REPORT Improving Nutrition Through Multisectoral Approachesdocuments.worldbank.org/curated/en/625661468329649726/pdf/75102... · Women’s empowerment ... 2010-2015 ... Improving

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Improving Nutrition Through Multisectoral

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© 2013 International Bank for Reconstruction and Development/ International Development Association or The World Bank

1818 H Street NW Washington DC 20433Telephone: 202-473-1000Internet: www.worldbank.org

This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors or the governments they represent.

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Table of ContentsAcronyms .............................................................................................................................................................9

Glossary of Key Terms..........................................................................................................................................11

Acknowledgements ............................................................................................................................................20

Executive Summary .............................................................................................................................................21

CHAPTER A. Introduction....................................................................................................25

I. Rationale and strategic context ......................................................................................................................26Interest in the “forgotten MDG” re-emerges...............................................................................................26Economic growth, poverty, and malnutrition ..............................................................................................27Scaling Up Nutrition (SUN): A new global framework and a roadmap for action ............................................28

II. Nutrition is a multisectoral problem with multisectoral solutions ....................................................................30Determinants of malnutrition....................................................................................................................30Key sectors for maximizing nutrition impacts.............................................................................................32Think multisectorally, act sectorally ..........................................................................................................33Rationale for World Bank involvement .......................................................................................................33

III. Nutrition basics..............................................................................................................................................37What is malnutrition? ...............................................................................................................................37What are the consequences of malnutrition? .............................................................................................38Who is most vulnerable to malnutrition?....................................................................................................39Why is intervening in nutrition important?.................................................................................................40Where is malnutrition most prevalent? ......................................................................................................41How can countries improve the nutrition status of their population? ............................................................41How does the World Bank cost its investments in nutrition? ........................................................................43

CHAPTER B. Economic Growth, Poverty, and Nutrition .........................................................45

I. Objectives ...................................................................................................................................................46

II. Background ...................................................................................................................................................46

III. What is the cross-sectional relationship between poverty and malnutrition?...................................................48

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TABlE Of CONTENTS | Improving Nutrition Through Multisectoral Approaches

IV. How far can economic growth take us? ............................................................................................................51

V. How equitable are nutritional outcomes? ........................................................................................................53

VI. Why is progress on improving nutritional outcomes lagging in South Asia? ....................................................54

VII. What are the implications for policy? ............................................................................................................55

VIII. Emerging operational research and knowledge gaps ....................................................................................57

CHAPTER C. Improving Nutrition through Agriculture ..........................................................59

I. Objectives ...................................................................................................................................................60

II. Rationale ...................................................................................................................................................60

III. Why is agriculture important for nutrition? .....................................................................................................61

IV. Why is nutrition important for agriculture? .....................................................................................................63

V. Pathways from agriculture to nutrition and available evidence .........................................................................65Pathway 1. National macroeconomic growth ..............................................................................................65Pathway 2. Higher food production, lower food prices................................................................................66Pathway 3. Increased income....................................................................................................................67Pathway 4. Home consumption ................................................................................................................68Pathway 5. Women’s empowerment ..........................................................................................................70

VI. Systematic review results and knowledge gaps ...............................................................................................71Cost effectiveness .......................................................................................................................................71

VII. Principles for nutrition-sensitive agriculture projects ....................................................................................72

VIII. The World Bank’s agriculture program .........................................................................................................73

IX. Challenges for nutrition-sensitive agriculture at The World Bank .....................................................................74

X. Addressing Nutrition through agriculture Projects at The World Bank ...............................................................76Current status: Mainly through unintentional effects ..................................................................................76Taking it further: Addressing nutrition explicitl ..........................................................................................78 Key Questions to consider in designing nutrition-sensitive agriculture projects ...........................................88Measuring nutritional outcomes through agricultural projects ....................................................................89“Do no harm” considerations....................................................................................................................91

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XI. Summary ...................................................................................................................................................92

Annex C-1. Guidance matrix of agricultural interventions explicitly targeting nutrition .........................................................142

Annex C-2. List of all gender disaggregated indicators included inWorld Bank agriculture (AES) projects approved in FY10 and FY11........................................................................152

Annex C-3. Food consumption indicators ............................................................................................................................154

Annex C-4. Suggested nutrition resources ..........................................................................................................................158

Annex C-5. Recent reviews and strategies to mainstream nutrition into agriculture ..............................................................160

CHAPTER D. Improving Nutrition through Social Protection .................................................95

I. Background ...................................................................................................................................................96

II. Objectives ....................................................................................................................................................97

III. How can we maximize the impact of income on nutrition? ..............................................................................98Enhancing the role of income in transfer programs.....................................................................................99 Nature of transfers: Cash versus in-kind transfers .....................................................................................101Including nutrition counseling or micronutrient supplementation components...........................................102Enhancing the role of income in other social protection programs:

Public works, insurance, and microfinance ...........................................................................................102

IV. How can social protection programs promote the link with other servicesto increase their nutritional impact? .............................................................................................................104

Conditioning transfers to access to services.............................................................................................106firm versus soft conditions .....................................................................................................................108Conditional versus unconditional transfers...............................................................................................110Conditional “in-kind” transfers: School feeding and school health and nutrition programs..........................110Promoting access to services: Community-based growth promotion programs ............................................111

V. Is there a role for targeting transfers to the nutritionally vulnerable? ..............................................................113Targeting by demographic group .............................................................................................................113Targeting by nutritional status or risk ......................................................................................................114

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VI. Concluding remarks .....................................................................................................................................114

VII. Emerging operational research and knowledge gaps ....................................................................................116

Annex D-1.ANNEX Additional Resources .............................................................................................................................162

CHAPTER E. Improving Nutrition through Health ...............................................................119

I. Objectives ..................................................................................................................................................120

II. Rationale ..................................................................................................................................................120Poor nutrition affects health outcomes ....................................................................................................123 Poor health affects nutrition outcomes ....................................................................................................123

III. What are the key health sector interventions to improve nutrition, and what will they cost? ..........................123

IV. Which nutrition objectives can be achieved through the health sector, and how? ..........................................126Reduce micronutrient deficiencies among the most vulnerable groups.......................................................126Reduce the prevalence of anemia in pregnant and lactating women and children 0-24 months ....................127Promote good feeding and nutritional care practices for the most vulnerable populations...........................129Treat and prevent illness.........................................................................................................................132Reduce low birth weight .........................................................................................................................133Improve reproductive health and family planning .....................................................................................134Treat moderate and severe acute undernutrition in children ......................................................................135

V. What are the challenges and lessons learned for delivering improved nutrition through the health sector?......136

VI. Conclusion .................................................................................................................................................138

Annex E-1. Guidance matrix: Health sector and nutrition linkages and programming ..........................................................163

Annex E-2. Menu of actions to address undernutrition by delivery mechanism ...................................................................169

Annex E-3. WHO’s health systems strengthening framework and nutrition .........................................................................172

Annex E-4. Contribution to mortality of nutrition interventions ...........................................................................................175

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Annex E-5. Links to other key resources ..............................................................................................................................175

Annex E-6. Suggested nutrition resources ..........................................................................................................................177

List of Figures

Figure A-1. Higher than expected child stunting and underweight rates in manycountries given GDP levels, particularly in South Asia..........................................................................................27

Figure A-2. The emergence of the Scaling up Nutrition (SUN) movemen ................................................................28

Figure A-3. Determinants of child nutrition and interventions to address them .....................................................30

Figure A-4. Women’s status and reductions in child undernutrition (contributions in reductions 1970-95) ..............31

Figure A-5. Malnutrition, by type .........................................................................................................................37

Figure A-6. Undernutrition and the window of opportunity: A child’s first 1,000 days ............................................39

Figure A-7. Progression of malnutrition in developing countries from 1990-2010 ...................................................41

Figure B-1. Trends in poverty, hunger and malnutrition.........................................................................................46

Figure B-2. Malnutrition prevalence over time (stunting=height-for-age)..............................................................48

Figure B-3. Cross-country correlation between poverty rates and measures of malnutrition...................................49

Figure B-4. Episodes of changes in poverty and malnutrition ...............................................................................50

Figure B-5. Estimates for the change in stunting incidence in 2015 ......................................................................52

Figure B-6. Trends in chronic malnutrition (stunting), by wealth quintiles ............................................................53

Figure B-7. Dietary diversity is low in South Asia ..................................................................................................54

Figure B-8. Other proximate factors related to child malnutrition..........................................................................55

Figure C-1. Cross-country link between agricultural GDP and child underweight ...................................................66

Figure C-2. Ethiopia: Prevalence of stunting among children under 5 (by income quintile) ....................................68

Figure C-3. Five focal areas of AES projects ...........................................................................................................73

Figure C-4. Disbursement focus of agriculture and related sectors ........................................................................74

Figure C-5. Pipeline of biofortification crops for release in Africa and Asia ............................................................83

Figure C-6. Measuring nutrition-sensitive agricultural projects ............................................................................89

Figure D-1. Potential pathways of social protection programs to impact nutrition .................................................97

Figure D-2. Elements of social protection programs relevant for nutrition outcomes .............................................98

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Figure D-3. Income transfers in select countries as a percentage of per capita spending ......................................100

Figure E-1. Health sector-specific framework for child nutrition ...........................................................................121

Figure E2. The malnutrition-infection cycle ........................................................................................................122

List of Tables

Figure A-1. Nutrition and poverty: Prevalence of child stunting by income quintile indicates that malnutrition rates are high even among those who are not poor.....................................................28

Figure B-1. Statistical relationship between malnutrition and income....................................................................51

Figure C-1. Determinants of child nutrition and interventions to address them ......................................................64

Figure C-2. Determinants of child nutrition and interventions to address them......................................................92

Figure E-1. Determinants of child nutrition and interventions to address them.....................................................129

List of Boxes

Figure A-1. The SUN framework: Three key elements ............................................................................................29

Figure A-2. The South Asia Regional Assistance Strategy for nutrition, 2010-2015 ................................................36

Figure A-3. What activities are included under Code 68? ......................................................................................43

Figure C-1. Selected gender disaggregated indicators in AES projects (approved in FY10 and FY11) ........................79

Figure C-2. Commonly used food consumption indicators .....................................................................................91

Figure D-1. Assessing the relative impacts of cash and food transfers on nutrition in Nepal .................................102

Figure D-2. Djibouti social safety net project that combines workfare with a nutrition intervention ......................103

Figure D-3. Variations on the theme: Nutrition co-responsibilities in CCTs in Latin America..................................105

Figure D-4. Strengthening the nutrition impact of the Peru CCT program ............................................................109

Figure D-5. Targeting the needs of acutely malnourished children ......................................................................114

Figure D-6. What should be monitored in SP programs to keep nutrition as a focus? ............................................115

Figure D-7. Priority objectives of nutrition-sensitive social protection .................................................................116

Figure E-1. Success in reducing maternal anemia in Nepal ..................................................................................124

Figure E-2. Growth monitoring and promotion: A useful delivery platform ...........................................................131

Figure E-3. Increasing exclusive breastfeeding rates in Sri Lanka ........................................................................131

Figure E-4. Tools that can guide prioritization of nutrition investments ...............................................................139

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AcronymsAAA Analytical and Advisory Work

AES Agriculture and Environmental Services

AFASS Acceptable, feasible, Affordable, Safe, Sustainable

AIN-C Atención Integral a la Niñez con Base Comunitaria (Community-Based GrowthPromotion Programs in latin America)

ANC Ante-Natal Care

ARD Agriculture and Rural Development

ARV Anti-Retroviral

BMGF The Bill & Melinda Gates foundation

BMJ British Medical Journal

CAADP Comprehensive Africa Agriculture Development Programme

CAS Country Assistance Strategy

CCT Conditional Cash Transfer

CDD Community Driven Development

CIP Country Investment Plan

CGIAR Consultative Group for International Agricultural Research

CGAP Consultative Group to Assist the Poor

CMAM Community Management of Acute Malnutrition

CSFP Civil Society fund Program

CSO Civil Society Organization

DALY Disability-Adjusted life Years

DDS Dietary Diversity Score

DfID Department for International Development

DPL Development Policy loan

EG Enterprise Groups

FANTA food And Nutrition Technical Assistance

FCS food Consumption Score

FY fiscal Year

GAFSP Global Agriculture and food Security Program

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ACRONYMS | Improving Nutrition Through Multisectoral Approaches

GAP Gender Action Plan

GDP Gross Domestic Product

GHI Global Health Initiative

GFRP Global food Price Response Program

GNP Gross National Product

GMP Growth Monitoring and Promotion

HACCP Hazard Analysis and Critical Control Points

HHS Household Hunger Scale

HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome

HKI Helen Keller International

HLTF High-level Task force

HMIS Health Management Information System

HNP Health, Nutrition, and Population

ICT Information and Communication Technology

IDD Iodine Deficiency Disorder

IEG Independent Evaluation Group

IFA Iron-folic Acid

IFPRI International food Policy Research Institute

IIP Iron Intensification Project (Nepal)

IMCI Integrated Management of Childhood Illness

IPT Intermittent Preventive Treatment

ITN Insecticide-Treated Nets

IUGR Intrauterine Growth Restriction

IYCF Infant and Young Child feeding

IYCN Infant and Young Child Nutrition

LIC lower Income Country

MAHP Months of Adequate Household food Provisioning

MDG Millennium Development Goals

M&E Monitoring and Evaluation

MNP Micronutrient Powders

MPI Multi-dimensional Poverty Index

MSG Monosodium Glutamate

MUAC Middle-Upper Arm Circumference

TAHEA Tanzania Home Economics Association

TB Tuberculosis

TTL Task Team leader

UCT Unconditional Cash Transfer

OFSP Orange-fleshed Sweet Potato

ORS Oral Rehydration Salts

PAD Project Appraisal Document

PAL Programa de Apoyo Alimentario (Mexico in-kind transfer program)

PER Public Expenditure Review

PDO Project Development Objective

PNC Post-Natal Care

PRAF Programa de Asignación familiar (Honduras conditional cash transfer program)

PRN Programme de Renforcement de la Nutrition(Senegal Nutrition Reinforcement Programme)

PSNP Productive Safety Net Programme (Ethiopia)

RAS Regional Assistance Strategy

RDA Recommended Dietary Allowance

RESEPAG Relaunching Agriculture: Strengthening Agriculture Public Services Project (Haiti)

RH Reproductive Health

RMT Regional Management Team

RSR Rapid Social Response

RUCF Ready-to-Use Complementary foods

RUSF Ready-to-Use Supplementary foods

RUTF Ready-to-Use Therapeutic foods

SAFANSI South Asia food and Nutrition Security Initiative

SAM Severe Acute Malnutrition

SAR South Asia Region

SD Standard Deviations

SDN Sustainable Development Network

SME Small and Medium Enterprises

SP Social Protection

SSA Sub Saharan Africa

SSN Social Safety Net

STI Sexually Transmitted Infection

SUN Scaling Up Nutrition

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ACRONYMS | Improving Nutrition Through Multisectoral Approaches

Glossary of Key Terms Active Labor Market Program (ALMP): Social protection programs that have economic and social objectives of in-creasing the probability of the unemployed finding jobs, productivity and earnings, and improving social inclusionand participation associated with productive employment. These programs are considered “active” as they includeactivities to stimulate employment and productivity, rather than “passively” providing insurance schemes and/ortransfers.

Acute malnutrition (wasting): low weight-for-height defined as more than 2 standard deviations (SD) below themean of the sex-specific reference data. Wasting is usually the result of a recent shock such as lack of calories andnutrients and/or illness, and is strongly linked to mortality.

Adequate Intake (AI): Recommendations for nutrient intake when insufficient information is available to establish arecommended dietary allowance (RDA). AIs are based on observed or experimentally determined estimates of the av-erage nutrient intake that appears to maintain a defined nutritional state in a specific population.

Adequately iodized salt: Salt containing 15-40 parts per million of iodine. At the population level, household accessto iodized salt should be greater than 90 percent, constituting universal salt iodization.

Agricultural GDP: The returns to land, labor, and capital used in agriculture. Agricultural gross domestic product(GDP) constitutes a good indicator of farm income trends, assuming farmers own most of the land and capital andsupply most of the labor used in the sector.

Agricultural GDP of the agricultural population (or Agricultural GDP/worker): The ratio of total GDP for the agriculturesector divided by the estimated number of economically active workers claiming agriculture as their main source ofincome (the agricultural population).

Agricultural population: The agricultural population comprises all persons depending for their livelihood on agricul-ture, hunting, fishing, or forestry, and includes all persons actively engaged in agriculture and their non-working de-pendents.

Anemia: The condition of having a hemoglobin concentration below a specified cut-off point, which can change ac-cording to age, gender, physiological status, smoking habits, and altitude at which the population being assessedlives. The World Health Organization (WHO) defines anemia in children under five years of age and pregnant womenas a hemoglobin concentration <110g/l at sea level. Although the primary cause of anemia worldwide is iron defi-ciency, it often coexists with a number of other anemia causes, including malaria and other parasitic infections;acute and chronic infections that result in inflammation and hemorrhages; deficiencies in other vitamins and miner-als, especially folate, vitamin B12 and vitamin A; and genetically inherited traits, such as thalassemia.

Bioavailability: The degree to which the amount of ingested nutrient is absorbed and is available for use in the body.

Biofortification: The development of micronutrient-dense staple crop varieties using traditional breeding practices orbiotechnology.

Body Mass Index (BMI): A measure of body fatness, calculated as weight (kg) divided by the square of height (m2). ABMI of <18.5 is considered underweight, ≥25 signifies overweight, and ≥30 signifies obesity. Although BMI is a goodmeasure for determining a range of acceptable weights, it does not take into consideration some important factors,such as body build, i.e., relative contributions of fat, muscle, and bone to weight.

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GlOSSARY Of KEY TERMS | Improving Nutrition Through Multisectoral Approaches

Breastmilk substitute: Any food marketed or otherwise represented as a partial or total replacement for breastmilk,whether or not suitable for that purpose.

Childhood obesity: Weight-for-height that is >2 SD (see Overnutrition). Childhood obesity is associated with a higherprobability of obesity in adulthood, which can lead to a variety of disabilities and diseases, such as diabetes and car-diovascular diseases.

Chronic malnutrition (stunting): low height-for-age, defined as more than 2 SD below the mean of the sex-specificreference data. Stunting is the cumulative effect of long-term deficits in food intake, poor caring practices, and ill-ness.

Colostrum: The first fluid secreted by the breast during late pregnancy and the first few days after birth. This thickfluid is rich in immune factors and protein.

Community-Based Management of Acute Malnutrition (CMAM): The management of acute malnutrition through (a)inpatient care for children with severe acute malnutrition with medical complications and infants under six-months ofage with visible signs of severe acute malnutrition; (b) outpatient care for children with severe acute malnutrition;and (c) community outreach.

Community nutrition program: A community-based program intended to prevent growth faltering, control morbidity,and improve survival of children by promoting breastfeeding, providing education and counseling on optimal feedingpractices, preventing diarrheal disease, and monitoring and promoting growth.

Complementary feeding practices: A set of 10 practices recommended for caregivers to implement from 6 to 24months, at which point breastmilk and/or breastmilk substitutes alone are no longer sufficient to meet the nutri-tional needs of growing infants. Poor breastfeeding and complementary feeding practices, coupled with high rates ofinfectious disease, are the principal proximate causes of malnutrition during the first two years of life.

Complementary food: Any food, whether manufactured or locally prepared, suitable as a complement to breastmilkor to infant formula, when either becomes insufficient to satisfy the nutritional requirements of the infant (at about 6months of age).

Conditional Cash Transfer (CCT): A social safety net program aimed at reducing both present and future poverty bylinking a targeted transfer of cash to compliance with a pre-specified investment, usually in child education orhealth.

Cretinism: The stunting of body growth and poor mental development in the offspring that results from inadequatematernal intake of iodine during pregnancy.

Demographic targeting: A targeting method in which eligibility is based on age.

Diarrhea: The passage of three or more loose or liquid stools per day or more frequently than is normal for the indi-vidual. Diarrhea is usually a symptom of gastrointestinal infection, which can be caused by a variety of viral and para-sitic organisms. Severe diarrhea leads to fluid loss and plays a particularly important role in nutrition and growthfaltering, perhaps because of its association with malabsorption of nutrients and appetite suppression. The adjustedodds of stunting at 24 months of age increases by 5 percent with each episode of diarrhea in the first 24 months oflife.

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Dietary Diversity: The number of food groups consumed over a given period of time. Household-level dietary diversitycan be used as an indicator of household food security, and individual-level dietary diversity is an indicator of dietquality for an individual (typically measured for women or young children).

Early initiation of breastfeeding: Initiation of breastfeeding within one hour of birth. As a public health statistic, it ismeasured as the proportion of children born in the past 24 months who were put to the breast within one hour ofbirth.

Exclusive Breastfeeding (EBF): The feeding of an infant only with breastmilk from his/her mother or a wet nurse, orexpressed breastmilk, and no other liquids or solids except vitamins, mineral supplements, or medicines in drop orsyrup form.

Food-based transfer/food-based safety net program: A food-based safety net program intended to support food con-sumption. It differs from other safety net programs in that it is tied to food either directly or through cash-like instru-ments (food stamps, coupons) that may be used to purchase food.

Food fortification: The addition of one or more micronutrients (vitamins and minerals) to a food during processing.Ideally, food fortification provides a public health benefit with minimal risks to health in the population.

Food-For-Work Programs (FFW): This type of program provides food rations in exchange for a given amount of workdone or a stipulated wage rate. ffW programs have long been used to protect households against the decline in pur-chasing power that often accompanies seasonal unemployment, climate-induced famine, or other periodic disrup-tions by providing them with employment.

Food security: According to the UN, food security exists when all people, at all times, have physical and economic ac-cess to sufficient, safe and nutritional food to meet their dietary needs and food preferences for an active and healthylife. The concept of food security includes the pillars of food availability, access, utilization, and stability/vulnerabil-ity.

Food stamp, voucher, or coupon program: A type of safety net program that uses food-related mechanisms to deliveran income transfer to a target population. The specific instruments used to buy food (stamps, voucher, coupon) mayrestrict beneficiaries to buying only a few specific foods or allow them to purchase any food in the market.

Fortified Blended Foods (FBF): Blends of partially precooked and milled cereals, soya, beans, or pulses, fortified withmicronutrients. Special formulations may contain vegetable oil or milk powder. Corn Soya Blend (CSB) and WheatSoya Blend (WSB) are often used in emergency food distributions.

Global acute malnutrition is weight-for-height of -2 z-scores or more below the median, according to the WHO’s childgrowth standards (moderate and severe wasting).

Global Hunger Index (GHI): An index that ranks 84 developing and transitional countries using the following threeequally weighted indicators to describe the state of countries’ hunger situation: (i) the proportion of people who areundernourished; (ii) the prevalence of underweight children under the age of five; and (iii) the under-five mortalityrate. By using these three indicators, the GHI captures various aspects of hunger and undernutrition, and takes intoaccount the special vulnerability of children to nutritional deprivation (IfPRI).

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Hidden hunger: Micronutrient malnutrition or vitamin and mineral deficiencies, which can compromise growth, im-mune function, cognitive development, and reproductive and work capacity.

HIV/AIDS: Human immunodeficiency virus (HIV) is a retrovirus that affects cells of the immune system, destroying orimpairing their function. As the disease progresses, the immune system becomes weaker, and the person becomesmore susceptible to infection. The most advanced stage of HIV infection is acquired immunodeficiency syndrome(AIDS).

Home garden / homestead food production: A small plot or plots around the home, managed by household mem-bers, where a variety of crops including vegetables, fruits, legumes, tubers, non-food plants, e.g., medicinal herbs,spices, fuel material are grown throughout the year and often livestock and fish are raised, primarily for householdconsumption. They typically use low-cost inputs and indigenous varieties, as well as local knowledge and practicesand community participation. Home gardens have multiple uses, including improving diets within the household,provide inputs for other farm activities, e.g., fodder for animals, provide shade or natural fencing, raise income fromthe sale of garden produce, and empower women, who most typically manage home gardens. Nutritional impact ofhome gardening is increased when combined with nutrition education and linked with other health and developmentactivities in the community.

Human Development Index (HDI): A summary composite measure of a country’s average achievements in three basicaspects of human development: (i) health, as measured by life expectancy at birth; (ii) knowledge, as measured bythe adult literacy rate and the combined primary, secondary, and tertiary gross enrollment ratio; and (iii) a decentstandard of living, as measured by GDP per capita in purchasing power parity in terms of US$.

Hunger: A feeling of discomfort, illness, weakness, or pain due to prolonged involuntary lack of food that goes be-yond the usual uneasy sensation of temporary absence of food in the stomach (Panel to Review the USDA’s Measure-ment of food Insecurity and Hunger, 2006). The sensation of hunger that results from a lack of food in the stomach isuniversal, but there are different manifestations and consequences of hunger, including undernourishment, malnu-trition, and wasting.

Infant and Young Child Feeding (IYCF): Refers to specific recommendations and guiding principles for optimal nutri-tion, health, and development of children. A set of eight population-level IYCf indicators have been developed to: (i)assess IYCf trends over time; (ii) improve targeting of interventions; and (iii) monitor progress in achieving goals andevaluate the impact of interventions (WHO, 2008).

Infant and Young Child Nutrition (IYCN): A term that encompasses all aspects that relate to the nutrition of infantsand young children (0 to 24 months).

In-kind transfers: The transfer of ownership of a good or asset other than cash, or the provision of a service withoutany counterpart.

International Code on Marketing of Breastmilk Substitutes: A set of recommendations to regulate the marketing ofbreastmilk substitutes, feeding bottles, and teats. This code aims to contribute “to the provision of safe and ade-quate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use ofbreastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriatemarketing and distribution” (Article 1).

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Intrauterine Growth Retardation (IUGR): The poor growth of a baby while in the womb, which results in birth weightbelow a given percentile cut-off (typically the 10th percentile) for gestational age.

Iodine: An essential component of at least two thyroid hormones that are necessary for skeletal growth and neuro-logical development.

Iodine deficiency: The condition resulting when iodine intake falls below recommended levels, tested through me-dian urinary iodine concentration (normal range 100-199 +a/l).

Iodine Deficiency Disorders (IDD): All of the consequences of iodine deficiency in a population that can be preventedby ensuring that the population has an adequate intake of iodine. IDD can affect children at any stage of rapidgrowth, with the greatest negative impacts on cognitive development occurring during pregnancy. Symptoms rangefrom mild impairment of brain development and subtle degrees of brain damage, goiter, hypothyroidism, reproduc-tive disorders (spontaneous abortion, stillbirth, congenital abnormalities, perinatal mortality) to its most severeform, cretinism. Iodine deficiency is the primary cause of preventable mental retardation and brain damage in theworld.

Iron: A key building block of hemoglobin, which plays a central role in oxygen transport throughout the body.

Iron deficiency: The most common nutritional deficiency in the world, resulting from insufficient iron in the body dueto inadequate consumption of bioavailable iron, blood loss, or unmet increased iron requirements due to infection,pregnancy, rapid growth, dietary habits, or any combination of these.

Iron Deficiency Anemia (IDA): The condition in which the body does not have enough healthy red blood cells due to adeficiency in iron. Iron deficiency (above) and iron deficiency anemia are associated with fetal and child growth fail-ure, compromised cognitive development in young children, lowered physical activity and labor productivity inadults, and increased maternal morbidity and mortality. Women and young children are the most vulnerable to IDA,which increases the risk of hemorrhage and sepsis during childbirth, and is implicated in 20 percent of maternaldeaths. furthermore, children with IDA suffer from infections, weakened immunity, learning disabilities, impairedphysical development, and in severe cases, death.

Large for Gestational Age (LGA): Birth weight above a given high percentile cut-off (typically the 90th percentile) forgestational age.

Lipid-Based Nutrient Supplements (LNS): Refers generically to a range of fortified, lipid-based products (includingRUTf, and other highly concentrated supplements used for “point-of-use” fortification) used for the prevention andtreatment of acute malnutrition. lNS typically contain milk powder, high-quality vegetable oil, peanut paste, sugar,and micronutrients, and provide 120 to 250 kcal/day.

Low Birth Weight (LBW): A birth weight of less than 2,500g. At the population level, the proportion of infants with alow birth weight often serves as an indicator of a multifaceted public health problem that includes long-term mater-nal malnutrition, ill health, hard work, and poor health care in pregnancy.

Malaria: A disease caused by the Plasmodium parasite that is transmitted via the bites of infected Anopheles mos-quitoes; symptoms include fever, headache, vomiting, and anemia, and the disease can be fatal.

Malnutrition: Poor nutritional status caused by nutritional deficiency or excess (undernutrition or overnutrition).

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Measles: A highly contagious viral disease that mostly affects children and can be prevented through routine immu-nization. Measles infection substantially increases vitamin A utilization and therefore causes vitamin A deficiency inchildren whose body stores are marginal prior to infection.

Mid-Upper Arm Circumference (MUAC): The circumference of the upper arm measured at the mid-point between thetip of the acromial process (shoulder) and the tip of the olecranon process (elbow).

Micronutrient(s): Vitamins and minerals that are needed in small amounts by the body to produce enzymes, hor-mones, and other substances essential for proper growth and development. Iodine, vitamin A, iron, and zinc are themost important in terms of prevalence and severity; deficiencies are a major threat to the health and development ofpopulations worldwide, particularly children and pregnant women in low-income countries.

Micronutrient deficiency(ies): Deficiencies in one or more essential vitamin or mineral, often caused by diseaseand/or lack of access and/or consumption of micronutrient-rich foods such as fruit, vegetables, animal products, andfortified foods. Micronutrient deficiencies increase the severity and risk of dying from infectious disease such as diar-rhea, measles, malaria, and pneumonia. More than two billion people in the world are estimated to be deficient in io-dine, vitamin A, iron, or zinc.

Microfinance: The provision of small-scale financial services to people who lack access to traditional banking serv-ices; usually implying very small loans to low-income clients for self-employment or entrepreneurial activity, oftenwith the simultaneous collection of small amounts of savings. Simple application processes, provision of services inunderserved communities, targeting poor and female clients, and group lending are traditional features of microfi-nance (Karlan, D. and N. Goldberg. 2007. Impact Evaluation for Microfinance. Washington, DC: The World Bank.).

Multiple micronutrient powder: A tasteless powder that comes in the form of individual sachets, containing the rec-ommended daily intake of 16 vitamins and minerals for one person. They can be sprinkled into home-prepared foodafter cooking or just before eating.

Moderate malnutrition: Weight-for-age between -2 and -3 z-scores below the mean of sex-specific reference data(moderate underweight).

Moderate Acute Malnutrition (MAM): Weight-for-height between -2 and -3 standard deviations below the mean ofsex-specific reference data (moderate wasting).

Non-Agricultural GDP/worker: The difference between the total national and agricultural GDP divided by the differ-ence between total national and agricultural employment.

Nutrition security: The ongoing access to the basic elements of good nutrition, i.e., a balanced diet, safe environ-ment, clean water, and adequate health care (preventive and curative) for all people, and the knowledge needed tocare for and ensure a healthy and active life for all household members.

Obesity: A condition characterized by excess body fat, defined as a BMI of 30 or more.

Oral Rehydration Solution/Salts (ORS): A liquid electrolyte solution that is used for the management of diarrheaamong children. ORS is typically distributed in ready-to-use sachets that are added to one liter of clean water.

16


Overnutrition: A state in which nutritional intake greatly exceeds nutritional need. Overnutrition manifests itself asoverweight (BMI≥25) and obesity (BMI≥30). In children, overnutrition is defined as weight-for-height >2 SD (>2 SD isoverweight and >3 SD is obese).

Overweight: A condition characterized by excess body fat, defined as a BMI between 25 and 30 kg/m2.

Pension: Non-contributory cash income given to older persons (usually by the government and/or other social pro-grams).

Pneumonia: A serious bacterial lung infection that is transmitted by direct contact with infected people and is theleading cause of death in children worldwide. Malnutrition is considered a key risk factor for pneumonia; maintaininggood nutritional status is thus important to prevent infection.

Protein-Energy Malnutrition (PEM): A condition resulting from insufficient consumption of energy and protein, result-ing in wasting.

Public works: Social protection programs where income support for the poor is given in the form of wages (in eithercash or food) in exchange for work effort. These programs typically provide short-term employment at low wages forunskilled and semiskilled workers on labor-intensive projects such as road construction and maintenance, irrigationinfrastructure, reforestation, and soil conservation. They are generally seen as a means of providing income supportto the poor in critical times rather than as a way of getting the unemployed back into the labor market.

Ready-to-use Supplementary Food (RUSF): A high-energy nutrition supplement that is particularly suited as a nutri-tional support in emergency situations or in the context of nutritional programs for the prevention or treatment ofmoderate malnutrition and deficiency-related illnesses.

Ready-to-use Therapeutic Food (RUTF): A high energy and protein ready-to-eat food with added electrolytes, vitaminsand minerals, specifically designed to treat SAM in the rehabilitation phase. RUTf is typically oil- and/or peanut-based; it does not have to be mixed with water so is microbiologically safe and enables outpatient treatment.

Replacement food: Replacement foods are food products given to an infant whose mother is HIV/AIDS positive, to re-place breastmilk. Replacement foods are recommended over exclusive breastfeeding only when they are acceptable,feasible, affordable, sustainable, and safe (AfASS).

Respiratory tract infections: Infections that affect the air passages, including the nasal passages, and the bronchiand lungs. Acute Respiratory Tract Infections (ARI), including pneumonia, have been implicated in nutrition throughgrowth faltering, likely due to the contributing factors that define the disease and include anorexia, fever, pain, vom-iting, and associated diarrhea.

School feeding programs: A form of supplementary feeding that encourages children’s school enrollment and im-proves their ability to pay attention in class. These programs vary and may include the provision of breakfast, lunch,a midmorning snack, or a combination of these. Sometimes, school feeding programs are integrated with health andnutrition education, parasite treatment, health screening, and provision of water and sanitation.

Severe Acute Malnutrition (SAM): Weight-for-height more than 3 standard deviations below the mean of sex-specificreference data (severe wasting).

17


Small for Gestation Age (SGA): Birth weight below a given low percentile cut-off (typically the 10th percentile) for ges-tational age. SGA and IUGR are not synonymous; some SGA infants (e.g., those born to short mothers) may representmerely the lower extreme of the “normal” fetal growth distribution, while other normal weight infants may actuallyhave been exposed to one or more growth-inhibiting factors. In individual cases, it is usually difficult to ascertainwhether the observed birth weight is the result of restricted in utero growth. Therefore, classifying an infant as IUGRis based de facto on the established cut-off for SGA.

Smallholder farmer: Marginal and sub-marginal farm households that own and/or cultivate typically less than twohectares of land. Smallholder farmer households constitute a large proportion of the population in the developingworld and of households living in poverty and hunger.

Social protection: The set of public interventions aimed at supporting the poorer and more vulnerable members ofsociety, as well as helping individuals, families, and communities manage risk. Social protection includes safety nets(social assistance), social insurance, labor market policies, social funds, and social services.

Social Safety Net (SSN): Noncontributory transfer programs targeted in some manner to the poor and those vulnera-ble to poverty and shocks—analogous to the U.S. term “welfare” and the European term “social assistance.”

Stunting (chronic malnutrition): low height-for-age, defined as more than 2 SD below the mean of the sex-specificreference data. Stunting is the cumulative effect of long-term deficits in food intake, poor caring practices, and/or ill-ness.

Supplementary feeding programs: A direct transfer of food to target households or individuals, most commonly ma-ternal and child feeding and school feeding. The food may be prepared and eaten on- site or given as a dry ration totake home. Supplementary feeding is often provided as an incentive for participation in public services such as pri-mary health care and education.

Unconditional Cash Transfer (UCT): A social safety net program aimed at reducing both present and future povertythrough a transfer of cash to vulnerable and specifically targeted populations.

Undernourished: A person whose usual food consumption, expressed in terms of dietary energy (kcal), is below theenergy requirement norm. The prevalence of undernourishment in a specified population is sometimes used as ameasure of food deprivation. This term is not to be confused with undernutrition.

Undernutrition: Poor nutritional status due to nutritional deficiencies. The main three indicators of undernutrition arestunting, wasting, and underweight.

Underweight: low weight-for-age defined as more than 2 SD below the mean of the sex-specific reference data.

Vitamin A: An essential micronutrient that plays an essential role in vision and immune response.

Vitamin A Deficiency (VAD): The condition resulting when vitamin A intake falls below recommended levels. Vitamin Adeficiency may be exacerbated by high rates of infection, and greatly increases the risk that a child may die from dis-eases such as measles, diarrhea, and acute respiratory infections, and is the leading cause of childhood blindness.Vitamin A deficiency compromises the immune systems of approximately 40 percent of the developing world’s chil-dren under five and leads to the deaths of as many as one million young children each year.

18


Wasting (acute malnutrition): low weight-for-height defined as more than 2 SD below the mean of the sex-specificreference data. Wasting is the result of a recent shock such as lack of calories and nutrients and/or illness, and islinked strongly to mortality.

Weather-index insurance: A product designed to provide compensation to farmers when specific weather events areinsufficient (rainfall) or destructive (cyclones, floods) for farmers to grow and optimize their yields. Weather index in-surance does not measure changes in yields; rather it measures changes in weather, assuming that if the weather ispoor, the farmers’ yields will be too.

Window of opportunity: The period between conception and age two when irreversible damage caused by malnutri-tion can and should be prevented.

Zinc: An essential micronutrient that plays a critical role in the structure of cell membranes and in the function of im-mune cells.

Zinc deficiency: The condition resulting when zinc intake falls below recommended levels. Zinc deficiency is associ-ated with growth retardation, malabsorption syndromes, fetal loss, neonatal death, and congenital abnormalities.Zinc supplementation reduces the duration and intensity of diarrheal illness and reduces clinical disease caused byacute respiratory infections and malaria.

19


AcknowledgementsThis document was produced by a team led by Meera Shekar (AfTHW) and leslie Elder (HDNHE). Authors includeHarold Alderman (HDNSP), leslie Elder (HDNHE), Aparajita Goyal (AES), Anna Herforth (HDNHE), Yurie TanimichiHoberg (AES), Alessandra Marini (lCSHS), Julie Ruel-Bergeron (HDNHE), Jaime Saavedra (PRMPR), Meera Shekar(AfTHW), Sailesh Tiwari (PRMPR), and Hassan Zaman (PRMPR).

first round peer reviewers were liz Drake (DfID), Ariel fiszbein (HDNCE), Margaret Grosh (lCSHD), and Julie Mclaugh-lin (SASHN). In the second round, peer reviewers were Bénédicte de la Brière (HDNCE), Margaret Grosh, (lCSHD),Steven Jaffee (EASVS), Claudia Rokx (ECSH1), Shelly Sundberg (The Bill & Melinda Gates foundation), and Anna Taylor (DfID).

This document benefitted greatly from consultations with the following Task Team leaders (TTls) and developmentpartner colleagues: Erick Abiassi (AfTAR), Diego Arias Carballo (lCSAR), Katie Bigmore (AfTHE), luc laviolette(SASHN), Gayle Martin (AfTHD), Rasit Pertev (AfTAR), Animesh Shrivastava (SASDA), Joana Silva (MNSSP), Eileen Sullivan (EASHH), Shelly Sundberg (The Bill & Melinda Gates foundation), Ajay Tandon (EASHH), Anna Taylor (DfID), laketch Imru (AfTAR), Oluwole Odutolu (AfTHE), and Boubou Cisse (AfTED).

The team gratefully acknowledges inputs and support received by both peer reviewers and participants of the TTl and partner consultations, as well as the funding support for this study from DfID, the Japan Trust fund for Scaling Up Nutrition, and the Rapid Social Response Trust fund.

20

ACKNOWlEDGEMENTS | Improving Nutrition Through Multisectoral Approaches

Executive SummaryThis report responds to the global development community’srequest for operational guidance to maximize the impact of invest-ments on nutrition outcomes forwomen and young children. The importance of nutrition guidance hasbeen expressed by the World Bank’sregional teams, especially South Asiaand Africa, the World Bank’s AdvisoryCouncil of foundation leaders meet-ings, as well as the wider Scaling UpNutrition (SUN) donor partnersgroup. This report is a first step to-wards operationalizing a multisec-toral approach to improve nutritionworldwide.

The recommendations in this docu-ment build on the extensive nutritionresearch and evidence to-date on is-sues of malnutrition. The authors’aim is to mainstream nutrition activi-ties into multisectoral action in WorldBank operations through a series ofguidance notes that are focused ini-tially on the three sectors of agricul-ture, social protection, and health,including an overview of the link be-tween nutrition and poverty reduc-tion. “Malnutrition” refers only toundernutrition and micronutrient de-ficiencies in this document, and notovernutrition. The overweight/obe-sity aspects of malnutrition are notaddressed.

contextual examples, the note ismeant as generic guidance. Theserecommendations will need to beadapted to each country and opera-tional context.

Rationale and Strategic Context(Module A). Recent assessments ofthe Millennium Development Goals(MDGs) show slower progress thanexpected. The global developmentcommunity recently has recognizedthat one reason for slow gains in theMDGs is the lack of investment in nu-trition, the virtually “forgotten MDG.”Research confirms that investing innutrition significantly multiplies posi-tive outcomes in maternal and childhealth, cognitive function and educa-bility, human capital, and economicgrowth and poverty reduction. How-ever, despite the proven high returns,36 countries carry about 90 percentof the global burden of undernutri-tion, and nutrition investments areinadequate in many of these coun-tries. To finance the scale up of effec-tive nutrition solutions globally, anestimated $10.3 billion per year is re-quired, but current donor invest-ments fall far below this amount.1 Inmany developing economies, nutri-tion improvement is further ham-pered by an emerging problem ofoverweight and obesity in addition topre-existing undernutrition, whichleads to the “double burden” of un-dernutrition coexisting with over-weight and obesity.

The guidance notes are designed toassist World Bank staff, donor part-ners, and country-level implementerswith adjusting the design of existingor future operations in their respec-tive sector to be more nutrition-sensitive. When relevant, some of thenotes are accompanied by a succinct,operational matrix that highlights theobjectives, tracking indicators, op-portunities, trade-offs, and issues ofpolicy coherence. Where nutritionalevidence is weak, it is noted. Where itis strong, the notes provide program-matic guidance that will help thesesectors to adopt a “nutrition lens” asthey develop new programs and proj-ects. Each self-contained note can beapplied to each sector or used to-gether as one coherent cross-sectoralapproach. The document is dividedinto five modules, some of which in-clude a list of additional resources.

Module A provides the intellectualand theoretical rationale for a multi-sectoral response to malnutrition.This module is targeted at a wider de-velopment policy audience.

Modules B through E are targetedspecifically at World Bank and otheragencies’ staff and country clientsthat design and support projects andprograms in poverty reduction, agri-culture, and rural development, so-cial protection, and health. Whileevery effort has been made to makethe information as specific as possi-ble, and to give concrete country and

21

ExECUTIVE SUMMARY | Improving Nutrition Through Multisectoral Approaches

1 BMGf. 2011.

Poverty, Economic Growth, and Nutrition (Module B). Global povertyhas declined significantly in the lasttwo decades, but this has not beenaccompanied by commensurate re-ductions in global hunger nor im-provements in nutritional outcomes.Since hunger and malnutrition arelinked intricately to poverty, the di-vergence in the trends of these indi-cators is puzzling. We investigatewhy nutritional status generally hasremained poor despite widespreadreduction in income poverty, and dis-cuss policy implications. An emerg-ing clear message is that eventhough economic development is re-lated significantly to malnutrition,economic growth alone often is insuf-ficient to improve malnutrition rates.furthermore, there are considerableinequities in nutritional outcomesacross socioeconomic groups; therate of progress in nutritional out-comes varies over time; and in sev-eral countries, the gaps between therich and poor have widened. for ex-ample, South Asia and Africa’s com-parative malnutrition rates arestriking. Relative to the “predicted”levels of malnutrition (stunting andunderweight) given poverty rates,South Asian countries are lagging be-hind, while many African countriesare doing better than their povertylevels would predict.

Improving Nutrition through Agri-culture (Module C). Global momen-tum, including that catalyzed by theglobal Scaling Up Nutrition (SUN)movement framework and roadmap,is bringing the agriculture, food secu-rity, and nutrition agendas closer to-

gether so that investments in one willhave positive impacts on the other.While nutrition investments are de-signed to improve human capital andto have a positive impact on physicalwell-being and work capacity, includ-ing agricultural productivity, the po-tential benefits of agricultureinvestments on nutrition have yet tobe maximized. This module explainswhy agriculture is important for nutri-tion, and vice versa. The available ev-idence indicates four strongprinciples for action in areas wherethe World Bank’s agricultural pro-grams can contribute Priority objec-tives.

Although the World Bank’s agricul-ture projects have, to date, only ad-dressed nutrition implicitly orunintentionally, there is growingawareness inside and outside of theWorld Bank of the importance ofleveraging agriculture to improve nu-trition. Of the 21 countries that havemet the goal of halving the propor-tion of the population below the min-imum level of dietary energyconsumption, only six are on track tomeet the underweight goal.2 This isan example of the limits of improvingnutrition implicitly through agricul-ture. Simply increasing household in-come or raising agriculturalproductivity is insufficient to improveundernutrition.

This module provides practical guid-ance for maximizing the nutrition im-pacts of agriculture investments byaction on the following fronts: (i) in-corporate nutrition-sensitive analysisand activities into agriculture project


22

Priority objectives to enhance nutrition in agriculture programs

1. Invest in women: safeguard andstrengthen the capacity ofwomen to provide for the foodsecurity, health, and nutrition oftheir families.

2. Increase access to year-roundavailability of high-nutrient con-tent food.

3. Improve nutrition knowledgeamong rural households to en-hance dietary diversity.

4. Incorporate explicit nutritionobjectives and indicators intoagriculture investments.

2 Armenia, Georgia, Ghana, Jamaica, Nicaragua, and Vietnam have met the hunger goal andare on track to meet the underweight goal.

Priority objectives of nutrition-sensitive social protection

1. Target activities to the most nutritionally vulnerable popula-tions such as pregnant women and children under 24 months.

2. Include nutrition education andcounseling activities within social protection interventions toincrease household awareness of care giving and health seeking behaviors.

3. Integrate nutrition services into SP interventions, e.g. growth monitoring and promotion, and/oractivities for improved growth anddiet quality.

4. Reduce the acute and long-termnegative financial impacts of external financial, price, andweather shocks by scaling up programs in times of crises and bytargeting shock-affected areas.

Priority objectives to improvenutrition through the healthsector

1. Reduce micronutrient deficiencies.

2. Reduce anemia in pregnant andlactating women and children 0-24months.

3. Promote good feeding and nutri-tional care practices.

4. Treat and prevent illness.

5. Reduce low birth weight.

6. Improve reproductive health andfamily planning.

7. Treat moderate and severe under-nutrition in children.

design and food security policy dia-logue; (ii) measure the progress ofactivities affecting nutrition periodi-cally through relevant output indica-tors; and through outcome indicatorssuch as food consumption indicatorsat least at baseline/mid-term/projectcompletion; (iii) ensure that agricul-ture projects and policies do notcause unintended harm to nutrition.

Improving Nutrition through SocialProtection (Module D). While mostsafety net programs include an in-come transfer component—and manyvulnerable households lack adequateincome to purchase key inputs tomaintain notable nutrition out-comes—the evidence shows that in-creased income alone is ofteninsufficient to have a major impact onnutrition. Thus, other components,such as directing transfers to women,targeting the most vulnerable andthe correct age group (-9 to 24months), and adding a nutrition edu-cation or a micronutrient supplemen-tation component to social protectionprograms can play an essential rolein generating impact. Alternative op-tions to improve nutrition for themost vulnerable populations are re-viewed to strengthen the design ofexisting or future interventions in so-cial protection. We discuss the path-ways through which these programscan influence nutritional outcomesand the different policy choices thatcan derive from each of them by ask-ing three broad questions: (i) Howcan we maximize the impact of in-come transfers on nutrition? (ii) Withwhat services might the social pro-tection programs be linked? (iii) Whoshould be targeted?

Improving Nutrition through Health(Module E). This guidance note aimsto assist World Bank and other pro-gram staff in maximizing the nutritionimpacts of health investments andpolicies, with a special focus on un-dernutrition among women and chil-dren under two years of age indeveloping economies. The strongsynergies between health and nutri-tion are highlighted and key evi-dence-based nutrition interventionsthat can be delivered through thehealth sector are presented. Imple-menting such interventions is cost-effective and can achieve largereductions in morbidity, mortality,and undernutrition, furthering healthsector goals. The main nutrition-related objectives that fall within thehealth sector are outlined in the boxbelow. Evidence-based interventionsto address each objective, along withimplementation considerations, arepresented as options to integrate nu-trition interventions in health invest-ments and policies.

23


IntroductionMeera Shekar,

Julie Ruel-Bergeron, Anna Herforth

C H A P T E R - A

I. Rationale and strategic contextInterest in the “forgottenMDG” re-emerges

Recent assessments of the MDGsshow that progress in nutrition hasbeen slower than expected. Theglobal development community re-cently recognized that one reason forslow gains in the Millennium Devel-opment Goals (MDGs) is the lack ofinvestment in nutrition, the virtually“forgotten MDG.”1 Research showsthat investing in nutrition signifi-cantly multiplies the positive out-comes for maternal and child health,cognitive function and educability,human capital, and economic growthand poverty reduction. However, de-spite the proven high returns, 36countries carry about 90 percent ofthe global burden of child undernutri-tion,2 and nutrition investments areinadequate in many of these coun-tries. This is partly due to the inade-quacy of total global investments innutrition, which comprise only asmall fraction of the estimated needs(about $10.3 billion), and a very smallproportion of the current spending insectors such as health or agriculture.In many developing economies, nu-trition improvement is hampered fur-ther by an emerging burden ofobesity, leading to the “double bur-

den of malnutrition,” with undernu-trition coexisting with overweightand obesity.

The global community now concursthat increasing investment in nu-trition will accelerate progress on arange of MDGs, especially MDGs 1(poverty), 2 (education), and 4 and 5(maternal and child health). Nutritioninvestments will support poverty re-duction efforts, and have the poten-tial to augment GDP in developingcountries by at least 2-3 percent.3 Ac-celerating progress on the MDGs by2015 therefore requires urgent invest-ments in nutrition. Translating thehigh level of national and interna-tional political consensus and com-mitment and the available evidenceinto Nutrition-specificactions—delivered primarily throughthe health sector—and nutrition-sensitive actions delivered throughseveral other sectors is now the challenge. This report lays thegroundwork for multisectoral actionby providing the overall rationale forsuch action and the programmaticguidance on how to incorporate nu-trition actions into the World Bank’sand its partners’ investments inpoverty reduction, agriculture, socialprotection,

CHAPTER - A | Introduction

26

Nutrition-specificA term that refers to interventionsthat directly address inadequate di-etary intake or disease—the immedi-ate causes of malnutrition.Nutrition-specific interventions arethose identified in The Lancet serieson maternal and child undernutrition(2008), including micronutrient sup-plementation, deworming, treatmentof severe acute malnutrition, andbreastfeeding promotion, which di-rectly addresses dietary intake anddisease for infants.

_____________________________

Nutrition-sensitiveA term that refers to interventions ordevelopment efforts that, within thecontext of sector-specific objectives,also aim to improve the underlyingdeterminants of nutrition (adequatefood access, healthy environments,adequate health services, and carepractices), or aim at least to avoidharm to the underlying or immediatecauses, especially among the mostnutritionally vulnerable populationsand individuals. Various actions thatwould address the determinants ofmalnutrition are possible in manysectors. In health, for example, re-productive health services can im-prove birth spacing; in agriculture,the investment and input-deliveryportfolio may be diversified to in-clude more nutrient-dense foods; insocial protection, cash transfers canhave conditionalities for vaccina-tions and growth monitoring; in edu-cation, efforts to keep girls in schoolcan be strengthened; in water andsanitation, improved water provisioncan prioritize the most nutritionallyvulnerable areas or populations;other actions exist in many othersectors. 1 MDG1 includes a target to halve, between 1990 and 2015, the proportion of children

under age 5 who are underweight.

2 Child undernutrition is defined as low weight-for-age (underweight); low height-for-age(stunting or chronic malnutrition); low weight-for-height (wasting or acute malnutrition);and micronutrient deficiencies (minerals and vitamins).

3 SUN framework, http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/PolicyBriefNutrition.pdf, Repositioning Nutrition, http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdf.

Economic growth, poverty,and malnutrition

Malnutrition rates remain surpris-ingly high in several countries withrobust economic and agriculturalgrowth. This paradoxical situation ofeconomic growth and malnutrition isstarkly evident in India, as well as inmany other countries (figure A-1). Inthese countries, many children areborn with low birth weights. for therest of their lives, these children con-tinue to track at low heights andweights and to suffer from often ir-

table economic growth and pro-pooragricultural growth policies.4 How-ever, while economic growth, povertyreduction, and agricultural productiv-ity all contribute to better nutrition,in most countries, gains in economicgrowth or agricultural productivityalone have been insufficient to im-prove child nutrition outcomes.5

reparable damage to human capital.Even though poor children are morelikely to be malnourished, a surpris-ingly large percentage of those in thehighest income quintiles—wherefood security is not a likely limitingfactor—are also underweight orstunted (Table A-1). In general, nutri-tion outcomes have improved morequickly in countries with more equi-

27


4 Webb, P. and Block, S. 2011. Support for agriculture during economic transformation: Impacts on poverty and undernutrition. Proceedings of the National Academy of Sciencesof the United States of America. www.pnas.org/cgi/doi/10.1073/pnas.0913334108

5 See Module B on poverty and nutrition for more details and discussion on this issue.

Source: World Bank. World Development Indicators as of 09/10/2010. Height-for-age and weight-for-age are for the latest year for which data are available. GDP per capita in constant 2005 PPP Int’l $ is for the year corresponding to the year in which the nutrition data was collected. All observations are between 2000 and 2008. Analysis by John Newman.

PCT M

ALNO

URIS

HED

(WEI

GHT F

OR A

GE)

Burundi

Afghanistan

Guatemala

AngolaNepal India

Bangladesh

Pakistan

MaldivesTajikistan

MongoliaBotswana

Gabon

Belize

Sri Lanka

Mexico

Saudi Arabia

Czech RepublicChile

Brazil

JamaicaTrinidad and Tobago

ThailandSuriname

JordanMoldora

Afghanistan

Nepal

India

Bangladesh

Pakistan

Maldives

Gabon

MexicoBelarus

Sri Lanka

Saudi Arabia

Czech RepublicChile

Jordan

Ghana

Namibia

Algeria Botswana

Kyrgyz Republic

0K 5K 10K 15K 20KGDP PE R CAPITA 2005 PPP

HEIGHT FOR AGE WEIGHT FOR AGE

GDP PE R CAPITA 2005 PPP

FIGuRE A-1. HIGHER THAN ExPECTED CHILD STuNTING AND uNDERwEIGHT PREvALENCE RATES IN MANy COuNTRIES GIvEN GDP LEvELS, PARTICuLARLy IN SOuTH ASIA

Scaling up Nutrition (SuN): A new global framework and aroadmap for action

The Scaling up Nutrition (SuN)movement was launched in 2010 inresponse to the continuing highrates of global malnutrition. Abroad informal global partnershipwas established through a collabora-tive process of consensus building onhow to scale up nutrition interven-tions (see figure A-2). The fruits ofthis intensive work program betweendeveloping countries, academic andresearch institutions, civil society or-ganizations, the private sector, bilat-eral development agencies, UnitedNations agencies (fAO, UNICEf, WfP,and WHO), and the World Bank re-sulted in the SUN framework for Ac-tion and the SUN Roadmap.

