AREVIEW OF

POSSIBLE WORLD BANK ACTIONS

ON MALNUTRITION PROBLEMS

AMERICAN TECItNICAl ASSISTANCE CORPORATION

1725 EYE STREET, N.W.

WASHINGTON D.C. 20006

JANUARY 1912

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I A REVIEW

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OF POSSIBLE WORLD BANK ACTIONS

MALNUTRITION PROBLEMS

Prepared by:

S. Chafkin J. Pines A. Berg

R. Longhurst (IBRD)

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American Technical Assistance Corporation

1725 Eye Street, N. W.

Washington, D. C. 20006

I January, 1972 I

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I I TABLE OF CONTENTS

I Letter of Transmittal I I. INTRODUCT ION

I I. MALNUTRITION AND ITS RELATIONSHIP TO DEVELOPMENT

I BackgroundMagnitudes and Nutrition andI Options Facing

I I I I. THE EXTENT AND United Nations

I World Health Organization (WHO)

Food and Agricultural Organization (FAO)

UN Agencies Involved in Nutrition

I Direct Feeding ProgramsGaps the Bank Can Fill

I IV. GENERAL CONSIDERATIONS AFFECTING

BANK PARTICIPATION

Arguments AgainstArguments For

I V. POSSIBLE WORLD BANK ROLES IN NUTRITION Non-Operational Bank RolesI Sponsorship of Research Operational Bank Roles

I Inclusion of Nutrition Implicationsin Project Proposal Analysis Identification and Preparation ofI "Nutri tion Projects 'l

I The "Nutr it i on Sector II Survey VI. SOME SPECIAL PROBLEMS POSED BY NUTRITION

PROJECT PROPOSALSI VII. ORGANIZATIONAL IMPLICATIONS OF ALTERNATIVE

BANK ROLES

I VI I I. CONCLUSIONS I

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Effects of Malnutrition Development

Countries

NATURE OF THE RESPONSE

Children's Fund (UNICEF)

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7 14 16 21

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I TABLE OF CONTENTS (Continued)

I APPENDICESI

I A-l.

I A-2.

B.

I C. I D. I

E.

I F.

I G. I H. I I I I I I I

Panel of Experts Consulted in Preparation

of ATAC Report

Partial List of Individuals and Organizations

Consulted

Types of Nutrition Activities

Excerpts from Report of the UN Economic and

Social Council (E/4829) summarizing UN

Activities to Alleviate Protein Problems

World Health Organization and Associated

Agencies (including Pan American Health

Organization) Projects and Costs

UNICEF Budget and Activities

Food and Agriculture Organization Nutrition

Activities, Including Proposals for World Bank

Consideration

Other Sources of Assistance in Nutrition,

Including UN Agencies Other Than FAO, WHO and UNICEF

FAO/WHO/UNICEF Protein Advisory Group

PAG Statement No. 12, 1 March 1971 (Revised)

Research and Development Areas (Provisional)

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I AMERICAN TECHNICAL ASSISTANCE CORPORATION I

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January 11, 1972

I Dr. Shlomo Reutlinger

I Economics Department

I International Bank for Reconstruction

and Development Washington, D. C.

Dear Dr. Reutlinger:

In accordance with our contract with the Bank of September 24,I 1971, there is transmitted herewith A Review of Possible World Bank Actions on Malnutrition Problems.

1 This report is designed to provide the Bank with a broad overview of the problems of malnutrition and of the activities being undertaken related thereto, in order to clarify choices ofI act i on that the Bank mi gh t cons i der. I t was not intended to serve as a definitive work on malnutrition and could not be one, given the time constraint and terms of reference of our assign

1 ment. Nevertheless, we have ranged beyond our terms of reference in order to respond in part to the questions, comments, and sug1 gestions put forward during our consultations with Bank staff, including those emerging from review of the draft version of this report. To respond fully would have required a report1 several times this size. We would be glad to discuss in greater detail, those points treated briefly in the report on which the Bank desires our further views.

1 In this connection, we invite your attention to the Conclusions section at the end of the report. While we originally intended to restrict the report to arraying choices for the Bank, we1 have, in that section, in response to several Bank staff requestsfor our recommendations, set forth what seems to us to be a reasonable immediate course of action for the Bank.

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1 1725 EYE STREET, N. W., WASHINGTON, D. C. 20006 TELEPHONE: (2021293-1053 CABLE: ATACK WEST COAST OFFICE: 843 MONTGOMERY STREET. SAN FRANCISCO, CALIFORNIA 94133

I I Dr. Shlomo Reutlinger International Bank for Page 2

Reconstruction and Development

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I Finally, our work benefited from the advice and assistance

that you, Dr. Weiss, and your other colleagues in the Bank, as well as officers of the U.N. specialized agencies, provided

I during this assignment. We hope that this report

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Enclosures

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proves useful.

Sincerely,

~~f-h r?kj~ S. H. Chafkin

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I . INTRODUCTION

I I Over the past few years, the World Bank Group has inten

sified its attention to the basic problems affecting the lives

of the people of developing countries. It has identified as

I key problems--flowing largely from the unanticipated growth of population--severe malnutrition, rising unemployment, and

I I the growing inequality of the distribution of income. In his

address to the Board of Governors on September 27, 1971, the

President of the World Bank Group stated:

IIUnless we deal with these fundamental issues, developI ment will fail .•• Development programs have not as yet faced up to the adjustment that the consequences of continuing population growth require. Two of theseI consequences--widespread malnutrition and chronic and growing unemployment--require particular attention. II

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This report reviews the possible roles, if any, which the

I World Bank might play in assisting developing countries to attack the problem of widespread malnutrition. In accordance

with our terms of reference, the report has been prepared to

I cover the following areas: A. To provide the Bank with an orderly summary of major

I I nutrition program activities, by country, currently

being undertaken and planned with the assistance of

international, national, and private agencies;

I B. To assess the current and prospective projects and identify significant gaps from the standpoint of

I possible areas for Bank attention and/or action for the next two years;I

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I C. To identify possible alternative roles (if any) for

the Bank's participation in the nutrition field based I on the foregoing assessment; and I

D. To identify for the Bank what organizational actions

would be appropriate for particular roles it might I choose, as well as provide the basis of a nutrition

work program within the Bank should it choose to I engage itself more intensively in nutrition problems.

I While not within our terms of reference, the report, at the

request of Bank staff members, also touches on the extent and I nature of the malnutrition problem, the relationship between I malnutrition and economic development, and the problem of

priorities faced by countries considering programs aimed at I malnutrition.

In preparing this report, a wide range of sources of I information and expert opinion was utilized. Information on I current nutrition-related activities in developing countries

was assembled from country reports to UN Headquarters, from I FAO, WHO (including PAHO), UNICEF, and UNDP, from the Tropical

Products Institute, 'and from bilateral program reports. Con I sultations were held with nutrition experts from international Iagencies, the FAO/WHO/UNICEF Protein Advisory Group, universities, and private research organizations, and with a distinguished I panel of experts from a number of countries in Asia, Africa

and Latin America during and following the October, 1971 I I

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I Conference on Nutrition, Planning and Economic Development

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I I held at MIT. Finally, information and advice were solicited

from members of the professional staff of most of the depart

ments within the Bank.

I A few definitions may be helpful. As used in this report, the term "malnutrition" follows the definition used

2I in a recent WHO manual, namely "a pathological state resulting I from a relative or absolute deficiency or excess of one or more essential nutrients sufficient to produce disease ••• II I The terms "nutrition-related activities or projects"

refer to those activities or projects which in whole or in

I part are undertaken primarily to yield some result other than nutrition but which nevertheless also may have an impact on

I nutrition. Thus, a nutrition-related pr~ect may be one I designed primarily to increase production of a particular food

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to improve farm income and, secondari ly, to increase the supply

I of that food in order to improve diets generally. The term IInutrition project" as used in this report is a

project aimed at causing a specific improvement in the nutri

tional condition of a specified population within a stated

period of time. This improvement may be through increased

I I See Appendix A-l and A-2. 2

Scrimshaw, N. S., C. E. Taylor, and J. E. Gordon, Interactions of Nutrition and Infection, WHO Monograph SeriesI No. 20, Second Edition, (Geneva: WHO, 1968).

