(introduction...)

Nutrition is improving for many people in the world, but for most not nearly fast enough. The problems are becoming concentrated in sub-Saharan Africa and South Asia. In sub-Saharan Africa the nutrition situation is actually worsening overall. More than half the malnourished children in the world are in South Asia, due both to the prevalence being much higher than elsewhere (nearly double that of sub-Saharan Africa) and to the enormous population. Regional trends shown in Figure 1.1 illustrate this; these cover the period 1975-1990, in line with the perspective of this report. Together sub-Saharan Africa and South Asia account for 70% of the world's underweight children.

Figure 1.1: Trends in Prevalence of Underweight Children, 1975-1990

Source: ACC/SCN (1992) page 11

At the International Conference on Nutrition in 1992 all governments endorsed the ambitious goals of the World Summit for Children of 1990, calling for halving the 1990 underweight prevalence by the year 2000(UN, 1990; FAO/WHO, 1992). An idea of the size of this task can be seen from the fact that, in South Asia, the rate of improvement for the 1980s was -0.5 percentage points per year²; to meet the goals in the 1990s about three percentage points per year reduction is needed, six times the historical trend. Again, in sub-Saharan Africa, a static situation would need to turn into an improvement of -1.5 percentage points per year, higher than that seen in any country in the region since measurements began in the 1970s. Nonetheless, in some countries in the world, notably in South East Asia, rates of improvement have been fast enough to meet such goals. In fact, for these and for much of South America and the Near East, the end of hunger and malnutrition as major social problems is coming into sight. The basic question addressed here is how can nutrition improve more rapidly for the rest-the majority-of the world's malnourished.

² A negative sign for prevalence change means reduction, i.e. improvement; this is used throughout.

Not only have some countries shown rapid improvement, but a number of effective nutrition programmes have now been operating on a large scale for a considerable time. Although evaluations are often inadequate, it is likely that many of these have substantially improved nutrition. Considerable experience now exists on how to manage and make these programmes more effective (ACC/SCN, 1991). There is a basis at country and programme level for learning how nutrition improves and applying this to future policy.

The widely-agreed framework for analyzing nutrition problems and actions is now widely agreed, based on the UNICEF strategy conceptual framework, as shown in Figure 1.2 (UNICEF, 1990). The "underlying causes" of inadequate access to food, insufficient health services and an unhealthy environment, and inadequate care for women and children, were reflected in the structure for the International Conference on Nutrition in 1992. This categorization of food/health/care guided analysis of "nutrition-relevant actions" at an SCN workshop in November 1990 (Gillespie and Mason, 1991), which in turn led to the present exercise.

Figure 1.2: Causes of Malnutrition

Source: UNICEF(1990)

By 1992, then, some important background existed: trends in nutritional status were known in many countries; there was considerable experience of nutrition programmes; and there was a broadly accepted framework for analysis. Analyses of national trends for reporting on the world nutrition situation provided context, showing for instance that economic growth could account for part, but by no means all, of changes seen (ACC/SCN, 1994, p5). The case studies which provide the basis for this paper were undertaken to help gain a deeper understanding at national and sub-national level. Emphasis here has been given to learning from successes, with an emphasis on larger countries.

Case studies were commissioned to find out how nutrition improved, in ten countries. The framework of food/health/care, and the policies related to these, as laid out in Nutrition-Relevant Actions (Gillespie and Mason, 1992), acted as guidance. In synthesizing from these, the focus here is moved a step nearer to operational decisions that affect nutrition-in economics, social sector investments, nutrition programmes, and institutions-which form chapter headings. This also allows clearer linkage with the concerns in the mainstream of development thinking, as discussed for example by the World Bank and UNDP. The World Bank's World Development Report provides a wide range of indicators to monitor the pace of social and economic development and the eradication of poverty (e.g. World Bank, 1994). UNDP's Human Development Report (e.g. UNDP, 1994) focuses on public spending for human development priorities, (especially in the social sector) and on changes in human development per se, using an index which incorporates national incomes, adult literacy, and life expectancy. In neither of these publications is nutrition the central focus of concern, although relevant data are monitored.

In this synthesis, on the other hand, nutrition is the primary outcome of concern; changes in economic development and levels of poverty, in human development expenditures, and in nutrition policies and programmes, are examined to better understand what drives nutrition. In this sense, nutritional improvement is seen as an outcome -as an objective in its own right. The concept of nutrition as a human right reinforces this (e.g. Jonsson 1993). The purpose of understanding how nutrition improves in the case study countries is to help apply the lessons elsewhere.

Nutritional improvement is becoming recognized as an important route to better health, and enhanced human capital. Both these involve cycles through time, of varying lengths. The interaction of malnutrition and infection, recognized as a major public health issue (Scrimshaw et al., 1968; Tomkins and Watson, 1989) operates as a cycle, or perhaps is better described as a spiral, as shown in Figure 1.3. In this illustration, episodes of disease lead to declining nutritional status (marked by growth failure in children), which reduces resistance to disease, increasing vulnerability further; the way back is better nutrition (Mason, 1996).

