Why Invest in Nutrition? Meera Shekar Human Development Network World Bank 2006
Three key Issues Why reducing malnutrition is essential to poverty reduction? Is malnutrition a BIG problem? How can we improve nutrition?
Reducing Malnutrition is essential to poverty reduction Nutrition Not just a welfare issue Not just a human rights issue Nor is it primarily a food or a consumption issue alone Nutrition is an Investment Issue, and Improved nutrition is one of the DRIVERS of economic growth
Reducing Malnutrition is essential to poverty reduction Malnutrition Poverty GDP losses 2-3% Leads to a >10% potential reduction in lifetime earnings for each malnourished individual 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 (Improved nutrition can be a driver of economic growth) Source: Alderman et al (2003)
The vicious cycle of poverty and malnutrition Income poverty Low food intake Frequent infections Hard physical labor Frequent pregnancies Large families Malnutrition Direct loss in productivity from poor physical status Indirect loss in productivity from poor cognitive development and schooling Loss in resources from increased health care costs of ill health Source: Modified from World Bank (2002a); Bhagwati et al. (2004).
SAR (2) Afghanistan Bhutan Progress on non-income poverty (nutrition MDG) On track (34/143=24%) Some improvement, but not on track (26/143=18%) AFR (7) Angola EAP (5) China MNA (6) Algeria EAP (3) Cambodia LAC (4) El Salvador MNA (1) Morocco Benin Indonesia Egypt Lao, PDR Guatemala Botswana Malaysia Iran Philippines Honduras Chad Thailand Jordan Nicaragua SAR (4) Gambia Vietnam Syrian Arab Rep Bangladesh* Mauritania Tunisia ECA (0) India Pakistan Zimbabwe** Sri Lanka ECA (6) Armenia Croatia Kazakhstan Kyrgyz Rep Romania Turkey Reducing Malnutrition is essential to poverty reduction LAC (10) Bolivia Chile Colombia Dominican Rep Guyana Haiti Jamaica Mexico Peru Venezuela SAR (0) AFR (14) CAR Congo, DR Côte d'ivoire Eritrea Gabon Ghana Kenya Madagascar Malawi Mozambique Nigeria Rwanda Sierra Leone Uganda Deteriorating status (26/143=18%) No trend data available (57/143=40%) AFR (13) Niger Burkina Faso Cameroon EAP (2) Mongolia Myanmar LAC (3) Argentina Costa Rica Panama SAR (2) Maldives Nepal AFR (13) Burundi Cape Verde Congo, R EAP (11) Fiji Kiribati Marshall Islands ECA (17) Belarus Bosnia- Herzegovina Comoros ECA (4) Equatorial Micronesia, FS Bulgaria Ethiopia Albania MNA (2) Guinea Palau Czech Republic Guinea Azerbaijan Iraq Guinea-Bissau Papua New Estonia Lesotho Russian Yemen, Rep Liberia Guinea Georgia Mali Federation Mauritius Samoa Hungary Senegal * Serbia & Namibia Solomon Islands Latvia Sudan Montenegro São Tomé & Timor-Leste Lithuania Tanzania* Principe Tonga Macedonia, FYR Togo Zambia Seychelles Somalia South Africa Swazil& Vanuatu 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
Reducing Malnutrition is essential to poverty reduction The income-malnutrition relationship The trickle-down effect is modest Percent of underweight children <5 (%) 40 30 20 10 1970's 1980's 1990's 0 0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 GNP per capita in $ (PPP) Income growth will improve nutrition, but at a slow rate that will not be sufficient to achieve the MDGs Source: Haddad et al (2003)
Reducing Malnutrition is essential to poverty reduction If we were to wait for income growth alone to achieve the nutrition MDG: India will likely achieve the MDG in 2035 Tanzania will achieve it in 2065 Data Source: World Bank (2006)
Reducing Malnutrition is essential to poverty reduction Nutrition and poverty India: Percent of children under 5 that are malnourished (by income quintiles) % Under-weight children (weight-for-age below 2 SD) % children anemic (HB<11 g/dl) Income Quintiles Lowest 60.7 78.8 Second 54.0 79.0 Middle 49.2 75.1 Fourth 38.9 72.3 Highest 26.4 63.9 Malnutrition affects the poorest most, & by targeting malnutrition we target the poor; but, it also affects the non-poor Source: Gwatkin et al. 2003
Reducing Malnutrition is essential to poverty reduction The Copenhagen Consensus ranks the provision of micronutrients as a top investment Above trade liberalization, malaria, water/sanitation Rating Challenge Opportunity Very 1. Diseases Control of HIV/AIDS Good 2. Malnutrition and hunger Providing micronutrients 3. Subsidies and Trade Trade liberalization 4. Diseases Control of malaria Good 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 9. Government Lowering cost of new business Fair 10. Migration Lowering barriers to migration 11. Malnutrition and hunger Improving infant/child malnutrition 12. Diseases Scaling up basic health services 13. Malnutrition and hunger Reducing the prevalence of low birth weight Poor 14-17 Climate/Migration Various Nutrition interventions are cost-effective best buys Source: Bhagwati et al. (2004)