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intake or improved biological utilization of nutrients.

This definition is important to bear in mind for several I reasons. It recognizes the vital importance of selecting

Iobjectives with respect to a target group deemed critical to the society, e.g., pre-school children or school-age children I or pregnant and nursing mothers or adult workers or rural

groups or urban groups. It thereby forces attention to I identifying the most effective delivery system in light of

Ifood habits, income status, costs, etc. It provides a basis for later evaluating the effectiveness of projects which are I implemented.

It is in this sense that a nutrition project differs from I a nutrition-related agriculture project which may have general

nutrition benefits associated with agricultural benefits. Thus, I a nutrition project may have agricultural, transportation, I education and health components aimed at changing the nutri

tional status of a particular target group and the test of its I effectiveness rests solely on whether the desired change was

achieved in the period of time selected. The measurements I might include reduced illness and mortality, increased accep I tance of family planning, successful development of particular

institutions, etc. I A "nutrition program" is a rational, interrelated and

mutually reinforcing combination of nutrition projects and/or I nutrition-related projects and activities designed primarily I to achieve a major specific nutrition objective with respect to

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I a specific population within a specified period of time.

I I (To the extent that a nutrition project is very broadly con

ceived, it may itself represent a nutrition program.) An

example of a nutrition program may be one which contains

I identifiable components for research and development, investment in expansion of production of specific food materials,

I I a processing component, a maternal and child health delivery

system, nutrition education activities, infectious and para

sitic disease control to improve nutrient utilization, govern

I ment legislation regulating the nutrient content of food,

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etc.--all of which are fitted to achieve a specified nutrition

I objective. Some components may be suitable for external loan financing and others may not be.

To the extent that development programs are aimed at

I increasing income of low-income groups or that agricultural

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investments are aimed at increasing the supply of basic food

I stuffs, it would be fair to say that all member countries have long been engaged in nutrition-related activities and projects.

I The continuing prevalence of widespread malnutrition, especially

among young chi ldren, suggests the possibility that a decision

to try to reduce substantially the severity of this problem

I within a reasonable period of time will require rather different and perhaps more direct approaches to the problem.

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This report, therefore, examines what member countries

and the Bank might do if they chose to accept an objective of

changing significantly the nutritional condition of a specified

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I population within a specified period of time. It is with

this definition in mind that this report now turns to the I extent of malnutrition and what member countries have been Idoing about it.

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I I I. MALNUTRITION AND ITS RELATIONSHIP TO DEVELOPMENT

I 1 Background

I A. Improved diet for many millions of human beings means, first of all, enough food because most low-income groups

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in the developing world have still to obtain sufficient calories

from the food they are able to grow or to buy. It is expected

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therefore that, for many years to come, an increase in purchasing

I power will still be used in the first instance by the large majority of those populations to improve their calorie intake.

Improved diet means also better quality of the diet in terms of

proteins, vitamins and minerals. Although, deficiency of

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vitamins and minerals may cause serious health problems, espe

I cially among children, the therapy is now well known and relatively easy to apply so that the magnitude of this problem

I is almost negligible in relation to the one created by lack of calories and proteins.

B. From the available information, it is obvious that

I conventional sources of protein, mainly the staple cereals, supplemented in various countries and to some extent by the

I I grain legumes or pulse crops, livestock products and fish,

must continue for the foreseable future to supply the bulk of

the protein needs for the world population. Within that

I situation, however, special consideration must be given to the growing child, from birth to puberty and more particularly

I immediately after weaning and up to the age of five, as well I

From material prepared by FAO for this report.

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I as to the mother, from the time of conception of her child

and through the whole period of pregnancy and lactation. I Protein/calorie deficiency at any stage for those two vul Inerable groups can lead to impaired bodily development and

also to impaired mental development of the child which may I not be fully rectified in later life, and to sub-optimal

health or even toearly death. Whenever possible the neces I sary nutrients should be derived from conventional foods, Ilocally available, but where the protein content in the diet is low, additional protein in concentrated form of less con I ventional sources may be provided, in order to reduce the

overall bulk of the ration so that it is acceptable to the I small stomach of the weaned baby and young children. The

Ineed for such special protein supplementation of traditional diets is also closely associated with the low levels of family I income and lack of knowledge of nutritional principles.

C. Countries may be arranged in seven dietary groups I according to the foods which constitute their source of pro

Itein. These groups are the following: 1. Countries with diets based on animal products I

(North America, Western Europe, the Plate River

countries); I 2. Countries with wheat-based diets (Central and Southern

Europe, North Africa and the Near East); I 3. Countries with diets based on millet and sorghum I

(the Savanna zone of Western and Eastern Africa);

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I 4. Countries with diets based on various cereals such

I as wheat, maize, rice (South America); I 5. Countries with maize-based diets (Central America

and Eastern Africa);

I 6. Countries with rice-based diets (Asia and the Far East); and

I 7. Countries with root-, and plantain-based diets (Equatorial Africa, the Caribbean).II

D. The following table and graph show that, according

I I to the Aature of the staple food, the diet provides an

average of about 90 grammes of total protein per caput per

day in the developed regions. In the developing countries

I supplies generally average from 42 to 70 grammes of total protein per caput per day but in certain countries, mainly in

I I Southeast Asia, they hardly reach 40 grammes. With regard to

the average per caput availability of protein from animal

I sources (higher quality protein), the variation is even wider,

ranging from 40 to 60 grammes per day in the developed regions

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to 6 to 30 grammes in developing countries. Inequalities among

I countries are much greater for proteins than for calories, mainly on account of differences in the protein content and

I value of the staple foods. Ranging from countries with a high

intake of animal proteins through those with cereal-based diets

(wheat, then sorghum and millets, then maize and rice) to those

I where roots and tubers are the main food items, a decrease in I

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-10-I ICalories and Proteins in the Diet

(per caput per day) I Protein IMain sources of protein from animal Total

in the diet Calories products protein

Type I: Animal products I Western Europe, Scandinavia, Canada, 3,090 57.8 g 90.2 g I USA, New Zealand, Austral ia, Israel,Uruguay, Argent rna . -.- - ".

Type I I: Wheat I Italy, Hungary, Poland, Chile, Spain, 2,760 23.2 g 81. 7 gGreece, Romania, Afghanistan, Yugo I slavia, Near East, Morocco

Type III: Maize I El Salvador, Guatemala, Honduras,

Mexico, South Africa, Kenya, Dahomey 2,490 19.2 g 70. 1 g I Type IV: Various cereals

Venezuela, Colombia, Surinam, Costa 2,580 26.4 g 63.8 g I Rica, Paraguay, Bolivia, Ecuador, Peru, Brazi 1

IType V: Millet and Sorghum Gambia, Senegal, Mali, Niger, Sudan, 2,125 17.3 g 63.8 gUpper Volta, Chad, Nigeria, Tanzania, I Ethiopia

Type VI: Rice I Ceylon, Taiwan, Japan, India, Pakistan, 2,030 8.1 g 53.5 gPhilippines, Madagascar, Thailand, IMalaysia, S. Korea Type VI I: Roots and Tubers I Cameroon, Ivory Coast, Congo (B), 2,030 9.2 g 42.3 gCongo (K), Gabon, Ghana, C.A.R., Togo, Uganda I Source: FAO Nutrition Newsletter 6, No.4, 1-29, 1968. I

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I -11I 9a101"j.£6 oo9;..f!'~}!!U.~..jn=~~~j,ou~ ~..e.a of Die!!

(by dcorca~in~ order of ~ptal protein)

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I Prot. (g)Cal.

~:.,.,.j Total proteinI [?:~1j Animal protein

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2,000

• ti-

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I II III Type of diet

VII

100

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I protein intake can be observed along with a fall in the protein

value of the diet, a deterioration of the calorie/protein I balance and finally a widening gap between protein requirement Iand intake.

