From Agriculture to NutritionPathways, Synergies and Outcomes

REPORT NO. 40196-GLB

THE WORLD BANKAGRICULTURE AND RURAL DEVELOPMENT DEPARTMENT

From Agriculture to Nutrition: Pathways, Synergies and Outcomes

© 2007 The International Bank for Reconstruction and Development / The World Bank1818 H Street, NWWashington, DC 20433

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Cover photos by World Bank staff members: vegetable produce at a Guatemalan marketby Curt Carnemark; Senegalese girl carrying cassava leaves by Lianqin Wang; mother inBangladesh feeding her child a food supplement by Shehzad Noorani.

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A C R O N Y M S A N D A B B R E V I AT I O N S vii

A C K N O W L E D G M E N T S ix

E X E C U T I V E S U M M A RY xi

Introduction 1World Food Security And Nutrition Situation 2Structure of the Report 7

Determinants of Human Nutrition and the Pathways Linking Agriculture and Nutrition 9

Pathways Linking Agriculture to Nutrition 12

The Impact of Agriculture Interventions on Nutrition Outcomes 15The Nutritional Impacts of Agricultural Interventions 16Gender Outcomes of Agricultural Interventions 30Lessons Learned 31

Case Studies 33Orange-Fleshed Sweet Potato Production and Vitamin A

Deficiency in Mozambique 33Legume Systems and Child Nutrition in Malawi 36Integrating Homestead Gardening and Primary Health Care

Activities in South Africa 38Homestead Gardening for Fruits, Vegetables, and Livestock

in Asia 39Lessons from the Four Case Studies 42

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Contents

The Changing Context of Agriculture and Nutrition Linkages 43Agricultural Policy 43Agricultural Technology 47Food Marketing Systems 50Food Consumption Patterns 53Conclusions 56

Institutional Frameworks for Action in the Agriculture Sector to AddressUndernutrition 59

Institutional Barriers to Coordinated Action in Nutrition 60Resource Allocation and Planning 61Sector Mandates and Priorities 61Unique Sectoral Worldviews 62Constrained Capacity for Nutritional Analysis 63Institutional Mechanisms to Enable Agriculturists to Address

Undernutrition 63Conclusions 67

Lessons Learned and Next Steps 69

A P P E N D I X 7 3

B I B L I O G R A P H Y 7 5

Figures1 Estimated Prevalence of Stunted Preschool Children 1980–2005 42 Estimated Prevalence of Underweight Preschool Children 1980–2005 53 Overweight and Obesity among Women 45–59 Years of Age, by WHO

Region 64 Estimated Prevalence of Overweight Preschool Children (%) 75 Conceptual Framework of the Determinants of Nutritional Status 107 Changes in Food Production per Capita over Time 486 Potential Impact of Technological Changes on Food Production and

Consumption 48

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iv Contents

Contents v

Boxes1 Messages from Publications on Agriculture and Nutrition, 1970s–2000s 112 Introducing Orange-Fleshed Sweet Potato in Rural Mozambique 342 Introducing Orange-Fleshed Sweet Potato in Rural Mozambique, Cont. 353 Legume Systems in Malawi: Building on Local Knowledge, Improving

Nutrition 374 Trade Liberalization and Food Availability: Synthesis of Cases in South Asia

464 Trade Liberalization and Food Availability: Synthesis of Cases in South Asia,

Cont. 475 Decline in Consumption of Pulses in India: The Effect of Technology and

Domestic Policies 496 Situating Nutrition Administratively within the Public Sector 607 The Institutional Study under the Agriculture-Nutrition Advantage Project

618 Nutrition and Sectorwide Approaches to Planning 629 Home Economists as Agricultural Extension Agents 66

Tables1 Prevalence and Number of Undernourished People in Developing Countries

1990–2003 32 Key Results from Selected Studies of Agricultural Commercialization 173 Summary of the Evaluation Findings of Horticultural and Nutrition Projects

214 Summary of Intervention Studies on Impacts of Animal Source Food

Interventions on Nutrition-Related Outcomes 255 Potential Effects of the Changing Context on Pathways Linking Agriculture

and Nutrition 446 Annual Average Growth in Retail Sales of Packaged Foods, 1996–2002 517 The Growth of Modern Retail in Developing Countries 528 Composition of Global Agricultural Food Exports (% of value) 539 Average Annual Growth in Global per Capita Consumption of Various Food

Items (%) 5410 Average Annual Share of Arable and Permanent Land Used for Harvest (%)

5511 Worldwide Annual Average Growth in Food Production (%) 56

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AVRDC Asian Vegetable Research and Development CenterBMI body mass indexCDD community-driven developmentFAO Food and Agriculture Organization (United

Nations)FRT Farmer Research TeamHACCP Hazard analysis critical control pointHIV/AIDS Human Immunodeficiency Virus/Acquired

Immune Deficiency SyndromeHKI Helen Keller InternationalIDRC International Development Research CenterIFPRI International Food Policy Research InstituteNGO nongovernmental organizationOECD Organization for Economic Co-operation and

DevelopmentOFSP orange-fleshed sweet potatoSETSAN Technical Secretariat for Food Security and

Nutrition (Mozambique)SFHC Soils, Food and Health Communities Study

(Malawi)SWAp sectorwide approachTANA The Agriculture-Nutrition Advantage ProjectUNESCO United Nations Educational, Scientific and Cultural

OrganizationUNICEF United Nations Children’s FundUSAID United States Agency for International

DevelopmentVITAA Vitamin A for AfricaVITAL Vitamin A Field Support ProjectWFSP white-fleshed sweet potatoWHO World Health OrganizationWTO World Trade Organization

Acronyms andAbbreviations

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This report was prepared by a multi-institutional and interdiscipli-nary team from the International Food Policy Research Institute(IFPRI) and the World Bank (WB). The key contributors were CorinnaHawkes, Marie Ruel, Mary Arimond, Zeina Sifri, Todd Benson,Devesh Roy, and Noora-Lisa Aberman (IFPRI), Peter Berti(HealthBridge, Canada), Jef Leroy (National Institute of PublicHealth, Mexico), Edward Frongillo (University of South Carolina),Nwanze Okidegbe, Lynn Brown, Gunnar Larson, and Chris Delgado(World Bank).

The task team would like to extend their thanks to the project ad-visors Nicolas Minot (IFPRI) and Peter Berti (HealthBridge), as wellas to Michelle Adato, Damiana Astudillo, Bonnie McClafferty, andGinette Mignot. The report’s content editor was Gunnar Larson(World Bank, Agriculture and Rural Development). Peer reviewersincluded Meera Shekar, James Garrett, Harold Alderman (WorldBank), Beatrice Rogers (Tufts University), and Bruce Cogill(UNICEF).

The task team thanks Sushma Ganguly (retired), Mark Cackler(Sector Manager and Acting Director of World Bank Agriculture andRural Development), and the ARD Management Committee for theirsupport and guidance. The team acknowledges Lisa Li Xi Lau for hersupport in the logistics and production of the report.

Acknowledgments

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INTRODUCTIONIn a world of food abundance, millions of people suffer from poor nu-trition. In some parts of the world, the poor have inadequate accessto energy from food to meet their energy requirements. In these loca-tions, food shortage is often a seasonal phenomenon and micronutri-ents are also generally lacking in the diet. Elsewhere, there is a stablesupply of energy but the poor have monotonous diets lacking in es-sential micronutrients. In other places a “nutrition transition” isunder way in which the poor and other consumers enjoy sufficientaccess to energy, and indeed often consume excessive amounts, butthe quality of their diets is unhealthy owing to a combination of fac-tors relating to nutrition and lifestyle. Excessive consumption com-bined with more sedentary lifestyles, often associated withurbanization, contributes to an increasing incidence of obesity andchronic disease such as diabetes in countries still plagued by under-nutrition. A combination of these nutritional problems adversely af-fects about 2 billion people worldwide.

The relationship between agriculture and human nutrition is farmore complex than the relationship between food production andfood consumption or the economic relationship between food supplyand food demand. Increased food production raises the availabilityof food, but by itself does little to ensure that poor and vulnerablepeople have access to the food that is produced. Nor does the grossquantity produced say much about the quality or nutritional value ofpeople’s diets. The persistence of malnutrition as a global publichealth concern despite the successes in increasing agricultural pro-duction belies any notion that malnutrition and undernutrition canbe solved entirely from the supply side. How then can agriculture,with its customary focus on productivity and yields, more effectivelycontribute to improved nutrition outcomes?

Expanding agriculture’s purview and capacity to embrace thosecontributing factors and determinants of nutrition that are tradition-ally the province of other disciplines or improving agriculture’s inter-face with other, nonagricultural sectors, suggest themselves aspossible ways forward. Those sectors that approach nutrition in rela-tion to its essential role in building and maintaining human capitalare particularly important prospective counterparts in this regard. Yetoperationally integrating the necessary inputs of other sectors intoagriculture interventions, or effectively coordinating the respective

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xii From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

contributions of sector ministries in larger develop-ment programs and policies, is in practice fraughtwith difficulty. Historically, multisector efforts in-tended to simultaneously address agriculture andnutrition have often been hindered by institutionalbarriers and insufficient resources.

The limitations of production-focused agricul-tural programs and interventions in delivering im-proved nutrition impacts have been recognized bysome in the agricultural community for decades. Inthe early 1980s a number of international develop-ment agencies undertook programs that sought toorient agricultural production to nutrition-relatedobjectives, and over time a substantial body of lit-erature developed around the analysis of the pro-grams’ results. A review of this literature yields anumber of insights as to how agricultural invest-ments can be designed and targeted to improve nu-trition outcomes. Malnutrition remains an urgentglobal public health concern. Yet the question ofhow agriculture can most effectively contribute toimproved nutrition outcomes remains essentiallyunanswered. It is therefore time to revisit what isknown and what can be done to improve the syn-ergies between agriculture and nutrition. The po-tential contribution of agriculture needs to bereexamined, especially in light of the changes thesector has undergone, by reviewing lessons frompast experience and by analyzing current develop-ments and what they mean for future change. Thatis the purpose of this report.

OBJECTIVEThe report seeks to analyze what has been learnedabout how agricultural interventions influence nu-trition outcomes in low- and middle-income coun-tries, focusing on the target populations of theMillennium Development Goals—people living onless than a dollar a day. It also sets out to synthesizelessons from past efforts to improve the synergiesbetween agriculture and nutrition outcomes. Thereport identifies a number of developments in agri-culture and nutrition that have transformed thecontext in which nutrition is affected by agricul-ture. These developments have considerable prac-tical significance for nutrition-related agriculturalprograms?including the design of those programsthat aim to improve nutritional outcomes. Finally,the report draws a number of practical conclusions

that shed light on how agricultural interventionsand investments may improve nutrition outcomesin low- and middle-income countries.

PATHWAYS LINKINGAGRICULTURE TO NUTRITIONA widely used conceptual framework published byUNICEF in 1990 identifies three main underlyingdeterminants of nutritional status: availability andaccess to food, the quality of feeding and care giv-ing practices, and the health of the surrounding en-vironment and access to health care services. Eachof these determinants is a necessary but not suffi-cient condition to good nutrition. The food supplychain linking food production with food consump-tion and human nutrition can be usefully consid-ered in terms of five pathways.

• Subsistence-oriented production for thehousehold’s own consumption

• Income-oriented production for sale in markets• Reduction in real food prices associated with

increased agricultural production• Empowerment of women as agents instru-

mental to household food security and healthoutcomes

• Indirect relationship between increasing agri-cultural productivity and nutrition outcomesthrough the agriculture sector’s contribution tonational income and macroeconomic growth

Household production for the household’s own con-sumption is the most fundamental and direct path-way by which increased production translates intogreater food availability and food security. The dif-ferent types of foods produced determine the im-pact of the production increase on diet quality. Theproduction of staple foods leads mainly to greateraccess to and consumption of energy. Increasedproduction of fruit, vegetables, and animal sourcefoods (dairy, eggs, fish, and meat) can likewiseraise access to energy, protein, and fat, but can alsogreatly improve the quality and micronutrient con-tent of diets. Some proportion of the food producedmay also be intended for sale on local markets.Some households may for instance meet their sta-ples requirements themselves while depending onmarkets for other products such as fruits and veg-etables. Others may rely mainly on home gardensfor fruits and vegetables. Whatever role produc-

tion-for-income plays in this scenario is secondaryto the principal purpose of producing food to meetthe household’s own food requirements.

Income-oriented production for sale in markets. Asagricultural households become more market ori-ented, production-for-own-consumption becomesless significant relative to income from the sale ofwhat is produced. Technology becomes more im-portant relative to the household’s resource endow-ment, and the selection of crops to be grown isbased principally on their tradability and the pricethey are expected to command in local markets.Extra income may be used to buy more food,higher-quality (more nutrient-dense) foods, or both;the balance between the two affects the final impactof this additional income on the household’s con-sumption of energy and micronutrients. The trans-lation of increased income into better childnutrition, in turn, depends on a series of intrahouse-hold factors and processes. These include women’sstatus, education, knowledge, health-related prac-tices, decision-making power, income, and access toand use of health and sanitation services.

The empowerment of women is a pathway that car-ries special significance for household nutritionoutcomes and in particular for children’s healthand nutrition outcomes. Women have consistentlybeen found to be more likely than men to invest intheir children’s health and well-being, and the in-come and resources that women control wield dis-proportionately strong effects on health andnutrition outcomes generally. Women who arereached by agricultural programs that relay infor-mation on nutrition issues appear to be particularlyeffective at delivering improved nutrition out-comes, and the effects appear to be most pro-nounced among the lowest income groups. Takentogether, these characteristics make women naturalpriorities for agricultural programs that aim at im-proving nutrition. These programs, however, musttake women’s time and resource constraints firmlyinto account and, where and when possible, seekmeans of relieving them.

Lowering food retail prices by increasing food pro-duction is another pathway linking agriculture tonutrition and is especially important in areas inwhich markets are less integrated. For net con-sumers, reduced food prices enable greater accessto food and essential nutrients, resulting in betterhealth and productivity for the general workforcewhile also freeing additional household resources

from food to other expenditures, including produc-tive investments.

Finally, agricultural growth itself represents an in-direct pathway to better nutrition through its con-tribution to macroeconomic growth and higherlevels of national income, which can support nutri-tional improvements by reducing poverty.Increases in agricultural productivity have beenvital factors in building sustained economicgrowth in both developed and developing coun-tries and have major impacts on poverty. Onecross-country analysis found that a 1 percent in-crease in agricultural yields lowers the percentageof a national population living on less than a dollara day by between 0.64 and 0.91 percent—a povertyeffect that appears particularly great in Africancountries (Thirtle et al. 2002). Overall, however, theeconomic growth-to-malnutrition relationship ismodest. A doubling of gross national product(GNP) per capita in developing countries has beenassociated with a much more modest reduction inchildhood undernutrition—on the order of 23 to 32percent (Haddad et al. 2003).

THE IMPACT OF AGRICULTURALINTERVENTIONS ON NUTRITIONOUTCOMESThe literature reviewed in this report documentsthe nutrition outcomes of agricultural programsand can be usefully classified by the type of com-modity the program involved: staples, fruits andvegetables, or animal source foods. Studies on thenutritional impacts of programs involving staplecrops such as maize and rice focused overwhelm-ingly on aggregate production and food availabil-ity rather than on individual- or household-levelindicators and therefore yielded little evidence thatis germane to this report. Moreover, the only agri-cultural interventions involving staple foods thathave been evaluated from a nutritional perspectiveconcern agricultural commercialization—the con-version from staple subsistence food production tocommercial food production. This type of interven-tion aims to improve nutritional outcomes throughboth the own-consumption and the income path-ways, with potential indirect impacts through theagricultural growth and price pathways. Evidencefrom the review of studies on agricultural commer-cialization shows increases in household income,

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xiv From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

including greater income controlled by women insome cases and greater household food expendi-ture. These changes did not, however, translate intosubstantial improvements in child nutrition. Inorder to improve childhood nutrition, agriculturalcommercialization interventions would most likelyneed to be complemented by components or paral-lel interventions that specifically target other deter-minants of child nutrition. These would includeimproved health, care giving practices, and accessto water and sanitation facilities to address the highrates of infections affecting young children in poorenvironments.

Agricultural interventions promoting increasedproduction of fruit and vegetables—such as thoseinvolving homestead gardens—carry considerablepotential to effectively address micronutrient defi-ciencies. The review identified a significant body ofevidence documenting the success of homesteadgardens in raising production, income, householdconsumption, and the intake of targeted fruit andvegetables by vulnerable population groups.Several programs also showed significant impactson dietary and biochemical indicators of micronu-trient deficiencies, and especially so when they in-cluded components designed to change behaviorthrough education and to empower women.

Programs and interventions involving animalsource foods have even greater potential to tacklemicronutrient deficiencies, especially vitamin A,iron, and zinc deficiencies. These micronutrientsare more readily bioavailable in animal sourcefoods than in plant foods. Several interventionsshowed gains in production, income, and house-hold food security, and significantly greater nutri-tion impacts when combined with interventionsinvolving women’s empowerment, education, andbehavior change.

Four case studies of agricultural interventionswere reviewed because of their unique contribu-tion to the body of knowledge on the linkages be-tween agriculture and nutrition. They include anorange-fleshed sweet potato intervention to im-prove vitamin A intake in Mozambique, a legumesystems and child nutrition program in Malawi, ahomestead gardening project integrated with pri-mary health care activities in South Africa, and anintegrated homestead gardening and livestock pro-gram in Asia. All four programs achieved their ul-timate objective of improving the intake of focus

nutrient-rich foods by target population groups,and the two studies that measured biochemical in-dicators showed reductions in vitamin A defi-ciency. Common elements that appear to havecontributed to the success of these four programsinclude a strong behavior change component, care-ful consideration of local contexts, partnershipbuilding with different community members topromote ownership, and a specific focus onwomen’s empowerment. The studies also reaffirmthat careful evaluation design is critical but re-mains a challenge, as does the scaling up of suc-cessful pilot programs.

Overall the review documents a wide range ofsuccessful agricultural interventions that have con-tributed to improved nutrition outcomes. In mostcases, however, the exact pathways by which im-pacts on nutrition have been achieved are difficultto track. Most studies document impacts on severalintermediary outcomes such as food security, in-come, or women’s empowerment, but without di-rectly modeling these pathways of impact tonutrition outcomes. Because these outcomes are soclosely intertwined, it is impossible to determinefrom this literature the relative importance of thedifferent pathways that connect agriculture andnutrition.

The key lessons learned from this body of evi-dence are that agricultural interventions are mostlikely to affect nutrition outcomes when they in-volve diverse and complementary processes andstrategies that redirect the focus beyond agriculturefor food production and toward broader considera-tion of livelihoods, women’s empowerment, and op-timal intrahousehold uses of resources. Successfulprojects are those that invest broadly in improvinghuman capital, sustain and increase the livelihoodassets of the poor, and focus on gender equality.

THE CHANGING CONTEXT OFAGRICULTURE AND NUTRITIONLINKAGESOver time, changes in the global environmenthave been modifying how agriculture affects nu-trition and have made the need for integratingagriculture and nutrition interventions even moreimperative. Four types of global changes are em-phasized in the report: changes in agricultural pol-

icy, agricultural technology, food marketing sys-tems, and food consumption patterns. Thesechanges affect the broader context within whichnutrition-oriented agricultural interventions areimplemented. They also affect each of the path-ways through which agriculture affects nutrition,notably consumption of own-production, pro-ducer incomes, and food prices.

Agricultural Policy

Agricultural policy in most developing countrieshas recently undergone a major paradigm shift aspart of what is often termed “globalization.”Although the role of the government in food mar-kets remains extensive, governments have disman-tled state marketing mechanisms and liberalizedtrade and investment. The level of taxation or “dis-protection” of agriculture has declined over timethrough trade liberalization in the nonagriculturalsectors and changes in exchange rate regimes.Private markets have generally assumed greater im-portance relative to state intervention, and agricul-ture’s increased market orientation has changedproducers’ incentives, with important effects onfood availability and prices.

At the national level, the impact of liberalizationon commodity prices will vary across commoditiesdepending on whether the country is a net-importeror a net-exporter of that commodity. The observedpattern of trade in which developing countries arenet exporters of high-value, micronutrient-richcrops implies that consumer prices are higher forthose products than the prices that would prevail ina closed economy. The reverse would hold for thesupply of macronutrients since many developingcountries are net importers of grains. Agriculturalpolicy changes can also affect nutrition through theproducer income pathway. Again, the overall im-pact of trade liberalization on income is likely to dif-fer depending on the initial status of the country (asa net importer or exporter), and across farmerswithin the country depending on whether they arenet producers or net consumers.

Agricultural Technology

The growth of agricultural technology has beendramatic over the past 25 years. Developments thatcarry particularly important implications for food

availability, prices, demand, and consumption areplant breeding and technologies related to food pro-cessing and marketing, such as those that maintaina cold-chain from farm to plate. Technologies thatincrease productivity, such as Green Revolutioncrop breeding technologies, have significantly re-duced food prices of the targeted crops. This in turnhas led to significant reductions in childhood mal-nutrition. Simulation models estimate that withoutthe Green Revolution, the proportion of malnour-ished children in South Asia would now be 12 to 15points higher than it is. Improvements in posthar-vest technology and marketing for fruit and vegeta-bles can also lead to significantly reduced consumerfood prices. Changes in technology affect the de-mand for agricultural labor and thus the income offarm and nonfarm households in rural areas. Newtechnologies can be labor saving or labor enhanc-ing; some may have no effect at all on labor de-mand. Studies published during the 1990sdocumented a variety of positive impacts of tech-nology change on labor demand, incomes, foodconsumption, and diet quality—but failed to ex-hibit an impact on childhood nutrition. (This was infact attributed to the failure of increased income andfood consumption to translate into better childcare,feeding, and health-seeking behaviors—key ele-ments of improved nutrition.) Biofortification, anagricultural technology that can increase the mi-cronutrient content of staples, may confer large ben-efits to poor rural populations who have little accessto expensive high-quality foods. These improvedcrops can benefit nutrition through the own-con-sumption pathway when they are consumed byproducers, through the income pathway when theyare sold, or through the food price pathway whenthey increase the availability of micronutrient-richfoods in the marketplace.

Food Marketing Systems

The past two decades have seen a major transfor-mation and consolidation of food retail and an ex-pansion of the food processing and food serviceindustries, especially in middle-income countriesand in urban areas of low-income countries. Thesetrends are driven by rising household incomes, ur-banization, improvements in transportation,lifestyle changes, and liberalized foreign invest-ment regulations. The rapid growth of supermar-

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xvi From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

kets in developing countries in the past 10 to 20years is increasingly important in shaping foodconsumption patterns and will most likely affectnutrition through changes in food availability andprices. With the rising availability and generallylower prices of processed foods in marketplacesand food service establishments throughout muchof the developing world, a growing proportion offood expenditures go to processed foods relative tofresh food sources. Changes in the composition ofagricultural exports also affect the types and priceof foods available and current trends show rapidgrowth in the share of agricultural products thatare processed compared with fresh products. Thischanging pattern of exports has implications fornutrition through the price pathway because it in-creases the availability of certain foods over othersin exporting and importing countries. Whereasconsumers in developing countries now consumemore processed foods and vegetable oils exportedfrom developed and other developing countries,consumers in industrialized countries now con-sume more fruits, vegetables, and fish exportedfrom developing countries.

Changing Consumption Patterns

The demand for higher-value, micronutrient-richfoods increases as incomes rise and livelihoods di-versify around expanding markets, many of themurban. Increasing incomes and urbanization drivechanges in demand that provide food supplierswith market signals that tend to reorient agricul-tural production away from the cultivation of sta-ples and toward higher-value products. Forsmallholders in particular, this reorientation isoften in effect compulsory, because the viability offarming lower-value staple crops relies on muchlarger scales of production than are possible onsmall farms. For food consumers, and especiallynet food consumers, the shift in consumption awayfrom staples and toward higher-value food sourcesbrings a phenomenon that is generically referred toas the “nutrition transition.” The phenomenon ismost pronounced in rapidly growing economiesand in urban areas, in which the proportion of foodprepared at home declines in relation to the pro-portion of processed foods consumed in and out-side the home. Diets tend to become increasinglyenergy-dense, and very often excessively so, at thesame time that automation, transportation, and

sedentary lifestyles are dramatically reducing thelevel of physical activity and thus energy require-ments. Negative outcomes like obesity, heart dis-ease, and diabetes quickly become endemic, whichin turn prompt additional changes in the demandfor food. Functional foods that carry health benefitsbecome the focus of advertising and the communi-cation of health-related information, with dramaticeffects on the types of foods that are demanded.The trend offers a variety of important opportuni-ties for producers who are able to respond to thechanging demand. As consumers manifest greaterwillingness to pay more for healthier foods, re-sponsive producers find a very real prospect thatthe downward pressure on prices exerted by in-creased production may be reversed. Howeverpromising this prospect may be, the ability of poorproducers to capitalize on the emerging opportuni-ties is contingent on a number of factors, not theleast of which is the risk of converting to the culti-vation of unfamiliar crops. In the final analysis,much will depend on the success of arrangementslike contract farming, which enables poor farmersto link their production with large, often supermar-ket-led supply chains.

Conclusion

Changes in agricultural policy, technology, mar-kets, and associated changes in food consumptionpatterns are changing the pathways through whichagriculture and nutrition are linked. Today, themore market-oriented nature of agricultural poli-cies means that agricultural technology and mar-kets play a more important role in determiningfood prices and rural incomes, as more food is con-sumed from the marketplace and less from house-holds’ own-production. The greater marketorientation of food production and consumptionhas increased the bidirectional links between agri-culture and nutrition. Agricultural production re-mains an important factor contributing tonutritional outcomes, but changing food and nutri-tional demands are exerting new effects on agricul-tural production. Agricultural programs withnutritional objectives need to take this changingcontext into account to ensure that the synergiesbetween agriculture and nutrition are successfullyexploited and lead overall to better developmentoutcomes.

INSTITUTIONSImproving nutritional outcomes is a decidedlymultisectoral goal and requires the involvement ofseveral players, including households and publicand private sector agents. It also requires the in-volvement of government institutions that formu-late public policy and that in so doing influence thesettings in which agriculture-nutrition pathwaysare or are not operationalized. Jurisdiction overfood production and food supply is generally as-signed to a country’s ministry of agriculture.Nutrition, however, is not ordinarily considered asector but rather a policy issue or area that does notfall cleanly within the jurisdiction of any particularministry or agency. Health ministries generally as-sume the most direct responsibility for nutrition,but they have no administrative jurisdiction or in-fluence over agriculture or trade—the most impor-tant sector ministries addressing food supply andavailability. Common sense may suggest the estab-lishment of a governmental multisector agency tocoordinate joint action among these ministries, acourse which has been pursued by a number ofcountries. These coordinating bodies have how-ever seen little if any success in achieving effectivecooperation between sector ministries, leaving lit-tle empirical basis for assuming that such institu-tional adaptations actually work. Concertedprogrammatic coordination between different min-isterial-level institutions tends to run headlong intothe bureaucratic barriers that divide spheres of re-sponsibility between different line ministries.Bureaucracies in general are organized to ration-ally divide responsibilities within institutions, notto orchestrate joint collaboration between them.Coordination between different government insti-tutions is therefore problematical, but cannot bedismissed altogether. Possibilities for such collabo-ration are by no means limited to systematic high-level institutional frameworks. More limited,lower-level opportunities for collaboration to ad-dress specific and local issues contributing to mal-nutrition appear to offer greater promise foreffective action. This local collaboration offers theprospect of incrementally improving higher-levelcoordination of multisectoral action to addressfood insecurity and malnutrition effectively on anational basis.

LESSONS LEARNED AND NEXT STEPSPolicy makers and practitioners have long aimed toinfluence nutritional outcomes through agriculturalprograms. Many of these programs supported com-mercialization and cash crop production or the pro-duction of fruit and vegetables or animal sourcefoods with overall objectives of raising agriculturalproductivity and household income. The assump-tion was that agriculture would tackle poverty andmalnutrition by increasing food production, lower-ing food prices, and increasing household income.While food production and household food avail-ability, income, and in many cases food consump-tion and diet quality increased, childhoodmalnutrition persisted. This led to the conclusionthat increasing agricultural production and incomewere probably necessary but clearly not sufficientconditions to reducing malnutrition. Far more sub-stantial impacts were achieved when agriculturalinterventions incorporated nonagricultural compo-nents or combined with complementary nonagri-cultural interventions that addressed otherdeterminants of child nutrition. These other deter-minants included maternal health-seeking andcaregiving practices. Arming women with knowl-edge about appropriate child feeding practices, theimportance of different micronutrients, and thefood sources in which those micronutrients areavailable was a particularly effective way of im-proving child health and nutrition outcomes.

Incorporating nonagricultural criteria likehealth and nutrition into the design and conduct ofagricultural programs to improve nutrition sug-gests developing an effective interface betweenagricultural and other institutions. Yet systematichigh-level coordination between different sectorministries is challenging given the bureaucraticbarriers that typically divide them. The reporttherefore examined alternative approaches to for-mulating a more comprehensive approach for agri-culture programs to embrace improved nutrition asa development objective.

The empirical evidence presented in this reportfocuses on agricultural programs and interventionscarried out at the level of local communities.Overall, the review found that the most successfulprojects were those that invested broadly in im-proving human capital and sustained and in-creased the livelihood assets of the poor. The four

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xviii From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

key lessons learned about how these programsshould be developed and implemented in order tohelp achieve improved nutrition outcomes aresummarized below.

• Develop and implement agricultural programsthat take into account local contexts. The impor-tance of designing programs that accommo-date prevailing agricultural and nutritionalconditions has long been recognized and en-tails developing a sound understanding ofproducers’ priorities, incentives, assets, vul-nerabilities, and livelihood strategies. Forthese programs to benefit nutrition, however,there is also a need to understand and targetthe major nutritional problems experiencedby the target communities an aspect that isusually ignored in agricultural program de-sign and development. Understanding themotives and constraints that affect householdconsumption decisions is no less importantthan understanding those that affect produc-tion decisions. Cultural norms, for instance,are often key factors determining whichhousehold members maintain control overwhich household resources, and influencesuch nutritionally vital decisions as the allo-cation of types and quantities of food amonghousehold members. Thus, successful agri-culture programs aimed at improving nutri-tion must first develop an understanding ofthe economic, social, and cultural factors thatdetermine household decisions concerninglivelihood, agriculture production, householdconsumption, and intrahousehold allocationof resources, as well as the context-specifichealth and nutrition problems that prevail.

• Develop and implement agricultural programsthat enable and empower women. The essentialrole of women in delivering health and nutri-tion outcomes makes gender an inevitablepriority area for agricultural programs andpolicies that seek to contribute to nutrition.Targeting women in their roles as economicagents and stewards of household food secu-rity and health generally entails increasingtheir access to productive resources and serv-ices—an ostensibly straightforward proposi-tion that in reality must take into account andpurposefully navigate around a variety ofwomen’s constraints, including cultural con-straints. The significance of women’s educa-

tion to the health and nutrition of their children is an established axiom of develop-ment planning. This education by no meanshas to be limited to formal education.Communication of information about healthissues such as appropriate child-feeding andchildcare practices, water sanitation, and foodsafety issues carries great importance for nu-trition by addressing caregiving and health asnecessary conditions of good nutrition. Otherpublic information services, including thoseagricultural extension services that convey in-formation about issues like integrated pestmanagement, likewise have important posi-tive health impacts and many can also be tai-lored to reach women.

• Develop and implement agricultural programsthat incorporate nutrition outreach and behaviorchange. Whether regarded as a resource or aservice, the value of information that is di-rected at behavior change among farmers andconsumers presents itself as a salient conclu-sion of this report. Agricultural interventionsthat include a nutrition education componentwill increase the likelihood of positive nutri-tional outcomes. Those who are armed withinformation and knowledge about the nutri-tional significance of the foods they produceand eat are able to make better productionand consumption decisions. Nutrition-relatededucation and communication strategies mayoffer instruction on food preparation andsafety and on child-care and feeding prac-tices, as well as on how to recognize and actupon signs of nutritional deficiencies. Here,too, targeting women with health and nutri-tion information is likely to have a still greatercatalytic effect, given their typically closer af-filiation with the household and their crucialrole as child caretaker.

* Provide small producers with help and support torespond to changes in the global environment andespecially to the changing food demand. Anti-cipating and responding to changing demandis a vital imperative for farmers in general, butamong poor farmers in developing countriesthe stakes are particularly high. A significantpart of their production is intended for theirhouseholds’ own consumption, and thereforemuch of the demand they are satisfying is theirown. With respect to the proportion of food

they produce for market, the changing agricul-tural context has important implications forthe prices they are paid for their products,while increasing demand for high-value foodsources represents an important opportunityto earn more income. Yet switching to new andunfamiliar crops and producing for foreignmarkets with stringent food quality and safetyrequirements is also fraught with risk, andboth opportunities and risks need to be ad-dressed by agricultural programs.

