Approaches toward alleviating a major development problem; lessons from four country projects


Approaches toward alleviating a major development problem; lessons from four country projects

Alan Berg

Malnutrition is pervasive in the developing world and so are its concomitant socioeconomic effects. A major conclusion derived from studies done by World Bank staff and those from other organizations to gauge the magnitude of malnutrition is that the nutrition problem cannot be expected to be solved in an acceptable period through the normal course of development, even with a substantial expansion of food production. Special measures for the malnourished are needed.

In approaching this problem the Bank, other international agencies, and national governments have been influenced by knowledge of the consequences of malnutrition, and the potential contribution of nutrition programs to development in general. Beyond obvious humanitarian considerations, malnutrition affects labor productivity, motivation, and the activity levels and learning capacity of children, and thus both the well-being and earning capacity of the poor. Nutrition programs, therefore, appear to represent an investment in the establishment of productive assets—physical and mental capacity—of the poor. Further, they are linked to health conditions, mortality rates, and fertility.

The Bank’s experience in this field demonstrates that although malnutrition clearly is associated with poverty, much nutritional improvement is possible without major income increases. Moreover, nutrition programs can be effective and, contrary to common assumptions, can be affordable. Some costs can be met through restructuring of existing programs. In cases where additional expenditures are required, most of the interventions tried to reduce malnutrition appeared affordable if extended in those countries.

The Bank’s nutrition work

Over the past decade, the Bank undertook or financed some 55 pieces of nutrition-related research and sector studies of malnutrition problems and their determinants in 16 countries. Bank research, among other things, examined the economic value of improved nutrition, the effects of food supplements on productivity, and the effects of malnutrition on the future earning capacity of children. However, a major part of the Bank’s experience has derived from its participation in nutrition projects in member countries.

Bank research indicated that simply increasing incomes and agricultural production was not expected to resolve malnutrition problems within a generation in most developing countries. The basic problem was one of insufficient caloric intake, complicated sometimes by specific nutrient deficiencies. Most governments were not reaching the very poor, especially the rural poor, with nutrition benefits, and few central ministries had the resources or organizations to mount a substantial national effort to combat malnutrition.

More than half of the malnourished in most developing countries were families of landless agricultural laborers, farmers with land holdings that were too small to be within the scope of most rural development programs, small-scale fishermen, and the urban unemployed. Nutrition problems were evident in all ages and both sexes, although the very young, and pregnant and lactating women generally were the groups most at risk. Apart from whether or not sufficient food was available, malnourished people often did not have the economic and sometimes the physical access to food, nor knowledge of how best to use their resources. Their health was so poor their bodies could not effectively use the food that they did consume.

Bank nutrition projects

The Bank initiated four nutrition projects between 1976 and 1980 in Brazil, Colombia, India, and Indonesia. All four countries had experienced economic growth, but nonetheless continued to face significant malnutrition problems similar to those of most other developing countries. The four Bank-assisted projects, while addressing the special needs of target populations, shared some common features (see table). All included one or more institution-building components and several operational components, usually including the delivery of nutrition services through primary health care systems, and a nutrition education component. The projects in Brazil, Indonesia, and Colombia were multisectoral, comprising nutrition-related elements affecting agriculture, water supply and sanitation, and food marketing, in addition to direct nutrition actions. The project in Tamil Nadu (India) concentrated on fewer activities.

The four, largely experimental, projects were designed, in part, to draw lessons for future nutrition-related activities of the countries and the Bank.

Operational lessons

Targeting and food supplies. The consumer food subsidy experiments in Brazil and Colombia and the institutional feeding programs in Brazil, Indonesia, and India used a variety of approaches to identify the specific populations that needed nutritional help and to direct appropriate nutrition services to those groups. The emphasis on targeting is an important break from the past, where mass coverage was the norm. The main lesson was that some forms of targeting are feasible and can indeed lower costs.

The consumer food subsidy programs in Brazil and Colombia promoted the idea of selective participation. The pilot project in Recife distributed food through several government-run supermarkets to coupon holders selected on income criteria. It demonstrated the difficulty of targeting by income in a setting where income reporting can be very arbitrary. The program showed that food coupon programs are more effective at reducing levels of child malnutrition if the subsidies are high enough to sustain participation. It also showed that heavy bookkeeping and related administrative costs are required to conduct an effective food coupon program, that downpayments for coupons pose a barrier to the lowest income group, and that the system must adapt to the frequent small purchases that low-income families are forced to make.

Building on lessons from the evaluations conducted during project implementation, the Brazilian consumer subsidy component test was modified, with apparent success, by confining it to very low income neighborhoods, making everyone eligible without requiring coupons or downpayments. Even though there may have been modest leakage of benefits to nontarget groups, the cost of this to the program was less than the costs of administering the food coupon system.

