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Malnutrition causes economic loss, half of all child deaths
World Bank Group
2006-03-06
It has long been known that malnutrition undermines economic growth and perpetuates poverty. Yet the international community and most governments in developing countries have failed to tackle malnutrition over the past decades, even though well-tested approaches for doing so exist. The consequences of this failure to act are now evident in the world's inadequate progress toward the Millennium Development Goals (MDGs) and toward poverty reduction more generally.
Persistent malnutrition is contributing not only to widespread failure to
meet the first MDG--to halve poverty and hunger--but to meet other goals in
maternal and child health, HIV/AIDS, education, and gender equity. The
unequivocal choice now is between continuing to fail, as the global community
did with HIV/AIDS for more than a decade, or to finally make nutrition central
to development so that a wide range of economic and social improvements that
depend on nutrition can be realized.
Three Reasons for Intervening to Reduce Malnutrition, High economic
returns high impact on economic growth and poverty reduction
The returns to investing in nutrition are very high. The Copenhagen Consensus
concluded that nutrition interventions generate returns among the highest of 17
potential development investments (table 1). Investments in micronutrients were
rated above those in trade liberalization, malaria, and water and sanitation.
Community-based programs targeted to children under two years of age are also
cost-effective in preventing undernutrition.
Overall, the benefit-cost ratios for nutrition interventions range between 5 and
200 (table 2).
Malnutrition slows economic growth and perpetuates poverty through three
routes--direct losses in productivity from poor physical status indirect losses
from poor cognitive function and deficits in schooling and losses owing to
increased health care costs. Malnutrition's economic costs are substantial:
productivity losses to individuals are estimated at more than 10 percent of
lifetime earnings, and gross domestic product (GDP) lost to malnutrition runs as
high as 2 to 3 percent. Improving nutrition is therefore as much--or more--of an
issue of economics as one of welfare, social protection, and human rights.
Reducing undernutrition and micronutrient malnutrition directly reduces poverty,
in the broad definition that includes human development and human capital
formation. But undernutrition is also strongly linked to income poverty. The
prevalence of malnutrition is often two or three times--sometimes many
times--higher among the poorest income quintile than among the highest quintile.
This means that improving nutrition is a pro-poor strategy, disproportionately
increasing the income-earning potential of the poor.
Improving nutrition is essential to reduce extreme poverty. Recognition of this
requirement is evident in the definition of the first MDG, which aims to
eradicate extreme poverty and hunger. The two targets are to halve, between 1990
and 2015:
The proportion of people whose income is less than 1 a day.
The proportion of people who suffer from hunger (as measured by the
percentage of children under five who are underweight).
The first target refers to income poverty the second addresses nonincome
poverty. The key indicator used for measuring progress on the nonincome poverty
goal is the prevalence of underweight children (under age five).Therefore,
improving nutrition is in itself an MDG target. Yet most assessments of progress
toward the MDGs have focused primarily on the income poverty target, and the
prognosis in general is that most countries are on track for achieving the
poverty goal. But of 143 countries, only 34 (24 percent) are on track to achieve
the nonincome target (nutrition MDG) (figure 1). No country in South Asia, where
undernutrition is the highest, will achieve the MDG--though Bangladesh will come
close to achieving it, and Asia as a whole will achieve it. More alarmingly
still, nutrition status is actually deteriorating in 26 countries, many of them
in Africa, where the nexus between HIV and undernutrition is particularly strong
and mutually reinforcing. And in 57 countries, no trend data are available to
tell whether progress is being made. A renewed focus on this nonincome poverty
target is clearly central to any poverty reduction efforts.
The alarming shape and scale of the malnutrition problem
Malnutrition is now a problem in both poor and rich countries, with the poorest
people in both sets of countries affected most. In developed countries, obesity
is rapidly becoming more widespread, especially among poorer people, bringing
with it an epidemic of diet-related noncommunicable diseases (NCDs) such as
diabetes and heart disease, which increase health care costs and reduce
productivity. In developing countries, while widespread undernutrition and
micronutrient deficiencies persist, obesity is also fast emerging as a problem.
