Report No. 7575-CE

Sri LankaNutrition Review

July 13, 1989

Population and Human Resources DivisionCountry Department I, Asia Region

FOR OFFICIAL USE ONLY

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ACRONYMS

AEU - Adult Equivalent UnitAGA - Assistant Government AgentARC - Administrative Reforms CommitteeARI - Acute Respiratory InfectionsBCG - Tuberculosis VaccineCFS - Consumer Finance SurveyCPI - Consumer Price IndexDD - Diarrheal DiseaseDHS - Demographic and Health SurveyDPT - Diphtheria, Whooping Cough and Tetanus ImmunizationFNPPD - Food and Nutrition Policy Planning DivisionFWAE - Farm Women's Agricultural Extension ProgramGA - Government AgentGDP - Gross Domestic ProductIDD - Iodine Defic'.ency DisordersIFPRI - International Food Policy Research InstituteJSP - Jana Saviya Progran (People Power Program)MPPI - Ministry of Policy P'anning and ImplementationLBW - Low Birth WeightMOPI - Ministry of Plan ImplementationMRI - Sri Lanka Medical Research InstituteNAFNS - National Agricultural, Food and Nutrition StrategyNFNCC - National Food and Nutrition Coordinating CouncilNHC - National Health CouncilOECD - Organization for Economic Cooperation and

DevelopmentOPV - Polio VaccineORT - Oral Rehydration TherapyrMB - Paddy Marketing BoardThriposha - Formulated, pre-cooked supplementary food used in

Ministry of Health intervention programUNICEF - United Nations Childrens FundUSAID - U.S. Agency for International DevelopmentWFP - World Food Program

IThis document has a triesnted distribution and masy be use by recipients only in the perfonnanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization.|

SRI LANKA

NUTRITION REVIEW

Table of Contents

Page No.

INTRODUCTION AND EXECUTIVE SUMMARY ......................... iii

Current Nutrition Problems and Causes . .......... iiiFood and Agriculture .. ivCurrent Interventions .. ivInstitutional Arrangements .. vIssues and Main Recommendations . . v

I. NUTRITION CONDITIONS AND CONSEQUENCES ...................... 1

Introduction .. 1Child Nutrition Status .................................. 2Maternal Nutrition Status .. 3Hicronutrient Deficiencies .. 4Recent Trends .. 5Comparisons ............................................. 5Functional Implications of Malnutrition . . 6

II. NUTRITION DETERMINANTS ..................................... 7

A. Determinants ............... 7Household Food Insecurity ............................... 7Behavioral Factors .. 9Infectious Diseases .. 10Most Seriously Affected Groups . . 12

III. NUTRITION IN SRI LANKA'S FOOD AND AGRICULTURE SYSTEM ....... 13

A. Dietary Patterns .. 13B. The Role of Agriculture .. 14

Rice Development .. 14Subsidiary Food Crops .. 15Food Production and Marketing Patterns . . 15Impact of Pricing .. 16Procurement and Distribution Policies . . 17Processing .. 18Nutrition Effects .. 8.................. i

IV. NUTRITION PLANNING AND PROGRAMMING ......................... 19

A. Institutional Arrangements .............................. 19B. Nutrition Objectives, Policies and Strategies . . 20

Objectives ............................................ 20Nutrition and Related Food and AgricultureStrategy Development .. 21National Nutrition Action Plan . . 25NAFNS Implementation Plan .. 27Implementation Status of Nutrition and NAFNS Plans ...... 28

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V. NUTRITION COSTS AND INTERVENTIONS .......................... 28

A. Nutrition I ntervention Progrsms ......................... 28Food Stamps ........................................... 29Thriposha ................. # ........................... 31On-site Feeding ....................................... 33Nutrition Education . . . 34Hea,th-related Interventions ......................... . 35New initiatives .... .......................... .......... 37Other Donor Activity. ........................... 38

B. Funding.... .............................................. 28

VI. ISSUES AND OPTIONS: AN ACTION AGENDA ...................... 38

A. Objectives .............................................. 39B. Policies and Strategies ................................. 39

Food and Agricultare . . . 39Health .............................................. 41Nutrition Education ... 41

C. Institutional Arrangements .. ................. ............ 41D. Programs ............................................. 42

Food Stamps ...... 42Rice Grading .. 43Augmented Distribution through Public Assistance

Scheme .. 44Thriposha . ............................................ 44Kola Kenda .......... * 44School Feeding ....... 45Nutrition Villages .. 45An Optional Approach to Nutrition Villages ............ 45

E. Recommendations ..... 46

ANNEX A - Tables 1-12

ANNEX B - The Ultra Poor

ANNEX C - Integrated Community Nutrition Intervention

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SRI LANKA

NUTRITION REVIEW

Introduction and Executive Summary

1. This report seeks to consolidate the most salient findings of exist-ing analysis to promote and help focus the development of future Sri Lankanutrition policies, strategies and programs. It results from the work of aBank nutrition review mission to Sri Lanka in May 1988,1/ and a brief missionby the Task Manager in March, 1989. The findings herein draw on extensivedocumentation from Sri Lanka, important analysis of 1981-82 and 1986-87household food consumption and expenditure data and the food stamps program bythe International Food Policy Research Institute (IFPRT) and others,agriculture sector work by the World Bank and the Orgatization for EconomicCooperation and Development (OECD) and evaluations of the thriposha programfunded by the U.S. Agency for International Development.

Current Nutrition Problems and Causes

2. Sri Lanka's record in the field of health is impressive. Healthindicators, including life expectancy, infant and child mortality and maternalmortality are significantly better for Sri Lanka than for other countries atsimilar levels of development. Moreover, an analysis of the most recenthousehold expenditure data (1986-87) indicates that caloric intake for thepoorest deciles has increased from very depressed levels in the 1980-82 period(a period characterized by a sharp increase in prices and the aftermath ofsubsidy elimination) to more acceptable if not yet nutritionally adequatelevels not seen among these groups since the 1969-70 period.

3. In light of this good performance in health and the recent improve-ments in food consumption, it is surprising that malnutrition among childrenand pregnant women should continue to be a major concern. Recent surveys andhealth service reports indicate that over 25Z of pre-school children arestunted from chronic malnutrition. Over 1OZ are acutely malnourished, whichis high, particularly in view of Sri Lanka's low infant and child death rates.Around 5Z are both stunted and wasted. Low birth weight, mainly attributableto maternal malnutrition, occurs in more than an estimated 202 of deliveries.Iron deficiency anemia affects more than an estimated half of low-income womenand the birth weights of their children. Iodine deficiency disease remainsprevalent in some densely-populated areas. More progress has taken placeagainst immunizable childhood diseases than against morbidity from two leadingcauses--diarrhea and acute respiratory infections.

1/ The mission consisted of James Greene, principal nutrition specialist,as task manager and three consultants: Dr. John Kevany, publichealth/nutrition specialist; Mr. James Levinson, economist, andMr. D. Tharmaratnam, financial analyst.

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4. Malnutrition in Sri Lanka results from a combination of threefactors. The primary one is household food insecurity, which affectspredominantly the lowest three income deciles in urban areas and the poorestrural decile through limited purchasing power reflecting low levels ofemployment and incomes. The others are poor health and family food behaviorwhich compound the corrosive effects of economic deprivation but also directlyaffect the nutrition status of pre-school children and pregnant and nursingwomen in less precarious economic circumstances. The continuing levels ofstunting in the face of declining proportion of food-insecure householdsunderscores the importance of adequate attention to health and behavioralfaccors.

Food and Agriculture

5 Food and agriculture have an important nutrition role in Sri Lankafrom both consumption and production perspectives. Domestic rice and coconutaccount roughly for 50Z and 20X, respectively, of average caloric intake.Bread, wheat flour and sugar are the next most important calorie sources. Inan attempt to encourage production, current agricultural policy encourageshigher, rather than lower, rice prices. The main beneficiaries are relativelysmall numbers of larger rice producers, since smaller ones for the most partare net purchasers of rice. Sugar prices well above world levels tax the low-income consumer disproportionately. Lack of research and development atten-tion to other field crops such as corn, coarse grains, yams and cassavaconstrain the development of both incomes from rain-fed land and alternativesources of relatively low-cost calories.

Current Interventions

6. Resources for nutrition have tripled since 1987. Sri Lanka nowbudgets more than an estimated Rs 6.0 billion yearly (around 9X of the currentgovernment budget) for nutrition, mainly on three food programs--food stamps,school feeding and thriposha. Food stamps benefitting around half thepopulation cost around RS 3.6 billion yearly. Daily lunches for Sri Lanka's4,000,000 school children will cost around Rs 2.6 billion yearly. Thriposha,a formulated and largely take-home supplement distributed mainly through thehealth system, is targeted to 580,000 malnourished preschool children andpregnant and nursing women. However, all three programs face problems. Thefood stamps program is poorly targeted; it reaches more people above thanbelow the poverty line. It also appears to have bypassed significant numbersof the very poor. Despi_e a recent doubling of the value of the stamps, thecurrent purchasing power is only around 702 of the original 1979 entitlement.The 3chool lunch program may have social benefits but cannot make up for theeffects of malnourishment in early childhood. Thriposha has yet to achieveits full nutritional potential largely because of uneven performance in regardto beneficiary screening, counselling and program management and monitoring.

7. Other supplementary feeding programs operate but with limited nutri-tional effectiveness. Nutrition education activities and health measuresagainst micronutrient deficiencies and non-immunizable childhood diseaseswhich affect nutrition status also appear to have limited impact.

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8. The Jana Saviva program (JSP) is supposed to eliminate or at leastdrastically reduce the need for food stamps by providing monthly transferpayments for 24 months to food stamp beneficiary families. The objective isfor the recipient families to become financially self-sustaining at the end ofthat period. However, the RS 28 billion estimated value of the annual JSPconsumption transfers are around five times the amount estimated to bring thepoorest quintile of the population up to middle-class levels of foodconsumption.

InstituL_onal Arrangements

9. Sri Lanka has had some success in articulating important features ofboth a national nutrition policy and strategies to implement it. Howe-ter,recent Government reorganization measures represent a prospective step backfrom Sri Lanka's previously progressive efforts to incorporate nutrition intonational development plans and set up an official focal point for thatpurpose. Until reorganization, Sri Lanka was one of relatively few developingcountries to try explicitly to incorporate nutrition into national developmentplans and set up a government focal point for that purpose. The NationalHealth Council, which consists of Cabinet Ministers and is chaired by thePresident, and the Food and Nutrition Policy Planning Division (FNPPD) of theMinistry of Plan Implementation (MOPI), were the principal channels for bothnutrition advocacy and intersectoral development of national nutritionpolicies, strategies and programs. FNPPD recently was disbanded, with MGPIincorporation into a new Ministryr of Policy Planning and Implementation.Under earlier arrangements, links between policy and strategy were fragile andefforts to translate strategy into programs were uneven. The recentreorganization weakens the nutrition and food planning framework stillfurther.

Issues and Main Recommendations

10. Sri Lanka needs to confront two principal nutrition issues. Thefirst is how to deal with chronic nutrition insecurity at the household level,which particularly affects the lowest income deciles in rural areas and thethree poorest urban deciles. The second is how to ensure adequate nutrientavailability and utilization by specific target groups, particularly youngchildren and pregnant and nursi.g mothers. Nutrition policies, strategies andprograms need to be directed specifically to both problems.

11. Over the longer-term, income and employment gains by the poor willdrive durable increases in their food consumption. However, even income andemployment generating programs for low-income groups by the poor need to becomplemented by other medium-term approaches.

12. A manifest need exists to review, revise, prioritize and quantifyexisting nutrition objectives and set them in a realistic time fram . Overthe next five years, it should be possible through improved program perfor-mance to achieve reductions of 25Z in stunting among younger children and inthe incidence of low birth weight and a 30? reduction in the incidence ofmaternal iron and folate deficiency. The government also may wish to setspecific minimum food intake goals as a contribution to both the above object-ives and improved health and nutrition of the most vulnerable segments of the

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population, such as maintaining daily consumption by the ultra-poor 2/ at no

less than 902 of estimated calorie needs, which would require more attentionto the lowest two urban income deciles.

13. Consideration should be given to focussing food and agriculturestrategy on increasing both food consumption or incomes of the poorest deciles

and the availability of lower-cost nutrients generally in short supply. In

that regard, three approaches might be considered which would dispropor-tionately benefit the most vulnerable. First, efforts to lower rice prices to

consumers through increased efficiency of production and post-harvest techno-

logy might be explored. The latter would include improvements in the rela-tively inefficient milling industry where, for reasons not entirely clear,

market factors nave not led to mode-nization. Second, reducing sugar pricesapproximately to world levels woul _mprove access to an important caloriesource for the poor, but the implications of such a move on the balance ofpayments and on government revenues should first be studied. Third, increas-

ing the output and marketinig of subsidiary field crops such as corn and manioc

could generate additional employment and incomes as well as provide an

optional source of relatively low-cost calories. Successful diversification,however, would require improved research and extension services and would not

necessarily succeed unless demand and relative agricultural output pricesprovided adequate incentives.

14. Nutrition also needs to be made a more central focus of the primary

health care agenda, mainly by more vigorous execution of current programs.Nutrition education strategies need to be developed to improve feeding prac-tices for weaning children and pregnant and nursing women; to counter iron andfolate, iodine and subclinical Vitamin A deficiencies; to institutionalizehome management of diarrhea, and to combat infectious disease.

15. Consideration also should be given to four program measures for those

at high nutritional risk. First, the Government needs to reconsider the scope

and costs of its apparent plans to replace food stamps with JSP transferpayments to food-insecure households. The cost of the proposed JSPconsumption component i;- estimated at around Rs 28,000 million per year. JSP

eligibility extends well beyond the relatively limited number of around

800,000 families at nutritional risk, according to the 1986-7 Consumer Finance

Survey (CPS). A well-targetted food stamp program for them alone would costless than RS 1,000 million per year. These and other families comprising the

poorest quintile of Sri Lanka's population could be brought to middle-classfood consumption levels for an estimated Rs 5,600 million yearly, less than

one-fifth the annual cost of the proposed JSP consumption corponent. Even

with JSP investments, it is likely that some poor families would continue to

need food support after two years. A targetted food stamp program based on

JSP survey procedures might be a relatively efficient way of meeting those

residual needs.

16. Second, introduction of cosmetically inferior grades of rice into the

market, if acceptable, would provide cheaper but equally nutritious options to

the present range of rice choices for low-income consumers and could prove

2/ Households which spend more than 80X of their income on food butconsume less than 80t of daily calorie requirements.

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cost-effective in raising their consumption levels. The cost of grading at themill could be passed along to other consumers through higher prices for thebetter-quality varieties.

17 . Third, the thriDosha program should be consolidated and strengthened.Improvements are needed in growth monitoring, beneficiary selection and familyuse of thriposha against growth failure, which in turn requires &.ore effectivenutrition education.

18. Fourth, the Government should consider the development of acommunity-based program to counter faltering growth among children under threeyears of age, low birth weight and iron and folate deficiency in pregnantwomen. Substantial improvements in child nutritional status are likely toresult from concentration on a combination of growth monitoring, healthinterventions, behavioral change and short-term food supplementation. Theincremental cost of such a national program would be around RS 140 million. Apilot effort is being developed under the IDA-aided Health and Family PlanningProject (Cr. No. 1903-CE).

19. Finally, the Government needs to re-establish a national focal pointfor food and nutrition planning and advocacy. The Administrative ReformsCommittee recommendation to establish a Nutrition Policy Council under thePrimie Minister, serviced by a Nutrition Policy Bureau, has considerable merit.If nutrition policy and strategy continues as a National Health Council (NHC)responsibility, then a separate division in MPPI would be the most appropriatelocale for either a re-established FNPPD or a successor division to serviceNHC's nutrition aBende aud carry out technical analysis. Moreover, there aretwo important tasks which the Government should carry out. First, it shouldpromptly complete analysis of the 1988 national nutrition survey, which(except in the uncovered North and East) is expected to provide the firstreliable data set for trend analysis of nutrition status since the lastnational survey ten years ago. Second, it should undertake detailed analysisof food expenditure and income data in the 1986-7 CFS as a basis for definingoptional strategies to meet the nutrition needs of food-insecure households.

20. The above recommendations are mutally reinforcing rather than mutallyexclusive. The proposed package of nutrition interventions would yieldsubstantial savings over the cost of existing programs through bettertargeting of the food stamps and school lunch programs. The relatively modestincremental expenditures on agricultural research, nutrition education andmicronutrient interventions would have large pay-offs in terms of nutritionalstatus. In sum, the proposed package would be cost-effective as well astechnically and managerially feasible. Its total cost of under than Rs 3,000million would be less than 402 of current nutrition outlays. Effectiveimplementation would permit Sri Lanka substantially to improve the nutritionstandards of its most vulnerable groups at a sustainable cost of less than twopercent of the recurrent government budget.

I. NUTRITION CONDITIONS AND CONSEOVENC S

Introduction

1.1 A paradoxical situation exists in respect of maternal and childnutrition in Sri Lanka. Overall health conditions have improved substantiallyover the past two decades. Steady development of social sector services hasbeen accompanied by a progressive increase in the coverage and, in respect ofat least some services, the quality of primary health care. High levels offormal education and an effective population policy, leading to a consistentreduction in fertility, have underpinned these advances. As a result,national health indicators are remarkably good in comparison to othercountries of similar income levels (see Table 1, below). However, significantvariations exist within Sri Lanka; estimated IMR for the escate sector in 1986was 49.6, almost twice the rate of the rest of the country, while neonatalmortality comprises 60-702 of total infant deaths, suggesting suboptimalmaternal health conditions.

Table 1.1: COMPARATIVE HEALTH INDICATORS BY GNP LEVEL

Country GNP Per capita Life Expect. IMR la CDR /b MHR /c(in US$, 1986) at birth (1986) (1985) per 100,000

(1986) live births(1980-84)

F HGhana 390 56 52 89 11 1,100Sri Lanka 400 72 68 29 2 90Mauritania 420 49 45 130 25 119Senegal 420 49 46 137 27 530Liberia 460 56 52 87 23 173Yemen PDR 490 51 49 142 50 100Indonesia 490 58 55 87 12 800

/a Infant Mortality Rate.lb Child Death Rate./c Maternal Mortality Rate.

Sourcest World Development Report, 1988, 1987. IBRD.The State of the World's Children 1988. UNICEF

1.2 Despite impressive gains in conventional health indicators based onmortality and service coverage, substantial malnutrition persists throughoutSri Lanka. More sensitila than mortality as an indicator of health and socialconditions, malnutrition particularly among pre-school children and pregnantwomen is a serious and unresolved problem.

Child Nutrition Status

1.3 Several national nutrition surveys since 1975 provide a useful basisfor assessing conditions and examining trends. Special studies in populationsubgroups have examined specific problems including anemia, goiter and VitaminA deficiency. Two recent studies on maternal and child health in the dry zoneand on perinatal and neonatal mortality provided further Information confirm-ing existing service statistics 11

1.4 The dry zone study indicated that parity, maternal stature and educa-tion, ante-natal care, place of delivery and maternal tetanus toxoid werestrongly associated with variations in perinatal and infant mortality. Themortality study indicated major gaps in home visiting patterns of publichealth midwives. However, it also fouad that birth attendance by untrainedpersonnel did not have a serious adverse effect on perinatal and neonatalmortality, suggesting that untrained workers use safe delivery practices.

1.5 The most recent national effort was a 1987 Demographic and HealthSurvey (DBS),21 which included anthropometric assessment of nearly 4,000children 3-36 months old in all parts of Sri Lanka except the troubled Northand East. The results were expressed in terms of stunting measured by heightfor age and representing chronic and longer-term malnutrition, wastlngv.sasured by weight for height and representing acute, short-term malnutritionand combined stunting and wasting representing a severe degree of past andcurrent nutritien deprivation.

1.6 The national prevalence of stunting was 27.51 with variations amongregions from 18.9 to 42.12. It was highest in the estate sector at 602 andlowest in urban populations. Stunting increased cumulatively with age and washighest with birth intervals less than 2 years. It was substantially higherfor children of mothers with no education (50.52) tian for those with evenprimary education (34.32) and lowest for those with more than secondary educa-tion (15.4Z). Many of these variables are highly intercorrelated and indicatethat stunting i. most severe in the work force of the estates in the south-central region.

