The role of social protection and agriculture in tackling chronic undernutrition
Research from Ethiopia and Bangladesh on the potential of nutrition sensitive interventions
Nutrition specific interventions such as micronutrient supplements and fortification, communication interventions to stregthen infant feeding practices and community management of acute malnutrition, can dramatically reduce infant and child mortality. Research has shown that there is a powerful economic case for these interventions, with every dollar invested returning around 15 dollars in economic benefits. Yet these nutrition specific interventions, powerful though they are at reducing infant and child mortality, appear to have limited impacts on chronic undernutrition. This limited impact has sparked interest in the potential for nutrition sensitive interventions – complementary programmes on other sectors that address the underlying determinants of malnutrition.
A major component of the Transform Nutrition consortium's research portfolio has been an examination of the potential of two sectors, social protection and agriculture, in two countries – Bangladesh and Ethiopia, to reduce chronic undernutrition. This Guide reports on the, sometimes unexpected, learning that has emerged as a result.
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Transform Nutrition is supported by the UK Department for International Development
Chronic undernutrition and social protection
Ethiopia operates one of the largest social protection interventions in sub-Saharan Africa, the Productive Safety Net Programme (PSNP). The PSNP provides public works employment and unconditional transfers of either cash or food to the rural poor. It is a well targeted programme that has improved household food security. However, work undertaken by Transform Nutrition in partnership with IFPRI found no evidence that the PSNP reduced either chronic undernutrition or acute undernutrition. While it is not possible to definitively identify the reason for this non-result, children’s diets in PSNP localities were poor, with most children consuming a monotonous diet of staple grains and little else. Most mothers had no or little contact with health extension workers, a source of information on appropriate complementary feeding practices.
Meanwhile Bangladesh has made remarkable progress in reducing chronic undernutrition but the prevalence of stunting, a reduced growth rate in children resulting from undernutrition, remains unacceptably high. Transform Nutrition participated with other development partners, most notably the World Food Programme, in the implementation and analysis of two, two-year, randomized control trials (RCTs) of nutrition sensitive social protection. In both RCTs, mothers in ultra-poor households were assigned to receive either cash, food, or a mix of cash and food. In one RCT, some mothers were given cash and participated in an intensive set of nutrition behaviour change communication (BCC) activities; in the second RCT, some mothers participated in the same set of nutrition BCC activities but received food instead. Relative to control households, all treatment arms improved household food security but in both RCTs, neither the cash, food, nor the mixed cash-food treatments improved children’s nutritional status.
But unlike Ethiopia’s PSNP, some households received both a transfer and nutrition BCC. Where the transfer was in the form of food, this had no effect on children’s nutritional status. But where mothers received cash transfer and the BCC component, saw a large reduction in child undernutrition, a seven percentage point reduction in stunting. There are a number of factors contributing to this reduction. Children in cash plus BCC households had a higher quality diet, consuming a wider range of foods most notably animal source foods. It was also clear that mothers learned more about good nutrition and as a result of their engagement with the programme saw improvements to their status within their households and their community.
Taken together, these studies suggest that social protection by itself may have little effect on improving children’s nutritional status. The Bangladesh study points to the importance of linking to nutrition BCC activities that improve women’s nutrition knowledge, enhance their status within their homes and communities, and encourage the consumption of more diverse foods, including animal source foods. Some of these ideas are now being adopted in Ethiopia.
Chronic undernutrition and agriculture
Food is needed for children to grow. So interventions that increase food supply should improve children’s nutritional status. Transform Nutrition’s work suggests that this simplistic narrative is misleading.
Take Bangladesh, a country that achieved rapid growth in rice productivity at a relatively late stage in Asia’s Green Revolution. Transform Nutrition created a multi-round district level panel to link changes in nutrition survey data with agricultural sample survey data over a period, between 1197 and 2011, in which rice yields rose by more than 70%. Rising rice yields were found to have a modest effect on weight-for-height ratios, a short run measure of children’s nutritional status but had no effect on chronic undernutrition or on children’s dietary diversity.
What could account for this type of non-result? A trio of papers looking at the links between agriculture and nutrition in Ethiopia provide some clues. The first study explores the relationship between pre-school children’s food consumption and household agricultural production. It found that increasing household production diversity leads to considerable improvements in children’s dietary diversity but this relationship does not hold for households that have access to food markets. The second brings in the links between market access and caregivers’ nutrition knowledge. The interesting finding here was that better nutrition knowledge leads to considerable improvements in children’s dietary diversity, but only in areas with relatively good market access. The third paper looks at the interplay between home production of foods and children’s diets, focusing on dairy . Here it was found that cow ownership raises children’s milk consumption, increases linear growth, and reduces chronic undernutrition. Also household cow ownership was less important where there is good access to local markets, suggesting that market development can substitute for household cow ownership.
Collectively, these Transform Nutrition studies point to a more nuanced picture of the links between agriculture and chronic undernutrition. Simply growing more staple foods appears unlikely to be sufficient to improve children’s nutritional status and simply telling mothers to feed their children a diverse set of foods is not helpful when those foods are not produced or are not available in local markets. Instead, agricultural development may contribute most to improvements in children’s nutritional status when it includes market-integration activities that make available a wider range of foods, when it is twinned with nutrition BCC activities and when the improvement in diet includes animal source foods.