Targeting in direct institutional feeding programs was best achieved through the weight-monitoring program set up in Tamil Nadu, designed to screen children for admission to a feeding program when their growth faltered and release them once weight increased satisfactorily.

One of the most important findings from the Bank’s experience in Brazil was that it was possible to reduce food prices for low-income families solely by reducing the costs of delivering food, through a more efficient food marketing system.

Scope of Bank nutrition projects in Brazil, Indonesia, Colombia, and India

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Source: World Bank data.

IDA credit.

Nutrition and primary health care. Good nutrition lowers infant and child deaths which, in turn, is generally expected to lessen the desire for more children. In addition, in the Bank’s experience, the delivery of family planning and nutrition services can be organized to complement each other. For instance, in Indonesia the family planning agency credited growth-monitoring and related nutrition activities with having provided an important inducement for villagers to get together to discuss and become involved in family planning work. In the design of a follow-up project now under preparation for the Bank, nutrition at the village level is closely linked to family planning services.

Because of their village base and close contact with mothers, community nutrition workers from the Bank-assisted nutrition project in Tamil Nadu have been cited by family planning staff there as the best sources for successfully identifying couples who would participate in family planning programs. Further, the full-time community nutrition worker in Tamil Nadu provides simple health services (e.g., deworming, diarrhea control, provision of vitamin A, and iron and folic acid), and at the weighing sessions and through regular home visits promotes use of health centers. Children identified as malnourished are at risk also for infection or other health problems.

A study of the Indonesian program demonstrated that village-level services were likely to offer a more efficient and more equitable use of resources than comparable services offered higher up in the health system, at a subdistrict health center, for example. The Colombian experience showed that a nutrition project could lead to expanded and improved primary health care, as potential food coupon holders visited local health centers to qualify for their rations.

Education. Nutrition education appears to be most effective when designed to modify highly specific behavior, rather than when designed to convey the kinds of general nutrition messages commonly preferred in the past. In Indonesia, this involved working with target audiences, learning their perceptions, and allowing them to try different approaches to improve their specific nutrition problems and to help formulate new ones before designing messages for use in the project. (One of the keys to success was the work of a nutrition anthropologist who lived in Javanese villages during most of the 14-month period of program formulation. She was able to determine, among other things, that the reason most children were underweight even though breastfeeding was nearly universal was that most village women nursed with only one breast.) The program’s objectives were based on what people could and would do. They addressed a few priorities, and they were transmitted simply and effectively by village workers in home visits and growth monitoring sessions. These efforts were reinforced by radio. The project was successful because it was built on the use of resources that already existed in the community.

The Brazilian experience indicated that nutrition education for mothers, along with providing nutrition and intellectual stimulation in a school setting for preschool children, had a marked effect in reducing subsequent school drop-out and repeater rates.

Community participation. All four projects mobilized, with some degree of success, both resources and volunteers in the community—leading to construction of nutrition and health facilities in Brazil; construction of water and sanitation systems in Colombia; mothers’ working groups in Tamil Nadu; and nutrition education through village nutrition workers in Indonesia—which went considerably beyond the standard concept of community participation through meetings to discuss nutrition education. Local participation helped defray costs and improve the projects’ quality.

Generally, participation by members of the community generates enthusiasm in the project, raises nutritional awareness, and improves the chances that project activities will continue after the project ends. But part-time volunteers with limited skills take more time than regular workers to get a job done, there are more of them to be trained, tasks must be fewer and simpler, and quality control and supervision are more difficult. Opportunities for community participation are culture-specific. Where extensive community participation is deemed feasible, experience from the Bank’s nutrition projects suggests that the main ingredients for success are appropriate and adequate training and supervision.

Project design. The Bank experience with nutrition projects indicates that the initial three as originally planned were too complex, trying to test numerous approaches and optimistically assuming a high degree of management and organizational skills. They were administratively cumbersome, cutting across organizational lines in governments and in the Bank. Communications and coordination among agencies were sometimes poor, particularly at the headquarters level; much less so at the field level.

Part of the complexity was created by the desire, late in the project preparation process, to add “productive” components. In stressing the need for directly productive components (such as food gardens in Colombia and Indonesia, and food industry activities in Brazil), a key point about the value of investment in nutrition was missed, that is, better nutrition makes all the other sectors more productive.

A less ambitious, more narrowly focused project consisting of no more than three or four well-integrated nutrition interventions, and carefully designed to limit needs for managerial skills, is more likely to be successfully implemented. Although nutrition projects should be more limited in scope than were the first three projects, successful experience in Tamil Nadu demonstrates that they need not be confined to one sector. The early projects, planned to last four or five years, were also unrealistically short to demonstrate the expected changes in nutritional status.