1.7 The prevalence of wasting was 12.92 nationally with regional varia-tions ranging from 9.9 to 16.82. Frequency rose sharply at 12-23 months to19.32 and was relatively independent of birth intervals. In relation tomaternal education, prevalence declined consistently from 15.2Z for no educa-tion to 11.8S for more than secondary education. However, the wasting andstunting figures among the well-educated also are high, suggesting that nutri-tion education is quite weak.

1.8 The prevalence of wasting in children on estates war remarkably low.With a frequency of 7.12 versus 13.62 and 13.42 in the rural population and

1/ Profiles of Women and Infants in the Drv Zone of Sri Lanka (1988).Perinatal and Neonatal Mortality - Some Aspects of Maternal and ChildHealth in Sri Lanka (1986). Department of Census andStatisticsJUNICEF.

2/ Sri Lanka Demographic and Health Survey 1987. Institute for ResourceDevelopment/Westinghouse and Department of Census and Statistics,Ministry of Plan Implementaticn, Government of Sri Lanka, May, 1988.

Col.mbo, respectively, children In the estate sector had about half the rateof wasting but double the rate of stunting of the general population. Thesefigures suggest that health and nutrition conditions In the estate sector werevery poor in 1984185 and improved dramatically from the second half of 1986.Increased employment levels and wages in the estate sector occurring shortlybefore the survey, combinea with progressive improvements In health and sani-tation conditions, might account for such anomalous findings. The alternativeexplanation is that the severity of stunting was such that the nutritionalenergy and nutrient neede of these children were reduced to a level consistentwith the food bupply available to them within the family. This degree ofadaptation to dietary limitations would seem unlikely to occur without otherhealth consequences such as rapid increases in general morbidity and morta-lity. The overall prevalence of combined stunting and wasting, representingacute malnutrition superimposed on chronic effects, was 4.72; no geographicbreakdown for this category is ovallable.

1.9 The 1987 survey is not strictly comparable to two earlier island-widenutrition surveys, in 1975-0 and 1980-2, which sampled children aged 6-59months. Additionally, the 1980-2 national survey used a different samplingframe and analytic methodology from the one in 1975-6. Therefore, it isdifficult to make definitive statements about nutritional trends in Sri Lankauntil the results of the 1989 national survey, which will be comparable withthe 1980-82 effort, become available. Wasting and stunting among rural andestate children combined in 1987 was 11.31 and 24.92, respectively, against1980-81 figures of 10.6Z and 24.4S, respectively. Despite age, geographic andother sampling differentials, tbs 1987 DHS findings imply that nutritionconditions are not improving for Sri Lanka's children.

1.10 A receht survey of school children in Colombo Municipality showed therate of stunting for a random sample of children 7-10 years at around 20.51and that of wasting 9.31, indicating that the effects of early stuntingpersist at later ages. The latter rate, indicatiag acute malnutrition, ishigh for an age group generally considered to be at low risk.

Maternal Nutrition Status

1.11 Maternal nutrition conditions in Sri Lanka can only be assessed frombirth weight data and from a series of imall studies carried out at differenttimes in various low-income subgronpe. One study reported 23X of women inearly pregnancy with height below 150 cm and 241 below 40 kg weight, indicat-ing past and current malnutrition associated with obstetrical risk.3/Pregnancy weight gain in deprived urban women has been reported ranging from0-3 kg, against a minimally desirable level of 7 kg. Another study reported amean weight gain of 4.5 kg associated with mean birth weights of 2.6 kg andlow birth weight (LBO) rate of around 301. l In 1986, the national level ofL9W was reported to be around 20-251, rising to 332 in the estate sector. Forthe 448 reported infant deaths in the estate sector in 1986, the average birthweight was 1.9 kg. The average birth weight of infants delivered in majormaternity units has declined from 2.9 kg to 2.7 kg in recent years. suggestingthat this problem is increasing.

3/ Profiles of Women and Infants, etc., oD. cit.

41 Lassalean Communitv Education Services Arnual ReDort 1985. Colombo.

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1.12 It is estimated that about 802 of reported LBW is attributable tofetal growth retardation, caused principally by maternal malnutrition andmalaria; in 1986, this amounted to about 57,500 low-weight births, or around17? of all live births. Clinical observations indicate that maternal malnu-trition is widespread, at least in the lower socioeconomic strata, and contri-buted to infant morbidity and mortality. The high (60-70Z) proportion ofneonatal to all infant deaths supports this conclusion, particularly given thehigh level of institutional deliveries and low level of neonatal tetanus.

Micronutrient Deficiencies

1.13 Anemia is highly prevalent in women of reproductive age although thewide variation of measurements and criteria applied make it difficult to quan-tify the problem precisely. Special studies and service reports indicateprevalences of 50-702 in pregnant women attending antenatal clinics. Theestate sector reported 79? low hemoglobin levels in pregnant women for thelast reading before delivery; however this may not have been adjusted fornormal hemodilution. Anemia, expressed as low hemoglobin levels, is alsoreported to be prevalent in preschool children, with rates of 60-702 reported,and may relate particularly to intestinal parasitism. Most reports do notdiscriminate between types of anemia, but macrocytic forms are reported. Lowdietary iron, Vitamin C and folic acid intakes, combined with high prevalenceof malaria and intestinal parasitism, are the principal causes.

1.14 Vitamin A deficiency existed in the past as a public health problembut now appears to be confined, at least in its clinical forms, to discreteareas and subgroups. Diagnostic criteria for clinical Vitamin A deficiencyare frequently imprecise and special training of observers is not often under-taken, making it difficult to quantify the severity of this problem. Ofgreater importance may be the contribution of subclinical Vitamin A deficiencyto morbidity and rortality from infectious disease. Experience in Indonesiaindicates that morbidity and mortality from acute respiratory infections andfrom diarrheal disease are substantially reduced by Vitamin A supplements inpopulations where deficiency is prevalent. (The Nutrition Department of theMedical Research Institute is planning a study of Vitamin A deficiency inGalle which would include biochemical assessment. This would provide impor-tant information on the prevalence of subclinical states and indicate whetherroutine megadose supplementation might be effective in reducing infectiousdisease levels in young children.)

1.15 Iodine deficiency disease (IDD) is a public health problem, particu-larly in Kalutara, Kegalle and Matale districts where a recent regional surveyof school children showed 10.52 with prominent goiter (Grade 3) and 21.92 withsubstantially enlarged thyroid glands (Grade 2); only 352 had normal glands.However, IDD also occurs in a number of other districts including, Galla,Hambantota, Kandy, Moneragala, and Ratnapura. An unusual feature of theproblem in Sri Lanka is the prevalence of goiter in coastal communities withaccess to marine foods which should provide an adequate iodine intake.However, many of the affected populations are reportedly very poor fishingcommunities who sell all or most of their catch to purchase rice and otherstaples.

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Recent Trends

1.16 Between 1981-2 and 1986-7, food consumption appears to have increasedsignificantly for the very poor, and unvevenly for the next lowest deciles.However, in recent years, underemployment has risen substantially,unemployment In now at an estimated 18-201 o: the work force and around 25Z ofthe population, concentrated In the rural sector, is below the poverty line.The poorest and most vulnerable groups remain as identified above, withspecial reference to dry-sone farmers, new settlers and small food-cropfarmers, augmented by small fishermen. Significantly, poverty also isreported among segments of plantation workers and in the informal urbansector. Geographically, lt is questionable whether the northern areas,disrupted by continued conflict, have managed to maintain their previouslyreported comparatively high calorie consumption levels. Additionally, overthe past three years food prices have continued to rise faster than wages.The health system and nutrition education have made steady, but notremarkable, progress and no extensive nutrition initiatives have becomeoperational.

Coamarisons

1.17 Malnutrition in Sri Lanka, as measured by the 222 of children withwasting between 12-23 months, is relatively low compared to other low-incomecountries with high Infant and child mortality rates such as Nepal (272),Burma (482) and India (372). lowever, it is substantially higher than Inlower mlddle-income countries (98$400-1,600 per capita) with comparably lowinfant and child death rates, such as Malaysia (61) Indonesia (172),Philippines (141) or Thailand (181). Table 1.2 below, compares Sri Lanka'snutrition Indicators with those of other countries at similar GNP levels andindicates that Sri Lanka's nutrition progress ls much less noteworthy than itshealth accomplishments. These comparisons underline the conclusion that SriLanka has made exceptLonal progress with relatively limited economic resourcesin reducing mortality and severe disease in infancy and childhood but has notmanaged to bring about corresponding improvements in nutrition conditions orin controlling morbidity from nonimiunizable infections of childhood.

Table 1 2: SRI LANKA, COMPARATIVE CHILD NUTRITION INDICATORS BY GNP LEVEL

S children under 5GNP with mild-moderate/

per capita I low severe malnutrition 2 of wasting(in US$, birth (1980-86 or latest (1980-86 or latest

Country 1986) weight available year) available year)

Ghana 390 17 2317 28Sri Lanka 400 20 25/10 22Mauritania 420 10 30/10 NASenegal 420 10 20/NA 20Liberia 460 NA 31/4 NAYemen PDRY 490 12 32/8 36Indonesia 490 14 27/3 17

Sources The State of the World's Children, 1988. UNICEF.

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Functional Implications of Malnutrition

1.18 In deciding the appropriate national priority to assign to thecontrol and prevention of Sri Lanka's malnutrition, the functional signifi-cance of its different forms needs to be assessed. The functional effects ofmaternal malnutrition are substantial and relatively easy to assess. Limitedweight gain in pregnancy is closely correlated with fetal growth retardationand low birth weight, which in turn carries a greatly increased risk ofserious morbidity and early infant mortality. Such a process is wasteful inbiological, psychological, social and economic terms and represents a clearpriority for i.tervention.

1.19 Wasting, particularly in the post-weaning period, is associated withdecreased immunocompetence resulting in increased frequency and severity ofcommon infections such as diarrheal disease and acute respiratory infections.Stunting represents an ultimately undesirable alaptation to limited dietaryintake. The degree to which this affects physical, mental and social perfor-mance cannot easily be defined and will vary with community and family condi-tions. It is certain, however, that the physical and psychological environ-ment in which protein-energy malnutrition develops results in social disadvan-tage, often of a permanent nature.

1.20 Severe anemia affects both physical and mental performance and mayreduce the effectiveness of educational inputs in children. It alsorepresents an obstetrical risk in pregnancy and adversely affects fetalgrowth. At the same time, there is considerable capacity for adaptation tominor decreases in hemoglobin levels, particularly if tlese occur over anextended time period. Thyroid enlargement in endemic goiter is initially asuccessful adaptation to low levels of iodine intake. As the conditionbecomes more severe, thyroid function is compromised and mental and physicalperformance are adversely affected. Maternal iodine deficiency is associatedwith an increased risk of cretinism in the offspring, which constitutes severeloss of physical, mental and social function. Recent evidence also suggeststhat subclinical nongoiterous iodine deficiency impairs mental function.Vitamin A deficiency in severe forms causes eye conditions that result in lossof acuity and eventually in blindness. Lesser degrees of deficiency areassociated with increased morbidity from infectious diseases.

II. NUTRITION DETERMINANTS

A. Determinants

2.1 Malnutrition in Sri Lanka results primarily from chronic householdfood insecurity exacerbated for some population groups by two sets of contri-butory factors: food-related behavioral patterns and morbidity. Householdfood insecurity arises from low incomes and limited purchasing power, theproduct of high underemployment and rapidly rising food prices. In urbanareas, it reflects job uncertainty and high prices of essential commodities.In rural areas, it reflects landlessness or subsistence agriculture in whichfamilies continue to be net purchasers of food.

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Household Food Insecurity

2.2 Periodic national surveys of consumer finance clearly demonstrate the

relationship between ecenomic status and food intake. Both the Labor Force

and Socioeconomic Surveys carried out by the Department of Census and

Statistics in the Ministry of Plan Implementation and the Consumer Finance

Surveys cerried out by the Central Bank show that purchase of food commodities

(or their imputed value if they are home-grown) represents, by a wide margin,

the major budgetary expenditure for Sri Lankan families. Food expenditures

averaged roughly 652 of total expenditures for the population as a whole in

1986/87, and 70X for the poorest two deciles, figures generally associated

with poverty threshholds in low-income countries. There is at the same time

substantial variation in the estimated cost of calories consumed, ranging from

just over SL Rs 5.4 per 1,000 calories in the poorest decile to just over

SL Rs 10 in the highest.5/ This reflects, as would be expected, a substantial

increase in expensive protein-rich foods as income increases. Meat

consumption, for example, increases thirtyfold over the income spectrum while

rice consumption only doubles. These studies also indicate that the food

consumption patterns of the poorest deciles are highly sensitive to any

changes in income or prices except as these affect rice intake, a dietery

given for all families.

2.3 Food consumption for middle- and upper-income groups improved or

remained constant between 1969 and 1981/82, but that for the poorest three

deciles declined steadily. (Caloric consumption per Adult Equivalent Unit, or

AEU, for the poorest decile dropped from 2,156 in 1969/70 to 1,566 in 1981/82

reflecting, in part the 1977 elimination of food subsidies.)6/ Over the same

period, the percentage of the population not achieving calorie adequacy rose

from 40 to 55? and the percentage of the population consuming less than 1,400

calories per day increased from 4 to 15?. Food intake of the poor probably

increased somewhat in the construction and tea boom years which immediately

followed as the Government's liberalization policies took hold. The 1985-86

Labor Force and Socio Economic Survey found that the percentage of households

not meeting caloric requirements dropped from 55? (1980-1) to 492 and that

caloric intake of the poorest decile improved marginally.71 Preliminary

analysis of the 1986-87 CFS indicates continued improvement in the caloric

intake of the poorest decile. Although comparison of expenditure deciles in

the older surveys and income deciles in the more recent ones is problematic,

data from 1986-7 would appear to indicate that food consumption levels for

some lov incume groups have improved, perhaps to 1969-70 levels, in the case

of lowest income estate workers, and certainly have not worsened. There are

no 1986-7 figures comparable to those in the 1500-1600 calories per adult

equivalent range for the poorest decile which were recorded in 1981-2 (these

after a very sharp increase in prices in early 1980). Instead, 1986-7 figures

are in the 1800-2000 range for the three poorest urban deciles as shown in

5/ See Annex A, Table 1.

6/ See Annex A, Table 2.

7/ Unfortunately, the available analysis in this survey and the 1986-87

Consumer Finance Survey is not by total expenditure deciles but by less

reliable (and probably significantly under-reported) income groups.

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Table 1.3 below, nearly 2000 for the poorest rural decile, and nutritionallyadequate on the estates. (All of these AEU figures would have been up toaround 170 calories lower in the absence of food stamps at 1987 entitlementlevels. See Annex ., Tables 7-9.) At the same time, however, despite somerestructuring of the food stamp program in 1986, these groups (poor urbandwellers, landless laborer families, some poor estate workers and recentmigrant families and the households of other underemployed workers in theunorganized sector) have been the disproportionate victims of risingunderemployment, deteriorating real wages, steadily eroding value of the foodstamps until 1989 and declining economic growth since 1985 and thus remainvulnerable in terms of household food security.

Table 1.8: DAILY CALORIE CONSUMPTION PER ADULT EQUIVALENT UNIT

Urban Rural Estte1969-70 /I 1981-82 pj 1988-87 /b 1969-70 /k 1981-82 /k 1966-87 /k 1969-70 /I 1981-82 /1 184-e7 /k

1,848 1,521 1,886 2,188 1,670 1,998 2,209 1,617 2,2162,192 1,771 1,796 2,482 2,082 2,148 2,691 2,180 2,4052,861 1,982 1,982 2,760 2,826 2,242 8,009 2,684 2,608

,I Expenditure Data./b Income Data.

Source: Annex A, Table 2, 1988-87 data based on Consumer Finance Survey

2.4 During 1969-82, the poorest decile increased its total nominalexpenditures (a more efficient proxy for income in these surveys) by just over300o (although this translated into an increase of only SL Rs 75 per personper year). Over the same period, the Colombo consumer price index (CPI)calculated by the Department of Census and Statistics registered a 3842increase and the cost of a food basket traditionally consumed by low-incomehouseholds rose by just over 400X. More than half of those increases occurredbetween 1977-82 while liberalization of the economy was beginning to takeshape. The difference of around 33? batween price and income (totalexpenditure) increases, 1969-82, explains in large part the decreased caloricintake of the poor over that period. However, between 1982-87, the ColomboCPI rose by 57?, while food prices registered a 54? increase, thereby modestlyreversing the previous relationship between them.

2.5 Since 1985, the combination of sluggish employment, drought and thedisruption caused by communal violence makes it unlikely that real incomeshave increased significantly. Annex A, Table 3 indicates that wages for low-skill construction workers have just kept up with food price rises, whileagricultural wages fell well behind in 1987. Even in the case of agriculturallaborers, real wage rates are unlikely to have increased significantly despiteincreased paddy production, given high rural unemployment (roughly 15X) andthe high percentage of rural wage earners willing to undertake additional workwhen available.

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2.6 Additionally, since the poor spend a larger proportion of income onfood, they are disproportionately affected by seasonal price changes which aremasked in annual consumer price indices. Seasonal increases of 502 in theopen market price of rice and even greater fluctuations in the prices of otherfoods have not been unusual in recent years. (In 1986, for example, the openmarket price of samba rice fluctuated from SL Rs 8 per kilogram in June toSL Rs 12 in January. In 1985, the price of gram rose from SL Rs 30 in Januaryto SL Rs 44 in September, while over the same period the price of coconut oildropped from SL Rs 19 to SL Rs 9.) There has been little evidence, however,of major regional shortages or regional price differentials.

Behavioral Factors

2.7 While household food insecurity represents a principal determinant ofmalnutrition in Sri Lanka, it is complicated by behavioral patterns,particularly of vulnerable population groups. The nutritional status of a12-month-old child of a poor family is not likely to be low simply because offamily income level (the marginal cost of feeding a young child is low,particularly in rural areas), but rather because of a combination of time andresource constraints aggravated by certain long-held but sometimes deleteriousfeeding practices.

2.8 Inappropriate dietary behavior occurs throughout the reproductive andgrowth cycle. Inadequate energy and nutrient intake during pregnancy,particularly the last trimester, is common in low-income households and arisesprimarily from inappropriate food distribution within the family. Householdfood insecurity results in priority-to those perceived as being economicallymost active. However, the concept of economic loss incurred by wastefulreproduction--high mortality in low-birth-weight infants resulting frommaternal malnutrition--is nct reflected in existing cultural practices. Thefailure to adhere to iron and folate supplementation regimes results in lowhemoglobin values that further affect fetal growth and increase the hazardsassociated with obstetrical hemorrhage. After delivery, maternal malnutritionadversely affects the quantity and, if severe, the quality of breast milk,with direct consequences for infant health and survival.

2.9 Initial lactation practices are crucial in delivering the optimaldose of maternal antibody to the newborn through colostrum. The Dry Zonestudy revealed that 30? of mothers did not feed colostrum, of whom halfthought it was harmful. The wide availability of powdered milk in retailoutlets and cooperative stores throughout the country (although controlled bya Marketing Code) has resulted in the introduction of such milk feeds at anearly age, in part to compensate for actual or perceived lack of breast milk;this in turn reduces the frequency of suckling and the volume of breast milk.This practice leads, paradoxically, to extended reliance on purchased milk asthe dietary staple with postponement of the introduction of semisolid foods toas late as one year. As the price of powdered milk is high (SL Rs 35/400 g)in relation to food stamp values (SL Rs 50/child), overdilution is used toextend the supply, thus reducing energy and protein intake. Where workingmothers delegate child care to older siblings, the high frequency of feedingrequired with low-density rice gruels is often neglected, while poor foodhygiene results in more frequent intestinal infections. These early feedingpractices result in a progressive deficit of energy and nutrients from 4

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months onwards. Longitudinal growth recording shows a marked leveling off inweight gain from 6 months, with subsequent reduction in height increments.From this position, it is difficult for the child to regain its initial growthmomentum, though it may continue to grow adequately at a lower trajectory.The delay in solid food supplementation and inadequate caloric density alsomay increase malnutrition and susceptibility to disease. An effectivenutrition education program could help counter these problems.

Infectious Diseases

2.10 Finally, infectious disease and other health factors invariably willhave a significant effect on nutritional status in Sri Lanka as elsewhere.Food intake is reduced, metabolism is elevated, absorption is limited, andlosses of energy and nutrients can be high. These effects are compouILdedwhen, as is often the case, feeding is not actively maintained dur!4:g theinfectious process. The frequency and severity of infectious disease isitself a function of poor environmental sanitation and inadequate food hygienewhich result in high levels of intestinal parasitism as well as diarrhealdisease.

