Re-Positioning Nutrition
HDNHE
Nov 2005
Malnutrition Poverty
• Leads to a >10% potential reduction in lifetime earnings for each malnourished individual
• GDP losses 2-3%
• Malnutrition (stunting) in early years linked to a – 4.6 cm loss of height in adolescence– 0.7 grades loss of schooling– 7 month delay in starting school
Source: Alderman et al (2003)
(Improved nutrition can be a driver of growth)
Source: Haddad et al (2003)
The income-malnutrition relationshipThe trickle-down effect is modest…
0
10
20
30
40
0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000GNP per capita (PPP)
Per
cent
of u
nder
wei
ght
child
ren
<5 (%
)
1990's
1970's1980's
India: Income alone is insufficient to reach the nutrition MDG
Data Source: World Bank (2005)
0
10
20
30
40
50
1998 2004 2010 2016
Pre
va
len
ce
of
un
de
rwe
igh
t (%
)
3.0% p.c. growth/0.3 elasticity3.0% p.c. growth/0.5 elasticity5.0% p.c. growth/0.5 elasticityMDG
2059
2034
2020
MDG will be met in
Nutrition and poverty…India: Percent of children under 5 whose weight for age is below -2SD z-score by income quintiles
Income Quintiles
% Under five children with weight-for-age
below –2 SD
% children 6-59 months with HB<11
g/dl Male Female Both Male Female Both Lowest 59.7 61.5 60.7 80.2 77.2 78.8 Second 51.7 56.5 54.0 80.0 77.8 79.0 Middle 47.2 51.3 49.2 75.0 75.1 75.1 Fourth 37.6 40.3 38.9 73.3 71.1 72.3 Highest 25.2 27.6 26.4 65.1 62.7 63.9
Source: Gwatkin et al. 2003
MDG 1- “Eradicate extreme poverty and hunger”
• Targets: Halve between 1990 and 2015– Proportion of people income is <1$/day (income poverty)
– Proportion of people who suffer from hunger (non-income poverty)
• Indicators for “hunger” (non-income poverty) target:– Prevalence of under-weight children (<5 yrs)– Proportion of population below minimum level of
dietary energy consumption
• Most reviews to-date have focused on income-poverty target – and the diagnosis is: “poverty goal on track”!!!
Progress on non-income poverty (nutrition MDG)On track (34/143=24%) Some improvement, but not on track (26/143=18%) AFR (7) Angola Benin Botswana Chad Gambia Mauritania Zimbabwe
EAP (5) China Indonesia Malaysia Thailand Vietnam
ECA (6) Armenia Croatia Kazakhstan Kyrgyz Rep Romania Turkey
LAC (10) Bolivia Chile Colombia Dominican Rep Guyana Haiti Jamaica Mexico Peru Venezuela
MNA (6) Algeria Egypt Iran Jordan Syrian Arab Rep Tunisia
SAR (0)
AFR (14) CAR Congo, DR Côte d'Ivoire Eritrea Gabon Ghana Kenya Madagascar Malawi Mozambique Nigeria Rwanda Sierra Leone Uganda
EAP (3) Cambodia Lao, PDR Philippines ECA (0)
LAC (4) El Salvador Guatemala Honduras Nicaragua
MNA (1) Morocco
SAR (4) Bangladesh* India Pakistan Sri Lanka
Deteriorating status (26/143=18%) No trend data available (57/143=40%) AFR (13) Niger Burkina Faso Cameroon Comoros Ethiopia Guinea Lesotho Mali Senegal Sudan Tanzania* Togo Zambia
EAP (2) Mongolia Myanmar
ECA (4) Albania Azerbaijan Russian
Federation Serbia &
Montenegro
LAC (3) Argentina Costa Rica Panama
MNA (2) Iraq Yemen, Rep
SAR (2) Maldives Nepal
AFR (13) Burundi Cape Verde Congo, R Equatorial
Guinea Guinea-Bissau Liberia Mauritius Namibia São Tomé &
Principe Seychelles Somalia South Africa Swazil&
EAP (11) Fiji Kiribati Marshall Islands Micronesia, FS Palau Papua New
Guinea Samoa Solomon Islands Timor-Leste Tonga Vanuatu
ECA (17) Belarus Bosnia-