To date, the Scaling Up Nutritionframework has been endorsed byover 100 partners worldwide and 30

developing countries have committedto scaling up nutrition. leaders ofthese countries are prioritizing nutri-tion as an investment in their peo-ple’s growth, and recognizingnutrition as an investment in eco-nomic and social development tostrengthen their nations. These coun-tries expect to see results within thenext five years. The SUN’s successalso depends on support from re-


28

lated initiatives in food security andagriculture, health, and vulnerabilityprotection, such as the Comprehen-sive Africa Agriculture DevelopmentProgramme (CAADP), UN High levelTask force (HlTf) for the Global foodSecurity Crisis, US Global Health Ini-tiative (GHI), US Global Hunger andfood Security Initiative, the HlTf onInnovative financing for Health, andothers.

TABLE A-1. NuTRITION AND POvERTy: PREvALENCE OF CHILD STuNTING By INCOME quINTILE INDICATES THAT MALNuTRITION RATES ARE HIGH EvEN AMONG THOSE wHO ARE NOT POOR

Regions Country Lowest 2nd 3rd 4th Highest

South ASiA

Bangladesh 59 53 45 43 30

India 61 54 49 39 26

Pakistan 54 47 43 37 26

AfricA

Benin 50 48 48 40 29

Burkina Faso 50 47 46 41 26

Ethiopia 52 54 51 49 40

Mozambique 54 53 52 41 26

Rwanda 61 55 52 50 35

Tanzania 50 49 46 43 23

Uganda 43 38 44 37 25

Data Source: Bredenkamp, C., Health Equity and Financial Protection datasheets, World Bank 2012.

FIGuRE A-2. THE EMERGENCE OF THE SCALING uP NuTRITION (SuN) MOvEMENT

PART

NERS

HIP

COM

PENT

ITIO

N

Higher sharedinterests &space for all

lowershared interests

SoCIAl/PolITICAl SuPPoRTwide constituency, shared

leadership, wider ownership

NuTRITIoN SCAlED-uP

AS CoRE PART of wIDER

DEvEloPMENT AGENDA

How, wHERE, wHAT CoST, wHoEvidence-based strategy for scale-up

TECHNICAl STRATEGIESProlific programs, populations, interventions

Translating the high level of nationaland international political commit-ment and evidence into Nutrition-specific and nutrition-sensitiveactions to reduce malnutrition in thehighest burden countries is the chal-lenge facing international develop-ment partners.

SUN principles and partnersThe SuN is based on three keyprinciples for improving nutritionoutcomes: (i) the primacy of country-level action; (ii) the focus on evi-dence-based and cost-effective ac-tions; and (iii) a multisectoralapproach (Box A-1). Many of the Nu-trition-specific interventions lie inthe health sector. In addition, manyother sectors have a key role to playin scaling up the indirect or nutrition-sensitive interventions through thesesectors. for example, there is muchto be done to ensure that socialsafety nets are designed to protectthose most nutritionally vulnerable,i.e., women and young childrenunder the age of two years, or thatagriculture investments do no harmto these vulnerable groups.

The “early riser” countriesunder the SUNThirty countries have expressed in-terest in the SuN movement. These“early risers” include Bangladesh,Benin, Burkina faso, Burundi,Ethiopia, The Gambia, Ghana,Guatemala, Indonesia, Kenya, KyrgyzRepublic, lao PDR, Madagascar,Malawi, Mali, Mauritania, Mozam-bique, Namibia, Nepal, Niger, Nige-ria, Peru, Rwanda, Senegal, Sierra

dow starts during pregnancy andcloses at about two years of age.These first “1000 days” offer the bestopportunity to lock-in future humancapital. If implemented at scale, in-terventions during this period canpotentially reduce undernutrition-re-lated mortality and morbidity by 25percent. Many of the proposed inter-ventions are delivered primarilythrough the health sector and aresummarized in Module E of this docu-ment. A similar body of evidence-based recommendations does notexist for multisectoral actions to max-imize nutrition improvement acrossother sectors. This document at-tempts to fill this gap. It providesguidance on scaling up interventionsacross several sectors and drawsupon the recent reviews of evidencespecified in each respective module.

leone, Tanzania, Uganda, Zambia,and Zimbabwe. Involvement in theSUN movement as an early riser en-tails political commitment buildingwithin governments, establishingmulti- stakeholder platforms, pro-moting goals and targets for reducingundernutrition, encouraging coher-ence and support of the movementthrough a global coalition of part-ners, and mobilizing support for ef-fective joint action at scale.

Evidence for actionThe evidence for action through thehealth sector (Nutrition-specific in-terventions) was presented in TheLancet Series on Maternal and ChildUndernutrition (2008), the Copen-hagen Consensus (2008), and theWorld Bank’s 2006 document Reposi-tioning Nutrition as Central to Devel-opment. The findings show that thereis a very small “window of opportu-nity” to improve nutrition outcomesand to prevent irreversible losses tohuman capital in countries. This win-

29


BOx A-1. THE SuN FRAMEwORk: THREE kEy ELEMENTS

1. Country-level action is key

• Country ownership and leadership

• Tailored to country- specific epidemiology

• Tailored to country- specific context and capacities

2. Scale up evidence-based cost-effective interventionsaction is key

• For prevention and treatment

• Highest priority to the window of opportunityfrom pregnancy to 24months

3. A multisectoral approach

• Accelerating action on the determinants of malnutrition

II. Nutrition is a multisectoral problemwith multisectoral solutionsDeterminants of malnutrition

The determinants of malnutritionare multisectoral. The immediatecauses are related to food and nutri-ent intake and to health. The underly-ing causes are embedded in thehousehold and community level con-text in which undernutrition occurs.These underlying causes are furtherimpacted by issues such as agricul-tural practices and climate change,lack of access to and availability ofclean water and sanitation, healthservices, girls’ education and genderissues, social protection, and socialsafety nets. The basic causes of un-dernutrition are rooted in institu-tional, political, and economic issuessuch as poverty reduction and eco-nomic growth, governance and stew-ardship capacities, environmentalsafeguards, and trade and patents is-sues, including the role of the privatesector. Addressing the special condi-tions in fragile states and reducingconflict, are also key in fragile/con-flict situations. A framework for themultisectoral causation of malnutri-tion is shown in figure A-3.


30

Source: Adapted from UNICEF 1990 and Ruel 2008.

FIGuRE A-3. DETERMINANTS OF CHILD NuTRITION AND INTERvENTIONS TO ADDRESS THEM

• Infant andyoung child nutrition andtreatment of severe undernutrition

• Micronutrientsupple-mentation & fortification

• Hygiene practices

• Agriculture &food security

• Health Systems

• Soc. protection/safety nets

• Water and sanitation

• Gender and development

• Girls’ education

• Climate change

• Poverty reduction &economicgrowth programs

• Governance,stewardshipcapacities &management

• Trade &patents (& role of private sector)

• Conflict resolution

• Environmentalsafeguards

CHILD NUTRITIONfooD/NuTRIENT

INTAKE HEAlTH

Accessto

food

Maternal & childcarepractices

Water &sanitation,

health services

INSTITuTIoNS

PolITICAl & IDEoloGICAl fRAMEwoRK

ECoNoMIC STRuCTuRE

ENvIRoNMENT TECHNoloGY, PEoPlE

NuTRITIoN SPECIfICINTERvENTIoNS

NuTRITIoN SENSITIvEINTERvENTIoNS

Evidence shows that direct actionsto address the immediate determi-nants of undernutrition can be fur-ther enhanced by action on someof the more distal or underlying de-terminants. for example, in additionto supporting improved infant andyoung child feeding practices, ad-dressing gender issues throughhealth, agriculture or education pro-grams can have a powerful impact inpreventing undernutrition by reduc-ing women’s workloads and allowingthem more time for child care. Simi-larly, in addition to providing mi-cronutrient supplements to addressvitamin and mineral deficiencies, im-proving food security, and enhancinghygiene and environmental issueshave been shown to improve nutri-tion outcomes among children (fig-ure A-4).

supplements and deworming. Thegains from these direct interven-tions can be further enhanced andsustained by improving water sup-ply and hygiene, and reducing re-infection. Improved hygiene andwater supply not only helps tobreak the cycle of disease andmalnutrition, it allows mothers tospend more time on the care oftheir children, thereby improvingchildren’s nutrition. The potentialimpact of even the most effica-cious interventions is very con-text-specific. Therefore,interventions need to be selectedfor each country and contextbased on an assessment of theepidemiology of the problem and

Multisectoral actions canstrengthen nutritional outcomes inthree main ways: (a) by acceleratingaction on determinants of undernutri-tion; (b) by integrating nutrition con-siderations into programs in othersectors which may be substantiallylarger in scale; and (c) by increasing“policy coherence” through govern-ment-wide attention to policies orstrategies and trade-offs, which mayhave positive or unintended negativeconsequences on nutrition.

a. Accelerating action on determi-nants of undernutrition. Nutri-tion problems such as irondeficiency anemia require directinterventions like iron-folic acid

31


FIGuRE A-4. wOMEN’S STATuS AND REDuCTIONS IN CHILD

uNDERNuTRITION

(contributions in reductions 1970-95)

Source: Smith and Haddad, 2000.

Women'seducation

43%

Women'sStatus

12%

HealthEnvironment

19%

National foodAvailability

26%

the context.6 for example, genderinterventions are more likely tohave an impact in South Asiawhere gender imbalances aremuch greater than in Africa. Whileanemia interventions are mostlikely to have an impact in areasand populations with a highprevalence of anemia.

b. Integrating nutritional consider-ations in programs in other sec-tors is critical to a multisectoralnutrition response to sustain thegains from direct Nutrition-spe-cific interventions. for example,while improving productivity andother agricultural goals will alwaysremain the primary objective ofthe agriculture sector, there is apotential opportunity to incorpo-rate nutrition considerations intosmallholder agriculture and rural

livelihoods programs, such as byintroducing biofortified crops intoagricultural research and technol-ogy dissemination programs.7 So-cial safety net programs can bedesigned to target women andyoung children, and can include astronger focus on nutrition, suchas using fortified foods (instead ofnon-fortified foods) for schoolfeeding programs, or by condition-ing cash-transfers on the use ofpreventive nutrition and healthservices. One powerful way to en-courage more emphasis on nutri-tion—and to hold those sectorsaccountable for nutrition results—is to include an appropriate nutri-tion related indicator (or avalidated proxy indicator) to meas-ure overall progress on nutrition inthese sectoral projects and pro-grams.

c. Increasing “policy coherence”through government-wide atten-tion to policies or strategies,and analyzing trade-offs, whichmay have positive or unintendednegative consequences on nutri-tion, is another critical meansfor mainstreaming nutrition intoother sectors. National develop-ment strategies vary significantlyby the extent to which nutritionalobjectives are incorporated eitheras a stand-alone issue or main-


32

6 IEG World Bank, 2010.

7 World Bank. 2006. Repositioning Nutrition as Central to Development; Spielman, D., and Pandya-lorch, R. 2009. Millions fed: Proven Successesin Agricultural Development. IfPRI: Washington, D.C.

streamed within other sectors.While capacity is clearly a bindingconstraint, ideally what is requiredis both better and timely reportingof nutritional consequences of dif-ferent sectoral policies and pro-grams, potentially similar to thePoverty and Social Impact Analy-ses (PSIA) used in Bank opera-tions.

key sectors for maximizingnutrition impacts

The key sectors for maximizing nutrition impacts are indicated infigure A-3. These include health,agriculture and food security, socialprotection (especially social safetynets), poverty reduction (although itis not a traditional “sector”), educa-tion (especially girls’ education),water and sanitation, environmentand climate change, private sector,and trade and intellectual propertyrights (especially in view of the grow-ing role of the private sector in foodand health systems in developingeconomies). Gender and governanceissues are crosscutting across sev-eral of these traditional sectors andneed special consideration.

Think multisectorally, act sectorally

while there is a strong case for act-ing across several sectors to im-prove nutrition outcomes, littleevidence exists demonstrating thesuccess of multisectoral projectsimproving nutrition outcomes. Ex-perience and evidence suggest thatwhile it is perfectly logical to thinkand plan multisectorally, actionsmust follow sector by sector, tailoredto the specific context, objectives,and operating environment of eachsector.8 This approach is further bol-stered by the fact that budget alloca-tions in institutions, as well as atcountry level, are made by sectors orministries, and governance and ac-countability structures follow similarsectoral limitations with sectorsholding themselves accountable forresults within their own domains.Based on this experience and evi-dence base, the current guidancenotes follow this mantra of thinkingmultisectorally but acting sector bysector. The guidance notes are beingdeveloped as modular sectoral inputsthat can be applied to each sector,but also pulled together into one co-herent cross-sectoral approach.

dren and minimize harmful, often un-intended consequences. An impor-tant first step in this effort is to assistregional teams to move rapidly to amultisectoral approach to nutritionby providing programmatic guidanceand tools as they develop new pro-grams. Adoption of this guidancewould signal a move towards opera-tionalizing nutrition-specific develop-ment. Experience from countries suchas Senegal suggests that when thisapproach is implemented well, withappropriate investments in capacitydevelopment and institutionalarrangements, results can beachieved.9

Rationale for world Bank involvement

The world Bank’s primary missionis poverty reduction and promotingeconomic growth in the poorestcountries of the world, many ofwhich carry the highest burdens ofmalnutrition. Through its invest-ments in multiple sectors, theworld Bank is well positioned tosupport a multisectoral approachto reducing the underlying and im-mediate causes of undernutrition.Moreover, the World Bank is one ofthe few development organizationsthat supports client countries actingacross sectors and at scale, andstrongly emphasizes governance andgender issues. The World Bank hasrecently scaled up its investments inseveral nutrition relevant sectors.The more direct nutrition-specific in-terventions implemented primarily bythe health sector will need to be com-plemented by the indirect nutrition-sensitive interventions implementedthrough sectors such as agricultureand food security, social protection,and water and sanitation. All sectorswill need to plan and implement in-vestments to maximize the nutritionbenefits for women and young chil-

33


8 The history of multisectoral projects is littered with non-performance. The 2007 World Bank Health Nutrition & Population (HNP) Strategystated that actions in other sectors were necessary to reach outcomes in health. Since then, there has been a steady increase in multisectoralprojects, with most of the increase being in AIDS projects. However, the performance of multisectoral AIDS projects in Africa has been less thansatisfac- tory. A criticism of multisectoral projects has been that the increased number of sectors involved has resulted in reduced clarity andspecificity of the role and responsibility of each sector. Also, lending in sectors outside of health, such as water and sanitation and education,has taken place independent of each other and the health sector. In the water and sanitation and transport sectors, projects with health objec-tives rarely collaborate with the Ministry of Health. (Ref: Improving Effectiveness and Outcomes for the Poor in Health, Nutrition and Popula-tion, IEG 2009). While PRSPs have helped policymakers link sector strategies with poverty reduction, progress has depended on the capacity ofthe country’s public sector, partner relationships with the government and relations among donors. There are also no intermediate indicatorsfor measuring progress, which reduces clarity and accountability of what is expected to be achieved by the PRSP. (Ref: The Poverty ReductionStrategy Initiative: An Independent Evaluation of the World Bank’s Support Through 2003, 2004).

8 More detailed information about the case of Senegal is available from James Garrett and Marcela Natalicchio, eds. “Working Multisectorally in Nutrition: Principles, Practices, and Case Studies,” IfPRI, 2011.

In fY12, the World Bank’s agriculturalprojects covered some 40 countriesand amounted to approximately $5.4billion in new IDA/IBRD assistance.The most common focus of theseprojects is either to raise agriculturalproductivity and/or to link farmers tomarkets. Nutrition-specific interven-tions in these projects remain largelyabsent, and nutrition sensitivity isstill weak. However, awareness, com-mitments, and integration of nutri-tion activities are growing. In thecontext of the global food price in-creases, initiatives such as theGlobal food Price Response Program(GfRP), had about 15 percent of the$1.5 billion allocation going towardsnon-agricultural interventions, suchas social protection and school feed-ing. Housed in the World Bank, theGlobal Agriculture and food SecurityProgram (GAfSP) was set up in April2010, at the request of the G20, toscale up support to country-led anddeveloped agriculture and food secu-rity plans and to help promote invest-ments in smallholder agriculture.GAfSP recently allocated US$46.5million to Nepal to enhance house-hold food security in the poorest andmost food insecure regions throughincreased agricultural productivity,household incomes, and awarenessabout health and nutrition in the mid-western and far-western develop-ment regions.

New strategies in social protectionand education hold promise for nu-trition. In the social protection sec-tor, nutritional considerations are notyet central to the design of safety


34

10 Business Warehouse, World Bank April 2012. Includes pipeline investments for 2012.

nets. But the Rapid Social Response(RSR) trust fund, as well as the newsocial protection strategy, offer realopportunities to mainstream nutri-tion issues among the poorest andthe most vulnerable populations intofuture social safety net designs tobuffer the impact of future crises. TheBank’s new education strategy is de-signed to be nutrition-sensitive, witha focus on early childhood develop-ment, albeit the true test will lie in itsimplementation at country level.Within the health sector, commit-ments for nutrition accounted foronly 5 percent and 4 percent of over-all health commitments in fY11 andfY12, respectively.10 Nutrition is still amarginal focus in the Results-Basedfinancing trust funds financed by theUK and Norway.

Nutrition must move to the centerof the discussion on poverty reduction strategies and on measuring progress on poverty reduction. Despite recent global dialogue on a composite povertymeasurement index that includes nu-tritional considerations, poverty con-tinues to be measured and reportedusing income and consumption met-rics alone. The measurement issue isrelevant in that most national devel-opment plans set core targets forpoverty reduction but do not reporton non-income metrics. However, re-cent progress has been made in thisarea under the Multi-DimensionalPoverty Index (MPI) developed by Ox-ford University. The MPI uses 10 indi-cators that reflect the MDGs andinternational standards of poverty.

The three dimensions in the MPI areeducation, health, and standard ofliving. A person is identified as multi-dimensionally poor if they experiencedeprivation in at least 30 percent ofthe weighted indicators. The two in-dicators for health are child mortalityand nutrition.

There are major opportunities to in-corporate small adjustments to IDAand IBRD investments across thesectors to make them more x with a potentially impressive impacton nutrition outcomes. Given theBank’s country-level convening power,its ability to advise on country poli-cies, and current and upcoming invest-ments and strategies in key sectors,the impact of this effort will likely gobeyond the World Bank to other devel-opment partners, and most impor-tantly, it will extend to country clients.

Rice fields

Photo: Thomas Sennett/World Bank

Five key lessons learnedBased on experience to-date, fivesteps are necessary for transformingnew operations across several sec-tors to be more nutrition-sensitive:

a. Explicitly incorporate nutritionalconsiderations into initial designof projects/policies.

b. Integrate nutritional considera-tions as elements of investments,not necessarily as the primary ob-jective.

c. Modify the design/consider alter-natives to minimize unintendednegative consequences and maxi-mize positive impacts.

d. Support nutritional objectiveswith technical capacity withincountries.

e. Monitor and evaluate nutrition im-pacts with appropriate indicators.

Challenges and opportunities forcross-sectoral work. Key challengesto cross-sectoral work include lack ofknowledge about the impacts of agri-culture and other sectors on nutri-tion, structural issues (such asinstitutional and sectoral administra-tive structures), staff time, budgets,related (dis)incentives, institutionallymandated coding of nutrition invest-ments (which often allows for owner-ship of products by only onesector/unit), and the political econ-omy of cross-sectoral work.

tion; IfAD included nutrition as oneof their core objectives in their newStrategic framework; fAO has priori-tized nutrition as a corporate priorityand is undergoing a process of main-streaming nutrition within the institu-tion; and the Bill & Melinda Gatesfoundation (BMGf) has just approveda new agriculture strategy that priori-tizes a focus on nutrition through thequality of foods produced and con-sumed. The European Commissionhas developed a “Reference Docu-ment” that provides guidance to theiraid administrators working withincountry teams to complement and ex-tend existing efforts by memberstates to explore how nutrition com-ponents can be incorporated intotheir projects and programs. Re-search and programmatic invest-ments in agriculture-nutritionlinkages made by BMGf, DfID, USAID,the UN, the Syngenta foundation,and others are cited in the agriculturemodule.11

The SuN donor partners group re-quested the Bank to develop guid-ance notes to translate current andexisting knowledge and researchinto practice and to increase thenutrition sensitivity of agricultureand social protection projects.12

Principals from the World Bank’s Ad-visory Council of foundation leadershave agreed to work together to in-corporate nutrition interventionsmore seamlessly into future agricul-ture and food security programs.

Potential solutions/incentives forcross-sectoral work. Several poten-tial solutions can be explored. Theseinclude results agreements with in-centives for cross-sectoral work. Ear-marked resources for cross-sectoralproducts/operations could alsoprove catalytic.

The South Asia Regional Assistance Strategy (RAS) on nutrition – a modelfor change? Experience from the implementa-tion of the SAR RAS strategy(Box A-2) over the first year suggeststhat when management commitmentis high, targets for cross-sectoralwork are not just achieved, but canbe surpassed.

Translating knowledge into practiceAlthough there is a body of literature demonstrating the importance of linking nutrition andother sectors, the challenge facingpartners is translating this knowl-edge in to practice. The Internationalfood Policy Research Institute (IfPRI)organized a first international confer-ence, “linking Agriculture with Nutri-tion and Health” in New Delhi infebruary 2011. Many development or-ganizations are starting to includemultisectoral linkages in their strate-gies. for example the new DfID strat-egy on nutrition highlights the needfor a multisectoral approach to nutri-

35


11 Information on guidance, statements, and strategies to link agriculture and nutrition, published by over 50 institutions, can be found in: fAO, 2012. Syn- thesis of Guiding Principles on Agriculture Programming for Nutrition. https://www.securenutritionplatform.org/Pages/DisplayResources.aspx?RID=32

12 This group includes the Bill and Melinda Gates foundation (BMGf), Canada, European Commission, france, Germany, Ireland, Japan, US, UK, and the World Bank.

To respond to the alarmingly highrates of child malnutrition in SouthAsia, the potentially severe conse-quences of the problem, and the mul-tisectoral nature of its determinants,the South Asia Regional ManagementTeam (RMT) adopted nutrition as a re-gional priority. The RMT also identi-fied the need for a framework thatwould ensure that the region main-tains and delivers on the resultsfocus, and hence a Results-BasedRAS for Nutrition was developed withextensive consultations at the coun-try and regional levels with staff fromdifferent sectors.

The strategy outlines the region’s vi-sion and approach to improving nu-trition. It draws upon collectiveknowledge, experience and thinking,and distills concrete actions that theregion can take in the immediate tothe medium term to translate com-mitment into results. Recognizingthat further development and refine-ment is possible, it is a “live” docu-ment meant to be updatedperiodically.

The RAS envisions that “Malnutritionwill no longer be a public healthproblem in South Asia by 2016.” Toachieve this vision, the strategy out-lines some key results and provides aroad map to scale up South Asia Re-gion’s work program on nutrition. Itproposes some strategic approachesto guide the scale up of this work pro-gram, with an emphasis on workingintersectorally, focusing on theBank’s areas of comparative advan-

tages to support client countries im-plementation of comprehensive pro-grams that integrate criticalnutrition-sensitive actions in multiplesectors. The overall objective of theRAS is to expand the scale, scope,and impact of the region’s work pro-gram, while building SAR Bank staff’sand clients’ commitment to, and ca-pacity for a multisectoral response tothe nutrition crisis. The RAS is ex-pected to meet its objective throughfour key results:

• Improved awareness and commit-ment by Bank staff and clients toaddressing maternal and child nu-trition;

• Increased World Bank lending foroperations aimed at improvingmaternal and child nutrition;

• Increased World Bankfunding/management of analyticalwork to address knowledge gapsin maternal and child nutrition;

• Successful implementation of amultisectoral convergence modelproject aimed at improving childnutrition indicators.

A June 2011 review of the RAS againstthese objectives suggests that all ob-jectives have been surpassed, and itis time now to raise the targets evenfurther. As of June 2011, awarenessand commitment in the region is atrecord high, several new analyticpieces have been developed, and op-erations are becoming more and


36

BOx A-2. THE SOuTH ASIA REGIONAL ASSISTANCE STRATEGy FOR NuTRITION, 2010-2015

more nutrition-sensitive. Three proj-ects in India, three in Nepal, three inPakistan, one in Afghanistan, andtwo projects in Bangladesh acrossthe human development, agricultureand environmental services (AES),and social protection are now ontheir way to becoming nutrition-sensitive.

In addition to the RAS, the South Asiafood and Nutrition Security Initiative(SAfANSI) was formed by a WorldBank and DfID partnership in 2010. Itseeks to increase the commitment ofgovernments and development agen-cies in South Asia to more effectiveand integrated food and nutrition se-curity policies and programs throughthree broad program areas:

• Analysis: improving evidence andanalysis on the most cost effectiveways to achieve food and nutritionsecurity in South Asia,

• Advocacy: improving awareness offood and nutrition security-relatedchallenges, and advocacy for ac-tion amongst relevant stakehold-ers,

• Capacity Building: strengtheningregional and in-country policy andprogramming capacity to achievefood and nutrition security out-comes.

SAfANSI currently has programs inAfghanistan, Bangladesh, Bhutan,India, Nepal, Pakistan, and Sri lanka.

The Bank’s regional teams, espe-cially South Asia and Africa wherethe burden of malnutrition is thehighest, have also requested thisguidance. In the South Asia Region(SAR), the SAR Regional ManagementTeam (as described earlier) is now ac-countable for supporting a multisec-toral response to malnutrition.13 Theother regions are also exploring amultisectoral approach to improvingnutrition results. Thus, this report isa first step towards operationalizingthis multisectoral approach. It hasevolved in response to the urgent de-mands of the development commu-nity, and builds on existing researchto facilitate translating knowledge into action. Where evidence is weak, itcalls for more evidence; where it isstrong, it provides programmaticguidance that will help these sectorsto adopt a “nutrition lens” as theydevelop new programs and projectswith client country counterparts. Inthis first phase, the focus is onpoverty reduction, agriculture andfood security, social protection, andhealth. These notes are accompaniedby a succinct, operational matrix thathighlights the objectives, tracking in-dicators, opportunities and trade-offs, and issues of policy coherencewhere relevant.

The Bank has also received fundingfrom the Knowledge and learningCouncil to fund a Knowledge Plat-form, known as “SecureNutrition”to link agriculture, food security,and nutrition. SecureNutrition hasboth an internal and external audi-

Nutrition Beam has done thisthrough the development of a net-work of development practitionersthat share knowledge and catalyzesynergies of interventions acrosssectors.

III. Nutrition basicswhat is malnutrition?

The term malnutrition encompassesall categories of poor nutritioncaused by insufficiency/deficiency orexcess. Malnutrition is internation-ally categorized as one or more of thefollowing types shown in figure A-5,and one or more types of malnutri-tion can coexist not only in onehousehold, but also in one single in-dividual.

ence. It aims to bridge operationalknowledge gaps between the threesectors, offering a space to exchangeexperiences, disseminating informa-tion and increasing coordination, col-laboration, and cogeneration ofknowledge. The platform is workingtowards building a community ofpractice by interacting with unitswithin the Bank as well as a compre-hensive external partner base thatwill actively contribute to the knowl-edge sharing and cogeneration activ-ities.

A similar initiative also has beenundertaken in the latin Americaand Caribbean region, known asthe lAC Nutrition Beam, which hasbeen created to maximize the im-pact on nutrition outcomes ofcross- sector investments and ini-tiatives within the lAC region. The

37


13 SAR Regional Assistance Strategy on Nutrition, Box A-2.

FIGuRE A-5. MALNuTRITION By TyPE

STuNTING

Also knownas chronicmalnutrition,stunting is a low height-for-age, defined asmore than 2SD below themean of thesex-specificreferencedata.

MALNUTRITIONuNDERNuTRITIoN ovERNuTRITIoN

wASTING

as acute malnutrition,wasting islow weight-for- height,defined asmore than 2SD below themean of thesex-specificreferencedata.

uNDERwEIGHT

low weight-for age, defined asmore than 2SD below themean of thesex-specificreferencedata.

MICRoNuTRIENTDEfICIENCIES

Also knownas “hiddenhunger,” aconsequenceof inadequateintake of essential micronutri-ents. Key micronutrientsinclude: iron,vitamin A, zinc,and iodine.

ovERwEIGHTAND oBESITY

A conditioncharacterizedby excessbody fat, typically defined forchildren as aweight-for-height ™2 SD,or for adults,a Body MassIndex (BMI) ™ 25.

what are the consequences of malnutrition?

At least 35 percent of child deaths areattributable to undernutrition.14 Themajority is due to the synergistic ef-fect of undernutrition and disease.An undernourished child who falls illis much more likely to die than awell-nourished child. Undernutritionis also responsible for 11 percent ofall disability- adjusted life years(DAlYs) lost globally, and up to aquarter of DAlYs in countries withhigh mortality.15

Because of their higher prevalences,mild and moderate undernutritionare responsible globally for a greaterproportion of child death and burdenof disease than severe undernutri-tion. Undernutrition results in lossesin brain development, physicalgrowth, and human capital develop-ment, costing undernourished indi-viduals to lose about 10 percent oflifetime earnings, and high-burdennations to lose approximately 2-3percent of GDP.16 Some of the specificconsequences of different forms ofmalnutrition are listed below.

• Stunting, or chronic malnutri-tion, reflects a long-term failure togrow, and is the cumulative effectof chronic deficits in food intake,poor caring practices, and illness.Children who are stunted are athigher risk of death. They also

have reduced physiological capac-ity and work output, reducedphysical growth, and poor educa-tional achievement, all of whichhold negative consequences for achild’s future. Adults who werestunted in childhood have beenshown to have lower earning po-tential when compared to thosewho reached their full growth po-tential.

• wasting, or acute malnutrition,is the result of a recent shock suchas lack of calories and nutrientsfrom famine, and/or severe andsudden illness. Wasting is oftenused to assess the severity ofemergencies during crisis situa-tions. A child who is severelywasted (z-score ) -3) is nine timesmore likely to die than a child whois not wasted.17

• underweight reflects inadequateweight status and serves as acomposite measure that capturesboth stunting and wasting.

• Micronutrient deficiencies, alsoknown as “hidden hunger,” areassociated with adverse healthoutcomes, including heighteneddisease prevalence and severity,poor cognitive function, and in-creased risk of mortality. Globally,approximately two billion peopleare deficient in one or more mi-cronutrients.18


38

o vitamin A deficiency (vAD) isthe result of inadequate di-etary intake of vitamin A. Vita-min A deficiency is the largestcause of preventable blindness(irreversible) and night blind-ness. Healthy functioning ofthe immune system dependson vitamin A, and VAD is a riskfactor for increased severity ofinfectious disease and mortal-ity.

o Iron deficiency is the mostwidespread preventable nutri-tional deficiency in the worldand affects both developingand developed nations, acrossall income groups. The conse-quences of anemia for chil-dren—approximately half ofwhich is due to iron defi-ciency—include increased mor-bidity and mortality, stunting,lower performance in school,cognitive delays, and apathy.In adults, anemia is associatedwith weakness and fatigue,lower productivity, and in-creased risk of maternal mor-tality from postpartumhemorrhage.

o Iodine deficiency is caused bylack of iodine in the diet, andcan cause irreversible mentalretardation (cretinism), goiter,reproductive failure, and in-

14 The Lancet Series on Child and Maternal Undernutrition, 2008.

15 Ibid.

16 World Bank. 2006. Repositioning Nutrition as Central to Development.

17 The Lancet Series on Child and Maternal Undernutrition, 2008.

18 UNICEf website, Micronutrients- Iodine, iron and vitamin A. Accessed february 21, 2012. < http://www.unicef.org/nutrition/index_iodine.html>

creased child mortality. Saltiodization is an extremely ef-fective means of ensuring ade-quate iodine consumption atthe population level.

o Zinc deficiency is estimated tobe widespread in countrieswith inadequate levels of zincin the food supply. Zinc defi-ciency is associated with stunt-ing and increased incidence ofdiarrhea and pneumonia.

• overweight and obesity are amajor risk for non-communicablediseases in adults, including car-diovascular diseases, diabetes,musculoskeletal disorders, andcertain types of cancers. Child-hood obesity is associated with ahigher chance of adult obesity,

given the rapid growth and develop-ment that takes place. As shown infigure A-6, stunting and underweightcan begin in utero, where childrenwho have not received adequate nu-trition during gestation are born witha negative z-score for either weight-for-age or height-for-age. Growth fal-tering occurs mainly before a child’ssecond birthday, when children areparticularly vulnerable to poor caringbehaviors, inadequate access tohealth services, and inappropriatefeeding practices, all of which canhave detrimental consequences fortheir health and survival.

Therefore, this critical period or “win-dow of opportunity” between preg-nancy and 24 months is whenundernutrition can and should beprevented.

premature death, and disability. Inaddition to future risks, obesechildren experience breathing dif-ficulties, increased risk of frac-tures, hypertension, early markersof cardiovascular disease, insulinresistance, and psychological ef-fects.

who is most vulnerable tomalnutrition?

The damage that occurs from under-nutrition in a child’s first 1,000 days,from pregnancy to 24 months of age,is largely irreversible. During this pe-riod, nutritional requirements aresubstantial, in terms of caloric andmicronutrient needs for both preg-nant women and young children

39


Source: Victora C.G., de Onis M., Hallal P.C., Blössner M., Shrimpton R. 2010. Worldwide timing of growth faltering: revisiting implications for interventions using the World Health Organization growth standards. Pediatrics.

AGE (MONTHS)

Z-SC

ORES

(WHO

)

AGE (MONTHS)

Z-SC

ORES

(WHO

)

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58

1

0.75

0.5

0.25

0

-.025

-.05

-.075

-1

-1.025

-1.5

-1.75

-2

Weight-for-age (WAZ)Weight-for-length (WHZ)Weight-for-age (HAZ)

FIGuRE A-6. uNDERNuTRITION AND THE wINDOw OF OPPORTuNITy: A CHILD’S FIRST 1,000 DAyS

why is intervening in nutrition important?

• High economic returns, high impact on economic growth, andpoverty reduction

o Overall, the benefit:cost ratiosfor nutrition interventionsrange between 5 and 200.19

o Malnutrition slows economicgrowth and perpetuatespoverty through direct lossesin productivity from poor phys-ical status; indirect losses frompoor cognitive function anddeficits in schooling; andlosses owing to increasedhealth care costs.

o Improving nutrition is essentialto achieving MDGs 1, 4, and 5.

• Malnutrition is an alarming problem worldwide

o Malnutrition is a problem inboth rich and poor countries,with the poorest people inboth sets of countries affectedthe most.

o Nearly a third of children in thedeveloping world remain un-derweight or stunted, and 30percent of the developingworld’s population suffers fromdeficiencies in micronutrientssuch as iron, vitamin A, zinc,and iodine.

o less than 25 percent of coun-tries will achieve the non-in-come poverty MDG target ofhalving underweight.

• Malnutrition has irreversible consequences that last a lifetime

o Undernutrition’s most damag-ing effect occurs during preg-nancy and in the first two yearsof life. The effects of undernu-trition during this critical win-dow on health, braindevelopment, intelligence, ed-ucational attainment, and pro-ductivity are largelyirreversible.


40

Productivity losses frommalnutrition are estimated at more than 10% of lifetime earnings, and up to 2%-3% of GDP.

19 Horton, S., Shekar, M., McDonald, C., Mahal, A., J.K. Brooks. 2010. Scaling Up Nutrition:What Will it Cost? Washington D.C.: The World Bank.

40

where is malnutrition most prevalent?

• Globally, undernutrition hasdecreased since 1990, albeit veryslowly. However, overnutrition hasbeen on the rise at an increasedrate over the last ten years (figureA-7).

• In Sub-Saharan Africa, malnutri-tion is on the rise. Both over-weight and underweightprevalence rates have increasedover the last twenty years, andstunting has been reduced byonly two percentage points in thissame time period.

• In Asia, malnutrition is decreas-ing, but South Asia still has boththe highest rates and the largestnumbers of malnourished chil-dren.

• In East Asia and the Pacific,latin America, and Eastern Eu-rope, many countries have a se-rious problem of chronicundernutrition and micronutri-ent malnutrition coexisting withhigh and rising rates of over-weight and obesity.

• Deficiencies of key vitamins and minerals continue to be per-vasive. In the developing world,35 percent of people lack ade-quate iodine, 40 percent of peoplesuffer from iron deficiency, andmore than 40 percent of childrenare vitamin A deficient.20

How can countries improvethe nutrition status of theirpopulation?

The Scaling Up Nutrition Move-mentAs discussed earlier, the Scaling UpNutrition (SUN) movement is advanc-ing globally. Its purpose is to encour-age increased political commitmentand programmatic alignment to ac-celerate reductions in global hungerand undernutrition.

• Malnutrition rates vary by in-come quintile, with the poorestbeing the most heavily affected.The prevalence of malnutrition isoften two or three times—some-times many times—higher amongthe poorest income quintile thanamong the highest quintile. How-ever, in many countries, undernu-trition is surprisingly high even inupper income quintiles, making itclear that income alone does notsolve the problem.

41


20 World Bank. 2006. Repositioning Nutrition as Central to Development.

FIGuRE A-7. PROGRESSION OF MALNuTRITION IN DEvELOPING COuNTRIES FROM 1990-2010

Source: UNICEF, 2011.

0

10

20

30

40

50

10

44.4

3.7

9.8

36.1

4.59.6

29.2

6.1

WastingStuntingOverweight

1990 2000 2010

Main elements of the SUNFramework• Start from the principle that

what ultimately matters is whathappens at the country level. In-dividual country nutrition strate-gies and programs, while drawingon international evidence of goodpractice, must be country“owned” and built on the coun-try’s specific needs and capaci-ties.

• Sharply scale up evidence-basedcost-effective interventions toprevent and treat undernutri-tion, giving highest priority tothe -9 to 24 month window ofopportunity, which has the high-est returns on investments. Aconservative global estimate of fi-nancing needs for these interven-tions is US$ 10+ billion per year.

• use a multisectoral approach totarget nutrition in related sec-tors and include indicators ofundernutrition as one of the keymeasures of overall progress inthese sectors. The closest action-able links are to food security (in-cluding agriculture), socialprotection (including emergencyrelief), and health (including ma-ternal and child health care, im-munization, and family planning).There are also important links toeducation, water supply and sani-tation, as well as to cross-cuttingissues like gender equality, gover-nance (including accountabilityand corruption), and statefragility.

• Provide substantially scaled updomestic and external assis-tance for country-owned nutri-tion programs and capacity. Tothat end, ensure that nutrition isexplicitly supported in global aswell as national initiatives for foodsecurity, social protection, andhealth, and that external assis-tance follows internationallyagreed upon principles of aid ef-fectiveness. Support major effortsat national and global levels tostrengthen the evidence base,which is important for advocacy.

Priority Interventions for Scaling Up NutritionTo curb child death and disability inthe short term, the immediate prior-ity interventions for Scaling Up Nutri-tion are the evidence-based directinterventions to prevent and treat undernutrition presented in the 2008lancet Series on Maternal and ChildUndernutrition. These Nutrition-specific interventions include:

• Promoting good nutritional practices

o Includes optimal breastfeedingand complementary feeding(after 6 months), and improvedhygiene practices (includinghandwashing)

• Increasing intake of vitaminsand minerals through provisionof micronutrients for young children and their mothers

o Periodic vitamin A supplements


42

o Therapeutic zinc supplementsfor diarrhea management

o Multiple micronutrient powders

o Deworming for children (to reduce loss of nutrients)

o Iron-folic acid supplements forpregnant women to preventand treat anemia

o Iodized oil capsules wheniodized salt is unavailable

• Provision of micronutrientsthrough fortification for all

o Salt iodization

o Iron fortification of staplefoods

• Therapeutic feeding for malnour-ished children with special foods

o Prevention or treatment ofmoderate undernutrition

o Treatment of severe undernu-trition (severe acute malnutri-tion) with ready-to-usetherapeutic foods (RUTf)

The Scaling up Nutrition movement also recognizes the urgent need for multisectoral action, but efficacy evidence is lessclear-cut for indirect nutrition-sensitive interventions. This document aims to address this gap.

How does the Bank cost its investments in nutrition?

In 2002, the Bank released an up-dated theme and sector coding sys-tem that provides the basis foranalyzing and reporting on the con-tent of Bank activities, includingBank budget allocations to strategicgoals and priority sectors. Theme andsector codes are assigned to all lend-ing operations, economic and sectorwork, technical assistance (non-lend-ing), research services, client train-ing, and other activities that directlyserve the Bank’s external clients. Ac-tivities that serve the Bank’s internalneeds, such as quality assurance,country assistance strategies, sectorstrategy papers, knowledge prod-ucts, and training of Bank staff, arenot coded for sectors and themes.

Although nutrition investments in theWorld Bank only represent a smallfraction of total investments, nutri-tion activities are often not capturedproperly due to a lack of awarenessand/or use of code 68, the Nutritionand food Security code. Code 68 ap-plies to projects with objectives andspecific activities related to improv-ing nutritional status or food securityat the household level. It also is usedwhen the actions described in Box A-3 are included in external, client-fo-cused activities.

43


• Promoting adequate infant andyoung child growth

• Improving breastfeeding practices

• Ensuring the adequate and timelyintroduction of complementaryfoods

• Implementing programs to reducemicronutrient malnutrition suchas fortification, supplementationor food-based strategies, and disease and parasite prevention and control, e.g.,helminths, tuberculosis, malaria,HIV/AIDS, etc.

• Improving adolescent and maternal nutrition and reducinglow birth weight

• Developing capacity in nutritionplanning and policy development,including consumption effects offood policy

• Improving institutional development and capacity to design, implement, and monitornutrition interventions

• Developing and integrating nutrition education and behaviorchange communication (BCC) into nutrition interventions

• Targeting food supplementationto malnourished women and children

BOx A-3. wHAT ACTIvITIES ARE INCLuDED uNDER CODE 68?

• Using food-based safety nets, including food stamps, food subsidies, and food for work withnutrition objectives

• Including nutrition componentsin early childhood development,school health, reproductivehealth, and other programs

• Ensuring that food security interventions, including incomegeneration, labor-saving technologies, improved marketingsystems, and food distributionnetworks, have explicit objectivesto improve household food security, food intake and/or nutrition outcomes

• Increasing crop/livestock production to benefit the mostmalnourished and food insecure

• Targeting emergency food aid tothe most vulnerable, includingfamine relief programs

• Developing and implementing nutrition monitoring and surveillance to improve nutrition interventions and affect policy change

• Developing policies and programs concerning diet-relatednoncommunicable disease prevention and control

Economic Growth,Poverty, and Nutrition

Sailesh Tiwari, Hassan Zaman, Jaime Saavedra

C H A P T E R - B

I. ObjectivesGlobal poverty has declined signifi-cantly in the last two decades butwithout commensurate declines inglobal hunger or improvements innutritional outcomes. Since hungerand malnutrition are linked intri-cately to poverty, the divergence inthe trends of these indicators is puzzling.

In this module, we investigate whynutritional status generally has remained poor despite widespreadreduction in income poverty, anddiscuss the policy implications ofthe situation. This section is tar-geted primarily at PREM economistsworking both on poverty reductionstrategies and economic policy is-sues that feed into a variety of lend-ing and non-lending outputs, rangingfrom the Bank’s Country AssistanceStrategies (CAS) to the DevelopmentPolicy loans (DPl), and Public Expen-diture Reviews (PER).

II. BackgroundHalving the proportion of peopleliving in extreme poverty andhunger by 2015 is one of the MDGs.Most recent estimates indicate that the poverty target willbe met given the rate of recentprogress.1 The number of people living in extreme poverty decreasedfrom 42 to 25 percent (see figure B-1), and the prevalence of hungerdeclined from 20 percent of under-nourished2,3 in 1990–92 to 16 percent in 2010. However, with the

CHAPTER - B | Economic Growth, Poverty, and Nutrition

46

1 “Global Monitoring Report: The MDGsafter the Crisis,” World Bank, 2010.

2 The fAO defines undernourishment ina country as the proportion of thepopulation below the minimum levelof dietary energy consumptiondeemed necessary for basic humanfunctioning in that particular country.It is essentially a measure of fooddeprivation and is based on the calcu-lation of three key parameters foreach country: the average amount offood available for human consump-tion per person, the level of inequalityin access to that food, and the mini-mum number of calories required byan average person.

3 “State of food Insecurity in theWorld,” fAO, 2009

global population still increasing,there is an increase in the actualnumbers of malnourished people.fAO estimates that a total of 925 million people were undernourishedin 2010, compared with 1.023 billionin 2009. That is higher than beforethe food and economic crises of2007-2008 and higher than the number in 1996, the year that leaders at the World food Summit set a goal of reducing the number of hungry people by half.

FIGuRE B-1. TRENDS IN POvERTy, HuNGER, AND MALNuTRITION

Source: WDI. Note: The plotted sample consists only of country-year pairs for which data onpoverty and the nutritional indicator were both available. This implies that the match may notalways happen for the most recent year in the data. We did pick the most recent year for coun-tries for which both data existed for more than one year.

0

10

20

30

40

50

42

16

27

34

14

24

31

14

22

living below $1.25/day, 2005 PPPUndernourishedUnderweight

1990-92 1995-97 2000-02

25

13

21

2005-07

Nutritional status is an importantcomponent of human welfare andeconomic development and slowprogress on improving nutritionalindicators is worrying in its ownright. But undernourishment also di-rectly impinges on adult productivity,particularly in rural, agricultural set-tings by lowering stature and physi-cal strength, and indirectly byincreasing the burden of disease andmorbidity. In addition, it retards cog-nitive development in children, un-dermining the development ofhuman capital, which is critical foreconomic growth in the longer term.In addition, there is growing recogni-tion both within and outside theBank that nutritional deprivation isan important complementary meas-ure to the standard income- relatedpoverty measures. As a result, manymulti-dimensional poverty measuresbeing developed take into accountnutritional status as one of the com-ponents of overall welfare.

There is a growing body of evidencethat nutritional deprivation in theearly years of life (including inutero) has persistent long-term ef-fects into adulthood. The primarychannel is through potential educa-tional attainment, which is lower forundernourished children.4 Childrenwho experience periods of malnutri-

depending on the nature of thework.8 Similarly, the median loss inreduced work capacity associatedwith anemia in adults has been esti-mated to be equivalent to 0.6 percentof GDP. The number goes up by an ad-ditional 3.4 percent when the sec-ondary effects of retarded cognitivedevelopment in children is factoredin.9 Overall, these studies reinforcethat poor nutritional status is a con-sequence of low income and also oneof its causes over a longer term.

In figure B-2, we present all ob-served measurements of chronicmalnutrition (stunting) in theworld Bank’s world DevelopmentIndicators database between 1990and 2009. Every dot represents acountry and the horizontal bar de-notes the mean value of the observa-tions for the given year, while theshaded area represents the range ofvalues that are +1 and -1 standard de-viation from the mean of that year. Anumber of interesting patternsemerge from this picture. first, look-ing at the +1 and -1 standard errorbands around the mean, it is evidentthat the overall decline in stuntingrates has been sluggish over theyears. The aggregate, however,masks significant heterogeneitywithin countries. Countries likeBangladesh, Vietnam, and Uzbek-

tion in their early childhood yearshave poorer test scores on cognitiveassessments, activity level, and at-tention span.5 They also tend to startschool later and are at a greater riskof dropping out before completing afull primary school cycle. InGuatemala, a recent study found thatbeing stunted at age six is tanta-mount to losing four grades ofschooling in terms of test perform-ance.6 The accumulated evidence onchild malnutrition suggests that chil-dren’s learning potential in schooland their productivity in later life is toa large extent predetermined by theirhealth and nutritional status beforethe age of two years.

Even in settings in which sufficientcalories are consumed, the lack ofdiversity in the dietary compositionof the poor deprives them of theoptimal consumption of essentialmicronutrients such as iron, iodine, phosphorous, vitamin A,and vitamin C. This issue becomesparticularly important in the contextof rising food prices as householdsuse substitution away from micronu-trient-rich food items such as meat,fish, eggs, milk, fruits, and vegeta-bles as a coping strategy to maintaintheir level of calories.7 Iron deficiencyin adults has been estimated to de-crease productivity by 5-17 percent,

47


4 Glewwe, P., Jacoby, H., and E. King. 2001. “Early childhood nutrition and academic achievement: A longitudinal analysis,” Journal of Public Economics, 81(3): 345-368.

5 Alderman, H. Hoddinott, J. and B. Kinsey. 2006. “long term consequences of early childhood malnutrition,” Oxford Economic Papers, 58(3): 450-474.

6 Maluccio, J. A., Hoddinott, J., Behrman, J. R., Martorell, R. Quisumbing, A. R. and A. D. Stein. 2009. “The impact of improving nutrition duringearly childhood on education among Guatemalan adults,” Economic Journal, 119 (537): 734-763.

7 Skoufias, E., Tiwari, S. and H. Zaman. 2011. “Can Cash Transfers Protect Dietary Diversity During Economic Crises? Some Evidence from Indonesia,” World Bank Policy Research Working Paper.

8 Horton, S. 1999. Opportunities for investment in nutrition in low-income Asia, Asian Development Review, 17: 246-273.

9 Ibid.

istan have made remarkable progressin reducing stunting rates, whileprogress has been much slower incountries such as Guatemala andYemen. On the other hand, countrieslike Benin have actually seen stunt-ing rates increase over the years. Thiscross-country heterogeneity in mal-nutrition trends raises importantquestions about the role played bythe prevailing economic context in

the evolution of nutritional indica-tors. Were the fastest growing coun-tries that were able to reduce povertyalso the countries that saw thelargest declines in malnutrition inci-dence? Or, is there no correspon-dence between poverty reductionand the improvements in nutritionalindicators? We explore this questionmore systematically in the subse-quent sections.


48

III. What is the cross-sectional relationshipbetween poverty andmalnutrition?Poverty and malnutrition are intri-cately linked. figure B-3 shows thepositive correlation between the nu-tritional indicators stunting and un-derweight and poverty in a crosssection of countries.

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

80

70

60

50

40

30

20

10

INCI

DENC

E OF C

HRON

IC M

ALNU

TRIT

ION

(HEI

GHT-

FOR-

AGE) Yemen

Vietnam

Bangladesh

Guatemala

BeninBeninUzbekistan

YEARFIGuRE B-2. MALNuTRITION PREvALENCE OvER TIME (STuNTING = HEIGHT-FOR-AGE)

Source: WDI.

Note: The red bar denotes mean malnutrition for each year. The shaded area signifies +1/-1 standard deviation of the incidence for each year. Sample composition varies from year to year and the frequency of observations for each country.

The data show that high rates ofmalnutrition are generally accom-panied by high rates of poverty inmany countries. Nepal, for instance,had roughly 68 percent of the popu-lation living below $1.25 a day in1996, and 56 percent of childrenunder the age of five were stunted.On the other hand, countries likeGuatemala and Yemen stand outagainst countries of similar income,for the surprisingly high incidence ofmalnutrition as measured by stunt-ing, despite relatively low nationalpoverty rates.10,11 Also remarkable aredifferences in child nutritional out-comes among countries with verysimilar poverty rates, e.g., the differ-ence in stunting incidence betweenBangladesh in 1992 and Gambia in2000 (figure B-3). Contrasting malnu-trition indicators between Sub-Saha-ran Africa (SSA) and South Asia, onecan make the following general ob-servation: countries in SSA appear tohave better malnutrition indicatorson average than one would predictbased on their poverty rates.Whereas it is the opposite case forcountries in South Asia.

49


10 The case of Guatemala is interesting because the stunting incidence is much higher than its level of poverty would predict, and there are severe inequalities within the country. Stunting rates in rural Guatemala, and particularly among the Mayan population, exceeds 80 percentand is perhaps a reflection of the overall inequality of wealth distribution in the country.

11 IEG, 2010, What can we learn from Nutrition Impact Evaluations? lessons from a Review of Interventions to Reduce Child Malnutrition in Developing Countries, World Bank.

REGION

STUN

TING

INCI

IDEN

CE (%

)

POVERTY RATE (51.25/DAY)

East Asia and Paci�cEurope and Central AsiaLatin America and CaribbeanMiddle East and North AfricaSouth AsiaSub-Saharan Africa

0 10 20 30 40 50 60 70 80 90

70

60

50

40

30

20

10

Bangladesh - 1992

Bangladesh - 2005

Guatemala - 1995

Gambin - 2000

Dominican Republic - 2001

Guatemala - 2002

Yemen - 1997Yemen - 2003

REGION

STUN

TING

INCI

IDEN

CE (%

)

POVERTY RATE (51.25/DAY)

East Asia and Paci�cEurope and Central AsiaLatin America and CaribbeanMiddle East and North AfricaSouth AsiaSub-Saharan Africa

0 10 20 30 40 50 60 70 80 90

70

60

50

40

30

20

10

Bangladesh - 1992

Bangladesh - 2005

Guatemala - 1995

Gambin - 2000

Dominican Republic - 2001

Guatemala - 2002

Yemen - 1997Yemen - 2003

FIGuRE B-3. CROSS-COuNTRy CORRELATION BETwEEN POvERTy RATESAND MEASuRES OF MALNuTRITION

Source: WDI. Note: The plotted sample consists of country-year pairs for which data onpoverty and the nutritional indicator were both available. Whenever a poverty statistic was not available for any country-year, for which we had data on malnutrition, we matched it with the closest poverty figure within a five-year window on either side. This implies that a stunting number for a particular country for 2002 could be matched with the closest poverty number available for the country from 1997 to 2007. The dotted line represents a linear fit.

using the data we have assembled,we can create a typology of coun-tries based on the changes inpoverty and nutrition indicators.We present this in figure B-4. Eachquadrant represents a combinationof an increase or decrease of thepoverty rate and malnutrition indica-tors. The third quadrant, for example,represents a decrease in poverty anda decrease in malnutrition incidence.Although most country-year pairs areconcentrated in this quadrant, thekey message here is that there areobservations in the other quadrants.That is, there are countries that havewitnessed episodes of decline inpoverty accompanied by a worsening

of nutritional indicators, an increasein poverty and improvements in nutri-tional indicators, and so on. In com-paring the figures for stunting andunderweight, it is noteworthy thatthe mass of country-year pairs in thethird quadrant for underweightseems to be larger than that forstunting. Since underweight is ameasure of short-run malnutrition,this could potentially reflect a greaterresponsiveness of the underweightindicator to income poverty. Overall,these plots reveal that poverty reduc-tion is neither necessary nor suffi-cient for improvements in nutritionalstatus.