2.11 Sri Lanka is making substantial progress against the six immunizablechildhood diseases. The Expanded Program of Immunization has achieved highcoverage levels throughout the country for DPT, BCG and OPV. Measles vaccinewas introduced recently and already covers about two thirds of the targetgroup. The recent DHS results showed that health cards were held for 822 ofchildren between 12-36 monthst for these the following coverage levels wererecordeds BCG--992, completed DPT--93Z, completed OPV--93Z and measles--68.5Z. These remarkably high levels of coverage have resulted in effectivecontrol of these six diseases and major reductions are recorded in healthstatistics reports (see Table 2.2).

Table 2.1: FREQUENCY OF IMMUNIZABLE DISEASES--1986(per 100,000 population)

Disease 1980 1986

Polio 1.8 0.1Diphtheria 0.3 0.0Pertussis 3.7 1.0Tetanus 8.4 2.1Tetanus neonatal 81.8 7.0Tuberculosis /a 42.1 40.9

/a Affects all ages, 0-14 year rate: 5.1/100,000 for 1986.

Source: 1986 Annual Health Bulletin, Ministry of Health, Colonibo.

2.12 Major problems exist, however, in respect of the nonimmunizablediseases, particularly acute respiratory infections, diarrheal disease,

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malaria and intestinal parasitism. All of these conditions have profoundeffects on the nutritional status of children which in turn influences thefrequency and severity of infectious episodes.

2.13 The combination of slow fetal growth, fetal malnutrition and immatu-rity appear to comprise the leading specific cause of childhood hospitaldeaths in Sri Lanka. Acute respiratory infections are the leading specificcause of hospital death in children <5 years. They represent between 10-302of child admissions and 30-352 of out-patient attendances. LBW children areat particular risk of death from this cause. Despite heavy emphasis oncontrol through oral rehydration, diarrheal disease is the third leadingspecific cause of hospital death in children under 5 years. Of all reporteddiarrheal deaths, 48.5Z are in children <5 years, of which 46Z, or 22? of thetotal, are in children <1 year. It represents 102 of all hospital admissionsof which 502 are for under-fives. At any one time, between 20-30? ofpediatric beds are occupied for dehydration.

2.14 Morbidity patterns have remained relatively stable in recent years asgauged by hospital data, the principal source. Respiratory infections are theprincipal specific cause of hospital admissions both generally and for pre-school children. Diarrhea ranks second for pre-school children and third,just after accidents and injuries, for the general population. Malaria is thefourth leading overall cause of hospital admission. The rate of hospitaliza-tion for malaria rose from 4371100,000 population in 1985, to 830 in 1986according to Ministry of Health statistics. Service data show that thepercentage of positive blood slides rose from 10? in 1985 to 28? in 1986;falciparum positive slides rose from 12 to 5.6? over the same period. Intes-tinal parasitism is acknowledged to be highly prevalent and special studieshave reported overall rates for soil-transmitted nematodes (ascaris, hookwormand trichuris) between 50-90Z. Children hospitalized for severe malnutritionhave parasite rates 2-3 times that of nonmalnourished admissions. Thecontinuation of these mortality and morbidity levels and patterns indicatesthat Sri Lanka needs to do more on the disease prevention and control frontsince all these problems are amenable to public health measures.

B. Most Seriously Affected Groups

2.15 Analysis of the 1979-82 national nutrition survey provided ageographic and socioeconomic map of malnutrition in Sri Lanka. Wasting wasmost widespread in Kurunegala and Puttulam districts, while stunting was mostprevalent in Kandy and Nuwara Eliya. Combined wasting and stunting washighest in Kandy and Nuwara Eliya as well as Amparai, Anuradhapura,Batticaloa, Polonnaruwa and Trincomalee districts.

2.16 Calorie intake patterns differed from anthropometric findings. Thegreatest calorie deficiencies were in Matale and Badulla, where around onethird of all households suffered more than a 302 intake deficit against estab-lished norms. In Hambantota and Moneragala districts combined, and in Galleand Matara districts combined, around 30? of all households suffered a similarcalorie shortfall. Only in the northern districts of Jaffna, Vavuniya, Mannarand Mullaitivu were less than 11? of all households so affected. Higherprevalence of malnutrition in areas of higher caloric intake imply thepresence of high rates of infection, intrafamily food distribution problems onboth.

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2.17 Agricultural and animal husbandry worker households appeared to havethe lowest calorie intakes, mainly on estates and rural farms. Laborer fami-lies appeared to be almost as badly.off from a nutritional perspective; thosein urban areas and the urban unemployed are at particularly high risk. Seri-ous regional differences prevent the postulation of a universally well-definedrelationship between land-holding and nutritional risk, but small holdings andlandlessness, as expected, seem to be associated with poor nutritionalperformance.

2.18 Biological factors associated with reproduction, growth, developmentand physical work increase the demand for energy and nutrients and determinethe form in which they can most effectively be assimilated. In addition,environmental conditions and behavioral factors associated with low income andpoverty increase the risk of infectious disease which further compoundseconomic and biological influences. As a result, low-income pregnant women,lactating mothers and preschool children are the most severely affected.

2.19 Protein-energy malnutrition is frequently accompanied by iron, folateand Vitamin A deficiency. Seasonal effects also operate. The high energyrequirements of planting and harvesting in unmechanized agriculture increasedemands on all economically active members of the rural family. Thus womenreaching the third trimester of pregnancy at planting or harvesting are atadditional risk of malnutrition and of producing a low-birth-weight infantwith seriously diminished chances of survival. Other seasonal factors such asdiarrhea incidence and malaria prevalence add further risk. Iodinedeficiency, being primarily determined by geography, affects a wider range ofsocioeconomic levels although reproductive women carry additional risk byreason of increased requirements. Districts of highest prevalence are Kandy,Nuwera Eliya, Kalutara, Ratnapura and Kegalle.

2.20 Sri Lanka's nutrition and health conditions consistently have beenworse in the estate sector, except for the remarkably low levels of acutechild malnutrition reported in the 1987 DHS. Rural populations have betternutrition levels than estates, in general, but worse than urban populations.Within urban groups, Colombo has higher nutrition levels than other cities.

2.21 Females are marginally more malnourished than males but differencesare much less pronounced than elsewhere in Asia. Malnutrition in women,including anemia, is most pronounced during lactation and pregnsncy, when itsgreatest impact is on the fetus during the last trimester of gestation.

2.22 Stunting increases progressively with age in childhood; acute malnu-trition is significantly higher following weaning in the second year of life.Child nutrition is in transition; severe manifestations have been relativelywell-controlled but conditions remain suboptimal.

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III. NUTRITION IN SRI LANKA'S FOOD AND AGRICULTURE SYSTEM

A. Dietary Patterns

3.1 The most basic food items in the Sri Lankan diet are rice and coconut(including coconut oil) which also are che most important domestic agricul-tural commodities. These, along with bread (most important in urban areas),wheat flour (more important among Tamil workers on the estates) and sugar,constitute 802 of calories in the Sri Lankan diet. (Rice itself contributesroughly 502 and coconut products roughly 202 on average.) For the poorestthree deciles, these commodities plus yams and cassava constitute almost 902of the calories consumed.

3.2 Of the major foods consumed, Sri Lanka imports wheat, sugar and asmall proportion of its rice. The country is approaching self-sufficiency inrice but from the standpoint of effective demand rather than nutritional need.Looking at consumption trends over time, up to 1985-86 there has been in urbanareas an increase in meat and dairy products among all income groups. Inrural areas, there was a slight increase in rice consumption up to 1981. By1986-87, rice consumption increased in absolute terms for the poorest deciles,but decreased somewhat as a percentage of total calories reflecting continueddietary diversification.8/ In the estate areas, the rice-wheat balance hasbeen shifting in favor of rice although wheat, used in the making of chapattisand dosas mainly by the Tamil population, still represents 172 of totalcalories. Sugar consumption has risen sharply. Finally, bread is nowconsumed in some amount by 902 of families in the country.

3.3 Unlike many other low-income countries, there are in Sri Lanka nomajor food staples disproportionately consumed by low-income groups whichmight lend themselves to policy intervention addressing nutritional needs ofthe poor. Rice is the major component of the diet for every income group, andvirtually all of the subsidiary food crops, as in the case of rice, areconsumed in greater quantities by upper-income groups. Accordingly, the typesof income-specific elasticity analysis for a range of food staples which hashelped identify intervention points in other countries may be less useful inSri Lanka.

B. The Role of Agriculture

3.4 Paddy production increased by close to 72 p.a., 1959-85, beforeslowing,9/ but production in the export-oriented tree crop sector--tea, rubberand ck onut--has been growing only fractionally. Tea and rubber productionhas actually been declining.101

3.5 The agricultural sector has been a relatively efficient absorber oflabor in the economy with a growth rate in agricultural employment of 1.52

8/ See Annex A, Tables 4 and 7.

9/ See Annex A, Table 5.

lo/ With the recent drought, coconut production also declined.

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p.a. between 1963 and 1980, although agriculture as a percentage of totalemployment has been slowly declining (from 52.92 to 45.92, 1963-86).11/ Thishas not been sufficient, however, to solve the country's chronic un- andunderemployment problems. During that period, unemployment fluctuated between12 and 252, and now stands at an estimated 18-20Z with around 25Z of thepopulation below the poverty line.

3.6 With the change of government in 1977, government expenditures inagriculture increased from less than 102 of total expenditures to over 20X.The greatest expenditure has been heavy capital investment in irrigation,most_y in the Mahaweli region; also a subsidy on fertilizer (612 of which isused in the paddy sector), producer price supports and credit.

Rice Development

3.7 In terms of policy attention and resource allocation, the govern-ment's primary emphasis within the agricultural sector has been on paddyproduction. Since independence, self-sufficiency in rice has been a prioritynational goal, and paddy farmers have been an important political constituencyof each government. The paddy sector has benefited from a range of policymeasures including irrigation, price support and subsidized fertilizer. Therealso is an impressive agricultural research infrastructure (some locallydeveloped varieties are equal to the best imported varieties) and the bulk ofagricultural extension outside of the tree sector is devoted to paddy. All ofthis has been justified as a way to achieve: (a) higher incomes for paddyfarmers; (b) increased self-sufficiency in rice; and (c) improvements in thebalance of payments (i.e. elimination of remaining rice imports). However,paddy research has focussed more on increasing production rather than on theefficiency and costs of rice production and Sri Lanka rem-ins a relativelyhigh-cost paddy producer, particularly when quality is taken into account.

Subsidiary Food Crops

3.8 Successive governments in Sri Lanka have had fairly well-definedstrategies in the area of paddy production, but this has not been the casewith the so-called subsidiary food crops (coarse grains, grain legumes, oil-seeds, chillies, onions, yams and tubers). These crops, produced in highlandareas of the wet zone (southwestern part of the country) under the so-calledchena (slash-and-burn) system of agriculture, have registered significantproduction increases over the past two decades, but mainly as a result of areaexpansion. There has been virtually no increase in yields, a reflection ofrelatively little policy and resource attention devoted to these crops.

3.9 To the extent that policy attention has been focused on subsidiaryfood crops, it has not necessarily been contsistent. Domestic production ofthese crops was protected by import restrictions which were lifted in the late1970s. In addition, producers of these crops have received neither priorityin the provision of credit nor new seed varieties. Moreover, increasingamounts of unirrigated highland land appropriate for subsidiary food cropshave been converted into paddy land. With more serious recent discussion of

11/ Source: Thorbecke, E. and Svegnar, J. 'Effects of MacroeconomicPolicies on Agricultural Performance in Sri Lanka, 1960-82.0 OECD,Paris, July 1985.

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agricultural diversification, the government has sought to stimulate produc-tion by instituting support prices for many cf these crops. In at least oneinstance (maize in 1987), however, the support price lad to large-scaleprocurement by the government which it then was unable to sell as feed becauseof the presence of lower-priced feed imports.

Food Production and Marketina Patterns

3.10 The importance of subsidiary food crops to the low-income populationis not so much in their consumption but rather in their marketed productionwhich is concentrated on smaller farms. The smallest quartile of landhold-ings, in fact, is located almost entirely in highland areas where such produc-tion is concentrated. Accordingly, the burden of minimal policy and program-matic attention to these crops has fallen mainly on small and marginalfarmers, for whom increased production probably would have a positive incomeeffect despite still unresolved questions of how to market significantlyhigher quantities at home and abroad.

3.11 The case of rice in Sri Lanka is different. Paddy proauction takesplace on both large and small holdings, but the major effect of the riceeconomy on the poorest deciles of the population is through rice consumptionrather than income generation. This has important nutritional and publicpolicy implications requiring some examination.

3.12 Of land-holding families (over 80Z of households in rural areas),between 42 and 541 of holdings (depending on the data source used) are lessthan one acre. This percentage is increasing as the average size of holdingerodes steadily over time. (The average size of a holding in 1982 was 402smaller than in 1946). According to reliable information, the larger theholding, the larger the proportion of that holding that is likely to bedevoted to paddy production. (Yet even among the larger landowners withholdings exceeding 2 acres, only 402 of land on the average is in paddyproduction, indicating more existing crop diversity than is sometimes recog-nized. Less than 22 of all holdings are exclusively paddy land.)

3.13 As expected, the larger the landholding the larger the proportion ofthe marketed crop. (Among the poorest quartile of paddy producers, only 8Zsell any paddy.) The strong correlation between size of landholding and thepercentage of household income emanating from production on that land isunusual.12/ Among small landholders, who invariably have off-farm employment,less than 52 of reported income (or, more often, imputed income) is the resultof their own agricultural production. The comparable figure for large land-owners is almost 5O0. Only a quarter of the smallest landowners report agri-culture as their primary occupation. Accordingly, incomes of these smallproducers are likely to be proportionately less affected by agriculturalpricing (see paras. 3.15-17, below).

3.14 Clearly most households grow food primarily for their own consump-tion. Analysis indicates, however, that most families which sell rice at thetime of harvest (because of the need for cash or because of inadequate on-farm

12/ See Annex A, Table 6.

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storage capacity) will buy back later in the year at least part of the quan-tity sold, and at substantially higher prices. Fully 84t 13, of rural house-holds in the country are net consumers of rice (purchasing more rice than theysell). Only when annual paddy production reaches 90 bushels (requiring around2.5 acres of paddy) is a household virtually certain to be a net seller.

Imnact of Prices

3.15 From the above, two tentative conclusions with respect to the effectsof rice prices are possible. These do not take Into account any indirecteffects of increased rlce production on overall rural employment and wages oron production or consumption levels of other crops.

(a) Assuming no significavt production decline, lower rice prices willdirectly benefit the &ajority (two thirds) of rural households whichdo not produce paddy as well as the urban and estate population.

(b) Of rice-producing households, on the foregoing assumptions, thosewith smaller holdings who are likely to be at substantial nutritionalrisk and purchase more rice than they sell (and also tend to havetheir major employment outside of agriculture) are likely to be netbeneficiaries from lower rice prices.

3.16 Analysis estimates that a 201 decline in rice prices would lead toroughly a 1OX Increase in caloric intake for the poorest decile.l41 This boostin caloric Intake would, in turn, reduce the percentage of poorest decilehouseholds consuming less than 802 of caloric needs (using the FAOIVHO Recom-mended Dietary Intake figures) from 751 to 571. For the second poorestdecile, the percentage falling below the 80S level would be reduced by half(from 48 to 241). These calculations assume zero or minimal effects onproductionlconsumption levels of other goods.

3.17 Conversely, among paddy-producing households, a 201 increase in riceprices would result In caloric intake losses for all but the quartile with thelargest holdings, under the above substitution assumption. For the majotityof paddy-producing households, increased income from higher producer priceswill not compensate for the higher prices they have to pay as consumers.151Higher prices thus result In a net transfer of income from smaller to largerproducers. Non-paddy producing consumers in the lower income deciles wouldsuffer s4$ilar declines in rice intake. In geueral, increased rice priceswill tend to hurt the poor even when they are paddy producers.

Procurement and Distribution Policies

3.18 Government procurement and food distribution policies also impact onnutrition by affecting both supply and demand. Producer price support for

13/ Source: Sahn, David. PFood Consumption Patterns and Parameters in SriLankas The Census and Contrcl of Malnutrition. Draft 1.International Food Policy Research Institute, Washington, D.C., June1985.

14/ Sahn, OD ct

15/ Ibid.

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rice was initiated in 1948 by the Department of Agrarian Services, then trans-ferred in 1971 to the Paddy Marketing Board (PMB) with actual procurementcarried out by Multipurpose Cooperative Societies. Of total rice produced inthe country (1.8 million tons or roughly 100 million bushels in 1987), onlyabout 5? was procured by the government. This compares with procuLement ashigh as 40 to 50? during the peak of the rice-rationing program in the 1970s.The bulk of rice consumption in the country now is dependent on market sup-plies provided by private traders.

3.19 The PMB support price for paddy, presently SL Rs 80 per bushel, isbetween 10 and 15? lower than the average market price which, in turn, hasaveraged 15? above the border price, 1983-87. Accordingly, the PMI serves asthe buyer of last resort. Its limited purchases are concentrated at the peakof the season when farm-gate prices are at their lowest. As a percentage oftotal ptoduction, this procurement is less than 52 of what it was at the peakof the rice rationing program. In addition to providing this floor price, thegovernment (through the Food Commissioner's Department) also has the capacityto ensure ceiling prices by injecting supplies onto the market during periodsof supply shortfalls and rising prices. With increased domestic rice supplyin recent years, however, there has been less frequent need for this ceilingprice imposition. Resolving the question of why the market price of riceremains high despite producer subsidies requires analysis of: (a) the extentto which government price intervention poliVies may have distorted the marketand (b) what would happen to paddy production if the government permittedmarket forces to determine prices and output.

Processing

3.20 The PMB arranges milling through its own mills and the private sectorand then provides the rice to the Food Commissioner's Department which, inturn, makes this rice and imported rice available to the cooperatives fordistribution including the food stamp program and to authorized dealers.

3.21 The Sri Lankan rice milling industry at present is a low-technologyindustry producing low-quality rice with high wastage. Of 27 mills operatedby the PMB, 13 are over 20 years old, and 40Z of overall operating capacity iscurrently disfunctional. Among other problems, most mills lack precleanersand mechanical dryers. Most of the.roughly 750 private mills also are old andin need of modernization, a process which the mills have resisted for reasonswhich are not entirely clear. One of the earlier factors was uncertaintyabout government policy, while generally unsettled cor.!itions have dampenedthe recent investment climate. Consideration is being given to incentives,including the waiving of import duties, to permit necessary renovation. Ifsavings are significant in terms of loss reductions and could lower the marketprice of rice and reduce foreign exchange requirements, moderrization may wellbe justified, particularly in the private sector which accounts for mostmilling. However, labor-displacing effects of modern processing technologiesalso would have to be taken into account.

3.22 Milling of imported wheat in the country is done in Trincomalee byPrima Flour Mills of Singapore. Its current 20-year contract with the Gov-erinent of Sri Lanka involves the milling and provision of 74? extractionwhite flour in exchange for the fiber and Vitamin B-rich outer portions of the

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wheat kernels which are then exported by Prima. Much of the wheat is providedon concessional terms by the United States, Canada (which has imposed restric-tions on export of the by-products) and, to a lesser extent, Australia.

Nutrition Effects

3.23 The agriculture sector influences the nutrition of Sri Lanka house-holds in ways which are important but difficult to quantify with precision.First, rice prices directly affect consumption by low-income groups. Second,production and prices of subsidiary food crops affect the incomes of poorfarmers. The foregoing points to the need to find ways of increasing theefficiency of rice production; lowering the cost of production can have thetwin benefits of lowering the market price of rice without hurting producerincomes. A stronger push for development of subsidiary food crops could raiseincomes and purchasing power of small producers while increasing the supply oflow-cost calories and animal feeds.

3.24 The choice of post-harvest technology also has collateral impact onfood consumption by the poor both as consumers benefitting from efficienciesor losing out if mechanized processes displace labor without creation ofcompensatory job opportunities. In any case, these production and consumptioneffects are likely to be more important than the impact of components inagriculture projects which seek to address nutritional deficiencies.16/Nevertheless, projects which seek, for example, to increase the proportion ofgreen leafy vegetables in home gardens to boost iron intake and decrease theincidence of iron-deficiency anemia can have a positive effect if well-imple-mented. Perhaps more importantly, they can link agricultural extensionservices to the needs of low-income families.

