Opportunities to Protect and Enhance Nutritionin the East Asia and Pacific Region

June 20, 2009

Judith S. McGuireWith assistance from Amber Willink and Eko Pambudi

7/9/2009

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68850

EXECUTIVE SUMMARY

The East Asia and Pacific region shows dramatic contrasts in nutrition. Many of the Pacific Islands have some of the highest obesity rates in the world (close to 80% among women in Tonga) while Cambodia, Laos and Timor Leste have some of the highest rates of underweight and stunting (close to or above 50%). Micronutrient deficiencies, especially anemia, persist even among the successful East Asian countries like China and Thailand. Women have high rates of anemia, excessive thinness, and short stature that are risk factors for maternal mortality, low birth-weight, and poor health. Many of the countries in the region are net food exporters and, on paper at least, have sufficient calories to feed their populations and yet the poor, isolated populations and ethnic minorities are food insecure. Major causes of child malnutrition include poverty and food insecurity, poor water and sanitation, women’s status, and young child feeding practices.

The food and fuel price spikes of 2007-8 and the current financial crisis threaten food security and nutrition in East Asia and Pacific region. Most of these economies, which grew at high rates before the crisis, were particularly vulnerable because they were highly integrated into world markets, many people lived close to the poverty line, their consumption basket and diet were heavily dependent on one commodity (rice) which has a uniquely shallow market structure, and because large numbers of people were already malnourished before the crisis started. Food price inflation has been accompanied by rising unemployment in certain sectors, particularly in urban areas, which has thrown some populations into a food security crisis.

Most of the high burden countries have in place already national social and economic policies that include nutrition as a key outcome. They also have national nutrition policies and nutrition programs. The common problem appears to be reaching the community level, management and quality control, consolidating services, and building and sustaining an institutional framework that is multi-sectoral, operational, self-directed, and focused on results at the community level. There are several policy, program, and institutional success stories in the region serve as a knowledge base for other countries.

This paper concentrates on the countries of the region with the highest burden of under-nutrition, examines their policy and programmatic context, and recommends Bank engagement in nutrition through its strong portfolio on community-driven development and conditional cash transfer programs. It proposes a three-pronged strategy with opportunities for follow up engagements in five countries (Cambodia, Indonesia, Lao PDR, Philippines, Vietnam and Timor Leste); sector work in those countries that lack adequate data (Papua New Guinea and the Solomon Islands); and a regional research program on preventing and mitigating obesity and diet-related chronic diseases. It also recommends setting up a regional knowledge network which facilitates sharing knowledge, procuring in bulk regional technical assistance, and creates a community of practice in which participating countries, individuals, and institutions support each other.

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Introduction

Improving nutrition is a key input to as well as outcome from development. In addition to being one of a human being’s most basic needs (and, many feel, an inalienable right), good nutrition is instrumental in building human capital: it affects survival, the immune system, cognitive development and learning capacity, physical strength, capacity, and endurance, and successful reproduction1. Malnourished and low birth-weight children have much higher risk of dying than normally nourished children and the survivors have reduced life chances. Low weight-for-age explains about one-third of total under-five mortality and over half of the post-neonatal portion of it. Severely and acutely malnourished children – the tabloid image of “malnutrition” -- are extremely frail and have very high mortality. But most of the nutrition-related mortality occurs in the mildly and moderately malnourished children. Stunted, underweight and unhealthy women who get pregnant are at greater risk of passing malnutrition on to the next generation especially if those women continue their physically demanding work schedule and don’t eat a good diet or get needed medical attention. Such women are also at greater risk of dying during childbirth. Data on women’s nutritional status (aside from anemia) are sorely lacking but the high rates of maternal mortality, low birth-weight, and anemia suggest that women’s malnutrition (both concurrent and vestiges of childhood malnutrition, like stunting) adversely affects a large number of women in the region. Child malnutrition adds up to 11% of the total global burden of disease. Stunting, severe wasting and low birth-weight account for 21% of deaths in children under 5 and burden of disease in children under 5 and an additional 11% of the disease burden is due to micronutrient deficiencies2. That does not count the substantial effect of anemia and under-nutrition on learning.

The East Asia and Pacific region shows dramatic contrasts in nutrition. Many of the Pacific Islands have some of the highest obesity rates in the world (close to 80% among women in Tonga) while Cambodia, Laos and Timor Leste have some of the highest rates of underweight and stunting. Micronutrient deficiencies, especially anemia, persist even among the successful East Asian countries like China and Thailand. Most of the countries are net food exporters and, on paper at least, have sufficient calories to feed their populations. The problem is that the poor and remote families can’t buy the diet they need and many factors other than food availability affect nutrition.

The food and fuel price spikes of 2007-8 and the current financial crisis threaten food security and nutrition in East Asia and Pacific region. Most of these economies, which grew at high rates before the crisis, were particularly vulnerable because they are highly integrated into world markets, many people live close to the poverty line, their consumption basket and diet are heavily dependent on one commodity (rice) which has a uniquely shallow market structure, and because large numbers of people were already malnourished or close to it before the crisis started. In addition, the region suffered through multiple natural disasters (cyclones, flooding, earthquakes, and epidemics) that further compromised food security.

While the developing countries of East Asia grew at 11.4% in 2007 they are projected to grow at only 5.3% in 2009. China and Vietnam’s growth rates are projected to fall from 13.0 to

1 World Bank. 2006. Repositioning Nutrition. 2 Black, R.E. et al. 2008. Maternal and Child Under-nutrition 1. Maternal and child under-nutrition: global and regional exposures and health consequences. Lancet 317: 5-40. Lancet Nutrition Series

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6.5% and 8.5 to 5.5%, respectively. In Southeast Asia (Indonesia, Malaysia, Philippines and Thailand) growth is predicted to fall from 6.2% to 0.7%, and the small economies from 6.7% to 1.6%3. This means that progress on reducing poverty will slow and poverty might increase in these countries. It also means that nutrition at risk.

Food price inflation exacerbates economic distress for the poor, who spend a large proportion of their income on food. As economic growth has stagnated, food prices have risen, causing food insecurity.

Table 1. Food Consumer Price Inflation

2006 2007 Q1 2008Cambodia 6.5 10 19.8 (1/2008)China 2.3 12.3 21.0Indonesia 14.7 11.4 12.4Lao PDR 9.8 8.2 7.5Malaysia 3.4 3.0 4.4Mongolia 3.0 25.5 32.2Philippines 5.5 3.3 7.0Vietnam 8.7 11.2 26.0

Source: Brahmbhatt and Christiansen, 2008

Luckily, previous economic growth and sound fiscal policies enabled most of the affected countries in the region to take decisive steps to protect the poor from the crisis. That is not enough, however. Because nutrition is a fundamental input to human capital, these countries need to protect and improve the nutrition of their populations during and after the crises. In particular, to reduce their vulnerability to future economic shocks they need to address the long term “structural” nutrition problem not just the transitory effects of the crisis. Now, while the governments and donors are paying attention to the crisis, is the time to put in place or strengthen programs to prevent malnutrition4.

This paper is funded by the Central Contingency Fund, which was set up to identify opportunities for the World Bank to help countries improve nutrition in this time of crisis. The purpose of this paper is to discuss the nutritional face of the East Asian economic crisis and present opportunities to scale up action against malnutrition. General information and trends are presented for the region as a whole and more detailed analysis is provided for the countries with the greatest burden of undernutrition (Cambodia, Indonesia, Lao PDR, Philippines, and Vietnam).

3 Appendix Table 4, Battling the Forces of Global Recession, 2009.. 4 A word on terminology. Undernutrition is used here to describe the physical effects of not getting enough to eat to cover needs. It includes growth failure in children (reflected in low weight-for-age, low height-for-age (stunting) and low weight-for-height (wasting)) and it includes weight, height, and thinness of women. It also includes micronutrient deficiencies as detected in physical, biochemical, and clinical signs. This is not the same as “undernourishment” or “undernourished” as used by FAO to express food energy availability (corrected for income distribution).

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I. The Nature of the Problem

Child malnutrition

The East Asia and Pacific region represents the global spectrum of nutritional well-being (see Table 4). Underweight in children under five ranges from close to zero in Samoa up to 36% in Cambodia, 40% in Lao PDR and 46% in Timor Leste (WHO, 2008). Similarly, stunting ranges from less than 5% in Tonga, Singapore, Fiji and Samoa up to 45% in Cambodia, and 49% in Timor-Leste. Trend data, where available, are highly variable and nutritional indicators do not always track national income data. China has been able to reduce its malnutrition quickly as a result of rapid economic growth but Vietnam, with rapid economic growth, has experienced slow improvement (from 59.7% stunting in rural areas in 1985 to 34% in 2007 or about 1 percentage point a year, about the secular rate worldwide. The Philippines, one of the wealthier countries in the region has the second highest rate of low birth-weight (45.2%) (exceeded only by Cambodia at 64%). Anemia – a major cause of cognitive deficit -- is widespread among women and preschool children. In Cambodia it affects close to two-thirds of preschool children and 80% of children under two years of age. Even in Thailand, anemia affects 25% of preschool children. Vitamin A deficiency ranges from less than 5% in Thailand and Malaysia to 61% in the Marshall Islands, 45% in Lao PDR, and 40% in the Philippines. These levels of vitamin A deficiency persist in spite of putative distribution of megadoses of vitamin A ranging from 35% of children in Timor Leste to 100% of children in DPR Korea. Iodine deficiency (measured in school children) ranges from 16% in China and Indonesia to 53% in Mongolia. Because iodine deficiency is basically a geological issue (if there is no iodine in the local soils, foods grown on those soils will not contain iodine), in the absence of mandatory iodization of salt, iodine deficiency becomes widespread. Salt iodization ranges from 12% in Cambodia to 100% in Fiji. Malnutrition is particularly severe in rural and remote areas and among ethnic minorities.

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Table 2. Basic nutrition indicators for major low-middle income EAP countries

Stunting <5 Underweight

<5 WastingSevere acute

(<-3Z w-h)Cambodia 48.2 32.9 8.9 0.5China 21.8 6.8 3.0 0.8Indonesia 28.6 24.4 14.4 0.9Lao PDR 48.2 36.4 17.5 7.6Malaysia 15.6 16.1 13.3 3.3Mongolia 23.5 4.8 2.7 1.1Myanmar 40.6 29.6 10.7 2.9Papua N.G. 50.2 24.6 6.3 1.6Philippines 33.8 20.7 6.0 1.6Korea DPR 44.7 17.8 8.7 3.5Singapore 4.4 3.3 3.6 0.5Solomon Islands 33.7 16.3 7.4 2.0Thailand 15.7 7.0 4.7 1.4Timor Leste 55.7 40.6 13.7 4.9Vietnam 36.0 20.0 8.0 3.0

Source: WHO Global Database on Child Growth and Malnutrition (using WHO Child Growth Standards). Note that anthropometry data are generally from the last five years except for PNG (1982-3) and Solomon

Islands (1989).

Where data are available, rural malnutrition is generally far worse than urban malnutrition (See Figure 1).

This is undoubtedly due in part to the fact that poverty is considerably higher than rural areas. Rural people also have far less efficient food and labor markets, less access to public services (especially schools and health services), and often lack such amenities as improved water supply and sanitation, modern floors in their homes, irrigation, and transportation. Ethnic minorities, who are at higher risk of malnutrition, also tend to live in remote and rural areas in East Asia.

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0

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20

30

40

50

60

Perc

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Tim

or L

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Lao

(200

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Cam

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Kor

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Mya

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(200

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Phi

lippi

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(199

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Vie

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(200

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Indo

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004)

Mon

golia

(200

5)

Chi

na (2

002)

Mal

aysi

a (1

999)

Thai

land

(200

5-6)

Fig. 1. Rural Urban Differences in Nutritional Status, selected EAP countries

Rural Stunting

Urban Stunting

Rural underweight

Urban Underweight

Source: DHS Cambodia, 2005

As can be seen from the following table, many countries have high levels of micronutrients deficiencies although vitamin A capsule and iodized salt coverage are high (Source WHO, 2008).

Sources: WHO Global Database on Child Growth and Malnutrition and UNICEF ChildInfo.

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Underweight and stunting evolve rapidly between birth and the second birthday in countries where malnutrition is a serious problem. This graph from Cambodia shows a typical pattern where malnutrition balloons after six months of age:

Source: Cambodia DHS, 2005

As can be seen from the following table, many countries have high levels of micronutrient deficiencies although vitamin A capsule and iodized salt coverage are high.

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Fig. 2. Cambodia, 2005 Malnutrition by Age

0

10

20

30

40

50

60

0.49 0.99 1.99 2.99 3.99 4.99

Age (years)

Perc

ent m

alno

uris

hed

UnderweightStuntedWasted

Table. 3 Micronutrient Indicators in Preschool Children

Anemia in Children under

5 Vit. A Deficiency (serum retinol)

Vit. A capsules (full coverage)

Deficient Urinary Iodine

Schoolchildren Iodized

salt Cambodia 63 22.3 76 73China 20 9.3 15.7 94Indonesia 45 19.6 87 16.3 73Korea DPR 32 27.5 69 20.4 58Lao PDR 48 44.7 19.8 84Malaysia 32 3.5 94Mongolia 21 19.8 93 52.8 83Myanmar 63 36.7 7 22.3 60Papua N.G. 60 11.1 83 74.7 36Philippines 36 40.1 95 23.8 45Solomon Islands 52 13.1 12Thailand 25 15.7 25Timor Leste 32 45.8 50 57.4 92Vietnam 34 12.0 95 60Sources: WHO Global Database on Anemia; Global Database on Vitamin A Deficiency (VAD), UNICEF State of the World’s Children 2009 (Table 2, vitamin A capsule coverage and iodized salt); WHO/SEAPRO, 2008

(Table 9.10) for iodine deficiency.

Anemia is a particularly severe nutrition problem, both for women and for children. The figures provided for children underestimate the problem. Children under the age of two have much higher rates of anemia than children 2-5 years old. Data from Philippines show a typical pattern for anemia by age:

Table 4. Evolution of Anemia over Age, Philippines 2003

Age Prevalence (%)6-11 months 65.912-23 months 53.024-35 months 34.836-47 months 24.848-59 months 18.860-71 months 14.06-12 years 37.4

Source: 6th National Nutrition Surveys. Pedro, et al.

This is because they are growing fast and are born with low iron stores (due to maternal anemia). Although breast-milk contains high quality iron, its contribution to the diet is small after the first six months of life and infant’s dietary intake contains poor quality and quantity of iron.

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Maternal Malnutrition

Maternal health and nutrition affects and is affected by reproduction and the physical labor of farm work and off–farm employment as well as the high physical costs of hauling water and fuel-wood, bearing and raising children, and household maintenance. Women’s health and nutrition, in turn, affects the health and nutrition of their offspring. Low birth-weight reflects the cumulative health and nutrition strains on women, reflecting as it does maternal stunting (a vestige of past nutrition), thinness, and poor health in general. Anemia is quite high among pregnant women in the region ranging from about 20% in Thailand to 66% in Cambodia. Maternal anemia reduces women’s s ability to work and predisposes them to higher mortality risks during childbirth. Many women in East Asia are so short (under 145 cm), thin (under 18.5 body mass index), and anemic that pregnancy poses serious risks to their lives and those of their unborn children. Pregnant women also have more night blindness (a symptom of vitamin A deficiency) and iodine deficiency disorders because of the demands of pregnancy. To prevent maternal malnutrition and its consequences for their offspring, interventions need to take place before and during pregnancy and include family planning, delayed marriage and first conception, feeding girls well before and during their adolescent growth spurt, and increased schooling (for better income options, to delay marriage, and to better manage information within the household) as well as good care and feeding during pregnancy.

There are a number of indicators of maternal factors that affect nutrition. These include the mother’s own nutrition and health status, high fertility and too closely spaced pregnancies, high physical workload, domestic violence, and poor access to preventive care. Maternal disadvantage expresses itself in high maternal mortality and low birth-weight as well as micronutrient status of infants. If women are iodine or folate deficient at the time they become pregnant, they are at greater risk of giving birth to mentally and physically handicapped infants. Anemic women are likely to give birth to infants with lower iron stores, thus hastening the onset of anemia in infancy (which is already quite high in all of these countries). Vitamin A deficient women have breast-milk that is deficient in vitamin A as well so that WHO recommends that postpartum women be given megadoses of vitamin A to protect the their health and that of their infants (megadoses of vitamin A during pregnancy are known to be terato-genic).

Very few detailed data are available on women’s nutritional status in the region. Only Cambodia has had comprehensive DHS surveys which explore women’s nutritional status. In Cambodia in 2005, 7.7% of women were found to be so short (less than 145 cm.) and 20.3% were so thin (BMI less than 19.5) that they are at elevated risk of obstructed labor and low birth-weight. These indicators were worse in rural areas. Only 1.2% were obese (2.6% in urban areas). Women’s nutrition showed the expected relationship with income (wealth). About half as many women in the 5th quintile (5.1%) were severely stunted (<145 cm) than in the lowest quintile (10.3%). Overweight and obesity which ranged from 4% in the bottom quintile to 17.6% in the wealthiest quintile. Overweight and obesity increased from 6% in 2000 to 10% in 2005. Anemia is high in all women (46.6%) and shows a significant relationship to wealth (from 55.5% in the lowest quintile to 34.7% in the highest quintile). Anemia improved between 2000 and 2005. Anemia also increases with high parity (54.1% for women who have had six or more children compared to 44.5% for women who have had no children). Pregnant women are more likely to be anemic (57.1%) than lactating women (53.6%) and non-pregnant non-lactating women (44.3%). Rural women are more likely to be anemia than urban women (48.4% vs. 37.7%), which is probably due to income but also to higher likelihood of intestinal parasites in

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rural areas. Only 17.6% of women reported taking the recommended 90 iron-folate tablets during pregnancy and only 10.7% took deworming medication during pregnancy to reduce blood loss to intestinal worms. Close to three-quarters of women reported using iodized salt.

In addition to women’s health and nutrition, women’s education has been shown to have a profound effect on child nutrition. To some extent this educational premium probably reflects lifetime advantages but education also probably conveys concurrent advantages with respect to income, self-confidence, and ability to manage complex information.

Table 5 shows the range of indicators for the main low and middle income EAP countries.

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Table 5. Maternal Factors that are Related to Malnutrition

Anemia in Pregnant women

Total Fertility

Contra-ceptive

prevalenceMMR

Low Birth

weight

Adult female obesity

Female Literacy (as proportion

of male literacy)

Women who feel domestic

violence against women

justified under certain

circumstancesCambodia 66.4 3.2 40.0 540 64.0 <10 79.0 55.2China 28.9 1.7 85.0 45 2.4 <10 93.0Indonesia 44.3 2.2 61.0 420 9.0 <10 93.0 24.8Lao PDR 56.4 3.2 38.0 660 18.0 10 83.0 81.2Malaysia 38.3 2.6 55.0 62 8.6 20 95.0Mongolia 37.3 1.9 66.0 46 4.1 10 101.0 20.4Myanmar 49.6 2.1 34.0 380 10.0 10 92.0Papua N.G. 55.2 3.8 26.0 470 10.0 <10 86.0Philippines 43.9 3.3 51.0 230 45.2 <10 101.0 24.1Korea DPR 34.7 1.9 62.0 370 7.0 10 94.0Singapore 51.1 1.3 62.0 14 13.0 15 50.9Solomon Islands 22.3 3.9 7.0 220 9.0 10 97.0Thailand 22.9 1.8 77.0 110 10.0 20 85.4Timor Leste 32.2 6.6 20.0 380 5.1 10 90.5Vietnam 66.4 2.2 33.0 150 64.0 <10 femlit 63.8

Sources: WHO (National Estimates of Anemia), WHO-SEARO (2008) Obesity, UNICEF State of the World’s Children 2009 and Child Info (the remainder)

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In Cambodia, detailed data are available, one can see the impact of close child spacing on nutrition.

Table 6. Relationship between child spacing and nutrition in Cambodia (2005)

Child Spacing

Height-for-age

Weight-for-

Height

Weight-for-Age

First Birth

29.7 7.8 30.8

<24 months

46.5 7.1 44.5

24-47 months

40.7 6.2 38.5

48+ months

33.9 8.8 32.0

Obesity

Much less is known about prevalence, causes of and solutions to obesity and diet-related chronic diseases than is known about under-nutrition. Data are lacking in many countries and trend data are sparse, except, perhaps, for China and the Philippines. The two nutrition problems are not unrelated. Low birth-weight, for instance, is associated with higher risk of diet-related chronic diseases in later life (the Barker hypothesis). Early under-nutrition following by excess food intake also appears to be related to cardiovascular disease. Physical activity is related to both problems as well with rural residents having very high levels of physical energy expenditure relative to their energy intake while urban residents have very low physical activity but high calorie intake. Even more problematic than the lack of data, however, is the lack of successful national or large-scale programs from which to learn. The nutrition community is divided over the importance of various dietary factors (calories, specific fats, specific carbohydrates, protein, micro-nutrients), the relative importance of physical activity and diet, the role of advertising, marketing, and modern food processing practices, and, most importantly, how to effect sustainable long-term behavioral change. For the EAP region, piloting practical programmatic approaches (rather than academic research) is urgently needed along with better epidemiological data collection. Much more work needs to be done to identify the best policy levers to use to prevent obesity and diet-related chronic disease from undermining health and economic gains in these countries.

Reaching the Hunger MDG

The goal of the first MDG is to halve poverty and hunger between 1990 and 2015. It is not surprising, given its impact on overall human development, infant, child and maternal mortality, and education, that halving underweight is included as an indicator for the first Millennium Development Goal. Improving nutrition is also intimately related to the rest of the outcome MDGs (see Appendix 1).