This report consists mainly of a review of empir-ical evidence about past and ongoing cases of agri-cultural interventions with nutrition-relatedobjectives and more broadly about connections be-tween agricultural production and nutrition. Itsanalysis of the practical implications of the lessons

learned sheds light on the dynamics and causal re-lations that agricultural practitioners should takeinto account when planning programs or providingpolicy advice that focuses the crosshairs of produc-tion goals onto a nutrition-related target or targets.There is by now good reason to anticipate that nutri-tional aims will come to play more prominently inthe calculus by which the value of agricultural pro-grams is rated. Future agricultural programs imple-mented with nutritional objectives will need toaddress the real challenge of going to scale andshould be carefully monitored and rigorously eval-uated to ensure that performance can be continuallytracked and improved. The expository account of-fered in this report, it is hoped, lays the groundworkfor more practical work in which the details of ap-plying these lessons operationally can be prescribed.

Executive Summary xix

1

In a world abundant with food, millions of people suffer from poornutrition. In some parts of the world, the poor have inadequate ac-cess to energy (measured in calories) from food. In these locations,food shortages are often seasonal phenomena, and the quantitativedeficit of food energy is generally matched by deficits in food qualityreflected in insufficient essential micronutrients including vitamin A,iron, zinc, folate, and many others. Elsewhere consumption amongthe poor is characterized by monotonous diets in which these mi-cronutrient deficiencies are found despite stable and sufficient in-takes of food energy. Still other places see a “nutrition transition”under way in which diets are characterized by excessive intakes ofenergy, largely from fat, added sugars, and energy-dense processedfoods, and in which lifestyles are characterized by generally low lev-els of physical activity. This combination of excessive energy intakeand low activity patterns is associated with overweight and obesityand a variety of chronic diseases including diabetes and heart dis-ease. Together these adverse nutrition outcomes affect some 2 billionpeople worldwide.

The factors that contribute to malnutrition and poor nutrition out-comes are complex and vary across production and consumption set-tings. Sector-specific strategies tend to approach nutrition issuesalong narrowly disciplinary lines and generally disregard contribut-ing factors that fall outside the purview of that particular field.Agriculture’s role as the source of food production makes its signifi-cance to nutrition unquestionable. Yet the persistence of malnutritionas a global public health concern despite increasing agricultural pro-duction belies any notion that the malnutrition and undernutritionproblem can be solved entirely from the supply side by increasingproduction. Nutrition is intrinsically multisectoral, and strategies toimprove nutrition outcomes should seek to purposefully integratethe contributions of relevant disciplines. How agriculture’s necessaryinput into nutrition issues is to be operationally coordinated with thelikewise necessary input of nonagricultural sectors is a more difficultmatter. Historically, multisector efforts intended to simultaneouslyaddress agriculture and nutrition have often been hindered by insti-tutional barriers and insufficient resources.

Agricultural investments and interventions supported by theWorld Bank and other international development and donor agencieshave seldom explicitly incorporated nutrition-related objectives. The

Introduction1

World Bank itself last examined this issue in 1981 ina study by Per Pinstrup-Andersen, which made anumber of recommendations for incorporating nu-tritional effects into the design and planning of agri-cultural policies and programs. A recent review ofits agriculture and rural development portfolio re-vealed little or no lending for nutrition issues to beincluded in agricultural education or extension ser-vices. The only nutrition-focused agricultural inter-ventions to receive significant support frominternational development and donor agencies inrecent years involved the still-developing technol-ogy of biofortification.

The contexts in which agriculture and nutritionare linked have, moreover, changed since the 1980s(Hawkes and Ruel 2006b). The focus of nutrition asa development issue, and a human developmentissue in particular, has expanded from an early em-phasis on energy-protein deficiency to include mi-cronutrient deficiencies, and more recently extendsto the relationship between excess energy intake,poor-quality diets, obesity, and chronic diseases.The agricultural context itself is also changing.Although 75 percent of the world’s poor still live inrural areas with poor access to markets and ser-vices, fewer people are now dependent on agricul-ture for their livelihoods and more are connected tomarkets. The percentage of poor people who live inurban areas in developing countries is growing.Urbanization reflects a migration away from rural,agriculture-based employment and into urbanlivelihoods. People in cities are less likely to experi-ence undernutrition and more likely to experiencethe “nutrition transition” toward energy-densediets high in fats, sweeteners, and highly refinedcarbohydrates (Popkin 1999). Overall, the processesof global market integration, or “globalization,”have increased the market-orientation of the agri-food system worldwide, unleashing dynamicsthroughout the food supply chain that affect foodproducers and consumers.

Malnutrition remains an urgent global publichealth concern. The question of how agriculturecan most effectively contribute to improved nutri-tion outcomes remains unanswered. It is thereforetime to revisit what is known and what can be doneto improve the synergies between agriculture andnutrition. The potential contribution of agricultureneeds to be reexamined, especially in light of thechanges the sector has undergone, by reviewing

lessons from past experience and by analyzing cur-rent developments and what they mean for futurechange. This is the purpose of this report.

More specifically, the report seeks to analyzewhat has been learned about how agricultural inter-ventions influence nutrition outcomes in low- andmiddle-income countries, focusing on the targetpopulations of the Millennium DevelopmentGoals—people living on less than a dollar a day. Italso sets out to synthesize lessons from past institu-tional and organizational efforts to improve the syn-ergies between agriculture and nutrition outcomes.The report identifies a number of developments inagriculture and nutrition that have transformed thecontext in which nutrition is affected by agriculture.These developments have considerable practicalsignificance for nutrition-related agricultural pro-grams—including the design of those programs thataim to improve nutritional outcomes. Finally, the re-port sets out a number of practical conclusions thatshed light on how agricultural interventions and in-vestments may improve nutrition outcomes in low-and middle-income countries.

WORLD FOOD SECURITY ANDNUTRITION SITUATIONThe Food and Agricultural Organization (FAO) es-timates that in 2000–03, 854 million people world-wide were undernourished, as defined by foodintakes that are continuously inadequate to meetdietary energy requirements (FAO 2006). The num-ber included 820 million people in developingcountries, 25 million in transition countries, and 9million in industrialized countries. In developingcountries, this represents a decline of only 3 millionpeople since 1990–92. And although significantprogress has been achieved in Asia, the number ofundernourished people in Africa has been increas-ing, as shown in table 1.

Food security, a broader concept than under-nourishment, necessarily goes beyond the satisfac-tion of people’s energy requirements throughsufficient intakes to encompass access to “suffi-cient, safe and nutritious food to meet dietaryneeds and food preferences for an active andhealthy life” (FAO 1996). A summary of the nutri-tional situation in the world is presented here inthree categories: childhood undernutrition, mi-cronutrient deficiencies, and overweight and obe-

2 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

sity and related chronic diseases. More completeanalyses of these trends are available in the 2006World Bank report Repositioning Nutrition forDevelopment and in the fourth and fifth reports onthe world nutrition situation issued by the UnitedNations Standing Committee on Nutrition in 2000and 2004.

Child Undernutrition

It is well recognized that the most nutritionally vul-nerable population groups are pregnant and lac-tating women, whose bodies must cope with theadditional nutritional stresses and demands ofpregnancy and lactation, and infants and youngchildren up to age two. The present report ad-dresses these vulnerable groups, but with a greateremphasis on children’s nutrition because most ofthe work linking agriculture and nutrition to datehas focused on this age group. Childhood under-nutrition is typically reflected in anthropometricindicators such as stunting (low height-for-age),wasting (low weight-for-height), and underweight(low weight-for-age). Stunting reflects the cumula-tive effects of inadequate nutrition, whereas wast-ing reflects more recent or acute weight loss. Thesesymptoms are nonspecific and reflect a combina-tion of nutritional deficiencies including protein,energy, and/or micronutrients. They may be sea-sonal or chronic. Dietary shortages of vitamin A,iodine, iron, and zinc are the most widespread mi-

cronutrient deficiencies and disproportionately af-fect women and young children.

Childhood undernutrition dropped globally be-tween 1980 and 2005. Stunting now affects approx-imately one-third of all children in the developingworld, compared to one-half in 1980. The propor-tion of underweight children fell from 38 percent to25 percent during the same period. Yet there werean estimated 164.79 million stunted and 137.95 mil-lion underweight children in developing countriesin 2005. Figures 1 and 2 show that most of the re-ductions in undernutrition since the 1980s havebeen achieved in Asia and Latin America. In Africa,the number of stunted children decreased, whilethe proportion and number of those who are un-derweight increased slightly

Micronutrient Deficiencies

Vitamin A, iron, zinc, and iodine are the mostwidespread nutritional deficiencies globally, andthey affect women and young children dispropor-tionately. They may or may not overlap with pro-tein and energy deficits. Vitamin A deficiency iswidespread throughout the developing world, af-fecting between 78 and 254 million people, includ-ing an estimated 127 million children (UN SCN2004; West 2002). Shortage of the nutrient in thediet can limit growth, weaken immunity, cause xe-rophthalmia (an irreversible eye disorder leadingto blindness), and increase mortality. Seventy per-

Introduction 3

Table 1 Prevalence and Number of Undernourished People in Developing Countries 1990–2003

Prevalence of Undernourished Number of Undernourished (%)a (million)

FAO Region 1990–92 2001–03 1990–92 2001–03

Developing countries 20 17 823.1 820.2Sub-Saharan Africa 35 32 169.0 206.2Near East and North Africa 8 9 25.0 37.6Asia 20 6 569.7 524.0Latin America and Caribbean 13 10 59.6 52.4

Source: FAO 2006.a. Undernourishment is defined as food intake that is continuously inadequate to meet dietary energy requirements.

cent of preschool children in Benin and Kenya aresubclinically vitamin A deficient, compared to just5 percent in Venezuela, revealing the wide vari-ability in the condition’s prevalence among devel-oping countries (Sommer and West 1996).

Iron deficiency is estimated to be the mostprevalent nutritional deficiency, affecting 4 billionto 5 billion people. The estimated prevalence ofiron deficiency among children under five years ofage in 80 developing countries in 2004 was 54 per-cent, as compared to an estimated 34 percent whoare vitamin A deficient. Again, the range in preva-lence between countries is wide. An estimated 20percent to 35 percent of children under five years ofage are iron deficiency anemic in Latin Americaand Southeast Asia, compared to an estimated 75percent to 85 percent in many African countries(Adamson 2004). In young children, iron deficiencymay impair growth, cognitive development, and

immune function. In school-age children, it can af-fect school performance, and in adults it may lowerwork capacity. Iron deficiency anemia is responsi-ble for tens of thousands of maternal deaths eachyear (UN SCN 2004).

Iodine and zinc deficiency are also widespreadand account for a large share of the poor develop-ment, health, and survival outcomes of children indeveloping countries (UN SCN 2004). Deficienciesof key vitamins and minerals continue to be perva-sive, and they overlap considerably with problemsof general undernutrition (underweight, wasting,and stunting).

Overweight, Obesity, and Diet-RelatedChronic Diseases

A set of very different nutrition-related outcomesaffect people whose nutrient intakes exceed their

4 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Figure 1 Estimated Prevalence of Stunted Preschool Children 1980–2005

Source: UN SCN 2004.

Note: Preschool children defined as children less than five years of age.

0

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energy expenditures, resulting in obesity and a va-riety of chronic diseases associated with excessweight, including heart disease and diabetes.Among poorer populations in particular, energy-dense, low-quality diets are likely to remain defi-cient in essential micronutrients. Overweight andobesity are now highly prevalent in every region ofthe world.1 The prevalence of overweight childrenunder five is also increasing throughout the devel-oping world. The prevalence of childhood obesityin the developing world increased by 17 percentbetween 1995 and 2005, whereas in Africa it in-creased by 58 percent. The reason that Africa is ex-periencing such an exaggerated trend is notentirely clear, owing to a lack of data, but the risein prevalence of overweight among mothers islikely to be part of the explanation (World Bank2006b). The prevalence of overweight is consider-ably higher in urban areas in the developing world,

but in Latin America, the Middle East, and SouthAfrica, overweight is also higher than underweightin rural areas (Mendez and Popkin 2004). Overall,the World Health Organization predicts that by2015, approximately 2.3 billion adults will be over-weight and more than 700 million will be obese(WHO 2006).

Overweight and obesity are strongly associatedwith the risk of several chronic diseases, includingdiabetes, cardiovascular diseases, and severaltypes of cancer. Figures 3 and 4 show trends inoverweight by region since the 1980s among adultwomen and among preschool children. Chronicdiseases are the largest cause of death in the world,

Introduction 5

Figure 2 Estimated Prevalence of Underweight Preschool Children 1980–2005

Source: UN SCN 2004.

Note: Preschool children defined as children less than five years of age.

AfricaAsiaLatin America and the CaribbeanAll Developing Countries

60

50

40

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01980 1985 1990 1995 2000 2005

%of

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1 Overweight is defined as a body mass index (BMI)(weight/height square) greater than 25; obesity is defined asBMI greater than 30.

led by cardiovascular disease (17 million deaths in2002, mainly from ischemic heart disease andstroke) followed by cancer (7 million deaths),chronic lung diseases (4 million), and diabetes mel-litus (almost 1 million) (Yach et al. 2004). Althoughchronic diseases have been the leading cause ofdeath in developed countries for decades, 80 per-cent of deaths from chronic diseases now occur indeveloping countries, in which cardiovascular dis-

ease is the leading cause of mortality (WHO 2005).The global prevalence of the leading chronic dis-eases is projected to increase substantially duringthe next two decades. The number of individualswith diabetes, for instance, is projected to rise from171 million or 2.8 percent of the global populationin 2000 to 366 million, or 6.5 percent in 2030—298million of whom will live in developing countries(Wild et al. 2004).

6 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Figure 3 Overweight and Obesity among Women 45–59 Years of Age, by WHO Region

Source: Source: James et al. 2004. Data collected between 1990 and 2000.

*Africa D comprises northern and western parts of Sub-Saharan Africa, e.g., Nigeria, Ghana.Africa E comprises central, eastern, and southern parts of Sub-Saharan Africa, e.g., Kenya, Mozambique.America A comprises North America and Cuba.America B comprises the Caribbean and some Latin American countries, e.g., Mexico, Venezuela.America D comprises some Latin American countries, e.g., Guatemala, Peru.Eastern Med B comprises much of the Middle East and some of North Africa, e.g., Tunisia, Saudi Arabia.Eastern Med D comprises countries in the Middle East, North Africa, and Asia, e.g., Egypt, Morocco.Europe A comprises most of Western Europe.Europe B comprises some of Eastern Europe and Central Asia.Europe B comprises the rest of Eastern Europe and Central Asia.Southeast Asia B comprises Indonesia, Sri Lanka, and Thailand.Southeast Asia D comprises most of South Asia, e.g., Bangladesh, India.Western Pacific A comprises Australia, New Zealand, Singapore, Japan, and Brunei.Western Pacific B comprises China and some countries of East Asia, e.g., Vietnam, and the Pacific Islands.

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STRUCTURE OF THE REPORTThe background and description of types of ad-verse nutrition outcomes given in this introductionare followed in chapter 2 by an analysis of the de-terminants of human nutrition, setting out a num-ber of pathways through which agriculture canpotentially affect nutrition. Chapter 3 presents a re-view of available evidence of how agricultural in-terventions influence nutrition outcomes. Chapter4 presents a series of four more detailed case stud-ies of agricultural interventions that had explicitnutrition-related objectives. Chapter 5 examinesthe changes in agriculture and nutrition that are af-fecting the operational contexts in which nutrition-focused agricultural interventions are carried out.Chapter 6 focuses on the institutional issues relatedto the operationalizing agricultural developmentstrategies that have nutritional objectives, primar-ily at the national level. It maps out the state-levelinstitutions involved with agriculture and nutri-tion and analyzes the barriers that have posedproblems for closer coordination in the past.Chapter 7 draws a set of conclusions as to how agri-cultural interventions and investments could ac-celerate improvements in nutrition in low- andmiddle-income countries.

Introduction 7

Figure 4 Estimated Prevalence of Overweight Preschool Children (%)

6

5

4

3

2

1

01995 2000 2005

Africa

Asia

Latin America and the Caribbean

All Developing Countries

Source: UN Standing Committee on Nutrition 2004.

Note: Preschool children defined as children under the age of 5.

9

International development agencies have been designing approachesand programs linking agriculture and nutrition to address the prob-lem of malnutrition since the 1960s. The conventional link has beenfrom agriculture to food security. The lack of an explicit indicator offood security led to the use of anthropometric indicators to measurenutritional status. Yet these indicators capture far more than food se-curity as illustrated in a conceptual framework of nutrition devel-oped by UNICEF (UNICEF 1990), (Figure 5).

Food security is just one underlying determinant of nutrition,along with the quality of maternal and child care, the adequacy anduse of preventive and curative health services, and whether individ-uals are living in a healthy environment. The more immediate deter-minants of nutritional status are dietary intake and health status. Thefocus of this report is on the connection between agricultural pro-duction and dietary intake via food security.

In the 1970s food price spikes prompted alarm and concerns aboutfood availability and brought the term “food security” into the de-velopment arena. Programs operated under an assumption that agri-culture’s primary role in this equation was to address protein-energydeficiencies by increasing food production and lowering food prices.During the Green Revolution the availability of staple cereals in-creased globally and prices fell proportionately, yet protein-energymalnutrition persisted. Publications on agriculture-nutrition linkagesbecame critical of what appeared to be an implicit assumption thatimproved nutrition would follow naturally from the gains achievedthrough production increases. Box 1 lists the key messages to emergefrom these publications during this period and afterward.

In 1981 the World Bank commissioned a report by Per Pinstrup-Andersen titled Nutritional Consequences of Agricultural Projects:Conceptual Relationships and Assessment Approaches, which argued thatif agricultural development was to better contribute to improving nu-trition, nutritional aims would have to be explicitly incorporated intoagricultural production decisions. Amartya Sen’s work on faminesand the concept of entitlements, together with the failure to achievereal improvements in nutritional outcomes, led food security practi-tioners to shift their attention to improving poor households’ incomeand their economic access to food.

Determinants of HumanNutrition and the

Pathways LinkingAgriculture and Nutrition

2

The change was reflected by the messagesemerging from publications produced in the early1990s (box 1). In particular, the nutritional implica-tions of agricultural commercialization (mainly theshift to cash cropping) were examined. Studiesfound that even when commercial agriculturalschemes increased income, they did not substan-tially improve child nutrition status, leading to theconclusion that income alone could not solve mal-nutrition. In the nutrition community, meanwhile,there was a distinct shift in the late 1990s awayfrom the concept of agriculture as an interventionto reduce energy deficiency and increase incomeand toward the importance of addressing mi-cronutrient deficiencies through agriculture. Aconference held in the Philippines in 1999,Improving Human Nutrition through Agriculture: TheRole of International Agricultural Research, broughttogether nutritionists and agricultural scientists toassess the role that agricultural research could play

in alleviating micronutrient malnutrition, includ-ing through emerging technologies such as biofor-tification (Bouis 2000). This reflected a shift inemphasis in nutrition programs in general. “Food-based” strategies were developed to promote mi-cronutrient intake, such as through homesteadgardening. At the same time the food security def-inition evolved from a focus on availability andeconomic access to include food utilization, en-compassing diet quality and care issues. This cul-minated in the 1996 World Food Summit definitionof food security:

Food security exists when all people, at alltimes, have physical and economic access tosufficient, safe and nutritious food to meettheir dietary needs and food preferences foran active and healthy life.

World Food Summit Plan of Action

10 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Figure 5 Conceptual Framework of the Determinants of Nutritional Status

Basicdeterminants

Nutritionalstatus

Healthyenviornment,

health services

Qualityof care

Householdfood security

Political & ideological framework

Economic structure

Institutions

Potential resourcesHuman, agro-ecological, technological

Dietaryintake

Healthstatus

Underlyingdeterminants

Immediatedeterminants

Outcome

Source: Adapted from UNICEF 1980.

Determinants of Human Nutrition and the Pathways Linking Agriculture and Nutrition 11

Box 1 Messages from Publications on Agriculture and Nutrition, 1970s–2000s

• Scrimshaw and Behar 1976—protein-energymalnutrition persists despite the major improve-ments in agricultural technology that have in-creased food production.

• Pinstrup-Andersen 1981—because malnutritionis caused by a variety of factors, simply expand-ing food production per se is insufficient to solveglobal nutritional problems. Increased food pro-duction and income are currently the explicitgoals of agricultural development projects; nutri-tion is only an implicit goal. If agricultural devel-opment plans and strategies are to contribute tosolving nutrition problems, they should includean explicit goal of reducing protein-energy mal-nutrition.

• FAO (Food and Agriculture Organization)1982—if development efforts are to reduce mal-nutrition effectively, nutritional considerationsmust be incorporated into projects of agriculturaland rural development.

• Pinstrup-Andersen et al. 1984—past agriculturalresearch has facilitated a rapid increase in foodproduction in developing countries, but that hasnot been sufficient to address nutrition needs byitself; nutrition should therefore be consideredexplicitly in decisions about the design of agri-cultural research in four key ways: focusing onspecific crops, considering the effects of the in-tervention on the overall diet; specifying the de-sired agricultural technology; and adaptingfarming systems to meet nutritional goals in low-income farm households

• Pacey and Payne 1985—the targeting of nutri-tionally vulnerable groups is needed to designagricultural interventions to support nutrition,such as through high-energy, low-cost foods anddrought- and pest-resistant crop varieties.

• Kennedy and Bouis 1993—agriculture affectsnutrition through three main pathways: income,sanitation and health environment, and time al-location.

• DeWalt 1993—impacts of agricultural commer-cialization on food consumption and child nutri-tion are mixed and highly determined by controlof production/income, allocation of household

labor, maintenance of subsistence production,land tenure, and pricing policies for food/non-food crops.

• von Braun and Kennedy 1994—negative effectsof agricultural commercialization on nutritionare not typical, but even when cash cropping in-creases income, it does not decrease child un-dernutrition; thus increased income cannot solvemalnutrition by itself.

• Bouis 2000—breeding nutritionally improvedcrops can play an important role in alleviatingmalnutrition.

• Ruel 2001—although evidence is still weak,some food-based agriculture strategies havebeen successful in reducing iron and vitamin Adeficiency, especially when they were combinedwith effective behavioral change and communi-cation interventions and had an explicit focus onwomen’s empowerment.

• Pretty and Hine 2001—the environmental andhealth problems associated with agriculture af-fect health and nutrition; sustainable agricultureprojects can have positive effects on health andnutrition such as through decreased pesticideuse and greater social capital among women.

• Allen 2003—increasing the production of animalsource foods is a potentially sustainable solutionto micronutrient malnutrition; the possible ad-verse effects of excessive increases in animalsource food consumption on fat and energy in-takes must also be addressed.

• Johnson-Welch 2002—taking a gender-sensitiveapproach to agricultural interventions canstrengthen the positive impact of agriculture onnutrition.

• Kataki and Babu 2002—nutrition should be con-sidered when agricultural technologies are de-veloped.

• Berti et al. 2004—investing in the target popula-tion broadly, rather than narrowly through agri-culture, improves the effectiveness ofagricultural interventions; investing broadly infive types of capital (natural, physical, social,human, and financial) increases prospects fornutrition improvement.

Source: Authors.

Yet even today the conception of “food security”employed by the agricultural community often ne-glects the nutritional aspects of this more completedefinition and in so doing misses important op-portunities to contribute to improved nutritionoutcomes. This persistent neglect was a driver inundertaking the work leading to this report. The1990s also marked a shift to greater focus onwomen, including intrahousehold resource alloca-tion issues in agriculture and income control andcaregiving. In the early 2000s efforts focused on therole of women and on the importance of combiningagriculture interventions with nutrition educationand behavior change to maximize their impact onnutrition (box 1). These complementary interven-tions and their focus on empowering women hadthe objective of not only increasing food availabil-ity and access, but also of ensuring appropriatechild-feeding, childcare, and health-seeking prac-tices to improve nutritional outcomes.

PATHWAYS LINKINGAGRICULTURE TO NUTRITIONThere are several pathways through which agri-culture can contribute to improved nutrition. Theagriculture-to-nutrition pathways can be charac-terized along a continuum between the most directand the least direct, the most direct being charac-teristic of subsistence production, the least directreflecting the macroeconomic effects of agriculturalgrowth on national—and indeed global—popula-tions. Particularly in the case of households thatproduce principally for their own consumption,food and nutrient consumption is directly affectedby the specific foods the households themselvesproduce. This relationship becomes more andmore complex as production becomes more marketoriented.

Agriculture can also affect nutrition through af-fecting health in general. Good nutrition is intu-itively a precondition for good health, but therelationship runs both ways. Good health is also aprecondition for good nutrition, enabling people tometabolize the nutrients they digest. Thus, if agri-cultural interventions support positive health out-comes—by providing conditions conducive to thereduction of infectious diseases, for instance—nu-trition outcomes can be improved. Agricultural in-terventions to improve food safety and reduce theincidence of food-borne diseases can, for example,

help improve nutrition by reducing diarrheal dis-eases. These broader links between agriculture andhealth are beyond the scope of this report but werediscussed in a recent study by the InternationalFood Policy Research Institute and a special jour-nal issue on agriculture and health linkages(Hawkes and Ruel 2006a; Hawkes et al. 2007).

• Five pathways linking agriculture with foodconsumption and human nutrition along thefood supply chain are described below:

• Increased consumption from increased foodproduction

• Increased income from the sale of agriculturalcommodities

• Increased empowerment of women as agentsinstrumental to improved household food se-curity and health and nutrition outcomes

• Reductions in real food prices associated withincreased food supply

• Agricultural growth, leading to increased na-tional income and macroeconomic growthand to poverty reduction and improved nu-trition outcomes

The pathways are archetypal, representingmodel forms that in reality are by no means self-contained or mutually exclusive. Subsistence pro-duction, for instance, generally takes placealongside production for sale because few house-holds are self-sufficient in food and because food isnot the only requirement that must be met. Incomeis therefore very important even among house-holds that produce principally for their own con-sumption. The income and price pathways arelikewise overlapping in that the price reductionsresulting from increased food supply are given inreal terms and as such serve to raise real income.

Pathway 1: Increased consumption from increasedfood production (production-for-own-consumption). Incases in which the degree of market orientation islow, food consumption is strongly influenced bythe level and pattern of agricultural production.The resource endowments of the households (suchas land and labor) along with the available tech-nology determine the level of production of differ-ent crops, which, in turn, affects the consumptionpatterns of the households. This agriculture-con-sumption linkage is particularly relevant in thecase of subsistence or semisubsistence households.

Increases in production can lead to greater foodavailability and consumption at the household

12 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

level. This, in turn, can increase the food intake ofyoung children, who are most at risk of malnutri-tion, assuming that intrahousehold allocation offood is equitable and takes into account their par-ticular needs. The type of food produced influenceswhether increases in production will affect mostlydiet quantity (energy intakes) or diet quality (mi-cronutrient intakes). Staple foods can contributesignificantly to alleviating energy (calorie) gaps,whereas fruits and vegetables, dairy, eggs, fish,and meat products can make key contributions toalleviating gaps in essential micronutrients such asiron, zinc, and vitamin A. Animal source foods andfruits and vegetables make staple foods morepalatable, thus leading to overall greater food in-take. Animal source foods themselves are also richsources of energy and protein. Some proportion ofthe food produced may very well be intended forsale in local markets. Some households may, for in-stance, meet their staples requirements themselveswhile depending on markets for other productssuch as fruits and vegetables. Others may relymainly on home gardens for fruits and vegetables.Whatever role production-for-income plays in thisscenario is secondary to the principal purpose ofproducing food for the household’s own food re-quirements.

Pathway 2: Increased income from the sale of agri-cultural commodities (production-for-income). As themarket orientation of agricultural households in-creases, the “production-for-own-consumption”pathway just described declines in significance.Rather, income from the sale of surplus productionnow assumes a primary role, while production forthe household’s own consumption becomes sup-plemental. And, rather than desirability for con-sumption, ability to sell becomes a principalcriterion influencing the foods produced. Increasesin income can in turn translate into improvementsin household food security and food consumptionas well as individual food intakes.

However, additional income often has little orno effect on energy intakes because householdstend to shift their consumption to purchase higher-quality, more expensive foods that do not neces-sarily provide more energy. Staple food producers,for instance, may use the income earned from thesale of their produce to buy fruits, vegetables, meat,and fish, and their households may consume theseas substitutes for some proportion of the staplesthey consume. This substitution may significantly

improve the micronutrient content of their diet,without necessarily increasing energy intakes. Ofcourse, the extent of the nutritional benefits relieson the nutrient content of the higher-value substi-tute food; but it also relies on how well the substi-tutes offset existing nutritional deficits within thehousehold. The distribution of different types offood among different individuals in the household,and among the more nutritionally vulnerable indi-viduals in particular, is also a vital determinant ofnutrition outcomes. The distribution of nutritionand other health-related benefits in the householdis a function of often complex decision-makingprocesses strongly determined by culture and tra-ditions. The people with the greatest influence overthese decisions tend to be those who control house-hold resources. In the production-for-own-con-sumption scenario, these resources center oncontrol over the household’s basic resource en-dowment of land, labor, and capital. In the pro-duction-for-income scenario, the most importantresource tends to be income, and the most impor-tant decision makers are those who control incomeflows. Thus who controls the income is critical—and in part explains why women are so vital in in-fluencing the pathway between agriculture andnutrition.

Pathway 3: Empowerment of women agriculturists.Studies from Africa, Asia, and Latin Americaclearly show that women’s income—and level ofcontrol over income—has a significantly greaterpositive effect on child nutrition and householdfood security than income controlled by men(Quisumbing et al. 1995; Katz 1994; Hoddinott andHaddad 1994). Women have consistently beenshown to be more likely than men to invest in theirchildren’s health, nutrition, and education. Thus,agricultural interventions that increase women’sincome and their control over resources can dra-matically increase the potential for positive childnutrition outcomes and health outcomes. The pos-itive effects of increases in women’s income onchildhood nutrition moreover appear most pro-nounced among the lowest income groups.

In their roles as agricultural producers and income earners, as well as in their roles as care-givers, women who are reached by communica-tion and education services that relay informationon health and nutrition issues appear to be partic-ularly effective agents in delivering improved nu-trition outcomes. These roles include child and

Determinants of Human Nutrition and the Pathways Linking Agriculture and Nutrition 13

elder care, food production, food preparation,water collection, and a variety of income-generat-ing activities, all of which have the potential tocontribute to improved nutrition. Thus, the incor-poration of a gender equity dimension in agricul-ture programs and the consideration of women’smultiple roles and constraints must be addressedfor agricultural programs to achieve positive nu-trition impacts.

Pathway 4: Lower real food prices resulting from in-creased food production. Increased food productioncan reduce food prices, thereby raising the real in-come of people who purchase this food in themarketplace. Food prices are also affected by na-tional food availability, which is a reflection of im-ports and exports as well as production. Lowerfood prices, in turn, can increase household foodsecurity and raise energy and micronutrient con-sumption.

Changes in food prices are largely driven bychanges in the technologies and marketing chan-nels employed by producers. Together, changes intechnologies and markets affect the cost of produc-tion and, often (but not always), consumer prices.Lower retail prices are likely to benefit consumersmore than the agricultural households selling thefood, but even so, the impact of lower prices on thenet incomes of the agricultural households will de-pend on new costs of production and the elasticityof demand. The most common example of this linkis the effect of Green Revolution technologies onthe price of grains.

Pathway 5: Macroeconomic growth arising fromagricultural growth. Agricultural growth can theo-retically lead to broad improvements in nutritionsimply by virtue of its contributions to macroeco-nomic growth and national income. Increases inagricultural productivity have been and remainimportant drivers of sustained economic growth,particularly among countries in relatively earlyphases of economic development. Some evidencesuggests that the growth in production results inlower food prices, higher real wages, and a relatedreduction in poverty rates. In theory, as outlined inthe food price pathway described above, reducedfood prices allow greater access to food, resultingin better nutrition for the general workforce whilealso freeing additional household resources fromfood and other expenditures, to savings and pro-ductive investments. Recent evidence confirmsthat growth in agricultural productivity is impor-tant for poverty reduction. A cross-country analy-sis published in 2002 found that a 1 percentincrease in agricultural yields effectively decreasesthe percentage of a country’s population living onless than a dollar a day by 0.64 percent to 0.91 per-cent, with a slightly higher reduction for Africancountries (Thirtle et al. 2002). Overall, however, theeconomic growth-to-malnutrition relationship ismodest. A doubling of gross national product(GNP) per capita in developing countries has beenassociated with a much more modest reduction inchildhood undernutrition—on the order of only 23to 32 percent (Haddad et al. 2003).

