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Smallholder agriculture's contribution to better nutrition.

Annex A. Ghana: Star agriculture performance, on track to meeting MDG1--but disappointing progress in stunting of pre-school age children

Observed changes in nutrition

Underweight and Stunting

The prevalence of underweight children under-five fell from 25% in 1994 to 14% in 2008, while stunting fell from 33.5% in 1994 to 29% in 2008, see Figure A.1. In both cases, Ghana has moved from high to medium severity, by the WHO classification. Undernutrition is worse among rural than urban children.

Micronutrient deficiencies

Micronutrition problems also prevail, though survey data available on micronutrition are sparse. In 2003, 70% of under-fives, and about 65% of pregnant women were at least moderately anaemic (15). While levels of dietary iron technically available in Ghana nationally as reported by FAO appear good compared to other countries, and have been improving, the problem of iron-deficiency anaemia remains severe in vulnerable populations. Analysts attribute high levels of anaemia in Ghana to poor bio-availability of iron in diets owing to low consumption of iron-absorption enhancing foods such as meat and vitamin-C rich foods, as well as malaria (16) and parasitic diseases such as hookworm (Agble, 2009).

Vitamin-A deficiency is also a public health issue in Ghana, where diets provide inadequate levels of vitamin A-rich foods. While statistics on vitamin A deficiency for preschoolers in Ghana are inadequate, evidence suggests young children do not eat enough vitamin A rich foods: See Figure A.2

Iodine deficiency is a problem in Ghana, where people's iodine levels are reportedly influenced by poor iodine availability in the soil, by some compounds in certain cassava varieties that aggravate iodine deficiency, and the fact that seafood rich in iodine, while in relatively good supply in coastal Ghana, is less available further inland (The Ghanaian Journal, 2009).

Data, as for other micronutrients, are poor: only available for some sub-national populations of school age children and women for the mid-1990s. While there is evidence that micro- nutrient deficiencies have eased, (17) in some districts from a severe to a mild public health issue (18), surveys are needed to determine extent and guide intervention.

Growth of economy

Economic growth has been good in Ghana since 1990. Real (2000) GDP per capita grew from around US$221 in 1990 to US$402 in 2011, an 82% rise: enough for Ghana to move from low income (LIC) to lower middle income country (LMIC) status.

Agriculture

Agricultural growth

Net production indices for Ghanaian cereals, crops and livestock show consistent growth from 1990 to 2010, overall at almost 5% a year. On a per-capita basis too they have been growing, at an equivalent of 2.3% a year; except for livestock which fell slightly from 1990 to about 2007 before it started to pick up again. Cereals growth also stuttered from around 2002 to 2007, before shooting up rapidly over the next 3 years. See Figure A.3

Food availability--and its price

Overall calorie supply grew from around 2000 kilocalories per person a day to close to 3000 kilocalories per person a day from 1990 to 2009 (FAOSTAT data). Undernourishment has been reduced dramatically, estimated by FAO at under 5% of the population by 2009, compared to 25 to 40% (19) in the early 1990s.

Both staple (20) and non-staple (21) supply has grown, with the share of available food from fruits and vegetables, oils and animal products rising from one quarter to one third. On average therefore, diversity of diets ought to be improving as supply of all foodstuffs has grown faster than population, see Figure A.4.

Though trends in real consumer prices for staple cereals have been relatively flat over the period in question (they fell over a longer period - see for instance Wiggins & Leturque, 2011), even increasing slightly in recent years. Prices for staple root crops like cassava have fallen slightly. In addition, the food portion of the Consumer Price Index has fallen in real terms.

At the same time, there has been good news for farmers reportedly achieving higher prices for many crops from cash crops like cocoa, to staples like maize and cassava, as well as complementary vegetables like tomatoes and eggplants which women farmers often grow and sell (FAOSTAT data).

Poverty

Overall poverty

Poverty rates at the national poverty line fell from 52% of the population in 1992 to 29% of the population in 2006 (World Bank WDI).

