The role of social protection and agriculture in tackling chronic undernutrition

Research from Ethiopia and Bangladesh on the potential of nutrition sensitive interventions

A woman processes rice in front of her house in Pukra, Habiganj district, Bangladesh|Save the Children
Edited by Alan Stanley
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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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John Hoddinott 

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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.





Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?
The Lancet, 2013
Maternal undernutrition contributes to 800,000 neonatal deaths annually; stunting, wasting, and micronutrient deficiencies are estimated to underlie nearly 3.1 million child deaths annually. Progress has been made with many interventions implemented at scale and the evidence for effectiveness of nutrition interventions and delivery strategies has grown since The Lancet Series on Maternal and Child Undernutrition in 2008.
The economic rationale for investing in stunting reduction
Wiley Online Library, 2013
This paper outlines the economic rationale for investments that reduce stunting. It presents a framework that illustrates the functional consequences of stunting in the 1000 days after conception throughout the life cycle: from childhood through to old age. It also summarises the key empirical literature around each of the links in the life cycle, highlighting gaps in knowledge where they exist. The considerable challenges in creating credible estimates of benefit/cost ratios for a plausible set of nutritional interventions to reduce stunting are documented. 
Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition?
The Lancet, 2013
Acceleration of progress in nutrition will require effective, large-scale nutrition-sensitive programmes that address key underlying determinants of nutrition and enhance the coverage and effectiveness of nutrition-specific interventions. The authors of this article in the 2013 Lancet Series on Maternal and Child Nutrition reviewed evidence of nutritional effects of programmes in four sectors - agriculture, social safety nets, early child development, and schooling.
The impact of Ethiopia's Productive Safety Net Programme on the nutritional status of children: 2008-2012
International Food Policy Research Institute, 2017
Ethiopia's Productive Safety Net Programme (PSNP) is a large-scale social protection intervention aimed at improving food security and stabilizing asset levels. The PSNP contains a mix of public works employment and unconditional transfers. It is a well-targeted program; however, several years passed before payment levels reached the intended amounts. The PSNP has been successful in improving household food security. However, children’s nutritional status in the localities where the PSNP operates is poor, with 48 percent of children stunted in 2012.
Accounting for nutritional changes in six success stories: a regression-decomposition approach
Global Food Security - journal, 2017
Over the past two decades, many developing countries have made impressive progress in reducing undernutrition. In this paper, the authors explore potential explanations of this success by applying consistent statistical methods to multiple rounds of Demographic Health Surveys for Bangladesh, Nepal, Ethiopia, Odisha, Senegal, and Zambia.The research finds that changes in household wealth, mother's education and access to antenatal care are the largest drivers of nutritional improvement, except for Zambia where large increases in bednet usage is the single largest factor.
Behavior change communication activities improve infant and young child nutrition knowledge and practice of neighboring non-participants in a cluster-randomized trial in rural Bangladesh
PLoS ONE, 2017
The objective of this study was to examine the impact on infant and young child nutrition knowledge and practice of mothers who were neighbours of mothers participating in a nutrition Behavior Change Communication (BCC) intervention in rural Bangladesh.It found that having a neighbouring mother participate in a nutrition BCC intervention increased non-participant mothers IYCN knowledge and that they were more likely to feed their children legumes and nuts, vitamin A rich fruits and vegetables and eggs.

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.

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Agriculture, nutrition and the green revolution in Bangladesh
Science Direct, 2016
This paper explores agriculture and nutrition linkages in Bangladesh, a country that achieved rapid growth in rice productivity at a relatively late stage in Asia's Green Revolution, as well as unheralded progress against undernutrition. To do so, the authors first outline a simple conceptual model to identify the different impacts that productivity growth in a food staple(s) might have on child nutrition outcomes, with a particular focus on changes in diets at the household and child level.
Agricultural production and children's diets: Evidence from rural Ethiopia
International Food Policy Research Institute, 2014
Study of the relationship between pre-school children's food consumption and household agricultural production using a large household survey from rural Ethiopia. Finds that increasing household production diversity leads to considerable improvements in children's diet diversity. However, this non-separability of consumption and production does not hold for households that have access to food markets.
Children's Diets, Nutrition Knowledge, and Access to Markets
Elsevier, 2017
Chronic undernutrition in Ethiopia is widespread and many children consume highly monotonous diets. To improve feeding practices in Ethiopia, a strong focus in nutrition programing has been placed on improving the nutrition knowledge of caregivers. This paper discusses the impact of caregivers' nutrition knowledge and its complementarity with market access.
Cows, missing milk markets and nutrition in rural Ethiopia
International Food Policy Research Institute, 2014
In rural economies encumbered by significant market imperfections, farming decisions may partly be motivated by nutritional considerations, in addition to income and risk factors. These imperfections create the potential for farm assets to have direct dietary impacts on nutrition in addition to any indirect effects via income. We test this hypothesis for the dairy sector in rural Ethiopia, a context in which markets are very thin, own-consumption shares are very high, and milk is an important source of animal-based proteins and micronutrients for young children