income countries (GNP greater than $2,500 per capita) are much more prone to obesity.12 In addition, the Barker hypothesis suggests that fetal food deprivation may result in postnatal programming that predisposes low- birthweight babies to cardiovascular disease and diabetes.13 Furthermore, in many areas obesity coexists with underweight.14 However, precise information on the size and scope of the overweight problem as well as the diet-NCD link and tested large-scale interventions on how to address them are still limited. Therefore, the priority here is to find out more about these issues as we move toward scaling up. · Efficacy and effectiveness of different nutrition interventions for preventing and mitigating the effect of HIV/AIDS. These interventions include the role of exclusive breastfeeding in preventing mother-to-child transmission of HIV/AIDS; the role of nutrition in enhancing the effectiveness of anti- retroviral therapy; and the role of food security in mitigating the risk of HIV infection. KEY PRIORITIES FOR ACTION RESEARCH IN NUTRITION: A PROPOSAL 143 · Linking nutrition data with larger global monitoring initiatives. Several larger global health and poverty monitoring initiatives (such as the Health Metrics Network) are under development. Development partners and funding agencies are keen to support integrated systems, and it is impor- tant that relevant nutrition indicators be included in these initiatives. This will need some research support. · Methodologies for evaluating nutrition actions in the context of programmatic approaches such as SWAps and Poverty Reduction Strategy Credits (PRSC)s. The current evaluation methodologies may need to be adjusted and adapted to these new approaches. In addition, the indicators that are used for assessing progress in nutrition are much harder to apply than those in other sectors. For example, the MDG progress indicator for the education sector is school enrollment rates. The nutrition indicator is underweight rates. While the education indicator is much closer to being a process or output indicator, the nutrition indicator is much more of an impact indicator--and the time frame for achieving an impact in under- weight is much longer than that for enrolling children in school. In the choice of indicators, we may be setting nutrition up for higher standards than other sectors. This issue needs some research. In addition, many traditional nutrition evaluations have looked for the benefits of pro- grams across population groups as whole--for example, low-birthweight prevention programs have looked for an impact among all pregnant women. However, emerging research has shown that these benefits may be unequally distributed across different groups (for example, the poor- est or the most malnourished may benefit more), or that benefits may be distributed differently across the mother-child dyad under different situations--yet the evaluation methodology used often limits the size and nature of the benefits that can be detected. Technical Annexes 1.1. Ten selected risk factors for major burden of disease 1.2. Trends in selected development indicators in developing countries 1.3. Percentage reduction in prevalence of malnutrition between 1990 and 2015 and number of years to halve prevalence of malnutrition 2.1. Estimated prevalence of malnutrition among preschool children by region 3.1. Obesity and chronic disease in the developing world 4.1. Country experiences in nutrition programming A. India: Two approaches to food supplementation-- The Tamil Nadu Integrated Nutrition Projects and the Integrated Child Development Services B. Senegal: Empowering communities by involving them in the design, delivery, and management of services C. India: The Tamil Nadu Integrated Nutrition Project-- attention to microlevel design and management D. Honduras: The AIN-C program--attention to microlevel design and management E. Managing multisector programs: What not to do-- experiences from World Bank­supported projects F. Thailand: Incorporating nutrition into community development indicators--the village information system G. Thailand: Sequenced partnership-building--making nutrition everybody's business H. China: Building commitment is not just about communication--the iodine deficiency control program 4.2. Nutrition as part of health services 5.1. Areas of focus in nutrition among development partners, by subject area 145 146 REPOSITIONING NUTRITION 5.2. Areas of focus in nutrition among development partners, by technical area 5.3. Mandate and focus of development partners in nutrition 5.4. Deciding how to invest in nutrition: A framework for making policy choices 5.5. Methodology for constructing the country prioritization matrix 5.6. Nutritional status of children Annex 1.1 Ten selected risk factors of major burden of disease Developing countries Developing countries Developed countries with high child and with low child with very low high or very high and low adult or low child adult mortalitya mortalityb mortality levelsc % % % Risk factor DALYs Risk factor DALYs Risk factor DALYs 1 Underweight 14.9 Alcohol 6.2 Tobacco 12.2 2 Unsafe sex 10.2 Blood pressure 5.0 Blood pressure 10.9 3 Unsafe water/ 5.5 Tobacco 4.0 Alcohol 9.2 sanitation/hygiene 4 Indoor smoke from 3.7 Underweight 3.1 Cholesterol 7.6 solid fuels 5 Zinc deficiency 3.2 Overweight 2.7 Overweight 7.4 6 Iron deficiency 3.1 Cholesterol 2.1 Low fruit and vegetable intake 3.9 7 Vitamin A 3.0 Low fruit and 1.9 Physical inactivity 3.3 deficiency vegetable intake 8 Blood pressure 2.5 Indoor smoke from 1.9 Illicit drugs 1.8 solid fuels 9 Tobacco 2.0 Iron deficiency 1.8 Unsafe sex 0.8 10 Cholesterol 1.9 Unsafe water/ 1.7 Iron deficiency 0.7 sanitation/hygiene Source: WHO (2002). Note: Calculation is based on WHO regions: a= AFR-D, AFR-E, AMR-D, EMR-D, SEAR-D b=AMR-B, EMR-B, SEAR-B, WPR-B c=AMR-A, EUR-A, EUR-B, EUR-C, WPR-A Unsafe sex disease burden is from HIV/AIDS and sexually transmitted diseases; iron deficiency disease burden is from maternal and perinatal causes, as well as direct effects of anemia; unsafe water, sanitation, and hygiene disease burden is from diarrheal diseases. 147 Annex 1.2 Trends in selected development indicators in developing countries 148 1970 1975 1980 1981 1984 1985 1987 1990 1993 1995 1996 1999 2000 2001 2002 2003 2005 ARC* IMR (/1000) 108 88 71 67 62 60 -1.80 U5MR (/1000) 167 133 105 98 91 87 -1.99 Energy availability (Cal) 2110 2146 2308 2444 2520 2602 2654 0.83 Underweight (%) 37.6 33.9 30.1 27.3 24.8 22.7 -2.99 Stunting (%) 48.6 43.2 37.9 33.5 29.6 26.5 -2.03 Poverty headcount (%) 40.4 32.8 28.4 27.9 26.3 22.8 21.8 21.1 -2.45 Source: IMR & U5MR: www.childinfo.org; underweight and stunting: SCN (2004); poverty headcount: Chen and Ravallion (2004); energy avail- ability: FAO Statistical Database (2005). Note: IMR = infant mortality rate; U5MR = under-five mortality rate; ARC = annual rate of change; per capita energy availability is an average of three years. TECHNICAL ANNEXES 149 Figure A.1 Trends in selected development indicators in developing countries 50 180 160 40 140 120 30 100 (/1000) undernutrition 80 20 child 60 % Underweight (%) Mortality 10 Stunting (%) 40 IMR (/1000) U5MR (/1000) 20 0 0 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 50 3000 2500 40 (%) 2000 (Kcal/d) 30 1500 20 Prevalence availability 1000 Underweight (%) 10 Stunting (%) Poverty headcount (%) 500 Energy Energy availability (Cal) 0 0 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 150 REPOSITIONING NUTRITION Figure A.2 Differences in aggregate per capita food availability and percent child underweight levels 3500 50 2800 40 (kcal/day) 2100 30 1400 20 underweight availability child food 700 10 % capita 0 0 Per 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 1980 1985 1990 1995 2000 2005 Africa Asia LAC Developing Developed Per capita food availability (kcal/d) % child underweight Source: SCN (2004); FAO Statistical Database (2005). Annex 1.3 Estimated percentage reduction in prevalence of malnutrition between 1990 and 2015 and number of years to halve prevalence of malnutrition, through economic growth alone Percentage reduction in prevalence of malnutrition, No. of years to halve the 1990­2015 prevalence of malnutrition Elasticity Econ. growth -0.3 -0.5 -0.7 -0.3 -0.5 -0.7 0.5 3.7 6.1 8.4 461.8 276.9 197.7 1.0 7.2 11.8 16.1 230.7 138.3 98.7 1.5 10.7 17.2 23.2 153.7 92.1 65.7 2.0 14.0 22.2 29.7 115.2 69.0 49.2 2.5 17.2 27.0 35.7 92.1 55.1 39.3 3.0 20.2 31.5 41.2 76.7 45.9 32.7 3.5 23.2 35.7 46.2 65.7 39.3 27.9 4.0 26.1 39.7 50.8 57.4 34.3 24.4 4.5 28.8 43.4 55.1 51.0 30.5 21.7 5.0 31.5 46.9 59.0 45.9 27.4 19.5 5.5 34.0 50.2 62.5 41.7 24.9 17.7 6.0 36.5 53.3 65.8 38.2 22.8 16.2 6.5 38.9 56.2 68.8 35.2 21.0 14.9 7.0 41.2 59.0 71.5 32.7 19.5 13.8 7.5 43.4 61.5 74.0 30.5 18.1 12.9 8.0 45.5 64.0 76.3 28.5 17.0 12.0 8.5 47.6 66.2 78.4 26.8 16.0 11.3 9.0 49.6 68.4 80.3 25.3 15.1 10.7 9.5 51.5 70.4 82.1 24.0 14.2 10.1 10.0 53.3 72.3 83.7 22.8 13.5 9.6 Source: Authors' calculation based on different per capita GDP growth (0.5 to 10.0 percent per capita per year) and elasticity assumptions (-0.3 to -0.7). For example, in countries with an annual GDP growth of 2.5 percent per capita and an elasticity of -0.5, one can expect a 27 percent reduction in underweight rates between 1990 and 2010. 151 Annex 2.1 Estimated prevalence of malnutrition among preschool children by region Stunting 1980 1985 1990 1995 2000 2005 Africa 39.0 37.8 36.9 36.1 35.2 34.5 Asia 55.1 48.2 41.1 35.4 30.1 25.7 LAC 24.3 21.1 18.3 15.9 13.7 11.8 Developing 48.6 43.2 37.9 33.5 29.6 26.5 Developed 2.8 2.8 2.7 2.6 Global 33.5 29.9 26.7 24.1 Underweight 1980 1985 1990 1995 2000 2005 Africa 23.5 23.5 23.6 23.9 24.2 24.5 Asia 45.4 40.5 35.1 31.5 27.9 24.8 LAC 12.5 10.5 8.7 7.3 6.1 5.0 Developing 37.6 33.9 30.1 27.3 24.8 22.7 Developed 1.6 1.4 1.3 1.1 Global 26.5 24.3 22.2 20.6 Overweight 1980 1985 1990 1995 2000 2005 Africa 3.3 4.2 5.2 Asia 2.6 2.5 2.5 LAC 4.4 4.3 4.3 Developing 2.9 3.0 3.4 Source: SCN (2004); de Onis (2004a). 152 Annex 3.1 Obesity and chronic disease in the developing world Many developing countries are starting to parallel the developed world, with increasing prevalence of overweight and obesity and associated chronic disease comorbidities. Overweight and obesity put individuals at higher risk for dyslipidemia, hypertension, hyperinsulinism, insulin resistance, and diabetes, all of which substantially increase the risk for cardiovascular disease. Obese individuals may also suffer from respiratory disorders and certain types of cancer. In 2001, it was estimated that chronic diseases con- tributed to approximately 60 percent of the 56.5 million total reported deaths in the world and to approximately 46 percent of the global burden of dis- ease. Reflecting this trend, the World Health Organization (WHO) has recently made a call to action to put overweight and obesity at the fore- front of public health policies and programs. There are many potential reasons for the strikingly high prevalence of overweight and obesity and their comorbidities in developing countries. Behavioral factors, including dietary intake, physical activity, and sedentary behaviors, have been important contributors to the development of obe- sity. Intakes of total fat, animal products, and sugar are increasing simul- taneously with decreases in the consumption of cereals, fruits, and vegetables. Decreased energy expenditure, due to an increasingly sedentary lifestyle and a reduction in labor-intensive occupations, is a second and equally important explanation for the increased rates of overweight and obesity in the developing world. Major changes in lifestyle have occurred over the past several decades, and have caused an "obesogenic environ- ment" because of the easy availability of high-energy food combined with an increasingly sedentary lifestyle. Although obesity is the result of a complex interplay between genetics and environment, obesity and chronic diseases are largely preventable. There is compelling evidence for the power of societal and environmental factors to contribute to weight gain. Beyond the medical treatment neces- sary for the people who are already overweight or obese, there is an under- utilized opportunity for primary prevention through cost-effective and 153 154 REPOSITIONING NUTRITION sustainable interventions. Given the limited resources of the developing world in particular, it is clear that obesity prevention needs to be incorpo- rated into existing nutrition programs. Unfortunately, little is known about the prevention and treatment of overweight and obesity on a population level, particularly in developing countries. Interventions addressing obesity span from clinic-based, one-on-one consultations with a primary-care physician to large-scale policy or social marketing initiatives. Clinical interventions target adults and children who are already overweight or obese. There are several possibilities for clinic- based interventions, which include dietary management, exercise pro- grams, pharmacological treatment, psychotherapy, behavior modification, and surgical treatment. Most successful programs have combined diet and exercise approaches with behavior therapy. School-based programs are becoming increasingly popular in the United States due to the captive audience of children in the school setting. The find- ings from studies of school-based interventions are modest at best, and do not always sustain results over time. Workplace interventions include pro- motion of stair use, on-site recreational facilities and programs, incentives for active commuting to work, and physical activity and nutrition counsel- ing. Although most worksite interventions are able to show short-term changes in behavior, in large part they are not able to assess whether any change in body mass index (BMI) or adiposity resulted from the program. The most successful programs have taken a community-level approach, and have addressed obesity through multiple, simultaneous and different avenues. The key elements of the successful interventions include having an environmental and multidisciplinary approach; generating local adap- tations of programs; exploring cultural norms and fitting the program within those constructs; adhering to a social-ecological model of behavior change; and taking a multifaceted approach to include multiple stake- holders, including health professionals, educators, and policy makers. Unfortunately, many of these types of programs have not been sufficiently evaluated. Those that have been evaluated do not always show any impact on BMI, and some have actually shown an increase in BMI across the course of the program. A wide variety of policy interventions are possible and have achieved mixed success. Social marketing campaigns are another approach to obe- sity prevention, but have been shown to be only marginally successful. The programs are generally successful in raising awareness about health issues, particularly through the use of mass media and point-of-purchase pro- motions, multichannel marketing, and consumer-driven research. However, it is very difficult to capture any changes in individual-level behavior or health status change. TECHNICAL ANNEXES 155 Despite the apparent, albeit moderate, effectiveness of several types of interventions, there are operational challenges that exist to addressing the problem of obesity in the developing world. The primary challenge is the lack of financing and institutional capacity to approach the problem in many developing countries. Several other political and economic issues hinder the effectiveness of interventions in developing countries. These include lack of understanding by key decision makers, such as health ministers, that obesity and chronic disease are critical issues and threats to public health; a misguided perception by policy makers that obesity is a result of personal irresponsibility and therefore outside of the domain of policy; and an assump- tion that global development and economic growth are the most important goals for the developing world, with disregard for the health consequences that come along with such economic growth. A related challenge is that tran- sitional economies are facing the dual burden of undernutrition simulta- neous with a high prevalence of obesity. In addition to these political and economic barriers to effective prevention and control of obesity are strong cultural and social norms working against that goal. Large gaps in research relating to obesity prevention and management have been identified. The primary gap is the lack of high-quality evaluations of obesity prevention interventions. Another important gap in the research arena is the lack of behavioral research, including research on the envi- ronmental, familial, and societal influences on food intake and physical activity. Cost-effectiveness will certainly be enhanced through improved targeting of programs and interventions to the populations who will benefit most. Source: Fernald (2005). Annex 4.1 Country experiences in nutrition programming A. India: Two approaches to food supplementation-- The Tamil Nadu Integrated Nutrition Projects and the Integrated Child Development Services India's Tamil Nadu Integrated Nutrition Program (TINP) operated in about 20,000 villages. It began in 1980, and was absorbed by the national Integrated Child Development Services Program (ICDS) in 1997. The two programs had quite different approaches to food supplementation. TINP served children a slightly sweetened snack food early in the morn- ing, which was seen by mothers as a supplement, rather than a meal. ICDS feeding is at lunchtime, and so substitutes for a meal at home. The ICDS timing suits older children, who can walk to the feeding center. TINP's early morning supplementation was at a time when mothers could bring children under three--the most nutritionally vulnerable--to the nutrition center before they went to work. TINP supplemented only children who were malnourished or whose growth was faltering; they "graduated" from supplementation when their growth was back on track. ICDS feeds a specific number of children every day, who may or may not be malnourished or growth faltering. Since the same children are fed every day, food is seen as an entitlement, rather than a temporary supplement designed to get the child back on track and to show mothers how they can prevent or treat malnutrition at home by feed- ing small, affordable amounts of extra food. The TINP system was both more effective in terms of reducing malnutri- tion, and cheaper, because an average of 25 percent of children were sup- plemented on a given day, in comparison to ICDS' 40 percent. But, because different children came into TINP supplementation as and when their growth faltered, 75 percent of TINP children got supplementation at different times, thus encouraging broad community acceptance of the program. Source: Heaver (2003a). 156 TECHNICAL ANNEXES 157 B. Senegal: Empowering communities by involving them in the design, delivery, and management of services In Senegal's first World Bank­supported Community Nutrition Project: · Clients helped influence the design of services during a pilot interven- tion a year before the main project began. They determined what open- ing hours for the nutrition centers best suited them. They also insisted on more information, education, communication sessions, and themes than the designers of the pilot had originally intended. · The choice of community nutrition workers was approved by local steer- ing committees representing the community, which then met their nutri- tion workers and their supervisor once a month to review progress. · Community nutrition workers organized "social mobilizations" bimonthly to keep the broader community informed about progress. · Project clients contributed about 3 percent of the costs of running the nutrition centers; the amount was nominal, but the principle of user charges made the nutrition services more accountable to the community. · During the project, communities were encouraged to analyze their local problems and take action to deal with them. One initiative was that day- care centers for children were started in 137 nutrition centers at the request of and financed by the community. · During the project, communities were involved in field level steering committees that included local representatives of the ministries of Finance; Social Action; Women, Children and Family Affairs, and Health; the pro- ject's executing agency; women's leaders, leaders of youth clubs and other local associations and nongovernmental organizations; and local religious leaders. These committees helped with information exchange, synchronization of activities, and building good interpersonal relations and commitment. Source: World Bank (2001b). C. India: The Tamil Nadu Integrated Nutrition Project-- attention to microlevel design and management · Recruitment criteria: Outreach workers had to be from their local com- munity. In addition, as much as possible, they were chosen from women who were poor, but whose children were nevertheless well nourished. Before they even began nutrition counseling, they were proof to the com- munity that poverty need not be an impediment to good nutrition. 