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?

UN Conceptual Framework for Undernutrition Undernutrition Care Health and sanitation Household food security Poor DietInfection Economic performance, Governance, political systems, natural resource endowment immediate underlying basic

Why does nutrition matter? Foundational for the MDGs –Mortality –Morbidity –Learning –Productivity

Infant and Maternal Undernutrition is Leading Cause of Global Burden of Disease Source: Ezzati et. al. 2002

Why is it a matter for public policy? Missing markets –Financing the Lifecycle –Intergenerational externalities –Inequalities –Information symmetries Economic growth is insufficient

Irreversibility Shrimpton et. al. 2001

Income Growth does not Reduce Child Undernutrition Quickly Enough

Emphasis for direct interventions by country typology Undernutrition Ability of public sector to address 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 to support broad malnutrition reduction 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 G and 2006 –12 in Commission for Africa Report –0 in DFID Social transfers and chronic poverty

Percentage of total ODA spend on Direct Interventions

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 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?