Stunted. Current attempts to Eradicate Undernutrition

Lawrence Haddad

Institute of Development Studies

Global Classroom

Outline• What is undernutrition?

• Why does it matter?

• Why is it a matter for public

• Which interventions work and why?

• How to move nutrition higher up the development agenda?

Child Undernutrition numbers are Increasing in SSA and Still Very High in South Asia

2730

34 3741

44

89 91 8881

7264

1980 1985 1990 1995 2000 2005

Sub-Saharan Africa Asia-South-central

Source: Based on estimates from de Onis and Blossner 2003

Millions

UN Conceptual Framework for Undernutrition

Undernutrition

CareHealth and sanitation

Household food security

Poor Diet Infection

Economic performance,Governance, political systems,

natural resource endowment

immediate

underlying

basic

Why does nutrition matter?• Foundational for the MDGs

– Mortality– Morbidity– Learning– Productivity

Child Undernutrition is Responsible for Half of All Child Deaths

0

5

10

15

20

25

30

35

neonataldeaths

pneumonia other Measles

% o

f ch

ild

dea

ths

proportion of deaths from being underweight

Source: Black RE, Morris SS, Bryce J 2003

1.8

1.8

1.9

2.3

2.4

2.7

2.8

3.7

4

4.1

4.4

6.3

9.5

vitamin A deficiency

low fruit and veg intake

zinc deficiency

high bmi

iron deficiency

indoor smoke from solid fuels

high cholesterol

unsafe water, sanitation and hygiene

alcohol

tobacco

high blood pressure

unsafe sex

infant and maternal underweight

Infant and Maternal Undernutrition is Leading Cause of Global Burden of Disease

Source: Ezzati et. al. 2002

Economic Costs of Undernutrition are Enormous

7.9

65.2

4.2

2.7 2.4

7.2

3.9

2

3.8

Source: Horton and Ross 2003

% of GDP lost due to iron deficiency anemia

Discounted Present Value of long-term effects attributable to supplementation/fortification in a single year

Why is it a matter for public policy?

• Missing markets– Financing the Lifecycle– Intergenerational externalities– Inequalities– Information symmetries

• Economic growth is insufficient

Irreversibility

-2

-1

0

0 6 12 18 24 30 36 42 48 54 60

Age (months)

Weig

ht

for

age Z

-sco

re

Africa Latin America and Caribbean Asia

Shrimpton et. al. 2001

-70

-60

-50

-40

-30

-20

-10

0

Per

u

Mo

rocc

o

Jam

aica

Nep

al

Ken

ya

Vie

tnam

Mo

zam

biq

ue

Eg

ypt

Pak

ista

n

Kyr

gz

So

uth

Afr

ica

Ro

man

ia

Red

uct

ion

in

ch

ild

mal

nu

trit

ion

(p

erce

nt

of

init

ial

valu

e)

Source: Haddad, L. et. al. 2004.

Decline in child malnutrition due to 2.5 percent annual growth in per capita income, 1990s to 2015

Income Growth does not Reduce Child Undernutrition Quickly Enough

Emphasis for direct interventions by country typology

Undernutrition

Ability of public sector

toaddress malnutri

tion

high * Targeted nutrition programs (e.g. WIC in USA)

med

* Early childhood development* Other food fortification

• Develop national guidelines on complementary foods

• Community-based behavior change

Low• Safe motherhood: the nutrition of girls and

women* Breastfeeding promotion

* Iron supplementation* Salt iodization

* Vitamin A mass dose with immunizations* Deworming schoolchildren

Emphasis at indirect level by country typology

Undernutrition

Ability of public sector

tosupport broad

malnutritionreduction

high* Improved crisis prevention information

networks

med

*Encourage network of community-based child care centers for poor mothers

*Reform of universal food subsidies to target to poor

*Target microcredit to women*Improve access to sanitation for poor

low

*Agriculture and food price policy to focus on improving availability of micronutrient

rich foods*Greater access to education for girls

* AIDS prevention campaigns* Improve safe water access

Commitments: Mentions of Nutrition• In Speeches (from Jan 2005)

– DFID: 0/50

– EC: 0/28

• In Press releases (from Jan 2005)– DFID: 0/197

– EC: 0/239

• In policy documents– 0 in G8 2005 and 2006

– 12 in Commission for Africa Report

– 0 in DFID Social transfers and chronic poverty

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

Canad

a

France

Germ

any

Italy

Japan

Nether

lands

Spain

Sweden UK

USA EC

95-99

00-04

Percentage of total ODA spend on

Direct Interventions

0%

2%

4%

6%

8%

10%

12%

14%

16%

95-99

00-04

Percentage of total ODA spend on

Indirect Interventions

What constrains higher prioritisation?• The context-- weak institutional incentives

– no nutrition indicators in reporting frameworks– institutional orphan

• The message--lack of a simple story– “fuzzy” versus “silver” bullets– difficulty of attribution– lack of easy resonance with current policy frameworks

• The connectors--few, isolated and lacking visibility– failure of professional education at tertiary level– weak professional career incentives

Causes for optimism?

• CCTs

• Trends in randomised controlled trials

• Long wave issues—youth perspectives

• Diet-related chronic disease

• Governance agenda

Recommendations for Governments and Donors

• The context– use underweight as indicator for MDG1 on poverty

• The message– nutrition audit of indirect nutrition spend

– support nutrition surveys to name and shame and highlight poor governance

– generate research on a new generation of cost-effectiveness studies; policy process studies

• The connectors--few, isolated and lacking visibility– appoint a nutrition champion

– re-design higher education initiatives – e.g. Masters in Development Practice

Implications for Research

• Need a new generation of cost-effectiveness studies• More political and policy process studies• More institutional design studies

The Cost-Effectiveness of Targeting: Progresa in Mexico

Cost of targeted program to reduce poverty index by one unit Cost of non-targeted program to reduce poverty index by one unit

Source: Adapted from Skoufias, Davis and de la Vega 2001

Nutrition expenditure (rupees) per malnourished child in 8 Indian States

8.2

29.2

3.5

18.2

4.610.9 13.5

73.2

0

10

20

30

40

50

60

70

80

Source: Measham and Chatterjee 1999

Rands to create one day of employment, South Africa

Source: Hoddinott, Adato, Haddad and Besley 2001

Institutional arrangements and service delivery

Conclusions

• Undernutrition thinking desperately needs a development practice perspective—neither health nor agriculture sectors have made it a priority

• More political, institutional, policy process analyses needed

• Need a greater link to the governance agenda

• Need new graduate programmes stressing connections and the politics of undernutrition

• Some optimism that the context is becoming more receptive to changed thinking

Example questions for local investigation

• What percent of infants suffer from undernutrition in your local community? Check your perceptions against the data—how different? What do you think are the main causes of undernutrition in your area?

• The pros and cons of targeting versus universal access—dividing or uniting communities?

• The local politics of getting resources to children—mandated or voluntary?

• Variations in the design of service delivery in your area—where is it most obvious? Why?