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According to UNICEF’s calculations5 Cambodia, China, Indonesia, Malaysia, Mongolia, Singapore, Thailand, and Vietnam are all on track to meet the goal (or they were before the economic crisis). Lao PDR, Myanmar and Philippines are making insufficient progress and Timor Leste is making no progress. The remainders of the countries in the region have insufficient data. The nutrition MDG, like the maternal mortality goal, is lagging behind the under 5 child mortality goal, which has been or will be achieved in virtually all countries in the region (except for Timor Leste, Myanmar, and Papua New Guinea).

What about severe acute malnutrition?

In the last few years there has been much publicity about “ready to use therapeutic foods” (Plumpynut and plumpy paste are the two best known versions). Originally designed to save the lives of acutely malnourished children without having to hospitalize them, the makers of these foods are now promoting them as part of prevention. It is hard not to draw parallels between Plumypnut and the infant formula industry, however. While the use of RUTF in recuperation of severely acutely malnourished children has been shown to be effective such interventions should only be used in emergency life-saving situations and as one tool in the medical toolkit. To begin with RUTF are quite expensive (field personnel estimate $70 per case of severe acute malnutrition). Second, it only addresses the immediate problem. Once the child has recuperated, s/he returns to the environment that created the acute malnutrition in the first place, whether that is a contaminated environment, parental neglect, improper management of disease, or economic hardship. Decades ago it was found that recidivism from acute malnutrition was high. The studies of RUTF so far have not studied recidivism.

Proponents of RUTF now want to move from therapeutic uses into what they call “prevention”. This also includes a new disturbing trend in food aid to feed all children as a “preventive” measure. By relying on exogenous, formulated foods, these programs are not just creating demand for an unaffordable food; they are denigrating the traditional, readily available and at the same time sending a clear message to parents that it is not in their power to adequately feed their own children. In virtually every culture there is some combination of a locally grown carbohydrate (corn, rice, wheat, potato, sweet potato), protein source (legumes, milk, meat or fish) and vegetables (leafy greens, squash) that can be combined to make a nutritionally adequate weaning food that honors cultural traditions, is within the means and culinary powers of normal families, supports local food systems, and is resilient in the face of inflation, world trade hiccups, and market disruptions. It is quite bizarre that the French, for whom eating and culture is paramount, would be promoting a technological convenience food for infants that sever the relationship between food and culture (Plumpynut is produced exclusively by a French firm).

We now know that the technological “improvements” in the Western diet have had profound negative influences on nutrition, including obesity and diet-related chronic diseases like cardiovascular diseases, some cancers, hypertension, and diabetes6 not to mention the negative effects on small business, the environment and climate. Some would argue that

5 UNICEF ChildInfo http://www.childinfo.org/undernutrition_mdgprogress.php6 Popkin, B. The World is Fat.

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divorcing genetic evolution from culture and environment is a recipe for a new kind of malnutrition (Nabhan). A series of studies have shown that Hawaiians reintroduced to traditional foodstuffs and lifestyles (complemented with Western health services and a traditional spiritual practice) were able to lose weight and lower risk factors for a variety of chronic diseases. While certain donors and NGOs are heavily promoting these expensive techno-foods as an alternative to affordable diets made in the home, the Bank should be reluctant about getting on that bandwagon.

Focusing the effort.

As can be seen from the above data, underweight and stunting (collectively called growth failure), low birth-weight, and anemia are the most prevalent unaddressed (or under-addressed) nutrition problems in East Asia. Obesity and diet-related chronic diseases are emerging problems particularly in China, Indonesia, the Philippines, Vietnam, and most of the Pacific Islands. The “window of opportunity”7 between conception and two years of age is the most critical period in East Asia and the Pacific region for preventing growth failure and anemia. Policies and programs which purport to address the problem need to reach these children and their families and communities with effective preventive programs. For cost reasons, to prevent damage to human potential, and to prevent suffering, prevention must take priority over curative care. This priority has been proven time and again historically as well as in recent reviews.

From the data presented above, it is clear that there are a small number of countries in the EAP region which have markedly higher rates of under-nutrition and growth failure: Cambodia, Indonesia, Lao PDR, Myanmar, Papua New Guinea, Philippines, Korea PDR, Solomon Islands, Timor Leste and Vietnam. Two of those countries, Korea PDR and Myanmar, have very limited engagement with the World Bank lending and will not be included in this document. Two other countries – Papua New Guinea and the Solomon Islands – have data so old and unreliable that much more work would need to be done on the ground to understand the problem sufficiently to address it intelligently. Nonetheless, there is good reason to believe there is severe under-nutrition in both countries. Timor Leste is without doubt one of the most severely affected countries in the region and there is much that should be done there. The Pacific Islands have some surprisingly severe micronutrient deficiencies, but their most obvious nutrition problem is obesity, exacerbated by weakening of local agriculture, heavy dependence on imported food shipped long distances, and undifferentiated local economies. While the food, fuel, and financial crises might adversely affect the Pacific islands, the focus of the Central Contingency Fund is on addressing under-nutrition. For the remainder of this paper, therefore, the focus will be on the countries with severe nutrition problems where the World Bank can, within a relatively short time frame, improve the targeting, content, quality and coverage of national nutrition programs the address those nutrition problems that undermine national development.

II. Why the region with the highest economic growth still has such high rates of malnutrition

7 World Bank. 2006. Repositioning Nutrition as Central to Development.

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Malnutrition is an outcome of many different development processes. One might even say it is the bottom line of development, since studies have shown it to be affected by water, roads, education, agriculture, poverty, health, housing, physical activity, cooking smoke, women’s status, culture, social dysfunction (alcohol and drug abuse, domestic violence), and psycho-social stimulation. The UNICEF Conceptual Framework (Fig. 1) has long been used to convey this multi-causality. While the immediate causes of poor child growth and development are food, feeding and caring behaviors and disease (especially diarrhea), many other factors play important and sometimes even larger roles. Smith and Haddad found that women’s education accounted for 43% of the reduction of malnutrition between 1970 and 1995, food availability another 26%, safe water 19% and women’s status 12%18. On a straight correlation basis, of all the factors described here the highest correlation is between adult literacy and stunting (R2=0.65).

Poor water/sanitation and

inadequate healthservices

Child m alnutrition,death and disability

Inadequate maternal and child-

care practices

Insufficient accessto food

Quantity and quality of actualresources - human, economicand organizational - and the

way they are controlled

Potential resources: environm ent, technology, people

Figure 1: Causes of Child Malnutrition

Inadequatedietary intake Disease

Basiccauses atsocietallevel

Outcomes

Immediatecauses

Underlyingcauses athousehold/family level

Political, cultural, religious,econom ic and social system s,including women’s status, lim it theutilization of potential resources

Inadequate and/orinappropriateknowledge anddiscrim inatoryattitudes lim ithousehold access toactual resources

Source: The State of the World’s Children 1998

8 Smith, L.C. and L. Haddad. 2000. “Explaining child Malnutrition in Developing Countries: A Cross-Country Analysis.” Research Report 111, International Food Policy Research Institute, Washington, DC.

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Income and Poverty

Svedberg has recently shown that over half of the stunting in the world (1998-2002) can be explained by income (log national per capita)9. The problem is that aggregate income data are associated with a large number of other factors that are also known to affect nutrition (not the least of which are education, food supply, infrastructure, and quality of public services). There is a vicious cycle between malnutrition and poverty. Poverty creates malnutrition (through reduced access to food, poor health environment, and less access to services) and malnutrition creates poverty (through reduced work productivity, educational failure, and poor health). In DHS surveys, the lowest quintile always has more stunting and underweight than the highest one or two quintiles10. While it is generally true that poor children are more likely to be malnourished than rich children, it is also true that even among poor people a large proportion of children are NOT malnourished and that the highest income groups still have malnourished children. In Cambodia, a little more than twice as many children in the lowest quintile are malnourished compared to those in the highest quintile (46.7% and 19.4%, respectively). It is worthwhile noting that even in the poorest quintile more than half of the children are well nourished. That is to say that the majority of the poorest parents are able to nourish their children adequately. Something in addition to poverty is causing malnutrition. Particularly important are such factors as water and sanitation, fertility and child spacing, many household behaviors (including hygiene, breastfeeding, infant feeding, care of the sick child, and psychosocial stimulation), maternal employment and childcare choices, parental (especially mother’s) education, family dysfunction (particularly drug and alcohol abuse and domestic violence), and access to information and services. Underweight prevalence is disaggregated below by wealth quintile where available from MICS and DHS:

9 Svedberg, Peter. Has the Relationship between Undernutrition and Income Changed?” Copenhagen Consensus, 2004; Commment on Hunger and Malnutritio at http://www.copenhagenconsensus.com/Default.aspx?ID=223. 10 Ergo, A, M. Shekar and D.R. Gwatkin. Inequalities in malnutrition in Low and Middle-Income Countries. Updated and Expanded Estimates. World Bank Country Reports on HNP and Poverty, Jan. 2008.

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Sources: Child Info, UNICEF (Laos, Mongolia, Thailand, Vietnam), DHS (Cambodia), Friedman (2006) citing IFLS 2000 (Indonesia).

Clearly in some countries (Cambodia and Lao PDR), the wealth effect is large. It is interesting to note that although the poorest are equally malnourished in Indonesia and Vietnam, the wealth effect is much greater in Vietnam. It would appear that at low levels of malnutrition (Thailand and Mongolia) there is little difference between the poorest and the wealthiest quintiles. Over time the relationship between poverty reduction and nutrition improvement is non-linear (see Appendix 2). In some countries (Cambodia, Indonesia and China), poverty has decreased more slowly than malnutrition (in China poverty since 1990 has decreased faster than stunting but not underweight). In other countries (Philippines, Thailand, and Lao PDR), however, poverty is decreasing faster than malnutrition. At the very least this shows that poverty and malnutrition have an indirect relationship with each other.

Food Supply

Table 4 presents FAO data of food availability during the 2003-2005 period. The average calorie requirement is around 2100 calories per day (although actual needs could be considerably different based on age, sex, and activity levels). When national calorie availability and lack of access to adequate calories are plotted against stunting (not shown) there is a weak correlation (r2=0.305 and 0.118, respectively). At any rate, the availability of food seems not to explain malnutrition as well as per capita income (straight regression $PPP Atlas method) (r2=0.65).

Fig. 4 Nutrition Status by Weatlh Quintile EAP

0

5

10

15

20

25

30

35

40

45

50

Q1 Q2 Q3 Q4 Q5

Quintile

Perc

ent U

nder

wei

ght

Cambodia (2005)Laos (2006)Mongolia (2005)Thailand (2005)Vietnam (2006)Indonesia (2000)

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Table 7. EAP Calorie Availability 2005

Calories available/capita

% not having access to adequate calories11

Poverty Rate (date)

Brunei/Darussalam 3210 <5China 2990 9 16.6 (00)Cambodia 2160 26 34 (97)Fiji 3010 <5Fr. Polynesia 2900 <5Indonesia 2440 17 7.5 (02)Kiribati 2830 5Korea PDR 2150 32Korea Rep 3030 <5Lao PDR 2300 19 26.3 (97-98)Malaysia 2860 <5 <2 (97)Mongolia 2190 29Myanmar 2380 19New Caledonia 2780 9Philippines 2470 16 15.5 (00)Samoa 2820 <5Solomon Islands 2450 9Thailand 2490 17 Timor Leste 2160 22Vanuatu 2730 7Vietnam 2650 14 <2 (00)

Source: Calories FAO (http://www.fao.org/faostat/foodsecurity/MDG_en.htm), Poverty WB (http://devdata.worldbank.org/wdi2005/Table2_5.htm)Appendix 1. The MDGs and Nutrition

Food Prices

There are few reliable national data showing impact of the recent crises on nutrition. One can only surmise from reduced economic growth and poverty reduction, and food price inflation that food insecurity increased for those segments of society most dependent on markets for income and food. Between 2005 and 2008 the price of rice rose from $286 to $650 a metric ton. In the first five months of 2009 it has fallen to $567. Because rice constitutes a large proportion of the calorie intake and consumption basket of many East Asian countries (see Table 5), this price spike probably resulted in a shift toward lower priced food stuffs and may have resulted in dietary stress. The causes of the rice price spike included dollar depreciation, uses of other grains for bio-fuels, agricultural factors, panic buying by large rice importers, export restrictions by rice exporters, and speculation12. The food price spike could have had

11 This is termed “undernourished” by FAO12 Milan Brahmbhatt and Luc Christiaensen. Rising Food Prices in East Asia: Challenges and Policy Options. World Bank, May 2008 and Timmer, C.P., Rice Price Formation in the Short Run and the Long Run: The Role of Market Structure in Explaining Volatility. Center for Global Development Working Paper

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both positive and negative impacts on food security. Higher prices generally stimulate greater production over time (and the 2008 harvest was 3.5% bigger than 2007’s) and they increase income of farmers, many of whom are poor, but they also constrain consumption of the poor.

Table 8. Role of Rice in Diet and Food Basket in East Asia

CountryRice as a

proportion of calories

Rice as a proportion of food consumption

basketCambodia 69China 34Indonesia 46 40Korea DPR 30Rep. Korea 30Malaysia 31Myanmar 68Philippines 47 50Thailand 32 36Vietnam 65 43

Source: IRRI Table 16

Major rice importers (the Philippines is the world’s largest rice importer) suffered the most from this price spike and they also exacerbated it by trying to make major purchases when the market was most volatile, which drove the price up further (Brahnbatt and Christiansen, 2008). The major rice exporters (Thailand is the world’s largest exporter of rice) probably benefited from the price spike. Vietnam, however, to protect its national consumers, put export controls on rice to reduce its exportation, thus dampening income effects on farmers. This also caused the price to rise on world markets.

172, 2009.

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Table 9. 2004 leading EA rice importers and exporters (tons)

Rice Importing Countries Rice Exporting countriesPhilippines (1 M) Thailand (10 M)China (928K) Vietnam (4.1 M)Korea PDR (523K) China (901K)Indonesia (390K) Myanmar (150K)Hong Kong (326 K)Korea (Rep) (206)Also: Malaysia, Timor Leste Also: Cambodia, Lao,

Source: http://internationaltradecommodities.suite101.com/article.cfm/rice_import_dependent_countries and

FAO.

Many countries in the region have instituted policies and programs to moderate the price of rice. These include reducing import tariffs (China, Fiji, Indonesia, Solomons), export reductions or taxes (Cambodia, China, Indonesia, Vietnam), reducing food grain taxes (Cambodia, China, Fiji, Indonesia, Mongolia), price controls or consumer subsidies (China, Fiji, Indonesia, Malaysia, Mongolia, Philippines, Solomons, Thailand, Timor Leste), and releasing stocks to increase supplies (Cambodia, China, Indonesia, Malaysia, Mongolia, Philippines, Timor Leste) 13. Only Laos took no action to control the price of rice but it suffered fairly low rice price inflation.and it has recently inaugurated a Conditional Cash Transfer program. Most of the policy interventions are expensive and can have perverse long-term impacts on food security. A generalized rice subsidy, for instance, can incur an enormous fiscal cost (in the Philippines the rice subsidy is estimated to consume 1.6% of GDP).

The nutritional impact of the ballooning price of rice would depend on what “inferior” foodstuffs were available to substitute for rice and how well the poor gained access to and utilized rice alternatives. Maize, tubers, and plantains are starchy substitutes in many East Asian countries but little published work has examined the ways in which consumers changed their eating patterns when rice prices were high. Usually those most dependent on the market for their food (urban poor, landless, subsistence and semi-subsistence farmers) are the most adversely affected by such price spikes. Rice substitutes may require more processing, more time and fuel for preparation, or be less available in urban markets. But the nutritional effect depends on more than carbohydrate substitutes. For infants and toddlers (indeed for everyone, but young children are more vulnerable), rice is particularly deficient in protein and micronutrients, even if is supplemented with breast-milk (which it should be until two years of age). Families with children who grow well usually augment rice with vegetables, legumes, and animal protein to make a more nutritious food. During economic hardship, however, these additions to the rice may be sacrificed and the quantity and the quality of the diet deteriorate. While adults can usually withstand long periods of moderate deprivation, young children, especially those under the age of two, are more fragile. Thus, during economic crisis, it is critical to protect the very young children. Pregnant women also need to be protected since they are more likely to give birth to low birth-weight infants when they can’t get enough to eat.

13 Bhrabhatt and Christiansen, Table 3.

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The only nutrition data available on the crisis suggest that infants in urban areas are particularly at risk. In Cambodia nutritional wasting of children under 5 in urban areas increased from 9.6% to 15.9% between 2006 and 2008.

If the recent economic crises had a significant impact on nutrition, it is because of the underlying vulnerability of the population. Those countries with the highest levels of malnutrition before the crisis were the most vulnerable to nutritional impacts of the shocks. This includes relatively well-to-do countries like Vietnam, Indonesia and Philippines (which have inexplicably high rates of malnutrition) as well as the poorest countries of the region, Lao PDR and Cambodia. Whether the populations of Myanmar and Korea PDR, which had high rates of malnutrition beforehand, are affected or not is unknown due to the closed door policy of the governments. Mongolia, which started with relatively low rates of malnutrition, seems to have been buffeted back and forth by the various shocks and might well show some impacts on nutrition. Malaysia and Thailand, which started with low rates of malnutrition, have been deeply shaken by the economic strains but it is unlikely that malnutrition will rise significantly in part due to high income (Malaysia) and to nutrition policy in Thailand.

Breastfeeding Practices

Although covered below under “Habits, Beliefs, and Practices”, breastfeeding should rightfully be considered a food supply issue. The prevalence of exclusive breastfeeding during the first six months of life is shockingly low throughout the region. Likewise, the proportion of infants still being breastfed at 20-23 months is very low as well.

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Table 10. Breastfeeding Practices in EAP

Exclusive Breastfeeding(< 6 months)

Still Breastfeeding

(20-23 months)Cambodia 60 54China 51 15Indonesia 40 59Korea DPR 65 37Lao PDR 23 47Malaysia 29 12Mongolia 57 65Myanmar 15 67Papua N.G. 59 66Philippines 34 32Solomon Islands 65Thailand 5 19Timor Leste 31 35Vietnam 17 23

Source: State of the World’s Children 2009, Table 2

Land Use

In Laos, Cambodia and Vietnam, rural people have long relied on hunted and foraged wild food which are important dietary sources of protein and micronutrients. These foods derive from the forests, lakes and waterways. In recent year’s privatization, deforestation, and natural resource exploitation in general have eliminated or made inaccessible many of these food sources. While efforts are underway in all three countries to preserve and sustainably manage these wild lands and waters, their nutritional importance is not necessarily being taken into account. Assuring the local people can continue to use traditional hunted and foraged foods should be factored into land use decisions.

Water and Sanitation

Because diarrhea and intestinal worms are a major cause of growth failure and anemia, the availability of improved water sources and sanitation are of great concern to those interested in preventing malnutrition. On average, the lower and middle income countries of EAP generally have good access to improved water and sanitation although rural and poor populations are likely to have much less access. The best correlation between nutrition and water and sanitation has an R2 of 0.47 and 0.49 between underweight and improved water and improved sanitation, respectively.

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Table 11. Water and Sanitation in EAP High Burden countries

Improved water

Improved sanitation

Cambodia 65 28China 88 65Indonesia 80 52Lao PDR 60 48Malaysia 99 94Mongolia 72 50Myanmar 80 82Papua N.G. 40 45Philippines 93 78Korea DPR 100 36Singapore 100 100Solomon Islands 70 32Thailand 98 96Timor Leste 62 41Tonga 100 96Vietnam 92 65

Source: ChildInfo, UNICEF

Disease

Disease and malnutrition are often involved in a downward spiral. Disease causes anorexia and heightens nutritional requirements which, in turn, result in nutrition’s deteriorating over the course of malnutrition-prolonged disease. Malnutrition causes immune deficiency which increases susceptibility to infection and duration of illness. Diarrhea is probably the most important disease from a nutrition perspective. Water-borne and food-borne (including disease spread by the hands that feed) diseases are usually the cause of diarrhea. Respiratory infections, measles, and HIV are also important for nutrition. Parasitic diseases, particularly intestinal worms and malaria, have an important role to play in under-nutrition and iron deficiency anemia which is widespread in the region. As health care has improved in the region, vaccine preventable and drug treatable diseases have waned. One presumes that diarrhea and intestinal parasites have reduced as more people wear shoes14 and water and sanitation have improved. Many of the poor, especially the rural poor, still lack access to these advantages. The high prevalence in anemia in most of these countries suggests that much more work needs to be done on improving sanitation in tandem with improving the quality of the diet and feeding behaviors for young children. There is a modest cross-country correlation (R2 = 0.5) between sanitation and weight for age (but not between other water, sanitation, and nutrition variables) in EAP.

14 Hookworm, one of the major intestinal parasites, enters the body through bare feet.

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Seasonality

In many countries in the EAP region seasonality is a major factor in malnutrition. There is seasonality of food supply as well as of disease (diarrhea, respiratory infection, and malaria, in particular). In Cambodia, for instance, temperature and rainfall peak in April, May and June. The 2000 and 2005 DHS surveys (as reported by UNICEF in 2008 MICS report) found that diarrhea, fever and ARI are highest in February and lowest in July. Not surprisingly, underweight goes up steadily from February to June wasting increases in April and May.

Lack of Childcare

Where women are actively engaged in wage labor or agricultural labor, it is often necessary or desirable to leave an infant at home while the mother works. Usually the caretaker is a sibling or other family member. Women’s work poses challenges to breastfeeding unless the woman is encouraged to express milk and willing to feed the child on demand during the night hours. Making sure that both mothers and caretakers know what to feed the infant, how often, and how aggressively are critical to preventing inadequate nourishment. In many East Asian countries, women’s employment has been critical to economic growth. This employment should be complemented with increasing the availability of high quality crèches and daycare centers that safeguard children’s nutrition and provide psycho social stimulation to enhance cognitive development. Seasonal community crèches might also be encouraged when women’s work out in the fields is demanding. Few data exist on the availability, quality, or impact on child growth and development of daycare services in East Asia. The Philippines has made a special effort to improve quality and availability but it is not clear how successful they have been. When childcare is provided by children (older siblings), there is a real risk that both diet and hygiene will be inadequate.