Underweight children and overweight adults are now often found in the same
households in both developing and developed countries.
Nearly one-third of children in the developing world remain underweight or
stunted, and 30 percent of the developing world's population continues to suffer
from micronutrient deficiencies. But the picture is changing (figure 2):
In Sub-Saharan Africa malnutrition is on the rise. Malnutrition and HIV/AIDS
reinforce each other, so the success of HIV/AIDS programs in Africa depends in
part on paying more attention to nutrition.
In Asia malnutrition is decreasing, but South Asia still has both the highest
rates and the largest numbers of malnourished children. Contrary to common
perceptions, undernutrition prevalence rates in the populous South Asian
countries-- India, Bangladesh, Afghanistan, Pakistan-- are much higher (38 to 51
percent) than those in Sub-Saharan Africa (26 percent).
Even in East Asia, Latin America, and Eastern Europe, many countries have a
serious problem of undernutrition or micronutrient malnutrition. Examples
include Cambodia, Indonesia, Lao PDR, the Philippines, and Vietnam Guatemala,
Haiti, and Honduras and Uzbekistan.
In a recent WHO study (De Onis and others 2004b), underweight prevalence in
developing countries was forecast to decline by 36 percent (from 30 percent in
1990 to 19 percent in 2015)--significantly below the 50 percent required to meet
the MDG over the same time frame (figure 3). These global data mask
interregional differences that are widening disturbingly. Much of the forecast
global improvement derives from a projected prevalence decline from 35 to 18
percent in Asia--driven primarily by the improvements in China. By contrast, in
Africa, the prevalence is projected to increase from 24 to 27 percent. And the
situation in Eastern Africa--a region blighted by HIV/AIDS, which has major
interactions with malnutrition--is critical. Here underweight prevalences are
forecast to be 25 percent higher in 2015 than they were in 1990.
Many countries (excluding several in Sub-Saharan Africa) will achieve the MDG
income poverty target (percentage of people living on less than 1 a day), but
less than 25 percent will achieve the nonincome poverty target of halving
underweight (figure 3). Even if Asia as a whole achieves that target, large
countries there including Afghanistan, Bangladesh, India, and Pakistan will
still have unacceptably high rates of undernutrition in 2015, widening existing
inequities between the rich and the poor in these countries.
Deficiencies of key vitamins and minerals continue to be pervasive, and they
overlap considerably with problems of general undernutrition (underweight and
stunting). A recent global progress report states that 35 percent of people in
the world lack adequate iodine, 40 percent of people in the developing world
suffer from iron deficiency, and more than 40 percent of children are vitamin A
deficient.
Trends in overweight among children under five, though based on data from a
limited number of countries, are alarming (figure 4)--for all developing
countries and particularly for those in Africa, where rates seem to be
increasing at a far greater rate (58 percent increase) than in the developing
world as a whole (17 percent increase). The lack of data does not allow us to
give definitive answers for why Africa is experiencing this exaggerated trend
however, the correlation between maternal overweight and child overweight
suggests that one of the answers may lie therein.
Comparable data for overweight and obesity rates among mothers show similar
alarming trends. Countries in the Middle East and North Africa have the highest
maternal overweight rates, followed by those in Latin America and the Caribbean.
However, several African countries have more than 20 percent maternal overweight
rates.
Also evident is that overweight coexists in the same countries where both child
and maternal undernutrition are very widespread and in many countries with low
per capita GNP (figure 5). In Mauritania, more than 40 percent of mothers are
overweight, while at the same time more than 30 percent children are
underweight. Furthermore, as many as 60 percent of households with an
underweight person also had an overweight person, demonstrating that underweight
and overweight coexist not only in the same countries but also in the same
households. In Guatemala, stunted children and overweight mothers coexist.
Again, these data support the premise that, except under famine conditions,
access to and availability of food at the household level are not the major
causes of undernutrition.