Costs. The annual cost of Bank project components on which aggregated data are available ranged widely, from $49,000 for the introduction at subdistrict level of the nutrition delivery component in Tamil Nadu to over $4 million in the national Colombian food subsidy program. Many obvious factors contributed to the differences—the size and nature of the project; the size of the food transfer, if any; the extent of targeting; and so on. Costs also varied by country, because of differences in wages, food prices, and food consumption patterns. Annual costs per beneficiary ranged from $2 in Indonesia’s nutrition education program to $35 and $21 in the Colombian and Brazilian consumer food subsidy programs respectively.

To what extent can governments afford nationwide interventions? This depends on a number of factors, not the least being the importance a government assigns to the malnutrition problem and its willingness to commit resources in this area.

Many low-income countries are now spending 6 percent of their budgets or less on health and nutrition together. However, a number of countries have devoted substantial portions of their budgets to consumer food subsidies, generally not perceiving or budgeting them as nutrition programs. In 1975, such subsidies accounted for 21 percent of Egypt’s total government expenditures, 19 percent of Korea’s, 16 percent of Sri Lanka’s, and 12 percent of Morocco’s. In 1981, the urban food subsidy in China accounted for 13 percent of government expenditures. Although for many countries these levels have proved too high to sustain in the long run, the examples suggest substantial resources are made available, albeit sometimes with objectives other than just improved nutrition in mind. Costs for the nutrition actions taken under the Bank-assisted projects would, if carried out on a national scale, range from 0.1 to 2.6 percent of national budgets.

Cost-effectiveness. To more fully assess the appropriateness of nutrition interventions, it is of course necessary to attempt to quantify their effects or benefits and then relate such measures to costs. Much attention has been given to attempting to measure effects in these projects.

In Indonesia, the nutritional status of children up to 24 months old in five areas where nutrition education under the project was offered can be compared with that in five areas that received more standard nutrition assistance, including more conventional nutrition education. One year after the full implementation of the communications strategy, there were significantly smaller proportions of malnourished children in the project villages, as measured by weight for age. There were no significant differences between the villages before the nutrition education project and no other factors were found to explain the improvements. One of the standard government programs with which it was compared cost nearly three times as much to cover a population of 100,000.

The cost per child in Tamil Nadu of ending malnourishment ranges from $33 to $126 per year, depending on the severity of the condition. These costs are strikingly lower than those of well-documented, more traditional nutrition rehabilitation programs in Haiti, where improvement in weight in comparison to the weight of a control group of children was estimated to cost $600 per child and the cost to eliminate a case of third-degree malnutrition compared with control groups was $3,600.

In short, compared with many of the earlier interventions (which generally had either indiscriminate coverage or, if targeted, often involved one-on-one treatment and oversight from highly trained professionals), the large-scale concepts tried under the Bank-assisted project efforts appear to have shown the feasibility of pushing per capita beneficiary costs down to relatively low levels. The low-cost nutrition education as practiced in Indonesia looks particularly attractive. That it was cheaper than programs requiring distribution of food comes as no surprise; the question is whether it was effective. The evidence has shown that nutrition education alone can make a difference in improving nutritional status. Nutritionists have long held out the promise of this possibility; the Indonesian experience is the first time it has been demonstrated in an operational setting. Even at the high end of the cost spectrum, a consumer food subsidy program, if targeted properly, is affordable in certain contexts.

General lessons

The Bank’s management has recognized malnutrition as an important development problem, and one the institution should address. Because of the obvious relationships between nutrition, population, and health, much of the Bank’s work will be in the context of integrated programs. However, free-standing nutrition projects in some situations may be appropriate. These may follow one or more of the following approaches: (1) reduce infant and child morbidity and mortality and promote child growth; (2) improve formation of human capital and labor productivity; and (3) control the major micronutrient deficiency diseases—iron-deficiency anemia, iodine-deficiency goiter, and blindness induced by deficiency of vitamin A. Experience has shown that free-standing nutrition projects focus attention on malnutrition problems and attack them in ways that, at least for now, other Bank projects have not been able to.

Experience with the four nutrition projects has shown that several nutrition actions with demonstrated benefits are technically feasible, cost-effective, and affordable. Whether these can be mounted and effectively administered on a large scale depends, of course, on available resources, but most importantly, on the existing infrastructure. The limitations in absorbing external assistance for such efforts in some countries, particularly in sub-Saharan Africa, pose special problems. In general, however, the type of analysis employed and the underlying principles of the proposed actions are transferable.

Population Change and Economic Development

The provocative statement on demographic policy reprinted from World Development Report 1984 to ensure its continuing availability

Published for the World Bank by Oxford University Press.

  • Links population change in developing countries to economic growth
  • Shows how population growth rates can be affected by public policy
  • Explains the success of different countries in reducing fertility
  • Presents a valuable compilation of statistics on all aspects of fertility and the social and economic factors that influence population change
  • Features numerous tables, case studies, and multicolor maps and graphics