IV. NUTRITION PLANNING AND PROGRAMMING

4.1 Sri Lanka is one of relatively few developing countries explicitly totry to integrate nutrition into national development plans and to set upseveral Government mechanisms ior that purpose. Sri Lanka has had somesuccess in articulating both important features of a national nutrition policyand selected measures to carry it out. However, the links between policy andstrategy elements need strengthening and efforts to translate strategy intoeffective programs have been uneven.

A. Institutional Arrangements

4.2 The apex political body for nutrition concerns is the National HealthCouncil (NHC), currently chaired by.the President, which consists of theCabinet. Set up in 1980, the NHC's main mandate is to consider policy and

16/ Sahn's analysis, discussed earlier, for example, while extremelyhelpful in sorting out the rice production/consumption dynamic, doesnot attempt to include the indirect effect of rice price changes onemployment and wagen or the production and substitution affectsnecessary for such quantification.

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strategy issues relating to health. It meets an average of at least twicemonthly and nutrition is frequently a major agenda topic. When he was PrimeMinister, the President emphasized the need to develop tregeted interventionprograms against a perceived deterioration in nutrition conditions. ANational Health Development Committee presided over by the Secretary of Healthacts as NHC secretariat. It consists of the secretaries of Agriculture,Ayurveda, Education and heads of relevant departments. Other mechanisms toaddress nutrition issues also have operated in Sri Lanka but have yet to bereactivated under the present Government. A National Food and NutritionCoordinating Committee (NFNCC), chaired by the Minister of AgriculturalDevelopment and Research, was set up to coordinate responsibility for food andnutrition policy but later was supplanted by a number of technical committeeschaired by senior administrators. These included a standing committee onnutrition considerations in development sectors and committees for thriposha,food stamps and nutrition education and communications. A NationalAgricultural Pricing and Food Policy Committee had oversight responsibility tothe Cabinet for food policy concerns including availability, imports, pricing,procurement, distribution and buffer stocks. Chaired by the CabinetSecretary, membership comprised the Secretary to the President and thesecretaries of Agricultural Development and Research, Finance and Planning,Food and Cooperatives and Plan Implementation (MOPI).

4.3 Until recently, explicit responsibility for promoting the inclusionof nutrition considerations into food and other national planning efforts,interministerial nutrition coordination and the incorporation of nutritioncomponents into ministerial action programs rested with the Food and NutritionPolicy Planning Division (FNPPD) of MOPI. However, FNPPD recently wasdismantled through MOPI incorporation into the new Ministry of Policy Planningand Implementation (MPPI), leaving a vacuum which needs to be filled becauseof FNPPD's important and unique role. Over its 12 years of operation, FNPPDtook the lead in setting the national nutrition agenda by performing orcommissioning key analytic tasks and translating the results into policy andstrategy frameworks. It also promoted the establishment of district food andnutrition committees staffed with full-time MOPI personnel, to develop, planand fund local nutrition initiatives. Chaired by either the District Ministeror the Government Agent (GA) as his nominee, the district committees metquarterly. A similar structure operated at the sub-district (divisional)level, chaired by the Assistant GA, and was to be established in around 6,700village councils (gramodava mandalavas). Where they were tried out, thecommittees were unevenly effective, reflecting the varying skill andcommitment levels by local FNPPD staff and higher-level officials' perceptionof district priorities. FNPPD also serviced the technical committeesdeveloped by NFNCC. Moreover, FNPPD managed a diverse portfolio of nutritionactivities including the kola kenda program, nutrition education andcommunications as well as the forthcoming National Nutrition Survey. FNPPDthus served as both a focal point for national and district nutritionplanning, programming and advocacy and the Government's prime technicalresource on nutrition.

4.4 However, as :ndicated in paras. 4.7-4.25 below, the previous combina-tion of institutional arrangements was both too complex and not particularlyeffective in getting key ministries-and other actors to agree on and carry outa coherent national nutrition strategy. Recognizing the need to simplify and

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unify that intersectoral responsibility at a high political level, theAdministrative Reforms Committee (ARC) recommended establishment of a NationalNutrition Policy Council to be chaired by the Prime Minister. The Councilwould be the focal point for formulation and monitoring of national nutritionpolicy. It would consist of representatives of all concerned ministries,special interest groups and--essential under administrative decentralization--the Provincial Councils. A Nutrition Policy Bureau, presumably the successorto FNPPD, would service the Council from the Prime Minister's Office. Ifbroadened to include similar responsibilities for national nutrition strategy,the ARC recommendation is a promising approach to the thorny problem ofintersectoral nutrition coordination. However, the Government may decide thatNuC should continue to set and monitor the national nutrition agenda. If so,a separate technical division is needed to help NHC address nutrition issuesin sectors other than health and to carry out technical analysis for theCouncil. MPPI would be a logical home for such a division. The Governmentalso needs to carry out two important analytic tasks for nutrition strategyplanning. First it should complete the analysis of the 1989 nationalnutrition survey, which will provide the first reliable assessment ofwidespread nutrition trends over the last ten years. Second, it shouldanalyze food expenditure and income data from the 1986-7 CFS. Both combinedwill provide a key basis for defining optional strategies to address nutritionneeds of food-insecure households.

B. Nutrition Objectives. Policies and Strategies

Obiectives

4.5 Sri Lanka's nutrition objectives were enunciated in both an FNPPDmemorandum on national nutritional status introduced in July, 1980, by thePresident and approved by the Cabinet, and a second memorandum issued by thePresident two years later. Those objectives are to reduce:

(a) mortality and nutrition-related morbidity among children under fouryears of age

(b) the incidence of chronic and/or acute protein-energy under-nutritionamong infants and pre-schoolers, with special emphasis on districtslsectors where incidence is higher than the national average

(c) the prevalence of maternal under-nutrition, thereby reducing thenumber of low birth weight babies and enhancing the mother's capacityto breast-feed, provide better child care and actively participate infamily and community welfare activities, and

(d) the incidence of nutritional anemia among infants, pre-schoolers,pregnant women and women of child-bearing age.

4.6 The Cabinet memo also identified six equally ambitious planning orintervention areas as the main paths to those nutrition goals:

(a) formulation of a food and agriculture strategy based on food produc-tion, consumption and nutrition needs

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(b) strong emphasis on income distribution in all development programsand activities to sustain low income groups and improve their shareof real income

(c) maximization of essential food distribution schemes and nutritionservices to..target groups..until development (enables them] to meettheir specific needs

(d) continuous review and monitoring of the entire pricing structure..topromote the production of low-cost food staples and the developmentof cheap nutrition-oriented food technologies to sustain..low-incomegroups

(e) the inclusion of suitable nutrition components in all developmentplanning policies as a pre-requisite..to maintain satisfactory nutri-tional levels and

(f) strengthened intersectoral coordination at central and local govern-ment levels through appropriate infrastructure development so that anintegrated nutrition package involving population, food production,nutrition, sanitation and primary health services could be betterimplemented.

Nutrition and Related Food and Agriculture Strategy Development

4.7 In late 1983, FNPPD wove a number of important nutrition-relatedfindings into a status report and a set of short, medium and longer-termstrategy recommendations. The report drew on the earlier memos to Cabinet,comparative results of national 1979-82 district nutrition surveys of pre-school children against 1975/76 survey data, evaluations of major interventionprograms including food stamps and thriposha, and an analysis of changes infood availability, as well as per capita consumption and wages in relation tocalorie needs. The report stated that 1980/81 calorie consumption of thelowest three income deciles had fallen below 1969/70 levels although overallper capita calorie consumption had recovered after dipping in the mid '70s.The percentage of households with inadequate caloric intake also had risensignificantly between 1969/70 and 1980/81:

Table 4.1: SRI LANKA: Z OF HOUSEHOLDS WITH INADEQUATE CALORIE INTAKE,1969/70 AND 1980/81

Sector 1969/70 1980/81 2 change

Rural 32 43 34Urban 30 50 67Estate 20 33 65

Source: Nutrition Strategy. Ministry of Plan Implementation, Colombo, 1984.

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The report pointed out that apolicy measures aimed at improving..socio-economic conditions of the masses should not ignore the short-term need fortargeting resources...to specific segments of the population considered tobe..malnourished or at risk or belonging to the real poverty groups."

4.8 The resulting short-term strategy called for:

(a) enhancement of food and income supplementation through

-- higher wage rates or higher agricultural prices to producers

-- increased value of food stamps, indexed to prices and based onper capita rather than household incomes, with higher incomecut-offs, administrative improvements and more careful targeting

-- stabilization of open market food prices to protect the pooragainst inflation, and

-- review and monitoring of food aid to ensure proper beneficiarycoverage, nutritional adequacy and management

(b) expansion of supplementary feeding programs, particularly

-- thriposha. with emphasis on greater outreach, coverage anddelivery system efficiency, and

-- school biscuits, especially for those in th.e first three yearsof school

(c) promotional campaigns for breast-feeding, sound weaning practices anduse of low-cost nutritious foods, and

(d) expansion of maternal and child health programs, including clinics,special field programs for pre-schoolers such as early detection ofnutrition deficiencies, on-site feeding, immunization and treatmentof minor ailments through voluntary and paramedical personnel.

4.9 The main medium and longer-term strategy recommendations were:

(a) development of an agriculture and food strategy for supply of low-cost food staples to low-income groups, with special attention toproduction of low-cost protein rich crops against nutritionally-inferior, higher-cost commodities

(b) research and development towards production of low-cost weaning andcomplementary infant foods based on indigenous raw materials anddevelopment of low-cost food technologies

(c) exploration of the feasibility of fortifying suitable staples withsoya, iodine, minerals, iron and Vitamin A

(d) increased investment in development of social infrastructure such aswater supply, housing and sanitation

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(e) development of a national nutrition education policy for implementa-tion through the formal education system, standardized trainingprograms for planners, educators, administrators and extensionworkers and expanded interpersonal and mass media programs coordina-ted by FNPPD and planned and executed by appropriate agenciesincluding the Ministry of Information and Broadcasting.

4.10 In 1984, the National Planning Division of the Ministry of Financeand Planning drafted a National Agricu."ture, Food and Nutrition Strategy(NAFNS) drawing on the work of FNPPD and seven interministerial task forces:crop agriculture, smallholder tea and rubber, coconut, fisheries, livestock,land and water resources development and nutrition. The explicit nutritioncontent of the strategy focussed on two main themes: expansion of agriculturalemployment and food supplementation for vulnerable populations, principallythrough the food stamps program. However, other aspects of the draft strategyalso could have positive nutrition implications. Improved marketing couldbenefit lower-income consumers to some extent. Research could lead toincreased yields of manioc, corn and other subsidiary field crops in areaswhere rice production is uncertain. Efforts to lower the production cost ofrice could benefit low-income groups. Conversely, the recommendation forcontinued subsidies to stimulate sugar production could work against thepoorest deciles, for whom sugar is a significant calorie source, if domesticprices thereby remained well above border prices.

4.11 Later that year, MOPI issued a national nutrition strategy documentwhich again suggested that the food consumption situation had deterioratedbetween 1969/70 and 1980/81 for lower income groups. Income distribution hadworsened, around 55? of households failed to meet calorie adequacy against 40Zearlier, and the budgeted family food share had risen to around 702 of house-hold income against 52Z ten years earlier. It identified Badulla, Hambantota,Kandy, Moneragala and Nuwara Eliya as highest priority districts for nutritionintervention, based on the 1979-82 national survey, with Galle, Kegalle,Matara and Ratnapura grouped as the next highest. The strategy repeatedearlier emphasis on generating income for the poor through agriculture, parti-cularly in Galle, Kegalle,Matara and Ratnapura, but effectively also in otherdistricts such as Badulla, Hambantota, Kurunegala, Matale, Moneragala andPuttalam. Where agriculture would be a less effective instrument(Anuradhapura, Amparai, Batticaloa, Colombo, Gampaha, Kalutara, Jaffna, Kandy,Mannar, Mullaitivu, Polonnaruwa and Trincomalee), food supplementation wouldbe the intervention of choice. National production of legumes, pulses andsoybean should be encouraged to supplement and, over the long term, partiallysubstitute for rice. The strategy also called for efficiency improvements inthe food stamps program to reduce leakago, while ensuring maintenance of thereal value of the program for those at greatest nutritional risk.

4.12 During this same period, IFPRI (see para 5.6) contributed to thestrategy dialogue by collaborating with FNPPD to analyze Sri Lankan foodconsumption patterns and the workings of the food stamp program. The mainconclusions of that extensive and careful analysis 17/ confirmed thenutritionally precarious and worsening situation reported by FNPPD. Inconducting its food consumption work, IFPRI paid attention to particularly at-risk group--the "ultra-poor", families who spend more than 80Z of income for

17/ Sahn. op. cit.

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food but achieve less than 80 calorie adequacy by accepted internationalstandards.18/ Around an estimated eight percent of Sri Lanka households, or aconservatively estimated 1.3 million persons on the basis of presentpopulation figures, would be in that group. At least an additional twomillion moderately poor persons suffer serious calorie shortfalls on the basisof IFPRI's estimates, also mainly in the lowest three expenditure deciles.According to IFPRI's analysis, the families of two occupational groups,comprising over half the households in the lowest two income deciles and 302of all households, are at greatest risk. They are non-classified laborers,who make up 30? of the households in the lowest two income deciles, and 12? ofall households, and agricutbural and animal husbandry workers, who are theprincipal earners in over 202 of households in the lowest two deciles andaround 17? of Sri Lanka's total households.

4.13 IFPRI's main conclusions were that a combination of growth emphasiz-ing redistribution to the lowest income deciles and moderation in rice priceswas key to eliminating malnutrition in Sri Lanka. It also recommendedindexing the value of food stamps to either rice prices or cost-of-livingchanges in view of the sensitivity of the poor to even modest price and incomeshifts. Regarding other food commodities, IFPRI recommended considering waysto raise economically viable production and subsidize or lower the consumercost of foods eaten mainly by the poor, e.a. yams, cassava or other roots,tubers and coarse grains. The report pointed out that most agriculturalresearch had focussed on increasing rice production at the expense of othercommodities and, for example, had failed to explore adequately the potentialrole of coarse grains such as corn, millet and sorghum as rice substitutes andincome sources on marginal lands for the poor.

4.14 In February, 1985, the NFNCC held a special meeting to discuss theNAFNS and its individual strategy papers. A number of recommendations emergedfrom that discussion which did not significantly reflect either the MOPIstrategy paper or IFPRI's findings, but later found their way into an NAFNSaction plan (see para. 4.23), indicating a lack of effective coordinationbetween the NFNCC and FNPPD.

4.15 The MOPI nutrition strategy document, IFPRI's reports and the NAFNSall agreed that both targetting improvements and maintenance of the real valueof the food stamps program were necessary. However, on the agriculture front,differences in approach on key agricultural issues were apparent. Theseincluded relative emphasis on calorie, vs. protein consumption, higherproducer vs. lower consumer prices for rice and sugar and the role of subsi-diary food crops. The next stage of the process--translating strategies intoaction plans and programs--also continued to reflect the differences ratherthan effective coordination among the key institutional actors.

National Nutrition Action Plan

4.16 In May, 1986, FNPPD in collaboration with relevant agencies prepareda comprehensive food and nutrition action plan based on the 1984 NAFNS (seepara. 4.10) and MOPI (see para. 4.11) nutrition strategy documents, as well as

18/ See Annex B.

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IF,4RI's findings. The plan effectively reviewed the nutrition situation andits policy implications in the context of each of six key sectors, andproposed short, medium and longer-term actions to meet the nutrition andrelated socio-economic needs of target groups over the next 10 years. The sixsectors were: food, trade and shipping; agriculture and livestock; fisheries;health: social services and plantations; education and communication, and(NGOs). The principal objectives of the action plan were to reduce:

- chronic undernutrition by at least 7.5? in the short-to-medium term (3-5 years) and by a further 5-7.5X in the medium-to-long term (5-1u years);

- acute undernutrition by 5? in the short-to-mediumterm and by a further 2.52 in the long term;

- iron deficiency by 20-30? particularly among children,mothers and the work force over the next 15 years; and

- goiter incidence in the major goiter pockets to around2.5?.

Other objectives were to contain levels of Vitamin A and B deficiencies to thepresent level of under 2? and to increase the purchasing power of the poor.The national steering committee for the plan was chaired by the Secretary,MOPI. The committee and support staff included senior representatives ofFinance and Planning, Agriculture, Ayurveda, Education, Fisheries, Health,Mahaweli, Rural Industrial Development, Social Services, Trade, the plantationsector, the Central Bank and non-governmental agencies as well as nutritionand communication experts.

4.17 The action plan called for reorientation of sectoral and subsectoralplans in each concerned ministry to take account of consumption and healthfactors affecting nutritional status. It recommended general actions cuttingacross individual development sectors as well as specific measures withineach. Overall recommendations over the next five years were made at bothdistrict and national levels. The plan recommended strengthening districtfood and nutrition planning by upgraded staffing and training, increased plan-ning budgets and better coordination with population and health infrastruc-ture. Nationally the plan urged greater use of available human resources inline ministries for nutrition education, adoption of a lead role by theWomen's Affairs ministry in regard to the role of women in nutrition andimproved coordination within the NFNCC and between it and the NHC. The mostsignificant longer-term overall recommendation was for the establishment ofnutrition considerations, including incorporation of a specific and budgetednutrition subsector with projects and activities, into all relevant sectoralplanning programs, and the establishment of nutrition cells in line ministriesfor that purpose. The plan also recommended that FNPPD take responsibilityfor setting up, managing and coordinating a nutrition surveillance system tobe implemented in coordination with agencies including the Ministry of Health,the Department of Census and Statistics, the Central Bank and the Registrar-General's Department.

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4.18 Among the proposed agricultural initiatives were two with particu-larly important potential benefits to low-income groups: improving the effi-ciency of rice production through better post-harvest technology (which theNAFNS had recommended) and developing the subsidiary food crops sector, withparticular emphasis on low-cost starchy staples (e.2. yams, cassava) andcoarse grains, pulses, legumes and oilseeds. In addition to improving profit-ability, improved rice processing could result in savings to consumers.Particularly in vulnerable areas of Moneragala, northern Badulla, Batticaloaand Amparai, subsidiary food crops including maize and cassava are importantcash and seasonal food crops, respectively, for both low-income producers andconsumers.

4.19 Other noteworthy agricultural recommendations were to reorientresearch priorities to the nutrition needs of the lower income deciles, toexplore food fortification, including soy-fortified flour as a possible foodstamp commodity, and to promote home Sardens. On the marketing side, thepossibility of using Agrarian Service Centers to sell a select basket of cheapnutritious foods for food stamps was suggest-d. To carry out nutrition exten-sion and related activities more effectively, reorganization and diversifica-tion of the Home Economics Extension Division of the Ministry of Agriculturealso was recommended.

4.20 The action plan called over the next five years for the health sectorto "accept a major responsibility' regarding prevention of malnutritionthrough promotion of family health services and expanded nutrition education,emphasizing improved worker-client interaction; household rehabilitation ofmalncurished children through home visiting and monitoring, promotion ofimproved weaning practices, and nutrition manpower development. Over thelonger-term, the establishment of a national nutrition surveillance system forat-risk groups was proposed along with health-related nutrition research anddefining a nutrition role for the ayurvedic sector, particularly in regard togrowth monitoring, supplementary feeding, and immunization.

4.21 Regarding broader aspects of nutrition education, trair.ing and com-munication, the report recommended a number of important measures over thenext five years. The proposed agenda included expansion of staff nutritiontraining for all institutions engaged in community nutrition education, par-ticularly in the agriculture, health and NGO sectors; upgrading of nutritioneducation in the school and university system, and nutrition sensitization ofconcerned officials, particularly at district and village levels. It alsourged each sector to develop combined mass media and interpersonal communica-tion programs consistent with its technical responsibilities under appropriateoverall coordination and technical supervision.

4.22 Finally, the plan suggested closer government-NGO linkages in respectof food, nutrition and health in addition to inclusion of NGOs on sectoralplanning committees in each public agency concerned with nutrition planningand development. NGOs, on the other hand, should aim to link up with andsupplement government nutrition efforts through sharing resources, personneland experiences.

