“Synergies in Child Nutrition: Interactions Among Health &

Environment, Care Practices, and Food

Emmanuel SkoufiasThe World Bank Group

January 2016

Outline

1. Motivation 2. Contributions of study3. The UNICEF Conceptual Framework4. Operationalizing the UNICEF Framework

�Countries and data sources�Ideal vs. available data

5. Prevalence of Adequate F, C, HE6. Evolution of stunting rates and Prevalence of

Adequacy in F, C and HE7. Synergies8. Take-Aways & Policy Considerations

2

Motivation

�Increases in real GDP and income are insufficient for reductions in child malnutrition.

�“The determinants of malnutrition are multi-sectoral and the solution to malnutrition requires multi-sectoral approaches.”

�Nutrition-sensitive interventions in different sectors e.g. agriculture, health, water & sanitation.

3

Contributions of the study

�Identifies data limitations and areas for improvement

�Among the first comprehensive investigations

�Informs broad policy design & choices�“Systematic Diagnostic” of the main correlates and determinants of malnutrition�Identifies potential “binding constraints” (e.g. inadequate H&E, or Care, or Food) in reducing malnutrition�Evidence on synergies: more rigorous justification for multi-sectoral interventions

4

The UNICEF conceptual framework

The UNICEF framework (UNICEF 1990) highlights the role of 3 main underlying causes

a) food security, b) child care practices, and c) Environment & Health

play in child nutrition.

One of the fundamental ideas underpinning this conceptual framework is that there are substantial interactions and synergies among food security, health environment, and care.

5

Intergenerational

consequences

Short-term consequences:

Mortality, morbidity, disability

Long-term consequences:

Adult height, cognitive ability, economic

productivity, reproductive performance,

overweight and obesity, metabolic and

cardiovascular diseases

Inadequate dietary intake Diseases

Household food securityInadequate care and

feeding practices

Unhealthy household

environment and inadequate

health services

Household access to access to adequate quantity and quality of resources:

Land, education, employment, income, technology

Inadequate financial, human, physical and social capital

Social cultural, economic and political context

IMMEDIATE

causes

UNDERLYING

causes

BASIC

causes

MATERNAL AND CHILD

UNDERNUTRITION

Source: the Executive Summary of “The Lancet Maternal and Child Nutrition Series 2013.

Operationalizing the UNICEF framework

�Review: the ideal data/info needed (from nutrition discipline) contrasted against the data available from surveys

�Definition of "adequacy" in F, C and H&E: based on the underlying components using thresholds based on accepted international standards

8

Thresholds for Adequacies

1. USAID (2012) “Maternal Dietary diversity and the implications for children’s diets in the context of food security.” USAID’s Infant and Young Child Nutrition project www.iycn.org

2. WHO (2013) “Table 2, Summary of WHO Position papers-recommended routine immunizations for children”

3. WHO and UNICEF (2006) “Core questions on drinking-water and sanitation for household surveys”

4. WHO (2008) “Indicators for assessing infant and young child feeding practices – part I: definition”

5. UNICEF (1990) “UNICEF Strategy of improved nutrition of children and women in developing countries A UNICEF Policy Review”, New York

9

Region Country - data source

SAR

Bangladesh (Helen Keller 2010, 2011 and IFPRI 2011)

Nepal (DHS 2001 and 2011)

LAC

Bolivia (DHS 2003 and 2008)

Peru (DHS 2005 and 2012)

EAP

Cambodia (DHS 2005 and 2010)

Indonesia (Riskesdas 2010)

SSA

Ethiopia (DHS 2000 and 2011)

Zimbabwe (DHS 2005 and 2010)

Table 1: Countries and Data Sources

Context and Data

Most samples are mainly rural,

� apart from Bolivia, Peru, Zimbabwe and

Bangladesh (HK) for which urban make up one third-to half of the sample.