Habits, Beliefs, and Practices

In Cambodia, Lao PDR, Vietnam, Indonesia, and Philippines, a number of operational research projects and program interventions have shown that beliefs and practices underlie the poor nutrition of women and infants. Particularly important are beliefs and practices revolving around giving infants colostrum (the antibody-rich first milk after delivery), the early introduction of non-breastmilk liquids and foods to infants under six months, the bland, watery, and starchy diet fed to weanlings, and the proscription of certain foods for infants and pregnant women. Due to local customs, mothers routinely underestimate how many young children can eat, how often they should eat, and how thick infant food should be. Habits, beliefs, and customs (possibly in conjunction with poverty) often keep families from giving young children vegetables, fruits, and animal products. The common perception (among foreign aid donors) that habits and customs change only slowly is belied both by commercial marketing success and by programmatic experience in these countries. In Cambodia, for instance, the country was able to improve exclusive breastfeeding rates markedly through a behavior change program. In Laos, Trials of Improved Practices showed that poor rural pregnant women were willing to eat more food and to make and feed a multi-component improved weaning food to infants. In Vietnam, a “positive deviance” program showed that some poor women helped their children grow well by adding small crustaceans and leaves into the weaning foods. Their success strategies were communicated to other local mothers and malnutrition improved markedly. In Indonesia, a nutrition counseling program combined with growth monitoring, family planning, and home

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gardening caused profound improvement in child growth. In Thailand, a similar multifaceted community based growth promotion program enabled Thailand to show remarkable improvement in child nutrition between 1980 and 2000. The bottom line is that people will change behaviors, including intimate behaviors like breastfeeding and eating, if excellent social marketing principles are applied.

Summary

To summarize, the East Asia and Pacific Region has serious nutrition problems, far more serious than should be expected from their income levels. The causes are multiple:

Suboptimal breastfeeding due to a combination of traditions and beliefs, women’s work, misinformed health personnel, and marketing practices of manufacturers of breast-milk substitutes. Initiation of breastfeeding within one hour of birth is very low (15% in Asia), exclusive breastfeeding to six months is too low (only in DPR Cambodia, Korea, China, Mongolia, and some Polynesian islands is it greater than 50%), and few mothers nurse their child for the first two years of life.

Inadequate complementary feeding. Young child feeding contributes to malnutrition because weaning foods are of poor nutritional quality, watery, fed in inadequate quantity and too infrequently and often contaminated.

Women’s nutritional status – the high proportion of short, thin, and anemic women coupled with heavy workloads and high fertility mean that women’s own health, quality of life, and work capacity are impaired, they are at much greater risk of death and disability during pregnancy, and they are likely to pass on malnutrition to their offspring through low birth-weight and other nutritional handicaps.

Low access to clean water and improved sanitation in rural and remote areas coupled with poor hygiene leads to more diarrhea and intestinal parasites which leads to more malnutrition

Loss of access to forests and watercourses reduces access to high quality scavenged foods that traditionally enriched the diet

Poor outreach of government services to remote communities means that sick women and children can’t get timely attention, schooling is inadequate, agricultural extension fails and food production flounders, the social safety net isn’t in place to catch those who need help, and people are distrustful of government. Lack of decent childcare services means that women are torn between contributing to family income and nurturing their children.

Poverty, isolation, minority ethnicity all increases the likelihood of malnutrition.

III. Policy Framework

Most nutrition policies are a long laundry list of desiderata without any prioritization, budgeting, or grounding in actual programs. They are usually over ambitious in both goals and in number of programs. As a result, the institutional capacity is overwhelmed, no single program is done well, and lack of results weakens political support. Heaver, in his review of Thailand’s successful program credits their success with “using national nutrition investment plans (rather than policy statements unlinked to resources commitments) as a way of generating a national vision of what needs to be done, giving visibility to nutrition, and giving each

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implementing agency clear responsibilities.”15 Heaver also stresses the need for popular support for nutrition as key to sustaining the long-term commitment required to make a program successful. The politics of policy – including popular politics as well as party politics – was emphasized strongly in a recent World Bank meeting on food policy16. Little empirical work has been done in EAP (or anywhere) to understand how technical issues, operational capacity, and policy processes interact to produce broad-based sustainable improvements in nutrition.

Country studies in Thailand (still successful), Indonesia (once successful), and the Philippines (unsuccessful) suggest that the following issues are important. First, nutrition should be included explicitly in the national economic and/or planning policies and it must be framed as a development investment. While Thailand has had an explicit nutrition policy in addition to nutrition’s inclusion in national plans and economic policies. This was matched with multi-sectoral institutional involvement in programs over the long term. Indonesia did not have an explicit nutrition policy but had a strong voice in the planning ministry in Indonesia that assured that nutrition was considered in national five-year plans and that it obtained budgetary resources. Early on Indonesia had strong multi-sectoral support for a comprehensive national program, but since the 1990s it has become a strictly health concern and, simultaneously, lost political support and quality. The Philippines included nutrition in both national economic plans and policies and separate nutrition policies. It had multi-sectoral programs and institutional involvement but its programs have never quite managed to perform well. Perhaps this is due to larger issues of governance. Contrast those experiences with China’s where nutrition was never included in national policies and yet nutrition has improved dramatically, largely without large-scale nutrition programs. The economic transformation appears to have been responsible for improved nutrition, at least among the urban population. On the basis of these few examples, one would have to conclude that incorporating nutrition into national economic policies and plans is useful but methodical attention to program design and implementation must accompany it.

Two areas in which a national policy appears to have made a marked impact is in food fortification and breastfeeding. Policies that make the International Code on the Marketing of Breastmilk Substitutes national policy lay down a line in the sand concerning what are ethical and unethical practices for infant formula companies. Many of those companies try as hard as they can to undermine the Code and they succeed, where enforcement is lax. If the country takes the Code seriously though – particularly hospitals and public sector health personnel as well as consumer watchdogs, breast-milk has a fighting chance against infant formula. Prohibiting infant formula, however, while heartily embracing other seemingly magical formulated foods (lipid based foods and ready to use therapeutic foods used outside the therapeutic milieu, for instance) runs the risk of confusing the public about what constitutes a nutritious infant food and undermining breastfeeding even more. With the Code embodied in national legislation, strong breastfeeding promotion programs can make a major difference in infant feeding. In Cambodia, for instance, a UNICEF sponsored campaign to increase exclusive breastfeeding is credited with increasing exclusive breastfeeding in children under six months 15 Heaver, R. Thailand’s National Nutrition Program: Lessons in Management and Capacity Development. Heaver, R. and Y. Kachondam. HNP Discussion Paper. 2002. 16 Marcela Natalicchio Menno Mulder-Sibanda James Garrett Steve Ndegwa Doris Voorbraak, eds.. 2008. Carrots and Sticks: The Political Economy of Nutrition Policy Reforms. HNP Discussion Paper. World Bank.

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from 11% to 60%. The Code has been fully incorporated into law in Philippines (34% EBF), partially so in Cambodia (60% EBF), China (51% EBF), Indonesia (40% EBF), Lao PDR (23% EBF) and PNG (59% EBF), and not at all incorporated in Myanmar (15% EBF).

National level fortification requires, at the very least standardization and verification to work. Experience with iodized salt suggests that fortification legislation should be obligatory and complemented with public education and an accurate, honest, and systematic process for assuring that the food is fortified properly. The regulatory enforcement system is the most difficult step in instituting food fortification. Universal Salt Iodization is mandated in Cambodia, China, Korea DPR, Indonesia, Thailand, and Vietnam, although not always effectively enforced, as evidenced by the figures in Table 3.

IV. What Works to Improve Nutrition

Recent publications17 have reiterated the long and established literature on what works to improve nutrition. Table 4 in the Bank’s Repositioning Nutrition18 lays out quite clearly the most promising approaches. The “short route” interventions have been reiterated in the Lancet nutrition series19. These can be summarized as follows:

Behavior change: promoting breastfeeding and complementary feeding of infants, hygiene, and adherence to micronutrient supplements

Micronutrients: supplementation, fortification, and improving diet Other health interventions (deworming, treated bed-nets, intermittent preventive

malaria treatment, baby-friendly hospitals) Conditional cash transfer programs or microcredit with nutrition education Community based nutrition programs that include a range of the above Treatment of severe acute malnutrition

Nutrition interventions are among the best development bargains because for a modest program cost (except for food or cash transfers are involved) they yield very high returns in the form of better school outcomes, higher work productivity, and better health.

17 World Bank. Repositioning Nutrition, 2006; Bhutto, Z.A. et al. Maternal and Child Undernutrition 3. What works? Interventions for maternal and child undernutrition and child survival. The Lancet 371, Feb. 2, 2008. pp. 417-40 and Web Appendix 17 to that chapter available at http://download.thelancet.com/mmcs/journals/lancet/PIIS0140673607616936/mmc17.pdf?id=0e96c9e6421f9512:50c74dbc:1224127705a:-34ed1246635589546 ; Behrman, J.R., H. Alderman and J. Hoddinott. Hunger and Malnutrition. 2004. Copenhagen Consensus, 2004 available at http://www.copenhagenconsensus.com/Default.aspx?ID=223 and Horton, S., H. Alderman and J.A. Rivera. Copenhagen Consensus 2008 Challenge Paper Hunger and Malnutrition. 2008 at http://www.copenhagenconsensus.com/Default.aspx?ID=1149 18 World Bank. 2006. Op. cit. 19 www.globalnutritionseries.org

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Table 12. Benefit-Cost of Nutrition Interventions

Benefit Cost 200420 Benefit Cost 200821

Breastfeeding promotion in hospitals

9–16

Integrated child care programs 5–67Iodine supplementation (women) 4–43Vitamin A supplementation (children < 6 years)

15–520

Iron fortification (per capita) 176–200Iron supplementation (per pregnant women)

6–14

Micronutrient supplement (vitamin A and zinc in diarrhea treatment)

17

Iodized salt and iron fortification 9.5Biofortification 16Deworming preschoolers 6Community based nutrition promotion

12.5

It should be noted that none of the reviews looked at program quality or operational factors that contribute to success.

The constraint now, as always, is in designing and implementing high quality programs. Appendix Table 17 to Chapter 3 in the Lancet nutrition series provides an excellent summary of experiences with large-scale nutrition programs. To prevent growth failure (stunting and underweight) in children under two almost always requires a community nutrition program which helps mothers, caretakers, and families do a better job of caring for their children 22. This is because feeding young children should happen several times a day, every day of the year. It is not episodic, like immunizations or disease treatment, and therefore is not amenable for being dealt with at a health clinic. The best solution, one which has been shown to work in many countries (including Indonesia, Thailand, Honduras, Peru, Sri Lanka, Bangladesh, Uganda, Zambia, Madagascar, Senegal, and elsewhere) is a comprehensive community based growth promotion program which combines nutrition counseling, basic health services, and other actions to address the underlying causes of malnutrition. In some countries, such programs have included income generation, small scale food production, community water source improvement, improved public sanitation, microcredit, family planning, daycare centers, and local weaning food production. How all of these services are combined, managed, and phased in is entirely dependent on local circumstances and the management skills of program staff. The availability of community driven development projects and programs in a variety sectors offers an excellent platform from which to work, starting perhaps with using child growth as both an

20 Behrman, Jere R., Harold Alderman, and John Hoddinott. 2004. “Nutrition and Hunger.” In Global Crises, Global Solutions, ed. Bjorn Lomborg.Cambridge, UK: Cambridge University Press.21 Horton, S., H. Alderman, J.A. Rivera. Copenhagen Consensus 2008 Challenge Paper. Hunger and Malnutrition. 200822 Mason, J., D. Sanders, P. Musgrove, Soekirman, and R. Galloway. 2006. Community Health and Nutrition Programs. Chapter 56 in Disease Control Priorities in Developing Countries 2nd Edition, D. Jamison, et al. eds.

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motivating outcome and a measure of accountability. By the same token, many countries are introducing conditional cash transfer programs which also offer a different opportunity to help families and communities use additional income to improve child growth and development.

The most important characteristics of successful programs have been good management: i.e. a systems approach to design and implementation (especially the communications for behavior change component) and good quality supervision. As shown in Indonesia, unfortunately, it is not enough to design and implement a good program. Its political and institutional support needs continual care and feeding as well.

V. What’s on the ground now?

Indonesia, Thailand, Cambodia, and Vietnam all have national nutrition programs, at least on paper. They are all ostensibly community based. Indonesia’s and Thailand’s appear to truly have national coverage that extends to the community level while Cambodia’s and Vietnam’s look good on paper but fail to reach the community. In the Philippines, many noble programs have been rolled out, but few have had the longevity or the quality control to effectively get to scale. The remainder of the countries have a mixed bag of national breastfeeding promotion programs, micronutrient programs (mostly vitamin A supplements and uninspiring iron supplementation programs for pregnant women), clinic based nutrition services, and small scale community programs (mostly implemented by NGOs). Going to scale, getting to the community, and improving quality of services (particularly communications for behavior change) are challenges in all countries. In the Philippines one of the problems is the failure to eliminate old programs when new ones are added so that the effort gets diluted.

Independent of the nutrition programs, many countries have instituted various kinds of community driven development schemes in a variety of sectors. Community based growth promotion, carried out as part of efforts to enhance community driven development across the sectoral spectrum, offers the ideal vehicle to integrate services and engage communities, not just households, in improving child nutrition. In addition several countries are considering conditional cash transfer programs which also can be adapted to nutrition.

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Country Policy and Planning Documents that Include Nutrition Institution(s) charged with nutrition Programs

Cambodia National Strategic Development Plan 2006-2010 (and earlier Poverty Reduction Strategy)Strategic Framework for food Security and Nutrition in Cambodia 2008-2012Health Sector Strategic Plan (2008-2012)National Policy on Infant and Young Child FeedingNutrition Investment PlanSalt IodizationCode on Breastmilk Substitutes

Council on Agriculture and Rural Development (coordinating body)National Nutrition Council (Ministry of Planning)Food Security and Nutrition Working Group (donors)National Maternal and Child Health Center (MOH)Provincial Nutrition Coordinating CommitteesVillage Health Support Groups

National Nutrition Program (includes community based programs and micronutrients)

Indonesia Five Year PlanNational Action Plan for the Prevention of Malnutrition (2005-9), MOHSalt IodizationCode on Breastmilk Substitutes

Directorate of Community Nutrition (MOH) BAPPENAS (planning)M. of Industry (salt)PKK (wives of civil servants, involved in Posyandu)Few NGOs

Posyandu (community based growth promotion and primary health care)Bidan di Desa (antenatal care, childbirth assistance, and postnatal attention)

Lao PDR National Socio-Economic Development Plan 2006-2010National Growth and Poverty Eradication Strategy 2004-2006National Nutrition Policy (2008)Health Strategic Plan 20008-2015, Accountability, Efficiency, Quality, Equity. April 2008

Dept. of Hygiene and Prevention, MOH (current focal point for nutrition)Nutrition center or institute to be created in MOHNational Science Council at Prime Minister’s Office to establish National Nutrition CouncilAgriculture and Forestry Sector to develop strategies for food security that encompass nutritionNational Commission for Mother and Child to establish a National Committee on NutritionLao Women’s Union (involved in new Bank community nutrition project)Many NGOs

Disaggregated nutrition-related services provided through several different health departments and centers as well as other ministries. Community Nutrition Project (WB, 2009)

Philippines Medium Term Philippine Development PlanMedium-Term Philippine Plan of Action for Nutrition (includes rice subsidy, salt iodization,

National Nutrition Council (rotating chair between ag, health, and social affairs)Dept. of Health

Barangay Nutrition ScholarsAccelerated Hunger Mitigation Program (includes increasing

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Country Policy and Planning Documents that Include Nutrition Institution(s) charged with nutrition Programs

food fortification, nutrition education, supplemental feeding, and food-for-school)Responsible Parenthood and Natural Family Planning ProgramEarly Childhood Care and Development ActCode on Breastmilk Substitutes

Food and Nutrition Research Institute, Dept. of Science and Technology

productivity in production, backyard gardening, and irrigation), improving ports and farm to market roads, efficient transport, and food for school and daycare centers).

Vietnam Strategy for Socio-Economic Development 2001-2010Comprehensive Poverty Reducation and Growth Strategy (2002)Poverty Alleviation Strategy, 2001-2010National Nutrition Strategy 2001-2010

Dept. of Reproductive Health (main responsibility for child malnutrition prevention program) in collaboration with Dept. of Preventive Care and HIV/AIDS Prevention and Control in MOH (policy dialogue and strategic planning)Dept. of Food Hygiene and SafetyNational Institute of Nutrition (standing agency and coordinator of National Steering Committee; technical and implementing with network down to grass root level)

National Targeted Program on Child Malnutrition Prevention (focused on most difficult provinces)Women and child nutrition programVitamin A supplementationCommunity based water and nutritionFood Hygiene and Safety Program

32

VI. Institutional Issues

It is popular these days to blame all ills on institutional weakness and to prescribe academic training as the solution. There is no evidence, however, that this has improved programs. To build capacity to design and implement programs, it is more important to build capacity by providing action learning, hands-on experience, and shared learning opportunities with other nutrition program managers. In the East Asia and Pacific Region, country experiences (past and present) provide an excellent training ground for learning and knowledge generation to create the institutional capacity needed to develop and improve national nutrition programs. In addition to proposing specific country initiatives, this paper proposes setting up a regional nutrition learning organization comprised of operational staff from each county, to build national and regional institutional capacity as well as to solicit and take advantage of external technical assistance as and when needed.

Heaver, in analyzing the successful Thai experience, found that they did not follow the standard textbook advice about institutional strengthening. For one thing, he credits their success with “managing implementation of the nutrition sector through a series of committees, rather than by fiat through a single agency, which encouraged a wide variety of interest groups to feel that nutrition was their business, rather than another agency’s.”23 A similar approach was also used early on in Indonesia. Thailand’s program was a multi-sectoral, community driven growth promotion program which “partially empowered communities by involving them in needs assessment, planning, beneficiary selection and program implementation, but keeping central government control over resource allocation, so as to ensure a coherent national program.”24 Most importantly, rather than sending staff to universities, the Thais simply recruited two outstanding national universities to provide long-term support.

Some gross indicators of nutritional institutional capacity include the existence of a national nutrition policy (including adoption of the Code on the Marketing of Breast-milk Substitutes), one or more public organizational entities charged with implementation of the national policy, existence of national nutrition programs (which may or may not be freestanding programs), inclusion of nutrition in annual budgets, and coverage of needy and underserved populations (particularly children under two and the rural poor). In the final analysis, though, the institutional capacity should be measured by the quality and impact of the policies and programs. There are several different institutional homes for nutrition in the EA Region. In China, nutrition rests in Chinese Center for Disease Prevention and Control. In Cambodia and Timor Leste, nutrition is dealt with in a department within the health ministry. In Thailand, nutrition is the responsibility of the Ministry of Health but it relies on technical assistance from the Mahidol and Kasetsaert Universities. In the Philippines, nutrition is managed by the National Nutritional Council, with revolving sectors taking the chairmanship, a Food and Nutrition Research Institute within the Department of Science and Technology. The Department of Health manages many components of the program, though (micronutrient supplements, nutrition within health services, antenatal and postnatal care). In Indonesia, the Planning Ministry

23 Heaver, R and Y. Khachonddam, op. cit. 24 Ibid.

33

(BAPPENAS) and the Ministry of Health share joint responsibility for nutrition. In Vietnam one Department has major responsibility for nutrition but there is also a National Institute of Nutrition affiliated with the Ministry. Laos has not had a special body responsible for nutrition but three new entities are proposed in the new nutrition policy.

In East Asia, as in the rest of the world, the Ministry of Health tends to give short shrift to nutrition. So that even though many of the necessary nutrition services are provided by the health ministry that may not be the strongest institutional home for nutrition. When Indonesia’s model nutrition program was implemented, nutrition was particularly championed by the family planning council (BKKBN), the planning ministry, and agriculture, the sum total of which kept nutrition high on the agenda of the health personnel. In recent years, however, as nutrition has been brought into the health ministry, it has weakened considerably. For some reason, nutrition institutes throughout the world, including in East Asia, tend to move more toward research and product development rather than toward implementation. This is true in Vietnam as well.

VII. Bank Portfolio and Opportunities

The World Bank, until quite recently, had no active nutrition projects in the EAP region. The Lao Community Nutrition Project was just approved as this report was being written. There are nutrition components or services in health projects in Cambodia, Laos, Philippines, Vietnam, and Timor Leste. It is worth noting that the World Bank has a long and respectable history in nutrition in East Asia and Pacific region. Freestanding nutrition projects were critical to the expansion of the two most successful nutrition programs in the region: Thailand’s national nutrition program and Indonesia UPGK program. They were also among the Bank’s first nutrition loans. The importance of nutrition both to the client and to the Bank in these projects was signaled by having freestanding nutrition projects, with dedicated staff on client as well as the Bank sides. Subsequent projects in Indonesia, in which nutrition was subsumed under a larger health context, led to inadequate attention being paid to the problems the nutrition program encountered in its new institutional constraints. Interestingly enough, this same thing happened in Tanzania when the Bank imbedded a successful national nutrition program within a health framework. The Bank has also been involved, less successfully, in nutrition projects in the Philippines and Vietnam. Bank involvement with salt iodization in China was deemed successful but the Bank has not played a major role in nutrition in nutrition in China otherwise. In Laos and Cambodia and Timor Leste, Bank health projects have provided some support to nutrition activities but mostly small-scale and punctual efforts.