4.23 Complementing the plan, which would represent a sound medium-termapproach to Sri Lanka's nutritio;; problems, was a set of preliminary project

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proposals with estimated budgets totalling around Rs 100 million over fiveyears for proposed inclusion in the 1987 Public Investment Program. Severalof the proposals would appear to contribute only indirectly to the main goalsof the action plan, but they pointed to the emergence of useful awareness ofnutrition as a program concern in sectors other than health.

NAFNS Implementation Plan

4.24 One month after FNPPD preparation of the national nutrition actionplan, the Ministry of Finance and Planning published a separate NAFNS imple-mentation plan of prioritized but unbudgeted proposals confined to the foodand agriculture sectors which contained several with potentially importantnutrition implications. The highest-priority proposals with greatest nutri-tion potential were: rice research to develop varieties and production tech-nologies for different agro-ecological environments; implementation of policyinitiatives, production and marketing programs to promote other field crops;development of screening and indexing mechanisms for the food stamp program,and incorporation of nutrition considerations into district development plans.However, that implementation plan did not speak to the question of how best toorient the food and agriculture initiatives to the needs of low-incomeconsumers or discuss an implementation timeframe.

Implementation Status of Nutrition and NAFtIS Plans

4.25 Translating these generally soundly-oriented planning documents intoactive programs has been disappointingly slow because of fiscal constraintscombined with line ministry difficulties in setting operational objectives andformulating detailed operational plans and budgets. Moreover, the disintegra-tion of the NFNCC (see para. 4.2) has closed off a Cabinet-level politicalforum analogous to the NHC to reach consensus on major policy, strategy andprogram aspects of nutrition from a food and agriculture perspective. Theabsence of a unifying focal point to harmonize the ideas of individualagencies has led to sometimes conflicting institutional approaches.Establishment of an active National Nutrition Policy Council and NationalNutrition Bureau (see para. 4.4) to develop consensus and push implementationmight help resolve that problem.

V. NUTRITION COSTS AND INTERVENTIONS

A. Nutrition Intervention Programs

5.1 Sri Lanka's largest publicly-funded nutrition intervention programsconsist mainly of targeted food interventions at the household level, on-sitepLeschool and school feeding and nutrition education. MCH and othercollateral programs also address nutrition issues.

5.2 The two household food interventions--food stamps and thriposha--account for around two thirds of total nutrition expenditure in Sri Lanka.Food stamps are targeted to families by income and represent essentially afamily income transfer. Thriposha, a widely-acceptable take-home supplementis targeted to malnourished preschoolers and selected women in pregnancy orlactation.

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Food Stamps

5.3 The food stamp program was introduced in 1979 as part of the economicreforms package of the new government. The stamps replaced a rice rationing/subsidy program which had operated since before independence and is widelythought to have contributed to some of Sri Lanka's favorable social indica-tors, including a substantial reduction in levels of acute child malnutrition.The objective of the food stamps program was to protect low-income consumersfrom the adverse impact of removing food subsidies which had accounted for asmuch as 152 of total government expenditure and 52 of GNP in the mid-70's. Itwas also felt that the rationing and subsidy programs had been, on balance, arelatively ineffective and costly way of targetting benefits to the poorestincome deciles.

5.4 Food stamps are redeemable at cooperative stores for basic foods,such as rice, at market prices. As originally designed, eligibility was con-fined to households with declared monthly incomes of less than Rs 300. Themonthly value of the stamp entitlement varied with beneficiary age. Thoseunder eight years of age received Rs 25; those between eight and 12 yearsreceived Rs 20 and those older than 12 years received Rs 15. Food stamphouseholds also received kerosene stamps to counter rising fuel costs, themonthly value of which rose from an initial Rs 9.50 to around Rs 22 by 1987.

5.5 'While targeted to the poorest, the new program emerged as incomesupplementation for a much larger population, totalling an estimated 6.8 mil-lion. IFPRI analysis as part of a research project funded by USAID 19/indicated that the poorest and second income quintiles received only 382 and282, respectively, of total food stamp outlays. In addition, as many as 102of eligible persons were not included in the program. IFPRI concluded thatlimiting eligibility to the poorest income quintile would not have seriouslyaffected consumption levels of less-poor consumers who also received foodstamps. (That may no longer be true as a result of deteriorating real incomesin a substantial population segment.) Inflation compounded the effects ofmistargeting. The actual value of the unindexed stamps declined by almosttwo-thirds between 1979 and 1987.

5.6 In 1985-6 the program was restructured to increase the value of thestamps for the poor without increased government expenditure. In addition toshifting implementation responsibility to the Social Services department,principal changes were: opening the rolls to most of the eligible but non-participating households, raising the eligibility cut-off point to householdsreporting under Rs 700 monthly income and weighting family assistance levelsby income. Under the new arrangements, households with reported monthlyincomes of less than Rs 300 were eligible to receive stamps for at least fivemembers. Households with reported monthly incomes of Rs 300-399, Rs 400-599,and Rs 600-700, were eligible for stamps for four, three and two members,respectively.

5.7 Several other measures also were introduceu to improve targetting ofnew entrants. A series of district Poor Relief Committees was set up in 1987.

19/ Edirisinghe, Neville, The Food Stamp Scheme in Sri Lanka.International Food Policy Research Institute, Washington, D.C. October1986.

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Each consists of four officials and a nominated member who screen outunqualified applicants. Those whose prelipiinary applications are approvedprovide further information to be checked by a government Committee memberthrough personal visit. The names of household heads finally approved by theCommittee are publicly listed as a further safeguard against wrongfulinclusion or exclusion. As a result of these changes, the total number ofper&ons receiving food stamps rose by around 102 to 7.6 million--472 of thetotal population--while the cost of the program remained at around Rs 1.6billion, through reduced benefits to those at the upper end of incomeeligibility. Under those arrangements, stamps reached around 1.7 millionchildren under seven years of age, 801,000 children aged 8-12 years, andaround 5.1 million adults. To what extent the restructuring particularlybenefitted the most severely deprived is unclear, but they appear to have atleast shared in the new enrollment opportunity. Unfortunately, the shift inentry criteria was not accompanied by elimination of unqualified existingbeneficiaries. Moreover, in December, 1988, the Cabinet decided to add to therolls all those on the waiting list and in January, 1989, decided to doublethe value of the stamps. This combination of changes raised the cost of theprogram by 125Z and increased the number of beneficiaries to over eightmillion.

5.8 Food stamps now provide the equivalent purchasing power of fewer than1,000 calories per day to a low-income family of five. According to IPPRIanalysis of 1981-82 data the additional food stamp income raised calorieconsumption by 122 and 61 in the lowest two income quintiles, respectively.The analysis also concluded that because of leakages to higher-incomerecipients, who should have been excluded from the program, food stamps forthe lowest income quintile have cost the government "150 percent more thanwhat it cost the recipient households to purchase the given amount ofcalories.' It also reported that "food stamp incomes appeared to increasecalorie consumption of preschool-aged children in the lowest quintile by 5.4percent; all other members in the same households increased their calorieconsumption by nearly 10 percent due to food stamps.'

5.9 The current purchasing power of food stamps should be sufficient toundergird the nutritional needs of most food-insecure households, although theprogram as a whole is inefficient because of substantial overenrollment.Analysis of the 1986-7 CFS indicates a daily family calorie shortfall of 1,268and 680 in the lowest urban and rural income deciles, respectively, excludingfood stamps. The next higher deciles, and the estate sector, are in lessprecarious conditions. At current purchasing power and levels of food stamps,only families in the lowest two urban income deciles still would need furthersupport to reach minimally acceptable consumption levels of 2,000 calories peradult-day. As shown in Annex A, Table 10, the annual cost of a perfectlytargeted food stamp program meeting raising the consumption threshhold to2,000 calories per person-day for all food-insecure Sri Lanka families wouldbe less than RS 1,000 million--less than one-third the currently budgetedoutlay.

Thriposha

5.10 Thriposha is distributed to up to 580,000 pregnant and nursing womenand malnourished children under five years of age. A 50-gram serving contains

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186 calories and 13 grams of protein, along with vitamins and minerals. Theration is estimated as adequate to meet around 402 of the protein and anaverage of around 152 of the daily calorie needs of an under-three child.Child beneficiaries are identified mainly through monthly weighing at MCHfacilities, where pregnant and nursing women are also enrolled by medicalpersonnel on the basis of clinical signs of anemia or breast-feeding problems.

5.11 Thriposha is a formulated, pre-cooked food consisting of locally-grown and processed corn and soya combined with imported non-fat dried milk(NFDM) donated by the US Government under Public Law 480. A vitamin-mineralpremix is part of the formula but has been unevenly available over the pastyear. The Ministry of Health (MH) finances local commodity and operatingcosts of the program and distributes thriposha. Around 500,000 beneficiariesare expected to receive the supplement monthly on a take-home basis throughhealth centers. Some 60,000 estate and 20,000 voluntary agency (largelythrough Sarvodava) beneficiaries are expected to receive on-site supplementa-tion. The number of enrolled beneficiaries actually collecting thriposhatends to vary somewhat by month, according to program records. However, parti-cipation began to increase steadily in late 1987 and rose to around 92Z ofthose enrolled in the program by February, 1988, the last month for which datawere available to the mission. Around 59Z of the beneficiaries were childrenaged 13-59 months; 162 were children aged 7-12 months; 14Z were pregnant and10X were lactating women, and the other 12 was hospital cases. That coveragetotals around 472 of all children aged 7-12 months, 202 of those aged 13-59months, and 322 of women in the last six months of pregnancy or first sixmonth3 of lactation.

5.12 CARE, tha US voluntary agency, initiated the program in 1972 and hasplayed a major collaborative role in its design and implementation, includingthe establishment and oversight of thriposha production facilities with AID-funded technical assistance. CARE also assists in program monitoring toassure accountability for distribution to service delivery points and to bene-ficiary families. Discussions currently are under way regarding: (a) theplanned phaseout 'jy 1991 of AID commodity assistance to the program, (b) howbest to implemert a 1987 Cabinet decision to double current thriDosha produc-tion capacity and (c) prospects for privatizing production rather than contin-uing it under Government auspices.

5.13 Two evaluations of the program have highlighted both its accomplish-ments and shortcomings. One, conducted under AID contract, found throughlongitudinal analysis of beneficiaries that "the package of services[including thriposha] provided through MCH clinics improved nutritionalstatus" although it was not possible to segregate the impact of thriposhaalone. It went on to conclude that thrinosha targetting was generally effec-tive: four of five child beneficiaries were either malnourished or at seriousrisk. It also observed that the program had the important spin-off effect ofincreasing family contact with the public health system.

5.14 The AID-sponsored evaluation suggested operational and managementimprovements to the program. These included better compliance with andmonitoring of targetting procedures, commercialization of thriposha productionand more involvement of mothers in growth monitoring by weighing their ownchildren and filling out growth charts. It also observed that sharing of

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thriposha among family members took place, possibly diluting its nutrLtionalimpact. Reduction or termination of the program might be difficult since somany poor beneficiary families had become dependent on thriposha as anentitlement. The other evaluation, published by FNPPD, also noted deficien-cies in the beneficiary screening procers and problems of thriposha leakage toineligible family members. It observed that nutrition/health monitoring andfinancial record-keeping needed considerable improvement at the field leveland made several recommendations regarding logistics of thriposha suipply toMCH facilities.

5.15 A subsequent AID-government workshop to review thriposha recommendedgovernment clarification as to whether the program was meant as supplementalfeeding for general nutrition improvement or a nutrition safety net for mal-nourished preschoolers and mothers. It also cited ineligible beneficiaries,the lack of adequately-linked nutrition education and the need to incorporatethriposha more effectively into a comprehensive preventive care program.

5.16 MH since then has taken steps to improve the logistics aspects of theprogram, but fundamental problems inherent in most take-home supplementationefforts persist. The quality of growth monitoring is variable; both the regu-larity and accuracy of the process are uncertain. In some areas monthly weigh-ing is by village volunteers, each responsible for around 25 families. Super-vision is constrained by other demands on health worker time and performancequality has not been formally assessed. These same time pressures also affectthe regularity and reliability of weighing by health workers. In theory,thriposha eligibility is determined by the subdivisional Medical Officer ofHealth. In practice, the task can devolve to the peripheral health worker whohas little incentive to screen beneficiaries on nutritional criteria sincethriPosha supply often exceeds demand. Sufficient and clearly allocated timeare required for effective performance of counselling and educational aspectsof the growth monitoring process but frequently receive low priority againstcompeting tasks.

5.17 Additionally the nutritional response to thriposha is not closelymonitored and criteria for terminating supplementation are vague. Conse-quently, little motivation exists for health staff involved with the programto ensure the achievemen. of normal child growth patterns.

5.18 The economic cost of producing and packing a 750g packet of thriposhais currently estimated at Rs 23.05, including the imputed value of donatedcommodities. Those unit costs are projected to decline as cheaper localcommodities replace expensive NFDM. However, the financial costs of th_iposhaproduction are already artificially high because of the requirement to buymaize from the Paddy Marketing Board at a negotiated rather than the openmarket price and a support price for domestic soy which is well above borderlevels. The Government should consider liberalizing proctiement arrangementsto lower the production cost of thriposha.

5.19 Doubling local production of thriposha would keep availabilityconstant when AID's pre-processed input phases out. Current annualbeneficiary coverage is around 405,000 under-five children and 128,000pregnant and nursing women. If properly targeted, the available thriposhasupply could supplement all children aged 6-59 months who a:e likely to be

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either acutely malnourished or both stunted and wasted, with enough left overto cover an additional 1OZ of that population whose growth may otherwise befaltering. It also could provide supplementation to the 25? of pregnant womenat high risk of low-birth weight babies and 252 of new mothers who may needsupplementation during lactation.

On-site Feeding

5.20 FNPPD and the Ministry of Indigenous Medicine for some yearscollaborated in an effort to popularize kola kenda, a nutritious gruel, as asupplement for children. The product usually consists of mung bean, rice, thejuice and sometimes mashed pulp of local varieties of green leaves (e.g.kotukola, mukunvenna, hatavariva. penella and batu) and, when affordable.coconut milk. The gruel varies in content, consistency and nutrient value,depending on its local composition. However, a six-ounce cup is said tocontain around 180-200 calories, some micronutrients aMd a proportional amountof high-quality protein. The value of the raw materials, including fuel,varies, but mission calculations in the field averaged Rs 1.20 per serving.The importance of kola kenda is that it is a community-based intervention.The government provides cooking utensils worth Rs 2,500 to each facility wherethe community agrees to provide the raw materials and cook the gruel ence ortwice a week. Sarvodava provides kola kenda up to_five times weekly to around29,000 beneficiaries at over 1,000 pre-schools; FNPPD reports that the supple-ment also is avpilable at more than 1,200 schools in 23 districts. The use ofan indigenously-designed supplement through extension community participationhas considerable potential merits. However, wide variations in composition ofthe supplement and its sporadic delivery generally hamper the value of kolakenda as a nutrition intervention.

5.21 The new Government recently announced a national free lunch programfor all of Sri Lanka's estimated 4,000,000 school children. The program is toprovide a 500-calorie cooked meal for 180 school days annually at a dailybudgeted cost of Rs 3 per beneficiary. Provincial Councils are to implementthe program with assistance from the ministries of Education; Agriculture,Food and Cooperatives; Health and Women's Affairs; Social Welfare, and PublicAdministration, Provincial Councils and Home Affairs. Commodities are to beprocured by officials at each school. Community v-:unteers are expected tohtelp prepare the meals. An initial Rs 2 billion has been budgeted for theprogram for calendar 1989 on the implicit assumption that annualize costs willrun around Rs 2.6 billion. However, it is more likely Lhat the real cost ofthe program will be substantially higher. The cost of calories now averagesaro. d Rs 7 per thousand for average diets. Administrative costs, either assup.'.ementary staff payments or calculated as the opportunity cost of time,will add a minimum 20? to the program. Combined with inflation, these factorsmake it likely that the total cost of the program will approach Rs 4.55 perstudent-day, or around Rs 3.3 billion for the first year alone. Schoolfeeding may promote better school performance and reduced absenteeism, but asa nutrition intervention is of lower priority than efforts to counter pre-school malnourishment and miconutrient disorders, which particularly duringthe formative first three years of life have a more profound and permanentimpact on child growth and development.

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Nutrition Education

5.22 Relatx. ly small amounts of nutrition education take place through anumber of agencies. These include activities funded both centrally and atdistrict levels through FNPPD. the interesting work of the Farm Women'sAgricultural Extension program, some Ministry of EducAtion programs and someas part of MCH efforts. The Secretary, MOPI, chairs a special sub-committeeto monitor and coordinate nutrition education and communication programs whosemembership includes representation from FNPPD, the media and the ministries ofAgriculture, Education, Health and State. However, a national set of nutri-tion education objectives and a strategy to carry out them out has yet to bedeveloped.

5.23 FNPPD's nutrition education programs have centered on seminars andworkshops for officials and community leaders and the creation of publicnutrition awareness. Emphasis has been on the use of radio, the press andtelevision; preparation of nutrition education readers and other publicationsfor schools, and tne publication of nutrition periodicals for the generalpublic. However, in the absence of clear objectives or a strategy, the impactof these efforts is likbly to be limited. The World Food Programme (WFP) hasprovided food commodities to compensate pregnant and nursing women, parents ofmalnourished children ai.. community leadezs for the opportunity costs ofattending a pilot FNPPD nutrition education program in seven districts. Thenutrition education activities ranged in duration from one to 26 days, theproject included mobile health clinics to immunize children and reached around79,000 adults and 166,000 children. Expansion and refinement of that programwith WFP assistance is now under consideration based on an evaluation of thepilot phase, which is underway.

5.24 At the district level, applied nutrition programs in around 24 of SriLanka's 25 districts have included nutrition education workshops and promotionof home gardens. However, the allotted funds have been modest, running aroundRs 2-3 million yearly from the decentralized budget. The 1988 allocation roseto Rs 10 million but local absorptive capacity limited expenditures to aroundRs 4 million, including costs of kola kenda, salt iodization, promotion ofhome gardens and nutrition education seminars.

5.25 With FAO and then UNICEF support, since 1976 the Farm Women'sAgricultural Extension (FWAE) program of the Department of Agriculture hassought to work with rural women to promote better community health and nutri-tion through household food production, improved management and organizationof home activities and better planning and preparation of nutritious meals. Anetwork of 33 female subject matter specialists carries out class and house-hold instruction in home gardening; home, food and nutrition management andincome-generating activities such as bee-keeping, floriculture and handi-crafts. The current UNICEF-aided program, begun in 1984, covers 6,860families in eight of the 22 districts where FWAE already operates as an effortto increase the income and health and nutrition standards of ten of thepoorest families in each village. The program is to expand to all of SriLanka's 25 districts coverage over the next four years as more FWAE staff getrecruited and trained. Although not yet formally evaluated, the combinationof extension and health and nutrition education, provided on a woman-to-womanbasis, is an attractive approach which, while labor intensive for FWAE, couldprove t3 be cost-effective.

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Health-Related Interventions

5.26 Widespread iron and folate deficiency problems particularly affectingpregnant and nursing women and probably preschool children (see para 1.11) areaddressed by distribution of iron supplements and messages regarding appro-priate dietary practices through peripheral health workers. However, mostobservers agree that compliance is uneven and the iron deficiency problem hasfailed to show significant improvement in recent years. Ministry of Healthguidelines recommend 200 mg of iron thrice daily, which some women toleratepoorly. Small-scale testing by a Sri Lanka voluntary agency indicates that 60mg daily is effective in raising hemoglobin levels and well-tolerated by womenwhen administered with a meal, a finding which suggests the need to consideradjusting current guidelines.

5.27 In early 1987 the Cabinet approved remedial action against iodinedeficiency disorders through a pilot project for salt iodation in Kalutaradistrict, where the sale of unfortified salt has been banned. The NationalSalt Corporation produces and distributes half-kilo packets mainly throughcooperative stores at a retail price of Rs 2.75 per bulk kilo against Rs 1.75for common salt. The Sri Lanka Standards Institute maintains qualLty contrcl;the Medical Research Institute (MRI) is responsible for baseline and follow-upsurveys to determine impact. However, the program operates on quite a limitedscale. Annual distribution of around 20 metric tons is enough to meet theyearly needs of only around 4,000 beneficiaries. It is estimated that by theyear 2,000, when Sri Lanka's population is likely to be around 20 million, thecountry's total salt consumption would be around 100,000 tons. According toan international fortification expert, in current prices the investment costof physical facilities and equipment to fortify that salt would be US$5.8million and the annual operating cost of fortification including chemicals,labor, power, overheads and depreciation would run around US$3.3 million, oraround US$0.17 (Rs 5) per capita.20/

5.28 However, lack of effective demand is likely to be more of a long-termconstraint to salt iodation than technical or managerial issues. Low-incomehouseholds tend to prefer coarse or even rock salt, which is cheaper andabsorbs less moisture than finely-granulated varieties. Elimination of tradi-tional salt varieties from the market would be difficult until a combinationof education, availability and pricing generated sufficient demand for theiodized product. In the interim, the government could consider an optionalapproach to goiter control: injectible iodine for married women in high-riskareas who intend to have more children. At a cost of US$0.25 per dose, theiodized oil confers three years of protection for both the woman and herfetus. Delivery would be feasible through the Health ministry's extensiveinfrastructure. Assuming that around 300,000 women would be an upper boundfor the program, annual delivery costs would run less than Rs 1 million.