11

Table 2: Components of Food Security

Ideal Indicators AVAILABLE

Children's Dietary Diversity Score Yes (Not HK)

Mom’s Dietary Diversity Score No

Minimum Acceptable Diet (for children 6-24 months) Yes

Food Insecurity Experience Scale No (Only HK)

Household Hunger Scale No

Coping Strategy Index No

Relative prices of different food groups No

PROXIES IF IDEAL INDICATORS ARE NOT AVAILABLE

Household Dietary Diversity Score (for child/mom) Helen Keller

Starchy Staple Ratio or the Fraction f household Calories Derived from Starchy

Staples

Notes: There are also population based measures such as the percent of households who cannot afford a

balanced diet, and the percent of people lacking access to calories

Components of adequate food

�Child’s dietary diversity of 4 or more from 7 food types

�Household level food insecurity (Helen Keller)

�Minimum meal frequencies

�Minimum acceptable diet (6-24 months)

13

Table 3: Components of Care

IDEAL AVAILABLE

Workload and time availability of caregiver No

Social support for caregiver No

Psychosocial care No

Caring Behaviors: Breast-feeding Yes

Caring Behaviors: Health seeking No

Caring Behaviors: Complementary feeding Yes

Caring Behaviors: Hygiene No

Caring Behaviors: Child feeding index No

Notes: Another important indicator of care is maternal education through there is no consensus about the threshold

(or level of education) for adequate

Components of adequate care (mostly behavioral)

�Exclusive breastfeeding under 6 months

�Initial breastfeeding within 1-3 hours of birth �(Bolivia & Peru DHS >=3 hrs only)

�Intro of complementary feeding during 6-8 months (solid, semi-solid, or soft foods)

�Continued breastfeeding until 24 months

15

Table 4: Components of Environmental Health

IDEAL AVAILABLE

Access to safe water Yes

Access to improved sanitation Yes (except Bolivia)

Community level sanitation Yes (except Bolivia, Ethiopia,

Indonesia, and HK)

Use of prenatal services Yes (except Indonesia)

Age appropriate immunization status Yes (except HK)

Vitamin A supplementation status (typically for children 6 months and older) Yes (except Indonesia, Bolivia)

ORS use for treatment of diarrhea No

Notes: A population-based measure is the percent of the populations receiving antibiotic treatment for pneumonia

Components of adequate health & environment

�Adequate household sanitation (see appendix)

�Adequate village level sanitation (> 75%)

�Safe drinking water source (see appendix)

�Complete vaccinations

�Prenatal check-ups 4 or more

�Vitamin A supplement for child (tablet, drops) [Peru?]

17

Message 1:

� There are major gaps in data collected by DHS and other nutrition-related surveys� Fewer data gaps for health & environment

� but more data gaps for food and care

Adequacies Bangladesh (HK)

19

29

50

13

0

10

20

30

40

50

60

70

80

90

100

Adequate food Adequate care Adequate

environment

Perc

enta

ge %

2010

Adequacies Resource-rich vs. Resource-poor Bangladesh 2010

(HK)

20

38

50

1713

52

5

0

10

20

30

40

50

60

70

80

90

100

Adequate foodAdequate care Adequate

environment

Perc

enta

ge %

Resource-rich

Resource-poor

�Adequacy in food�Quite low and

�Improvements in Cambodia, Peru, Zimbabwe; Large increase in Bolivia (?)

�Decline in Bangladesh

21

45

55

72

50 51

31

80

67

54

13

49

22

86

69

33

78

66

30

67

37

86

81

66

40

3026

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD (HK, '11)BGD (IFPRI, '11)

BOL ('08)ETH ('11)

IDN (RKD, '10)KHM ('10)

NPL ('11)PER ('12)

ZWE ('10)

Source: Author estimates.Note: (1) Dietary diversity: 4 out of 7 food groups. In Indonesia based on household (not child specific) dietary diversity;(2) Meal frequency depends on age

Components of Adequate Food

Dietary diversity > 5 months Exclusively breastfed < 6 months

Meal frequency Food security

Figure 5b: The Evolution of Access to Adequate Food Security

29

14

34

57

51

12 12

68

3134

29 28

4346

15

22

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

ee

t crite

ria

BGD, HKBGD, IFPRI

BOLETH

IDNKHM

NPLPER

ZWE

Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010;Ethiopia 2000, 2011; Indonesia 2010; Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010.Note: (1) Bangladesh (HK) includes food security but no information on meal frequencies.(2) Bolivia (2003) does not include information on dietary diversity.(3) Indonesia (RKD) only has information on household level dietery diversity, and no information on meal frequencies.

