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close this bookOvercoming 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.)
View the document(introduction...)
View the documentForeword
View the documentAcknowledgments
View the document1. Exploring the Causes of Malnutrition
View the document2. Determinants of the Nutritional Status of Children
View the document3. Data and Methods
View the document4. New Evidence from Cross-Country Data, 1970-95
View the document5. How Has Child Malnutrition Been Reduced in the Past?: A Retrospective
View the document6. Projections of Child Malnutrition in the Year 2020
View the document7. Priorities for the Future
View the document8. Conclusions
View the documentAppendix: Cross-Country Studies: Methodological Issues and Past Findings
View the documentReferences
View the documentRecent Food, Agriculture and the Environment Discussion Papers

5. How Has Child Malnutrition Been Reduced in the Past?: A Retrospective

Having identified a number of reasons for children to be underweight and estimated the relative strengths of the causes, we can now infer the contributions of each determinant to the reduction in malnutrition that took place over the study period, 1970 to 1995. To do so also requires information on how much each determinant has actually changed during the period. To obtain this information, the data set is expanded to include all available data on the basic and underlying determinant variables at six points in time: 1970, 1975, 1980, 1985, 1990, and 1995. The mean levels of the determinants for each of these years as well as their total change over the study period are given in Table 9.

From this historical information, the estimated contribution of each underlying determinant to reductions in the developing-country prevalence of child malnutrition from 1970 to 1995 is derived (see the first column of the upper panel of Table 10).13 The total estimated contribution, a reduction of 15.9 percentage points, is quite close to the 15.5 percentage-point reduction estimated for all developing countries in Table 1. Figure 2 summarizes the estimated share of each determinant’s contribution to the total reduction in malnutrition. The change in each over the period on an equivalent scale of 100 percent is presented in Figure 3. Note that safe water access increased the most, while the female-to-male life expectancy ratio increased the least.

13 The fixed-effects parameter estimates of Table 6 are used to formulate a predicting equation for the change in child malnutrition prevalence during 1970-95. This yields the total predicted reduction in the prevalence. The total contribution of each determinant is then calculated as the determinant’s regression coefficient multiplied by its change from 1970 to 1995. The percentage contribution of each determinant is calculated as its total contribution multiplied by 100 and divided by the predicted change in the child malnutrition prevalence over the period.

Improvements in women’s education have contributed by far the most to the total reduction in child malnutrition - 43 percent (Figure 2). The contribution of improvements in health environments was also substantial, 19 percent. Improvements in per capita food availability contributed about 26 percent due to both a strong effect and fairly substantial increases, from 2,092 kilocalories per capita in 1970 to 2,559 in 1995. The lowest contribution (12 percent) came from improvements in women’s status as gauged by the female-to-male life expectancy. While this factor has a potentially strong per unit impact, it has improved little. Together, women’s education and relative status have contributed to more than half of the 1970-95 reduction in the prevalence of malnutrition in developing countries. Much of the reduction was thus probably due to improvements in maternal and child care, the main means through which women’s education and status influence a child’s nutrition. Some of the effects may also be through improved household food security.

Figure 4 traces the contributions of the underlying determinant variables to changes in the prevalence of developing-country child malnutrition for five-year intervals starting with 1970-75 and ending with 1990-95. The change in the prevalence of malnutrition over the five-year periods appears on the vertical axis of the figure. When there was a reduction in child malnutrition associated with increases in a determinant, the bar falls below zero. A bar value above zero indicates that child malnutrition increased as the result of a reduction in the level of a variable.