50

FIGuRE B-4. EPISODES OF CHANGES IN POvERTy AND MALNuTRITION

Source: WDI. Note: The plotted sample consists only of country-year pairs for which data onpoverty and the nutritional indicator were both available. This implies that the match may not always happen for the most recent year in the data. We did pick the most recent year forcountries for which both data existed for more than one year.

% P

OINT

CHA

NGE I

N ST

UNTI

NG IN

CIDE

NCE

Gamb06

Pak01

Viet06

Gua99

Ugan01

Ugan05

Peru00Tanz00

Camb00

Mong04Camb00 Ugan06

Hond01Bang96

Bang06 Bang00

Sri 00Uzbe02

Viet00

Cent00

Nige06Zamb99

Buru00

Mong06Guin06

% POINT CHANGE IN POVERTY INCIDENCE4020-20

-20

-10

010

-40 0

% P

OINT

CHA

NGE I

N UN

DERW

EIGH

T

Gamb06

Pak01Viet06

Peru00Tanz00

Mong04

C

Ugan06

Hond01

Bang96Bang06

Sri 00

Uzbe02

Viet00

Nige06

Zamb99

Buru00

Mong06Guin06

% POINT CHANGE IN POVERTY INCIDENCE

4020-20

-20

-50

105

-40 0

IV. How far can economic growth take us?while a reduction in incomepoverty is neither necessary norsufficient for improvements in mal-nutrition, many countries haveseen progress in both indicators.As such, it is worth assessing thegrowth-malnutrition elasticity. Werun a cross-country fixed effect regression of the incidence ofstunting and underweight on log ofper capita GDP, controlling for the ini-tial level of inequality, human devel-opment, and public expenditure inhealth. Since the availability of thenutrition indicators are determinedby the periodicity of the surveys, welimit our sample to country-year pairsfor which the nutrition indicators werequire are available. Between 1981and 2007, we end up with 255 coun-try-year pairs for 78 countries. The re-sults of the regressions are reportedin Table B-1.

To make the implications of the es-timated coefficients explicit, weperform the following hypotheticalanalysis. from the base year (whichis different for each country and isdetermined by the year for which wehave the most recent nutrition data)to 2015, we allow the per capita in-come growth rate in each country inour sample to be the highest growththe country has registered in the lastdecade. Using the elasticities impliedby our estimated coefficients, we canretrieve what the implied malnutri-tion rates would be in 2015. We re-port the change in malnutritionincidence between the base year andthe predicted incidence in 2015 infigure B-5. To incorporate the effectof inequality, we consider predictionsunder three scenarios in 2015: (a)distribution neutral growth; (b)growth accompanied by a 5 percentreduction in inequality, and (c)growth accompanied by a 5 percentworsening of inequality.

for both stunting and underweight,log per capita GDP appears with anegative coefficient, which is whatwe anticipated. The magnitude ofthe coefficients implies that a dou-bling of per capita income would re-duce stunting by 14.8 percentagepoints and underweight incidence by11.4 percentage points. The initiallevel of inequality appears with apositive sign, indicating that malnu-trition is higher in countries withhigh levels of inequality. The interac-tion between initial inequality andthe per capita GDP measure is in-tended to capture any inequality in-duced heterogeneity in therelationship between income levelsand the malnutrition indicators. Thepositive and significant estimates forthis interaction confirm the exacer-bating effect of inequality on malnu-trition indicators. The female literacyrate and public expenditure on healthare positively associated with im-provements in malnutrition rates.

51


TABLE B-1. STATISTICAL RELATIONSHIP BETwEEN MALNuTRITION AND INCOME

VARIABLES Stunting incidence Underweight incidence

Log per capita GDP -14.77*** -11.36***

(-4.74) (-5.20)

Initial inequality (GINI) 0.09** 0.11**

(2.32) (2.17)

Initial inequality x Log per capita GNP 0.13*** 0.10**

(3.09) (2.09)

Female literacy rate -0.02** -0.00

(-2.03) (-0.34)

Public expenditure on health (% of GDP) -0.39* -0.40***

(-1.93) (-2.90)

Country fixed effect Yes Yes

Number of countries 78 78

Observations 255 255

Note: All the data used are from WDI. Robust t-statistics in parentheses. Significance level of *** is 1%; ** is 5%; and * is 10%.

figure B-5 shows that the reductionin malnutrition incidence would be small if one relied entirely oneconomic growth—even if thisgrowth were accompanied by reductions in inequality. for instance, consider the case ofUganda. If the country grew by 7.2percent from 2006 to 2015, and thiswas accompanied by no change in inequality, the reduction in the inci-dence of severe malnutrition wouldonly be 7 percent, or roughly 0.8 percent per year. Based on this, theimplied growth elasticity of stuntingfor Uganda is –0.11.12 Notice also that for countries like Nepal andGuatemala, where growth has beenrelatively low, malnutrition may increase in 2015, unless nutritionspecific measures are put in place to address it. On the other hand, fastgrowing countries like Rwanda andVietnam at best also will see a reductionin malnutrition incidence of roughly 4 percentage points. The overall take-away finding from this analysis isthat growth has in and of itself littleimpact on reducing chronic malnutri-tion. Another finding is that equity dimensions are important as illus-trated by the importance of both initial inequality and simulations ofthe impact of reduced inequality. Inthe following section, we highlightdifferences in malnutrition trends between the richest and the poorestquintiles in a selection of countries.


52

12 The average growth elasticity of stunt-ing for all the countries in the samplewas closer to -0.3 which is slightlylower than what has been found forunderweight in Haddad et al (2004),“Reducing Child Malnutrition: How farDoes Income Growth Take Us?” WorldBank Economic Review.

NOTE: 2015-a corresponds to the scenario in which the growth is distribution neutral. 2015-b is thescenario in which the growth is accompanied by a 5 percent decline in inequality, and 2015-c corre-sponds to the scenario in which growth is accompanied by a 5 percent increase in inequality.

FIGuRE B-5. ESTIMATES FOR THE CHANGE IN STuNTING INCIDENCE IN 2015

-2

-1

0

1

2

3

2015-a2015-b2015-c

Bang

lade

sh

-4

-3

-5

Guat

emal

a

Mal

awi

Nepa

l

Nige

r

Rwan

da

Tanz

ania

ugan

da

viet

nam

BANGLADESH

V. How equitable arenutritional outcomes?Demographic and Health Surveys,the source of most malnutrition in-dicators, do not collect informationon household income and expendi-ture, but do collect information onassets. Using assets as a measure ofhousehold wealth, malnutritiontrends can be analyzed for the richestand the poorest quintiles of thewealth distribution for any givencountry. In figure B-6, we presentdistributions for a selection of coun-tries that typify the different direc-tions in which trends can move.

ened in recent years. The distribu-tional breakdown of these aggregateindicators reveals that it is the poor-est quintile that may be driving thissince malnutrition has declined forthe richest. A somewhat similar storyemerges for Nigeria and Boliviawhere improvements at the nationallevel have been accompanied bygains at the top of the distribution(with some reversal in 2008 in Nige-ria), but a worsening or relativelyslower progress at the bottom. Over-all, these differential patterns acrosswealth groups in the evolution ofmalnutrition trends highlight the im-portance of taking into account theequity dimension when assessingmalnutrition indicators (also seeErgo, Shekar, and Gwatkin, 2008).

for most countries, the aggregateindicators show overall improve-ments in the malnutrition indicatorover the years, but the pattern ofthe decline is different for differentwealth groups. In Bangladesh, atleast in the most recent period, therehas been quicker progress amongthe lowest quintile compared to thericher. This is exactly the opposite ofwhat we see in Tanzania, where therehave been larger gains in nutritionaloutcomes at the top of the distribu-tion, and to a lesser extent inEthiopia as well. Ethiopia is also in-teresting in how similar the levels ofmalnutrition are for the lowest quin-tile and the country as a whole. Burk-ina faso, on the other hand, showsthat severe malnutrition has deep-

53


NOTE: Increase of chronic malnutrition as measured by percentage of children below five years of age thatare two standard deviations below the median of the reference population.

FIGuRE B-6. TRENDS IN CHRONIC MALNuTRITION (STuNTING), By wEALTH quINTILES

70605040302010

01996/97 1999/00 2004 2007

ETHIOPIA70605040302010

02005 2005

TANzANIA70605040302010

01996 2004-051999

BuRkINA FASO70605040302010

02005 2005

NIGERIA70605040302010

01990 20082003

Bottom Top Total

BOLIvIA70605040302010

01998 20082003

VI. Why is progress onimproving nutritionaloutcomes lagging inSouth Asia?Countries in Africa and South Asiadominate the list of countries withthe worst malnutrition indicators.The comparison of malnutrition ratesconditional on poverty or level of in-come between these regions, how-ever, reveals a striking contrastbetween the two regions. All SouthAsian countries (with the exception ofSri lanka) are performing worse thanthe “predicted” level of chronic mal-nutrition given their poverty rates,while a majority of African countriesare doing better than what theirpoverty levels would predict (figureB-3). This raises interesting ques-tions about non-income determi-nants of nutritional outcomes andhighlights the possible importance ofdietary diversity, gender relations,and hygiene in improving child nutri-tion. There is evidence from interna-tional data on the fact that welldiversified diets are associated withbetter child nutrition.13 One way tomeasure dietary diversity is to con-sider what is called the “starchy sta-

ple ratio,” which is defined as theshare of total calories in the local dietthat is derived from starchy staplessuch as rice, wheat, sorghum, etc.According to Bennett’s law, starchystaple ratio declines with income,which basically means that as house-holds become better off they switchaway from cereal dominated diets todiets that have a larger share of vari-ous kinds of meat, fruits and vegeta-bles, dairy products, and so on.However, for countries in South Asia,the shift from cereal-dominated dietsto a more diversified diet appears to


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13 Arimond, M., and M.T. Ruel. 2004.“Dietary diversity is association withchild nutritional status: evidence from11 demographic and health surveys,”Journal of Nutrition, 134(10).

14 Deaton, A. and J. Dreze. 2008. “food and Nutrition in India: factsand Interpretations,” Economic andPolitical Weekly, 44(7): 42-65; Ergo,A., Shekar, M. and D. Gwatkin. Inequalities in Malnutrition in low-and Middle-Income Countries, January 2008, mimeo, World Bank;Haddad, l., Al- derman, H., Appleton,S., Song, l., Y. Yohannes. 2004. “Reducing child malnutrition: How far does income growth take us?”World Bank Economic Review, 17(1).

The starchy staple ratio is the ratio of total calories derived from staple cereals such as rice and wheat. These are calculated for each country in the sample using data on calorie share obtained from the FAO for a wide variety of food sources.

have been minimal: the starchy sta-ple ratio for most South Asian coun-tries is larger than what one wouldpredict from their level of incomes(see figure B-7). As a result, evenwhen nutrition is adequate in termsof calorie sufficiency, there is achronic deficiency in terms of keymicro and macronutrients. In Indiafor example, the ratio of average in-take to the recommended daily al-lowance among children aged 4-6 isonly 16 percent for vitamin A, 30 per-cent for fat, 35 percent for iron, and45 percent for calcium.14

FIGuRE B-7. DIETARy DIvERSITy IS LOw IN SOuTH ASIA

STAR

CHY

STAP

LE R

ATIO

LOG PER CAPITA GDP4 6

0

.2

.4

.6

.8

8 10 12

Sri Lanka

PakistanIndia

Nepal

Bangladesh

In figure B-8 we present a compari-son of South Asia and Sub-SaharanAfrica for the following indicatorsthat are related to child malnutri-tion: proportion of children aged 0-6months that are exclusively breast-fed; (b) proportion of children thatare born with low birth weights; and(c) the proportion of children that arecovered by existing vitamin A supple-mentation programs. It becomes ap-parent that while South Asia scoresbetter on the breastfeeding indicator,it is behind Sub-Saharan Africa onthe low birth weight indicator and vi-tamin A supplementation.

This discussion serves to highlightthe multidimensional nature ofchild malnutrition and the need fora coordinated strategy that in-volves interventions not only toraise income but also health, edu-cation, agriculture, and empower-ment outcomes. In addition, there isalso a growing need to understandempirically the dynamics that governthe allocation of resources within thehousehold and how these changeduring times of crisis. The dynamicsof resource allocation are also impor-tant to understand and incorporateinto the design of policy because oth-erwise, aggregate household level in-terventions (such as cash transfers)run the risk of perpetuating and evenworsening inequities within house-holds.

trition is higher than expected rela-tive to poverty levels. More analyticalwork is necessary to identify whichpart of the causal chain determiningnutritional outcomes requires morepolicy attention in these countries.

There are considerable inequitiesin nutritional outcomes across so-cioeconomic groups and the rate ofprogress in nutritional outcomesvaries over time. In several coun-tries, the gaps between the rich andpoor have widened. Our results showthe importance of a country’s initialinequality in determining nutritionaloutcomes. Hence, policies focusingon improving equity are essential.

VII. What are the implications for policy?

The following four policy implicationsemerge from this analysis:

while economic development onaverage is related to malnutrition,promoting economic growth doesnot necessarily lead to an improve-ment in malnutrition rates. In addi-tion, while poverty and nutritionaltrends on average are closely corre-lated, in many countries they are not.In these countries, e.g., Guatemala,India, Philippines, Egypt, Tunisia, it isimportant to understand why malnu-

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FIGuRE B-8. OTHER PROxIMATE FACTORS RELATED TO CHILD MALNuTRITION

0

20

40

60

%

Exclusive breastfeeding(0-6 months)

vitamin a Supplementation

80

100Sub-Saharan AfricaSouth Asia

2000 2009 2000 2009 2000 2009

low Birthweight

The comparison between malnutri-tion rates in South Asia and Africaare striking. The results clearly showthat relative to the “predicted” levelof chronic malnutrition i.e., stuntingand underweight, given povertyrates, South Asian countries are lag-ging behind, while many Africancountries are doing better than whattheir poverty levels would predict.Gender relations, dietary diversity,and hygiene are possible factors ex-plaining this and illustrate the impor-tance of multisectoral interventions.

The relatively poor nutritional out-comes in the Middle East and inSouth Asia illustrate the risks andinefficiencies of subsidizing or freedistribution of starchy food staplesto improve nutrition outcomes.While the political economy of thesemeasures are such that they may re-main in place for many years to come,improvements can be made that willensure greater nutritional gains. Onesuch effort is fortifying food productswith essential micronutrients, suchas rice and wheat flour, which are


56

distributed through poverty reduc-tion and social protection programs.Considerable progress has beenmade in this area and new technol-ogy implies that the price premiumfor fortified products is relatively low,e.g., 3-4% for fortified rice, and couldpossibly be subsidized to ensure ac-cess by the poor. In addition, otherdirect nutritional interventions suchas promotion of breastfeeding, nutri-tion education, deworming, and im-proved hygiene practices remaincrucial in reducing malnutrition.

VIII. Emerging opera-tional research andknowledge gapsA better measurement tool thatcaptures the food insecurity athousehold levels is becoming in-creasingly necessary. Unlike incomepoverty and nutritional outcomessuch as stunting and underweight,there is lower consensus around anappropriate measure of food securityat the household and individuallevel. fAO publishes aggregate un-dernourishment or hunger numbersas a proxy for food insecurity. WfPproduces a food consumption scoreand a vulnerability map. IfPRI pro-duces a global hunger index, which ismeasured as a weighted average offAO’s hunger measure, underweightincidence, and mortality of childrenunder five within each country. All ofthese measures are varied in theirmethodology and often show contra-dictory results. Moreover, there isvery limited distinction between na-tional and household/individual foodsecurity measures. A unified ap-proach to measuring and trackingfood security at the household levelhas become increasingly necessaryto identify and monitor the effects ofvarious kinds of shocks on vulnerablehouseholds and target interventionsaccordingly.

finally, country economists work-ing on a variety of Bank outputssuch as the CAS, PER and DPls areuniquely positioned to elevate theimportance of nutrition in the na-tional policy agenda and to do so ina manner that recognizes the mul-tisectoral nature of the inputs thatgo into improving nutritional out-comes. These inputs span trade poli-cies that define tariff rates onagricultural products, fiscal policiesthat guide subsidies for agriculturalinputs such as fertilizers and electric-ity, regulatory issues that determinethe marketplace organization forfood, transportation and logistics,and the efficiency of government pro-grams, such as cash transfers, thatmay aim to improve or protect nutri-tional status directly.

There is a growing need to under-stand the dynamics that govern theallocation of resources within thehousehold and how these changeduring times of crisis. The dynamicsare important to understand and in-corporate into the design of policy.Otherwise, aggregate householdlevel interventions, such as cashtransfers, risk perpetuating and evenworsening inequities within house-holds. Existing survey instrumentshave limited information on food con-sumption at the individual level. As aresult, most analyses of food securitythat originate from these datasets in-evitably are based on food availabil-ity as opposed to actual intake.Innovative and cost-effective ways ofincorporating modules that can elicitinformation on actual intakes at theindividual level have to be exploredbecause there are important differ-ences in individual food security, par-ticularly between gender groups, andeven within the same household.

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Improving Nutrition through Agriculture

Yurie Tanimichi Hoberg, Anna Herforth, Meera Shekar, Aparajita Goyal

C H A P T E R - C

Agriculture has a strong influence onfood consumption and nutritionalstatus. Agriculture’s influence is max-imized when nutrition is explicitlyconsidered and progress is meas-ured.

I. ObjectivesThe overall objective of this moduleis to offer practical guidance tosupport world Bank staff, develop-ment partners, and country imple-menters in maximizing the positivenutrition impacts of agricultural in-vestments, and minimizing the un-intended negative consequenceson nutrition. The World Bank’s sup-port to agriculture aims to contributeto meeting the MDG1 of halvingpoverty and hunger by 2015, and theindicators for the hunger goal deal-ing directly with nutrition, i.e., preva-lence of underweight among childrenunder five years of age, and the pro-portion of the population below theminimum level of dietary energy con-sumption. These indicators do notnecessarily decline in tandem. Of the21 countries that have already metthe goal of halving the proportion ofthe population below the minimum

level of dietary energy consumption,only six are on track to meet the un-derweight goal.1 Among those coun-tries showing insufficient progresstoward reducing underweight, Malihas shown no progress on under-weight.2

The specific objectives of this guid-ance note are to support worldBank staff, partner agencies, andcountry clients efforts to makeagriculture investments more nutrition-sensitive in the followingways:

(1) enhance the design of agricultureinvestments and policies to maximizethe impact on nutrition outcomes forthe poor; (2) measure the progress ofactivities affecting nutrition periodi-cally through relevant output andoutcome indicators, such as foodconsumption indicators; (3) minimizethe unintended negative nutritionalconsequences of agricultural inter-ventions and policies on the lives ofthe poor, especially women andyoung children; and (4) support gov-ernments and partners in designingsustainable and coherent policies toimprove nutrition outcomes for thepoor.

CHAPTER - C | Improving Nutrition through Agriculture

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1 Armenia, Georgia, Ghana, Jamaica, Nicaragua, and Vietnam have met the hunger goal and are on track to meet the underweight goal.

2 The 10 countries showing insufficient progress in reducing underweight are Azerbaijan, Congo, Guyana, Mali, Morocco, Myanmar, Nigeria, SaoTome and Principe, Solomon Islands, and Uruguay. Morocco and Uruguay have limited data but progress appears insufficient based on averageannual rates of reduction of 1.2% and 0.8%, respectively. five countries have no data on underweight progress: Chile, Cuba, Gabon, Kuwait, andSt. Vincent and the Grenadines, http://www.childinfo.org/undernutrition_tables.php.

3 The SUN responds to the continuing high levels of undernutrition and the uneven progress towards the MDGs to halve poverty and hunger by theyear 2015. The SUN framework was developed by specialists from governments, academia, research institutions, civil society, private companies,development agencies, and UN organizations, including the World Bank. It is endorsed by more than 100 organizations and was launched inWashington in April 2010, www.scalingupnutrition.org.

4 Malnutrition is defined as a condition resulting from ingesting an unbalanced diet lacking in certain nutrients i.e., undernutrition or excess intakei.e., overnutrition, or a misproportioned diet. As stated in Section A of the report, this document focuses primarily on undernutrition.

II. Rationale

The message that agriculture playsa major role in nutrition (and viceversa) is gaining traction withinand outside of the world Bank.There is considerable global momen-tum to bring the agriculture, food se-curity, and nutrition agendas closertogether so that investments in onewill have positive impacts on the oth-ers. The new global SUN frameworkand Roadmap3 have identified nutri-tion-sensitive development in keysectors as one of the two most urgentpriorities for addressing malnutri-tion, Agriculture is at the top of thelist of key sectors.4 leaders from 27client countries are ready to scale upnutrition investments through multi-sectoral approaches and are known

as the “SUN early riser countries.”(See Section A for more details on the SUN.)

A series of briefs and papers also re-sulted from an international confer-ence hosted by IfPRI in february 2011on “leveraging Agriculture for Im-proving Nutrition and Health.”Achieving nutrition results throughagriculture has been the subject ofseveral recent reviews and strategynotes prepared by major develop-ment partners, such as fAO, IfAD, theEuropean Commission, USAID’s feedthe future Program, USAID’s Infantand Young Child Nutrition Project(IYCN), DfID, as well as major interna-tional CSOs such as World Vision,Save the Children UK, and ActionAgainst Hunger (ACf). (See Annex C-5for a list of recent reviews and strate-gies.)

The world Bank has also increasedattention to the need for linkingagriculture and nutrition. for exam-ple, SecureNutrition, a new know-ledge platform financed by the Bank,was established in fY12 to link agri-culture, food security and nutrition.5

SecureNutrition is led by a team fromHealth, Nutrition and Population(HNP), Agriculture and EnvironmentalServices (AES), and Poverty Reduc-tion and Equity (PRMPR). Its goal is toengage a community of practice toexchange knowledge, awareness,and capacity to support food securityinterventions to improve nutritionoutcomes. One of the key target audi-

farmers, who are the primary targetpopulation of World Bank agricultureprojects. When farmers are under-nourished, they are less productive.furthermore, undernourished chil-dren are less likely to attend school.These children in smallholder fami-lies are less likely to transition out ofsmall-scale farming, and thereby failto get out of the poverty trap. Povertyreduction and improvement in well-being among the world’s vulnerablefarmers will be more meaningful andsustainable if addressing undernutri-tion is part of the package for thebroad rural population which will ulti-mately benefit the population in themost vulnerable first 1,000 days frompregnancy to 24 months.6

why should agriculture staff beconcerned with nutrition? Don’t thehealth and social protection sectorsadequately cover nutrition? Agricul-ture has a unique and critical role inimproving nutrition outcomes, andthe following five reasons explainwhy.

a. Agriculture is the sector bestplaced to affect food produc-tion and consumption of nutri-tious foods needed for healthyand active lives. Physical andeconomic access to adequateand affordable nutritious food isprimarily a function of the agri-culture sector through support toincreased production and im-proved post-harvest storage andprocessing. Agriculture’s unique

ence groups of SecureNutrition is theWorld Bank’s staff. There has beenincreasing demand within the WorldBank for knowledge on how to linkagriculture and nutrition, especiallyfrom the South Asia region, wherethe South Asia food and Nutrition Se-curity Initiative (SAfANSI) providesthese resources. The most basic ra-tionale for Bank engagement in thislinkage is the critical importance ofnutrition to human capital develop-ment and ultimately to the reductionof poverty.

The next sections discuss the uniquecontributions of agriculture to nutri-tion and why nutrition action cannotbe left to other sectors outside ofagriculture; explain how improvednutrition contributes to core agricul-tural objectives; review briefly thepathways from agriculture to nutri-tion; and recommend practical inter-ventions to consider.

III. Why is agricultureimportant for nutrition?In support of its mission to fightpoverty, the world Bank works toreduce poverty through sustainableagriculture and rural development.Undernutrition is intimately linkedwith both poverty and smallholderfarmer well-being and is a major con-straint to rural development among

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5 The Knowledge Platform is cohosted by HNP, AES, and PRMPR and has received funding for fY12-14 from the Knowledge and learning Council.for more information, see http://www.securenutritionplatform.org.

6 World Bank. 2006. Repositioning Nutrition as Central to Development, http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdf.

role in food production and con-sumption makes it indispensablefor enabling people to have con-sistent access to nutritious diets(food security).

b. Agriculture has the most directinfluence and contact with themajority of households in theworld where undernourishedindividuals reside. Beneficiariesof typical agriculture projectsoverlap with those most affectedby undernutrition: the rural poor.Seventy-five percent of theworld’s poor are rural, and mostof those are smallholder farmers.Any development activity reach-ing this population has enor-mous potential to impact onfactors that constrain human

capital and well- being, of whichnutrition is an essential part. forexample, agriculture extensionworkers have direct and ongoingcontact with smallholder farm-ers, and therefore have a uniqueopportunity to strengthen mes-sages regarding consumption ofnutritious foods.

c. Agricultural-led growth is morepro-poor than non-agricultural-led growth; thereby increasingagriculture’s potential to im-prove nutrition. Agriculturalgrowth is at least twice as effec-tive in reducing poverty as GDPgrowth originating outside agri-culture and is therefore pro-poor.7 Agriculture-led growth has


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7 World Bank. 2008. World Development Report 2008: Agriculture for Development.

8 Webb P. and S. Block. 2011. Support for agriculture during economic transformation: Impacts on poverty and undernutrition. PNAS, www.pnas.org/cgi/doi/10.1073/pnas.0913334108.

led to faster (though still insuffi-cient) declines in undernutritionthan non-agricultural growth.8

d. A large percentage of ruralwomen are employed in theformal or informal agriculturesector. Women contribute over50 percent of the agriculturelabor force in many developingcountries. AES investments willhave a large direct impact on nu-trition outcomes for the entirehousehold through increaseddiscretionary income and re-duced workloads for women.

e. Some agriculture projects couldcause unintended nutritionalharm. Nutritional status ofhousehold members is stronglyinfluenced by clean water, dis-ease occurrence, food quality,and child care practices. Severalunintended but related conse-quences, such as reducing-women’s available time for childcare, have been documented asarising from some agricultural in-terventions. Possible harms andmitigation strategies are in-cluded at the end of this module(see Table C-2).

IV. Why is nutrition im-portant for agriculture?

The linkage between agricultureand nutrition has reciprocal bene-fits. Improving nutrition can benefitagricultural sector performance atleast in the following four ways.

a. Improved nutrition means im-proved smallholder well-being.Reducing malnutrition amongthe world’s most vulnerable peo-ple is core to the World Bank’smission of poverty reduction andcore to agriculture’s role of re-ducing poverty and improvingwell-being of vulnerable farmersin the “three worlds of agricul-ture,” presented in the WDR2008, i.e., agriculture-based,transforming, and urbanized.When agriculture projects im-prove nutrition, they more fully

mined that every one percent in-crease in height is associatedwith a four percent increase inagricultural wages.11 Iron defi-ciency anemia results in lowerwork capacity.12 In an agriculturalcontext, anemia has been shownto reduce productivity by 17 per-cent.13 Overall, malnutrition di-minishes lifetime earnings by 10percent or more, and reducesGDP by 2-3 percent in the worstaffected countries.14 Investmentsin human capital, including nutri-tion, consistently have beenshown to increase productivity.15

c. Nutrition knowledge may be anadded incentive to transition toa diversified production model.Transition of households to di-versified production is an oft-cited goal for the agriculturalsector to raise household in-come, minimize risk exposure,

reach the goal of improving thewell-being of farmers and poorpeople living in rural areas.

b. Nutrition investments improvehuman capital and have a posi-tive impact on agricultural pro-ductivity. Smallholder farmersare often among the populationsmost likely to be malnourished.Women smallholder farmers,who form a majority of the agri-cultural labor force in manycases, are disproportionatelylikely to be malnourished. Under-nutrition accounts for 11 percentof all DAlYs lost globally, and upto a quarter of DAlYs in countrieswith high mortality.9 This is nat-urally reflected in lost agricul-tural productivity. Evidenceshows that when farmers aremalnourished, they are less pro-ductive.10 One analysis deter-

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9 Black, R.E., Allen, l.H., Bhutta, Z.A., Caulfield l.E., de Onis, M., Ezzati, M., Mathers, C. J. Rivera et al. 2008. Maternal and child undernutrition:global and regional exposures and health consequences. lancet 371:243-60; World Health Organization. 2002. World Health Report 2002: Re-ducing Risks, Promoting Healthy life. Geneva: WHO.

10 D.E. Sahn. “The impact of poor health and nutrition on labor productivity, poverty, and economic growth in Sub-Saharan Africa,” in The AfricanFood System and Its Interaction with Human Health and Nutrition, P. Pinstrup-Andersen, ed. (Ithaca, NY: Cornell University Press/UNU Press);McNamara, P.E., Ulimwengu, J.M., and K.l. leonard. 2010. Do Health Investments Improve Agricultural Productivity? International food PolicyResearch Institute Discussion Paper.

11 Haddad, l.J., H.E. Bouis. 1991. The impact of nutritional status on agricultural productivity: wage evidence from the Philippines. Oxford Bulletinof Economics and Statistics 53(1): 45-68.

12 Haas J.D, Brownlie, T. 2001. Iron deficiency and reduced work capacity: A critical review of the research to determine a causal relationship. J Nutrition 131: 676S-690S.

13 Basta, S.S., Soekirman, Karyadi, D., and N.S. Scrimshaw. 1979. Iron deficiency and productivity of adult males in Indonesia. American Journalof Clinical Nutrition 32, 916-925.

14 Harold Alderman. 2005. “linkages between Poverty Reduction Strategies and Child Nutrition: An Asian Perspective.” Economic and PoliticalWeekly 40 (46):4837–42; World Bank. 2006. Repositioning Nutrition as Central to Development, http://siteresources.worldbank.org/NUTRI-TION/ Resources/281846-1131636806329/NutritionStrategy.pdf.

15 World Bank, 2008. World Development Report 2008: Agriculture for Development.

16 for example, a Kenyan CSO (farm Concern International) won a World Bank CGAP award for its approach of nutrition-focused marketing of Afri-can leafy vegetables, driving up the value of these horticultural products 213 percent in five years and substantially increasing incomes andinter- est among farmers interested in growing them. C. Irungu. 2007. “Analysis of markets for African leafy vegetables within Nairobi and itsenvirons,” Global facilitation Unit for Underutilized Species (GfU); Ewbank, R., Nyang, M., Webo, C., and R. Roothaert. 2007. “Socio-EconomicAssessment of four MATf-funded Projects,” fARM-Africa Working Paper No. 8, http://www.farmafrica.org.uk/smartweb/news-views/re-sources/4.

17 International food Policy Research Institute. 2011. Agriculture, Nutrition, Health: Exploiting the links. Washington, D.C.: IfPRI.

and promote ecosystem re-silience. Nutrition education andinformation can be leveraged toimprove both supply and de-mand for high-value vegetables,fruits, legumes, fish, and live-stock products. Nutrition knowl-edge among farmers could be anadditional incentive for farmersto diversify their productionmodel to include nutritious,high-value crops, beyond thewidely recognized incentives toreduce risk exposure to weather,biotic stress, or price shocks. Ad-ditionally, nutrition knowledgeamong consumers can increasedemand for high-value nutritiousproducts substantially, and in-crease income for farmers whogrow them.16

d. Adopting a nutrition lens is likelyto improve women’s participa-tion and empowerment, with im-portant effects on income andproductivity, in addition to nutri-tion and gender equity. Approxi-mately half the world’s farmersare women. In some countries,the ratio is much higher. InSoutheast Asia, women supplyup to 90 percent of the labor re-quired for rice cultivation.17

Women account for 70 percent offarm labor and perform 80 per-cent of food processing inAfrica.18 Gender equity is a corpo-rate priority of the World Bank

Most Bank agriculture projectsmeasure women’s participationin projects as an indicator of gen-der equity. Retaining female par-ticipation may improve ifagriculture projects adopt a nu-trition lens. Apart from theirlivelihoods, women farmers’main time demands come frominfant and child care and feed-ing. Agricultural projects that donot account for women’s majorrole in child care are likely to seefemale participation in projectsflag. Structuring programs sowomen with small children canmeet care needs for their in-fants/young children can in-crease female participation andimprove project outcomes. Ifwomen had the same access to


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18 Cramer l.K., S.K. Wandira. 2010. Strengthening the Role of Women in the food Systems of Sub-Saharan Africa to Achieve Nutrition and Health Goals.In: The African food System and Its Interaction with Human Health and Nutrition, P. Pinstrup-Andersen, ed. (Ithaca, NY: Cornell University Press/UNUPress).

19 fAO 2011. The State of food and Agriculture 2010-11, Rome, as quoted in WDR 2012.

productive resources as men,they could increase yields ontheir farms by 20-30 percent,raising total agricultural outputin developing countries by 2.5-4percent, and reducing the globalnumber of hungry people by 12-17 percent.19 By implementingprograms so women can fulfilltheir multiple roles, agricultureprojects can achieve a triple win:they can become more nutrition-sensitive (to the feeding and careneeds of children and mothers),while improving gender equityand concomitantly agricultureprojects’ core productivity objec-tives.

In summary, evidence shows thatwhen agriculture investments haveexplicit nutrition objectives that

TABLE C-1. FIvE PATHwAyS LINkING AGRICuLTuRE TO NuTRITION

Pathway Strength of pathway

1) Increasing overall macroeconomic growth modest effect

2) Increasing access to food by higher production and decreased food prices modest effect

3) Increasing household income through the sale of agricultural products variable effects

4) Increasing nutrient dense food production for household consumption some evidence

5) Empowering women through targeted agricultural interventions strong evidence

Source: Adapted from World Bank 2007.

are tracked and measured over theproject’s lifetime, positive impactscan be expected for both nutritionand agriculture outcomes.

V. Pathways from agriculture to nutritionand available evidenceAgriculture can impact nutritionoutcomes to varying degreesthrough several pathways,20 someof which are stronger than others(see Table C-1). Evidence to date hasshown that among the five mainpathways, household consumptionand women’s empowerment (includ-ing control of economic resources)are the closest links to nutritionalstatus and yield the greatest results.

relation between child underweightwith agricultural GDP (adjusted forthe size of the agricultural popula-tion).25 Some longitudinal analysesreport no significant correlation be-tween annual economic growth andreductions in stunting.26 In India,states with rapid agricultural growthbetween 1992 and 2005 showed in-consistent changes in undernutritionduring the same period; while over-all, the correlation appeared positive.Some states showed no improve-ments in stunting or underweight,and in one state, there was an increase in underweight in women.27

Overall, the effect of GDP growth on undernutrition appears strongerfrom agriculture rather than non-agriculture growth, but the effect isquite modest regardless. further information on the relationship between economic growth and undernutrition can be found in Module B of this guidance note.

A. Pathway 1. National macroeconomic growth

Economic growth from agriculturehas a modest effect on undernutri-tion.21

A recent longitudinal analysis foundthat agricultural per capita incomewas more strongly associated withstunting reductions than non-agricul-tural income presumably, becausegrowth from agriculture benefits thepoor more than growth from othersectors.22,23 Absolute reductions instunting were nonetheless modest; adoubling of per capita agricultural in-come was associated with approxi-mately a 21 percent decline instunting.24 A World Bank analysisshows a similar magnitude of effect,with a 15 percent reduction in stunt-ing and an 11 percent reduction in un-derweight from a doubling of totalGDP (see Module B). figure C-1 belowshows the lack of cross-sectional cor-

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20 There are various ways of categorizing the agriculture-nutrition pathways depending on the level of detail. World Bank (2007) uses five path-ways, while IfPRI identifies four pathways (excluding macroeconomic growth). TANDI (2010) spells out seven pathways, which are essentiallythe same as those listed here (excluding macroeconomic growth), but disaggregated in greater detail. Pathway 3, listed here, is split into twoseparate pathways (one pathway linking household income, food expenditures, and nutrition outcome, and another pathway linking house-hold income, non- food expenditures, health status, and nutrition outcome), and Pathway 5 is split into three functions of women’s empower-ment.

21 Stunting (short height-for-age) and underweight (low weight-for-age) are two different indicators of undernutrition; estimates of the effect ofGDP change have been made for both indicators.

22 At the same time, obesity prevalence increased at a greater rate with agricultural than non-agricultural growth.

23 Webb, P. and S. Block. 2011. Support for agriculture during economic transformation: Impacts on poverty and undernutrition. PNAS, www.pnas.org/cgi/doi/10.1073/pnas.0913334108.

24 This estimate was lower (about 15 percent reduction from a doubling of agricultural GDP in the range of low-middle-income countries) whencon- trolling for overall income per capita

25 In India, which accounts for about one-third of the global population of malnourished children, strong agricultural growth has resulted inreduc- tions in malnutrition. Despite great increases in food production, due to the Green Revolution from 1965 to the early 1980s, child malnu-trition rates did not drop concomitantly. In fact, malnutrition rates in India continue to stagnate at unacceptably high levels today (nearly halfof all children are stunted, 48 percent). In contrast, most African countries—despite continuing challenges in food security and agriculture—have lower rates of child malnutrition compared with most South Asian countries (albeit the absolute rates are still high).

26 As reported in “A life free from Hunger,” Save the Children UK, 2012.

27 Gillespie, S. and S. Kadiyala. 2012. “Exploring the Agriculture-Nutrition Disconnect in India,” in S. fan and R. Pangya-lorch, eds. ReshapingAgricul- ture for Nutrition and Health. Washington, DC: International food Policy Research Institute.

B. Pathway 2. Higher food production,lower food prices

Increasing food calorie availabilityis a blunt tool to address food security and nutrition.

various agricultural technology in-terventions, if effectively imple-mented, will result in reduced food

prices due to increased production,increased efficiency in marketingchannels, or a reduction of distortivepolicy measures, including tradepolicies, etc. Reduced food pricesraise relative household income fornet-consumer households, which intheory would better economic accessto food or health care, as discussedin Pathway 3. It is important, how-ever, that “food” is understood as all


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28 It is important, however, that “food” is understood as all foods needed for healthy and active lives.[footnote] When food is interpreted as equivalentto calories, the connection to nutrition is weak.

29 fAO defines “food security” as “a situation that exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences for an active and healthy life, fAO 1996: World food Summit Declaration andPlan of Action. Rome.

foods needed for healthy and activelives.28 When food is interpreted asequivalent to calories, the connec-tion to nutrition is weak.29

National calorie supply is corre-lated with reduced undernutritionbut is not deterministic. A multi-country descriptive analysis showsthat per capita calorie supply (includ-ing imports) is correlated with re-

Source: State of the World’s Children, UNICEF 2009; FAO Statistical Yearbook 2009.

FIGuRE C-1. CROSS-COuNTRy LINk BETwEEN AGRICuLTuRAL GDP AND CHILD uNDERwEIGHT

50

45

40

35

30

25

20

15

10

5

0500 1000 1500 2000 2500 3000

Agricultural GDP of the agricultural population ($ constant 2000 prices)

% u

nder

weig

ht (c

hild

ren

< age

5)

Yemen India

MadagascarBurundi

Cambodia Myanmar

SomaliaEthiopia

Pakistan Lao PDR

Eritrea

MauritaniaDR Congo

Philippines

ParaguayKyrgyzstanKazakhstan Mexico

PanamaGahon

Morocco Suriname

Ecuador

UzbekistanPeruEl Salvador

Columbia JordanUruguay

Dominican Republic

UgandaIndonesia

TogoPapua New Guinea

HaitiTanzania, UnitedRepblic of

Egypt

Guinea-Bissau

Botswana

MongoliaHonduras

Central African RepublicSri Lanka

GuineaGuatemala

Namibia

BhotanEquatorial

GuineaCongo

duced undernutrition, especially atthe lowest daily per capita energysupplies (below 2,300 kcal/ per-son).30 While the trend is significant,the variance is striking: at that levelof calories, underweight rates span arange from approximately 10 percentto 70 percent. The correlation be-tween calorie supply and undernutri-tion within Sub-Saharan Africaappears weaker than in other re-gions. As noted above, of the coun-tries meeting the MDG1 target tohalve hunger, fewer than 1/3 are ontrack to meet the MDG1 target tohalve undernutrition, showing thelimited translation of national-levelcalorie availability to nutritional im-provements.

limited associations between sta-ple crop production and nutritionalstatus have been observed withincountries. for example, in Vietnam, amajor rice exporting country, 36 per-cent of children are stunted, and 19percent are underweight. A WorldBank-funded analysis from theMekong Delta in Vietnam showedthat the provinces with the highestrice production levels were precisely

C. Pathway 3. Increased income

Increasing household income hasvariable effects on nutrition.

on average, poverty and undernu-trition are correlated, and move-ment out of poverty is importantfor improved nutrition. In fact, theultimate higher-level objective ofmost agricultural projects is to improve the beneficiaries’ overallwell-being, especially their house-hold income. Higher household incomes have the potential to improve nutrition outcomes, mainlyby increasing the households’ abilityto purchase and consume foods thatare more nutritious and/or to pay for more and better health care to improve the household members’health.

The evidence, however, shows thathousehold income does not neces-sarily lead to improved nutritionalstatus of its most vulnerable mem-bers.34 In a particularly striking ex-ample, 40 percent of children inEthiopia are stunted, even in thewealthiest quintile (see figure C-2).35

In India, similarly high stunting ratesamong the highest income quintilehave declined only marginally and remain at about 25 percent, despiterapid economic growth.36 Module Bof this guidance note shows manycountry examples where poverty reduction is not accompanied by a re-duction in malnutrition.

those with the highest child stuntingrates.31 Some provinces leading therice export expansion had a lower re-duction in malnutrition thanprovinces where rice production de-clined as land was shifted into horti-culture and aquaculture.

one factor in the disconnect between food production and nutritional outcomes may be thepersistent practice of defining andmeasuring food as calories, in-stead of focusing on the diversityof foods needed for a healthy andactive life.32 for low-income coun-tries, most research to date on priceelasticities of demand has focusedon calories, and therefore has notprovided information on the effectsof relative price changes of nutrient-dense foods or other factors, such asdisease patterns. One recent studyshows that prices of non-staples in-creased substantially more thanstarchy staples in Central Java duringthe food price crisis in 1999. Theseprice increases were accompanied bystrong reductions in the consumptionof meat, fish, vegetables, fruit, eggs,and milk.33

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30 Smith, l.C. and l. Haddad. 2000. Explaining child malnutrition in developing countries: A Cross-Country Analysis, International food Policy Research Institute, Washington, D.C.

31 World Bank 2011. Unpublished draft report. Vietnam’s Mekong Delta Region: MalnutritionAmongst Plenty. Can Tho University.

32 Other factors in this disconnect may be the gap between production, consumption, and utilization of food by the body, e.g., due to non-food factors such as disease.

33 Skoufias, E., Tiwari, S., H. Zaman . 2011. Can we rely on cash transfers to protect dietary diversity during food crises? Policy research working paper 5548. World Bank.

34 World Bank. 2006. Repositioning Nutrition as Central to Development,http://siteresources.worldbank.org/NUTRITION/Resourc- es/281846-1131636806329/NutritionStrategy.pdf.

35 Reproduced from the World Bank Nutrition Country Profile for Ethiopia,www.worldbank.org/nutrition/profiles.

36 India National family Health Survey (NfHS-3), India, 2005-06. Mumbai: International Institute for Population Sciences; Calverton, Maryland, USA: ICf Macro.

Empirical evidence shows limitednutrition impact for householdswith increased incomes throughcommercial agriculture. A WorldBank review of the literature (2007)concludes: “Overall, cash-croppingschemes (whether staple crops orother) did not have a significant im-pact—negative or positive—on childnutritional status.” However, house-hold incomes generally improved inalignment with the primary goals ofthe cash crop projects. Consumptioneffects were variable and dependedon the amount of the income in-

crease, how much of the increasedincome was controlled by women,and the changes in relative prices.

when evaluating the impact of in-come on nutrition, available evi-dence shows that it is important tolook not just at the household levelbut also at gender-disaggregateddata. Women’s access to income isstrongly correlated with improved nu-trition in many settings.38,39 It mayseem that intra-household resourceallocation is beyond the scope ofproject planning – but in fact, the de-


68

37 www.worldbank.org/nutrition/profiles

38 Often, there are time-income trade-offs on nutritional status outcomes as well; both maternal time and maternal income are shown to be important for nutrition.

39 UNICEf 2011. Gender Influences on Child Survival, Health, and Nutrition: A Narrative Review. UNICEf and liverpool School of Tropical Medicine.;Smith, l.C., Ramakrishnan, U., Ndiaye, A., Haddad, l., R. Martorell. 2003. The Importance of Women’s Status for Child Nutrition in Developing Countries. IfPRI Research Report 131. Washington, D.C.: IfPRI.

40 One negative example comes from The Gambia, where a large-scale rice irrigation project resulted in higher total income for beneficiary households, but in reduced equity of labor and resource control: women’s discretionary income decreased, while their labor commitment increased. Conversely, a dairy farming intervention in Kenya resulted in significant shares of income accruing to women.

41 J. Dey. 1981. “Gambian Women: Unequal Partners in Rice Development Projects,” Journal of Development Studies 17 (3).

42 Mullins, G., Wahome, l., Tsangari, P., and l. Maarse. 1996. “Impacts of Intensive Dairy Production on Smallholder farm Women in Coastal Kenya,”Human Ecology 24 (2): 231–53.

sign of agricultural projects, includ-ing which commodities are the focusand who is able to sell those, canhave a strong affect on women’s re-source control.40,41,42

D. Pathway 4. Home consumption

Increasing nutrient dense food production for home consumptionshows some evidence of improvingdiets and micronutrient status.

In households that consume atleast some of what they produce,an increase in production can di-rectly affect the diet and nutri-tional status of householdmembers. Evidence indicates that di-etary impacts differ based on thetype of food the household produces.That is, the effect of production ondiet cannot be explained by thefoods’ monetary value alone. Thispathway is particularly important incontexts where market access is lim-ited and households routinely de-pend on self-production for somecomponents of their diets. The bestevidence for nutritional effects of in-creased production for home con-sumption is found from increasingsmall-scale production of nutrient-dense foods.

Source: DHS 2005. Reproduced from the World Bank Nutrition Country Profile for Ethiopia.37

FIGuRE C-2. ETHIOPIA: PREvALENCE OF STuNTING AMONG CHILDRENuNDER 5 (By INCOME quINTILE)

Prevalence of Stunting Among Children under 5(%)

Richest

fourth

Middle

Second

Poorest

0 10 20 30 40 50 60

Increasing nutritious food produc-tion can be achieved in three dis-tinct ways:

a. Adding the production of specificnutrient-dense foods, such asfruits and vegetables, fish, andlivestock;

b. Increasing nutritional content ofthe food produced, e.g., throughcrop biofortification, mineral fer-tilization, and industrial food for-tification;43

c. Improving the preservation of nu-tritious food for year-round ac-cess and to eliminate seasonalfood shortages.

Evidence supports the connectionbetween crop diversification, di-etary quality, and micronutrientstatus. A recent DfID-funded reviewof agricultural interventions to im-

amount of death and disability.48

Seasonality of nutrient-dense foodproduction can be important, as theyare typically much more perishablethan staple grains.49 low-stock sea-sons affect child growth and cyclicalmalnutrition rates through bothcaloric and micronutrient depriva-tion.

Nutrition education enhances dietaryconsumption effects, as well as po-tential for consumer demand. Whileincreased production of nutritiousfoods may have some independentimpact on dietary consumption andmicronutrient status, the evidenceshows that nutrition educationaround those foods strongly en-hances the effect.50 A review of food-based approaches to reduce iron andvitamin A deficiency found that onlythose food-based interventions witheducation, social marketing, or massmedia demonstrated impact on nutri-tional outcomes.51,52

prove nutrition found that with veryfew exceptions, home garden pro-grams increased the consumption offruit and vegetables; aquaculture andsmall fisheries interventions in-creased the consumption of fish; anddairy development projects increasedthe consumption of milk.44 In con-texts where diets are heavily starch-based, consumption of thesenutritious foods is very likely to movedietary patterns closer to those rec-ommended globally and by manycountries.45 There is some evidencethat consumption of these foods in-creased micronutrient intakes andstatus, especially vitamin A.46 Stud-ies that have examined the connec-tion between crop diversity anddietary diversity among smallholdershave found positive correlations.47

Biofortified crops have also beendemonstrated to improve vitamin Aand iron intakes – alleviating two ofthe deficiencies causing a large

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43 Biofortification is a method of breeding crops to increase their nutritional value. Biofortification differs from ordinary fortification (or industrialfood fortification) because it focuses on making plant foods more nutritious as the plants are growing, rather than having nutrients added tothe foods when they are being processed. Major organizations involved in biofortification include a CGIAR program called HarvestPlus(www.harvestplus.org mainly focused on Africa and Asia), and AgroSalud (www.agrosalud.org focused on latin America). IRRI is also involvedin the biofortification of rice.

44 Masset, E, Haddad, l., Cornelius, A., J. Isaza-Castro. 2012. “Effectiveness of agricultural interventions that aim to improve nutritional status ofchildren: systematic review.” BMJ, v.344. Open access, available at http://www.bmj.com/content/344/bmj.d8222.

45 fAO repository of food-based Dietary Guidelines, http://www.fao.org/ag/humannutrition/nutritioneducation/fbdg/en/.46 Masset, E., Haddad, l., Cornelius, A., J. Isaza-Castro. 2012. “Effectiveness of agricultural interventions that aim to improve nutritional status of

children: systematic review. BMJ, v.344. Open access, available at http://www.bmj.com/content/344/bmj.d8222; leroy, J. and E.A. frongillo.2007. “Can interventions to promote animal production ameliorate undernutrition? J Nutr 137: 2311-16.

47 Remans, R., flynn, D.f.B., DeClerck, f., Diru, W., J. fanzo et al. 2011. “Assessing Nutritional Diversity of Cropping Systems in African Villages.”PloS ONE 6(6): e21235. doi:10.1371/journal.pone.0021235; A. Herforth. “Promotion of Traditional African Vegetables in Kenya and Tanzania: ACase Study of an Intervention Representing Emerging Imperatives in Global Nutrition” (Ph.D. diss. Cornell University, 2010); Torheim, l.E.,Ouattara, f., Diarra, M.M., Thiam, f., Barikmo, I., Hatloy, A. and A. Oshaug. 2004. “Nutrient adequacy and dietary diversity in rural Mali: Associ-ation and determinants,” European Journal of Clinical Nutrition 58, 594–604. doi:10.1038/sj.ejcn.1601853.

48 low, J., Arimond, M., Osman, N.,Cunguara, B., Zano, f. and D. Tschirley. 2007. “A food-Based Approach Introducing Orange-fleshed Sweet Po-tatoes Increased Vitamin A Intake and Serum Retinol Concentrations among Young Children in Rural Mozambique,” Journal of Nutrition 137;Haas, J.D., J.l. Beard, l.E. Murray-Kolb, A.M. del Mundo, A. felix, G.B. Gregorio. 2005. “Iron-biofortified rice improves the iron stores of non-anemic filipino women,” Journal of Nutrition, 135: 2823-2830.

49 World Bank. 2007. Pathways from agriculture to nutrition: Pathways, Synergies and Outcomes,http://siteresources.worldbank.org/ExTARD/Re- sources/final.pdf; M. Ruel. 2001. “Can food-Based Strategies Help Reduce Vitamin A andIron Deficiencies? A Review of Recent Evidence,” food Policy Review 5. International food Policy Research Institute.

50 World Bank. 2007. Pathways from agriculture to nutrition: Pathways, Synergies and Outcomes, http://siteresources.worldbank.org/ExTARD/Re-sources/final.pdf; Berti, P.R, Krasevec, J. and S. fitzgerald. 2004. “A review of the effectiveness of agriculture interventions in improving nutri-tion,” Public Health Nutrition 7 (5): 599-609.

51 These studies have focused on household-level production and consumption; the effect of price changes on consumption of nutritious foods inthe absence of education has not been well studied in low-income contexts. However, nutrition education also has been shown to affect allo-cation of household food budgets and to reduce price elasticity of demand for foods rich in micronutrients (Block 2003).

52 M. Ruel. 2001. “Can food-Based Strategies Help Reduce Vitamin A and Iron Deficiencies? A Review of Recent Evidence,” food Policy Review 5. International food Policy Research Institute.

E. Pathway 5. Women’s empowerment

Empowering women shows strongevidence for improving nutrition.

Strong evidence indicates that im-proving women’s status, particu-larly when combined with nutritioneducation, results in positive nutri-tion impact. A multi-country analysisfound that improvements in women’sstatus and education were responsi-ble for over half of the reductions inchild underweight from 1970-1995.53

Women’s low status and decision-making power in South Asia is a largepart of the explanation for the “Asianenigma” of higher undernutritionrates, despite greater economicgrowth, than in Sub-Saharan Africa.Since gender, like nutrition, is not asector, the chance of improvingwomen’s status and gender equityrests in practice with other sectors.Among all aspects of women empow-erment, the most relevant for nutri-tion are (i) increasing women’saccess to and control over re-sources—primarily incomes, and (ii)reducing time constraints.

Increasing women’s discretionaryincomes. A large body of evidenceacross many regions consistentlyfinds that income controlled by

women has a significantly greaterpositive effect on child nutrition andhousehold food security than incomecontrolled by men.54 Projects that in-crease the likelihood that women areable to control resources accruingfrom their labor—through inclusionof training and market opportunitiesfor crops and animal products womensell, for example—improve genderequity and are likely to improve nutri-tion as well.

Reducing time and labor con-straints. A careful balance needs tobe struck between nutritional gainsfrom improved incomes and potentiallosses from increased time burden.Agriculture projects that increase thetime or labor required from womencan have unintended negative conse-quences. When affordable child careservices are unavailable, care of ba-


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53 Smith, l.C. and l. Haddad. 2000. Explaining child malnutrition in developing countries: A Cross-Country Analysis, International food Policy Re-search Institute, Washington DC.

54 UNICEf 2011. Gender Influences on Child Survival, Health, and Nutrition: A Narrative Review. UNICEf and liverpool School of Tropical Medicine.

55 N. Ilahi. 2000. The Intra-household Allocation of Time and Tasks: What Have We learnt from the Empirical literature? Policy Research Report onGender and Development, Working Paper Series No. 13. Washington, D.C., World Bank Development Research Group; Blackden, C.M., and Q.Wodon. 2006. “Gender, Time Use, and Poverty in Sub-Saharan Africa: Introduction,” in Gender, Time Use, and Poverty in Sub-Saharan Africa eds.C.M. Blackden and Q. Wodon. World Bank Working Paper No. 73 (Washington, D.C.: World Bank), 1-10.