5.29 Vitamin A deficiency is believed relatively low in Sri Lanka atpresent. However, it has been high in the past and areas and groups withhigher prevalence persist. Combined with continuing high morbidity fromrespiratory and intestinal infections, this evidence suggests that fairlywidespread subclinical deficiency may exist. Vitamin A supplementation

20/ Communication from S. Venkatesh Mannar to IBRD staff, March 1988.

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currently takes place sporadically where the frequency of clinical signsexceeds WHO-defined thresholds; there are no plans for general pre-schoolprophylaxis. Vitamin A is not administered routinely to measles casesalthough proven effective in reducing complications. Experience in Indonesiaindicates that Vitamin A prophylaxis in pre-school populations with marginalnutrition and health status is effective in reducing mortality and morbidity,particularly from diarrheal disease and acute respiratory infections. SriLanka might consider the benefits of mass vitamin A prophylaxis for pre-schoolchildren on that basis. Based on current international costs for high-dozeoral Vitamin A, the mission estimates that a national pre-school program wouldcost around Rs 2 million.

5.30 In addition to addressing micronutrient deficiency problems, MCHinterventions can improve the biological utilization of available nutrients.They affect nutrition status by improving weight gain during pregnancy,promoting breast-feeding and safe weaning practices and by effective controlof non-immunizable infectious diseases through oral rehydration, prompt treat-ment of acute respiratory infections and deparasitization. Malariaprophylaxis in pregnancy and effective household control measures for childrenalso would contribute. Against these needs, health sector performance hasbeen mixed. Sri Lanka has promulgated and enforced a comprehensive code regu-lating infant food formulas and breast milk substitutes. However, low birthweigh remains a key factor affecting infant nutrition status. Control andtreatment are considered routine aspects of MCH care, but available morbiditydata indicate that diarrhoea, respiratory morbidity, intestinal parasites andmalaria remain as nagging problems which the health system needs to addressmore vigorously.

5.31 The use of oral rehydration therapy (ORT) is the preferred controlmeasure until environmental sanitation measures eliminate diarrhea as a publichealth problem. However, the 1987 DHS and Dry Zone studies indicate thatalmost twice as many families know about than actually use ORT. Furtherstrengthening of promotional and educational programs against diarrhoeaprobably are needed, perhaps on a campaign basis.

5.32 At present, acute respiratory infections are treated with antibioticsonly by medical staff. Primary health programs in other countries havesuccessfully lowered qiortality by providing antibiotic cover to small childrenat lower levels of care through paraprofessionals. Oral co-trimoxazole can beadministered easily to small children at the village level by auxiliarypersonnel. Routine deworming of children with mebendazole, has proven effec-tive elsewhere and is worth Sri Lanka consideration in areas of particularlyhigh infestation. However, the per-beneficiary incremental costs, at aroundUS$7.01 per year, would be too high for mass national administration. Thepresent approach to treatment of presumptive malaria fever with chloroquinemight be strengthened by continual or seasonal chemoprophylaxis withpyrimethamine/dapsone, as in the Gambia.

Other Initiatives

5.33 Spurred by the apparent deterioration in nutrition status, theCabinet in late 1987 approved the Prime Minister's suggestion that Sri Lankadevelop a short-term project to improve nutrition standards of children aged

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6-36 months with assistance from donors including the World Bank. FNPPDexamined the matrix of existing interventions to see whether they could bemodified to meet the Cabinet's objectives but concluded that it would bedifficult quickly to rationalize the food stamps or thriposha programs tobring about desired changes. For example, needed improvements in thriposhatargeting, nutrition education and management would produce only medium-termresults.

5.34 In response to the Cabinet mandate, FNPPD formulated a pilot projectfor 'nutrition villages" in Sri Lanka. This effort would blend selectedfeatures of nutrition programs in other developing countries of Asia toimprove the status of the ultra-poor through a combination of poverty allevia-tion, employment 2nd nutrition interventions. The estimated cost of theprogram over five years would be around Rs 1,600 million, equivalent to one7ear's food stamps outlay. It would aim at generating adequate and self-sustaining incomes for 189,000 poverty-stricken frmilies comprising around 1.1million beneficiaries, while improving the nutritional status of preschoolchildren and pregnant and nursing women.

5.35 Beneficiaries would be selected first through growth monitoring toidentify households with moderately or severely malnourished or micronutrientdeficient preschool children and pregnant or nursing women. Economic criteriawould then be applied to screen households further, including consideration offood stamp recipient or landless households or those without any economicactivity. Seventy-five households would be considered a "nutrition village"from an organizational and managerial perspective. A panel headed by theAssistant Government Agent would make final selection of beneficiaries and'villages" .

5.36 The components of the project would consist of a Rs 2,500 familysubsidy over two years to each participating household, food supplementation,environmental sanitation and nutrition education. The subsidy would be basedon criteria and principles to be worked out at the district level by theGovernment Agent and concerned agencies; it would be expected to result inself-sustaining income generation and employment for one family member.During this period, eligible preschoolers and women wouid receive on-site foodsupplementation five days a week at a budgeted cost, respectively, of Rs 3.50and Rs 5 per daily ration. The suggested dietary combinations are mixtures ofcereals (preferably rice) and pulses, kola kenda, egg and margarine-smearedbread and milk and a bun or biscuits. Environmental sanitation would beimproved through a latrine for each household and three community wells per'village'. Intensive nutrition education would take place to improve familyfeeding and related practices.

5.37 This proposal is now being pilot-tested in 28 villages where, for themost part, surveys have taken place and, in some, food supplementation hasalready gotten under way. An impact evaluation is scheduled for mid-1989.

Other Donor Activity

5.38 In addition to donor support referred to above, several local andforeign voluntary and government agencies also are active in smaller-scalenutrition interventions. These include Redd Barna, a Norwegian voluntary

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agency undertaking food production, supplementation, health and nutritioneducation programs in several parts of the country, including the north; boththe UK and US. Save the Children foundations, and the local Saukyadhanamovement.

B. Costs

5.39 Sri Lanka's nutrition spending has tripled since 1987. At aroundRe 6.2 billion (US$188 million at current exchange rates), Sri Lanka's totalnutrition spending constitutes around 9Z of projected total and around 12% ofprojected recurrent Government expenditure for 1989. Around US$109 millionequivalent, or 602 of those nutrition outlays, are for a single Governmentsubsidy program--food stamps. A second program--school lunches--accounts forone-third of currently budgeted nutrition costs. Another household foodsupplementation program--Government distribution of thriposha for mothers andchildren with CARE assistance--accounts for a further 42 of overall nutritionoutlays. Other Government, voluntary agency and official foreign aid programsaccount for the residual 3Z. Until the recent jump in food stamp costs andthe introduction of the school lunch program, annual nutrition expendituresvaried by around a nominal 62 in recent years, principally because: (a) foodstamps accounted for a steady Rs 1.6 billion annually, (b) other existingprograms remained relatively constant and (c) the few aew nutritioninitiatives involved minimal spending, particularly in the face of overallbudgetary constraints.

VI. ISSUES AND OPTIONS: AN ACTION AGENDA

6.1 Sri Lanka's nutrition problems are essentially twofold. The first ishow to deal with chronic nutrition insecurity at the household level, affect-ing the lowest three urban and lowest rural income deciles. The second is howto ensure adequate nutrient availability and utilization by specific targetgroups, particularly young children and pregnant and nursing mothers. Thelatter problem exacerbates the already inadequate availability of food to poorhouseholds and is responsible for a 252 rate of low birth weight, child nutri-tion deficits particularly during weaning in the second year of life andsubsequent high rates of childhood stunting. Nutrition policies, strategiesand programs should be directed specifically to both the household and vulner-able group problems.

6.2 Over the long run, income and employment gains will drive durableincreases in food consumption by Sri Lanka's poor, if focussed on thosespecific groups. The following observations are based on the assumption thatsuch efforts will be intensified. However, they also need to be complementedby concerted and coherent medium-term approaches. In some cases, this can beaccomplished by redirecting efforts, in others by intensifying what is nowunder way and in still others by new combinations of existing interventions.However, it would be inappropriate and misleading to assume that nutritionprograms could meet the country's long-term nutrition needs in the absence offocussed income growth and employment generation.

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A. Obiectives

6.3 A manifest need exists to review, revise, prioritize and quantifyexisting nutrition objectives (see para. 4.5) and to phase and sequence theminto realistic time horizons. Reductions of 251 in stunting among childrenunder the age of three years, for example, while ambitious probably could beachieved in at least parts of Sri Lanka but would take a minimum of five yearsof steady effort, as would a similar reduction in the number of low birth-weight babies. Significant reductions in stunting for older pre-schoolchildren would take somewhat longer to emerge. A 30? reduction in the inci-dence of maternal iron and folate deficiency and substantial reductions inmanifest IDD also should be possible over five years if given sufficientpriority. Programs with the potential to affect such changes are already inexistence but need considerable strengthening (see paras. 5.4-5.34).

6.4 The government may also wish to consider setting specific minimumfood intake goals as an intermediate contribution to both the above objectivesand to the improved health and nutrition of the most vulnerable segments ofthe population. Increasing daily consumption by the poorest 202 of the popu-lation, for example, to an adult per capita average of 2,000 calories wouldhelp provide a safety net against continued nutritional deprivation untiltheir incomes rose to acceptable levels.

B. Policies and Strategies

6.5 The Government's general nutrition intentions can be inferred from anarray of available statements and documentation reflecting an abiding politi-cal and administrative concern about the problem. However, existing policiesand strategies are necessary but generally not sufficient instruments to guideprogram development. Those affecting food supply and distribution pay onlymarginal attention to consumption issues. Health strategies have had mixedsuccess in preventing growth failure and reducing iron and folate and othermicro-nutrient deficits and rates of nonimmunizable infectious diseases.

Food and Agriculture

6.6 In the food and agriculture sectors, two criteria should be cor,sid-ered in designing economically viable nutrition-oriented policies and strate-gies. First, they should seek disproportionately to benefit the poor in termsof food consumption and/or income increases. Second, they should aim toincrease the availability of lower-cost nutrients generally in short supply.

6.7 Against that backdrop, three areas require further immediate develop-ment. First, efforts to lower rice prices to consumers through increasedproductivity and improved post-harvest technology also are needed. Second,steps to reduce sugar prices approximately to world levels should be consi-dered but the implications of such a move on the balance of payments and ongovernment revenues should first be studied. Sugar is an important source ofcalories to the poorest deciles and the present price structure taxes low-income groups disproportionately as a source of general revenue. Third,policies and strategies to increase the production and marketing of subsidiaryand food crops such as corn or manioc should be developed and implemented, inorder to raise incomes and promote diversification including development ofthe domestic feed market. Successful diversification, however, would require

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improved research and extension services and would not necessarily succeedunless demand and relative agricultural output prices provided adequateincentives. Both the field crops and rice interventions were earlieridentified by FNPPD as key development areas (see para. 4.17).

6.8 The argument favoring lower rice prices derives partly from opinionthat government subsidy of paddy production may have inhibited development ofboth the tree crop subsector and other food crops by discouraging farmers fromdiversifying to other crops. Productivity increases leading to a reduction infinancial incentives to paddy production (e.g. credit, fertilizer and producerprice supports would tend to lower rice prices to consumers and thereby alterthe wheat/rice price ratio. This might make rice relatively more attractiveto consumers and reduce the country's dependence on imported wheat. Thisargument is reinforced by concerns that economically unattractive options forsurplus disposal could arise if Sri Lanka produced more rice than needed fordomestic consumption and tried to enter the export market with a relativelyhigh-cost, lower-quality commodity. Advocates of diversification also arguethat subsidiary crop development would be more labor-intensive and would gene-rate greater employment, particularly if marketability of these field cropscould be increased through promotion of dietary change.

6.9 However, there also is an argument on nutritional grounds that areduction in rice prices would benefit all but the largest paddy producers.Farmers' net returns on paddy production have been decreasing gradually inrecent years for several reasons with the result that some less productivelands have been taken out of production. (The profitability of paddy produc-tion varies considerably by region and generally is less profitable in the wetzone and marginal areas than in the irrigated dry zone.) In addition therehas been discussion of reducing the existing bias toward paddy production byintroducing effective irrigation charges, a possible land tax increase andexpansion of agricultural services to include other crops. Moreover,fertilizer costs, which represent around 8-102 of the current costs of paddyproduction, are likely to increase both in world terms and through a reductionof the input subsidy. These factors also point to the need for productivityincreases in the paddy sector.

6.10 Resistdnce to a decrease in the paddy procurement price (it wasincreased from Rs 70 to Rs 80 per bushel in August, 1988) rests on two argu-ments: production would decrease and rural incomes would therefore fall.Both common sense and recent analysis for the OECD 21/ support the importanceof price as a determinant of paddy production. Given limited alternatives,lower price support by itself would not be likely to result in major reductionof paddy on productive land. Whether a reduction in profit margins wouldsignificantly affect production or the provision of employment by largerproducers--the net sellers of rice--who account for an estimated 30-402 ofannual yields, needs to be determined. However, there also are indications,which need verification that shifts in land use have taken place on moremarginal rather than productive landholdings in the wet zone, as net returnshave decreased since 1986.

21/ Thorbecke and Svegnar op. cit.

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6.11 Because the present market price for paddy is higher than the pro-curement price and public procurement is relatively low, there may not be anexisting mechanism for the government to reduce rice prices substantially ifit wished to do so. However, by curtailing further increases in the paddyprocurement price, the Government could encourage more efficient and lower-cost production and let market forces benefit low-income consumers.

Health

6.12 Continuing micronutrient deficiency problems, the uneven quality ofthrigosha implementation and scant attention to nutrition education underscorethe need to incorporate nutrition more fully into Sri Lanka's strategic agendafor primary health care. The most important single development would be forthe Ministry of Health both to send clear signals to its regional managersthat pre-school and maternal nutrition are a high-priority concern by assist-ing districts in the preparation of realistic annual plans and programsspecifically to control anemia, IDD, subclinical Vitamin A deficiency andgrowth failure in small children, which would need to be monitored bothlocally and from Colombo. However, the health system would need to strengthits central and regional management-and operations for these initiatives to beeffective.

Nutrition Education

6.13 Strategies to improve behavior directly affecting nutrition statusare needed as a linking mechanism at the interface of nutrition and both foodconsumption and health. However, they are not currently in place, althoughFNPPD provides an institutional base for their development. One key strategicobjective would be to improve calorie intake by pregnant and nursing women andearly introduction and use of semi-solid and solid foods for weaning children.A second would be effective reduction in iron and folate deficiency in preg-nant women, which contributes to low birth weights. Another would be fully toinstitutionalize home management of diarrhea combined with action to combatother infectious diseases. The strategy to achieve those goals would involvea mix of both face-to-face and mass media efforts carried out by an intersec-toral combination of government and voluntary agencies. FNPPD in consultationwith those agencies should take the lead in drafting the national nutritioneducation agenda for endorsement by the Cabinet.

C. Institutional Arrangements

6.14 A broad array of instruments for nutrition advocacy and to promotecoordination and improvement at policy, strategic and program levels haveoperated with uneven effectiveness. Differences between the NAFNS and FNPPD'sfood and agriculture priorities remain unresolved. The gap between FNPPDrecommendations and actions to improve nutrition intervention programs remainsunclosed. Establishment of the proposed National Nutrition Policy Councilunder the Prime Minister, serviced by a Nutrition Policy Bureau, or the re-establishment of a division like FNPPD in MPPI to service the NHC (seepara. 4.4) could help ensure that nutrition has an appropriately high-levelpublic focal point and that consistent and coherent nutrition policies,strategies and programs were developed, implemented and properly monitored.

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D. Programs

6.15 In addition to the strategic considerations above, certain programoptions also should be considered, particularly for the main existing inter-ventions.

Food Stamps

6.16 As indicated above, the food stamp program has faced two fundamentalproblems since its inception. The first is the regularly eroding value of theunindexed stamps with inflation. The second is the poorly targeted, and henceunnecessarily costly, nature of the program.

6.17 In December 1988 the government addressed the first of theseproblems, at least temporarily, by doubling the value of the food stamps. (Alow income family of five now receives stamps worth roughly Rs 200 per monthrather than Rs 100). These higher food stamp values will, as indicated below,bring the average family of five in each income decile, except for the pooresttwo urban deciles, to consumption levels of at least 2,000 calories per personper day.

6.18 The problem of poor targeting, however, has not been addressed.Recent analysis of 1986-7 CFS data by staff of the National Planning Divisionindicates that during that period nearly one-third of households 22/ in thepoorest quintile of the population did not receive food stamps. At the sametime gross underreporting of incomes and lack of controls in most rural areashave led to a situation in which only 10 of the 25 districts reported lessthan 502 of their population receiving food stamps. Five districts actuallyreported more than 702 of their population receiving them.

6.19 Based on preliminary analysis of the 1986-7 CFS data, (see Annex A,Tables 7-9), it appears that effective targeting of the program could bringall income deciles to near adequacy in terms of caloric intake 231 at afraction its current cost.

6.20 At present the only population groups not consuming, on average,2,000 calories per day without food stamps are the three poorest urban decilesand the poorest rural decile. Of these only the two poorest urban decileswould continue to fall short with the now doubled food stamp values, these byroughly 90-135 calories per person per day or roughly Rs 100 per household permonth. (See Annex A, Table 10).

6.21 The cost of reaching 'near adequate" caloric intake for each of thesefour deciles with a perfectly targeted food stamp program, as indicated inthat table, is Rs 986 million or roughly 27? of the estimated CY 1989 food

22/ When households are ranked by total household income.

23/ "Near adequacy' here is defined as 2,000 calories per adult equivalencyunit. It is important to note, however, that consumption for eachdecile is an average figure, and many families, by definition, willfall below it.

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stamp program. With detailed household financial information presently beingcollected in preparation for the JSP, it should be possible to carry out awell-targeted food stamp program.

6.22 The Government intends to replace food stamps with monthlyconsumption allowances under the JSP, which is intended to substantiallyeliminate poverty over a two-year period. However, the annual Rs 28,000million estimated annual cost of the proposed JSP consumption allowance ismore than 28 times the estimated cost of a well-targetted food stamp program.Moreover, even raising food consumption of the poorest quintile up to middle-class levels would cost less than an estimated 20Z of projected JSPconsumption outlays.

6.23 Overall, two features would seem essential for an effective Sri Lankatargeting system. First, the system needs to be visibly insulated from thepolitical process and consciously biased against upper-income participation asa way of focussing attention on the poorest deciles. Second, it should relyinitially on reported expenditures rather than continually misreported incomesas more accurate determinants of calorie intake. The most important precondi-tion is, of course, a commitment to ensuring both inclusion of the poor andexclusion of the ineligible. Previous reluctance to drop higher-income bene-ficiaries may be difficult to overcome.

6.24 Rice Grading. At present, rice represents roughly 75Z of food stamppurchases. The quality of rice available through cooperative stores forpurchase with food stamps is relatively high. If consumers were given theoption of purchasing lower quality (but nutritionally equal or superior) riceat a lower price, the caloric value of the stamps could appreciate consider-ably at little public cost. Initial inquiries indicate that there may well beconsiderable interest among lower income food stamp recipients in such anoption, which might involve making broken or undermilled raw rice, or both,available for food stamps at cooperative shops, or at least ensuring thatcooperative stores have a constant and adequate supply of the cheapest ricevarieties currently in the market.