Prevalence of Adequacy in Food

Year 1 Year 2

Figure 5c: Adequate Food Security by Household Wealth

13

3834 34

47

53

12 13

67 68

32

37

2529

46 47

18

25

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD (HK, '10)BGD (IFPRI, 11)

BOL ('08)ETH ('11)

IDN ('10)KHM ('10)

NPL ('11)PER ('12)

ZWE ('10)

Source: Author estimates.Note: (1) Bangladesh (HK) include food security but not information on minimum acceptable diet.(2) Indonesia (RKD) only has information on household level diatery diversity, nothing else.

By wealth

Prevalence of Adequacy of Food

Resource Poor Resource Rich

�Adequacy in care: �High overall and

� increased significantly over time � e.g. Cambodia, Ethiopia, Nepal, Peru, Bangladesh

25

55

68 69

91

51

10096

67

7880 80

4951 50

83

69

48

100

78

69

59

82

67

45 44

98

81

74

86

80

30

63

8482

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD (HK, '11)BGD (IFPRI, '11)

BOL ('08)ETH ('11)

IDN (RKD, '10)KHM ('10)

NPL ('11)PER ('12)

ZWE ('10)

Source: Author estimates.Note: (1) Exclusive breastfeeding for first 6 months; (2) Complementary feedings for 6- to 8-month olds;(3) Breastfeeding within 1 hour of birth (100 minutes for Bolivia and Peru);(4) Breast-fed for 24 months or currently breastfeeding if less than 24 months.

Components of Adequate Care

Exclusive breastfeeding Early breastfeeding initiation

Complementary feedings Breast-fed up to 24 months

Figure 6b: The Evolution of Access to Adequate Care

50

55

84

59 59

28

37 36

28

52

24

38

55

61

3639

020

40

60

80

10

0

BGD, HKBGD, IFPRI

BOLETH

IDNKHM

NPLPER

ZWE

Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010;Ethiopia 2000, 2011; Indonesia 2010; Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010.Note: (1) In Peru and Bolivia early initiation of breastfeeding is within 100 minutes, not within 60 minutes as in others.(2) Bolivia 2003 does not include information on Vitamin A supplemenation.(3) Bangladesh (HK, 2011) does not include information on vaccinations.(4) Bangladesh (IFPRI) does not include information on early initiation of breastfeeding

Prevalence of Adequacy in Care

Year 1 Year 2

Figure 6c: Access to Adequate Care by Household Wealth

5250

89

81

64

56

3937

40

34

5451

3639

72

52

4038

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho

me

et crite

ria

BGD, HK '10BGD, IFPRI '11

BOL '08ETH '11

IDN '10KHM '10

NPL '11PER '12

ZWE '10

Source: Author estimates.Note: (1) In Peru and Bolivia early initiation of breastfeeding is within 100 minutes, not within 60 minutes as in others.(2) Bangladesh (IFPRI) does not include information on early initiation of breastfeeding(3) Indonesia does not include information on complementary feeds for 6 to 8 month olds.

By wealth

Prevalence of Adequacy of Care

Resource Poor Resource Rich

23

53

80

26

72

80

72

67

15

28

47

17

80

64

58

30

55

7276

95

10

66

61 60

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD (HK, '11)BGD (IFPRI, '11)

BOL ('08)ETH ('11)

IDN (RKD, '10)KHM ('10)

NPL ('11)PER ('12)

ZWE ('10)

Source: Author estimates.Note: For Bangladesh (HK) Vitamin A supplementation is only for children over 6 months.

Components of Adequate Health

Adequate vaccinations 4+ prenatal visits

Vitamin A supplementation

Figure 7c: The Evolution of Access to Adequate Environment

1714

45

71

81

0 1

49

5

10

2

16

32

3836

31

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD, HKBGD, IFPRI

BOLETH

IDNKHM

NPLPER

ZWE

Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010;Ethiopia 2000, 2011; Indonesia 2010; Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010.Note: (1) Bolivia (2003 and 2008) do not include improved sanitation.(2) Ethiopia, Nepal, Bolivia, and Indonesia do not include community sanitation.

Prevalence of Adequacy in Environment

Year 1 Year 2

Figure 7e: Access to Adequate Environment by Household Wealth

8

22

38

50

63

94

0 1

41

54

0

17

7

20

11

57

4

50

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD, HK '10BGD, IFPRI '11

BOL '08ETH '11

IDN '10KHM '10

NPL '11PER '12

ZWE '10

Source: Author estimates.Note: (1) Bolivia does not include improved sanitation.(2) Ethiopia, Nepal, Bolivia, and Indonesia do not include community sanitation.