56 Rao S., Kanade, A., Margetts, B.M., Yajnik, C.S., lubree, H., Rege, S., Desai, B., Jackson, A., C.H.D. fall. 2003. “Maternal activity in relation to birthsize in rural India.” The Pune Maternal Nutrition Study. European Journal of Clinical Nutrition 57: 531–542; Pitchaya, T., Geater, A., Virasakdi, C., K.Ounjai. 1998. “The Effect of Heavy Maternal Workload on fetal Growth Retardation and Preterm Delivery: A Study among Southern Thai Women,”Journal of Occupational & Environmental Medicine 40 (11):1013-1021; Barnes, D.l., Adair, U.S., Popkin, B.M., 1991. Women’s Physical Activity andPregnancy Outcome: A longitudinal Analysis from the Philippines. International Journal of Epidemiology 20 (1): 162-172.

bies may be relegated to child sib-lings (usually older girls), childrenmay be breastfed less often, time forfood preparation may be limited re-sulting in less nutritious diets, familymembers may be less likely to accesshealth services, other agriculturalproduction may suffer, and womenmay avoid off-farm income-earningopportunities.55 Excessive maternalactivity during pregnancy may alsoresult in increased risk of poor birthoutcomes.56 Time- intensive projectsmay also come at the expense ofother income-generating activitiesthat would result in women’s controlof income, the importance of which isaddressed above. This points to aneed for timesaving and productivity-enhancing technologies for gender-specific tasks carried out by women(e.g., weeding and food processing).

VI. Systematic reviewresults and knowledgegapsSystematic reviews show few well-designed evaluations to measurethe impact of agriculture on nutri-tional status, but they do showsome impact on intermediate out-comes, such as diet and incomes.One of the most thorough reviews ofthe nutrition impact of agriculturalprojects, which explicitly target nutri-tion outputs, is the recent DfID-funded systematic review.57 Thereview found only a small set of stud-ies from which to summarize the evidence, because too few well-designed studies exist to draw anystrong conclusions about agricul-ture’s impact on nutritional status.The review however did find that agri-culture had an impact on intermedi-ate outcomes, such as diet andincomes, which the studies were bet-ter powered to detect. A summary ofthe key results of the DfID review isas follows.

• Of the 300+ studies screened,58

only 23 studies had enough in-ternal validity to be included inthe review (studies without base-line measurement or a valid com-parison group were excluded).Most of these were evaluationsof homestead gardening.

• Of nine studies that measuredanthropometry, four showed im-pact on underweight rates, and

The review underscores importantgaps in the evidence and lessonsfor future studies. There is a strongneed for more well-designed analy-ses of the impact of agricultural inter-ventions on nutrition to informprogram decisions. The systematicreview suggests that future studiesshould better measure intermediateoutcomes, such as dietary intake, di-etary diversity, and incomes, andonly attempt to analyze agriculture’seffect on nutritional status whensample sizes and study designs per-mit adequate power.

Cost-effectiveness

Cost-effectiveness data is highlydesirable to inform decisions to in-clude nutrition goals in agriculturalprojects, but such information iscurrently minimal. Two kinds ofcost-effectiveness information couldbe collected. The most useful ap-proach would be to compare the cost-effectiveness of a nutrition-sensitiveintervention with a business-as-usualintervention to reach the primaryagriculture sector goals of productiv-ity and income. To date, this evidenceis non-existent.

The second approach, somewhatavailable is data on the cost-effec-tiveness of an agriculture interven-tion in reaching nutritional statusgoals. The cost-effectiveness of bio-fortification has been the most stud-ied among all agricultural

only one documented an impacton stunting. The authors notethat stunting rates are slower tochange and most studies likelywere not of sufficient duration toobserve a change.

• A meta-analysis of four studiesthat measured vitamin A status—based on interventions designedto increase vitamin A rich food in-take—found an overall significantpositive impact.

• Most studies (19 of the 23) founda positive impact on diet compo-sition, based mostly on con-sumption of the foods produced,although typically, the total dietwas not assessed. Several stud-ies also found positive effects onincome, but income measure-ment and comparison sufferedfrom methodological weak-nesses.

The lack of a stronger demon-strated impact on nutritional sta-tus—despite some impact ondiet— is attributable mainly tomethodological issues. first, de-spite ambitious goals, few studiesactually measured nutrition impacts,and measurement was inconsistentamong those that did. Second,among the studies looked for agricul-tural impact, many had methodologi-cal problems (such as power andsample size) and analytical rigor.

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57 Masset, E., Haddad, l., Cornelius, A., J. Isaza-Castro. 2012. “Effectiveness of agricultural interventions that aim to improve nutritional status ofchildren: systematic review,” BMJ; v.344. Open access, available at http://www.bmj.com/content/344/bmj.d8222.

58 The 300+ reviewed studies were all peer-reviewed journal articles. Specific inclusion criteria required that the articles were written after 1990,in English, and that the reviewed intervention (i) took place in a low-income or middle-income country, (ii) aimed to improve child nutritionalstatus through income or diet, and (iii) investigated the impact of an agricultural intervention on at least one of the following: nutritional sta-tus, micronutrient intake, dietary diversity, income, or program participatio

1. Invest in women: safeguard andstrengthen the capacity ofwomen to provide for the foodsecurity, health, and nutrition oftheir families.

_________________________

2. Increase access to and year-round availability of high-nutrient content food.

_________________________

3. Improve nutrition knowledgeamong rural households to enhance dietary diversity.

_________________________

4. Incorporate explicit nutritionobjectives and indicators intoproject and policy design.

interventions. The 2008 CopenhagenConsensus concluded that biofortifi-cation was the fifth most cost-effec-tive intervention to advance globalwelfare. Estimates of cost-effective-ness of biofortification are between$10-$120/DAlY saved, withbenefit:cost ratios of between 50:1and 4:1, based on the assumption ofthe adoption of two biofortified cropsin low-income countries of Africa andSouth Asia.59,60 Another analysis esti-mated the cost-effectiveness of bio-fortified beans in Nicaragua between$96-379/DAlY saved.61

VII. Principles for nutrition-sensitiveagriculture projectsTo be successful, efforts to maxi-mize nutrition impact first need toincorporate nutrition goals explic-itly into the design and implemen-tation of agriculture projects andpolicies. The available evidence sug-gests that maintaining the business-as-usual approach focus onagricultural productivity, economicgrowth, and household-level incomehas a limited scope for reducing un-dernutrition. The current approachmisses opportunities that are uniqueto the agriculture sector to enhancenutrition, such as improving produc-tion and consumption of foods to di-versify diets, leaving the

responsibility of filling the gaps leftby poor diets to other sectors. It alsomisses opportunities to improvefarmer well-being and female partici-pation, among other goals.

The agriculture sector can addressnutrition more fully, which willlikely result in additional gains inproductivity, demand for high-value products, and householdwell-being. The available evidenceindicates four strong principles foraction in areas in which agriculturehas tremendous growth potential.

VIII. The World Bank’sagriculture programCurrently, there are very few agri-culture projects supported by theworld Bank that explicitly targetnutrition. That is not to say that thecurrent portfolio of projects do notcontribute to nutrition. They may wellbe doing so. However, any nutritioneffects are often unintentional andconsequently their scale, impact orexact pathway is often undocu-mented.

The Bank’s agriculture strategy.The official strategic framework forthe Bank’s agriculture sector is the2008 World Development ReportAgriculture for Development. The re-port suggests a four- pronged ap-

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CHAPTER - C | Improving Nutrition through Agriculture and Rural Development

59 The results are described in Horton, Alderman, and Rivera. 2008. Copenhagen ConsensusMalnutrition and Hunger Challenge Paper.

60 J.V. Meenakshi et al. 2007. How cost-effective is biofortification in combating micronutrientmalnutrition? An ex-ante assessment. HarvestPlus Working Paper No. 2, IfPRI, WashingtonD.C.

61 S. Perez Suarez. 2010. “DAlYs: a methodology for conduction economic studies of food-basedinterventions such as biofortification,” in eds. B. Thompson and l. Amoroso, Combating Micronutrient Deficiencies: food-Based Approaches (fAO and CABI International).


proach to agricultural developmentthat should be differentiated acrossthe “three worlds of agriculture,” i.e.,agriculture-based countries, trans-forming countries, and urbanizedcountries.

The four policy objectives of theWorld Development Report 2008 areas follows:

a. Improve market access; establishefficient value chains,

b. Enhance smallholder competi-tiveness; facilitate market entry,

c. Improve livelihoods in subsis-tence agriculture and low-skillrural occupations,

d. Increase employment in agricul-ture and the rural non-farm econ-omy; enhance skills.

Nutrition is mentioned specificallyas an approach under the third pol-icy objective: “… improving the nutri-tional value of foods produced forhome consumption.” This is only oneof the possible ways that agriculturecan improve nutrition, and even forthis objective Bank projects haveonly addressed it indirectly. Themuted stance towards nutrition wasmirrored in the follow-up action plan,the Agriculture Action Plan 2010-2012, although the updated version2013-2015 plan will likely include nu-trition as a cross-cutting “lens”alongside other topics such as cli-mate change, jobs, and gender.

The Bank ’s agriculture program isorganized across five focal areas:three thematic areas and two cross-cutting across the thematic focalareas (see figure C-3). The three the-matic focal areas are (i) raising agri-cultural productivity, (ii) linkingfarmers to market and strengtheningvalue chains, and (iii) facilitatingagricultural entry, exit, and rural non-farm income. The two cross-cuttingfocal areas are (i) reducing risk andvulnerability, and (ii) enhancing envi-ronmental services and sustainabil-ity. These focal areas will remain thesame in the updated Agriculture Action Plan being developed for fY13-15.

According to the world BankGroup’s Agriculture Action PlanfY10-12, the world Bank Group hascommitted to double the agricul-ture portfolio from an average of$4.1 billion during the pre-food cri-sis years of fY06-08 to $6.2-$8.3billion in fY10-12. In the post-crisisyears, the World Bank Group hasbeen averaging about $6 billion ayear on agriculture and rural develop-ment operations. This represents atremendous opportunity to main-stream nutrition-sensitive agricul-ture, especially since nutrition is nota sector per se, and the World Bank’snutrition lending program is signifi-cantly smaller.62

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62 IBRD/IDA lending coded to nutrition increased from an annual average of $97 million in fY06-08 to $150 million/year in fY09-11.

Source: World Bank Group Agriculture Action Plan 2010-2012.

FIGuRE C-3. FIvE FOCAL AREAS OF THE BANk’S AGRICuLTuRE PROjECTS

Raise agricultural productivity

Link farmers to market &strengthen

value chains

Facilitate agricultural

entry, exit & ruralnon-farm income

Reduce risk and vulnerability (cross-cutting)

Enhance environmental services and sustainability (cross-cutting)

Raising agricultural productivity isthe largest focal area of The Bank’sagriculture program. In terms of therelative importance in the portfolio,raising agricultural productivity com-prises about three-quarters of thedisbursement volume in fY10-11 (seefigure C-4). Key activities in this the-matic area include agricultural tech-nology research and dissemination,water management, land administra-tion, and livestock management. Ofthis volume, about half was specifi-cally for investments in irrigation anddrainage, which includes improvingriver basin management, strengthen-ing water rights, construction, reha-bilitation and modernization ofirrigation and drainage systems, andimproving water use efficiency. A fur-ther 15 percent of the disbursementvolume in fY10-11 was for the the-matic focus area on linking farmers tomarket. Key activities in this thematicarea include expanding market infra-structure, strengthening producer or-ganizations, rural finance, and foodsafety. finally, the thematic area fa-cilitating agricultural entry, exit, andrural non-farm income comprisedabout 9 percent. Key areas includeimproving the rural (non-farm) invest-ment climate, expanding rural (non-farm) infrastructure, and upgradingskills to prepare rural residents to mi-grate out of rural areas. furthermore,roughly 15 percent of the total dis-bursement in the above three the-matic areas had a dual objective ofreducing risk and vulnerability andenhancing environmental servicesand sustainability, respectively.

Nutrition as a “lens” for agriculture. Given the cross-cuttingnature, nutrition-sensitive agriculturecan be incorporated into all of thefive focal areas of the World Bank’sagriculture program. In this sense,nutrition is similar to the treatment of cross-cutting relevant non-agricultural “lenses,” such as gender, jobs, climate, smart agricul-ture, and landscape approaches.


74

IX. Challenges for nutrition-sensitiveagriculture at TheWorld Bankwhy has nutrition not been mainstreamed into agriculture?Despite the increased awareness ofmainstreaming nutrition into agricul-tural operations for a more consciousand direct impact on improving nutri-tional outcomes, there are currentlyvery few agriculture projects sup-ported by the World Bank that explic-itly include objectives or targets forimproving nutrition outcomes. Thereasons are many and include the fol-lowing.

Source: World Bank Agriculture and Environmental Services Department

FIGuRE C-4. DISBuRSEMENT FOCuS OF AGRICuLTuRE AND RELATED SECTORS

Agriculture productivity increased from 71 to 76 percent

Disbursements

fY06-08$2.8 billion annual average

fY10-11$3.3 billion annual average

Cross-cutting themes: Roughly 15% of lending (productivity,markets, non-farm) had a focus on vulnerability and

environmental sustainability, respectively

Productivity Markets Non-Farm

limited evidence base. As summa-rized above in the “Systematic Re-view Results” section, there are fewimpact evaluations of agricultural in-terventions explicitly targeting nutri-tion.63 Among them, the majority (19)demonstrated impact on improvedconsumption of specific nutrient-richfoods. The few that measured changein vitamin A status showed a signifi-cant positive impact. Only a fewdemonstrated impact on child an-thropometry, i.e., stunting, under-weight, wasting, mainly due tomethodological weaknesses in moststudies. Another significant gap inevidence is the absence of cost-effectiveness information to meetagricultural objectives using a nutrition-sensitive approach as opposed to a business-as-usual ap-proach. With competing demandsand a strong focus on results, pro-posing activities without a strong evi-dence basis is challenging.

Strong accountability and focus onresults. As part of its operationalpolicies, World Bank projects un-dergo a standard appraisal processthat appraises various aspects ofproject design, such as fiduciary,technical, financial/economical, andsafeguards. Bank staff are expectedto demonstrate project linkages withrelevant country and Bank strategies.This is done through a clearly articu-

low awareness of how food securityinterventions can best improve thenutrition of the most vulnerable. TheWorld Bank, as a financial institutionproviding recipient executed loansand credits to developing countrygovernments, is especially sensitiveto client demand. Because the major-ity of World Bank operations are notgrants- based, governments wouldbe reluctant to take out a loan for anagricultural activity that cannotdemonstrate a certain level of techni-cal and financial feasibility. There-fore, despite strong evidence to thecontrary, nutrition still is consideredmainly the domain of the health sec-tor, and very few of the World Bank’sclients have sought to include nutri-tion activities in non-health sector in-terventions. Nevertheless, there maybe reason to expect some greater de-mand in coming years. Some SouthAsian64 and African countries, for ex-ample, have begun to treat nutritionas a government-wide priority, espe-cially under the SUN movement.65 In-creasing the awareness of foodsecurity measured by its quality andnot simply by calories may alsoprompt client requests for food secu-rity programs to achieve a greaterfocus on nutrition, for examplethrough country plans of the Compre-hensive African Agriculture Develop-ment Programme (CAADP).66

lated singular project developmentobjective together with a resultsframework that describes the tar-geted objective of each separatecomponent leading to achieving theproject development objective. Activ-ities viewed as overly complex withscant evidence of success have littlechance of surviving the layers of re-view required for a typical project.Bank staff have expressed concernsthat proposing to include nutrition-sensitive agriculture activities will re-sult in the project being criticized asa “Christmas tree project,” a deroga-tory term for a project that is loadedwith seemingly novel but untestedand unrelated activities that arebound to fail.

weak client demand. Insufficientnutrition attention or awareness byWorld Bank staff has been mirroredby Ministries of Agriculture. Undernu-trition is an invisible problem largelybecause it is unobservable to thenaked eye and not listed on deathcertificates as the cause of death.The major reasons for the lack ofclient demand for nutrition interven-tions—despite wreaking dire conse-quences on human capital anddevelopment—are the invisibility ofstunting and micronutrient deficien-cies (literally called “hiddenhunger”); very low technical nutri-tion capacity in most countries; and

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63 Masset, E., Haddad, l., Cornelius, A., J. Isaza-Castro. 2012. “Effectiveness of agricultural interventions that aim to improve nutritional status ofchildren: systematic review,” BMJ; v.344. Open access, available at http://www.bmj.com/content/344/bmj.d8222.

64 To respond to the prioritization on nutrition by many South Asia countries, the Bank’s South Asia region has developed a region-wide multi-sectoral nutrition strategy. The South Asia AES unit also manages a trust fund specifically to link agriculture and nutrition called the SouthAsia food & Nutrition Security Initiative (SAfANSI). SAfANSI is a multi-donor trust fund supported by AusAID and DfID, which seeks to pro-mote coordinated efforts within and between countries to improve food and nutrition security in South Asia, www.worldbank.org/safansi.

65 “SUN early riser countries,” which have indicated their interest and commitment to reducing undernutrition, currently include Bangladesh,Benin, Burkina faso, Burundi, Ethiopia, The Gambia, Ghana, Guatemala, Haiti, Indonesia, Kenya, Kyrgyz Republic, laos PDR, Madagascar,Malawi, Mali, Mauritania, Mozambique, Namibia, Nepal, Niger, Nigeria, Peru, Rwanda, Senegal, Sierra leone, Tanzania, Uganda, Zambia, andZimbabwe.

66 Nutrition is covered in the Comprehensive African Agriculture Development Programme (CAADP) under Pillar 3: food Supply and Hunger. Nutri-tion is also the subject of recent and upcoming regional workshops to improve the mainstreaming of nutrition into CAADP plans, e.g., WestAfrica CAADP Regional Nutrition Programme Development Workshop, held November 9-12, 2011, Dakar, Senegal.

Inherent difficulties of multisec-toral activities. Given the WorldBank’s sectoral organization, i.e.,agriculture and rural development inthe Sustainable Development VicePresidency and nutrition in theHuman Development Vice Presidency,and also due to client governments’structures, it is inherently difficult towork on multisectoral activitiesacross vice presidencies or min-istries. Therefore, responsible partiesor their managers usually have littleincentive to work beyond their “coreareas.” They also lack professionalcontacts to easily solicit technicalsupport in areas beyond their coremandate or mandatory safeguard re-quirements covering certain environ-mental and social aspects. However,it is worth noting that the Bank’s nu-trition portfolio is much smaller thanthat of AES. IBRD/IDA lending codedto nutrition increased from an annualaverage of $97 million in fY06-08 to$150 million/year in fY09-11.67

Each of these challenges needs tobe addressed to mainstream nutri-tion-sensitive agriculture withinworld Bank operations. Introducingnutrition-sensitive agriculture re-quires a behavioral change to workacross silos. This requires sensitiza-tion or awareness building among allparties, including Bank clients, coun-try directors, and the rest of thecountry management team, Bankagriculture staff, and

their managers. Nutrition needs to beviewed by all parties as an integralfactor necessary to improving humancapital and well-being, and the im-portant role played by agriculture inachieving this goal must be unam-biguously understood.

X. Addressing Nutritionthrough Agriculture-Projects at the WorldBank

A. Current status: Mainlythrough unintentional effects

Some agriculture projects at theBank already address nutrition, al-beit implicitly and without measur-ing its effect on nutritionaloutcomes (since any nutritional out-come would be unintentional). Theproject activities affect the four nutri-tion-related goals in a significantway, i.e., invest in women, improvenutrition knowledge among ruralhouseholds for enhanced dietary di-versity, and increase access to andyear around availability of high nutri-ent content food.

a. Invest in women. As part of theBank’s commitment to improvingits performance on gender anddevelopment, the Bank adoptedthe Gender Equality as Smart


76

67 Typical nutrition activities funded by the Bank include the promotion of optimal infant and young child feeding practices (including breastfeedingand complementary feeding), distribution of micronutrient supplements (particularly vitamin A), community-based growth monitoring and promotion activities, and capacity building for the implementation of nutrition-specific and nutrition-sensitive interventions (both within and outsideof the health sector). Nutrition-sensitive interventions within the health sector (through non-nutrition health projects) include prenatal care activities, malaria prevention and treatment, and HIV prevention and treatment, for example.

68 The Gender in Agriculture Sourcebook, developed jointly by fAO, IfAD, and the World Bank presents good practice examples and considerationsacross all AES thematic areas.

Economics Gender Action Plan(GAP) in 2007. Since then, theBank has been tracking gendermainstreaming across all the-matic areas according to a com-mon approach established by theSDN, namely including genderanalysis and/or gender inclusiveconsultations, gender-respon-sive design, and gender-respon-sive M&E, or inclusion of at leastone gender-responsive indicatorin the project results framework.In fY11, gender analysis was car-ried out in 91 percent of agricul-ture (AES) projects, up from 69percent in the baseline (fY07-09). Gender-responsive designwas carried out in 74 percent ofagriculture (AES) projects, upfrom 59 percent. And finally, gen-der-responsive M&E was in-cluded in 62 percent ofagriculture (AES) projects, upfrom 28 percent. (See Box C-1 fora sample of gender disaggre-gated indicators that were usedin projects approved in fY10 andfY11. A full list of projects isavailable in Annex C-2).

These gender elements are allassessments at the project de-sign stage. Currently, there areno assessments on gender inte-gration done for the implementa-tion stage.68 Also, with regards tothe gender-responsive M&E, theindicators currently collected byagriculture (AES) projects do not

fully cover the range of genderempowerment issues that aremost critical for nutrition, i.e., (i)women’s access to land andother productive assets, (ii)women’s participation in incomegenerating activities, and (iii)women’s control over cash fromagricultural activities.69

Specifically, none of the gender-disaggregated indicators used inprojects approved in fY10 andfY11 captured the intra- house-hold allocation of income be-tween men and women, or thedimension of women’s ability tomake decisions about purchases.

b. Increase access to and year-round availability of high nutri-ent content food. The Bank hasagriculture projects that support“nutritious foods” beyond basiccereals, e.g., livestock, fisheries,dairy, fruits and vegetables.These projects are typically notjustified based on their contribu-tion to dietary diversity, butrather on grounds of income di-versification, higher incomes, orsafety nets (in the case of live-stock). Therefore, analyses of theself-consumption rate of sup-ported producers (which is howproduction support to such sub-sectors would affect dietary di-versity), and other relatednutrition indicators are typicallyabsent. In terms of scale, sup-port to high nutrient contentfoods is not large. for example,only $146 million and $61 million

search Corporation (EMBRAPA) inpartnership with HarvestPlus andits regional affiliate AgroSalud.As HarvestPlus and other biofor-tification efforts scale up theirdissemination, the Bank couldpotentially support national agri-cultural research systems in in-creasing their role in testing anddisseminating these biofortifiedcrops.

c. Improve nutrition knowledgeamong rural households to en-hance dietary diversity. On im-proving nutrition knowledge, areview of approved Project Ap-praisal Documents does not re-veal how much, if any, is actuallybeing financed. This is becausenutrition education is typicallyoffered as part of a menu in a de-

were committed to support live-stock and fishery related projectsin fY10 and fY11 respectively,and not all of these projects weretargeted to increase access forsmallholders; some were nar-rowly focused on non-livelihoodaspects such as animal safety.

However, the Bank has no experi-ence to date supporting cropsthat have been bred specificallyto have higher nutritional con-tent, i.e., biofortified crops, suchas the orange fleshed sweet po-tato (OfSP) that has been devel-oped by HarvestPlus (a CGIARprogram) and disseminated inUganda and Mozambique, or cas-sava, maize, and other crops70

developed and disseminated bythe Brazilian Agricultural Re-

77


69 IfPRI, USAID’s feed the future, and Oxford Poverty and Human Development Initiative developed a “Women’s Empowerment in Agriculture In- dex,” which is a composite index of various women empowerment indicators, including women’s control over use of income and access to assets, http://www.ifpri.org/sites/default/files/publications/weai_brochure.pdf.

70 EMBRAPA has developed a biofortification program called BiofORT, which is currently working on eight crops: pumpkin, rice, sweet potatoes,beans, cowpeas, cassava, maize, and wheat.

mand driven setting, such as incommunity driven developmentprojects or women empoweringlivelihood projects and not aslarge predefined investment cat-egories.

d. Incorporate explicit nutritionobjectives and indicators. Be-cause there are almost no proj-ects that explicitly targetnutrition objectives, it is no sur-prise that almost no projects in-clude explicit nutritionindicators. To date, no projectsinclude direct nutrition indica-tors such as child anthropomet-rics or food consumptionindicators.

B. Taking it further: Addressingnutrition explicitly The impact of agricultural projectscould be greatly scaled up if nutri-tion considerations are addressedmore directly. for example, in anaquaculture project, larger fish maybe more profitable to sell at the mar-ket and therefore promoted due to fi-nancial reasons, but smaller fish areoften higher in vitamin A, iron, andzinc, since they are consumed whole,including the head, organs, andbone.71 Therefore, if the project in-tended to improve nutrition, it couldseek to include small fish togetherwith the more commercial large fish,and it should intentionally seek toimprove access among the most vul-


78

71 Roos, N., Islam, M.M., and S.H. Thilsted. 2003. “Small indigenous fish species in Bangladesh:Contributions to Vitamin A, Calcium, and Iron intakes,” Journal of Nutrition, 133: 11.

nerable households. It would also beimportant to promote the preserva-tion of some of the cultivated food forhome consumption. This is particu-larly true for commercialization proj-ects that emphasize sales to improveincomes, where small amounts con-served for home consumption, partic-ularly by the most nutritionallyvulnerable family members, can sig-nificantly improve nutrient intakes.

Nutrition-sensitive agriculture forworld Bank agriculture projects.Nutrition-sensitive agriculture aimsto maximize impact on nutrition out-comes for the poor, while minimizingthe unintended negative nutritionalconsequences of agricultural inter-ventions and policies on the lives ofthe poor, especially women andyoung children. As stated earlier,there are numerous guidance notesdeveloped by other organizations,which attempt to list ways of ad-dressing nutrition explicitly throughagriculture (see Annex E-5). This sec-tion attempts to distill interventionsthat are particularly relevant forWorld Bank supported agricultureprojects, which are large scale (oftennational or covering a large part of acountry), government executed, andon a credit or loan basis (i.e., notgrants). They therefore need to bejustified on economic/financialgrounds using standard economicand financial rates of return as perBank appraisal guidelines.

BOx C-1. SELECTED GENDER DISAGGREGATED INDICATORS IN wORLD BANk AGRICuLTuRE (AES) PROjECTS

(APPROvED IN Fy10 AND Fy11)

Total number of beneficiaries (for entire project): Direct and indi-rect project beneficiaries (number), of which female (percentage) in(Benin, CAR, Chad, Kenya, Mali, Nepal, Sierra Leone, West Africa Regional, Zambia).

Overall household income: Percentage increase in agricultural income of participating household (disaggregated by male and female headed households*) (India, Uganda).

women’s access to land and other productive assets• Percent of women with use or ownership land rights registered

(both joint and individual) (India).

• At least 40% of new land titles are provided directly to womenand/or jointly with their spouse/partner (Nicaragua).

• At least 70% of the modernized registries’ clients (and 70% of women) rate its services as satisfactory (third level on a four-level scale) (Honduras).

• Number of water users provided with irrigation and drainage services, disaggregated by % female (Azerbaijan, Malawi).

• Number of farmers benefitting from operational community assets, disaggregated by % female.

women’s participation in income-generating activities• Percent of women income-generating activities (Djibouti).

• Targeted vulnerable groups (women, young people, and land-less) develop related markets and sustainable income-generating activities (AGRs) (Tunisia).

• Percent of rural enterprise participants who are youth (<30yrs old) or women (Jamaica).

• Women receive minimum 30% of all productive subprojects(Brazil).

• At least 30% participating small and medium enterprises (SME)and enterprise groups (EG) will have increased direct and/or indirect employment by at least 30%. Of these, at least 35% will be women (Afghanistan).

women’s control over cash

None

79


72 This relates to the nutrition-related goal of “Invest in women,”

The list of suggested activities,which are expected to improve nu-trition outcomes, are presented ac-cording to the five focus areas ofthe world Bank Agriculture ActionPlan together with some good prac-tices. Given the fact that the Banksupports very few nutrition-sensitive agriculture projects to date,most of the examples are from a non-Bank context, which the Bank may besupporting. The matrix in Annex C-1summarizes this list of suggested ac-tivities, together with suggested out-put and outcome indicators. Tosupport these activities, nutritionperspectives should be incorporatedinto the Bank’s analytical and advi-sory (AAA) work, since these oftenshape or influence project design orthe thinking on particular topics.

i. Raise agricultural productivity

Suggested nutrition-sensitive in-terventions:

Promotion of time saving technolo-gies72: Promotion of technologiesthat improve productivity and timesavings for productive and domestictasks performed by women. WDR2012 shows that for reasons that re-main unexplained, even whenwomen contribute a substantial frac-tion (or in some cases, all) of earnedhousehold income, they continue tobe largely responsible for houseworkand care work. Therefore, realizingwomen’s dominant role in this area,any technology that would save time

* WDR 2012 notes that simply comparing female and male-headed households can exaggerate gender differences,because such comparisons fail to account for the number of working-age adults in the household, and the numberof dependents. Not surprisingly, female-headed households with a male present often fare better than those with no male households fare, and in some cases, do as well as male-headed households. Therefore, WDR 2012 suggests the use of a more nuanced categorization of rural households for such indicators to be relevant.

Source: World Bank Agriculture and Environmental Services Department.

on tasks performed by women wouldresult in more time for women to ded-icate to domestic tasks or incomegenerating activities.

Good practice examples73

• Easier to use and lighter farmingtools for tasks typically carriedout by women, e.g. planting,weeding, grinding.

• Plastic drum seeders for directseeding instead of broadcastingor transplanting rice seedlings,allowing for mechanized weed-ing as seeds are deposited instraight lines.

• Mechanized mills to replacehand pounding or grating (e.g. inBotswana sorghum mills have re-duced the time needed toprocess 20 kg of sorghum from 2-4 hours to 2-4 minutes).

• Water and fuel wood collectionis a time consuming task prima-rily carried out by women andchildren. As such, rainwater har-vesting, protected springs,wheelbarrows, donkey carts,

treadle pumps to significantlyshorten time that women spendon these activities.

Potential trade-offs• focusing on women’s income

generation could reduce timeavailable for domestic tasks in-cluding child care and healthcare (see Table C-2 for mitigationconsiderations during the designphase).

• labor-saving technologies couldresult in loss of employment forother workers who were previ-ously performing the time con-suming task as a laborer.

Incorporation of a food securityand nutrition dimension into thenational agricultural innovationsystem.74 Depending on the countrycontext, this could imply incorporat-ing food security and nutrition mod-ules into extension system curricula,or increasing access to private tech-nical service providers specialized infood security and nutrition.75 Severalguidance papers on linking agricul-ture and nutrition recommend the de-


80

73 See Module 7 Thematic Note 4 “labor-Saving Technologies and Practices” in the World Bank/fAO/IfAD, “Gender in Agriculture Sourcebook,” for afull discussion on labor saving technologies.

74 This relates to the nutrition-related goal of “Improve nutrition knowledge among rural households to enhance dietary diversity.”

75 In many African countries, home economics extension workers delivered nutrition education and training to rural women in the 1970s. But, many ofthese workers have disbanded in recent years during the transformation in the agricultural sector that demanded the integration of agricultural ex-tension services and required extension staff to deliver diverse services. These gaps typically are filled by NGOs. Given that most home economicsextension workers are women, they are likely to be an effective channel to reach rural women. Even in cases where a home economics extensionforce exists, food security and nutrition modules need to be specifically incorporated and ideally coordinated with seeds and services available fromagricultural extension or projects, since the breadth of home economics extension coverage is broad and encompasses all aspects of domesticlivelihood.

76 Herforth, A., Jones, A., and P. Pinstrup-Andersen. 2012. “Prioritizing nutrition in agriculture and rural development projects: Guiding principles foroperational investments.” World Bank HNP Discussion Paper.

77 World Bank 2012, World Development Report: Gender Equality and Development.

livery of simple nutrition messagesaround specific crops via agriculturalextension agents or other technicalexperts.76 This approach can be effec-tive if messages are targeted to thefarmers growing the crops, and pack-aged together with delivery of seedsor other pertinent information aboutthe crop. In many contexts, it is nor-mal for such a worker to talk to farmhouseholds about both food produc-tion and consumption decisions.Close coordination between agricul-ture and health sector staff can alsobe effective. Challenges include thefact that globally, only 15 percent ofextension agents are women, and inAfrica, a mere seven percent.77 Giventhe reality that food security and nu-trition messages are most likely to bedelivered effectively by and towomen, this poses a challenge, espe-cially in contexts where the socialnorm prevents women from interact-ing with non-family males. Including men in nutrition education, however, is also an important practice.

Good practice examples• The success of the biofortified

OfSP project in Mozambique wasdue in part to integrated exten-sion agent pairs of a male agri-cultural agent and a femalenutrition agent embedded in vil-lages to conduct group educationsessions on a variety of agricul-tural and nutrition topics, includ-ing production methods,storage, marketing, infant andyoung child feeding and hygienepractices.78

• A home gardening program inIndia showed consumption andnutrition impact when messageswere communicated from multi-ple kinds of extension workers,e.g., agricultural extensionists,health workers from India’s inte-grated early childhood program,and village-level workers.79

• Kenya’s Ministry of Agriculturemaintains a cadre of home eco-nomics extension workers thathas nationwide coverage.

• The Tanzania Home EconomicsAssociation (TAHEA) providestraining to farmers on nutritionand preparation and promotionof OfSP through agricultural ex-tension services.

cronutrients that are difficult to ob-tain in adequate quantities fromplant source foods alone, and rela-tively small amounts of these foodscan substantially increase nutrientadequacy.81 Increasing vegetable andfruit consumption is important forproviding micronutrients and formaintaining or increasing healthfuldietary patterns as obesity andchronic disease rates are rising inmost developing countries. foodpreservation technologies such assolar drying can reduce seasonalityof fruits and vegetables.

• The Haiti Re-launching Agricul-ture: Strengthening AgriculturePublic Services II Project (RE-SEPAG II) aims to integrate a nu-trition module in the trainingcurriculum of agricultural exten-sion agents and also to facilitatethe production of nutrient densefoods through the use of bioforti-fied seeds already present inHaiti, and zinc based fertilizers.

Potential trade-offs• Adding food security and nutri-

tion training could overload al-ready overburdened extensionworkers or technical serviceproviders.

Support to increase productivity ofsmall-scale nutritious food produc-tion, e.g., livestock, dairy, fish,legumes, fruits and vegetables.80

Most small-scale farmers with marketaccess still consume a portion of thefood items they grow. Therefore, byencouraging farmers to grow nutri-tious foods such as fruits and vegeta-bles, legumes, milk, eggs, fish andmeat, the consumption pattern offarmers can be affected positively(particularly if some nutrition educa-tion is also included). Animal sourcefoods can provide a variety of mi-

81


78 low, J.W., Arimond, M., Osman, N., Cunguara, B., Zano, f. and D. Tschirley. 2007. “A food-Based Approach Introducing Orange-fleshed SweetPotatoes Increased Vitamin A Intake and Serum Retinol Concentrations among Young Children in Rural Mozambique.” Journal of Nutrition, 137.

79 I. Chakravarty. 2000. “food-Based Strategies to Control Vitamin A Deficiency.” food and Nutr Bulletin 21: 135-43.

80 This relates to the nutrition-related goal of “Increase year-round access to and availability of high nutrient content food.”

81 See Journal of Nutrition Supplement November 2003, “Animal Source foods to Improve Micronutrient Nutrition and Human function inDeveloping Countries” for a full discussion on nutritional benefits of animal source foods.

Good practice examples• The Bangladesh Integrated Agri-

cultural Productivity Projectfunded by GAfSP Trust fund aimsto improve the productivity of se-lected horticultural crops (fruitsand vegetables), fish and live-stock. The project will supportthe development of backyardpoultry through building the ca-pacity of (women) breeders byimparting appropriate trainingon routine vaccinations and de-worming, well-ventilated nightshelters, brood management,and animal nutrition.

• An agriculture project in SouthAfrica provided nutrition educa-tion about consuming vitamin Arich foods, such as orange anddark green vegetables, and foundthat only the households withgardens growing these crops increased consumption of vita-min A and showed significantlyimproved vitamin A status.82

The impact results suggest thataccess to a supply of vitamin A-rich vegetables was needed to act on education about nutri-tious food consumption.

Potential trade-offs• Subsidized, small-scale live-

stock/fishery projects for house-hold food security are seldomprofitable at the enterprise level.

• livestock production can havehigh negative externality on theenvironment, particularly inlarger-scale production.

• There is an increased risk ofzoonotic disease, particularly inlarger-scale production (seeTable C-2 for mitigation consider-ations during the design phase).

Enhancing capacity of nationalagricultural research institutions topromote the breeding for and dis-semination of developed bioforti-fied crop varieties and fortifiedinputs.83 Biofortified crops use plant-breeding techniques to improve thenutritional content of food with keymicronutrients, such as iron, zinc,and vitamin A. Some of the bioforti-fied crops use traditional plantbreeding techniques, such as thecrops being developed by Harvest-Plus (a CGIAR program), while othersuse transgenic techniques such asthe Golden Rice being developed bythe International Rice Research Insti-tute of the CGIAR. Typically, the mostprofitable, highest yielding varietiesare targeted to add micronutrient-dense traits so that there are notrade-offs between yield and nutri-


82

82 faber, M., M.A.S. Phungula, S. Venter, M.A. Dhansay, A.J. Spinnler. 2002. “Homestead Gardens focusing on the Production of Yellow and Dark-Green leafy Vegetables Increase the Serum Retinol Concentrations of 2–5-Year-Old Children in South Africa.” American Journal of Clinical Nutrition76: 1048–54.

83 This relates to the nutrition-related goal of “Increase year round access to and availability of high nutrient content food.”

84 Rengel, Z., Batten, G.D., and D.E. Crowley. 1999. “Agronomic Approaches for improving the micronutrient density in edible portions of field crops,”field Crops Research 60: 27-40.

85 x.Y. Cao x et al. 1994. “Iodination of irrigation water as a method of supplying iodine to a severely iodine-deficient population in xinjiang, China,”Lancet 344, 107-110.

tional content. field-testing and dis-semination of many of these bioforti-fied varieties could be included underBank-supported AES projects. So far,the OfSP is the only biofortified cropto have been released in Africa orAsia, although a strong pipeline ex-ists for the next several years (seefigure 5 for the pipeline of biofortifi-cation crops in Africa and Asia). Inlatin America, EMBRAPA has devel-oped a strong pipeline of biofortifiedcrops, such as cassava, maize,beans, etc., in partnership with Har-vestPlus and its regional affiliateAgrosalud.

Zinc and iodine fertilizers can in-crease nutrient content of food inareas where soils, and therefore thefoods produced, are low in these im-portant human micronutrients. Ap-plying zinc as a fertilizer to the soilcan double or triple zinc content ofcereal grains, depending on the cropspecies and variety.84The effect onchildren’s zinc intakes or anthropom-etry has not been specifically docu-mented. Zinc in fertilizers for AESprojects is a potential win-win solu-tion since it can improve agriculturalproductivity and increase zinc con-tent of crops thus improving nutri-tion, e.g., improving children’sgrowth. fertilization with iodine-containing irrigation water has alsomet with great success where imple-mented.85

Good practice examples• from 2007-09, HarvestPlus re-

leased vitamin A-rich OfSP inUganda and Mozambique;24,000 households werereached and the adoption was 68percent, increasing the OfSPshare (among all sweet potatoes)to 47 percent, and increasing vi-tamin A intake by infants, chil-dren, and women by up to 100percent, resulting in improved vi-tamin A status.

• Zinc fortified fertilizers haveshown preliminary results in in-creasing crop yield and also thezinc content of the producedcrops upon human consumption.Not only is zinc one of the mostcommon deficient micronutrientsfor humans, it is the most com-monly deficient micronutrient inagricultural soils, mainly in arid

crops are unlikely to be adoptedeven if they are high in nutritivevalue.

ii. Link farmers to marketand strengthen valuechain

Marketing projects to supportsmallholders’ participation in thevalue chain of nutritious foods,e.g., vegetables, fruits, dairy, live-stock and fish.87 Support tostrengthen the marketing or post-harvest aspects of nutritious foodscan increase the chance that farmerswill grow and consume them, particu-larly if combined with some nutritioneducation. Improving market accessfor nutritious foods provides farmersadditional incentive to produce thefoods, and may involve partnerships

and semi-arid regions. The Inter-national Zinc Association (a non-profit organization) and Harvest-Plus are leading a global zinc fer-tilizer project with trials going onin 20 countries.86

Potential trade-offs• fertilizers with micronutrients

may be unaffordable without sig-nificant subsidy.

• farmers growing biofortifiedcrops may be less likely to mar-ket them successfully withoutsignificant consumer sensitiza-tion.

• Note that yield is typically not atrade-off. Biofortified crop linesare developed to have competi-tive yield traits, based on the un-derstanding that low-yielding

83


86 Trials are ongoing in Argentina, Australia, Brazil, Canada, China, Ethiopia, Germany, Guatemala, India, Iran, Kazakhstan, laos, Mexico,Mozambique, Pakistan, South Africa, Thailand, Turkey, Zambia, and Zimbabwe. for more details, see www.harvestzinc.org.


FIGuRE C-5. PIPELINE OF BIOFORTIFICATION CROPS FOR RELEASE IN AFRICA AND ASIA

CROP NUTRIENT TARGET ADDITIONAL RELEASE(Secondary nutrient) COUNTRY TRAITS YEAR

Bean Iron (Zinc) DR Congo, Rwanda Virus resistant, heat &drought tolerant 2012

Cassava Vitamin A DR Congo, Nigeria Virus resistant 2011

Maize Vitamin A Nigeria, Zambia Disease resistant, drought tolerant 2012

Pearl Millet Iron (Zinc) India Mildew resistant, drought tolerant 2012

Sweet Potato Vitamin A Mozambique, Uganda Virus resistant, drought tolerant 2007

Rice Zinc (Iron) Bangladesh, India Disease & pest resistant 2013

Wheat Zinc (Iron) India, Pakistan Disease resistant 2013

Source: HarvestPlus, 2012.

with actors along the value chainsuch as traders and supermarkets.These interventions can include re-moving bottlenecks along the valuechain such as reducing post-harvestloss, improving auxiliary infrastruc-ture such as roads, storage facilities,and wholesale markets, improvingthe availability of market informationor other risk management tools, andstrengthening the framework of foodsafety standards, e.g., reducing afla-toxins.

Good practice examples• The World Bank-supported Haiti

RESEPAG II aims to develop ca-pacity building in food harvest-ing and storage techniques, e.g.,to reduce aflatoxin and improvefood processing techniquesthrough capacity building andtechnical assistance such as for-tification and food quality con-trol, including laboratorycapacity to analyze micronutrientcontents.

Potential trade-offs• Subsidized, small-scale live-

stock/fishery projects for house-hold food security are seldomprofitable at the enterprise level.

• livestock production tends tohave high negative externality onthe environment.

• food safety standards to reduceaflatoxin could compromisefarmer profit margin if farmershave to pay for compliance costs.

• There is an increased risk ofzoonotic disease, particularly inlarger-scale production (seeTable C-2 for mitigation consider-ations during the design phase).

Promoting the production, market-ing, and consumption of nutritiousindigenous foods, e.g., develop-ment of an indigenous knowledgesystem.88 Conservation of indige-nous food plants are often under-taken for biodiversity reasons andmethodologies for collecting and an-alyzing them are developed. Amongthese indigenous food plants, someare particularly rich in micronutrientsand/or can enhance the bioavailabil-ity of micronutrients in other staplecrops when consumed together.

Good practice examples• The Ministry of Agriculture in

Malawi identified the Moringatree as a potential solution to thecountry’s vitamin A deficiencyproblem, given its higher nutri-tious content compared to all


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89 C. Irungu. 2007. “Analysis of markets for African leafy vegetables within Nairobi and its environs,” Global facilitation Unit for Underutilized Spe-cies (GfU); Ewbank, R., Nyang, M., Webo, C., and R. Roothaert. 2007. “Socio-Economic Assessment of four MATf-funded Projects,” fARM-AfricaWorking Paper No. 8, http://www.farmafrica.org.uk/smartweb/news-views/resources/4.

90 C. Irungu. 2007. “Analysis of markets for African leafy vegetables within Nairobi and its environs,” Global facilitation Unit for Underutilized Spe-cies (GfU); A. Herforth. 2010. “Promotion of Traditional African Vegetables in Kenya and Tanzania: A Case Study of an Intervention RepresentingEmerging Imperatives in Global Nutrition. Ph.D. diss. Cornell University.

other common leafy green veg-etables commonly consumed inMalawi. Based on this finding,the government developed an in-digenous knowledge system fornutritional plant species, whichincludes a system of collecting,documenting, and using indige-nous knowledge.

• A horticulture project in Kenya,Tanzania, Malawi, and Rwanda,implemented by a Kenyan CSO(farm Concern International) andsupported by BMGf, has sup-ported smallholders’ participa-tion in the commercialization ofnutritious traditional African veg-etables. farm Concern Interna-tional won a World Bank CGAPaward for its nutrition-focusedmarketing approach to Africanleafy vegetables, driving up thevalue of these horticultural prod-ucts 213 percent in five years,and substantially increasing in-comes and interest among farm-ers interested in growing them.89

A “commercial village model” al-lows smallholder groups to mar-ket their vegetables to partneringsupermarket chains and otherurban markets, includes nutri-tion education for both farmersand consumers, and has suc-cessfully increased farmer in-comes as well as consumption.90

• A small company in Botswanahas received international recog-nition for its approach to harvest-ing and drying wild fruits rich invitamin C and dietary fiber. Itprocesses the wild fruits accord-ing to HACCP standards for retail,to buyers such as Air Botswana,which provides income to localfarmers and pastoralists whoharvest the fruit.91

Potential trade-offs• Markets for indigenous foods

may be small, therefore limitingcommercial potential.

Promotion of regional/national in-dustrial food fortification.92 foodfortification refers to the addition ofmicronutrients to processed foods,and is considered a valid technologyfor reducing malnutrition when peo-ple cannot consume a balanced dietadequate in every nutrient.93 In mostcountries, the Ministry of Healthoften leads industrial food fortifica-tion. However, fortification typicallyrequires the cooperation of the Min-istry of Agriculture or food SafetyAgencies, as it relates to the process-ing of food. Therefore, although noindustrial food fortification has beendone to date, they could be includedin AES projects that support the gov-ernment’s policy or production of

developing policy guidelines forboth private sector and publicsector involvement in fortifica-tion activities. However, the proj-ect Implementation CompletionReport shows that the actual for-tification process was delayeddue to disagreement betweenthe government and the privatesector on modalities of imple-mentation including the fortifica-tion processes, type offortificants to be allowed, mi-cronutrients premixes to beused, and development of thenutrition policy.94

• Some examples of food fortifica-tion in developing countries be-yond iodized salt include vitaminA enriched sugar in Central Amer-ican countries and Zambia, ironfortified fish sauce in Vietnamand China, iron enriched currypowder in South Africa, vitamin Aenriched MSG powder in thePhilippines, and folic acid en-riched wheat flour in Chile.

Potential trade-offs• None identified.

major cereals such as wheat and ricethrough an activity to fortify them atthe national or regional level.

food fortification has a long historyof use in industrialized countriesfor the successful control of defi-ciencies in vitamins A and D, sev-eral B vitamins, iodine, and iron.fortification can take numerousforms from universal fortificationmandated by the law, e.g., folic acidfortification of wheat flour in Canada,the US, and many latin Americancountries to lower birth defects, totargeted fortification for vulnerablegroups, market-driven fortification,to household-based fortification,e.g., “sprinkles” and micronutrient-rich spreads. However, whateverform it takes, proper government reg-ulation is necessary as part of the na-tional food safety and public healthpolicies to ensure that the benefits offortification are indeed ensured.

Good practice examples• The recently closed Second

Health Sector Development Proj-ect in Tanzania included a foodfortification component in its ad-ditional financing at the specificrequest of the Ministry of Healthand Social Welfare. The projectsupported the government’s Nu-trition and food Commission in

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91 Wildfoods (Pty) ltd of Botswana won the 2008 PhytoTrade Africa Natural Product Award, http://www.phytotradeafrica.com/downloads/press/PhytoTrade_Africa-NP-Awards-Press-Release.pdf.


93 for more details on food fortification, see “Guidelines on food fortification with micronutrients,” WHO and fAO, 2006.

94 World Bank. 2011. Implementation Completion Report of the Tanzania Health Sector Development Phase II, World Bank Report NumberICR00001511.

iii. Reduce risk and vulnerabilityBroaden food security policy dia-logue to include nutrition perspec-tives.95 Country demand for projectsto improve food security often basediscussion on a view equating foodsecurity with national-level grainstocks. Abundant evidence hasshown that this approach alone is un-likely to address household food in-security among the most vulnerable.This disconnect is reflected in theMDG1 hunger target (which dealswith national-level calories) and theMDG1 undernutrition target, dis-cussed above. The World Bank has arole in engaging in food security dia-logues so that plans would better tar-get food insecure households, andwould ensure that nutritional qualityof food is regarded as part of food se-curity policies. Addressing seasonalfood shortages can serve as an entrypoint to achieving the goal of increas-ing year-round production of nutri-tious food.

Good practice examples• Nepal has developed a strong de-

velopment partnership in theareas of food and nutrition secu-rity. In 2010, in consultation withdonors, civil society organiza-tions and other stakeholders, theGovernment of Nepal developeda Country Investment Plan (CIP)

to address agriculture and foodsecurity issues comprehensively,including nutritious food avail-ability, access, and utilization.Building on this, it submitted aninvestment proposal to theGAfSP and was competitivelyawarded a grant of US$46.5 mil-lion in June 2011. Nepal has alsodeveloped, again in consultationwith relevant development part-ners and stakeholders, a Multi-sectoral Nutrition Plan of Action.These coordination efforts arelikely to attract more planned re-source allocation from the gov-ernment and developmentpartners, e.g., the Asian Devel-opment Bank, currently support-ing the formulation of atwenty-year Agricultural Develop-ment Strategy, is likely to followup with a project on food secu-rity. USAID is in the process oflaunching its feed the future Ini-tiative in the mid- and far-westregions and has an ongoingSuaahara Program.

Potential trade-offs• None identified.

Promotion of nutritional home-stead garden plots with appropri-ate nutrition education.96

Homestead gardens can be in back-yards, containers, small patches ofavailable land, vacant lots, on


86

95 This relates to the nutrition goal of “Incorporate explicit nutrition objectives and indicators.”


97 Berti, P.R, Krasevec, J., and S. fitzgerald. 2004. “A review of the effectiveness of agriculture interventions in improving nutrition,” Public Health Nu-trition 7 (5): 599-609; M. Ruel. 2001. “Can food-Based Strategies Help Reduce Vitamin A and Iron Deficiencies? A Review of Recent Evidence.” foodPolicy Review 5. International food Policy Research Institute.

rooftops, and on roadsides. They aregenerally close to home and man-aged by family members. Their prod-ucts include fruits, vegetables,herbs, legumes, and sweet potatoes,and most are grown for householdconsumption. Studies have foundthat complementary investmentssuch as nutrition education and tar-geting women increase the likelihoodof household gardens showing posi-tive nutritional outcomes.97 Home-stead gardens also could bepromoted through rural CDD projects,but in such a case, the selection ofthe actual investment is typically de-mand driven and therefore cannot bepreselected.

Good practice examples• The NGO Helen Keller Interna-

tional (HKI) started the home-stead food production programin Bangladesh in 1990, targeting1,000 households with a combi-nation of home gardening andnutrition education. It has sinceexpanded to five countries(Bangladesh, Burkina faso, Cam-bodia, Nepal, and the Philip-pines). The original modelfocused on vitamin A rich vegeta-bles and fruits such as sweetgourd, black arum leaves, andbottle gourd leaves. Becausegiven evidence shows lower thanexpected bioavailability of pro-vitamin A, HKI has sought to

include animal husbandry intothe broader homestead food pro-duction model.

• The Bank’s Civil Society fundProgram (CSfP) funded a projectin Malawi to promote householdgardens for balancing nutritionalrequirements while improvinglivelihoods.98 A CSO called lakeMalawi Projects (Malawi) imple-mented the project, whichdemonstrated to the islandershow to make and sustain theirown gardens year round, includ-ing training them on what veg-etables and fruits to cultivate,how to conserve soil, and makecompost and animal manure.Other than for home consump-tion, most of the households onthe islands grow fruits and veg-etables to generate income tomeet other daily needs.

Potential trade-offs• Subsidized homestead garden

schemes could pose a financialsustainability risk.

iv. Facilitate agriculturalentry, exit, and rural non-farm incomeInvestments to improve opportuni-ties for off-farm laborers (espe-cially women).99 Given the widerange of women’s and men’s needsfor rural non-farm services, it is criti-

in which 24 percent of memberswere women, despite the initialgender stereotype that womenwere unfit for construction work.Another initiative was the “localdevelopment (financing) win-dow” to assist communities inplanning, skill development, andseeking funding to support localdevelopment projects once roadaccess was established.

• The Asian Development Banksupported the Community live-stock Development project inNepal, which recognized thatwomen contribute about 70 per-cent of the work in livestock rear-ing. To increase femaleparticipation in technology-re-lated training at district and re-gional centers far from theirhome and village, the projectprovided child care facilities attraining sites.

cal to ensure gender equity in theplanning, decision-making, and man-agement process or service provi-sion. Rural services to enhance non-farm income encompass a wide rangeof services, including rural transport,rural energy, ICT, water and sanita-tion facilities, and employment insur-ance.

Good practice examples• The second phase of the Peru

Rural Roads Project, supportedby the World Bank and the Inter-American Development Bank,was highly recognized by the NGO community for its participatory, inclusive design,and implementation with inter-connected, complementary, gender-informed initiatives. Onesuch initiative was the microen-terprises for road rehabilitation,

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98 World Bank website. Vegetable gardening improving livelihoods in Malawi, available from http://go.worldbank.org/W4AGQIYY20.

99 This relates to the nutrition-related goal of “Invest in women.”

Potential trade-offs• Reduction in women’s time could

reduce quality of care and feed-ing for infants and young chil-dren. (See Table C-2 formitigation considerations duringthe design phase.)

v. Enhance environmentalservices and sustainabilityRangeland management or soil car-bon sequestration projects that in-crease legume production for foodor fodder.100 legumes are an impor-tant source of nutrition for both hu-mans and livestock by providingprotein, minerals, fiber, and vita-mins. By biologically fixing nitrogenin the soil, legumes also provide arelatively low-cost method of replac-ing otherwise expensive inorganic ni-trogen in the soil. Moreover, legumesalso improve other soil physicalproperties, provide ground cover andreduce soil erosion, increase soil or-ganic matter, microbial activity, andlowers soil temperature, and sup-press weeds and pests. legumes arecrops grown primarily by women inmany settings, and women often pre-fer to grow edible species of legumesto meet their combined goals of foodsecurity, fodder, and soil improve-ment.