E. Besides the inequalities of protein intake among I countries which emerge from the study of the Food Balance Sheets

and which are salient in spite of the high degree of aggregation I of their data, household consumption surveys show that there are Ialso wide differences in food and protein intake among various socio-economic groups and among individuals, according to the I region, the season, the family income, etc. These surveys show

that, generally, the protein content of the diet and particularly I proteins from animal sources increases as income rises and that

Ithere is a gradual shift from the cheaper foods such as roots and tubers, cereals and grain legumes to more expensive ones, I in particular animal products and consequently to sources of

more and better proteins. I F. The relationship between improved diet and rising

income and consequently with higher living standards should, I however, be carefully analyzed. In the early stages of economic I development, a rise in income is followed primarily by an

increased consumption of staple foods. For the foods having a I low or medium protein content, the increasing income, therefore,

is not synonymous with immediate improvement in the quality of I the diet. It is only in a subsequent phase, when the calorie I

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I needs are fulfilled, that the diet begins to diversify and

I I that the demand for protein from animal sources increases

sharply. Thus, inequalities of protein intake among countries

are not as closely linked with income levels as might be expected.

I To a very large extent, they stem from the ecological and cul

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tural conditions that have determined the choice of staple foods.

I There is, therefore, a certain rigidity of the structure of the diet, which indicates that efforts for economic development

alone are not sufficient to improve the nutritional status of

I a population. G. The rigidity of the diet structure is also due to the

I fact that protein foods of high quality like meat and fish are scarce and, therefore, too expensive. A better distribution ofI the protein foods at world level or a distribution of the pro

I tein resources at national level according to the individual needs are unlikely to be implemented in the immediate future.

I On the other hand, the delayed impact of raising income on the quality of the diet,and particularly among the vulnerable groups,

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will maintain and even increase the present inequalities among

nations for many years to come, in the absence of effective

nutrition solutions. This is particularly true in rapidly

,I urbanizing areas where the prevalence of severe protein calorie malnutrition among pre-school children is far greater than in

I rural areas. I

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I Magnitudes and Effects 'of Malnutrition

For the purposes of this report, it may be useful to note I the following: I

A. The World Food Program (FAD) recently estimated that

the magnitude of the population most vulnerable to the mal I nutrition problem includes 65 million mothers and 130 million

1 pre-school children in need of food aid. I

B. FAD has found that protein/calorie malnutrition is the Ibiggest single contributor to child mortality in the developing

countries. Children under age five account for two-thirds or I more of the deaths in most developing countries (India 65 per

cent, UAR 67 percent, Brazil 79 percent, Pakistan 81 percent) I

although they account for less than 20 percent of the population. I(In industrialized countries, mortality of the same age group accounts for fewer than five percent of total deaths.) I

C. PAHO has estimated that malnutrition is th~ underlying

or associated cause of more than 50 percent of the deaths of I one to four year olds in Latin America. Since this estimate

Iis based on identification of examining physicians, the true figure is probably higher. About 65 percent of childhood I deaths in Jamaica had malnutrition as a primary or contributory

factor. I

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Derived from "Strategies for Establishing National Supplementary Feeding Programs, II a paper prepared byWorld Food Program (FAD) for UN Protein Advisory Group I Meeting, December, 1971.

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I D. About 55 percent of all deaths of children from

I infectious or parasitic diseases are nutrition related. I E. FAa reports that two-thirds of the estimated 800

million surviving children in developing countries will encoun

I ter sickness or disabling diseases brought on or aggravated by

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protein/calorie malnutrition.

I F. WHO reports that as much as 30 percent of children suffer from second and third-degree malnutrition (below 75

percent of standard body weight).

I Other nutritional deficiencies are worth noting. In

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India, at least a million cases of blindness are a direct

I result of inadequate Vitamin A intake. In Indonesia, the numbers are probably as great. This deficiency exacerbates

I protein/calorie malnutrition and sharply increases the chances

of death. In India, 10-15 percent of all children suffer from

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some ocular manifestation of Vitamin A deficiency.

I Iron deficiency anemia is common in women and children in developing countries. An estimated 50 percent of Indian

I children are anemic. Some 56 percent of pregnant women in

South India and 80 percent in North India are anemic. This

condition contributes directly to high maternal death rates

I and a high rate of low-weight and premature births. Thus, nutritional deficiencies result in:

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high mortality rates

retarded physical growth

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1 I impaired learning and behavior

physical deformities I high incidence of illness Ilowered productivity as adults

increased load on health services I less efficient use of education

possibly less acceptance of family planning to the I extent that reduced infant and child mortality are Ipre-conditions for successful population control.

2 Nutrition and Development I

A body of literature has developed the theory of human Icapital, measuring returns to investment in people. Work

along these lines, especially on the returns flowing from I investment in education, has emphasized recognition that the

quality of the labor force is an important factor in economic I growth. Economists have devised methods to measure the returns I

IThis point was identified only in the early 1960 l s and has baan· the subject of a substantial-number ef- recent--fnvestigations. The state of current understanding was presentedin the summary of the October, 1971 International Conference I on Nutrition, National Development and Planning by Professor Derr i ck Je 11 i ffe. "Wi.th regard to the 1ater effects of c;;h i 1 dhood ma 1nutri t ion on menta 1 deve 1 opment, the evT dence I resulting from experimental animal studies is absolutelyclear. Also, the evidence with regard to human subjectshas reached the level of clarity and assurance that puts it beyond reasonable doubt. II I

2 Based on Berg and Muscat, "Nutrition and Development: The View of the Planner, II American Journal of Clinical Nutrition, I February, 1972.

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I I to investment in health. These methods include the comparison

of the costs of preventing a death with the worker's future

I I income had he lived. Another measurement is the investment

in human capital (health services, food, clothing, education,

housing and other expenditures to enable a person to develop

I his particular skills) that is lost through death any time

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prior to retirement. A variation of this approach measures

I the economic cost of debility, where death is not a factor-medical care, loss in output as a result of loss of work days

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or reduction in work capacity. This cost can be compared with

I proposed expenditures for preventing illness. An improvement in nutrition (or an avoidance of under

I nutrition or malnutrition) can be equivalent to curing (or preventing) any other disease. Improved nutrition can:

return an absent worker to activity;

I overcome a debility that reduces a worker's

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productive capacity;

I lengthen working life span; improve an individual's comprehension and retention

of things taught; and

I increase absorption of training, agriculture extension advice, etc.

I The foregoing results increase the flow of earnings above what it would have been in the absence of improved nutrition andI health.

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I It is recognized that reduction of malnutrition may not

reduce medical costs in developing countries where there is a I potential case load exceeding the treatment capacity of the I health services system. However, it would enable the system

to reach more people and restore their productivity. I It can also be argued that developing countries are usually

assumed to have a substantial labor surplus and that improvement I in the nutritional status of workers would add nothing to Inational production. Nevertheless, even in rural areas, it is

common for labor to be in short supply during harvest and other I periods of intense activity. With the spread of irrigation,

spurred by the development of higher yielding and faster I maturing varities, slack time during the agriculture year is Idiminishing. Also, even where open unemployment exists, many functions affected by a worker's malnourishment cannot be I satisfactorily fulfilled by hiring additional workers. In

other words, quantity cannot substitute for quality, especially I in machine-paced jobs, and malnutrition might be reflected in

shoddy output. Malnutrition also is reflected in accident rates I and absenteeism. The literature contains examples of factories I which introduced feeding programs and achieved lower rates of

accidents and absenteeism. I As development proceeds, human quality becomes more impor

tant than sheer physical capacity. Timely initiative, physical I dexterity and comprehension of sophisticated techniques all I become critical to successful application of new technologies.

Even the small farmer is affected. If protein malnutrition I

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during childhood has impaired his mental development, and

I undernourishment as an adult is compounding his disadvantages, his efficiency as a farm entrepreneur is not increased by the

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presence of unemployed labor in the neighborhood.

I It is interesting to note in this connection that the concept of adequate nutrition is commonly incorporated into

the planning of military establishments. In some developing

countries, nutrition research is directed at the relationship

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of nutrition to the effectiveness of the soldier.