Rural poverty

Rural poverty prevalence fell from 64% in 1992 to 39% in 2006 (World Bank WDI). Absolute numbers of poor fell in rural areas by 1.7 million, while absolute numbers of urban poor fell by almost half a million, despite a boom in urban population of almost 80%, see Figure A.5.

Wealth is strongly linked to malnutrition of children, with the richest quintile seeing far lower levels of both stunting and underweight in their preschoolers than the poorest quintile: See Figure A.6

Health

Under-fives mortality rate

The mortality rate of under-fives fell from 121 deaths per 1,000 live births in 1990 to 78 deaths per 1,000 live births in 2011. While this level is below the low-income country average, it is about 30 more than the world average.

Water & sanitation

Just over half the population had access to an improved water source in 1990, but by 2010 the proportion had risen to 86% (22). The biggest improvements were seen in rural areas, where in 1990 only 36% of the population had access to an improved water source. This had risen to 80% by 2010 (World Bank WDI).

In contrast, progress in increasing access to improved sanitation has been discouraging. World Bank estimates 7% of the population had access to improved sanitation in 1990 and only 14% had access to improved sanitation by 2010--under half the levels of access seen in low income countries on average.

Female empowerment

Female schooling

Literacy rates for young (15 to 24 years) females went from 65% in 2000 to 80% in 2009 (World Bank WDI data).

The female net enrolment in primary school for 2007-2010 was 77%. Secondary school female net enrolment over the same period was 44% (UNICEF, 2012).

Schooling matters for the nutrition of future generations. In Ghana about 30% of under- fives of mothers with no or only primary education are stunted, compared with about 18% of those whose mothers have a complete secondary education or more. Underweight rates varied similarly with education of mothers--from 17% of children of uneducated mothers underweight, to only 7% of children with mothers with at least secondary education being underweight (Data from GSS & GHS 2009).

Teenage pregnancy rate

Adolescent fertility fell from 90 births per 1000 girls aged 15 to 19 in 1997, to 66 births per 1000 girls aged 15 to 19 in 2010. Ghana's trend on this indicator has followed a similar trajectory as that of lower middle income countries; well below the average level for low income countries.

Specific nutrition interventions

National nutrition interventions such as programmes for salt iodisation or vitamin A supplementation have helped improve micronutrient availability, but in general coverage is still not high (Agble, 2009). Furthermore, degree of implementation of various national nutrition programmes--for instance deworming of school age children or programmes to improve infant and young child feeding--are not well documented.

Agricultural interventions for nutrition

Agricultural interventions for nutrition can fall into three broad categories: Firstly, nutrition-sensitive gender empowerment; secondly, home gardens, small livestock, and aquaculture; and thirdly, bio-fortification of staple crops. Often the boundaries between the first two categories overlap on a programme level. Furthermore, agricultural interventions are frequently combined with non-agricultural initiatives, or included as part of larger programmes. Some examples from Ghana of these types of programmes for which evidence on nutrition- related outcomes can be found are set out below.

World Vision's CIDA-funded programmes Micronutrient and Health (MICAH) and Expanding Nutrition and Health Achievements through Necessary Commodities and Education (ENHANCE), both of which have been active in Ghana, involve a package of interventions of which agriculture is only a part.

MICAH began in 1996, and was predominantly a health and nutrition programme, involving supplementation, fortification, promoting best practices in breastfeeding and infant feeding, immunization campaigns, malaria control, treatment of worms and parasites, and improving water and sanitation.

On the agriculture side it also involved promoting small animal rearing, vegetable gardens and fruit trees, as well as providing education, information, and local capacity building. Though evauation of various components is not available, in Ghana, MICAH is credited with helping to spread acceptance of exclusive breastfeeding for six months, improving immunization coverage, and is also reported to have contributed to significant reduction in anaemia among children, women of reproductive age, and pregnant women (World Vision, 2009)

It was followed by ENHANCE, also health-focussed (23), but involving some training on home gardens. This programme was shown to have resulted in Ghanaian children aged 12 to 23 months in target communities seeing a 10% increase in animal-source food consumption, and a 33% increase in vitamin A intake (World Vision, Sep 2011).