158 REPOSITIONING NUTRITION · Work routines: These were clearly defined on a daily, weekly, and monthly basis. Growth monitoring, for example, was conducted on the same three days every month, so women knew when to bring their children to the nutrition center. This cut down the number of home visits workers had to make to monitor children. · Supervision and training: There was a field supervisor for every 10 com- munity workers, and a senior supervisor for every 60­70 workers. The training system was innovative in that the senior supervisor was also the preservice and in-service trainer of the workers in her area. This meant training could be tailored to workers' individual needs and cut out the expense of maintaining a network of training institutions. · MIS: Every month, data showing the proportion of children weighed and the number malnourished were posted on a chalkboard outside the nutrition center. This helped communities monitor progress. And every month, the data for all centers were analyzed by computer, and poor- performing centers were identified for special attention by supervisors-- "management by exception." Source: Heaver (2003a). D. Honduras: The AIN-C program-- attention to microlevel design and management AIN-C (Atención Integral a la Niñez en la Comunidad--Integrated Attention to Childhood in the Community) aims to promote self-reliance. The focus is on helping families improve the care of children under age two with their own resources, based on research showing that 92 percent of families had adequate food resources and that the reasons for child malnutrition were largely behavioral. This is different from programs that assume the family cannot adequately provide for its children, and immediately offer food, coupons, or cash to parents with malnourished children. AIN's field level management system has been carefully refined over a decade, and incorporates best practices from other community-based pro- grams. Key features include: Keeping it simple. Like the Tamil Nadu Integrated Nutrition Project (TINP), AIN focuses on child growth, rather than nutritional status. But unlike TINP, AIN's growth monitoring system does not rely on workers plotting each child's growth monthly on a graph. Instead, workers are given a table with figures showing how much weight a child of a given age (in years and months) should be putting on each month. They then have to make only a TECHNICAL ANNEXES 159 yes/no decision about whether the child's weight gain is adequate com- pared to the table. If not, workers discuss with the mother what is causing slow growth and agree on specific behavioral changes for improvement. Workers have counseling cards, developed through a trials of improved practices (TIPs) formative research process, to help them tailor their advice to the family's particular situation. The card helps workers differentiate their advice by the child's age, adequacy or inadequacy of weight gain, ill- ness status, and breastfeeding status. The card may suggest several areas for improvement, but the worker selects only one or two behaviors that the mother is willing to follow in the ensuing month. These could be as simple as nursing from both breasts at each feeding, or giving half of a tor- tilla to the child at two meals during each day. Next month, the mother gets feedback in the form of the child's weight gain, showing whether the behav- ior change made a difference. Progress monitoring is done through an innovative 5-bar graph (see below for an example), which tracks five simple indicators in each village each month: the number of children under age two in the community, the number weighed that month, the number gaining adequate weight, the number with inadequate weight gain, and the number gaining inadequate weight for two or more months. Community action. Once a quarter, the previous month's monitoring data (see below) are reported to the community at a meeting at which the com- munity at large makes decisions and works collectively for the betterment of its children. Collective action is key because many problems causing poor child growth go beyond the power of a family to correct: contami- nated water sources, garbage disposal, childcare, and poor health center outreach are all problems that families need to work together to fix. Treatment as well as prevention. Another important intervention is the detection, assessment, and treatment of common childhood illnesses, espe- cially diarrhea and pneumonia, in children under age five. Once the com- munity workers have mastered the core AIN program for children under age two, focused primarily on home-based preventive actions, they are trained in AIN's illness and newborn modules (based on the Integrated Management of Childhood Illnesses [IMCI] approach), which focuses more on identifying danger signs, expedited referral, and some community-ini- tiated treatment. They are also given timers to diagnose the rapid breath- ing that indicates pneumonia and an antibiotic to treat it. AIN is being studied and adapted by other countries, such as Bolivia, El Salvador, Ghana, Guatemala, Nicaragua, Uganda, and Zambia. Source: Griffiths and McGuire (2005). 160 REPOSITIONING NUTRITION 5-bar graph as presented to the community to stimulate discussion of changes in child growth over time April May June July 2 2 2 2 5 5 5 5 2 2 2 2 4 4 4 4 2 2 2 2 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 2 2 2 2 0 0 0 0 1 1 1 1 9 9 9 9 1 1 1 1 8 8 8 8 1 1 1 1 7 7 7 7 1 1 1 1 6 6 6 6 1 1 1 1 5 5 5 5 1 1 1 1 4 4 4 4 1 1 1 1 3 3 3 3 1 1 1 1 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 9 9 9 9 8 8 8 8 7 7 7 7 6 6 6 6 5 5 5 5 4 4 4 4 3 3 3 3 2 2 2 2 1 1 1 1 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Indicator Indicator Indicator Indicator Indicators: 1. Number of children younger than 2 years listed in the register. 2. Number of children younger than 2 years who attended the weighing session this month. 3. Number of children younger than 2 years with adequate growth this month. 4. Number of children younger than 2 years with inadequate growth this month. 5. Number of children younger than 2 years with inadequate growth this month and last month. TECHNICAL ANNEXES 161 E. Managing multisector programs: What not to do-- experiences from World Bank­supported projects · Rwanda's Food Security and Social Action Project initially put the finance ministry in charge of the project; it had no experience with program implementation and no presence in the field. Later in the project, inter- sectoral coordination was moved to the Ministry of Local Government, which handled it more successfully. · In the Bangladesh Integrated Nutrition Project, the responsibility for multisectoral coordination was at too low a level to be effective. It was given to an Inter-Sectoral Nutrition Cell in the health ministry's project management unit, which had little influence over the other participating agencies--the Ministry of Agriculture and the Ministry of Fisheries and Livestock. · No clear arrangements were made for managing nutrition as part of early childhood development (ECD) activities in Argentina's first World Bank­assisted Maternal and Child Health and Nutrition Project. The ECD centers had strong community support, but no institutional home in the government, not in the education ministry, whose focus was on schools, nor in the health ministry, which was more concerned with strengthening its own clinics than with nutrition outreach through preschool centers. Source: World Bank Project Implementation Completion Reports. F. Thailand: Incorporating nutrition into community development indicators--the village information system Four government ministries (health, agriculture, education, and interior), led by the Ministry of Public Health, jointly developed the Basic Minimum Needs (BMN) system. It was piloted in Korat province in the northeast, and then picked up by the National Economic and Social Development Board, Thailand's planning ministry, and implemented nationwide. There are 32 BMN indicators, divided into eight groups, as follows: Adequate Food and Nutrition 1. Proper nutrition surveillance from birth to age five years and no mod- erate and severe protein-energy malnutrition (PEM). 2. School children receive adequate food for nutritional requirements. 3. Pregnant women receive adequate and proper food, and delivery of newborn babies with birthweight not less than 3,000 grams. 162 REPOSITIONING NUTRITION Proper Housing and Environment 4. The house will last at least five years. 5. Housing and the environment are hygienic and in order. 6. The household possesses a hygienic latrine. 7. Adequate clean drinking water is available all year round. Adequate Basic Health and Education Services 8. Full vaccination with BCG, DPT, OPV, and measles vaccine for infants under one year of age. 9. Primary education for all children. 10. Immunization with BCG, DPT and typhoid vaccine for primary school children. 11. Literacy among citizens 14 to 50 years old. 12. Monthly education and information in health care, occupation, and other important areas for the family. 13. Adequate antenatal services. 14. Adequate delivery and postpartum services. Security and Safety of Life and Properties 15. Security of people and properties. Efficiency in Food Production by the Family 16. Growing alternative crops or soil production crops. 17. Utilization of fertilizers to increase yields. 18. Pest prevention and control in plants. 19. Prevention and control of animal diseases. 20. Use of proper genetic plants and animals. Family Planning 21. Not more than two children per family and adequate family planning services. People's Participation in Community Development 22. Each family is a member of self-help activities. 23. The village is involved in self-development activities. 24. Care of public properties. 25. Care and promotion of culture. TECHNICAL ANNEXES 163 26. Preservation of natural resources. 27. People are active in voting. 28. The village committee is able to plan and implement projects. Spiritual or Ethical Development 29. Being cooperative and helpful in the village. 30. Family members are involved in religious practices once per month. 31. Neither gambling nor addiction to alcohol or other drugs by family members. 32. Modest living and expenses. Source: Heaver and Kachondam (2002). G. Thailand: Sequenced partnership-building-- making nutrition everybody's business Building a constituency at the technical level Thailand's three nutrition champions (two from the health sector and one from agriculture) built up a broader group of "friends of nutrition" across the government by sending key staff from the planning ministry and line agencies for overseas nutrition training together, and through follow-up seminars combining staff from different government departments. Involving civil society: Mass communication The nutrition champions enlisted the support of the private sector to finance a much-repeated television ad, showing children in the northeast of the country who were so poor that they were reduced to eating earth to fill their stomachs. There was a nationwide sense of shame that this could happen in Thailand. Bringing key policy makers on board They convinced senior managers in the finance and planning ministries that putting money into nutrition was an investment rather than a social wel- fare expenditure, since it would make Thailand more productive and com- petitive. The military government saw the advantages of a multisectoral rural development program for national stability and security as well as for economic development. 164 REPOSITIONING NUTRITION Widening the consensus Once commitment had been built up in central government, seminars for provincial governors helped to bring regional governments into the part- nership. In the villages, all government agencies were involved in advo- cacy for community development, raising public awareness and encouraging people to volunteer. Appropriate management arrangements: High-level support and organizational incentives A national nutrition committee, chaired by the deputy prime minister and with representatives from all concerned line agencies, helped raise the pro- file of nutrition. Though financial allocations are controlled by the plan- ning ministry, each line agency is responsible for managing its part of the multisector program, and so each feels that nutrition is its business. Source: Heaver and Kachondam (2002). H. China: Building commitment is not just about communication--the iodine deficiency control program This $152 million World Bank­supported project, rated highly satisfactory, introduced new technologies in 200 firms in 31 provinces. Success factors included: · Commitment to salt iodization was built before the project began, through informal dialogue with local representatives of the United Nations Development Programme (UNDP), United Nations Children's Fund (UNICEF), United Nations Industrial Development Organization (UNIDO), and WHO, before the World Bank became involved; and by political leaders' involvement in international meetings facilitated by the Micronutrient Initiative (MI). · There was a systematic plan to ensure that high level political commit- ment was disseminated to stakeholders at all levels. Government allied with civil society--for example, the All China Women's Federation--to run public awareness campaigns on the importance of iodization. In addition: ­ A strong, legislative framework requiring salt to be iodized, and a strong regulatory framework to ensure that it actually happened, were developed. TECHNICAL ANNEXES 165 ­ A free-standing project for iodine was carved out of a much larger health sector loan: this helped focus attention on the issue. ­ The salt industry was put in the driver's seat of the project, and its authority and responsibility helped ensure commitment to effective iodization. ­ The environment was favorable: a national focus on industrial reform meant that industry saw the project as an opportunity to modernize through the project's capacity-building work in management, moni- toring, packaging, marketing, and quality control. Hence industry and the health ministry had a common goal in successful project imple- mentation. ­ A carefully planned implementation management framework was defined, so all stakeholders knew what was expected of them and were monitored. ­ Senior World Bank management expressed strong interest in the pro- ject and actively monitored its progress. ­ Strong coordination between the development partners and regular informal technical assistance from local UN agencies helped sustain commitment. ­ There was continuity of both country and World Bank project teams. Source: World Bank (2001a). Annex 4.2 Nutrition as part of health services Child growth and development interventions center on health and nutrition: 1. Breastfeed exclusively for the first six months of infant's life. 2. Then feed freshly prepared, energy and nutrient rich complementary foods while continuing breastfeeding for two years. 3. Ensure adequate micronutrients through the diet or supplementation. 4. Continue feeding sick children, and offer them more fluids. 5. Ensure that every pregnant woman has adequate antenatal care. 6. Ensure that children get a full course of immunizations. 7. Ensure that children in malaria-endemic areas sleep under insecticide- treated bednets. 8. Give appropriate home treatment for infections, especially oral rehy- dration for diarrhea and drugs for malaria. 9. Recognize when sick children need professional care and seek it. 10. Follow health workers' advice about treatment, follow-up, and referral. 11. Dispose of feces safely, and wash hands afterwards and before touch- ing food. 12. Promote mental and social development through talking, playing, and providing a stimulating environment. Source: Hill, Kirkwood, and Edmond (2004). The BASICS approach to incorporating nutrition into health services The Basic Support for Institutionalizing Child Survival (BASICS) Projects are U.S. Agency for International Development (USAID) contracts to fight needless childhood deaths in the developing world (see www.basics.org). The current $100 million BASICS contract began in October 2004. It helps expand effective child health interventions, such as newborn health, vitamin A supplementation and other essential nutrition actions, immu- 166 TECHNICAL ANNEXES 167 nization, pediatric AIDS, the treatment of diarrhea and pneumonia, and malaria control. It supports activities to increase the use of child health and nutrition interventions by families, communities, and health systems. Essential Nutrition Actions (ENA)* is an approach, developed as part of the BASICS project, to expand the coverage of six proven nutrition inter- ventions through actions at health facilities, in communities, and through communications channels: · Exclusive breastfeeding for six months. · Adequate complementary feeding from about age 6 months to 24 months, with continued breastfeeding. · Appropriate nutritional care of sick and severely malnourished children. · Adequate intake of vitamin A for women and children. · Adequate intake of iron for women and children. · Adequate intake of iodine by all members of the household. There has been experience with implementing ENA at the community level in Benin, Ethiopia, Ghana, Madagascar, and Senegal. ENA is also being incorporated into the pre-service of doctors and other health professionals in the medical schools and paramedical training institutions of Ethiopia, Ghana, and Madagascar. The table below illustrates how different nutrition actions can be incorporated into the routine work of health personnel. Essential nutrition actions in health services When you see clients for You should provide The content should be Prenatal care Breastfeeding counseling Breastfeeding immediately after delivery, the importance of colostrums and exclusive breastfeeding (EBF), solving problems that prevent estab- lishing breastfeeding, and mother's diet. Iron/folate supplements One daily tablet (60 mg iron) and counseling throughout pregnancy for 6 months (180 tablets), counsel- ing on side effects and com- pliance, and when and how to get more tablets 168 REPOSITIONING NUTRITION Essential nutrition actions in health services (continued) When you see clients for You should provide The content should be Delivery and Breastfeeding assistance Immediate initiation of breast- postpartum and counseling (all mater- feeding, check for position care nities should follow the and attachment, management "10 Steps for Baby of common problems, dura- Hospitals"). tion of EBF up to about six months, dangers of giving water or liquids, and how to express breast milk. Vitamin A supplement for One dose of 200,000 IU mothers administered to the mother after delivery (within the first eight weeks). Postnatal Exclusive breastfeeding Assess and counsel on prob- checks check; reinforce good diet lems, teach prevention of and rest for mothers. "insufficient milk," how to increase milk supply, manage problems, and mother's diet. Immunizations With tuberculosis vaccine Complete one dose of 200,000 (BCG) contact, check moth- IU for women within eight er's vitamin A supplement. weeks after delivery (within six weeks if not breastfeeding). During National One dose of 100,000 IU for Immunization Days (NIDs) infants age 6­11 months; and and community outreach one dose of 200,000 IU for for immunizations, check children age 12­59 months, and complete children's every 4­6 months. vitamin A. With OPV-3 and measles One dose of 100,000 IU for immunization, check infants age 6­11 months; and infant's vitamin A. one dose of 200,000 IU for children age 12­59 months should be given every 4­6 months (for infants under age 6 months, use 50,000 IU per dose). TECHNICAL ANNEXES 169 Essential nutrition actions in health services (continued) When you see clients for You should provide The content should be Well-baby Assess and counsel on Counseling and support for visits breastfeeding; assess and EBF in the first 6 months, counsel on adequate counseling and support for complementary feeding adequate complementary (use locally adapted feeding from age 6­24 recommendations). months, continuation of breastfeeding to age 24 months. Use iodized salt for all family meals. Check and complete vita- See protocols above under min A, iron, and antimalar- immunizations, INNACG ial protocol. (1998). Sick child visits Screen, treat, and refer IMCI and WHO (1997) severe malnutrition, protocols for severe vitamin A deficiency, and malnutrition, vitamin A anemia. deficiency, and anemia. Check and complete See protocols above under vitamin A protocol. immunizations. Also provide vitamin A supplements for measles, diarrhea, and malnutrition according to WHO/UNICEF/IVACG. Assess and counsel on Increase breastfeeding while breastfeeding; assess and child is sick. Counsel and counsel on adequate support EBF in the first 6 complementary feeding months; counsel and support (use locally adapted for adequate complementary recommendations). feeding for age 6­24 months, continuation of breastfeeding to age 24 months. Continued and recuperative feeding for sick children. Source: Sanghvi and others (2003). Note: * Acharya and others (2004). Annex 5.1 Areas of focus in nutrition among development partners, by subject area 170 Food policy/ Nutrition in agriculture/ maternal and General HIV and rural child health/ Types Organizations malnutrition Micronutrients nutrition development child feeding UN agencies UNICEF X X X X SCN* X X X X X WFP X X WHO** X X X X X FAO X X Multilateral World Bank X X X X X agencies ADB X X X X Bilateral DFID X agencies SIDA X CIDA X X USAID X X X X X GTZ X DANIDA X NORAD JICA X TECHNICAL Dutch X Ireland AID Public/private GAIN X ANNEXES partnerships Private sector/ WABA X NGOs Manoff Group X X AED X X X HKI X X MI X MOST X CARE X X X La Leche League X FANTA X X X X BASICS X X X Research Harvest Plus X X institutions IFPRI/CGIAR X X Note: Tables 5.1 and 5.2 are indicative only and are based on a subjective review of Web sites and common knowledge about the focus of each organization. *Functions primarily as a coordination body. **Functions primarily as a technical body. 171 Annex 5.2 Areas of focus in nutrition among development partners, by technical area Mainstreaming 172 nutrition into Monitoring Commitment Capacity PRSCs, PRSPs and Organizations building development and SWAps evaluation Research G N SN G N SN G N SN G N SN T A O UN agencies UNICEF X X X X X SCN X WFP X WHO X X X X FAO* X X X Multilateral World Bank X X X X X X X X agencies ADB X X X X Bilateral DFID* X X agencies SIDA CIDA USAID X X X GTZ X DANIDA X X NORAD X TECHNICAL JICA Ireland AID Public/private GAIN*** X X X ANNEXES partnerships Private sector/ WABA** X X NGOs Manoff Group X X X AED X X X HKI X X X X X MI*** X X X X X X MOST*** X X X X CARE X X La Leche League** X FANTA X X BASICS X X X Research Harvest Plus* X institutions IFPRI/CGIAR X X X X Note: G-Global; N-National; SN-Subnational; T-Technological research; A-Applied research; O-Operational research. * Focus primarily on food security. ** Focus primarily on infant feeding/breastfeeding. *** Focus primarily on micronutrients. 173 Annex 5.3 Mandate and focus of development partners in nutrition (Information for this annex has been extracted primarily from the Web sites of the relevant agencies/groups.) Mission statement/ Institutions mandate Nutrition strategy UN agencies WHO/ The importance · WHO shares responsibility with UNICEF Department of WHO's role in reporting on child mortality, maternal of Nutrition in promoting health, nutritional status, etc. for Health and nutrition is well · WHO, along with the Food and Development elucidated. Agricultural Organization (FAO), con- (NHD) vened International Conference on "Because of the Nutrition, 1992. fundamental · Key documents include: role nutritional Turning the Tide of Malnutrition: well-being Responding to the Challenge of the plays in health 21st Century; Nutrition for Health and human and Development: A global agenda development, for combating malnutrition, 2000. and the world- · Consistent with nine goals and nine wide magni- strategies of the World declaration and tude of malnu- Plan of Action for Nutrition, NHD trition-related works through seven priority areas of mortality and action through a multisectoral frame- morbidity, work. WHO has · The main objectives: always includ- 1. Capacity building for assessing and ed nutrition addressing nutrition-related prob- promotion, and lems; development of nutrition poli- the prevention cies and programs. and reduction 2. Help develop scientific knowledge, of malnutrition, methodologies, standards, strategies, among its key etc., for detecting and preventing all health-promo- forms of malnutrition deficiencies tion instru- and excesses, including improve- ments." ments in horticulture and farming systems. 