14 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

15

Outlined in the previous chapter are the potential pathways link-ing agriculture and nutrition. But what is the evidence documentingthe actual contribution that agriculture has made to nutrition out-comes via these pathways? This chapter reviews this evidence, fo-cusing on the first three pathways: increased consumption fromincreased food production, increased income from the sale of agri-cultural commodities, and empowerment of women agriculturists.Identifying evidence on the latter two pathways—the effect of lowerfood prices and agricultural growth—proved much more difficult,given that there is little documentation of the nutrition outcomes ofthese changes at the household or individual level.

The review is based on a systematic search of recently publishedliterature and a limited search of unpublished documents, as well aspersonal contacts with project officers and international agency staff.The search centered on studies of agriculture interventions that hadevaluated individual-level nutrition outcomes, such as child nutri-tional status, individual food or nutrient intakes, and diet quality.2 Itdrew on previous reviews (Peduzzi 1990; Soleri et al. 1991a, 1991b;Gillespie and Mason 1994; Ruel 2001; and Berti et al. 2004) with thepurpose of updating and expanding on them. Much of the analysisrelated to animal source foods was taken from Leroy and Frongillo(forthcoming). A description of search methods and results is pro-vided in the appendix.

“Interventions” are defined broadly to mean changes purposefullyintroduced into an existing agriculture system to promote new tech-nologies, management practices, production and marketing meth-ods, and other aims that may or may not include componentsdesigned to improve nutrition. Those that do entail explicit nutritionobjectives are emphasized in this report because these interventionsare more likely to document nutrition outcomes. The nutrition out-comes themselves are treated in terms of the following.

• Household-level food consumption, which includes household-level consumption of foods and food groups, or energy (calo-ries), and household expenditure on foods and food groups

The Impact of Agriculture Interventions

on Nutrition Outcomes

3

2 Other types of agricultural interventions, such as nonfood crops or oil seed crops ortechnology-based rather than crop-based interventions, were excluded from the re-view because they typically fail to examine nutrition impact.

• Individual food and nutrient intake, which in-cludes intakes of macro- and micronutrientsand of foods rich in specific micronutrientsthat are the focus of interventions such asthose addressing vitamin A and iron defi-ciencies

• Nutrition status, which includes anthropomet-ric indicators, such as height, weight, andbody mass index, and micronutrient-specificindicators, such as serum retinol (indicator ofvitamin A status) and hemoglobin (indicatorof iron status)

THE NUTRITIONAL IMPACTS OFAGRICULTURAL INTERVENTIONSInterventions involving staple foods. The only agricul-tural interventions involving staple foods that havebeen evaluated from a nutritional perspective con-cern agricultural commercialization—the conver-sion from staple subsistence food production tocommercial food production. Although the evalua-tions had assessment of impacts on nutrition out-comes as an objective, the interventions themselveswere not designed to affect child nutritional statusper se; objectives were more general and aimed atincreasing food production incomes for farmhouseholds, or both. The evaluations thus mea-sured the interventions’ impact on nutrition out-comes through the production-for-income pathway(indirectly, agricultural commercialization mayalso have had indirect effects through the agricul-tural growth and price pathways).

Some early conceptual reviews of links betweenagricultural commercialization and nutrition hadsuggested the potential for negative impacts, al-though some of these examples related to conver-sion to nonfood crops (Fleuret and Fleuret 1980).One early review showed mixed effects on nutri-tion, some negative and some positive, but alsoidentified methodological issues that constrainedinterpretation and comparison (von Braun andKennedy 1986). Given these uncertainties, the au-thors designed and undertook a series of mi-crolevel case studies that included assessment ofnutrition outcomes as an explicit objective (vonBraun and Kennedy 1994). The study’s focus wason the impact of commercialization on energy in-takes rather than on diet quality or micronutrientintake and was therefore consistent with the then-

prevailing idea that energy intakes were the pri-mary constraint in the diets of the poor (McClaren1974; Waterlow and Payne 1975). Still, shifts to-ward more diversified diets were documented ininstances in which they occurred. These studiesalso reported results disaggregated by incomegroup and examined the role of control of incomeby women as opposed to men.

Results from these and closely related studieswere synthesized, yielding a series of conclusionsthat are summarized in table 2 (DeWalt 1993;Kennedy et al. 1992; von Braun and Kennedy 1994).The principal results did not differ substantially be-tween case studies of the commercialization of sta-ple food crops versus other cash crops. In sum, thecase studies documented fairly consistent positiveimpacts on focus crop production, household in-come, and food expenditures, but no substantialimpacts on young child nutritional status (the mainindicator assessed across studies). In one case inwhich subsistence food production was not main-tained, outcomes were worse. DeWalt (1993) con-cluded that a focus on commercialization per sewas misplaced and that impacts on food consump-tion and child nutrition were determined by con-trol of production and income, allocation ofhousehold labor, maintenance of subsistence pro-duction, land tenure, and pricing policies for bothfood and nonfood crops. Kennedy et al. (1992) alsoattributed the lack of impact on child nutritionalstatus to the generally high levels of morbidity ob-served in project areas.

• Overall, the authors made the following nu-trition-related conclusions:

• Generally, participation in cash-crop schemesresulted in increased household income.

• Increases in income were accompanied by increases in food expenditures, but impactson consumption were also dependent onchanges in relative prices.

• Dietary energy intakes increased in mostcases but decreased in some, as food expendi-tures shifted to more expensive items such asmeat and fruits; potential improvements indiet quality were suggested but not quantita-tively assessed.

• Increases in women’s income were docu-mented in some studies and were generallylinked to increases in household energy con-sumption; this effect was most pronouncedamong the lowest income groups.

16 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

The Impact of Agriculture Interventions on Nutrition Outcomes 17

Tabl

e2

Key

Res

ults

from

Sele

cted

Stud

ies

ofA

gric

ultu

ralC

omm

erci

aliz

atio

n

Diff

eren

ces

inD

iffer

ence

sin

indi

-C

ount

ryC

rop

Inte

rven

tion

orSt

udy

desi

gnD

iffer

ence

sho

useh

old

ener

gyvi

dual

ener

gyin

take

sO

ther

Ref

eren

ces

tech

nolo

gica

lcha

nge

Con

cern

wit

hm

etho

dsin

inco

mea

cons

umpt

iona

and

nutr

itio

nals

tatu

ske

yre

sult

s

Wes

tKen

yaIrr

igat

edric

e

Nie

mei

jera

ndH

oorw

eg19

94b

Nie

mei

jere

tal.

1988

d

Rw

anda

Pota

toes

Bla

nken

etal

.19

94b

(von

Bra

unet

al.

1991

)c

Zam

bia

Hyb

ridm

aize

Kum

aran

dSi

andw

azi1

994b

2ric

eirr

igat

ion

sche

mes

.Irr

igat

edla

ndw

asex

prop

riate

dan

dre

dist

ribut

edto

smal

lhol

ders

forr

ice

prod

uctio

non

ly.

Initi

ally

,all

tena

nts

lived

onsc

hem

ebu

tev

entu

ally

som

em

oved

offs

chem

e.N

oliv

esto

ckan

don

lysm

allr

ain-

fed

plot

son

sche

me.

Expa

nsio

nof

pota

topr

o-du

ctio

nin

form

erfo

rest

rese

rve,

allo

win

gac

cess

toad

ditio

nall

and

for

food

prod

uctio

n.D

urin

gre

fore

stat

ion,

toke

epw

eeds

dow

n,po

tato

prod

uctio

nw

asal

low

ed.

How

ever

,pot

ato

culti

va-

tion

expa

nded

rapi

dly

and

unco

ntro

llabl

y.

Intro

duct

ion

ofhy

brid

mai

ze.A

num

bero

fdif-

fere

ntva

rietie

sw

ere

in-

trodu

ced

over

ape

riod

ofye

ars.

Cro

ss-s

ectio

nals

ur-

vey

com

parin

g

Res

iden

tten

ants

Non

resi

dent

tena

nts

Indi

vidu

alric

egr

ower

sN

on-r

ice

grow

ers

No

rand

omiz

atio

nan

dno

cont

rolf

orse

lect

ion

bias

Cro

ssse

ctio

nals

urve

yco

mpa

ring

Farm

sw

ithan

dw

ithou

tacc

ess

to“e

xtra

”fo

rest

rese

rve

land

unde

rpot

ato

(mon

ocro

pped

)

No

rand

omiz

atio

nan

dno

cont

rolf

orse

lect

ion

bias

Rep

eate

dho

useh

old

surv

eys

com

parin

g

Hou

seho

lds

inhi

ghan

dlo

wad

optin

gar

eas,

asw

ella

san

dad

opte

rsan

dno

n-ad

opte

rs

Tota

linc

omes

wer

esi

mila

rac

ross

allf

our

grou

ps,b

utso

urce

sof

inco

me

wer

ele

astd

iver

sefo

rres

iden

tte

nant

san

dm

ostd

iver

sefo

rind

ivid

ual

rice

grow

ers.

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toes

grow

non

“ext

ra”

land

wer

eth

eon

lycr

opm

arke

ted

toa

sign

ifica

ntde

gree

,but

the

amou

ntso

ldva

ried

from

8%to

45%

base

don

wea

lthqu

artil

e;po

tato

prod

uc-

tion

expa

nded

rura

lwag

ela

bor

mar

ket.

Inco

mes

wer

e33

%–4

5%hi

gher

inhi

ghad

optio

nar

eas

whe

ther

hous

ehol

dad

opte

dor

not;

inco

mes

ofad

opte

rsw

ere

Hou

seho

lden

ergy

cons

umpt

ion

in-

crea

sed

with

in-

crea

sing

dive

rsity

ofin

com

eso

urce

s.

A10

%in

crea

sein

inco

me

was

asso

ci-

ated

with

a5%

in-

crea

sein

ener

gyco

nsum

ptio

n.

Alo

wer

degr

eeof

com

mer

cial

izat

ion

rais

eden

ergy

in-

take

sov

eran

dab

ove

pric

ean

din

-co

me

effe

cts.

Perc

apita

cons

ump-

tion

ofen

ergy

and

othe

rnut

rient

sfo

l-lo

wed

sam

epa

ttern

asin

com

e(h

ighe

rin

take

sam

ong

adop

ters

and

inhi

ghad

optio

nar

eas)

Chi

lden

ergy

inta

kes

wer

elo

wes

tand

nu-

tritio

nals

tatu

sw

assu

bsta

ntia

llyw

orse

amon

gre

side

ntte

n-an

ts.O

ther

grou

psfa

red

bette

rand

wer

esi

mila

r.

Incr

ease

sin

hous

e-ho

lden

ergy

con-

sum

ptio

nw

ere

asso

ciat

edw

ithbe

tterc

hild

nutri

-tio

nals

tatu

s,bu

tth

atef

fect

was

very

smal

l.

Chi

ldnu

tritio

nal

stat

usw

asm

ore

stro

ngly

rela

ted

tohe

alth

and

sani

tatio

n.

Res

ults

forc

hild

nutri

tiona

lsta

tus

wer

em

ixed

:H

ighe

rwei

ghtb

utlo

wer

heig

htin

high

adop

tion

area

s(y

oung

child

ren)

and

low

erw

eigh

tam

ong

In-d

epth

follo

w-u

pst

udy

amon

gre

side

ntte

nant

hous

ehol

dsre

-ve

aled

high

erpe

rca

pita

food

expe

ndi-

ture

sfro

min

com

eco

ntro

lled

byw

omen

.

Fem

ale-

head

edho

useh

olds

cons

umed

mor

een

ergy

(per

unit)

;thi

sef

fect

was

stro

nges

tin

poor

est

hous

ehol

dsan

ddi

dno

thol

din

wea

lthie

st.

(con

tinue

d)

18 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes Ta

ble

2K

eyR

esul

tsfr

omSe

lect

edSt

udie

sof

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icul

tura

lCom

mer

cial

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ion,

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t.

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eren

ces

inD

iffer

ence

sin

indi

-C

ount

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rop

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rven

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udy

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gnD

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ence

sho

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old

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ener

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take

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ther

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eren

ces

tech

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gica

lcha

nge

Con

cern

wit

hm

etho

dsin

inco

mea

cons

umpt

iona

and

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itio

nals

tatu

ske

yre

sult

s

The

Gam

bia

Irrig

ated

rice

von

Bra

unet

al.

1994

b

von

Bra

un19

88d

Mex

ico

Sorg

hum

DeW

alte

tal.

1990

d

Larg

e-sc

ale

rice

irrig

atio

nsc

hem

e.Ex

plic

itat

tem

ptto

mai

ntai

ntra

ditio

nal

use

right

sof

wom

enfa

rmer

sth

roug

hgi

ving

wom

enpr

iorit

ydu

ring

regi

stra

tion

ofpl

ots.

Prod

uctio

nte

chno

logy

inth

esc

hem

eis

hete

ro-

gene

ous

with

vary

ing

leve

lsof

wat

erco

ntro

l.

Ado

ptio

nof

sorg

hum

prod

uctio

nin

area

sfo

r-m

erly

dom

inat

edby

subs

iste

nce

agric

ultu

re(m

aize

and

bean

s);

sorg

hum

prod

uctio

n

No

rand

omiz

atio

n;au

thor

sad

dres

sed

sele

ctio

nbi

asby

com

-pa

ring

high

and

low

adop

tion

area

s,as

wel

las

adop

ters

/non

adop

ters

Rep

eate

dho

useh

old

surv

eys

inar

eaof

new

stat

e-ow

ned,

larg

e-sc

ale

rice

irrig

atio

nsc

hem

e,w

ith4

prod

uctio

nsy

stem

s:

Trad

ition

alsw

amp

rice

Smal

lpum

pirr

igat

ion

Parti

alw

ater

cont

rol

(rain

ortid

e)C

entra

lirr

igat

ion

drai

nage

No

rand

omiz

atio

n;au

thor

sex

plor

edde

term

inan

tsof

adop

tion.

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ogra

phic

met

hods

(par

ticip

anto

bser

vatio

nan

din

form

alin

terv

iew

s)fo

llow

edby

aho

useh

old

surv

eyin

four

com

mun

i-tie

sin

whi

chso

rghu

m

25%

high

erth

anno

nado

pter

s

New

tech

nolo

gyre

sulte

din

subs

tant

ially

incr

ease

dyi

elds

and

allo

wed

ase

cond

crop

,but

did

noth

ave

larg

eim

pact

onm

ar-

kete

dsu

rplu

s.

Subs

titut

ion

effe

cts

inla

bor

allo

catio

nm

eant

that

incr

ease

dric

epr

oduc

tion

was

acco

mpa

nied

byde

crea

ses

inot

herc

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lsan

dgr

ound

nuts

(–$0

.64

per$

1.00

rice)

.

Inco

mes

wer

ehi

ghly

dive

rsifi

ed.

Acc

ess

togo

odqu

ality

and

irrig

ated

land

Con

sum

ptio

n(e

n-er

gy)i

ncre

ased

with

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nditu

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ein

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(hun

gry)

and

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ons.

A10

%in

crea

sein

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pend

iture

was

asso

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ated

with

a5%

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ease

inen

ergy

(wet

seas

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sum

ptio

nw

asno

tcor

rela

ted

with

hous

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dce

real

prod

uctio

n,bu

twas

corr

elat

edw

ithw

omen

’ssh

are

ofce

real

prod

uctio

n

(Nei

ther

food

cons

umpt

ion

nor

diet

ary

inta

kew

ere

mea

sure

d.)

olde

rchi

ldre

n.In

adop

ting

hous

ehol

ds,

youn

gch

ildhe

ight

was

slig

htly

high

erbu

tw

eigh

tand

heig

htw

ere

low

eram

ong

olde

rchi

ldre

n

Wom

en’s

seas

onal

wei

ghtfl

uctu

atio

nsw

ere

buffe

red

inho

useh

olds

with

grea

tera

cces

sto

new

rice

land

.

Chi

ldhe

ight

was

low

-es

tin

the

low

este

x-pe

nditu

requ

artil

e(Q

)bu

tsim

ilara

cros

sQ

2_Q

4.

Chi

ldw

eigh

tin-

crea

sed

with

hous

e-ho

lden

ergy

inta

kes;

acce

ssto

new

rice

land

did

noth

ave

othe

rind

epen

dent

effe

cts,

posi

tive

orne

gativ

e.

Ther

ew

asno

rela

tion-

ship

betw

een

sorg

hum

prod

uctio

nan

dch

ildnu

tritio

nals

tatu

s.In

com

ew

asas

soci

-at

edw

ithch

ildnu

tri-

Trad

ition

alsw

amp

rice

was

a“w

omen

’scr

op”;

sche

me

soug

htto

ensu

rew

omen

?sac

cess

tone

wpr

ojec

tric

ela

nd;h

owev

er,

hold

ing

title

tola

nddi

dno

tens

ure

cont

rol

ofne

wre

sour

ces.

Wom

en’s

cont

rolo

fpr

oduc

tion

and

in-

com

ew

asde

crea

sed

forn

ewhi

gher

inpu

tan

dhi

gher

-yie

ldin

gric

e,re

sulti

ngin

ade

fact

osh

iftof

reso

urce

san

dco

ntro

l. (con

tinue

d)

The Impact of Agriculture Interventions on Nutrition Outcomes 19

Tabl

e2

Key

Res

ults

from

Sele

cted

Stud

ies

ofA

gric

ultu

ralC

omm

erci

aliz

atio

n,C

ont.

Diff

eren

ces

inD

iffer

ence

sin

indi

-C

ount

ryC

rop

Inte

rven

tion

orSt

udy

desi

gnD

iffer

ence

sho

useh

old

ener

gyvi

dual

ener

gyin

take

sO

ther

Ref

eren

ces

tech

nolo

gica

lcha

nge

Con

cern

wit

hm

etho

dsin

inco

mea

cons

umpt

iona

and

nutr

itio

nals

tatu

ske

yre

sult

s

incr

ease

dto

mee

tin-

crea

sing

dem

and

for

lives

tock

feed

.

was

prod

uced

asa

cash

crop

.

Com

mun

ities

repr

e-se

nted

rang

eof

ecol

ogi-

calc

ondi

tions

,la

ndho

ldin

gsi

ze,i

rrig

a-tio

nas

wel

las

acce

ssto

cred

it,te

chni

cala

ssis

-ta

nce,

and

mar

kets

.

No

rand

omiz

atio

n.

dete

rmin

edin

-co

me,

rath

erth

anpa

rtici

pa-

tion

inca

shcr

oppi

ng.

tiona

lsta

tus,

buto

nly

wea

kly.

Sour

ce:

Aut

hors

.a In

com

ean

dho

useh

old

cons

umpt

ion

expr

esse

dpe

rad

ulte

quiv

alen

tuni

t.b I

nclu

ded

invo

nB

raun

and

Ken

nedy

1994

.c In

Ken

nedy

etal

.199

2.d I

nD

eWal

t199

3.

• Overall, participation in cash-croppingschemes did not have a significant impact—negative or positive—on young child nutri-tional status.

• Children’s morbidity levels were generallyhigh and not affected by the schemes andwere interpreted to be a major constraint toimproving child nutritional status.

Evidence from this set of studies suggests thatcash cropping was often associated with greaterhousehold income, including, in some cases,greater income controlled by women, as well asgreater food expenditures. This usually translatedinto greater household-level energy intake, butsometimes households shifted to more expensivesources of energy. When this shift occurred, it mayhave resulted in greater dietary diversity, which isgenerally a sign of improved overall diet quality,but the studies did not specifically assess this as-pect. Impacts on child nutritional status were lim-ited and mixed. The studies therefore suggest thatalthough agricultural interventions that promotecommercialization may effectively increase incomeand food expenditures, they are not sufficient toimprove childhood nutrition if they are not com-plemented by interventions that specifically ad-dress other determinants of child nutrition such asimproved health, diet quality, child feeding, andother caregiving practices.

Interventions involving fruits and vegetables.Despite the existence of a wide variety of fruit andvegetable production systems, only homesteadgarden production systems have been imple-mented and evaluated with an explicit nutritionobjective. These primarily target the first pathway,increasing own production for consumption, witha secondary pathway of income increases fromsales of higher-value products.

Homestead gardens take a wide variety offorms, in backyards, farmyards, kitchens, contain-ers, small patches of available land, vacant lots, onrooftops and tabletops, and along roadsides andthe edges of fields. They are generally close to ahouse and source of water and are managed byfamily members using low-cost inputs. Their prod-ucts include fruits, vegetables, herbs, condiments,and sometimes secondary staples like legumes andsweet potatoes, most of which are grown forhousehold consumption. The nutrition impacts ofhomestead gardens have been relatively well doc-umented. This section draws on previous reviews,

starting with the VITAL reviews and then reviewsby Gillespie and Mason (1994), Ruel (2001), andBerti et al. (2004).

In 1990 and 1991 the USAID-funded Vitamin AField Support Project (VITAL) carried out an as-sessment of past and then-current household gar-den interventions and their impacts on nutritionoutcomes. The aim was to inform the planning offuture research and initiatives. Focusing on the ef-fects of homestead gardens on the intake of vitaminA-rich foods and improving vitamin A status, thereview yielded a number of recommendations ondesign, targeting, and evaluation of homesteadgardens as a means of strengthening their nutri-tional impact. The main recommendation was thatinterventions should focus on women (through thefemale empowerment pathway) and provide nu-trition education services to promote appropriateprocessing, storage, and cooking techniques of vit-amin A-rich foods. They should also promote a di-verse variety of vitamin A-rich foods to meet bothsubsistence and marketing needs and take into ac-count cultural preferences when foods to be intro-duced are selected.

A review by Gillespie and Mason published in1994 considered 13 programs aimed at improvingdiet quality, seven of which included homesteadgardening. Four of these were combined with so-cial marketing activities, and all four exhibited anumber of indirect benefits such as increasingwomen’s income and social status. Yet only oneproject, carried out in Bangladesh, showed a posi-tive effect on vitamin A status in addition to in-creased energy intakes and improvements in theeconomic status of women. A summary of the eval-uation findings of horticultural and nutrition pro-jects is presented in table 3.

The results of more recent evaluations includedin the reviews by Ruel (2001) and Berti et al. (2004)are summarized in table 3. The Ruel review pub-lished in 2001 found that the interventions that didnot include a nutrition education component (gen-erally those conducted before the mid-1990s) failedto achieve significant impacts on nutritional out-comes. Subsequent interventions that incorporatededucation, social marketing, and mass media cam-paigns together with homestead garden initiativesdid demonstrate impacts. The main conclusion ofthe review was that homestead gardening com-bined with effective promotional and educationalinterventions have the potential to improve the nu-

20 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

The Impact of Agriculture Interventions on Nutrition Outcomes 21

Tabl

e3

Sum

mar

yof

the

Eval

uati

onFi

ndin

gsof

Hor

ticu

ltur

alan

dN

utri

tion

Proj

ects

Cou

ntry

and

Ref

eren

ces

Type

ofin

terv

enti

onD

esig

nN

utri

tion

impa

ctas

sess

edO

ther

impa

ctas

sess

ed

Ban

glad

eshR

,B

Gre

iner

and

Mitr

a19

95

*Ban

glad

eshR

,B

HK

I/AV

RD

C19

93

Ban

glad

eshR

IFPR

Ieta

l.19

98

Ethi

opia

R,B

Aya

lew

etal

.19

99a

Aya

lew

etal

.19

99b

Gua

tem

alaB

Phill

ips

etal

.199

6

Indi

aR

Cha

krav

arty

2000

Hom

este

adga

rden

ing

with

pro-

visi

onof

seed

s,fa

rmin

ged

uca-

tion,

and

nutri

tion

educ

atio

n

Hom

este

adga

rden

ing

with

veg-

etab

les,

train

ing

onag

ricul

ture

,pr

ovis

ion

ofse

eds,

nutri

tion

ed-

ucat

ion

Veg

etab

lepr

oduc

tion,

fish-

pond

s,an

dcr

edit

and

agric

ul-

tura

ltra

inin

g

Trai

ning

onag

ricul

ture

,foo

dpr

epar

atio

nse

ssio

ns,a

ndpr

ovi-

sion

ofse

eds,

heal

th,a

ndnu

tri-

tion

educ

atio

n

Prov

isio

nof

seed

s,ex

tens

ion

serv

ices

,and

nutri

tion

educ

a-tio

nfo

rthe

prom

otio

nof

vita

-m

inA

-ric

hfo

ods

Hom

este

adga

rden

ing

and

nutri

tion

and

heal

thed

ucat

ion

Pre-

post

,w

ithco

ntro

l

Pre-

post

,w

ithco

ntro

l

Pre-

post

,with

3gr

oups

:fish

-po

nds,

vege

ta-

bles

,con

trol

Pre-

post

,w

ithco

ntro

l

Pre-

post

,w

ithco

ntro

l

Pre-

post

Slig

htde

crea

sein

nigh

tblin

dnes

s,in

dica

ting

impr

oved

vita

min

Ast

atus

Impr

ovem

ents

inst

untin

gan

din

unde

rwei

ght

No

chan

gein

hem

oglo

bin

inan

ygr

oup,

impl

ying

noch

ange

iniro

nst

atus

Low

erpr

eval

ence

ofcl

inic

alsi

gns

ofvi

tam

inA

defic

ienc

yin

treat

-m

enta

rea

No

data

colle

cted

onnu

tritio

nin

-di

cato

rs(o

nly

diet

ary

indi

cato

rs)

Dec

reas

ein

ocul

arsi

gns/

sym

p-to

ms

ofvi

tam

inA

defic

ienc

y

Incr

ease

inpe

rcen

tage

ofho

useh

olds

grow

ing

veg-

etab

les

and

fruit

inbo

thtre

atm

enta

ndco

ntro

land

incr

ease

dkn

owle

dge

offu

nctio

nof

vita

min

A

Incr

ease

inve

geta

ble

prod

uctio

n,si

zeof

plot

culti

-va

ted,

year

-rou

ndav

aila

bilit

yof

vege

tabl

es,i

n-co

me,

wom

en’s

cont

rolo

veri

ncom

e,ve

geta

ble

cons

umpt

ion

perc

apita

,chi

ldre

n’s

vege

tabl

ein

-ta

ke.I

nter

vent

ion

child

ren

had

few

erre

spira

tory

infe

ctio

ns.

Incr

ease

dpr

oduc

tion

offis

han

dve

geta

bles

.No

incr

ease

inco

nsum

ptio

nof

fish

infis

hpon

dgr

oup.

Incr

ease

inve

geta

ble

inta

kein

vege

tabl

egr

oup.

Intre

atm

enta

rea

mor

ega

rden

san

dbe

tter

know

ledg

e,at

titud

es,a

ndpr

actic

es(K

AP)

abou

tvi

tam

inA

and

clin

ical

eye

sign

sof

defic

ienc

y.M

ore

dive

rsifi

eddi

et,h

ighe

rvita

min

Afo

odfre

quen

cysc

ores

.

Con

trolc

hild

ren,

who

are

with

outg

arde

nsw

ithvi

tam

inA

-ric

hve

geta

bles

,hav

em

ore

vita

min

Ade

ficie

ncy.

Incr

ease

inpe

rcen

tage

ofho

useh

olds

grow

ing

vege

tabl

es.4

0%of

hous

ehol

dsso

ld10

%–2

5%of

prod

uce.

Bet

terk

now

ledg

e,at

titud

es,a

ndpr

actic

eson

vita

min

A,a

ndw

eekl

yin

take

ofvi

tam

inA

-ric

hga

rden

prod

uce

mor

eth

ando

uble

d. (con

tinue

d)

22 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes Ta

ble

3Su

mm

ary

ofth

eEv

alua

tion

Find

ings

ofH

orti

cult

ural

and

Nut

riti

onPr

ojec

ts,C

ont.

Cou

ntry

and

Ref

eren

ces

Type

ofin

terv

enti

onD

esig

nN

utri

tion

impa

ctas

sess

edO

ther

impa

ctas

sess

ed

Indo

nesi

aR

dePe

eet

al.1

998

Ken

yaR,

B

Hag

enim

ana

etal

.19

99

Nep

alR,

B

CA

RE/

Nep

al19

95

Nig

erR

Parla

toan

dG

otte

rt19

96

Peru

R

Car

rasc

oSa

nez

etal

.199

8

Phili

ppin

esB

Bru

net

al.1

991

Solo

net

al.1

979

Popk

inet

al.1

980

Phili

ppin

esB

Solo

net

al.1

996

Soci

alm

arke

ting

with

mas

s-m

edia

and

1-on

-1co

mm

unic

a-tio

nto

incr

ease

inta

keof

targ

eted

vita

min

A-r

ich

food

s

Intro

duct

ion

ofa

new

varie

tyof

swee

tpot

atoe

san

dtra

inin

gin

food

-pro

cess

ing

tech

niqu

es;n

u-tri

tion

educ

atio

n

Hom

este

adga

rden

ing,

irrig

a-tio

n,ag

ricul

ture

exte

nsio

n,se

eds

Prom

otio

nof

hom

epr

oduc

tion,

mul

timed

iaed

ucat

ion

cam

-pa

ign

prom

otin

gco

nsum

ptio

nof

vita

min

A-r

ich

food

s

Nut

ritio

ned

ucat

ion

inco

mm

unity

kitc

hen

with

capa

city

build

ing

Prom

otio

nof

prod

uctio

nof

vita

min

A-r

ich

fruits

and

vege

tabl

es,w

ithpr

ovis

ion

ofse

eds

and

seed

lings

and

advi

ceon

agric

ultu

ralp

ract

ices

Prom

otio

nof

hom

este

adga

r-de

nsw

ithso

me

targ

etve

geta

-bl

es;p

rovi

sion

ofse

eds

and

cutti

ngs;

mas

sm

edia

cam

-pa

igns

,soc

ialm

arke

ting,

and

nutri

tion

educ

atio

n.

Pre-

post

Pre-

post

,w

ithco

ntro

l

Pre-

post

Pre-

post

Pre-

post

mem

bers

/no

n-m

embe

rs

Paire

dpr

e-po

st

Pre-

post

,with

cont

rol

Incr

ease

dse

rum

retin

olw

ithin

-cr

ease

deg

gco

nsum

ptio

n,do

se-

resp

onse

rela

tions

hip

indi

catin

gim

prov

edvi

tam

inA

stat

us

No

data

colle

cted

onnu

tritio

nin

dica

tors

(onl

ydi

etar

yin

dica

tors

)

Det

erio

ratio

nof

nutri

tiona

lst

atus

ofch

ildre

ndu

ring

stud

y(n

oco

ntro

l)

No

data

colle

cted

onnu

tritio

nin

-di

cato

rs(o

nly

diet

ary

indi

cato

rs)

Red

uctio

nin

prev

alen

ceof

anem

ia

Impr

oved

wei

ght-f

or-h

eigh

tand

decr

ease

inse

vere

was

ting.

No

chan

gein

seru

mre

tinol

orcl

inic

aley

esi

gns

ofse

vere

vita

min

Ade

ficie

ncy,

impl

ied

noch

ange

invi

tam

inA

stat

us

No

data

colle

cted

onnu

tritio

nin

-di

cato

rs(o

nly

diet

ary

indi

cato

rs)

Incr

ease

dpe

rcen

tage

ofch

ildre

nan

dm

othe

rsco

nsum

ing

atle

ast1

egg

inpr

evio

usw

eek;

incr

ease

inam

ount

ofve

geta

bles

prep

ared

/pe

rson

/day

and

invi

tam

inA

inta

kefro

meg

gsan

dpl

ants

Hig

herv

itam

inA

food

frequ

ency

scor

esfo

rch

ildre

nin

inte

rven

tion

vers

usco

ntro

lgro

up

Incr

ease

inpe

rcen

tage

ofho

useh

olds

prod

ucin

gve

geta

bles

.Ins

uffic

ient

Vita

min

Ain

take

for

mot

hers

and

child

ren

pre

and

post

.

Incr

ease

inw

omen

’skn

owle

dge

ofvi

tam

inA

,in

take

ofvi

tam

inA

-ric

hve

geta

bles

(chi

ldre

n),

and

purc

hase

and

cons

umpt

ion

ofliv

er,a

food

targ

eted

byth

ein

terv

entio

nto

incr

ease

vita

min

A(b

yw

omen

and

child

ren)

Incr

ease

dqu

ality

ofdi

etan

din

take

ofiro

n-ric

hfo

ods

asw

ella

svi

tam

inA

,hem

eiro

n,an

dpr

opor

tion

ofab

sorb

able

iron

Incr

ease

inch

ildre

n’s

vita

min

Ain

take

Incr

ease

dpr

oduc

tion

of5

type

sof

vege

tabl

esw

ithin

crea

sed

vege

tabl

eco

nsum

ptio

nan

dvi

tam

inA

inta

kein

inte

rven

tion

grou

p.D

ecre

ase

invi

tam

inA

inta

kein

cont

rolg

roup

by48

%.

