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Chapter 9. Conclusions

Thirty percent - 167 million - of all developing-country children under five are currently underweight. This study uses historical cross-country data to improve understanding of the relative importance of the various causes of malnutrition for the developing countries as a whole and by region. In this way, it attempts to contribute to the debate on how to make the best use of available resources to reduce child malnutrition in developing countries now and in the coming years to 2020. It is hoped that the study will help policymakers who are committed to reducing child malnutrition prioritize their resource investments in order to reduce and eventually eliminate child malnutrition in the developing countries.

The conclusions of the report are based on estimations undertaken with careful consideration to data quality and statistical soundness. The research is guided by a well-accepted, comprehensive conceptual framework. It employs household survey-based, nationally representative data on child underweight prevalences that have been subjected to strict quality-control standards. It employs an estimation methodology - fixed-effects panel regression - that accounts for unobserved heterogeneity across countries, thus reducing bias in parameter estimates. Specification tests indicate that the models estimated are a reasonably good representation of the quantitative relationships between child malnutrition and the determinants considered.

Research Findings

This report has found strong evidence that the quality of countries' health environments, women's education, women's status relative to men's, and national food availability are important determinants of child malnutrition throughout the developing world. Termed "underlying-determinant variables," these factors were found to have statistically significant and quantitatively strong impacts on the prevalence of underweight children for a sample of 63 countries, representing 88 percent of the developing world population. The report also confirms that per capita national incomes and democracy, termed "basic-determinant variables," are also important factors. Lying at a deeper level of causality, these factors affect malnutrition mainly through facilitating investment in the underlying-determinant variables.

Past Progress: How Was It Achieved?

The regression results are used to estimate the contribution each factor made to the 15.5 percentage-point reduction in the prevalence of child malnutrition from 1970 to 1995. Among the underlying-determinant variables, increases in women's education contributed the most, accounting for 43 percent of the total reduction. Improvements in national food availability contributed 26 percent of the reduction, health environment improvements 19 percent. Because there was little improvement in women's relative status, its contribution - while still substantial - was the lowest (12 percent).

In South Asia, in addition to women's education, improvements in women's relative status and health environments made particularly large contributions. While South Asian countries' national food availabilities deteriorated during the world food crisis of the early 1970s, improvements in the 1980s made a large contribution. In Sub-Saharan Africa, child malnutrition has largely been reduced through improvements in health environments and increases in women's education. National food availability made very little contribution overall, although its positive impact on child nutrition in the last 10 years has demonstrated its potential. Declines in women's status relative to men's in the region have muted the positive impacts of the other determinants. In East Asia and the Near East and North Africa (NENA), increases in women's education and national food availability have made the greatest contributions. In Latin America and the Caribbean (LAC), women's education has been a major contributor throughout the 25 years; the other underlying-determinant variables have contributed relatively little.

In terms of the basic-determinant variables, improvements in per capita national income have made a substantial contribution, an estimated 7.4 percentage-point reduction in the developing-country prevalence of child malnutrition. The contribution was positive for all regions except Sub-Saharan Africa, where per capita national income declined during 1970-95. While democracy has a potentially large contribution to make, it made no contribution because no progress was made in this area for the developing countries as a whole during the period. Deteriorations in democracy have had a negative impact on child nutrition in South Asia and East Asia. Democracy's contribution has been positive for Sub-Saharan Africa, NENA, and LAC.

Child Malnutrition in the Year 2020

The regression results are also used to project the prevalence and numbers of malnourished children to the year 2020 under three scenarios for growth in the four underlying-determinant variables. A status quo scenario assumes that the nonfood variables increase at the rate they did over the 1985-95 period, while a pessimistic scenario assumes a 25 percent cut in the rate of change and an optimistic scenario assumes a 25 percent increase. For national food availability, IFPRI IMPACT model projections for per capita dietary energy supply are employed.