Good practice examples• The Soils, food, and Healthy

Communities Project in Malawi

supported by the InternationalDevelopment Research Center ofCanada and others aims to im-prove the health, food security,and soil fertility of resource poorhouseholds in northern Malawithrough participatory researchthat tests legume systems.101 Theproject has demonstrated somenutritional outcomes such asnearly tripling the frequency oflegume consumption by youngchildren, which has led to im-provements in weight and heightgrowth of the children.

Potential trade-offs• Increased land management with

legumes may require more labor.Increases in women’s labor mayreduce time spent on other im-portant tasks. (See Table C-2 formitigation considerations duringthe design phase.)

C. Key Questions to consider indesigning nutrition-sensitiveagriculture projectsThe questions below broadly coverthe basic set of questions that the project team may want to consider as they design a nutrition-sensitive agriculture project. These questions may be useful in reviewing the agricultureand nutrition linkage of a project’sdesign.

• What is the nature of the prevail-ing nutrition problems (energy


88


101 See http://soilandfood.org/ for more information about the project, as well as published research results.

and protein deficiency, micronu-trient deficiency or overweightand obesity) in the country or re-gion where the project or policywill be operating?

• Which population groups suffermost from these problems, e.g.,smallholder farm families, land-less laborers, indigenousgroups, urban poor, women, chil-dren? Is it reasonable to expectthat the project could reach oneor more of these groups?

• How is the project expected to in-fluence gender-specific time de-mands, e.g., weeding, watering,marketing, etc.? Are time de-mands for women likely to re-duce time for child care? If so,can additional time demands beoffset with labor-saving tech-nologies for women?

• Who in the household is mostlikely to control how the addi-tional income is spent? Can proj-ect design be adjusted toincrease women’s discretionaryincome?

• Do farmers reside close enoughto markets that they would rea-sonably be expected to use in-come to purchase most of theirdietary components? If not, isthere anything the project coulddo to improve access to diversediets, especially for women andyoung children, e.g., diversifiedproduction, improved infrastruc-ture?

• Do farmers have access to mar-kets where they would be able tosell perishable foods? Is it feasi-ble to incorporate farm productpreservation into project design?

• Could the project design inte-grate nutrition education/behav-ior change strategies intoproduction- and income-relatedgoals, e.g., demand creation fornutrient-dense crops such as bio-fortified crops?

• Are there opportunities to in-clude relevant nutrition informa-tion into the current training andactivities of agriculture sectorstaff, e.g., training on nutritionalattributes of biofortified cropsand minor crops?

• Is the AES project targeted in thesame geographic area as otherhealth, water and sanitation, andsocial protection programs,which are also important for re-ducing malnutrition? If yes, is itfeasible to encourage agricul-ture, health, and social protec-tion staff to consider jointsupervision and monitoring vis-its?

• Is the project likely to affect thequantity and quality of wateravailable to the households inthe community or risk of water-borne disease?

However, at the outcome level, meas-urement of changes in food consump-tion is an important step todetermine if projects have positiveeffects on diet and food security,given that a major pathway of nutri-tion impact for agricultural projects isthrough food consumption effects(either by household production orthrough market purchase, see figureC-6).102 Such outcome indicatorscould be measured at project mile-stones such as baseline, mid-term,and project completion together withother outcome and impact indicators.

D. Measuring nutritional outcomes through agricultureprojects

Explicit nutrition objectives and interventions would need to be accompanied by indicators tomeasure progress at the output,outcome, or impact levels. The matrix in Annex C-1 includes outputand outcome level indicators for thelisted interventions. Indicators at theoutput level (collected every sixmonths for Bank projects) are projectspecific, e.g., days of nutrition edu-cation provided to beneficiaries etc.

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102 Additionally, since improvements inwomen’s access to economic resourcesis an important pathway to nutrition,AES projects should also include indi-cators on women’s access to (i) landand other productive assets, (ii) cashfrom agricultural sales, and (iii) abilityto make decisions about purchases fordaily needs, as discussed above. (SeeBox 1 earlier in the chapter.)

FIGuRE C-6. MEASuRING NuTRITION-SENSITIvE AGRICuLTuRE PROjECTS

Nutrition-sensitiveagriculture activity

Productivity Household income

More or better consumption

Nutritional status

Project level indicators for nutrition-sensitive activities

Existing agriculture indicators

Food expenditure indicators• $ spent on food purchase (LSMS)

Food consumption indicators• % of produced food consumed• # of days in the last week where any

amount of X was consumed• % change in grams/day of X consumes• Composite indiced: e.g. dietary diversity

score, food consumption score

Anthropometric indicators• % increase in body mass index• % reduction in proportion of

underweight, stunted, wasted

Biochemical indicators• Blood samples etc.

Nutritional status is measured withanthropometric or biochemical in-dicators. If the intent is to improvethe nutritional status of project bene-ficiaries, the impact can most directlybe measured by using anthropomet-ric or biochemical indicators com-monly used in nutrition or healthprojects.103 Collecting anthropometricor biochemical indicators would re-quire additional training and re-sources, such as medical equipment,for M&E staff that collect data foragricultural projects. Also, the sam-ple size and project duration must belarge enough to have power to ob-serve a difference in these indicators.Therefore, attempts to measure ef-fects on anthropometry may not beappropriate in all circumstances, andpower calculations should be done apriori to assure that time and effortare not wasted. AES projects could

take a first step towards measuringnutrition outcomes by incorporatingfood consumption indicators duringassessments at project milestonedates such as baseline, mid-term,and project completion (or more fre-quently, if possible), as many ofthese have been validated to be cor-related with nutrition status.

food consumption indicators havebeen developed to measure dietaryquality without having to conduct afull food intake survey, whichwould be costly and cumbersometo administer. In addition to simpleindicators that can be constructedbased on project interventions, e.g.,percent of produced food consumed,number of days in the previous weekwhere any amount of x (nutritiousfood) was consumed, percent change


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103 Commonly used anthropometric indicators are stunting (height-for-age: measures chronic malnutrition) and underweight (weight-for-age) amongchildren under 5 years old, or body mass index (BMI) among women; the most common biochemical indicators are of vitamin A status (serumretinol), and iron status (hemoglobin or serum ferritin).

in grams/day of x consumed, estab-lished indices are commonly used byother international organizations,such as fAO and WfP, to measureprogress at the outcome level.

food consumption indicators couldbe employed by agricultural proj-ects to capture nutritional out-comes. Collecting data on foodconsumption does require some ad-ditional training of the enumerator orproject M&E staff, but it requires nospecial medical equipment like theanthropometric or biochemical meas-ures. Therefore, for agricultural proj-ects, using such consumptionindicators is a practical option to pro-vide relevant information about thenutrition-related impacts of projects.for example, dietary diversity scoresare simple to collect at the householdlevel (to indicate food access), or atthe individual level (to indicate di-etary quality). Other indicators, suchas the Household Hunger Scale(HHS), developed by the USAID foodand Nutrition Technical Assistance(fANTA) project, are useful indicatorsof household food security. AnotherfANTA-developed food security indi-cator, Months of Adequate House-hold food Provisioning (MAHfP), canalso be useful to indicate year-roundcontinuity of food security. (See BoxC-2 and Annex C-3 for more details oneach index indicator and alternativederivations using these indicators).Each of these indicators is relativelystraightforward to collect, and foodconsumption indicators most rele-vant for the project’s expected im-pact on diets and food security canbe selected.

There are several food consumptionindicators developed for differentpurposes. The Dietary Diversity Score(DDS) and the Food ConsumptionScore (FCS) measure dietary quality,the MAHFP measures continuity offood access, and the adapted HHSmeasures the subjective experienceof food insecurity.

The Dietary Diversity Score consistsof a simple count of the differentfood groups that a household or anindividual has consumed over thepreceding 24 hours.104,105 Thehousehold dietary diversity score ismeant to reflect household access toa variety of foods, while individualscores are meant to reflect nutri-tional quality of the diet. The dietarydiversity scores have been validatedfor several age and sex groups, e.g.,infants between 6-23 months, andwomen between 15-49 years old, asa measure for micronutrient ade-quacy of the diet. These scores arebeing used by WHO, FAO and USAIDFeed the Future projects.106

It captures changes in the house-hold’s ability to address vulnerabilityin such a way as to ensure that foodis available above a minimum levelthe year round. It has been incorpo-rated as a standard impact indicatorin all Africare’s food security pro-grams.

The Household Hunger Scale is ameasure of the degree of food inse-curity (i.e., access) in the householdover a recall period of four weeks:the higher the score, the more foodinsecure the household. This indica-tor has demonstrated the potentialfor both internal and external valid-ity, and has been shown to have astrong relationship with householdincome and wealth scores. TheHousehold Hunger Scale is beingused by FAO and USAID Feed the Fu-ture projects.109

For a more detailed description ofeach of the indicators, see Annex C-3.

The Food Consumption Score is acomposite score based on dietary di-versity, food frequency, and relativenutritional importance of differentfood groups consumed by thehousehold, which can be used as aproxy measure of food security. In-formation about frequency of con-sumption (in days) by a householdover a recall period of the past sevendays is collected from a country- spe-cific list of food groups. The foodconsumption score has been vali-dated against per capita calorie con-sumption, and several alternativeindicators of household food secu-rity such as percentage expenditureson food, asset, and wealth indices.The food consumption score isbeing used widely by WFP in theirsurveillance activities.107

Months of Adequate HouseholdFood Provisioning measures house-hold food accessibility throughoutthe past year, and reflects the sea-sonality aspect of food security.108

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104 Guidelines for measuring household and individual dietary diversity. fAO 2012.

105 fANTA. 2006. Household Dietary Diversity Score (HDDS) for Measurement of Household food Access: Indicator Guide. Version 2.

106 fANTA. 2006. Developing and Validating Simple Indicators of Dietary Quality and Energy Intake of Infants and Young Children in DevelopingCountries: Summary of findings from analysis of 10 data sets. Working Group on Infant and Young Child feeding Indicators. food and NutritionTechnical Assistance (fANTA) Project, Academy for Educational Development (AED), Washington, D.C.

107 World food Programme. 2008. Technical Guidance Sheet - food Consumption Analysis: Calculation and Use of the food Consumption Score infood Security Analysis.

108 Bilinsky P, A. Swindale. 2010. Months of Adequate Household food Provisioning (MAHfP) for Measurement of Household food Access: Indicator Guide. Version 4. fANTA-2.

109 Ballard, T., J Coates, A Swindale, M Deitchler. 2011. Household Hunger Scale: Indicator Definition and Measurement Guide. fANTA-2.

110 USAID’s Infant & Young Child Nutrition Project (IYCN) has recently developed a Nutritional Impact Assessment Tool that directly attempts tominimize these unintended negative consequences, http://www.iycn.org/resource/nutritional-impact-assessment-tool/.

BOx C-2. COMMONLy uSED FOOD CONSuMPTION INDICATORS

E. “Do no harm” considerationsIn considering the suggested listof interventions, agriculture proj-ect teams needs to ensure that noinadvertent harm is caused.110 Con-text assessment during the designphase will allow project teams to as-sess potential harms and develop

mitigation strategies appropriate forthe circumstance. for example, alter-native child care arrangements maybe more easily attained in one placethan another, which has implicationsfor the strength of the potentialtrade-off between increased laborand decreased child care quality.livestock projects may have a higher

probability of negative externalities,including zoonotic disease transmis-sion, in some situations than in oth-ers. Monitoring of potential harmfulimpact during the project implemen-tation also would provide informationimportant for triggering mitigationstrategies.

1. Invest in women: safeguard and strengthen the capacity ofwomen to provide for the foodsecurity, health, and nutrition of their families.

_________________________

2. Increase access to and year-round availability of high-nutrient content food.

_________________________

3. Improve nutrition knowledgeamong rural households to enhance dietary diversity.

_________________________

4. Incorporate explicit nutritionobjectives and indicators intoproject and policy design.


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111 USAID’s Infant & Young Child Nutrition Project (IYCN) has recently developed a Nutri-tional Impact Assessment Tool that directly attempts to minimize these

Some common examples of unin-tended negative consequences ofagriculture projects are shown inTable C-2 below, with suggestedapproaches to avoiding or mitigat-ing them. The mitigation measuresfor irrigation projects are importantbecause a large part of Bank agricul-ture (AES) investments are for irriga-tion and drainage investments.

XI.SummaryThis module has laid out the ra-tionale for why agriculture is im-portant for nutrition, and viceversa. Agriculture is a key sector inreducing undernutrition, togetherwith health, social protection, educa-tion, and other sectors. The availableevidence supports four strong princi-ples for action in the agriculture sec-tor, and they are areas fortremendous growth in programming.

TABLE C-2. COMMON NEGATIvE CONSEquENCES OF AGRICuLTuRAL INTERvENTIONS

Observed negative impacts Possible mitigation measures

Irrigation projects may cause an increase in hydrophilic vector-borne • Include analysis of hydrophilic vector-borne diseases in disease such as malaria, schistosomiasis, and Japanese encephalitis environmental safeguard analysis, and ensure mitigation

measures are established

Animal husbandry projects may cause an increased risk • Strengthen mitigation measures and risk management of zoonotic diseases framework of zoonotic infections in program design

Reduction in women’s access to resources if projects shift production • In project social analysis or gender analysis, gather information toward male-dominated crops on who is benefiting from intervention activities, and develop

strategies to ensure equitable intra-household access to resources

Reduction in women’s time available for child care, impacting child • Include women’s time use analysis in project gender analysis tohealth and nutritional status determine labor time requirement by women

• Introduce time saving technologies for tasks commonly performed by women

Production increase/price reduction in calorie- dense foods may • Promote production and consumption of micronutrient rich cropsunfavorably alter dietary quality and may contribute to obesity and` • In the project design phase, check levels of obesity as well chronic diseases. as undernutrition111

• In project Results Frameworks, include food consumption indicators to monitor consumption trends which could affect likelihood of obesity and chronic disease

Although to date the Bank’s agri-culture and rural developmentprojects have only addressed nutri-tion implicitly or unintentionallythrough other objectives, there isgrowing awareness inside and out-side of the Bank that leveragingagriculture activities will boost nu-trition outcomes. Of the 21 coun-tries that have already met the goalof halving the proportion of the pop-ulation below the minimum level ofdietary energy consumption, only sixare on track to meet the underweightgoal. While Mali has met the goal ofreducing hunger, it has shown noprogress on reducing underweight.This case demonstrates the limit oftrying to achieve nutrition outcomesimplicitly through agriculture. Im-proving household income or raisingagricultural productivity focused onstaple grains and income alone is in-sufficient to reduce undernutrition.

The annexes of this module aimsto provide practical guidance toagriculturists in maximizing thenutrition impacts of world Bankagricultural investments. This mod-ule calls on Bank staff to take actionon the following fronts: (i) incorpo-rate nutrition-sensitive analysis andactivities into agriculture project de-sign and food security policy dia-logue; (ii) measure the progress ofactivities affecting nutrition periodi-cally through relevant output indica-tors; and through outcome indicatorssuch as food consumption indicatorsat least at baseline/mid-term/projectcompletion; (iii) ensure that agricul-ture projects and policies do notcause unintended harm to nutrition.

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Improving Nutrition through Social Protection

Alessandra Marini, Harold Alderman, Meera Shekar

C H A P T E R - D

I. BackgroundNutrition is widely seen as a multi-sectorial issue. This guidance notebuilds on evidence to date regardingthe links between social protection(SP) and nutrition outcomes, andaims to guide World Bank staff andcountry level implementers in con-verting existing or future World Bankoperations in the SP sector in to morenutrition-sensitive and nutrition-specific programs (see Module A formore details).

The new world Bank Social Protec-tion Strategy presents social pro-tection systems as aimed atbuilding resilience by ensuringthat individuals and families arewell-protected against the suddenshocks that are likely to overwhelmthem. These systems improve equityat both national and global levels byreducing poverty and destitution.They also promote opportunities to

improve people’s productivity and in-comes by preserving and buildingtheir human capital, and facilitatingaccess to better jobs and income,which can propel them out ofpoverty.

Investments in nutrition and earlychild development are increasinglyrecognized as integral componentsof a coherent social protection sys-tem to prevent the intergenera-tional transmission of poverty. Inaddition, they are key determinantsof long-term economic growth. Whenchild nutrition is improved the risk ofmortality is reduced, future humancapital is built, and productivity is in-creased. Thus, focusing on improvingnutrition furthers the objective of in-creasing opportunities, enhancingboth nutrition and social protection.

CHAPTER - D | Improving Nutrition through Social Protection

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1 The Lancet Series on Maternal and Child Undernutrition (2008), available at www.thelancet.com; Copenhagen Consensus Results 2008; availablefrom www.copenhagenconsensus.com; World Bank, 2006. Repositioning Nutrition as Central to Development, the World Bank, Washington D.C.

How can social protection inter-ventions affect nutritional out-comes? Nutritional status reflectsthe interplay of food consumption,access to health and sanitation, andnutrition knowledge and care prac-tices. Social protection programs typ-ically increase income (linked to foodaccess), as well as influence the tim-ing, and to a degree, the control ofthis income. Additionally, such pro-grams may have greater impact onnutrition by fostering linkages withhealth services or with sanitationprograms, and specifically throughactivities that are related to nutritioneducation or micronutrient supple-mentation. Moreover, by taking intoconsideration the relatively narrowwindow of opportunity for investingin nutrition, programs can be tar-geted to enhance their impact on nu-trition. The critical window opensduring pregnancy and closes at abouttwo years of age. These “1,000 days”offer the best opportunity to lock-infuture human capital. Interventionsduring this period can potentially re-duce undernutrition- related mortal-ity and morbidity by 25 percent ifimplemented at scale.1 figure D-1 il-lustrates the key pathways throughwhich a social protection program isexpected to have an impact on nutri-tion, grouped under three categories:transfers, links with health services,and targeting the most vulnerable.

This module will specifically discussthese pathways under three broadquestions and the different policychoices that can derive from each ofthem: (i) How can we maximize theimpact of income on nutrition? (ii)How might social protection pro-grams be linked to nutrition, and withwhat services? And, (iii) Who shouldbe targeted?

grams. This module analyzes the dif-ferent policy choices related to the el-ements of SP programs that affectnutritional outcomes, namely: in-come, links with health and sanita-tion services, and targeting the mostvulnerable. figure D-2 exemplifiesthe key policy options arising whendesigning typical SP programs. Animportant part of the discussion iscentered on transfer programs due tothe key role they play in countries’social policies, and because of theirdemonstrated flexibility in adjustingtheir design to include nutrition-sen-sitive considerations.

II. Objectives

The specific objective of thismodule is to support world Bankstaff and country clients instrengthening the design of SP interventions to maximize their impact on nutrition by consider-ing alternative options for the mostvulnerable populations. Social pro-tection programs often aim at in-creasing household income orsupporting the household’s con-sumption smoothing ability, and pro-moting access and links to services,such as health and education. Target-ing considerations by either incomeor age are generally key elements ofthe design of social protection pro-

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FIGuRE D-1. POTENTIAL PATHwAyS FOR SOCIAL PROTECTION PROGRAMS TO IMPACT ON NuTRITIONTa

rget

nut

ritio

nally

vu

lune

rabl

e/th

e poo

r

Improved Nutritional Status

Improved Diet

Income Supplements Counseling Education Services

Less Infectious Disease

1

1

2

2

3

Income

Links with health/sanitation

Targeting the vulnerable

Source: Adapted from Neufeld, 2006.

3

Possible components of social protection programs

To Food Improved Care Sanitation Services

III. How can we maximize the impact ofincome on nutrition?

Understanding how the relationshipbetween income, consumption, andnutritional outcomes works, and how to strengthen the relationship is perhaps the most immediate consideration. We pay special attention to transfer programs because of their increasing impor-tance among social protection programs and because of their design flexibility.

A first sub-question under thistheme is what is the range of theexpected impact of income on nutrition? If a fiscally sustainabletransfer program can increase ahousehold’s access to food and itsability to obtain quality health andsanitation services and/or increasewomen’s control over incomes, thenthe key programmatic considerationfor nutritional outcomes is reachingthe vulnerable.2 If, on the otherhand, a transfer is not expected toaddress fully the most limiting constraints, then additional designfeatures might be considered to augment the impact of increasedhousehold income.


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2 Two broad categories of income transfers are typically foreseen in social protection programs: (i) long-term transfers to alleviate the consequences of structural poverty, and (ii) short-term transfers to deal with the transitory income fluctuations for families that may not be poorenough to justify long-term transfers but still need consumption smoothing arrangements of some sort if hit by a shock. Depending on whetherthe shock is idiosyncratic or covariate, the government response could be an individual or community-level transfer. literature has generally focused on the impact of long-term transfer on nutrition (CCT or UCT, or feeding programs), although there is evidence that emergency relieftransfers, such as food aid during crises, can deter the long-term effects of shocks on child growth (Alderman, Yamano, and Christiansen, 2005; Woldehanna, 2010).

3 Alderman, H. and Sebastian l. 2009. “Anemia In low Income Countries Is Unlikely to be Addressed by Economic Development without Additional Programs,” Food and Nutrition Bulletin, 30 (3): 265-270.

Evidence shows that economicgrowth will only reduce malnutri-tion slowly. However, transfer pro-grams often increase beneficiaries’expenditures by 10 percent, and oc-casionally by more than 20 percent.Transfers of this magnitude can con-siderably contribute to improving apopulation’s nutrition. In the designphase of a safety net project, the expected impact on nutrition can bebased on the planned size of thetransfer and data from householdsurveys; in the absence of such sur-veys, global experience on the deter-minants of nutrition can assist inplanning. for example, Haddad(2003) confirms that income growth,even when evenly distributed over apopulation, has a positive, albeit rel-atively modest, impact on undernu-trition rates. As a general rule,country level rates of undernutrition,measured as low weight-for-age, de-cline at roughly 50 percent of the ratethat gross national product (GNP) percapita increases; household surveysshow comparable rates of improve-ment in nutrition as incomes rise.likewise, anemia—measured as hemoglobin levels below 10.9 g/dl—declines at roughly 25 percent of the rate of income growth.3 fromanother perspective, malnutritionrates among the richest 40 percent ofthe population in a country with highoverall rates of malnutrition, such asIndia or Malawi, are only somewhatless than malnutrition rates for thepoorest 40 percent. To illustrate,based on the most recent nutrition

FIGuRE D-2. ELEMENTS OF SP PROGRAMS RELEvANT FOR NuTRITION OuTCOMES

Income/Consumption

• Size• Frequency• Control• Nature (in kind/cash)

Link withservices

• Conditionalities (firm/soft)

• Promoting access to services (supply side)

Targeting• By income• By nutritional status• By age group

quESTIONS TO CONSIDER wHEN DESIGNING TRANSFER PROGRAMS:

• How much of a transfer would make a difference?

• What is the role of payment frequency?

• Would providing the income to women make a difference?

• Do in-kind transfers have an advantage over cash transfers?

• Can the role of income bestrengthened by additional design features, including thedegree to which conditionaltransfers improve upon the performance of unconditionaltransfers?

• Can the program design accommodate social promotioncampaigns on improved nutritional practices or micronutrient supplementation?

survey available for Pakistan, provid-ing transfers or income growth to thepoorest 40 percent of the populationto attain the same wealth as the me-dian family would virtually eliminatepoverty in Pakistan. Nonetheless,over 38 percent of the entire popula-tion of children would still be mal-nourished.4

Despite the low growth-nutritionelasticity, for a subset of house-holds, cash remains a binding con-straint for inputs needed for goodnutrition. There is evidence thattransfers, even when unconditional,including food stamps, frequentlyhave stronger impact on nutritionthan other sources of additional in-come. That is, when income transfersare part of SP programs, they seem tochange the budgeting process. Thishas been documented in some con-texts, for example in the US foodstamp program, and in cash transfersin Ecuador or take home rations forfemale students in Burkina faso.5

A. Enhancing the role of income in transfer programs

i. Size of “payment” or income transfers

The size of income payment andtransfers matters. It is difficult todefine what the best amount of trans-fer ought to be, whether it is compen-sating for expenses that relate toprogram participation or fulfillmentof conditions, or whether it is an in-centive to lift the household out ofpoverty. It is also difficult to separatethe impact of the transfer from that ofother program components. The ex-perience of PRAf, Honduras’ condi-tional cash transfer program, wherethe relatively low impact of the pro-gram was linked to the limited size ofthe transfer, seems to suggest thatthe actual size of the transfer canmake a difference on the program im-pact.6

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4 If household surveys that contain both anthropometric data and expenditures are available,they can be used to make country specific estimates anywhere a transfer is being consid-ered. However, because demographic and health (DHS) or UNICEf multiple indicator clustersurveys (MICS) data can only provide the basis for an ordinal ranking of wealth, some inter-pretation is still needed to estimate the impact of a given cash transfer. This limitation, how-ever, is hardly insurmountable. If other data sets allow one to estimate income orexpenditures by wealth quintiles, the two sources of complementary data allow an estimateof the impact of an income transfer on nutritional outcomes for the average household in aquintile.

5 Kazianga, H., de Walque, D. and H. Alderman. 2009. Educational and Health Impact of TwoSchool feeding Schemes: Evidence from a Randomized Trial in Rural Burkina faso. WorldBank Policy Research Working Paper #4976; Breunig, R. and I. Dasgupta. 2005. “Do Intra-household Effects Generate the food Stamp Cash-Out Puzzle? American Journal of Agricul-tural Economics. 87(3): 552-68; fraker, T., Martini, A. and J. Ohls. 1995. “The Effect of foodStamp Cashout on food Expenditures: An Assessment of the findings from four Demonstra-tions,” Journal of Human Resources 30(4): 633-49; Paxson, C. and N. Schady. 2007. DoesMoney Matter? The Effects of Cash Transfers on Child Health and Cognitive Development inRural Ecuador. World Bank Policy Research Working Paper 4226. Washington, D.C.: WorldBank, 2007; P. Kooreman. 2000. “The labeling Effect of a Child Benefit System,” AmericanEconomic Review 90(3): 571-583.

6 IfPRI, 2003, Proyecto PRAf/BID fase II: Impacto Intermedio, Sexto Informe, Washington D.C.,International food Policy Research Institute.

The size of the transfer in the Hon-duras program was only one-third thesize of the transfer in programs con-sidered most successful in reducingchronic malnutrition, such as Mexico,Colombia or Nicaragua. Comparedwith latin America, South Asia andsome Middle Eastern countries havesignificantly smaller transfers as apercentage of per capita spending(see figure D-3).7

ii. Frequency of payment

frequency and reliability of paymentis an important feature of mosttransfer and social pension pro-grams as well as public works pro-grams. When payments are frequentand reliable they directly support so-cial protection objectives. Paymentsof small amounts on a monthly or bi-monthly basis have the advantage ofensuring regular expenditures aimedat covering daily necessities, includ-ing the key nutritional inputs. How-ever, we know of no studies thathave tested the relative impact ofmore regular payment’s conditionson the amount over time. Reducedfrequency, on the other hand, re-duces the administrative costs of pro-grams. The introduction of newpayment technologies may help tolower the costs of aligning paymentfrequency with beneficiary needs.

potential for increased friction withina household. However, cultural speci-ficity should be taken into account,as in some contexts the contrary maybe true.8 In general, there is evi-dence that women’s control of in-come increases expenditure more onchildren than men do.9 However,there is limited experimental evi-dence in the context of CCTs.10

iii. Control of income

female control of income accompa-nying a transfer program has beenassociated with shifts in householdexpenditure patterns towards chil-dren’s needs. female control of in-come regularly is incorporated intothe design of a transfer program withmodest but real costs in terms of thewoman’s time allocation, as well as a

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7 fiszbein, A. and N. Schady, with francisco H.G. ferreira, f. H.G., Grosh, M., Kelleher, N., Olinto, P. and E. Skoufias. 2009. Conditional CashTransfers for Attacking Present and Future Poverty. World Bank Policy Research Report.

8 In some countries in the Middle East and North Africa, giving transfers to men has been associated with resources spent on the family or children more than in the case of women (lebanon, for example, as described in IfES, IWPR, and CIDA Topic Brief, 2009).

9 Haddad, l. and Hoddinott, J., H. Alderman and DEC. 1994. “Intra-household resource allocation: an overview,” Policy Research Working Paper Series 1255, The World Bank.

10 Gitter S.R. and B. l. Barham, 2008, “Women and Targeted Cash Transfers in Nicaragua,” World Bank Economic Review, 22(2), 271-290.

Source: Fiszbein and Schady, 2009.

FIGuRE D-3. INCOME TRANSFERS IN SELECT COuNTRIES AS A PERCENTAGE OF PER CAPITA SPENDING

Tran

sfer,

as a

% of

per

capi

ta sp

endi

ng

30

25

20

15

10

5

0

ChileCo

lombia

Ecuad

oreHon

durasJam

aica

Mexico

Nicarag

uaBan

gladesh

Cambod

iaPak

istan

Turkey

CONSIDERATIONS wHEN DESIGNING IN-kIND TRANSFER

PROGRAMS

• How do food markets work(availability, procurement, distribution, etc.)?

• Is there a food emergency?

• Are food prices very volatile?

• Carefully evaluate the nature ofthe food distributed versus thenutritional problem.

• Carefully evaluate unexpectedconsequences on local markets.

B. Nature of transfers: Cash versus in-kind transfers

Despite its importance for devel-opment assistance in low-incomecountries, there are few rigorousevaluations of the impact of foodversus cash aid on households.Until recently, in-kind assistance wascommon in low-income countries,both to promote food consumptionand because financial services werelimited. However, cash-based pro-grams are being developed that takeadvantage of information technologyinnovations for beneficiary identifica-tion and for delivering cash transfers.While transfer programs in lAC wereamong the first to shift from in-kindassistance (including subsidizedfood) to cash, new technology has al-lowed cash to reach beneficiaries inremote places such as pastoral com-munities of northern Kenya.

Both forms of assistance have ad-vantages and disadvantages. food-based transfers may perform betterwhen markets for food do not func-tion well or in the aftermath of a dis-aster. On the other hand, withproper monitoring, often enhancedby improvements in IT and mobilephone transfers, cash entails loweraverage logistical costs (thereforehigher coverage), and gives benefici-ary households greater freedom torespond to their own priority needs.The impact of in-kind transfers on nu-trition depends in part on whetherthe commodity is provided inamounts smaller than would havebeen otherwise purchased (infra-marginal), in which case the impactis similar to a cash transfer of similarvalue.

In contrast, extra-marginal pro-grams—transfers for an amountgreater than the household wouldhave consumed without the trans-fer—tend to increase food con-sumption. Studies in Bangladeshindicate that recipients of in-kindtransfers show preference for thatmodality, while recipients of cashprograms prefer their means of sup-port. However, in times of pricevolatility, preference is generally forin-kind transfers as their real value isprotected. This was noted in the Pro-ductive Safety Net Program (PSNP)for Ethiopia in 2008. Overall, be-cause the advantages of in-kind foodprograms are often small, in non-emergency situations and especiallywhen markets are working, the lowercost of cash distribution may be thedeciding factor in choosing the formof transfer.

The Mexican Progresa (then opor-tunidades) Program evaluated thepossibility of delivering its foodsupport component in cash or in-kind transfer from the beginning.levy and Rodriguez (2005) concludedthat considerations of efficiency andefficacy highlighted the convenienceof delivering cash transfers, de-linked from consumption patterns,rather than in-kind transfers. Sk-oufias (2008), in a review of the fooddistribution program PAl in Mexico,found that while transfers have alarge and positive impact on con-sumption and poverty reduction, irre-spective of the nature of the transfer(cash or in-kind), cash transfers hadhigher impact on height-for-age z-scores of children younger than twoyears. Additionally, in-kind transfers

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in the context of populations that arenot energy deficient should be care-fully designed to ensure that they arenot associated with an increase inenergy consumption, as was the casefor the in-kind transfer program PAlin Mexico.11 A final considerationdemonstrates that in remote areas, acash infusion may push up localprices, as seen in an example fromMexico.12 While this implies a needfor monitoring in general, marketstend to be fairly well integrated.

Coupons and food stamps serve anintermediary role. Relative to cash,coupons and food stamps have addi-tional logistical costs related to theirredemption system, but, as they useexisting market channels, they havefewer direct costs than food distribu-tion programs. In principle, trackingcoupon redemptions offers an inher-ent means of monitoring, althoughthis advantage, relative to cash dis-tribution, is declining with improvedtechnology for cash transfers.

C. Including nutrition counseling or micronutrientsupplementation componentsIf improving nutritional status is akey objective, an income or in-kindtransfer alone may be insufficient.Specific design features can aug-ment impact, such as including a nu-trition counseling component,providing micronutrient supple-ments, or deworming drugs. The link-ing of a transfer with nutrition may be

achieved through simple communica-tion of the objectives of the transferor through a more concerted strategyof raising public awareness viahealth/nutrition education programsthat may accompany such transfers.Examples of this include group-baseddemonstration/education sessions,individual counseling or nutrition education, such as the one providedthrough community-based growthpromotion programs (see Module E).

D. Enhancing the role of income in other social protec-tion programs: Public works,insurance, and microfinanceSome considerations discussed previously for transfer programs,such as size and frequency of payment and control of income, apply to the design of other socialprotection programs. However, some elements that are specific toother programs’ design are worthdiscussing separately.

i. Accommodating time demands for women inpublic works programsA well-designed public works program accommodates the timedemands on women. The overlapbetween public works and nutrition is often considered slight and mainlyreflecting the increased calorie demands of labor intensive activities,as well as the indirect impact of


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BOx D-1. ASSESSING THE RELATIvE IMPACTS

OF CASH AND FOOD TRANSFERSON NuTRITION IN NEPAL

DfID and the World Bank are under-taking a two-stage research study tocompare the relative impact of cash,food transfers, and enhanced nutri-tion counseling for women. Thestudy will include an initial 2.5-yearrandomized controlled trial in theTerai region of Nepal to assess therelative impact of three interven-tions to reduce low birth weight andto improve maternal and neonatalhealth and nutrition compared tocurrent approaches. If the efficacytrial proves successful, the most ef-fective approach will then be testedin an effectiveness study under nor-mal operating conditions, includingin challenging geographical environ-ments in South Asia, with the objec-tive of developing scalable models.IFPRI and WFP are funding similarevaluations in other countries to as-sess the difference in impact be-tween food and cash.

_______________________________

quESTIONS TO CONSIDER wHEN DESIGNING PuBLIC wORkS

PROGRAMS

• Which payment would make a difference?

• What is the role of frequency of payments?

• Would including a crèche make a difference and attractmore women?

• Can the program design accommodate counseling on improved nutritional practices ormicronutrient supplementation?

11 leroy, J.l., Gadsden, P., Rodríguez-Ramírez, S. and T. González de Cossío. 2010. “Cash and In-Kind Transfers in Poor Rural Communities in Mexico Increase Householdfruit, Vegetable, and Micronutrient Consumption but Also lead to Excess Energy Consumption,” J. Nutr, 140 (3): 612-617.

12 Cunha, J.M., G. De Giorgi, and S. Jayachandran, The Price Effects of Cash Versus In-KindTransfers, NBER Working Paper No. 17456.

these demands on the household,and of course reflecting the role of income and women’s control. Theparticipation of women in publicworks programs can be enhanced if the programs provide a crèche. A well-designed crèche may also provide early child development andcare. In India, for example, mobilecrèches for construction workers isone such successful model. Thesecrèches are designed to travel withthe workers as they move from construction site to site.

As pregnant and lactating womenhave high-energy demands fortheir child, a well-planned publicworks program can offer produc-tive tasks that are suited to thisconstraint. Women can be involvedin managing a crèche, providing similar services within the widercommunity, or attending childcareclasses, as an alternative to more energy intensive tasks (See Box D-2 for an example from Djibouti).Argentina’s Jefes y Jefas program, avariation of a public works project,allowed beneficiaries to substitute20 hours of training a week for man-ual labor. While relatively few individ-uals selected this option, a degree offlexibility still existed. Public worksprojects can also offer flexible hoursor piecework to accommodate moth-ers’ time constraints.

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Djibouti has high rates of childhoodmalnutrition (affecting 33% of thechildren), unemployment (hoveringat 55%), and poverty (affecting 42%of the population). In addition, overthe last four years the country hasbeen confronted with recurrentdroughts that negatively affectedpoor and vulnerable households, andcreated emergency needs. In re-sponse, the government is imple-menting an innovative social safetynet (SSN) program “Djibouti CrisisResponse: Employment and HumanCapital Social Safety Nets,” combin-ing short-term employment with anutrition intervention for the poorand vulnerable. The project supportsa crisis response that provides the

basis for a (productive) safety net by(i) improving the design and effec-tiveness of a public works programso it becomes an effective socialsafety net, (ii) generating new short-term job opportunities for the poorand vulnerable; and (iii) improvingnutrition practices among participat-ing households through behavioralchange interventions. The programlinks creation of employment oppor-tunities to improvement of nutri-tional practices by adding anutrition and growth promotion com-ponent to the traditional cash-for-work program to leverage the effectof the additional income on the fam-ily’s nutritional status.

BOx D-2. DjIBOuTI SOCIAL SAFETy NET PROjECT THAT COMBINES wORkFARE wITH A NuTRITION INTERvENTION

INTEGRATED APPROACH: “ALL [FAMILy MEMBERS] AGAINST MALNuTRITION”

Workfare: Increasedhousehold income.Offers short-term employment in:

• Community works (for all) chosen (and built) by the community from catalogue (e.g. containment walls)

• Services (for women only), mainly plastic bags collection, community-level recycling and transformation into blocks to pave footpaths

Common Goal: Prevent Malnutrition

Nutrition: Enhanced nutrition practices.Targets vulnerable non-working members(young children andpregnant women)

Focus on first 1,000 days of life• Monthly community

meetings (e.g. sensitization on exclusive breastfeeding)

• Bi-weekly home visits by a community worker

• Food supplements distributed during the lean season

ii. Strengthening the role of insurance by promoting utilization of servicesInsurance is one way to smoothconsumption over time and acrosshouseholds. Households hit by ashock face the dilemma of either con-serving productive assets for futureconsumption or stabilizing consump-tion by drawing down assets. How-ever, formal insurance plays a smallrole in the risk reduction strategy oflow-income households. This in partis because of the lack of insurancemarkets, which reflects real struc-tural aspects of incentives for clientsand the costs of monitoring theirlosses. While innovations such asweather indexing have increased therange of instruments available, mostevidence indicates that individual in-surance for livelihoods that is actuar-ially fair and therefore attractive toprivate providers without subsidies,remains beyond the budgets of low-income households. If subsidies areconsidered, the issues of targetingare similar to those for transfer pro-grams in general.

weather index insurance to miti-gate damage by droughts, cy-clones, or floods may be viable atthe community or similar aggregatelevel. Indeed, financial or self-insur-ance may be feasible at the nationallevel. If so, the payout when there isa shock is also at the aggregate level,and a program or distribution rule isneeded to get the benefits to thewider population. The decisionsneeded for this are similar to the pro-grammatic decisions needed for as-sistance following a disaster orfinancial crisis. While health insur-

ance may also play a role in incomesmoothing—health shocks often area larger risk factor for impoverish-ment than are weather shocks.Health insurance differs from weatherinsurance in many essential features.for example, collective payouts orcollective indices do not seem appro-priate. More important, in addition toconsumption smoothing, one objec-tive for public involvement is to en-courage utilization of services,especially preventative and primaryhealth. Since children have a rela-tively low risk of incurring cata-strophic health costs, the primaryrole of health insurance for childrenis promoting the use of health facili-ties. Targeted subsidies for health in-surance and the linkage of insurancewith conditional transfers, as inGhana or Mexico, are means to linksocial protection with health insur-ance. Conceptually, fee waivers forchildren’s primary health needs canalso serve this function, though inpractice, fee waivers have a tendencyto be under budgeted and thus starvehealth services of funds.

iii. Smoothing consumption by promoting microfinanceMicrofinance–including savingspromotion, some forms of insur-ance, and credit provision– canassist low-income households inentrepreneurial opportunities, aswell as to smooth consumption. Insome countries, as in Kenya, the pri-vate sector has designed financialproducts to serve the needs of rurallow- income households, facilitatedby cell phone access. In others,NGOs have taken the lead in broad-


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ening the access to financial serv-ices. To the degree that these effortsraise incomes or assist in consump-tion smoothing, they increase foodand health security. financial deep-ening is often accompanied by finan-cial literacy enhancing programs. forexample, group-lending programsmay hold regular educational meet-ings for participants. In a few cases,communication on health and nutri-tion has been included in thesemeetings. These are similar to thetraining sessions that are part ofsome CCT programs (such as the plat-icas in Mexico’s Oportunidades).However, it is difficult to separate therole of access to credit and bankingfrom the role of information, andthere are still few evaluations of suchprograms. Transfer programs, how-ever, have a different objective thanfinancial deepening, and the balanceof adding wider social objectives tothe latter is largely unexplored.

IV. How can socialprotection programspromote the link withother services to in-crease their nutritionalimpact?

Access to services can be pro-moted through links withtransfer programs or directlyby promoting access to serv-ices at local level. The sameprinciples of social inclusionthat pervade most social pro-tection programs underliesome nutrition interventions.

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latin America has pioneered the useof CCTs. Because of persistent stunt-ing rates, many countries have taken

advantage of CCTs’ reach to vulnera-ble groups to attach nutrition co-responsibilities (conditions). The

BOx D-3. vARIATIONS ON THE THEME: NuTRITION CO-RESPONSIBILITIES IN CCTS IN LATIN AMERICA

chart below summarizes the healthand nutrition co-responsibilities ofCCT programs in several countries inlatin America and the Caribbean.

COuNTRy PROGRAM NuTRITION CO-RESPONSIBILITIES

Brazil Bolsa Familia • Children <7 yrs: complete immunizations and attendance at growth monitoring 2x/year

• Pregnant and lactating women: attendance at ANC and PNC checkups and health and nutrition education sessions

Bolivia Bono Juana Azurduy • Children <2 yrs (with no other siblings <2 yrs): attendance at bimonthly checkups• Pregnant and lactating women (with no children <2 yrs):

attendance at 4 prenatal checkups, institutional birth, and postnatal checkups

Colombia Familias en Acción • Children < 7 yrs: attendance at regular health checkups (growth monitoring, nutritional status and development; hygiene and diet education; vaccinations)

Dominican Solidaridad • Children <6 yrs: immunizations and attendance at regular health checkupsRepublic • Pregnant and lactating women: attendance at ANC and PNC visits

• Adolescents and head-of-households: attendance at quarterly workshops

Guatemala Mi Familia Progresa • Children <7 yrs: attendance at regular health checkups (immunizations, growth monitoring, deworming, vitamin A supplementation, supplementary feeding)

• Children 6-15 yrs: iron folic acid and fluoride supplementation, deworming• Pregnant and lactating women: attendance at ANC and PNC visits, iron folic acid

supplementation,education on complementary feeding and health

Mexico Oportunidades • All family members: attendance at health checkups 2x/year• Pregnant women, children <2 yrs, malnourished children: attendance at monthly

health education sessions

Panama Red de Oportunidades • Children < 5 yrs: regular health checkups• Pregnant women: ANC visits every 2 months

Peru Juntos • Children < 5 yrs: regular health check-ups (including growth monitoring, receipt of fortified complementary food and vitamin supplements, vaccinations, deworming)

• Pregnant women and mothers: attendance at ANC and PNC appointments (including reproductive health education and food assistance), institutional birth

Verification that co-responsibilitieshave been fulfilled prior to the cashtransfer requires a well- functioningchain of information flow from thepoint of service delivery/utilizationto a central clearinghouse for the CCT

program where data are compiled.Means of verification range from fill-ing out lists of beneficiaries onpaper, to scanning beneficiary bar-codes, and electronic filing of co-re-sponsibilities in an online system.

Brazil’s CCT program, which serves12 million households, decentralizesverification by municipality, whilemost other countries have a centrallymanaged system.

Source: Ochoa, Marini, Silva, 2011.

A. Conditioning transfers to access to serviceslinking income transfers to compliance with a conditionality (orco-responsibility) can function as apowerful incentive for the use ofhealth and nutrition services.

Conditional Cash Transfers (CCT)are a well-known type of programthat aims at reducing both presentand future poverty. By linking a tar-geted transfer to health seeking be-havior(s), or to participation ineducation through the “conditionali-ties” or “co-responsibilities,” CCTscan change the effective price of preventive health care and offset liquidity constraints that reduce investments in children. The co-responsibilities vary according tocontext, responding to the salientproblems of each country, and takinginto consideration the availability ofservices and the operational capacityto administer and manage the CCT(see Box D-3). Close links betweenthe CCT administration and thehealth sector are generally very im-portant, since the health sector mustprovide adequate coverage and qual-ity of the services required as co-re-sponsibilities. Health sector staffalso often verify beneficiaries’ use ofservices.

The idea of conditioning transfersis not based on a paternalisticview that poor mothers do notknow how to spend their moneyadequately. Rather, conditionalitiesare based on the expectations thatthey will have an impact on pricesand preference ordering: even whenpeople optimize their budget, lowerprices have a strong impact on de-mand, possibly even stronger thanthe income effect itself. It is conceiv-able that these conditionalities (orco-responsibilities) may also allowpoor mothers additional bargainingpower in the use of these additionalresources for the care of their youngchildren.

The evidence indicates that mostCCT programs achieve changes inservice utilization. However,changes in outcomes seem less fre-quent, and when observed, theyare less uniform.13,14 There aremany reasons for this, includingmeasurement challenges and the du-ration of the evaluations, but anotherconcern is the quality of services. If ahealth CCT is conditioned on a preg-nant woman receiving prenatalcheck-ups or bringing an infant togrowth promotion sessions, the im-pact depends critically on whetheranything happens at these visitsother than simple measurement andwhether the “promoted” services areaccessible and available. Therefore,the design of these CCTs needs to


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quESTIONS TO CONSIDER wHEN DESIGNING CONDITIONAL

PROGRAMS

• What is the role of the “condition”? Which objective is it trying to achieve?

• What is the cost of monitoringconditions? Is it worth monitoring conditions “firmly”?

• Does it make sense to “punish”households that do not complywith conditions?

• What are the reasons behind non-compliance?

• Is it worth introducing conditions at the community level?

13 Because the first wave of CCTs was in latin America, more evaluations exist from this region.

14 fiszbein, A., and N. Schady, with ferreira, f.H.G., Grosh, M., Kelleher, N., Olinto, P. and E. Skoufias. 2009. Conditional Cash Transfers for Attacking Present and future Poverty. WorldBank Policy Research Report.

balance the demand side (which iscatalyzed by the CCTs) with the sup-ply side of health, nutrition, and pop-ulation (HNP) services and genderempowerment programs, ensuringthat all the key pieces are in placeand working well. A recent paperfound that the Juntos CCT Program inPeru made a significant impact onnutritional status of the most mal-nourished children. It also found thatconditional on being beneficiaries ofthe program, nutritional impact iscorrelated to the duration of expo-sure and to the education level of themother.15

There is some evidence from edu-cation that the presence of condi-tions affects service utilizationbetter than the transfer amount.That is, providing a large transfer in-creases service utilization margin-ally, compared to a small transfer. Atthis time, however, such evidence isonly available from education pro-grams and needs to be verified inhealth care.16

Some programs are experimentingwith conditions or co-responsibili-ties at the community level. The In-donesia Generasi program, forexample, has introduced grants forcommunities to address health andeducation needs. In one pilot, com-munities that performed well in im-proving selected indicators were

care as both a right and an obliga-tion can address social exclusion.Such empowerment may stimulateimproved health care, as was notedin a study of prenatal care in Mex-ico.17 In Peru, after technical assis-tance identified coverage gaps inservices to beneficiaries of Peru’sJuntos CCT, a subsequent projectaimed to rectify this imbalance by in-creasing demand for nutrition serv-ices by strengthening theoperational effectiveness of the Jun-tos CCT program and at the sametime improving the coverage andquality of the supply of basic preven-tive health and nutrition services inthe targeted communities (see BoxD-4 for more details).18

provided additional funds. The pro-gram builds on the successful experi-ence of CDD programs, their existingeffective machinery, and their socialcapital. The program constitutes aninteresting example of results-basedfinancing, by promoting results atthe community level. While initialevaluation results do not indicate ro-bust differences relative to the coreprogram, the innovation is not partic-ularly costly, and variations of thetheme are under consideration andevaluation.

Even when the enhancement ofservice quality is not directly in thehands of a CCT program, the factthat a program presents health

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15 Jaramillo, M. and A. Sanchez. 2011. Impacto del Programa Juntos sobre nutricion temprana, GRADE Documento de Investigacion 61, lima, Peru.

16 Baird, S., McIntosh, D. and B. Ozler. 2010. Cash or Conditions? Evidence from a Cash Transfer Experiment; filmer, D. and N. Schady. 2009. “Are there diminishing returns to transfer size in conditional cash transfers?” Policy Research Working Paper Series 4999, The World Bank.

17 Barber, S. and P. Gertler. 2010. “Empowering women: how Mexico’s conditional cash transfer programme raised prenatal care quality and birthweight. Journal of Development Effectiveness,” 2 (1): 51-73.

18 World Bank. 2012. Building Resilience and Opportunity, The World Bank’s Social Protection and labor Strategy 2012-2022. Washington DC.

In poor, rural areas, parents attend to farming early and often don’t have time to preparemeals for their children to take to school. Through a national school feeding program inlaos, students get at least a third of their daily energy and nutrition needs. In this photo,a student is enjoying her vegetables. Oudomxay province, lao PDR. Photo: Bart Verweij / World Bank

However, even programs that ap-pear to combine all the essentialingredients seem to perform poorerthan expected. Oportunidades inMexico, for example, touches on nu-trition by including: (i) a substantialin size-cash transfer, (ii) parental ed-ucation, (iii) micronutrient supple-mentation, and (iv) linkage withhealth services in its program. How-ever, many still argue that the impacton nutrition outcomes, particularlyanemia, is less than one would haveexpected. Why is that the case? first,impact on height is limited, given theamount of time needed to detectsuch a change, which typically tendsto be longer than the study’s periodand/or length of programs.19 Sec-ond, it is important for any SP pro-gram to ensure that the differentcomponents are articulated and thatnutritional knowledge is incorporatedand tailored to the needs of the spe-cific context. In Mexico, for example,the Oportunidades program is under-going continuous modifications to re-inforce its impact on nutritionaloutcomes, incorporating lessonslearned from international best prac-tices and from local evaluations. Toincrease acceptance and use of mi-cronutrient supplements, minimizethe costs, and decrease the unde-sired impact on overweight and obe-sity, the program recentlyimplemented a new health and nutri-

tion strategy that restructured the nu-trition education, emphasizing train-ing and introducing culturallyadequate material, and replaced dis-tribution of food supplements withmicronutrient sprinkles in urbanareas. This comprises an importantexample of how a program shouldcontinuously evaluate itself and stayabreast of the latest innovations inthe nutrition sector.


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19 World Bank Independent Evaluation Group. 2010. What can we learn from nutrition impactevaluations? Washington, D.C.: World Bank.

20 Another interesting example of soft condition comes from the Ecuador Bono de Desarrollo Humano (BDH) CCT program which introduced a randomized verification of co-responsibilities in urban areas to reduce the cost of monitoring.

B. Firm versus soft conditionsEven when they include only “soft”conditions, i.e., co-responsibilitiesthat are advocated but not strictlyenforced, CCTs can enhance thepotential nutritional impact of atransfer program. These soft condi-tions may be considered a form of be-havior promotion—one that is fairlyexplicit about the recommended ac-tions.20 firmer conditions to pro-mote health-seeking behaviors,which monitor and enforce compli-ance, have an additional impact. Thisis not based on a patronizing viewthat the poor do not know how tospend their money wisely, as occa-sionally depicted. Rather, this de-rives from a simple expectation thatlowering a price increases demandmore than an equivalent incometransfer does.

Children having a meal at school. Ghana. Photo: © Arne Hoel/The World Bank

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Peru’s CCT program Juntos began in2005 and serves more than half amillion households. The program tar-gets poor rural households with chil-dren under 14 years. It transfersapproximately US$38 to the motherof each beneficiary household permonth, which represents 15% of totalhousehold consumption. The co-re-sponsibilities of receiving the pay-ment include regular health visits forpregnant women and children under-5 years, and school attendance of atleast 85% for school-age childrenwho have not yet completed elemen-tary education. While the programhad shown some positive results as

of 2008, they were far below the pro-gram’s potential. Poverty was re-duced, beneficiaries were spendingmore on nutritious food, and therewas a significant increase in the uti-lization of health services (mainly incheck-ups and vaccination). However,there was no impact in other keyservice utilization, such as prenatalcheck-ups, and no impact on finaloutcomes (malnutrition). Meanwhile,the rate of chronic malnutrition(stunting) in Peru remained at 31%,far higher than expected given per-capita income. In 2007, the govern-ment placed nutrition at the forefrontof its social policy, committing to re-

BOx D-4. STRENGTHENING THE NuTRITION IMPACT OF THE PERu CCT PROGRAM

ducing chronic malnutrition in chil-dren under-5 by 9 percentage pointsin five years. Juntos is at the core ofthe strategy to reduce undernutri-tion, and since no nutrition impactwas observed, it needed to bestrengthened. As part of the GoP’soverarching commitment to improv-ing nutrition, and assisted by WorldBank non-lending technical assis-tance, an effort was made to identifykey bottlenecks in the program andcreate a plan to strengthen its func-tioning to reach better nutrition out-comes. Highlighted results of thisanalysis are summarized in the tablebelow.

BOTTLENECk LINE OF READjuSTMENT

Inadequate (low) coverage of target Improved targeting (priority for children aged 0-2yrs)population (<2yrs old)Transfer scheme inappropriate for Adjustment of incentive scheme, i.e., amount, co-responsibilities, frequency desired incentives of paymentCash transfers to households without New process of cash transfer delivery; Compliance verification through health andinformation about the compliance education sectorsand/or without compliance of co-responsibilitiesLimited supply capacity of health and Guarantee the supply of health and education services through the standardizationeducation services of basic packages, including nutrition such as distribution of micronutrient powdersLack of a managerial monitoring system Establish a monitoring system that tracks the supply of service i.e., are services

dependably available and high qualityInadequate institutional Establish an adequate and professionalized structure, e.g., clarify operational implementation structure rules and staff, fill vacant director position

An important and innovative aspectto the modification of Juntos is thechanges were pilot-tested in one dis-trict of Peru (San Jerónimo, ApurimacRegion) to validate the functioning ofthe revamped program and to fine-tune aspects for national scale up.This involved the establishment of amultisectoral inter-agency workinggroup (known as the “Grupo Apuri-mac”) that turned out to be critical to

the program’s success. The group isan important instrument for coordi-nation across the different sectors(particularly between Juntos and Min-istry of Health). Its goal was to coor-dinate the delivery of transfers anddemand incentives to targetedhouseholds by providing a basicpackage of interventions in healthand nutrition. In 2010, the programapproved a new operational manual

with the objective to improve pro-gram aspects related to the affiliationprocess and the process of verifica-tion of co-responsibility. It is ex-pected that implementing thereforms will contribute to improvingthe impact of final outcomes and theprogram’s capacity to break the inter-generational cycle of poverty.