I Improved nutrition will yield additional economic benefits. It will raise the returns of other investments related to human

I well-being such as education where the malnourished chi ld often is unable to cope with school expectations in terms of atten

dance and rate of learning. Lower incidence of communicable

I diseases among adequately nourished people will, in turn, reduce

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the exposure to these diseases of others. Increased income of

I the well-nourished worker (or of the well-nourished chi ld when he enters the labor force) will improve the living standards

and future productivity of his dependents. This includes

I housewives who are economically important for many reasons, not

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the least of which is the quality of care for the young. Finally,

I an important contribution to lower rates of population growth may be to keep children alive by means of reducing malnutrition.

I As parents' confidence in the survival chances of their earlier

children rises, their economic and social security needs for

additional children to insure achievement of desired family

size declines.I •

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In addition to the' foregoing economic benefits, improvement

in nutrition can yield certain intangible effects. Thus, how I many superior minds and potential leaders are being lost or I repressed because of malnutrition? For societies which place

a premium on egalitarianism, intellectual loss caused by mal I nutrition is the strongest obstacle to attaining this social

goal. A malnourished child's chances for social mobility are I greatly restricted no matter what else is offered in education I or other avenues designed by policy makers to facilitate upward

movement within a society. I Even where significant opportunities exist for returns to

better nutrition, one needs to weigh the costs in relation to I benefits. Will the increase in production achieved by the I proposed nutrition expenditure be greater than the input or

resource cost to achieve that increase? How wi 11 it compare I with returns to alternative investments. The answers depend

on whose malnourishment is being corrected, what increments of I productivity can be expected from the target group, how much Ithe nutrition investment will cost, whether the productivity

effect is immediate or delayed, and in the latter case, what I discount rate is applied to obtain the present values of benefits

and costs to be compared. I Even in a labor-surplus market, there are several groups I

from whom a fairly short-run payoff could be obtained: workers

in machine-paced occupations; students for whom malnutrition I limits potential returns from education and health expenditures;

and small farmers facing the more exacting demands of new I I

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I agricultural technologies. The most lasting and numerically

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widespread impact, however, probably would derive from providing

adequate nutrition to mothers in the last trimester of pregnancy

and to children from six months up through three years of age.

I Illustrative calculations by Berg and Muscat of returns in the form of additional income to a worker in India over a 35

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year working life from an investment in child nutrition only

during the six months to three years ages would represent a

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IIbreak even" using a discount rate of ten percent. What, in

I fact, the actual rate of return will be depends on a large number of factors. The higher the initial income, the smaller

proportionately need be the break even increase in productivity.

The larger the potential mental shortfall due to malnutrition,

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the greater might be the increase in potential performance from

I better nutrition. Whether the range of mental shortfall is relevant to future productivity depends on what occupational

I difference the performance improvement can lead to. In addition, the idea of increased productivity should be broadened

to include the values of the side benefits and enhanced returns

I to other investments, mentioned above.

I Options Facing Countries

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Countries have lived with malnutrition for a very long

I time. Most of them have not assigned a high priority to nutrition programs in development plans and budgets. Such

activities as they have undertaken tend to be those which do

not require significant amounts of funds or which an external

source of assistance is willing to finance. Thus, nutrition

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I activities are ad hoc and usually in the form of some feeding

programs, some nutrition education, and some food technology I work. So long as nutrition program proposals do not represent I a substantial claim against limited resources, problems of

choice are not serious. I It is when these proposals require substantial expendi

tures that the country contemplating them faces difficult I choices. A review in February, 1971 of nutrition program possi

1 Ibi1ities in Pakistan illustrates this problem. Apart from agricultural development programs aimed at I

increasing cereals, livestock, poultry and fish production,

there existed no national nutrition policy or nutrition pro I gram of consequence for vulnerable groups which cannot afford

Ifoods providing high quality protein. This void was apparently an inevitable result of the particular set of priorities estab I lished by government in the face of severe limitations of

resources. I It was, therefore, not at all clear that the country's

current and future investments of resources in education, I health, and family planning projects would be optimized without I basic improvements in nutrition. Indeed, trade-offs between

such expenditures and nutrition needed to be considered. In I the same sense, as subsidies for wheat were phased down, an

I American Technical Assistance Corporation, "A Review of I

Nutrition Program Possibilities in Pakistan," a report

prepared for U. S. Agency for International Development,

February, 1971. I

I

- ------------

I -23

I

I

opportunity existed for shifting subsidy programs to stimulate

I pulse production and to affect market prices. (In India, wheat expansion p6licies had adversely affected pulse produc

tion--in effect, a subsidy for malnutrition.)

I The government had sponsored studies of malnutrition in

I

the country, skilled technical people were available, and

I proposals for nutrition programs had been made. The latter usually suffered from a failure to suggest priorities among

I nutrition activities in light of the shortage of financial

resources and management capabilities.

The choices facing Pakistan at the time of the survey were

I severely limited by internal and external financial stringencies, so that significantly increasing the total investment in nutri

I I

tion was not likely in light of competing claims. In addition,

its existing delivery systems for health services, family

I I

planning and rural development were already strained in coping

I with non-nutrition services. Thus, the option of launching even limited feeding programs presented serious difficulties.

While it seemed feasible to expand existing nutrition educa

tion programs, this action alone was not likely to produce

I

significant results. The most promising avenue for action lay

I in fortification of staple cereals. It seemed possible as a near-term strategy to concentrate on increasing the availabi lity

I of fortification materials for future fortification programs. Thus, the production of acceptable protein concentrates could

I

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-24

I be fitted into existing-public and private programs for develop

ment of an oi lseeds industry, without intolerable claims against I resources. I

India chose a rather different approach. Its nutrition

activities over the past five years included nutrition research I and surveys, feeding programs, new food development, and forti

fication of bread. Within the past two years, there has emerged I a costly commitment to reach all pre-school children in India

with feeding programs and to make special efforts to link nutri I tion with family planning programs. Nutrition planning is now I an established element of overall development planning.

All countries will face the difficult resources allocation I choices required by a decision to finance major nutrition

activities (cutting back on other programs, increasing taxes, I using limited amounts of foreign assistance, etc.). They will I face the problem of reordering priorities and of income re

distribution implied by programs seeking to reach low-income I groups. In addition, they will face the difficult choices as

to target group selection and alternative forms of nutrition I intervention. I

There are considerable risks associated with investing

scarce resources in nutrition programs. Thus, heavy investment I in school feeding programs may be misplaced as compared with

the 0-3 year age group. A massive fortification program reaches I many people who do not need the nutrient and may not even reach Iinfants most in need because of child feeding practices. A

I

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I -25

I child feeding program to supplement home feeding may lead to

I withdrawal of food from the child at home, thus resulting in I no net nutritional benefit for the child. Investment in the

production of an enriched weaning food may be wasted if the

I product is priced beyond the reach of those most in need or if necessary educational efforts to promote consumption are

I not undertaken. I I I I I I I I I I I I I

I -26

I

IIII. THE EXTENT AND NATURE OF THE RESPONSE

When compared to the magnitude and impl ications of the I problem, the specific response to malnutrition is noteworthy

for its modest scale, its fragmentation, and its lack of I operational orientation. This condition is partly explained

by the nature of the evolution of nutrition activities in I developing countries; a brief look at this background may be Ihelpful in understanding the current picture.

A. Interest in operational nutrition programs emerged I from medical origins. For more than half a century, less

developed countries have sponsored laboratory and cl inical I research directed to this problem. In some 20 of the larger

Ideveloping countries, and several of the smaller ones, special nutrition institutes or nutrition wings of other medical I research facilities have been establ ished. From this medical

research base grew a medically-oriented response to the problem. I Answers to malnutrition were sought in the forms of pediatric

nutrition wards in hospitals, health centers and, later, nutri I tion rehab; I itation centers. The medical approach has been I cAaracterized by its 'emphasis on curative rather than preventive

malnutrition, and by the small proportion of the population I (probably less than 1 per cent) reached in this manner.