Bio-fortification

Varieties of orange-fleshed sweet potato (OFSP), a good source of beta-carotene, were introduced to Ghana in 2005. The extent to which they are grown and consumed nationally is unknown, though white sweet potatoes have a relatively long history of cultivation in Ghana. OFSP are a good candidate for promotion through home garden schemes.

Initial studies found positive responses in terms of people's consumption, and are currently being followed with programmes such as a USAID/HortCRSP project looking at how to incorporate sweet potatoes into more diverse food preparations--to improve economic welfare for farmers, processors, and others in the supply chain, as well as so boost OFSP consumption (HortCRSP 2010, 2012). Evaluations are not yet available.

Maize is another contender for bio-fortification in Ghana. Ghana is one of the initial target countries for dissemination of HarvestPlus maize (24) biofortified with Vitamin A (Pixley & Mcclafferty, 2006). Studies have shown that while people's preferences for maize are highly varied within regions, people are willing to pay for bio-fortified maize in Ghana, and willing to change preferences given clear information (De Groote et al., 2010). The need for public campaigns through channels such as rural radio have been discussed (ibid).

In 2005, potential new maize sources for high iron and zinc were identified by CIMMYT (Pixley & McClafferty, 2006) though varieties are not available yet in Ghana.

High quality protein maize is another type of bio-fortified food that has been developed and transferred to Ghana, where the varieties are drought tolerant as well as resistant to Striga, a parasitic weed (Atser, 2010). It is possible that this combination of physical hardiness and nutritional character could aid adoption.

While opportunities for bio-fortification in Ghana appear strong, not enough is known about the extent to which biofortified crops are being taken up by farmers; the suspicion is that as yet none of these varieties are widespread.

Interpretation

It seems that good agricultural and economic growth has improved food access and diversity, while reduced poverty means wasting has been reduced considerably since destitution is so much less common. But the high and only slowly declining stunting may reflect a combination of (a) Low birth weights from previously undernourished mothers, (b) inadequate care, too little breastfeeding, low quality weaning foods, dirty water, (c) infant diseases, (d) micro-nutrient effects whereby deficiencies cause disease and otherwise prevent normal growth. Agble et al (2009) cite feeding practices and low access to health services as among the main causes of chronic malnutrition in preschoolers.

Ghana emerges as a clear case in which agriculture can play its role in reducing malnutrition--up to a point. From here on, it looks as though priorities lie with health, water, sanitation, education, and so forth.

What could agriculture do for better nutrition in this case? At the margin:

* Bio-fortification of staple foods--clear potential exists

* Home gardens, as a way to combat micro-nutrient deficiency, in particular to encourage consumption of vitamin-A and vitamin C-rich foods.

* On top of home gardens, growth in a more diverse range of agricultural products ought to improve availability of complementary foods high in nutrients--as for instance a thriving green bean export sector in Kenya has contributed to higher availability of green beans domestically (25). Better availability ought to help bring down prices and help people to choose healthier diets (26)

To realize the full potential of strategies like these, they need to be accompanied with good education about nutrition and child feeding and care practices.

Annex B. Bangladesh: good progress on undernutrition over the last 20 years but more needed to maintain momentum.

Observed changes in nutrition

Underweight and Stunting

National surveys show a decline from staggering levels of stunting around 60% and 70% in the early 1990s to 41% in 2011, see Figure B.1. While these drops in the rate of stunting are impressive--20 to 30 percentage point reductions over 16 or 17 years--they are reductions from severe levels.

Progress on underweight has been similar. Some 62% of children under five were underweight in 1990 in Bangladesh, falling to 36% in 2011. This is another impressive reduction but undernutrition remains a major public health and economic problem in Bangladesh (Muiruri et al., 2012).