6.25 The availability of cheaper human-grade rice brokens (used widely infair price shops in India) may be too limited for widespread use in Sri Lankabut should be explored, since they sell at two-thirds to one-half the price ofcommonly-eaten rice. Additionally, with existing milling equipment, it mightbe possible to increase the supply of undermilled raw rice, already said to beavailable in large quantities and up to 252 less expensive (depending on theseason) than rice presently available in the cooperative stores. If under-milled rice were purchased by lowest decile households, it would increase by20Z the caloric value of the stamps and would provide half of the caloriesneeded by this group to reach 8SZ adequacy. An alternative would be to makesuch rice available only for those 6 months of the year--October to March--when rice prices are higher (by as much as 251) and lower quality rice lessavailable on the open market. This would at least provide the low-incomefamily with food stamps providing roughly constant caloric value throughoutthe year. If domestic brokers were successfully added to the system at aneven lower price, benefits would be correspondingly higher.

- 43 -

6.26 Introduction of undermilled raw rice or similar lower quality varie-ties into the cooperative stores would not be without problems, chief amongthem being shorter shelf life. In addition, the acceptability of a particularvariety, even among low income households, will not be uniform through thecountry. Moreover, rice millers may not consider it economic to screen forbrokens and sell the better-quality rice at higher prices. Accordingly, care-ful testing will be necessary (a) to assess the feasibility of producingbrokens as well as the shelf life of a range of lower quality rice varieties;and (b) determine--by actual placement of such rice in cooperative stores--thequantities that would ba purchased by each income group in the program in eacharea of the country and in each major season.

Thriposha

6.27 This program appears to need operational improvemei.t. It is aimed atan appropriate target group and the supplement itself is of acceptablequality. However, correctible deficiencies have limited its value as a nutri-tion intervention (see paras. 5.16-5.21). Therefore, the mission recommends athorough review of the prugram to improve growth monitoring, beneficiaryselection and family use of thriosha as an intervention against child growthfailure in accord with program intentions. The latter goal would require moreeffective nutrition education than presently exists.

Kola Kenda

6.28 Principally organized by communities themselves, the kola kendaprogram (see para. 4.20) is more important from community involvement thannutrition perspectives. Consideration should be given to intensifying its usefor at-risk children under three years of age and to ensuring that childrenreceive the supplement frequently enough to obtain substantive nutritionbenefit.

School Feeding

6.29 This program represents a significant financial share of child-directed interventions. However, it reaches children whose problemsfrequently originate before birth and are essentially the product of earlynutrition and health deficiencies. From a nutrition perspective, school feed-ing has lower priority and potential than successful efforts targeted to themost vulnerable younger groups, although it may be considered important onsocial or other grounds. However, in a resource-constrained environment, thegovernment may wish to shift those resources to other interventions such asdeworming, goiter control and nutrition education.

Nutrition Villages

6.30 The ambitious nutrition village concept (see paras 5.35-5.39) isattractive as a multisectoral construct but extremely difficult from a plan-ning and implementation perspective. Proposed program inputs vary in scope,complexity and lead time for expected impact. Effective coordination amongthe concerned institutional actors also will require careful planning andmonitoring to ensure that interventions take place on time and at essentiallevels. Carrying out the; pilot program in even 40 such villages, as currently

- 44 -

anticipated, may strain implementation capability unless the inputs are care-fully phased and sequenced. Additionally, the new program may divert energiesfrom essential and lower-cost improvements to existing delivery programs whichcould have more widespread and systemic impact. For these reasons, it isrecommended that the government consider restructuring the nutrition villagesconcept in a more limited fashion and that considerable attention be paid tothe detailed design of the implementation system and its management.

An Optional Approach to Nutrition VillaRes

6.31 Restructuring the nutrition villages concept also would integrate keyinterventions directly at the village level through a limited service deliverypackage. Interventions -;ould include weight monitoring, infectious diseasecontrol, micronutrient supplementation, nutrition education and selectiveshort-term on-site food supplementation for at-risk mothers and youngchildren. The precise mix of services and their relative priorities wouldderive from careful initial analysis at the community level. The deliverymechanism could be a combination of non-government organizations with signifi-cant village outreach capacity such as Sarvodava. the national network of anestimated 42,000 health volunteers, organized through the Ministry of Healthand communities which themselves might wish to organize such programs at thevillage level.

6.32 If administratively feasible, this approach might prove a cost-effec-tive alternative to present modes of nutrition aelivery through the healthsystem. Consonant with principles of both decentralization and people-baseddevelopment, it could constitute a core program around which to developincome-genereting activities at a later stage. Thriposha could be the supple-ment until communities were in a position to develop their own weaningmixtures. The broad outline of a protocol for testing this approach isAnnex C to this report.

E. Recommendations

6.33 In addition to calling for a review and reformulation of nutritionobjectives and strategies, this report proposes a package of programs in fivespecific areas: (a) agricultural research, prices and production, (b) foodinterventions targeted to both low-income households and particularly high-risk groups, (c) a concerted attack on micronutrient deficiencies, (d) nutri-tion education and (e) a community-based nutrition and health program.

6.34 On the agriculture side, the mission recommends research in two keyareas: rice productivity and post-harvest technology to lower the cost ofproduction of rice and the development of improved production and marketingsystems for subsidiary field crops. The present investment rate on agricul-tural research is estimated at about 0.71Z of the agricultural gross domesticproduct. A doubling of the research percentage has been recommended.However, even an ePrmarked 20Z increase in the present rate probably wouldpermit reasonable levels of productivity-oriented research (see para. 6.7) onboth rice and development of better production and marketing systems for otherfield crops. Since agriculture contributes around 28Z to GDP, the researchincrement would amount to less than Rs 80 million per year.

- 45 -

6.35 In regard to food interventions, the cost of rice grading (seeparas. 6.20-6.22) would be negligible, as screening costs would be offset byhigher market prices for the better-quality offtake. Based on 1986-7 CFSdata, careful targeting could reduce food stamps expenditure to aroundRs 1,000 million per year, thereby saving Rs 2,600 million annually.Restricting the school lunch program to children in Standards I and II wouldreduce the cost of that program to Rs 1,000 million annually as a saving ofRs 1,600 million per year. Improving the thriposha program (see para. 6.25)involves the better use of existing levels of investment and recurrentresources rather than new outlays.

6.36 The addition of routine vitamin A administration for young children(see para. 5.31) and iodized oil for goiter control (see para. 5.30) wouldcost around Rs 2 million and Rs 1 million, respectively.

6.37 Based on figures recently prepared for family planning communica-tions, a substantial national nutrition education effort (see para. 6.13)could be carried out for around an estimated Rs 24 million per year. Theincremental annual costs of the proposed community intervention project (seeparas. 6.29-6.30) scaled up to national level would be around an estimatedRs 140 million using existing thriposha production.

6.38 While the agricultural research recommendations might take 5-8 yearsto bear fruit, the other interventions could product results over a shortertime frame. Rice grading would take one year of experimentation followed, ifsuccessful, by 18-24 months to be nationally operational. The health inter-ventions would take 2-3 years to show significant impact. Nutrition educationwould work in a 3-5 year time frame. The community nutrition initiative wouldtake around 7 years to reach full national coverage.

6.39 Table 6.1 below shows current estimated costs of Sri Lanka's mainnutrition interventions and the financial implications of adopting the programrecommendations in this report. It highlights the considerable savings thatcould be obtained through better targeting of the food stamp and school lunchprograms, as well as the relatively small cost of agricultural research,nutrition education and micronutrient interventions which could have largepay-offs in terms of improved nutrition status.

6.40 In sum, the proposed program package would be cost-effective as wellas managerially and technically feasible. Its total cost of under Rs 3,000million would be less than 40? of current nutrition outlays. Effectiveimplementation would permit Sri Lanka substantially to improve the nutritionstandards of its most vulnerable groups at a sustainable cost of less than 2?of the recurrert Government budget.

- 46 -

Table 6.1: MAJOR NUTRITION INTERVENTIONS:mISUWRECoWmmENDATIONS AND COST TO GOVERNMENT

Estimated Current Mission Incremental Annual Total AnnualAnnual Costs Recommendation Cost or Savings Cost

(In S.L. Re '000)

ExistinE F-ood Sta a8,800,000 Effectively retarget to (2,600,000) 1,000,000

lowest three urban andlowest rural deciles

ThriDosha 200,000 Tilghten up worker perf*r- 200,000mance; use growth moni-toring more effectively;defer program expansionin favor of increasedefficiency

School Lunch 2,600,000 Limit beneficiaries to (1,600,000) 1,000,000Standards I and II

Kole Kenda negligible Focus on under-three negigible negligiblechildren; Increasefrequency and regularityof use

Nutrition Villages 820,000 (at full Restructure as fully (180,000) 140,000national coverage) integrated community

nutrition and healthprogram

NewNpricuitural Research 400,000 Research on rice 80,000 480,000

productivity andsubsidiary food crops

Nutrition Education negligible Focused program to change 24,000 24,000specific behaviorpatterns

Micronutrient Inter- negligible Regular supplementation 8,000 8,000ventions (vitamin A of target groupsiodized oil)

Rice Grading negligible Test use of cosmetically negllgible negligibleInferior varieties

Totals 7.120.000 (4.273,000) 2.897,000

/a Includes agricultural research and cost of nutrition villages at full national coverage.

-47 -

ANNEX A- Tables

-48 - ANNEX ATable 1

SRI LANKA

NUTRITION REVIEW

Average Calorie Price by Expenditure Group. 1980/81, 1989

Per capitaexpenditure Calorie Price (Re/Calorie x 1.000)(Decile) Urban Rural Estate All Island

80-81 1989 80-81 1989 80-81 1989 80-81 1989

1 2.31 5.82 2.10 5.29 2.14 5.39 2.14 5.392 2.54 6.40 2.22 5.59 2.14 5.39 2.24 5.643 2.62 6.60 2.33 5.87 2.34 5.90 2.37 5.974 2.65 6.68 2.39 6.02 2.38 6.00 2.42 6.105 2.90 7.31 2.43 6.12 2.42 6.10 2.51 6.336 2.85 7.18 2.50 6.30 2.33 5.87 2.54 6.407 2.97 7.48 2.58 6.50 2.56 6.45 2.65 6.688 3.28 8.27 2.76 6.96 2.46 6.20 2.84 7.169 3.52 8.87 2.86 7.21 2.83 7.13 3.03 7.6410 4.45 11.21 3.70 9.32 3.58 9.02 4.01 10.11

Total 3.24 8.16 2.55 6.43 2.46 6.20 2.67 6.73

Source: Sahn, David, 'Food Consumption Patterns and Parameters, in Sri Lanka:The Causes and Control of Malnutrition," Draft 2. June 1985, IFPRI,using data from the 1980/81 Labor Force and Socio Economic Survey,and updated to 1989 prices using Colombo Consumer Food Price Index.

ANNEX ATable 2

SRI LANKA

NUTRITION REVIEW

Per Adult Equivalent Calorie Consumption by Expenditure Decile by Sector, 1969170. 1978/79, 1980/81. and 1981182

(calories/adult equivalent/day)

Per capita 1691970 1978/79 1980/81 1981/82

expenditure All All All All

decile Urban Rural Estate Island Urban Rural Estate Island Urban Rural Estate Island Urban Rural Estate Island

1 1,848 2,183 2,209 2,166 1,668 1,749 1,712 1,730 1,477 1,613 1,584 1,587 1,521 1,670 1,617 1,588

2 2,192 2,482 2,691 2,500 2,089 2,142 2,432 2,147 1,853 2,076 2,088 2,047 1,771 2,062 2,186 2,031

3 2,361 2,780 3,009 2,774 2,213 2,368 2,765 2,378 2,099 2,309 2,322 2,280 1,982 2,326 2,584 2,306

4 2,481 2,989 3,178 2,984 2,340 2,568 2,963 2,575 2,282 2,626 2,217 .2,526 2,317 2,674 2,836 2,662

5 2,812 3,116 3,449 3,134 2,480 2,781 3,298 2,783 2,376 2,898 2,864 2,681 2,486 2,778 3,047 2,7B8

8 2,771 3,252 3,808 3,279 2,586 2,978 3,616 2,983 2,617 2,914 3,314 2,890 2,624 3,009 3,377 2,983

7 2,884 3,322 3,864 3,391 2,797 3,070 3,822 3,118 2,678 3,211 3,272 8,124 2,793 3,202 2,748 3,175

8 3,010 3,666 4,090 3,888 3,037 3,369 3,908 3,353 2,816 8,339 3,936 3,288 3,092 3,620 4,084 3,494

9 3,210 3,728 4,302 3,798 3,317 3,663 4,758 3,690 3,082 3,765 4,289 3,627 3,261 3,866 4,548 3,760

10 3,625 4,194 6,042 4,316 3,689 3,797 4,800 3,762 3,872 4,248 4,106 3,877 3,560 4,158 4,394 3,905

Average 2,913 3,121 3,452 3,180 2,756 2,784 3,548 2,852 2,629 2,807 2,994 2,791 2,796 2,828 3,344 2,866

Source: Sahn, David. 'Changes In Living Standards of the Poar In Sri Lanka During a Period of Macroeconomic Restructuring'. World

Development, Vol. 16, No. 6, 1987.

- 50 - ANNEX ATable 3

SRI LANKA

NUTRITION REVIEW

Indices of Wages and Food Prices. 1982-87

Construction Wages La Agricultural Wages Food Prices /c(1982 = 100) (1982 - 100) (1982 - 100)

1983 120.59 118.34 112.41

1984 130.42 128.47 132.77

1985 140.17 133.09 132.85

1986 148.23 141.62 142.40

1987 159.04 139.61 154.75

la Wages for an unskilled carpentry helper; Sources Central Bank of SriLanka.

lb Wages for paddy harvesting (male).

/c Source: Colombo Consumers Price Index.

ANN ATable 4

SRI LANMA

NUTRITION REVIEW

Comparison of Annual Per Capita Intake for Particular Foods1980-81: 1985-86 - Rural

Eszenditure DecilesDl D2 ______DIO__AveraDe

198Q-81 1985-d l9W-81 1985- '18-1 83-dOf i980-81 1985-80 198u-ni1 0965-6

Rural

Rice 155.4 106.5 201.2 162.1 218.4 194.3 354.1 364.3 258.8 251.9(lbs) 200.0 209.0 218.0

Bread 17.7 26.1 23.1 36.1 31.5 43.3 63.3 82.2 35.3 56.6(lbs) 35.3 34.1 36.7

Sugar 150.9 187.6 220.6 274.8 269.5 327.6 681.3 890.2 360.0 489.6(oz) 376.9 398.5 410.6

Estates

Rice 140.7 103.1 181.8 142.4 236.3 179.9 415.5 396.3 259.1 234.1206.5 223.3 242.4

Urban

Rice 124.8 105.5 157.1 157.6 178.9 182.3 223.9 243.1 201.8 204.6153.4 150.3 163.3

Bread 46.7 44.8 59.9 61.1 56.8 72.4 105.5 117.0 77.3 90.073.4 62.3 67.4

Sugar 174.9 272.0 240.9 359.5 267.9 490.1 641.7 944.7 427.5 653.6538.2 435.3 485.1

Sources: Labor 'orce and Socio Economic Surveys 1980-81 and 1985-86 (preliminary tables). Bureauof Census and Statistics.

-52 - ANNEX ATable 5

SRI LANKA

NUTRITION REVIEW

Sir Lanka. Paddy Production. Imports and Government Procurement 1959-82(millions of bushels and percentages)

Share ofShare of paddy government

GPS/PMB imports as procurementProduction Imports procurement percentage of as precentage(million bu) (million bu) (million bu) production of production

(1) (2) (3) (4) (5)

1959 36.4 37.9 16.6 104 461960 43.1 38.8 20.8 90 481961 43.1 36.3 22.2 84 511962 48.0 30.4 27.0 63 561963 49.2 40.2 25.7 82 521964 50.5 39.9 29.4 79 581965 36.3 39.6 23.1 109 641966 45.7 35.4 28.0 77 611967 54.9 27.4 15.4 50 281968 64.5 25.1 14.9 39 231969 65.9 19.0 13.7 29 231970 77.4 38.4 26.2 50 341971 66.9 24.4 32.7 36 491972 62.9 24.7 26.4 39 421973 62.9 19.1 13.7 30 361974 76.8 21.7 20.9 28 271975 55.3 33.0 11.6 60 211976 60.0 30.5 12.9 51 221977 80.4 39.0 24.6 49 311978 90.6 11.5 32.3 13 361979 91.9 15.2 25.9 17 281980 102.2 13.6 10.1 13 101981 106.8 11.2 4.7 10 41982 103.3 11.5 4.0 11 41983 124.2 9.0 16.2 7 131984 121.0 1.9 8.5 2 71985 133.0 13.4 5.1 10 41986 129.4 16.2 7.7 12 61987 106.4 7.5 3.2 7 3

Source: Agricultural Statistics of Sri Lanka (1981), Central Bank data andFood Commissioner. Thorbecke E. and Svegnar, J., "Effects ofMacroeconomic Policies on Agricultural Performance in Sri Lanka,1960-82, OECD July 1985.

T*- £Table 6

Sol L#MIA

WiRITIM NVIE

Val" of Production ae Share of leo. by Landholding Sin

Share of Income frm Different SourcShare of Val"g of Pomionb,

No. of Aworsg Avrae tol o Agricalt 1 Hams O1usina _ ramittnoeshouseholds paddy fod high land Paddjcoco sales coosIption profit. VW staMP. Othere

Size of Helding(Acre.)

0 - 0.24

Urben 262 0.001 0.101 1.11 11.96 0.20 0.20 20.01 60.70 10.28 17.65Rural 484 0.003 0.114 4.09 15.87 1.78 11.05 64.49 15.63 18.85All-Island a 744 0.002 0.108 2.39 1.90 1.46 2.81 13.62 54.16 1U.10 14.57

0.2S - 0.72

Urban 120 0.020 0.848 2.6 21.29 1.64 2.10 16.25 44.92 13.10 19.78Rural 607 0.032 0.854 9.93 25.17 8.02 7.09 10.76 56.76 12.8 10.10All-Island la 9U6 0.0o0 0.354 5.89 25.81 3.88 6.48 11.07 64.55 12.60 11.29

0.78 - 2.0

Urban 52 0.816 0.S0 18.7 40.70 8.93 5.69 11.08 50.a0 9.81 19.25Rural 076 0.278 1.044 27.18 22.70 12.10 18.41 11.64 41.16 11.63 10.14Al -Islndf 931 0.274 1.035 26.34 28.70 11.70 12.96 11.69 41.70 11.37 10.68

2.0 or more

Urba 42 8.526 6.278 36.70 J5.40 15.57 7.64 1S.91 81.17 5.86 22.88Rure' 764 2.039 2.960 62.41 17.31 80.75 16.24 18.16 21.44 7.15 9.27All-Tslnd /a 797 2.116 8.126 41.51 16.24 29.91 17.3 1s.1 21.99 7.06 10.02

Lr Includes 41 eato holdins.

Source: Sohn, David., 'Food Consumption Patterns ond Parameters In Sri Lanka. The Cau and Control of Valnutrition, Oraft 2, June 13S.

-54- ANNEX ATable 7

SRI LANKA

NUTRITION REVIEW

Daily Calorie Consumption per Adult Equivalency Unit: Rural

LowestDecile 1 Decile 2 Decile 3 three deciles

Rice 979 (49.0)fa 1,072 (49.9) 1,138 (50.8) 1,067 (50.0)

Wheat Flour 51 (2.6) 50 (2.3) 57 (2.5) 53 (2.5)

Coconuts 376 (17.3) 392 (18.2) 385 (17.2) 383 (17.9)

Coconut Oil 59 (3.0) 61 (2.8) 66 (2.9) 62 (2.9)

Sugar 115 (5.8) 128 (6.0) 133 (5.9) 127 (6.0)

Roots and Tubers 57 (2.9) 68 (3.2) 61 (2.7) 62 (2.9)

Bread 140 (7.0) 140 (6.5) 155 (6.9) 145 (6.8)

Subtotal of 7 1,777 (89) 1,912 (89) 1,994 (89) 1,899 (89)items

other 221 226 248 235

Total, including 1,998 (1,830 2,138 (1,988 2,242 (2,128 2,134food stamps at pre- without without without1989 levels food food food

stamps] stamps] stamps]

La Figures in parentheses indicate percentage of total calories.

Source: Based on data from the 1986-87 Consumer Finance Survey, Central Bank ofSri Lanka.