Markets are failing
Markets are failing to address the malnutrition problem wherever families do not
have the money to buy adequate food or health care. Human rights and equity
arguments, as well as economic return arguments, can be made for governments to
intervene to help such families. But malnutrition occurs also in many families
that are not poor--because people do not always know what food or feeding
practices are best for their children or themselves, and because people cannot
easily tell when their children are becoming malnourished, since faltering
growth rates and micronutrient deficiencies are not usually visible to the
untrained eye. The need to correct these informational asymmetries
is another argument for government intervention (box 1). And governments should
intervene because improved nutrition is a public good, benefiting everybody for
example, better nutrition can reduce the spread of contagious diseases and
increase national economic productivity.
What Causes Malnutrition and How Should Governments Intervene?
Contrary to popular perceptions, undernutrition is not simply a result of food
insecurity: many children in food-secure environments and from nonpoor families
are underweight or stunted because of inappropriate infant feeding and care
practices, poor access to health services, or poor sanitation. In many countries
where malnutrition is widespread, food production is not the limiting factor (
box 2), except under famine conditions. The most important factors are, first,
inadequate knowledge about the benefits of exclusive breastfeeding and
complementary feeding practices and the role of micronutrients and second, the
lack of time women have available for appropriate infant care practices and
their own care during pregnancy.
Undernutrition's most damaging effect occurs during pregnancy and in the first
two years of life, and the effects of this early damage on health, brain
development, intelligence, educability, and productivity are largely
irreversible (box 3). Actions targeted to older children have little, if any
effect. Initial evidence suggests that the origins of obesity and NCDs such as
cardiovascular heart disease and diabetes may also lie in early childhood.
Governments with limited resources are therefore best advised to focus actions
on this small window of opportunity, between conception and 24 months of age,
although actions to control obesity may need to continue later.
In countries where mean overweight rates among children under age five are high,
a large proportion of children are already overweight at birth-- suggesting
again that the damage happens in pregnancy. These results are consistent with
physiological evidence that the origins of obesity start very early in life,
often in the womb, though interventions to prevent obesity must likely continue
in later life.
Income growth and food production, as well as birth spacing and women's
education, are therefore important but long routes to improving nutrition.
Shorter routes are providing health and nutrition education and services (such
as promoting exclusive breastfeeding and appropriate complementary feeding,
coupled with prenatal care and basic maternal and child health services) and
micronutrient supplementation and fortification. Experience in Mexico shows that
in middle-income countries conditional cash transfers, coupled with improved
health and nutrition service delivery on the supply side, have gotten poor
people to use nutrition services. Other countries, such as Bangladesh, Honduras,
and Madagascar, have successfully used government-nongovernment partnerships to
mobilize communities to tackle malnutrition through community-based approaches.
Experience in dealing with different forms of malnutrition is at different
stages of development:
For undernutrition and micronutrient malnutrition, several large-scale
programs have worked (in Bangladesh and Thailand, in Madagascar, and in Chile,
Cuba, Honduras, and Mexico). The challenge is to apply their lessons at scale in
more countries. The issue is less about what to do than about how to strengthen
both countries' and development partners' commitment and capacity to scale up.
By contrast, for overweight and diet-related NCDs, low birthweight, and the
complex interactions between malnutrition and HIV/AIDS, there are few tried and
tested large-scale models. Action research and learning-by-doing are the
priority here, but large-scale HIV or NCD control efforts cannot be successful
without addressing nutrition--so the challenge is to shorten the time lag
between developing the science and scaling up action.
Although some successful programs have been scaled up without comprehensive
nutrition policies, policy is important as well. Few countries have
well-developed and well-resourced nutrition policies. More often, policies in
other sectors (trade, foreign exchange, employment, gender, agriculture, social
welfare, and health) have a haphazard, sometimes negative effect on nutrition
and become unintentional but de facto nutrition policies. Poverty and Social
Impact Analyses (PSIAs) should be more widely used to assess the intentional and
unintentional effects of development policies on nutrition outcomes. And the
capacity to advise policy makers about the nutrition implications of policy
needs to be developed in a focal institution, such as a ministry of finance or a
poverty monitoring office.