Source: Vargas, 2011.

Some programs have introducedcommunity-based conditionalitiesto generate social pressure onminimum utilization of servicesand to promote inclusion of themost vulnerable. In the case of In-donesia, the community set the pro-gram conditionalities, offeringincentives to identify communityproblems, seeking solutions to im-prove specific health and educationindicators, and increasing bothusage and funding of communityservices.

C. Conditional versus unconditional transferswhen choosing between a condi-tional and an unconditional trans-fer, the key question to ask is, Arethe expected gains worth the ap-preciable costs of monitoring andreporting? Monitoring conditionscan be complex and expensive.Caldes (2006) estimates that the costof monitoring conditionalities canrange between 8 and 15 percent ofthe total budget of a program. An un-conditional transfer assumes thatpreferred expenditures can beachieved simply by an increase in in-come, rather than by accompanyingthe income transfer with a loweredprice. for example, the existence of astrong community-based growth pro-motion program in Senegal has cre-ated enough demand for nutritionactivities that an unconditional trans-fer was considered enough to in-

crease participation and change inpractices. While no experiments com-pare health outcomes between a CCTand a UCT, a related experiment onschool participation in Malawi foundthat while unconditional transfers in-creased schooling, the CCT had amuch larger impact.21 A similar in-ference was made in regards toEcuador and Mexico’s transfer pro-grams based on whether the house-hold was informed about theconditions or did not receive theforms to monitor the children’s atten-dance.22 Still, unconditional trans-fers can play an important role incontexts where the cost of monitor-ing compliance with co-responsibili-ties is very high. Their impact can bestrengthened by ensuring a mini-mum set of conditions: e.g., by en-suring that the transfer is given tomothers, taking advantage of thebeneficiary registry to target the mostvulnerable with a specific nutritioneducation campaign or micronutrientsupplementation, depending on thenature of the nutrition problem.

D. Conditional “in-kind” transfers: School feeding andschool health and nutritionprogramsSchool feeding programs—bothschool meals and take-home ra-tions—can be viewed as condi-tional in-kind transfers. Schoolmeal programs can have a modestimpact on household expenditures,


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21 Baird, S., McIntosh, D. and B. Ozler. 2010. Cash or Conditions? Evidence from a Cash Transfer Experiment.

22 Schady, N. and M.C. Araujo. 2008. “Cash Transfers, Conditions, and School Enrollment in Ecuador,” Economía 8 (2) 43–70; De Brauw, A. and J. Hod-dinott. 2008. Must conditional cash transfer programs be conditioned to be effective? The impact of conditioning transfers on school Enrollment inMexico, IfPRI Discussion Paper 57, Washington, D.C., International food Policy Research Institute.

23 Alderman, H. and D. Bundy. “School feeding Programs and Development: are we framing the question correctly?” World Bank Research Observer,forthcoming.

but as they are untargeted within aschool, they are generally smallerthan targeted UCTs or CCTs. Schoolfeeding programs are conditioned onschool attendance; thus, that iswhere their impact is most apparent,particularly in regards to girls’ atten-dance. School meal programs are notdesigned to address the most criticalnutritional constraints in low-incomesettings, simply because they are nottargeted at the most vulnerable pe-riod in child development. Nonethe-less, the indirect effects of girlsremaining in school can contribute toimproved maternal and infant nutri-tion outcomes via delayed marriageand older age at first childbearing.

from a nutrition perspective, thehighest payoff comes from reach-ing children before school age, butrecent studies from Burkina faso andUganda23 have shown that school-feeding programs may have a posi-tive impact on younger siblings.What in the past was termed leakagefrom the targeted school- aged childmay in fact be sharing with more vul-nerable family members. However,there is currently not enough evi-dence or experience to assesswhether take-home rations or schoolmeals have a higher potential to im-pact younger household members.This benefit is, nevertheless, indi-rect.

School feeding programs can alsocontribute directly to nutrition ofschool-age children if the mealsare fortified, particularly with iron

and folic acid. While school feedingprograms are not designed to im-prove nutrition status during themost vulnerable “1,000 days windowof opportunity” from pregnancy toage two, they can contribute to im-proving nutrition status amongschool-age children. Individualschool programs and populations re-quire close attention; however, asemerging research suggests thatrapid weight gain after the age of twomay predispose previously under-nourished children to obesity andnon-communicable diseases later inlife.

further, while few school feedingprograms currently use fortifiedfoods, the range of appropriatetechnology has broadened with re-cent advances in extruder fortifiedrice, (which adds less than 5% to thecost of this staple), and a range ofother fortification options, such aswheat flour and maize meal, anddouble fortified salt (salt fortifiedwith iodine and iron). However, thepotential for fortification is some-what problematic with the increasedfocus on local sourcing of foods.local foods are less likely to be cen-trally processed, and thus, less likelyto be fortified at scale.

The use of premixed packages ofmicronutrients, such as a variantof micronutrient “sprinkles” thatare designed for school-aged chil-dren may enhance the nutritionalvalue of the meals. These premixescan be added to school meals, al-though their efficacy or doses forschool settings is not yet determinedsince they originally were designedfor home use with young children.

finally, creating a partnership be-tween health and school adminis-trations that would facilitate theprovision of deworming medicinescan be forged around schoolmeals. Although deworming of chil-dren is undertaken on a biannualbasis, which does not correspond toschool-meal programs or take- homerations. Partnerships have proven tobe effective for preschool as well asprimary school-age children. Suchprograms, however, are not currentlyincluded within safety nets or widersocial protection systems, despitestrong evidence of impact on childgrowth in populations where worminfestations are endemic, a potentialwin-win situation.

Alternatively, a school health program can provide deworming,and iron and folic acid supple-ments as part of a wider programof school health. The efficacy andbenefit-cost ratios for such school-based vitamin and mineral supple-mentation programs is clearlydemonstrated (especially when coupled with deworming), though the coverage and effectiveness of afull-scale program remains contin-gent on capacity and cross-sectoralprogramming. Safety net programscould help scale up these interven-tions with large potential benefits for nutrition at low marginal costs.However, some health ministries arereluctant to entrust this responsibil-ity to educational staff, and someteachers are reluctant to accept it.

School-based health and nutritionprograms can be vehicles for nutritional education. for example,meal programs can be linked to encouraging handwashing. Addingsuch encouragement to a schoolmeal program costs little, whileadding school feeding programs to ahealth promotion campaign may becostly and may make the benefitsless persuasive.

In some cases, school meals canpromote diet diversity. In other con-texts, particularly in latin America,school meal programs have intro-duced healthy diets to counter trendsin childhood obesity, but the long-term contribution of these re-designed programs to preventingobesity is not yet determined.

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E. Promoting access to services: Community-basedgrowth promotion programsCommunity-based growth promo-tion programs are based on thesame principles of social inclusionthat are applicable to most socialprotection programs. Several coun-tries use a strategy of community-based growth promotion, which in-corporates these key interventionsand strengthens knowledge and ca-pacity at the community level, as wellas creates demand for health and nu-trition services by bringing services

closer to the communities. Suchstrategies have proven effective inimproving mothers’ knowledge, atti-tudes, and practices related to childnutrition, boosting family demand forhealth care and reducing malnutri-tion. In addition to linkages throughCCTs, social protection projects havefostered community nutrition as partof their social inclusion strategy,even in the absence of a transfer pro-gram, like in the case of HondurasAIN-C.

Successful, large-scale child-growth promotion programs wereestablished in the 1980s in Ja-maica, India (Tamil Nadu Inte-grated Nutrition Project andothers), and Tanzania (Iringa). fol-lowing these initial successes, com-munity growth promotion has alsobeen supported in Madagascar(Seecaline), Senegal (PRN), and Hon-duras (AIN-C), among others, achiev-ing sharp declines in childmalnutrition in the first five years,with a more gradual rate of decline inmoderate and mild malnutritionthereafter.

The main characteristic of theseinitiatives is their communitybasis, which has allowed them toaddress a wide variety of malnutri-tion’s causes, often with a focus onwomen and children under age two.Main interventions include nutritioneducation or counseling, typically ac-companying and based on child

growth monitoring, linked to adviceon and access to maternal care serv-ices during pregnancy, promotion ofexclusive breastfeeding and appro-priate and timely complementaryfeeding, and health and care prac-tices and referral to health centers.Some programs also have providedmicronutrient supplements for preg-nant mothers and children, and im-munization and related services.Program experiences have high-lighted the importance of: (i) femalecommunity workers as service deliv-ery agents; (ii) regular child growthmonitoring (weight) paired with awell-trained agent providing counsel-ing and communication to themother, who benefits from effectiveand regular supervision in weighing,recording, and counseling; (iii) well-designed, culturally appropriate, andconsistent nutrition education aimedat promoting specific nutrition prac-tices.

Although community-based growthpromotion programs offer a prom-ising approach to addressing un-dernutrition, common problemsrelated to agent training, support,and motivation, barriers faced bybeneficiary mothers in implementingrecommended behavior changes, andthe cost-benefit of expensive foodsupplementation programs for moth-ers and children, remain as overarch-ing challenges that merit furtherattention.24 Overall, results havebeen better when community-basedgrowth promotion programs are


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24 World Bank. 2006. Repositioning Nutrition as Central to Development, the World Bank, Washington D.C.; Marini, A., Bassett, l., Bortman, M., flores, R., Griffiths, M. and M. Salazar. 2009. Promocion del Crecimiento para Prevenir la Desnutricion Cronica. Estrategias con Base Comunitaria en Centro America, the World Bank, Washington D.C.

linked to supply-side interventionsthat improve access to health services.

CDD projects and social funds canincorporate nutrition into basicservice provision. The first genera-tion of Bank supported social fundsfocused on countries with low capac-ity and transition economies. Themain objective of such funds was toinvolve communities in prioritizingand constructing infrastructure. Thismodel is still applied to fragile statesand in post-conflict environments. Inmany other places, however, thismodel has evolved. The new objec-tive is to strengthen local govern-ment in decentralized servicedelivery. local governments may bethe most practical place to achievemultisectoral integration, an elusivegoal of integrated nutrition planning.Nutrition projects, such as the com-munity-based growth promotion pro-grams in Senegal, Madagascar orCentral America can use techniqueslearned from social funds to enhancecommunity participation.

V. Is there a role fortargeting transfers to the nutritionally vulnerable?Most social protection programs usesome sort of poverty targeting. Tostrengthen the impact on nutritionoutcomes, social programs typicallyhave the choice of combining povertytargeting with targeting by demo-graphic group, geographic area or bynutritional status. Targeting is a keyoperational feature of most socialprotection programs.

A Targeting by demographicgroupClearly, age-based or group target-ing can direct transfers to the mostat-risk age groups. for example,most CCTs include children as a prior-ity. In Africa, children affected byHIV/AIDS are often prioritized as aparticular focus. Pregnant women arealso a likely target group. Targetingyoung children and pregnant womenis consistent with the global evidenceindicating that the period betweenconception and the first two years ofa child’s life is a critical window ofopportunity during which good nutri-tion is decisive for healthy human de-velopment. After the age of two, mostlosses to human capital and futureproductivity attributable to undernu-trition during this period are irre-versible. However, when defining thedetails of a program, it is importantto take into account potential unex-pected effects of the incentive.

Targeting unconditional transfersto the elderly can be an importantpoverty reduction policy; however,they are difficult to justify on thegrounds of their positive impact onchildren. Some programs target un-conditional transfers to the elderlypartially because they are labor poor,and thus there are few disincentiveissues for labor. However, an addi-tional justification commonly voicedis that they spend their income on atrisk children, which is based on amisinterpretation of the evidence.While it is the case that pensionersoften do support children, as Duflo(2003) recorded, this study referredto an uncharacteristically large pro-gram. Moreover, it only found thatspending on children pertained to fe-male recipients. While an argumentmay be made for prioritizing elderlyon equity grounds, justifying UCTs tothe elderly based on the trickle downimpact on children is disingenuous.This logic, in effect argues for ac-cepting large amounts of leakagefrom the nominal target group of chil-dren in part because targeting theelderly is convenient. In the eventthat a social pension is a policychoice, and the program is targeteddue to a limited budget, skippinggeneration households with direct re-sponsibility for children would be ahigh priority due to the overlap of eq-uity and the economic returns to in-vesting in children. Generally,focusing on nutrition vulnerabilitywill entail exclusion of some poorhouseholds with no children living inthe household or with children whoare outside the age associated withthe greatest risk of malnutrition.

Some programs have a fixed perhousehold transfer to avoid fertilityeffects. However, Peru’s Juntos CCTprograms found that this served as adisincentive to register children inthe program since the burden of co-responsibility increased with thenumber of children, but payment didnot. Other programs increase pay-ments in accord with the number ofchildren eligible, but capped them ata maximum number of beneficiaries.This gives a family an incentive toregister the child. Indeed, some pro-grams make birth registration a co-responsibility. This can be aided bya monitoring system used to trackparticipants in maternal health pro-grams and in CCTs that include as-sisted births as a program activity.

A focus on this critical periodserves to promote future earnings.Indeed, not only are prenatal servicesoften included in CCTs, pregnantwomen can be particularly receptiveto nutritional education and guidanceon issues such as breastfeeding andprovision of colostrum. Additionally,a few CCTs have been targeted to-wards adolescent girls, but theseusually have schooling or preventionof sexually transmitted infections(STIs) as the main objectives (as inMalawi). To date, no nutritional out-comes have been reported for ado-lescents. Nevertheless, it is plausibleto include education on child care, aswell as the distribution of micronutri-ents in the design of a program tar-geted to adolescents, especiallysince iron and folic acid for adoles-cent girls is important for theirhealthy development and the futureof their children.

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Ready to use therapeutic foods (RuTfs)or ready to use supplementary foods(RuSf) may be employed successfullyto mitigate the effects of such crisesand to deal with children that are al-ready malnourished. They function as asort of targeted unconditional in-kindtransfer. RuTfs are less susceptible tospoilage than powdered milk-basedsupplementary foods, do not requiremixing with water, and can be used bycommunity health workers to addressacute malnutrition, especially in emer-gencies, or in situations when marketsare failing. various studies have shownthat RuTf can be used to reduce mortal-ity in a cost-effective manner for treat-ing severe malnutrition (about$200/child/episode). However, distin-guishing the intrinsic advantage ofproducts promoted with RuTf from theadvantages of the community-basedmanagement of care may be difficult,and in many situations it may be hardto provide such care at scale. Still, thiscurative function is only one dimensionof their potential benefits of RuTf. Ar-guably, they can also be useful in pre-venting malnutrition within a safety netprogram. The practicality of distribut-

B. Targeting by nutritional status or riskTargeting transfers to householdswith malnourished children hasthe conceptual advantage of beingresponsive to transitory shocks,unlike most indicators used to con-struct proxies for poverty, whichare relatively static. This approachwas used to prioritize nutrition pro-grams in Tamil Nadu’s community nu-trition program, but targetingmalnourished children is not com-monly used in safety net programs.One purported disadvantage of thisapproach is it may create an incentivefor a family to keep a child malnour-ished. While such abuse is possible,verifying or disproving the extent ofsuch behavior is difficult. This formof targeting also has the disadvan-tage of only reaching children whoare malnourished or on the thresh-old, rather than being preventative.

Heightened risk is another basis ofnutrition targeting. Many safety netstrategies seek counter-cyclical pro-grams that can be scaled up in thewake of weather, price, or financialshocks. Employing the same strat-egy, it may be possible to target asafety net scale up to the increasedrisk of malnutrition through preven-tive efforts in a population, leavingmore clinical nutritional interventionsto address observed cases of severeand acute forms of malnutrition. Eventhough the evidence on the conse-quence of price, financial or climaticshocks on nutrition is robust, assess-ing the impact of programs designedto offset these shocks is difficult, forboth ethical and logistic reasons.Nevertheless, evidence on changesof food aid allocation attributed to

rainfall deviations in Ethiopia or onrollout of supplementary feeding pro-grams in response to Indonesia’s fi-nancial crisis, confirms thatlarge-scale programs can prevent in-creases in malnutrition.

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BOx D-5. TARGETING THE NEEDS OF ACuTELy MALNOuRISHED CHILDREN

ing RuTfs to children at heightenedrisk of malnutrition, but who are notyet malnourished, remains controver-sial due in part to the costs of many ofthe products designed for use in ther-apeutic settings. Concerns also existthat RuTfs and especially RuSfs, mayreplace breastfeeding, thereby under-mining one of the most cost-effectivenutrition inputs. further, the feasibil-ity and the cost-effectiveness of RuSfsis still being researched, albeit newproducts such as lipid-based nutri-tional supplements show great prom-ise.

Despite these concerns, distributingpeanut or grain and soy-based RuTfs,geographically and temporally tar-geted to children in crises, may serveas a bridge between their well-estab-lished role in therapeutic feeding forthe severely malnourished and theirstill controversial use to prevent mal-nutrition among the chronically poor.Reformulating the RuTfs so they areless expensive and nutrient dense,while retaining their convenience,may make the preventative approachmore acceptable and feasible at scale.

VI. Concluding remarkswhile most safety net programs in-clude an income transfer compo-nent, and many vulnerablehouseholds seem to lack adequateincome to purchase key inputs fornutrition outcomes, the evidenceshows that increased income alone

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The relevant outcomes most com-monly tracked within SP programsare consumption (or expenditures)and anthropometric measures ofnutritional status of young chil-dren, both acute and chronic. Acase can be made that tracking con-sumption is less important than mon-itoring the incidence of programparticipation. This implies that themain focus remains on monitoringthe targeting efficiency in terms ofthe share of transfers that reach thepoor, as well as the amount of up-stream leakage from the program, ifany. If transfers have a small impacton labor or on private remittances, asis generally the case, a dollar trans-ferred to the poor will lead to a dollarof savings and consumption com-bined. It is difficult to argue that SPprogram objectives have a desired ortarget distribution for the share ofsavings or consumption out of thistotal. Arguably, welfare economicsand an adherence to consumer sover-eignty also imply that the householdallocates its budget efficiently. To besure, this point is debatable, but lessso when intra-household allocationis already considered and the pro-gram targets female recipients. Thissaid, tracking food expenditureswithin a SP program is politic. Moni-toring food consumption is, however,data intensive especially in ruralcommunities where self-productionand seasonal fluctuations add to thechallenge of data collection. Data ondiet diversity or meal frequency oftenserve as a source of relatively easyindicators to monitor with the advan-tage that these can be collected for

individuals in a target age grouprather than for a household as a unit.Diet diversity is usually measuredusing a simple count of foods or foodgroups over a given reference periodand has been found to be strongly as-sociated with direct measures of mal-nutrition.

It should be noted, however, thatfrom the standpoint of nutrition,consumption data reveal informa-tion about inputs into nutrition, al-beit critical ones, and notoutcomes. Nevertheless, food secu-rity measured by this and similardata is an issue of household welfarethat is closely aligned with the socialprotection (SP) strategy and of intrin-sic interest. SP programs, particu-larly CCTs, also track inputs such asparticipation in health activities in-cluding public awareness campaigns(for example, the platicas in Pro-gresa) and attendance in clinics andvitamin A or deworming medicinedistribution. Similarly, school feed-ing programs track enrollment andattendance within monitoring sys-tems, and less commonly, schoolperformance. The latter, however, isa key component of many impactevaluations, especially those thathave a multi-year panel.

Malnutrition indicators are oftencollected on a regular basis withcommunity health coverage, al-though self-selection into publichealth programs will influence theinterpretation of these indicators.Anthropometric measures such asunderweight or stunting as well as

BOx D-6. wHAT SHOuLD BE MONITORED IN SP PROGRAMS TO kEEP NuTRITION AS A FOCuS?

overweight are more commonly mon-itored than are measures of micronu-trient status such as vitamin andmineral deficiencies. (Seeglossary/definitions). Stunting is lowheight-for-age because of prolongedinadequate nutrition or poor health.It implies long-term undernutritionand poor health. Underweight ismeasured as low weight-for-age; itcould imply stunting and/or wasting,and is one of the indicators used intracking MDG1c. Wasting is lowweight-for-height and describes a re-cent or current severe process, usu-ally a consequence of acute fooddeprivation or severe disease. Allthese indicators are commonly col-lected to gauge undernutritionamong children; wasting data is es-pecially useful in emergency situa-tions and humanitarian crises. Whileobesity is often thought of as a corre-late of affluence, the current profes-sional opinion of the causes ofobesity is that it often reflects earlydeprivation, including prenatal un-dernutrition.

Source: Vargas, 2011.

is often insufficient to have a majorimpact on nutrition. Thus, othercomponents, such as directing trans-fers to women, targeting the mostvulnerable and the correct age group,adding nutrition education or a mi-cronutrient supplementation or a de-worming component can play anessential role in generating impact ofboth transfers and other types of so-cial protection programs, such aswelfare, pension or insurance. Thepriority objectives of SP interventionsare outlined in Box D-7 below.

VII. Emerging opera-tional research andknowledge gapswhile all projects need their re-sults evaluated to a degree, giventhe resource costs for establishinga means to determine the causalimpacts of innovative programs atscale and the time frame neces-sary for assessing cumulative im-pacts, research needs to beselective and prioritized. Some is-sues that might be considered as pri-ority themes for the interaction ofsocial protection and nutrition in-clude:

• Evaluating the cost effectivenessof soft versus hard conditions inCCTs in lICs. What basic countrysystems are needed to be inplace to implement conditionali-ties (or co- responsibilities) atscale? What is the cost of moni-toring, and how will outcomes beimproved by these expendi-tures? These modalities need tobe compared in the same settingover the same time period andwith the same amount of transferoffered.


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1. Target activities to the mostnutritionally vulnerable populations.

2. Include education activitieswithin SP interventions to in-crease household awarenessof care giving and health seek-ing behaviors.

3. Integrate nutrition servicesinto SP interventions, e.g.growth monitoring and promo-tion, and/or activities for im-proved growth and dietquality.

4. Reduce the acute and long-term negative financial im-pacts of external financial,price, and weather shocks byscaling up programs in timesof crises.

BOx D-7. PRIORITy OBjECTIvESOF NUTRITIoN-SENSITIvE

SOCIAL PROTECTION

A woman holds an infant during a community meetingHeenabowa – community clubgathering. Sri lanka. Photo: Simone D. McCourtie /World Bank

• Designing results-based incen-tives or other means to increasecommunity participation in theaccountability of the supply ofservices linked to CCT programs.

• for CCTs with nutrition condition-alities, assessing the marginalbenefits of different size of in-come transfers. Assessing thebenefit-cost ratio for RUTf usedto prevent malnutrition in re-sponse to drought or financial

The general topic has been wellresearched (especially in regardsto food aid), but under some cir-cumstances, fortification (orhome fortification pre-mixes)may provide value added to lo-cally sourced in- kind assistance.

• Also, for school feeding, the im-pact of programs aimed at pre-venting obesity or reducing itsprevalence need to be assessed.

• Exploring the potential role ofmicrofinance for improving nutri-tion outcomes for the poor.

crises and developing and test-ing alternative and more cost- ef-fective products.

• Improving targeting mecha-nisms/systems.

• Assessing the impact of full-scale programs for supplementa-tion or fortification within homegrown (local sourcing) for schoolfeeding. This is a subset of themore general issue of the circum-stances under which food basedtransfers may be appropriate.

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Improving Nutrition through HealthJulie Ruel-Bergeron, Leslie Elder, Anna Herforth

C H A P T E R - E

I. ObjectivesThe overall objective of this mod-ule is to assist world Bank staff inenhancing the nutrition impacts ofcurrent and pipeline health invest-ments and policies, with a specialfocus on undernutrition amongwomen and children under-twoyears of age in developingeconomies. This brief will informWorld Bank staff and country-levelimplementers about the linkages between health and nutrition to encourage them to integrate nutrition-specific interventions inhealth investments and policies. This will contribute to the decline of the global burden of hunger andpoverty, help achieve the nutritionMDG1, as well as the child and maternal health-related MDGs 4 and5, build future human capital, and enhance economic and socialprospects at the global, regional, and country levels.

The specific objectives of this briefare to support Bank staff, partneragencies, and country clients in thefollowing: (1) enhance the design ofhealth investments and policies tomaximize impact on nutrition out-comes for the poor; and (2) supportgovernments in designing sustain-able and coherent health policies andprograms that provide explicit atten-tion to nutrition issues in the contextof the national health strategy.

II. Rationaleundernutrition is the single largestcause of child death globally and inmost low-income and lower middle-income countries. Responsible forover 35 percent of all child deaths,undernutrition increases the mortal-ity rate from infectious disease.1,2,3

While severe wasting greatly in-creases the risk of death, starvation,and visible undernutrition as seen infamines, it is responsible for rela-tively few of all child deaths attribut-able to undernutrition. A muchgreater proportion of child deaths aredue to moderate undernutrition be-cause of its high prevalence. If chil-dren have poor nutritional statuscoupled with malaria, pneumonia,and other infectious diseases, theyare much more likely to die thanwell-nourished children are.

There is a global resurgence ofawareness and a concomitant in-crease in support for nutrition. TheScaling Up Nutrition movement, orSUN, is both a by-product and amajor reason for this renewed inter-est and momentum. More than 100agencies and institutions have en-dorsed the SUN framework for Ac-tion, and there is rapid progresstoward operationalizing the frame-work at the national level in countrieswith some of the highest burdens ofundernutrition in the world.

CHAPTER - E | Improving Nutrition through Health

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1 Pelletier, D.l., frongillo, E.A. Jr., Schroeder, D. and J.P. Habicht. 1995. “The effects of malnutrition on child mortality in developing countries,”Bull World Health Org., 73: 443-48.

2 Caulfield l.E., de Onis M, Blossner M., and R.E. Black. 2004. “Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. AJCN, 80: 193-98.

3 Black, R.E., Allen, l.H., Bhutta, Z.A., Caulfield, l.E., de Onis, M., Ezzati, M., Mathers, C. and J. Rivera J. 2008. “Maternal and child undernutrition:global and regional exposures and health consequences,” lancet 371: 243-60.

A central tenet of the SuN frame-work is the multisectoral nature ofmalnutrition and the need to investin actions that will address undernu-trition through a variety of sectors.The immediate causes of malnutri-tion are inadequate food and nutrientintake, and disease. The underlyingcauses stem from household food in-security, poor maternal and childcare practices, inadequate access tohealth care, lack of clean water, poorsanitation and hygiene, gender in-equities, and low levels of educationfor girls, among others.

The more direct, nutrition-specific in-terventions (usually deliveredthrough the health sector) addressthe immediate causes of malnutritionthrough actions such as promotion ofexclusive breastfeeding and adminis-tration of vitamin A supplements toyoung children. Nutrition-sensitiveinterventions include actions deliv-ered through sectors such as health,agriculture, and social protection,which are expected to yield positiveresults for nutrition (for example, re-productive health services to enableadequate birth spacing), or to reduceharmful impacts on nutritional status(for example, combining health-sec-tor delivered counseling on the needfor increased rest during pregnancywith agricultural projects that incor-porate labor-saving devices forwomen to reduce excessive energyexpenditure).

The highest priority target popula-tions are pregnant women andchildren up to 24 months. This win-dow of opportunity represents thecrucial period in any individual’s lifewhen poor nutrition can result in irre-versible deficits in cognitive develop-ment and linear growth leading toreduced productivity as adults. In ad-dition, there is some evidence thatundernutrition in the first two yearsof life is related to adult conditions ofobesity and non-communicable dis-eases such as diabetes and heart dis-ease.

The delivery of nutrition interven-tions through the health sector is afamiliar strategy, although the in-terventions are not always deliv-ered effectively at scale, e.g.,during contact points such as antena-tal and postnatal care, well and sickchild services, or community-basedhealth outreach services.4 Healthsystems strengthening programs andpublic insurance mechanisms canalso have increased impacts on nutri-tion. for example, nutrition-specificactivities are particularly relevant intwo of the six building blocks of the2007 WHO Health Systems Strength-ening framework for Action: deliveryof health services and medical prod-ucts, with the remaining four build-

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4 There is less known about the most effective approaches to preventing andtreating overweight and obesity. A growing number of low- and middle-income countries are facing a double burden of malnutrition. A shift in diet tooverconsumption of energy-dense, nutrient-poor foods, high in fat, salt, and refined sugar, combined with lowerlevels of physical activity has resulted in overweight and obese adults and children. Paradoxically, undernutritionpersists in the same communities as overnutrition, and even in the samehouseholds.

FIGuRE E-1. HEALTH SECTOR-SPECIFIC FRAMEwORk FOR CHILD NuTRITION

Child malnutrition, health status and survival (MDGs 1 and 4)

-Infant and youngchild nutrition andtreatment of severeundernutrition-Prevention and treatment of childhood illnesses: diarrhea,malaria, ARI

-Safe and effective delivery of healthand nutrition services to vulnerable groups-Micronutrient supplementationand fortification-Hygiene and health practicesthat impact nutritional status

-Human resources for health/ capacitybuilding in nutrition programs-Maternal and child insurance schemed-Regular nutritiondata collection/ nutrition surveillance-Increased and results-based financing schemesfor nutrition, focusing on vulnerable groups-Stewardship to enforce nutritionguidelines and regulations (e.g. food fortification, nutrition policies) Source: Adapted from UNICEF 1990.

Accessto

food

Caring and

feedingpractices

HEAlTH woRKfoRCE

HEAlTH INSuRANCE

HEAlTH INfoRMATIoN

HEAlTH fINANCING

lEADERSHIP AND GovERNANCE

Access to

healthservices

Inadequatefood/

Nutrient intake,

undernutrition

Increased disease:

incidence,severity, duration

Nutrition-specificNutrition-sensitive

ing blocks providing opportunities toaffect nutrition and health outcomesindirectly through a high-performingworkforce, a good health financingsystem, a well-functioning informa-tion system, and adequate leader-ship and governance of the healthsystem (figure E-1 and Annex E-3).

The relationship between nutritionand the health sector is the mostobvious and well understoodamong the potential sectoral part-ners as conceived by the multisec-toral approach to undernutrition. Themalnutrition-infection cycle is de-

fined by inadequate dietary intakethat causes weight loss, which leadsto growth faltering, and eventually ei-ther to increased vulnerability to dis-ease, increased morbidity, and/orseverity of disease (figure E-2). Dis-ease often leads to problems of al-tered metabolism, nutrient loss, andmalabsorption, and lack of appetitecausing weight loss, growth faltering,and undernutrition. Because of thisvicious cycle, including nutrition inhealth sector activities is central tomeeting the health sector goals, aswell as MDGs 4 and 5, of reducedmorbidity and mortality in womenand children under- five years.


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Nutrition interventions as part of health programs help to prevent infection, and serve as an important feature of effective disease management. In general,wherever nutrition is a problem — as marked by growth faltering in children and/or micronutrient deficiencies — nutritional supportthrough health services can havesignificant impacts on both nutrition and health.

-Tomkins and Watson (1989)

FIGuRE E-2. THE MALNuTRITION-INFECTION CyCLE

Inadequate dietary intake, undernutrition

Source: Adapted from Tomkins and Watson (1989).

Weight loss, growth faltering,

lowered immunity,mucosal damage

Increased disease: IncidenceSeverity Duration

Appetite loss, nutrient loss,

malabsorption, altered

metabolism

A. Poor nutrition affects health outcomesThe pathway between poor nutri-tion and health status operateslargely through a compromised im-mune system due to micronutrientdeficiencies as well as growth fail-ure.

• Vitamin A deficiency increasesthe incidence and risk of dyingfrom measles, respiratory tractinfections, and diarrhea.

• Other micronutrient deficiencies(zinc, iodine, and iron), also de-press the immune system.

• Poor maternal nutrition duringpregnancy can cause intrauterinegrowth restriction (IUGR), leadingto low birth weight (lBW), andincreased risk of infections, poorgrowth, and greater risk of adult-onset of chronic diseases in off-spring.

• Undernutrition can acceleratethe severity of infectious dis-ease, and the progression ofHIV/AIDS.

B. Poor health affects nutritionoutcomesThe reverse linkage from poorhealth to poor nutrition operatesprimarily through changes in me-tabolism, malabsorption, and ap-petite loss, as well as behavioral

III. What are the keyhealth sector interven-tions to improve nutri-tion, and what willthey cost?

In 2008, The lancet published theMaternal and Child undernutri-tion Series,5 which estimated thatmore than one-third of all childdeaths (3.5 million) are attributa-ble to maternal and child undernu-trition.

Paper #3 (What works? Interventionsfor maternal and child undernutritionand survival)6 lays out the results ofan extensive review of interventionsto address undernutrition in preg-nant women and children, and identi-fies the most efficacious actions forreducing undernutrition and nutri-tion-related mortality. Those resultsform the basis of the recommendedinterventions outlined in this report,as well as the prioritization schemeoutlined in Table E-1. The interven-tions are included in the SUN frame-work for Action (2010), which wasendorsed by over 100 internationalagencies, CSOs, universities, and bi-lateral organizations.7

The World Bank estimated the cost ofdelivering the 13 key interventions8

identified in The Lancet Paper #3. Theinterventions are grouped into threecategories: behavior change, mi-cronutrients and deworming, and

changes affecting feeding prac-tices. At a systems level, access toand quality of health care and healthinsurance that covers basic services,for example, directly influences achild’s health status and risk ofdeath, which in turn affects nutritionthrough the pathways describedbelow. Examples of interactionswhere poor health affects nutritionoutcomes include the following:

• Malaria frequently causes irondeficiency and anemia.

• Measles and diarrheal infectionsincrease the body’s vitamin A re-quirements and can precipitatesevere forms of deficiency (e.g.,blindness).

• Parasitic infections (e.g., hook-worm) cause iron deficiency andanemia; both bacterial and para-sitic infections can reduce ab-sorption of vitamin A from thegut.

• Infections often suppress ap-petite and decrease the amountof food that is consumed, leadingto lack of catch-up growth,weight loss, and micronutrientdeficiencies.

• Maternal infections and poorhealth (e.g., HIV/AIDS, depres-sion) that limit the ability ofwomen to care properly for theirchildren.

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5 This series is available from http://www.thelancet.com/series/maternal-and-child-undernutrition.

6 Bhutta, Z.A., Ahmed, T., Black, R.E., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S.S., Sachdev, H.P.S. and M.Shekar. 2008. “What works? Interventions for maternal and child undernutrition and survival,” lancet, 371: 417-40.

7 Scaling Up Nutrition: A Framework for Action from http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/Policy-Brief- Nutrition.pdf.

8 Horton, S., Shekar, M., McDonald, C., Mahal, A. and J.K. Brooks. 2010. “Scaling Up Nutrition: What Will it Cost?” Washington D.C.: The WorldBank.


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10 A detailed table on public health priority categorization, data and references provided in Annex E-4.

11 for the combination of all three interventions by community volunteers to facilitate community organization; educate households about breastfeeding, complementary feeding, and handwashing; and to distribute micronutrient powders, iron-folic acid supplements, and refer cases offaltering growth.

12 This includes 2 rounds per child per year, at $0.60 per round per child.

13 Cost refers only to children 24-59 months. There are no cost estimates currently available for children 12-24 months, who would require syrupsthat are more costly to purchase and to deliver.

14 The public health priority of salt iodization has less to do with mortality, and more to do with its effect on cognitive development and lifelonglearning and earning potential.

15 This cost estimate includes the provision of a small amount of complementary food for selected children 6-23 months of age.

16 These are rough estimates based on Caulfield et al.’s (1999) estimate that increased intake of 71-164 kcal per day for children younger than oneyear of age, as a result of complementary feeding, could decrease deaths due to malnutrition by 2-13%, depending on underlying presence ofmalnutrition in the community.

TABLE E-1. ESTIMATED COSTS, BENEFITS, PRIORITy, AND FEASIBILITy OF SCALING uP SELECTED NuTRITION INTERvENTIONS

Intervention Estimated Unit Estimated Cost Contribution Implementation Cost (USD) Effectiveness or to mortality Feasibility

Benefit: Cost reduction10 * = less feasibleratio (USD) ** = more feasible

*** = most feasible

1. Breastfeeding promotion $7.50 per child $53-153 per hiGh *and support <5yrs11 DALY saved

2. Complementary feeding LoW *promotion (provision of food is outlined in intervention 12)

3. Handwashing with soap and LoW *promotion of hygiene behaviors

4. Vitamin A supplementation $1.20/child/yr12 $3-16 per DALY saved hiGh * * *

5. Therapeutic zinc supplements $1/child/yr $73 per DALY saved hiGh * *

6. Multiple micronutrient $3.60/60-sachet $12.20 per DALY saved insufficient * *powders course/child (zinc) data

37:1 benefit:costratio (iron)

7. Deworming $0.25/round/Child13 6:1 benefit: cost ratio No data * * *

8. Iron-folic acid supplements $2/pregnancy/yr 8:1 benefit: cost ratio hiGh * *for pregnant women

9. Iron fortification of staple foods $0.20/person/yr 8:1 benefit: cost ratio LoW * *

10. Salt iodization $0.05/person/yr 30:1 benefit: cost ratio LoW 14 * *

11. Supplementation with $2.16/person/yr 15:520 benefit:cost ratio hiGh * * *Iodized oil capsules (for women)

12. Prevention and treatment $0.11/child/day15 $500-1,000 per MEDiuM *of moderate malnutrition DALY saved16in children 6-23 months of age

13. Treatment of severe $200/child treated $41 per DALY saved hiGh * * acute malnutrition

preventive and therapeutic feeding.The total financing required to imple-ment the 13 interventions is esti-mated at US$11.8 billion per year for100 percent coverage of the targetgroups. Of this sum, $1.5 billion is ex-pected to come from wealthier pri-vate households to cover costs forcomplementary and fortified foods,and the remaining $10.3 billion frompublic resources worldwide. TheBank’s estimate includes education,capacity building, and delivery mech-anisms, in addition to the basic sup-plies needed for each intervention.The intervention costs are brokendown as follows: $2.9 billion for be-havior change programs; $1.5 billionfor micronutrients and deworming;and $6.2 billion for preventive andtherapeutic feeding, with the remain-der ($1.2 billion) for capacity devel-opment and monitoring andevaluation (M&E).

the health sector still has a steward-ship role to play in terms of policy de-velopment and enforcement ofguidelines and regulations that are inline with international standards. Al-ternatively, or in addition to tradi-tional lending, other types of lendingsuch as Development Policy loans(DPls), present excellent opportuni-ties to support the development andenforcement of nutrition policies, in-cluding those related to food fortifi-cation. The matrix in Annex E-1summarizes nutrition interventionsfor integration into routine and spe-cialized service deliverystrategies/approaches in the healthsector. A compilation of technicalguidelines by intervention (outliningdosages and age groups) is providedin Annex E-5. Contact points betweenthe health sector and individualhouseholds provide the settings forintegrated service delivery for manynutrition interventions. These are de-scribed in detail in Annex E-2.

The return on investment for theseactivities would be over one millionchild deaths prevented; 30 milliondisability adjusted life years (DAlYs)saved; 30 million fewer stunted chil-dren under the age of five years (a20% reduction from current rates);and a remarkable halving of theprevalence of severe acute malnutri-tion.9 Table E-1 represents thesecosts and cost:benefit ratio by inter-vention at an individual level, com-bined with contribution to mortality,and implementation feasibility.

The majority of the interventionsto scale up for improved nutritionoutcomes are most feasibly deliv-ered through the health sector,with the exception of the fortificationof foods with micronutrients (e.g.,salt iodization and fortification ofstaple foods with iron and other mi-cronutrients). In this case,

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9 Ibid.

Mortality reduction Legend Implementation Feasibility Legend

High Mortality reduction *** high capacity setting Most feasible to implement, requires very little between 10-80% additional infrastructure and/or human resources

to implement.

Medium Mortality reduction ** medium capacity setting More difficult to implement, requires some existingbetween 5-10% infrastructure, has higher costs in most cases,

and higher human resource investments.

Low Mortality reduction * low capacity setting Most difficult to implement, requires existing between 0-5%; or no infrastructure, and significant human resource demonstrated/ direct investments.effect on mortality

Sources: Horton et al. 2010. CORE Group Workbook April 2010 - Nutrition Program Design Assistant: A Tool for Program Planners; IZincG Technical Brief 1. 2007;Bhutta et al., 2008; Brown et al., 2009; Imdad et al., 2011; Lamberti et al., 2011; Yakoob et al., 2011.

IV. Which nutrition objectives can beachieved through thehealth sector, andhow?

A. Reduce micronutrient deficiencies among the mostvulnerable groupsMicronutrient deficiencies, alsoknown as “hidden hunger,” cancause deficits in physical andmental development, which if ex-perienced in early life, are often ir-reversible. The major deficiencies interms of prevalence and severity arevitamin A, iodine, iron, and zinc defi-ciencies. Vitamin A deficiency is theleading cause of childhood blind-ness, as well as a risk factor for in-creased severity of infectious diseaseand mortality, leading to the deathsof as many as one million young chil-dren each year.17 Iodine deficiencydisorders (IDD) affect cognitive devel-opment and reduce IQ between 10and 15 points;18 18 million childrenare mentally impaired as a result of IDD.19

Iron deficiency is associated withfetal and child growth failure, com-promised cognitive development (1.7lower IQ points per 10g/l decrease in

hemoglobin)20 in young children, low-ered physical activity and labor pro-ductivity in adults, and increasedmaternal morbidity and mortality.Zinc deficiency is associated withstunting and increased incidence andduration of diarrhea and pneumonia.

Interventions in the health sector toaddress micronutrient deficiencies:

a) Promote and ensure routine micronutrient supplementation

• Provide routine vitamin A supplementation to children

• Provide multiple micronutrient supplements or powders (MNP) to young children

• Provide iron-folate supplements to pregnant and lactating women. Provide routine iodized oil capsules when iodized salt isnot available, focusing on pregnant and lactating women and young children

b) Promote and provide steward-ship for population-level con-sumption of locally availablefortified staple foods


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17 Micronutrient Initiative. 2011. Our Programs; Information on Vitamin A, Iodine, Iron, Zinc, and folic Acid, accessed on May 08 2011 from: <http://www.micronutrient.org/english/View.asp?x=576>

18 World Bank. 2006. Repositioning Nutrition as Central to Development: A Strategy for large-Scale Action. Washington, D.C.: The World Bank.

19 Micronutrient Initiative. 2011. Our Programs; Information on Vitamin A, Iodine, Iron, Zinc, and folic Acid accessed on May 08, 2011 from: <http://www.micronutrient.org/english/View.asp?x=576>

20 Black, R.E., Allen, l.H., Bhutta, Z.A., Caulfield, l.E., de Onis, M., Ezzati, M., Mathers, C. and J. Rivera. 2008. “Maternal and child undernutrition:global and regional exposures and health consequences,” lancet, 371: 243-60.

• Steward the food fortification process (salt, flours, etc.), including legislation, marketing, production, and quality assurance of fortified foods

• Promote use of iodized salt if it is available

• Promote the use of other fortified staple foods, such as oil and sugar, (vitamin A), flour (iron and folate), rice (zinc, iron and folate)

c) Promote dietary diversificationfor children and pregnant/lactat-ing women based on availableand nutritionally rich foodsthrough counseling at all routinehealth service contacts

Considerations when imple-menting interventions to reducemicronutrient deficiencies:• what is the prevalence of each defi-

ciency? Are deficiencies particularlycommon in certain population groups(i.e., the poorest, women, infants, orchildren)?

• If routine coverage with vitamin A sup-plements is 80% or higher, vitamin Asupplements may not need to be in-cluded with supplementary immuniza-tions.

• what is needed to generate politicalsupport and funding for multiple mi-cronutrient supplementation?

• Is there a possibility to engage withthe private sector to create and marketfortified products (being cautious ofcreating perverse incentives)?

• If most vulnerable households alreadyconsume iodized salt, then iodized oilcapsules would not be advised.

• Are fortified foods accessible and con-sumed by the most vulnerable?

• what is the current status of food for-tification regulation and laws? Is therean enforcement mechanism to ensurecompliance with food fortification reg-ulation and laws?

• Do the typical diets of the most vulner-able groups suggest particular mi-cronutrient gaps?

• what are the typical infant feedingpractices related to micronutrient-richfoods in target locations? what al-ready works well, which practicescould benefit from change to improvehealth, and what are the barriers toimproving practices?

• which delivery channels already existand are functioning well enough toimplement the suggested interven-tions? what are some of the barriersto implementation, and how can thesebe surpassed?

d) Promote optimal infant andyoung child feeding practicesthrough traditional and innova-tive behavior change methods,including mass media marketingof optimal behaviors, peer-to-peer counseling, and extensionto other influential audiencessuch as fathers, grandmothers,and mothers-in-law, among oth-ers:

• Exclusive breastfeeding from0-6 months, including early initiation and use of colostrum

• Continued breastfeeding and optimal complementary feeding using age-appropriate nutrient- rich foods with adequate frequency, nutrient density, food diversity, and consistency21

e) Integrate micronutrient supplementation activities, such as vitamin A and iron supplementation (through ironsupplements or MNPs) into abasic package of free services(through health insuranceand/or government provisionmechanisms).

B. Reduce the prevalence ofanemia in pregnant and lac-tating women and children 0-24 monthsIron deficiency is the most commonpreventable nutritional deficiency.It affects all nations and is foundin all income groups. The wHo es-timates that two billion individualsare anemic and up to five billionare iron deficient.22 The large ma-jority of anemia is estimated to becaused by dietary deficiencies. fifty percent of anemia is a direct result of iron deficiency (due to lackof sufficient consumption of high-iron containing foods, such as animalproducts and legumes), with the re-mainder due to other dietary defi-ciencies such as vitamin A deficiency,deficiencies of vitamin B12 and fo-late, and health conditions that inter-act negatively with iron status, suchas malaria, HIV, other infectious dis-eases, sickle cell disease, and otherinherited anemias.23 The conse-quences of anemia for children in-clude increased morbidity andmortality, stunting, lower academicperformance, cognitive delays, andapathy.24 In adults, anemia is associ-ated with weakness and fatigue,lower productivity, and increased riskof maternal mortality associated withpostpartum hemorrhage.

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21 See PAHO/WHO. 2003. Guiding Principles of Complementary feeding of the Breastfed Child.(link provided in Annex E-3.)

22 M. Black. 2003. “Animal source foods to improve micronutrient nutrition and human func-tion in developing countries: Micronutrient deficiencies and cognitive functioning.” J.Nutr,133: 3927S-3931S.

23 Ibid.

24 Children who suffer from anemia have an average of 1-2 lower IQ points per 10g/l decreasein hemoglobin levels, Black et al. 2008.

Interventions in the health sector toreduce the prevalence of anemia:

a) Provide daily iron and folic acidsupplements to pregnant andlactating women

b) Provide supplemental iron25 tochildren to prevent and treat iron deficiency anemia

c) Provide multiple micronutrientsupplements or powders (andguidance for use) to young children

d) Promote and provide dewormingtreatments

• Provide routine deworming treatments twice-yearly to children in high worm burden communities

• Provide deworming treatments for pregnant women (after the first trimester) in hookworm endemic areas

e) Promote and provide steward-ship for population-level consumption of locally-available iron-fortified staplefoods such as wheat/soy/corn-based flours, and rice

• Steward the food fortification process (salt, flours, etc.), including legislation, marketing, production, and quality assurance of fortified foods

f) Prevent and treat malaria inmalaria-endemic areas

• Provide insecticide-treated nets (ITN) for pregnant and lactating women and children

• Provide intermittent preventive treatment (IPT) for pregnant women (2 visits,3 for HIV+ women)

• Identify and treat cases of malaria

g) Delay cord clamping at time ofdelivery. Immediate cord clamp-ing has been shown to increasethe incidence of iron deficiencyand anemia during the first halfof infancy, with lower birthweight infants and infants bornto iron deficient mothers being at particular risk. Delayed cordclamping (clamping done after 2-3 minutes versus within tenseconds or less of birth) allowsextra blood flow from the placenta to the fetus, thereby


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Considerations when implementing interventionsto reduce anemia:

• What is the prevalence of anemiain reproductive-age women andinfants and children? Is anemiain the setting mainly due to irondeficiency, to infection, malaria,hookworm, or to other factors?

• What is the burden of malaria,the existing coverage and use ofITNs and IPT, and opportunitiesfor further scale up?

• What would be the most effective channel through which IFA supplements could bedelivered to pregnant women(depending on capacity, supplychains, and use by the most vulnerable pregnant women)?

• What are the opportunities to increase iron intake among the most vulnerable through improved diets, in combinationwith supplementation programs?

• Which facilities and staff need to be targeted to adopt delayedcord clamping as a standard obstetric practice?

25 Refer to the WHO statement on Iron supplementation of young children in regions wheremalaria transmission is intense and infectious disease highly prevalent at http://www.who.int/child_adolescent_health/documents/pdfs/who_statement_iron.pdf for specificguidance on prevention and treatment of iron deficiency anemia in children in specificdisease-context settings.

26 PAHO. Essential Delivery Care Practices for Maternal and Newborn Health and Nutrition.

27 Andersson, O., Hellstrom-Westas, l., Andersson, D. and M. Domellof. 2011. “Effect of de-layed versus early umbilical cord clamping on neonatal outcomes and iron status at 4months: a randomized control trial,” British Medical Journal, 343:d7157.

shoring up the infant’s ironstores from which it draws during the first six months oflife.26 This effect was further confirmed by a recent study27

where cord clamping improvedthe iron status of infants, and therisk of iron deficiency was lowerat four months of age comparedto infants who did not receive the intervention.

h) Integrate routine iron supple-mentation, intermittent preven-tive treatment of malaria, anddistribution of ITNs into a basicpackage of free services for preg-nant women and young children(through health insuranceand/or government provisionmechanisms).

C. Promote good feeding and nutritional care practicesfor the most vulnerable populationsworldwide, 20 percent of childrenunder five are underweight, and32 percent of children under fiveare stunted. In most countries, poorchildren are more likely than richerchildren to suffer from stunting andother forms of undernutrition due tothe strong influence of poverty on access to and availability of food, education, health, and a hygienic environment.28 However, this is notalways the case. Undernutrition may

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28 Black, R.E., Allen, l.H., Bhutta, Z.A.,Caulfield l.E., de Onis, M., Ezzati, M.,Mathers, C. and J. Rivera. 2008. “Maternal and child undernutrition:global and regional exposures andhealth consequences,” Lancet, 371: 243-60.

In 1998, a National MicronutrientSurvey found that 75% of Nepalesewomen were anemic. In response tothis shocking statistic, the Govern-ment of Nepal intensified its mi-cronutrient program, the IronIntensification Project (IIP) in fivedistricts, followed by a scale up insubsequent years to achieve cover-age rates of 70 out of Nepal’s 75 dis-tricts in 2011.

The IIP is a program that aims to in-crease coverage of interventions inpregnant women that are known toreduce maternal anemia. The IIP isbased upon delivery of a package ofinterventions by female communityhealth volunteers, encourage atten-dance at antenatal visits, provideIFAs and deworming medicine, andcounsel women on the importance ofanemia reduction, and use, benefits,

BOx E-1. SuCCESS IN REDuCING MATERNAL ANEMIA IN NEPAL

and side effects of IFA.

Under this model, Nepal has beensuccessfully implementing the IIP,with results indicating increased ANCattendance (almost double), con-sumption of IFA (increased 3-4times), and deworming coverage of60% in 2009 (from zero in 2001) (Seefigure below). National data on theprevalence of maternal anemia showsubstantial decreases between 1998and 2006: from 68%

to 36% in women of reproductiveage, and from 75% to 42% in preg-nant women. Indirect effects of re-ductions in anemia may have alsocontributed to reductions in maternalmortality, which decreased in Nepalfrom 539 deaths per 100,000 in1996, to 281 per 100,000 in 2006.

ANTENATAL CARE COvERAGE AND INTERvENTIONS LIkELy TO BE ASSOCIATED wITH MATERNAL ANEMIA

PREvALENCE REDuCTIONS IN NEPAL, 2001-2009

ATTENDING ANC100

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SOURCE: Pokharel, R.K., Maharjan, M.R., Mathema, P. and P. Harvey. August 2011. Success in Delivering Interventions to ReduceMaternal Anemia in Nepal: A Case Study ofthe Intensification of Maternal and Neonatal Micronutrient Program. Government of Nepal, USAID, MI, UNICEF, A2Z, FHI360.

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directly reflect poor dietary choicesand/or feeding practices among vulnerable groups despite availablenutritionally rich and diverse foods. The intergenerational cycle of undernutrition begins whena child is born small. The child ismore likely to suffer from undernutri-tion in childhood and through ado-lescence, leading to undernourishedpregnant women giving birth to lowbirth weight infants, perpetuatingthe cycle. Other basic and underlyingcauses of undernutrition, such as en-vironmental, economic, and sociopo-litical contextual factors, are alsoimportant contributors to undernutri-tion across all societal levels.

Interventions in the health sector topromote good feeding and nutritionalcare practices:

a) Promote dietary diversificationand adequate weight gain forpregnant women and children’sdiets

b) Promote/protect early initiationand exclusive breastfeeding forthe first six months of life (indi-vidual and group counseling)

• Counsel pregnant women, partners, mothers-in-law andother influential actors on optimal breastfeeding practices such as early initiation, use of colostrum, and exclusive breastfeeding for the first six months of the baby’s life

• Continue promotion/supportof optimal breastfeeding through individual counseling of mothers; ensure that health-system support strategies align theirmessages with those of community- based breastfeeding promotion (e.g., mother-to-mother peer support groups, etc.).

• Support and implement the development of policies that protect optimal breastfeeding at the population level, including legislation and enforcement regarding breastmilk substitutes and hospital care(Baby-friendly Hospital Initiative, for example).

c) Provide counseling and supportfor optimal complementary feed-ing from six months (individualand group counseling), includingcounseling on feeding during ill-ness and in support of catch-upgrowth during convalescence.


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Considerations when implementing interventionsto improve feeding and nutritional care of vulnerable populations:

• What are the existing opportuni-ties to improve diets in the targetpopulation? Can improvedknowledge be expected to overcome barriers to access?

• What are the infant feeding practices in target locations?Which positive existing practicescould be promoted, and whichpractices could benefit fromchange to improve health?

• What are the main factors limiting exclusive breastfeeding:cultural norms, marketing ofbreastmilk substitutes, healthstaff, stigma, women’s work,etc.? How can these be over-come, and who would be themost effective group to counselin addition to new mothers (husbands, mothers-in-law,health staff, etc.)?

