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