An important alternative to the health sector approach is the community approach to malnutrition. Rather than engage in straight nutrition projects or nutrition components in health projects, there is a strong emphasis in several countries on community driven development, community grants, local participation and accountability, and conditional cash transfers. Taken together, the Bank portfolio particularly in Cambodia, Indonesia, Lao PDR, the Philippines, Vietnam and Timor Leste provides the minimum structure upon which to build a community based, multi-sectoral nutrition improvement program. These community programs include:

34

Country Community based initiatives that could serve as foundation for community nutrition program

Cambodia Rural Investment and Local Governance Projects (2) (en extension of the Seila Program)

Land management and Administration Project Community Organization Project Empowerment for the Poor in Siem Reap Project Demand for Good Governance Project 2nd Health Sector Support Project Civil Society Engagement and Small Grants project

Indonesia National Program for Community Empowerment in Urban Areas, PNPM Rural II, Community Facilitators Development Program, National Program for Community Empowerment in Rural Areas, Farmer Empowerment through Agricultural Technology and Organizations, KDPs, Community Based Settlement Rehabilitation for Yogyakarta, Early Childhood Education and Development Project, Integrating Environment and Forest Protection into the Recovery and Future

Development of Aceh, Community based Settlement Reconstruction and Rehabilitation Project for NAD

and NIAS, Community Recovery in Earthquake Affected Areas through UPP, SPADAs, Third Urban Poverty Project, Second Water and Sanitation for Low Income Communities project.

Lao PDR Health Services Improvement project Poverty Reduction Fund Project Lao Environment and Social Project

Philippines Mindanao Rural Development Project (Phase 2), which promotions participation in using a community fund for agricultural development,

National Sector Support for Health Reform (which focuses only on supply of health care services)

emerging support for 4Ps Women’s Health and Safe Motherhood, ARMM Social Fund, Kalahi CIDSS, Support for Strategic Local Development and Investment projects.

Vietnam Vietnam Rural Water, through an NGO, Red River Delta Rural Water Supply and Sanitation, Forest, Sector Development Project, and Community Based Rural Infrastructure).

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VIII. Options and Recommendations

The Bank has the opportunity to make a major contribution to reducing regional malnutrition in several high burden countries, including three of the 36 countries that contain 90% of the world’s malnutrition. Some of these countries – Indonesia and Cambodia – are ripe for the picking. Others, like Philippines and Vietnam, have political issues that could impede rapid effective action.

It is difficult in a desk review to know what is really happening on the ground. Each of the country studies have attempted to consolidate existing information on nutrition and nutrition programs in those countries. To the extent that the Bank wishes to engage in nutrition in the region, it is strongly recommended that consultants working on the ground in those countries expand and validate the country studies.

There are three tiers of countries with respect to malnutrition: 1) those that are ready to expand and improve nutrition programs at scale (Cambodia, Indonesia, Lao, Philippines, Vietnam and Timor Leste; 2) those the need further investigation to determine the need, the institutional capacity, and the feasible programmatic options (PNG, Solomon Islands) and 3) those which don’t make sense to work in now (Myanmar, Korea DPR, Pacific islands). In the first tier countries, local legwork needs to be done to ascertain country interest and commitment and institutional capacity. In the second tier countries, the Bank should engage in sector work to understand the nutrition problem better. The over-nourished pacific islands have been excluded from this list. Because programming to prevent and reduce obesity is in its infancy, further research will be needed to devise some promising strategies and test them out on one or more islands. This should constitute its own separate regional research project.

Cambodia Indonesia Lao Philippines VietnamSeverity of nutrition problem

+ + + + +

Institutional capacity*

2 5 1 5 3

Ongoing health project

+ + + +

Ongoing social protection project or program

+ + +

Policy and project support for participatory community

+ + + + weak

36

Cambodia Indonesia Lao Philippines Vietnamprojects

Prep work done on content for nutrition counselling

+ + + +/- weak

*1 = little capacity, 5=high capacity

If the Bank chooses not to opt for a major regional initiative on nutrition, the alternatives are to work through social protection programs (particularly CCTs and community development funds) to enhance the focus and impact on nutrition. The third alternative is business as usual, financing minor efforts within health programs.

What Next

If the Bank wishes to make a substantial impact on malnutrition in the East Asia and Pacific region, it should first make a very public commitment to doing so. As a first step is should invest staff and contractor resources in fleshing out the opportunities proposed here for Cambodia, Indonesia, Lao PDR, Philippines, Vietnam and Timor Leste. Based on that work, the region should develop a multiyear plan of action which would first prepare projects for the focus countries. Part of preparation would include creating a regional knowledge network (to include the five focus countries plus Thailand and other countries with an interest in the topic). It would make sense to develop a regional technical assistance project to work with the knowledge network and help all the countries prepare high quality projects. Perhaps trust funds or a bilateral donor could be identified to fund the TA and the knowledge network.

At the same time the Bank should undertake serious sector work in Papua New Guinea and the Solomon Islands to determine whether the problem and the institutional capacity are appropriate for Bank investment. A two-country piece of sector work might make sense given their relative proximity.

The Bank would also during this time frame launch a new regional research program to identify effective policies and programs to prevent and mitigate obesity and diet-related chronic diseases with a special focus on the China, Philippines, Vietnam, and the Pacific Islands with high rates of obesity. The research would also be aimed toward developing a regional (or even wider) knowledge network to help countries develop and implement programs.

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Appendix Table 1. Nutrition and the MDGs

MDG How nutrition relates to it Relevant development sectors that affect or are affected by

nutrition1: Halving poverty and hunger In addition to the explicit goal of

halving underweight in children under five, improving nutrition contributes to reducing poverty by enhancing physical capacity and productivity, improving education outcomes, and reducing disease and death through its effect on the immune system.

Child growth and development is the outcome of many development sectors including health, water and sanitation, agriculture, community development, education, infrastructure, and more. The poverty line is usually based on a least cost food basket designed to meet nutritional needs.

2. Universal education Malnutrition in early live reduces IQ and impairs learning ability. In addition, parents often sent malnourished children to school at a later age.

Early childhood education programs that extend childcare and psychosocial stimulation to children under two can provide much needed nutrition and compensatory help for at-risk children. Parental education, particularly that of women, has more impact on nutrition of children than income.

3. Promote gender equality Providing the opportunity for girls and boys to grow and develop properly gives them an equal chance at excelling at school, being productive workers, and contributing to society

Good nutrition counseling empowers women to become knowledge workers in the home and community. By helping women successfully care for their children, they gain confidence and self-esteem in a non-controversial endeavor.

4. Reduce child mortality Undernutrition has been shown to contribute to almost one-third of under-5 mortality and to over half of the post-neonatal portion U5MR. Underweight, micronutrient deficiencies, and low birth-weight (evidence of maternal malnutrition) all contribute to elevated infant and child mortality.

Many health interventions that will save child lives (treatment of diarrhea and respiratory infections, hygiene, immunization, micronutrient supplements, prenatal care, treatment of parasites, and prevention of malaria can and should be integrated with growth promotion.

5. Improve maternal health Malnutrition is sometimes passed down through generations through maternal malnutrition. A short, thin, anemic woman is more likely to

Family planning programs, especially child spacing, will not only benefit the woman but it will improve the nutritional chances of her child. Good

38

MDG How nutrition relates to it Relevant development sectors that affect or are affected by

nutritiongive birth to a small or preterm baby whose life chances are curtailed. Many women in high risk environments “eat down” during pregnancy to avoid having a big baby. Maternal malnutrition, especially iron deficiency anemia, affects her survival and health over the course of pregnancy and childbirth. Improving girls’ nutrition (in early childhood, during the school years, and particularly during adolescence) will help girls grow up to be taller and reduce their risk during reproductive years. Early first conception, high parity and closely spaced pregnancies affect both maternal nutrition and the health and nutrition of her offspring.

reproductive health programs will benefit both mother and child by preventing unwanted and unhealthy pregnancies and promoting good maternal health and nutrition. A strong healthy woman is more than a better mother, she is also a stronger worker and will produce more on the farm or in employment. She will also get sick less often.

6. Combat HIV/AIDS, malaria and TB

Certain nutritional deficiencies (vitamin A and possibly zinc) make HIV transmission more likely and impair the effectiveness of ARVs. PLWHA often are anorexic and yet a good diet helps them tolerate the medications better. Breastfeeding, if done exclusively, has been found to be safer for infants of HIV positive women than bottle feeding in low resource situations.

Pregnant women are far more vulnerable to malaria and anemia (which potentiate each other). Preventing and treating them together is safer and more efficient.

Environmental Sustainability Food security is an important component of nutrition and risk mediation. Food security is intimately related to protection of watersheds, forests, and the general health of the local ecosystem. In Cambodia and Laos, forest foods and wild caught fish are major sources of proteins, micronutrients, and general dietary diversity. In addition, climate change

When local peoples are empowered to manage forest and water resources upon which they depend for foraged foods, important protein and micronutrient food sources, they are more likely to be better stewards of the land and water than commercial exploiters. Deforestion can be assisted through introduction of higher efficiency cooking technologies

39

MDG How nutrition relates to it Relevant development sectors that affect or are affected by

nutritionthreatens to alter the food system. Deforestation often occurs for fuel-wood and charcoal production for cooking.

and methods and access to non-wood based fuel sources.

Water resources Drinking water is as essential to good health and nutrition as are foods. But water can be a source of infection and parasites which, in turn, deplete the body of energy and nutrients and thus contribute to malnutrition. The human energy outlays for carrying water for home use can be high enough to threaten nutritional status and usually it is the girls and women who carry water. Irrigation water can contribute to greater food security if it results in excessive drawdowns that threaten the water table and cause deterioration in the home water supply. Farming systems support which takes into account both nutritional needs and hydrological limitations is important for meeting economic, health, and nutrition goals.

Improved water supply and sanitation programs reduce both the energy cost of water procurement and, when combined with hygiene education, reduce the waterborne and water washed diseases that contribute to malnutrition.

40

Appendix 2. Country Poverty and Nutrition Trends (where trend data available).

Poverty and Malnutrition Trends Cambodia

y = -1.0127x + 2063R2 = 0.6091

y = -1.2654x + 2567.2R2 = 0.8713

y = -1.3615x + 2773.1R2 = 0.9905

0

10

20

30

40

50

60

70

1992 1994 1996 1998 2000 2002 2004 2006

Year

Mal

nutr

ition

/Pov

erty

Rat

es

Poverty

Stunting

Underw eight

Linear (Poverty)

Linear (Underw eight)

Linear (Stunting)

Lao PDR Poverty vs. Malnutrition Trends

0

10

20

30

40

50

60

1992 1994 1996 1998 2000 2002 2004

Year

Perc

ent

Poverty

StuntingUnderweight

Linear (Poverty)Linear (Stunting)

Linear (Underweight)

Indonesia Poverty vs. Nutrition

0

10

20

30

40

50

60

70

1994 1996 1998 2000 2002 2004 2006 2008

Year

Perc

ent

Indonesia Poverty

Indonesia Stunting

Indonesia Underweight

Linear (Indonesia Stunting)

Linear (Indonesia Poverty)

Linear (Indonesia Underweight)

41

Philippines Poverty vs. Malnutrition Trend

0

10

20

30

40

50

60

1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

Perc

ent

wt-age

poverty

Linear (wt-age)Linear (poverty)

Thailand Poverty vs. Malnutrition

0

5

10

15

20

25

30

35

1985 1990 1995 2000 2005 2010

Year

Perc

ent

Stunting

Underweight

Thai pov

Linear (Thai pov)

Linear (Underweight)Linear (Stunting)

China Poverty vs. Malnutritrion Trend

0

10

20

30

40

50

60

70

1989 1991 1993 1995 1997 1999 2001 2003 2005

Year

Perc

ent

Poverty 65Underweight

Stunting

Poverty

Linear (Underweight )

Linear (Stunting )

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Appendix 3. How growth monitoring and promotion helps community development

1. A good summative indicator of human development with well documented correlations with other outcomes like mortality, morbidity, educational achievement, work productivity.

2. Assessing the growth of children under two years of age focuses community and health care personnel’s attention on preventing problems.

3. Child nutritional status is an MDG goal (#1) and instrumental to achieve other MDGs (child mortality, education for all, gender equality, maternal health).

4. Child growth and nutritional status is quantitative, affects all children, can be expressed as a continuous variable (for evaluating impact) or as a binary variable (for monitoring, reporting, supervision, etc.).

5. Children under two are highly sensitive and responsive to changes in environment (food, infection, family distress) both in terms of causality and solutions.

6. Focusing on child growth forces integration of services (nutrition, infection control, immunization, maternal nutrition, family planning) and sectors (water and sanitation, poverty and food security, health and social programs).

7. Growth is not event dependent (like illness or death or harvest); growth happens 24/7/365 for children under 2. If there is inadequate growth, there’s a problem.

8. Solutions aren’t rocket science (often available in the home and community); with facilitation, the community can discover most of its own solutions. Sometimes, solving the problem entails creating a local enterprise (weaning foods production, childcare center) which can generate income. Where exogenous solutions are needed, the community can use child growth data as advocacy tool and documentation to demonstrate need (voice).

9. Children’s healthy growth and development is an outcome valued by local people as well as national government and a useful predictor of future educational performance, work productivity, and reproductive health. Nutritional status is normally distributed with accepted international standards.

10. Child growth is affected by a number of developmental priorities: food availability and price, poverty and income, water and sanitation, health, domestic violence and acute distress in the family, maternal health and nutrition, gender, childcare, education, behavior (affected by marketing and advertising).

11. Child growth is easy to measure (a weighing scales) and there are many ways of expressing growth that are simple and communicative. The most difficult part of it is not getting an accurate weight but getting an accurate age. As a program matures, age becomes precise because of local surveillance system.

12. Child growth is also an effective means to target service and raise demand for underutilized services, especially (but not restricted to) nutritional counseling and preventive and curative health services.

13. Verifiable, replicable measurements. Which means it can be useful for accountability. 14. Means of reaching reproductive-aged women before they become pregnant (again) and

thus do preventive health care. 15. Where similar programs have been instituted (e.g. Honduras) the structure has provided

well organized mechanism for emergency assistance and reporting (e.g. after hurricane). 16. Enables systematic addition of services and sectors on an as needed basis.

43

An example of how community based growth monitoring and promotion has been used (Indonesia, Honduras): All children under two weighed monthly. The adequacy of their growth is checked against numerical standards for monthly weight gain (no more interpolating graphs). Note that one does not classify children into “well nourished” and “malnourished” because growth is a dynamic process. If a small child falls below the cutoff on the chart but is gaining adequate weight, he is growing well. Counseling is given immediately after the growth is assessed and the message is tailored to specific needs of each child (based on their growth performance). Every month, each village fills out a bar chart to show the total number of children under 2, the total number of children attending growth monitoring that month, the total number gaining adequate weight, the total number not gaining adequate weight and the number of children failing to gain adequate weight two or more months in a row. By comparing the first with the second bar, the village health worker can see her coverage and how many people failed to show up. She then pursues those absentees through home visits. She also compares the second and third bars to see how well she’s doing. Theoretically, she should try make the third bar equal the second bar. She can easily compare last month’s performance to this month’s performance by pulling out the bar graph from the previous month. From the discussion she had with the parent or babysitter for the children in the third column, she can tell who needs extra attention (a home visit) and referral. The fourth column children generally need supplementary services because their family has not been able to reverse their decline on their own (this may be because of extreme poverty, extended illness, poor child care, alcoholism, or domestic violence). In Indonesia, the bar graph was filled up and sent by mail to the health center where the data were aggregated and sent further up the health system. These five indicators can be used all the way up the health system to provide supportive supervision, to report coverage, to monitor program quality, to assess the severity of the nutrition problem in an area, and to identify operational problems that need attention. It is a simple but elegant system. Every three or four months the competitive performance of the community’s children is presented at an open meeting. Community members are encouraged to brainstorm about solutions and then act on the consensus priority. In Sri Lanka, community brainstorming usually resulted in childcare centers and wells.

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References

WHO Regional Offices for South-East Asia and the Pacific. 2008. Health in Asian and the Pacific. Chapter 9. Reproductive health, child and adolescent health, nutrition, and health for older persons.

Havemann, K. and P. Pridmore. Social Cohesion: The Missing Link to Better Health and Nutrition in a Globalized World. Arusha Conference, “New Frontiers of Social Policy”. Dec. 12-15, 2005.

East Asia and Pacific Region, Regional Strategy Update. Draft. February 19, 2009 (PPT presentation)

UNICEF. 2008. State of Asia-Pacific’s Children.

World Bank. Rising Food and Fuel Prices: Addressing the Risks to Future Generations. October 12, 2008.

World Bank. East Asia: Navigating the Perfect Storm. Dec. 2008.

World Bank. Battling the Forces of Global Recession. April 2009.

Caulfield, L.E., S. E. Richard, J.A. Rivera, P. Musgrove, and R.E. Black. Stunting, Wasting, and Micronutrient Deficiency Disorders. Chapter 28 in Disease Control Priorities, 2nd Edition. Jamison, D. et al. editors. World Bank, 2006.

UNICEF. State of the World’s Children 2009.

Brahmbhatt, M. and L. Christiaensen. 2008. Rising Food Prices in East Asia: Challenges and Policy Options. May 2008.

Ravenga, A. Rising food prices: Policy options and World Bank response. 2008.

Alderman, Harold, Simon Appleton, Lawrence Haddad, Lina Songand Yisehac Yohannes. Reducing Child Malnutrition: HowFar Does Income Growth Take Us? Centre for Research in Economic Development and International Trade,University of Nottingham. CREDIT Research Paper, 01/05.

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Cambodia

While Cambodia has some of the worst nutritional indicators in the EAP region, it is also one of the most hopeful countries for effective action. Not only has its economy proved itself resilient in the recent economic shocks, it has also laid the groundwork for forward motion. This is due in large part to collaboration among donors, a focus on community based action, and significant dossier of programs that can be adapted to the task of improving nutrition.

Nature of the nutrition problem

Malnutrition is a serious problem in Cambodia but improving slightly. UNICEF reports that Cambodia is likely to achieve the first MDG goal25.

Table 1. Chronic Malnutrition in Children under 5 (NCHS standards)

Stunting Underweight Wasting Severe Wasting

2000 (DHS) 45 45 15 42004 (CSES) 54 462005 (DHS) 37 36 7 12008 (MICS) 40 29 9

Malnutrition is worse in rural areas than in urban areas. Stunting is 30.5% in urban areas compared to 38.3% in rural areas. Underweight is 34.7% in urban areas compared to 35.7% in urban areas. This lack of difference between urban and rural is curious especially given the dramatic differences among provinces and among wealth quintiles (see below). Perhaps the rural areas contain a more heterogeneous mix of economic classes than usual.

Malnutrition starts at an early age. In fact most of the problem arises before the child’s second birthday. The following table (from DHS 2005) shows average z-scores for height and weight of Cambodian children. The average child is slightly malnourished even before six months implicating maternal malnutrition and low birth-weight are part of the problem. Nutrition deteriorates precipitously in the first two years of life.

25 UNICEF ChildInfo: http://www.childinfo.org/undernutrition_mdgprogress.php

46

This suggests that breastfeeding and infant feeding are critical problems. Recent data from UNICEF (MICS, 2008) suggest that underweight has continued to fall in children under 2 but increased slightly in the 2-5 year olds since 2005.

Causes of malnutrition.

As with most countries, the causes of malnutrition range from inadequate quantity and quality of food, poor feeding practices, including breastfeeding, for young children, high infection rates and parasitic diseases, high fertility, lack of safe water supply, domestic violence, and time constraints particularly of women. Suboptimal breastfeeding practices are a major cause of malnutrition in early infancy. Although most infants are put to the breast within a day of their birth, over half are given some “prelacteal feed” (water, a milk, or a traditional or symbolic liquid), which is not only inferior to colostrums (the antibody rich first milk) but also potentially a source of infection. While virtually all infants should be exclusively breastfeed until six months of age, in Cambodia only 45.6% of 4-5 month olds are thus fed. Diarrhea is both a cause of malnutrition and an effect of poor nutritional practices (bottle feeding, unhygienically prepared food, contaminated water). Diarrhea prevalence is highest in the 6-24 month old age group – 32% of the 6-12 month olds and 28% of the 12-24 month olds had had diarrhea in the past two weeks (DHS 2005). Access to “improved” water sources in Cambodia increased from 38 to 65% and access to improved sanitation increased from 51-62% from 2000 to 2006 (WDI) but it would seem that this did not translate directly into improved nutrition. The Food Security and Nutrition Strategic Framework points out that this water is not reliably available year round.

The World Bank sent a nutrition consultant to investigate the problems with infant feeding in 2006 and USAID sent another team in 2007. In both cases, the consultants found that the underlying causes of malnutrition were usually poor feeding practices. A rich and varied diet

Fig. 1 Cambodia, 2005 Malnutrition by Age

0

10

20

30

40

50

60

0.49 0.99 1.99 2.99 3.99 4.99

Age (years)

Perc

ent m

alno

uris

hed

UnderweightStuntedWasted

47

is available in rural Cambodia (including foraged foods) that contains animal proteins, fruits and vegetables, and grains but families often don’t want to feed them to young children. Another problem is that mothers do not engage in “active feeding” – encouraging the fussy child to eat – nor in adequate dietary management of disease (feeding the child during and after infection). Finally, some mothers are feeding young children empty calorie junk foods. Nonetheless, the USAID team discovered one village that made an improved “bobor” (baby food) with meat and vegetables added which had been taught to them a dozen years before in a GTZ program. This suggests that even rural villagers are willing to adapt their young child feeding practices when approached in a sensitive way.

Income and malnutrition

There are significant differences in nutrition across wealth groups (Table 2). In 2005 Stunting was more than three times greater in the lowest quintile than in the highest one; underweight was almost 50% higher in the fifth quintile compared to the first one. Although stunting has diminished between 2000 and 2005, the trend across quintiles was almost identical. Similarly, the rate of malnutrition is twice as high for children borne of mothers with no schooling (45.8%) compared to those with secondary education or better (22.2%) (2005 DHS). Although malnutrition appears to be related to income, the national income growth rate has not resulted in pari passu reduction in malnutrition. While GNI/capita increased almost 60% from 2000 and 2005, good nutrition improved only a quarter as much.