B. The need for more -- especially nutritional supple- I ments became clearer in the emergencies during and following I

I

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I -27

I

I World War I I. The response was the institutional child feeding I program now organized in more than 100 countries, reaching an

estimated 90 mill ion children at an approximate cost of three

I quarters of a bill ion dollars a year. Most of this program is in the form of foreign donated foods, but the receiving coun

I I tries themselves contribute an estimated $200 million a year to

meet administrative and logistical expenses and for local food

inputs. Total cost per child averages about $9 a year ($4.51

I in Costa Rica; $8 in India; $9.45 in Turkey; $13.00 in Liberia). Basic questions are whether the program reaches the right chil

I I dren (commonly, less than 10 per cent of the beneficiaries are

of the vulnerable but difficult-to-reach preschool age group), and

whether the program benefits those neediest elements in the

I population. C. Recognition that improved nutrition could be attained

I I in part by better use of resources already or potentially

available led to efforts in the 1950 l s to bring about conscious

changes of food practices. Several forms of nutrition education

I have been attempted, with the major emphasis being on the UN sponsored (FAO-WHO-UNICEF) village-level Appl ied Nutrition

I Program (or variations thereof) now underway in some 20 countries. This program, in the judgment of UNICEF and others, hasI

I not been noteworthy for its success. In the past four years,

efforts have been made to involve professional communicators in

I

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I

nutrition education (until now nutrition education primarily I had been in the hands of nutritionists and health educators) I and several large mass media programs, e.g., Zambia and India,

are now under way. I D. In the early 1960 ' s, with an increased a~preciation

of the magnitude of the problem, there was recognition that the I cost of existing nutrients was a basic constraint. This, in I part, led to the development of technologies aimed at providing

low-cost solutions. New processes for soybean, cottonseed, I groundnut and other oilseeds have made possible large sources

of protein seldom previously used in most countries for direct I human consumption. Work also has advanced on fish protein

Iconcentrate and protein derived from single cell origin, with special interest in petro-protein. At least a dozen food I technology institutes have been estab1 ished in developing coun

tries to promote such work. 'rhe new nutrient sources have been I used both (1) to fortify existing food staples and (2) in the

formulation of new food forms. Several large-scale government I fortification projects currently are operational, (e.g., I protein, vitamin, and mineral fortification of atta and bread

in India) and others are close (e.g., Vitamin A fortification I of sugar in Central America), New foods are being processed

in several developing countries, for use in institutional I feeding programs. (The largest of these is India ' s Bal Ahar, I programmed this year to produce 100 mi 11 ion pounds.) Industrial

I

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I I involvement has been courted and commercialization instituted

I

on approximately 25 products. Primarily due to cost and price

I problems, industry's nutritional impact to date has been insignificant.

E. Agriculture attention consciously directed to nutrition

I objectives primarily has been on the development of cereal

I

staples with higher nutrient content (e.g., the high-lysine

I opaque-2 maize, now planted in Latin America). Recently, concern has been shown about the need to upgrade yields of tradi

I tional protein sources such as legumes. Agriculture projects

aimed at meat, fish and, in many countries, milk production

generally have 1 ittle direct nutritional impact on malnutrition

I of the needy. F. In the late 1960 ' s,there was a beginning appreciationI

I of the need for broader scope and more systematic planning for

nutrition programs. Interest in the problem was being evi

I

denced in Planning Commissions and Finance Ministries in several

I countries. Efforts have been initiated (India) or are soon to be initiated (Iran, Ecuador) for full-scale systems analysis of

I the nutrition problem. With the kind of evolution outl ined above, there are several

categories of existing nutrition activities: medical, agricul

I tural, child feeding programs, new food development, fortification, food marketing, nutrition education, planning, and

I

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I development of local institutes. From the experience to date, I several .genera1 izations might be drawn:

1. With the exception of institutional child feeding I programs, nutrition activities have been small,

Iprimarily in the form of experiments and pilot projects. 2. Most nutrition" projects to date have been made possible I

by food and financial grants.

3. Activities generally have been ad hoc in conception, I lacking integrated analysis that matches response to

need and compares options. I 4. Most programs consciously developed with a nutrition I

objective have concentrated on direct face-to-face

health or education techniques. I 5. The nutrition field has been the province of the medical

scientist and the food technologist, whose contributions I to date largely are responsible for the current level of I knowledge and the developed capacity to respond to the

problem. Efforts by these same disciplines (in the I absence of others) to move the field into operational

channels have been less successful. I It should b~ noted that much of the reported UN activity and I

expenditures are at best indirectly related to the nutritional

status of particular population groups. Thus, for example, work I to increase the supply of meat and fish mayor may not directly

benefit the nutritional status of low-income households, partic I cularly young children. I

I

I - 31

I I The most extensive attention to nutrition within the UN

family is being given by the fol lowing three agencies. (As

I may be noted in the Appendix G, UNDP, UNESCO, UNIDO and other UN bodies also provide assistance in the field.)

I United Nations Children's Fund (UNICEF)

I Expenditures by UNICEF program for 1968, 1969 and 1970 are included in Appendix E. Nutrition expenditures in 1970I were $5.57 mill ion or 14 percent of total program expenditures

I ($39.90 mill ion). UNICEF, in collaboration with FAD and WHO, has attacked the problem of child malnutrition in three main

I ways. For children in rural areas, the main approach has been through appl ied nutrition programs which combine nutritionI

I education with the stimulation of production of nutritious foods

at the community and family level. The other two approaches

I I

--assistance to local manufacture of high protein weaning foods

I and support for local dairies-- are mainly addressed to children in cities. UNICEF has also assisted nutrition training and

orientation courses for a wide range of personnel. Although in

special situations UNICEF continues to provide imported milk

or special food mixtures for children, the days when UNICEF was

I supplying imported milk powder on a large scale are now past. UNICEF regards that

I lithe problem (of child nutrition) cannot be solved solely by such means as creating nutrition institutes, conducting nutrition surveys and training nutritionists.I It must be tackled in the context of national agricultural planning and each country must formulate

I

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-32I

I

national food and nutrition pol icies and programs as part of its long-range developmental effort. The IWorld Indicative Plan published by FAO in 1969 can serve as a valuable instrument in that process." 1

IUNICEF further notes that II As food and nut r it ion pol icy needs to take account of four principal 1ines of action: I (a) increasing food supp1 ies at the consumer level;

I(b) changing and improving food habits; (c) increasing purchasing power; and I (d) fighting environmental factors which reduce the

metabol ic use of food and make people need more

food to resist disease,lI 2 I

UNICEF reports on its ANP programs as having mixed

3

success. Few of these programs have gone beyond the stage I of pilot experiments. There has not been efficient coordi I nation at field level among the Ministries of Agriculture,

Education and Health and the programs have lacked the im I

portance to attract good administration.

I World Health Organization (WHO)

WHO describes the functions of its nutrition unit as I follows:

I General Progress Report of the Executive Director, I UNICEF, United Nations, New York, 1971, p.45.

2 I Op. cit., p. 46 .

3 Andre, L.M., Evolution in the Conception and Implementation I

of Food and Nutrition Programs, mimeo., UNICEF, New York,

October, 197 I . I

I

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I I 11(1) to provide technical guidance on nutrition

in relation to the maintenance of health and the prevention of diseases such as protein-calorieI malnutrition, endemic goitre, pellagra, beri-beri, nutritional anemias, and nutritional diseases of the eye.

I (2) to take responsibil ity for the work undertaken by 'rM0, through the Prote in Adv i sory Group, in the joint FAO/UNICEF/WHO program for the development ofI protein-rich foods; (3) to give technical guidance on education inI nutrition; (4) to initiate, promote and coordinate research on aspects of nutrition that require internationalI collaborat ion; (5) to advise the World Food Program on the nutritionI aspects of its activities; and (6) to service the expert Advisory Panel on Nutrition."

I I The personnel in nutrition consists of three medical

officers, a scientist and three secretarial personnel. Con-

I

sultants are also hired. The administrative budget for this

I central office is $95,000 in 1972. The total nutrition ob1 igation for projects was $1.14 mill ion in 1970; this will

I increase to $1.62 million by 1973. In 1970, these obligations represented 2.1 percent of all WHO expenditures. In 1971,

there are approximately 50 WHO nutrition projects in operation.

I Details of expenditures by project and country are provided in

Append i x D.

I

I Proposed Regular Program and Budget Estimates for the

Financial Year 1 January - 31 December 1972, Official Records of the World Health Organization, No. 187, WHO,

I Geneva, December, 1970.