Table 9 - Underlying-determinant and basic-determinant variable means, 1970-95

Variable

1970

1975

1980

1985

1990

1995

Absolute change, 1970-95

Average annual change, 1985-95

Underlying-determinant variables










Access to safe water (percent)

30.2

45.4

52.4

60.7

69.9

70.3

40.1

0.96


Female secondary school enrollment (percent)

15.6

25.4

28.4

30.6

36.4

46.6

31.0

1.6


Female-to-male life expectancy ratio

1.022

1.026

1.033

1.040

1.045

1.048

0.024

0.0008



Female life expectancy (years)

55.2

58.5

60.4

63.5

65.3

66.0

10.79

0.25



Male life expectancy (years)

54.0

56.9

58.5

60.8

62.4

63.0

9.04

0.22


Per capita dietary energy supply (kilocalories)

2,092

2,089

2,226

2,380

2,472

2,559

467

17.9

Basic-determinant variables










Per capita GDP (US$ PPP)

1,011

1,163

1,361

1,378

1,673

2,121

1,111

44.8


Democracy (1 = least democratic)

2.85

2.99

3.75

3.31

3.24

2.71

-0.14

-0.06

Notes: These data are population-weighted. They are estimated using data for the countries in the data set only (Comoros was dropped from the sample due to the absence of population data). In some cases where data were not available for a sample country for a particular year, extrapolations were undertaken.

Table 10 - Estimated contributions of underlying- and basic-determinant variables to changes in the prevalence of child malnutrition, by region, 1970-95

Variable

All regions

South Asia

Sub-Saharan Africa

East Asia

Near East and North Africa

Latin America and the Caribbean


(percentage-point change in underweight rate)

Underlying-determinant variables








Health environment

-3.06

-4.56

-2.07

-2.74

-0.45

-1.80


Women’s education

-6.82

-4.61

-3.39

-9.27

-9.64

-6.98


Women’s status relative to men’s

-1.84

-3.85

+1.27

-1.36

+0.28

-1.65


National food availability a

-4.14

-3.44

-0.048

-6.11

-2.34

-0.77


Total percentage-point change

-15.9

-16.5

-4.2

-19.5

-12.4

-11.2

Basic-determinant variables b








Per capita national income a

-7.39

...

...

...

...

...


Democracy

+0.18

...

...

...

...

...


Total percentage-point change

-7.2

...

...

...

...

...

Notes: The estimates in this table are obtained by multiplying the coefficients of the proxy variables for each determinant (see Table 5) by the change in the proxy over 1970-95. The changes are obtained from Smith and Haddad 2000, Appendix Tables 25-29.

a These estimates take into account the changing coefficient of the proxy variable (DES and GDP) as its level changes.

b As discussed in the previous chapter, the regression coefficients of the basic-determinants model cannot be applied to the regions separately due to fundamental structural differences across the regions. Thus, contributions for the basic-determinant variables are not broken down by region.


Figure 2 - Share of reduction in child malnutrition attributed to underlying variables, 1970-95

There are several points to note:

· The prevalence of child malnutrition has declined fairly steadily among developing-country children, dropping about 3.2 percentage points every five years since the early 1970s. The largest reduction, 4.0 percentage points, came in the 1975-80 period. Since then the reductions have been smaller.

· The contribution of improvements in health environments has declined over the 25-year period; in the early 1990s it contributed little.

· Women’s education made its greatest contribution in the early 1970s and early 1990s. Its contribution dropped dramatically between 1970 and 1980; since then it has gradually increased. This factor contributed 84 percent of the total 2.7 percentage-point reduction in the prevalence of underweight in the early 1990s.

· Corresponding to the world food crisis of the 1970s, per capita food availability declined during 1970-75, leading to a slight increase in child malnutrition. As the Green Revolution picked up, the developing countries saw substantial increases in their food supplies. The contribution of food availability to declines in malnutrition were steady and substantial in the late 1970s and early 1980s. Despite continued increases in the late 1980s and early 1990s, the contribution of food availability to reductions in child malnutrition has leveled off because the strength of their impact has declined.

· As improvements in women’s status have fluctuated over the 25-year period, so too has their contribution to malnutrition reductions. The greatest contribution was made in the early 1980s; since the late 1980s it has declined considerably.