(con

tinue

d)

The Impact of Agriculture Interventions on Nutrition Outcomes 23

Tabl

e3

Sum

mar

yof

the

Eval

uati

onFi

ndin

gsof

Hor

ticu

ltur

alan

dN

utri

tion

Proj

ects

,Con

t.

Cou

ntry

and

Ref

eren

ces

Type

ofin

terv

enti

onD

esig

nN

utri

tion

impa

ctas

sess

edO

ther

impa

ctas

sess

ed

Prom

otio

nof

hom

este

adga

r-de

nsan

dsa

leof

prod

uce;

nutri

-tio

ned

ucat

ion

and

agric

ultu

reed

ucat

ion

Prom

otio

nof

hom

epr

oduc

tion,

cons

umpt

ion

and

stor

age

ofvi

t-am

inA

-ric

hfo

ods;

heal

than

dnu

tritio

ned

ucat

ion

Prom

otio

nof

sola

rdrie

rs;n

utri-

tion

and

heal

thed

ucat

ion.

Seed

dist

ribut

ion;

train

ing

ofw

omen

farm

ers;

prom

otio

nof

gard

ens,

fishp

onds

,and

rais

ing

chic

kens

;nut

ritio

ned

ucat

ion

and

soci

alm

arke

ting

Hom

este

adga

rden

s,fis

hpon

ds,

anim

alhu

sban

dry,

nutri

tion

educ

atio

n

Prom

otio

nof

hom

este

adga

r-de

nsw

itha

focu

son

vita

min

A-

rich

crop

s,nu

tritio

ned

ucat

ion

form

othe

rs

Surv

eyof

thos

ew

ith&

with

out

hom

este

adga

rden

s(b

asel

ine;

10–1

2ye

ars

late

r)

Trea

tmen

t/co

ntro

l

Post

Pre-

post

,with

cont

rol

Pre-

post

,w

ithco

ntro

l

Trea

tmen

t/co

ntro

l

Post

Pre-

post

No

data

colle

cted

onnu

tritio

nin

-di

cato

rs(o

nly

diet

ary

indi

cato

rs)

Low

erse

rum

vita

min

Aan

dhi

gher

helm

inth

sin

treat

men

tar

ea.(

Ove

rall,

high

erin

take

ofvi

-ta

min

A-r

ich

food

sas

soci

ated

with

high

erse

rum

vita

min

A.)

No

data

colle

cted

onnu

tritio

nin

dica

tors

(onl

ydi

etar

yin

dica

tors

)

Incr

ease

dse

rum

retin

ol,d

e-cr

ease

dvi

tam

inA

defic

ienc

y(in

scho

olgi

rls).

Incr

ease

dm

ean

he-

mog

lobi

n,de

crea

sed

anem

ia,a

ndlo

wse

rum

ferr

itin

(not

sign

ifica

nt)

impl

ies

impr

oved

iron

stat

us.

Dat

aco

llect

edon

lyon

diet

ary

indi

cato

rs

Clin

ical

eye

sign

sof

seve

revi

ta-

min

Ade

ficie

ncy

decr

ease

dto

al-

mos

tzer

o,im

plyi

ngim

prov

edvi

tam

inA

stat

us.

Con

sum

ptio

nin

crea

sed

fors

ome

nutri

ents

,de

crea

sed

foro

ther

s.

Hig

herp

erce

ntag

eof

hous

ehol

dsw

ithho

mes

tead

gard

ens

and

prod

ucin

gvi

tam

inA

-ric

hve

geta

bles

intre

atm

enta

rea.

Bet

terk

now

ledg

e,at

titud

es,

prac

tices

abou

tvita

min

A,h

ighe

r%us

ing

sola

rdr

iers

forv

itam

inA

food

s,hi

gher

7-da

yfre

quen

cyof

inta

keof

vita

min

Afo

ods.

8%of

wom

enad

opte

dso

lard

riers

inin

terv

entio

nar

ea.N

osi

gnifi

cant

incr

ease

in%

selli

ngor

inin

com

efro

mse

lling

drie

dve

geta

bles

.Vita

min

Afo

odfre

quen

cysc

ore

high

erin

treat

men

tgro

upan

dam

ong

adop

ters

with

incr

ease

din

take

ofan

imal

prod

ucts

.

Incr

ease

dkn

owle

dge,

attit

udes

,and

prac

tices

onvi

tam

inA

and

iron;

incr

ease

dvi

tam

inA

inta

ke;

noch

ange

infa

tint

ake;

incr

ease

iniro

nin

take

inso

me

targ

eted

grou

ps;i

ncre

ase

invi

tam

inC

inta

kein

lact

atin

gw

omen

.No

chan

gein

cont

rols

.

Trea

tmen

tgro

up:l

ower

seve

rity

and

inci

denc

eof

resp

irato

ryin

fect

ions

;bet

terg

row

th;g

reat

erfru

itan

dve

geta

ble

inta

ke;g

reat

eren

ergy

,pro

tein

,and

vita

min

Aan

dC

inta

kein

child

ren.

Bet

terk

now

l-ed

ge,a

ttitu

des,

and

prac

tices

inm

othe

rs.

Perc

apita

vege

tabl

epr

oduc

tion

incr

ease

dfiv

efol

dan

din

crea

sein

inta

keof

ener

gy,p

rote

in,a

ndfa

t.

Sene

galB

Bru

net

al.1

989

*Tan

zani

aR,B

Kid

ala

etal

.200

0

Tanz

ania

R

Mul

okoz

ieta

l.20

00

Thai

land

R,B

Smita

siri

and

Dha

nam

itta

1999

Smita

siri

etal

.199

9A

ttig

etal

.199

3

*Vie

tnam

R

Engl

ish

etal

.199

7En

glis

han

dB

adco

ck19

98

Vie

tnam

B

Ngu

etal

.199

5

Sour

ce:

Aut

hors

.N

ote:

Rev

iew

edby

Rue

l200

1an

dB

erti

etal

.200

4.*

=ca

sest

udy

inte

rven

tion;

R=

Rue

lrev

iew

;B=

Ber

tire

view

;abb

revi

atio

ns:N

A=

nota

vaila

ble;

HH

=ho

useh

old.

tritional status of populations—but that homesteadgardening alone is much less likely to improve nu-trition. The review also emphasizes that using agender-sensitive approach to agricultural interven-tions could strengthen their impact on nutrition.

The review published by Berti and colleagues in2004 used a sustainable livelihoods framework toassess whether different agricultural interventionsinvest in different types of capital: human, physical,social, environmental, and financial. Interventionsthat invest more broadly in various types of capital,as is usually the case with homestead gardeningprograms, tended to have a greater impact on nu-trition than those that focus more narrowly on agri-culture. The authors concluded that the agriculturalinterventions most likely to be successful invest innatural, physical, social (including gender consid-erations), human (especially nutrition education),and financial capital.

The 2001 and 2004 reviews led to a common con-clusion that homestead gardening projects after themid-1990s were successful if they incorporatedhuman capital–related components, notably com-munication and nutrition education activities tar-geting behavior change among their audiences,and the incorporation of gender considerations inproject design. The power of nutrition educationhas been identified in other studies. Block (2003),for example, demonstrated that nutrition knowl-edge is a key determinant in how household foodbudgets are allocated. Households with nutritionknowledge allocate substantially larger shares oftheir household food budgets to foods rich in mi-cronutrients and are unwilling to reduce con-sumption when staple food prices increase. Thisimpact is not due to maternal schooling per se,which has been independently demonstrated toimprove child nutrition outcomes.

Interventions involving animal source foods. Leroyand Frongillo (forthcoming) reviewed 15 interven-tion studies on animal source foods, including 4 onaquaculture, 5 on dairy production, 3 on poultry,and 3 in which livestock production was one com-ponent of larger integrated projects. The findingsconcerning the impacts of these studies on produc-tion, income and expenditure, women’s status, anddietary intake and nutritional status are summa-rized in table 4, together with additional studies re-viewed for this report. The studies cover several ofthe pathways outlined in chapter 2, including in-creased production of own consumption and in-

creased income, including increased incomeamong women agriculturists. Most of the studiesshowed a positive impact on production of animalsource foods, despite the large variability of pro-motional interventions. Similarly, most interven-tions that measured income or expenditures alsoreported increases in these indicators.

However, impacts on dietary intake and nutri-tional status showed mixed results. For aquacul-ture interventions, one intervention may haveactually decreased dietary quality because it led toa switch from consumption of small fish (which areconsumed whole and contain high levels of cal-cium and vitamin A) to greater consumption oflarger fish with poorer micronutrient density (Rooset al. 2003; Bouis et al. 1998). In another, there wereno differences in total fish consumption betweenthe fish-producing and non-fish-producing house-holds (Roos et al. 2003). In a third study, interven-tion households appeared to have consumed morefish, but the analyses were not subject to statisticaltesting (Thompson et al. 2000).

Similarly mixed results were found for dairy in-terventions. In one intervention in India, house-holds in villages with milk cooperatives actuallyconsumed less milk than households in villageswithout cooperatives. The overall nutrient con-sumption of households with cows in interventionvillages did, however, rise, whereas nutrient con-sumption among nonproducing households fell(Alderman 1987). In another intervention in India,children in households that produced more than 5liters of milk per day had adequate dietary proteinintake, although none of the groups met their en-ergy requirements (Begum 1994). A third interven-tion in East Africa found that households withcrossbred cows consumed more energy, fat, pro-tein, retinol, and iron than nonadopters, and inKenya, women participating in the intervention re-ported increased milk consumption (Ahmed et al.2000; Mullins et al. 1996).

Poultry interventions in Bangladesh and Egyptsaw higher intakes of a range of nutrients amongparticipating households than among nonpartici-pating households (Galal et al. 1987; Nielsen 1996).Another poultry intervention in Bangladesh didnot lead to increased egg or chicken consumption,but participating households did eat more fish,suggesting that the intervention led to increasedincome and subsequent dietary change (Nielsen etal. 2003).

24 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

The Impact of Agriculture Interventions on Nutrition Outcomes 25

Tabl

e4

Sum

mar

yof

Inte

rven

tion

Stud

ies

onIm

pact

sof

Ani

mal

Sour

ceFo

odIn

terv

enti

ons

onN

utri

tion

-Rel

ated

Out

com

es

Cou

ntry

and

Des

ign

Die

tary

inta

kean

dIn

com

ean

dR

efer

ence

sIn

terv

enti

onC

once

rnw

ith

Met

hods

Prod

ucti

onnu

trit

iona

lsta

tus

expe

ndit

ure

Wom

en’s

stat

us

Ban

glad

esh

Bou

iset

al.1

998

Ban

glad

esh

Roo

set

al.2

003

Ban

glad

esh

Thom

pson

etal

.20

00

Poly

cultu

refis

hpr

oduc

tion

inho

useh

old-

owne

dor

grou

p-m

anag

edpo

nds

(or

vege

tabl

epr

oduc

tion)

toim

prov

ein

com

e;so

me

nu-

tritio

ned

ucat

ion

was

pro-

vide

d,bu

tprim

ary

obje

ctiv

ew

asno

tbet

ter

nutri

tion

Poor

farm

ers

train

edin

carp

cultu

re.H

ouse

hold

pond

sw

ere

stoc

ked

with

carp

and

eith

erm

ola

(spe

cies

very

rich

invi

ta-

min

A)o

roth

ersm

alli

n-di

geno

usfis

hsp

ecie

s(S

IS)

Aqu

acul

ture

exte

nsio

n(p

ond

aqua

cultu

re)

Hou

seho

lds

wer

eex

pect

edto

adap

tmon

ocul

ture

oftil

apia

orsi

lver

barb

orpo

lycu

lture

ofna

tive

and

exot

icca

rpsp

ecie

sus

ing

farm

reso

urce

s.

Thre

egr

oups

:a.

Ado

pter

sb.

Pote

ntia

lado

pter

s(in

noni

nter

vent

ion

villa

ges)

c.R

ando

mse

lect

ion

hous

ehol

dsno

tin

a.or

b.

Non

rand

omas

sign

-m

ento

fhou

seho

lds

togr

oups

Trea

tmen

t/con

trol—

post

Unc

lear

sele

ctio

nof

hous

ehol

ds

No

rand

omiz

atio

n

Trea

tmen

t/con

trol

2co

ntro

lgro

ups:

neig

hbor

ing

hous

e-ho

lds

insa

me

villa

gean

dot

hers

from

othe

rar

ea.

No

rand

omiz

atio

n,no

stat

istic

alte

sts

n.a.

No

diffe

renc

ein

prod

uctio

nbe

twee

nm

ola

and

SIS

pond

s

Bot

hex

tens

ion

reci

pien

tsan

dne

ighb

ors

have

high

eryi

elds

than

cont

rol

farm

ers.

No

effe

cton

fish

con-

sum

ptio

n;sh

iftto

larg

erfis

h,i.e

.,ef

fect

onnu

tritio

nals

tatu

sm

aybe

nega

tive

Mod

este

ffect

thro

ugh

incr

ease

inin

com

e

Pres

choo

lers

are

favo

red,

parti

cula

rlybo

ys

Prog

ram

effe

cton

nutri

-tio

nals

tatu

sno

test

imat

ed

No

diffe

renc

ein

fish

inta

kebe

twee

npr

oduc

ing

and

nonp

rodu

cing

HH

s

47%

ofth

em

ola

was

cons

umed

inth

eho

use-

hold

,cov

erin

g21

%of

the

reco

mm

ende

dvi

ta-

min

Ain

take

Inte

rven

tion

and

neig

hbor

ing

hous

ehol

dsse

emed

toco

nsum

em

ore

fish.

Posi

tive

butv

ery

mod

esti

ncre

ase

inin

com

e

n.a.

Ret

urn

onin

vest

-m

ents

high

erin

ex-

tens

ion

hous

ehol

ds

Dem

ands

ontim

ere

lativ

ely

smal

l

n.a.

n.a.

(con

tinue

d)

AQ

UA

CU

LTU

RE

26 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes Ta

ble

4Su

mm

ary

ofIn

terv

enti

onSt

udie

son

Impa

cts

ofA

nim

alSo

urce

Food

Inte

rven

tion

son

Nut

riti

on-R

elat

edO

utco

mes

,Con

t.

Cou

ntry

and

Des

ign

Die

tary

inta

kean

dIn

com

ean

dR

efer

ence

sIn

terv

enti

onC

once

rnw

ith

Met

hods

Prod

ucti

onnu

trit

iona

lsta

tus

expe

ndit

ure

Wom

en’s

stat

us

Indi

a

Ald

erm

an19

87

Indi

a

Beg

um19

94

Ethi

opia

Ahm

edet

al.2

000)

Tang

kaet

al.1

999)

Inte

grat

ing

rura

lhou

seho

lds

into

am

arke

teco

nom

yby

incr

easi

ngth

eus

eof

purc

hase

din

puts

and

incr

easi

ngth

em

arke

ted

surp

lus

Dai

ryco

oper

ativ

esw

ere

setu

pin

the

villa

ges.

Dai

ryD

evel

opm

ent

Proj

ecto

fthe

Indi

ango

vern

men

t;fo

rmat

ion

ofda

iryco

oper

ativ

es

Mar

ket-o

rient

edda

iryin

gfo

rsm

allh

olde

rmix

ed-c

rop

and

lives

tock

farm

ers;

use

ofcr

ossb

red

dairy

cow

sfo

rm

ilkpr

oduc

tion

and

trac-

tion;

farm

ers

with

cros

sbre

dco

ws

enco

urag

edto

grow

fodd

eran

dre

ceiv

edtra

inin

gon

impr

oved

hygi

ene

and

re-

stric

ted

graz

ing;

also

vete

ri-na

ryan

dbr

eedi

ngse

rvic

es.

Trea

tmen

t/con

trol;

pre/

post

com

paris

ons

ofho

useh

olds

invi

l-la

ges

with

and

with

out

dairy

coop

erat

ives

No

rand

omiz

atio

n

Trea

tmen

t/con

trol—

post

3gr

oups

intre

atm

ent:

larg

e(L

P)(>

5l/d

ay),

med

ium

(MP)

(2.5

–5l/d

ay),

and

smal

lpro

duce

rs(S

P)(<

2.5

l/day

))

No

rand

omiz

atio

n,no

stat

istic

alte

stin

g,no

cont

rolf

orco

n-fo

unde

rs,n

ode

tails

onin

terv

entio

n

Trea

tmen

t/con

trol—

post

Poor

desi

gn,n

oba

se-

line,

noco

ntro

lfor

self-

sele

ctio

nbi

as,n

ora

ndom

izat

ion,

met

hodo

logy

poor

lyde

scrib

ed,n

oco

ntro

lfo

rcon

foun

ders

Vill

ages

with

coop

erat

ives

prod

uced

twic

eth

eam

ount

ofm

ilkas

cont

rol

grou

p(re

sult

of>

no.o

fcro

ss-

bred

cow

s).

n.a.

n.a.

Hou

seho

lds

invi

llage

sw

ithco

oper

ativ

esco

nsum

edle

ssm

ilk.

The

nutri

entc

onsu

mpt

ion

ofm

ilk-p

rodu

cing

hous

ehol

dsin

inte

rven

tion

villa

ges

rose

,an

dth

atof

nonp

rodu

cing

hous

ehol

dsfe

ll.

Onl

ych

ildre

nin

the

LPm

eet

prot

ein

RD

A.

LPch

ildre

nha

veth

ehi

ghes

ten

ergy

inta

keal

so(d

ono

tm

eetR

DA

).

Ove

rall,

prot

ein

and

ener

gyre

quire

men

tsbe

stm

etin

LPan

dw

orst

inM

P.

Ener

gyin

take

19%

high

erin

parti

cipa

ting

hous

ehol

ds

Inta

keof

fat,

prot

ein,

retin

ol,

and

iron

also

high

er

(Ahm

ed,J

abba

r,an

dEh

ui20

00)

Inco

me

and

expe

n-di

ture

incr

ease

d.

n.a.

Inco

me

oftre

atm

ent

hous

ehol

ds72

%hi

gher

Hig

heri

ncom

eas

so-

ciat

edw

ithhi

gher

food

and

nonf

ood

expe

nditu

re(A

hmed

,Jab

bar,

and

Ehui

,200

0)

n.a.

n.a.

No

appa

rent

in-

crea

sein

wom

en’s

labo

rinp

ut

Men

’sin

com

esbe

nefit

edsi

gnifi

-ca

ntly

mor

efro

min

tens

ified

dairy

-in

gth

anw

omen

’s(T

angk

a,O

uma,

and

Staa

l,19

99)

(con

tinue

d)

DA

IRY

The Impact of Agriculture Interventions on Nutrition Outcomes 27

Tabl

e4

Sum

mar

yof

Inte

rven

tion

Stud

ies

onIm

pact

sof

Ani

mal

Sour

ceFo

odIn

terv

enti

ons

onN

utri

tion

-Rel

ated

Out

com

es,C

ont.

Cou

ntry

and

Des

ign

Die

tary

inta

kean

dIn

com

ean

dR

efer

ence

sIn

terv

enti

onC

once

rnw

ith

Met

hods

Prod

ucti

onnu

trit

iona

lsta

tus

expe

ndit

ure

Wom

en’s

stat

us

Ken

ya

Mul

lins

etal

.199

6

Egyp

t

Gal

alet

al.1

987)

Ban

glad

esh

Nie

lsen

etal

.200

3

Ban

glad

esh

Nie

lsen

1996

Nat

iona

lDai

ryD

evel

op-

men

tPro

ject

:int

ensi

veda

iryte

chno

logy

thro

ugh

intro

duct

ion

ofcr

ossb

red

cow

s,fo

dder

prod

uctio

n

Mor

ean

dB

ette

rFoo

dPr

ojec

t

Com

bine

dac

tiviti

espr

o-m

otin

gpl

antp

rodu

ctio

nw

ithan

imal

prod

uctio

n(p

oultr

y).4

7%of

poul

tryfa

rmer

sw

ere

wom

en.

Parti

cipa

tory

Live

stoc

kD

evel

opm

entP

roje

ctsu

p-po

rting

sem

isca

veng

ing

poul

trypr

oduc

tion;

loan

san

dte

chni

cala

ssis

tanc

epr

ovid

edth

roug

hw

omen

’sgr

oups

Savi

ngsc

hem

es,t

echn

ical

train

ing

forp

oultr

yre

arin

gan

dcr

edit

prog

ram

s;pr

ojec

tben

efici

arie

sal

lw

omen

Bef

ore

(reca

ll)/a

fter

No

cont

rolf

orse

lf-se

lect

ion

bias

;no

rand

omiz

atio

n;ba

selin

eda

taco

llect

edby

reca

ll;sm

alls

ampl

esi

ze

Trea

tmen

t/con

trol

(ado

pter

sco

mpa

red

with

nona

dopt

ers)

No

cont

rolf

orse

lf-se

lect

ion

bias

;no

rand

omiz

atio

n;no

clea

ruse

ofst

atis

tics

Trea

tmen

t/con

trol—

post

Unc

lear

sele

ctio

nof

hous

ehol

ds,n

ora

ndom

izat

ion,

smal

lsa

mpl

esi

ze

Bef

ore/

afte

r

Unc

lear

met

hodo

logy

n.a.

Incr

ease

inpo

ultry

prod

uctio

n(a

ndin

mai

ze,p

eanu

t,an

dw

heat

prod

uctio

n)

Egg

prod

uctio

nsi

g-ni

fican

tlyhi

gher

inad

optin

gho

use-

hold

s

No

diffe

renc

ein

chic

ken

prod

uctio

n

Chi

cken

prod

uctio

nin

crea

sed

Incr

ease

dm

ilkco

nsum

ptio

n

Iron,

tota

lpro

tein

,and

anim

alpr

otei

nin

take

high

erin

adop

t-in

gho

useh

olds

Prev

alen

ceof

iron-

defic

ienc

yan

emia

drop

ped

insc

hool

-age

child

ren

durin

gth

esa

me

time

perio

d.

Egg

and

chic

ken

cons

umpt

ion

notd

iffer

ent

Wom

enan

dgi

rlsin

adop

ting

hous

ehol

dsat

em

ore

fish.

HH

cons

umpt

ion

ofeg

gs,

chic

ken,

fish,

mea

t,an

dm

ilkin

crea

sed.

Freq

uenc

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ease

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e

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ents

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n.a.

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ken

sale

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gho

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prov

edec

onom

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28 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes Ta

ble

4Su

mm

ary

ofIn

terv

enti

onSt

udie

son

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cts

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tem

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2003

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ish

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land

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and

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nam

itta

1999

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en-fo

cuse

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ntio

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prom

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inA

inta

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nclu

ding

nutri

tion

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heal

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tion,

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ing

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rden

ing

and

food

prep

arat

ion,

dist

ribut

ion

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geta

ble

seed

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gard

encl

ubs.

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pond

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esto

ck,

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ega

rden

s,an

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tion

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atio

n

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base

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ogra

m

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trol

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treat

men

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lgoa

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ats)

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cont

rolf

orse

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lect

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tmen

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y1

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rven

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ndom

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r

Trea

tmen

t/con

trol

All

ofth

ene

wly

star

ted

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lega

rden

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ring

inte

rven

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rtici

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gho

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olds

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tion

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ifica

ntly

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ated

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vege

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ega

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hip

No

othe

rdat

aon

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uctio

n

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erpr

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-tio

nof

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,veg

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bles

,and

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ent

com

mun

ity

n.a.

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ning

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ults

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ren

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rtici

patin

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k

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rate

(.46/

wk)

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ntly

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eth

anco

ntro

ls(.2

9)

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cton

child

an-

thro

pom

etry

;clin

ical

vita

-m

inA

defic

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entio

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oup

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eof

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tabl

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ruits

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A,

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ups,

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reat

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rven

tion

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p

n.a.

n.a.

n.a.

n.a.

n.a.

(con

tinue

d)

MIX

OF

INTE

RV

ENTI

ON

S

The Impact of Agriculture Interventions on Nutrition Outcomes 29

Tabl

e4

Sum

mar

yof

Inte

rven

tion

Stud

ies

onIm

pact

sof

Ani

mal

Sour

ceFo

odIn

terv

enti

ons

onN

utri

tion

-Rel

ated

Out

com

es,C

ont.

Cou

ntry

and

Des

ign

Die

tary

inta

kean

dIn

com

ean

dR

efer

ence

sIn

terv

enti

onC

once

rnw

ith

Met

hods

Prod

ucti

onnu

trit

iona

lsta

tus

expe

ndit

ure

Wom

en’s

stat

us

Ban

glad

esh,

Nep

al,C

ambo

dia

HK

I200

3,20

04,

2004

a20

06

targ

eted

to10

-to

13-y

ear-

old

scho

olgi

rls;g

irls

re-

ceiv

edw

eekl

yiro

nsu

pple

-m

ento

f60

mg

ferr

ous

sulfa

te;i

mpr

oved

scho

ollu

nche

s;po

ultry

rais

ing,

fishp

onds

Inte

grat

ion

ofan

imal

com

-po

nent

sin

toex

istin

gga

r-de

ning

activ

ities

:pou

ltry

and

eggs

inal

lcou

ntrie

s,m

ilkan

dfis

hin

Ban

glad

esh

Nut

ritio

ned

ucat

ion

tar-

gete

dto

wom

en,n

utrit

ion

impr

ovem

entt

arge

ted

atpr

esch

oolc

hild

ren

Bef

ore/

afte

r,in

clud

ing

quar

terly

mon

itorin

gda

ta—

Cam

bodi

a,N

epal

Ban

glad

esh,

befo

rean

daf

ter,

incl

udes

cont

rolg

roup

,qua

r-te

rlym

onito

ring

data

Cam

bodi

a,B

angl

ades

h—m

edia

nnu

mbe

rof

eggs

pro-

duce

din

-cr

ease

d

Inco

nsis

tent

findi

ngs

for

iron

inta

ke

No

incr

ease

sin

fati

ntak

e

Scho

olgi

rlsha

dim

prov

edse

rum

retin

olan

dse

rum

ferr

itin.

Hou

seho

ldch

icke

nliv

erco

nsum

ptio

nin

crea

sed

Prop

ortio

nof

liver

from

own

prod

uctio

nin

crea

sed

(Nep

al,C

ambo

dia)

Incr

ease

ineg

gco

nsum

p-tio

n(B

angl

ades

h,C

ambo

dia)

.Chi

ldre

nin

proj

ecta

rea

cons

ume

doub

leth

enu

mbe

rof

eggs

perw

eek

com

pare

dw

ithru

ralB

angl

ades

h.

InB

angl

ades

h,C

ambo

dia,

and

Nep

al:3

0%–6

6%of

inco

me

from

selli

ngpo

ultry

used

topu

r-ch

ase

food

.A

dditi

onal

food

pur-

chas

edin

Cam

bodi

a55

%fis

h,8%

beef

/por

k

InB

angl

ades

had

di-

tiona

linc

ome

used

topu

rcha

sem

ilk,

fruit,

and

fish.

Prog

ram

inch

ars

ofB

angl

ades

hta

rget

edto

war

dw

omen

.End

line

data

show

that

wom

en’s

enga

ge-

men

tin

deci

sion

mak

ing

onho

use-

hold

expe

nditu

res

isgr

eate

r.

Sour

ce:

Ada

pted

from

Lero

yet

al.2

007,

incl

udin

gno

tes

tota

ble.

Add

ition

alm

ater

iali

nta

ble

for

HK

Iint

erve

ntio

nsin

Ban

glad

esh,

Nep

al,a

ndC

ambo

dia.

MIX

OF

INTE

RV

ENTI

ON

S,C

ON

T.

Three of the interventions focusing on animalsource foods incorporated nutrition education andwere combined with fruit and vegetable produc-tion (see “mixed interventions” in table 4). InEthiopia, children in participating households hadslightly more diverse diets and were significantlymore likely to drink milk four or more times a week(Ayalew et al. 1999a; Habtemariam et al. 2003). InVietnam the intervention group had higher intakesof vegetables, fruits, energy, protein, vitamin A,and iron and exhibited higher growth rates amongchildren (English et al. 1997). It is not clear whetherthe animal production caused the positive effectsbecause the interventions were multifactorial. InThailand, vitamin A intake increased in the inter-vention and the control groups, but the increasewas greater in the intervention group (Smitasiriand Dhanamitta 1999).

Leroy and Frongillo (forthcoming) concludedthat the interventions associated with marked im-provement in dietary intake and nutritional statushad one of two key characteristics: either womenplayed a critical role in the intervention or the in-terventions included a nutrition education compo-nent. The conclusion was consistent with those ofearlier reviews, such as Ruel (2001). The only well-conducted study to contradict these conclusionswas a study on the dairy cooperatives in India dur-ing the 1980s (Alderman 1987).

The authors note that an important questiononly partially answered in the reviewed studieswas whether the reported increases in consump-tion were a direct effect of increased production oran indirect effect of increased income. For exam-ple, Alderman (1987) found that the increased nu-trient consumption of milk-producing householdswas not due to an increase in milk consumption,and so was likely to have come through the in-come pathway.

GENDER OUTCOMES OFAGRICULTURAL INTERVENTIONSThe role of women farmers has received much at-tention in the past few decades. In 1995 the UNFood and Agriculture Organization estimated thatwomen provide more than half the labor requiredfor food production in the developing world andthat this proportion is even higher in Africa. This isimportant from a nutritional perspective because

women’s status and their and control over incomeare critical to improved nutrition outcomes.

Yet women farmers face a series of constraintsthat limit their potential as agricultural producersand their control of the resources that flow from theadoption of new technologies. The constraints arewell-documented and include weak land rights,limited access to common property resources, lackof equipment and appropriate technology, limitedcontact with agricultural extension, lack of accessto credit, and lower levels of education(Quisumbing et al. 1995). All of these constraintsconspire to substantially lower the productivity ofwomen farmers, resulting in high opportunitycosts for households and communities (Aldermanet al. 1995; Quisumbing et al. 1998).

Efforts to ensure that women benefit from agri-cultural development interventions can be broadlyclassified into three types of approaches: “women-only” projects, projects targeted to both womenand men but with some resources allocated specif-ically for women, and projects in which gender is-sues are fully “mainstreamed.” A review of theevidence by Pena et al. (1996) found that the thirdapproach is the most likely to improve women’sstatus in a sustainable way.

Interventions that seek to increase women’s ac-cess to or ownership and control of resources aregenerally quite complex. Failure to understand cul-tural norms and the gender dynamics within thehousehold can result in unanticipated outcomes. Inthe Gambia, for example, a project geared to in-creasing women’s rice production was so success-ful that the land it was grown on was reclassifiedinternally within the household. This resulted inoutput from that land being sold by men as op-posed to women. Women therefore lost their orig-inal income stream, but did retain an increasedlabor commitment (Dey 1981). Vegetables andlegumes are often regarded as women’s crops.Recognizing this, a project in Togo was successfulbecause it promoted the introduction of soybeansas a legume rather than as a cash crop. Promotionas a cash crop would have resulted in the cropswitching to male control.

The review in preparation by Leroy andFrongillo (forthcoming) of interventions promot-ing the production of animal source foods also as-sessed their impact on maternal income orwomen’s control over income. The results werequite mixed. For example, an intervention involv-

30 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

ing intensified dairy farming in Kenya showed thatan important share of the additional income wascontrolled by women, whereas in Ethiopia men’sincomes benefited significantly more from intensi-fied dairying than did women’s (Mullins et al.1996; Tangka et al. 1999). Overall, the review foundthat whether women’s income is likely to increasedepends on the livestock or aquaculture produc-tion system, the nature of the intervention, and cul-tural beliefs and practices relating to gender. Evenif the intervention is targeted to women’s livestockand aquaculture activities, women may lose con-trol over the income generated by those activities.

The authors also noted that women’s livestockownership rights may not be as stable as men’s. Ingeneral, stress and constraints lead to an erosion ofwomen’s ownership rights because women’s own-ership of livestock is often considered a “secondaryright.” Evidence from around the world shows thatthe rights of pastoral women and their control overlivestock management and marketing are beingeroded (Niamir-Fuller 1994).

The authors concluded that women’s controlover income from livestock production activitiesis very site- and production system-specific.Livestock provides a real opportunity for womento increase their income in some situations. Inother situations, however, it merely leads to a sig-nificant increase in women’s workload without aconsiderable effect on their control over the addi-tional resources. This conclusion is most likelyalso applicable to other types of food productionsystems.