Under the status quo scenario, 18 percent of developing-country children under five are projected to be malnourished in 2020. The prevalence rises to 22 percent under the pessimistic scenario and falls to 15 percent under the optimistic scenario. The payoffs to the optimistic scenario can best be realized in Sub-Saharan Africa and South Asia. What is particularly striking is that even under an optimistic scenario the absolute numbers of malnourished children in Sub-Saharan Africa are projected to be higher in 2020 than in 1995. Based on the status quo projections, a sharp regional shift in the location of child malnutrition is predicted: South Asia's share will fall from 51 percent in 1995 to 47 percent in 2020, but Sub-Saharan Africa's share will increase from 19 percent in 1995 to near 35 percent in 2020.

Priority Actions for the Future

An assessment of the relative effectiveness of the four underlying-determinant variables in terms of their potential for generating future reductions in child malnutrition is carried out. The assessment takes into account the relative strength of impact of each variable and its distance from the desirable level as of 1995, but not the relative cost of investing in it. It finds that improvements in national food availability and in women's education offer the best hope for future reductions in child malnutrition in Sub-Saharan Africa and South Asia. In South Asia, an additional priority is to improve women's status relative to men's. In East Asia, NENA, and LAC, the primary priority for reducing child malnutrition is improving women's education; the second highest priority is to improve women's relative status. Additional secondary priorities are national food availability for East Asia and health environment improvements for LAC. Policies for increasing national food availabilities should consider measures to reduce population growth as well as to increase food supplies, and should be formulated with the goal of improving food security.⁴⁶

⁴⁶ Simply maintaining the determinants at their current levels will require substantial resources in many countries. This is particularly so for national per capita food availability, which has to be maintained in the face of increasing populations and a fairly fixed amount of cultivable land.

A key message of this report is that significant achievement can be made toward reducing malnutrition through actions in sectors that have not been the traditional focus of nutrition interventions. A second key message is that any comprehensive strategy for attacking the problem of child malnutrition must include actions to address both its underlying and basic causes. Without improvements in national incomes and democracy, the resources and political will to invest in the underlying-determinant factors - in health environments, women's education and status, and food availabilities - will not be there. If improved national incomes and democracy are not directed to improvements in the underlying-determinant factors, on the other hand, they will make little difference. Investments in all of the factors will support the crucial role of direct nutrition programs at the community level.

Contributions to the Resolution of Key Debates

This research contributes to the resolution of five important debates currently under way in development policy and research circles. First, why has child malnutrition been rising in Sub-Saharan Africa? The report finds that some of the increase is likely due to deteriorations in the status of women relative to men and per capita national incomes. Stagnation in national food availability and women's education have also held back improvements in child nutrition. Finally, debt and structural adjustment, increasing conflict levels, and the rise of HIV/AIDS may all play a part.

Second, why are child malnutrition rates in South Asia so much higher than in Sub-Saharan Africa? This study identifies a key variable as the source of the "Asian enigma": women's status relative to men's. Regardless of the levels of the factors influencing child malnutrition that are identified in this report, however, a large disparity in prevalences of child malnutrition would persist between the two regions. The source of this remaining difference is time-invariant factors specific to South Asian countries that the report has not been able to explicitly identify. Some possibilities might be the region's monsoon climate, high population densities, and deeply entrenched beliefs about child feeding practices.

Third, how important is food availability as a determinant of child malnutrition at the national level? The report finds that when it is very low (below a per capita DES of approximately 2, 300 kilocalories), it is a particularly strong determinant. But, after a certain point is reached (at a per capita DES of approximately 3, 120 kilocalories), further increases are unlikely to aid in reducing child malnutrition. For countries with such high food availabilities, efforts to promote food security must focus on promoting access to food at the household level. The regions in which improved food availability has the most to contribute in the coming decades are South Asia and Sub-Saharan Africa. Pro-active efforts to improve food availability through means that simultaneously increase the incomes of the poor (without compromising care of children) are likely to result in greater nutritional benefits than efforts focused solely on raising food supplies.