By wealth

Prevalence of Adequacy of Environment

Resource Poor Resource Rich

Figure 7d: The Evolution of Access to Adequate Health Services

21

1618

42

78

4 5

18

4

35

0

13 13

8

22

27

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD, HKBGD, IFPRI

BOLETH

IDNKHM

NPLPER

ZWE

Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010;Ethiopia 2000, 2011; Indonesia 2010; Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010.Note: (1) Bangladesh (IFPRI) has Vitamin A supplementation for 6 to 24 month olds only.(2) Indonesia does not have information on prenatal checkups or Vitamin A supplementation.

Prevalence of Adequacy in Health

Year 1 Year 2

Figure 7f: Access to Adequate Health Services by Household Wealth

13

25

11

22

38

47

26

1719

31

38

9

14 14

4

22

30

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD, HK '10BGD, IFPRI '11

BOL '08ETH '11

IDN '10KHM '10

NPL '11PER '12

ZWE '10

Source: Author estimates.Note: (1) Bangladesh (IFPRI) has Vitamin A supplementation for 6 to 24 month olds only.(2) Indonesia does not have information on prenatal checkups or Vitamin A supplementation.

By wealth

Prevalence of Adequacy of Health

Resource Poor Resource Rich

Message 2

� Ranking (in most countries) of % of pop w/ adequate:1. Care

2. Food Security

3. Health & Environment

The low ranking of Health & Environment is not due to poor data or bad measurements

� Community level of sanitation is the most lagging component of adequate Health and Environment in ALL countries

34

Evolution of Chronic Malnutrition & Adequacies in F, C, & EH

�Stunting �High but

�has decreased significantly over time for both 0-5 yr old children and 0-2 yr olds

35

32

30

37

25

20

29

27

44

3130

42

26

22

17

30

26

010

20

30

40

Perc

en

tag

e o

f ch

ildre

n w

ith H

AZ

< -

2 S

D

Bangladesh (HK)Bangladesh (IFPRI)

BoliviaCambodia

EthiopiaIndonesia (RKD)

NepalPeru

Zimbabwe

Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010; Ethiopia 2000, 2011; Indonesia 2010 (RKD); Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010

Based on official DHS estimates when available

Stunting in children 0 to 23 months

Stunting year 1 Stunting year 2

36

33

43

32

27

43

40

58

44

34

57

41

29

18

35

32

020

40

60

Perc

en

tag

e o

f ch

ildre

n w

ith H

AZ

< -

2 S

D

Bangladesh (HK)Bangladesh (IFPRI)

BoliviaCambodia

EthiopiaIndonesia (RKD)

NepalPeru

Zimbabwe

Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (HK, IFPRI); Bolivia 2003, 2008; Cambodia 2005, 2010; Ethiopia 2000, 2011; Indonesia 2010 (RKD); Nepal 2000, 2011; Peru 2005, 2012; Zimbabwe 2005, 2010

Based on official DHS estimates when available

Stunting in children 0 to 59 months

Stunting year 1 Stunting year 2

42

26

44

32

35

16

37

35

32

28 28

25

47

30

20

6

25

22

010

20

30

40

50

Perc

en

tag

e o

f ch

ildre

n w

ith H

AZ

< -

2 S

D

BGD, HKBGD, IFPRI

BOL*ETH*

IDNKHM

NPL*PER*

ZWE

Source: Author estimates. Data for Bangladesh from 2010 (HK) and 2011 (IFPRI); Bolivia 2008; Cambodia 2010; Ethiopia 2011; Indonesia 2010 (RKD); Nepal 2011; Peru 2012; Zimbabwe 2010. *Stunting for under 36 month olds. The rest under 24 month olds.

Stunting in children 0 to 23 or 35 months

Resource poor Resource rich

Message 3:

�Correlation (and likely causation) between decline in stunting and increases in prevalence of adequacies in F, C, and H&E

�In the past few years efforts on reducing malnutrition have concentrated on care (C)

�Hardly any progress towards improving health & environment (H&E)

�Mixed/spotty record on improving food adequacy

39

Synergies

Some background

40

47

8

23

6

15

2

020

40

60

80

10

0P

erc

enta

ge

of

ch

ildre

n w

ho

me

et

cri

teri

a

Source: Author estimates.