LESSONS LEARNEDDuring the past 30 years development researchersand practitioners have generated substantial newinformation and insights into the best strategiesfor ensuring that agricultural interventions reachthe poor, improve welfare, and have a positiveimpact on nutrition outcomes. Production isclearly an essential component of these interven-tions. The nature of the intervention will deter-mine the effect on macro- or micronutrientsupply: staple crops, for instance, can increase en-ergy, whereas animal source foods can increaseprotein and micronutrients such as iron and vita-min A. But the special challenge of integratedagricultural-nutrition interventions is to translate

increased production into increased householdconsumption and individual intakes.

Overall, the review documented a wide rangeof agricultural interventions that have con-tributed to improved nutrition outcomes. In mostcases, however, the exact pathways by which im-pacts on nutrition have been achieved are difficultto track. The reason is that studies document im-pacts on several intermediary outcomes such asfood security, income, or women’s empower-ment, but without directly modeling these path-ways of impact to nutrition outcomes. Becausethese outcomes are so closely intertwined, it is im-possible to determine from this literature the rel-ative importance of the different pathwayslinking agriculture and nutrition.

It is also clear that agricultural interventionshave not always been successful in improving nu-trition outcomes. For instance, although all the an-imal source food interventions reviewed weresuccessful in increasing production of animalsource foods, many failed to improve nutrition out-comes. That is because production alone is insuffi-cient to bring about improved nutrition if it doesnot simultaneously address—or is complementedby other interventions that address—other deter-minants of nutrition such as improved healthcare.Agricultural interventions thus cannot be expectedto achieve impacts on nutrition outcomes unlessthey are integrated with complementary efforts toaddress other issues such as high levels of morbid-ity and inappropriate child-feeding practices.

The review of evidence presented above sug-gests a number of general lessons about how agri-cultural interventions can be designed to achievenutrition-related objectives. Most of these lessonspertain to processes and general approaches ratherthan packages of specific components and shouldbe considered by planners when devising morestrategic approaches to nutritional goals:

Follow an integrative process of planning and imple-mentation. Successful interventions usually incorpo-rate both agricultural and nutrition considerationsat all phases of planning. Intervention activitiesshould be integrated with other health and devel-opment services and should work in partnershipwith different actors in the field.

Take local agricultural and nutrition contexts intoaccount, and seek opportunities to build relation-ships with local partners that are intimately famil-iar with these contexts. Successful interventions

The Impact of Agriculture Interventions on Nutrition Outcomes 31

often work with local groups and organizations—often nongovernmental organizations—that arewell placed to engage and consult with farmers asparticipants in designing interventions and devel-oping or adapting technologies. These local coun-terparts can be especially valuable in identifyingopportunities to relate the intervention with exist-ing programs and to integrate intervention compo-nents into those programs. These opportunities canbe important, and capitalizing on them can yieldpositive effects on the intervention’s sustainability.Successful gardening interventions are an excellentexample. Those which have carefully consideredtraditional gardening practices and the goals andpreferences behind gardeners’ production deci-sions have a distinct advantage. Highly relevant,adaptive, and sustainable changes can be intro-duced by identifying and making available im-provements that satisfy the gardeners, using thegardeners’ own criteria and accounting for and ac-commodating the gardeners’ own priorities, incen-tives, vulnerabilities, assets, constraints, andlivelihood strategies. This requires a trusting, col-laborative relationship between the researcher orproject personnel and the participating commu-nity—a relationship in which the project personnelare necessarily attentive and sensitive listeners andin which the community knows that its concernshave been addressed. Local engagement is also im-portant in ensuring that the scope and causes of nu-trition problems among targeted groups areaccurately identified. The importance of local en-gagement suggests that a suitable approach in-cludes investing in pilot studies before large-scaleprograms are initiated and then incorporatingwhat is learned about the existing conditions, cli-mate, and local culture.

Mainstream gender. Women play multiple rolesin both agricultural production and nutrition, andinterventions that consider trade-offs betweentheir respective roles and their time and labor con-straints are more likely to lead to positive out-comes. Successful interventions are more likely totake into account the range of factors that differ-entially enable or constrain men and women interms of access to resources like land and serviceslike credit. These influence and often determinetheir roles as decision makers in the household orcommunity. The significance of gender equity isparticularly critical because women’s status and

decision-making power directly affect the nutri-tional status of their children.

Incorporate communication and education compo-nents that target behavior change. Interventions thatsuccessfully translate increased production intobetter nutrition outcomes, especially for children,usually incorporate communication strategies thatrelate the significance of positive or negative be-haviors to health and nutrition effects. Informationis a vital resource, and households that areequipped with an understanding of nutrition- andhealth-related information display a tendency to-ward more favorable allocation of food and healthbudgets. Raising awareness of the health benefitsof a newly available food commodity, one for in-stance that addresses a prevalent local micronutri-ent deficiency, may be an important factor in itsadoption among producers, including those grow-ing food for their own households’ consumption.The importance of educational components is per-haps most pronounced among mothers, whoseroles as caregivers extend to other, nonfood deter-minants of nutrition, such as hygiene and sanita-tion practices and preventive and curative health.Armed with sufficient information, they are more-over more likely to know when it is necessary toavail household members of health services.

Monitor and evaluate progress. Interventions withsustainable impacts are generally characterized byeffective monitoring and feedback loops that en-able responsiveness to the shifting realities partici-pants face. The nutrition-related objectivespursued by the agricultural intervention will mostlikely remain unchanged, but the factors that actupon that objective may very well be in flux.Changing livelihood strategies may be a particu-larly important set of developments to track, andhere too, monitoring is likely to benefit consider-ably from good rapport between project personneland participants.

Taken together, these lessons show that agricul-tural interventions are most likely to have an im-pact on nutrition outcomes when they involvediverse and complementary processes and strate-gies that redirect the focus beyond agriculture forfood production and toward broader considerationof livelihoods and optimal intrahousehold use ofresources. Successful projects are those that investbroadly in improving human capital and that sus-tain and increase the livelihood assets of the poor.

32 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

33

The four case studies of agricultural interventions presented in thischapter, none of which were included in previous reviews, provideinsights into new approaches to the agriculture-nutrition nexus. Allfour interventions, explicitly aimed at integrating agriculture and nu-trition during planning and implementation, took into accountlessons learned in previous interventions and documented quantita-tive diet or nutrition outcomes at the individual level.

ORANGE-FLESHED SWEET POTATOPRODUCTION AND VITAMIN A DEFICIENCY IN MOZAMBIQUEBackground. The first case study provides new insights into the use ofa new technology, biofortification, as a nutrition-focused agriculturalintervention. Staple foods interventions are generally not viewed asdirect routes toward improving nutrition outcomes. This is particu-larly true in the case of primary staples like rice, maize, wheat, andcassava, which are good sources of energy but not of bioavailable mi-cronutrients. Biofortification, the process of breeding food crops thatare rich in bioavailable micronutrients, is attempting to overcomethat limitation. One biofortified staple crop—orange-fleshed sweetpotato (OFSP)—is already being widely disseminated, particularly inSub-Saharan Africa. Unlike most staple crops, even unimprovedOFSP is rich in vitamin A, and efforts to biofortify OFSP have in-cluded selection and breeding for still higher concentrations of the vi-tamin A precursors known as carotenoids.

OFSP has been selected as a focus crop in a number of efforts to im-prove vitamin A intakes, including the Vitamin A for Africa (VITAA)partnership and the HarvestPlus biofortification program. OFSP ispromising for a number of reasons. It contains very high levels ofcarotenoids; it is well accepted by the young children who are usuallytargeted; and it is easy to cultivate, is vegetatively propagated, and isfairly drought-resistant once established. It is also a good source of en-ergy for children and adults. Together these qualities make OFSP anexcellent food security crop. It is also less labor-intensive than mostother staple crops, and this is particularly helpful to labor-constrainedhouseholds, such as those affected by HIV/AIDS. It can be plantedover a broad range of time without considerable yield loss and can fill

Case Studies4

some seasonal gaps in energy and vitamin A in-takes. Finally, prices are generally low enough thatfamilies will choose to keep some OFSP for homeconsumption, rather than selling all they produce.

This case study reports on the results of the“Toward Sustainable Nutrition ImprovementProject” in Mozambique (Low et al. 2007a; Low etal. 2007b; Low et al. 2005). The project is purpose-fully built on lessons learned from an earlier OFSPintervention project in Kenya (Hagenimana et al.2001).3 Box 2 presents a summary of the programcharacteristics and set of interventions and lessonslearned.

Assessing impact. Evaluation design and data col-lection. The evaluation employed a prospective,quasi-experimental design. The objective was tomeasure the impact of the intervention on chil-dren’s vitamin A status (using serum retinol) andto document changes in the intermediate factorsleading to the nutritional impact, that is, changes inknowledge, OFSP production and consumption,and vitamin A intake. Three districts were pur-posefully selected. Within districts, villages were

34 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Box 2 Introducing Orange-Fleshed Sweet Potato in Rural Mozambique

ContextA two-year intervention research project in drought-prone areas of Zambézia Province in CentralMozambique. The area is characterized by high levelsof young child malnutrition, a monotonous diet withcassava as the primary staple, and a very poor re-source base. Vitamin A deficiency is highly prevalentin rural Mozambique and in the study area (58 per-cent at baseline). White-fleshed varieties of sweetpotato (WFSP) were already widely cultivated andconsumed in the area.

Program modelThe following three related elements—each necessaryand none sufficient alone—were addressed to in-crease intakes and improve child serum retinol:

• Increase farmers’ access to improved orange-fleshed sweet potato (OFSP) vines and roots.

• Increase nutrition knowledge and create demandfor OFSP.

• Ensure sustainability through market develop-ment.

Interventions:• Farmers received free OFSP vines via farmers’

associations (as per government extension prac-tice at the time).

• Demand was stimulated through multiple com-munication channels: community theatre and

radio spots and visible presence at local markets,as well as nutrition extension.

• Integrated agricultural and nutrition extensionservices reached 718 women farmers and 323men. Extension supported production, storage,processing, commercialization, and marketing tocreate demand.

• Nutrition extension aimed to improve infant andyoung child feeding practices using OFSP as oneinput.

• A grading/pricing scheme was developed inpartnership with a trader, rewarding quality.

• Several processed products were developed andmarketed (“golden bread” and OFSP juice).

Year 2 results and impact:• Ninety percent of intervention households pro-

duced OFSP (vs. 11 percent controls); of these30 percent sold OFSP.

• Mean sweet potato plot size increased morethan 10-fold in intervention households.

• Agronomic performance was acceptable, withyields similar to WFSP.

• OFSP was the cheapest source of vitamin A (perretinol unit) in local markets.

• Intervention children were 10 times more likelyto eat OFSP frequently.

• Vitamin A intakes among intervention childrenwere 8 times higher than controls; energy in-

continued

3. Project website: http://aec.msu.edu/fs2/tsni/index.htm.

stratified by distance to services and other charac-teristics and randomly selected within strata.Within villages, all households with age-eligiblechildren were invited to participate; in interventionareas, study participation also entailed participa-tion in local farmers’ groups. A series of nine sur-veys were undertaken. Information was gatheredon socioeconomic and demographic characteristicsof households, agricultural production, child mor-bidity, adult and child anthropometry, parentalnutrition knowledge, food frequency, dietary in-takes, and biochemical indicators. In addition,sweet potato plots were measured annually, andmarket prices were monitored monthly.

Impact results. The evaluation showed a markeddecrease in vitamin A deficiency among interven-tion households, from 60 to percent 38 percent.That was accompanied by significant changes inseveral of the intermediary factors along the im-pact pathway, that is, large increases in productionof OFSP as well as positive changes in knowledgeabout vitamin A and child intake of vitamin A.

Strengths and limitations of the evaluation. The pri-mary strengths of the evaluation component lay inthe prospective design and in the comprehensiveseries of surveys, which documented a wide rangeof intermediate as well as final outcomes. The main

design limitation was that participation in inter-vention areas was restricted to those willing to joinfarmers’ groups, which precluded a full explo-ration of determinants of adoption. This also raisedthe possibility of a self-selection bias, but this threatto internal validity was addressed in the analysis.In addition, the time frame did not allow an as-sessment of sustainability. Finally, this pilot projectwas relatively small. Nevertheless, the study re-sults provide “proof of concept” and support therelevance and the potential for impact of the largerVITAA, biofortification, and other efforts.

Innovations. The project took several steps to en-sure effective implementation and to maximize thepotential for impact of this innovative agricultureand nutrition intervention. Key features of the pro-ject planning and implementation, which are be-lieved to have contributed to its success, includethe following:

• Integrated agriculture and nutrition compo-nents at every stage of planning and imple-mentation;

• Established links between researchers andcommunities through implementing partners;

• Identified and selected nutrient-dense vari-eties that also addressed the needs of farmersand the preferences of consumers;

Case Studies 35

Box 2 Introducing Orange-Fleshed Sweet Potato in Rural Mozambique, Cont.

takes and intakes of several other micronutrientswere also higher.

• Prevalence of low serum retinol among youngchildren decreased from 60 percent to 38 per-cent (no change in control communities).

Lessons learned and questions for the future:• Free vines meant farmers had limited incentive to

preserve vines for planting next season; sustain-ability depends on ability and willingness of farm-

ers to invest in improved vine conservation andmultiplication or a willingness to pay for vines.

• The extension package was relatively intensive;more operational research is needed to identifythe lowest cost and most cost-effective packageof interventions that can achieve public healthimpacts.

• Further research is needed to determine whetheradoption of OFSP is sustained without continualinput on demand creation side.

Sources: Towards Sustainable Nutrition Improvement webpage: http://www.aec.msu.edu/fs2/tsni/index.htm, accessed February 27, 2007;Low et al. 2007b; Low et al. 2007a.

Project partners included Michigan State University; the Nutrition Division of the Ministry of Health, Mozambique; World VisionMozambique; the National Institute for Agronomic Investigation (Mozambique); the Southern African Root Crops Research; and Helen KellerInternational. The project was funded by the Micronutrient Initiative, the Rockefeller Foundation, the United States Agency for InternationalDevelopment, and HarvestPlus.

• Were grounded in thorough knowledge ofcontext;

• Gave due consideration to the roles of womenand the constraints they face as farmers;

• Included strong nutrition education and de-mand creation components, using multiplechannels and targeting multiple audiences;

• Addressed sustainability through efforts todevelop local markets for OFSP;

• Employed quasi-experimental evaluation de-sign and gathered detailed data on interme-diate outcomes to enhance assessment ofimpact.

LEGUME SYSTEMS AND CHILDNUTRITION IN MALAWIBackground. The second case study highlights thepotential for a crop often overlooked as a nutrition-focused intervention: legumes. Legumes do notprovide extremely high quantities of any individ-ual micronutrient. But they are good sources of arange of macro- and micronutrients, and they sub-stantially improve the quality of grain/root/tuber-based diets, for both young children and otherfamily members. The incorporation of legumeplant residues can improve soil fertility and poten-tially increase future harvests. For these reasons,interventions involving legume systems are beingimplemented by a variety of organizations.4 Withinthe health sector, a number of nutrition educationinterventions have aimed to increase young childintake of legumes. Yet there are very few docu-mented examples of agricultural interventions thatfocused on legumes and that also recorded impactson individual diets or nutrition outcomes. Onesuch study is the Soils, Food, and Health Commu-nities Study (SFHC) in northern Malawi’s SoilsFood and Health Communities Project (Kerr andChirwa 2004).5 The SFHC study explored whethera legume system intervention could improve soilfertility, food security, and child nutrition (Kerr2006; Kerr and Chirwa 2004).

Assessing impact. Design and data collection. TheSFHC project was designed as a participatory re-search project introducing legume systems andusing an ecosystem framework to examine the sys-tems’ links with food security and health. Projectdocuments identify “monitoring change” as an ob-jective, and the wide range of research activities un-

dertaken were not necessarily designed to measureand attribute impacts. Nevertheless, some study el-ements incorporated a quasi-experimental ap-proach, including the use of random sampling forquantitative surveys in intervention and compara-ble control villages over the life of the project. Intotal, 24 research activities were undertaken be-tween 2000 and 2004, including focus group dis-cussions, semistructured interviews, participatorymapping, indicator development, yield collectionexercises, soil and biomass sampling, and quantita-tive surveys covering dietary intakes, anthropome-try, and hemoglobin measurement. The qualitativeexercises covered a range of topics, including childcare and feeding, legume expansion, and the natureof crop residue use and seed exchanges.

Evaluation results. Box 3 summarizes the resultsof the study so far. One notable success is reflectedby the expansion of farmer participation, whichgrew from 183 farmers in 7 villages in the first yearto nearly 3,000 farmers in 77 villages in the fourthyear. This included a relatively high participationby women (Bezner Kerr and Chirwa 2004).Preliminary results also indicate that the projectsucceeded in nearly tripling the frequency oflegume consumption by young children, relative tocontrols (PATH Canada 2004). Further analyses ofchild nutrition outcomes, including anthropomet-ric outcomes, are ongoing (P. Berti, personal com-munication).6

Strengths and limitations of the evaluation.Available documentation did not allow an assess-ment of the evaluation design and sampling. Theevaluation’s strengths lay in its use of rich qualita-tive information, which provided insights into theimplementation, adoption, and demand for projectactivities.

Innovations. Like the OFSP intervention study,this project built on a range of lessons from the

36 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

4. See, for example, the Collaborative Crop Research Programat http://mcknight.ccrp.cornell.edu/projects/index.html.This program supports several legume systems projects inAfrica (Tanzania, Malawi, and Mozambique) and LatinAmerica (Bolivia and Ecuador) aimed at improving the useof legumes, improving child nutrition, or both.

5 Web site: http://www.healthbridge.ca/food_soil_e.cfm.Accessed February 27, 2007.

6 The project is also continuing in a second phase; see theHealthBridge (formerly PATH Canada) website athttp://www.healthbridge.ca/food_soil_e.cfm for a projectdescription.

past. Agricultural and nutrition concerns were in-tegrated from the outset. Gender issues and othersocial relations were carefully assessed and ad-dressed, nutrition education was aimed at ensur-ing impacts on child diets, and a number ofresearch elements did allow some monitoring andassessment of impacts. Strong participatory andqualitative approaches were employed throughoutthe life of the project. Farmer research teams, com-

prising farmers selected by community members,carried out research along with external teammembers. The methods used to select farmer re-search team members were designed to ensure rep-resentation of less-advantaged communitymembers, thus addressing an important shortcom-ing experienced by several past efforts in whichteams were dominated by men and better-offhousehold members.

Case Studies 37

Box 3 Legume Systems in Malawi: Building on Local Knowledge, Improving Nutrition

ContextA three-year participatory research project (intensivecase study) in Mzimba District, northern Malawi. The area is characterized by high levels of young child malnutrition and a monotonous diet with maizeas the primary staple. A variety of legumes are grownin the region. Soils are deficient in nitrogen, and inputuse is low.

Program model:• Human health and nutrition can be enhanced

through design of solutions based on ecosys-tem management.

• Farmer Research Teams (FRT) can be used totest and promote agricultural innovations.

• To achieve nutrition impacts, FRT embrace andemphasize links between legume productionand child nutrition in all farmer meetings, train-ings, and farm visits.

Legume systems tested:• Maize intercropped with pigeon pea• Pigeon pea intercropped with soybean, then ro-

tated with maize• Pigeon pea intercropped with groundnut, then

rotated with maize• Mucuna pruriens (velvet bean) rotated with

maize• Tephrosia vogelii intercropped with maize

Process/qualitative results:• Participation increased rapidly from 183 farmers

(year 1) to nearly 3,000 farmers (year 4).• Participating farmers developed indicators and

assessed legume systems with regard to effectson soil fertility, food security, child nutrition,and gender and other social issues.

• Farmers’ motivation for adoption was to pro-vide family food, not to enhance soil fertility or to sell.

• Choice of legume systems reflected their role infilling seasonal food gaps.

• Legume system “best” for soil fertility had manyundesirable qualities (very long cooking time,need to bury residue during busy season) andwas not adopted.

• FRT were overwhelmed in year 2, leading to development of village committees to supportFRT.

• Majority of committee members were women,who cited link with child nutrition as their mo-tive for joining.

• Men were reported to make decisions aboutcrop use and sale, but, in fact, women retainedsome control over both.

• Discussions of gender role changes met with resistance from men and grandmothers, but a focus on child health served to “neutralize”conflicts.

Sources: Soils Food and Health Communities Project webpage: http://www.healthbridge.ca/food_soil_e.cfm accessed February 27, 2007;Kerr and Chirwa 2004; PATH Canada 2004.

Project partners included PATH Canada, the Ekwendeni Mission Hospital, and the Farmer Research Teams. The project was funded by theInternational Development Research Centre (Canada).

INTEGRATING HOMESTEADGARDENING AND PRIMARYHEALTH CARE ACTIVITIES INSOUTH AFRICABackground. The third case study focuses on yellowfruits and vegetables, including dark green leafyvegetables in South Africa and is a useful exampleof an agricultural intervention that explicitly part-nered with the health sector. The pilot study wasimplemented in 1999 in a rural village in Kwazulu-Natal, South Africa, to promote the production ofthese crops at the household level. The project ef-fectively linked an agriculture intervention with aset of health-sector activities to stimulate greaterconsumption of the products. The interventionpackage included both an agriculture interventionand a health-nutrition intervention.

Agricultural intervention. The project provided acourse on the theoretical and practical aspects ofvegetable production, such as soil preparation, fer-tilizers, planting and sowing dates, plant spacing,irrigation, crop rotation, cultivar choice, weeding,maintenance, pest and disease management, andharvesting (Faber and Benade 2003). Homesteadgardens were present prior to the intervention andincluded traditional garden crops such as cabbage,maize, vitamin A-rich pumpkin, and imifino (a col-lection of dark-green leaves). A total of ninedemonstration gardens were established with thefollowing crops: butternut squash, carrots, orange-fleshed sweet potatoes, and spinach, along with apapaya tree. These crops were new additions to thegardens but were already familiar to communitiesin the area through their availability for purchasein local markets (Faber et al. 2002a).

Health-nutrition intervention. In 1995 a commu-nity-based growth-monitoring program was estab-lished in partnership with the health sector. Theprogram is a primary health care activity run bynutrition monitors through home-based centersknown as Isizinda. The project was able to engagethe Isizinda as a focal point to promote the localproduction and consumption of provitamin A-richfoods. They also served as agricultural demonstra-tion and training centers and as nutrition educationcenters providing instruction on the relation be-tween vitamin A and health, the identification ofvitamin A-rich foods, and cooking methods.

Vegetables produced in the demonstration gardenswere cooked at the Isizinda on days when childgrowth was monitored (Faber et al. 2002b).

Assessing impact: Evaluation design and data col-lection. Serum retinol concentrations of 165 chil-dren ages two–five were collected at baseline, andtheir food consumption was recorded during across-sectional survey covering the interventionvillage. A neighboring village served as a controlvillage. One year after implementation, the moth-ers of a convenience sample of 100 two- to five-year-old children (50 from households with aproject garden and 50 from households without aproject garden) were interviewed. Data collectedincluded food intake from 24-hour recalls. A cross-sectional survey was also organized 20 monthsafter program implementation; serum retinol con-centrations of 221 children (110 from the experi-mental village and 111 from the control village)were measured, along with information on dietaryintake and growth of the children, and maternalknowledge on vitamin A.

Results of the one-year follow-up revealed thatdietary vitamin A intake increased significantly inchildren from households with a project garden,and to a lesser extent in children from householdswithout a project garden. Twenty months into im-plementation, results revealed that after the onsetof the intervention, the number of project gardensgradually increased to reach a total of 126 gardens(including demonstration gardens). Only 8 per-cent of the households with project gardens soldsome proportion of the produce for cash. Betweenbaseline and the 20-month follow-up, there was asignificant increase in maternal knowledge scoresin the experimental village compared with thecontrol village.

At the same time, significantly more children inthe intervention village than in the control villageconsumed carrots, pumpkin or butternut squash,spinach, and imifino—all vitamin A-rich foods.From baseline to follow-up, serum retinol concen-trations increased significantly in the experimentalvillage and decreased significantly in the controlvillage. At follow-up, children from the interven-tion village had higher serum retinol concentra-tions than children in the control village; thereverse was true at baseline. Among the children inthe experimental village, those from households

38 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

without a project garden had significantly lowerserum retinol concentrations than did those fromhouseholds with a project garden, and their con-centrations were similar to those of children fromthe control village. Because all households in theintervention village were exposed to the same nu-tritional education and agricultural demonstrationsessions regardless of whether they had a projectgarden, the finding above suggests that access tosupply was critically more important than was ed-ucation without ready access.

Strengths and limitations of the evaluation. Thehome-gardening program had a positive effect onserum retinol concentrations, habitual intake of tar-geted garden crops, and maternal knowledgeabout nutrition. In addition, villagers appreciatedthe fact that they no longer had to buy vegetablesand recognized the health benefits apparent amongtheir children. The evaluation did, however, haveseveral weaknesses. The treatment and controlgroups were not randomized, and the effect of theintervention was assessed using a cross-sectionalsurvey comparing households with and withoutgardens. Self-selection of households (i.e., partici-pating or not in the garden project) was not con-trolled for, and for logistical reasons, the evaluationsurvey was done at the beginning of the new grow-ing season for many crops (20 months), whenmostly spinach and carrots are available. Had theevaluation been conducted at 24 months, then or-ange-fleshed sweet potatoes and butternut squashwould have been in abundance. It is likely that theeffects on consumption and nutritional statuswould have been even larger.

Innovative features and success factors. The successof this project appears to be attributable, at least inpart, to successful coordination among multidisci-plinary groups of agriculturists, nutritionists, andthe community. The inclusion of complementaryproject components such as the primary health careactivity (which monitored child growth) and nutri-tion education likewise also contributed to the pro-ject’s success. Nutrition and agriculture educationwere found to be necessary but not sufficient con-ditions to achieving marked improvements in nu-trition. This finding suggests that, at least in thiscontext, food insecurity was a significant constraintto behavior change and that the collaboration be-tween agriculture and health allowed the synergiesbetween the two sectors to improve nutrition.

HOMESTEAD GARDENING FORFRUITS, VEGETABLES, ANDLIVESTOCK IN ASIABackground. The fourth case study involved home-stead gardening for fruits, vegetables, and livestockin Bangladesh and is notable not only for the rangeof commodities it dealt with, but also because it is arare example of an intervention that was scaled upfrom the community to the national level and wasultimately replicated in other countries.

Homestead gardening in Bangladesh is a mainlyseasonal activity, with about 70 percent of fruitsand vegetables being produced in winter.Vegetable and fruit production satisfies less than 30percent of national demand. In an attempt to gaina better understanding of existing gardening prac-tices, Helen Keller International (HKI) conducted asmall assessment in north-west Bangladesh in1988. On the basis of the findings, HKI developeda pilot program among 1,000 households between1990 and 1993. The aims of the program were to (1)explore the feasibility of promoting low-cost veg-etable gardens combined with nutrition educationand (2) identify constraints that might prevent in-creased production and consumption of vitamin A-rich foods among poor households.

The pilot program provided a wealth of infor-mation on the successes and challenges of garden-ing programs in Bangladesh and provided HelenKeller International with the information it neededto expand the program. Among the results wereencouraging data suggesting that household pro-duction of fruits and vegetables could be possiblethroughout the year with some technical assistanceand support. A midterm evaluation in 1992 con-firmed that the combined homestead gardening,nutrition education, and gender aspects of the pro-gram had a very positive impact on vegetable con-sumption among women and young children. Themonitoring and evaluation system of the pilot pro-gram also identified challenges that needed to beovercome. For instance, households were unable tosustain change without a regular supply of qualityseeds and other inputs. Scaling up the pilot wouldrequire greater understanding of a number of is-sues, including cultural beliefs about child feeding,maternal food intake during pregnancy, intra-household food distribution, and the role womenplay in program activities.

Case Studies 39

The large quantity of data provided by the pilotprogram was then used to develop a larger-scalehomestead gardening program, including the needfor adequate management and human resources toimplement a large-scale community program. Thepilot study was expanded in collaboration withlocal NGOs and the government of Bangladeshinto the “NGO Gardening and Nutrition EducationSurveillance Project” in 1993 (Talukder et al. 2000).Eventually, the program was scaled up to national-level coverage, supporting 900,000 householdssupporting 4.5 million beneficiaries.

On the basis of the success of the experience inBangladesh, the project was replicated by HelenKeller International in Cambodia, Nepal, and thePhilippines and adapted to Niger (HKI 2004, 2006).Recognizing that micronutrients like vitamin A areless bioavailable from vegetable sources, HKIbegan a pilot extension of its home-gardening pro-gram by integrating animal husbandry inCambodia, Bangladesh, and Nepal. The incorpora-tion of an animal-source food intervention bene-fited richly from collaboration with a long-running,well-established program with capacity for nutri-tion education, production training, and monitor-ing and evaluation.

Intervention elements and scope. The objectives ofthe Bangladesh homestead gardening programwere threefold:

• To increase the number of households thatsustainably produce different varieties ofvegetables and fruits throughout the year

• To increase the number of households pro-ducing more varieties of vegetables

• To increase consumption of vitamin A-richfoods and improve the nutritional status ofthe most vulnerable groups

The gardening and nutrition education activitieswere linked with the ongoing development pro-grams of local NGOs. Strong linkages were estab-lished with participating communities to ensuresustainability. The NGOs’ work with women’sgroups helped them to address the social and cul-tural constraints faced by women in Bangladesh.These NGOs were supported financially by HKIfor the first three years of the project. The estab-lishment of village-level nurseries and homesteadgardens was conducted by the NGOs in conjunc-tion with community groups. The village nurseriesserved as a community support service network in

which demonstrations and training on low-cost,low-risk gardening practices were conducted andseeds, seedlings, and saplings were produced anddistributed. Most of the village nurseries in the pro-gram operated as small enterprises.

Each NGO was encouraged to form 45 villagenurseries per subdistrict, with a minimum of 800square meters serving 5 to 10 villages. Five to 10working groups of the NGOs of approximately 20women each were linked to each nursery to partic-ipate in the gardening program. A group leader orselected individual was identified to develop andmanage the nursery. The group leader also facili-tated nutrition and health education through peereducation among the women’s groups. HKI pro-vided training and technical assistance to the agri-culturists and extension agents of the partnerNGOs and, together with them, provided technicalassistance based on the needs of the householdsand nursery owners. This technical assistance wasdesigned to reinforce and improve existing posi-tive gardening and consumption practices.

Program monitoring was an essential part ofprogram implementation and was particularly im-portant in scaling up. Monitoring was used to iden-tify problems and priorities and develop solutionsbased on sharing between the beneficiaries and theprogram staff. In addition to the monitoring of pro-gram activities, HKI staff regularly supervisedNGO field and management staff. By implement-ing the program in partnership with NGOs, house-holds continue to receive technical support forhomestead gardening and the program continuesto expand without input and resources from HKI.

Gender was an important focus of project activ-ities. Women in rural Bangladesh have tradition-ally managed seasonal homestead gardening, fromsowing to harvesting and storing seeds. Thus theprogram actively targeted women in an effort toprovide them with new opportunities to generateincome related to homestead gardening. Womenare also generally responsible for procuring andpreparing food for their children. It is estimatedthat at least 90 percent of the targeted householdsare represented by women.

To incorporate animal source foods into the in-tervention, model farms were established with ex-isting village nurseries. The animal source foods offocus were poultry in Cambodia and Nepal andpoultry, milk, and fish in Bangladesh. Each modelfarm supported a number of households with

40 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

training and support for household poultry rear-ing, including improved breeding stock andchicken management services. Nutrition educationfocused on dietary diversity, micronutrient con-sumption, and maternal and child nutrition (HKI2003). In Cambodia, the village-level poultry farmswere owned by village farmers and run as mi-croenterprises.

Assessing impact. The NGO Gardening andNutrition Education Surveillance Project used anintegrated monitoring system to provide regularfeedback on program progress. The data were col-lected on a regular basis using a simple question-naire on seed production, vegetable and fruitproduction and consumption, and income. In ad-dition, a cross-sectional survey was conducted inFebruary and March 2002 to evaluate the economicand social impact of the program on its beneficia-ries and the sustainability of the program.

This evaluation comprised three groups of 720households each, totaling 2,160 households, rep-resenting active program participants, formerprogram participants, and control households.Structured questionnaires were used, and data onhomestead garden production were estimated inkilograms by the homestead caretaker. Additionalinformation was collected on the adoption ofyear-round production practices, consumptionlevels of garden produce, amounts of cash gener-ated, changes in the ability of women to con-tribute to household livelihoods, and otherdevelopments.

