A Conceptual Framework for Investing in Nutrition

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A CONCEPTUAL FRAMEWORK FOR INVESTING IN NUTRITION: ISSUES, CHALLENGES, AND ANALYTICAL APPROACHES

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One in seven people in the world do not get enough to eat, and one in three does not get enough of the nutrients they need to live a healthy and productive life. We have got a very serious malnutrition problem on our hands. Part of that problem can be resolved by understanding the causation including how does the food system affect nutrition, and how does it affect human health? Per Pinstrup-Andersen, 2001 World Food Prize Laureate and Graduate School Professor at Cornell University

The malnutrition challenges facing humanity have been recognized for a long time. Economists have approached this challenge from an economic growth and investment perspective. For example, two broad sets of economic arguments have been put forth in the last 50 years. The first set of literature focused on the efficiency wage hypothesis, which says the productivity and earning potential of individuals depend on their ability to work. Their ability to work in turn depends on their nutritional status. Well-nourished people could accomplish more than malnourished individuals (Majumdar, 1956; Leibenstein, 1957). Further, the wage rates also determine the income spent on food, and hence there needs to be a certain minimum wage level that can meet the nutritional needs of the population for it to be productive and to contribute to economic activities (Mirrless, 1975; Stiglitz, 1976; Dasgupta, 1995). Another set of nutrition economists were concerned about the contribution of income increases to nutritional consumption (Timmer, 1981; Wolfe and Behrman, 1984; Behrman and Deolalikar, 1987; Deaton, 1988; Subramanian and Deaton, 1996; Bhargawa, 2008). They approached the problem of malnutrition from the demand for food and nutrition perspective. They argued economic growth is essential for increasing household incomes and this increased income can contribute to the improved nutritional status of the households. This set of studies have estimated the demand changes in the intake of food and nutrients due to changes in the incomes of the households. We review these studies in detail in Chapter 6, Consumer Theory and Estimation of Demand for Food. The estimates of demand for food and nutrients with respect to changes in income and prices have varied depending on the quality of data availability, methods of estimation, and the level of disaggregation of the households (see some of the earlier literature for example, Pitt (1983), for Bangladesh; Behrman and Deolalikar (1987), Babu (1989), Subramanian and Deaton (1996), Dawson and Tiffin (1998), for India; Sahn (1988) for Sri Lanka; Bouis and Haddad (1992) Nutrition Economics. DOI: http://dx.doi.org/10.1016/B978-0-12-800878-2.00003-7 © 2017 Elsevier Inc. All rights reserved.

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for the Philippines; Ravillion (1990), for Indonesia; and Alderman (1988) for Pakistan). The hypothesis that income increases will help address malnutrition depend on the estimated income calorie relationships in a given society. The debate on the nature and magnitude of these estimated relationships and the methods to improve them continues among economists. Yet the nutritional status of the population does not just depend on income alone, although income to access food and nutrition may be of prime importance. Even if income is adequate, translation of the income at the household level into food consumption and nutrition depend on a host of other factors (Smith and Haddad, 2015). In this chapter we present a conceptual framework to identify these factors. The rest of the chapters in this book explore the linkages among various indicators, and causal factors of food security and nutrition at the household and individual levels.

PROBLEMS OF POVERTY, HUNGER, AND MALNUTRITION In developing nutrition policies and intervention programs, understanding the nature and extent of malnutrition problems at the global, national, and local levels is a first step. Further, as the problem of malnutrition is often expressed in conjunction with other developmental and welfare indicators such as food insecurity, hunger, and poverty, studying their interconnectedness is important (Babu, 2009). The causal relationship among them and the related challenges on one hand, and their influence on the other can provide additional insights into the understanding of the malnutrition challenges themselves. In this chapter we begin with an overview of such interconnectedness in the developing world which is followed by a conceptual framework for understanding the causes of malnutrition in order to identify a broad set of policy and program directions for reducing malnutrition as identified in the literature. We begin with the interconnectedness of the concepts of poverty, hunger, food insecurity, malnutrition, and health. The approach to study the multiple dimensions of poverty has recognized nutritional status as a poverty indicator for quite some time (Sen, 1981; Babu and Subramanian, 1988; Rhoe et al., 2008). These concepts can be thought of as indicators of the welfare of the individual or group of individuals at the household level, although ensuring them at the household level does not automatically guarantee all the members will achieve them (see chapter: Intra-Household Allocation and Gender Bias in Nutrition: Application of Heckman Two-Step Procedure on intrahousehold allocation). Fig. 3.1 shows the interrelationship of various welfare indicators that also bring together various disciplines. Development economists are often concerned with a reduction in poverty as a major objective. Agricultural development programs focus on the availability of macro and micronutrients (FAO, 2015), while the health indicators include nutrition indicators as the starting point. Educationalists look at nutrition issues from the context of cognitive ability and school achievement of children (see chapter: Economics of School Nutrition: An Application of Regression Discontinuity on school nutrition). These welfare indicators are not only interconnected, but often are caused by same set of subset of variables and have a cyclical causal relationships. One can start the cycle anywhere with any of the variables in one of the boxes, and tell the story of individual and household welfare from the perspective of the indicator.