• What training is needed to improve staff capacity to delivercounseling messages?

• What training is needed to buildnutrition capacity in country, including nutritionist trainingcurricula, sensitization of high level policymakers and academics?

• How will the quality of counseling be monitored?

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Sri Lanka, with its well-developed health system and good health infrastructure, has experienced impressive improvements in exclusivebreastfeeding (EBF) rates.

In 1995, only 17% of women were practicing EBF. Given that over 95% of women receive antenatal care and deliver in health facilities, improvements in extensive lactation management training for nearly all health workers in the field and in hospitals has made it possible to provide skilled assistance to mothers across the country. High-level political commitment at various points in time, a culture supportive of breast-feeding and parents, effective transmission of infant and youngchild feeding (IYCF) messages through multiple communication channels,a high literacy rate among women, and good “health-seeking behaviors”of parents likely contributed to the increase of EBF over the ten-yearperiod. In 2006/7, 76% of Sri Lankan women were practicing EBF.

Community outreach by public health midwives also played an importantrole in these results: two home visits are made within the first 10 days of a normal delivery to provide added support to mothers. IYCF is also acomponent of the country’s integrated health and nutrition package, providing a sustainable platform for continued support in this area.

BOx E-3. INCREASING ExCLuSIvE BREASTFEEDING RATES IN SRI LANkA

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Growth monitoring and promotion(GMP) programs hold an enormouspotential when used as a platform or entry point for the delivery of apackage of essential nutrition services, as well as a link to the formal health system in the case of a community-based center or gathering point that is separate from a health post or clinic. Althoughthe results of GMP have been mixed,in cases where the growth promotioncomponent was carried out effec-tively and linked to delivery of other essential nutrition services,there is better evidence (such asfrom the AIN-C Program in Honduras– see Schaetzel et al. 2008, World Bank 1996).

Essential services that would be delivered through GMP includeweighing/measuring children at setintervals, determining the adequacyof growth, engaging in dialogue withparents to determine reasons forsuccess or causes of problems, referral to health services as needed,and agreement with the caregiversabout actions that will support continued positive child growth or correct growth faltering.

Counseling messages include discussion of optimal young childfeeding practices such as exclusivebreastfeeding 0-6 months, adequatecomplementary feeding, and feedingduring and after illness, among others. Caregivers are encouraged to seek health care services for sick children (e.g., IMCI); ensurethat children are immunized; useproper handwashing techniques;and ensure that children receive micronutrient supplements asneeded (e.g., vitamin A).

BOx E-2. GROwTH MONITORING AND PROMOTION: A uSEFuL DELIvERy PLATFORM

17

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76

D. Treat and prevent illnessIllness is a direct cause of undernutrition. Increasing access to high-quality health care, eitherthrough global-level health systemimprovements, government provision, or universal insurancemechanisms for vulnerable groups isa high priority to reduce the burdenof undernutrition. Moreover, actionsthat directly target key infections thatcause undernutrition in children, and women in some cases, and thatoften lead to mortality synergisticallywith undernutrition, are diarrhea,respiratory tract infections (includingpneumonia), measles, malaria, and HIV/AIDS, and TB. Therefore, addressing these illnesses should be a high priority of the health sector. Hygiene interventions alsooften fall under the health umbrella;poor hygiene is strongly linked with nutrition through the pathway of an unsanitary environment, poorhandwashing, and food preparationpractices that increase the risk ofparasitic infection and diarrhea.

Interventions in the health sector toprevent and treat illness:

a) Provide coverage of a basic package of essential health andnutrition services for pregnantwomen and children, e.g., immunizations, sick-child

services, malaria treatment and prevention, etc.

b) Encourage/deliver full course ofchildhood immunizations

c) Provide quality sick-child careservices, for example, IMCI29

d) Provide counseling and supportfor improved hygiene practices,including handwashing

e) Provide intermittent preventivetreatment (IPT) and ITN to preg-nant and lactating women to pre-vent malaria

f) Promote/protect early initiationand exclusive breastfeeding forfirst six months of life, includingcases where the mother is HIV+,unless AfASS criteria can be metfor replacement feeding (Is re-placement feeding acceptable,feasible, affordable, sustainable,and safe?)30

g) Treat malaria

h) Provide therapeutic zinc supple-ments with oral rehydration salts(ORS) for diarrheal disease man-agement

i) Identify and treat women who areHIV+ during pregnancy and en-sure that both their clinical and


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Considerations when implementing interventionsto treat and prevent illness:

• How often do parents use child health services when their children are sick, and what are the barriers to use?

• Based on capacity and clientuse, what are the most promising channels to delivercounseling on hygiene and other information?

• What is the prevalence of diarrhea, and through whichchannels could therapeutic zinc be delivered?

• How will an adequate supply ofzinc supplements be ensured?

• What training is needed to improve staff capacity to deliver counseling messages?


29 IMCI is a strategy combining improved management of childhood illness with aspects ofnutrition, immunization, and other important disease prevention and health promotionactivities. The objectives of IMCI are to reduce deaths and the frequency and severity ofillness and disability, and to contribute to improved growth and development. Developedby the WHO and UNICEf, the strategy includes three main components: (1) Improvementsin the case-management skills of health staff through the provision of locally adaptedguidelines on IMCI, and through activities to promote their use; (2) Improvements in thehealth system required for effective management of childhood illness; and, (3) Improve-ments in family and community practices.

30 Outlined in WHO’s Guidelines on HIV and Infant feeding, 2010.

Considerations when implementing interventionsto reduce low birth weight:

• What is the prevalence of lowbirth weight, and what are themain factors behind it in the setting, e.g., smoking, too little food, excessive energy expenditure during pregnancyand maternal infections?

• Who are the key decision makersabout nutrition and health carepractices during pregnancy, e.g.,women themselves, husbands,mothers-in-law?

• Can counseling be delivered toall key decision makers?



• What infrastructure and fundingis needed to provide access tohealth and nutrition servicessuch as prenatal care and protein- energy supplementationto pregnant women? Is there apossibility of local sourcing ofthe food?

nutritional needs are met (e.g.,provision of ARVs, counseling onproper feeding practices, foodsupport)

E. Reduce low birth weightlow birth weight (< 2500g) oftenreflects the poor health and nutri-tion of mothers, and is associatedwith continued poor nutrition in in-fancy and childhood. Poor maternalnutrition (e.g., low body massindex/being too thin), and infections,including malaria,31 are associatedwith intrauterine growth restriction(IUGR), leading to poor fetal growthand low birth weight, which is asso-ciated with an increased risk of mor-bidity and mortality in the newbornperiod.32,33 Being stunted in utero in-creases the risk of stunting in in-fancy and childhood, which in turnincreases the risk of short girls, whoare more likely to give birth to chil-dren with low birth weight, thus per-petuating the intergenerational cycleof compromised growth. The conse-quences of being born undernour-ished are grave: IUGR infants sufferfrom impairment of most immunefunctions and face an increased riskof diarrhea and pneumonia, with aneonatal risk of death that is 10times higher for infants weighing 2-2.5kg than for those weighing 3-3.5kg.34

Interventions in the health sector toreduce low birth weight:

a) Ensure the provision of afford-able (free or low cost) health andnutrition services (such as thosedescribed below) through differ-ent mechanisms, including insur-ance schemes, social safety netprograms, government provision,etc.

b) Prevent/treat maternal infec-tions, e.g., malaria prophylaxisand treatment; testing and man-agement of syphilis and otherSTIs

c) Provide counseling and supportfor increased dietary intake(quality and quantity) duringpregnancy; reduced maternalworkload; prevention and treat-ment of anemia; decreased in-door air pollution; reducedtobacco consumption; avoidanceof gender violence; planning forcontraception after delivery

d) In situations where food short-age for pregnant women is prob-able, provide maternalsupplements of balanced energyand protein

e) Provide iron folate supplementa-tion for pregnant women

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31 Black, R.E., Allen, l.H., Bhutta, Z.A., Caulfield, l.E., de Onis, M., Ezzati, M., Mathers, C. and J. Rivera. 2008. “Maternal and child undernutrition: global and regional exposures and health consequences,” Lancet, 371: 243-60.

32 Elder, l and l. Kiess. 2004 Nuts and Bolts. Washington D.C.: The Human Development Network at the World Bank.

33 Black, R.E., Allen, l.H., Bhutta, Z.A., Caulfield, l.E., de Onis, M., Ezzati, M., Mathers, C. and J. Rivera. 2008. “Maternal and child undernutrition: global and regional exposures and health consequences,” Lancet, 371: 243-60

34 Gillespie, S. and R. flores. 2000. The Life Cycle of Malnutrition. Washington D.C.: The International food Policy Research Institute.

F. Improve reproductive healthand family planning

The nutritional status of women,particularly adolescents who arestill growing and have higher nu-tritional requirements, age at firstpregnancy, birth spacing, and sex-ually transmitted infections, affectfetal growth and the nutritionalstatus of infants. ReproductiveHealth (RH) is therefore an underly-ing determinant of nutritional status,and RH interventions are important toreduce undernutrition of adoles-cents, women and children.

The age of a woman’s first preg-nancy can have serious implica-tions for both the mother andchild’s health outcomes. Childrenborn to women aged 15-19 yearsold are at highest risk of infantand child mortality, and there is ahigher risk of morbidity and mor-tality for the young mother.35 Manyhealth problems are particularly as-sociated with negative outcomes ofpregnancy during adolescence, in-cluding anemia, malaria, HIV andother STIs, postpartum hemorrhage,obstetric fistula, and mental disor-ders such as depression.36 Moreover,stillbirths and death in the first weekand month of life are respectively 50percent and 50-100 percent higheramong babies born to adolescentmothers in comparison those born toa mother who is over 20 years old.37

The time between pregnancies isstrongly associated with neonatal,infant and under-five mortality,low birth weight, and stuntingand underweight in children. Thelonger the interval between birth andconception, the more time themother has to recover nutritionallyfrom her previous birth, and thus thebetter the nutritional and health out-comes for both mother and child.Moreover, the proper timing of a sub-sequent birth helps to prevent dis-placement of a young child fromreceiving breastmilk during his/ hercritical early growth period (0-24months), reducing their risk of un-dernutrition and mortality. Childfeeding practices are in fact protec-tive against short birth intervals, asexclusive breastfeeding extends theperiod of lactational amenorrhea,lengthening the period between birthand the return to fertility.

Reproductive health and family planning interventions in the health sector:

a) Include nutrition-sensitive fam-ily-planning and reproductivehealth services as an affordable(free or low cost) and accessibleservice as part of part of a basicinsurance package or govern-ment provision for adolescentand pregnant women


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Considerations when implementing interventionsto improve reproductivehealth and family planning:

• Is the use of contraceptives socially acceptable to womenand to men?

• What barriers exist to contraceptive use (lack of access, lack of supply, stigma)?

• What are the current normsaround adolescent pregnancyand birth spacing?

• Is LAM viable given breastfeeding norms?

• Who needs to be reached withcounseling messages about delaying age at first pregnancy,adequate birth spacing andcontraceptive use (women, men, adolescents, religiousleaders, etc.)?



35 WHO. 2011. Making Pregnancy Safer: Adolescent Pregnancy. Geneva: WHO, accessed onfebruary 9, 2012, http://www.who.int/maternal_child_adolescent/topics/maternal/adolescent_pregnancy/en/index.html

36 Ibid.

37 Ibid.

Considerations when implementing interventionsto treat moderate and/or severe acute malnutrition:

• What is the prevalence of moderate and severe acute undernutrition?

o Note that routine screening for SAM is only necessary in certain contexts and conditions, such as emergencies, shocks, or countries with chronically high levels of wasting

• What is the capacity to procureand deliver therapeutic feedingat the community level (funds,supply of therapeutic foods, ac-cessible venues, and well-trained staff)?

• Where and how frequently ischildren’s nutritional statusmeasured? Are there adequatereferral systems for treatment?

b) Provide integrated postpartumfamily planning: Counseling onlactational amenorrhea method(lAM); use of progestin- onlymodern contraception after shiftfrom lAM; healthy spacing ofpregnancies

c) Promote and counsel adolescentwomen on delayed age of firstpregnancy, birth spacing andmodern contraceptive use

G. Treat moderate and severe acute undernutrition in childrenInterventions to prevent undernu-trition are well established andproven to be cost-effective; preven-tion is preferable and more effec-tive than a curative approach interms of both cost and recurrenceof disease.38 However, acute under-nutrition (moderate or severe wastingor low weight- for-height) affects asmuch as one-tenth of children under-five years globally, primarily in condi-tions of extreme poverty, in conflictsettings, and during natural emer-gencies in developing countries. It iscategorized according to severity,where severe acute malnutritionrefers to children whose weight/height is a z-score below -3 standarddeviations (SD), and moderate acutemalnutrition refers to children whosez-score is below -2 SD. The risk of

death or disability from childhood ill-nesses increases substantially withdescending z-scores of weight forheight. for example, a child whoseweight for height is -3 SD has a riskof death that is 9.4 times higher thanthat of a child with a weight forheight in the normal range (-1 SD andabove), and 3 times higher for a childwhose weight for height is between -2 to -3 SD. for both moderate and se-vere acute malnutrition, the overallcase fatality rate ranges from 5 to 60percent.39

for severe acute malnutrition(SAM) without complications,treatment in the community/outside of health facilities is preferred. Community-based management of severe acute malnu-trition (CMAM) was made possible bythe introduction of ready-to-use ther-apeutic foods (RUTf), which containall of the needed nutrients for chil-dren to reverse growth failure andachieve catch-up growth, combinedwith the use of simple color-codedmeasuring tapes for middle-upperarm circumference, which allowscommunity-based workers to diag-nose acute malnutrition. The lipid-rich food (often peanut-based) isready to eat directly from the sachetor container, requires no water forpreparation, is good for 24 monthsafter manufacture, and for up to 24hours after opening.

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38 Ruel, M., Menon, P., Habicth, J-P., loechl, C., Bergeron, G., Pelto, G., Arimond, M., Maluccio,J., Michaud, l. and B. Hankebo. 2008. “Age-based preventive targeting of food assistanceand behavior change and communication for reduction of childhood undernutrition in Haiti:a cluster randomized trial, The Lancet, 371 (9612): 588-595.

39 Manary, M.J. and H.l. Sandige. 2008. “Management of acute moderate and severe childhoodmalnutrition, British Medical Journal, 337: 1227-1290.

for moderate acute malnutrition,children are treated with supple-mental food that contains all therecommended daily allowance ofmicronutrients along with energyand protein for catch-up growth.Typically, this is a fortified cereal andlegume blended flour.40 fortifiedlipid-based spreads are being stud-ied to treat moderate acute malnutri-tion in Africa, and there is ongoingexperimentation with use of ready-to-use supplemental foods (RUSf) forthis purpose.

Moderate and severe undernutritiontreatment interventions in the healthsector:

a) Ensure that a national policy orprotocol for CMAM is in placeand up-to-date and that commu-nity mechanisms and facilitiesare equipped to implement it

b) Ensure routine community-basedscreening of acute malnutritionusing simple measures such asmiddle-upper arm circumference(MUAC) measurements

c) Implement community-basedtherapeutic feeding programs(ready-to-use therapeutic foods)for the treatment and case-management of severe acutemalnutrition (<-3WAZ)

• In contexts with high rates ofmoderate acute malnutrition,community-based rather than health-sector based interventions comprise a more effective means of addressing the problem, through distributions of supplemental fortified or cereal/legume blends

d) Ensure that referral proceduresfor complications of acute malnu-trition are established and uti-lized at community level

e) Monitor and maintain adequatestocks of drugs and medicinesneeded to treat severe acute mal-nutrition

f) Strengthen capacity-building ofthe health workforce to be ade-quately trained in the implemen-tation of the CMAM model

V. What are the chal-lenges and lessonslearned for deliveringimproved nutritionthrough the healthsector?While a consensus is emerging onwhat to do to address malnutrition,evidence is weaker on how to imple-ment key interventions, especially inlight of a renewed focus on globalhealth systems strengthening anduniversal health coverage. Part ofthis tentativeness reflects the pre-dominant research focus on the effi-cacy rather than the effectiveness of


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40 Bergeron, G. and T. Castleman. 2012.“Program responses to acute andchronic malnutrition: divergences andconvergences,” Advances in Nutri-tion, 3:1-8.

interventions, and in some cases, alack of distinction between the two.for example, the growth monitoringand promotion intervention platformmay be interpreted as having low ef-ficacy, when in fact poor results aredue to suboptimal implementation.The lack of clear evidence on how todeliver interventions also reflects thereal variations in circumstances andcapacity across country and local set-tings, which makes it difficult to rec-ommend any one mode of delivery tobe universally applied. Annex E-2gives brief definitions of importantcontact points in the health sector,and lists key nutrition interventionsthat could be delivered through eachcontact point, depending on local ornational circumstances.

In addition to the general challengeof defining the how to mainstreamnutrition activities into the healthsector, a number of specific opera-tional challenges have been identi-fied by TTls. These include:

• lack of technical nutritionstaff to support the integration,implementation, and supervisionof nutrition projects. Both withinthe Bank at the country level, nu-trition capacity is extremely lim-ited. The number of technicalnutrition experts that can becalled upon to support projectpreparation and implementationof health projects that includenutrition components is largelyinsufficient. TTls and countrycounterparts have specificallyhighlighted the lack of staff sup-port as a barrier to integratingnutrition into their projects.

• Although this is slowly changing,a lack of awareness of nutri-tion and its critical role forhuman capital development,including in the health sector,limits the integration of nutritionactivities in other sectors.

• Nutrition is not a priority forclient governments; therefore,client demand for nutrition activities is generally lacking. A number of regions have increased demand for nutritionactivities through high-level advocacy efforts, but awarenessbuilding is largely dependent onthe presence of a “champion” for nutrition working either inthat country or region (TTl, manager, etc.).

• In this context, the implementa-tion of nutrition activities isvery often dependent on thepresence of a “champion fornutrition” at the manageriallevel. Having the support for nu-trition activities at a higher levelis essential for applying the nu-trition lens to Bank operations.

• lack of recent data on nutritionlimits the effect that nutrition“champions” can have in termsof advocacy to increase demandfor nutrition activities. Althoughnational-level basic nutritiondata (anthropometric indicators,for example) are generally avail-able, it is often collected at 5+year intervals, which in manycases means that the only avail-able data is as much as ten years

• Identification of a core set ofmaternal and child health andnutrition indicators for effec-tive nutrition outcomes, as ap-propriate for each context, is achallenge for TTls. Process indi-cators are particularly importantto monitor for assessment of im-plementation quality. While an-thropometric indicators areuseful for impact analysis, mostare not fast changing enough foruse as monitoring indicators.

Given those challenges, there aresome broad lessons learned on ef-fectively integrating nutrition into thehealth sector to reduce undernutri-tion:

• Interventions should be priori-tized based on (1) what the pri-mary nutrition problems arewithin a country or local context,and (2) the existing human andinstitutional capacity to imple-ment health and nutrition pro-grams. Refer to Box E-4 for aquick reference to tools that cansupport the prioritization of nu-trition interventions based oncountry context.

• Existing health contacts (ANC,PNC, family planning, ChildHealth Days/Weeks, c-IMCI, etc.)are often effective entry pointsfor integrating nutrition activitiesinto the health system.

• Capacity building and training iscritical at the community, clinic,educational (pre- and in-service)

old. Moreover, given the diffi-culty of measuring micronutrientdeficiencies, data on such indi-cators tends to be either out-dated (in some cases, up to 20years old), or based on output-level indicators (number of vita-min A capsules distributed,rather than rate of vitamin A defi-ciency, for example).

• Nutrition activities are largelyunderfunded. Nutrition activi-ties are mostly funded by trustfunds, and comprise a minimalportion of the Bank’s budget.Tracking exact disbursements fornutrition is challenging becausenutrition-sensitive activities arenot always coded correctly,which applies to projects thathave objectives and specific ac-tivities related to improving nu-tritional status or food security atthe household level. Therefore,funding for nutrition throughtrust funds is highly variable, andtracking is inconsistent.

• Difficulty in prioritization ofinterventions. Often, TTls arefaced with a long list of nutritioninterventions, without guidanceor information on how to priori-tize them. This guidance noteaims to address this challenge,and encourages TTls to useavailable resources, such as theNutrition Country Profiles,41 aswell as the priority-setting ma-trix provided at the beginning ofthis note (based on effect of in-terventions on mortality).

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41 Nutrition Country Profiles were done for 68 countries around the world with the worst nutrition indicators. These profiles are brief, two-page doc-uments that contain a synopsis of the country’s nutrition situation based on relevant indicators. These also include key recommendations basedon the country’s nutrition problems, as well as costing and cost-effectiveness calculations of scaling up core micronutrient interventions. Seewww.worldbank.org/nutrition/profile

and national policy level. Capac-ity includes knowledge and moti-vation of health care workers,adequate staffing and physicalspace to deliver services, andsupply chains for just-in-time de-livery of products, equipmentand maintenance. Programs thatincrease demand for a certainhealth or nutrition product (e.g.,iron folic acid supplements forpregnant women), must ensurethat the supply of commoditieswill meet increased demand.

• Community acceptance at a mini-mum, and ideally community par-ticipation in nutrition activitiesare important for effective uptakeof interventions. Knowledgeablelocal health staff and/or forma-tive research can assess the cul-tural acceptability ofinterventions and how they canwork within existing norms formaximum comprehension andacceptability.

• Community health workers, es-pecially those who are paid andtrained, comprise an essentialavenue for the expansion and de-livery of nutrition services, par-ticularly in terms of reaching themost vulnerable and geographi-cally isolated populations.

• What gets measured gets man-aged—or more accurately—onlywhat gets measured has achance of being managed. Nutri-tion indicators, such as micronu-trient program coverageindicators and nutritional statusindicators, should be a part ofHMIS systems and regularly com-piled at levels where prompt ac-tion can be taken to improvedelivery. Measuring nutrition canalso generate political supportfor addressing demonstratedproblems.

• Multisectoral planning, “thinkingmultisectorally” but acting sec-torally, using a shared model ofprogram delivery can achievesustainability and synergies thatimprove nutrition outcomes. forexample, micronutrient supple-mentation programs are oftencriticized for their reliance onlong- term donor provision ofcommodities. Ideally, these pro-grams are coupled with promo-tion of dietary change,fortification efforts, smallholderagriculture and home-gardeningprograms, and deworming activi-ties that are delivered throughother sectors, i.e., private sector,agriculture, and education, that


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contribute to achieving sustaineddietary diversity and increasedmicronutrient intake.

• In the spirit of multisectoralplanning and actions, the healthsector should exercise its stew-ardship role to improve healthand nutrition outcomes throughthe implementation of nutrition-sensitive policies and programsin other sectors, as well as themonitoring and quality assur-ance of these. for example, thehealth sector has the capacity tolegislate for food fortification,and should work with the privatesector to market, produce, anddistribute such products to thepopulation, while maintainingthe role and responsibility ofproduct safety and quality.

VI. Conclusion• undernutrition is the largest

contributor to child deaths,which has direct implications for the health sector’s goal of reducing child mortality.

• MDGs 1, 4, and 5 will not bereached if undernutrition is notaddressed. The health sector isthe best-placed sector to de-liver most of the nutrition in-terventions that have beenrigorously evaluated, recom-mended, and costed, andwhich would avert one millionchild deaths annually, and save30 million DAlYs annually.

• Table E-1. Estimated Costs, Bene-fits, Priority, and Feasibility ofScaling Up Selected Nutrition In-terventions. This table liststwelve evidence-based interven-tions, which can be selected onany of all of the following crite-ria: cost, cost:benefit ratio, pub-lic health priority based ondeaths averted, implementationfeasibility, and country statusrelative to public health cut-offpoints. Further information canbe found in “Scaling Up Nutri-tion: What will it cost?” (WorldBank 2010), available atwww.worldbank.org/nutrition

• Nutrition Country Profiles: short,two-page documents that sum-marize the nutrition situationand key interventions needed for68 of the highest nutrition bur-dened countries worldwide.These are available fromwww.worldbank.org/nutrition/profiles.

• Annex E-2: Menu of Actions toAddress Undernutrition by Deliv-ery Mechanism. Interventionscan be prioritized based on pres-ence of existing delivery plat-forms.

• Annex E-6: Suggested NutritionResources, which include linksto databases containing themost recent nutritional dataworldwide, as well as docu-ments that take a global view ofthe nutrition situation.

• A new HNP Knowledge Exchangeprovides information on nutri-tion staff in the Bank and usefulinternal and external publica-tions on nutrition. It is nowavailable on HDN’s intranet site,or can be found by entering thefriendly URL(FURL) HDKE.

• The cost for basic nutrition interventions is minimal inboth real terms and when compared with returns on investment.

• The health sector can andshould reduce undernutritionthrough interventions that targetmicronutrient deficiencies, opti-mal feeding and caring practices,treatment and prevention of ill-ness, reduction of low birthweight, improvements in repro-ductive health and family plan-ning, and treatment of moderateand severe malnutrition in chil-dren.

• Health system strengtheningcan and should support nutri-tion through nutrition-sensitivepublic insurance mechanisms,delivery of high quality services,availability and access to med-ical products (specifically, nutri-tional supplements andtherapeutic foods), a high-per-forming workforce, a good health

financing system, a well-func-tioning information system, andadequate leadership and gover-nance of the health system. Pri-oritization of activities willdepend on (1) what the source ofnutritional problems are in thespecific project/country setting,and (2) the capacity to imple-ment nutrition programs giventhe available and existing deliv-ery mechanisms/platforms forservice delivery. A great numberof needed interventions are in-cluded in the guidance aboveand organized in the followingannexes; refer back to Table E-1to assist in choosing priority in-terventions. The World Bank nu-trition country profiles show themain nutritional problems andtop five priority interventionsspecific to each of the 68 highestburden of undernutrition coun-tries, are a resource to assistTTls in prioritizing interventionsfor the contexts in which theywork.

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BOx E-4. TOOLS FOR TTLS THAT CAN GuIDE PRIORITIzATION

OF NuTRITION INvESTMENTS

A N N E x

Annex for Chapters C, D and E

1 An Agriculture Action Plan 2013-2015 isbeing prepared. This is expected to utilizethe same five focus areas as the originalAgricultural Action Plan.

2 Principle 4 is an over-arching goal, whichcould potentially be included in any AESproject in any of the five focus areas of theWorld Bank Agriculture Action Plan.

Annex C-1. Guidance matrix of agricultural interventions explicitlytargeting nutrition

This table summarizes World Bankagricultural (AES) interventions thatexplicitly target nutrition and are ex-pected to demonstrate impact on en-hancing nutrition outcomes. for eachidentified intervention, sample indi-cators and any trade-offs or neededpolicy coherence are presented. The table also includes a rough approximation of the degree to whichidentified interventions already areimplemented through World Bank operations. The table is organized according to the five focus areas ofthe World Bank Agriculture ActionPlan 2010-20121 and the four Principles for Nutrition-sensitiveAgriculture2 as identified in the main text.

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Five Focus Areas of the world Bank Agriculture Action Plan

I. Raise Agricultural Productivity

II. Link farmers to markets and strengthen value chains

III. Reduce risk and vulnerability

IV. Facilitate agricultural entry, exit, and rural non-farm income (cross-cutting across focus areas I-III)

V. Enhance environmental services and sustainability (cross-cutting across focus areas I-III)

Priority objectives to enhance nutrition in agriculture programs

1. Invest in women: safeguard and strengthen the capacity of women to provide for the food security, health and nutrition of their families

2. Increase year round access to, and availability of high nutrient content food

3. Improve nutrition knowledge among rural households to enhance dietary diversity

4. Incorporate explicit nutrition objectives and indicators into project and policy design

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3 Women are typically the main actors in poultry, small ruminant, and micro-livestock production, as well as dairying.

I. RAISE AGRICuLTuRAL PRODuCTIvITy

Nutrition Identified Indicators and Potential Degree to which related goals interventions mechanisms for trade-offs already addressed in

measuring impact on existing AES projectsnutrition outcomes (High/Medium/Low)

Invest in women • Promotion of technologies • % change in labor - • Focusing on women’s • High at design stage that improve productivity productivity of agricultural income generation could (overall gender integration inand timesavings for pro- tasks by women reduce time available for AES project design is good)ductive and domestic domestic tasks including tasks performed by • Change in women’s time child care • Medium at implementation women used for domestic tasks stage (indicators for tracking

including care of infants • Could result in loss of em- exist but should be followed and young children ployment for other female up more closely)

workers who were previously performing the time consuming task as a laborer

Improve nutrition • Expansion of the • # of days of home • May require large resource • Lowknowledge among number of home economics extension outlay to adequately train rural households economics specialists service received by home economics extension to enhance dietary in extension force beneficiaries workersdiversity

• Dietary diversity score(for women and children)

• Capacity training of home • # of days of training • Male extension workers • Loweconomics extension work- received by home econom- may not be receptive to ers and key extension work- ics extension workers and advising on nutrition ers (horticulture, livestock,3 key extension workers related interventionsaquaculture, etc.) on nutrition related interventions • Dietary diversity score • Culturally, male extension

(for women and children) workers may not be able to work with female farmers

Increase year- • Support to increase • % change of (livestock, • Subsidized, small-scale • Lowround access to productivity of small-scale milk, fish, fruits & livestock/fishery projects (livestock and aquaculture)and availability of nutritious food production vegetables) production for household food high nutrient (e.g., livestock, dairy, security are seldom profitable • Medium/Highcontent food fish, fruits and vegetables) • # of days in the last at the enterprise level (horticulture)

week where any amount of (animal meat, fish, • Livestock production milk, fruits & vegetables) tends to have high was consumed by negative externality on household members natural resources(disaggregated by gender and children)

• % change in grams/day • Dietary diversity scoreof (animal meat, fish, milk, (for women and children)fruits & vegetables) consumed by household • Seasonal fluctuation of

dietary diversity scores

• # of months in the past 12 months the household did not have adequate food to meet its needs

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I. RAISE AGRICuLTuRAL PRODuCTIvITy (CONTINuED)



• Support for (horticulture, • # of client days of (fruits & • Lowlivestock, and aquaculture) vegetables, livestock, aqua-

culture) extension services provided to farmers (disaggregated by gender)

• # of days in the last week where any amount of (animalmeat, fish, milk, fruits & vegetables) was consumed by household members(disaggregated by gender and children)

• % change in grams/day of (animal meat, fish, milk, fruits & vegetables) consumed by household


• Seasonal fluctuation of dietary diversity scores

• # of months in the past 12 months the household did not have adequate food to meet its needs extension workers

• Enhancing capacity of • # of biofortified varieties • Negligible (biofortified national agricultural research made available to farmers varieties are only now being institutions to promote made available)the breeding for and • # of farmers using dissemination of developed biofortified varietiesbiofortified varieties

• Enhance capacity of • # of farmers using zinc • Fertilizers with • Low (fortified fertilizer)national agricultural and iodine containing micronutrients may be research institutions to fertilizers unaffordable without promote the dissemination significant subsidyof zinc and iodine containing fertilizers

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II. LINk FARMERS TO MARkET & STRENGTHEN vALuE CHAINS



Increase year- • Marketing projects to • % change of net sales • Subsidized, small-scale • Lowround access to support smallholders’ from (livestock, milk, fish, livestock/fishery projects (livestock and aquaculture)and availability of participation in the value fruits & vegetables) for household food security high nutrient chain of nutritious foods are seldom profitable at the • Medium/High (horticulture)content food (e.g., livestock, dairy, fish, • Volume of (dairy, livestock, enterprise level

fruits & vegetables) fish, fruits & vegetables) marketed • Livestock production tends

to have high negative • # of days in the last week externality on naturalwhere any amount of resources(animal meat, fish, milk, fruits & vegetables) was consumed by household members (disaggregated by gender and children)


• Dietary diversity score(for women and children)• Seasonal fluctuation of dietary diversity scores

• # of months in the past12 months the household did not have adequate food to meet its needs

• Promoting the production, • Volume of nutritious • Markets for indigenous • Low (indigenous foods)marketing and consumption indigenous foods produced, foods may be limited, of nutritious indigenous marketed, and/or therefore limiting

consumed

• Promotion of regional/ • Volume of industrially • Negligible (industrial national industrial food fortified food produced food fortification)fortification (flour, vegetable oils, etc.), which may • % change in share of include national/regional fortified food within its institutional reform to total regional/nationalstrengthen food safety productionstandards, legislations and enforcement

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III. REDuCE RISk AND vuLNERABILITy



Incorporate • Broaden food security •# of sector AAAs that • None • Lowexplicit nutrition policy dialogue to include include analysis of nutritionobjectives and nutrition perspectivesindicators

Increase year-round • Promotion of nutritional • # of households with • Homestead gardens could • Low access to and homestead garden plots nutritional homestead be promoted through rural availability of high (which may include crops, gardens established and CDD projects, but the nutrient content trees and animal maintained selection of the actual food husbandry) with appropriate investment is typically demand

nutrition education • Household and child driven and cannot bedietary diversity score (for preselectedwomen and children)

• Subsidized homestead • % of households with garden schemes could basic nutrition knowledge pose a financialpromoted by the project sustainability risk

Iv. FACILITATE AGRICuLTuRAL ENTRy, ExIT & RuRAL NON-FARM INCOME (CROSS-CuTTING ACROSS I, II AND III)



Invest in women • Investments to improve • Share of women actively • Lowlabor condition for off-farm participating in the laborers, e.g., transportation, planning and decision sanitary facilities, employ- making of new servicement insurance, ICT provision

• Number of satisfactory women who have used the provided facilities/programs

• Change in women’s time used for domestic tasks including care of infants and young children

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v. ENHANCE ENvIRONMENTAL SERvICES AND SuSTAINABILITy (CROSS-CuTTING ACROSS I, II AND III)



Increase year- • Conservation of indigenous • # of ha of non-farm land • Financial incentives may • Lowround access to food plants (development containing indigenous have to be provided to and availability of of an indigenous food plants conserved encourage conservation of high nutrient knowledge system) non-farm lands in order to content food • # of nutritious indigenous conserve indigenous food

food plant germplasms plantscollected, analyzed, and documented

• Rangeland management • # of ha (rangeland/ • Lowor soil carbon sequestration fallows) with edible projects that increase leguminous cover crops)legume production for food or fodder

vI. RAISE AGRICuLTuRAL PRODuCTIvITy



Invest in women • Promotion of technologies • % change in labor • Focusing on women’s • High at design stage that improve productivity and productivity of agricultural income generation could (overall gender integration in timesavings for productive tasks by women reduce time available for AES- project designand domestic tasks domestic tasks including is good)performed by women • Change in women’s time child care

used for domestic tasks • Medium at implementation including care of infants • Could result in loss of stage (indicators for tracking and young children employment for other exist but should be followed

female workers who were up more closely) previously performing the time consuming task as a laborer

Improve nutrition • Expansion of the number • # of days of home • May require large resource • Lowknowledge among of home economics economics extension outlay to adequately train rural households specialists in extension service received by home economics extension to enhance force beneficiaries workersdietary diversity


• Capacity training of home • # of days of training • Male extension workers • Loweconomics extension received by home may not be receptive to workers and key extension economics extension advising on nutritionworkers (horticulture, workers and key extension related interventionslivestock,4 aquaculture etc.) workerson nutrition related • Culturally male extension interventions • Dietary diversity score workers may not be able to

(for women and children) work with female farmers

4 Women are typically the main actors in poultry, small ruminant, and micro-livestock production, as well as dairying.

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vI. RAISE AGRICuLTuRAL PRODuCTIvITyy (CONTINuED)



Increase year-round • Support to increase • % change of (livestock, • Subsidized, small-scale • Low access to and productivity of small-scale milk, fish, fruits & livestock/fishery projects (livestock and aquaculture) availability of high nutritious food production vegetables) production for household food security nutrient content (e.g., livestock, dairy, fish, are seldom profitable at the • Medium/Highfood fruits and vegetables) • # of days in the last week enterprise level (horticulture)

where any amount of (animalmeat, fish, milk, fruits & • Livestock production tendsvegetables) was consumed to have high negative by household members externality on natural (disaggregated by gender resourcesand children)

• % change in grams/day of (animal meat, fish, milk, fruits & vegetables) was consumed by household


• Seasonal fluctuation of dietary diversity scores


• Support for (horticulture, • # of client days of (fruits • Subsidized, small-scale • Lowlivestock, and aquaculture) & vegetables, livestock, livestock/fishery projects extension workers aquaculture) extension for household food

services provided to farmers security are seldom profitable (disaggregated by gender) at the enterprise level

• # of days in the last week • Livestock production tends where any amount of (animal to have high negative meat, fish, milk, fruits & externality on natural vegetables) was consumed resourcesby household members (disaggregated by gender and children)


• Dietary diversity score • Seasonal fluctuation of (for women and children) dietary diversity scores


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vI. RAISE AGRICuLTuRAL PRODuCTIvITyy (CONTINuED)



• Enhancing capacity of • # of biofortified varieties • Negligible (biofortified national agricultural made available to farmers varieties are only now research institutions to being made available)promote the breeding for • # of farmers usingand dissemination of biofortified varietiesdeveloped biofortified varieties

• Enhance capacity of • # of farmers using zinc • Fertilizers with • Low (fortified fertilizer)national agricultural research and iodine containing micronutrients may be institutions to promote the fertilizers unaffordable without dissemination of zinc and significant subsidyiodine containing fertilizers

vII. LINk FARMERS TO MARkET & STRENGTHEN vALuE CHAINS



Increase year-round • Marketing projects to • % change of net sales • Subsidized, small-scale • Lowaccess to and support smallholders’ from (livestock, milk, fish, livestock/fishery projects (livestock and aquaculture)availability of high participation in the value fruits & vegetables) for household food security nutrient content chain of nutritious foods are seldom profitable at the • Medium/Highfood (e.g., livestock, dairy, fish, • Volume of (dairy, livestock, enterprise level (horticulture)

fruits & vegetables) fish, fruits & vegetables) marketed • Livestock production tends

to have high negative • # of days in the last week externality on natural where any amount of (animal resourcesmeat, fish, milk, fruits & vegetables) was consumed by household members (disaggregated by gender and children)

• % change in grams/day of (animal meat, fish, milk, fruits & vegetables) was consumedby household


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vII. LINk FARMERS TO MARkET & STRENGTHEN vALuE CHAINS (CONTINuED)



• Seasonal fluctuation of • # of months in the pastdietary diversity scores 12 months the household

did not have adequate foodto meet its needs

• Promoting the production, • Volume of nutritious • Markets for indigenous • Low (indigenous foods)marketing and consump- indigenous foods produced, foods may be limited tion of nutritious indigenous marketed, and/or consumed therefore limiting foods, e.g., development of commercial potentialan indigenous knowledge system

• Promotion of regional/ • Volume of industrially • Negligible (industrial food national industrial food fortified food produced fortification)fortification (flour, vegetable oils, etc.) which may • % change in share of include national/regional fortified food within its total institutional reform to regional/national productionstrengthen food safety standards, legislations and enforcement

vIII. REDuCE RISk AND vuLNERABILITy



Increase year-round • Promotion of nutritional • # of households with • Homestead gardens could • Low access to and homestead garden plots nutritional homestead be promoted through rural availability of high (which may include crops, gardens established and CDD projects, but the nutrient content trees and animal husbandry) maintained selection of the actual food with appropriate nutrition investment is typically

education • Household and child demand driven and cannot dietary diversity score (for be preselectedwomen and children)

• Subsidized homestead • % of households with garden schemes could pose basic nutrition knowledge a financial sustainability riskpromoted by the project

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Ix. FACILITATE AGRICuLTuRAL ENTRy, ExIT & RuRAL NON-FARM INCOME (CROSS-CuTTING ACROSS I, II AND III)



Invest in women • Investments to improve • Share of women actively • Financial incentives may • Low labor condition for off-farm participating in the have to be provided to laborers, e.g., transportation, planning and decision encourage conservation of sanitary facilities, making of new service non-farm lands in order to employment insurance, ICT provision conserve indigenous food

plants• Number of satisfactory women who have used the provided facilities/programs

• Change in women’s time used for domestic tasks including care of infants and young children

x. ENHANCE ENvIRONMENTAL SERvICES AND SuSTAINABILITy (CROSS-CuTTING ACROSS I, II AND III)



Increase year- • Conservation of indigenous • # of ha of non-farm land • Financial incentives may • Low round access to food plants (development containing indigenous have to be provided to and availability of of an indigenous food plants conserved encourage conservation of high nutrient knowledge system) non-farm lands in order to content food • # of nutritious indigenous conserve indigenous food

food plant germplasms plantscollected, analyzed, and documented

• Rangeland management • # of ha (rangeland/ • Lowor soil carbon sequestra- fallows) with edible tion projects that increase leguminous cover crops)legume production for food or fodder

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Annex C-2. List of all gender disaggregated indicators included inWorld Bank agriculture (AES) projects approved in FY10 and FY11

Agricultural Technology• Direct and indirect project beneficiaries (number), of which female (percentage) (for entire project) (Central Africa Re-

public, Nepal, Zambia, West Africa Regional)• Percentage of direct female beneficiaries of improved technologies for agricultural and animal production (Democratic

Republic of Congo)• Percentage of women benefitting from investment sub-projects (Mali)• Percentage of participating farmers (male/ female) adopting new technology packages (for production, post-harvest,

processing, etc.) (Burundi)• Percentage increase in agricultural income of participating households (by gender) (Uganda)• Proportion of target population below the minimum level of dietary energy consumption, disaggregated by gender

and vulnerable group (Togo)• Proportion of farmers in project affected areas using improved methods (disaggregated by gender) (Rwanda)• Producers specialized in certified seed production - indigenous - women within project context (Nicaragua)• Number of project beneficiaries (of whom 40% are female) (for entire project) (West Africa regional)• Number of water users provided with irrigation and drainage services – disaggregated by % female) (Malawi)• Number of farmers benefiting from operational community assets – disaggregated by % female (Malawi)• Number of people trained, of which % female (Malawi)• Number of female and male water users provided with improved irrigation and drainage services (Azerbaijan)• Women account for at least 25% percent of people trained (Egypt)• Number of female project direct beneficiaries using package of improved inputs (Central Africa Republic)• Percentage of female project direct beneficiaries adopting improved animal husbandry practices (Central Africa Republic)• Percentage increase of agricultural output in the project area, disaggregated by male and female headed

households (Ethiopia)

Community Driven Development• Direct project beneficiaries, female (for entire project) (Chad, Mali)• Representation of women and young graduates managing income-generating activities (Tunisia)• Minimum of 70% of sampled women representatives in the community development councils (CDCs) take active part

in decision-making related to community development (Afghanistan)• At least 50% of decision-making positions (chairperson or treasurer of various subcommittees) are occupied by

women, at village level (Sri lanka)• Women as % of participants in village project management groups (China)• At least 60% of women and ethnic minorities satisfied with public representation and service delivery (Vietnam)• 30% of CBO/CADEC members are women (Haiti)• direct project beneficiaries (number) of which women (percentage) / indirect project beneficiaries (number) of which

women (percentage) (Sri lanka)• Percent women self-help group (SHG) members (India)

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• At least 20% increase in incremental income against base year for 50% of the target households by end of project;disaggregated by gender and youth (India)

• At least 70% of target households have increased their incomes; disaggregated by gender and youth ((India)• At least 80% of the community based organizations (CBOs) (Village Poverty Reduction Committees, Panchayat level

federation) have accessed and managed project funds according to project rules and procedures; disaggregated bygender and youth ( India)

• The number of women income-generating activities (Djibouti)• Percent of women, youth, and elderly participating in community based organizations (CBOs) and community repre-

sentative committee (COPRODEPs) (as measured by the percent of members in CBOs who are participating; CBO at-tendance at COPRODEP prioritization meetings) (Haiti)

• Percent of subprojects specifically targeting women, youth, and the elderly (subprojects proposed, managed, and/orbenefiting these groups) (Haiti)

• Project beneficiaries, of which female (for only community organization members) (Nepal)• Targeted vulnerable groups (women, young people, and landless) develop related markets and sustainable income

generating activities (AGRs) (Tunisia)• Village rehabilitation and development direct project beneficiaries, of which female is over 50% (Sri lanka)

Linking Farmers to Market• Number of project beneficiaries, direct/indirect (40% of which is female) (for entire project) (Sierra leone)• Direct project beneficiaries, of which female (40% ) (for entire project) (Benin)• Percent of rural enterprise participants who are youth (< 30 years old) or women (Jamaica)• Number of women in farming households reporting increased access to, and use of, information on improved farming

practices, processing and marketing (Papua New Guinea)• Women receive minimum 30% of all productive subprojects (Brazil)

Land Administration• Percent of women with use or ownership land rights registered (both joint and individual) (India)• At least 40% of new titles are provided directly to women and /or jointly with their spouse/partner (Nicaragua)• At least 70% of the modernized registries’ clients (and 70% of women) rate its services as satisfactory (third level on a

four-level scale) (Honduras)

others• Natural resource management, direct beneficiaries % of which are female (Kenya)• Emergency, number of mandals with 100% children immunization (below one year) and full ANC check-up for women

(Sri lanka)• Integrated, 10% per annum increased in farmer based organization (fBO) capacity for production, post-harvest

management and marketing of products (including by women members) over baselines (Ghana)• Non-farm, at least 30% of participating small & medium enterprises (SMEs) and enterprise groups (EGs) will have

increased direct and/or indirect employment by at least 30%. Of these at least 35% will be women (Afghanistan)

Annex C-3. Food consumption indicators

a. Dietary Diversity Score (DDS)Description. The dietary diversityscore, developed by the USAID-funded food and Nutrition TechnicalAssistance (fANTA) project and byfAO,1 consists of a simple count ofthe different food groups that ahousehold or an individual has con-sumed over the preceding 24 hours.The household dietary diversity scoreis meant to reflect household accessto a variety of foods, while individualscores are a proxy for nutrient ade-quacy of the diet of individuals. forexample, the Women’s Dietary Diver-sity Score reflects the probability ofmicronutrient adequacy of the dietfor women of reproductive age, andthe Infant Dietary Diversity Score reflects the dietary quality of children aged 6–23 months.

validation. The dietary diversity scoreshave been validated for several ageand sex groups as proxy measures formacro and/or micronutrient ade-quacy of the diet. Scores have beenpositively correlated with adequatemicronutrient density of complemen-tary foods for infants and young chil-dren,2 and macronutrient andmicronutrient adequacy of the dietfor non-breastfed children,3,4,5,6 ado-lescents7 and adults.8,9

use. Since the scores are used for dif-ferent purposes, the calculations arebased upon different numbers offood groups. Twelve food groups arecommonly proposed for the house-hold: nine for women and seven forinfants.10 There are no establishedcut-off points in terms of number offood groups to indicate adequate orinadequate dietary diversity for thehousehold or individual. Because ofthis, the mean score or distributionof scores is recommended for analyt-ical purposes and to set appropriate

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1 Guidelines for measuring household and individual dietary diversity. fAO 2011; fANTA 2006. Household Dietary Diversity Score (HDDS) for Measurement of Household food Access: Indicator Guide. Version 2.

2 fANTA. 2006. Developing and Validating Simple Indicators of Dietary Quality and Energy Intake of Infants and Young Children in Developing Countries: Summary of findings from analysis of 10 data sets. Working Group on Infant and Young Child feeding Indicators. food and Nutrition Technical Assistance (fANTA) Project, Academy for Educational Development (AED), Washington, D.C.

3 Hatloy, A., Torheim, l. & Oshaug, A. 1998. food variety--a good indicator of nutritional adequacy of the diet? A case study from an urban area in Mali,West Africa. European Journal of Clinical Nutrition 52(12):891-8.

4 Ruel, M., Graham, J., Murphy, S. & Allen, l. 2004. Validating simple indicators of dietary diversity and animal source food intake that accurately reflect nutrient adequacy in developing countries. Report submitted to Gl-CRSP.

5 Steyn, NP, Nel, J.H., Nantel, G., Kennedy, G., labadarios, D. 2006. food variety and dietary diversity scores in children: are they good indicators ofdietary adequacy? Public Health Nutrition 9(5): 644-650.

6 Kennedy, G., Pedro, M.R., Seghieri, C., Nantel, G. & Brouwer, I. 2007. Dietary diversity score is a useful indicator of micronutrient intake in non breast-feeding filipino children. Journal of Nutrition 137: 1-6.

7 Mirmiran, P., Azadbakht, l., Esmaillzadeh, A. & Azizi, f. 2004. Dietary diversity score in adolescents- a good indicator of the nutritional adequacy ofdiets: Tehran lipid and glucose study. Asia Pacific Journal of Clinical Nutrition 13(1): 56-60.

8 foote, J., Murphy, S., Wilkens, l., Basiotis, P. & Carlson, A. 2004. Dietary variety increases the probability of nutrient adequacy among adults. Jour- nal of Nutrition 134: 1779-1785.

9 Arimond, M., Wiesmann, D., Becquey E., Carriquiry, A., Daniels, M., Deitchler, M., fanou-fogny, N., Joseph, M., Kennedy, G., Martin-Prevel, Y. &Torheim, l.E. 2010 Simple food group diversity indicators predict micronutrient adequacy of women’s diets in 5 diverse, resource-poor settings. Journal of Nutrition 140(11): 2059S-2069S.

10 fAO. 2011. Guidelines for measuring household and individual dietary diversity. Rome: fAO.11 World food Programme. 2008. Technical Guidance Sheet - food Consumption Analysis: Calculation and Use of the food Consumption Score in food

Security Analysis.

program target values of the DDS.Moreover, the calculation of percent-age of individuals or householdsconsuming certain food groups orcombinations of nutrient dense foodgroups can be another important analytical tool.

b. Food Consumption Scores (FCS)Description. The food ConsumptionScore (fCS) is a frequency-weighteddiet diversity score that was devel-oped by WfP as a proxy measure offood security. Information about fre-quency of consumption (in days) by ahousehold over a recall period of thepast seven days is collected from acountry specific list of food groups.11

The consumption frequency of eachfood group is multiplied by an assigned weight that is based on itsnutrient content; the values aresummed to obtain the fCS.

validation. International food PolicyResearch Institute12 carried out vali-dation of the fCS for three countries– Burundi, Haiti, and Sri lanka.13 Thestudy found that fCS is positivelycorrelated with calorie consumptionper capita and validated the fCSagainst several alternative indicatorsof household food security, such asthe dietary diversity scores for differ-ent age and sex groups. Moreover,strong and expected correlation hasbeen found between fCS and otherproxy indicators of food consump-tion, food access, and food security(percentage expenditures on food,food procurement source, wealthindex, asset index, number of mealseaten per day, harvest and produc-tion indicators) by using the datafrom Burundi and Mali.14 Similar re-sults were also found from theCameroon Comprehensive food Se-curity and Vulnerability Analysis(CfSVA) project.

use. The fCS has been in use by theWfP as part of their communityhousehold surveillance and otherdata collection efforts. The fCS canbe used to describe the general foodconsumption pattern and the currentfood security situation. In addition,the mean fCS and the mean number

use. The MAHfP indicator captureschanges in the household’s ability toaddress vulnerability in such a wayas to ensure that food is availableabove a minimum level year round.Measuring the MAHfP has the advan-tage of capturing the combined ef-fects of a range of interventions suchas improved agricultural production,storage, and strategies to increasethe household’s purchasing power. Ithas been incorporated as a standardimpact indicator in all of Africare’sfood security programs.

d. Household Food InsecurityAccess Scale (HFIAS)Description. HfIAS, developed by theUSAID-funded food and NutritionTechnical Assistance (fANTA) project,consists of nine items and four fre-quency responses.17 The HfIAS scoreis a continuous measure of the de-gree of food insecurity (i.e., access)in the household in the past fourweeks (30 days), with the minimumscore 0 and the maximum score 27.The higher the score, the more foodinsecurity the household experi-enced.

of days that different food groups inthe food consumption clusters areconsumed, can also be calculated tointerpret the composition of the diet.

c. Months of Adequate Household Food Provisioning(MAHFP)Description. MAHfP measures house-hold food accessibility throughoutthe past year, and reflects themonthly and seasonality aspect offood security.15 To capture improve-ments in household food access ac-curately over time, data in MAHfPshould be collected during the periodof greatest food shortages (such asimmediately prior to the harvest).This will increase the accuracy of re-call for the number of months whenthe household did not have sufficientfood. Subsequent data collectionshould be undertaken at the sametime of year.

validation. The MAHfP score has notbeen validated against other meas-ures of food security or dietary in-take, but one research paper foundthat MAHfP scores tracked withHfIAS scores in three different coun-tries in Africa.16

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12 International food Policy Research Institute (IfPRI). 2009. Validation of the world food program’s food consumption score and alternative indicators of household food security.

13 International food Policy Research Institute (IfPRI). 2009. Validation of the world food program’s food consumption score and alternative indicators of household food security.

14 World food Programme. 2008. Technical Guidance Sheet - food Consumption Analysis: Calculation and Use of the food Consumption Score infood Security Analysis.

15 Bilinsky P, A. Swindale. 2010. Months of Adequate Household food Provisioning (MAHfP) for Measurement of Household food Access: Indicator Guide. Version 4. fANTA-2.

16 Remans R, flynn DfB, DeClerck f, Diru W, fanzo J, et al. 2011. Assessing Nutritional Diversity of Cropping Systems in African Villages. PloS ONE 6(6): e21235. doi:10.1371/journal.pone.0021235

17 Coates, J, A Swindale, P Bilinsky. 2007. Household food Insecurity Access Scale (HfIAS) for Measurement of food Access: Indicator Guide. Version 3. fANTA.

validation. Studies found that theHfIAS measurement instrumentshows validity and reliability inmeasuring household food insecurityin the contexts of rural Tanzania andin urban Iran.18,19 food securitythrough improved access, as meas-ured by HfIAS, was positively asso-ciated with household wealth status.HfIAS was negatively associatedwith maternal age and householdsize. An important recent study onthe validity of the HfIAS determinedthat despite a number of years ofwork to develop a cross-culturallyvalid measure of the experience offood insecurity, most of the ques-tions in the scale may not be exter-nally valid.20 Drawing from sevendata sets (Mozambique, Malawi,West Bank/Gaza Strip, Kenya,

Zimbabwe and South Africa) andusing statistical modeling, the studydetermined that though the surveyhas been shown to be internally validin a number of settings (it measureswhat it should be measuring in thosesettings) the questions are not exter-nally valid (it does not measure thesame things in different settings, andtherefore cannot be compared acrosscultures).

use. The HfIAS is being used by fAOand USAID feed the future projects.It is important to note that while thescale does not allow for the compari-son of data across settings, it canachieve other intended goals, suchas measuring change over time (inone group and one setting), or com-

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18 Knueppel D, Demment M, Kaiser l. 2010. Validation of the Household food Insecurity Access Scale in rural Tanzania. Public Health Nutr. 2010Mar;13(3):360-7.