Evaluation results. The program increased theproduction and consumption of fruits and vegeta-bles in the areas it covered and increased the num-ber of varieties consumed. Monitoring showed thatthe percentage of households without a homesteadgarden decreased from 25 percent at baseline toless than 2 percent after one year (Talukder et al.2000). After one year of participation in the pro-gram, the percentage of households who practicedyear-round (developed) gardening had increasedsignificantly from 3 percent to 33 percent. Thenumber of varieties and the volume of vegetablesproduced in developed gardens were three timeshigher than those produced using traditional gar-dens. The cross-sectional evaluation conducted inwinter 2002 revealed that households participatingin the project produced a median of 135 kg of veg-etables and 24 kg of fruit in the preceding threemonths, compared with 46 kg of vegetables and 14

kg of fruits during the same period for controlhouseholds (Bushamuka et al. 2005).

Results also revealed that children in house-holds with developed gardens consumed 1.6 timesmore vegetables. Among children ages 12–59months who had not received a vitamin A capsulein the six months prior to the survey, the risk ofnight blindness was lower when their house had ahomestead garden. Thus, having a homestead gar-den appeared to reduce the need for vitamin Asupplementation.

Seventy-three percent of the gardens were man-aged by women, and women were the main deci-sion makers concerning gardening practices andthe use of the income earned by selling garden pro-duce (Talukder et al. 2000).

Households earned, on average, the equivalentof US$8 on a bimonthly basis by selling the fruitsand vegetables. The main use of this income wasfor food and also to invest in seeds, seedlings,saplings, poultry, or other income-generating ac-tivities. Nearly 10 percent of households saved in-come generated from the garden. Results alsorevealed that households with improved or de-veloped homestead gardens consumed micronu-trient-rich, noncereal foods more frequently thandid other households. These foods, such as lentilsand animal products, are not actually produced inthe garden, but were purchased using incomegenerated from the selling of garden produce(HKI 2003).

Chicken liver is a particularly rich source of vit-amin A and other essential micronutrients. InCambodia and Nepal, the percentage of house-holds consuming chicken liver increased from 21percent to 35 percent and from 28 percent to 41 per-cent, respectively, among those households con-suming it from their own production.

In Bangladesh and Cambodia, egg productionand consumption increased. In Bangladesh, 94percent of the participant households consumedeggs in the seven days before the survey—an in-crease of 48 percentage points over the baseline.More important, egg consumption increased dis-proportionately among women and children, al-most doubling. There were no changes in eggconsumption in the control group. Nutrition edu-cation emphasized both intrahousehold distribu-tion issues and micronutrient consumption andfocused on the special needs of women and youngchildren.

Case Studies 41

Strengths, limitations, and conclusions. This pro-gram is a success story of the scaling up of a small-scale gardening program. Limited experienceexists of successful scaling up of gardening and nu-trition programs, and the Bangladesh model is onethat has been well documented and has been suc-cessfully replicated in several countries in Asia.

The program continues to expand in Bangladeshinto new areas and to additional households in thecurrent working areas. The gardening model hasbeen adopted by the Government of the People’sRepublic of Bangladesh and has become part of aprogram of the Department of AgricultureExtension. In 1997, HKI started the phaseout oftechnical and financial support to NGOs that hadalready received three years of its support.Monitoring information from these areas one yearafter the withdrawal shows that the households aremaintaining their improved gardening practicesand continue to consume fruits and vegetablesmore regularly.

LESSONS FROM THE FOUR CASE STUDIESThe case studies drew from the experience of manyprevious interventions. All four employed a nutri-tion education component directed at behaviorchange in the participating communities. Each ofthem also took local contexts into account, builtpartnerships with different members of the com-munities to promote ownership, and purposefullyinvolved women and targeted their empowerment.

All four interventions achieved their ultimateobjective of improving the intake of focus nutrient-rich foods by target population groups, especiallywomen and young children. The two studies thatmeasured biochemical indicators of vitamin A de-ficiency also documented a significant reduction inthe prevalence of vitamin A deficiency in children.The Bangladesh study documented reductions innight blindness (a clinical sign of vitamin A defi-ciency) among children of households with ahomestead garden. Although none of the studiesrigorously modeled the pathways of impact the interventions followed, the marked increasesrecorded in production, consumption, and intakesuggest that the direct pathway of consumption of

own production was the dominant one. The in-come pathway was not as consistently docu-mented, thereby preventing a firm conclusionabout its relative importance across the four casestudies. The Bangladesh-Africa study, however,does document an impact on income, which trans-lated into purchasing and higher-quality foods andoverall enhanced diet quality and nutrient intakes.

The case studies each made a unique contributionto the current understanding of potential modalitieslinking agriculture and nutrition and key successfactors. The biofortified orange fleshed sweet potatointervention, which resulted in large increases in vi-tamin A intakes and status, provides encouragingsignals for future interventions involving this newlybred crop. The focus on gender in the legume pro-ject was highly successful in achieving meaningfulincreases in legume consumption in young children.In South Africa, the successful partnership betweenthe agricultural and health sectors appears to be re-sponsible for the impacts on maternal knowledgeand vitamin A status. That study also underlines theimportance of boosting food availability and accessthrough agriculture in contexts in which food inse-curity is a major constraint to behavior change. InBangladesh, both the production-consumption-in-take pathway and the income pathway appeared tohave played a role in improving vitamin A intakeand status. The Bangladesh case study is also aunique example of the successful scaling up of ahomestead garden project and of the importance offocusing on women.

Earlier reviews had noted the importance ofproperly designing and conducting evaluations ofagriculture and nutrition interventions to betterdocument impact and best practices. The case stud-ies reaffirm that careful evaluation design is criticalbut remains a challenge because all the method-ologies employed had certain limitations. Scalingup also remains a challenge. With rare exceptions,the interventions remain small in scale and un-likely to achieve broad impacts. To scale up agri-cultural interventions to have a broad andsustainable impact requires their integration intothe activities of institutions, both in the agriculturesector and in other sectors whose activities can con-tribute to improved nutrition outcomes. These in-stitutional issues are dealt with in chapter 6.

42 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

43

The economic and policy context surrounding agriculture-nutritionlinkages has been changing rapidly during the past 25 years. Thischapter examines four types of change that drive behaviors amongproducers and consumers and that together are transforming theagricultural landscape and its relationship to human nutrition.

• Agricultural policy• Agricultural technology• Food marketing systems• Food consumption patterns

These changes affect the broader context in which nutrition-ori-ented agricultural interventions are implemented. They also affecteach of the pathways through which agriculture affects nutrition, no-tably consumption of own-production, producer incomes, and foodprices. The effects on these three pathways, which are the subject ofthis chapter, are summarized in table 5.

AGRICULTURAL POLICYUntil the 1970s and 1980s, domestic agricultural and food policies inmany developing countries assumed an interventionist stance. Thepolicies applied principally to staple crops, but extended outward toagricultural products generally, including fruits and vegetables.Government agencies often controlled trade in food products withlaws that limited private trading, notably by restricting the purchaseor movement of production output by private firms. These interven-tionist policy regimes tended to discriminate against agriculture andin favor of urban-industrial growth. Examples of such policies in-cluded import substitution, financial-sector controls, and overvaluedexchange rates as well as taxing agriculture to subsidize urban andindustrial development (Christensen and Witucki 1982; World Bank1986; Krueger, Schiff, and Valdes 1991; Bhagwati 1993; Delgado 1995;Sanders et al. 1996; Sahn et al. 1997; Teranishi 1997; Badiane 2000;Thorbecke 2000). Agriculture was seen primarily as fuel for industrialgrowth rather than as a source of growth in itself.

Since that time, agricultural policy in most developing countrieshas undergone a major paradigm shift as part of what is often termed“globalization.” Although the role of the government in food marketscontinues to be extensive, governments have dismantled state mar-keting mechanisms and liberalized trade and investment. In addition,

The Changing Context of Agriculture and

Nutrition Linkages

5

through changes in exchange rate regimes andtrade liberalization in the nonagricultural sector,the levels of taxation or “disprotection” of the agri-cultural sector have declined over time. Overall,private markets have assumed greater importancerelative to state intervention.

Trade liberalization has been a particularly im-portant policy change. Until the 1970s and 1980s,developing-country governments favored restrict-ing international food trade to limit import compe-tition and to prevent export-driven increases infood prices. This changed with the culmination ofthe Uruguay Round and the Agreement onAgriculture in 1994, which resulted in the develop-ment of a more open multilateral system for tradein agricultural products. Although the pace of re-forms would later stall during the Doha Round ofthe World Trade Organization a decade later, anumber of North-South preferential tradingarrangements would still come into existence.Preferential trading arrangements have signifi-

cantly altered the effective trade regime for agri-cultural producers in many countries as well as theavailability of products for consumers. Two promi-nent examples are the European “Everything butArms” initiative and the US “African Growth andOpportunity Act,” both of which give expandedaccess to selected low-income countries. Somecountries such as Bangladesh have also attemptedunilateral liberalization. Regional trade agree-ments have also been developed, increasing at arate of 15 percent in the 1990s (FAO 2004). Thesechanges have resulted in a rising share of outputbeing traded, as well as changes in the compositionof trade. The average tariff on nonagriculturalgoods fell from about 40 percent in 1947 to 4.7 per-cent by the end of the Uruguay Round in 1993.Since 1971, global agricultural exports have grown

44 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

7 These calculations are based on FAO statistics for agriculturalexports and the World Development Indicators for agricul-tural value added and the US dollar GDP deflators.

Table 5 Potential Effects of the Changing Context on Pathways Linking Agriculture and Nutrition

Pathways linking agriculture and nutritionFrom increased production to

Changing Context Increased consumption Increased income Lower food prices

Agricultural Policy Can alter the incentives for Can have the effect of Can have the effect of sale of food products into increasing or decreasing increasing or decreasing the marketplace, thus producer incomes consumer food pricesaltering availability for own-consumption

Agricultural Technology Can expand the range of Impact of agricultural tech- Rising productivity and crops available for nology on labor demand new crop varieties arising own-consumption can be positive or negative; from agricultural tech-

that affects producer incomes. nologies can lead to lower food prices.

Food Marketing Systems New marketing arrangements Rising power of private mar- Can have the effect of can alter producer incentives keting institutions can affect increasing or decreasing to sell food into the market- producer incomes positively consumer food pricesplace rather than produce for or negatively. own-consumption.

Food Consumption Less food now consumed Can create opportunities for Can have the effect of Patterns from own-production. income generation by small increasing or decreasing

Pattern of consumption farmers consumer food pricesdiversified because of demonstration effect

Source: Authors.

at 3 percent a year in real terms, while agriculturalproduction has grown at 0.7 percent a year. As a re-sult, the share of agricultural production that is ex-ported has doubled, rising from 19 percent in 1971to 40 percent in 2003.7

This shift in agricultural policy has importantimplications for nutrition. The increased marketorientation of agriculture has altered the incentivesfor food producers to sell their products in the mar-ketplace, thus altering availability for own-con-sumption. There are also important implicationsvia the food price pathway and the income path-way, as discussed below.

Agricultural policy changes and food prices.Agricultural policy can affect food consumptionpatterns by creating incentives, disincentives, orboth to the production of different foods, and there-fore their relative availability and prices (Nugent2004; Hawkes 2007a, 2007b). Liberalization of agri-culture and trade policy has particularly strong im-plications. In theory, liberalization can lead todecreases or increases in consumer prices. At thenational level, the impact on commodity prices willvary across commodities, depending on whetherthe country is a net importer or a net exporter of thatcommodity. The observed pattern of trade in whichdeveloping countries are net exporters of high-value, micronutrient-rich crops implies that con-sumer prices are higher for those products than theprices that would prevail in a closed economy. Thereverse would hold for the supply of macronutri-ents because the developing countries broadly arenet importers of grains.

Trade reforms affect food prices in part by af-fecting the amount of food available. Thus, theprice of importable food products decreases withtrade liberalization (as supply increases with im-ports) and the price of exportable food product in-creases with liberalization (as domestic supplydecreases). Box 4 presents a synthesis of cases inSouth Asia that have undergone changes in theirtrade policies and have experienced different out-comes in food availability for consumption. The re-lationship between trade reforms and foodavailability, accessibility, and stability has been ex-plored by FAO in a series of 15 country case stud-ies (Thomas 2006). Enormous differences inoutcomes were observed between the 15 countries,some attributable to the nature and extent of the re-forms themselves, others attributable to the het-erogeneity of initial conditions. Modest growth in

food availability was recorded in Kenya andMalawi, whereas in China, per capita supplies ofthe principal nutrients improved dramatically. InTanzania, per capita availability of the main nutri-ents declined following reform. The effects of struc-tural policy reforms on household incomes tend torely on the overall response of the economy to thereforms. In countries in which postreform eco-nomic growth was inadequate, poverty was likelyto deepen. Overall the study concluded that foodavailability, accessibility, and stability could beworsened in the short to medium term if trade lib-eralization is introduced without a policy packagedesigned to offset its negative effects—especiallyfor countries in earlier stages of economic develop-ment. The Economic Research Service of the U.S.Department of Agriculture has also examined this question. The service used a computablemodel to assess the direct impact of agriculturalliberalization on the “nutritional gap” (i.e., percapita food availability relative to minimum nutri-tional requirements) in 67 low-income countries(Trueblood and Shapouri 2001). According to thebaseline forecast from the model, the nutritionalgap was projected to be 21.9 million tons in 2010. Interms of the impact on prices, the study projectedthat long-run, real-world food prices would rise byabout 12 percent and that developing country ex-ports would increase by about 30 percent followingglobal trade liberalization. When fed into themodel, these price changes led to a reduction in nu-tritional gaps in the studied countries by 6.4 per-cent. These gains are relatively modest because ofthe lack of producer response in developing coun-tries, the declining share of agriculture in total ex-ports, and the small share of food imports in totaldomestic food availability.

Agricultural policy changes and producer incomes:In theory, the impact of trade liberalization onproducer incomes depends on whether the sectorin question was protected or taxed initially.Sectors that were protected initially would facegreater import competition and could lose out,whereas those that were taxed initially could ben-efit from new opportunities from trade liberaliza-tion. Theoretically, if resources (including labor)could be effortlessly transferred across sectors,then the transition following trade liberalizationwould be less detrimental to household income,with subsequent implications for food consump-tion. In reality, the structural features of the de-

The Changing Context of Agriculture and Nutrition Linkages 45

veloping countries imply that resources are notfreely mobile across sectors and those employedin the protected sectors would, in fact, sufferlikely job and income losses due to trade liberal-ization. When the group of losers from trade lib-eralization includes a large section of the poor, asmay well be the case in many developing coun-

tries, then trade liberalization can result in a risein poverty, at least in the short run. The impact oftrade liberalization on income is therefore likelyto differ, depending on the initial status of thecountry (as a net importer or net exporter) andthen within the country across net producers andconsumers.

46 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Box 4 Trade Liberalization and Food Availability: Synthesis of Cases in South Asia

Between 1971 and 2002 there was a clear increase inthe availability per capita per day of calories and fat inSouth Asia although the availability of proteins in-creased only marginally. The exceptions areBangladesh with respect to proteins and Sri Lanka forfat, both of which have remained stagnant over time.In Bangladesh, significant increases in the availabilityof calories and fats took place in two periods, onceduring the late 1980s and then during the late 1990s.In India, significant increases in the availability ofcalories and proteins occurred during the 1980s, andincreases in the availability of fats occurred fairlysteadily from the late 1970s. Nepal witnessed a pat-tern similar to India’s, except that steady increases inthe availability of fats started from the early 1980s. InPakistan, a steady increase in the availability of allthree nutrients has been seen over time, except fortwo phases of deterioration in calorie and proteinavailability from 1976 to 1985 and again during theearly years of this century. Sri Lanka presents a pictureof a fluctuating scenario, with improvement, stagna-tion, or deterioration for the three nutrients.

Nepal is the only country in the region in whichfood import dependency rose in the 1980s and has re-mained stable at modest levels subsequently; SriLanka witnessed the sharpest fall in import depen-dency. But during this period, Nepal achieved thehighest levels of availability per capita per day of bothcalories and proteins from levels much lower than therest of the countries, whereas Sri Lanka has slipped inits rankings in the case of calories and fats. Only inNepal did availability of cereals grow faster than do-mestic production. In Bangladesh, availability grew atthe same rate as production, whereas in India,

Pakistan, and Sri Lanka, availability has grown at aslower rate than domestic production. Underlying thedifferential rates of growth of production and avail-ability is the role of stocks and trade in determiningavailability and consumption.

Could these differences in the nutrient availabilityacross countries of South Asia be explained by the dif-ferences in their policy regimes? Did the very policiesthat helped improve food self-sufficiency hurt house-hold-level food and nutrition security? The case of ce-reals suggests that this could possibly be the case,although the relationship between nutrient availabilityand trade reforms presents mixed evidence from SouthAsia. Except in Nepal, significant stock accumulationhas taken place in all countries through the use ofprice support/buffer stocking schemes. India, Pakistan,and Sri Lanka continue to pursue stocking policies vig-orously. Nepal had only a notional buffer stock policy,and in Bangladesh, the importance of such interven-tionist domestic policies waned over time.

In regard to trade flows, India turned from being anet importer of cereals into a net exporter beginning inthe 1990s, and Pakistan recently became a net ex-porter. Although net imports of cereals as a percentageof availability declined steadily in Sri Lanka, it has re-mained more or less stable over time in Bangladesh.Nepal is the only country, having been a net exporterof cereals in the 1970s, that became a net importerbeginning in the 1980s, although the share of net im-ports in availability is just 1 percent. Nepal’s porousborder with its main trading partner, India, effectivelyrenders its trade regime nearly free, despite thelow/moderate tariffs that it maintains. Similarly,Bangladesh’s border with India is also relatively

(continued

AGRICULTURAL TECHNOLOGYThe growth of agricultural technology has beendramatic during the past 25 years. Developmentsthat carry particularly important implications forfood availability and patterns of food demand andconsumption are plant breeding—focused mainlyon increasing yield and productivity, but more re-cently on increasing crop nutrient content—andtechnologies related to food processing and mar-keting, such as those that maintain a cold chainfrom farm to plate. The effects of developments inagricultural technology on food production andconsumption can be classified into three impacts(shown in Figure 6). The first is the impact on rela-tive prices and on the relative profitability of dif-ferent products for producers. The second istechnology’s impact on the labor and incomes ofagricultural households. The third is the role oftechnology in introducing new food products withdifferent nutritional properties.

Technology’s impacts on relative prices and relativeprofitability of different food products. Agricultural

technology has long focused on plant breeding andvarietal improvements designed to raise produc-tivity and yields. In the past 50 years, technologicalchange has led to spectacular outcomes, such as theGreen Revolution in wheat and rice and the broadacceptance of single-cross hybrids in maize(Baenzinger 2006).

In 2003 a study published in the journal Sciencepresented an analysis of the contribution of GreenRevolution crop breeding technologies to produc-tivity by crop, region, and by decade between the1960s and 1990s. Figure 7 shows the evolution offood production per capita. With the exception ofSub-Saharan Africa in the 1980s, the production offood per capita shows an increasing trend that canbe largely attributed to new crop varieties(Evenson and Gollin 2003). During the same timeperiod, foods not subject to varietal improvementssaw little or no productivity change and as a resulthave risen in price and been removed from manyproduction portfolios. The case of pulses in India,which have seen little if any varietal improvement,sharply rising relative prices, and declining aver-

The Changing Context of Agriculture and Nutrition Linkages 47

Box 4 Trade Liberalization and Food Availability: Synthesis of Cases in South Asia, Cont.

porous, although to a lesser extent. Sri Lanka, an is-land nation, does not have a porous border like Nepalor Bangladesh; hence, the tariffs it maintains do per-haps bind its trade flows.

Reforms in these countries started at different times.Bangladesh started trade liberalization from the early1980s; India, from the early 1990s (with little agricul-tural trade liberalization coming even later); Nepal,from the early 1990s; Pakistan, from the 1980s; andSri Lanka, from the late 1970s. Reforms initiated in theearly 1980s in Bangladesh seem to have acceleratedthe growth in per capita availability. In India, the im-provement in per capita availability occurred primar-ily during the 1980s, that is, earlier than the reforms.Although there was hardly any change in the 1970sand in the early 1990s, the late 1990s witnessed a de-cline in the per capita availability of cereals, in partdue to a rise in cereals exports following the liberal-ization that started in the 1990s. In Nepal, the growthpattern of per capita availability closely mirrors that of

India. That is expected; given that Nepal is a land-locked country and India is its main trading partner,the food price and supply would depend on the situa-tion prevailing in India.

For Pakistan and Sri Lanka, no obvious patternemerges between trade reforms and per capita avail-ability of cereals. The decline in per capita availabilityof cereals in Pakistan started in the 1970s, even beforethe initiation of trade reforms in the 1980s, when thedecline continued to occur. The 1990s was a periodof recovery, and by 2002, the level of availability percapita was more or less back to the levels of the1971–75 period. Sri Lanka presents a picture of nearlystatic availability per capita over the years, except fora brief rise in the late 1970s, followed by a fall to ear-lier levels in the 1980s. Although the 1990s witnesseda small decline in the per capita availability, the earlyyears of this century have seen a recovery back to thelevels that prevailed in the early 1970s.

Sources: Ahmad et al. 2006; Chowdhury et al. 2006; Jha and Srinivasan 2004; Pyakuryal et al. 2005; Ravi et al. 2004; Weerahewa 2004.

48 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Figure 6 Potential Impact of Technological Changes on Food Production and Consumption

Technological change in agriculture• In production• In marketing

Technological change outside agriculture• Access to services• Access to information

Impact onrelative pricesand relativeprofitabilityof differentproducts

Impact onlabor and incomes ofagriculturalhouseholds

Impact onintroduction

of new products or

varieties

Demand forcaloricenergy

Foodconsumption

Figure 7 Changes in Food Production per Capita over Time

Source: FAOStat (adapted from Diao et al. 2005).

Source: Authors.

Production per capita (index bases 1989–91)

China140

130

120

110

100

90

80

70

60

50

China Asia Developing less ChinaAfrica Developing LACDeveloping Countries World

1960s 1970s 1980s 1990s

Africa Developing

WorldLACAsia

Developing Countries

age consumption, provides a particularly useful il-lustration (box 5).

In contrast, real food prices of the crops subjectto productivity gains declined during the 1980sand 1990s, for the world as a whole and for mostdeveloping countries. Using the IMPACT modeldeveloped by the International Food PolicyResearch Institute (IFPRI), analysts simulated whatfood prices would have been in the absence of theGreen Revolution. The simulated prices were usedto calculate the economic availability of food and,in turn, the impacts on childhood malnutrition.According to the study, had the Green Revolutionnot occurred, the proportion of malnourished chil-dren in developing countries would have been 6 to8 percentage points higher than it is. In South Asia,the percentage would have been 12 to 15 pointshigher (Evenson and Gollin 2003).

Many other agricultural technologies have im-plications for food prices. For fruits and vegetables,

for example, postharvest technology and market-ing are likely to play a more important role in re-ducing prices. Estimates from the Rabobank (2006)conjecture that postharvest losses lead to thespoilage of up to 30 percent of the fruits and veg-etables produced in India. Postharvest losses infruits and vegetables were as high as 50 percent inMalawi in 2001 (Mwangwela 2001). In such a sce-nario, improved postharvest technology could sig-nificantly affect marketing costs and consumerfood prices.

Technology’s impacts on labor and incomes of agri-cultural households. Technological change affects thedemand for agricultural labor and thus the incomeof farm and nonfarm households in rural areas.There are a number of different impact scenarios.As production expands there may be an increase inthe demand for labor that has a positive effect onthe incomes of landless laborers. Alternatively,technological change that leads to more mecha-

The Changing Context of Agriculture and Nutrition Linkages 49

Box 5 Decline in Consumption of Pulses in India: The Effect of Technology and Domestic Policies

Pulses are consumed by almost all categories ofhouseholds in India. Many consumers in India relyon cereals and pulses as primary sources of proteinand calories. This is particularly important in a country in which many consumers exclude meat for religious reasons or for reasons of affordability.According to Price et al. (2003), stagnant productionand a rising population caused the per capita avail-ability of pulses in India to fall between 1979 and2001. That is in sharp contrast to the case of rice and wheat, the availability of which rose steadily.Moreover, the decline occurred alongside increasesin per capita income. This suggests that relativeprices and the availability of substitutes were the factors behind this trend.

Indeed, index data on wholesale prices in India indicate that between 1980 and 2000, prices forpulses rose significantly relative to other food items.The annual growth rate in pulse prices was 2.1 per-cent, five times the growth rate in wheat prices andfour times the growth rate in rice prices. During thesame time period, the annual growth rate in the pricesof edible oils and eggs was negative. Consumption

data show that with changes in relative prices, house-holds exhibit significant substitution toward alterna-tive food products, and to a lesser extent, substitutionamong different pulse varieties.

Although several factors have been at play in caus-ing low levels of pulse production in India, the lack oftechnological progress in pulse production is unques-tionably one of them. With regard to trade policy, noother major food item in India has had a consistentlymore open import regime. Still, pulse imports havebeen low. Part of the reason is the lack of productionof the preferred, low-cost varieties by large supplierslike Canada and the United States. Moreover, the lo-gistical costs for exporters in these distant countriestend to be high, despite the low tariffs and completelack of nontariff barriers.

More important, little varietal improvement has oc-curred in pulses domestically. Yields have remainedmore or less flat since the 1970s. In addition, govern-ment policies have tended to favor cereals such as riceand wheat through support pricing and input subsi-dies. That has further reduced the acreage underpulses in India.

Source: Price et al. 2003.

nization could reduce labor demand. It is possiblethat labor-augmenting and labor-saving technolo-gies could be introduced simultaneously, makingthe impact ambiguous. Technological change mayalso depress prices and, under conditions of lowdemand elasticity, negatively affect the incomes ofsome farmers, particularly those who do not adoptthe technology or those who adopt it late.

A 1993 report (Kennedy and Bouis 1993) pub-lished by the International Food Policy ResearchInstitute provided a number of such examples inwhich agriculture-nutrition linkages workedthrough changes in labor demand. An earlier studypublished in 1987 had examined households thatadopted modern rice varieties in the North ArcotDistrict of Tamil Nadu between 1973 and 1983. Inthose households, the real value of consumptionhad doubled during that period, with a shift toward more varied diets as demand for labor increased during the early phases of the GreenRevolution (Hazell 1987). Subsequent phases of theGreen Revolution, however, saw increasing trendstoward mechanization and related declines inlabor demand (Binswanger and von Braun 1991).The studies examining the relationship betweenagricultural commercialization and nutrition out-comes summarized in chapter 3 included someprojects involving technology adoption. Overall,those studies found that although income and foodexpenditures were affected, impacts on child nu-tritional status were limited and mixed. In a morerecent study, women with the most access to newrice varieties experienced less seasonal fluctuationin body weight, 1.1 kilograms compared with a 2.9-kilogram fluctuation for women with the least ac-cess (Kerr 2006). An earlier study of pregnantwomen in the Gambia indicated that less bodyweight fluctuation between the dry season and therainy season, combined with an additional 500calories a day, would likely lead to improvementsin birth weights (Lawrence et al.1987). These stud-ies dealt with staple crops. For perishable crops likefruits, vegetables, livestock, and fish, access topostharvest infrastructure and affordable technol-ogy are also likely to affect farm incomes.

Technology and the introduction of new food prod-ucts. Agricultural technologies can affect the nutri-tional properties of foods by increasing micro-nutrient content, for example through biofortifica-tion. Biofortified crops can benefit nutritionthrough the own-consumption pathway when

they are consumed by producers, or through theincome pathway if sold, or the food-price pathwayif it makes micronutrient-rich foods more availablein the marketplace.

Plant breeding technologies can also expand therange of crops available for people to plant inhomestead gardens), thus again bringing potentialnutritional benefits through the own-consumptionand food price pathways. For example, a joint FAO(Food and Agriculture Organization) and AVRDC-RCA (Asian Vegetable Research and DevelopmentCenter–Regional Center in Africa ) project to re-duce vitamin A and iron deficiencies sought tostagger the production of different varieties of in-digenous vegetables, many of which are seasonal,to provide greater continuity throughout the year(Aphane et al. 2003).

FOOD MARKETING SYSTEMSThe past 20 years have seen substantial change inthe ways that food is marketed from farm-to-plate.An important development has been the rise of domestic and international marketing systems con-trolled by private actors rather than state market-ing mechanisms. More open trade and investmenthave made buying companies, products, and ser-vices easier across national borders, so creating in-centives for agri-food companies to grow andtransnationalize through vertical integration andglobal sourcing. The modernization of agriculturalmarketing channels has had huge implications foragricultural producers via the income and own-consumption pathway. The increasing importanceof private institutions has strong implications forproducers’ incomes, and new marketing arrange-ments have altered their incentives to sell food intothe marketplace relative to producing for own-con-sumption. The process has also had important im-plications for food consumption patterns byaltering the range and mix of products available inthe marketplace, the price of the food, and the wayit is sold and promoted, all of which affect con-sumption decisions. Three changes in the market-ing chain are particularly important from a foodconsumption perspective: food processing, foodretail, and food exports.

Food processing. Food processors have emergedas important actors in the agricultural marketingchain. Instead of selling crops direct for prepara-tion in the home, agriculture increasingly supplies

50 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

raw materials to the food processing industry forthe production of durable foods. This has implica-tions for nutrition through the food price pathway,because it has altered the availability and prices ofprocessed foods in the marketplace. As food pro-cessing has become a more important componentof the marketing chain, the share of processed foodin total consumption has risen. Global sales ofprocessed foods are US$3.2 trillion, of which aboutUS$2.0 trillion is spent on packaged food andUS$1.2 trillion on beverages. These global figuresare strongly affected by demand in industrializedcountries, where consumers spend about half theirfood budget on processed, packaged foods (Minotand Roy 2006). Consumers in lower-middle-in-come countries spend less on processed foods—about one-third, while in low-income countries likeKenya, India, and Vietnam, the proportion is lessthan 15 percent (Gelhar and Regmi 2005).However, what is notable is that the rate of increaseof expenditure is far higher in developing relativeto developed countries, as shown on Table 6. InIndia, recent evidence points to a notable shift to-ward processed foods over time. A demand modeldeveloped at the International Food PolicyResearch Institute (IFPRI) projects that Indian ex-penditures on processed foods will rise faster thanexpenditures on both total food and nonfoodgoods (Ravi and Roy 2006).

Food retail. Agricultural producers now sell moreand more of their products directly to large-scaleretail outlets (supermarkets, hypermarkets), ratherthan to local markets or to wholesalers. Supermar-kets have been growing rapidly in recent years indeveloping countries, driven largely by the growthof transnational enterprises (Table 7).8 Among

developing countries, supermarkets’ share of theretail food market is highest in middle-incomecountries such as Brazil, Argentina, and Thailand,and lowest in low-income Asian countries, such asBangladesh and Vietnam. Supermarkets in devel-oping countries are better able to handle bothprocessed foods and fresh products, but in mostdeveloping countries, processed foods tend to havea smaller share of the market than fresh fruits andvegetables.

These changes have implications for nutritionthrough the food-price pathway. Supermarketshave the potential to increase or lower food prices(Kuipers 2005; World Bank 2006). Because ofhigher marketing efficiency, food prices in super-markets could be lower. At the same time, therecould be a premium on food prices as a result of theconvenience and the standards that the supermar-kets provide. Also, if the growth of supermarketsleads them to gain dominant market power, theycould exploit the inelasticity of food demand to in-crease prices (Minot and Roy 2006).

Two empirical facts are important to considerwhen trying to assess the potential impact on foodprices. First, supermarkets have not yet become thesupply source for all consumers in developingcountries. There is ample evidence of supermarketsand traditional retail existing side by side. In manyplaces, the emergence of supermarkets has createda segmented market, with the richer sections of thepopulation sourcing their consumption from su-permarkets and the low-income class sourcingfrom traditional retail. Second, in many developing

The Changing Context of Agriculture and Nutrition Linkages 51

Table 6 Annual Average Growth in Retail Sales of Packaged Foods, 1996–2002

Per capita retail sales Total retail growth of Per capita growth of of packaged foods 2002 packaged foods 1996–2002 packaged foods

Country group ($) (%) (%)

High income 979 3.2 2.5Upper middle income 298 8.1 6.7Lower middle income 143 28.8 28.1Low income 63 12.9 11.9

Source: Euromonitor data analyzed by Gehlhlar and Regmi 2005.

8 The data must be interpreted with caution because the defin-itions of supermarkets and retail sales differ across countries.

countries, including those like South Africa, inwhich the coverage of retail by supermarkets ishigh, there is no evidence for any substantial in-crease in food prices.