CAUSES OF MALNUTRITION: A CONCEPTUAL FRAMEWORK

Poverty

Food insecurity

Nutritional status

Cognitive ability

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Labor productivity

School/attendance achievement Health status Work capacity

FIGURE 3.1 Interconnectedness of poverty, food security, and nutrition. Source: Adapted from Dasgupta, P. (1995). The population problem: theory and evidence. J. Econ. Lit., 33 (4), 1879 1902; Flores (2001); Gillespie et al. (2013); (IFPRI-GNR, 2015).

In the context of nutritional status, e.g., it can be seen as an end in itself, but also could be treated as an input into good health. Analysts focusing on labor productivity on the other hand will look at health as an input to contributing to work capacity and to labor productivity indirectly and also directly in the short run and in the long run. Increasing health status has been seen as a key welfare indicator in which good nutrition is seen as a key contributing factor along with other variables including lifestyle, taste, preferences, and eating habits, to name a few. The cyclical nature of the linkages can be seen at least from one angle. A highly productive labor force, in an economy that produces adequate employment opportunities, should contribute to reduced poverty which further can result in reduction in hunger and under-nutrition, which can improve the health status and along with other variables can increase labor productivity.

CAUSES OF MALNUTRITION: A CONCEPTUAL FRAMEWORK In this section we focus on child malnutrition and its causal factors in order to develop a set of policy issues that are confronting the developing community. Fig. 3.2 presents the conceptual linkage of the factors affecting malnutrition at various stages. This time test framework continues to evolve and allows for modification depending on the context of the problem at hand and the emphasis of the variables to be studied. We present the original version with some adaptation to capture the spirit with which the international development community quickly adopted it when it was developed in the early 1990s. Fig. 3.2 provides a simple but comprehensive framework for understanding the causes of optimal nutrition. The causes of optimal nutrition are separated into three groups of causes. The first group of immediate causes, namely inadequate dietary intake and illness, interact in a negatively synergetic way to contribute to malnutrition. On the next level, household and community deficits

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Adult development

Optimal nutrition

Immediate causes

Adequate dietary intake Macro, micro nutrition, over nutrition

Underlying causes

Labor productivity

Health Status/Disease Childhood disease, noncommunicable disease

Policies that increase adequate access to food Food production, market, trade policies, social safety nets

Policies that increase adequate care for children and women Access, control knowledge of care

Policies that increase health services and unhealthy environment Hygiene, water, sanitation

Adequate education; knowledge sharing; behavioral education

Basic causes

Resource, control and use Human, economic and organizational resources; resource pricing policy Political and Ideological factors Legal structures; food rights; organized advocacy Economic structure Potential resources: poverty/natural resources/agricultural technology

FIGURE 3.2 Determinants of optimal nutrition. Source: Based on UNICEF (1991); Smith and Haddad (2000); FAO, 2006.

in food security, inadequate access to health (reflected by safe water availability, sanitation, and primary health care), and household child care behavior and practices also interact. Summarized as “food security, health, and care” factors, these are the underlying causes of malnutrition. At the more basic level the causes such as control and use of resources, capacity in a society to make use of resources for productive purposes, and the broad set of factors associated with the

CAUSES OF MALNUTRITION: A CONCEPTUAL FRAMEWORK

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socioeconomic and political structures of the society determine the status of the underlying causes of malnutrition. Studies have confirmed that the food supplies at the country level are not the most important determinant of nutrition. Other complementary factors such as maternal knowledge, caring practices, access to health services, and water and sanitation are also important determinants of nutritional status (Engle et al., 1999; Smith and Haddad, 2003, 2015). Much has been learned over the years about addressing the challenges of malnutrition. In the process of attaining nutrition security, achieving secure access to food combined with a sanitary environment, adequate health services, and knowledgeable care to ensure a healthy life for all individuals (World Bank, 2005), several well established facts must be underscored. Malnutrition is not necessarily just a matter of adequate food intake. Food security does not guarantee nutrition security at the household or individual levels. A nation may have adequate food at the aggregate level for all of its population, but households may not have access to such food, either because of low purchasing power or due to remoteness in physical access to food. Similarly, a household may have adequate food yet individual household members may not have adequate access to food, care, and the health determinants of nutrition. An exception where food intake alone can make some serious dents in the problem of malnutrition is a situation where the population is suffering from prolonged drought and famine conditions (Babu and Pinstrup-Andersen, 1994). Malnutrition occurs because of poor household purchasing power, even when food is available in the market. Yet, even nonpoor households have malnourished children and individuals, partly due to distorted household priorities in terms of nutrition, which primarily emanates from the lack of information on the benefits of nutrition. Thus, improvements in nutrition do not automatically result from efforts to reduce poverty or broad economic growth (Ruel and Alderman, 2013). Furthermore, malnutrition does not differentiate between subsistence-oriented households and market-oriented households. Subsistence households can suffer from malnutrition if they have adequate food, but do not have health and appropriate health care practices (Smith and Haddad, 2015). Market-oriented households are also equally vulnerable even if they earn income from the sale of crops, but do not invest that income in improving their nutritional status (Babu and Mthindi, 1994; Babu et al., 2015). Female-headed households are likely to spend their income, even if it is less than male-headed households, on the nutritional objectives of their children (Kennedy and Peters, 1994). Yet, due to a low resource level and poverty that normally strikes female-headed households, they remain vulnerable to malnutrition (Quisumbing and Meizen-Dick, 2012). Broad-based nutrition strategies are feasible on a massive scale and work in reducing malnutrition (Shekar et al., 2016). Cost-effective programs have been implemented in many countries toward the attainment of better nutrition and health (Bhutta et al., 2013). Malnutrition is a multidimensional problem, measured in multiple facets such as calorie deficit, hunger, micronutrient deficiencies, overweight, and obesity, with varying outcomes ranging from mental impairedness, to blindness, and being a cause of noncommunicable diseases. Thus, addressing malnutrition requires a multidimensional approach (USAID, 2014). Malnutrition has generational implications as well. A low birth weight female grows up to be a stunted girl who is anemic and malnourished, and who as a pregnant woman will give birth to a low birth weight baby, so the cycle of malnutrition continues over the next generation (Gillespie et al., 2015). Addressing the problems of malnutrition has high economic returns and can enhance the process of economic growth and poverty reduction (World Bank, 2006). Malnutrition does not only affect developing countries. It is also prevalent in middle and high income countries. As countries develop