174 TECHNICAL ANNEXES 175 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy WHO/NHD 3. Promote sustainable health and cont. nutrition benefits of targeted food and development projects. Works with World Food Program (WFP) to ensure effectiveness of food aid interventions. 4. Maintains global database for moni- toring and evaluation (M&E) and reporting on world's major forms of malnutrition, effectiveness of pro- grams, and achievement of targets at national, regional, and global levels. · The seven priority areas are: PEM: Management of severe malnutri- tion; spearheading a study to recalcu- late and overhaul existing growth curves: 1. Micronutrients: With partners, NHD provides techni- cal tools, scientific standards, guide- lines and methodologies to build up national programs, such as salt iodization programs; evaluates iodine deficiency disorders (IDD) programs in collaboration with UNICEF; maintains the global data- bank on IDD; promotes breastfeed- ing, supplementation, food fortifica- tion, and home gardens for eradicat- ing vitamin A deficiencies; increases iron intake and infection control; and conducts research on vitamin A sup- plementation. 2. Obesity: Raising awareness; developing strategies that will make healthy choices easier to make; collaborating to calculate economic impact of obe- sity and to analyze the impact of globalization and rapid economic transition on nutrition. 176 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy WHO/NHD 3. Infant feeding: cont. · Promoting baby-friendly hospital initiative with UNICEF. · Intensifying technical support to improve complementary feeding practices. 4. Emergencies: Provision of manuals and guidelines on managing nutrition in emergen- cies; rapid nutrition assessments; promoting safe-feeding practices; and caring for the nutritionally vul- nerable. 5. Guiding food aid for development: · WHO's Food Aid for Development (FAD) office assists elaboration of WFP's policies, guidelines, and country programs. · It assists WFP in identification, formulation, and evaluation of supplementary feeding programs. 6. Developing effective food and nutrition polices and programs: · WHO sees household food securi- ty as a basic human right. Undertaking a multicountry, mul- tidisciplinary study since 1995 examining causal factors of mal- nutrition. · Other priority areas include developing global nutrition data banks and global net- work of collaborating centers in nutrition · Advisory group on Nutrition and HIV/AIDS. UNICEF Mandated to Nutrition strategy embodies their conceptual advocate for the framework developed in 1990. protection of Focus areas include: children's 1. Micronutrients: rights, to help Works with governments in both donor meet their basic and developing countries to develop inno- needs, and to vative programs to deliver micronutrients TECHNICAL ANNEXES 177 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy UNICEF, expand their in foods or through health care services cont. opportunities to (salt iodization, folate, capsules and vita- reach their full min A supplementation) (DFID is a partner potential. supplying capsules). Assists countries to Nutrition is one formulate and use national recommenda- of the eight key tions on multi-micronutrients. program areas · Not much focus on food-based implied in the strategies. medium-term 2. Infant and child feeding: strategic frame- · Promotion of EBF, timely introduction work. A new of complementary foods. health and · Also on the forefront of developing pol- nutrition strate- icy guidelines for infant feeding in HIV; gy is under capacity building of national institu- development. tions to develop their own guidelines and training, including training in counseling of mothers in infant feeding choices. · Immunization Plus as part of Child Health Weeks, including malaria com- ponents in some countries. 3. Maternal nutrition/low birthweight: Low-Birthweight Prevention Initiative is being piloted in 11 countries. The initiative includes the use of multiple micronutrient supplements for pregnant women. · Will complement UNICEF's Care for Women and Children Initiative, which focuses on women's education, work- load, physical health and nutrition sta- tus, emotional well-being, reproductive health, and care during pregnancy and lactation. 4. Growth Monitoring and Promotion (GMP): · Working with WHO to develop new international growth references. Support for growth monitoring in more than 40 countries. · Expansion of therapeutic centers for severely malnourished children, espe- cially in emergencies. 178 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy UNICEF, 5. Community-based programs: cont. · Strengthens local capacities to run such programs. · Triple A approach (assessment, analy- sis, action) for community mobilization. 6. Nutrition information and surveillance systems: · Supports generation of data on many key indicators of children's and women's well-being, including their nutrition status. · Supports updated data on selected nutrition indicators in the "childinfo" Web site. 7. Emergencies: Most of the above in emergencies. · National and regional nutrition surveil- lance to analyze the possible links between malnutrition and HIV/AIDS in Southern Africa. WFP As the food aid Strategic and Financial Plan 2002­5: arm of the UN, The goal for 2002­5 is: "Excellence in provid- WFP uses its ing food assistance that enables all planned food to: beneficiaries of WFP relief activities to sur- · Meet emer- vive and maintain healthy nutritional status, gency needs. and enabling the social and economic devel- · Support eco- opment of at least 30 million hungry people nomic and every year." social devel- · Aligning future polices and operations opment. with "Enabling Development." Policies and guidelines currently exist for procure- "Works to put ment and for donors. hunger at the · Development activities are envisioned to center of the enable hungry poor to work toward sus- international tainable food security, adequate nutrition, agenda, pro- and economic development. moting policies, · Combating micronutrient deficiencies: strategies, and · Production and low-cost blended foods, operations that including building national capacities directly benefit (pilot in Ethiopia, India, Madagascar, the poor and North Korea, and Malawi). hungry." · Piloting standardization of premixed blended foods. TECHNICAL ANNEXES 179 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy WFP, cont. · Provision of fortified commodities--oil and blended food, especially in emer- gencies, high-energy biscuits, iodized salt, wheat, and maize flour fortified with vitamins and minerals. · Training staff and NGOs in nutrition issues. · Research on dietary diversity as an indica- tor of food security, and on ration compo- sition quality in relation to nutrition out- comes. Project review committee screens all food interventions and examines quali- ty and appropriateness. Supports research on the micronutrient impact of fortified biscuits derived from wheat. Supports research into effectiveness of blanket com- plementary food distribution for malnutri- tion prevention (Haiti). · Monitors the cost effectiveness of local purchases within country redistribution of foods. Enabling Development (1999); Reaching mothers and children at critical times of their lives (1997): · Supplementary feeding using blended foods. · School feeding (especially girls), as women's education could potentially reduce child malnutrition. · Improving livelihoods route to improving nutrition. · Acting early: Improving Vulnerability Analysis Mapping (VAM). Emerging issues: · Urban food insecurity and HIV. · Urban food insecurity: process of under- standing the complex socioeconomic issues, informal safety nets, and how they respond to crisis. · HIV: policy statement (October 2002 draft). 180 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy UN Standing The mandate of Three main areas for action: Committee on SCN is to: 1. Promote harmonized approaches among Nutrition · Raise aware- the UN agencies, and between the UN (SCN) ness of nutri- agencies and governmental and non- tion prob- governmental partners, for greater overall lems and impact on malnutrition. mobilize 2. Review the UN system response to commitment malnutrition overall, monitor resource to solve allocation, and collate information on them--at trends and achievements reported to global, specific UN bodies. regional, 3. Advocate and mobilize to raise awareness and national of nutrition issues at global, regional, and levels. country levels and mobilize accelerated · Refine the action against malnutrition. direction, Ending Malnutrition by 2020: increase the An Agenda for Change in the Millennium. scale, and Final Report to the ACC/SCN by the strengthen Commission on the Nutrition Challenges of the coher- the 21st Century, February 2000. ence and · Proposes a new paradigm of nutrition, impact of which incorporates the double burden actions of undernutrition and diet-related adult against mal- diseases. nutrition · Focus on preventable disorders in middle worldwide. and old age. · Promote · Why have global plans of action such as cooperation International Conference on Nutrition among UN (ICN) and World Food Summit (WFS) agencies not achieved more? and partner · Lack of motivated actors to drive the organiza- nutrition agenda. tions in · Failure of health and agriculture support of sectors to combine forces for a coherent national action. Lack of intersectoral approach efforts to highlighted. end malnu- New agenda identifies four major tasks: trition in this 1. Assessment of national policies and plans generation. developed in response to SCN. 2. Coordination of UN efforts. TECHNICAL ANNEXES 181 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy SCN, cont. 3. New mechanism for developing national polices for diet and physical activity. The commission proposes National Nutrition Councils based on Norwegian and Thai experiences. 4. Acceptance of National Nutrition Councils to be the major focus for international support. FAO/ Food and ESN is responsible for: Economic Nutrition · Maintaining food and nutrition country and Social Division profiles. Department/ aims to: · Stimulating and maintaining analysis of Food and · Raise aware- food composition data (INFOODS). Nutrition ness of the · Nutrition assessments and monitoring, Division benefits of including FIVIMS, State of Food Insecurity (ESN) combating in the World Reports, and FAO statistical hunger and databases on foods available for consump- reducing tion. malnutrition. · Organizing consultations on nutrient · Assist requirements with other key partners. countries in · Building the necessary program activities identifying and support at the government and insti- people who tutional levels to respond to identified are food- needs, and thus reverse the situation; insecure and working on understanding urban nutri- vulnerable to tion, incorporating nutritional needs in nutritional NARS agenda. problems. · Identify best practices, monitor impact on · Promote behavior, consumption, biochemistry, and food safety function. and prevent · Initiatives to develop appropriate locally foodborne based complementary foods. diseases. · Provide fortification recommendations · Focus on and technical assistance on food legisla- consumer tion, standards and food control, and protection quality assurance. In collaboration with and fair WHO, provide standards and guidelines practices in for labeling, nutrition and health claims, food trade. and nutritional quality. 182 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy FAO, · It has pri- · Household Food Security and Community cont. mary respon- Nutrition Group, together with the sibility for Nutrition Information, Communication coordinating and Education Group (http://www. FAO nutri- fao.org/es/ESN/nutrition/education_ tion-related en.stm), directs their activities toward activities in developing and implementing effective follow-up to community-centered programs: international · Focus areas include food-based, com- meetings and munity-centered approaches, including agreements. home gardens, food fortification, and preparing and planning for food emer- gencies. · Nutrition in HIV/AIDS. Developed guide, "Living well with HIV/AIDS." · Nutrition Information, Education, and Communication (IEC) Division's activities · Antihunger program: Reducing hunger through sustainable agriculture and rural development and wider access to food (FAO, Rome, 2002) (http://www.fao.org/DOCREP/004/Y715 1E/Y7151e00.HTM). Multilateral agencies World Mission · Supports a multisectoral approach Bank/Health, statement of (including Poverty Reduction Strategy Nutrition, and HNP: "Assist Papers [PRSPs], sectorwide approaches Population clients to [SWAps]) to nutrition that targets the (HNP) improve health, poor, especially young children and their nutrition, and mothers. population · Focuses on community nutrition pro- outcomes of grams, food fortification programs, and poor people food policy reforms. and protect · Increasing focus on micronutrient defi- people from the ciencies, the impact of nutrition on educa- impoverishing tion and learning ability, and early child effects of ill- development projects. ness, malnutri- · The Bank's nutrition strategy is explicitly tion, and high being framed in terms of accelerating fertility." progress towards achieving nutrition rele- vant MDGs. TECHNICAL ANNEXES 183 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy HNP, cont. · Investing in capacity development within the World Bank and also at the national levels to enable nutrition part- ners to be at the negotiating table when the reforms, SWAps, and PRSPs are dis- cussed. · Continued advocacy on how nutrition actions can best be positioned within the new programming environment. · Health Systems Development (HSD) group, under HNP, in the next two to three years will reorient its activities to focus on building the global knowledge base and institutional support needed to help countries accelerate progress toward achieving their MDG targets. · Sector Strategy: Health, Nutrition, and Population, 1997. Key objectives stated include: · Improve the health, nutrition, and pop- ulation outcomes of the poor, and to protect the population from the impov- erishing effects of illness, malnutrition and high fertility. · Enhance the performance of health care systems by promoting equitable access to preventive and curative health, nutri- tion, and population services that are affordable, effective, well managed, of good quality, and responsive to clients. · Secure sustainable health care financing by mobilizing adequate levels of resources, establishing broad-based risk pooling mechanisms, and maintaining effective control over public and private expenditure. · Bank-supported programs in agriculture and rural development, water and sanita- tion, social protection, early child develop- ment, and maternal and child health can have significant impact on nutrition. 184 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy Asian The Bank's Activities in the health sector will be guided Development overall ap- by five strategic considerations outlined in Bank (ADB) proach to the the Policy for the Health Sector (1999): health sector is · The Bank will work to improve the health to assist devel- of the poor, women, children, and indige- oping member nous peoples by: (a) increasing its lending country govern- for the health sector and maintaining its ments to ensure current emphasis on primary health care their citizens (including reproductive health, family have broad planning, and selected nutrition interven- access to basic tions); and (b) focusing on vulnerable preventive, pro- groups with particular attention to motive, and women, and measuring the extent to curative ser- which the poor, women, and indigenous vices that are peoples have access to health services. efficacious, · The Bank will maintain a focus on achiev- cost-effective, ing tangible, measurable results by: and affordable. (a) further strengthening monitoring and From: ADB. evaluation of all health sector activities; 1999. Policy for (b) emphasizing interventions with strong the Health evidence of effectiveness; (c) improving Sector. Manila. the quality of loans at entry; and (d) improving implementation of health sector activities. · The Bank will support the testing of innov- ative approaches and the rapid deployment of effective and affordable new technolo- gies through: (a) financing pilot tests of new approaches to health care financing, organization, and management; and (b) helping support the deployment of new technologies, particularly new vaccines. · The Bank will play a significant role in health sector reform by encouraging developing member country (DMC) governments to take an appropriate and activist role in the health sector. This will involve engaging in policy dialogue to encourage the DMCs to: (a) increase their budgetary allocations for primary health care; (b) diversify their sources of health care financing; (c) collaborate more exten- sively with the private sector; and TECHNICAL ANNEXES 185 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy ADB, cont. (d) increase support for public goods such as research, health education, and regula- tion. · The Bank will increase the efficiency of its health sector investments by: (a) help- ing to strengthen management capacity of the public sector in the DMCs; (b) improving its economic and sector work and strengthening linkages with other sectors; and (c) further strengthen- ing its collaboration with partner institu- tions operating in the health sector. A review of this policy is planned for 2005/2006, at which time it is anticipated nutrition and population considerations will be more explicitly considered and integrated into ADB's policy for the sector. Bilaterals Norway-- Action Plan for Combating Poverty in Ministry of the south toward 2015, March 2002: Foreign · Increase in development assistance to Affairs 1 percent of gross national income (GNI) by 2005. · Mentions education and health, but not nutrition. NORAD · NORAD "Nutritional considerations in Norwegian Institutional aims to development cooperation" argues that set-up for achieve last- NORAD should explicitly incorporate nutrition ing improve- nutritional considerations in its plan not clear ments in for 2000-5. http://www. political, eco- · Recommends supporting partner norad.no/ nomic, and countries' national plan of action for food social condi- and nutrition in formulation and imple- tions for the mentation. entire popu- · Building or strengthening institutions lation within · Supporting nutrition surveillance the limits systems. imposed by (Not clear if these recommendations have the natural been implemented.) 186 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy NORAD, environment Other key documents include: cont. and the natur- · Focus on NORAD: Statement to the al resource starting on development cooperation base. policy 2002: Report on NORAD in 2002 · Has links to (expands on the Action Plan). health/educa- · Annual Report 2001--NORAD: tion and HIV, Emphasizes that health and education but not nutri- are the most important areas of focus. tion. Nutrition not even overtly mentioned. Denmark/ · Danish assis- · No clear nutrition strategy mentioned. Danish tance will in · But "to help poor by investing in educa- International the future con- tion and health" is the primary goal. Development centrate on its · More focus on women. Agency original main (DANIDA) objective: pro- moting sus- tainable devel- opment through poverty-ori- ented econom- ic growth. · A critical review con- ducted in 2002. Results will appear in appropriation bill of 2003. Japan/ Technical assis- · Nutrition per se not prominent. Japanese tance aimed to · Priority areas are dependent on regional International transfer technolo- and country level issues. Therefore, Co-operation gy and knowl- JICA's priorities in Agency edge that can South America are very different from (JICA) serve the socio- Africa. economic devel- · Food security, agriculture develop- opment of the ment, and health care are priority developing issues in Africa. In South America, countries. TECHNICAL ANNEXES 187 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy JICA, cont. http://www.jica.go. issues include strengthening jp/english international competitiveness, No environment-friendly agriculture, institutional etc. set-up for · Global issues of concern include: nutrition · Poverty, gender, environment, apparent education, and health. · Population and AIDS. · Trade and peace building. · Disability. Canada/ · "CIDA supports · "Canada will commit 25 percent Canadian sustainable devel- of its ODA to basic human needs International opment activities as a means of enhancing its focus Development in order to reduce on addressing the security of the Agency poverty and to individual." (CIDA)/ contribute to a · Under the priority area of "Basic Health and more secure, equi- human needs," CIDA supports Nutrition table, and prosper- health and nutrition. ous world." · Contributed to the creation of · Health and Nutri- Micronutrient Initiative (MI). tion: "Canada is Extract from CIDA's Action Plan on active in promoting Health and Nutrition, 2001: Guidelines health and nutri- through 2005: tion in developing · Contribute to reduction in poverty countries and by investing in health, nutrition, countries in transi- and water. tion, focusing on · Rights-based approach, gender the poorest and analysis. most marginalized · Integrated and targeted nutrition people--who are programs: protecting women's most often women nutrition, improving child feeding and children." practices. · Vitamin A supplementation and salt iodization. · Food security: food-based strate- gies, emphasizes the need to devel- op new ways of examining impacts. · Has research and capacity develop- ment program for tropical diseases and reproductive health, but not nutrition. 