Adequacy status in Zimbabwe (2010)

None Food only

Care only Environmental health only

Two of three adequacies All three adequacies

20%3%

36%

3%

39%

13%24%

0%

6%0%

33%

3%14%

2%

34%

1%

15%2%

Bangladesh (HK, 2010) Bangladesh (IFPRI, 2011) Bolivia (2008) Cambodia (2010)

Ethiopia (2011) Indonesia (RKD, 2010) Nepal (2011) Peru (2012)

Zimbabwe (2010)

None

Food

Care

Env & Health

Two of three

All three

Source: Author estimates.

Recent year

Figure 9: Adequacy status

42%

3%

41%

3%11% 11%

52%

34%

3%19%

9%

20%5%

38%

9%

36%

10%32%

22%

55%

6%

33%

6%25%

31%6%1%

33%

3%

49%

14%

24%

1%12%1%

21%

7%

32%

40%

53%

7%

29%

11%

Bangladesh (HK, 2010) Bangladesh (IFPRI, 2011) Bolivia (2008) Cambodia (2010)

Ethiopia (2011) Indonesia (RKD, 2010) Nepal (2011) Peru (2012)

Zimbabwe (2010)

None

Food

Care

Env & Health

Two of three

All three

Source: Author estimates.

Recent year

Figure 10a: Adequacy status - Resource-poor

28%

12%

25%

6%

24%

5% 16%

41%2%

37%

3% 15%

9%

10%

11%39%

15%

32%

12%25%

4%

26%

56%

6%

30%

1%7%

28%

32%1%3%

33%

4%

42%

14%

23%

3%

15%3%

30%

17%22%

1%

30%

1%

44%

8%18%

9%

17%4%

Bangladesh (HK, 2010) Bangladesh (IFPRI, 2011) Bolivia (2008) Cambodia (2010)

Ethiopia (2011) Indonesia (RKD, 2010) Nepal (2011) Peru (2012)

Zimbabwe (2010)

None

Food

Care

Env & Health

Two of three

All three

Source: Author estimates.

Recent year

Figure 10b: Adequacy status - Resource-rich

C, F, HE, Synergies, and HAZ

45

.

.

Regression Model Estimated:

Interpretation of coefficients: conditional mean of HAZ given adequate access to

Synergies

46

The coefficient yields information on whether there are additional (extra) gains (or losses) in HAZ scores derived from access to adequate care only or access to adequate food only.

A significant and positive value of the coefficient implies synergies from the simultaneous access to adequate care and adequate food security in the production of child nutrition.

.

.

-.5

0.5

11.5

2C

oe

ffic

ient e

stim

ate

fro

m M

ode

l B

BGD, HKBGD, IFPRI

BOLETH

IDNKHM

NPLPER

ZWE

Source: Author estimates. Data for Bangladesh (HK) 2010; Bangladesh (IPRI) 2011; Bolivia 2008; Cambodia 2010; Ethiopia 2011; Nepal 2011; Peru 2012; Zimbabwe 2010

Figure 11: Synergies among adequacies

Environment & Food Environment & Care

Food & Care

-.5

0.5

11.5

Coe

ffic

ient e

stim

ate

fro

m M

ode

l B

BGD, HKBGD, IFPRI

BOLETH

IDNKHM

NPLPER

ZWE

Source: Author estimates. Data for Bangladesh (HK) 2010; Bangladesh (IPRI) 2011; Bolivia 2008; Cambodia 2010; Ethiopia 2011; Nepal 2011; Peru 2012; Zimbabwe 2010

Figure 12: Total effects among adequacies

Environment & Food Environment & Care

Food & Care

Message 4:

� Synergies among C, F, and HE, are strong. �18 out of 25 coefficients on synergy are positive�10 out of 18 positive coefficients are statistically significant

�Countries with malnutrition problems have a great potential in exploiting such synergies

�A renewed and perhaps more determined effort is needed in exploiting such synergies

49

Take-aways�In most countries % of pop w/ adequate Care is the highest and H&E the lowest:

1. Care2. Food Security3. Health & Environment

�Correlation (and likely causation) between decline in stunting and increases in prevalence of adequacies in F, C, and HE

�In the past few years efforts on reducing malnutrition have concentrated on care

�Hardly any progress towards improving health & environment(E&H)

�Mixed/spotty record on improving food adequacy

50

Policy considerations�Synergies among C, F, and HE, are strong.