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and progress, the nature of the problem changes from one of under-nutrition to that of overnutrition. The multi-sectoral nature of the nutrition problem involves various sectors such as agriculture, health, and food; ministries have made efforts to jointly address malnutrition, which remains an arduous task in many developing countries (Ruel and Alderman, 2013; USAID, 2014). Given that malnutrition is an integral part of the human development index, there is a window of opportunity that exists to improve nutritional status, thereby increasing the human development of a country. Recognizing that the Sustainable Development Goals (SDGs) can be achieved through better nutrition helps in increasing the attention of policy makers toward better nutrition investment, since SDGs critically depend on better nutritional outcomes (IFPRI-GNR, 2015; Wage, 2015). A coordinated effort is needed to focusing on nutritional goals at global and national levels. Small-scale successful interventions never add up to make a large impact on nutrition due to lack of capacity, poor governance, and low priority for nutrition among the decision-makers. The study of economic aspects of nutrition issues, programs, and policies can help in understanding various cost-effective ways and means to improve nutrition. Improving investments at national and global levels and integrating nutrition with a broad set of development plans and programs will require a broader perspective of nutrition (Shekar et al., 2016).

RATIONALE FOR INVESTING IN NUTRITION The study of the economics of nutrition helps to understand various options and strategies for investing in nutrition. But why should a country, a community, a household, or an individual invest in nutrition? There is broad agreement that improving nutrition increases human productivity. Increased productivity should in turn contribute to increased returns per unit of labor. This helps in increasing the household income if the household is a subsistence household, or when it employs a well-nourished labor force. At the societal level, increased productivity results in efficient provision of both private and public goods. At the national level increased investment in nutrition contributes to a productive labor force, and hence to acceleration of economic growth. The indirect benefits of a better nourished population include reduced health care costs, and less days lost from sick leave and absence from work. Yet, the focus on nutrition as an economic investment in the economy continues to be limited (Hoddinott et al., 2013; WHO, 2013; Shekar et al., 2016). It is well established that malnutrition leads to direct economic loss (Horton and Ross, 2003; Horton and Stekel, 2013). The strongest linkages between malnutrition and productivity occur through human capital development in the early years of human life. For example, The Cost of Hunger Studies in Africa show that the annual cost of under-nutrition ranges from 3% to 16% of the national income (Hoddinott, 2016). The World Bank (2006) earlier noted that a 1% loss in adult height due to stunting can result in a 1.4% reduction in productivity of a person throughout his or her life. It also noted that eliminating anemia can result in a 5 17% increase in productivity. Such productivity can contribute up to 2% of the GDP where anemia is a serious health issue. It also reported that 60% of the deaths in the world are due to health related challenges that have their origin in poor nutrition (World Bank, 2006). A lack of investment in improving malnutrition results in high costs in terms of higher budget outlays and eroded national income (World Bank, 2006). A malnourished population will produce

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less output per worker, will lose opportunities for using their mental capacity effectively due to low cognitive skills in different types of occupations and jobs, and will incur high costs of health related expenses, as they tend to be susceptible to malnutrition-induced illnesses including noncommunicable diseases. As children they perform poorly in school and reduce the quality of human capital, which results in significant losses to the economy (Hoddinott et al., 2013). For example, earlier reviews (Behrman et al., 2004; World Bank, 2006) have documented the following specific losses due to malnutrition challenges: low birth weight reduces the IQ of children by 5%; stunting can reduce the IQ by 5 11%; iron deficiency reduces IQ by 10 15%; children who are malnourished early in life have lower scores on the tests of cognitive function, psychomotor function, and fine motor skills; and the reduction of attention span and lower activity levels in school add to the problem of poor performance and a low level of success later in life. Neglecting investment in addressing nutrition challenges can result in heavy losses to society. However, evaluations of large-scale nutrition intervention programs have shown that nutrition investments in such programs have high returns. Over the years countries have attempted to address the problems of malnutrition through large-scale interventions such as national nutrition programs and early child intervention programs. Experience to date shows that investing in nutrition is a worthwhile economic activity with high benefit cost ratios (Behrman et al., 2004; Hoddinott et al., 2013). Several earlier estimates have been suggested on the potential benefit of improving nutrition as well. For example, Alderman and Behrman (2004) suggest that preventing low birth weight is worth US$580 per child. Further, the landmark publication (Repositioning Nutrition as Central to Development, World Bank, 2006) documents serious evidence on the importance of nutrition investments at country levels as follows: obesity and noncommunicable diseases cost, e.g., China 2% of its national income. In India, the productivity losses from stunting, iodine deficiency, and iron deficiency together result in the loss of 2.95% of its national income. Preventing micronutrient deficiencies in China could increase the GDP between $2.5 and $5 billion, representing 0.2 0.4% of its annual GDP. In India, micronutrient deficiencies continue to cost $2.5 billion per year, which is about 0.4% of its annual GDP. In Sierra Leone, neglect of the problem of anemia among women will lead to an agricultural productivity loss of $94.5 million over the next 5 years (World Bank, 2006). Nutrition is a sector that will require public intervention, since market forces alone cannot improve the nutritional status of the population. If every individual in a society is guided by the knowledge of the benefits and costs of good nutrition with complete information on how to effectively use food, health, and caring practices to achieve the goal of nutrition, then there would be no need for public intervention. But in many societies, particularly in developing countries, the information that is necessary for educating and motivating individuals and households toward achieving better nutrition is lacking. Thus, identifying such missing elements at the individual, household, and country levels and filling such gaps requires public intervention. The study of the economics of nutrition by understanding individual and household behaviors toward nutritional investment and the associated costs could help in the process of designing and implementing effective policies and programs for reducing malnutrition (Sunny Kim and Phuong Nguyen, 2016). Yet without such strategic interventions, the cost to society of a malnourished population could be substantial. Malnutrition affects both developed and developing countries. In developing countries undernutrition results in higher health service costs of children due to morbidity, and higher costs due to the additional care needed for malnourished children. In the developed world, over-nutrition affects health care costs as well. For example, in the United States, over-nutrition is a major cause of