Policy also has a potential role in diminishing the poor health and negative
economic outcomes associated with the increase in overweight and obesity in
developing countries through both demand-side and supply-side interventions.
If effective interventions exist, why have they not been scaled up in more
countries?
Nutrition programs have been low priority for both governments and development
partners for three reasons (box 5). First, there is little demand for nutrition
services from communities because malnutrition is often invisible families and
communities are unaware that even moderate and mild malnutrition contributes
substantially to death, disease, and low intelligence and most malnourished
families are poor and hence have little voice. Second, governments and
development partners have been slow to recognize how high malnutrition's
economic costs are, that malnutrition is holding back progress not only toward
the malnutrition MDG but also toward other MDGs, or that there is now
substantial experience with how to implement cost-effective, affordable
nutrition programs on a large scale. Third, there are multiple organizational
stakeholders in nutrition, so malnutrition often falls between the cracks both
in governments and in development assistance agencies--the partial
responsibility of several sectoral ministries or agency departments, but the
main responsibility of none. Country financing is usually allocated by sectors
or ministries, so unless one sector takes the lead, no large-scale action can
follow.
How the international development community can help countries do more
Countries need to take the lead in repositioning nutrition much higher in their
development agenda. When countries request help in nutrition, development
partners must respond first by helping countries develop a shared vision and
consensus on what needs to be done, how, and by whom, and then by providing
financial and other assistance. This report argues that much of the failure to
scale up action in nutrition results from a lack of sustained government
commitment, leading to low demand for assistance in nutrition. In this
situation, the role of development partners must extend beyond responding when
requested to do so by governments. They must use their combined resources of
analysis, advocacy, and capacity-building to encourage and influence governments
to move nutrition higher on the agenda wherever it is holding back achievement
of the MDGs (table 3). This role can be fulfilled only if the development
partners share a common view of the malnutrition problem and broad strategies to
address it, and if they speak with a common voice. The development partners
therefore also need to reposition themselves. They need to convene around a
common strategic agenda in nutrition, focusing on scaled-up and more effective
action for undernutrition and micronutrients in priority countries and on action
research or learning-by-doing for overweight, low birthweight, and HIV/AIDS and
nutrition. This repositioning must involve reviewing and revising the current
inadequate levels of funding for nutrition. For example, though the World Bank
is the largest development partner investing in global nutrition, between 2000
and 2004 its investments in the short route interventions that improve nutrition
fastest amounted to not more than 1.5 percent of its lending for human
development--and only 0.3 percent of total World Bank lending.
Although we do not wish to propose a global one size fits all
approach to addressing malnutrition, we do recommend that when developing
strategies specific to a country or region, countries and their development
partners pay special attention to the following:
Focusing strategies and actions on the poor so as to address the nonincome
aspects of poverty reduction that are closely linked to human development and
human capital formation.
Focusing interventions on the window of opportunity--pregnancy through the
first two years of life--because this is when irreparable damage happens.
Improving maternal and child care practices to reduce the incidence of low
birthweight and to improve infant-feeding practices, including exclusive
breastfeeding and appropriate and timely complementary feeding, because many
countries and development partners have neglected to invest in such programs.
Scaling up micronutrient programs because of their widespread prevalence,
their effect on productivity, their affordability, and their extraordinarily
high benefit-cost ratios.
Building on country capacities developed through micronutrient programming to
extend actions to community-based nutrition programs.
Working to improve nutrition not only through health but also through
appropriate actions in agriculture, rural development, water supply and
sanitation, social protection, education, gender, and community-driven
development.
Strengthening investments in the short routes to improving nutrition, yet
maintaining balance between the short and the long routes.