I

I -34

I

I

Food and Agricultural Organization (FAO)

FAO reports that its Nutrition Program in 1970 accounted I1 for over 250 field projects. It also reports particular

concentration on formulation of national nutrition pol icies, I execution of food consumption surveys and avoidance of food Iwaste. Increased emphasis was laid in 1970 on high-level training courses for policy makers and administrators at I national and local levels and on the development of more nutri

t i ou s crops. I The approved budget for 1970-71 for the Nutrition Division

of FAO is $2.26 million; expenditures in 1968-1969 were $2.44 I million. The total FAO budget for 1970-71 is $72.22 million; I expenditure for 1968-1969 was $60.00 mill ion. Hence, nutrition

represents 4.1 percent of 1968-1969 expenditures and 3.1 per I cent of 1970-1971 outlays. The personnel in the Nutrition

Division are 37 professionals and Director, 36 General Service I and 94 Field Project Officers. Samples of FAO projects are I provided in Appendix F.

IUN Agencies Involved in Nutrition No compendium now exists covering nutrition activities I

which have been undertaken in developing countries. Appendix C

to this report provides examples of countries which have launched I major types of nutrition activities and other appendices set forth

I The Events of 1970, FAa document Gil: INF/7111, January,1971.

I

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I -35I

information obtained from principal sources of assistance inI I

this field. Excerpts from the report of the UN Economic and

Social Council (E/4829) of 8 June 1970 summarizing the nutri

tion work of the United Nations family of organizations are

I presented in Appendix C. I Direct Feeding Programs

I

Because direct feeding programs represent the most

I important and costly nutrition effort now under way in developing countries, it may be useful to review briefly the

I requirements and the existing programs. Using the estimate

cited earl ier of about 195 mill ion pre-school children and

mothers in need of food aid, the World Food Program has

I estimated an annual cost of US$1.8 bill ion to meet the food 1

requirements of the group_I I

The vulnerable groups now constitute a small fraction of

existing feeding programs using donated foods from the U.S.,

I

the World Food Programme, Canada, EEC countries, and other donors.

I The total annual cost (including shipping and administration) of such programs is the equivalent of about US$800 mill ion

I (including local food and administration services provided by recipient countries). The two largest programs--U.S. and WFP-

together probably reach fewer than 15 million pre-school

I 1

Wor 1 d Food Programme (FAO), liSt rateg ies for Es tab 1ish i ngI National Supplementary Feeding Programs," paper prepared

for PAG Meeting, December, 1971.

I

I

-36

children and mothers out of the total group in need of 195

million. All existing feeding progr.ams probably do not reach

more than 25 million in this group.

It is important to note that all such feeding programs do

not necessarily meet all nutritient deficiencies nor are the

pre-school children reached those most in need. The data

suggest that most of the food goes to school-age and thus less

vulnerable children and that reallocation of food distribution

would be beneficial. Unfortunately, it would be both politically

difficult to cut back school feeding programs and logistically

difficult and expensive to construct a delivery system to reach 1

a greatly increased number of pre-school children.

The costs and other problems of direct feeding suggest a

number of avenues of action:

1. seeking efficiencies in such programs;

2. seeking alternative lower-cost nutrition solutions,

such as fortification of staples or new low-cost

nutritious children's foods (trading off the certain

ties of direct feeding for lower costs and greater

It should be noted that this emphasis on pre-school children and mothers assumes a program objective affecting such a target group. A good case could be made for a program aimed at the low-income adult labor force on the grounds that a sick father results in shutting off a family's principal source---of income and thereby adversely affects the diet of the whole family. In addition, such a program might yield significantbenefits to the society in the form of increased productivity,entrepreneurial institutions, etc. Similarly, one may justifyinvestment in school feeding as a device for keeping children in schoo 1.

I I I I I I I I I I I I I I I I I I I

I -37

I

I I coverage) or improvement of nutrient util ization

through health and sanitation measures, etc.;

I 3. re-examining priorities of target groups (e.g.,

concentrating only on the 0-3 age group or only on

urban low-income groups).

I 4. intensified efforts to increase production of selected foods in developing countries, improving marketing and

other programs to bring down market prices;I I 5. re-examination by food donors of the possibil ities

I

for expanding their food donation programs by delib

I erately programming production to produce surpluses for this purpose; and

I 6. concentration on those nutritional deficiencies which, while costly, require considerably lower levels of

expenditure than direct feeding aimed at protein/

I calorie malnutrition. Vitamin A fortification of all salt in India would cost the equivalent-of about

I I US$27 mill ion per year or almost one percent of the

Government's budget; iron fortification would cost

the equivalent of about US$4 million per year or one

I fifth of the funds set aside annually for nutrition

I

in the Indian Fourth Five Year Plan.

I A number of the foregoing avenues of action may lend themselves to Bank participation.

I

I

-38 I Gaps the Bank Can Fill I

This review of th~ nature of the malnutrition problem and

responses to it indicates several gaps in what the various I agencies are doing which the Bank might help fill.

II. Adequate attention to nutrition requires, in the first

instance,attention from key leaders of governments, I including those with whom the Bank regularly consults

--ministers of finance and heads of planning bodies. I 2. Nutrition problems and remedies cut across sectors,

traditional ministries (and UN special ized agencies) I and require analysis of health problems, agricultural I production systems, food distribution, food processing,

pricing pol icies, education and mass communications, I family planning, transportation, consumer preferences,

development finance and economics. No international I agency has thus far undertaken the scope of analysis I needed to help countries formulate national nutrition

pol icies and programs. The Bank can make a significant I contribution in this regard in collaboration with UN

specialized agencies by encouraging the kind of analysis I needed to facil itate decision-making on nutrition problems Iand remedies.

3. The amounts of assistance thus far appl ied specifically I to nutrition problems, other than for direct feeding

programs, are far too small to have a consequential I impact. The Bank group, as the principal international I source of loan funds, can help provide needed resources, at least in a few country situations. I

I

I -39

I IV. GENERAL CONSIDERATIONS AFFECTING BANK PARTICIPATION

I

I

Arguments Against

I Although the Bank has already indicated its willingness to assist member countries on malnutrition problems, it may be

useful to review some of the arguments raised against extensive

I Bank involvement. A. The Bank Cannot Do Everything

I The magnitude of malnutrition is such that any substantial attack on the problem will require a reordering of priorities

I I

and would represent a substantial claim against Bank staff time

and financial resources. Nutrition is inextricably linked with

health problems and might lead to proposals for financing com

I prehensive health services. The Bank does not presently finance health projects. Nutrition and health are IIsoftli areas and unduly

I I extensive Bank participation might complicate the Bank's borrowings

from private money markets.

B. The Countries Are Not Ready

I Nutrition is generally not given a high priority in development plans. Few countries have even begun to develop a national

I I nutrition program. Few project possibilities have been identified

that are of any scale and that seem suitable for loan financing.

Countries may be unwilling to utilize their limited debt servicing

I capacity to borrow for this purpose•. Nutrition is linked with social welfare and as such may be more suitable for grant assis

I tance. I

I

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I C. The Bank is Not Ready

IIt is not organized nor does it have the expertise to help in formulating projects or to make sound judgments about project I proposals. Nutrition projects are likely to require more local

currency than foreign exchange and to entail continuing support I for recurring operating costs rather than for capital equipment.

Even if countries were willing to borrow, it is not clear that I the Bank should lend under these circumstances. I

D. The State of the Nutrition Art is Not Ready

In many countries, adequate data are not available to pro I vide a basis for a reasonably precise analysis of the nature,

extent and significance of the malnutrition problem. Further, I the complexities and the interactions of tangible and intangible Ivariables affecting malnutrition and alternative remedial actions

raise questions about whether benefits in fact flow from a given I investment and if so, whether these can be measured or even

adequately defined at this time. For example, the existence of I enteric diseases could vitiate the benefits of providing additional Inutrients. There are simply too many unknowns--biologically,

socially, culturally, etc. The B~nk would face the prospect of I financing essentially experimental projects in order to learn

the answers to key questions about achieving change in nutritional I status. IE. Nutrition is a Result of, Not a

Contribution to, Development

Better'-nutrition will follow economic growth. When employ- I ment and incomes increase, better diets will become attainable, I

I

I -41

I especially as maldistribution of income is corrected. The

I

I Bank, already heavily engaged in attacking development problems,

is increasing its attention to income distribution problems,

and thus may already be doing the most important tasks leading

I to better nutrition.