Figure 3 - Changes in explanatory variables, 1970-95, on an equivalent scale of 100 percent

Notes: This figure shows the increase in each underlying-determinant variable over 1970-95 on an equivalent scale that allows comparison across variables even though they are measured in different units. Each variable is transformed by equating the minimum of its developing-country range to 0, the maximum to 100, and the in-between numbers to their relative positions on this scale. The variable ranges are given in Table 8, column (3). The shaded area in the bar for each variable starts with its 1970 transformed value and ends with its 1995 transformed value.


Figure 4 - Contributions of underlying-determinant variables to changes in child malnutrition, all regions, 1970-95

The bottom panel of Table 10 gives the contribution of the basic determinants. Democracy has actually deteriorated slightly. Despite its potentially positive contribution, its declining trend is associated with a slight increase in child malnutrition. Improvements in per capita national income, however, have been quite large. For the full sample of countries, per capita GDP rose from $1,011 in 1970 to $2,121 in 1995, more than doubling. This large increase, in combination with the strong influence of the variable, has facilitated an estimated 7.4 percentage-point reduction in child malnutrition. The influence of national incomes in reducing malnutrition throughout the developing world over the 25-year period since 1970 has thus been quite strong.

In Figure 5, the contributions of national income and democracy are broken down into five-year periods. While democracy made positive contributions in the 1970s, it has declined since then, putting a drag on improvements in child nutrition. Except for the early 1980s, the contribution of national income has increased steadily since the 1970s. Its greatest contribution came most recently: in the 1990-95 period alone it contributed to a 3 percentage-point decline in malnutrition.


Figure 5 - Contributions of national income and democracy to changes in child malnutrition, all regions, 1970-95

Because the strength of impact of the basic determinants differs fundamentally across the regions, specific estimates of their contributions in each region cannot be undertaken. It can be inferred, however, that the contribution of national income has been positive for all regions except Sub-Saharan Africa (where it declined). The contribution of democracy has been positive for Sub-Saharan Africa, NENA, and LAC, but, due to deteriorations in democracy, it has been negative in South and East Asia.

The regions’ experiences have also differed with respect to the contributions of the underlying determinants, as reported in Table 10. 14 Estimates by region for five-year periods are given in Table 11.

14 As has been demonstrated, there are no significant differences in the functional relationships between the underlying determinants and child malnutrition. Thus the contributions of these determinants can be quantified using the full-sample coefficient estimates of Table 6, column (1).

The overall reduction in the prevalence of child malnutrition in South Asia for the 25-year period is estimated to be 16.5 percentage points. The greatest contributions to this reduction have come from increased education of women and improvements in health environments, at about 28 percent each. Improvements in women’s relative status have accounted for about 25 percent of the reduction, and improvements in food availability about 20 percent. The factors’ relative contributions have fluctuated greatly over the study period (Table 11). In the early 1970s, reductions in child malnutrition from improvements in health environments, women’s education, and women’s relative status were completely undermined by reductions in food supplies. As a result, no progress was made. By the late 1970s food availability had improved: it contributed substantially to the reductions in child malnutrition of the 1980s and early 1990s. In the 1980s malnutrition declined precipitously in the region (by more than 11 percentage points) due to improvements in all of the factors. However, in the 1990-95 period the pace of improvement was severely curtailed by slower growth in health environment improvements and food availabilities. 15 While women in the region continue to have the lowest status compared to men of all developing-country regions (the 1995 female-to-male life expectancy ratio was 1.02), small improvements have made a steady contribution over the 25 years.

15 This declining contribution is partially due to a declining impact as food supplies increased over the period.

The total reduction in Sub-Saharan Africa’s child malnutrition rate over the study period is estimated to be only 4.2 percentage points (Box 1). Most of this reduction was brought about by increases in women’s education, followed by improvements in health environments. Increased education of women made strong contributions in all periods except for the late 1980s, when enrollments actually declined. Improvements in health environments have made their greatest contribution since 1985. Women’s relative status has continually declined in the region since the 1970s, most precipitously after 1985, thus worsening the prevalence of child malnutrition in the region. Changes in food availabilities have played a large, though not always positive, role overall. Substantial improvements in the late 1980s and early 1990s were outweighed by deteriorations during the 1970-85 period.