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obesity, which is a major health issue involving an estimated cost of $123 billion (CDC, 2008). However, intervention programs generally have high returns on their investments. Behrman et al. (2004), present the main findings of returns on various nutrition intervention programs. The benefit cost ratios for nutrition intervention programs are generally quite high. For example, they show that breast feeding promotions in hospitals have a benefit ranging from 5 to 67 times its cost; for integrated child care programs the benefit ranges from 9 to 16 times its cost; iodine supplementation of women ranges between 15 and 520 times cost. The benefits of Vitamin A supplementation for children less than 6 years of age ranges from 4 to 43 times the cost, and that of iron fortification has the highest benefit of all, ranging from 176 to 400 times the cost. Finally, iron supplementation for pregnant women brings a benefit of 6 14 times its cost (Behrman et al., 2004). Understanding the market failures associated with the provision of nutrition from private individuals and households, and designing policies and programs that can close the information gaps on nutrition through nutrition education can help in designing and implementing public nutrition intervention programs that can result in a well-nourished population—a public good that benefits the society as a whole.

NUTRITION AND OTHER DEVELOPMENT OBJECTIVES A broad perspective on improving nutrition and its relationship to other development objectives becomes important when the society has competing goals and strategies, all of which require budget resources. How is nutrition improvement related to poverty reduction objectives? While undernutrition and micronutrient malnutrition are direct indicators of poverty, as mentioned earlier, they can occur in societies where poverty is not a major development problem. Yet, the problem of under-nutrition has strong linkages with income poverty. For example, as the World Bank (2006) noted, the poorest income quantiles have 2 3 times more prevalence of malnutrition than the highest income groups. Furthermore, certain segments of society are more affected with nutritional problems when they live in poverty. For example, in countries where women’s nutrition lags behind, improving the nutrition of adolescent girls and women can reduce such inequality among various segments of society (FAO/ADB, 2013). Finally, poverty and malnutrition reinforce each other through a vicious cycle (Babu and Sanyal, 2008). Poverty is associated with poor diet, an unhealthy environment, physically demanding labor, and high fertility, all of which contribute to malnutrition problems. Chronic malnutrition resulting from poverty reduces human capital, and thus future income prospects of individuals and households. Malnourished women from low income households are likely to give birth to low birth weight babies, thus perpetuating the cycle of poverty. Studying nutrition interventions in the context of poverty reduction strategies and developing poverty reduction programs with a nutritional focus will require a full understanding of the socioeconomic determinants of nutrition, both as a development input and as an outcome of the development process output. A lot is known about what programs and policies work and what does not in improving nutrition. Much of this knowledge is based on localized and small-scale interventions, although few large-scale interventions have been studied for their nutritional impact (Gillespie et al., 2013). Major knowledge gaps continue to exist when scaling up effective interventions. Several operational challenges should be studied and understood to explain poor scaling up of nutrition