Herzegovina Bulgaria Czech Republic Estonia Georgia Hungary Latvia Lithuania Macedonia, FYR Moldova Poland Slovak Republic Tajikistan Turkmenistan Ukraine Uzbekistan
LAC (12) Belize Brazil Dominica Ecuador Grenada Paraguay St. Kitts &
Nevis St. Lucia St.Vincent & the
Grenadines Suriname Trinidad &
Tobago Uruguay
MNA (2) Djibouti Lebanon
SAR (2) Afghanistan Bhutan
The Copenhagen Consensus ranks the provision of micronutrients as a top investment…
Above trade liberalization, malaria, water/sanitation…
Rating Challenge Opportunity 1. Diseases Control of HIV/AIDS 2. Malnutrition and hunger Providing micronutrients 3. Subsidies and Trade Trade liberalization
Very Good
4. Diseases Control of malaria 5. Malnutrition and hunger New agricultural technologies 6. Sanitation and Water Small-scale water technologies 7. Sanitation and Water Community-managed systems 8. Sanitation and Water Research on water in agriculture
Good
9. Government Lowering cost of new business 10. Migration Lowering barriers to migration 11. Malnutrition and hunger Improving infant/child malnutrition 12. Diseases Scaling up basic health services
Fair
13. Malnutrition and hunger Reducing the prevalence of low birth weight Poor 14-17 Climate/Migration Various
Source: Bhagwati et al. (2004)
…And the benefit:cost ratios for investing in direct nutrition interventions are very high.
Global trends in underweight (Children 0-4 Years)
1980-2005
Data Source: de Onis et al (2004)
0
15
30
45
60
75
1980 1985 1990 1995 2000 2005
Pre
vale
nce
of
un
der
wei
gh
t (%
)
AfricaAsiaLACDevelopingDeveloped
0
40
80
120
160
200
1980 1985 1990 1995 2000 2005N
o. o
f u
nd
erw
eig
ht
child
ren
(m
illio
n)
AfricaAsiaLACDevelopingDeveloped
Global trends in underweight (Children 0-4 Years)
1980-2005
Data Source: de Onis et al (2004)
0
15
30
45
60
75
1980 1985 1990 1995 2000 2005
Pre
vale
nce
of
un
der
wei
gh
t (%
)
BangladeshIndiaChina
0
40
80
120
160
200
1980 1985 1990 1995 2000 2005N
o. o
f u
nd
erw
eig
ht
child
ren
(m
illio
n)
AfricaAsiaLACDevelopingDeveloped
Maternal Overweight Rates
0
20
40
60
80
0 15 30 45 60% child (<3y) underweight (WAZ<2)
% m
ater
nal
ove
rwei
gh
t (B
MI>
=25)
AFREAPECALACMNASAR
Egypt
J ordan
MauritaniaGuatemala
Yemen
IndiaBangladesh
HaitiNigeria
Cambodia
Zimbabwe
Turkey
Uzbekistan
P eru
Ghana
0
20
40
60
80
0 10 20 30 40 50% maternal undernutrition (BMI<18.5)
% m
ater
nal
ove
rwei
gh
t (B
MI>
=25)
AFREAPECALACMNASAR
Egypt
J ordan
Mauritania
Zimbabwe
Yemen
Bangladesh
India
NigeriaHaiti
Guatemala
Cambodia
Armenia
Turkey
Uzbekistan
P eru
Ghana
Data Source: Measure DHS com; Author’s calculations
Malnutrition affects both poor and rich countries…and Underweight children and overweight adults are often found in the same poor countries/households
The “Window of Opportunity” for Improving Nutrition is very small…pre-pregnancy until 18-24 months of age
-2.00
-1.75
-1.50
-1.25
-1.00
-0.75
-0.50
-0.25
0.00
0.25
0.50
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60
Age (months)
Weig
ht
for
ag
e Z
-sco
re (
NC
HS
) Latin America and Caribbean
Africa
Asia
Source: Shrimpton et al (2001)
Poor water/sanitation and
inadequate healthservices
Child nutrition,survival and development
Inadequatematernal and child-
care practices
Insufficient accessto food
Quantity and quality of actualresources - human, economicand organizational - and the
way they are controlled
Potential resources: environment, technology, people
Causes of Child Malnutrition