188 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy Sweden/ The overall Health Sector policy states that SIDA Swedish goal of Swedish supports research, including malnutri- International development cooper- tion: Development ation is to raise the · Emphasizes health sector develop- Agency standard of living of ment through bilateral and multilat- (SIDA) poor people in the eral cooperation. world. The Swedish · Malnutrition is mentioned as "other Health and Parliament has sectors" that could affect health. education adopted the follow- · SIDA's Poverty Programme 1996: are under the ing six specific objec- Food security is one of the priority Department tives to achieve this areas under the Department of for Democracy overall goal: Natural Resources and Environment. and Social · Economic growth. No elaboration provided. Development · Economic and Key documents include: (DESO). political indepen- · SIDA Looks Forward--SIDA's dence. Programme for Global Development There seems · Economic and (not available on line). to be no house social equality. · Policy for development cooperation: for nutrition. · Democratic devel- Health sector, 1997. opment in society. · Perspectives on poverty, 2002 (fleet- · The long-term ing mention of nutrition). sustainable use of natural resources and protection of the environment. · Equality between men and women. Germany/ GTZ: Agriculture and agriculture German research are priority areas. Agency for · The only publication on nutrition Technical listed on the Web is on certification Assistance of organic foods. (GTZ) TECHNICAL ANNEXES 189 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy Ireland Aid The Government · Programs and projects to meet the basic is committed, needs include food security, health care, through its Action education, and clean water supplies. Programme for Report of the Ireland Aid review the Millennium, to committee, February 2002 reaching the target http://www.irlgov.ie/iveagh/irishaid/ for development irlaidreview.pdf: aid of 0.45 percent · It endorses its food security program. of gross national · No nutrition-specific strategy. product (GNP) by Reaching the UN Target--A millennium the year 2002. decision for Ireland, Ireland Aid, 2000 http://www. http://www.irlgov.ie/iveagh/irishaid/ irlgov.ie/iveagh/ 2000report/IrelandAid.pdf irishaid/overview /default.htm USAID USAID places the USAID'S strategy incorporates nutrition highest priority through its development assistance on alleviating program by: undernutrition · Identifying projects based on nutrition and is focused on and food consumption problems. improving nutri- · Including nutrition as a factor in tion through project design in: sectoral programs · Agriculture projects. in agriculture, · In health through primary health health, food aid, care. population, and · In food aid through targeting education as well appropriate rations to at-risk as direct nutrition groups. programs. · In population by complementing family planning services. · In education through promotion of nutrition education in schools, training community health workers, providing advanced training for professionals. · Targeting sectoral projects at indi- viduals/households who are at risk to developing nutrition problems. · Monitoring and evaluating nutrition impacts of projects. 190 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy USAID, · Complementing sectoral projects with cont. nutrition projects. · Utilizing the private sector in food pro- grams where feasible. · Encouraging the development of national policies. · Coordinating with less developed country (LDC) governments/donors to reach nutrition goals. · USAID has also developed a strategy to provide food and nutrition assistance in HIV/AIDS programs. Country programs include: · Rwanda: USAID provides assistance to NGOs to provide food to approxi- mately 29,000 children affected by HIV/AIDS as part of a comprehensive package of services. · Uganda: USAID has a five-year, $30 million program, which is the largest of its kind in the world. The program tar- gets approximately 60,000 individuals who have HIV/AIDS or live in house- holds where providing HIV/AIDS care is undermining the ability to meet food and nutrition needs. The target popula- tion receives intensive nutrition educa- tion in addition to food aid. The pro- gram involves communities in food dis- tribution to raise awareness, reduce stigma, and mobilize community involvement in HIV/AIDS activities. U.K. Depart- DFID's strategy for achieving the MDG ment for target of reducing hunger by 2015: International · Promote a shared analysis of the causes Development of hunger and malnutrition and of (DFID) progress towards the hunger MDG. TECHNICAL ANNEXES 191 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy DFID, cont. · Better integration of food security into poverty reduction efforts. · Promote the development of human capital. · Promote trade reforms that strengthen the food security of poor. · Better response to drought, conflict, and emergencies. · Better systems to identify who is hungry, where, and why. No explicit nutrition strategy. Proposed global nutrition priorities for DFID based on existing gaps (International Food Policy Research Institute [IFPRI] study, 2003): · Embed nutrition components within development actions. · Manage and generate practical knowledge at the intersection of livelihoods, the life- course, and lifestyles. · Develop capacity to integrate nutrition within sector initiatives. · Use and develop nutrition indicators to measure progress of nonnutrition activities · Highlight the key role of nutrition as both a driver of development and a nonexclusive investment opportunity. Private Sector/NGOs Academy for AED helps AED is involved in several large projects, Educational communities mostly funded by USAID, which outline its Development secure stable strategy for addressing the different aspects (AED) food sources of nutrition: (Funding and improve · CHANGE PROJECT--develops tools and mainly from their overall strategies to facilitate individual and social USAID health and behavior change relevant to child health, and other well-being. maternal health, infectious disease, and partners) HIV/AIDS. A major focus is improving individual and household behaviors. 192 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy AED, cont. With programs · Ethiopia Child Survival and Systems addressing Strengthening Project (ESHE)--Focus of issues such as the project is to increase the survival rates breastfeeding, of young children in Ethiopia through malnutrition, improved vaccination and nutritional sup- and food secu- plementation. The program provides vita- rity, AED helps min A, iron, and folate supplementation foster healthy coverage for women and children and communities promotes exclusive breastfeeding for around the infants and continued breastfeeding to at world. least 24 months of age. · Food and Nutrition Technical Assistance AED is a leader Project (FANTA)--Supports integrated in applying food security and nutrition programming. behavior Helps integrate nutrition into the strategic change and planning process; provides analyses for social market- food security and nutrition policy devel- ing methodolo- opment, and shares information and gies to public knowledge with partners. health nutrition · LINKAGES--This program focuses on problems, par- increasing breastfeeding and related prac- ticularly in tices to improve maternal and reproduc- breastfeeding, tive health through technical assistance infant feeding, and training. feeding of · Preventing Type II Diabetes infants born to (STOPP-T2D) (funded by George HIV-positive Washington University)--This initiative mothers, and is to design a social marketing strategy micronutrient and communications program for middle deficiencies. schools in the United States to promote Over the last physical activity and healthy food choices. five years, AED · PROFILES (multiple funders)--Engages has built up one national leaders in policy dialogue and of the largest public health nutrition. It has been concentrations credited with raising awareness about of public health nutrition, building consensus, building nutrition capacity, and developing leadership skills experts outside of nutrition advocates. academia. TECHNICAL ANNEXES 193 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy AED, cont. Areas of focus · Support for Analysis and Research in include policy Africa (SARA)--Provides assistance to analysis and African institutions to develop and pro- advocacy, eval- mote policies to increase sustainability, uation and quality, efficiency, and equity of a variety monitoring, and of health services, including nutrition. comprehensive · Useful tools and publications: planning for · Breastfeeding and maternal nutrition: food security. Frequently asked questions. · Child health counseling cards, Dominican Republic. · Community heath worker incentives and disincentives: How they affect motivation, retention and sustainability. · Food and nutrition implications of ART in resource limited settings. · HIV/AIDS Mitigation: Using what we already know. · Quantifying the benefits of breastfeed- ing: A summary of the evidence. Hellen Keller Provide tech- · Research and Development: Development International nical assistance, of dietary assessment methods; testing (HKI) training, and plant varieties and gardening methods; and M&E for developing and testing postflood garden- homestead ing rehabilitation practices. Compliance food produc- with international code of breastfeeding. tion (gardening, · Provide advice to agriculture ministries fisheries, within countries to think about production poultry, and of nongrain foods and appreciate the animal importance of food for better health. husbandry). · Provide technical assistance and training to support ongoing programs with local partners in six countries in Africa and Asia. · Conduct surveillance and program monitoring to monitor anemia and iron deficiency, evaluate program coverage and the impact of homestead food production on nutrition status, household income, food consumption, and women's empowerment. 194 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy HKI, cont. · Conduct food surveys, including FRATs, to determine food patterns for fortification and the impact of iron-fortified candy. · Provide assistance to countries to develop guidelines, training, and materials to implement new policies on vitamin A supplementation for children postpartum and sick children. · Conduct operational research on anemia programs for school-age children and young infants and help develop national surveys to identify iron deficiency and the impact of interventions on anemia. · Integrate malaria and vitamin A in program interventions. · Monitor breastfeeding practices and evaluate program impact, MI The Micro- · Support for the Fresh Food Initiative (FFI), nutrient Initia- planning and implementation of national tive (MI) is a food fortification programs for iron, folic not-for-profit acid, and other nutrients, and technical organization guidelines. specializing in · Research and development: efficacy and addressing effectiveness studies. Promote use of red micronutrient palm oil by households and school feed- malnutrition. ing programs in West Africa; promote cul- MI is governed tivation and use of orange-fleshed sweet by an interna- potatoes in Southern Africa; efficacy of tional Board carotene-rich sweet potatoes in improving of Directors. vitamin A staples; efficacy of double- MI supports fortified salt; impact of iron supplements and promotes on school performance. food fortifica- · Procure premix and equipment. tion and sup- · Conduct national and subnational impact plementation evaluations. programs in · Conduct vitamin A stability studies. Asia, Africa, · Provide program planning/implementa- and Latin tion and technical assistance to govern- America and ments and oil refining in core countries. TECHNICAL ANNEXES 195 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy provides techni- · Pilot and scale up programs for production cal and opera- and distribution of complementary foods, tional support as well as conduct research on the efficacy/ in those coun- effectiveness of complementary foods. tries where · Procure vitamin A capsules and support micronutrient program implementation; design oral malnutrition is dropper technology; and develop field most prevalent. methods for biochemical assessment. MI carries out · Promote and conduct impact studies on its work in the effect of multiple micronutrient sup- partnership plements for special feeding programs. with other · Provide expert training workshops and international capacity building for understanding how agencies, gov- to develop effective fortification programs. ernments, and · Provide technical guidelines for flour industry. fortification. Private sector Manoff Group The Manoff The Manoff Group addresses nutrition Group provides through a variety of programmatic assistance in approaches. communica- · Strategic program design. tions and · Consultative research: Trials on improved behavior- practices (TIPs) is the core method for the centered plan- consultative research process. TIPs offers: ning, manage- · In-depth understanding of child feed- ment, and ing practices. evaluations for · Adaptation of feeding recommenda- health, nutri- tions to specific situations. tion, and popu- · Understanding the motivations and lation projects. constraints to change behavior. · Flexibility. · Quick and inexpensive field research. · A bridge between the nutrition pro- gram and the family and community. · Training in nutrition counseling. 196 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy Manoff Group, · Community mobilization: The Manoff Group cont. has a variety of approaches, including com- munity-based growth promotion model, community surveillance, and behavior change approach. · Product marketing: This is driven by a behavior change strategy based on forma- tive, consultative research. Examples of products that Manoff Group projects have promoted are: · Iron tablets in Indonesia, Pakistan, India, and Bolivia, among other countries. · Vitamin A capsules in Thailand, Indonesia, and El Salvador, among other countries. · Vitamin A­fortified sugar in Zambia, Bolivia, and El Salvador. · Iron-fortified wheat products in Nicaragua. · Country program experience includes: · Communicating importance of breastfeed- ing to families in Pakistan and Indonesia. · Identification of/education on nutritious weaning foods in El Salvador, India, and Zambia. · Community counseling on importance of nutrition for growth in Honduras and the Dominican Republic, among other coun- tries. · Micronutrient supplementation and nutri- tion education programs for school chil- dren in Egypt and Indonesia. · Young child feeding in El Salvador, India, and Guatemala. · Manoff Group has produced useful resources for general health and nutrition communication, micronutrient malnutrition, maternal health, and environmental health. TECHNICAL ANNEXES 197 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy Global GAIN's mandate GAIN will combine the strengths of Alliance for is to forge an public and private sector organizations to: Improving alliance of public, · Mobilize private industry, international Nutrition private, and civil donors, and foundations in support of (GAIN) society partners food fortification initiatives in low- committed to income countries. eliminating vita- · Tap the expertise and resources of the min and mineral corporate sector in technology transfer, deficiencies glob- business development, trade, and ally. GAIN has marketing. adopted the goals · Work with the UN and other multilat- for country level eral agencies to set international stan- operations from dards and establish systems for quality the United assurance and control. Nations General · Utilize public sector capabilities to Assembly Special address legislative and regulatory bar- Session on riers to food fortification. Children in May · Develop a broader role for NGOs and 2002 to: civic organizations in food fortification. · Achieve · Link food fortification efforts with sustainable other essential interventions, such as elimination of micronutrient supplementation and vitamin A defi- dietary diversification. ciency by 2010. · Reduce anemia N.B.: Fortification of staple foods and prevalence, condiments is determined by country including iron situation and not by GAIN. deficiency, by one-third by Research and development: 2010. · GAIN will prioritize research needs · Eliminate IDD (global and regional) as well as capac- by 2005. ity development. · Accelerate · GAIN follows a code of fortification progress toward and is developing a global advisory reduction of group on fortification within the other vitamin context of the already existing WHO and mineral IMAGE. deficiencies · Elevate nutrition on national agendas through dietary and further the MDGs. diversification, 198 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy GAIN, food fortifica- · Provide support to the National Food cont. tion, biofortifi- Authority (NFA) building partnerships. cation, and supplemen- tation. Research Institutions IFPRI · IFPRI's mission IFPRI uses four sets of criteria to determine is to provide its priorities as part of its nutrition strategy: policy solutions 1. The work program must conform that cut hunger to IFPRI's mission to provide policy and malnutri- solutions that reduce hunger and tion. This mis- malnutrition. sion flows from 2. Research and outreach should address the CGIAR emerging issues that most directly affect mission: "To food security, nutrition, and poverty. achieve sus- 3. Research, capacity-strengthening, and tainable food policy-communications activities should security and be based on IFPRI's dynamic compara- reduce poverty tive advantage to produce results in developing applicable to many countries--that is, countries international public goods. through scien- 4. Stakeholders and partners should be tific research consulted to identify food policy and research- research that all parties believe will help related activi- develop policies to reduce hunger and ties in the fields malnutrition. of agriculture, These criteria work as a decision tree: livestock, Research and outreach activities must meet forestry, fish- all four criteria in order to be included on eries, policy, IFPRI's agenda. and natural resources man- IFPRI places a high priority on activities agement." Two that benefit the greatest number of poor key premises people in greatest need in the developing underlie world. In carrying out its activities, IFPRI IFPRI's mis- seeks to focus on vulnerable groups, as sion. First, influenced by caste, class, religion, ethnici- sound and ty, and gender. appropriate TECHNICAL ANNEXES 199 Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy IFPRI, local, national, IFPRI is also committed to providing cont. and interna- international food policy knowledge as a tional public global public good; that is, it provides policies are knowledge relevant to decision makers essential to both inside and outside the countries achieving sus- where research is undertaken. New tainable food knowledge on how to improve the food security and security of low-income people in devel- nutritional oping countries is expected to result in improvement. large social benefits, but in most instances Second, research the private sector is unlikely to carry out and the dissemi- research to generate such knowledge. nation of its IFPRI views public organizations and the results are criti- private sector in food systems both as cal inputs into objects of study and as partners. the process of Given the large body of national and raising the qual- international food policy research, IFPRI's ity of the debate added value derives from its own cut- and formulating ting-edge research linked with academic sound and excellence in other institutions, such as appropriate other Consultative Group on food policies. International Agricultural Research IFPRI's mission (CGIAR) centers, universities, and other entails a strong research institutes in the South and emphasis on North, and from its application of this research priori- knowledge to national and international ties and quali- food policy problems. ties that facili- tate change. HarvestPlus Biofortification is · Research and development is the main a strategy of focus of HarvestPlus. getting plants · Conducts research on food and agri- to fortify their cultural policies that impact the seeds/roots dietary quality of the poor; conducts through plant cost benefit analyses of alternative breeding. An inter- interventions and efficacy trials. disciplinary global · Develops social marketing messages alliance of research such as encouraging consumers to institutions and switch from white to consumption of implementing yellow/orange varieties in breeding 200 REPOSITIONING NUTRITION Mandate and focus of development partners in nutrition (continued) Mission statement/ Institutions mandate Nutrition strategy HarvestPlus, agencies has vitamin A carotenoids; develops cont. been assembled messages to promote food and to develop bio- agricultural policies that enhance dietary fortified vari- quality. eties and to dis- · Collaborates with government extension seminate them agencies, NGOs, and private sector to to farmers in disseminate biofortified varieties by developing working through established seed countries. markets and developing new seed HarvestPlus is markets as necessary. the name of this global program. Annex 5.4 Deciding how to invest in nutrition: A framework for making policy choices Deciding how best to improve nutrition can be a controversial process because: · Many different interventions can have an effect on nutrition. · At least 10 variables need to be taken into account in deciding what to do. · Needs, priorities, and constraints vary between countries, between regions and population groups within countries, and over time, so gen- eralizing is impossible. · People see different priorities for action, depending on their under- standing about what causes malnutrition and their knowledge about the range of possible interventions. · There are often vested interests in expanding one type of program rather than another. The biggest impact on malnutrition comes from multisectoral programs that include most of the menu of nutrition interventions set out in table 3.1 of the main volume of this report. But for various reasons--because they lack the commitment, or the funds, or the managerial capacity--most countries where malnutrition is serious cannot expect to implement a broad, multi- sectoral nutrition program on a national scale, at least in the short and medium term. The issue is how such countries, which cannot do every- thing, should decide what to do as a priority. Here are six sets of questions that provide a framework for decision making. While it makes sense to consider them initially in the order pre- sented, the decision-making process needs to be iterative, since the answers to some later questions may require reconsideration of earlier questions. Who addresses these questions is as important as how they are addressed. The more stakeholders that are involved in the policy choice process, the more chaotic and difficult it is likely to be. On the other hand, the more stakeholders that have been involved and hence understand the rationale for policy decisions, the greater the likelihood of commitment to imple- menting the chosen policies. 