As with stunting prevalence, underweight is worse among rural than urban children.

Micronutrient deficiencies

Micronutrient deficiencies, particularly iron deficiency anaemia and iodine deficiency are widespread in Bangladesh, and multiple deficiencies are common (Muiruri et al., 2012). While up to date nationally representative information is not common for micronutrient status, some trends over the last two decades have been observed.

The problem of iron-deficiency anaemia remains severe in the under-five population, where in 2004, almost 70% of rural under-fives were at least moderately anaemic (27). This is an increase from 47% recorded in this population in both 1997 and 2001. Rural pregnant women's rate of anaemia improved: from 49% in 1997 to 39% in 2004 (WHO Global Database on Anaemia) (28).

Probably the most progress has been made combatting vitamin A deficiency. Night blindness is often caused by diets with insufficient vitamin A. In Bangladesh this deficiency is not as prevalent as others and is now likely below WHO's threshold of 1% (Muiruri et al., 2012).

Some progress has also been made in combatting iodine deficiency in Bangladesh--with prevalence of low iodine levels in urine falling nationally from close to 70% in 1993 to about 43% in 1999 (Who Global Database on Iodine deficiency). Though later comparable statistics do not appear in the WHO database, a 2004 survey revealed 39% of women and girls of reproductive age (15-44) were iodine deficient, while in pregnant women the prevalence was 56% (Muiruri et al., 2012). Prevalence in rural areas was higher than in urban areas.

Rickets, caused by calcium and or vitamin D deficiency (29) has emerged as a public health problem over the last two decades, with up to 8% of children clinically affected in some areas (Cravari et al., 2008). Muiruri et al. (2012) contend over half a million children in Bangladesh are currently affected by rickets.

Growth of economy

The World Bank classifies Bangladesh as a low income country (LIC). GDP per capita measured in constant 2000 USD grew from around US$280 in 1990 to US$588 in 2011, a rise of 110%.

Agriculture

Agricultural growth

Net production indices for Bangladeshi cereals, crops and livestock show overall growth from 1990 to 2010 at an annual equivalent of 3.7%. On a per-capita basis too they have been growing, at an average of 1.9% a year, though mostly since the late 1990s. Growth in the livestock indices has been the most consistent, while growth for cereals (agriculture and crops are largely driven by the cereals index) was slow over the first half of the 2000s, see Figure B.2.

Food availability--and its price

Increased supply of cereals in particular has contributed to reduced calorie undernourishment by FAO's estimates, though the rate of reduction has plateaued in recent years. While the estimates show a sharp improvement from the mid-1990s to the early 2000s (from 38% in 1994 to 18% in 2000), for most of the 2000s progress appears to have stagnated, leaving around 17% of the population estimated undernourished in 2011 (30).

This growth in cereal production has unfortunately not contributed much to dietary diversity. Bangladesh has the dubious distinction of being the country with the second highest staple (cereals plus starchy roots) contribution to total calories in the world, at 81% in 2009, after only Eritrea (82%). Diets in Bangladesh depend heavily on rice, with insufficient diversity to guarantee good micro-nutrition. Other Asian countries with similar poverty prevalence which had in 1990 similarly restricted sources of food supply (Cambodia and Lao PDR for example) have made more progress than Bangladesh on diversifying diets.

The price of rice has remained relatively the same in real terms since the late 1990s (FAO GIEWS coarse rice price data); except for two periods of crisis in 2007/08 and 2010/11.

Bangladesh is vulnerable to food crises, though its vulnerability appears to have decreased from 1990 to 2011. Food aid deliveries which might indicate vulnerability have tended to decline over the last few decades (31). This in spite of the fact that relative food prices in general (32) rose about 10% from their 2000 levels by mid-2011.

On average, household expenditure on cereals was 38% of food expenses in 2000, and 36% in 2010. Expenditure on a more diverse variety of food was stronger in urban areas, where 28% of food expenses went on cereals in 2010, compared to about 40% in rural areas in 2010.