I I The foregoing arguments addressed to limiting Bank involve

ment in malnutrition problems could presumably be rebutted along

the following lines by advocates of Bank initiatives in this

I field:

I Arguments For

A. The Problem Needs Early Intensified Attention

I The very magnitude of the problem, its social, political

I

and economic implications for the future, and the inadequacy

I of remedial efforts to date, are what led the Bank's President, in his recent statements, to urge intensified attention to

-malnutrition and to announce Bank willingness to provide assis

tance. Indeed, the Bank is already considering the inclusionI 1

I

of a child feeding program in a population project in India at

I the request of the Government of India. In some respects, this exercise of leadership by the Bank may be one of the most impor

tant forms of Bank involvement. While the Bank may not be the

I ideal instrument for operating in this field, its prestige and influence may stimulate more action by more suitable instruments.

I I See address to the U.N. Economic and Social Council, October 28, 1971. I

-42-I I

B. The Bank Has Skills to Contribute

Further, the Bank1s participation in consideration of I nutrition projects might bring a broader conceptual approach

Iand an analytical capability which the field of nutrition planning badly needs. It is important to recognize that, to a I very considerable extent, current nutrition activities have

been quite narrowly conceived. Responsibility for nutrition I is often lodged in health ministries and nutrition project pro

posals tend to flow from health-oriented nutrition scientists, I physicians and, in some cases, food technologists. Because I of the nature of malnutrition and its multi-sectoral and multi

discipline character--agriculture, transportation, marketing, I education, family planning, industry, health, finance, economics-

there is a need for much broader and deeper country-oriented I analysis of the problems and of alternative projects and programs I if consequential improvements are to be achieved. This is an

approach which the Bank appears to be developing in other pro I blem areas (e.g., agriculture, rural development, urban projects)

and in which the Bank has a clear comparative advantage compared I with other organizations participating in nutrition activities. IThus, in a very practical sense, the problem needs the Bank rather

than the other way around. I C. The Bank Has Financial Resources Which Are Needed

In addition, as the principal international source of loan I capital, the Bank sooner or later must find some means of supporting I

I

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I -43

I

I

efforts in an area which badly needs additional financial

I resources and which as a result has been characterized by token programs and pilot projects, almost entirely grant

I

financed, which are rarely expanded. Some of these projects,

I with appropriate modification efforts, might be suitable for Bank financing. At the very least, the Bank could encourage

I countries to evaluate systematically the performance of existing projects to determine their potential effectiveness if expanded

with Bank assistance.

I D. The Bank's Loan Ground Rules Are Flexible

I

Earlier Bank decisions to participate in education and

I population control programs have led to precedents which answer some of the arguments for very limited Bank involvement in

I malnutrition problems. The Bank has already decided, in certain

cases, to finance local currency costs and to finance recurring

operating costs for a specified period,especially where the Bank

I wishes to encourage innovation. It does not presently require, in population and education projects,the rigorous rate-of-return

I I

ana 1 ys is requ i red for proj ects in other fie 1ds. It judges

country capacity to repay on the country's overall financial

I I

position rather than on each project's financial viability.

I E. The Bank Can M.ake Itself "Ready" for Nutrition Having decided to enter the fields of population and educa

tion, the Bank made itself "ready" by establishing organizational

entities and assembling expert staff. It can do so in nutrition,

should it so decide. On another readiness question, population

I

I

I -44

I and educa t i on presented the issue of proj ect "sof tness II in

Ithe Bank's loan portfolio with no adverse effect on the Bank's position as a borrower in private money markets. It is doubtful I that the Bank's engagement in nutrition projects will have any

significant effect on its overall financial position. Although I probably more costly, nutrition programs, in some respects,

present fewer problems than population control. Nutrition I is less "sensitive" than family planning and consumer motivation I is higher. Unlike population programs, certain nutrition projects,

such as fortification, require no large administrative apparatus I and the technology is available. Health and nutrition are elements

in human capital formation and as such are related to economic I development. I

F. Some of the Member Countries Are "Ready" for

Nutrition Projects

IThere thus remain the questions of whether member countries are "ready" to increase attention to nutrition and whether bank- I able projects are likely to be developed. Member countries appear

to be increasingly concerned with accelerating beneficial social I change. Improved nutrition is a fundamental element in any

program to correct social inequity and nutrition programs are, I in effect, a form of income redistribution. A few countries I (such as India, Zambia, Colombia, Chile) have incorporated nutri

tion as a component of their economic development planning. At I

the October, 1971 MIT International Conference on Nutrition,

National Development and Planning, representatives of a number I

I

I

I -45

I of developing countries reported the increased priority being

I accorded by their governments to nutrition. The stimulus provided by Bank expression of interest in the problem will

I

I

tend to intensify attention and project development efforts

by member countries. Enough is known about the problem and

possible solutions in at least a few countries to provide a

I basis for report.

I

I

I

I

I

I

I

I

I

I

I

I

I

the kinds of Bank activity discussed later in this

--

I -46

I v. POSSIBLE WORLD BANK ROLES IN NUTRITION I

The concern for malnutrition problems manifested in

IMr. McNamara's addresses to the Board of Governors and to the United Nations Economic and Social Council can be translated I into Bank actions ranging from occasional reiteration that a

serious problem exists to extensive pol icy and organizational I changes leading to financing of major projects with nutrition

goals. The options described below reflect logical cluster I points along the continuum of Bank involvement, although the I Bank might elect a response combining activities from several

levels. These choices are treated below in non-operational I (i.e. non-project activities) and operational (i.e. project

related activities) categories of Bank actions. There is, of I course, a greater I ikel ihood of synergistic effects from I involvement in all of the functional areas, , because -of their

interdependence~ I A. Non-Operational Bank Roles

Although financing investment projects remains the I primary interest and activity of IBRD, its prestige, influence, Iand non-project activities can be formidable assets for affect

ing the attitudes of borrowing-country governments to nutrition. I Many observers credit increased family planning activities in

the developing world as much to Bank informal influence as to I project activity. A similar Bank role in nutrition is feasible Iand usefu I .

I

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I -47

I 1 • Focusing Attention on Nutrition as a DevelopmentI Priority

I I I I I I I I I I I I I I I I

a.

b.

The recent speeches by the President of the

Bank have begun this process not only among

leaders, planners and economist? of member

governments but also within the development

community generally, including World Bank

staff. This process can be continued by top

officers of the Bank formally in other appro

priate contexts, including consortia and con

sultative groups, as well as informally in

the frequent consultations between Bank staff

members and member governments. Indeed, the

Bank as the organizer of a consortium might

play the role of catalyst in stimulating joint

action by donors in a large-scale nutrition

program, possibly by encouraging a nutrition

working group within the framework of a con

sortium.

This influence can be powerfully reinforced

by including consideration of nutrition prob

lems and their implications in the Bank's annual

country economic reports and agricultural

and other sector reviews. Even if the Bank

does not engage in nutrition project lending,

such consideration will tend to generate atten

tion, may influence agricultural production

and food pricing pol icies, and help shape

I -48

I expenditure priorities by member governments Iand donors of technical and financial ass is

tance other than the Bank. By this means, I the Bank is in a position to broaden devel

opment views beyond the traditional preoccu I pation with aggregate economic growth to the Iconsideration of improved nutrition as a legiti

mate national goal. I c. The Bank could consider the inclusion of some

work on nutrition planning as part of the I curr i cu h-:!m ot: the Economi c Development Inst i

Itute. This step would provide a valuable adjunct to the training program and may signi I ficantly increase the likelihood of intensified

analytical attention to nutrition problems by I member governments. There exists now only a

tiny cadre of people trained in nutrition pro I blem analysis and programming and no institutions I which provide such training on a continuing basis.

I 2. Expanded Relationships with Agencies Concerned with

Nut r i t jon I a. The Bank recently has become a member and a

financial contributor to the Protein Advisory I Group. I t can thus keep abreast of, and feed

Iback to Bank staff technical information I

I

I -49I

I

accumulated and generated by the PAG.