201 202 REPOSITIONING NUTRITION Question 1: How does the environment constrain what can be done, and what opportunities does it offer? The different nutrition options need to be considered in the context of the political, cultural, institutional, and financial environment. A situation analysis is therefore the first step in the policy choice process, focusing on both constraints and opportunities. Constraints Questions to ask include: · Is government commitment to poverty reduction, to human develop- ment, and to improving nutrition real, or mainly rhetoric? · Are politicians committed to nutrition programs (some food subsidy programs, school feeding) that bring political benefits, but have little impact on nutrition? · How far do public expenditure constraints limit what new initiatives can be taken? · How far do managerial constraints limit what new initiatives can be taken? · Do governance problems hamper the implementation of social sector programs? · What are the limitations of the available nutrition data and the capacity to analyze it? Opportunities Questions to ask include: · What policies and programs do politicians favor, and how might invest- ing in nutrition further their goals? · What cultural values might support increased attention to nutrition, and what community organizations or mutual help traditions might facilitate program implementation? · What small-scale nutrition interventions exist that might be made more cost-effective and scaled up? · What existing nutrition-related programs--in health, agriculture, social protection, and water and sanitation--have institutional capacity that can be built on? · What institutional capacity is there outside government--NGOs, social research institutes, commercial consultants? TECHNICAL ANNEXES 203 Question 2: What makes the most technical and economic sense? The variables to be taken into account here are epidemiology and cost- effectiveness. Epidemiology The type of malnutrition problem, its extent and seriousness, what causes it, and who suffers from it (age groups, sex, and geographical location) all need to be reviewed. Countries vary greatly in their epidemiological needs: · In many middle and high-income countries, overnutrition is the main manifestation of malnutrition, and interventions in nutrition education and food policy are the corresponding priorities. · Micronutrient malnutrition is a problem in more than 55 countries, both low and middle income. Food fortification is a solution for the popula- tion at large, but supplementation is needed for high-risk groups--for example, for anemic pregnant women who need more iron than they can absorb just from fortified foods. · Protein-energy malnutrition (PEM) is a problem in more than 60 coun- tries. Here, looking at what causes it is crucial. The most common cause of PEM is parents' poor child feeding and caring practices, and the cor- responding solution is growth monitoring and education about breast- feeding and weaning, as well as better diets for pregnant and lactating women. But if disease is an important cause of malnutrition, then health, water, or sanitation interventions can be as important; and if food secu- rity is a problem, then indirect interventions against malnutrition should be considered (see below). UNICEF's food-health-care framework for understanding the causes of malnutrition is useful here (UNICEF 1990). · Both micronutrient malnutrition and PEM are a problem in more than 50 countries. Cost-effectiveness The direct interventions against malnutrition are all cost-effective. But relative cost-effectiveness varies between interventions and in different country circumstances, for example: · While both PEM and micronutrient interventions are cost-effective ways to reduce malnutrition, micronutrient interventions are relatively more cost-effective (Lomborg 2004) because they cost less per client and are easily added to existing health programs. 204 REPOSITIONING NUTRITION · If a country has already invested in one type of program, it is often more cost-effective to improve or expand that, rather than create a new, different type of program because extra investment at the margin of an existing program to remove bottlenecks to performance usually has a very high payoff. Cost-effectiveness and epidemiological considerations need to be bal- anced. Globally, growth promotion programs focusing on improving caring practices have been neglected because there have been lobbies for invest- ing in health and agriculture, but not in care. Yet poor caring practices are probably the biggest worldwide cause of PEM. So countries need to be careful about investing only in cheap micronutrient programs or in expand- ing food security programs because they are already in place if they have a caring practice problem that is not being systematically addressed. Question 3: What will actually work on the ground? The key variables here are commitment, capacity, and affordability. Commitment Nutrition programs get off the ground, and get sustained, only if key politi- cians, officials, and local communities are committed to them. So invest- ment decisions should not be taken only on the basis of what is technically and economically rational, but also on the basis of what is politically ratio- nal. For example, investments in children are often politically popular. So tackling malnutrition through child development programs can make polit- ical sense, as well as reaping benefits from the synergy between improv- ing health, nutrition, and early stimulation simultaneously. Approaches for assessing commitment are suggested in Heaver (2005b). Capacity Countries' limited technical capacity often constrains their ability to design nutrition programs, and limited management capacity often constrains their ability to expand programs, ensures their quality, and makes service providers accountable for results. When capacity is limited, it makes sense to start with nutrition interventions that build on existing capacity. It is usually possible to build on existing health system capacity: one example is incorporating vitamin A supplementation into outreach services for immunization; another is incorporating nutrition into health clinic services using the IMCI approach. Food fortification uses the existing capacity of TECHNICAL ANNEXES 205 private sector food manufacturers and distributors. And several govern- ments have successfully used existing NGO capacity to deliver growth pro- motion outreach services. Affordability Sometimes nutrition interventions can have a high impact and be highly cost-effective without being affordable at scale. Small-scale, donor-financed projects frequently develop effective but expensive interventions without considering whether they can be scaled up. So it is essential for govern- ments and development partners to get together and decide to test out in projects only things that have a chance of going to scale. Examples of interventions that usually are affordable at scale because they are rela- tively cheap are vitamin A and iodine supplementation, food fortification, and IMCI. Question 4: What is the right balance between direct and indirect interventions? The direct interventions are usually the most cost-effective way to improve nutrition. A list of what are commonly defined as the direct (short route) interventions is given in table 3.1 of the main volume of this report. There is some confusion about where food stands as an intervention. Traditionally, food security interventions are classified as indirect, because, while they improve household food security, they may not directly affect the nutritional status of at-risk family members--infants, for example. But it seems inappropriate to classify food as an indirect intervention where it does directly improve nutritional status, as with, for example: · Food supplements targeted on growth-faltering children under age three in the TINP (Heaver 2003a). These both directly improved their nutri- tion and taught mothers about the nutritional benefits of feeding small amounts of extra food. · Food supplementation targeted on low-BMI pregnant women in Bangladesh (Pelletier, Shekar, and Du forthcoming), which substantially improved their nutritional status. · Food aid geographically targeted on families in drought-affected areas of Ethiopia, which likewise had direct nutritional benefits (Yamano, Alderman, and Christiaensen 2004). Food aid for families uprooted by conflict, or without able-bodied adults due to war or AIDS, is another example. 206 REPOSITIONING NUTRITION · Food-for-work schemes that are targeted seasonally so families can main- tain their food consumption during the preharvest lean season, or when harvests fail. Targeted food supplementation can therefore be direct intervention. A useful review of advantages and disadvantages of different food-based safety nets can be found in Rogers, Lorge, and Coates (2002). The indirect interventions are usually a second order investment priority for improving nutrition. But they can be first order priorities under certain country circumstances. For example: · Immunization is a priority wherever coverage is low, since the common infectious diseases cause children's growth to falter. · Oral rehydration is a priority wherever diarrhea is a leading cause of malnutrition, and water supply and sanitation programs can also be effective in reducing diarrhea (Fewtrell and Colford 2004). · Treatment for malaria and intestinal parasites may be a high priority wherever high parasite loads weaken children's ability to absorb nutrients. Otherwise, the relative cost-effectiveness of the indirect interventions seldom justifies financing them in preference to direct interventions on purely nutritional grounds. For example, stimulating economic growth improves nutrition, but it takes so long to change nutritional status that it is not a priority nutrition intervention--although, of course, economic growth is needed to reduce income poverty, and to finance the taxes that pay for direct nutrition programs. But governments finance many indi- rect interventions anyway, with the aim of reducing income poverty. Where such interventions are already being financed, steps can often be taken to design them so they have an impact on nutrition as well as incomes. For example: · By targeting livelihood creation programs on families suffering from malnutrition, as with the poultry-rearing activities in Bangladesh's National Nutrition Program. · By combining microcredit/income generation programs with nutrition education, which increases the likelihood of some of the extra income being spent on improving nutrition. · By coordinating the implementation of water and sanitation and health and nutrition programs so as to maximize their synergy, as in Honduras's Nutrition and Health Project (World Bank 1992) and Senegal's Community Nutrition Project (World Bank 2001b). TECHNICAL ANNEXES 207 Question 5: Who gets how much? The key variables here are coverage, intensity, quality, and targeting. Coverage, intensity, and quality Governments are often preoccupied with program coverage, both because they want to reach as many needy clients as possible and because of the polit- ical rewards of extending programs into new geographic areas. But when resources are scarce, there is a significant trade-off between a program's cov- erage and its intensity and quality. Intensity is measured by the amount of money spent per beneficiary, or the number of workers for a given client population. Mason and others (forthcoming) argue that to get a reasonable level of quality and impact, community nutrition programs need to spend in the range of $5­$10 a child per year, and have about one full-time worker (or a correspondingly larger number of part-time workers) for every 500 target families. Many programs have gone for high levels of coverage at the expense of intensity and quality. India's Integrated Child Development Services (ICDS) program, whose quality and impact is low, and which spends only about $2 a child per year on nutrition, is an example. Targeting There is therefore a trade-off, often unacknowledged, between getting a low-quality program to a large number of clients, and getting a higher qual- ity program to a smaller number of clients. From an epidemiological and economic perspective, it is rational to target a higher-intensity, higher-qual- ity program on limited geographic areas or high-risk population groups with high levels of malnutrition, rather than to seek universal, low-quality coverage. Targeting on the basis of highest need is not only equitable, but often the fastest way to get results because it is easier to reduce malnutri- tion from high to medium levels than from medium to low levels. For exam- ple, TINP, which was targeted on vulnerable children under age three, was able to reduce severe malnutrition from about 8 percent to about 4 percent in the first two years the program came into a new geographic area. But while targeting high-intensity programs on the neediest may be epi- demiologically and economically rational, benefiting only the most disad- vantaged--who are seldom influential voters--may not be politically rational. The trade-off between tight targeting and political and commu- nity support can be resolved in various ways. In the case of TINP, a pro- gram in which food supplementation was tightly targeted on malnourished children under age three, only 25 percent of children received food 208 REPOSITIONING NUTRITION supplementation at any given time; but because children whose growth was faltering received supplementation, and because most children's growth faltered at some time or other, 75 percent of children benefited from supplementation at one time or another--thus ensuring wide community support for the program (Heaver 2003a). Question 6: How should things evolve over time? If there aren't the funds to get adequate-intensity, adequate-quality pro- grams to everyone, and if tight targeting on the neediest is politically dif- ficult, another way to resolve this trade-off is to postpone more expensive, higher-intensity interventions and concentrate in the short run on less costly interventions that can reach more people. In practice, this usually means concentrating on micronutrient programs (see Question 2), which can often satisfy financial and political rationalities at the same time. Since micronu- trient malnutrition is widespread and serious, these programs are an epi- demiological priority too. The problem is that PEM also has to be tackled in poor countries, where it contributes to as many as half of child deaths, as well as to disease, low school enrollment, and poor school performance. Because programs to pro- mote child growth are those where many countries have invested least, and since growth promotion programs are fairly expensive, deciding what to do about PEM, and when, often presents the hardest of policy choices for very poor countries. Four rules of thumb can be applied to help decide how things should evolve over time. Short-run plans should be pragmatic Priorities for the next five years should be pragmatically determined, based on a mix of criteria: what is epidemiologically important; what will get political support; what is cost-effective and affordable; and what can be implemented given existing management capacity, and taking into account where past investment has gone and hence where there is a base for doing more. Box 5.2 in the main volume of this report gives some examples of what countries might do in the short run when commitment or financial and managerial capacity are weak. A long-term vision should be developed This should set out the desired type and coverage of nutrition programs, and the policies, institutions, commitment, capacity, and finance that need to be put in place over a 10- to 15-year period to enable and support them. TECHNICAL ANNEXES 209 Levels and trends in malnutrition and its causes (food insecurity, poor health, and inadequate caring practices) should be used to define what interventions are needed. Foundations for the future should be laid An implementable set of additional activities required to move the coun- try along the path to its long-term vision should be built into the short- term plan. These might include policy analysis; building the data and evidence base; advocacy and alliance-building to strengthen commitment to the next generation of programs (see Heaver 2005b for details); and action research through small-scale projects to test service delivery strategies, and in particular to find out what intensity of resource use is required to reach an acceptable level of quality and impact. Hard decisions about reorienting expenditures should not be ducked The process of preparing PRSPs is supposed to facilitate prioritizing the actions that will do most to reduce poverty. But currently, though most PRSPs identify malnutrition as an important symptom of poverty, they either fail to include actions or budgets for improving nutrition; include funds only for micronutrient programs; or include as nutrition interven- tions actions such as school feeding that actually have little impact on nutri- tion (Shekar and Lee 2005). Since malnutrition is both a major cause of income poverty and a key manifestation of poverty itself, if the PRSP process is to be meaningful, it should be used to reallocate resources from uses that have less impact on poverty to tackling malnutrition. This will mean working to ensure that: · Items that do not do much to benefit nutrition are not included in the nutrition budget (for example, school feeding, which primarily benefits school enrollment, should be funded from the education and not the nutrition budget). · Resources are reallocated from lower-impact indirect interventions to higher-impact PEM interventions targeted on high-risk groups if there is not enough government budget for both (for example, reallocations might be made from general food subsidies or from livelihood creation programs with no direct impact on food security and nutrition). · Resources are reallocated to nutrition programs from other sectors with less direct impact on poverty (for example, by reducing power subsi- dies or selling state-owned manufacturing enterprises). Annex 5.5 Methodology for constructing the country prioritization matrix The construction of the matrix in figure 5.2 (see page 125) is based on the available prevalence data2 for underweight (WAZ<2), stunting (HAZ<2), overweight (WHZ>2), iron deficiency anemia (IDA), and subclinical vita- min A deficiency (VAD) among children in World Bank client countries. Information on prevalence of wasting (WHZ<_2) and iodine deficiency disorders (IDD), measured by total goiter rate, is also included. Out of 146 countries eligible for Bank financing, data are available from 126 countries for stunting and/or underweight, 82 countries have over- weight data, and 80 countries have IDA and VAD data. Wasting and IDD data are available for 120 and 70 countries respectively. However, trend data are available for most countries only for underweight and stunting rates. Cutoffs used to identify nutrition problems of public health significance Category of public health Under- significance Stuntinga weight Wasting OverweightbIDAc VADc IDDc Severe 40 30 15 10 40 20 30 Moderate 30­39 20­29 10­14 5­9 20­39 10­20 20­29 Mild 20­29 10­19 5­9 3­4 5­19 2­9 5­19 aWHO (1995, 2000). bBy definition, only 2.3 percent of the children should have weight-for-height Z score >2. Countries with more than 1, 2, or 3 time(s) higher than this normal prevalence are, respec- tively, categorized as having mild, moderate, and severe levels of overweight. c WHO (2000). For the purposes of this prioritization of countries for action in nutrition, we used cut-offs corresponding to moderate malnutrition for underweight, wast- ing, IDA, VAD, and IDD. However, in view of the fact that stunting is an indi- cator of chronic undernutrition, and in view of the longer-term consequences of even mild stunting on economic productivity (see chapter 1), as well as the emerging nature of the noncommunicable disease (NCD) problem, we used lower cut-offs (corresponding to mild stunting and mild overweight) to identify countries where these agendas need to be pursued through devel- opment partner support. See figure 5.2 and accompanying text. 210 Annex 5.6 Nutritional status of children ARC* in IDD ARC* in ARC* in Country U5MR Stunting Underweight Wasting Overweight VAD IDA (TGR) stunting underweight AFR Angola 260 45.2 30.5 6.3 55 72 33 -0.033 -0.057 211 Benin 151 30.7 22.9 7.5 1.3 70 82 4 0.041 -0.049 Botswana 110 23.1 12.5 5.0 30 37 17 -0.056 -0.080 Burkina Faso 207 36.8 34.3 13.2 1.6 46 83 29 0.017 0.008 Burundi 208 56.8 45.1 7.5 1.1 44 82 42 Cameroon 166 29.3 22.2 5.9 2.9 36 58 12 0.017 0.055 Cape Verde 38 16.2 13.5 5.6 Central African Rep. 180 28.4 23.2 6.4 0.8 68 74 11 -0.010 Chad 200 29.1 28.0 11.2 45 76 24 -0.107 -0.109 Comoros 79 42.3 26.0 11.5 3.8 0.031 0.031 Congo, DR 205 38.1 31.0 13.4 58 58 -0.028 -0.017 Congo, Rep. 108 27.5 23.9 5.5 32 55 36 Côte d'Ivoire 191 25.1 21.2 7.8 1.5 0.006 -0.023 Equatorial Guinea 152 Eritrea 80 37.6 39.6 12.6 30 75 10 -0.047 -0.007 Ethiopia 171 51.5 47.2 10.5 30 85 23 -0.028 0.003 Gabon 85 20.7 11.9 2.7 41 43 27 0.005 -0.008 212 Nutritional status of children (continued) ARC* in IDD ARC* in ARC* in Country U5MR Stunting Underweight Wasting Overweight VAD IDA (TGR) stunting underweight Gambia, The 126 19.1 17.1 8.2 64 75 20 -0.114 -0.107 Ghana 97 25.9 24.9 9.5 1.9 60 65 18 0.000 -0.018 Guinea 165 41.0 33.0 9.1 40 73 23 0.041 0.034 Guinea-Bissau 211 30.4 25.0 10.3 31 83 17 Kenya 122 33.0 22.1 6.1 3.5 70 60 10 -0.003 -0.008 Lesotho 132 45.4 17.8 5.4 54 51 19 0.045 0.003 Liberia 235 39.5 26.5 6.0 38 69 18 Madagascar 135 48.6 33.1 7.4 1.0 42 73 6 -0.008 -0.023 Malawi 182 49.0 25.4 5.5 6.7 59 80 22 0.000 -0.013 Mali 222 38.2 33.2 10.6 1.3 47 77 42 -0.048 0.042 Mauritania 183 34.5 31.8 12.8 17 74 21 -0.050 -0.040 Mauritius 19 9.7 14.9 13.7 4.0 Mozambique 205 35.9 26.1 7.9 26 80 17 -0.213 -0.017 Namibia 67 28.5 26.2 8.6 3.3 59 42 18 REPOSITIONING Niger 264 39.7 40.1 13.6 1.1 41 57 20 0.002 0.000 Nigeria 201 33.5 30.7 15.6 3.3 25 69 8 -0.026 -0.019 Rwanda 203 42.6 24.3 6.8 2.1 39 69 13 -0.017 -0.024 São Tomé and Principe 118 28.9 12.9 3.6 Senegal 138 25.4 22.7 8.4 2.6 61 71 23 -0.012 0.005 Seychelles 16 5.1 5.7 2.0 3.5 NUTRITION Sierra Leone 284 33.8 27.2 9.9 47 86 16 -0.003 -0.005 Somalia 225 23.3 25.8 17.2 South Africa 65 22.8 9.2 2.5 6.7 33 37 16 -0.108 Sudan 94 34.3 40.7 13.1 0.026 TECHNICAL Swaziland 149 30.2 10.3 1.3 38 47 12 Tanzania 165 43.8 29.4 5.4 2.5 37 65 16 0.002 0.003 Togo 140 21.7 25.1 12.3 2.5 35 72 14 -0.225 0.139 Uganda 141 39.1 22.8 4.1 2.8 66 64 9 0.003 -0.019 Zambia 182 46.8 28.1 5.0 3.3 66 63 25 0.016 0.018 ANNEXES Zimbabwe 123 26.5 13.0 6.4 4.2 28 53 9 0.043 -0.035 EAP Cambodia 138 44.6 45.2 15.0 42 63 18 -0.045 -0.012 China 38 14.2 10.0 2.2 4.3 12 8 5 -0.111 -0.078 Fiji 21 2.7 7.9 8.2 1.2 Indonesia 43 42.2 24.6 4.0 26 48 10 -0.046 Kiribati 69 28.3 12.9 10.8 11.1 Lao, PDR 100 40.7 40.0 