THE MALNUTRITION ISSUE

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.