�Countries with serious chronic malnutrition problems have a great potential in exploiting such synergies

�Need for more systematic data collection (closing the gaps in data collected by DHS and other nutrition-related surveys)

�Renewed effort is needed in exploiting such synergies on the policy arena

�Sector-specific nutrition-sensitive interventions are one way to take advantage of synergies present within specific sectors. BUT one must also ensure that the stronger synergies (highlighted in this study) derived from interactions across sectors are realized, (e.g. increases in the level of adequate Food or H&E).

�WHO within the World Bank or within countries?�And HOW?

�Challenges posed for “prioritization” among broad sectoral policies�Perhaps it is best to raise adequacy in C, F, and H&E, to some minimum level before prioritization among interventions against malnutrition becomes a meaningful concern

51

Thank you

52

Appendix

Thresholds for water and sanitation

53

Improved Sources of drinking water

Piped water into dwelling

Piped water to yard/plot

Public tap or standpipe

Tubewell or borehole

Protected dug well

Protected spring

Rainwater collection

Unprotected springUnprotected dug wellCart with small tank/drumTanker-truckSurface water (river, dam, lake, pond, stream, canal, irrigation channels)Bottled water; bottled water is improved only if a secondary source of improved water for other uses (personal hygiene and cooking)-- DHS does not distinguish so put it in “unimproved”

54

“Improved” sources water “Unimproved” sources water

Source: WHO and UNICEF (2006) “Core questions on

drinking-water and sanitation for household surveys”

Improved Sanitation *

Flush toilet�Piped sewer system�Septic tank�Pit latrine�Special case “flush/pour flush to unknown place/not sure/DK where” as respondents might not know if their toilet is connected to a sewer or septic tank

Ventilated improved pit latrine (VIP)Pit latrine with slabComposting toilet

Flush/pour flush to elsewhere

Pit latrine without slab

Bucket

Hanging toilet or hanging latrine

No facilities or bush or field

55

“Improved” sanitation facilities “Unimproved” sanitation facilities

Source: WHO and UNICEF (2006) “Core questions on

drinking-water and sanitation for household surveys”

* Lack of data on shared facilities status

Table 5: Comparability of indicators across years and countries pl

Country and data year

Food Environmental health Care

Ma

xim

um

ag

e (

mo

nth

s)

Die

tary

div

ers

ity

Fo

od

se

curi

ty

Me

al

fre

qu

en

cy

Acc

ep

tab

le d

iet

Se

con

d r

ou

nd

co

mp

ara

ble

to

fir

st r

ou

nd

Co

mp

ara

ble

acr

oss

co

un

trie

s

Imp

rove

d s

an

ita

tio

n

Co

mm

un

ity s

an

ita

tio

n

Acc

ess

to

sa

fe w

ate

r

Va

ccin

ati

on

s

Pre

na

tal

che

cku

ps

Vit

am

in A

su

pp

lem

en

tati

on

Se

con

d r

ou

nd

co

mp

ara

ble

to

fir

st r

ou

nd

Co

mp

ara

ble

acr

oss

co

un

trie

s

Exc

lusi

ve

bre

ast

fee

din

g

Imm

ed

iate

skin

-to

-skin

co

nta

ct

Co

mp

lem

en

tary

fe

ed

ing

(6

-8 m

on

ths)