15.4 42 54 14 -0.024 -0.009 Malaysia 8 20.1 -0.047 Marshall Islands 66 Micronesia, FS 24 Mongolia 71 24.6 12.7 3.6 3.9 29 37 15 -0.010 0.003 Myanmar 108 41.6 28.2 8.2 35 48 17 0.007 -0.002 Palau 29 Papua New Guinea 94 43.2 29.9 5.5 1.6 37 40 Philippines 37 32.1 31.8 6.5 0.8 23 29 15 -0.017 -0.006 Samoa 25 3.8 4.2 Solomon Islands 24 25.7 21.3 6.6 1.1 Thailand 28 13.4 17.6 5.4 1.2 22 22 13 -0.089 -0.028 Timor-Leste 126 46.7 42.6 Tonga 20 1.3 0.9 Vanuatu 42 20.1 12.1 5.5 0.051 Vietnam 26 36.5 33.8 8.6 0.7 12 39 11 -0.045 -0.029 213 214 Nutritional status of children (continued) ARC* in IDD ARC* in ARC* in Country U5MR Stunting Underweight Wasting Overweight VAD IDA (TGR) stunting underweight ECA Albania 24 31.7 14.3 11.1 0.097 0.284 Armenia 35 12.9 2.6 1.9 6.3 12 24 12 0.017 -0.075 Azerbaijan 96 19.6 16.8 8.0 3.7 23 33 15 -0.031 0.127 Belarus 20 Bosnia-Herzegovina 18 9.7 4.1 6.3 Bulgaria 16 Croatia 8 0.8 0.6 0.8 5.9 0.067 -0.077 Czech Republic 5 1.9 1.0 2.1 4.1 Estonia 12 Georgia 29 11.7 3.1 2.3 11 33 21 Hungary 9 2.9 2.2 1.6 2.0 Kazakhstan 99 9.7 4.2 1.8 4.3 19 49 21 -0.122 -0.170 Kyrgyz Republic 61 24.8 5.8 3.4 18 42 21 -0.160 REPOSITIONING Latvia 21 Lithuania 9 Macedonia, FYR 26 6.9 5.9 3.6 5.0 Moldova 32 Poland 9 Romania 21 10.1 3.2 2.3 2.3 0.023 -0.060 NUTRITION Russian Federation 21 11.0 5.5 -0.074 0.054 Serbia and Montenegro 19 5.1 1.9 -0.072 0.043 Slovak Republic 9 Tajikistan 116 30.9 4.9 18 45 28 0.000 TECHNICAL Turkey 41 16.0 8.3 1.9 2.9 18 23 23 -0.050 -0.047 Turkmenistan 86 22.3 12.0 5.7 18 36 11 Ukraine 20 15.9 3.2 6.2 Uzbekistan 65 31.3 18.8 11.6 14.4 40 33 24 LAC ANNEXES Argentina 19 12.4 5.4 3.2 7.3 0.485 0.522 Belize 40 6.2 Bolivia 71 26.8 7.6 1.3 6.5 23 59 4 0.000 -0.053 Brazil 37 10.5 5.7 2.3 4.9 15 45 4 Chile 12 1.5 0.8 0.3 7.0 8 -0.121 -0.052 Colombia 23 13.5 6.7 0.8 2.6 -0.021 -0.045 Costa Rica 11 6.1 5.1 2.3 6.2 0.083 Dominica 15 Dominican Republic 38 6.1 4.6 1.5 2.8 18 25 11 -0.110 -0.090 Ecuador 29 26.4 14.3 2.4 El Salvador 39 18.9 10.3 1.4 2.2 17 28 11 -0.021 -0.008 Grenada Guatemala 49 46.4 24.2 2.5 4.0 21 34 16 -0.017 -0.024 Guyana 72 10.0 11.8 11.4 2.3 -0.046 Haiti 123 22.7 17.3 4.5 2.8 32 66 12 -0.040 -0.044 Honduras 42 29.2 16.6 1.1 1.4 15 34 12 -0.029 -0.008 Jamaica 20 4.4 3.8 3.8 6.0 -0.068 -0.061 Mexico 29 17.7 7.5 2.0 3.7 -0.217 -0.271 Nicaragua 41 20.2 9.6 2.0 2.8 9 47 4 -0.010 -0.013 Panama 25 18.2 8.1 1.0 3.7 0.122 0.057 Paraguay 30 13.9 3.7 0.3 3.9 13 52 13 Peru 39 25.4 7.1 0.9 6.4 17 50 10 -0.028 -0.051 St. Kitts and Nevis 24 St. Lucia 19 10.8 13.8 6.1 2.5 215 216 Nutritional status of children (continued) ARC* in IDD ARC* in ARC* in Country U5MR Stunting Underweight Wasting Overweight VAD IDA (TGR) stunting underweight St. Vincent and the Grenadines 25 23.5 19.5 Suriname 40 9.8 13.2 6.5 Trinidad and Tobago 20 3.6 5.9 4.4 3.0 Uruguay 15 9.5 4.4 1.4 6.2 Venezuela 22 12.8 4.4 3.0 3.0 5 41 10 0.002 -0.032 MNA Algeria 49 18.0 6.0 2.7 9.2 -0.001 -0.063 Djibouti 143 25.7 18.2 12.9 Egypt, Arab Rep. of 39 18.7 4.0 5.1 8.6 7 31 12 -0.045 -0.057 Iran, Islamic Rep. of 41 15.4 10.9 4.9 3.3 23 32 9 -0.068 -0.122 Iraq 125 22.1 15.9 5.9 0.002 0.032 Jordan 33 7.8 5.1 1.9 5.7 -0.101 -0.033 Lebanon 32 12.2 3.0 2.9 20 21 11 REPOSITIONING Morocco 43 23.1 9.5 2.2 6.8 29 45 -0.009 -0.011 Syrian Arab Republic 28 18.8 6.9 3.8 8 40 8 -0.044 -0.089 Tunisia 26 12.3 4.0 2.2 3.5 -0.101 -0.148 Yemen, Rep. of 114 51.7 46.1 12.9 4.3 40 59 16 0.024 0.061 SAR Afghanistan 257 47.6 49.3 16.1 4.0 53 65 48 NUTRITION Bangladesh 73 44.7 47.7 10.3 1.1 28 55 18 -0.030 -0.023 Bhutan 94 40.0 18.7 2.6 2.0 32 81 India 90 44.9 46.7 15.7 1.6 57 75 26 -0.024 -0.024 Maldives 77 36.0 45.0 20.0 1.2 0.060 0.031 TECHNICAL Nepal 83 50.5 48.3 9.6 0.5 33 65 24 -0.016 0.001 Pakistan 101 36.3 38.2 14.2 3.1 35 56 38 -0.104 -0.005 Sri Lanka 19 20.4 32.9 13.3 0.1 -0.077 -0.015 ARC=Annual rate of change. ANNEXES See also Figure 2.12 and Maps 1.1­1.4 217 218 REPOSITIONING NUTRITION Notes 1. Epidemiology, cost-effectiveness, commitment, capacity, affordability, where past investment has gone, who should benefit, coverage, intensity, timing. 2. Stunting, underweight, wasting, IDD data from SCN (2004). VAD and IDA data from UNICEF and MI (2004b). Overweight data from De Onis and Blossner (2000). References ACC/SCN (Administrative Committee on Coordination/Subcommittee on Nutrition of the United Nations). 1997. "Effective Programmes in Africa for Improving Nutrition, Including Household Food Security." Symposium Report. SCN News 15. Geneva. ACC/SCN. 2000. Low birthweight: Report of a Meeting in Dhaka, Bangladesh on 14­17 June 1999, ed. J. Pojda and L. Kelley, Nutrition Policy Paper #18. Geneva: ACC/SCN in collaboration with ICDDR,B. Acharya, Karabi, Tina Sanghvi, Serigne Diene, Vandana Stapleton, Eleonore Seumo, Sridhar Srikantiah, and others. 2004. Using `Essential Nutrition Actions' (ENA) to Accelerate Coverage with Nutrition Interventions in High Mortality Settings. Published for the U.S. Agency for International Development by the Basic Support for Institutionalizing Child Survival (BASICS II) Project, Arlington, VA. Adams, R.H. 1998. "The Political Economy of the Food Subsidy System in Bangladesh." Journal of Development Studies 35(1): 66­88. AED (Academy for Educational Development). 2003. PROFILES: Summary of assessment findings and future directions. Available at http://www.aedprofiles.org/media/publications/PROFILES%20EVAL UATION%20BRIEF.pdf. Aguayo, V.M., S.K. Baker, X. Crespin, H. Hamani, and A. Mamadoultaibou. 2005. "Maintaining High Vitamin A Supplementation Coverage in Children: Lessons from Niger." New York: Helen Keller International Africa, Nutrition in Development Series, Issue 5. Alderman, Harold. 2002. "Subsidies as a Social Safety Net: Effectiveness and Challenges." Washington, DC: World Bank, Social Protection Discussion Paper 0224. Alderman, Harold, and Jere R. Behrman. 2004. "Estimated Economic Benefits of Reducing Low Birth Weight in Low-Income Countries." Washington, DC: World Bank HNP Discussion Paper. Alderman, Harold, and Kathy Lindert. 1998. "The Potential and Limitations of Self-Targeted Food Subsidies." Oxford: Oxford University Press. World Bank Research Observer 13(2): 213­29. 219 220 REPOSITIONING NUTRITION Alderman, Harold, J.G.M. (Hans) Hoogeveen, and Mariacristina Rossi. 2005. "Reducing Child Malnutrition in Tanzania: Combined Effects of Income Growth and Program Interventions." Washington, DC: World Bank Policy Research Working Paper 3567. Allen, Lindsay H., and Stuart R. Gillespie. 2001. What Works? A Review of the Efficacy and Effectiveness of Nutrition Interventions. Geneva: United Nations Administrative Committee on Coordination Subcommittee on Nutrition, Asian Development Bank, and International Food Policy Research Institute. Anderson, M.A. 1981. "Health and Nutrition Impact of Potable Water in Rural Bolivia." Journal of Tropical Pediatrics 27: 39­46. Attanasio, Orazio, Erich Battistin, Elma Fitzsimons, Alice Mesnard, and Marcos Vera-Hernández. 2005. "How Effective Are Conditional Cash Transfers? Evidence from Colombia." London: The Institute for Fiscal Studies, Briefing Note No. 54. Barker, David J.P. 2002. "Fetal Programming of Coronary Heart Disease." Trends in Endocrinology and Metabolism 13(9): 364­8. ------. 2004. "The Developmental Origins of Well-Being." Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences. 3591449: 1359­66. Barker, David J.P., Johan G. Eriksson, T. Forsén, and Clive Osmond. 2002. "Fetal Origins of Adult Disease: Strength of Effects and Biological Basis." International Journal of Epidemiology 31(6): 1235­39. Barker, David J.P., T.W. Meade, C.H. Fall, A. Lee, C.K. Phipps, and Y. Stirling. 1992. "Relation of Fetal and Infant Growth to Plasma Fibrinogen and Factor VII Concentrations in Adult Life." British Medical Journal 304(6820): 148­52. Barros, F.C., and J.S. Robinson. 2000. "Addressing low birthweight through interventions in pregnancy." Technical consultation on low birthweight. New York: Jointly organized by the U.S. Department of Agriculture, the Human Development Network of the World Bank, and UNICEF. Beaton, George H., R. Martorell, K.J. Aronson, B. Edmonston, G. McCabe, A.C. Ross, and B. Harvey. 1993. "Effectiveness of Vitamin A Supplementation in the Control of Young Child Morbidity and Mortality in Developing Countries." Geneva: The United Nations, Administrative Committee on Coordination/Subcommittee on Nutrition State-of-the- Art Series, Nutrition Policy Discussion Paper 13. Behrman, Jere R., and John Hoddinott. 2001. "An Evaluation of the Impact of PROGRESAon Preschool Child Height." Washington, DC: International Food Policy Research Institute FCND Discussion Paper 104. Behrman, Jere R., and Mark R. Rosenzweig. 2001. "The Returns to Increasing Body Weight." Philadelphia: Penn Institute for Economic Research, Working Paper 01-052. Available at http://ssrn.com/abstract=297919. REFERENCES 221 Behrman, Jere R., Harold Alderman, and John Hoddinott. 2004. "Nutrition and Hunger." In Global Crises, Global Solutions, ed. Bjorn Lomborg. Cambridge, UK: Cambridge University Press. Berg, Alan. 1987. Malnutrition: What Can Be Done? Lessons from World Bank Experience. Baltimore and London: Johns Hopkins University Press for the World Bank. ------. 1992. "Sliding toward Nutrition Malpractice: Time to Reconsider and Redeploy." American Journal of Clinical Nutrition 57: 3­7. Bhagwati, Jagdish, Robert Fogel, Bruno Frey, Justin Yifu Lin, Douglass North, Thomas Schelling, and others. 2004. "Ranking the Opportunities." In Global Crises, Global Solutions, ed. Bjorn Lomborg. Cambridge, UK: Cambridge University Press. Bhargava, S.K., H.P.S. Sachdev, C.H. Fall, Clive Osmond, R. Lakshmy, David J.P. Barker, and others. 2004. "Relation of serial changes in childhood body mass index to impaired glucose tolerance in young adulthood." New England Journal of Medicine 350: 865­75. Bryce, J., C. Boschi-Pinto, K. Shibuya, Robert E. Black, and the WHO Child Health Epidemiology Reference Group. 2005. "New WHO Estimates of the Causes of Child Deaths." Lancet 365: 1147­52. Burger, S.E. and Steven A. Esrey. 1995. "Water and Sanitation: Health and Nutrition Benefits to Children." In Child Growth and Nutrition in Developing Countries: Priorities for Action, ed. Per Pinstrup-Andersen, David Pelletier, and Harold Alderman, Ithaca, NY: Cornell University Press. Caballero, B. 2005. "A nutrition paradox--underweight and obesity in developing countries." N Engl J Med 352(15): 1514­1516. Cairncross, Sandy, and Vivian Valdimanis. 2004. "Water Supply, Sanitation, and Hygiene Promotion." Fogarty International Center, Disease Control Priorities Project Working Paper 28. Bethesda, MD: National Institutes of Health. Available at www.fic.nih.gov/dcpp. Caldes, Natalia, David Coady, and John A. Maluccio. 2004. "The Cost of Poverty Alleviation Transfer Programs: A Comparative Analysis of Three Programs in Latin America." Washington, DC: International Food Policy Research Institute FCND Discussion Paper 174. Carroll, Amy, Lisa Craypo, and Sarah E. Samuels. 2000. "Evaluating Nutrition and Physical Activity Social Marketing Campaigns: A Review of the Literature for Use in Community Campaigns." A Report to the Center for Advanced Studies of Nutrition and Social Marketing, University of California, Davis. Caulfield, Laura E., Stephanie A. Richard, and Robert E. Black. 2004. "Undernutrition As an Underlying Cause of Malaria Morbidity and Mortality in Children Less Than Five Years Old." American Journal of Tropical Medicine and Hygiene 71(Supplement 2): 55­63. 222 REPOSITIONING NUTRITION Caulfield, Laura E., Mercedes de Onis, Monika Blössner, and Robert E. Black. 2004a. "Undernutrition as an Underlying Cause of Child Deaths Associated with Diarrhea, Pneumonia, Malaria, and Measles." American Journal of Clinical Nutrition 80: 193­98. Caulfield, Laura E., Stephanie A. Richard, Juan A. Rivera, Philip Musgrove, and Robert E. Black. 2004b. "Stunting, Wasting, and Micronutrient Deficiency Disorders." Version of 23 December 2004, prepared for Disease Control Priorities in Developing Countries, second edition (DCP2). Chen, Jun-shi, X. Zhao, X. Zhang, S. Yin, J. Pioa, J. Huo, and others. 2005. "Studies on the Effectiveness of NaFeEDTA-fortified Soy Sauce for Controlling Iron Deficiency: A Population-Based Intervention Trial." Food and Nutrition Bulletin 26(2): 177­86. Chen and Ravallion. 2004. "How Have the World's Poor Fared since the Early 1980s?" Washington, DC: World Bank Research Observer 19(2). Chhabra, Ritu, and Claudia Rokx. 2004. "The Nutrition MDG Indicator: Interpreting Progress." Washington, DC: World Bank HNP Discussion Paper. Christiaensen, Luc, and Harold Alderman. 2004. "Child Malnutrition in Ethiopia: Can Maternal Knowledge Augment the Role of Income?" Economic Development and Cultural Change 52(2): 287­312. Christian, Parul, Subarna K. Khatry, Joanne Katz, Elizabeth K. Pradhan, Steven C. LeClerq, Sharada Ram Shrestha, and others. 2003. "Effects of Alternative Maternal Micronutrient Supplements on Low Birth Weight in Rural Nepal: Double Blind Randomized Community Trial." British Medical Journal 326:571. Coady, David. 2003. "Alleviating Structural Poverty in Developing Countries: The Approach of PROGRESAin Mexico." Washington, DC: International Food Policy Research Institute, IFPRI Perspectives, Vol. 23. Coleman, Karen J., and Eugenia C. Gonzalez. 2001."Promoting stair use in a U.S.-Mexico border community." American Journal of Public Health 91: 2007­9. Coleman, Karen J., Claire Lola Tiller, Jesus Sanchez, Edward M. Heath, Oumar Sy, George Milliken, and David A. Dzewaltowski. 2005. "Prevention of the epidemic increase in child risk of overweight in low-income schools." Archives of Pediatric & Adolescent Medicine 159: 217­24. Coutsoudis Anna, Kubendran Pillay, Elizabeth Spooner, Louise Kuhn, and Hoosen M. Coovadia. 1999. "Influence of Infant-Feeding Patterns on Early Mother-to-Child Transmission of HIV-1 in Durban, South Africa: A Prospective Cohort Study." Lancet 354: 471­76. Coutsoudis, Anna, François Dabis, Wafaie Fawzi, Philippe Gaillard, Geert Haverkamp, D.R. Harris, and others and The Breastfeeding and HIV International Transmission Study Group (BHITS). 2004. "Late Postnatal REFERENCES 223 Transmission of HIV-1 in Breast-Fed Children: An Individual Patient Data Meta-Analysis." Journal of Infectious Diseases 189 (12): 2154­66. Darnton-Hill, I., P. Webb, P.W.J. Harvey, and others. 2005. "Micronutrient deficiencies and gender: social and economic costs." Am J Clin Nutr 81(S): 1198S­1205S. De Onis, Mercedes, and Monika Blössner. 2000. "Prevalence and Trends of Overweight among Preschool Children in Developing Countries." American Journal of Clinical Nutrition 72: 1032­39. De Onis, Mercedes, Monika Blössner, Elaine Borghi, Richard Morris, and Edward Frongillo. 2004a. "Methodology for estimating regional and global trends of child malnutrition." International Journal of Epidemiology 33: 1260­70. De Onis, Mercedes, Monika Blössner, Elaine Borghi, Edward Frongillo, and Richard Morris. 2004b. "Estimates of Global Prevalence of Childhood Underweight in 1990 and 2015." Journal of the American Medical Association 291(21): 2600­06. Deitchler, Megan, Ellen Mathys, John Mason, Pattanee Winichagoon, and Ma Antonia Tuazon. 2004. "Lessons from Successful Micronutrient Programs. Part II: Program Implementation." Food and Nutrition Bulletin 25(1): 30­95. Delisle, Hélène, V. Chandra-Mouli, and Bruno de Benoist. 2000 (posted). "Should Adolescents Be Specifically Targeted for Nutrition in Developing Countries: To Address Which Problems, and How?" World Health Organization/International Nutrition Foundation for Developing Countries. Available at http://www.who.int/child- adolescent-health/New_Publications/NUTRITION/Adolescent_ nutrition_paper.pdf. Diagana, Bocar, Francis Akindes, Kimseyinga Savadogo, Thomas Reardon, and John Staatz. 1999. "Effects of the CFA Franc Devaluation on Urban Food Consumption in West Africa: Overview and Cross-Country Comparisons." Food Policy 24: 465­78. Dickin, K., M. Griffiths, and E. Piwoz. 1997. "Designing by Dialogue: A Program Planners' Guide to Consultative Research for Improving Young Child Feeding." Washington, DC: Health and Human Resources Analysis Project, The Manoff Group, Support for Analysis and Research in Africa. Available at http://sara.aed.org/publications/child_ survival/nutrition/dbyd_feeding/D%20by%20D_Feed%20(full).pdf. Doak, Colleen M. 2002. "Large-Scale Interventions and Programmes Addressing Nutrition-Related Chronic Diseases and Obesity: Examples from 14 Countries." Public Health Nutrition 5(1A): 275­77. Doak, Colleen M., L.S. Adair, M. Bentley, C. Monteiro, and Barry M. Popkin. 2005. "The Dual Burden Household and the Nutrition Transition Paradox." International Journal of Obesity 29: 129­36. 224 REPOSITIONING NUTRITION Dolan, Carmel, and F. James Levinson. 2000. "Will We Ever Get Back? The Derailing of Tanzanian Nutrition in the 1990s." Washington, DC and New York: Draft paper submitted for the World Bank-UNICEF Nutrition Assessment. Processed. Dowda, Marsha, James F. Sallis, Thomas L. McKenzie, Paul Rosengard, and Harold W. Kohl III. 2005. "Evaluating the Sustainability of SPARK Physical Education: A Case Study of Translating Research into Practice." Research Quarterly for Exercise and Sport 76: 11­19. Elmendorf, Edgard A., Cecilia Cabanero-Verzosa, Michèle Lioy, and Kathryn LaRusso. 2005. "Behavior Change Communication for Better Health Outcomes in Africa: Experience and Lessons learned from World Bank Financed Health, Nutrition, and Population Projects." Washington DC: Africa Region Human Development Working Paper Series No. 52. Eriksson, Johan G., T. Forsén, J. Tuomilehto, Clive Osmond, and David J.P. Barker. 2001. "Early Growth and Coronary Heart Disease in Later Life: Longitudinal Study." British Medical Journal 322: 949­53. Esanu, Cristina, and Kathy Lindert. 1996. "An Analysis of Consumer Food Price and Subsidy Policies in Romania." Washington, DC: World Bank ASAL Unit, Romania. Ezzati, Majid, Alan Lopez, Anthony Rodgers, Stephen Vander Hoorn, Christopher Murray, and the Comparative Risk Assessment Collaborating Group. 2002. "Selected Major Risk Factors and Global and Regional Burden of Disease." Lancet 360(9343): 1­14. FANTA(Food and Nutrition Technical Assistance Project). 2004. "HIV/AIDS: A Guide for Nutritional Care and Support." 2nd Edition. Food and Nutrition Technical Assistance Project. Washington, DC: Academy for Educational Development. FAO Statistical Database Data. 2005. Last updated on Aug 22, 2004. http://faostat.fao.org/faostat/collections?subset=nutrition. Fawzi, Waifaie, Gernard Msamanga, Donna Spiegelman, and David J. Hunter. 2005. "Studies of Vitamins and Minerals and HIV Transmission and Disease Progression." Journal of Nutrition 135: 938­44. Fawzi, Waifaie, Gernard Msamanga, Donna Spiegelman, R. Wei, S. Kapiga, E. Villamor, and others. 2004. "A Randomized Trial of Multivitamin Supplements and HIV Disease Progression and Mortality." New England Journal of Medicine 351: 23­32. Fernald, Lia. 2005. "Obesity and Chronic Disease in the Developing World." Washington, DC: World Bank Background Paper. Fewtrell, L., and J. Colford. 2004. "Water, Sanitation and Hygiene Interventions, and Diarrhoea: A Systematic Review and Meta-Analysis." Washington DC: World Bank Health, Nutrition, and Population Discussion Paper. REFERENCES 225 Fiedler, John L. 2000. "The Nepal National Vitamin A Program: Prototype to Emulate or Donor Enclave?" Health Policy and Planning 15(2): 145­56. ------. 2003. "A Cost Analysis of the Honduras Community-Based, Integrated Child Care Program (Atención Integral a la Niñez­Comunitaria, AIN-C). Washington, DC: World Bank HNP Discussion Paper. Fiedler, John L., D.R. Dado, H. Maglalang, N. Juban, M. Capistrano, and M. V. Magpantay. 2000. "Cost Analysis As a Vitamin A Program Design and Evaluation Tool: A Case Study of the Philippines." Social Science and Medicine 51: 223­42. Galloway, Rae. 2003. "Anemia Prevention and Control: What Works." A joint product of the Food and Agriculture Organization, the Micronutrient Initiative, the Pan American Health Organization, UNICEF, the U.S. Agency for International Development, the World Bank, and the World Health Organization. Gastein Opinion Group. 2002. "Health at the Heart of CAP: Health and Common Agricultural Policy Reform Opinion and Proposals of an Expert Working Group." Gastein, Austria: European Health Policy Forum. Gertler, Paul. 2000. "Final Report: The Impact of PROGRESA on Health." Washington, DC: International Food Policy Research Institute, Food Consumption and Nutrition Division. Available at ww.ifpri.org/themes/progresa/pdf/Gertler_health.pdf. Gillespie, Stuart R. 2001. "Strengthening Capacity to Improve Nutrition." Washington, DC: International Food Policy Research Institute, FCND Discussion Paper 106. ------. 2004. "Scaling Up Community Driven Development: A Synthesis of Experience." Washington, DC: World Bank Social Development Paper 69. Gillespie, Stuart R. 2002 "Nutrition in Transition." Washington DC: International Food Policy Research Institute, New and Noteworthy in Nutrition Issue No. 36:7. Gillespie, Stuart R., and Lawrence Haddad. 2003. "The Relationship between Nutrition and the Millennium Development Goals: A Strategic Review of the Scope for DFID's Influencing Role." London: U.K. Department for International Development. Gillespie, Stuart R., and Suneetha Kadiyala. 2005. "HIV/AIDS and Food and Nutrition Security: From Evidence to Action." Washington, DC: International Food Policy Research Institute, Food Policy Review No. 7. Gillespie, Stuart R., John Mason, and Reynaldo Martorell. 1996. "How Nutrition Improves." Geneva: The United Nations, Administrative 226 REPOSITIONING NUTRITION Committee on Coordination/Subcommittee on Nutrition State-of-the- Art Series, Nutrition Policy Discussion Paper 15. Gillespie, Stuart R., Milla McLachlan, and Roger Shrimpton, eds. 2003. Combating Malnutrition: Time to Act. Health, Nutrition, and Human Development Series. Washington, DC: World Bank. Gragnolati, Michele, M. Shekar, M. Dasgupta, C. Bredenkamp, and Y.K. Lee. Forthcoming. The Challenge of Persistent Child Undernutrition in India and the Role of the ICDS Program. Washington, DC: World Bank. Grantham-McGregor, Sally, Lia Fernald, and K. Sethurahman. 1999. "Effects of Health and Nutrition on Cognitive and Behavioural Development in Children in the First Three Years of Life." Food and Nutrition Bulletin 20(1): 53­99. Griffiths, M., and J.S. McGuire. "A New Dimension for Health Reform: The Integrated Community Child Health Program in Honduras." 2005. In Health System Innovations in Central America: Lessons and Impact of New Approaches, ed. Gerard La Forgia. Washington, DC: World Bank Working Paper 57. Gwatkin, D.R., S. Rutstein, K. Johnson, E.A. Suliman, and A. Wagstaff. 2003. Initial Country-Level Information about Socio-Economic Differences in Health, Nutrition, and Population. 2nd edition. Washington, DC: World Bank. Habicht, Jean-Pierre, C.G. Victora, and J.P. Vaughan. 