Two empirical studies provide some insightsinto the impact of supermarkets on food prices.Neven et al. (2006) compared prices in Nairobi su-permarkets with the prices of similar products intraditional retail. The prices of nine fresh produceitems were, on average, 6 percent higher in super-markets, and the prices of processed food productswere, on average, about 3 percent lower. Consumersurveys revealed that the urban poor boughtprocessed foods in supermarkets and fresh pro-duce in wet markets, as would be expected, giventhese price relationships. A similar analysis of hor-ticultural products in Argentina found that theprices for fruits and vegetables were, on average, 6percent and 14 percent higher in supermarkets, re-spectively, relative to traditional retail outlets(Ghezan et al. 2002). However, the average pricefor all food and beverages was 5 percent lower insupermarkets. Despite the large market share ofsupermarkets in Argentina (70 percent in 2000),small fruit and vegetable shops continued to dom-inate horticultural retail sales. The authors cite sur-vey results indicating that 71 percent of fresh fruitsand vegetables were bought from traditional retailoutlets.

Food exports. As already noted, trade liberaliza-tion has enabled a significant increase in theamount of agricultural products that are exportedrather than consumed in domestic markets. Themodernization of agricultural markets has also fa-cilitated the expansion of the development and in-tegration of international food marketing systems,including the extensive supply chains that servelarge food retail industries. Trade liberalization isalso associated with a shift in the commodity com-position of international food trade toward higher-value products, accelerating a trend under waysince the 1960s. Between the 1960s and the 1990s,grain exports fell sharply from 15 percent to 8 per-cent of the total value of agricultural trade (table 8).At the same time, exports of higher-value agricul-tural products, such as fruits and vegetables, meat,dairy products, eggs, and fish and seafood, grewfrom 29 percent to 42 percent of total value. Theshare of fish and seafood, in particular, increasedfrom less than 5 percent to more than 13 percent ofworld agricultural trade.

The composition of agricultural exports has alsochanged in terms of the share of processed versusfresh products. It has been estimated thatprocessed food exports grew 4.2 percent per yearbetween 1980 and 1994—twice as fast as primaryproduct exports (Athukorala and Sen 1998) and,according to FAO, the share of processed products

52 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Table 7 The Growth of Modern Retail in Developing Countries

Growth in supermarkets

Number of Share of supermarkets Annual Information Country Year supermarkets in total food sales Period growth rate source

Argentina 2001 57 (1)Brazil 2001 75 (1)Guatemala 2001 35 (1)Mexico 2001 45 (1)Bangladesh 2004 30 1% 1999–2004 97% (1)India 2000 2% 2003–2008 24-49% (2)Pakistan 2000 800 10% (3)Indonesia 2003 1,307 25% 1989–2002 15% (4), (5)Philippines 1995 3,989 68% 1994-2001 30% (6)Thailand 2004 600 54% 2001-2002 11% (7)Vietnam 2003 <70 <2% (8)China 2003 37,000 30%(urban) 1995-2002 36% (9)

Sources: (1) USDA 2004a; (2) Chengappa et al. forthcoming ; (3) SDPI 2004; (4) Chowdhury et al. 2005; (5) USDA 2003; (6) Digal andConcepcion 2004; (7) USDA 2002; (8) Tam 2004; and (9) Hu et al. 2004.

in agricultural exports increased from 41 percent inthe 1980s to 51 percent in the 1990s (FAO 2004). Thegrowth in the share of agricultural exports that areprocessed can be seen in almost all commodity cat-egories. The exceptions to this pattern are fruitsand vegetables. The share among world agricul-tural exports of both primary and processed fruitsand vegetables has increased during this period,but growth in fresh fruit and vegetable exports hasbeen greater. The proportion of processed foodsthat are exported does, however, remain smallerthan the proportion of agricultural commoditiesthat are exported, probably, in part, arising fromthe higher tariffs imposed on processed products(Gelhar and Regmi 2005).

This changing pattern of exports has implica-tions for nutrition through the food-price pathwaybecause it increases the availability of certain foodsover others in exporting and importing countries(Hawkes 2006, 2007a, 2007b). Whereas consumersin developing countries now consume moreprocessed foods and vegetable oils exported fromdeveloped and other developing countries, con-sumers in developed countries now consume morefruits, vegetables, and fish exported from develop-ing countries. Another important trend is the in-creased export of animal feed, which has enabledthe rapid growth of livestock production aroundthe world. Hawkes (2007a) cites an example fromColombia, in which trade liberalization in the 1990sled to increased imports of corn for animal feedfrom the United States—directly stimulating thegrowth of the poultry industry. Subsequently, poul-try prices plummeted in Colombia and consump-tion soared, whereas beef consumption declined.

FOOD CONSUMPTION PATTERNSEconomic growth, demographic change, urban-ization, and global media and mass marketinghave stimulated rapid changes and diversificationin food consumption patterns. The shifting patternis evident in increasing demand for high-valuefoods relative to cereals and pulses in most devel-oping countries (Popkin 2006). Per capita con-sumption of cereals and pulses contracted duringthe 1990s, while annual vegetable consumptiongrew 3.7 percent; fish and seafood, 2.2 percent; andfruit and meat, between 1 percent and 2 percent(table 9). Less of this food is consumed from own-production and more purchased from the market-place. Regionally, between 1982 and 2002, Eastand South Asian countries saw per capita con-sumption of vegetables and fruits rising quickly.Meat, milk, eggs, fish, and seafood consumptiongrew more slowly, but still increased more thanthe consumption of staples. In 2002, East andSoutheast Asia exhibited the highest per capitaconsumption of vegetables in the developingworld, at 64 kilograms per person per year, andthe highest consumption of fish and seafood, at 26kilograms per person per year.9 Increases in con-sumption of high-value food products were par-ticularly high in China, in which, between 1962and 2002, per capita intake of vegetables grew 4.9percent; fruit, 8 percent; and meat, 8.7 percent. In

The Changing Context of Agriculture and Nutrition Linkages 53

Table 8 Composition of Global Agricultural Food Exports (% of value)

1964–73 1974–83 1984–93 1994–2003

Cereals 19.50 20.94 19.29 19.26Pulses 1.18 1.24 1.53 1.51Meats 9.74 10.97 13.26 13.96Vegetable oils 5.56 7.72 8.51 10.58Fruits 8.90 7.75 9.54 12.07Eggs 0.87 0.85 0.79 0.66Milk 0.22 0.39 0.70 1.19Other 54.03 50.15 46.38 40.77Total 100.0 100.0 100.0 100.0

Source: FAOStat 2007.

9 The FAO definition of fruits and vegetables includes rootcrops such as potatoes and sweet potatoes. Because theseitems are almost staples in some countries, the definitionoverstates the share of the nonstaple food.

2002, the Latin American and Caribbean regionhad the highest annual per capita consumption offruits in the developing world, at 102 kilogramsper person; the highest meat consumption, at 61kilograms; and the highest milk and eggs con-sumption, at 113 kilograms. Processed food con-sumption has risen in all regions.

As part of these trends, the consumption ofhigh-calorie, nutrient-poor foods is also rising, no-tably of vegetable oils, meat, processed foods, andfood prepared away from home. These dietarychanges toward high-calorie, nutrient-poorprocessed and prepared foods are accompanied bychanging, generally lower, levels of physical activ-ity, as occupations shift to service-sector jobs, especially in urban areas. In these settings, con-sumers in developing countries are now experi-encing what is termed the “nutrition transition”toward some of the problems as well as the bene-fits of populations in industrialized countries: therise in overweight, obesity, and associated chronicdiseases like heart disease, hypertension, and dia-betes (Popkin 1999, 2002; Popkin and Du 2003).

As consumption patterns have changed, so haveagricultural production patterns. Global produc-tion of oil crops, for example, increased by about1.9 million tons annually between 1990 and 2005.Production of vegetables has also increasedmarkedly, growing at 4.2 percent per year. An in-creasing share of arable and permanent land is nowused for vegetable and fruit production, and al-most all of this increase is occurring in developingcountries (Minot and Roy 2006). The share of the

arable land used for vegetable and fruit cultivationhas remained stable in the developed countries, buthas increased markedly in most developing re-gions, as reflected in table 10. The share of landused for cereals and pulses production declined indeveloped countries and in Latin America, but re-mained constant or slightly increased in Asia andAfrica, implying that fruits and vegetables have re-placed other crops. The growth in grain productiondeclined from more than 4 percent annually in the1960s to less than 1 percent in the 1990s (table 11).The production of high-value agricultural com-modities in contrast has grown between 2 percentand 5 percent annually during the past 40 years,with the exception of milk, which grew between 1percent and 2 percent.10

These changes in production patterns are inpart a response to changes in consumer demand,in part a stimulator of consumer demand (Hawkes2007a, 2007b). They have implications for nutritionthrough the food-price pathway and also throughthe income pathway because smallholder produc-tion that answers the growing demand for high-value food sources may have a positive effect on

54 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

10 The shift in Chinese production has been particularly dra-matic. China reduced the share of arable land in cereals byhalf between 1975 and 2002, while grain productivity almostdoubled. The share of land used for fruit production has in-creased from 2 percent in the late 1970s to 6 percent in 2002.Similarly, for vegetables, land use has risen from 3 percent inthe mid-1970s to 13 percent in 2002. In 2002 China accountedfor 47 percent of total world vegetable production (in volumeterms) and 15 percent of fruit production.

Table 9 Average Annual Growth in Global per Capita Consumption of Various Food Items (%)

Food item 1962–71 1972–81 1982–91 1992–2002 1962–2002

Cereal (excluding beer) 0.5 0.8 0.4 –0.4 0.3Pulses –2.0 –1.5 –0.3 0.0 –1.0Vegetables –0.3 0.8 1.4 3.7 1.5Fruits (excluding wine) 1.5 0.5 0.8 1.8 1.2Milk (excluding butter) and eggs 0.1 0.2 0.0 0.6 0.2Meat 1.8 1.1 1.1 1.3 1.3Fish, seafood 2.0 0.8 1.0 2.2 1.4Years for vegetable oils 1990–95 1996–2004Vegetable oils 1.35 2.84

Source: FAOStat 2005.Note: Consumption is measured in kilograms. Data for fish and seafood are up to 2001.

the producer’s consumption by raising income.For example, in South and Southeast Asia, diver-sification into high-value food commodities led tothe development of innovative supply chains,opening new prospects for augmenting income,generating employment, and promoting exports(Barghouti et al. 2004; Pingali 2004; Deshingkar etal. 2003; Pokharel 2003; Wickramasinghe et al.2003; Goletti 1999). Food security, moreover, im-proved in regions in which agricultural diversifi-cation took place in favor of horticulture, animalhusbandry, and aquaculture (Barghouti et al. 2005;Dorjee et al. 2002).

From the perspective of poverty reduction, di-versifying production toward high-value crops isparticularly appealing. Most high-value food com-modities such as fruits, vegetables, poultry, and

fish are labor-intensive, have low gestation peri-ods, and generate quick returns. These qualitiesserve to make them highly suitable for smallhold-ers, representing an often perfect opportunity toutilize their surplus labor and augment their in-comes (Barghouti et al. 2004; Weinberger andLumpkin 2005). Whether a smallholder-dominatedeconomy can actually diversify and whether small-holders participate substantially in the diversifica-tion of production toward high-value products iscontext specific. A 2006 assessment of diversifica-tion toward high-value crops in India from thepoint of view of participating smallholders foundevidence that the probability of a household diver-sifying into vegetable cultivation is higher forsmaller farmers (Birthal et al. 2006). Vegetable cul-tivation was preferred over fruit cultivation, which

The Changing Context of Agriculture and Nutrition Linkages 55

Table 10 Average Annual Share of Arable and Permanent Land Used for Harvest (%)

Agricultural item and region 1962–71 1972–81 1982–91 1992–2002 1962–2002

Cerealsa 48.4 49.5 47.6 45.0 47.6Africa 38.9 37.2 40.0 44.7 40.3East and Southeast Asia 54.4 55.1 53.8 53.8 54.3Latin America and Caribbean

Caribbean Caribbean 35.4 35.1 33.8 29.4 33.3South Asia 60.2 62.7 63.4 62.2 62.1Developed countries 43.1 44.8 42.5 38.1 42.0

Pulsesa 4.8 4.3 4.5 4.5 4.5Africa 5.9 5.5 5.7 7.9 6.3East and Southeast Asia 2.2 2.5 2.7 3.6 2.8Latin America Caribbean 5.7 5.7 6.1 5.0 5.6South Asia 13.0 12.8 12.9 12.1 12.7Developed countries 2.0 1.4 1.7 1.4 1.6

Fruits (excluding melons)a 1.9 2.2 2.6 3.1 2.5Africa 3.0 3.5 3.9 4.2 3.7East and Southeast Asia 2.5 2.8 3.2 3.7 3.1Latin America Caribbean 2.2 2.7 3.6 4.1 3.2South Asia 1.1 1.2 1.6 2.1 1.5Developed countries 1.8 1.9 1.9 1.9 1.9

Vegetables (including melons)a 1.7 1.7 2.0 2.6 2.0Africa 1.4 1.6 1.9 2.2 1.8East and Southeast Asia 2.8 3.0 3.1 3.4 3.1Latin America Caribbean 1.2 1.1 1.2 1.3 1.2South Asia 1.9 2.3 2.7 2.9 2.4Developed countries 1.2 1.2 1.2 1.2 1.2

Source: FAOStat 2005.aData correspond to world average.

is generally less labor-intensive and more capital-intensive (with respect to start-up and workingcapital); both of these characteristics are to the dis-advantage of small farmers.

The transition toward high-value agriculture is,however, not without constraints, especially forsmallholders. When the high-value commoditiesare products the farmers have not grown before,they will lack information on production methods,marketing opportunities, and the probable distrib-ution of net returns. This problem can be particu-larly acute when producers have to satisfy highlyspecific quality and food safety requirements(Minot and Roy 2006). Larger farmers are also oftenbetter able to bear the risks associated with pro-ducing and marketing high-value commodities.Furthermore, for a small farmer to allocate land toa commercial crop may imply depending on mar-ket purchases to meet food requirements, an addi-tional source of risk. Some high-value agriculturalcommodities also require significant investment,including the use of specific inputs. Fruit produc-tion involves planting trees and waiting 3-5 yearsfor them to begin producing. Farmers in develop-ing countries, particularly poor farmers, often lackthe savings or access to credit needed to make theseinvestments. In the case of highly perishable high-value commodities, production locations near mar-kets and good marketing infrastructure areparticularly important (Torero and Gulati 2004).Small farmers are also less likely to enjoy access topostharvest technologies. Yet the competitiveness

of small farmers relative to large farmers is notfixed and can change over time, usually as a resultof changes in physical, human, or social capital.Farmers may acquire new equipment or buildphysical capital, like irrigation works, that reducesthe cost of production. Farmer’s skills and humancapital change over time as a result of learning-by-doing, aided in some instances by technical assis-tance provided by buyers (Minot and Roy 2006).

CONCLUSIONSChanges in agricultural policy, technology, mar-kets, and associated changes in food consumptionpatterns are affecting the dynamics of the pathwaysbetween agriculture and nutrition. Today, the moremarket-oriented nature of agricultural policiesmeans that agricultural technology and marketsplay a more important role in determining foodprices and rural incomes, and more food is con-sumed from the marketplace rather than from own-production. The greater market orientation of foodproduction and consumption has increased thebidirectional links between agriculture and nutri-tion: agriculture still affects nutrition, but food andnutritional demands increasingly affect agriculture(Hawkes and Ruel 2006b). It is a twofold process.First, the increasing importance of the cash econ-omy arising from changes in agricultural policy,technology, and markets, and from rising incomesand urbanization, is increasing the power of con-sumers in the marketplace. Second, the rise of food

56 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Table 11 Worldwide Annual Average Growth in Food Production (%)

1962–71 1972–81 1982–91 1992–2002 1962–2002

Africa 38.9 37.2 40.0 44.7 40.3Cereals (excluding beer) 4.1 2.4 1.5 0.7 2.1Pulses 0.6 -0.2 2.9 0.4 0.9Vegetables 1.7 2.7 3.2 5.2 3.2Fruits 3.4 2.1 1.8 2.8 2.5Milk (excluding butter) and eggs 1.5 1.8 1.4 1.3 1.5Meat 3.9 2.9 2.9 2.7 3.1Fish and seafood 5.4 1.4 2.8 2.9 3.0Vegetable oils 4.11 4.25 4.07 4.42 4.35Oil crops 3.30 3.96 3.31 3.90 3.63

Source: FAOStat 2005.Note: Production is measured in metric tones. Vegetables include root crops such as potatoes and cassava. Fish and seafood datapertain to 1962–2001.

marketing institutions, such as food processors, re-tailers, and exporters, is reducing the power of agri-cultural producers in the agricultural supply chain.

The rising role of the market has implications forthe relative importance of each of the pathways be-tween agriculture and nutrition: in general, the linkbetween agriculture and nutrition is becomingmore distant as income and food prices becomemore important in determining food consumptionpatterns relative to own-production. Agriculturalprograms with nutritional objectives need to takethis changing context into account. With the risingrole of the consumer in the marketplace, there are

more opportunities for nutrition-focused agricul-tural interventions to improve the nutrition of netfood consumers rather than just net producers.There are also more opportunities for changingfood consumption patterns among food consumersto be exploited as a means of indirectly improvingnutritional outcomes among producers (via in-come and price). Although not dealt with in thischapter, it would also be important to take into ac-count the impact of changing contexts on the em-powerment of women agriculturists and thedevelopment of human capital, given their criticalrole in improving nutritional outcomes.

The Changing Context of Agriculture and Nutrition Linkages 57

59

The viability of using agricultural interventions to improve human nu-trition outcomes has been empirically established by case studies andanalyses like those presented in earlier chapters. These provide im-portant precedents with valuable lessons for the planning and designof agricultural programs and interventions. While nutritional status it-self is an individual-level attribute, the determinants of nutritional sta-tus extend far beyond the control of the household of which theindividual is a member. Institutions are identified as “basic” determi-nants of nutritional status in the UNICEF conceptual framework pre-sented in chapter 2. Government institutions establish policies andpriorities and implement programs that affect nutritional outcomes atthe aggregate national as well as at the household and individual lev-els. They can therefore be instrumental in ensuring that agriculturalprograms are effective in meeting national nutritional goals.

Agriculture ministries clearly have a central role to play in scalingup pilot agricultural programs and interventions, but experience hasdemonstrated the insufficiency of approaching nutrition entirelyfrom the production side. Nutrition is, of course, also a consumption-side issue. Health and education, in particular, pertain to nutrition inrelation to their essential roles in human capital formation and inhuman development. Yet prescribing systematic coordination be-tween different sector institutions as a means of achieving a morecomprehensive approach to improved nutrition is problematic, giventhe bureaucratic barriers that characterize the administrative divisionof responsibilities and jurisdictions between them.

This chapter examines the barriers that inhibit sectorally-definedinstitutions from organizing and carrying out joint cross-sectoral ef-forts to improve nutrition outcomes at a national level. It also identi-fies possible opportunities to work around these barriers to achievegreater impacts that no one sectoral institution is capable of. Its focusis on government institutions, based on the assumption that govern-ments are chiefly responsible for providing infrastructure, resources,and services to promote and maintain the social and economic wel-fare of its citizens. The focus on government institutions is not to sug-gest that nongovernmental actors cannot make importantcontributions to improved nutrition. Nongovernmental organiza-tions often provide many of the multisectoral goods and services thatthe undernourished require. Indeed, nongovernmental organizationswere responsible for the success of a number of nutrition-orientedagricultural interventions reviewed in this report. Detailed analysisof the specific role of nongovernmental organizations in effectively

Institutional Frameworksfor Action in the

Agriculture Sector toAddress Undernutrition

6

linking agricultural interventions to improved nu-tritional outcomes is, however, beyond the scope ofthis report.

INSTITUTIONAL BARRIERS TOCOORDINATED ACTION INNUTRITIONThe conceptual framework of the determinants ofnutritional status is useful in identifying the sec-toral institutions that are directly relevant to im-proving nutrition and in mapping their roles in anycoordinated efforts to address nutrition issues.However, in the details of undertaking these effortswithin the bureaucracy of the state, the clarity ofthe framework is often lost, as barriers to mountingharmonized efforts across the various sectors ofstate are encountered.

“Bureaucracy” has long carried negative conno-tations of inflexible or convoluted procedures thatimpede rather than facilitate effective collective ac-tion. Yet bureaucracies have emerged as a gener-ally successful solution to the problem ofmanaging the activities of states and other large or-ganizations, being organized ideally on the basis ofclear goals, a rational coordinated functional spe-cialization of subunits, formal operating proce-dures, and clear lines of authority. In virtually allcountries, the state is organized administrativelywithin a bureaucratic framework of sector min-istries, which includes separate ministries for

health, education, agriculture, and trade. The exer-cise of political and administrative power followsthis framework, and resource allocations, incen-tives, and systems of accountability are managedaccordingly.

The underlying difficulties constraining agricul-ture and other sectoral institutions from effectivelyacting in concert to address the problem of under-nutrition stem from the nature of the state bureau-cracy. Most bureaucracies are not organized in amanner that facilitates broad, effective actionacross sectors to address a problem. Even thoughundernutrition might be the responsibility of thepublic sector, the sectoral organization of the pub-lic bureaucracy clearly hinders undertaking the ac-tion necessary.

To identify the bureaucratic elements that werefound to impede efforts by the state to address un-dernutrition in a comprehensive cross-sectoral man-ner, an institutional study of the linkages betweenagriculture and nutrition was carried out in Ghana,Mozambique, Nigeria, and Uganda as a componentof the Agriculture-Nutrition Advantage (TANA)project described in box 7. The study identified fourparticularly important overlapping barriers thatprevent the problem of undernutrition from beingaddressed by the agricultural sector jointly with thehealth, education, and other relevant sectors: the re-source allocation and planning processes within thebureaucracy, differing sector mandates and priori-ties, differing sectoral worldviews, and capacityconstraints for nutritional analysis within sectors.

60 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Box 6 Situating Nutrition Administratively within the Public Sector

Within the institutional structure of most states, nutri-tion rarely stands as a sector in its own right. It typi-cally falls somewhere within the lower organizationallevels of the health ministry, often as a department inthe public health subsector—reflecting a predomi-nantly medical view of malnutrition as a public healthissue. Alternatively—and reflecting the multisectoraldeterminants of malnutrition and its significance as adevelopment problem—nutrition may be situated ad-

ministratively within a coordinating body led by an in-tersectoral agency. This agency is sometimes housedwithin a prime minister’s office or ministry of financeor planning. In Nigeria and Mozambique, both typesof institutions may be found, with that in the Ministryof Health responsible for implementation of nutrition-related public health activities, whereas strategic andpolicy issues are the concern of the nutrition coordi-nating body.

Source: Benson et al. 2004.

RESOURCE ALLOCATION ANDPLANNINGResource allocation processes of budgeting and per-sonnel management often make it difficult to mountcross-sectoral action within a state bureaucracy. Likeall economic entities, the state functions under con-ditions of limited resources. Consequently, each sec-tor, in seeking to carry out its mandates, willcompete with other sectors for the resources it re-quires. Typically, the resource allocation process ofgovernment is judged a zero-sum game. For exam-ple, a state-level nutritionist interviewed for thestudy in Nigeria noted that funding is at the core ofwhy there is little interaction between the agricul-ture and health sectors:

“Everyone wants to be in charge. If [theHealth sector] writes proposals that includesome agricultural components, [the Agricul-ture sector] is unhappy with Health, as Agri-culture feels that Health is on their turf, taking resources that should be theirs.”(Benson, forthcoming)

Moreover, if independent assessments are madeof the way a sector made use of the resources it re-ceived, sector-specific criteria are generally used asthe criteria. The resource allocation mechanismsprovide no incentives for carrying out joint coordi-

nated activities that would achieve a higher level ofimpact. That being the case, the attainment of nu-trition objectives will tend not to be advanced byroutine sector planning mechanisms. In this re-gard, sectorwide approaches to planning are likelyto make efforts to address undernutrition in a co-ordinated, cross-sectoral way even more difficult toundertake, as discussed in box 8.

SECTOR MANDATES ANDPRIORITIESFormally stated mandates and objectives are im-portant organizing mechanisms for bureaucraciessince they help to define courses of action and todistinguish areas of institutional specializationwithin the bureaucracy as a whole. They define thescope of action for a sector or institution and serveto identify the particular, unique competencies thatthe institution should possess to meet those objec-tives. These priorities also feed back into the plan-ning system because they are the basis by which aninstitution or sector can make substantive claimson state resources. Moreover, for the individualcivil servant working in a sector ministry oragency, personal incentives such as career ad-vancement tend to revolve around the contributionthat each makes to the attainment of these sector-

Institutional Frameworks for Action in the Agriculture Sector to Address Undernutrition 61

Box 7 The Institutional Study under the Agriculture-Nutrition Advantage Project

The Agriculture-Nutrition Advantage (TANA) project,which ran from 2001 through 2004, aimed tostrengthen and expand linkages between nutritionistsand agriculturists, particularly through employing gen-der-sensitive approaches to reduce hunger and under-nutrition in Ghana, Mozambique, Nigeria, andUganda. In each country, the project was centered onthe activities of national project teams made up ofagriculturists, nutritionists, and gender specialists. Theproject was implemented by the International Centerfor Research on Women in partnership with theInternational Food Policy Research Institute.

The objective of the institutional study under theTANA project was to assess the extent to which the

agriculture and nutrition communities in each countrywork as partners to reduce malnutrition, to gauge thepotential gains from increased collaboration, and tounderstand the various constraints to such collabora-tion. Principally a qualitative study, the scale of analy-sis was at the national level in the four projectcountries. Key documents that focused on food, nutri-tion, agricultural development, and master develop-ment planning in each country were reviewed. Thedocumentation obtained before fieldwork beganserved to guide the broad content of the interviewssubsequently carried out. Between 30 and 40 semi-structured interviews with agriculturists, nutritionists,and policy makers were conducted in each country.

Source: Benson et al. 2004.

specific objectives, rather than broader, multisec-toral development goals.

The problem for nutrition as a development pri-ority is that addressing the problem of undernutri-tion may not be accepted by any one sector as apriority for which it is responsible and towardwhich it will allocate the resources it controls, in-cluding human resources. Particularly as doing sorequires engagement with other sectors to addressthe problem sustainably, there are compelling prag-matic reasons for agricultural and other state insti-tutions to judge that it should not be among theirprimary concerns. Improved nutrition can be de-fined among a set of secondary objectives for a sec-tor. However, with multiple objectives, the chancesof conflict emerging between the various objectivesof a sector are more likely. Some prioritization is re-quired. A senior agricultural researcher in Nigerianoted that agriculturists have historically been mostconcerned with raising yields and, second, with theprofitability of farming. Certainly, they may be will-ing to take into account nutritional considerations,but at the end of the day, he asserted, increasingcrop yields is the principal criterion used to judgethe effectiveness of agriculturists in Nigeria(Benson et al. 2004). Consequently, one generallysees little evidence in the organization of the agri-cultural sector of any effective attention being paidto what are seen as secondary concerns, such as nu-trition. Thomson (1978) notes that most national-level ministries prefer mandates that are entirelywithin their own sectoral sphere of influence andcontrol. “Such circumscribed objectives are muchless time-consuming and much more easily admin-istered; rivalries, jealousies, and frustrations arelessened; and it is more satisfying to the personalambition of the ministry staff; as credit for success

cannot be in dispute and any lack of success is moreeasily locked away in the ministry’s cupboard.”Attaining nutrition objectives clearly requires arange of action that is less neatly circumscribedwithin a single sector.

UNIQUE SECTORALWORLDVIEWSThe specialized training that sector specialists re-ceive tends to lead to discrete, nonoverlappingareas of expertise and qualitatively differentworldviews. Knowledge and information that per-tain directly to one’s own discipline is selectivelyembraced, while other matters are discarded fromconsideration as being irrelevant to the attainmentof sector objectives. Agriculture-sector objectivesrelate principally to increasing yields, profits, andother benefits that farmers derive as producers. Assuch, the language and methods that agriculturistswill use, both in technical analyses and in imple-mentation of programs, will be quite different fromwhat are used in other sectors, such as health andeducation. Nutrition considerations will not fitneatly or completely into the worldview of agri-culture or, for that matter, any of the core sectors ofgovernment.

The significance of this factor was observed inMozambique, in which the Technical Secretariatfor Food Security and Nutrition (SETSAN), a cross-sectoral food security and nutrition coordinationbody for which the Ministry of Agriculture pro-vided secretariat services, was seen by most ob-servers to perform its functions with regard to foodsecurity issues reasonably well. However, SETSANhad no nutrition experts among its staff and hadnot developed a conceptual approach to guide its

62 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Box 8 Nutrition and Sectorwide Approaches to Planning

The sectorwide approaches (SWAps) to policy formu-lation, planning, and implementation that have beenpromoted in many developing countries in recentyears, including in agriculture, tend to work againstnecessary cross-sectoral efforts to address develop-ment problems. Yet, such SWAps have their own logicof effectiveness and efficiency that is difficult to reject.

Thus, in making use of them, explicit recognition ofthe contributions that the sector concerned can maketo addressing cross-sectoral development problems,such as undernutrition, must be included in the scopeof such planning exercises. Otherwise, they are likelyto retard rather than foster progress in reducing under-nutrition.

Source: Authors.

work in addressing malnutrition in the country.Consequently, despite its relative successes in ad-dressing food security issues, because of difficul-ties in defining how nutritional problems in thecountry should be addressed, SETSAN was felt tohave generally failed to coordinate cross-sectoralefforts to address malnutrition (Benson et al. 2004).The observed lack of cross-sectoral exchange or un-derstanding as a factor impairing action to addressundernutrition is not uncommon. The lack ofshared perspectives, concepts, and practices fre-quently results in the various sectors that couldwork jointly to address undernutrition finding itdifficult to find common ground from which tolaunch such efforts (Maxwell and Conway 2000).

CONSTRAINED CAPACITY FORNUTRITIONAL ANALYSISIdentifying the cause of a nutritional problem iscentral to mounting effective action to address it.Ignorance of what are the determinants of poor nu-tritional status and an inability to ascertain what re-sources and actions are needed to sustainablyreduce undernutrition in a particular context arepart of the explanation for the inability of agricul-turists or specialists in other sectors to address theproblem of undernutrition (Gillespie 2001). Thiswas seen in all four countries in which the TANAinstitutional study was conducted. In Mozambique,fewer than a dozen nutritionists have master’s levelor higher backgrounds. In Nigeria, on the otherhand, the skills of hundreds of professional nutri-tionists have not been applied effectively across sec-tors, and no positive trends in undernutrition are in evidence. In the agricultural sector in all fourcountries, staff with expertise in nutrition was either absent (Nigeria and Mozambique), withering(Uganda), or relatively isolated within the sector(Ghana) (Benson et al. 2004). Consequently, it is notnecessarily surprising that the agriculture sector ineach of these countries was seen to be contributingto improved nutrition only indirectly, if at all.Building capacity for nutrition analysis among spe-cialists across sectors increases the probability thatthey will recognize the synergies that can be at-tained by undertaking efforts in concert.

The barriers to the agricultural sector in most de-veloping countries accepting some of the responsi-bility for the problems of undernutrition in societyare quite substantial. Many of these barriers are not

perverse, but reflect, first, a rational organization ofthe state into sectors that enable it to fulfill many ofits duties and, second, the fact that nutrition con-cerns fit poorly within this bureaucratic organiza-tion. Barriers also emerge because the areas ofexpertise, the analytical methods, and the tools thatagriculturists bring to the tasks with which they arecharged are quite different from many of those thatare needed to address undernutrition comprehen-sively. For a broad effort to reduce undernutrition,agriculture will need to overcome the many diffi-culties of communication and coordination of ac-tivities across its sectoral boundaries. In the nextsection, several approaches by which agriculturecould institutionally play a greater role in reducingundernutrition are assessed.

INSTITUTIONAL MECHANISMS TOENABLE AGRICULTURISTS TOADDRESS UNDERNUTRITIONThe various institutional barriers that hamper theagriculture sector from acting either alone or withother sectors to effectively and sustainably reduceundernutrition are not easily overcome. Giventhese constraints, it is unlikely that any single solu-tion to overcoming them can be found in most con-texts. Rather, a more opportunistic, incrementalapproach will most likely yield more durable re-ductions in undernutrition. This section considersseveral possible components of efforts that theagricultural sector could be a part of or undertakeon its own to address undernutrition: multisectoralnutrition planning agencies; cross-sector issues aspolicy priorities; the inclusion of nutrition objec-tives in agricultural activities; community-drivendevelopment; and including nutrition topics inagricultural training.