Integrating appropriately designed and balanced nutrition actions in country
assistance strategies, sectorwide approaches (SWAps) in multiple sectors,
multicountry AIDS projects (MAPs), and Poverty Reduction Strategy Papers (PRSPs).
In addition to these generic recommendations, practical suggestions are
available for how countries might take some of these considerations into account
as they position nutrition in their national development strategies.
Next Steps
Scaled-up and more effective action requires addressing key operational
challenges:
1. Building global and national commitment and capacity to invest in nutrition.
2. Mainstreaming nutrition in country development strategies where it is not now
given priority.
3. Reorienting ineffective, large-scale nutrition programs to maximize their
effect.
Action research and learning-by-doing need to focus on:
1. Documenting how best to strengthen commitment and capacity and to mainstream
nutrition in the development agenda.
2. Strengthening and fine-tuning service delivery mechanisms for nutrition.
3. Further strengthening the evidence base for investing in nutrition.
At the global level, the development community needs to unite in explicitly
rethinking and repositioning the role of malnutrition as an underlying cause of
slow economic growth, mortality, and morbidity, and agree to:
Coordinate efforts to strengthen commitment and funding for nutrition within
global and national partnerships.
Pursue a set of broad strategic priorities (such as the six outlined above)
for the next decade, contributing wherever they have the most comparative
advantage.
Focus on an agreed-on set of priority countries for investing in nutrition
and for mainstreaming and scaling up nutrition programs.
Focus on an agreed-on set of priority countries for developing best practices
in building commitment and capacity, mainstreaming nutrition, and reducing
overweight and obesity.
Make a collective effort to switch from financing small-scale projects to
financing large-scale programs, except where small projects with strong
monitoring and evaluation components are required to pilot-test interventions
and delivery systems, or to build capacity in nutrition.
At the country level, the development community needs to scale up its assistance
by helping all countries that have micronutrient deficiencies develop a national
strategy for micronutrients, finance it, and scale it up to nationwide coverage
within five years--without crowding out the larger undernutrition agenda.
The development community must also support countries with undernutrition
problems as follows:
Identify and support at least 5 to 10 countries with serious nutrition
problems that have the commitment to work with development partners to
mainstream nutrition into SWAps, MAPs, and Poverty Reduction Strategy Credits (PRSCs).
In countries that have little experience in nutrition, nutrition projects may be
the first step in other cases, specific efforts to develop country capacity
will be needed.
Identify and support three to five countries where large-scale investments
need to be reoriented to maximize their effect. In these countries, provide
coordinated support to reorient program design and to strengthen implementation
quality and monitoring and evaluation.
Identify and support at least three to five countries where nutrition issues
loom large but appropriate action is not being taken. In these countries, focus
on building commitment, analyzing policy, and developing intervention strategies
that can be financed with assistance from development partners.
To help achieve these goals, the development partners will need to cofinance a
grant fund to catalyze action in commitment-building and action research,
complementing the Bank's recent allocation of 3.6 million from the Development
Grant Facility to help mainstream nutrition into maternal and child health
programs. Large-scale funding for the national actions outlined above should
come through normal financing channels, rather than through the creation of a
special fund for nutrition. Initial estimates suggest that the costs of
addressing the micronutrient agenda in Africa are approximately 235 million per
year. Costs for other regions and for other aspects of the nutrition agenda have
yet to be estimated. Other estimates are much larger (750 million for global
costs for two doses of Vitamin A supplementation per year between 1 billion
and 1.5 billion for global saltiodization, including 800 million to 1.2
billion leveraged from the private sector and several billion dollars for
community nutrition programs). A more detailed costing exercise is being
undertaken by the World Bank to come up with more rigorous figures.
The agenda proposed here needs to be debated, modified, agreed on, and acted on
by development partners with developing countries. Without coordinated, focused,
and increased action, no significant progress in nutrition or toward several
other MDGs can be expected.
Report: Repositioning Nutrition
http://siteresources.worldbank.org/NUTRITION/Resources/281846-1131636806329/NutritionStrategy.pdf
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