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interventions. Building a global and national commitment and the necessary capacity to invest in nutrition requires personnel who are knowledgeable about the economic, efficiency, and equity benefits of nutrition interventions. Similar knowledge is needed for mainstreaming nutrition in country development strategies and for reorienting ineffective but potentially beneficial large-scale nutrition intervention programs. Studying the economics of nutrition can increase capacity for action research on nutrition interventions, and for improving nutrition through learning by doing (Babu 1997a,b, 2011). Such on-theground challenges as fine-tuning service delivery mechanisms and strengthening the evidence base for investing in nutrition will require basic training in the evaluation of nutrition programs. Global initiatives continue to face daunting challenges due to inadequate capacity for effective coordination to strengthen high level commitment and funding for nutrition interventions. Focusing on priority countries for investment in nutrition and scaling up of nutrition programs will require trained capacity that has good exposure to develop best practices, mainstreaming nutrition as a development objective. To switch from financing small-scale projects to financing large-scale programs, capacity for program design, implementation, monitoring, and evaluation are also necessary (Babu, 1997c). Given the key and fundamental role that nutrition plays in the development process, it has been seen as a health and development goal over the years. At the global level as early as 1948 the constitution of the World Health Organization specifically included the improvement of nutrition among its declared functions. Nutrition has since been a major development objective through various international declarations and conventions (WHO, 2005). The declaration of Alma Ata in 1978 recognized the promotion of food and nutrition as one of its essential elements of primary health care (WHO, 1978). The Global Strategy for Health for All formulated in 1981 brought out the importance of monitoring nutrition as an indicator of well-being of populations, and identified nutrition as one of its pillars (WHO, 1981). The World Summit for Children in 1990 identified eight nutrition-related goals for children (UNICEF, 1990). The World Declaration and Plan of Action for Nutrition lists nine goals for nutrition interventions and actions (FAO/WHO, 1992). Health for All in the 21st century also includes malnutrition and micronutrient deficiencies among its targets (WHO, 2000). The World Food Summit in Rome in 1996 identified food and nutrition security for all as its prime goal. The Millennium Development Goals identify directly or indirectly in its six out of eight goals the importance of increasing nutrition (Haddad and Gillespie, 2002). Several of the Sustainable Development Goals either directly or indirectly relate to and depend on achieving the global nutritional targets discussed in the last chapter on “Global Nutrition Challenges” (IFPRI-GNR, 2015; Wage et al., 2015). Although recognized at global and national levels, nutrition remains a global development challenge and the problems of nutrition along with other food and health related challenges continue to thwart the development process in many developing countries. Identifying nutritional challenges and developing specific nutritional goals and incorporating them into national development policies and strategies needs attention at both the global and national level (Babu, 1999, 2001). Improving food and nutrition security and providing the population with adequate quantities and quality of food continue to be a major challenge. Assessing, analyzing, and monitoring nutrition as an input to the development process, as well as an outcome of development, requires special attention (Babu and Mthindi, 1995a). All this will require a full understanding of the role of nutrition and its economic consequences on society. Designing and implementing nutrition programs and policies requires an understanding of the behavior, incentives, and benefits of nutritional interventions at individual, household, community, national, and global levels (Babu and Mthindi, 1995b).

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Various chapters of this book contain analytical tools needed for the study of the economics of nutrition which will enable the reader to provide the basis for understanding complex nutritional challenges and for designing programs and policies that could serve as a major input into nutrition decision-making at various levels.

NUTRITION CHALLENGES AND THEIR ECONOMIC POLICY ANALYSIS Recent reviews of the nutritional challenges facing development communities highlight several knowledge and capacity gaps in moving forward with evidence based policy making in developing countries. In the last 30 years various factors contributing to nutrition problems have been identified and studied for their policy implications. In the rest of the chapters we try to analyze these determinants of nutrition using different analytical methods. They are worth highlighting here in order to show our choices of policy themes for the chapters and the analytical procedures we demonstrate for readers to gain the needed skills for conducting data-based quantitative analysis and using them in guiding the policy making process in the countries where they work. Nutrition challenges in a country are inextricably linked to the macroeconomic and microeconomic policy environment in the country. The linkages between the economic growth process, its magnitude and speed, and its effects on poverty and nutrition levels are worth studying in their own right, and to gain better understanding of the inter-sectoral linkages they bring about as they affect several sectors that influence nutritional outcomes. Continued and positive economic growth can bring down poverty, hunger, and malnutrition. Yet as we know, the rate of reduction in poverty is more than the rate of reduction in malnutrition. Why does such a disparity occur? What other missing elements play their role in keeping the malnutrition level stubbornly high in developing countries? Economic transition also brings about dietary transition and the demand for food with higher nutritive value, and the demand for processed food rich in fat and sugar increases (Webb and Block, 2012). The marginal propensity to consume food and nutrient increases as income increases, at least for the poorer segments of the society. Understanding the implications of changes in prices and incomes requires a basic understanding of the economic choices households and individuals make in allocating their resources. The microeconomics of food and nutrition choices are introduced in Chapter 4, Microeconomic Nutrition Policy. The issues related to the implications of macro and trade policies are introduced in Chapter 5, Macroeconomic Aspects of Nutrition Policy. While nutrition program interventions are increasingly evaluated through randomized control trials, national level policy making on income transfers, food subsidies, and price changes require an understanding of the factors affecting the demand for food and nutrients (Pinstrup-Andersen, 2012). The theory of consumer demand, their assumptions and restrictions as they apply to an empirical estimation of the demand parameters help in understanding the implications of the policy and program interventions on food and nutrient intake (Jensen and Miller, 2012). In addition, sector wide analysis such as multimarket models, and economy wide analysis such as general equilibrium models require estimation of the parameters of demand systems. We introduce the readers to the theory and empirical specifications of demand systems in Chapter 6, Consumer Theory and Estimation of Demand for Food. The nutritional implications of food demand comes from estimating the relationship between price and income changes and nutrient consumption. Applied policy