Bre

ast

fee

din

g f

or

24

mo

nth

s

Se

con

d r

ou

nd

co

mp

ara

ble

to

fir

st r

ou

nd

Co

mp

ara

ble

acr

oss

co

un

trie

s

Cambodia (2005) 24Y N Y Y A Y Y Y Y Y Y A Y Y Y Y A

Cambodia (2010) 24 Y N Y Y Y A Y Y Y Y Y Y Y A Y Y Y Y Y A

Ethiopia (2000) 36Y N Y Y B Y Y2 Y Y Y Y C Y Y Y Y B

Ethiopia (2011) 36 Y N Y Y Y B Y Y2 Y Y Y Y Y C Y Y Y Y Y B

Nepal (2000) 36Y N Y Y B Y Y2 Y Y Y Y C Y Y Y Y B

Nepal (2012) 36 Y N Y Y Y B Y Y2 Y Y Y Y Y C Y Y Y Y Y B

Bolivia (2003) 36Y N N N N N Y Y Y N Y Y4 Y Y C

Bolivia (2008) 36Y N Y Y N B N N Y Y Y Y N Y Y4 Y Y Y C

Peru (2005) 36Y N Y Y B Y Y Y Y Y Y B Y Y4 Y Y C

Peru (2012) 36Y N Y Y Y B Y Y Y Y Y Y Y B Y Y4 Y Y Y C

Zimbabwe (2005) 24Y N Y Y A Y Y Y Y Y Y A Y Y Y Y A

Zimbabwe (2010) 24Y N Y Y Y A Y Y Y Y Y Y Y A Y Y Y Y Y A

Bangladesh (HK, 2010) 24Y Y N N Y Y2 Y Y Y Y3 Y Y Y Y A

Bangladesh (HK, 2011) 24Y Y N N Y Y Y2 Y N Y Y3 N Y Y Y Y Y A

Bangladesh (IFPRI, 2011) 24Y N Y Y n/a A Y Y Y Y Y Y n/a A Y N Y Y n/a

Indonesia (RKD, 2010) 24Y1 N N N n/a Y N Y Y N N n/a Y Y Y Y n/a A

NOTES: Y = yes, N = no; 1At the household level instead of child-specific; 2Community sanitation not included in the environment adequacy measure used in the regressions (only in summary statistics). 3Vitamin A

supplementation information asked for only 6 to 24 month olds. 4Within first 100 minutes (not 60 minutes) as is used in the other countries.

Adequacies by wealth group

� Adequate food is slightly higher among resource-rich children, � with larger differences in Bangladesh HK and Zimbabwe.

� In most countries the prevalence of adequate care is higher among resource-poor children� Resource rich mothers working � compromises care

� breastfeeding and care is easier to intervene than other sectors such as water and sanitation.

� Most countries have very low prevalence of adequate environmental health

57

13

3834 34

47

53

12 13

67 68

32

37

2529

46 47

18

25

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD (HK, '10)BGD (IFPRI, 11)

BOL ('08)ETH ('11)

IDN ('10)KHM ('10)

NPL ('11)PER ('12)

ZWE ('10)

Source: Author estimates.Note: (1) Bangladesh (HK) include food security but not information on minimum acceptable diet.(2) Indonesia (RKD) only has information on household level diatery diversity, nothing else.

By wealth

Prevalence of Adequacy of Food

Resource Poor Resource Rich

5250

89

81

64

56

3937

40

34

5451

3639

72

52

4038

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD (HK, '10)BGD (IFPRI, 11)

BOL ('08)ETH ('11)

IDN ('10)KHM ('10)

NPL ('11)PER ('12)

ZWE ('10)

Source: Author estimates.Note: (1) In Peru and Bolivia early initiation of breastfeeding is within 100 minutes, not within 60 minutes as in others.(2) Bangladesh (IFPRI) does not include information on early initiation of breastfeeding(3) Indonesia does not include information on complementary feeds for 6 to 8 month olds.

By wealth

Prevalence of Adequcy of Care

Resource Poor Resource Rich

5

17

7

12

25

46

02

710

0

7

2

10

2 2 1

17

020

40

60

80

10

0P

erc

en

tag

e o

f ch

ildre

n w

ho m

eet crite

ria

BGD (HK, '10)BGD (IFPRI, 11)

BOL ('08)ETH ('11)

IDN ('10)KHM ('10)

NPL ('11)PER ('12)

ZWE ('10)

Source: Author estimates.Note: (1) Bolivia does not include improved sanitation.(2) Ethiopia, Nepal, Bolivia, and Indonesia do not include community sanitation.(3) Bangladesh (IFPRI) has Vitamin A supplementation for 6 to 24 month olds only.(4) Indonesia does not have information on prenatal checkups or Vitamin A supplementation.

By wealth

Prevalence of Adequcy of Environmental Health

Resource Poor Resource Rich

53

7

29

0

11

0

44

8

18

9

17

4

020

40

60

80

10

0P

erc

enta

ge

of

ch

ildre

n w

ho

me

et

cri

teri

a

Resource-poor Resource-rich

Source: Author estimates.

By wealth

Adequacy status in Zimbabwe (2010)

None Food only

Care only Environmental health only

Two of three adequacies All three adequacies