Poverty

Overall poverty

Poverty prevalence at the national poverty line has decreased from 57% in 1992 to 32% in 2010 (World Bank WDI). Of the 32% poor, about 50 million people, 18% (about 27 million) are below the lower poverty line, which means they cannot afford a basic diet (Muiruri et al., 2012).

Bangladesh's latest Demographic and Health Survey identifies very clear connections between income and stunting and underweight of preschoolers, see Figure B.4

Rural poverty

Rural poverty declined from 59% of the rural population in 1992 to 35% in 2010 (World Bank WDI data). Absolute numbers of rural poor fell by close to 14 million from 1992 to 2010 (33).

Health

Under-five mortality rate

The mortality rate of under-fives fell impressively from 139 deaths per 1,000 live births in 1990 to 46 deaths per 1,000 live births in 2011. While these rates have always been better than the LIC average, by 1999 they were better than LMIC average rates, and by 2006 fell below world average rates. Improvements in infant vaccination will have helped: for infants (12-23 months) they rose from about 60% in 1993/94 to 86% in 2011, well above the norm seen in LICs.

Water & Sanitation

Rates of access to improved water sources went from 77% in 1990 to 81% in 2010 nationally --well above the LIC average (World Bank WDI data).

Progress in access to improved sanitation was also encouraging, going from 39% in 1990 to 56% in 2010 (World Bank WDI data).

Female empowerment

Child stunting is significantly affected by several female empowerment indicators in Bangladesh, including attitudes towards domestic violence, mothers' education, height, and age at first marriage (Bhagowalia et al., 2012). Food access at household level may be unfair to women and young children owing to unequal distribution and cultural norms that require for example men eating first or boys receiving larger portions of high-nutrient foods than girls (Muiruri et al., 2012; CARE, 2012).

Female schooling

Women's status in Bangladesh is playing catch-up (34), though laudable improvements have been seen in indicators such as literacy of young women that rose from 38% in 1991 to 79% in 2000.

Net enrolment ratio for girls in primary school was 93% over 2007 to 2010. The same ratio for secondary school female participation over the same period was 43% (UNICEF, 2012).

Teenage pregnancy rate

The adolescent fertility rate dropped from about 130 births per 1000 women aged 15-19 to about 73 births per 1000 women aged 15-19 from 1997 to 2010. This is important for child nutritional status as early pregnancy exacerbates risks of perpetuating the intergenerational cycle of undernutrition (Muiruri et al., 2012). In Bangladesh, more than two thirds of girls are married before they turn 18, with early pregnancy contributing to the negative cycle of small mothers, stunted by chronic undernutrition, giving birth to low birth-weight (LBW) babies (35).

Specific nutrition interventions

Specific national nutrition interventions such as vitamin A supplementation and salt iodisation have seen success in improving features like vitamin A status or iodine deficiency. About 60% of under-fives in 2011 had received a vitamin A capsule in the 6 months prior to the survey (BDHS, 2011); though rates varied considerably across regions, as well as according to mothers' levels of education and wealth (see Figure B.5.). Vitamin A deficiency has been reduced significantly, but even here coverage is lacking.

Bangladesh's first large-scale nutrition intervention, formed in the 1980s and active from 1995 to 2002, the Bangladesh Integrated Nutrition Plan (BINP) spent only 6% of its budget during the 1990s. Evaluation of its aim (to reduce severe underweight by 40% and moderate underweight by 25%) was hampered by lack of necessary monitoring and evaluation guidelines (36) (Taylor, 2012).

Its successor, the National Nutrition Programme (NNP), ran from 2002 to 2011. This programme reportedly provided some 20% of the population (and 30% in 2009), with information, advice and counselling by Community Nutrition Promoters (Taylor, 2012). Behaviour Change Counselling has a large role to play in improved nutrition, particularly where wealth and education are no guarantee of ensuring best practices. Consider for example Figure B.6 which shows a clear relationship between better child feeding practices and better child nutrition outcomes with increasing wealth and education of mothers. Even among the most wealthy and well-educated, less than two-fifths adhere to the recommended child diets.