East Asia has seen the fastest decline in the prevalence of child malnutrition during the study period - down 20 points. The greatest contribution to this decline came from increases in women’s education, followed by improvements in food availability and health environments. In the early 1970s, child malnutrition declined sharply, by more than 6 percentage points, mostly because of increases in women’s education. Progress since this period has not been as great, but it has continued steadily. The contributions of improvements in health environments and women’s relative status declined and were minimal in the 1990s. Improvements in food availability have taken place at a relatively fast pace in East Asia, rising from 1,998 kilocalories per capita in 1970 to 2,720 in 1995. Overall they have contributed to a 6 percentage-point reduction in the prevalence of child malnutrition in the region. Most of the contribution occurred in the 1970-85 period. As per capita dietary energy supplies have increased, their potency in reducing child malnutrition has weakened. Thus, during 1985-95, even though they increased at a fairly fast pace, they made relatively little contribution to reductions in child malnutrition.

Table 11 - Estimated contributions of underlying- and basic-determinant variables to changes in the prevalence of child malnutrition, by region, 1970-95, for five-year periods

Variable/period

All regions
(1)

South Asia
(2)

Sub-Saharan Africa
(3)

East Asia
(4)

Near East and North Africa
(5)

Latin America and the Caribbean
(6)


(percentage-point change in underweight rate)

Underlying-determinant variables

Health environment



1970-75

-1.16

-1.48

-0.38

-1.19

0.60

-1.25



1975-80

-0.53

-0.85

-0.24

-0.49

-0.34

-0.17



1980-85

-0.63

-0.25

-0.28

-1.21

0.33

0.00



1985-90

-0.70

-2.07

-0.72

0.10

-1.07

-0.04



1990-95

-0.03

0.09

-0.44

0.05

0.03

-0.33


Women’s education



1970-75

-2.14

-0.36

-0.65

-3.75

-1.62

-1.56



1975-80

-0.67

-0.71

-0.90

-0.34

-2.12

-1.80



1980-85

-0.49

-1.21

-1.28

0.44

-2.68

-1.30



1985-90

-1.27

-1.31

0.14

-1.70

-2.50

-0.64



1990-95

-2.26

-1.02

-0.70

-3.92

-0.73

-1.68


Women’s status relative to men’s



1970-75

-0.30

-0.85

0.15

0.03

0.15

-0,59



1975-80

-0.51

-0.75

0.10

-0.46

0.14

-0.77



1980-85

-0.52

-0.72

0.21

-0.66

0.06

-0.19



1985-90

-0.34

-0.89

0.57

-0.24

0.01

-0.15



1990-95

-0.18

-0.65

0.24

-0.03

-0.08

0.05


National food availability



1970-75

0.04

2.67

0.86

-1.17

-1.04

-0.22



1975-80

-2.32

-0.47

-0.12

-3.60

-0.56

-0.45



1980-85

-1.44

-2,55

0.92

-0.89

-0.35

0.07



1985-90

-0.22

-2.34

-1.09

-0.21

-0.33

-0.04



1990-95

-0.21

-0.74

-0.63

-0.24

-0.06

-0.13


Total percentage-point change

-15.9

-16.5

-4.2

-19.5

-12.4

-11.2

Basic-determinant variables


Per capita national income a



1970-75

-1.02

...

...

...

...

...



1975-80

-1.32

...

...

...

...

...



1980-85

-0.11

...

...

...

...

...



1985-90

-1.96

...

...

...

...

...



1990-95

-2.98

...

...

...

...

...


Democracy



1970-75

-0.18

...

...

...

...

...



1975-80

-0.96

...

...

...

...

...



1980-85

0.55

...