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analysis involves estimation of nutrient demand parameters. We introduce this in Chapter 7, Demand for Nutrients and Policy Implications, and show how demand parameters can be used to study nutrition policy. As discussed in the last two chapters - Chapter 1, Why Study Economics of Nutrition? and Chapter 2, Global Nutrition Challenges - and in this chapter above, malnutrition is a multi-sectoral challenge. This recognition requires the policy analyst to go be beyond the food and agriculture sectors to understand the implications of nonfood factors on nutritional outcomes. Intervention strategies in nutrition have to be coordinated with key ministries such as water, sanitation, gender, education, social protection, and food and agriculture (Smith and Haddad, 2015). However, such coordination requires understanding of the contributions of the factors related to primary health care, immunization, breast feeding, mothers education, child spacing, and other socioeconomic and cultural determinants that are context specific to communities and countries. We address these issues in Chapter 8, Socioeconomic Determinants of Nutrition: Application of Quantile Regression, and apply quantile regression analysis. Intra-household dynamics have nutritional implications, as the resources available for the individual members of the household matter. In several societies women still receive a lesser share of the household resources, and yet make most of the nutrition decisions for the family. Gender bias in nutrition intake has serious implications for emergency and long-term policy making processes (Babu et al., 1993; Babu and Chapasuka, 1997). Policies that aim at empowering women through education and targeted interventions that increase their decision-making power at the household level are key for improving the nutritional status of women and children. We introduce the binary outcome model and their estimation methods in Chapter 9, Intra-Household Allocation and Gender Bias in Nutrition: Application of Heckman Two-Step Procedure, to gain a better understanding of the nutritional implications of the variables affecting intra-household dynamics. There is increasing recognition that the factors associated with hygiene, sanitation, access to clean water, and child care have an important role to play in determining the nutritional outcome in a population (Spears, 2012). Yet, these variables are not well studied in the nutrition literature. Further, the implications of policies affecting these variables fall under sectors other than agriculture and health, the traditional sectors held responsible for nutrition. In addition, nutrition education and behavioral changes have gained increased momentum in the study of nutrition behavior. In Chapter 10, Economics of Child Care, Water, Sanitation, Hygiene, and Health: The Application of the Blinder Oaxaca Decomposition Method, we introduce these thematic issues and apply decomposition methods to study the differences in the outcome variables between two geographical groups of households. Program evaluations can save resources if the pilot nutrition interventions are studies for their benefits and costs (Banerjee and Duflo, 2009). Nutrition interventions that combine different instruments are reviewed in Chapter 11, Methods of Program Evaluation: An Analytical Review and Implementation Strategies. This chapter also demonstrates various methods of program evaluations developed and applied over the years. For improving programs and their scaling up, emphasis also needs to be placed on the process lessons from pilot interventions in addition to the impact of the programs on nutritional outcomes. Nutritional implications of social safety net programs have not been fully understood. Limited studies exist that directly address the nutritional objectives (Grosh et al., 2008; FAO, 2015). We review the literature on social safety nets in Chapter 12, Nutritional Implications of Social Protection: Application of Panel Data Method, and apply panel data methods to study the

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nutritional implications of social protection programs. School nutrition programs are a special type of nutritional intervention which aim to attract children to school, keep them in school, and improve their nutritional intake (Alderman, 2010). Food for education programs have been used to reduce the nutritional burden of households (Ahmed and Babu, 2006). The outcome of the program interventions, however, depend on the context in which these programs are designed, implemented, and evaluated. In Chapter 13, Economics of School Nutrition: An Application of Regression Discontinuity, we review the current status of the literature on school feeding programs and apply regression discontinuity models to explain the gains from school nutrition interventions. Overweight and obesity coexist in communities along with under-nutrition challenges. Designing interventions in this context requires innovation (Babu, 2002; Pinstrup-Andersen, 2013). We introduce nonparametric estimation methods to study obesogenic factors and other food security indicators at the household level in Chapter 14, Economic Analysis of Obesity and Impact on Quality of Life: Application of Nonparametric Methods. How food systems could be changed to address the emerging food and nutrition issues is discussed in Chapter 15, Agriculture, Nutrition, Health: How to Bring Multiple Sectors to Work on Nutritional Goals, which demonstrates that innovations are needed in designing interventions through research and innovation for increasing dietary diversity, bio-fortification, food safety, and nutritional enhancement throughout the food value chains. While addressing nutritional challenges, particularly micronutrient deficiencies which continue to be a major set of nutrition challenges, designing cropping patterns that meet the nutritional needs of households could be an important approach (Pinstrup-Andersen, 2013). Yet agricultural extension workers lack knowledge about nutritional needs, and approaches to connect the needs of the farming households to advice on the crops that could be grown in the context of the agroecology, resource constraints, and market considerations are required (Babu et al., 2016). In Chapter 16, Designing a Decentralized Food System to Meet Nutrition Needs: An Optimization Approach, we use a simple linear programming model incorporating the nutritional needs of farming families. Further, we show how the results developed from such farm level models could be useful in recommending cropping patterns that can help farming households to meet their nutritional needs. In the final chapter, we highlight the need for coordinated efforts to increase nutrition governance, accountability, capacity, funding, and sustainability to achieve global nutritional targets.