1999. "Evaluation Designs for Adequacy, Plausibility, and Probability of Public Health Programme Performance and Impact." International Journal of Epidemiology 28: 10­18. Haddad, Lawrence. 2003. "Redirecting the Nutrition Transition: What Can Food Policy Do?" In "Food Policy Options: Preventing and Controlling Nutrition-Related Noncommunicable Diseases." World Health Organization and World Bank HNP Discussion Paper, Washington, DC: World Bank. Haddad, Lawrence, and Lisa C. Smith. 1999. "Explaining Child Malnutrition in Developing Countries: A Cross-Country Analysis." Washington, DC: International Food Policy and Research Institute Discussion Paper 60. Haddad, Lawrence, Harold Alderman, Simon Appleton, Lina Song, and Yisehac Yohannes. 2002. "Reducing Child Undernutrition: How Far Does Income Growth Take Us?" Washington, DC: International Food Policy Research Institute FCND Discussion Paper 137. Haddad, Lawrence, Saroj Bhattarai, Maarten Immink, Shubh Kuman, and Alison Slack. 1995. "More Than Food Is Needed to Achieve Good Nutrition by 2020." Washington, DC: International Food Policy and Research Institute 2020 Vision Brief 25. Haddad, Lawrence, Christine Pena, Chiruzu Nishida,Agnes Quisumbing, and Alison Slack. 1996. "Food Security and Nutrition Implications of REFERENCES 227 Intrahousehold Bias: A Review of Literature." Washington, DC: International Food Policy Research Institute FCND Discussion Paper 19. Handa, Sudhanshu, and Mari-Carmen Huerta. 2004. "Using Clinic-Based Data to Estimate the Impact of a Nutrition Intervention." www.unc.edu/~shanda/research/ Handa_Huerta_Program_Bias_ V1.pdf. Hawkes, Corinna, Cara Eckhardt, Marie T. Ruel, and Nicholas Minot. 2005. "Diet Quality, Poverty, and Food Policy: A New Research Agenda for Obesity Prevention in Developing Countries." SCN News 29: 20­22, special issue: Overweight and obesity: a new nutrition emergency? Heaver, Richard. 2002. "Improving Nutrition: Issues in Management and Capacity Development." Washington, DC: World Bank Health, Nutrition, and Population Discussion Paper. ------. 2003a. "India's Tamil Nadu Nutrition Program: Lessons and Issues in Management and Capacity Development." Washington, DC: World Bank Health, Nutrition, and Population Discussion Paper. ------. 2003b. "Nutrition and Community-Driven Development: Opportunities and Risks." Washington, DC: World Bank Social Development Notes 89. ------. 2005a. "Good Work--But Not Enough of It: A Review of the World Bank's Experience in Nutrition." Washington, DC: World Bank. ------. 2005b. "Strengthening Country Commitment to Human Development: Lessons from Nutrition." Washington, DC: World Bank Directions in Development Series. Heaver, Richard, and Yongyout Kachondam. 2002. "Thailand's National Nutrition Program: Lessons in Management and Capacity Development." Washington, DC: World Bank HNP Discussion Paper. Hendricks, Michael, Romy Saitowitz, and John Fiedler. 1998. "An Economic Analysis of Vitamin A Interventions in South Africa." Photocopy. Child Health Unit, University of Cape Town. Hill, Zelee, Betty Kirkwood, and Karen Edmond. 2004. "Family and Community Practices That Promote Child Survival, Growth, and Development: A Review of the Evidence." Geneva: World Health Organization. Ho, T.J. 1985. "Economic Issues in Assessing Nutrition Projects: Costs, Affordability, and Cost Effectiveness." Washington, DC: World Bank PHN Technical Note 85-14. Hoddinott, John, and Emmanual Skoufias. 2003. "The Impact of PRO- GRESA on Food Consumption." Washington DC: International Food Policy Research Institute FCND Discussion Paper 150. Honorati, M., J. Armstrong Schellenberg, H. Mshinda, M. Shekar, J.K.L. Mugyabuso, G.D. Ndossi, and D. de Savigny. Forthcoming. "Vitamin 228 REPOSITIONING NUTRITION A Supplementation in Tanzania: The Impact of a Change in Programmatic Delivery Strategy on Coverage." Horton, Susan. 1993. "Cost Analysis of Feeding and Food Subsidy Programmes." Food Policy 18(3)192­99. ------. 1999. "The Economics of Nutritional Interventions." In Nutrition and Health in Developing Countries, ed. Richard D. Semba and Martin W. Bloem. Totowa, NJ: Humana Press, Inc. Horton, Susan, and J. Ross. 2003. "The Economics of Iron Deficiency." Food Policy 28(1): 51­75. Horton, Susan, Tina Sanghvi, Margaret Phillips, John Fiedler, Rafael Perez- Escamilla, Chessa Lutter, Ada Rivera, and A.M. Segall-Correa. 1996. "Breastfeeding Promotion and Priority Setting in Health." Health Policy Planning 11(2):156­68. Hunt, J.M. 2005. "The Potential Impact of Reducing Global Malnutrition on Poverty Reduction and Economic Development." Asia Pac J Clin Nutr 14(S): 10­38. Hunt, Joseph Michael M., and M.G. Quibria. 1999. Investing in Child Nutrition in Asia. Manila: Asian Development Bank and UNICEF, ADB Nutrition and Development Series 1. Iannotti, Lora, and Stuart Gillespie. 2002. Successful Community Nutrition Programming: Lessons from Kenya, Tanzania, and Uganda. New York: UNICEF. Iliadou, Anastasia, Sven Cnattingius, and P. Lichtenstein. 2004. "Low Birthweight and Type 2 Diabetes: A Study on 11,162 Swedish Twins." International Journal of Epidemiology 33(5): 948­53. Iliff, Peter J., Ellen G. Piwoz, Naume V. Tavengwa, Clare D. Zunguza, Edmore T. Marinda, Kusum J. Nathoo, and others. 2005. "Early Exclusive Breastfeeding Reduces the Risk of Postnatal HIV-1 Transmission and Increases HIV-Free Survival." AIDS 19(7): 699­708. IASO (International Association for the Study of Obesity). 2004. Global obe- sity epidemic putting brakes on economic development. Available at http://www.iotf.org/media/releaseoct28.htm. IFPRI (International Food Policy Research Institute). 2003. "Going after the Agriculture-Nutrition Advantage." IFPRI Forum September 2003. Only page number available: Pg. 7 International Obesity Task Force. 2003. International Obesity Task Force Press Statement. [http://www.iotf.org/media/iotfaug25.htm]. Accessed on 05/06/05. Jennings, J., Stuart Gillespie, J. Mason, Mashed Lotfi, and T. Scialfa. 1991. Managing Successful Nutrition Programs. Geneva: The United Nations, Administrative Committee on Coordination, Subcommittee on Nutrition, Nutrition Policy Discussion Paper 8. REFERENCES 229 Johnston, Timothy, and Susan Stout. 1999. Investing in Health: Development Effectiveness in the Health, Nutrition, and Population Sector. Washington, DC: World Bank Operations Evaluation Department Report. Jolly, R. 1996. Kenya: Our Planet: Poverty, Health, and the Environment. Nutrition. UNEP. Can be accessed at http://www.ourplanet.com/ imgversn/122/jolly.html Jones, Gareth, Richard W. Steketee, Robert E. Black, Zulfiqar A. Bhutta, Saul S. Morris, and the Bellagio Child Survival Study Group. 2003. "How Many Child Deaths Can We Prevent This Year?" Lancet 362: 65­71. Jonsson, Urban. 1997. "Success Factors in Community-Based Nutrition- Oriented Programmes and Projects." In Malnutrition in South Asia: A Regional Profile, ed. Stuart Gillespie. Katmandu, Nepal: UNICEF Regional Office for South Asia. Kahn, Emily B., Leigh T. Ramsey, Ross C. Brownson, Gregory W. Heath, Elizabeth H. Howze, Kenneth E. Powell, and others. 2002. "The Effectiveness of Interventions to Increase Physical Activity: A Systematic Review." American Journal of Preventive Medicine 22(4S): 73­107. Kimm, Sue. 2004. "Fetal Origins of Adult Disease: The Barker Hypothesis Revisited--2004." Current Opinion in Endocrinology & Diabetes 11(4): 192­96. Lee, Min-June, B.M. Popkin, and S. Kim. 2002. "The Unique Aspects of the Nutrition Transition in South Korea: The Retention of Healthful Elements in Their Traditional Diet." Public Health Nutrition 5(1a): 197­203. Leith, Jennifer, Catherine Porter, SMERU Institute, and Peter Warr. 2003. Indonesia Rice Tariff Reform. On World Bank's PSIA website. Can be accessed at: http://web.worldbank.org/WBSITE/EXTERNAL/ TOPICS/EXTPOVERTY/EXTPSIA/0,,contentMDK:20490211~menuPK: 1108036~pagePK:148956~piPK:216618~theSitePK:490130,00.html Levinson, James. 2002. "Searching for a Home: The Institutionalization Issue in International Nutrition." Washington, DC and New York: World Bank­UNICEF Nutrition Assessment Background Paper. Processed. Maluccio, John A., and Rafael Flores. 2004. "Impact Evaluation of a Conditional Cash Transfer Program: The Nicaraguan Red de Protección Social." Washington, DC: International Food Policy Research Institute FCND Discussion Paper 184. Mannar, Venkatest, and Erick Boy Gallego. 2002. "Iron Fortification: Country Level Experiences and Lessons Learned." Journal of Nutrition 132: 856S­858S. Mannar, Venkatest, and R. Shankar. 2004. "Micronutrient Fortification of Foods--Rationale, Application, and Impact." Indian Journal of Pediatrics 71: 997­1002. 230 REPOSITIONING NUTRITION Manoff International, Inc. 1984. Nutrition Communication and Behavior Change Component: Indonesian Nutrition Development Program. Volume IV: Household Evaluation. New York: Manoff International, Inc. Marsh, David R., and David G. Schroeder, eds. 2002. "The Positive Deviance Approach to Improve Health Outcomes: Experience and Evidence from the Field." Food and Nutrition Bulletin 23(4, Supplement): 3­6. Martorell, Reynaldo, K.L. Khan, and Dirk Schroeder. 1994. "Reversibility of Stunting: Epidemiological Findings in Children from Developing Countries." European Journal of Clinical Nutrition 48(Supplement): S45­S57. Mason, John B., Philip Musgrove, and Jean-Pierre Habicht. 2003. "At Least One-Third of Poor Countries' Disease Burden Is Due to Malnutrition." Bethesda, MD: National Institutes of Health, Fogarty International Center, Disease Control Priorities Project Working Paper 1. Mason, John B., Joseph Hunt, David Parker, and Urban Jonsson. 2001. "Improving Child Nutrition in Asia." Manila: Asian Development Bank. ADB Nutrition and Development Series 3. Mason, John B., R. Galloway, J. Martines, Philip Musgrove, and D. Sanders. Forthcoming. "Community Health and Nutrition Programs." In Disease Control Priorities in Developing Countries, ed. Dean Jamison, George Alleyne, Joel Breman, Mariam Claeson, David Evans, Prabhat Jha, and others. 2nd edition. Oxford and New York: Oxford University Press for the World Bank. Matsudo, S., D. Andrade, T. Araujo, E. Andrade, L.C. de Oliveira, G. Braggion, and S. Matsudo. 2002. "Promotion of Physical Activity in a Developing Country: The Agita Sao Paulo Experience. Public Health Nutrition 5(1A): 253­61. Matta, Nadim, Ronald Ashkenas, and Jean-François Rischard. 2000. Building Client Capacity through Results. Washington, DC: World Bank Internal Report. Matte, Thomas D, Michaeline Bresnahan, Melissas Begg, and Ezra Susser. 2001. "Influence of Variation in Birth Weight within Normal Range and within Sibships on IQ at Age 7 Years: Cohort Study." British Medical Journal 323(7308): 310­14. Miura, Katsuyuki, H. Nakagawa, M. Tabata, Y. Morikawa, M. Nishijo, and S. Kagamimori. 2001. "Birth Weight, Childhood Growth, and Cardiovascular Disease Risk Factors in Japanese Aged 20 Years." American Journal of Epidemiology 153(8): 783­89. Monteiro, Carlos A., Wolney L. Conde, B. Lu, and Barry M. Popkin. 2004. "Obesity and Inequities in Health in the Developing World." International Journal of Obesity 28: 1181­86. Mora, José O., and Josefina Bonilla. 2002. "Successful Vitamin A Supplementation in Nicaragua." Basel, Switzerland: MOST (the United REFERENCES 231 States Agency for International Development Micronutrient Program) Newsletter 3. Morris, Saul, Pedro Olinto, Rafael Flores, Eduardo A.F. Nilson, and Ana C. Figueiro. 2004. "Conditional Cash Transfers Are Associated with a Small Reduction in the Rate of Weight Gain of Preschool Children in Northeast Brazil." Journal of Nutrition 134 (9): 2336­42. Neiman, Andrea B., and Enrique R. Jacoby. 2003. "The First `Award to Active Cities Contest' for the Region of the Americas." Revista Panamericana de Salud Pública 14(4): 277­80. NIHCM (National Institute for Health Care Management). 2003. "Childhood Obesity: Advancing Effective Prevention and Treatment: An Overview for Health Professionals." Washington DC: Prepared for the National Institute for Health Care Management Foundation Forum. Nugent, Rachel. 2004. "Food and Agriculture Policy: Issues Related to Prevention of Noncommunicable Diseases." Food and Nutrition Bulletin 25(2): 200­207. Orbach, Eliezer, and Gedion Nkojo. 1999. "Assessing the Treatment of Capacity in Africa Region Projects." Washington DC: World Bank. Osrin, David, Anjana Vaidya, Yagya Shrestha, Ram Bahadur Baniya, Dharma Sharna Manandhar, Ramesh K. Adhikari, and others. 2005. "Effects of Antenatal Multiple Micronutrient Supplementation on Birthweight and Gestational Duration in Nepal: Double-Blind, Randomized Controlled Trial." Lancet 365: 955­62. Panneth, N., and Susser M. 1995. "Early origin of coronary heart disease (the `Barker hypothesis')." BMJ 310: 411­412. Pelletier, David L., Edward Frongillo, and Jean-Pierre Habicht. 1994. "Epidemiologic Evidence for a Potentiating Effect of Malnutrition on Child Mortality." American Journal of Public Health 83(8): 1130­33. Pelletier, David L., M. Shekar, and L. Du. Forthcoming. "Bangladesh Integrated Nutrition Project: Effectiveness and Lessons." South Asia Region Human Development, and Human Development Network, World Bank. Pelletier, David L., Kassahun Deneke, Yemane Kidane, Beyenne Haile, and Fikre Negussie. 1995. "The Food-First Bias and Nutrition Policy: Lessons from Ethiopia." Food Policy 20(4): 279­98. Pollitt, Ernesto. 1990. Malnutrition and Infection in the Classroom. Paris: UNESCO. Popkin, Barry M., Susan Horton, and Soowon Kim. 2001. "The Nutritional Transition and Diet-Related Chronic Diseases in Asia: Implications for Prevention." Washington, DC: International Food Policy Research Institute FCND Discussion Paper 105. Prentice, Andrew M. 2003. "Intrauterine Factors, Adiposity, and Hyperinsulinaemia." British Medical Journal 327:880­81. 232 REPOSITIONING NUTRITION Puska, Pekka, Pirjo Pietinen, and Ulla Uusitalo. 2002. "Influencing Public Nutrition for Noncommunicable Disease Prevention: From Community Intervention to National Programme--Experiences from Finland." Public Health Nutrition 5(1A): 245­51. Puska, Pekka, E. Vartiainen, J. Tuomilehto, V. Salomaa, and A. Nissinen. 1998. "Changes in Premature Deaths in Finland: Successful Long-Term Prevention of Cardiovascular Diseases." Bulletin of the World Health Organization 76(4): 419­25. Quisumbing, Agnes R. 2003. "Food Aid and Child Nutrition in Rural Ethiopia." Washington, DC: International Food Policy Research Institute FCND Discussion Paper 158. Radhakrishna, R., and K. Subbarao. 1997. India's Public Distribution System: A National and International Perspective. Washington, DC: World Bank. Ranatunga, P. 2000. A Government/Non-Government Collaboration in Poverty Alleviation--with a Nutrition Entry. Self-published. Ravelli, Anita C.J., Jan H.P. van der Meulen, Clive Osmond, David J.P. Barker, and Otto P. Bleker. 1999. "Obesity at the Age of 50 Years in Men and Women Exposed to Famine Prenatally." American Journal of Clinical Nutrition 70: 811­16. Ravelli, Anita C.J., Jan H.P. van der Meulen, R.P.J. Michels, Clive Osmond, David J.P. Barker, C.N. Hales, and Otto P. Bleker. 1998. "Glucose Tolerance in Adults after Prenatal Exposure to the Dutch Famine." Lancet 351: 173­77. Ravelli, G.P., Z.A. Steing, M.W. Susser. 1976. "Obesity in young men after famine exposure in utero and early infancy." N Engl J Med 295:349­53. Rawlings, Laura B. 2004. "A New Approach to Social Assistance: Latin America's Experience with Conditional Cash Transfer Programs." Washington, DC: World Bank Social Protection Discussion Paper 416. Reinikka, Ritva, and Jakob Svensson. 2004. "Local Capture: Evidence from a Central Government Transfer Program in Uganda." Quarterly Journal of Economics 119(2):679­705. Republic of Uganda­Ministry of Health. 2004. Nutritional Care and Support for People Living with HIV/AIDS in Uganda Guidelines for Service Providers. Kampala: STD/AIDS Control Program. Richards, Marcus, Rebecca Hardy, Diana Kuh, and Michael E.J. Wadsworth. 2001. "Birth Weight and Cognitive Function in the British 1946 Birth Cohort: Longitudinal Population Based Study." British Medical Journal 322: 199­203. ------. 2002. "Birthweight, Postnatal Growth, and Cognitive Function in a National UK Birth Cohort." International Journal of Epidemiology 31: 342­48. Rivera, Juan A., Daniela Sotres-Alvarez, Jean-Pierre Habicht, Teresa Shamah, and Salvador Villalpando. 2004. "Impact of the Mexican Program for REFERENCES 233 Education, Health, and Nutrition (PROGRESA) on Rates of Growth and Anemia in Infants and Young Children: ARandomized Effectiveness Study." Journal of the American Medical Association 29121: 2563­2641. Rogers, Beatrice Lorge, and Jennifer Coates. 2002. "Food-Based Safety Nets and Related Programs." Washington, DC: World Bank Social Protection Discussion Paper 0223. Rokx, Claudia. 2000. "Who Should Implement Nutrition Interventions?" Washington, DC: World Bank HNP Discussion Paper. Roseboom, T.J., J.H. van der Meulen, C. Osmond, D.J. Barker, and others. 2000. "Coronary Heart Disease after Prenatal Exposure to the Dutch Famine, 1944­45." Heart 84(6):595­98. Ross, Jay S., and Miriam H. Labbok. 2004. "Modeling the Effects of Different Infant Feeding Strategies on Infant Survival and Mother-to-Child Transmission of HIV." American Journal of Public Health 94(7): 1174­80. Sanghvi, Tina, Serigne Diene, John Murray, Rae Galloway, and Ciro Franco. 2003 (revised). "Program Review of Essential Nutrition Actions: Checklist for District Health Services." Arlington, VA: Published for the U.S. Agency for International Development by the Basic Support for Institutionalizing Child Survival (BASICS II) Project. Sari, Mayang, Martin W. Bloem, Saskia de Pee, Werner J. Schultink, and Soemilah Sastroamidjojo. 2001. "Effect of Iron Fortified Candies on the Iron Status of Children Aged 4­6 Years in East Jakarta, Indonesia." American Journal of Clinical Nutrition 73: 1034­39. SCN (United Nations Standing Committee on Nutrition). 2004. Fifth Report on the World Nutrition Situation: Nutrition for Improved Development Outcomes. Geneva: SCN. Serlemitsos, John A., and Harmony Fusco. 2001. "Vitamin A Fortification of Sugar in Zambia, 1998­2001." Washington, DC: The Most Project. http://www.mostproject.org. Shekar, Meera, and Y-K. Lee. 2005. "Mainstreaming Nutrition in the Context of the World Bank's Poverty Reduction Strategies. What Does It Take?" Washington, DC: World Bank. Shekar, Meera, Mercedes de Onis, Monika Blössner, and Glaine Borghi. 2004. "Will Asia Meet the Nutrition Millennium Development Goal? And If It Does, Will It Be Enough?" Department of Nutrition for Health and Development, World Health Organization. Unpublished memo. Shrimpton, Roger, Cesar G. Victora, Mercedes de Onis, Rosângela Costa Lima, Monika Blössner, and Graeme Clugston. 2001. "The Worldwide Timing of Growth Faltering: Implications for Nutritional Interventions." Pediatrics 107: e75. Smith, Lisa C., and Lawrence Haddad. 2000. "Overcoming Child Malnutrition in Developing Countries: Past Achievements and Future 234 REPOSITIONING NUTRITION Choices." Washington, DC: International Food Policy Research Institute, Food, Agriculture, and the Environment Discussion Paper 30. Smith, Lisa C., Harold Alderman, and Dede Aduayom. 2005. "Food Insecurity in Sub-Saharan Africa: New Estimates from Household Expenditure Surveys." Draft. Washington, DC: International Food Policy Research Institute. Smith, Lisa C., Usha Ramakrishnan, Aida Ndiaye, Lawrence Haddad, and Reynaldo Martorell. 2003. "The Importance of Women's Status for Child Nutrition in Developing Countries." Washington, DC: International Food Policy Research Institute Research Report 131. Sothern, Melinda S., J.N. Udall Jr., R. Suskind, A. Vargas, and U. Blecker. 2000. "Weight Loss and Growth Velocity in Obese Children after Very Low Calorie Diet, Exercise, and Behavior Modification." Acta Paediatrica 89(9): 1036­43. Sothern, Melinda, H. Schumacher, T. von Almen, L. Carlisle, and J.N. Udall Jr. 2002. "Committed to Kids: An Integrated, Four Level Team Approach to Weight Management in Adolescents." Journal of the American Dietetic Association 102(3): S81­S85. Strauss, John, and Duncan Thomas. 1998. "Health, Nutrition, and Economic Development." Journal of Economic Literature 36(2): 766­817. te Velde, Saskia J., Jos W.R. Twisk, Willem Van Mechelen, and Han C.G. Kemper. 2003. "Birth Weight, Adult Body Composition, and Subcutaneous Fat Distribution." Obesity Research 11(2): 202­088. Tennyson, Ros. 2003. The Partnering Toolbook. London and Geneva: The International Business Leaders Forum (IBLF) and the Global Alliance for Improved Nutrition (GAIN). Timmer, C. Peter, Walter P. Falcon, and Scott R. Pearson. 1983. Food Policy Analysis. Baltimore, MD: Johns Hopkins University Press. Toh, C.M., S.K. Chew, and C.C. Tan. 2002. "Prevention and Control of Non- communicable Diseases in Singapore: A Review of National Health Promotion Programmes." Singapore Medical Journal 43(7): 333­39. Tontsirin, Kraisid, and Stuart Gillespie. 1999. "Linking Community-Based Programs and Service Delivery for Improving Maternal and Child Nutrition." Asian Development Review 17(1, 2): 33­64. Tontsirin, Kraisid, and Pattanee Winichagoon. 1999. "Community-Based Programmes: Success Factors for Public Nutrition derived from Experience of Thailand." Food and Nutrition Bulletin 20(3): 315­322. Troutt, David Dante. 1993. The Thin Red Line: How the Poor Still Pay More. San Francisco, CA: West Coast Regional Office, Consumers Union of the United States, Inc. Tuck, Laura, and Kathy Lindert. 1996. "From Universal Food Subsidies to a Self-Targeted Program: A Case Study in Tunisian Reform." Washington, DC: World Bank Discussion Paper 351. REFERENCES 235 UNICEF (United Nations Children's Fund). 1990. Strategy for Improved Nutrition of Children and Women in Developing Countries. A UNICEF Policy Review. New York: UNICEF. UNICEF and MI (Micronutrient Initiative). 2004a. Vitamin and Mineral Deficiency: A Global Damage Assessment Report. Available at http://www.unicef.org/media/files/davos_micronutrient.pdf. UNICEF and MI. 2004b. Vitamin and Mineral Deficiency: A Global Progress Report. Available at http://www.micronutrient.org/reports/reports/ Full_e.pdf. UNICEF and WHO (World Health Organization). 2004. Low Birth Weight: Country, Regional, and Global Estimates. New York: UNICEF. Van Roekel, Karen, Beth Plowman, Marcia Griffiths, Victorio Vivas de Alvarado, J. Matute, and M. Calderon. 2002. BASICS II Midterm Evaluation of the AIN Program in Honduras, 2000. Published for the United States Agency for International Development by the Basic Support for Institutionalizing Child Survival Project (BASICS II). Von Braun, Joachim. 1995. "Agricultural Commercialization: Impacts on Income and Nutrition and Implications for Policy." Food Policy 20(3): 187­202. Vor der Bruegge, Ellen, Joan E. Dickey, and Christopher Dunford. 1997 (updated 1999). Cost of Education in the Freedom from Hunger Version of Credit with Education. Davis, CA: Freedom from Hunger Research Paper 6. Wagstaff, Adam, and Naoko Watanabe. 