_ 55 - ANNEX ATable 8

SRI LANKA

NUTRITION REVIEW

Daily Calorie Consumption per Adult Eauivalencv Unit: Urban

LowestDecile 1 Decile 2 Decile 3 three deciles

Rice 678 (36.9)/a 730 (40.6) 811 (40.9) 750 (40.2

Wheat Flour 27 (1.5) 36 (2.0) 48 (2.4) 39 (2.1)

Coconuts 362 (19.7) 306 (17.0) 317 (16.0) 311 916.7)

Coconut Oil 59 (3.2) 51 (2.6) 64 (3.2) 59 (3.2)

Sugar 149 (8.1) 132 (7.3) 151 (7.6) 144 (7.7)

Roots and Tubers 24 (1.3) 28 (1.6) 23 (1.1) 25 (1.3)

Bread 261 (14.2) 243 (13.5) 270 (13.6 259 (13.9)

Subtotal of 7 1,560 (85) 1,526 (85) 1,684 (85) 1,587 (85)items

Other 276 270 298 280

Total, including 1,836 [1,683 1,796 (1,656 1,982 [1,881 1,867food stamps at without without withoutpre- 1989 levels food food food

stamps] stamps] stamps]

/a Figures in parentheses indicate percentage of total calories.

Source: Based on data from the 1986-87 Consumer Finance Survey, Central Bank ofSri Lanka.

- 56 - ANNEX ATable 9

SRI LANKA

NUTRITION REVIEW

Daily Calorie Consumption per Adult Equivalency Unit: Estate

LowestDecile 1 Decile 2 Decile 3 three deciles

Rice 1,018 (45.9)Ia 1,148 (47.7) 1,254 (50.1) 1.172 (48.6)

'Wheat Flour 382 (17.2) 409 (17.0 437 (17.5) 417 (17.3)

Coconuts 350 (15.8) 363 (15.1) 341 (13.6) 3SO (14.5)

Coconut oil 101 (4.6) 93 (3.9) 89 (3.6) 92 (3.8)

Sugar 112 (5.1) 117 (4.9) 117 (4.7) 117 (4.8)

Roots and Tubers 40 (1.8) 36 (1.5) 36 (1.4) 37 (1.5)

Bread 101 (4.6) 119 S4.9) 104 (4.2) 109 (4.5)

Subtotal of 7 2,105 (95) 2,286 (95) 2,378 (95) 2,294 (95)items

Other 111 119 125 120

Total, including 2,216 (2,050 2,4056 (2,239 2,503 [2,390 2,414food stamps at pre- without without without1989 levels food food food

stamps] stamps] stamps]

/a Figures in parentheses indicate percentage of total calories.

Source: Based on data from the 1986-87 Consumer Finance Survey, Central Bank ofSri 'anka.

ANNEM ATable 10

SRI LANKA

NUTRITION REVIEW

Calorie and Cost Reauirements of Neetina Needs of Calorie DeficientPopulation Deciles Through Food Stamps at 1989 levels

(1] (2] (3] (4] [51 [6] (7)Amiual cost of

perfectlyAdditional Gap between targeted food-calories Calories per Cost of Value of '89 colums 4 & stamp program inneeded to AEU per day meeting food stamps 5 per house- in meeting

consume provided by column 1 per ABU per hold per caloric2,000 per AEU '89 food stamp Calorie needs day month deficiency Icper day la program lb gap per day Ic (Re) (Rs) (Rs million)

after foodstamps

_ .~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.Rural

Decile 1 170 251 - 0.90 1.33 - 373

Urban

Decile 1 317 228 .89 1.85 1.33 78.0 234

Decile 2 344 208 136 2.20 1.33 130.5 279

Decile 3 119 202 - 0.79 1.33 - 100

Total 986

Cost of '89 Food Stamp Program 3,600

la Assumes no food stamps.Lb Assuming a family of five with two children under the age of 8.c To reach 2,000 calories per adult equivalency unit per day based on cost of calories per expenditure

decile (Annex A. Table 1).

_ ~ ~~ ~~~~ ~ ~~~~~ __ _ _ __ __

ANNX ATable 11

SRI LANKA

NUTRITION REmIEW

Additional Income Necessary for Low-Income Quintile to

Consume Middle Income Diets and Relation to JSP Allowances

Additionalper capita Additional

monthly food per capita

Per capita expenditures monthly income Jana Saviya

monthly food necessary necessary monthly

Per capita Per capita expenditures to achieve to achieve consumption

monthly total monthly food without middle Income middle income ellowance Id

expenditures expenditures food stamps consumption lb consumption Le over column 5

(Rs) (Rs) (Re) (RI) (Rs) (Ru)

Rural

Decile 1 362 254 228 109 168 124

Decile 2 374 259 233 104 160 132

Urban

(Decile 1 le 547 402 375 20 31 261)

Decile 2 449 318 291 104 160 132

Estate

Decile 1 433 311 285 99 152 140

Decile 2 475 349 323 61 94 198

la Based on data from 1986-87 Consumer Finance Survey but using 1989 prices.

lb i.e., the food expenditure levels of decile 6 (Rural - Rs 337; Urban - Ru 395; Estate - Ru 384).

/c Assuming 651 of income increments are spent on food.

Id Ru 292 per person per month.le Skewed by small number of persons per spending unit and high percentage of adults.

- 59 - ANNEX ATable 12

SRI LANKA

NUTRITION REVIEW

Annual Cost of Bringing Consumption of Poorest Quintile in Each Sectorto Middle Class Levels /a

Additional percapita monthlyincome necessary

No. of persons to achieve middlein decile income consumption Annual cost

(Rs) (Rs)

Rural

Decile 1 1,152,000 1168 2,322,432,000

Decile 2 1,152,000 160 2,211,840,000

Urban

Decile 1 352,000 31 130,944,000

Decile 2 352,000 160 675,840,000

Estate

Decile 1 96,000 152 175,104,000

Decile 2 96,000 94 108,288,000

Total 5,624,448,000

Annual Cost of '89 Food Stamp Program 3,600,000,000

Proposed Annual Consumpition AllowanceUnder Jana Saviya Program 27,993,000,000

la Based on data from 1986-87 Consumer Finance Survey but using 1989 prices.

- 60 -ANNEX BPage 1

SRI LANKA

NUTRITION REVIEW

The Ultra Poor

Michael Lipton 1/ has defined as 'ultra poorw those households whichspend at least 80Z of daily calorie on food and consume less than 80? of dailycalorie requirements. Assuming the existence of other fixed expenditures, theindex identifies families which spend virtually all available resources onfood and yet fall significantly short of caloric adequacy.

On the basis of data from the 1980181 Labor Force and Socio EconomicSurvey, 8Z of Sri Lankan households in rural (7.7Z) and urban (8.1Z) areaswould be defined as ultra poor, with the estate figure roughly 4Z (Table 1attached).2/

When compared with the moderately poor whom Lipton defines asconsuming less than 80Z of calorie requirements but spending less than 80Z ofincomes on food, Sahn's analysis (same reference) indicates that the ultrapoor pay less per calorie, have larger families, and have fewer amenities butconsume no fewer total calories. This implies a minimum calorie level (justover 1,600 per AEU) below which households will utilize every resource foradditional food but above which other needs may be met. It further indicatesthat income and price related interventions, as opposed to behavior-relatedapproaches are necessary for the ultra-poor.

As seen in Table 2, attached, 52Z of the income of the ultra poorcomes from wages and salaries indicating the importance for this group ofemployment generation. Over 18? of-income is derived from the combination ofpensions, remittances and food stamps, all largely beyond the control of thesehouseholds.

1/ M. Lipton, "Poverty, Undernutrition and Hunger," World Bank StaffWorking Paper No. 597, 1983.

2/ Sahn, David. op. cit.

ANNEX BTable 1Page 2

Percent Households Not Achieving 801 and 100_ PAOIRHO Dietary Reauirements la

Urban Rural EstatePer capita -C0? Reqs. c80Z Reqs. <80? Reqs.expenditure and food and food and food(Deciles) 4100% Reqs. <cOZ Reqs. Share > 0.8 <100Z Reqs. d802 Reqs. Share > 0.8 <1002 Reqe. c80Z Req.. Share > 0.8

1 100.0 95.0 45.0 97.9 83.6 41.4 100.0 84.6 28.2

2 95.5 67.2 26.9 88.6 48.1 19.7 94.1 31.4 11.8

3 88.7 43.7 18.3 72.8 24.9 8.5 61.4 18.2 4.5

4 80.3 31.3 6.3 48.7 14.8 3.4 28.4 6.2 0

5 65.9 24.7 5.9 40.5 7.1 1.4 39.0 6.8 0

6 54.8 16.7 2.4 22.5 4.8 0.6 1.8 1.8 0

7 44.3 5.7 0 15.6 2.6 0.3 3.5 0 0

8 33.0 11.3 0.9 10.2 1.8 0.6 2.0 0 0

9 17.8 3.1 0 4.3 0.3 0 0 0 0

10 18.5 5.9 0 5.7 3.1 0.7 0 0 0

Total 49.9 24.5 8.07 42.9 20.4 7.7 32.6 13.3 3.8

La Based on 1978 FAOIWHO Recommended Daily Allowances.

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Table 2Page 3

Sources of Income for the Ultra-Poor(Share of Total Income)

Wages and Salaries 52.8

Business Profits 9.8

Pensions, Remittances and Food Stamps 18.3

Sale of Agricultural Products 4.5

Rents, Dividends and interest 0.1

Home Consumption 6.2

Other non-money sources 5.6

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Page 1

SRI LANKA

HEALTH AND FAMILY PLANNING PROJECT

Integrated Nutrition Intervention

Proiect Objectives

1. The overall objective is to control malnutrition in at-risk popula-tion groups--younger pre-school children and pregnant and nursing women--through targeted interventions at the village level delivered by a trainedcadre of multipurpose community volunteers.

2. The specific objectives in project areas will be tot

(a) reduce the prevalence of maternal malnutrition and iron deficiencyanemia by 25X;

(b) reduce the incidence of low birth weight by 25Z;

(c) reduce the frequency of wasting in 12-23 month old children by 75Zand eliminate severe clinical malnutrition; and

*d) reduce the prevalence of stunting in children aged 24-36 months by302.

Proiec. Content

3. Intervention at the village level will have a household focus,targeted to pregnant and lactating women, infants and children under threeyears. It will be delivered through a specially trained cadre of villagenutrition volunteers (VNV) operating under the supervision of health servicestaff at the Gramodaya level. The intervention will have four major compon-ents: growth monitoring and supplementation, dietary behavior modification,infectious disease control and micronutrient supplementation.

Growth Monitoring and Supplementation

4. In each village, all children aged 6-36 months will be weighedmonthly either at nutrition centers or at home. Growth performance will bemeasured by weight increments and assessed against specified norms; those withgrowth failure will receive supplementation. The supplement will be designedto meet about one-third of their daily energy and nutritional requirements. Itwill consist either of thriposha or a community-developed combination ofcereal, pulse(s), oil/sugar and vitamin pre-mix. Caloric density in the com-munity-based supplement may be raised by the additicn of a small amount ofgerminatcd flour or other malts which speed and raise the transformation ofstarch into sugar.

5. The supplement will be administered to at-risk children for aninitial 90-day period, on site for the first two weeks and at home thereafter.

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Page 2

At the end of 90 days' supplementation, weight gain will be assessed againstspecific exit criteria. If these are met, the child will graduate fromsupplementation and will return to routine monitoring; if not, fixed-termextensions will be provided until weight gain criteria are met satisfactorily.

6. During supplementation mothers will receive intensive remedial educa-tion on a group basis and individual counseling to deal with the conditionsspecific to their case. Compliance with all preventive health routines(immunization, de-worming, micronutrient dosage, etc.) would be checked by thehealth worker and any gaps in knowledge or coverage corrected. These proced-ures would be designed to deal with and prevent recurrence of particularhealth problems and to promote improved nutrition status.

7. Pregnant women at risk of delivering low birth weight babies alsowould receive a daily food supplement from the second trimester of pregnancythrough the first six months after delivery. Whether the principal objectivewould be to gain a specific amount of weight during pregnancy or to achieve aminimum term weight could be decided auring the design phase.

Dietary Behavioral Change

8. A broad-based information, education and communication (IEC) programbased on social marketing techniques would be developed to raise awareness ofthe problems of malnutrition, identify their causes and solutions and promotethe use of ihtervention services. Comiunity volunteers would delivar messagesthrough appropriate media and techniques available at the village levelsupported by materials and resources prepared for the project by the HealthEducation Officer of the Regional Directorate of Health Services. A campaignor pulse approach would be used to introduce such topics as the nutritionimplications of maternal dietary and work patterns, feeding colostrum andbreast milk, early supplementation and safe weaning, intra-family food distri-bution, child care practices rnd their delegation within the family, foodpreparation and hygiene, food purchasing and home economy, and storage andconservation techniques. The specific topics would be defined on the basis ofinitial analysis of both behavioral practices and customs in the community andwhat family and community opinion leaders are prepared to accept. Continuousmonitoring of information uptake and adoption would be maintained. The out-come of these activities would be to change current practices of home econo-mics, child care and nutrition so that scarce household resources would beused with maximal efficiency to improve dietary intake.

Infectious Disease Control

9. Diarrheal disease (DD), acute respiratory infections (ARI), malarie(MAL) and intestinal parasitism (IP) represent the main infectious burden oninfants and preschool children. Proven, effective measures for their controlwould be strengthened or introduced under the project in collaboration withprimary health services.

10. The major activity related to DD control would be to improve theapplication of ORT knowledge by mothers. The recent Demographic and HealthSurvey indicated that while 70? of mothers knew about ORT, only 40? hadactually applied it during the last episode occurring in a child under three

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Page 3

years of age. This suggests that there is considerable scope for reducing thenutrition impact of diarrhea in the target population. In the preparatoryphase of the project, actual and perceived constraints on ORT use, as well asthe reasons for ignorance in the rest of the population, would be identifiedby a special study and corresponding measures incorporated into the projectdesign. These would include such activities as improving the distribution ofORS (Jeevani) and intensifying IEC inputs on the preparation and use of homesolutions.

11. Currently, ARI's in infancy and early childhood are treated withantibiotics only at the sub-divisional health center and above under thesupervision of physicians. Limited access to this level of care often resultsin critical delays in the application of effectivi treatment to a e-

4ouslyill child. Several service studies have shown that making antibiot i avail-able at lower levels of care under controlled conditions can signil 'antlyreduce ARI severity and associated mortality without major cost increases.Problems of leakage and misuse are controllable with closer supervision andcareful management practices. Such antibiotics as oral co-trimoxazole aresafe, effective and easily administered by auxiliary personnel; their use atlower levels would take place in the project.

12. Malaria control would be strengthened under the project, whererequired, by the introduction of continuous or seasonal prophylaxis forchildren 3-36 months with pyrimethamineldapsone in conjunction withchloroquine treatment of presumptive fevers. The provision and promotion ofmalaria bed nets for infants and preschool children would be explored.

13. Routine intestinal deparasitization of young children in areas ofhigh endemic infestation has a positive effect on nutrition status. Theproject would first analyze the extent of the problem and the speed of wormbuild-up in the gut of younger children. It would then introduce periodicroutine treatment of children with mebendezole or other effective anti-helminthics appropriate to area infestation patterns. This would complementcurrent vector cortrol and environmental sanitation measures at the villagelevel.

Micronutrient Supplementation

14. Part of the social marketing communications program would be anintensive campaign to promote compliance with iron and folate supplementationby pregnant and nursing women. Variations in dosage also would be pilot-tested for effectiveness and acceptability.

15. Project areas affected by iodine deficiency would be provided withiodized salt at a price subsidized to compare with common salt. In remote orother areas where use of iodized salt was not feasible, consideration would begiven to the routine administration of oral iodized oil bienially or semi-annually.

16. In areas or subgroups where clinical Vitamin A deficiency is preva-lent, routine megadose prophylaxis would be instituted on a semi-annual basis.If the planned Medical Research Institute biochemical survey reveals thatsubclinical deficiency is common in children in the project areas, routine

- 66 - ANEX CPage 4

supplementation would be incorporated with the added potential of improvinginfectious disease control. The outcome of these control measures would be toimprove the biological efficiency of energy and nutrient use by reducing thefrequency and severity of common nonimmunizable childhood infections.

17. All of the above components are direct, family-oriented measuresdesigned to produce an immediate impact on malnutrition. However, they wouldhave to be phased and sequenced rather than introduced all at the same time.The manner in which mair. tasks will be distributed between volunteer workersand health staff would have to be considered in the context of existing localservice patterns.

Project Organization and Service Delivery

18. The Food and Nutrition Planning and Policy Division (FNPPD) of theMinistry of Plan Implementation would have overall responsibility for projectplanning and design. Other line ministries and technical agencies would beinvolved in the process. At the district level, village selection, leadagency assignment and project implementation would be the responsibility ofthe Government Agent and Assistant Government Agent, mediated through Districtand Divisional Development Committees, which would be responsible for coordi-nating inputs.

19. Design of project interventions other than salt iodization would takeplace at the village level with community participation regarding the mix ofservices and how they should be delivered. The key delivery personnel would bea cadre of specially trained village nutrition volunteers (VNV) working withinthe framework of government and/or voluntary agencies. Ideally, the fourareas of intervention would be carried out mainly by this cadre, who would beadvised, supervised and supported by corresponding services staff at theGramodaya or subdivisional level. The degree to which this can be applied inpractice will have to be considered in the planning phase.

20. Volunteers would be women recruited from the villages in which theywould work and selected by village authorities in consultation with GramodayaDevelopment Committees. VNV's would be trained on a district or regionalbasis for a period of 2-3 months, with major emphasis on skills required tocarry out specific project tasks under village conditions. Trainers wouldsubsequently be assigned at the AGA level as supervisors, each with responsi-bility for 10-20 VNVs.

21. Volunteers would receive continuous in-service training throughweekly/fortnightly supervision visits combined with monthly trips to a servicefacility for supplies, payment of expenses and formal in-service trainingsessions. Each VNV would cover around 50 households with about 20-30 youngchildren and 10-15 pregnant/lactating women, totalling 30-45 target groupsubjects. Estimating around 20Z growth failure prevalence initially, foodsupplementation would be provided to about 4-6 children at any one time, inaddition to pregnant (from the second trimester) and lactating women.

22. A criterion for village participation in the program would be commu-nity donatior. of a room or building which the VNV would use as a simplevillage nutrition center (VNC). The project would finance basic equipment.

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23. The VNV first would conduct a census of the population and establisha register of participants. All existing cases of wasting would start supple-mentation at once. Routine growth monitoring would track the rest of thetarget group for subsequent selection of eligible children. Monthly weighingwould take place at the center but nonattenders would be visited at home. TheVNV would work in close collaboration with the health worker, who wouldapprove eligibility, and with extension/local staff of other collaboratingagencies. All complex health problems would be referred to the health worker.

24. The project would set up a simple management information system (MIS)for VNV and other local staff and supervisors to monitor and improve perform-ance. It would use micro-computers at the AGA level and would compile andanalyze routinely collected service data. Output would be fed back to thelocal level with appropriate comment while aggregated data would be trans-mitted to regional and central levels. FNPPD would be responsible fornational analysis and associated follow-up. The Nutrition Department of theMedical Research Institute would be responsible for epidemiological researchbased on the data and information. Special evaluation studies would becarried out at regular intervals by the same department, based on predeter-mined indicators of project implementation and impact.

Implementation

25. FNPPD estimates that it would be possible to establish this type ofproject in about 100 villages (5000 households) in the first year, but thiswould not allow for training and other preparatory steps. The same proposalestimates that an additional 200 villages could be covered in the second year,thereby involving a total of around 15,000 households.

26. The preparation of detailed budgets will derive from decisions on therange of interventions to applied, the tasks that can be undertaken by the VWEand whether she is to be paid, etc. However, food costs would be minimized bythe use of thriposha and the transfer of kola kenda funds, where now avail-able, to this pilot project. An setting-up cost of Rs 3,500 per villagenutrition center would be a reasonable maximum. Other investment costs wouldbe for the development and carrying out of preservice training and the start-up costs for intervention design, including communications programs and theMIS system. Incremental operating costs would be limited mainly to micro-nutrient supplements, antihelminthics, antibiotics not now being suppliedthrough primary health care, monitoring and evaluation costs and travel costsfor supervision and training. The total five-year incremental investment andoperating base costs of the project would be expected to be less than Rs8,000,000, or Rs 267 per beneficiary-year (counting all pregnant and lactatingwomen and children under three years of age as beneficiaries) or Rs 21 percapita-year for the 75,000 population in the project area.