Achievements of the NNP beyond Behavior Change Counselling were lacking, notably in therapeutic malnutrition treatment. In 2008 only 20% of Bangladesh's severely malnourished children could be managed in health facilities (Taylor, 2012). Plans were similarly unambitious in terms of coverage 37.

Some large-scale specific nutrition interventions have seen impressive results in Bangladesh. In collaboration with USAID and the GoB, CARE's Strengthening Household Ability to Respond to Development Opportunities (SHOUHARDO) project is an excellent example; described as the first large-scale project using a rights-based livelihoods approach to addressing malnutrition (38) (Smith et al., 2011). An evaluation found extraordinary impact on stunting among children 6-24 months old: around 4.5 percentage points per year rate of reduction from early 2006 to late 2009. Over the same period for the same age group in Bangladesh, stunting declined only 0.1 percentage points per year. Targeting the poor helped to accelerate these reductions (ibid). More detail on SHOUHARDO is provided in the next section as an example of nutrition sensitive gender empowerment.

Agricultural interventions for nutrition in Bangladesh

Nutrition sensitive gender empowerment

SHOUHARDO is an outstanding example of a direct intervention putting women's empowerment at its centre (Feed the Future, 2012). Agricultural interventions were only one part of a package of interventions carried out at community level in rural areas, targeting the most vulnerable, including (numbers are % of participating households) (Smith et al., 2011):

* Mother and Child Health and Nutrition (MCHN)--33%

* Sanitation--19%

* Women's empowerment--25%

* Field crop production/fisheries--36%

* Homestead gardening & livestock rearing--46%

* Income generating activities--37%

* Food/cash for work--11%

* Savings groups--32%

An evaluation of SHOUHARDO discovered the single-most effective intervention was women's empowerment (Smith et al., 2011). Another key finding was the presence of strong synergies between different types of intervention. Regarding agricultural interventions, extremely strong synergies were observed between agricultural production/fisheries interventions and MCHN interventions, implying a very large reduction in stunting could be achieved by combining these interventions compared to small reductions they might achieve alone (Smith et al, 2011).

Significant synergies were also demonstrated between sanitation and MCHN; women's empowerment and MCHN; women's empowerment and participation in savings groups; and field crop production/fisheries promotion and participation in sanitation.

Home gardens and small livestock

Helen Keller International (HKI) began a homestead food production (HFP) programme in the early 1990s which has since expanded dramatically. In 20 years, HFP reached nearly 4% of Bangladesh's population, covering just over half the country's subdistricts (Ianotti et al., 2009).

HFP promotes home gardens, small livestock production, and nutrition education with the aim of increasing consumption of micronutrient-rich foods and improving health and nutritional status of women and children. Establishing HFP systems crucially involved agricultural and non-agricultural aspects (Ianotti et al., 2009):

* Establishing village model farms;

* Forming mother's groups

* Providing gardening and livestock inputs

* Behaviour Change Communication

* Community mobilization

* Making links with health and other sectors

The programme, implemented by NGO partners and government has improved food security for nearly five million vulnerable Bangladeshis across the country via: increased production and consumption of micronutrient-rich foods; increased income from gardens and expenses on micronutrient-rich foods; women's empowerment; enhanced partner capacity; and community development (Ianotti et al., 2009).

HFP also had more diverse impacts on people's welfare owing to the extra income generated. One study showed that extra income from sale of HFP garden products was spent on food (36%), education (35%), clothes (26%), productive assets (18%), health care (15%), housing (5%), and social activities (3%) (Ianotti et al., 2009). Another found that income from sale of poultry products went for savings (40%), followed by productive assets (37%), education (33%), food (30%), and clothes (14%) (ibid).