Table 2. Malnutrition Rates by Wealth Quintile, Cambodia

Q1 Q2 Q3 Q4 Q5Stunting 2000 52.6 48.4 42.6 41.5 27.5Stunting 2005 46.7 42.5 36.5 35.5 19.4Underweight 2000 52 47.9 42 43.1 33.5Underweight 2005 42.9 39.8 33.5 34.3 23.1

Source: DHS Surveys 2000, 2005

Clearly, nutrition is not improving apace with economic growth. Cambodia is a rice exporter and expects to increase its rice exports substantially in coming years. Yet the PRSP suggestions that “even within rice producing provinces 30% of communes face chronic food shortages” (PRSP, 2002, pg. 27). A combination of poor roads, lack of agricultural extension, poorly developed markets and insufficient irrigation contribute to food insecurity. Landlessness contributes as well – 20% of farmers are landless and 40% have access to less than 0.5 ha of land.

48

Geography of malnutrition

According to the 2005 DHS survey, stunting is worst in Pursat (61.6%), Siem Reap (53.3%), Mondor Kiri/Rattanak Kiri (54.0%), Otdar Mean Chey (47.3%), Preah Vihear/Steung Treng (42%), and Kampong Thom (41.1%) and best in Phnom Penh (22.3%). The 2004 World Bank poverty assessment found the highest rates of poverty in many of these same regions as well as poorest access to roads and services. Like poverty, malnutrition is most likely to be highest in remote and mountainous areas and among ethnic minorities.

Micronutrient malnutrition

Young children are highly vulnerable to anemia, usually caused by iron deficiency, intestinal worms, and malaria. As noted earlier, anemia has strong implications for cognitive development and later school performance. Anemia among children under 18 months of age is well over 80% (DHS 2005)! It decreases as children get older (in large part because they are growing less rapidly) but still 62% of all children under five are anemic. The only anemia control program in place for preschool children is a pilot program to promote micronutrient “sprinkles” to be added at home to the baby food. The Micronutrient Initiative estimates that 17% of Cambodian school children have goiter due to iodine deficiency and 22.3% of children under six vitamin A deficiency26. Inexplicably, 76% of children purportedly receive either vitamin A supplements or vitamin A rich foods and 72% of the households use iodized salt27.

Women’s nutrition

Eight percent of women are so short (<145 cm.) and 20% are so thin (BMI <18.5) that pregnancy poses an elevated survival risk for them and for the children they are carrying 28. Anemia poses additional threats to women’s health and survival and that of their unborn children. Anemia in reproductive-aged women fell from 58% in 2000 to 47% in 20053. This may be due in part to the prenatal iron supplementation program. According to the DHS almost two-thirds of pregnant women receive iron supplements but a recent report from the government states that many states experienced stock outs in 2008. The MICS 2008 survey reports that 1.6% of pregnant women suffer from night blindness, a sign of vitamin A deficiency but that 98.5% consume vitamin A rich foods and 27.3% of postpartum women receive a megadose of vitamin A3. Iodine deficiency is widespread and results in increased rates of stillbirth and compromised mental capacity in children born to iodine deficient women. Obesity in women was 1.5% in 2008, up from 0.9% in the 2005 DHS.

26 WHO Global Database on Vitamin A Deficiency27 DHS Cambodia, 200528 DHS, 2005

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Likely effects of recent shocks

The historically malnourished in Cambodia are most likely concentrated in rural remote and mountainous areas in households are subsistence farmers, landless laborers or ethnic minorities. To some extent the historically malnourished are sheltered from the global economic crisis by their lack of integration into markets although 46% of their dietary value comes from purchased food (Strategic Framework for FSN). These households would be most affected by reductions in remittances from newly unemployed relatives, possibly by the return of newly unemployed household members, and by inflation in prices of food and economic inputs. The rural poor have traditionally been able to forage or hunt for food (and that food is especially rich in protein and micronutrients) from common property like lakes, rivers, and forests, but these resources are increasingly being deforested , privatized or otherwise made unavailable (ADB Participatory Poverty Appraisal, 2004).

The most recent nutrition data on the impacts of the recent shocks in Cambodia suggest a slight deterioration in acute nutritional status overall but a serious impact in urban areas. Initial results from the UNICEF (MICS) Cambodian Anthropometric Survey suggest that acute malnutrition increased from 8.4% (Sept. 2005-March 2006) to 8.9% in Nov. 2008 (not statistically significant though reversing the trend in recent years. Acute malnutrition in urban areas, however, increased from 9.6% to 15.9% in that same period, which is alarming. Food price inflation in mid 2008 followed by the more recent collapse in tourism and exports might well have caused an uptick in acute malnutrition among urban children especially those with parents suffering wage losses.

The newly malnourished are likely to be resident in Phnom Penh, be in households dependent on employment in export-related industries, tourism, and construction, and entirely dependent upon the market for their food. Infants of women working in the textile industry are particularly vulnerable because they may not be receiving breast-milk (for which substitutes are either expensive or nutritionally inadequate or both). Economic shocks can provide an incentive to breastfeeding because it is “free”, but weaning is not necessarily reversible without tremendous commitment.

The FSN Forum is discussing (April 2009) the most appropriate response to the economic shocks, which includes strengthening the health system’s ability to deal with severe acute malnutrition, scaling up micronutrient programs, improving infant and young child feeding (at the community and facility level, using behavior change tactics, and enforcing breastfeeding protection legislation), improving maternal nutrition (micronutrients and nutrition education during pregnancy, family planning), targeted “food-related interventions”, social safety nets, water, sanitation and hygiene improvement, food fortification, and food production. This is a thoughtful and feasible list of actions. Attention to the immediate problem, however, should not divert attention from the long-term underlying malnutrition problem. If children had been well nourished at the beginning of the crisis, the impacts would have been far less widespread and severe.

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Policies and programs

Cambodia is fortunate to have a comprehensive development plan (National Strategic Development Plan 2006-2010) that establishes national priorities, steers ODA and NGO efforts into high priority areas, and is geared toward achieving the millennium development goals. It reinforces Cambodia’s commitment to addressing malnutrition through community-based programs. The 2002 PRSP cited evidence that community based nutrition programs in Cambodia are cost-effective with a cost/benefit ration of 1:8. It also stated that “[to] address the specific causes of malnutrition, it is necessary for the communities to make their own assessment and analysis of the problems they face before appropriate actions can be taken at all levels. Although the PRSP has been superseded by the National Development Strategy Paper, the latter paper reinforces the commitment to addressing malnutrition and to community based programs.

Cambodia is fortunate also to have strong donor coordination and partnership. Key strategies in both health and agriculture, moreover, include nutrition in a central and high priority way. The country’s Consultative Group of donors developed seventeen technical working groups among which is the Food Security and Nutrition (FSN) Technical Working Group which is actively monitoring both historic and transitory nutritional problems. The FSN working group is currently actively involved in developing a nutrition-oriented social safety net. The Council for Agricultural and Rural Development is the coordinating body for food security and nutrition issues in Cambodia and the National Nutrition Council, at the Ministry of Planning, is the lead agency for the formulation of nutrition policy. In other words, the key institutional and policy architecture is in place to address the problem. The national Nutrition Investment Plan 2003-2007 was reviewed annually and a new Nutrition Investment Plan is in process and an annual operational plan for 2009 is available. An excellent “Strategic Framework for Food Security and Nutrition in Cambodia 2008-2012” lays out a comprehensive and sensible set of policies and programs. The National Policy on Infant and Young Child feeding has just been released and it too is first rate. The country appears to have devoted a considerable amount of attention to communications and behavior change strategies. The World Bank and USAID have provided substantial technical assistance to develop locally relevant nutrition counseling messages and materials for promoting infant and young child feeding. Careful community-based research has gone into message development and thus the basic platform upon which to build a strong program is already in place.

The country in 2006 put in place a Code on the Marketing of Breast-milk Substitutes and has instituted (with UNICEF support) both a Baby Friendly Hospital Initiative and a Baby Friendly Community Initiative to support breastfeeding. The country showed a dramatic rise in exclusive breastfeeding in children under six months from 12% in 2000 to 60% in 2005 DHS surveys. Compliance enforcement with the Code needs strengthening. Cambodia also has a law requiring iodization of salt although enforcement is weak.

The National Nutrition Program (out of the National Maternal and Child Health Center of the Ministry of Health) includes a large number of programs, studies, and pilots that include the full gamut of nutrition options: community based nutrition promotion programs, upgrading quality of facility based nutrition services, protection and promotion of breastfeeding, care of sick, acutely malnourished, and HIV/AIDs affected children, micronutrient programs, women’s nutrition, capacity building, and information systems. There appears to have been a fairly object

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assessment of the performance of the National Nutrition Program (imbedded in the 2009 operational plan). This plan shows that coverage is relatively low and there is need for improved management, greater attention to implementation at the periphery, and insufficient attention to supervision, quality control, and helping the operational districts do their jobs. Their diagnosis of the problem is insufficient manpower at the national level but one wonders whether a higher priority might be to strengthen capacity (not formal nutrition training or conferences) at the district level.

In addition to the National Nutrition Program and operational plans (supported in part by the Bank’s HSSP project), there is also a Strategic Framework for Food Security and Nutrition in Cambodia 2008-2012 which highlights programs that affect nutrition both within and outside of the health sector. The Health Strategic Plan 2008-2015 also places high priority on improving maternal and child nutrition. The Nutrition Operational Plan for 2009 is currently being discussed.

It almost appears that there are too many coordinating bodies and actors working in nutrition. One wonders how, for instance, the National Nutrition Council and the Council for Agricultural and Rural Development coordinate on nutrition and how the lower levels of government take care of cross sectoral coordination and collaboration. Without an on the ground assessment, it is difficult to sort out the institutional arrangements.

Although the rhetoric in the plans and strategies emphasizes decentralization, the reality appears to be heavily weighted toward the central level (FSN Working Group, Nutrition Group within National Maternal and Child Health Center, Ministry of Planning, and Council for Agricultural and Rural Development) and toward studies, policies, reports, and pilots. Perhaps this is in keeping with the normative role of the central Ministries however a complementary effort is needed at the province (Provincial Nutritional Coordination Committees), district, commune and village level (Village Health Support Groups). Capacity building, moreover, seems to be heavily weighted toward large meetings and technical content and academic training and less on management and communications.

Beyond the narrow nutrition area, the priority within development programs is on decentralization, giving voice and agency to communes, districts, and communities. The Seila and Seth Koma programs which have been strengthening local decision making and implementation have been operating in the country since 2000. The upcoming rural participation and infrastructure project proposes to improve the quality of people’s participation

Donors and NGOs in Nutrition.

Cambodia has many partners in the nutrition field including major donors and U.N. agencies (UNICEF, WHO, WFP, FAO), banks (ADB, WB), bilaterals (EU, GTZ, Japan, USAID) and NGOs (ADRA, Union Aid Abroad – APHEDA, Reproductive and Child Health Alliance, Cambodian Health Education Development, CARE, CARITAS, Church World Service, Clinton Foundation, Cooperation for Prosperity, Development Partnership in Action, Groupe de Recherche et d’exchanges technologiques, Helen Keller International, International Relief and Development, Lutheran World Federation, Partners for Development, Save the Children, and World Vision). The NGOs appear to work well with each other and the government to achieve national goals.

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According to the CAS 2008 there is weaker coordination among donors, government agencies, and NGOs in the health sector than in other sectors. A common theme for most donors, however, is the need for accountability and improved governance. WHO and UNICEF have jointly sponsored a Nutrition Landscape analysis for the country (although a report could not be found).

WB strategy in country

The World Bank focuses on four key themes in Cambodia: improving the climate for private sector investment, strengthening public service delivery, increasing access of local communities to natural resources and participation in their management, and supporting greater social accountability, particularly through support to strengthened local government and civil society activity.

The CAS notes that one of the governance issues impeding decentralization is the lack of mechanisms for villages and citizens to participate in local planning, implementation, and to hold local government to account. Also it notes an underdeveloped accountability framework limits capacity of civil society to articulate demand for improved accountability. Under Objective 6 the CAS notes that service delivery facilities are unavailable for poor communities and there is a lack of accountability systems to monitor quality and performance. Of particular relevance to nutrition within the portfolio are the Good Governance, Empowerment for the Poor in Siem Reap, Rural Investment and Local Government, Community Forestry and the Second Health Sector Support projects.

The Bank’s first Health Sector Support Project provided considerable support for the national nutrition program primarily to central functions and preparatory work (community based research necessary to develop nutrition counseling materials, for instance). The second Health Sector Support Project (co-financed with AusAID and DfID) does not specifically address nutrition but “calls for increased community participation, multi-sectoral responses toward improving health, and empowering communities to hold health systems more accountable.” (PID pg. 7) and notes that “program support will be based on the Strategic Framework on community Participation of the MOH.” Just as the Health Sector Support Project is improving the quality of services at clinics, so a community-nutrition program could strengthen and rationalize demand for facility-based services and draw health personnel into the community to deliver preventive care.

The Bank is engaged in strengthening community voice and management of development programs. Community driven development projects and community nutrition projects could enhance each other’s performance. The community development project benefit from the hard indicators (growth of children) provided by the community nutrition program. These indicators are not only objective, replicable, and meaningful; they are also emotive and capable of mobilizing the community to ensure that young children are given their best possible chance in life. Child growth provides, in a word, an easy and effective mechanism for holding communities and the state accountable for development programs. The community nutrition program benefits from the Platform type projects by taking advantage of the prior community organization efforts and drawing enabling the community to draw in the sectoral investments (land use, water, roads) needed to address the causes of malnutrition. Both types of project

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would benefit from the efficiency and synergies in management and supervision. The following Bank-financed community development projects in Cambodia could be used as platforms for a community nutrition project:

Rural Investment and Local Governance Projects (2) (en extension of the Seila Program)

Land management and Administration Project Community Organization Project Empowerment for the Poor in Siem Reap Project Demand for Good Governance Project 2nd Health Sector Support Project Civil Society Engagement and Small Grants Project

Proposed nutrition options

All roads in development assistance in Cambodia lead to decentralization, de-concentration, accountability, and good governance. In keeping with this goal and the FSN Strategic Plan and in light of previous experience (in Cambodia (Seila), Thailand, and elsewhere), it is proposed that the Bank concentrate on integrating the existing community-based nutrition program into on-going community driven development efforts. A community nutrition approach would consolidate and piggyback on existing but independent community based health and nutrition programs in Cambodia (breastfeeding promotion through Baby Friendly Communities Initiative, identification, care and referral of the sick child through Community based Integration Management of Childhood Infections (C-IMCI), micronutrients, infant and young child feeding, community mobilization and oversight by village health support groups, and promotion of malaria control by village health workers) and create demand for the strengthened facilities based health services. In addition, by monitoring the growth of children and using it to mobilize the community in a number of sections, a community nutrition program will enable communities to integrate services across sectors (water, agriculture, health, social safety nets, infrastructure, governance) and provide hard data which communities can use to demand services, show accountability, and measure impact. A community based nutrition program is completely consistent with the existing nutrition program portfolio of the government, donors, and NGOs and fits in seamlessly with the also strengthens the new Health Sector Strategy of the government as well as the Strategic Framework for food Security and Nutrition. The information generated by a community based nutrition program could revitalize the Provincial Nutrition Coordinating Committees and commune councils and provide them with an operational planning tool and an information system and enhance national nutrition capacity by providing opportunity for learning by doing.

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References

National Policy on Infant and Young Child Feeding, October 2008Cambodia Nutrition Investment Plan. Second Annual Progress Report, 2004

Collins, D., E. Lewis, K. Stenberg. Scaling Up Child Survival Interventions in Cambodia: The Cost of National Programme Resource Needs. Final Report 19 june 2007. USAID/BASICS/WHO.

Poverty Reduction Strategy Paper, 2002.

National Nutrition Program (NNP). Annual Operational Plan (AOP) 2009

Trip Report, Kingdom of Cambodia, August 21-31, 2007. IYCN Project. USAID/IYCN.

Impact of Global Economic Crisis on Food Security and Nutrition. Food Security Forum. 10 April 2009 (PPT presentation)

Upcoming EC Food Security Assistance to Cambodia. 10 April 2009. Food Security Forum, 39 th

Session (PPT presentation)

Cambodia Anthropometrics Survey, 2008. Initial Findings of National Survey. (PPT presentation)

DHS, Cambodia 2000DHS, Cambodia 2005

Strategic Framework for Food Security and Nutrition in Cambodia 2008-2012. May 2008

National Strategic Development Plan 2006-2010.

Health Sector Policy 2. 2008 Annual Progress Report on the Implementation of the National Nutrition Program and Minimum Package of Activities (MPA) Module 10. January 2008.

Cambodia. Halving Poverty by 2015. World Bank, 2006.

Picado, J.I. 2006. Final Consultancy Report. Research on Infant and Young Child Feeding Practices in Five Provinces of Cambodia.

ADB. Participatory Poverty Assessment. 2002.

World Bank. Country Assistance Strategy Progress Report for the Kingdom of Cambodia for the Period FY05-08. April 17, 2008.

World Bank. 2009. Sustaining Rapid Growth in a Challenging Environment. Cambodia Country Economic Memorandum. Draft, January 14, 2009

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IndonesiaNature of the Nutrition Problem

Indonesia has made remarkable progress in reducing malnutrition since the 1970s due to a combination of economic growth, agricultural development, improvement in water and sanitation, and a community-based nutrition program. In fact, Indonesia’s old family nutrition program (UPGK) continues to be a model for community nutrition programs.

A significant proportion of Indonesia infants are born at low birthweight (9%) and then a growing number of children become malnourished between birth and their third birthday. Using the new WHO standards for 2004 data, 28.6% of preshool Indonesian children are stunted, one 24.4% are underweight, and about 14.4% are wasted (0.9% severely so).

UNICEF concludes that Indonesia is likely to reach the nutrition MDG29. Since 2000, however, there has been little improvement in malnutrition (Fig 1). The uptick in undernutrition in 2005, the current global financial crisis, and poor nutrition program performance (Friedman et al, 2006; Sciortino, 2007, Soegianto, 2008; ADB, 2007) suggest that progress has stalled.

29 UNICEF ChildInfo: http://www.childinfo.org/undernutrition_mdgprogress.php

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Source: WHO Global Database on Child Growth and Malnutrition

The causes of child malnutrition in Indonesia are well-documented and predictable: suboptimal breastefeeding, poor complementary feeding practices in children under two, high levels of diarrhea and other infectious diseases, maternal malnutrition, and poverty/food insecurity. Taken together, these factors explain the deterioration the relationship between age and undernutrition.

Breastfeeding has been a particular focus of attention because breastmilk is the ideal food for children under six months and because it provides an excellent uncontaminated easily digested food source of protein and micronutrients for children over six months. Between 2002-3 and 2007 there has been a deterioration in breastfeeding practices.

Table 1. Breastfeeding Practices in Indonesia2002-3 2007

Immediate breastfeeding (within one hour of birth)

38.7 43.9

Exclusive breastfeeding under six months

40% 32%

Median duration of breastfeeding

22.3 20.7

Ever breastfed 96 95

Source: DHS 2002-32007

Fig. 1 Indonesia Historic Trends in Nutrition (NCHS stds)

0

5

10

15

20

25

30

35

40

45

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006

Year

Perc

ent U

nder

wei

ght

UnderweightLinear (Underweight)

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Complementary feeding is often inadequate with respect to frequency, quantity, consistency, and nutritional quality. The 2007 DHS survey found that only 41% of children under 5 were fed “appropriately”. There are traditional high nutritional quality foods available in rural Indonesia for infants (tempeh and tofu; leafy greens; oil) but such excellent local foods may be supplanted by nutritionally inferior purchased foods or by public food supplementation commodities (DHS 2002-3; ADB, 2007).

Maternal nutrition is also poor. The IFLS 2000 found that 14% of reproductive aged women were chronically energy deficient (BMI under 18.5) 30 and the 2007 DHS survey found that 2.2% reported night blindness. Nightblindness during pregnancy is alarmingly high in W. Sumatra (3.9%), Bangka Belitung (4.7%), E. N.T. (5.9%) and S. Kalimantan (4.2%)31. IFLS (2000) found that 18.8% of women 15-49 years of age were anemic32 (Friedman, et al 2006) whereas the 2008 Basic Health Survey (cited in “MDG 1 Target 2”) found that 24% of pregnant women were anemic even though 80% of pregnant women were said to receive iron supplements (Friedman, 2006). In 2007 79% of women reported receiving iron supplements during their previous pregnancy and 29% reported receiving the recommended 90 or more tablets.

As expected, malnutrition differs between rich and poor (Table 2). According Friedman et al. anemia is 23% among poorest quintile women vs. 15% in the highest quintile. Night blindness during pregnancy is 3.1% among poor women vs. 0.9% among the rich. Excessive thinness in women (BMI <18.5) is 16% among the poor and 11% among rich women.

Table. 1 Differences in nutrition status by wealth quintile

Q1 Q2 Q3 Q4 Q5Stunting 42.7 37.2 32.9 24.3 19.6Underweight 29.4 28.5 28.0 25.5 20.6Wasting 11.8 10.9 11.4 9.7 7.1Anemia (<5s) 56.3 58.6 57.4 42.8 43.7Anemia (women 15-49)

22.8 19.4 18.8 17.2 15.3

BMI <18.5 women 15-49

16.2 17.5 13.8 13.1 10.7

BMI >=25 women 15-49

14.9 18.3 20.9 24.0 26.6

Source: Friedman, 2006 based on IFLS 2000.

