|Overcoming Child Malnutrition in Developing Countries - Past Achievements and Future Choices. 2020 vision for Food, Agriculture, and the Environment. Discussion paper 30 (IFPRI, 2000, 73 p.)|
Although the percentage of children who are malnourished has declined in many countries of the developing world in recent years, the absolute number of malnourished children is rising in some regions, particularly in Sub-Saharan Africa. IFPRIs 2020 vision is of a world where every person has access to sufficient food to sustain a healthy and productive life and where child malnutrition is absent. This paper aims to determine which of the various causes of malnutrition are most important for the developing countries as a whole and by region, thus enabling policymakers to prioritize their investments and make the best use of available resources to reduce malnutrition now and in the coming years.
Weighing the Determinants of Malnutrition
Of the four explanatory variables representing the underlying determinants of child malnutrition - national food availability, womens education, womens status relative to mens, and access to safe water - womens education has the strongest impact on child malnutrition, followed closely by per capita food availability. Increases in womens status relative to mens and improvements in the quality of a countrys health environment also have strong effects on child malnutrition and are necessary for reducing it. However, they do not have as strong an influence as womens education and per capita food availability for the developing countries as a whole. It should be noted that as the amount of food available per person in a country increases, the marginal effect of this factor declines, weakening its force. Thus, for some individual countries with abundant food supplies per person, the strength of impact of national food availability is weak in comparison to all of the other underlying-determinant factors.
The variables representing the basic determinants of child malnutrition - per capita national income and democracy - both have a strong impact on child malnutrition. Increases in per capita national income have a very strong influence because they increase public and private investment in all of the underlying-determinant variables - in education or health facilities, for example. Increased democracy leads to reductions in malnutrition by increasing investment in health environment improvements and in per capita food availability. For the developing countries as a whole, per capita national income has a greater impact on child malnutrition than does democracy. However, like per capita food availability, national income has a declining marginal effect. For some countries with high per capita incomes, democracy will be the more potent force for reducing child malnutrition.
Great strides have been made in reducing child malnutrition in the developing countries over the last few decades. From 1970 to 1995, the percent of underweight children under five declined from 46.5 to 31 percent. Corresponding to the strong influence of womens education and the substantial progress made in increasing it over the period, education is estimated to be responsible for 43 percent of this reduction. Improvements in per capita food availability account for about 26 percent of that reduction, while improvements in the health environment account for 19 percent. Because, on the whole, there was little improvement in womens status relative to mens over the 25 years, its contribution - while still substantial - was the lowest of the four variables - 12 percent.
For the basic determinants, improvements in per capita national income have made a very large contribution. They are estimated to be responsible for roughly half of the total reduction in the prevalence of child malnutrition over 1970-95. While increased democracy has great potential for bringing about reductions in child malnutrition, because no progress has been made in this area for the developing countries as a whole, it made no contribution.
Shifting the Future Focus
If current trends continue, the prevalence of child malnutrition in the year 2020 is projected to remain high. Eighteen percent of all developing-country children under age five, or 140 million children, will still be underweight. South Asia and Sub-Saharan Africa will remain the regions with the highest rates of child malnutrition. A sharp regional shift in the location of child malnutrition is projected: South Asias share of the total number of children will fall from approximately 51 percent to 47 percent, but Sub-Saharan Africas share will rise from 19 percent to near 35 percent. The absolute number of malnourished children in Sub-Saharan Africa is expected to be higher in 2020 than it was in 1995.
But it is not too late to change this prediction. The findings of this study indicate that significant progress can be made toward reducing child malnutrition through accelerated action in sectors that have not been the traditional focus of nutrition interventions. Efforts to improve womens education, raise food supplies (or reduce population growth or both), bolster womens status, and create healthful environments should be an integral part of strategies for reducing child malnutrition in the future. These initiatives should be seen as complements to more direct nutrition interventions, such as feeding programs and nutrition education.
Any comprehensive strategy for resolving the problem of child malnutrition must include actions to address both its underlying and basic causes. This is a key message of this paper. If the economic resources of the developing countries, as indicated by national incomes, cannot be raised, increased investment in health environments, womens education and relative status, and food availability will not be forthcoming. Similarly, if a democratic government is not in place, people will not be able to bring pressure on governments to have their needs met. But just having sufficient income and a democratic government are not enough. Increased national incomes must actually be spent on improvements in the underlying determinants, which requires knowledge of their roles in reducing child malnutrition and political commitment to doing so.