...

...

...

...



1985-90

0.09

...

...

...

...

...



1990-95

0.67

...

...

...

...

...


Total percentage-point change

-7.2

...

...

...

...

...

Notes: Estimates are based on the regression coefficients reported in Table 5 and estimated changes in each variable as reported in Smith and Haddad (2000).

Box 1

Why Has Child Malnutrition Been Rising in Sub-Saharan Africa?

Sub-Saharan Africa is the only region in which the prevalence of child malnutrition has been increasing. From 1985 to 1995, it increased from 29.9 percent to 31.1 percent (see the table below). Of the four underlying-determinant variables, only one - women’s relative status as proxied by the female-to-male life expectancy ratio - was moving in the wrong direction during the period. Two others, national food availability and women’s education - both of which remain at extremely low levels - were almost stagnant. In addition, national income for the region declined significantly: per capita GDP fell by $52. The decline in this important basic determinant of child malnutrition is responsible for slow progress in all of the underlying-determinant factors and a slight increase in poverty. Therefore, it seems likely that deterioration in women’s relative status and per capita national income, along with stagnation in women’s education and food availability, at least partially explain the deterioration in child malnutrition in the region. Other factors may be deterioration in the capacity and outreach of government services under the impact of debt and structural adjustment; the rising incidence of HIV/AIDS (Ramalingaswami, Jonsson, and Rohde 1996); and conflict (Messer, Cohen, and D’Costa 1998). The decline in the ratio of women’s life expectancy to men’s is puzzling. It may be because women in Sub-Saharan Africa are more vulnerable to HIV/AIDS than men are, which itself reflects women’s lower status (Brown 1996; Howson et al. 1996).

Trends in the determinants of child malnutrition in Sub-Saharan Africa, 1985-95


1985

1995

Percentage change, 1985-95

Child malnutrition (percent underweight)

29.9

31.1

4.0

Access to safe water (percent)

33.5

48.8

45.7

Female secondary school enrollment (percent)

16.4

19.0

15.8

Female-to-male life expectancy ratio

1.066

1.054

-1.1

Per capita dietary energy supply (kilocalories)

2,035

2,136

5.0

Per capita national income (PPP US$)

830

778

-6.3

Democracy

2.01

2.44

21.4

Poverty (percent) a

38.5

39.1

1.6


Sources: Smith and Haddad 2000, Tables 1 and 26. Poverty data are from Ravallion and Chen 1996, Table 5.

Notes: With the exception of the poverty rates, these data are population-weighted means over all countries in the data set in each region. The poverty measure employs an international poverty line of $1 per person per day at 1985 purchasing power parity.


a Poverty figures are for 1983 and 1993.

Almost all of the reduction in the child malnutrition prevalence of the Near East and North Africa region has come from increases in women’s education. 16 The share that can be attributed to health environment improvements has fluctuated - the net result being a small contribution of 3.6 percent. Women’s relative status deteriorated in most periods, muting improvements in child nutrition. Improvements in food availabilities account for 19 percent of the reduction in child malnutrition. As for East Asia, food availabilities have improved in all periods, but their impact has declined. By 1995, kilocalories per capita per day had reached 3,172, a point at which improvements have little if any further impact.

16 The results for this region should be treated with caution given that the majority of countries in the region are not represented in the sample (see Table 2).

Latin American and the Caribbean experienced an estimated 11 percentage-point reduction in child malnutrition over the study period, most of which took place during 1970-80. Since then, reductions in child malnutrition have continued at a much slower pace. Like the other regions, the greatest contribution (62 percent) came from expansions in female education. The contribution of improvements in health environments has steadily declined. Strong improvements in women’s relative status in the 1970s were followed by very small improvements in the 1980s. By the early 1990s there was a slight decline, muting the overall reduction in malnutrition of the period. Food availabilities improved in the 1970s, but declined slightly in the early 1980s. Their contribution has been minimal since the early 1980s.