CONCLUSIONS In this chapter the issues related to policies and programs that affect nutritional outcomes are identified through a conceptual framework, connecting them to larger poverty, hunger, and food security issues. The need for investment in nutrition policies and programs has evolved over the years, and has been highlighted in major conventions and declarations. The need for investing in nutrition and highlighting it as a central challenge of development has been pursued vigorously by the international and bilateral agencies over the last 30 years. However, the challenge of bringing together several sectors that contribute to the nutritional program, policy development, and implementation still remains (WHO, 2013; FAO/WHO, 2014; USAID, 2014). In order to connect various methodological approaches to address the challenges identified in Chapter 2, Global Nutrition Challenges and Targets: A Development and Policy Perspective, and Chapter 3, A Conceptual Framework for Investing in Nutrition: Issues, Challenges and Analytical Approaches, the rest of the chapters of

CONCLUSIONS

37

this book introduce and demonstrate the issues, analytical methods, empirical strategies, and policy insights from the results. Table 3.1 below summarizes the broad set of issues and the chapter contents that may help the reader to choose the policy theme and the related chapter for easy navigation through the contents in the rest of the pages of this book. Table 3.1 Policy challenges addressed and methodological approaches used in various chapters of this book S. No.

Thematic/Policy Issues

Chapter and Methods Applied

1

Economic growth is essential for reduction in poverty and malnutrition. However, the rate of reduction in malnutrition is less than the reduction in poverty.

2

Malnutrition is a multi-sectoral challenge and needs to go beyond the health and agriculture sectors. Intervention strategies have to be coordinated with key ministries such as water, sanitation, gender, education, social protection, and food and agriculture.

Chapter 1, Why Study the Economics of Nutrition?, Chapter 2, Global Nutrition Challenges and Targets: A Development and Policy Perspective, Chapter 3, A Conceptual Framework for Investing in Nutrition: Issues, Challenges and Analytical Approaches, also Chapter 4, Microeconomic Nutrition Policy, Chapter 5, Macroeconomic Aspects of Nutrition Policy, Chapter 6, Consumer Theory and Estimation of Demand for Food; Chapter 4, Microeconomic Nutrition Policy, and Chapter 5, Macroeconomic Aspects of Nutrition Policy, address micro- and macroeconomic aspects of nutrition. Chapter 2, Global Nutrition Challenges and Targets: A Development and Policy Perspective, Chapter 3, A Conceptual Framework for Investing in Nutrition: Issues, Challenges and Analytical Approaches, Chapter 4, Microeconomic Nutrition Policy, Chapter 10, Economics of Child Care, Water, Sanitation, Hygiene, and Health: The Application of the Blinder Oaxaca Decomposition Method, Chapter 12, Nutritional Implications of Social Protection: Application of Panel Data Method, Chapter 13, Economics of School Nutrition: An Application of Regression Discontinuity, and Chapter 17, Future Directions for Nutrition Policy Making and Implementation. An introduction to the issues are developed in Chapter 2, Global Nutrition Challenges and Targets: A Development and Policy Perspective, and Chapter 3, A Conceptual Framework for Investing in Nutrition: Issues, Challenges and Analytical Approaches; Chapter 8, Socioeconomic Determinants of Nutrition: Application of Quantile Regression, and Chapter 10, Economics of Child Care, Water, Sanitation, Hygiene, and Health: The Application of the Blinder Oaxaca Decomposition Method, cover in more detail. (Continued)

38

CHAPTER 3 A CONCEPTUAL FRAMEWORK FOR INVESTING IN NUTRITION

Table 3.1 Policy challenges addressed and methodological approaches used in various chapters of this book Continued S. No.

Thematic/Policy Issues

Chapter and Methods Applied

3

Policy environment, leadership, governance, coordination, financing, and sustainability of interventions are key for such coordination of multi-sectoral activities.

4

In addition to food and nutrition intake, issues related to primary health care, immunization, breast feeding, mothers education, child spacing, and other socioeconomic and cultural determinants that are context specific need to be fully understood.

5

Intervention strategies that help to improve service delivery in sanitation, child care, clean water, and nutrition education for behavioral change are needed to increase the effectiveness of nutritional investments.

6

Empowering women through education and interventions that increase their decision-making power at the household level is key for improving woman and child nutrition. Continued understanding of the intra-household dynamics

Chapter 2, Global Nutrition Challenges and Targets: A Development and Policy Perspective, Chapter 3, A Conceptual Framework for Investing in Nutrition: Issues, Challenges and Analytical Approaches, and Chapter 17, Future Directions for Nutrition Policy Making and Implementation. These chapters cover the issues of coordination, governance, accountability, funding, sustainability, and impact. Chapter 2, Global Nutrition Challenges and Targets: A Development and Policy Perspective, Chapter 3, A Conceptual Framework for Investing in Nutrition: Issues, Challenges and Analytical Approaches, Chapter 8, Socioeconomic Determinants of Nutrition: Application of Quantile Regression, and Chapter 17, Future Directions for Nutrition Policy Making and Implementation. Issues related to immediate causes (Fig. 3.2) are addressed in these chapters. In Chapter 8, Socioeconomic Determinants of Nutrition: Application of Quantile Regression, we introduce the quantile regression technique to study the determinants of nutrition. Chapter 2, Global Nutrition Challenges and Targets: A Development and Policy Perspective, Chapter 3, A Conceptual Framework for Investing in Nutrition: Issues, Challenges and Analytical Approaches, Chapter 10, Economics of Child Care, Water, Sanitation, Hygiene, and Health: The Application of the Blinder Oaxaca Decomposition Method, and Chapter 17, Future Directions for Nutrition Policy Making and Implementation. Issues related to understanding causes are discussed here. In Chapter 10, Economics of Child Care, Water, Sanitation, Hygiene, and Health: The Application of the Blinder Oaxaca Decomposition Method, we introduce decomposition techniques to study the differences in outcome variables. Chapter 2, Global Nutrition Challenges and Targets: A Development and Policy Perspective, Chapter 3, A Conceptual Framework for Investing in Nutrition: Issues, Challenges and Analytical Approaches, and Chapter 9, IntraHousehold Allocation and Gender Bias in

CONCLUSIONS

39

Table 3.1 Policy challenges addressed and methodological approaches used in various chapters of this book Continued S. No.