Multisector Nutrition Planning Agencies

The cross-sectoral nature of the determinants ofnutritional status has long been recognized. A com-mon approach in grappling with the problems ofmounting necessary action to address undernutri-tion across disparate sectors has been to establishnational multisectoral nutrition planning agenciesto ensure that coordinated efforts are undertaken.However, of the many such agencies that were setup in the 1960s and 1970s, few catalyzed substan-tial reductions in malnutrition. Without any real

Institutional Frameworks for Action in the Agriculture Sector to Address Undernutrition 63

authority over the range of sectors involved, theyproved ineffective in coordinating efforts acrossthese sectors. Moreover, as the political leaderswho championed their formation turned their at-tention to other issues, the material commitment ofgovernment to address malnutrition dwindled,and the agencies were starved of operational re-sources. Consequently, in the following decades,coordinated cross-sectoral programs to reducemalnutrition in many countries were replaced bysector-specific projects focused primarily on tech-nical nutrition interventions (Levinson 2000).

Such multisectoral coordination agencies re-main a common feature of national strategies to address undernutrition. Few of these agencies established in recent years demonstrate any greatersuccess than those created 30 to 40 years ago.Mozambique, Nigeria, and Uganda have estab-lished such agencies during the past 5 to 10 years,with no evidence of greater or more effective im-pacts on malnutrition than in Ghana, in which nosuch agency is in place (Benson, forthcoming). Thechallenges of cross-sectoral coordination remain asdaunting now as they were in the past, with agen-cies generally lacking adequate authority or resources to introduce incentives to compel cross-sector coordination.

In reflecting on why many such attempts at co-ordinating efforts to address undernutrition havebeen unsuccessful, a clear problem relates to theseagencies’ scope of action. The agencies frequentlyhave been too involved in implementation, partic-ularly when they have insufficient authority to di-rect how the sectors concerned actually go abouttheir tasks. Heaver (2005) suggests that a betterarrangement would be to allow the sectors the lat-itude and resources to carry out their own pro-grams, with the nutrition coordination agencybeing granted the necessary authority to defineoverall policies and strategies and to guide the al-location of resources. Government should makeuse of the existing sectoral infrastructure to imple-ment programs, however imperfect it may be, andbuild on what is already in place (Kennedy 1994).A lesson that seems to have been widely recog-nized, if not widely learned, is to “plan multi-sec-torally, but implement sectorally” (Maxwell andConway 2000).

As such, multisectoral coordination agencieshave a place in the implementation of governmentstrategies to sustainably reduce levels of undernu-

trition. With sufficient authority and resources,cross-sectoral coordination bodies can ensure thatproper incentives—both positive and negative—are introduced to motivate sector institutions toprioritize activities and allocate resources targetingimproved nutrition outcomes. Cross-sectoral nutrition coordination bodies can operate the accountability mechanisms needed to ensure that sector agencies carry out their mandated nutrition-related activities in alignment withbroader government strategies to address malnu-trition. Moreover, such agencies should be ex-pected to continually engage in relevant nationaland sectoral policy processes, including in agricul-ture, to ensure that undernutrition continues to beviewed by political leaders and sector managers asa development priority (World Bank 2006a).

Cross-Sector Issues as Policy Priorities

In a normative sense, formal policies define in quiteexplicit terms what is considered the commongood for the citizens of a nation and serve as state-ments of how government intends to prioritize itsactions and its expenditures. Formal statements ofpolicy are arguably more important for definingpriorities when related to issues, such as nutritionissues, that fall outside of sector-specific interests.Whereas sector-specific mandates and worldviewsserve to motivate action to address issues that fallwithin the competencies of a single sector, such in-centives are absent for cross-sectoral issues.Making it clear that the priorities of government in-clude mounting effective action to reduce under-nutrition is one way in which sector priorities canbe swayed toward paying closer attention to theneeds of the undernourished. Public resource allo-cations to the agriculture sector may be made con-tingent on how much the sector has contributedand plans to contribute to the attainment ofbroader development objectives, such as those ar-ticulated in a master development plan or aPoverty Reduction Strategy. This can put in placestronger incentives for agriculturists to formulatework plans that go beyond their traditional narrowsectoral objectives. With that objective in mind,Ugandan nutritionists participated effectively in2004 in revising the Poverty Eradication ActionPlan, the government’s master development strat-egy, resulting in heightened attention to undernu-trition within this broader policy (Benson et al.

64 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

2004). However, follow-up research is needed todetermine whether the increased emphasis on nu-trition in this policy actually has led to increased at-tention to the problem of undernutrition in theannual work plans of the various state sectors inUganda or in the allocation of resources to attainimproved nutrition objectives.

For such high-level policy statements to influ-ence sectoral efforts to address undernutrition, sus-tained interest by political leaders in attainingbroad improved nutritional outcomes is required.Political champions for the attainment of improvednutrition are needed: individuals who are politi-cally well connected, are persistent in character,and have access to many of the multiple arenas andinstitutional venues in which policy debates areundertaken. Such champions have been shown tobe a key element in several instances in which sig-nificant changes were brought about in the prioritygiven to state efforts to combat undernutrition(Rokx 2000). Similarly, international donors canprovide important incentives by providing fund-ing and capacity building opportunities to agenciesin the agricultural sector or other sectors so thatthey can work toward reducing the numbers of theundernourished in a country or area. However, ifimplemented in a one-off fashion, the sustainabil-ity of such changes is open to question (Winikoff1978). If attention to undernutrition enjoyed a highprofile in national policy process or in donor prior-ities, subsequent changes in leadership of govern-ment or of donor organizations often result in adiminished profile for nutrition as a developmentobjective. Continual strategic advocacy for nutri-tion action thus becomes an important element ifagriculture and other sectors are to undertake ac-tions at a level and for a length of time sufficient tobring about substantive reductions in the numbersof undernourished in the population.

Nutrition Objectives for AgriculturalActivities

Activities with clear nutrition implications in theagricultural sector have been the focus of much of the technical content of this report. These in-clude the production and consumption of staplefood crops, fruits and vegetables, and animalproducts that are rich in micronutrients or other-wise contribute to a high-quality diet and the use of agricultural communication channels to

enhance nutritional knowledge within farminghouseholds. Although their success in contribut-ing to improved nutritional outcomes varies de-pending on the pathways by which the desirednutritional effects are obtained, such activities docompel their implementers in the agricultural sec-tor to undertake nutritional analyses to identifythe nutritionally vulnerable in the population inwhich they work and to diagnose the causes ofthat malnutrition. Such analyses, if conducted inan informed manner, will highlight the importantcontribution that agricultural initiatives can makein assisting the undernourished, the need for com-plementary action on the part of other sectors, andthe importance of improved nutrition as an inputto a more productive agricultural sector. With suf-ficient political support, initial efforts by agricul-turists to contribute to improved nutrition shouldincrease in scope and complexity as the determi-nants of improved nutrition are increasingly madeclear to those involved through practice. The nu-trition objectives of agricultural activities can fos-ter a more holistic vision of what is needed acrossthe various public sectors to sustainably improvenutrition. However, progress in this regard is notassured, as the example in box 9 shows.

Community-Driven Development

Community-directed efforts also can provide im-portant incentives for agriculturists to contribute toefforts to reduce undernutrition, often working inconcert with other sectors. Community-driven de-velopment (CDD) gives control of many local de-velopment activities to those who will be mostaffected by them, the local residents (Dongier et al.2003). When governments support such efforts,they usually also commit to contributing state re-sources and expertise to the community as itsmembers work to realize their development ambi-tions. However, communities are unlikely to prior-itize their development needs neatly according tounique sectoral competencies (Mason 2000). Thatbeing the case, community expectations that stateagencies will help them address a problem requir-ing contributions from multiple sectors, such as un-dernutrition, provide important incentives forcross-sectoral action to be undertaken. In instancesin which governments are strongly committed tosupporting community-driven efforts, there maybe sufficient incentives from community demands

Institutional Frameworks for Action in the Agriculture Sector to Address Undernutrition 65

for cross-sectoral activities to flourish despite thebureaucratic organization of the sectors. For exam-ple, community nutrition programs that involvecross-sectoral teams from government agencies inproviding community facilitation services have ledto substantial reductions in undernutrition in sev-eral Asian countries (Tontisirin and Gillespie 1999).

Moreover, the local scale at which action willbe taken by the agents of the various public sec-tors concerned also may enable such action to beperformed more easily. The resource conflicts be-tween sectors that were noted as constrainingcross-sectoral undertakings typically play out atthe national level in most countries. At more locallevels, civil servants may have more limited con-trol over how resource allocations are madeacross the sectors. However, the ability of local-level state agencies to work collaboratively in as-sisting communities will vary on a case-by-casebasis. In both Ghana and Uganda, countries inwhich the decentralization of state functions hasprogressed to a greater extent than in most other

African countries, district-level agriculturistsstated that local concerns were not necessarilymore important than sectoral concerns in guidingtheir actions (Benson et al. 2004). These agricul-turists were still subordinate to sectoral superiors,they operated with limited resources, and manyof the incentives that motivated their individualefforts hampered rather than fostered cross-sec-toral action to assist communities. Consequently,although community-driven development maypromote increased attention from agriculturists tolocal nutrition problems, there is no guaranteethat it will do so.

Nutrition in Agricultural Training

As was shown earlier in the review chapters, agri-culture may provide important elements neces-sary for sustained improvements to nutritionalstatus in specific contexts, particularly amongfarming populations. If improving nutrition is ahigh priority development objective of govern-

66 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Box 9 Home Economists as Agricultural Extension Agents

Progressive increased attention to nutrition withinagriculture is not assured. Agricultural extension ser-vices offer a case in point. Such services provide achannel for reaching rural smallholder householdswith information on how they might provide bettercare to their nutritionally vulnerable members. In the1970s and 1980s, recognizing this, many extensionservices in Sub-Saharan Africa, including Ghana andUganda, included among their fieldworkers homeeconomists, most of whom were women. Their func-tion was primarily to work with women in farminghouseholds on both production and consumption is-sues, including nutrition. However, during the past 20years, most extension services have been reorganized,including through programs of “professionalization,”whereby field extension agents had to meet minimumprofessional qualifications to be retained in the ser-vice. Because these qualifications were primarily agri-

cultural production-oriented, most home economistswere eliminated from extension services.

Moreover, the service has also become more maledominated as a result. That is due to gender sorting inschool, in which boys are more likely than girls to fol-low the natural sciences-focused course of study neces-sary to attain professional qualifications in agriculture.Several important determinants of nutritional statushave strongly gendered characteristics, particularlybreastfeeding, weaning, childcare, and meal prepara-tion. Consequently, although information on such nutri-tion concerns may still feature among information thatextension agents offer to farming households, male ex-tension agents are a poor choice as messenger on thesetopics. We should expect that the level and quality ofknowledge on nutrition obtained by farming house-holds from extension agents certainly has not improvedwith the restructuring of extension services.

Source: Benson et al. 2004.

ment, attaining that objective will require a moresophisticated understanding of the determinantsof improved nutrition by professionals in the pub-lic sectors concerned. Providing training inhuman nutrition to agriculturists is an importantcomponent of this objective. Whatever the sectoror sectors, “the choice of the most appropriate in-tervention will depend on who is malnourishedand why” (Kennedy 1994). Providing training innutritional analysis will make it more likely thatagricultural projects and programs that seek toimprove the nutritional status of the target popu-lation will be based on a clear conceptual and an-alytical framework for the way the nutritionalgoals will be attained. Similarly, it will also allowfor better identification and understanding of theneeds of the undernourished that the agriculturalsector can assist in meeting and enable bettermonitoring of project performance in meetingthose needs. However, few countries, if any, nowrequire that their agricultural trainees acquire abasic understanding of the determinants of im-proved nutrition.

CONCLUSIONSThe institutional barriers that agriculturists, partic-ularly those in the public sector, face in trying tomount effective action to assist the undernourishedare durable and strong. The fact that the organiza-tion of these institutions is relatively ineffective foraddressing the problem of undernutrition in soci-ety is unlikely to be sufficiently compelling to causethese institutional structures or the manner inwhich they operate to change. Consequently, al-though strong action by the agricultural sector orbroad coordinated action by several sectors maylogically appear to be required to reduce levels ofundernutrition, in practice an opportunistic ap-proach may be more effective. Such a strategywould use existing individual activities in the agri-cultural sector and in other sectors in an instru-mental way to address important context-specificdeterminants of undernutrition. Working in thisincremental manner appears more likely to be suc-cessful than mounting a large-scale cross-sectoraleffort that is a poor match for the institutionalframework in which it would be implemented(Lynch 1979). Experience from many cross-sectoralefforts, focused on both nutrition and other prob-

lems, demonstrates that there is considerable meritin being task or problem oriented, starting small,achieving short-term goals, and building on thesesuccesses iteratively to address larger problems(Maxwell and Conway 2000).

Coordinated cross-sectoral efforts may be nec-essary to sustainably reduce undernutrition.However, given the past failure of such efforts,new initiatives should first be piloted before beingscaled up, particularly in those institutional envi-ronments in which bureaucratic structures andprocesses are rigid. In such cases, “contrary to log-ical argument, the complex etiology of malnutri-tion does not necessarily demand a complexresponse” (Ross and Posanai, cited in Levinson1995). Individual sectoral responses will often bethe best that can be realistically expected. No nu-trition program at the outset should depend on in-tersectoral coordination for its success. The riskthat such coordination is not going to happen istoo great (Levinson 1995). In instances in whichcross-sectoral action is required, alternative part-ners to other sectors in the state bureaucracy, suchas NGOs, may offer greater potential for success.However, simply ensuring that the agriculturesector, or, for that matter, any other sector with arole to play in improving nutrition, takes that roleseriously is an important first step. Coordinatedefforts should follow only once such commitmentsare clear.

Moreover, the causes of undernutrition arecontext specific. Agriculturists need to be clearabout what they can contribute in resolving mal-nutrition in a particular context. Having this clearunderstanding not only guides program design,but it also enables agriculturists to evaluatewhether means other than agriculture might be more efficient in attaining specific goals of nutritional improvement. There are likely to besignificant opportunity costs associated with agri-culturists devoting their energies to nutrition objectives (Pinstrup-Andersen 1982). These costsneed to be evaluated. Consequently, capacity fornutrition analysis is critical to any planning byagriculturists to address aspects of the problem ofundernutrition.

The undernourished can improve their nutri-tional status through agricultural means. There aremany good reasons for providing incentives toagriculturists to address problems of undernutri-

Institutional Frameworks for Action in the Agriculture Sector to Address Undernutrition 67

tion in a dedicated manner. However, Levinson(1995) suggests that the reverse relationship is alsoimportant. “Increased agricultural production perse is insufficient if that production does not addresshunger and malnutrition through its production orconsumption effects.” Attention to the nutrition

benefits to which agriculture can contribute forcesthe sector to consider more rigorously who benefitsfrom increased agricultural productivity and tochange its priorities and activities where necessaryin light of these considerations.

68 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

69

This report analyzes what has been learned about the way agricul-tural interventions influence nutrition outcomes in low- and middle-income countries. It synthesizes lessons from past institutional andorganizational efforts and identifies developments in agriculture andnutrition that have transformed the context in which nutrition out-comes are affected by agriculture. Emerging from this analysis is thefact that agriculture carries real potential to contribute to improvednutritional outcomes. Agricultural programs should thus include nu-trition as a specific objective and a clear plan of how to implement nu-trition-sensitive agricultural interventions and how to achieveimpact. The experience of agricultural programs that have done sopoints to a number of general lessons. The very inclusion of nutri-tional objectives by these programs reflects an implicit recognitionthat investing in agricultural production and growth does not neces-sarily result in improved nutrition. Nor do improved nutrition out-comes flow automatically from increased agricultural production,lower food prices, or higher incomes. Although these pathways maybe instrumental in satisfying a number of necessary conditions forimproved nutrition, they are not in themselves sufficient. The persis-tence of malnutrition despite the generally overwhelming success offood production belies any notion that the solution to adverse nutri-tion outcomes is attainable through the production side alone.Nutritional criteria have to be explicitly incorporated into the designof agricultural programs if nutritional objectives are embraced and iffood production is to effectively answer the demand for foods withparticular nutritional qualities. That represents both a challenge andan opportunity for agriculture and its major actors.

Incorporating nonagricultural criteria such as health and nutritioninto the design and conduct of agricultural programs suggests devel-oping an effective interface between agricultural and other institutions.Yet systematic high-level coordination between different sector min-istries is challenging, given the bureaucratic barriers that divide them.The report therefore examined alternative approaches to formulatinga more comprehensive approach to improving nutrition as a develop-ment objective. The prominence of nutrition as a policy priority in na-tional development plans and poverty reduction strategies mayprovide a useful starting point. At this level, nutritional objectives tran-scend the administrative divisions between different government-sec-tor institutions while still requiring their respective contributions.

Lessons Learned and Next Steps7

Those institutions may find and capitalize on op-portunities to work together, but their effective in-puts should not be contingent on such activecollaboration coming to pass. In this light, programsand policies can be planned multisectorally, yet becarried out sector by sector. Insofar as sector institu-tions are held accountable for their performance inachieving improved nutritional outcomes this ac-countability will provide them with incentives to explicitly address undernutrition within their re-spective mandates and work programs.

Sector ministries compete for limited govern-ment resources. If their budgetary allocations aremade contingent on their contribution to reducingmalnutrition as a national policy priority, their ef-fectiveness in that role is more likely to become aninstitutional priority as well. Similarly, interna-tional donors can provide important incentives byoffering funding and capacity building opportuni-ties to agencies in the agricultural sector or othersectors so that they work toward reducing thenumbers of undernourished in a country or area.To improve the chances of that happening, agricul-tural institutions should develop the internal ca-pacity to analyze the nutritional implications of theprograms they plan.

The context in which agricultural programs areimplemented is shifting as agricultural and tradepolicies change, as new technologies are intro-duced, and as food marketing systems develop.These changes, which generally work to increasethe market orientation of agriculture, affect thepathways linking agriculture to nutrition by alter-ing the types and quality of the foods available inthe marketplace, the price of food, the income offood producers, and the amount of food consumedfrom own-production. They are also affecting non-food factors that contribute to nutritional improve-ments, such as human capital. In addition, changingfood consumption patterns affect the market de-mand that agricultural production seeks to satisfy.These changes present program planners with amoving target in tailoring programs to fit local real-ities. They also present practitioners and policymakers with new factors to consider as they seek toreplicate successful experiences across localitiesand scale them up to provincial and national levels.

The empirical evidence presented in this reportfocused on agricultural programs and interventionscarried out at the level of local communities. Themost successful such projects were those that in-

vested broadly in improving human capital and thatsustained and increased the livelihood assets of thepoor. Below we summarize the key lessons learnedabout how these programs should be developedand implemented to help achieve improved nutri-tional outcomes. The recommendations should beimplemented taking the changing context of agri-culture and nutrition into account, and they shouldbe accompanied by the investments in human capi-tal and institutional changes needed for successfulimplementation.

Take local contexts into account. Designing pro-grams to accommodate prevailing agricultural andnutritional conditions entails developing a soundunderstanding of producers’ priorities, incentives,assets, vulnerabilities, and livelihood strategies. Thisis all too familiar to agricultural planners and can besaid of virtually any agricultural intervention. Theneed to evaluate and target major nutritional prob-lems experienced by the community in program de-sign is less familiar, but is an essential requirementfor any agricultural intervention that has nutrition-related objectives. Understanding the motives andconstraints that affect household consumption deci-sions is in this sense no less important than under-standing those that affect production decisions.

Many of these factors relate to household eco-nomics and to local perspectives of socioeconomicrealities. Some, however, are attributable to culturalnorms that in and of themselves have little if any-thing to do with economics—but that may bearheavily on the rationales behind households’ eco-nomic decisions. They may determine outrightwhich household members maintain control overwhich household resources and may influence nu-tritionally vital decisions such as the allocation ofdifferent quantities and types of food among house-hold members. From that angle, women emerge asvitally important agents, both in their roles as pro-ducers and as custodians of household welfare.Their importance, moreover, generally increases inthe lowest-income settings and among householdswith high dependency ratios—in which a large proportion of household members are nonearningand often nutritionally vulnerable dependents.Beginning with pilot programs and conscientiouslyemploying evaluation criteria before going to scalecan be a particularly effective way to ensure thatlocal contexts are taken into account.

Enable and empower women. The resources and in-come flows that women control wield dispropor-

70 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

tionately positive impacts on household health andnutrition. In some parts of the world, women tendto lack access to economic opportunities outsidethe domestic sphere to which traditional customsoften confine them, especially in rural areas. Theyare also very often severely constrained by timeand the multiple—often simultaneous—roles theyplay as producers and caregivers. Agricultural pro-grams and policies that empower and enablewomen and that involve them in decisions and ac-tivities throughout the life of the program achievegreater nutritional impacts. Such programs in-crease women’s control over income and other pro-ductive resources like credit by targeting them intheir roles as economic agents.

Incorporate nutrition outreach and behavior change.Using information services to change the behaviorof producers in order to make them more produc-tive or better able to respond to market signals is fa-miliar to agricultural practitioners. Similarinformation services can be employed to change be-havior among people in their roles as consumersand as decision makers within their households.Women’s access to services can be as important tohousehold nutrition as their access to income andproductive assets. Access to health services is a nat-ural priority, but even this access presupposes thatpeople know when to avail themselves of such ser-vices. Information services can educate women bothin their roles as economic agents and as typically theprincipal stewards of household nutrition, food se-curity, and health. While women are by no meansthe sole intended audience of such knowledge, tar-geting women with health and nutrition informa-tion is likely to have even greater catalytic effect,given their typically closer affiliation with thehousehold.

People who are armed with information andknowledge about the nutritional significance of thefoods they produce and eat are able to make betterproduction and consumption decisions. Health in-formation services provide a potent means ofchanging behaviors to reduce the high levels ofchildhood morbidity that are associated with inap-propriate feeding practices, premature weaning,and childcare generally. Providing householdswith health information about sanitary food prepa-ration and water use and the prevention of infec-tious and food-borne diseases can dramaticallyimprove nutrition outcomes—particularly with re-spect to those diarrheal illnesses that dispropor-

tionately afflict children and increase their risk ofdying. Agricultural extension services and publicinformation campaigns such as those dealing withintegrated pest management are also important ve-hicles for conveying health-related information.

Nutrition-related education and communicationstrategies may offer instruction on food preparationand safety, child care and feeding practices, and thenutritional qualities of different foods. A womanarmed with information that enables her to recog-nize the symptoms of a vitamin A deficiency andwho has learned about key sources of this nutrientis better placed to make an appropriate dietary ad-justment—especially when she has participated inan agricultural program involving a food sourcethat can be applied to that nutrient deficiency. Awoman equipped with knowledge that enables herto recognize a particular medical condition is like-wise by definition better placed to treat it or toknow when the affected family member should betaken to a health service provider.

Information is something that is required fromhouseholds and communities as well as somethingto be made available to them. The subjective eco-nomic, social, and cultural reasons that underliehousehold production and consumption decisionsare largely inaccessible to program personnel fromoutside the participating community. Indigenousknowledge and livelihood strategies are very oftenunspoken and may encompass local understand-ing of opportunities and risks that carry importantpractical merit for nutrition programming—meritthat may very well not be obvious to the outsideobserver. In areas in which community-based,local civil society or nongovernmental organiza-tions are active, they may represent importantsources of information on local perspectives andpresent agricultural programs with valuable part-nerships with which to engage local communities.Community-based organizations represent impor-tant reservoirs of social capital and are embeddedin target communities in which community mem-bers make collective decisions about how local re-sources are to be used and how livelihoods are tobe advanced. Other organizations that have oper-ated for years in local communities are likely tohave established relationships of intimate trust andrapport with families and individuals in local com-munities and are able to listen to local concerns andadvise on possible resolutions. These can be con-duits of two-way information flows between pro-

Lessons Learned and Next Steps 71

gram administrators and community membersand are often well-situated to serve as agents inmonitoring and evaluation. Local organizations,moreover, are often relatively free of the sectoraldivisions of higher-level bureaucracies and mayemploy agriculturists and health and nutrition ex-perts from local government agencies who are wellaware of each other’s activities, concerns, and pri-orities and, as such, can operate in a more effectiveand coordinated manner.

An additional lesson learned through the reviewis that poor producers should be provided with help andsupport to respond to changing food consumption pat-terns. Anticipating and responding to changing de-mand is a vital imperative for farmers in general,but among poor farmers in developing countriesthe stakes are particularly high. A significant partof their production is intended for their house-hold’s own consumption and therefore much of thedemand they are satisfying is their own. With re-spect to the proportion of food they produce formarket, the changing agricultural context has im-portant implications for the prices they are paid fortheir products, and increasing demand for high-value food sources represents an important oppor-tunity to earn more income. Yet switching to newand unfamiliar crops and producing for foreignmarkets with stringent food quality and safety re-quirements are also fraught with risk, and both op-portunities and risks need to be addressed byagricultural programs.

Next Steps. There are a number of important is-sues not covered in this paper that deserve separateinvestigation and analysis. The effects of climatechange and the implications of agricultural pro-duction shifting from food products to biofuels arematters of serious concern for food security, health,and nutrition. Analysis of their potential impactson food production and prices suggests itself as animportant object of future research.

The experience of past and ongoing agriculturalinterventions with nutrition-related objectives andthe connections between agricultural productionand nutrition more broadly, shed light on a num-ber of variables and causal dynamics that agricul-tural practitioners should take into account whenplanning programs or providing policy advice.Focusing the crosshairs of production goals ontonutrition-related targets is something that agricul-tural planners are likely to be called upon to domore often, for there is good reason to anticipatethat nutritional aims will come to play more promi-nently in the calculus by which the value of agri-cultural programs are rated. Future agriculturalprograms implemented with nutrition objectiveswill need to address the real challenge of going toscale and should be carefully monitored and rigor-ously evaluated to ensure that performance can becontinually tracked and improved. It is hoped thatthe expository account offered in this report laysthe groundwork for more practical work in whichthe details of applying these lessons operationallycan be prescribed.

72 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

73

METHODOLOGY USED IN CHAPTER3 (STAPLES)The following searches were carried out for the purposesof the literature review.

• The most recently published review (Berti et al.2004) employed a documented search strategy withsearch date of November 2001. We repeated theirsearch to cover the years 2001–2007, with slightmodifications to their search terms (below). Wesearched in PubMed and in Science Citation IndexExpanded and Social Sciences Citation Index (lattertwo via Web of Science). This search was verybroad and yielded approximately 1,700 items in-dexed in Medline and approximately 1,800 itemsindexed in Web of Science.– (agricult* OR “sustainable development” OR

“rural development” OR “food production” OR farm*) AND (nutriti* OR anthropom* OR diet* OR “child growth”)

– Search limits also excluded studies with animals as subjects; search date March 2007.

• In addition, to ensure that no relevant studies weremissed, we supplemented with Medline searchesusing the following terms:– nutriti* AND agriculture AND (trial OR interve*

OR effect* or effic* OR program OR policy)– “food security” AND agriculture AND (trial OR

interve* OR effect* or effic* OR program OR policy)

– These latter two searches yielded 105 items and overlapped with the broader searches.

• Third, we searched forward (Web of Science citedreference search) from three previous reviews(Kennedy et al. 1992; DeWalt 1993; Berti et al. 2004and evaluated resulting studies for relevance.

• In addition, in February 2007, a number of websiteswere searched for project results papers, includingthe following:– Bioversity International (formerly the

International Plant Genetic Research Institute and the International Network for the Improvement of Banana and Plantain): http://www.bioversityinternational.org/

– Collaborative Crop Research Program:http://mcknight.ccrp.cornell.edu/projects/nutrition.html

– Food and Agriculture Organization:http://www.fao.org/documents/

– HarvestPlus Program:http://www.harvestplus.org/

– Healthbridge Canada (formerly Programme for Appropriate Technology in Health, Canada): http://www.healthbridge.ca/foodandnutrition_e.cfm

– International Center for Research on Women: http://www.icrw.org/

– International Food Policy Research Institute: http://www.ifpri.org/

– International Fund for Agricultural Development: http://www.ifad.org/

– Michigan State University, Towards Sustainable Nutrition Improvement Project: http://www.aec.msu.edu/fs2/tsni/index.htm

Appendix

METHODOLOGY USED IN CHAPTER 4 (FRUITS ANDVEGETABLES)

Databases

A structured electronic search of the PubMed data-base was conducted. It included publications from1980 to January 2007. Other limits included humanstudies in the following languages: English,French, Italian, and Spanish. Significant effortswere also made to identify other studies throughsearches in the “gray literature” by accessing rele-vant Web sites. In addition, a number of expertsfrom various international organizations were con-tacted through e-mail to ask for copies of reportsdocumenting their experiences. The obtained re-ports were included in this review. Additionalpublications were obtained by going through thereferences of the retained publications to identifythose that were relevant for this topic. Finally, anumber of articles and reports were obtained fromcolleagues who already had articles available thathad been compiled for previous reviews.

Search Terms

After extensive testing, the following string ofsearch terms proved the most effective in identify-ing the relevant literature:

(“Nutrition Disorders”[MeSH] OR“Nutritional Status”[MeSH]) AND(“Agriculture”[MeSH] OR Horticulture OR Garden) AND (“Nutrition

Assessment”[MeSH] OR Dietary GuidelineOR School-based intervention OR ProgramOR Intervention OR Promotion OR PolicyOR Nutrition Education OR Prevention OR“Education”[MeSH] OR “Behavior”[MeSH]OR “Marketing”[MeSH] OR Mass-mediaOR “Schools”[MeSH] OR“Communication”[MeSH] OR “InterventionStudies”[MeSH] OR “Public Policy”[MeSH]OR “Randomized Controlled Trials”[MeSH]OR “Health Education”[MeSH] OR“Government Programs”[MeSH] OR“National Health Programs”[MeSH] OR“Health Promotion”[MeSH] OR “NutritionPolicy”[MeSH] OR “prevention and con-trol”[Subheading] OR “Guidelines”[MeSH]OR Impact OR Efficacy OR Effectiv*

Inclusion/exclusion criteria: Only high-qualitystudies were included, that is, those that had an ex-perimental or quasi-experimental design for whichthe intervention was clearly described and that in-cluded tests of statistical significance in the impactanalysis.

Searches

The PubMed search using the search string listedabove resulted in a total of 188 articles. All weresubjected to a title and abstract scan for relevance,and a total of 72 were found to be relevant. Theywere evaluated in more detail, and a total of 26 ofthese articles were obtained in full-paper form forinclusion in this document. Several of these paperswere background or historic documents that didnot report on a specific intervention.

74 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

75

Adamson, P. 2004. “Vitamin and Mineral Deficiency: A GlobalProgress Report.” The Micronutrient Initiative and UNICEF.

Adato, M., and R. Meinzen-Dick. 2007. Agricultural Research, Livelihoods,and Poverty. Studies of Economic and Social Impacts in Six Countries.Baltimore, MD: The Johns Hopkins University Press for IFPRI(International Food Policy Research Institute).

Ahmad, M., C. Cororaton, A. Qayyum, M. Iqbal, and P. Dorosh. 2006.“Impact of Domestic Policies towards Agricultural TradeLiberalization and Market Reform on Food Security in Pakistan.”IFPRI (International Food Policy Research Institute), Washington,DC (photocopy).

Ahmed, M. M., M. Jabbar, and S. Ehui. 2000. “Household-LevelEconomic and Nutritional Level Impacts of Market-Oriented DairyProduction in the Ethiopian Highlands.” Food and Nutrition Bulletin21 (4): 460–65.

Alderman, H. 1987. “Cooperative Dairy Development in Karnataka,India: An Assessment.” Research Report 64. IFPRI (InternationalFood Policy Research Institute), Washington, DC.

Alderman, J., J. Hoddinott, L. Haddad, and C. Udry. 1995. “GenderDifferentials in Farm Productivity: Implications for HouseholdEfficiency and Agricultural Policy.” IFPRI (International FoodPolicy Research Institute), Washington, DC.

Allen, L. 2003. “Animal Source Foods to Improve MicronutrientNutrition and Human Function in Developing Countries.” Journalof Nutrition 133: 3875S–78S.

Allen, L., and S. Gillespie. 2001. What Works? A Review of the Efficacy andEffectiveness of Nutrition Interventions. Geneva: United NationsAdministrative Committee on Coordination, Sub-Committee onNutrition, in collaboration with the Asian Development Bank.

Aphane, J., M.L. Chadha, and M.O. Oluoch. 2003. “Increasing theConsumption of Micronutrient-rich Foods through Production andPromotion of Indigenous Foods.” AVRDC (Asian VegetableResearch and Development Center)—The World Vegetable Center.Tainan, Taiwan.

Athukorala, P., and D. Sen. 1998. “Processed Food Exports formDeveloping Countries: Patterns and Determinants.” Food Policy 23(1): 41–54.

Attig, G. A., S. Simtasiri, K. Ittikom, and S. Dahanamitta. 1993.“Promoting Homestead Gardening to Control Vitamin A Deficiencyin North-Eastern Thailand.” Food, Nutrition and Agriculture 7: 1825.

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