Fourth, how important are women's status and education? This research report confirms the now overwhelming evidence that women's education has a strong impact on children's nutrition. It also establishes that women's status relative to men's is an important determinant of child malnutrition in all developing-country regions. These findings confirm women's key role in the etiology of child nutrition, whether through the pathway of maternal and child care or household food security. Together, improvements in women's education and status alone were responsible for more than 50 percent of the reduction in child malnutrition that took place from 1970 to 1995. More emphasis should be placed on improving them in the future, especially on women's status and education in South Asia and on women's education in Sub-Saharan Africa.

Fifth, how important are national incomes and political factors such as democracy, and through what pathways do they affect child malnutrition? This report finds that national incomes have a very strong influence on child nutrition. Increases in per capita national income during 1970-95 contributed to almost half of the total reduction in the prevalence of child malnutrition in developing countries, working via all four underlying-determinant factors. The existence of a significant link between the degree of democracy in countries and the prevalence of child malnutrition has been firmly established, with democracy contributing mainly through improvements in health environments and national food availability. Why democracy is important for these two factors and not for others needs to be better understood. Nevertheless, the analysis suggests that political variables have as valid a place in studies of malnutrition as they do in studies of economic growth.

Limitations of the Study

This research does not adequately consider two factors believed to have a strong influence on child malnutrition: food security at the household level and poverty. At present no cross-country comparable data are available on national rates of food insecurity from household survey data (Smith 1998a). Instead, data on per capita dietary energy supplies are used; these are an inadequate measure of food insecurity because they do not measure food access. While some cross-country data on poverty exist (World Bank 1998b), at present data are not adequate to reliably estimate this variable's influence on child malnutrition.

The second limitation of this study is its inability to address the sequential nature of optimal interventions for improving child nutritional status. In many cases one intervention, for example provisioning of health services, needs to be undertaken before others have any positive impact. The estimation methodology used here only permits estimating each explanatory variable's impact as if interventions were to take place simultaneously.

A third limitation of the study is that the costs of various interventions cannot be taken into consideration in setting policy priorities. But, from a practical standpoint, cost-effectiveness must play a crucial role in any decision about what kinds of policies and programs to put in place for reducing child malnutrition as quickly and efficiently as possible.

Directions for Future Research

This report points to a number of fruitful directions for future research. These include (1) a similar analysis for rates of stunting, which is a longer-term measure of nutritional deprivation than underweight; (2) separate estimations for male and female children under age five to determine if malnutrition is explained by different factors for boys than girls; (3) research into the sequencing of interventions to improve child nutrition and into the costs of various interventions; (4) an in-depth study of the roles of democracy and women's status; (5) research on the roles that debt, structural adjustment, conflict, and HIV/AIDS play in Sub-Saharan Africa's rising rates of malnutrition; and (6) an unraveling of the "black box" of time-invariant factors to further explain why South Asia's prevalence of child malnutrition is so much higher than Sub-Saharan Africa's.

This research has found evidence of a feedback effect of child malnutrition - that is, that today's child malnutrition contributes to higher levels of child malnutrition in the future. Although the evidence is weak at present, the existence of this linkage suggests that reducing child malnutrition at a fast pace today should reduce child malnutrition in the future at an even faster pace. A seventh suggested area of future research is prospective studies that use household-level data to ascertain the existence of this linkage and to estimate how strong it is.

Finally, an indicator of national prevalences of food insecurity - based entirely on household food consumption or expenditures survey data - is needed to clarify the role of food security in child malnutrition and to identify where food insecurity is located and how it changes over time. While in the past data were not available to complete this task, with the increased frequency of household food consumption surveys the development of such an indicator is now possible.

A Note of Caution

Finally, a caution to users of this study's findings: the results apply only at the very broad level of the developing countries as a whole and, more tentatively, to the developing-country regions. Their applicability to specific populations at more disaggregated levels is unknown. Careful analysis and diagnosis are needed for understanding the causes of child malnutrition for each subpopulation of the developing world, whether it be a country, a subnational region, a community, a household, or an individual child.