The scale of the nutrition problem is very large and extensive
The problem is large and extensive Global trends in underweight (Children 0-4 Years) Prevalence of underweight (%) 75 60 45 30 15 0 Rates of Under-nutrition Africa Asia LAC Developing Developed 1980 1985 1990 1995 2000 2005 1980-2005 No. of underweight children (million) 200 160 120 80 40 0 Numbers of underweight children Africa Asia LAC Developing Developed 1980 1985 1990 1995 2000 2005 Data Source: de Onis et al (2004)
The problem is large and extensive Global trends in underweight (Children 0-4 Years) Prevalence of underweight (%) 75 60 45 30 15 0 Rates of Under-nutrition 1980-2005 Bangladesh India China 1980 1985 1990 1995 2000 2005 No. of underweight children (million) 200 160 120 80 40 0 Numbers of underweight children Africa Asia LAC Developing Developed 1980 1985 1990 1995 2000 2005 Data Source: de Onis et al (2004)
The problem is large and extensive
The problem is large and extensive
The problem is large and extensive
The problem is large and extensive
The problem is large and extensive Maternal Overweight Rates % maternal overweight (BMI>=25) 80 60 40 20 0 Egypt Jordan Turkey Peru Guatemala M auritania Armenia Zimbabwe Haiti Ghana Nigeria Uzbekistan Yemen Cambodia AFR EAP ECA LAC MNA SAR India Bangladesh 0 10 20 30 40 50 % maternal undernutrition (BMI<18.5) % maternal overweight (BMI>=25) 80 60 40 20 0 Peru Egypt Jordan Turkey Zimbabwe Uzbekistan Guatemala Haiti Ghana Nigeria M auritania Cambodia Yemen AFR EAP ECA LAC MNA SAR India Bangladesh 0 15 30 45 60 % child (<3y) underweight (WAZ<2) Under-nutrition often co-exists with over-weight (both are forms of malnutrition) Data Source: Measure DHS; Author s calculations
Disabled by obesity. Some young women affected suffer from conditions such as early diabetes, heart disease, gallstones and arthritis, which may immobilise and eventually kill them. The obsession of some Mauritanians with female obesity is continuing to cripple a small but extremely vulnerable sector of its society. In Mauritania, when it comes to women, for many people fat is beautiful. Here in this desert country, where poverty and malnutrition affect many, obesity is seen as a badge of wealth and prestige. Source: BBC, 2005
How can we improve nutrition?
How can we improve nutrition? The Window of Opportunity for Improving Nutrition is very small pre-pregnancy until 18-24 months of age 0.50 Weight for age Z-score (NCHS) 0.25 0.00-0.25-0.50-0.75-1.00-1.25-1.50-1.75-2.00 Latin America and Caribbean Africa Asia 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 Age (months) Data Source: Shrimpton et al (2001)
How Can we Improve Nutrition? Short routes: Exclusive breast-feeding, appropriate complementary feeding, ante-natal care for mothers, (Knowledge, behavior change/demand side interventions); gender interventions, micronutrient supplementation & fortification Long routes: Income growth, women s education, agriculture and food production interventions, trade policies, macro-economic policies
How can we improve nutrition? Consensus on many issues... One size does not fit all! Focus on public sector resources on the poor to address non-income aspects of poverty (=nutrition) Focus investments on window of opportunity (prepregnancy to 2 years) Invest in micronutrients (where appropriate) Balance between long and short route (supply and demand-side) Invest in strengthening capacity and commitment
How can we improve nutrition? The Bank is the largest investor in nutrition globally 661 m$* across 36 projects (April 2005) But, Given the size and scope of the problem, current commitments to nutrition are modest This is 3.8% of HD theme, 0.7% of Bank-wide lending; *Includes food security
Three key Issues Reducing malnutrition is essential to poverty reduction and economic growth Malnutrition is a BIG problem Big in Africa BIGGER in South Asia Not insignificant in other regions We know how to improve nutrition and it has been done at scale in some countries
How can we improve nutrition? We must scale-up! where we have evidence and consensus Countries must take the lead Development partners: Provide sustained support for building commitment and capacity NGO partners: Continue to build country capacities and provide best-practice models Private sector: Strategic partnerships Research agencies: Strengthen M&E so we can continue to learn collectively PARTNERSHIPS are key The greatest challenge to scaling up nutrition is sustained country (and donor) commitment and capacity