Thematic/Policy Issues

Chapter and Methods Applied

in resource allocation and utilization of nutrition and health services are needed.

Nutrition: Application of Heckman Two-Step Procedure. Gender relations, intra-household decision-making, and women empowerment issues are addressed, with Chapter 9, IntraHousehold Allocation and Gender Bias in Nutrition: Application of Heckman Two-Step Procedure, introducing binary outcome models. Chapter 11, Methods of Program Evaluation: An Analytical Review and Implementation Strategies. Program evaluation methods are presented and reviewed in Chapter 11, Methods of Program Evaluation: An Analytical Review and Implementation Strategies. Current approaches to program evaluation are demonstrated with empirical results. Chapter 11, Methods of Program Evaluation: An Analytical Review and Implementation Strategies, Chapter 12, Nutritional Implications of Social Protection: Application of Panel Data Method. Protecting vulnerable groups from abject poverty and securing future generations from having malnutrition related damage requires social safety net programs. Chapter 12, Nutritional Implications of Social Protection: Application of Panel Data Method, applies panel data methods to study the impact of social safety nets. Chapter 11, Methods of Program Evaluation: An Analytical Review and Implementation Strategies, Chapter 13, Economics of School Nutrition: An Application of Regression Discontinuity. School nutrition programs help children in school and provide nutrition needed for normal growth of the children. In Chapter 13, Economics of School Nutrition: An Application of Regression Discontinuity, we introduce the Regression Discontinuity Model to study the benefits of school feeding programs. Chapter 2, Global Nutrition Challenges and Targets: A Development and Policy Perspective, Chapter 3, A Conceptual Framework for Investing in Nutrition: Issues, Challenges and Analytical Approaches, Chapter 10, Economics of Child Care, Water, Sanitation, Hygiene, and Health: The Application of the Blinder Oaxaca Decomposition Method, Chapter 17, Future

7

Monitoring and evaluation of programs implemented both for their process lessons and impact of the benefits are needed.

8

Social safety net programs require context specific approaches and the nutritional benefits from them can only be realized if they are specifically addressed to nutritional goals during the design stage.

9

School nutrition programs continue to be the most popular intervention to attract children to school, to keep them in school, and to increase their learning abilities. However, the results differ depending on the context and program design.

10

Overweight and obesity are increasing even in developing countries. Strategies to address overnutrition and under-nutrition in the same community and households require innovations in all sectors.

(Continued)

40

CHAPTER 3 A CONCEPTUAL FRAMEWORK FOR INVESTING IN NUTRITION

Table 3.1 Policy challenges addressed and methodological approaches used in various chapters of this book Continued S. No.

Thematic/Policy Issues

11

Micronutrient deficiencies continue to be a major set of nutrition challenges. Continuous multipronged interventions are needed for iodine, iron, Vitamin A, and other micronutrients; agriculture and food systems have a major role to play in solving micronutrient malnutrition problems. Designing interventions through research and innovation for increasing dietary diversity, bio-fortification, food safety, and nutritional enhancement throughout food value chains is critical.

12

Nutrition challenges are widespread, and yet the solutions require locality specific interventions. Designing and implementing decentralized context specific nutrition interventions that bring several sectors in a coordinated manner require local capacity at all levels.

Chapter and Methods Applied Directions for Nutrition Policy Making and Implementation. The increasing challenge of overweight and obesity calls for policies that can affect consumption patterns, as well as behavioral challenges. We introduce nonparametric techniques for studying factors affecting obesity. Chapter 2, Global Nutrition Challenges and Targets: A Development and Policy Perspective, Chapter 3, A Conceptual Framework for Investing in Nutrition: Issues, Challenges and Analytical Approaches, Chapter 15, Agriculture, Nutrition, Health: How to Bring Multiple Sectors to Work on Nutritional Goals, Chapter 17, Future Directions for Nutrition Policy Making and Implementation. Agriculture and food systems oriented interventions are studied in Chapter 15, Agriculture, Nutrition, Health: How to Bring Multiple Sectors to Work on Nutritional Goals. They include approaches to dietary diversity, bio-fortification, food safety, and value chain enhancements for nutrition. Chapter 16, Designing a Decentralized Food System to Meet Nutrition Needs: An Optimization Approach, Chapter 17, Future Directions for Nutrition Policy Making and Implementation. Decentralized interventions are needed to tackle locality specific problems. We introduce an optimization approach to designing cropping systems.

EXERCISES 1. Review the conceptual framework in Fig. 3.2. Develop a conceptual framework for your country of choice taking into consideration the unique agroecology, natural resource base, and labor and technology constraints. 2. List the various nutrition interventions in your country of choice and demonstrate how they are interconnected to various sectors. How could their coordination at the national, subnational, and community levels improve. Suggest approaches to the stakeholders to hold the program implementers accountable.