19 Mohammadi f, Omidvar N, Houshiar-Rad A, Khoshfetrat MR, Abdollahi M, Mehrabi Y. 2011. Validity of an adapted Household food Insecurity Access Scale in urban households in Iran. Public Health Nutr. 2011 Aug 2:1-9.

20 Deitchler, Megan, Terri Ballard, Anne Swindale and Jennifer Coates. Validation of a Measure of Household Hunger for Cross-Cultural Use. 2010.Washington, DC: food and Nutrition Technical Assistance II Project (fANTA-2), AED, 2010.

21 Ballard, T., J Coates, A Swindale, M Deitchler. Household Hunger Scale: Indicator Definition and Measurement Guide. fANTA-2, 2011.

paring groups within the same orsimilar settings (such as two urbanvillages in the same area). The indi-cator guidelines, however, clearlymentions that it should only be em-ployed after a proper in- countryqualitative assessment has been car-ried out and necessary refinement inthe questions have been applied.

e. Household Hunger Scale (HHS)Description. HHS21 is based on theHfIAS but has been modified tomake it more applicable across cul-tures. HHS consists of three itemsand three frequency responses: 0 fornever, 1 for rarely or sometimes, 2 foroften. The household hunger statusis categorized as “little to no hungerin the household” if the score is 0 or1, “moderate hunger in the house-hold” if the score is 2 or 3, and “Se-vere hunger in the household” if thescore is 4, 5, or 6.

RECALL PERIOD: 4 wEEkS

Household items: Frequency categories:

1. Worry that the household would not have enough food Never, Rarely, Sometimes, Often

2. Not able to eat the kinds of food preferred Never, Rarely, Sometimes, Often

3. Eat a limited variety of foods Never, Rarely, Sometimes, Often

4. Eat some foods that you really did not want to eat Never, Rarely, Sometimes, Often

5. Eat a smaller meal than you felt you needed Never, Rarely, Sometimes, Often

6. Eat fewer meals in a day Never, Rarely, Sometimes, Often

7. No food to eat of any kind in your household Never, Rarely, Sometimes, Often

8. Go to sleep at night hungry Never, Rarely, Sometimes, Often

9. Go a whole day and night without eating Never, Rarely, Sometimes, Often

validation. The HfIAS study men-tioned before22 proposed the House-hold Hunger Scale. The HHS hasdemonstrated the potential for bothexternal (cross-cultural) and internalvalidity, and has been shown to havea strong relationship with householdincome and wealth scores.

use. The HHS is most appropriatewhen large proportions of house-holds and individuals experiencefood deprivation and actual hunger.It can be used to monitor the preva-lence of hunger over time across lo-cations and assess progress towardsmeeting development commitments.The Household Hunger Scale is beingused by fAO and USAID feed the fu-ture projects.

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22 Deitchler, Megan, Terri Ballard, Anne Swindale and Jennifer Coates. Validation of a Measure of Household Hunger for Cross-Cultural Use. 2010.Washington, DC: food and Nutrition Technical Assistance II Project (fANTA-2), AED, 2010.

RECALL PERIOD: 4 wEEkS

Household items: Frequency categories:

1. No food to eat of any kind in your household Never, Rarely, Sometimes, Often

2. Go to sleep at night hungry Never, Rarely, Sometimes, Often

3. Go a whole day and night without eating Never, Rarely, Sometimes, Often

Annex C-4. Suggestednutrition resources

The Human Development Network iscurrently establishing a KnowledgeExchange for Nutrition, which willprovide key information on nutritionresources, including a list of nutritionspecialists within the World Bank,who could potentially assist in plan-ning nutrition-sensitive approachesin projects.

To understand the basic nutrition sit-uation in countries, the following re-sources are useful:

world Bank Nutrition Country Profiles (2011)

These are two-page profiles of the 68highest-burden-of-malnutrition coun-tries. They contain information onprevalence of malnutrition and itscauses, how the country’s state ofnutrition compares to countries withsimilar GDP or geography, informa-tion on current World Bank nutritionprojects in the country, cost for scal-ing up core micronutrient interven-tions, and suggested actions. Theseprofiles are useful for basic contextassessment and for making the caseto address nutrition through agriculture in high-burden countries.

http://www.worldbank.org/nutrition/profiles

uNICEf State of the world’s Children -data tables (2011)

The data tables in UNICEf’s annualflagship report present major nutri-tion indicators, comparable across allcountries, in a highly user-friendlyformat. It is updated annually.

http://www.unicef.org/sowc2011/pdfs/SOWC-2011-Statistical-tables_12082010.pdf

uNICEf Tracking Progress on Child andMaternal undernutrition (2009)

This publication provides profiles ofseveral high-burden-of-malnutritioncountries, presenting information onnutrition indicators and what propor-tion of child deaths are due to malnu-trition and other diseases.

http://www.unicef.org/publications/files/Tracking_Progress_on_Child_and_Maternal_Nutrition_EN_110309.pdf

uNICEf ChildInfo

This allows country-by-country track-ing of the MDG1 indicator on childunderweight (Indicator 1.8: % of Chil-dren under 5 moderately or severelyunderweight), underweight preva-lence by economic background, andunderweight and stunting data (thesame compiled in UNICEf State ofthe World’s Children reports).

http://www.childinfo.org/undernutri-tion_mdgprogress.php

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world Bank world Development Indicators

WDI contains two indicators for mal-nutrition (stunting, underweight), aswell as rural population and propor-tion of the population employed inagriculture, which can help to esti-mate likely risk of malnutritionamong farmers.

http://data.worldbank.org/

wHo nutrition databases(http://www.who.int/nutrition/data-bases/en/index.html)

WHO maintains several databases onnutrition, including:

• Nutrition landscape InformationSystem (NlIS) – a web-based toolwhich provides nutrition and nutri-tion-related health and develop-ment data in the form of automatedcountry profiles and user-defineddownloadable data

• WHO Global Database on BodyMass Index – contains updateddata on underweight, overweightand obesity, and related indicatorsfor all countries.

• National nutrition policies and pro-grams - The Global Database onNational Nutrition Policies and Pro-grams was established in 1995,initially to monitor and evaluatethe progress in implementing theWorld Declaration and Plan of Ac-tion for Nutrition. It has been fur-ther developed to monitor countryprogress in developing, strength-ening and implementing nationalnutrition plans, policies, and pro-grams, including multisectoral ac-tions, development of dietaryguidelines, undertaking of nutri-tion surveys, demographic, andepidemiological data.

• WHO Global Database on ChildGrowth and Malnutrition - an A-Zlist from which users can choose acountry to view available child malnutrition data and reference tables (in pdf). Caution: these tables are not easy to interpret fornon-nutritionists. UNICEF SOWC(see above) contains similar information.

• Vitamin and Mineral Nutrition Information System (VMNIS) – contains most recent data for anemia, iodine deficiency disorders, and vitamin A defi-ciency. Caution: these tables arenot easy to interpret for non-nutritionists. World Bank countrynutrition profiles (see above) contain similar information for 68 countries.

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Annex C-5. Recent reviews and strategies to mainstream nutrition into agriculture• A Synthesis of Guiding Principles on Agriculture Programming for Nutrition, of recommendations in common among many

different institutions, was recently supported by fAO. https://www.securenutritionplatform.org/ Pages/DisplayRe-sources.aspx?RID=32

• The European Commission’s Reference document (September 2011) provides guidance to country teams on how to incor-porate nutrition components into existing projects and programs. http://capacity4dev.ec.europa.eu/ topic/fight-ing-hunger

• The DfID commissioned systematic evidence review (Masset et al., 2011) summarizes existing evidence and programme theory of agricultural interventions, and identifies gaps in knowledge. This document is availablefrom: http://www.dfid.gov.uk/R4D/PDf/Outputs/SystematicReviews/ Masset_etal_agriculture_and_nutrition.pdf.An abridged version is published in BMJ 2012, v. 344. Open access, available at: http://www.bmj.com/ content/344/bmj.d8222

• The Bill and Melinda Gates foundation published a statement of their approach to optimize nutrition impacts fromagriculture, based on a review of evidence. http://www.gatesfoundation. org/agriculturaldevelopment/Pages/optimizing-nutrition-outcomes-from-investment-agriculture. aspx

• The world Bank’s From Agriculture to Nutrition (2007) document presents a review of evidence of agriculture interventions with a nutrition focus, and examines the changes in agriculture and nutrition that are affecting theoperational contexts in which nutrition-focused agricultural interventions are carried out, and the institutional issues related to these. This document is available from: http://siteresources.worldbank.org/ExTARD/ Re-sources/final.pdf

• DfiD’s Nutrition Strategy (2010) focuses on four strategic objectives of mobilizing and coordinating the internationalresponse, prioritizing countries and populations most vulnerable to malnutrition, investing in a multiple sectors to improve nutrition, and using evidence and demonstrating results. This document is available from:http://collections.europarchive.org/ tna/20100423085705/http:/dfid.gov.uk/Documents/publications/nutrition-strategy.pdf

• uSAID’s IYCN Nutrition and Food Security Impact of Agriculture Projects Review of Experiences(2011) showcases nutrition and food security impacts separately, and then integrates the two for a comprehensivelook and recommendations on sensitizing agricultural projects to be more nutrition friendly. This document isavailable from: http://www.iycn.org/2011/09/resources-for- agriculture-project-designers/

• fAo has a new corporate priority to mainstream nutrition into agriculture, reflected in several documents including Assist-ing the food and agriculture sector in addressing malnutrition and Investing in Food Security: Linking Agriculture toNutrition Security (2009) http://www.fao.org/fileadmin/user_upload/agn/pdf/food_and_Agr_sector_and_malnu-trition.pdf. http://www.fao.org/fileadmin/templates/ag_portal/docs/i1230e00.pdf

• IfAD Strategic framework 2011-2015: Enabling poor rural people to improve their food security and nutrition, raise theirincomes and strengthen their resilience. http://www.ifad.org/pub/strategy/index.htm

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• uSAID feed the future Guide 2010 is available at http://www.feedthefuture.gov/resource/ feed-future-guide, and thefeed the future Indicator Handbook: Definition Sheets are also available online. http://www.feedthefuture.gov/ resource/feed-future-handbook-indicator- definitions

• Action Against Hunger (ACf) operational document: “Maximizing the nutritional impact of food security and livelihoods interventions: a manual for field workers,” July 2011. http://www. actionagainsthunger.org/publication/ 2011/07/maximising-nutritional-impact-food-security-and-livelihoods-interventions

• Save the Children uK’s “A Life Free from Hunger” includes a substantial section on “harnessing the potential of agriculture to tackle malnutrition.” http://www.savethechildren.org.uk/resources/ online-library/life-free-hunger-tackling-child-malnutrition

• IfPRI’s 2020 International Conference on leveraging Agriculture for Improving Nutrition and Health website (2011), which includes links to Conference Briefs on various aspects of the three main topics discussed: agriculture, health, and nutrition. The 2020 conference link is at http://2020conference.ifpri.info/publications/

• Highlights from the leveraging Agriculture for Improving Nutrition and Health International Conference (IfPRI, 2011) includeskey themes that emerged from this conference, including videos that capture some exciting and thought-provokingmoments of the event, as well as a mini-documentary on the importance of bringing together agriculture, health,and nutrition. Videos and the highlights interactive booklet are available from: http://2020conference.ifpri.info/

• Bioversity International produced “a manual on implementing food systems field projects to assess and improve dietary diversity,and nutrition and health outcomes” (Oct 2011). http:// www.bioversityinternational.org/fileadmin/bioversityDocs/Research/Nutrition new_/Improving_ Nutrition_with_agricultural_biodiversity.pdf

• The Lessons from the Mainstreaming Nutrition Initiative article (Pelletier et al., 2011), which presents the main findingsfrom MNI’s country-level activities and provides concrete recommendations for nutrition agenda setting, policy formulation, and implementation. This article is available from: http://heapol.oxfordjournals.org/content/early/2011/02/03/heapol.czr011. full.pdf+html

• The Value Chains for Nutrition Brief (Hawkes and Ruel 2011), which provides a summary of the food supply chain, and the role that the agriculture sector can and should play between the production and consumption phasesthrough “value-chain” concepts, analyses, and approaches. This was presented during IfPRI’s 2020 Internationalconference, and the brief is available from: http://www.ifpri.org/sites/default/files/publications/ 2020anhconfbr04.pdf

• Zincworld’s Zinc Crops Improving Crop Production and Human Health website (2007), includes links to presentations andposters presented during this conference, focusing on zinc and human nutrition, soil and crop management, zincfertilizers and crop nutrition, and plant physiology, genetics, and molecular biology. The Zinc Crops conference linkis http://www.zinc-crops.org/ ZnCrops2007/page_session_1.htm.

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Annex D. Additional Resources• Caldes, N, Coady, D. and J. Maluccio, 2006. “The cost of poverty alleviation transfer programs: a Comparative

Analysis of three programs in latin America, World Development 34 (5): 818-837.

• E. Duflo. 2003. “Grandmothers and Granddaughters: Old-Age Pensions and Intrahousehold Allocation in SouthAfrica,” World Bank Economic Review, 17 (1): 1-25.

• Garrett, J., Bassett l. and A. Marini. 2009 “Designing CCT Programs to Improve Nutrition Impact: Principles, Evi-dence and Examples,” fAO Working Paper # 6.

• Grosh, M., Del Ninno, C., Tesliuc, E., A. Ouerghi. 2008. “for Protection and Promotion: the Design and Implemen-tation of Effective Safety Nets.” World Bank.

• Haddad, l., Alderman, H., Appleton, S., Song, l., and Y. Yohannes. 2003. “Reducing ChildMalnutrition: How far Does Income Growth Take Us?” World Bank Economic Review, 17(1): 107-131.

• R. Hermosillo. 2007. Más Oportunidades para la Nutrición, Experiencia del Programa Oportunidades de Méxicoen el mejoramiento del impacto nutricional, Note for Discussion, Mexico, Df.

• Horton, S., Shekar, M., Ajay, M., McDonald, C. and J. Brooks. 2009. Scaling up Nutrition: what will it cost? World Bank.

• levy S. and E. Rodríguez. 2005. Sin herencia de pobreza: el Programa Progresa - Oportunidades de México. Banco Interamericano de Desarrollo, Editorial Planeta Mexicana.

• Neufeld, Nutrition in the Oportunidades conditional cash transfer program: Strengths and challenges, presentation at the Third International CCT Conference, Istanbul, 29 June 2006.

• M. Ruel. 2003. “Operationalizing Dietary Diversity: A Review of Measurement Issues and ResearchPriorities,” Journal of Nutrition, 133 (11): 3911S-3926S.

• Skoufias E, Unar, M., T. González de Cossio. 2008. The impacts of cash and in-kind transfers on consumption andlabor supply: experimental evidence from rural Mexico. World Bank Policy Research Working Paper WPS4778.Washington, D.C.: World Bank.

• Vakis, R. and E. Perova. 2011. The longer the Better: Duration and Program Impact of Juntos inPeru, mimeo, World Bank, 2011.

• Vargas. 2011. Mejorando el diseño e implementación del Programa Juntos, 2008-2010.

• T. Woldehanna. 2010. Do pre-natal and post-natal economic shocks have a long-lasting effecton the height of 5-year old children? Evidence from 20 sentinel sites of rural and urban Ethiopia, Working Paper60, Young lives, Department of International Development, University of Oxford: Oxford.

• World Bank. 2009. Promoción del Crecimiento para Prevenir la Desnutrición Crónica, Washington, D.C.: World Bank

• World Bank. 2011. Juntos Results for Nutrition, Project Appraisal Document, Washington, D.C.: World Bank.

• Yamano, T., Alderman, H. and l. Christiansen. 2005. “Child Growth, Shocks, and food Aid in RuralEthiopia,” American Journal of Agricultural Economics, 87 (2): 273-88.

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ANNEx E-1. GuIDANCE MATRIx: HEALTH SECTOR AND NuTRITION LINkAGES AND PROGRAMMING

Sample Indicators and mechanisms for Trade-offs/interventions measuring impact on nutrition outcomes Policy coherence

PROGRAM OBJECTIVE: Reduce micronutrient deficiencies among the most vulnerable populations

• Provide routine vitamin A • Proportion of children ages 6-59 months • Effectiveness of dietary counseling supplementation to children who have received twice yearly vitamin A depends on its appropriateness to clients’

supplements circumstances; health and agriculture/• Provide multiple micronutrient home economics workers should share supplements or powders (and guidance for • Proportion of children 6-23 months knowledge around optimal dietsuse) to young children receiving multiple micronutrient powders based on available foods

• Provide iron-folate supplementation to • Proportion of women receiving iron-folate • The most effective mechanisms for pregnant and lactating women supplements during their pregnancy/ delivering interventions depend on local and

postpartum national contexts and systems in place• Promote use of iodized salt through counseling, marketing, subsidies, and other • Number of MCH projects that include • The use of campaign days to address many in-novative approaches such as requiring iodized salt purchase/provision health issues at once (vitamin A, vaccination,proof of purchase of iodized salt as a as a conditionality other issues) may result in lower budgetaryconditionality for receipt of MCH services resources for or use of routine health

• Proportion of children age 6-59 services • Provide iodized oil capsules to mothers/ months provided with iodized oil capsuleschildren in areas with high levels of iodine • Although social protection, government deficiency disorders when iodized salt is • Proportion of health care staff at (ANC, programs, and the private sector are in better not available at household level PNC, well-child, routine, etc.) contacts giving positions to provide iodized salt and other

counseling on dietary quality fortified foods, the health sector can play an • Promote dietary diversification of pregnant important stewardship and monitoring andwomen’s and children’s diets • Qualitative assessment of quality of dietary evaluation role of food fortification programs

counseling• Promote optimal infant and young child feeding practices through a mass media • Proportion of mothers who exclusively communications/behavior change campaign breastfed their youngest child for the

first 6 months of life• Develop and enact legislation for thefortification of a staple food. For example, • Proportion of children receiving a minimum fortification of flour/rice with iron, folate, acceptable diet at 6-23 months of agezinc; salt with iodine; oil/sugar with vitamin A • Presence of food fortification legislation

• Work with the Ministry of Commerce/ • Proportion of households consuming Finance to define and implement a commercially available fortified staple marketing and dissemination strategy foods (based on national legalof a fortified food requirements/guidelines for fortification)

• Work with aid organizations and/or the • Proportion of children receiving Ministry of Trade to set guidelines for/ micronutrient supplementation (as per what monitor the quality of incoming fortified foods is included in their insurance package)

during their health visits• Include micronutrient supplementation activities for children into the basic • Proportion of health centers that have package of interventions covered by adequate stock levels of micronutrients health insurance (as per micronutrients included in child/

maternal insurance package)

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ANNEx E-1. GuIDANCE MATRIx: HEALTH SECTOR AND NuTRITION LINkAGES AND PROGRAMMING (CONTINuED)


PROGRAM OBJECTIVE: Reduce prevalence of anemia in pregnant and lactating women and children 0-24 months

• Deliver iron-folic acid supplements to • Proportion of pregnant women who • The use of iron-fortified staple foods pregnant/ lactating women with emphasis received IFA supplements during pregnancy depends on their availability a and priceon problem solving to address side effects (or through ANC or PNC visits)for increased compliance • Effectiveness of dietary counseling

• Proportion of children 6-23 months depends on its appropriateness to • Provide multiple micronutrient receiving multiple micronutrient powders clients’ circumstances; health andsupplements or powders (and guidance for agriculture/home economics workers use) to young children • Proportion of children 24-59 months should share knowledge around optimal

receiving supplemental iron diets based on available foods• Provide supplemental iron1 to children to prevent and treat iron deficiency anemia • Proportion of children age 12-59 months • The most effective mechanisms for

receiving twice yearly deworming treatments delivering interventions depend on local• Provide twice yearly deworming of children and national contexts and systems in placein high worm burden communities • Proportion of pregnant women who

received a deworming treatment after their • Social protection programs and the private • Provide deworming for pregnant women first trimester of pregnancy sector are in better positions to provideafter the first trimester in areas with endemic fortified foods than the health sectorhookworm and other helminth infections • Proportion of women who know

that iron-fortified staple foods help to• Promote use of iron fortified staple foods prevent anemia through counseling and mass media communication strategies • Proportion of households who purchase

iron-fortified staple foods• In malaria endemic areas, provide intermittent preventive treatment (IPT) for • Proportion of pregnant women in malaria malaria and insecticide-treated bednets endemic areas who received IPT(ITN) to pregnant women, and promote and support the use of ITNs by mothers • Proportion of pregnant women/and children children sleeping under ITNs

• Treat malaria • Proportion of live births in health care facilities where cord clamping (delayed

• Delay cord clamping at time of delivery 3 minutes or more) is practiced

• Develop and enact legislation for the • Proportion of children <59 months fortification of a staple food (flour, rice) who are anemic with iron and folate

• Proportion of pregnant women who • Work with the Ministry of Commerce/ are anemicFinance to define and implement a marketing and dissemination strategy of an • Presence of food fortification legislationiron-fortified staple food

• Proportion of households consuming • Work with aid organizations and/ commercially available iron-fortified staple or the Ministry foods (based on national legal

requirements/guidelines for fortification)of Trade to set guidelines for/ monitor the quality of incoming iron-fortified foods • Proportion of pregnant women and children

receiving iron folate supplementation, • Include iron supplementation, multiple micronutrient powders, and/ordeworming, and malaria prevention and intermittent iron supplementationtreatment activities for pregnant women and children into the basic package of • Proportion of health centers that have interventions covered by health insurance adequate stock levels of anemia-prevention

supplies (iron folate supplements, multiplemicronutrient powders, ITNs, IPT, malaria drugs, etc.)

1 Refer to the WHO Statement on iron supplementation of young children in regions where malaria transmission is intense and infectious disease highly prevalent at http://www.who.int/child_adolescent_health/documents/pdfs/who_statement_iron.pdf for specific guidance onprevention and treatment of iron deficiency anemia in specific disease-context settings.

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PROGRAM OBJECTIVES: Promote good feeding and nutritional care practices for the most vulnerable populations

• Promote dietary diversification of • Proportion of health care staff at (ANC, • The most effective mechanisms for pregnant women and children’s diets PNC, well-child, routine, etc.) contacts delivering interventions depend on local and

giving counseling on dietary quality national contexts and systems in place• Promote weight gain among pregnant women through adequate diet and • Proportion of health care staff at (ANC, • Impact from growth monitoring and consumption of diverse foods PNC, well-child, routine, etc.) contacts promotion is variable based on the skill of the

giving counseling on breastfeeding staff in conveying effective growth• Promote/protect early initiation and promotion counseling that addressesexclusive breastfeeding for first six months • Existence of a baby-friendly community addresses individuals’ specific obstacles to of life (individual and group counseling) initiative optimal growth

• Counseling for optimal complementary • Proportion of women who know the feeding with continued breastfeeding from optimal length of exclusive breastfeeding6 months (individual and group counseling), including counseling on feeding during • Proportion of health care staff at (ANC,illness and in support of catch-up growth PNC, well-child, routine, etc.) contacts

giving counseling on optimal• Carry out growth monitoring and promotion complementary feeding

• Develop and implement policies that • Proportion of children under 6 months of protect optimal breastfeeding practices, age who are exclusively breastfedsuch as legislation for breastmilk substitutes and hospital care (baby- • Proportion of children receiving a minimumfriendly hospitals) acceptable diet at 6-23 months of age

• Proportion of infants born to HIV-positive women receiving appropriate feeding

• Child malnutrition rates (stunting, underweight)

• Proportion of mothers who bring their child to attend monthly growth monitoring and promotion sessions

• Proportion of hospitals providing maternity care designated as Baby-Friendly

• Existence of a national code for breastmilk substitutes

• Existence of a Baby-Friendly community initiative

• Proportion of women who know the optimal length of exclusive breastfeeding

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PROGRAM OBJECTIVES: Treat and prevent illness (with particular focus on diarrhea, acute respiratory infections, malaria, and HIV/AIDS)

• Implement comprehensive, high quality • Proportion of pregnant women screened • HIV screening and PMTCT counseling PMTCT programs (maternal screening, for HIV/ AIDS and TB during pregnancy is most effective if public education/ARV therapy, TB treatment, and counseling awareness is ongoing to reduce stigma,in IYC feeding choices) • Proportion of HIV/TB+ women receiving and if sufficient ARVs are available

ARV therapy/TB treatment during • Encourage/deliver full course of (pregnancy, lactation) • For HIV+ mothers, choice of breastfeeding + childhood immunizations ARV or formula feeding depends on local

• Proportion of HIV+ mothers counseled situations, sanitation, and economics • Provide quality sick-child care on PMTCTcounseling and services • The use of sick-child services and

• Proportion of health care providers who health care in general depends on many • Provide counseling for improved hygiene routinely counsel HIV+ women on PMTCT factors (distance, time available, financial practices including handwashing issues, stigma) in addition to quality of

• Proportion of children age 0-59 months care offered • Provide intermittent preventive treatment who received full course of immunizations(IPT) for malaria and insecticide-treated bednets (ITN) to pregnant women • Proportion of one-year-olds who

received at least one dose of measles• Promote/protect early initiation and vaccine in a given yearexclusive breastfeeding for first six months of life • Proportion of households where children

are taken to health care providers when ill• Advise on continued feeding during illness and catch-up feeding during • Proportion of households that have ITNsrecuperative period

• Proportion of clinics with sufficient supply• Treat malaria of anti-malarials to treat all confirmed

and suspected cases of malaria• Provide therapeutic zinc supplementsfor diarrheal disease management • Proportion of health care staff at (ANC,

PNC, well-child, routine, etc.) contacts giving• Provide coverage of a basic package counseling on handwashing of essential health and nutrition services (immunization, sick- child services, malaria • Proportion of health care staff at (ANC,treatment and prevention, PMTCT services, PNC, well-child, routine, etc.) contacts etc.) for pregnant and lactating women, giving counseling on breastfeedingand children

• Proportion of hospitals nationwide that areBaby-Friendly

• Existence of a Baby-Friendly community initiative

• Proportion of health service points where zinc supplements are stocked regularly

• Proportion of children who were given zinc as part of the treatment for acute diarrhea

• % of children (0–59 months) with diarrhea who received ORT and continued feeding

• Proportion of pregnant women and children enrolled in insurance program

• Proportion of health clinics that have adequate stock levels of essential health and nutrition supplies (ITNs, IPT, malaria drugs, ARVs, TB drugs, zinc supplements, ORT, childhood immunizations, etc.)

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PROGRAM OBJECTIVES: Reduce low birth weight

• Provide counseling for increased • Proportion of ANC visits where patients are • The most effective mechanisms for dietary intake (quality and quantity) screened for malaria delivering interventions depend on local and

national contexts and systems in place• Counsel pregnant women on reduced • Proportion of health care staff at (ANC, maternal workload; prevention and treatment PNC, etc.) contacts giving counseling on • Decreasing indoor air pollution depends on of anemia; decreased indoor air pollution; dietary quality, maternal workload, ability of households to access alternatereduced tobacco consumption; avoidance prevention and treatment of anemia; cooking fuel/settingof gender violence decreased indoor air pollution; reduced

tobacco consumption; avoidance of gender • Decreasing smoking and gender violence • In situations where food shortage for violence (each on a separate indicator) depend on larger public awarenesspregnant women is probable, provide campaigns, social support systems,maternal supplements of balanced energy • Proportion of women aged 15–49 years and taxes (for smoking) and protein with a live birth that received antenatal care:

(1) at least 4 times by any provider, (2) at • Prevent/treat maternal infections least once by skilled personnel

• Provide health insurance for pregnant • Proportion of last live births who werewomen that covers a basic package of weighed at birthhealth and nutrition services

• Percent of infants born at a low birth weight

• Proportion of pregnant women enrolled in insurance program

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PROGRAM OBJECTIVES: Improve reproductive health and family planning

• Provide iron-folate supplementation to • Proportion of women of reproductive age • Social marketing, public media and other women of reproductive age who received iron-folate supplements awareness-generating mechanisms are

helpful to support counseling messages• Provide integrated postpartum FP: • Proportion of mothers counseled on LAM delivered at individual contact pointsCounseling on LAM; use of progestin-only modern contraception after shift from LAM; • Proportion of mothers counseled on • LAM is not a failsafe method of birth controlhealthy spacing of pregnancies progestin-only contraception within 6 weeks

postpartum (or at each PNC visit)• Promote and counsel adolescent women at routine immunization and/or health • Proportion of mothers counseled on optimalcheck-ups on birth spacing and modern birth spacingcontraceptive use

• Proportion of fathers counseled on optimal • Involve men and community elders as birth spacingappropriate in education/outreach about benefits to families of lengthening time • Proportion of women of reproductive agebetween pregnancies enrolled in insurance program

• Provide a basic insurance package for • Proportion of health clinics that have women of reproductive age that includes adequate stock levels of contraceptivesfamily planning activities

PROGRAM OBJECTIVES: Treat moderate and severe acute undernutrition in children

• Ensure that all children attending health • Proportion of children attending health • Cutoffs for defining children eligible for services are screened for acute malnutrition services screened for acute malnutrition treatment may vary by context and

therapeutic food supply• Implement therapeutic feeding (including • Proportion of children with severe acute ready- to-use therapeutic foods) for malnutrition having access to appropriate • The use of therapeutic foods for prevention moderate (<-2 to -3 WAZ) and severe treatment including therapeutic foods of malnutrition is controversial acute malnutrition (<-3WAZ) in children delivered through clinics and community • Proportion of children <-2 to -3WAZ outreach services receiving therapeutic feeding

• Ensure that referral procedures are • Proportion of children <-3 WAZ receiving established and utilized at community therapeutic feedinglevel

• Child undernutrition rates (underweight, • Ensure adequate stocks of drugs and wasting)medicines needed to treat severe acute malnutrition • Child mortality

• Develop and implement a national policy • Proportion of health clinics with adequate for CMAM and nutrition surveillance, stock levels of therapeutic foods and drugsparticularly in emergency situations needed to treat severe acute malnutrition

with complications• Build/strengthen capacity at the communityand health clinic level to implement the • Existence of a national, up-to-date CMAM model CMAM policy

• Proportion of health clinic staff trained in CMAM

• Proportion of health clinics implementing CMAM

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Annex E-2. Menu of actions to addressundernutrition by delivery mechanism

Various health delivery channels maybe used to deliver interventions toimprove nutrition and/or reduce un-dernutrition. The effectiveness of anyone mechanism depends heavily oncontext, such as priority/ need to ad-dress undernutrition based on dis-ease burden, national or regionalpolicies and systems (health insur-ance, for example) already in place,staff capacity (coverage and quality),support from multilateral institutionssuch as UNICEf, consistency in sup-plies, availability and emphasis oncommunity systems, and behavioralnorms. The interventions provided inthe matrix (Annex E-1) are organizedhere by the mechanisms throughwhich they could be delivered.

Public health campaigns, such asChild Health DaysChild Health Days or Child HealthWeeks are typically held twice yearlyin six-month intervals, and involvesocial and community mobilizationthat promotes and provides healthand nutrition services, such as vacci-nations, vitamin and mineral supple-mentations, and deworming, amongothers, in geographic areas that haverestricted access to services.

• Provide twice-yearly vitamin Asupplementation to children 6-59months42

• Deliver quality counseling andfamily planning services for optimal birth spacing and modern contraceptive use

• Insure that health referral procedures are established and utilized

Community outreachCommunity outreach often involvescommunity health workers, paid orvolunteer, who make periodic homevisits and can provide a wide range ofservices, depending on their trainingand mission. It may also involvehealth services delivered throughschools, fairs, mobile clinics, orother venues easily accessible andgeographically close to intendedbeneficiaries.

• Encourage/deliver full course ofchildhood immunizations

• Deliver vitamin A supplements tochildren

• In malaria endemic areas, provideintermittent preventive treatment(IPT) for malaria and insecticide-treated bednets (ITN)

• Deliver quality growth monitoringand promotion

• Ensure that children are screenedfor acute malnutrition

• Promote early initiation and exclu-sive breastfeeding for first sixmonths of life

• Provide counseling on:

• Provide twice yearly dewormingof children in high worm burdencommunities

• Deliver full course of childhoodimmunizations

• Provide therapeutic zinc supplements for diarrheal diseasemanagement

• Screen children for acute malnutrition

Routine health service contactsRoutine contacts include visits tohealth care professionals, usually ini-tiated by clients, for routine physicalexams, evaluations for chronic prob-lems, diagnosis and treatment of ill-nesses, or reproductive healthneeds. In many countries, the Inte-grated Management of Childhood Ill-nesses approach (IMCI) is theprimary approach for diagnosis andtreatment of child infections and un-dernutrition.

• Promote dietary diversificationthrough counseling

• Promote use of iron fortified staple foods through counseling

• Treat malaria and other illness

• Provide therapeutic zinc supplements for diarrheal diseasemanagement

• Provide iodized oil capsulesand/or promote use of iodized salt through counseling

42 The blue text indicates interventions identified as having sufficient evidence of efficacy and effectiveness to recommend for implementation,either in all high-burden countries or in specific, situational contexts, by The lancet (2008) Series on Maternal and Child Undernutrition.

o Optimal complementary feeding from six months (individual and group counseling)

o Infant and young child feeding choices for PMTCT

o Continued feeding during illness and catch-up feeding during recuperative period

o Improved hygiene practices including handwashing

o Birth spacing and modern contraceptive use (to women, men, and adolescent girls)

• Provide therapeutic zinc supple-ments for diarrheal disease man-agement

• Ensure that health referral proce-dures are established and utilizedat community level

Sick/well-child health contactsWell-child health contacts usuallyoccur on a regular schedule, oftenone that coincides with immunizationschedules, to measure the growthand development of young children.Sick-child health contacts occurwhen a caretaker takes an ill child toa clinic, health post or hospital to re-ceive assessment and therapeuticcare. Community outreach may beused to refer and/or motivate care-givers to attend well-child visits andto seek care when children fall sick.

• Encourage/deliver full course ofchildhood immunizations

• Treat malaria

• Provide deworming of children inhigh worm burden communities

• Deliver vitamin A supplements tochildren

• Provide multiple micronutrientsupplements or powders (andguidance for use)

• Provide iodized oil capsulesand/or promote use of iodized saltthrough counseling

• Provide intermittent iron supple-mentation (syrup, tablets) to chil-dren to prevent and treat irondeficiency anemia

• Provide therapeutic zinc supple-ments for diarrheal disease man-agement

• Ensure that all children attendinghealth services are screened foracute malnutrition

• Provide counseling to promote:

o Dietary diversification

o Use of iron fortified staple foods

o Early initiation and exclusive breastfeeding for first six months of life

o Optimal complementary feeding from six months (individual and group counseling)



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• Implement therapeutic feeding(including ready-to-use therapeu-tic foods) for moderate (<-2 to-3WAZ) and severe acute malnutri-tion (<-3 WAZ) in children

Antenatal care contact (ANC)Pregnant women should receive atleast four ANC visits, which may be ata clinic, hospital, birth center, or de-livered by a nurse-midwife at home(as a form of community outreach).These visits serve to monitor mater-nal weight gain and/or fetal size,screen and treat pregnancy complica-tions, provide supplements, and de-liver key information aboutmaintaining health in pregnancy andlactation and preparing for birth.

• Provide deworming for pregnantwomen after the first trimester inareas with endemic hookworm

• Deliver iron-folic acid supple-ments to pregnant women


• In situations where food shortagefor pregnant women is probable orwhere screening criteria are estab-lished/used, provide maternalsupplements of balanced energyand protein

• Provide counseling for increaseddietary intake (quality and quan-tity) during pregnancy; reducedmaternal workload; preventionand treatment of anemia; de-creased indoor air pollution; re-duced tobacco consumption;substance abuse; avoidance ofgender violence

• Promote use of iron fortified staple foods through counseling

• In malaria endemic areas, provideintermittent preventive treatment(IPT) for malaria and insecticide-treated bednets (ITN)

• Treat malaria

• Prevent/treat maternal infections

• Screen women for HIV and TB

• for HIV/TB+ women, provide ARVand/or TB drugs and counselingon IYC feeding choices for PMTCT

Intrapartum/Delivery careDelivery (childbirth) attended by askilled health professional may takeplace in a health facility or at home,and is an opportunity for timely inter-ventions for maternal and neonatalhealth and nutrition.

• Delay cord clamping to improveinfants’ iron stores

• Promote/protect early initiationand exclusive breastfeeding forfirst six months of life

• Provide counseling on lAM, theuse of progestin-only modern con-traception after shift from lAMwhile lactating, and healthy spac-ing of pregnancies

• Provide contraceptives

Emergency health servicesEmergency services may be deliveredthrough existing health posts/clinicsor hospitals, or may require specialsetup of an expanded venue in thecase of widespread famine or a natu-ral disaster. They are often partner-ships between national governments,UN agencies and other multilateralorganizations, and/or CSOs.

• Implement therapeutic feeding(including ready-to-use therapeu-tic foods) for moderate (<-2 to -3WAZ) and severe acutemalnutrition (<-3 WAZ) in children

Postnatal care contact (PNC)Postnatal care visits in the six weeksafter delivery serve to monitor post-partum maternal and neonatal healthand nutrition, and to deliver counsel-ing and support for optimal IYCN, ma-ternal nutrition, and prevention andtreatment of infection or other healthproblems.

• Deliver iron-folic acid supple-ments to lactating women


• Provide counseling to promote:

o Dietary diversification

o Use of iron fortifiedstaple foods

o Exclusive breastfeeding for first six months of life

o Optimal complementary feeding from six months and beyond (individual and group counseling)



• Screen women for HIV and TB

• for HIV/TB+ women, provide ARVand/or TB drugs and counselingon IYC feeding choices for PMTCT

• Provide counseling on lAM; use ofprogestin-only modern contracep-tion after shift from lAM while lac-tating, and healthy spacing ofpregnancies

• Provide contraceptives

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ANNEx E-3. wHO’S HEALTH SySTEMS STRENGTHENING FRAMEwORk AND NuTRITION

HSS Description of HSS Where nutrition falls Building Block Building Block in this building block

Health Services Good health services deliver effective, safe, quality • Use of community systems to extend nutrition personal and non-personal health interventions to those services and messages to the most that need them, when and where needed, with minimum vulnerable populationswaste of resources.

Health Workforce A well-performing health workforce is one that works • Use of community systems to extend nutrition in ways that are responsive, fair and efficient to achieve services and messages to the most vulnerable the best health outcomes possible, given available populationsresources and circumstances. In other words, there are sufficient staff, fairly distributed; they are competent, • Capacity building of health staff for the responsive, and productive. assessment of malnutrition, as well as understanding

of key nutrition messages and issues

Health Information A well-functioning health information system is one that • Nutrition surveillance activities (for acute ensures the production, analysis, dissemination and use of malnutrition in high burden countries)reliable and timely information on health determinants, health system performance, and health status. • Regular collection of anthropometric indicators

to inform policy-making and resource allocation

Medical products, A well-functioning health system ensures equitable • Ensure adequate procurement and stock of vaccines, technologies access to essential medical products, vaccines, and nutritional supplies and medicines across all types of

technologies of assured quality, safety, efficacy and cost health structureseffectiveness, and their scientifically sound and cost-effective use.

Health Financing A good health financing system raises adequate funds • Insurance mechanisms that include basic and for health in ways that ensure people can use needed essential nutrition servicesservices and are protected from financial catastrophe or impoverishment associated with having to pay for them. • Use of externalities to increase funding for It provides incentives for providers and users to be efficient. nutrition (for example, drought in the horn of Africa

that leads to increased aid for nutrition activities)

Leadership and Leadership and governance involves ensuring strategic • Development and implementation of nutrition governance policy frameworks exist and are combined with effective policies and guidelines (nutrition policy,

oversight, coalition building, regulation, attention to system CMAM policy/guidelines, food fortification legislation)design and accountability.

• Quality assurance/monitoring and evaluation of national-level nutrition specific guidelines and legislation (for example, salt iodization)

In 2007, the World Health Organization articulated a framework for Action on Health Systems Strengthening (HSS) as a necessary action not only to improve health outcomes, but also to reach the Millennium Development Goals (MDGs). WHO’s Health Systems Strengthening framework is based on six building blocks, outlined in the table below.The relationship between health systems strengthening and nutrition is presented through these six building blockswith brief descriptions or examples of interventions that contribute to a stronger health system that is better prepared to address undernutrition.

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1 lamberti, l., fischer Walker, C., Noiman, A., Victora, C. and R. Black. 2011. “Breastfeeding and the risk for diarrhea morbidity and mortality.BMC Public Health 2011, 11(Suppl 3): S15.

2 Ibid.

3 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008.“for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40

4 lamberti, l., fischer Walker, C., Noiman, A., Victora, C. and R. Black. 2011. “Breastfeeding and the risk for diarrhea morbidity and mortality,”BMC Public Health, 11(Suppl 3): S15.

5 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008.“for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival.The Lancet, 371:417-40.

6 Ibid.

7 Imad, A., Yakoob, M., Sudfeld, C., Haider, B., Black, R., and Z. Bhutta. 2011. Impact of vitamin A supplementation on infant and childhood mortality,” BMC Public Health, 11(Suppl 3): S20.

8 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008.“for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival.The Lancet, 371: 417-40.

9 Imad, A., Yakoob, M., Sudfeld, C., Haider, B., Black, R., and Z. Bhutta. 2011. Impact of vitamin A supplementation on infant and childhood mortality,” BMC Public Health, 11(Suppl 3): S20

10 Ibid.

11 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008. “for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40.

12 Ibid.

ANNEx E-3. wHO’S HEALTH SySTEMS STRENGTHENING FRAMEwORk AND NuTRITION

Intervention Relative Risk/ Reduction in Deaths Contribution to mortality reduction

Support of Exclusive BF versus not BF = 14.40 RR all-cause mortality,1 Exclusive BF versus partial HIGHoptimal BF: BF = 2.84 RR all-cause mortality (more realistic to developing country contexts)2, 0-6 months 9.9% reduction in deaths at 24 months of age with 99% coverage3

Support of optimal BF: Continued BF versus not BF = 3.69 RR4 MEDIUM6-23 months

Complementary 1.1% reduction in deaths by 24 months of age with 99% coverage5 LOW feeding promotion

Hygiene interventions 0.1% reduction in deaths by 24 months of age with 99% coverage6 LOW

Vitamin A 15% reduction in all-cause mortality7; HIGHsupplementation in 7.1% reduction in deaths by 24 months with 99% coverage8children 0-59 months

Vitamin A 25% reduction of all-cause mortality9 HIGHsupplementation in children 6-59 months

Therapeutic zinc Reduction in mortality of children >12 months by ~18%,10 Reduce mortality risk by 9%,11 HIGHsupplementation 2.8% reduction in deaths by 24 months with 99% coverage12

• High = Mortality reduction between 10-80% • Medium = Mortality reduction between 5-10% • Low = Mortality reduction between 0-5%; or no demonstrated/direct effect on mortality

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ANNEx E-3. wHO’S HEALTH SySTEMS STRENGTHENING FRAMEwORk AND NuTRITION (CONTINuED)

Intervention Relative Risk/ Reduction in Deaths Contribution to mortality reduction

Multiple micronutrient Data from one study in Indonesia shows that MNS associated with a 22% reduction in Insufficient datasupplements infant mortality13

Deworming No data No Data

Iron-folic acid 73% reduction of anemia at term14 estimated to reduce risk of maternal death by 23%15 HIGHsupplements for pregnant women

Iron fortification of No effect on mortality, but reduces odds of iron deficiency anemia in children by 28%16 LOWstaple foods

Salt iodization Reduced risk of iodine deficiency by 41% in children,17 reduction of infant mortality LOWdecreased by 56.5% after iodization of water18

Supplementation with Reduced deaths during infancy and early childhood by 29%, (RR 0.71) and decreased risk HIGHiodized oil capsules of endemic congenital hypothyroidism at age 4 years (RR 0.27)19(for women)

Prevention and 3.1% reduction in deaths before 24 months of age (with 99% coverage with balanced MEDIUMtreatment of MAM/ energy protein supplementation)20GAM

Treatment of SAM 55% reduction in case-fatality21 HIGH

• High = Mortality reduction between 10-80% • Medium = Mortality reduction between 5-10% • Low = Mortality reduction between 0-5%; or no demonstrated/direct effect on mortality

13 Ibid.

14 lamberti, l., fischer Walker, C., Noiman, A., Victora, C. and R. Black. 2011. “Breastfeeding and the risk for diarrhea morbidity and mortality.BMC Public Health 2011, 11(Suppl 3): S15.

15 Ibid.

16 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008.“for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40

17 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008.“for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40.

18 Ibid.

19 Imad, A., Yakoob, M., Sudfeld, C., Haider, B., Black, R., and Z. Bhutta. 2011. Impact of vitamin A supplementation on infant and childhood mortality,” BMC Public Health, 11(Suppl 3): S20.

20 Bhutta, Z., Ahmed, T., Black, R., Cousens, S., Dewey, K., Guigliani, E., Haider, B., Kirkwood, B., Morris, S., Sachdev, H. and M. Shekar. 2008. “for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. The Lancet, 371: 417-40.

21 Ibid.

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Annex E-5. Links to other key resourcesAdditional resources that have been consulted in the preparation of this guidance note and that may be useful for fur-ther analysis on specific topics include the following:

• What works? A Review of the Efficacy and Effectiveness of Nutrition Interventions (ACC/SCN, 2001), a series in-tended for countries, development partners, and scholars, stressing three central themes for targeting nutrition in-terventions, applying scientific evidence in program planning, and creating opportunities for and engaging public,private, and civil sector partnerships into programming and investments. This policy paper is available in seg-ments, from http://www.unsystem.org/SCN/archives/ npp19/begin.htm#Contents

• The Lancet Series on Maternal and Child Undernutrition (The Lancet, 2008), which includes a five- paper seriesfocusing on undernutrition, vulnerable groups, consequences, proven interventions that work, and challenges inaddressing maternal and child undernutrition. http://www.thelancet.com/series/ maternal-and-child-undernutri-tion

• Scaling Up Nutrition: What Will it Cost? (Horton, S., Shekar, M., McDonald, C., Mahal, A., Brooks, J.K., 2010), a report that estimated the cost of scaling up a minimal package of 13 proven nutrition interventions from currentcoverage levels to full coverage of target populations in the 36 countries with the highest burden of undernutrition.http://siteresources.worldbank.org/ HEAlTHNUTRITIONANDPOPUlATION/Resources/Peer-Reviewed-Publications/ScalingUpNutrition.pdf

• Facts for Life (UNICEf, 2010) is a handbook that provides vital messages and information for changing behaviorsand employing best practices in health, nutrition, sanitation, child protection, among others, which can save andprotect the lives of children and help them grow and develop to their full potential.http://www.factsforlifeglobal.org/resources/factsforlife-en-full.pdf

• The Global Strategy for Infant and Young Child Feeding (WHO and UNICEf, 2003) includes guidelines on appro-priate feeding of infants and young children, highlighting the need for all health services to protect, promote, andsupport exclusive breastfeeding and timely and adequate complementary feeding, as a means of saving lives.http://whqlibdoc.who.int/publications/2003/9241562218.pdf

• Guiding Principles for Complementary Feeding of the Breastfed Child (PAHO, 2003), which can be used as thebasis for developing recommendations on complementary feeding, and to set standards for practical dietary guide-lines. http://whqlibdoc.who.int/paho/2003/a85622.pdf

• Iodine Requirements in Pregnancy and Infancy (ICCIDD, 2007), highlights the results of a consultation where con-sensus was reached on iodine requirements and monitoring in vulnerable age groups. This document includessuccess stories in iodine programming. http://www.iccidd.org/media/ IDD%20Newsletter/2007-present/feb2007.pdf

• Reaching Optimal Iodine Nutrition in Pregnant and Lactating Women and Young Children (WHO and UNICEf,2007), includes guidance on iodized salt evaluation at the country level, and the use of iodized oil as a means ofreaching vulnerable groups, primarily women and children in areas of severe iodine deficiency where universal saltiodization cannot be or is not implemented. http://www.who.int/ nutrition/publications/WHOStatementIDD_pregnancy.pdf

• Global Prevalence of Vitamin A Deficiency in Populations at Risk 1995-2005 (WHO, 2009), provides an overview,etiology, consequences, and control of vitamin A deficiency. http://whqlibdoc.who.int/ publica-tions/2009/9789241598019_eng.pdf

• How to Add Deworming to Vitamin A Distribution (WHO and UNICEf, 2004), provides practical guidance forhealth planners to promote the deworming of preschool children where vitamin A distribution campaigns areconducted. This document includes general information on benefits and practical issues about deworming,dosages and costs, as well as country case studies. http://whqlibdoc.who.int/hq/2004/WHO_CDS_CPE_PVC_2004.11.pdf

• Vitamin A in Child Health Weeks (Micronutrient Initiative) is a toolkit developed to assist district-level man-agers to plan, implement and monitor child health weeks or similar regular twice-yearly events to reach thegreatest number of children to improve their health and survival. http://www.micronutrient.org/CMfiles/What%20we%20do/Vitamin%20A/VASToolkit.pdf

• The Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia (INACG, WHO,and UNICEf, 1998) provide recommendations for iron supplementation in anemia control programs at the local,district, or national levels. These guidelines also integrate recommendations for the use of antimalarial and an-thelminthic medications, where appropriate, along with iron supplements to prevent and treat anemia.http://www.who.int/nutrition/publications/micronutrients/guidelines_for_Iron_ supplementation.pdf

• Worldwide Prevalence of Anemia 1993-2005 (WHO, 2008) provides an overview of anemia as a public healthproblem, its etiology, health consequences, method of assessment, and control of anemia.http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf

• Micronutrient Sprinkles for Use in Infants and Young Children (Sprinkles Global Health Initiative, 2008), pro-vides a background on Sprinkles/multiple micronutrient powders, guidelines on recommendations for theiruse, and recommendations for program monitoring and evaluation. http://www.sghi.org/resource_centre/GuidelinesGen2008.pdf

• Implementing the New Recommendations on the Clinical Management of Diarrhea (WHO, 2006), presents re-vised recommendations for the use of ORS and zinc supplementation in the management of diarrheal disease,as well information on what is needed to introduce and/or scale up ORS and zinc supplementation in the clini-cal management of diarrheal diseases. http://whqlibdoc.who.int/publications/2006/9241594217_eng.pdf

• Guidelines on HIV and Infant Feeding (WHO, 2010) are based on evidence and include systematic reviews,GRADE evidence profiles, risk-benefit tables, and discussion on the potential impact of the recommendationson HIV and infant feeding, human rights issues, and costs. http://whqlibdoc.who.int/ publica-tions/2010/9789241599535_eng.pdf

• HIV/AIDS, Nutrition, and Food Security: What We Can Do (World Bank, 2007), is a synthesis of existing techni-cal and international guidance on HIV, AIDS, nutrition, and food security from a broad range of UN, bilateral, re-search, and nongovernmental entities, aiming to provide guidance on how to integrate efforts in each of thesesectors into nutrition projects and programs for HIV and AIDS. http://siteresources.worldbank.org/NUTRI-TION/Resources/281846-1100008431337/ HIVAIDSNutritionfoodSecuritylowres.pdf.

• The European Commission’s Draft Reference document (October 2010), provides guidance to country teams onhow to incorporate nutrition components into existing projects and programs. A link to this document is not yetavailable.

• Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for Ac-tion (2007) addresses the urgent need to improve the performance of health systems as a means to improvinghealth outcomes. This framework lays out the basic concept and fundamental building blocks of health sys-tems for policy-makers within countries and in other agencies. http://www.who.int/healthsystems/strategy/everybodys_business.pdf

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Annex E-6. Suggested nutrition resourcesThe Human Development Network has established a Knowledge Exchange for nutrition, which provides key informa-tion on nutrition resources, including a list of nutrition specialists within the Bank, who could potentially assisthealth TTls in planning nutrition-specific and nutrition-sensitive approaches in projects.

for TTls to understand the basic nutrition situation in countries where they work, the following resources are useful:

World Bank Nutrition Country Profiles (2011)

These are two-page profiles of the 68 highest-burden-of-malnutrition countries. They contain information on preva-lence of malnutrition and its causes, how the country’s state of nutrition compares to countries with similar GDP orgeography, information on current World Bank nutrition projects in the country, cost for scaling up core micronutrientinterventions, and suggested actions. These profiles are useful for basic context assessment and for making the caseto address nutrition through agriculture in high-burden countries. http://www.worldbank.org/nutrition/profiles

UNICEF State of the World’s Children - data tables (2011)

The data tables in UNICEf’s annual flagship report present major nutrition indicators, comparable across all coun-tries, in a highly user-friendly format. Updated annually. http://www.unicef.org/sowc2011/pdfs/SOWC-2011-Statisti-cal-tables_12082010.pdf

UNICEF Tracking Progress on Child and Maternal Undernutrition (2009)

This publication provides profiles of several high-burden-of-malnutrition countries, presenting information on nutrition indicators and what proportion of child deaths are due to malnutrition and other diseases.http://www.unicef.org/publications/files/Tracking_Progress_on_Child_and_Maternal_Nutrition_ EN_110309.pdf

UNICEF ChildInfo

This allows country-by-country tracking of the MDG1 indicator on child underweight (Indicator 1.8:% of Childrenunder 5 moderately or severely underweight), underweight prevalence by economic background, and underweightand stunting data (the same compiled in UNICEf State of the World’s Children reports). http://www.childinfo.org/un-dernutrition_mdgprogress.php

World Bank World Development Indicators

WDI contains two indicators for malnutrition (stunting, underweight), as well as disease prevalence and health systems information, which can help to estimate likely risk of malnutrition among farmers.http://data.worldbank.org/

WHO nutrition databases (http://www.who.int/nutrition/databases/en/index.html) WHO maintains several data-bases on nutrition, including:

• Nutrition landscape Information System (NlIS)—a web-based tool which provides nutrition and nutrition-relatedhealth and development data in the form of automated country profiles and user- defined downloadable data

• WHO Global Database on Body Mass Index—contains updated data on underweight, overweight and obesity, andrelated indicators for all countries.

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• National nutrition policies and programs—The Global Database on National Nutrition Policies and Programs was established in 1995 initially to monitor and evaluate the progress in implementing the World Declaration and Plan of Action for Nutrition. It has been further developed to monitor country progressin developing, strengthening and implementing national nutrition plans, policies and programs, includingmultisectoral actions, development of dietary guidelines, undertaking of nutrition surveys, demographic, and epidemiological data.

• WHO Global Database on Child Growth and Malnutrition—an A-Z list from where users can choose a country toview available child malnutrition data and reference tables (in pdf). Caution: these tables are not easy to inter-pret for non-nutritionists. UNICEf SOWC (see above) contains similar information.

• Vitamin and Mineral Nutrition Information System (VMNIS)—contains most recent data for anemia, iodine defi-ciency disorders, and vitamin A deficiency. Caution: these tables are not easy to interpret for non-nutritionists.World Bank country nutrition profiles (see above) contain similar information for68 countries.

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