There are wide disparities among districts and provinces. The least malnutrition (low weight for age) is found in Bali (17.3%)DKI Jakarta (18,.8%), Jabar (18.9%) and Jogjakarta (12.5%) while the worst is found in Gorontalo (37.4%), Kalsel (30.7%), Maluku (31.2%) and NTT (36.0%) (2005 data, source WHO). That is to say there is a nearly threefold difference between the best and worst areas. Based on 2001 Susenas data, Friedman et al (2006) found that the districts

30 Friedman et al., 200631 Ibid.32 Ibid.

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with the highest proportion of both maternal (thinness based on mid upper arm circumference) and child (low weight-for-age) malnutrition is concentrated in NTT, NTB, South Sulawesi and East and Central Java. The rates of child malnutrition in the 30 worst off districts range from 31.8% in Lombok Timur to 80.6% in Barito Selatan. Maternal malnutrition in those districts ranges from 15.8% in Bekasi to 60% in TT Utara.

Overnutrition and obesity are apparently emerging health issues, especially among urban women, and probably contribute to the rise of diet-related chronic diseases. The 2003 data (WHO) show that 5.9% of children under five were overweight. At the same time that 14% of women were estimated to be underweight in 2000, about 21% of women were estimated to be overweight, including 27% in Jakarta (Friedman et al, 2006).

Some micronutrient deficiencies have been largely eliminated while others persist. Iron deficiency is clearly the most widespread nutritional problem. The IFLS found that nearly 70% of children 1-2 years old were anemic and undoubtedly a higher proportion of younger children would be anemic. Over half (53%) of preschoolers over one year of age were anemic. The 2007 DHS survey found that 70% of preschoolers had consumed iron rich foods but there are no data on coverage of iron supplementation programs for children although Friedman et al report that such programs exist in the eastern part of the country. With very high rates (85%) of salt iodization, it is believed the iodine deficiencies disorders are now limited to a small number of districts where artisanal salt is produced East Java, Bali, and southern Sulawesi). Effect of Recent Shocks

The impact of the recent food and fuel price spikes and the global financial crisis is difficult to gauge. While food production increased in 2008, exports of petroleum rose then fell as prices dropped. Unemployment is rising but inflation has dropped, especially food price inflation. Perhaps because of its experience with financial crisis in the late 1990s, he government has taken early and aggressive steps to protect the poor during the current crisis. The National Program for Community Empowerment program (PNPM) and a conditional cash transfer program were rapidly launched on a wide scale to get resources down to the community level and to protect the health and education of the poorest citizens. The impact on food security and nutrition of nutritionally at-risk groups can only be surmised. To the extent that urban unemployment increases among the poor, one would expect to see increases in food insecurity and possibly acute malnutrition among poor children. There are media reports of such things but it is difficult to ascertain the magnitude of the problem.

Policies and Programs

Nutrition has been included as an important element in the five year plans since the second Repelita in 1974. In recent national plans, nutrition has become buried in health and not accorded high level attention. The government instituted a national policy on the marketing of breastmilk substitutes since 1985.

Indonesia has had community based nutrition programs for over forty years and it has included nutrition in the national policy document for almost the same period of time. The Family Nutrition Improvement Program (UPGK), started in 1974, is widely considered to be a model for community based nutrition programs. It focused on monthly weighting of children

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under five, nutrition education, home food production , promotion of birth spacing, nutritional “first aid” (vitamin A capsules, iron folate tables, oral rehydration salts), referral of serious problems, provision of seeds for food production, and rehabilitative supplementary feeding. One of the most useful innovations of UPGK was the SKDN monitoring system (S is for the total target population, K is the number of the eligibles with a growth card, D is the number attending the last growth monitoring session, and N is the number gaining weight). Using a combination of SKDN indicators one can supervise the program, determine coverage, assess quality of services, and assess impact. The program had high level political support. Some particular strengths of the UPGK were that provincial and district level coordination boards were set up to oversee the program and that a number of ministerial level entities (health, family planning, agriculture, and religion) were involved in service delivery. UPGK was complemented with a similar community health program (PKMD) in which communities self-surveyed, diagnosed problems, and devised interventions. PKMD also included nutrition and food production. These programs were mutually reinforcing and built on the tradition of community self-help (Soegianto, 2008).

Since 1986, when UPGK was integrated with a number of health services into the posyandu, it has lost status and effectiveness as (some say because) it became more formalized as a health program and the family planning and food production components were dropped. In particular it is notable that the goal of Posyandu is explicitly the reduction of infant and maternal mortality (not malnutrition). As Indonesia was departing from UPGK, however, the model was being expanded and improved in other countries (most notably Honduras, Nicaragua, and Peru).

In recent years there has been much criticism of the nutrition component of posyandu, the successor to UPGK, because nutrition status has failed to improve, utilization of growth monitoring has fallen, and performance measures suggest poor implementation even as the cost has increased. Many have blamed the decentralization of the health system for posyandu’s weakness33. The weaknesses were apparent, however, long before decentralization took place ((Soegianto, 2008). In fact previous evaluations pointed out exactly what was wrong with the program but apparently efforts were not taken to remedy identified problems. Some problems can also be attributed to the capture of UPGK by the formal health system and, in recent years, by the addition of virtually untargeted supplementary feeding to the program mix.

Indonesia has had in place for decades a successful vitamin A supplementation program which has virtually eliminated severe vitamin A deficiency. Currently it distributes through Posyandu two megadoses of vitamin A per year to preschool children and a single megadose to postnatal women and it promotes consumption of vitamin A rich foods. Coverage in 13 provinces in 2000 was estimated to be 68.5% for vitamin A supplementation of children and 42.5% supplement coverage for postnatal women (Friedman et al). The 2007 DHS survey also found that 68.5% of preschoolers had received any vitamin A supplement although 87% had consumer vitamin A rich foods within the previous 24 hours. The country has also been successful in instituting salt iodization. In the 2000 survey, 84.8% of homes used iodized salt but only 82% of the salt was deemed to be adequately fortified.

33 Friedman, ibid.

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As early as 1985 Indonesia had begun to implement portions of what came to be known as the International Code on the Marketing of Breastmilk substitutes. As of 2004, IBFAN found that Indonesia’s regulation of the baby formula industry was incomplete and inadequately enforced. They found multiple examples of formula companies providing inducements to health workers and mothers and engaging in deceptive and persuasive marketing practices. Anecdotal evidence suggests that many problems with enforcement remain. On the brighter side, UNICEF has recently introduced a new training program for midwives on breastfeeding (“40 hour counselors”) which appears to be both popular and effective.

Public Investment in Nutrition

The World Bank states that public health investments have risen but are still inadequate (Rokx et al, 2009). Likewise it states that nutrition spending has risen absolutely and as a proportion of health spending. From 144 Billion IDR and 2.2% of the health budget in 2003 to 717 Billion IDR and 3.5% in 2007. Nutrition outcomes have not risen apace. Although some might argue for greater expenditure to address malnutrition – for instance a recent paper prepared for the World Bank34 suggests that for $483 million from 2009 to 2015, Indonesia could halve the prevalence of underweight preschool children. -- it is equally plausible that improving the composition and quality of expenditures would have greater impact than across the board increases. In particular, Indonesia has embarked upon a virtually untargeted food supplementation program through posyandu which appears to reach 70% of children under five –one document states that “complementary meals [were] a reward [for] visiting Posyandu” (Friedman et al, pg. 21). Food supplements in 2000 reached 76% of the highest quintile children vs. 72% of the poorest quintile children (Friedman et al). This is clearly not a pro-poor program and it undoubtedly distracts posyandu workers from more important counseling activities. Improvements in the quality of national nutrition program should be undertaken before any increment in spending takes place. Those improvements are likely to increase unit costs and total budget only modestly and, if the food handouts were eliminated, improvement could be cost neutral. As shown in the recent Lancet series, supplementary feeding for preschool children is not considered efficacious (Lancet series chapter 4).

Institutional Strengths and Weaknesses

Indonesia has a two-part institutional structure for nutrition, having a dedicated group in BAPPENAS (at national level), the planning commission, which does planning and budgeting, and Directorate of Community Nutrition (within Dept. of Public Health within Ministry of Health), which is in charge of technical guidance and support. Each of these entities has a provincial and district counterpart which guides (provincial) and implements (district) programs. There are supposedly nutrition sections at the central and provincial level but little budget to work with (Friedman, et al) and many districts lack the appropriate staff complement. Some districts no longer have a dedicated nutrition section and one (NTT) has two separate and overlapping sections. Nutrition is but one of many roles and responsibilities of provincial health offices and not one of the priority areas that receives budget (Friedman et al). At the district level nutrition is one of six major health programs but lacks staff and financial resources. In

34 Anon. MDG 1 Target 2: Halving Malnutrition in Indonesia by 2015. What is needed and what it will cost. Policy Note 17 April 2009.

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addition a semi-governmental organization, PKK, comprised of the wives of civil servants, is involved in posyandu nutrition and other nutrition activities.

In the 1970s, the family planning program was developed independently from the health system because it was such a high priority issue. BKKBN provided family planning separately from health services and was extremely successful, as demonstrated by the high rate of constraceptive usage in Indonesia.. If nutrition is an important priority for the Indonesia government -- and it would appear that malnutrition and maternal mortality are the MDGs Indonesia least likely to meet – then perhaps growth promotion should be set up as a separate commission or initiative, still linked to health services, but more closely allied with community development.

According to Friedman et al one of the problems with the shared responsibility for nutrition between planning and health is that the planning is done without good data on the nutritional status and program performance. While in the old days the SKDN system would have provided information on program performance, this is apparently lacking today.

Apparently the quantity and quality of nutrition staff at the national level are adequate but province and district nutrition staff may lack training in nutrition and post bacc education. Many puskesmas (health centers) lack nutrition staff and some of those in place are not formal permanent employees. Training has been weak since decentralization since lower levels apparently do not place high priority on staff development.

Since decentralization the funds flow and budgeting processes have become more opaque,less well-coordinated, and less evidence-based. No longer do earmarks guarantee funds for nutrition. Funds for training, monitoring and evaluation have been cut as ell. Evidence based decision making is not the rule.

At the district level the local parliament might take action on nutrition, but usually only when severe acute malnutrition is detected (Friedman, et al).

Donor and NGO Programs

The Asian Development Bank has recently started a Nutrition Improvement through Community Empowerment (NICE) program that proposes to strengthen posyandu growth promotion as a means of social mobilization. It is not clear how NICE and PNPM will coordinate. ADB also support water services and health. The UNICEF nutrition program concentrates on immunization, breastfeeding promotion, micronutrient supplements, and treatment of severe acute malnutrition. Local NGOs are active in fortification (KFI) and a number of local initiatives. International NGOs that have nutrition programs in Indonesia including CARE, Helen Keller International, Catholic Relief Services, World Vision, Oxfam, Mercy Corps, Islamic Relief, and Save the Children, some of which are devoted almost exclusively to emergency and post-emergency relief. The presence of NGOs in Indonesia is somewhat lower than other countries due to the special history and culture of the country.

The World Bank’s Program in Indonesia

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The Behavior Change Communications project in Indonesia was one of the first ever nutrition projects at the Bank. Until the 1990s, the Bank continued to support nutrition projects in Indonesia but nutrition became part of health sector projects in the 1990s. In recent years the Bank has not invested directly in nutrition except indirectly through health sector strengthening.

The CPS 2008-2012 lays out several key principles which provide an excellent framework for improving nutrition sufficiently to meet MDG 1 based on community mobilization. All of the five thematic areas (private sector development, infrastructure, community development and social protection, education, and environmental sustainability/disaster mitigation) are relevant to improving nutrition. The private sector is critical to improving the food supply, particularly with respect to food fortification which will be increasingly important to prevent micronutrient deficiencies in the urbanizing populations. Water supply and sanitation are critical to reduce women’s work as well as to reduce diarrhea, one of the main causes of malnutrition in young children. Historically community development and nutrition were intimately linked in Indonesia and, in the present environment, this link should be strengthened for greater effectiveness and sustainability. Malnutrition compromises educability and school readiness even as early childhood and childcare programs comprise an important route for preventing malnutrition in children under two whose mothers are too busy to provide adequate nutrition and stimulation. The over riding focus of the Bank’s program in Indonesia rests on community driven development which is precisely what is needed to improve nutrition.

The current portfolio of the Bank has a number of projects which affect nutrition and might be actively managed to improve nutrition more systematically. These include the water and sanitation projects, community driven development projects (various KDP projects), early childhood education, and the proposed new support for PNPM and a conditional cash transfer.

National Program for Community Empowerment in Urban Areas, PNPM Rural II, Community Facilitators Development Program, National Program for Community Empowerment in Rural Areas, Farmer Empowerment through Agricutural Technology and Organizations, KDPs, Community Based Settlement Rehabilitation for Yogyajarta, Early Childhood Education and Development Project, Integrating Environment and Forest Protection into the Recovery and Future

Development of Aceh, Community based Settlement Reconstruction and Rehabilitation Project for NAD

and NIAS, Community Recovery in Earthquake Affected Areas through UPP, SPADAs, Third Urban Poverty Project, Second Water and Sanitation for Low Income Communities project.

Unfortunately, the KDP/PNPM community grants have been limited largely to building posyandu structures rather than improving the quality of services provided within the

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structures35. In part this reflects poor program specifications and lack of outcome focus. Using SKDN to measure outcomes and opening up the menu of eligible community improvements while holding communities accountable for improvements in undernutrition could provide greater impact on MDG 1. The SKDN indicators have broad applicability, including as a rapid alert system for detecting deterioration of human welfare during downturns (as now). Enabling the communities to communicate rapidly (for example in text messages) the data collected monthly in growth promotion sessions (SKDN) could be invaluable for emergency readiness and early and rapid response to emerging problems.

Recommendations for Bank Action

The new initiatives of the government, particularly PNPM, offer an opportunity to update and revitalize the community based nutrition program and simultaneously support community driven development. This could be effected by updating the program to reflect what has been learned elsewhere about community based nutrition programs and imbedding growth promotion in the community rather than health services. In particular SKDN (or an upgraded version of it) could serve the community’s need for a “bottom line” for diagnosis, planning, proposal justification, and evaluation. Capturing as it does healthy child growth, it is an excellent proxy indicator for poverty and community development. Better yet, because the growth promotion kaders are from the community, this provides a unique indicator that the community itself can collect and analyze. In fact, if UPGK had continued, communities would be using these data today for local planning.

Specifically, the following reforms should be considered for the community based growth promotion program (nee UPGK and now imbedded in posyandu)::

1. Strengthen and support kaders with training, improved counseling materials, , supportive supervision, and systematic incentives.

2. Revise SKDN system to enhance the counseling component and redefine S to be all children under 3 and N to minimum adequate weight gain (using examples from Honduras and elsewhere)

3. Convert the current supplementary food into a cash incentive which can be used by communities, in conjunction with other cash grants, to improve nutrition

4. Return to the model of multisectoral participation and oversight of the community based growth promotion program. Consider creating new institutional structure for it which actively involves Village Community Empowerment, health, agriculture, education, infrastructure, and social protection ministries as implementing partners. .

What Next:

Further work needs to be done with a broad range of political actors in Indonesia to generate strong public support for self-reliant and community-driven approaches to preventing malnutrition. Plenty of evaluations have been done and made very similar recommendations. It’s time to implement the recommendations.

35 Sciortino, Rosalia. Maximizing KDP for Health. Sept. 2007. Consultant report to World Bank.

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The SKDN data should be incorporated into an emergency alert system which will have the added value of signaling to the underappreciated volunteers that their work matters. ICT could be provided to kaders or communities as a means of rapidly transmitting data and to provide status (and possibly an income source) to the kaders.

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References

Sciortino, R. Maximizing KDP for Health. Sept. 2007. Consultant report. Setboonsarng, S. Child malnutrition as a Poverty Indicator: An Evaluation of the Context of Different Development Interventions in Indonesia. ADB Institute Discussion Paper No. 21. Jan. 2005.

Anon. 17 April 2009. MDG 1 Target 2: Halving malnutrition in Indonesia by 2015. What is needed and what it will cost. Policy Note. World Bank. DHS Survey, 2007.

Friedman, J., P.F. Heywood, G. Marks, F. Saadah, Y. Choi. Health Sector Decentralization and Indonesia’s Nutrition Programs: Opportunities and Challenges. Consultant Report. Jan. 20, 2006. ADB. Proposed Loan and Technical Assistance Grant. Republic of Indonesia: Nutrition Improvement through Community Empowerment Project. August 2007.

World Bannk. 2009. COUNTRY PARTNERSHIP STRATEGY FOR INDONESIA FY2009-2012. Investing in Indonesia’s Institutions for Inclusive and Sustainable Development.

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Lao Democratic People’s RepublicNature of the Nutrition Problem

The most recent national survey data, from 2006, show that 36% of children under five were underweight, 48% are stunted, and 18% are wasted (8% severely so). As with most countries, nutritional status deteriorates precipitously in the first two years of life (Fig. 1). What is notable in Lao PDR, however, is how many children are malnourished already in the first six months of life. The prevalence of low birth weight (18%36) reinforces this. High early malnutrition suggests that maternal malnutrition and poor health are a root cause of child malnutrition. Maternal mortality rate is extremely high in the country (660 deaths per 100,00037) as well as anemia (56% of pregnant women), suggesting that improving women’s health and nutrition is critical not only for their own well-being but that of their children. Although infant mortality has fallen substantially over the last decade (from 77 in 2000 to 59 in 2006(WB)), it is unlikely to fall much further without attention to maternal and child malnutrition. Not surprisingly, women’s literacy is fairly low also (83% of male literacy and adult literacy is only 69% to start with).

Source: WHO Global Database on Child Growth and Malnutrition

Child feeding is undoubtedly a major cause of child malnutrition. Very few newborns are fed the nutritious antibody-rich colostrums (first milk) and they are even starved for a few days until the mature breast-milk comes in38. Fewer than one-fourth of infants under six months

36 Unicef ChildInfo http://www.childinfo.org/low_birthweight_profiles.php. 37 UNICEF, State of the World’s Children, 2009.38 Gillespie, A., H. Creed-kanashiro, D. Sirivongsa, D. Sayakoummane, and R. Galloway. Contulting with Caregivers. Using Formative Research to Improve Maternal and Newborn Care and Infant and Young Child Feeding in the Lao People’s Democratic Repaublic. Consultant Report. Oct. 2004.

Fig. 1. Lao PDR Nutrition and Age, 2000 (WHO stds)

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of age are exclusively breastfed, which is the ideal diet, and less than half of children 6-11 months receive “appropriate” complementary foods39. Young child feeding is also inadequate both in its late introduction (much later than six months of age), its poor quality, low frequency, and passive style of feeding. Only 10% of children, however, are reached by nutrition education programs40. Bank sector work in 20043 showed that women are eating poorly during both pregnancy and lactation because of tradition. It also showed that there are many food beliefs that negatively affect women and children. At the same time, the study showed that mothers are willing to make changes in their own diets if they will increase breast-milk production and to their children’s diets once they know what children should eat and how much they can eat.

In addition to the purely nutritional causes, high fertility (3.2), poor water and sanitation access (at best 60% and 48% respectively), intestinal parasites and malaria contribute to child malnutrition.

Nutrition indicators have improved slightly over time but they are still extremely high.

Source: WHO, Global Database on Child Growth and Malnutrition

Good and recent data are not available on micronutrient deficiencies. In 2000 12% of women had had night blindness from vitamin A deficiency during pregnancy, 48% of children under six were anemic (which means that a substantially higher proportion under two are anemic), and 20% of school children were low in iodine41 (WHO).

39 UNICEF, op. cit..40 REACH. Overview of country documentation Lao PDR. April 2009. 41 WHO Global Databases on Vitamin A and Iodine, respectively

Fig. 2 Lao Trends in malnutrition

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Since Laos is a food exporter, it does not appear that food supply is the chief cause of malnutrition. In addition to poverty, it is the heavy reliance on rice coupled with the loss of wild foods which provide protein and micronutrients which make for diet of poor quality.

Lao PDR is seen to be making insufficient progress toward achieving the nutrition MDG. Indeed, weight-for-age, the MDG indicator, is barely improving. An all out effort with high coverage and multi-sectoral interventions would be required to break the inertia on improvement in underweight.

Income and malnutrition

Although the economy has been growing at a rapid clip, poverty reduction has not kept pace. Up to date poverty data are not available but fairly recent (2005) analysis suggests that almost one-third of the population still lives below the poverty line (WB). Poverty is neither a necessary nor sufficient condition for malnutrition, but it is likely that rates of malnutrition are highest among the poor. Poverty has fallen faster than malnutrition (Fig. 3).

Source: World Bank Poverty Assessment and WHO Global Database on Child Growth and Malnutrition.

Lao PDR is rich in both natural and productive resources, including hydropower, which it is exploiting to the fullest … in fact over exploiting in the case of forests. The forests are a valuable source of high nutritional quality foods for the rural poor and the destruction of forests undoubtedly affects nutrition as well as rural livelihoods and environmental degradation. Part of the problem with food security relates to unexploded ordinance which affects 1/2 -2/3 of the potentially productive land and has caused disability and death. Behavior is likely to be a major determinant of malnutrition.

Fig. 3 Lao PDR Poverty vs. Malnutrition Trends

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Geography of malnutrition

The highest prevalence of chronic and acute malnutrition is in the South, where 46% of children are stunted and best in the Central region where 35% of children are stunted but most of the malnourished children live42. REACH analysis suggests that most of the nutrition programs are in the Northern region while NGOs are concentrated in the Central region. Vitamin A capsules (69%) and iodized salt coverage (75%) are the highest coverage nutrition interventions as well as deworming for school children. Otherwise, except for the 20% of women who receive some iron supplements through the health system, coverage by nutrition programs is very low.

II. Likely effects of recent shocks

The impacts of the food, fuel and financial crisis on nutrition in Lao PDR is likely to be concentrated among those employed in jobs related to exports (mining and agriculture) and tourism. Because the Lao economy is relatively undeveloped, it is less affected by the world economic crisis than economies more dependent upon trade. As a net food exporter, it may have been somewhat sheltered from the food price spike. The underlying and long term nutrition problem continues to be the highest priority.