Inadequate dietaryintake
Disease
Basic causes atsocietal level
Outcomes
Immediate causes
Underlying causes at household/ family level
Political, cultural, religious, economic and social systems, including women’s status, limit the utilization of potential resources
Inadequate and/or inappropriate knowledge and discriminatory attitudes limit household access to actual resources
Source: The State of the World’s Children 1998
FOOD HEALTHCARE
Malnutrition and Child Mortality
ARI19%
Diarrhoea19%
Measles7%
Malaria5%
Other32%
Perinatal causes18%
Figure 3:Malnutrition and child mortality:(11.3 mil <5 deaths/yr; 55% linked to malnutrition)
Malnutrition55%
Source: WHO, based on C.J. L. Murray & A.D. Lopez, The Global Burden of Disease, Harvard Univ. Press,Cambridge (USA), 1996; and D.L. Pelletier, E.A. Frongilo and J.P. Habicht, ‘Epidemiological evidence for apotentiating effect of malnutrition on child mortality’, in Amer. Journal of Public Heal th, 1993:83
Malnutrition is implicated in >55% under-5 deaths – a proportion unmatched by any disease other than the “Black death”.
Short and Long Routes to Improving Nutrition
• Long routes… income growth, women’s education, agriculture and food production interventions, gender interventions
• Short routes: Exclusive breast-feeding, appropriate complementary feeding, ante-natal care for mothers,… (Knowledge, behavior change/demand side interventions); micronutrient supplementation/fortification
• Many success stories via a balance between long and short routes: Mexico, Bangladesh, Madagascar, Thailand, Honduras, Chile, Cuba…
Why Invest in nutrition?
• Malnutrition reduces intelligence & productivity; slows economic growth; constrains poverty reduction
• Benefit-cost ratios are high
• The Bank now has sufficient experience and evidence (though learning thru strong M&E must continue)
The greatest challenge to scaling up is sustained country (and donor) commitment and capacity
The Bank is the largest investor in nutrition globally But, current commitments to nutrition* are modest (April 2005)
AFR EAP ECA LAC MNA SAR Total m$
Total # Investments
ED 12 17 7 35 4
RDV 47 11 58 5
SP 22 2 24 3
TR 141 141 2
HNP 80 12 7 39 25 242 404 22
TToottaall 330011 2233 77 5555 3322 224444 666622 3366 This is 3.8% of HD theme, 0.7% of Bank-wide lending;*Includes food security
Nutrition
• Not just a welfare issue
• Nor is it primarily a food or a consumption issue
• It is one of the drivers of economic growth
Summary recommendations... One size does not fit all!
• Focus on poor to address non-income poverty
• Focus investments on “window of opportunity” (pre-pregnancy to 2 years)
• Balance between supply and demand-side, long and short route interventions
• Invest in micronutrients (where appropriate)
• Maximize potential to improve nutrition thru policies/progs in:– Health, ARD, gender, water/sanitation, education, CDD – Systematic PSIAs for Macroeconomic and sectoral policies
Next steps: Re-position nutritionA Bank-led re-positioning of nutrition timely
Operational level (regions):• Scale up undernutrition and micronutrient
investments• Reorient existing large-scale investments as
needed• Invest in strengthening commitment and capacity• Support learning by doing:
– Overweight/obesity/NCDs; Nutrition in HIV – Mainstream nutrition in to
PRSPs/PRSCs/SWAps
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