I Further, it can draw on the PAG for technical advice, and in some circumstances,

I for experts to participate in Bank missions abroad, including those in connection with

the preparation of country economic reports.

I Equally important, the Bank can contribute an important economic and financial dimension

I to the deliberations of the PAG.

I

I b. For the same reasons, staff level relationships could be broadened between the Bank

I and the nut r i t ion depa rtments of FAO, WHO, UNICEF, PAHO, and the foreign assistance

agencies of donor countries supporting nutri

I tion projects in the developing countries. The Bank may also wish to participate in con

I ferences and working groups convened by reI gional organizations such as Institute for

Nutrition of Central America and Panama (INCAP)

I and the Latin American Nutrition Society (SLAN),

I

concerned with nutrition. While such partici

I pation by the Bank need not imply a commitment to provide financing, it would facil itate ex

change of information, sharpen analysis by the

I addition of economic and financial considerations, and generally encourage intensified

I

I

I -50

I attention to nutrition by recipient and I donor countries.

B. Sponsorship of Research I As noted earl ier in this report, many uncertainties

relating to nutrition inhibit investment decisions in nutrition I projects. Some of these uncertainties may be el iminated by selec I tive research efforts which the 6ank could stimulate ,for finance.

It is possible to conceive of three kinds of research efforts: I 1. The use of a particular operational project to I

generate data needed to clarify certain relation Iships. An example of this would be the proposed

inclusion of a child feeding component in the pop I ulation project now under discussion between India

and the Bank. This project provides an opportuni I ty to test the value of food as an incentive for Iutil izing family planning services, as well as the proposition that improved diet will reduce child I mortal ity which in turn will increase voluntary

limitation of family size. I 2. Research financed separately and carried out inde

Ipendently but linked to a project in a selected country. Examples might include the effect on I diet of an urbanization project, of a nutrition

education project, of an agricultural project de I signed to increase farm income, etc.

I

I

I -51

I 3. Research on problems which are not immediately

I I project oriented and the results of which would

have broad multi-country interest. Such areas

include the relationship between diet and income,

I diet and work performance, diet and health; the effect of severe malnutrition on the cost and

I I effectiveness of primary education; the develop

ment of rate-of-return methodology in the field

of nutrition and health investment. A number of

I such areas are listed in Appendix H. Bank leadership in forming and assisting in financing of the

I I Consultative Group on International Agricultural

Research could readily be extended to broadening

I the focus of the Group and the Technical Advisory

Committee. In addition to the Group's production

oriented investigations (including those on new

I varieties of legumes), it may be feasible to initiate studies that would improve the now-scanty

I I

data base available for planning more effective

distribution and use of that production by the

I

world's population.

I The FAG Nutrition Division has given high priority to survey research that will shift atten

I tion from the early work on definitions, symptoms, and effects of malnutrition to delineation of

I

I

-52- I I

family expenditure and consumption patterns. I This will help identify the determinants of con

sumer behavior and nutritIon levels. Bank con I sultations with WHO may also help make WHO health Ioriented research more relevant to economic plan

ners. Studies of variations of child mortal ity I by diet and income group and the relationships

between diet, infectious diseases, personal hy I giene and environmental sanitation in child mor Itality and morbidity are important in nutrition planning decisions. I

It would seem useful at an early date for the

Bank to consider how best to complement research I presently funded by the Group and the possibility

Iof intensified attention to this end in the PAG. Some shift in research orientation seems appro I priate after reviewing funding availability in

relation to broad food and nutrition problems. I An increase of annual Bank funding for research

accompanied by an attempt to expand financial I participation on the part of donor countries with I nutrition interest would be a major step toward

development of an adequate integrated research I program addressed to the problems of malnutrition

and the relationships critical to doing something I about them. An expansion of program-oriented I

I

I -53

I I research will tend to increase the corps of know

ledgeable analysts which member governments and

I

I institutions such as the Bank will need in plan

ning and implementing nutrition programs.

I It should be noted that some of the foregoing non-operational activities will lead member countries into project identification

I and thus will lead the Bank into consideration of project financingI proposals. Including nutrition in agricultural sector studies,

for example, may in some cases lead to recommendations for changes

I in cropping patterns and pricing pol icies affecting cereals and

I

pulses. In other cases such studies may identify the need for

I specific pulse production projects or storage technology to reduce waste.

c. Operational Bank Roles

I I Although the Bank's counsel and its assistance to re

search would stimulate nutrition-related interest and activity,

I

the incorporation of nutrition considerations into project del ib

I erations and content offers far more potential impact. Project activity by the Bank would confirm for developing countries the

I priority given to nutrition by the Bank and might move the activity out of the social welfare category into a broader developmental arena.

1 • Inc 1 us i on of Nu t r i t i on Imp 1 i cat ionsin Pro iec t Proposal Analysis

I I

As an immediate step, the BaRk can establ ish guide

1ines, and designate staff to monitor them, for

I

-54I

I

assuring that all nutrition-related project

proposals are reviewed and, where appropriate, I modified to take advantage of possible nutri Itional impacts or to eliminate avoidable negative nutrition consequences. Such projects are likely I to be mainly in the fields of agriculture (cereals, . legumes) and possibly also in education (inclusion I of nutrition in mass media programs), urbanization

(providing for child feeding centers), water I supply (located to reinforce existing nutrition I programs), transportation (to facilitate marketing

of fish), and perhaps other fields. This is analo I gous to the present Bank treatment of environmental

concerns. Bank attempts to assure adequate con I sideration of project income distribution and I employment consequences are simila~ though less

rigorous. I This '~hat about the project's effect on nu I

trition?" approach may in some cases prevent

negative nutrition effects and in other cases may I uncover some promising opportunities to recast

proposed project expenditure and activity pat I terns. The absence in most countries of an Iadequate data base for comparing intervention alternatives and designing a sound ~ntegrated I project with nutrition goals need not necessarily

bar action by the borrowing country and the Bank. I I

I -55

I

I

Nutrition-oriented adjustments could be made

I in currently planned projects where such action does not delay project decisions for an unreason

able period.

I All World Bank loans have some impact on nutrition through their effect on consumer income.

I

I Some, such as those for agriculture and irrigation,

influence food supply directly and this often con

tributes substantially to consumer nutrient intake.

I These nutritional results of Bank investments are

rarely considered in choosing and designing pro

I

I jects, so that they are at best by-products inci

dental to the pursuit of other Bank and borrower

objectives. At times, as in projects concerned

I principally with expanding agricultural exports,

I

there may be negative consequences for domestic nu

I trition of lower-income groups, e.g. expansion of acreage for cotton for domestic use with a displace

ment of food production. Here, too, the effects

I are sometimes not fully considered in project appra i sa 1.

I I The Bank need make no commitment to the

financing of a new class of "nutrition projects ll

and, nevertheless, may still broaden the nutri

I tional impact of project proposals (in process of preparation or submitted for Bank review)

I

I

I -56

I that already involve nutrition-related activities.

A decision to "consider nutrition" can produce im I portant nutritional improvement without affecting Ichoice of projects, through influence on their

structure and content during preparation and the I approval process.

a. Modifying Agriculture and Fisheries Proposals I No simple criteria can be given for deciding

Iwhen and how a project should be mod1fied to improve nutritional impact, but even the most rigorous pro I ject analysts should have little difficulty with

low-cost modifications that help nutrition without I fundamentally disturbing other aspects of project

return. FAO Development Centre staff identified I promising possibilities, for example, in uSing,for I domestic consumption, food not of export quality,

e.g., fish, bananas. Failure to do this in current I projects was partly due to the borrowers' impression

that the Bank gave low priority to such possibilities. I b. Modifying Population Proposals I

In addition to the more obvious nutritional

impacts through modification of agricultural and I fisheries export projects, other possibilities can

be identified. In population projects, for example, I the possible relationship between child survival, Iheavily influenced by nutrition, and parental

I

I

I -57

I motivation to limit family size means that

I I nutrition-related activity may impact heavily on

achievement of family planning goals. The admini

strative structures used to deliver family

I planning education and services can frequently be adapted with little difficulty to nutrition

I education and food delivery to pregnant women. Review of fu