III. Policies and Programs

Lao PDR passed a national nutrition policy in late 2008. This is an aspirational document that describes the problem and establishes a number of excellent goals and processes but it lacks detail on programs, timetables, and budgets. It lays out quite clearly the priority given to children under two and women of reproductive age, it focuses on breastfeeding and young child feeding (especially dietary diversity), and the need to give greater attention to ethnic minorities and remote populations. Some notable aspects of the National Nutrition Policy are its mention of making nutrition programs culturally sensitive, the emphasis on women’s playing an active role in planning and implementation, the principle of other development sectors’ doing no harm to nutrition, the principle of participatory management, monitoring and evaluation, and getting down to the village level. The document points out that the country needs a nutritional focal point and it charges the Ministry of Health with establishing a Nutrition Centre or Institute and the National Science Council in the Prime Minister’s Office with creating a national nutrition council under. This suggests that institutional capacity in nutrition is weak. One hopes that, starting from scratch, Lao PDR can avoid the problems encountered with nutrition institutes and centers in other countries (excessive emphasis on research and new food technologies, too many overseas meetings and graduate programs, being highly vulnerable to influence by donors, and inadequate insertion into the operational activities in health and other sectors.)

In 1998 Lao PDR passed many provision of the International Code on the Marketing of Breast-milk Substitutes. Also as recently as September 2008, however, researchers found that some Laotians were giving their infants a coffee creamer in the mistaken belief that it was an

42 REACH, op. cit.

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infant food (based on pictures on the label). Clear vigilance and enforcement of the Code are required.

Institutions

In the Ministry of Health the Department of Hygiene and Prevention and the MCH Center are the main organizational entities responsible for nutrition. In addition the Center for Information and Education on Health is involved in nutrition education. The Department of Hygiene and Prevention is currently the focal point for nutrition. It provides technical support and normative guidance. The MCH Center in the Ministry of Health delivers antenatal, delivery and postnatal care program in five provinces, provides micronutrients, does nutrition and hygiene education and promotes breastfeeding. The Center for Information and Education on Health designs, produces and disseminates IEC materials. The Ministry of Agriculture promotes home gardens and food processing (in conjunction with the Lao Women’s Union), livestock production, and nutrition education. The Ministry of education has a school health and nutrition program. The Lao Women’s Union, a quasi governmental organization is involved in village activities targeted to women in many different areas.

From the REACH analysis, it would appear that the coverage of national programs is low and they have some important building blocks of an effective behavior change communications strategy, much work is needed to pull together the disparate nutrition programs into a coherent whole.

Donors and NGOs.

Four UN agencies (FAO, WFP, WHO, UNICEF and UNFPA), three bilateral donors, the World Bank and the Asian Development Bank are involved in nutrition in Lao PDR. In addition, the REACH program (a joint venture of the U.N. agencies) has recently been undertaking a stock taking exercise there as part of its policy support and capacity building efforts. The ADB has a health sector development project in the northern part of the country, the Primary Health Care Expansion Project, and is undertaking a pilot project called “Developing Model Healthy Villages in Northern Lao PDR” which dedicates one “element” (out of 8) to nutrition. But it is not clear how much attention is being paid to nutrition in that project. Twenty-three NGOs are engaged in nutrition but apparently there is little coordination and, according to the REACH analysis, their breadth and coverage is low. The REACH Project has not assessed the quality of any of these programs.

World Bank Portfolio

The World Bank is focused on four key themes in Lao: sustaining growth, improving social outcomes, capacity development, and completing the Nam Theun 2 dam. The Bank has just approved its first nutrition project for Lao PDR, a Community Nutrition Project for $2 Million. This project will carry out a small scale trial of combining conditional cash transfers with a community based health and nutrition program. It will work with the Department of Hygiene and Prevention and the Lao Women’s Union on implementation. The only thing missing from the community-based behavior change program is the use of child growth monitoring to target

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counseling and supportive services. Child growth, a summary measure of the gamut of improvements in the community (including health services but also water and sanitation, agricultural gains, conservation of forests, and economic well-being), not only helps identify children that need to be seen at the health facility, it also helps the community identify common problems (e.g. water and sanitation; loss of forest foods) that can be acted upon by the community as a whole.

In addition to the Community Nutrition Project there are many existing Bank projects which work at the community level and could become platforms for a community nutrition program. The most relevant projects currently under implementation are the following:

Health Services Improvement project Poverty Reduction Fund Project Lao Environment and Social Project Sustainable Forestry for Rural Development Project

It would appear that the interest and will is there to support community driven development but the public sector capacity to reach the community level is limited. The use of the Lao Women’s Union to complement the normal public system is an excellent way to get to the local level fast. Care must be taken to ensure their technical capability to handle the program.

IV. Next Steps

The ink should be allowed to dry on the Community Nutrition Project but it will need considerable technical assistance and oversight. It will provide valuable evidence for and experience in community nutrition programs to fuel political support for future expansion. At the same time, it is possible to help the GOL get ready to gear up by providing additional support for development of the program (a social marketing strategy, communications materials, manuals, training materials, job descriptions, information systems, etc.). In addition, it is possible that NGOs would be willing to pick up the CNP’s approach and the LWU would be willing to take it to non-project areas (particularly those covered by participatory community programs. Presumably, if the CNP is successful, the Bank will be amenable to financing a national level scale up so some of the preparation could take place even as the project is getting off the ground. Needless to say, the Laotians should also be involved in any regional learning community and technical assistance program.

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References

REACH. Overview of country documentation Lao PDR. April 2009.

National Nutrition Policy. December 2008

World Bank. Lao PDR Poverty Assessment Report. September 2006

Emergency Project Paper, Lao PDR Community Nutrition Project. 5 May 2009.

Gillespie, A, H. Creed-Kanashiro, D. Sirivongsa, D. Sayakoummane, and R. Galloway. Consulting with Caregivers. Using Formative Research to Improve Maternal and Newborn Care and Infant and Young Child Feeding in the Lao People’s Democratic Republic. October 2004.

Health Strategic Plan 20008-2015, Accountability, Efficiency, Quality, Equity. April 2008

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Philippines

Today, the level of malnutrition in Philippines is much higher than would be expected from its level of income. The Philippines has probably had more and more varied nutrition programs than any other country in the region as well as a large amount of excellent nutrition and food policy research and technical assistance. Most of the programs proposed over time ere innovative concepts but they were tried out only on a small scale or only for a short period of time. The hype of new programs seems not to be matched by institutional endurance in implementation. Even today nutrition various programs seemed to be competing with each other and may cause information overload among politicians. The several nutrition institutions and organizations in Philippines were responsible for many of these ideas. They appear not to have been sufficiently internalized into the mainstream government structure.

The Philippines does a far better job of measuring malnutrition than preventing it although even measurement is a problem because the Philippines uses its own cutoffs and standards for defining malnutrition (as it has done for poverty). The Philippines has been monitoring the national nutrition series for many years. According to UNICEF, the Philippines is making insufficient progress to achieve the poverty and hunger although the trend data suggest that they are not far off (Fig. 1).

Sources: World Bank Poverty Assessments and WHO Global Database on Child Growth and Malnutrition.

Although the most recent data (2003) are not disaggregated by rural/urban differences, an earlier survey in 1993 showed that underweight rates were slightly higher in rural areas (31% vs. 28% under weight and 35% vs. 31% in stunting). This slight difference between rural and urban malnutrition seems odd given that poverty is much more severe in rural areas. According

Fig. 1 Philippines Poverty vs. Malnutrition Trend

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to the 2009 CPS, poverty head count rates in 2006 were 19% in urban areas vs. 46% in rural areas.

Table 1. Nutrition Status (% malnourished) in the Philippines, 2003

WHO standards

Philippine Analysis

Weight-Age 20.7 26.9%Height-Age 33.8 30%Weight-Height 6.0 5.5%

Source: WHO Global Database on Child Growth and Malnutrition and “6th National Nutrition Surveys. Pedro MRA, Cerdena, CM, Molano, WL, et al. 2006.

As can be seen from Fig. 2, malnutrition increases dramatically in the second and third years of life. There is wide variation among regions with the national capital region having about 20% underweight compared to close to 35% in the autonomous region of Muslim Mindanao (ARMM), which generally has the worst indicators in the Philippines.

In addition, the Philippines has a very high rate of low birth-weight – 45% -- which predisposes infants to higher risks of disease, malnutrition, and death. One source in 2004 found the highest rate (47%) being in the National Capital Region and one of the lowest in ARMM (7).43 These data are difficult to comprehend. As with other indicators, there are efforts to develop a national (lower) definition of birth-weight rather than use international standards.

43 Basics II. 2004. Newborn Health in the Philippines. A Situation Analysis.

Source: WHO Global Database on Child Growth and Malnutrition

Fig. 2 Philippines 2003 Malnutrition X Age

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The crude fertility rate is high (3.4 in 2001) and conception by women before their 20 th

birthday is also high (one third of women), both factors contribute to malnutrition risk.

As is commonly the case, high rates of child malnutrition can be traced to suboptimal breastfeeding and poor complementary feeding practices, poverty and food insecurity, infectious disease, poor education, maternal malnutrition, and excessive fertility. In 2003 although 90% of infants were ever breastfed, only 34% of infants under 6 months were exclusively breastfed and the mean duration of breastfeeding was only 5.6 months. Survey data from 20033 found that half of all infants were exclusively breastfeeding for less than 24 days, down from 1.4 months in 1998, and only 16% of 4-5 month old babies were exclusively breastfed. Reasons given by surveyed mothers were: not enough breast-milk (30%), mother working (17%), and nipple/breast problems (17%)44. Problems with promoting and protection breastfeeding include aggressive marketing of breast-milk substitutes, donations of formula after emergencies, insufficient enforcement of the Code, and insufficient promotion of breastfeeding. “In the face of growing food insecurity, Maria-Bernadita-Flores (Executive Director, National Nutrition Council) said the advocacy for breastfeeding as an anti-poverty measure “should be strengthened and sustained.”45

Even though 95% of preschool children supposedly receive two doses of vitamin A per year46, still 40% of that age group has had low or deficient levels of vitamin A in their blood47. Most of pre-schoolers diets don’t get enough energy, iron, and vitamin A in their diets … in fact on average they only get about 70-80% of their needs48. About 57% of household fail to consume enough energy to meet their needs. Although salt is supposed to be iodized and 75% of households in a UNICEF survey in 2005 had some iodine in their salt, only 44.5% of the salt was adequately iodized.

Women’s nutritional status is not good. In 1998 13.4% of adult women suffered from wasting (BMI <18.5) while 14.1% of females were overweight or obese49. Close to a fifth (18% and 20% of pregnant and lactating women, respectively) were deficient or low in serum vitamin A. Almost one quarter of lactating mothers and 18% of pregnant women were iodine deficient in spite of a national salt iodization program. In addition 12% of lactating women were considered chronically undernourished50. In 2005, 28% of pregnant women were estimated to be nutritionally at-risk (up slightly from 27% in 2003) because of excessive thinness or poor weight gain in pregnancy. . In 2006, about 40% of pregnant women were anemic, with levels exceeding 50% in some provinces in Mindanao. An equal number of lactating women were also anemic. Underweight pregnant women are more likely to deliver low birth weight babies, who in turn become vulnerable to malnutrition, poor health, and delayed psychosocial development. The

44 http://fex.ennonline.net/34/philippine.aspx45 http://www.irinnews.org/PrintReport.aspx?ReportId-7927446 State of the World’s Children, 200947 WHO Global Database on Vitamin A48 Sixth Nutrition Survey, 2003. 49 FAO, 2001. Philippines Nutrition Country Profile.50 MRA Pedro, C.M Cerdena, W.L. Molano, A. Constantino, L.A. Perlas, E.F. Palafox, L. Patalen, M. Chavez, J. Madriaga, E. Castillo and C.V.C. Barba. 6th National Nutrition Suerveys. FNRI, DOST. PPT Presentation. 2004.

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prevalence of iron deficiency anemia is high among pregnant (51%) and lactating (46%) women51.

Nearly half of pregnancies in the Philippines are unintended52. Decentralization has strengthened the hand of those who oppose public finance of contraception and so the rate of illegal abortion has risen as a result. This in turn can contribute to heightened anemia in women due to excessive blood-loss. Malaria is endemic in the Philippines and pregnant women are particularly vulnerable. Malaria causes anemia and weekly chloroquine treatment for pregnant women has been shown to reduce anemia in pregnant women.

Agricultural production and the population dependent on agriculture has fallen in the last generation as the agricultural lands, which are located around the main urban areas, have been converted to residential and commercial uses.

Recent food, fuel, and financial crisis

Just as the world was entering the food and fuel price spikes, Philippines was experiencing the best economic growth it had had in decades (although this growth failed to reduce poverty which increase slightly between 2003 and 2006). Nonetheless, the increase in the price of rice caused rioting and panic in the Philippines. The government announced it was reducing its school feeding program to target only the worst provinces and only the first three grades in schools in response. Being a net food and energy importer, the price spikes were a double whammy for Philippines. Philippines clutch purchase of rice in late 2007 is credited with causing speculation in rice which caused prices to soar. Once self-sufficient in rice, the Philippines is now one of the world’s largest importers of rice. Remittances constitute 10% of GDP (half from the US) in the Philippines and the global economic crisis could reduce them substantially.

Institutions

The Philippines has one the richest and most chaotic institutional and human resources bases in nutrition in the world. Nutrition appears to be a popular academic subject and nutritionists are scattered throughout the public and private sectors. There are nutrition positions in the provinces and municipalities and sometimes at lower levels but there is no obvious system for the structures. Nutrition committees exist at the regional, provincial, municipal and barangay (village) levels although it is not clear how well they are functioning.

The main interlocutor for nutrition is the National Nutrition Council (1974, highest policy level nutrition body). The NNC is currently housed in the MOH, having been moved from the Department of Agriculture in 2005, although the Departments of Agriculture and Local Government are vice chairs. Previously the NNC was located in the Dept. of Social Welfare,

51 Sixth Nutrition Survey, 2003. 52 Paradox and Promise in the Philippines: Joint Country Gender Assessment, 2008. Asian Development Bank, Canadian International Development Agency, European Union, United Nations Children’s Fund, United Nations Development Fund for Women, United Nations Population Fund, and National Commission on the Role of Filipino Women

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which might be a better home for it now that the 4Ps program as taken on nutritional goals. In addition to the NNC, other major nutrition actors include the Food and Nutrition Research Institute, in the Department of Science and Technology, and the private Nutrition Center of the Philippines, the Nutrition Foundation of the Philipplines, and the Philippines Association of Nutrition complemented with the International Rice Research Institute (IRRI. With decentralization since the mid 1990s, it is difficult to ascertain the chain of command in implementing nutrition programs. For instance, it is not clear what role the Barangay Nutrition Scholars play in the Accelerated Hunger Mitigation Program.

Implementation of nutrition interventions appears to be divided between the NNC (Barangay Nutrition Scholars) and the Department of Health (vitamin A supplementation, food fortification, enforcement of the Code, breastfeeding promotion and baby-friendly hospitals, and Garantisadong Pembata a program to promote good child caring behaviors to prevent disease). The Department of Health has recently instituted a food quality seal of approval (Sangkap Pinoy Seal Program) to identify properly fortified foods and other nutritious foods. It is not clear to what extent this applies to foods in general or just to those regulated by the Department/National Government.

As of 2004, there were more than 22,000 Barangay Nutrition Scholars, who are recruited, trained, and remunerated by the NNC but the structure in which they work depends to a large extent upon the Local Government Unit. Apparently there are provincial nutrition offices, Provincial nutrition action officers, Municipal nutrition action officers, “regional nutrition Action Coordinators”53, regional nutrition program coordinators, regional nutrition committees, and LGU nutritionists (possibly but not necessarily coordinated with or managed by the health bureaucracy) but it is difficult to obtain data on nutrition manpower and their relationship to the health and agriculture systems. It seems that LGUs have a great deal of discretion in whether and how they deal with nutrition. Annual awards are given to LGUs and individual BNS for outstanding work but the criteria for selection are unclear. There are news stories about food companies sponsoring nutrition meetings, including of nutritionists and BNS, which raises questions about whether there are professional codes of conduct to guide activities and recommendations of nutrition personnel.

Public Policies and Programs

In September 2004, the National Anti-Poverty Commission reviewed the social protection programs in the Philippines. The commission recorded 111 different programs implemented by a wide range of agencies. Of the programs, 11 were classified as safety nets, 11 as social insurance, 85 as social welfare and assistance category, and 4 as labor market interventions. While the programs seemed to address a wide range of risks, the Commission concluded there were major delivery and coverage weaknesses, including program overlap resulting from poor coordination among providers and government agencies. The commission also found targeting errors that resulted in under-coverage of the poor and leakage of benefits to the non-poor source gender paper). Many of these programs are nutrition programs.

53 http://www.pia.gov.ph/?m=12&fi=p081023.htm&no=72

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In 2002 the government assed the ECCD (Early Childhood Care and Development) Act which institutionalized an early childhood development programs for children under six. One goal was to reduce by 40% the proportion of underweight children. An evaluation of the earlier ECD program, which included food and micronutrient supplementation, growth monitoring, and parental education (inter alia) low participation rates in child feeding, (although in intervention regions it increased)The government implements food security, hunger, and malnutrition out of six departments (social welfare, health, agriculture, education and DEPAR). While the major agencies responding to social risks of food insecurity, hunger and malnutrition include local governments, NGOs, PCSO and NFA.

The decentralization program, instituted in 1991 through the Local Government Code, seems to have resulted in a great deal of disorganization, featherbedding, and random motion with respect to achieving national goals (like the MDGs). While some local governments perform well, others seem to be devoted more to bread and circuses than to development. The solution is not to recentralize (which wouldn’t be possible anyway) but to benchmarking performance and reform policy on devolution to improve incentives for good governance (CAS 2009) and to educate and empower the citizenry to become better overseers of local government. Social welfare programs in the Philippines suffer from two problems: lack of control over local governments and failure to phase out and/or integrate programs. The result is that there are a large number of uncoordinated nutrition-related programs in the country and a lack of strategic follow-through on the local level. One would think that the “National Plan of Action on Nutrition” (NPAN) would rationalize the national government’s approach and focus local government activities on key interventions, but this appears not to be the case. According to a case study done for the World Bank in 2003, nutrition programs have had low coverage (“typically two percent of children) and intensity and there the government has tended to believe more in income growth and food subsidies rather than direct nutrition programs to take care of malnutrition54. The current medium term development plan includes considerable attention to nutrition. The Medium-Term Philippine Plan of Action for Nutrition (MTPPAN) strategies include: (a) prioritizing nutrition and related services for infants and young children as well as pregnant women, especially those living in depressed areas; (b) intensifying delivery of nutrition interventions that include micronutrient supplementation such as vitamin A and zinc, food fortification, breastfeeding promotion, food assistance as well as food production in homes, schools, and community; (c) improving service delivery to address nutrition deficiency; (d) stronger nutrition perspective in disaster management; (e) effective coordination among those directly involved in nutrition interventions, among others.55

Since 1986 (Milk Code) and 1992 (Rooming In and Breastfeeding Act) the Philippines has had in place the full legislative suite to prevent unethical marketing of breast-milk substitutes and to protect and promote breastfeeding but both the quantity and quality of breastfeeding and news reports of violations of the Code suggest that enforcement is lax. Recently the Supreme Court turned nullified several important sections of the Milk Code that prohibit promotion of breast-milk substitutes and punish transgressors.

54 Gillespie, Stuart, M. McLachlan, R. Shrimpton. Combatting Malnutrition, Time to Act. 2003. World Bank. 55 http://www.neda.gov.ph/devpulse/pdf_files/DevPulse-Malnutrition.pdf

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In 1995 Philippines past a salt iodization law which promoted iodized salt. Given the low prevalence of adequately iodized salt, however, it would appear that enforcement is lax.

One of the Philippines early high visibility programs was the Barangay Nutrition Scholars program, started in 1978, which trained and deployed villagers to promote healthy growth and development in their own villages. There hasn’t been any large scale evaluation of effectiveness or impact of this program but it continues notwithstanding. BNS volunteers (given a small monthly honorarium) weigh village children (through Operation Timbang (not clear who is in charge)) and provide nutrition education. Although on paper the program continues today, it has faltered due to lack of financial, technical and moral support and the quality of the program is compromised by good counseling messages and materials.

In 2006 the government launched the Accelerated Hunger Mitigation Program a cluster of programs to cut hunger by half within a year (although it apparently extended beyond the year and, obviously, did not cut hunger in half). “This program aims to answer the causes of hunger: poverty, unavailability of food to eat, and a large family size”56.. The program aims to improve both supply and demand for food in the 40 (later 20) poorest districts. It includes a Food-for-School program (1 kg of iron fortified rice for 120 days to families of children in preschools, daycare centers, and grade 1in school), Gulayang Masa Program (an integrated backyard gardening program that provides seeds and planting materials and livestock), increasing agricultural productivity, Tindahan Natin (providing subsidized rice and noodles to 270,000 poor families through accredited stores in the national capital region). A nutrition education and promoting “responsible parenthood” (small family size) are carried out in all provinces. Port facilities and farm to market roads have also been improved as a mechanism to reduce marketing costs. Allied programs include public works and food-for-work programs, and micro credit.