2001. Socioeconomic Inequalities in Child Malnutrition in the Developing World. Washington, DC: World Bank. World Bank. 1989. Mozambique--Food Security Study. Washington, DC: World Bank. ------. 1994a. Impact Evaluation Report. India: Tamil Nadu Integrated Nutrition Project. Washington, DC: World Bank, Operations Evaluation Department. ------. 1994b. Enriching Lives: Overcoming Vitamin and Mineral Malnutrition in Developing Countries. Washington, DC: World Bank Development in Practice Series. ------. 1998. Implementation Completion Report. Sri Lanka: Poverty Alleviation Project. Washington, DC: World Bank. ------. 1999a. Consumer Food Subsidy Programs in the MENA Region. Washington, DC: World Bank Report No. 19561. ------. 1999b. Implementation Completion Report. Republic of Madagascar: Food Security and Nutrition Project. Washington, DC: World Bank. _______1999c. "Consumer Food Subsidy Programs in the MENA Region." Report No. 19561-MNA. Washington, DC: World Bank. 236 REPOSITIONING NUTRITION ------. 2000. Voices of the Poor: Can Anyone Hear Us? Washington, DC: World Bank. ------. 2001a. Implementation Completion Report. People's Republic of China: Iodine Deficiency Disorders Control Project. Washington, DC: World Bank. ------. 2001b. Implementation Completion Report. Republic of Senegal: Community Nutrition Project. Washington, DC: World Bank. ------. 2001c. India: Improving Household Food and Nutrition Security: Achievements and Challenges Ahead. Report 20300-IN. Washington, DC: World Bank. ------. 2002a. Poverty and Nutrition in Bolivia. Washington, DC: World Bank. ------. 2002b. Implementation Completion Report. People's Republic of Bangladesh: Integrated Nutrition Project. Washington, DC: World Bank. ------ .2002c. School Health at a Glance. Washington, DC: World Bank HNP at a Glance Series. ------. 2004. Implementation Completion Report. Republic of Indonesia: Intensified Iodine Deficiency Control Project. Washington, DC: World Bank. ------. 2005a. World Development Indicators. Washington, DC: World Bank. ------. 2005b. Global Monitoring Report 2005. Washington, DC: World Bank. ------. 2005c. Maintaining Momentum toward the MDGs" An Impact Evaluation of Interventions to Improve Maternal and Child Health and Nutrition Outcomes in Bangladesh. Operations Evaluation Department (OED). Washington, DC: World Bank. WHO (World Health Organization). 1995. Physical Status: The Use and Interpretation of Anthropometry. Report of a WHO Expert Committee. Geneva: WHO Technical Report Series 845. ------. 2000a. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO Obesity Technical Report Series 894. ------. 2000b. The Management of Nutrition in Major Emergencies. Geneva: WHO. ------. 2001. Diet, Physical Activity, and Health. EB109/14. Geneva: WHO. ------. 2002. World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: WHO. ------. 2004. Global Strategy on Diet, Physical Activity, and Health. Fifty-sev- enth World Health Assembly. WHA57.17. Geneva: WHO. Available at http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R17-en.pdf. ------. 2005a. Global Strategy on Diet, Physical Activity and Health. Available at http://www.who.int/dietphysicalactivity/en. ------. 2005b. Obesity and Overweight. Available at http://www.who.int/ dietphysicalactivity/publications/facts/obesity/en/. ------. 2005c. Nutrition and HIV/AIDS: Report by the Secretariat. EB115/12. Available at http://www.who.int/gb/ebwha/pdf_files/EB116/ B116_12-en.pdf. REFERENCES 237 Yamano, Takashi, Harold Alderman, and Luc Christiaensen. 2005. "Child Growth, Shocks, and Food Aid in Rural Ethiopia." American Journal of Agricultural Economics 87(2): 273­88. Zatonski, Witold A., Anthony J. McMichael, and John W. Powles. 1998. "Ecological Study of Reasons for Sharp Decline in Mortality from Ischaemic Heart Disease in Poland Since 1991." British Medical Journal 316: 1047­51. Zeitlin, Marian F., Hossein Ghassemi, and Mohamed Mansour. 1990. Positive Deviance in Child Nutrition. Tokyo: United Nations University. Zhao, Mingfang, Xiao Ou Shu, Fan Jin, Gong Yang, Hong-Lan Li, Da-Ke Liu, and Wanqing Wen. 2002. "Birthweight, Childhood Growth, and Hypertension in Adulthood." International Journal of Epidemiology 31: 1043­51. Zilberman, David. 2005. "Bringing Health into Agricultural Policy." Presentation abstract for the International Health Economics Association World Congress. Barcelona, Spain. July 10­13. Zlotkin, Stanley H., Claudia Schauer, Anna Christofides, Waseem Sharieff, Mélody C. Tondeur, and S.M. Ziauddin Hyder. 2005. "Micronutrient Sprinkles to Control Childhood Anaemia." PLoS Medicine 2(1): e1. Index Academy for Educational biofortification, 73 Development (AED), mandate and birth spacing, 10 focus in nutrition, 189­191 birthweight, IQ and, 25 access to health and environmental body mass index (BMI), xvii, 152 services, 53 wages and, 24­25 affordability, 203 Brazil, obesity intervention Africa programs, 83 mandate and focus in nutrition, 191 breastfeeding, 65, 67, 165, 166, 167 underweight and stunting, 7, 43, 44 development partners, 115 age-targeting, 89 HIV/AIDS and, 77­80 agriculture, 168­169 promotion, 134 policy, 90, 91 under 56 AIN-C program, 156­157 burden of disease anemia, xvii, 24, 72­73 risk factors, 145 children, 25 underweight and, 22 costs, 26 India, 33 Argentina, multisector programs, 159 calorie intake, work output and, Asia 24­25 low birthweight, 46 Canada, mandate and focus in malnutrition, 6 nutrition, 185 underweight and stunting, 7, 43, 44 capacity building, 115, 118, 121, 122, Asian Development Bank (ADB), 170­171, 202­203 182­183 assessing, 141 strengthening, 107, 109­111 research needs, 111 Bangladesh, 120 caregivers, 68 growth promotion programs, 66­67 cash transfers, conditional, 75­76, 133 low-birthweight prevention, 69­70 causes, intervention mismatches multisector programs, 159 and, 121 nutrition programs, 103, 107, 108 child mortality, ix, 22, 57, 209­216 Barker hypothesis, 48 trends, 146, 147 Basic Support for Institutionalizing children Child Survival (BASICS) projects, care and feeding, 53, 58­59, 64, 65, 164­167 68, 118, 134, 168­169, 175 behavioral practices. See children, care growth and development, 164 and feeding illnesses and treatment, 157 239 240 REPOSITIONING NUTRITION nutritional status by country, country strategies, 117­120 209­216 coverage, 205 older vs younger, 89 intensity vs, 88­89 See also infants credit, microcredit cum nutrition China education, 135 fortified foods, 73 micronutrient deficiencies, 26 nutrition programs, 107, 162­163 DALYs. See disability-adjusted obesity, 49 life years underweight, 7 delivery. See service delivery chronic disease, obesity and, 151­153 demand-side approaches, 63, 64 cognitive development, 25 Denmark, mandate and focus in commitment, 202 nutrition, 184 building, 121­122, 131nn.3, 7, development 170­171, 141, 162­163 activities, 176­177 research needs, 111 community, country level, 130 strengthening, 107­109 indicators, trends, 146, 147 weak, 108, 119 international development communication, 161 community, role, 13­14, 16 community action, 157 investments, 37 community-based growth promotion, MDGs and, 38 65­69, 132 nutrition and, 127, 140­141 research needs, 67­69 development partners, 18 community-based programs, 176 focus vs needs, 128­129 community development health sector bias, 131n.3 indicators, nutrition and, 159­161 mandate and focus, 172­198 participation, 160­161 nutrition agenda, 114­116 community-driven development nutrition focus areas, 168­169 (CDDs) programs, nutrition and, supporting nutrition, 114­116 100­101, 105 technical area, 170­171 community empowerment, 96, development strategies 155­156 country level, 18­19 community-level approaches, obesity, international, 16 152 next steps, 17­19 community workers deworming, 74 female, 66­67 diabetes, type II, 191 training, 67­68 diagnosis, 32 consensus, nutrition programs, 162 diet, research, 177 Copenhagen Consensus (2004), diet-related noncommunicable ix­x, 141 diseases (NCDs), ix, 24, 49­51, micronutrients, 2, 39 80­85, 142 quoted, vii disability-adjusted life years (DALYs), corruption, 100­111, 112n.20 22, 40n.23 cost-effectiveness, 142, 201­202, Dreze, Jean, quoted, vii 203, 204 obesity prevention, 153 costing, 141 earnings. See income costs economic growth, 22, 27­28, 136 malnutrition, 26 nutrition and, 11 nutrition programs, 18, 27, 28 underweight prevalence and, 30, 31 country prioritization matrix, methodology, 208 INDEX 241 education food female, 10, 137 access to, 58 microcredit and, 135 adequacy, 159 nutrition, 10, 67, 74, 134, 135 availability, underweight and, 148 obesity, 83 coupons, conditional, 75 policy, 91 insecurity, 177 services, 160 policy, 83, 90, 168­169 El Salvador, fortified foods, 72 pricing, 83 emergencies, 174, 176 food assistance programs, 74­77 employment, policy, 91 research needs, 76­77 empowerment, 96, 155­156 food intake energy inadequate, 11 availability, trends, 146 malnutrition and, 57 deficiency, obesity and, 51 food production, 10, 137­138 policy, 91 efficiency, 160 environment, 160 stunting and, 54­55 nutrition policy and, 200 food security, 53, 75 policy, 91 malnutrition and, 9, 42, 65 epidemiology, 201 nutrition security vs, 66 ethical development, 161 food subsidies, targeted social safety Ethiopia, 120 net programs vs, 74­75 Child Survival and Systems food supplements, 68­69, 70, 75, 177, strengthening Project, 190 203­204 evaluation. See monitoring and cost-effectiveness, 142 evaluation health care and micronutrient evidence base, strengthening, 142­143 interventions vs, 88 evidence-based strategies, 127 foreign exchange, policy, 91 expenditures, reorienting, 207 fortified foods, 71­72 funding, 18 future, foundations, 207 family planning, 138, 160 FAO, mandate and focus in nutrition, 179­180 GDP, 29­30 fast food, 89 malnutrition and, 26 fetal origins of adult disease, 48 Germany, mandate and focus finance and financiers, channeling in 186 and coordinating, 101­107 Ghana, nutrition programs, 109 research needs, 105, 107 Global Alliance for Improving weak capacity, 119 Nutrition (GAIN), mandate and financing, 141 focus in nutrition, 195­196 obesity prevention, 153 governance, 100­111 Finland, obesity intervention malnutrition and, 10­17 programs, 83 growth flour fortification, 72­73 failure, 25 folate monitoring and promotion, 67, 175 maternal deficiency, 23 See also community-based growth supplements, 165 promotion programs food aid, 174 Guatemala Food and Nutrition Technical fortified foods, 72 Assistance Project (FANTA), 191 overweight and stunting, 7­8 242 REPOSITIONING NUTRITION Habicht, Jean-Pierre, quoted, vii nutrition programs, 96, 108, 154, HarvestPlus, mandate and focus in 155­156 nutrition, 197­198 policy, 86 health care interventions, food underweight and anemia supplementation vs, 88 prevalence, 33 health policy, 91 Indonesia, growth promotion health sector, development partners, programs, 66­67 131n.3 infants health services, 160 feeding, 10, 174, 175 essential nutrition actions, 165 mortality, trends, 146, 147 nutrition and, 99­100, 164­167 See also children systems, 180­183 infection, under nutrition and, 56­57 height, 25 information systems, 159­161, 176, birthweight and, 48 179 Hellen Keller International (HKI), informational asymmetries, 32 mandate and focus in nutrition, intelligence (IQ), birthweight and, 25 191­192 intensity, coverage vs, 88­89 HIV/AIDS initiatives, 62, 77­82 international development lessons for nutrition, 116 community, role, 13­14, 16 malnutrition and, 6, 7, 12, 78 approach, 16 nutrition and, 77, 142­143, 168­169 See also development program experience, 80 interventions research needs, 81­82 causes and mismatches, 121 Honduras direct vs indirect, 203­204 fortified foods, 72 investments, reorienting, 120­121 growth promotion programs, 66­67 iodine deficiency disorders (IDD), nutrition programs, 96, 156­158 xvii, 7, 23, 25 Horton, S., quoted, vii global prevalence, 241 housing, 160 India, 26 human capital development, 24 iodized salt, 71, 133 human rights, nutrition and, 37 coverage rate, 241 Ireland, mandate and focus in nutrition, 187 IFPRI, mandate and focus in iron deficiency, 7, 23 nutrition, 196­197 prevalence by region, 53 immune function, 24 iron supplementation, 72­73, 74, immunization, 166, 204 133, 165 implementation, improving, 120­121 income, 204 growth, 10 Japan, mandate and focus in malnutrition and, 25, 29 nutrition, 184­185 underweight and, 31 income-nutrition elasticity, economic growth and, 30 lactation. See breastfeeding income poverty, 3 Latin America, 49 indicators, 112n.14 learning, 25 nutrition and, 33­34 LINKAGES, 191 India livelihood, 204 GDP, 29 long-term plans, 206­207 growth promotion programs, 66­67 low birthweight, xvii, 12, 22, 25, iodine deficiency, 26 46­48, 69, 175 low-birthweight prevention, 70 causes, 48 INDEX 243 prevalence and number by Mauritania region, 47 maternal overweight and child prevention programs, 69­71 underweight, 7 research needs, 71 overweight, 49 trends (1990­2015), 46 Mexico, obesity, 49 micronutrient deficiencies economics, 26 macroeconomic policies, 136 prevalence, 42 Madagascar, 120 trends, 6 growth promotion programs, 66­67 Micronutrient Initiative (MI), mainstreaming nutrition, 99­101, mandate and focus in nutrition, 117­120, 127, 140­141, 170­171 192­193 malaria, 204 micronutrients, 2, 168­169, 173, malnutrition, xvii 174­175, 176­177 causes, 10­17, 53 agenda, 130­131 costs, 26 Copenhagen consensus, 39 damage, x costs, 2 economics, 1 coverage, 40, 240, 241 extreme, xi food supplementation vs, 88 focusing actions, 122­126 programs, 11, 52­53, 71­73, 118 general, 168-169 research needs, 73 generational, 58 micronutrient supplementation and government intervention, 10­17 fortification, 10 HIV/AIDS interaction, 78 HIV/AIDS, 79 implications, 126 research, 141­142 income and, 29 Middle East, overweight, 49 maternal, 48 Millennium Development Goals mismatch between problem and (MDGs), ix, 1, 3 proposed solutions, 89 income poverty, 7 poverty and, 23 malnutrition and, 13 pregnancy until age two, 42 nutrition and, 15, 34­37, 38 prevalence and trends, ix, 5, 42, 45, mineral deficiency, 7 124, 149, 150 monitoring and evaluation, 96, reasons to reduce, 1­9 170­171 scope and cause, 42­61 obesity prevention, 153 shape and scale, 3­9 multisector programs, managing, 159 typology and magnitude, 125 Musgrove, Philip, quoted, vii window of opportunity, 58, 118 "malnutrition divide," 43 management, 178­179 noncommunicable diseases (NCDs), nutrition programs, 162 5, 12 managerial capacity, weak, 119 origin, 10 Manoff Group, mandate and focus in prevalence, 42 nutrition, 193­194 nonincome poverty, 3, 118 market forces, nutrition and, 32­33 progress, 36 markets, failing, 9 progress by country, 4, 35 Mason, John, quoted, vii NORAD, mandate and focus in maternal and child health, 168­169 nutrition, 183­184 maternal-child food supplementation, North Africa, overweight, 49 134 Norway, mandate and focus in maternal nutrition, 8, 175 nutrition, 183­184 244 REPOSITIONING NUTRITION nutrition, 63, 64 managing, 95­98 accelerating progress, 113­131 multisector programs, 159 adequacy, 159 national level, 96­97 data, linking with global prioritization of countries, 131 monitoring initiatives, 143 research needs, 14, 98 demand-side approaches, long and returns on, 26­27 short routes, 63, 64­65 Senegal, 155 economics and, 21­34 Thailand, 159­162 focused action research agenda, weak commitment, 14 supporting, 126­128 nutrition security, food security vs, 66 health services and, 164­167 nutrition services human rights and, 37 delivery approaches, 141 improvement, x, 62­94, 37­38, 118, facility-based integrated, 135 132­139 organization, 98­101 income poverty and, 33­34 research needs, 101 indicator, 143 strategies, national, 102­104 investment in, 15 strengthening delivery knowledge, 32 mechanisms, 141­142 long routes, 136­139 transition, 24 MDGs and, 15, 34­37 myths, 11, 57 next steps, 129­131 Obasanjo, Olusegun, viii poverty reduction and, 3 obesity, ix, 173 pregnancy to first two years, 12 obesity, origin, 10 priorities, 127 energy deficiency and, 51 priorities for action research, time of occurrence, 58 140­143 trends, xvii, 7, 8, 49­51 short routes, 132­135 obesity and overweight, programs, supply-side approaches, 63, 64 82­85 nutrition intervention, 57, 59 chronic disease and, 151­153 cost, 29 financing and institutional capacity, coverage rates, 39­40 153 efficacy, 142­143 interventions, 152 evaluating, 143 research, 155 matrix, 123 research needs, 84­85 prioritizing countries, 122­123 organization, 178­179 priority countries, 123­124 overweight, xviii, 10, 12, 50, 130, underweight and income 209­216 growth, 31 maternal, 8, 50 nutrition policies, 90­93 overweight and, 49 program experience, 92 prevalence, 124 research needs, 92­93 prevention, 142 unintentional, 91­92 trends, 7 nutrition programs, 13 undernutrition vs, 7­8, 51 benefit-cost ratio, 3, 27 underweight and, 49 China, 162­163 community level, 96 costs, 18, 28 partnerships, nutrition services country experiences, 154­163 building, 160­161 Honduras, 156­158 public-private, 98­99 India, 154, 155­156 Philippines, policy, 86­87 INDEX 245 policy, 13, 62, 83, 90­93, 168­169, 174 rehydration, 204 agriculture, 90, 91 research, 170­171, 177 choices, 87­89 resource constraints, 32 demand- and supply-side, 86 resources, nutrition action and, 11 food, 83, 90, 168­169 rice fortification, 72­73 framework, 199­207 roads, policy, 91 implications for, 58­59 rural development, 168­169 macroeconomic, 136 Rwanda, 188 nutrition, 90­93 multisector programs, 159 obesity, 152 process, 85­87 role, 85­89 salt iodidzation, 133 short routes vs long routes, 87 sanitation, 138 policy makers, nutrition programs, school, 25, 26 161 enrollment, 25 the poor, vs the better off, 89 feeding programs, 74 poverty obesity interventions, 152 definitions, 112n.13 sector-wide approach (SWAp), headcount, trends, 146 102­104, 105, 170­171, 180 income poverty, 3, 33­34, 112n.14 evaluating, 143 malnutrition and, 23, 57 security and safety, 160 reduction, nutrient and, 11 Sen, Amartya, quoted, vii targeting, 89 Senegal poverty-reduction strategy credits growth promotion programs, 66­67 (PRSCs), 104, 105, 170­171 nutrition programs, 155 evaluating, 143 service delivery poverty-reduction strategy papers mechanisms, 127 (PRSPs), 88, 89, 104, 170­171, 180 strategies, 101 pregnancy, 23, 64, 65 short-term plans, 206 diet, 70 Sierre Leone, anemia, 26 undernutrition, 56 social protection programs, 74­77 prioritization matrix, methodology research needs, 76­77 for countries, 208 social safety net programs, targeted, productivity, 22 vs food subsidies, 74 malnutrition and, 22­25 social welfare, policy, 92 PROFILES, 107, 109, 191 South Africa, obesity, 49 program approaches, 117­120 soy sauce fortification, 73 coordinated, 118­119 spiritual development, 161 timing, 119 stakeholder consensus, 142 program design and management, STOPP-T2D, 191 156­157 strategies, 118 programs, scaling up, 95­112, 113 stunting, xviii, 25, 209­216 operational challenges, 117­122 food production and, 54­55 PROGRESA, 76 incidence, 5­6 progress monitoring, 157 prevalence, 42, 43, 124, 239 PRSCs. See poverty-reduction strategy trends, 146, 147 credits sugar fortification, 72 PSRPs. See poverty-reduction strategy supply-side approaches, 63, 64 papers Support for Analysis and Research in public investment, and, 32­33 Africa (SARA), 192 public safety, policy, 91 surveillance systems, 176 246 REPOSITIONING NUTRITION SWAp. See sector-wide approach UNICEF, mandate and focus in Sweden, mandate and focus in nutrition, 174­176 nutrition, 186 United Kingdom, mandate and focus in nutrition, 188­189 United States, low-birthweight pre- Tamil Nadu Integrated Nutrition vention, 70 Program (TINP), 154, 156 urban food insecurity, 177 Tanzania, GDP, 29, 31 USAID, mandate and focus in Tanzania, nutrition programs, 108 nutrition, 187­188 targeting, 205­206 age, 89 food subsidies, 74­75 Vietnam, policy, 86 poverty, 89 vitamin A deficiency, xviii, 7, 22, 52 social safety net programs, 74 global prevalence and technical level, constituency, 161 supplementation coverage Thailand rates, 240 growth promotion programs, 66­67 vitamin A supplementation, 72, 132, nutrition programs, 97, 107, 108, 166, 167 159­162 vitamin deficiency, 7 policy, 86 trade, policy, 91 trials of improved practices (TIPs), 68, wasting, xix, 209­216 157 See also stunting Triple A process, 100 water supply, 138 tuberculosis vaccine, 166 weight, 25, 67 WFP, mandate and focus in nutrition, 176­177 Uganda, 188 WHO HIV/AIDS, 80 quoted (2004), vii UN, mandate and focus in nutrition, mandate and focus in nutrition, 178­179 172­174 undernutrition, xviii window of opportunity, 58, 118 causes, 53­54 women, status, education, and intervention coverage and, 238, 239 workload, 137 pregnancy and first two years, 10 work output, calorie intake and, prevalence, 124 24­25 programs, 11, 43­46, 130 workload, women, 137 window of opportunity, 12, 55 workplace interventions, obesity, 152 underweight, xviii, 8, 209­216 World Bank burden of disease, 22 mandate and focus in nutrition, incidence, 5­6 180­183 income growth and intervention, 31 quoted (2005), viii India, 33 support, 128­129 overweight and, 49 per capita food availability and, 148 prevalence, 6­7, 30, 33, 42, 43, 54, Zambia, fortified foods, 72 56, 60­61, 238 Zimbabwe, mal nutrition and rates, 143 earnings, 25 trends, 6, 146, 147 z-score, xix Persistent malnutrition contributes not only to widespread failure to meet the first Millennium Development Goal--to halve poverty and hunger--but also to meet other goals related to maternal and child health, HIV/AIDS, education, and gender equity. Underweight preva- lence among children is the key indicator for measuring progress on nonincome poverty, and malnutrition remains the world's most serious health problem--as well as the single largest contributor to child mor- tality. Nearly one-third of children in the developing world are under- weight or stunted, and more than 30 percent of the developing world's population suffers from micronutrient deficiencies. Moreover, new mal- nutrition problems are emerging: the epidemic of obesity and diet-related noncommunicable diseases is spreading to the developing world, and malnutrition is linked to the HIV/AIDS pandemic. Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action makes the case that development partners and devel- oping countries must increase investment in nutrition programs. This case is based on evidence that the scale of the problem is very large and that nutrition interventions are essential for speeding poverty reduction, have high benefit-cost ratios, and can improve nutri- tion much faster than reliance on economic growth alone. Moreover, improved nutrition can drive economic growth. The report proposes to the international development community and national governments a global strategy for accelerated action in nutrition. ISBN 0-8213-6399-9