Figure 1.3: Spiral of Malnutrition and Infection

Source: Mason (1996)

The quantitative demonstration that malnutrition kills in synergism with infection, and that even mild degrees of underweight carry an increased mortality risk (Pelletier et al., 1994), powerfully reinforces the significance of nutrition in health and survival. Such relationships lead to estimates that, through the indirect effects of malnutrition, the global burden of disease would be reduced by around 25% if malnutrition were eliminated (Mason et al., 1995). (This estimate updates earlier ones, in World Bank 1993a.) The non-specific public health effect of better nutrition has often meant that as with other interventions that affect a range of diseases, the potential effectiveness has been underestimated (Mosely and Becker, 1991). In fact, malnutrition as viewed here is very similar to the concept of "frailty" used by Mosely and Becker, 1991, which is defined as the biological risk of death, increased by exposure to a high infectious load and other insults; "current evidence suggests that birthweight, anthropometric status, and vitamin A levels would seem to qualify as useful indicators" of frailty (p.226). These authors comment that cost effectiveness considerations of interventions that affect multiple diseases simultaneously will be radically different if intervention strategies are considered in terms of their overall impact on health and survival rather than just as they relate to a single disease-precisely the same point as is made for nutritional improvement, which has also suffered from the analytical limitation of trying to apply nutrition to one disease at a time.

Figure 1.4: Intergenerational Cycle of Economic Growth, Human Capital and Nutrition

The long-term linkage of nutrition improvement to educability and human capital (Martorell et al., 1992; Pollitt, 1990) provides for expectation of a self-reinforcing, virtuous cycle from nutrition. The effect here is one of good early nutrition leading to better educated, more skillful, and stronger adults, thus favouring economic development and hence accelerating the cycle. Part of this would also be through better grown adults having higher birthweight children. Hope for accelerated progress in nutrition lies with the operation of such long-term cycles. This is illustrated in Figure 1.4, and since the concept is central to much of what follows, it is worth considering the details, both of the mechanisms and of possible policy interventions.

The two cycles shown in Figure 1.4 are essentially the same, repeated through time and reinforced. Starting at the point of economic growth in the top cycle, this can lead to a reduction in poverty and thus increased private means, as well as the possibility of greater public investment in the social sector, notably (in this case) in health and education. Both private and public resources provide the potential for improving current adult nutrition and health status, making the current generation fitter to increase productivity, and thus to further growth. A major effect is through the next generation: less poverty and increased health and education lead to a lower incidence of low birthweight, to better nutrition and growth and development of young children-not least through improved care. We now know that this has a long-term effect on educability, acquired skills, and physical fitness, such that when this generation of children in turn becomes adults, in the second turn of the cycle in the illustration, human capital is significantly enhanced, leading to improved productivity and a reinforcement of the cycle for that generation, and for the next. The connection between the healthy well-nourished child and the productive adult is biological and intellectual, making the individual better able to respond to opportunities in the environment.

The cycles in Figure 1.4 fit the structure used here. While economic growth is probably only influenceable to a limited degree by nutritional considerations, it can be shown to have an important effect on nutrition improvement, through routes such as those shown in Figure 1.4 - the details of which are elaborated at the underlying and basic level of the UNICEF framework. In Chapter 3, we consider economic growth as well as programmes directly intended to alleviate poverty and improve household food security. Human resource development through Figure 1.4 social sector expenditures in health and education is addressed in Chapter 4, while specific nutrition programmes are considered in Chapter 5. Finally, in Chapter 6 the issue of institutional capacity for nutrition, political economy and the role of specific nutrition policies in nutritional improvement are addressed.

Regarding the measure of the nutrition outcome used, while physical growth is not synonymous with nutritional status, the prevalence of young children experiencing various anthropometric deficits is one useful summary measure of the nutritional outcome, albeit non-specific to causes (see Beaton et al. 1990). The prevalence of children who are underweight, stunted or wasted, may be defined as the percentage, in a given age-sex group, of those more than 2 standard deviations below the NCHS median reference values for weight-for-age, height-for-age and weight-for-height respectively. In the country reviews, anthropometric data of young children (usually under-fives) were thus one main outcome of concern, along with indicators of micronutrient deficiency disorders and infant and child mortality. These indicators were used in the Country Reviews to build a picture of the nature, extent and severity of the nutrition problem and its changes over time, as far as data availability and reliability permitted. In this summary review we have focussed mainly on young child underweight prevalences.

The goal of the Country Reviews was to explain, as far as possible, the underlying reasons for the nutritional improvements observed in each case. To achieve this, the scope necessarily went beyond nutrition programmes per se-clearly, just as malnutrition is multi-causal, many actions have potential for affecting nutrition outcomes, and were thus relevant to the review. Questions concerning how successful actions were implemented, were also addressed, along with consideration of who designed and implemented them-what was the relative involvement of governments, institutions and communities? Such a broad scope required an understanding of the political economy of nutrition, institutional capacity and the inter-relationship between community-level dynamics and programmes.

The overall view was that momentum in nutritional change is established by long-term social and economic trends, policies and related investments. This may be disturbed by medium-term problems, and blown off course in time spans measured in years. Crises and shocks may be superimposed, with varying severity; when over though, the situation may revert more slowly than the onset of the crisis. Nutrition programmes, if appropriate, can accelerate progress, or cushion vulnerable groups from deterioration during medium to long-term crises. Human capital/resource development, particularly through education, has a long-run momentum-generating and multiplying effect. Necessary for this is some form of democracy and its institutions, which although culturally diverse, share characteristics of justice, human rights, and freedom. To effectively attack the causal factors and processes leading to malnutrition, at the levels and time periods over which they operate, policies should include a judicious mix of poverty-reducing, equitable growth, household food security actions, social service provision, and relevant nutrition programmes.

In sum, drawing on the country reviews, this synthesis aims to compare the country experiences-the nature and scope of nutrition-relevant actions, their pre-conditions, their place in overall development and their future prospects. The objectives are broadly to understand the determinants of trends in nutrition over the last decade or so in a selected number of countries; to identify policies and programmes that would accelerate the rate of nutritional improvement under different conditions; and to draw relevant lessons about the role and place of such policies and programmes.