There is also a national untargeted rice subsidy program that was estimated to absorb 1.6% of GDP between 2000 and 200557. There is some evidence that the national rice subsidy has high leakage (one report states that 40% of it reaches non-poor households 58). Then again, Philippines have a long history of poorly targeted food subsidies (IFPRI studies and further back). Geographic targeting is administratively simple and inexpensive to implement. However, with universal targeting at the school level it is unsurprising that a substantial amount of the benefits leak to non-poor beneficiaries.130 Also, some of the poorest families are missed, as distribution only occurs through DSWD accredited day care centers, and many of the poorer barangays do not have one. The size of the transfer is also an issue and it is unclear whether 1 kilogram is enough to improve the pupil’s nutrition. However, there is some evidence (from a monitoring survey of 412 homes and 52 schools in 17 provinces) to show that there has been a positive impact on school attendance. The program is thus achieving one part of its goal by keeping children in school in the face of poverty and hunger. Source UNICEF Gender paper.

Kalahi-CIDSS, financed by the World Bank, is a community grant program that empowers villagers to prioritize and implement activities with grants from the government. It currently covers over one million households living in poor communities in 42 provinces.

56 http://www.neda.gov.ph/devpulse/pdf_files/hunger%20mitigation.pdf57 http://www.manilatimes.net/national/2008/apr/02/yehey/top_stories/20080402top1.html58 http://newsbreak.com.ph/index.php?option=com_content&task=view&id=5652&Itemid=88889053

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Although nutrition is not an explicit part of the program, it could be if villagers wanted it. Most recently the “4Ps” program, a conditional cash transfer targeted to the poorest provinces and cities, provides cash transfers targeted to the poor when they utilize specific preventive health services (nutrition not specifically mentioned) and send their children to school. Both of these programs are run out of the Department of Social Welfare and Development.

One of the national nutrition priorities is for preschool children to drink a glass of milk a day. This could have the unintended effect of discouraging breastfeeding and it is a difficult message to justify given the high cost per calorie of milk, the land intensiveness of dairy production, the availability of good non-dairy sources of protein, and the likely high prevalence of lactose intolerance in the population.

Other Donor and NGO Programs

The Philippines has a very strong and focused “Philipppine Development Forum” (donor consultative group). The major issues are fighting corruption and improving public performance in a decentralized state. The working group on MDGs and social progress covers nutrition and health. The PDF helps donors and NGOs to coordinate and work together more effectively.

USAID has a number of integrated community health and nutrition programs going on, largely thru international NGOs (SAVE, Christian Children’s Fund, ACDI, International Aid) and has for a long time funded vitamin A supplementation programs, largely through Helen Keller International. UNICEF is quite active in nutrition in the Philippines, especially in breastfeeding promotion, salt iodization and vitamin A supplementation, and the special needs of children in ARMM.

Bank Strategy and Portfolio

With an eye to community based platforms that could benefit from and support community nutrition programs, the following projects in the Bank’s portfolio are worth noting.

Mindanao Rural Development Project (Phase 2), which promotions participation in using a community fund for agricultural development,

National Sector Support for Health Reform (which focuses only on supply of health care services)

Plus emerging support for 4Ps and Women’s Health and Safe Motherhood, ARMM Social Fund, Kalahi CIDSS, Support for Strategic Local Development and Investment projects.

The single over arching theme of the new CAS (April 2009) is weak governance. National elections will take place in mid 2010 and are likely to exacerbate matters. The Bank’s program will focus on poverty alleviation, governance, and getting services to the poor. Centerpieces of the Bank’s program are the community grants program (Kalalhi CIDSS) and a CCT program being piloted now (4 Ps). Sectoral strengthening in health and education are also important. The

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current Bank portfolio in Philippines provides a strong multi-sectoral framework within which some nutrition actions could be built or improved. In particular, the portfolio in education and (previously) ECD, the engagement in women’s health, and most importantly its support for a new CCT program (4Ps) and community grants (Kalahi CIDSS). One problem is that the Philippines is good at starting new programs but it never seems to end old ones. The trick will be to use new programmatic responses to consolidate programs.

What is needed (and next steps)

An on-the-ground assessment is needed on existing nutrition programs. Which are providing high quality services, which are well targeted, what is their impact, what needs to be done to make them more effective? To the extent that the Bank and the Philippines are going to put all of their poverty reduction eggs into the Kalahi CIDSS and 4Ps basket, the existing nutrition programs should be stopped and divided between:

clinic based services, delivered through LGU health facilities (treatment of severe malnutrition, some antenatal services) and strengthened as the supply side of 4Ps,

community based services (growth promotion, micronutrient programs, some antenatal services, preventive health services, ECD) which are strengthened and integrated with Kalahi CIDSS,

institute a system for early warning of nutritional deterioration from the financial crisis (or other unexpected eventualities). This could be incorporated into the community based nutrition program (as is done in Indonesia).

Any nutrition program will need to review, winnow, and revise existing program materials to meet current needs.

Opportunities for the Bank

The nutrition situation in Philippines today is similar to that in Mexico during the crisis in the mid 1990s: serious nutrition problems among the poor (and over-nutrition among the rich) coupled with an expensive and chaotic set of national nutrition related programs with many rent-seekers and bureaucrats benefiting from the existing programs. Mexico ended up instituting the World’s first conditional cash transfer (Progresa) as it phased out some (but, unfortunately, not all) of its food subsidy programs. What Mexico did not do (and what the Philippines should do) is to improve the quality of community based and health- facility-based nutrition services. But a prerequisite for any new investment in nutrition programs should be phasing out old programs. The Bank can help advice and guide the Philippines through this process.

References

Paradox and Promise in the Philippines: Joint Country Gender Assessment, 2008. Asian Development Bank, Canadian International Development Agency, European Union, United

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Nations Children’s Fund, United Nations Development Fund for Women, United Nations Population Fund, andNational Commission on the Role of Filipino Women

MRA Pedro, C.M Cerdena, W.L. Molano, A. Constantino, L.A. Perlas, E.F. Palafox, L. Patalen, M. Chavez, J. Madriaga, E. Castillo and C.V.C. Barba. 6th National Nutrition Suerveys. FNRI, DOST. PPT Presentation. 2004.

Basics II Project. Newborn Health in the Philippines. A situation analysis. 2004.

World Bank. Country Assistance Strategy Progress Report for the Republic of the Philippines. June 21, 2007.

Bert Hofman. Food and Energy Price Increases and Policy Options. N.d. PPT presentation.

Cabral, E.I. Social Protection Programs of the Government. PPT presentation 20 August 2008.

HabitoC.F. and R.M. Birones. Philippine Agriculture over the Years: Performance, Policies and Pitfalls. Paper presented at conference entitled “Policies to Strengthen Productivity in the Philippines.” June 27, 2005.

World Bank. Country Assistance Strategy for the Republic of the Philippines for the period 2010-2012. April 2009.

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Vietnam

Just under half (43%) of preschool children are stunted in Vietnam, over a quarter (27%) are underweight and 6% are wasted. Malnutrition is almost twice as serious in rural areas (29.1%) as in urban areas (16.2%). While the disparity between rural and urban has diminished only slightly over time (Fig. 1). Not surprisingly, the wealthy have much less malnutrition than the poor. While 46.2% of rural and 40.2% or urban poor under-fives are stunted, 24.2% of rural and 9.2% or urban wealthy are malnourished. Malnutrition shows the all-too-familiar deterioration in nutrition status between birth and the second birthday (Fig. 2). Although the levels of malnutrition are high, Vietnam has made better than average progress on reducing malnutrition in the region. In the early 1980s 51.5% of preschoolers were underweight. Vietnam has already achieved the nutrition MDG goal (Fig. 3).

There is a great deal of variation by region (between 18 and 45%). Malnutrition is most prevalent in Tay Nguyen (Central Highlands), the northwestern area and the northern part of the central area. Ethnic minorities, including Hmong, are at greater risk of malnutrition.

Micronutrient malnutrition is widespread. Over 10% of preschoolers have low vitamin A blood levels (2003) and 31.3% of women have low vitamin A levels in breast-milk. While 28.6% of under-fives were anemic in 2005, 56.9% of the 6-12 month olds were anemic. WHO reports that 60% of pregnant women currently take iron during pregnancy. A program to sell iron folate supplements is credited with the reduction in anemia. As of 2000, over three-quarters (78%) of households consumed effectively iodized salt yet iodine deficiency affected 42.8% of those tested59. NIN estimates that 30-40% of children under one are deficient in zinc.

Even as the country is making great progress on reducing malnutrition, signs of diet related chronic disease are emerging. Overweight is increasing especially in urban areas where, in 2004, 16% of the population was overweight. Hypertension is also high in cities (23% in urban Hanoi in 2001) (Phuong, 2006)

The causes of malnutrition are suboptimal breastfeeding, inadequate infant feeding practices, infectious disease and parasites, food insecurity and poverty. WHO reports that only 17% of infants are exclusively breastfed for the first six months of life and only 58% of mothers initiate breastfeeding within the first hour after birth.

Food production in Vietnam has grown substantially since the 1990s as a result of economic reforms and investments in agriculture. As income was rising, food prices were falling and many Vietnamese benefited nutritionally. The diet appears to be changing away from very high carbohydrates (particularly rice) to one with more meat and vegetables. Data from the Vietnam Living Standards Survey suggest that while the poor and ethnic minorities benefited from the quantity and quality improvements in food availability, it appears that rising inequity meant that certain population groups did not benefit as much from the transformation60.

59 Huynh Nam Phuong, and K. Lapping. Nutrition Situation in Viet Nam and Mainstreaming Opportunities. PPT presentation, Oct. 11, 2006. 60 Thang, N.M. and B.M. Popkin. 2004. Patterns of food consumption in Vietnam: effects of socioeconomic groups during an era of economic growth. Eur. J. Clin. Nutr 58: 145-153.

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As in Laos and Cambodia, it would appear the rural Vietnamese use forests as a source of highly nutritious foods. Reversing the deforestation of Vietnam in recent years may strengthen the food security of people dependent upon them for foraged foods as long as good forest stewardship and access are allowed for local people.

Impact of the food, fuel and financial crises

In 2007 and 2008, the prices of food, fuel, housing, land, education, and health all rose. Most likely the hardest hits were those living in urban and peri-urban areas and those relying on the market for a large proportion of their food. Complicating the global trends, were droughts and floods and a cold winter in food producing areas, urbanization, increased cash cropping, and poor productivity gains in agriculture61. The global financial crisis since late 2008 will undoubtedly reduce Vietnam’s rate of economic growth, although it will continue to be relatively good (5.5%). Its exports, textiles, food and footwear, had fallen in early 2009 but Vietnam has maintained or even grown its market share. In addition to falling exports, Vietnam suffered retrenchment on construction and tourism. Remittances are not expected to drop dramatically. Unemployment is likely to rise and those displaced might well be put into a food insecure situation but it is unclear how broad this impact will be. Although Vietnam is an agricultural exporter, there are still many food insecure households in rural and urban settings who are adversely affected by food price inflation (recently creeping up again) and loss of remittances from urban and overseas family members. The government announced a stimulus package including a cash transfer to poor households (WB 2009), exoneration of health insurance and education fees, and subsidized credit (Grosh, 2008) but it does not appear to be on the verge of implementing any massive social safety net programs to cope with the crisis.

Institutional Situation

According to the Mainstreaming Nutrition Initiative, there are 16 ministries involved in nutrition and overlapping programs (both national and international) Coordination is lacking at the provincial level and below. In some localities. Vietnam appears to be in the early transition phase from old style leadership educated in communist countries to younger more dynamic leaders educated in the West. Although ostensibly an open society, there are few “watch dogs” keeping the government honest. Within the Ministry of Health, two departments have main responsibility for nutrition: Dept. of Reproductive Health in collaboration with Dept. of Preventive Care and HIV/AIDS Prevention and Control (for Child Malnutrition Prevention) and Dept. of Food Hygiene and Safety. The National Institute of Nutrition is the standing agency and coordinator of the National Nutrition Steering Committee but it is more of a technical than policy institute. Officially NIN has a network down to the grassroots level but anecdotal information suggests that this network is weak. NIN implements the four existing nutrition programs (National Targeted Program for Child Malnutrition Prevention, a women and child nutrition program in 10 high priority provinces, a small community based nutrition and safe water program, and a vitamin A supplementation program for rural and mountainous areas (total budget about $11.7 Million). Although there are provincial level planning processes and

61 www.ifap.org/en/about/documents/worldfarmerscongress/foodcrisis+Vietnam.pdf

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“people’s committees”, there appears to be some disconnect with the Central level. The National Institute of Nutrition (NIN) is a semi-autonomous entity within the Ministry of Health. In the mid-1990s NIN implemented programs but its focus in recent years seems to be more in research and publications. The institute has a mandate to become self-sustaining by 2012 and as a result it appears to be willing to shift its focus to attract funding. According to anecdotal evidence, NIN is committed to behavior change communications and targeting and tailoring counseling messages but they lack the capacity to actually develop and implement such programs. The political entity, the Women’s Union, appears to be a strong link for non-sectoral community mobilization. Although reducing stunting appears to be a national priority, some of the efforts (heavy emphasis on micronutrients, free milk at schools and promoting milk drinking in children) are hardly the most cost-effective ways of preventing stunting.

It would seem that Vietnam is following the Chinese model of improving nutrition: relying primarily on economic growth to reduce malnutrition. As noted by one observer, “a national military-style campaign, which Vietnam excels in,” doesn’t work so well for tackling malnutrition.62

Public Policies and Programs

Vietnam has a National Nutrition Strategy 2001-2010 in which the goal is to reduce underweight to less than 20%, stunting to less than 25%, obesity to less than 5%, and to assure that no province has more than 30% stunting. It also stresses the need to reach ethnic minorities63. It is interesting to note that in the assessment of performance of the first national nutrition strategy, the government noted lack of coordination among sectors, that implementation was too vertical, its failure to reach the household level with behavior change messages, and insufficient social awareness and sense of responsibility for nutrition improvement. It also noted that trained staffs were insufficient to work at the community level, that efforts to mobilize community resources for nutrition was not well-developed and those local authorities don’t take responsibility for implementing nutrition activities. Notwithstanding the assertion that “nutrition activities must be supported firstly by the local authorities,” it does not appear that much headway has been gained on mobilizing communities for the multi-sectoral approach the document put forth. The remedy in the 2001-2010 nutrition strategy was to assign a broad range of sectoral ministries and other entities to a nutrition steering committee chaired by the Ministry of Health. Now there is a Plan of Action to Accelerate Stunting Reduction in Viet Nam 2008-2013 which includes the above goals as well as a goal to reduce low birth-weight (currently at 9%) to less than 6%. They plan to target and tailor the plan province by province based on stunting, poverty, and geography. Reproductive-aged women will receive multi-nutrient weekly supplements and deworming in high priority areas and deworming and social. Marketing of weekly iron-folate supplements in lower priority areas. Pregnant women are to receive daily multi-nutrients in high priority areas whereas the will receive daily multi-nutrition or iron folate supplements elsewhere. Children under 2 in high priority areas are to receive breastfeeding promotion, vitamin A supplementation, promotion of complementary feeding, deworming, zinc supplementation for diarrhea treatment, iodized salt,

62 http://www.irinnews.org/printreport.aspx?ReportId=84079. 63 Dr. N.C. Khan. Plan of Action to Accelerate Stunting Reduction in Viet Nam. Presentation at Standing Committee for Nutrition, 2008.

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and fortified complementary foods. Children in lower priority areas will receive the same but with “different funding mechanisms”64. Part of the program also includes promoting food production, disaster relief, nutrition education, health care services, and promotion of hygiene and sanitation at the family level. While the Women’s Union, private sector, and many ministries are mentioned as cooperating in the program, it is not clear how all these entities will work together and at what level. There are currently three national programs: National Program for Child Malnutrition Control, a national vitamin A deficiency program and an iron deficiency program. Vietnam, with help from WHO, has passed regulations limiting the marketing of breast-milk substitutes. There is an infant and young child feeding program at the central level managed by NIN/MOH but it seems that there is little implementation at the provincial and commune levels.

One of the more promising public programs appears to be MOLISA (ministry of Labor, Invalids, and Social Affairs) National Plan of Action for Hunger Eradication and Poverty Alleviation. A social safety net program which has a budget of $1 Billion and is intended to have food security and nutrition outcomes.

It would appear that commune leaders have an important role to play in promoting health and nutrition programs because they allocate budget for commune health workers and prevention programs. The study concluded that leaders’ lack of prioritization of anemia prevention combined with supply problems were major determinants of women’s taking iron supplements during pregnancy.65 For instance, a report on iron supplement consumption by pregnant women showed that women received more information on anemia from commune health workers

Programs from donors and NGOs

After Vietnam opened up in the 1990s, many donors rushed in and started programs but many f them are pulling back or pulling out over the next few years (Phuong, 2006). The country has been the host of a number of multi-donor nutrition initiatives including the “Mainstreaming Nutrition Initiative” of the World Bank, REACH (a collaborative program of UNICEF, WFP, the World Bank and a number of NGOs), Alive and Thrive (a Gates foundation initiative), and the WHO/UNICEF “Landscape Analysis” have taken place or have been proposed for Vietnam. Perhaps because of Vietnam’s remarkable success with economic growth, many donors are phasing out so at present there are musical chairs around nutrition. Plan, World Vision and Save the Children have been implementing area development projects that include nutrition. Although SAVE piloted a community nutrition program based on positive deviance in the early to mid 1990s, which documented impressive impacts on nutrition, they no longer support such a program because the process is highly demanding of both time and specialized expertise (which is lacking in Vietnam). UNICEF has a large. ADB has been the driving force behind a national fortification program (particularly the innovative iron-fortified fish sauce) but anecdotal evidence suggests that the fish sauce is not popular with consumers. ADB is also engaged in infrastructure and ECD. Vietnam is a major recipient of PEPFAR (HIV-AIDs) funds from the US

64 Khan, op. cit.65 Aikawa, R, M. Jimba, K.C. Nguen, Y. Zhao, C.W. Binns, and M.K. Lee. Why to adult women in Vietnam take iron tablets. BMC Public Health 2006, 6:144.

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government which include feeding programs (including ready-to-eat-foods) as part of clinical treatment and for orphans and vulnerable children. USAID is apparently looking into NIN’s producing RUTF, which would divert its attention even further from community based program implementation. GAIN, a global public private partnership promotes food fortification, has an active program in Vietnam as well. At the best of the Mainstreaming Nutrition Initiative, a Nutrition Partnership Group was formed in early 2007 to “galvanize the development community and to coordinate the nutrition programs funded by international donors and INGOs.” MNI, of which the goal is “to strengthen key health system capacities to enable effective delivery of IYCF-related interventions”66, is currently working with one province to attempt to strengthen planning processes.

Some notable successes in nutrition programs have included:

Household Food Security for Nutrition Improvement Project which was a community growth promotion, behavior change, small-scale agricultural technology, home gardens, and small grants. It improved infant feeding knowledge and practices and reduced 12.8% in two years. (FAO with Ministry of Agriculture and Rural Development plus NIN, 1997-2000),

Integrated food security project improved infant feeding practices, ante natal and delivery care utilization, growth promotion and vitamin A supplements. (GTZ),

Positive deviance program identified what innovative behaviors poor mothers of better nourished children had devised and disseminated those practices through education and cooking demonstrations. Reduced severe under-nutrition (<-3Z weight-age) from 23% to 6% in 24 months and the benefits persisted for the subsequent child born after participation ended.. Save the Children (1991-1995)67,

Community based behavior change program promoting maternal and newborn care, nutrition and micronutrients, and breastfeeding promotion. Its goal was to reduce maternal and neonatal mortality. Impact: reduced underweight from 35.4% to 27.2%, increased antenatal care visits, increased community capacity to respond to maternal or newborn emergency and ability to recognize danger signs. Used existing organizational system based on prevalent political administrative structure (Save the Children),

Integrated Child Nutrition Project in community empowerment program. Project maintained one year after funding ended. (JICA and Save the Children, Japan).

These successful experiences suggest that community based nutrition programs can be highly successful if they work through the existing political structure at the local level rather than indirectly through the health ministry.

World Bank in Vietnam

Surprisingly enough, given Vietnam’s Communist history and the World Bank’s emphasis elsewhere in the region on participation and community driven development, there is precious

66 http://mainstreamingnutrition.org/vietnam.aspx67 U. Agnes Trinh Mackintosh, David R. Marsh, and Dirk G. Schroeder. Sustained positive deviant child care practices and their effects on child growth in Viet Nam. Food and Nutrition Bulletin, vol. 23, no. 4 (supplement) . 2002

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little “power to the people” in the Bank’s portfolio in Vietnam. Health sector projects revolve largely around health financing, strengthening formal facilities and capacity building. The HIV/AIDs prevention project discusses provincial planning but nowhere do participatory local processes appear. In only four projects in Vietnam is there any discussion of participatory processes or engaging the community in planning or implementation (Vietnam Rural Water, through an NGO, Red River Delta Rural Water Supply and Sanitation, Forest, Sector Development Project, and Community Based Rural Infrastructure). This is consistent with anecdotal information that suggests central control is still very much a reality in the country. Although fighting corruption constitutes a major focus of the CPS, there is little mention of how “more participatory approaches” will actually be affected. The government for its part appears to have issued a “grassroots democracy decree” but it is not clear how long it will take to become a reality. The CPS mentions “including an empowering ethnic minorities in the development processes and mentions giving them “voice and participation in the development processes that affect them” through four different investments. The CPS aspires to improve participatory planning and governance but this issue plays a relatively minor role in the country strategy (compared to, for instance, those in Indonesia and Cambodia).

Recommendation for Vietnam

Given the large number of major donor nutrition initiatives in Vietnam, the lack of a knowledgeable and committed Bank staff member, and the weak platform for community based nutrition; it would be difficult for the Bank to launch a rapid and large scale nutrition effort there. The best option might be to engage in the Nutrition Partnership Group, provide punctual support through ongoing health, education, and infrastructure projects for opportunistic nutrition initiatives, and to wait until the decentralization process is more mature before embarking on a community nutrition program. To the extent that Vietnam comes forth with a new social safety net program to mediate the negative impact of the financial crisis on the poor, which might be the best vehicle for the Bank to use to prevent nutritional deterioration.

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Fig. 1

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