Given resource constraints and knowledge of the costs of alternative interventions, how should policymakers prioritize investments to reduce child malnutrition most quickly in the coming decades? The investments that should receive priority will differ from one geographical area to another because, first, the relative strength of the determinants impacts differ by area, and, second, because geographical areas differ in their current levels of achievement in reaching the desired levels of the determinants. The top priorities in each developing region are based on consideration of these two criteria.
In Sub-Saharan Africa and South Asia - the regions with the highest incidence of child malnutrition - improvements in per capita food availability and womens education offer the best hope for future reductions in child malnutrition. In South Asia, promotion of improved status for women should also be prioritized. In East Asia, NENA, and LAC, womens education should be given top priority, followed by womens status relative to mens. Additional secondary priorities are food availability for East Asia and health environment improvements for LAC. To maintain the necessary resource base and political will for these investments, investments in national income growth and democratic development must be accelerated as well.
Contribution to the Resolution of Key Debates
This paper contributes to the resolution of five important questions currently under debate in development policy and research circles. First, why has child malnutrition been rising in Sub-Saharan Africa? Here, all that can be said is that some of the increase is the result of the declining relative status of women and deterioration in per capita national income (and thus rising poverty). Stagnant per capita food availability and womens education have also held back improvements in child nutrition. Finally, debt and structural adjustment, increasing levels of conflict, and the rise of HIV/AIDS may be partly responsible, although these last factors are not studied in this report due to lack of data.
Second, why are child malnutrition rates in South Asia so much higher than in Sub-Saharan Africa? Womens low status, which is a much worse problem in South Asia than in Sub-Saharan Africa, seems to be a key source of the Asian enigma. Regardless of the levels of the factors influencing child malnutrition that are identified in this paper, however, a large disparity in the prevalences of child malnutrition between the regions would persist. The source of the remaining differences lies in factors that are specific to South Asian countries and that change very slowly over time. These factors are not explicitly identified in this study. Some examples might be the regions monsoon climate, high population densities, and deeply entrenched beliefs regarding child feeding practices.
Third, how important a determinant of child malnutrition is food availability at a national level? When per capita food availability is very low, it is the most important determinant of child malnutrition, more important than any other underlying determinant considered here. As more food becomes available, however, its potency in reducing child malnutrition diminishes. After a certain point is reached, further improvements are unlikely to reduce child malnutrition in the country as a whole. In countries where plenty of food is available, efforts to promote food security must focus on promoting access to adequate food at the household and individual level. The regions in which improved food availability has the most to contribute in the coming decades are again South Asia and Sub-Saharan Africa.
Fourth, how important are womens status and education? This study confirms the now overwhelming evidence that womens education has a strong impact on the nutrition of children. It also establishes that womens status relative to mens is an important determinant in its own right in all developing-country regions. These findings confirm that women play a key role in the etiology of child nutrition, whether through their role as providers of child care or through the role they play in promoting household food security. Together, improvements in womens education and status contributed more than 50 percent to the reduction in child malnutrition that took place from 1970 to 1995. More emphasis should be placed on improving them in the future, with particular stress being given to both womens education and status in South Asia and womens education in Sub-Saharan Africa.
Fifth, how important are economic factors (such as national incomes) and political factors (such as democracy), and through what pathways do they affect child malnutrition? This study found that national income levels have a strong influence on child nutrition: countries with higher incomes invested more public and private funds in all four underlying determinants. The research firmly establishes the existence of a significant link between the degree of democracy in countries and lower rates of child malnutrition, working mainly through improvements in health environments and national food availability. Why democracy is important for these two underlying determinants and not for others needs to be better understood, however.
In conclusion, all of the factors studied here - womens education and status, national food availability, the health environment, national income, and democracy - should be integral parts of future strategies for reducing child malnutrition. Current efforts to stem malnutrition in critical situations through the provision of nutrition safety nets should continue. However, accelerating reductions in child malnutrition now - and overcoming it in the future - will also require investment in interventions that address malnutritions root causes. It is hoped that the findings of this study will aid policymakers as they make choices among such investments.