Home gardens for nutritious food appear sustainable beyond interventions by implementers. One study comparing household production and consumption of vegetables compared levels of those active in HKI programmes, those who had completed programmes, and a control group. Households involved in the programmes grew about 10 varieties of vegetable in their gardens, compared to 6 in those who had completed the programme, and only 3 in the control group. Production in the active group for the 3 months of the study was 130kg, compared to 120kg in the completed group, and only 40kg in the control. Household consumption was better in both the active and completed groups, at 85 and 70kg respectively over the 3 months, compared to 38kg for the control group (Helen Keller Worldwide, 2003).

While evidence on increased consumption and food diversity is clear, more evidence is needed to demonstrate HFP programme impact on improving maternal and child micronutrient status (Iannotti et al., 2009). Some studies have nonetheless found clear benefits of HKI home gardens for intake and nutrition outcomes in Bangladesh, for instance a case where HKI sponsored home gardens in Northern Bangladesh led to increased intakes of vegetables by children and infants, improved stunting and underweight rates, and reduced their incidence of anaemia and night blindness (Berti et al., 2004).

Some studies of home gardens in Bangladesh show less clear nutrition outcomes. For example, another case in Berti et al., 200439 where although home gardens led to increased intake of vitamin A rich foods by some 10 to 20%, this did not lead to any change in incidence of night blindness.

This highlights the importance of combining home gardens with BCC and other nutrition- enhancing strategies such as women's empowerment, as well as in designing monitoring and evaluation to capture anthropometric or micronutrient status impacts.

Aquaculture

For Bangladesh's rural poor, fish provides an important source of protein. Small indigenous fish species (SIS) dominate, but supply is under pressure and a growing share of available fish is supplied by rural carp culture of both indigenous and exotic species. SIS have higher vitamin A than the cultured species, and are also a better source of calcium as most of their bones are eaten (Ahmed et al., 2012).

While studies show households with aquaculture ponds (there were some 1.3M of these in Bangladesh around 2000) do not consume more fish than those without ponds, there is potential for high vitamin A species of fish to be grown in ponds with good potential to improve levels of vitamin A available in average diets (Roos et al., 2000).

Mola for instance is a fish high in vitamin-A commonly eaten in Bangladesh. Researchers found that of the mola harvested in ponds, around 47% were eaten by pond-owning households, which contributed around 21% of vitamin A required over the period examined (Roos et al., 2000).

An evaluation of two Danida aquaculture extension project/components (40) running from 1989 to 2006, one in Mymensingh and the other in Greater Noakhali, found participants in the programmes had increased fish consumption, improved diets, nutrition, and health. Rising incomes were also used to buy more nutritional food and to access health care services. Non-participating households however showed similar improvements in diet, nutrition, health, and access to health services, making attribution to the aquaculture programmes difficult (Danida, 2009).

What is clear is that aquaculture has increased availability of fish nationally. In 1990, Bangladesh aquacultured fish production was around 200,000 tonnes, around 20% of fish production nationally. By 2005, this had risen to nearly 900,000 tonnes; contributing around 40% of total fish produced in Bangladesh (Danida, 2009).

Bio-fortification

Bio-fortification is in early stages in Bangladesh, with little evidence of programmes for bio-fortification or impacts. A number of species appear to have potential, including orange-fleshed sweet potato (OFSP), golden rice currently being investigated for efficacy by HKI (HKI, 2012), and high-zinc rice, which is currently under development in the hope it may become available in Bangladesh within the next five years (IRIN 2011).

Interpretation

Progress on nutrition indicators has been encouraging in Bangladesh, but several come from extreme positions. Empowerment of women for instance may produce impressive results in Bangladesh owing to low starting levels of women's empowerment (41). From 1990 to 2011, Bangladesh reduced stunting by 1 percentage point a year: an impressive rate, close to that achieved by China over a similar period. The trick for Bangladesh will be to maintain--or even accelerate this rate over the next decade.

Agriculture certainly has a role to play in reducing undernutrition in Bangladesh; as it already has. Agricultural growth has been good at improving staple access but diets depend too heavily on rice (42). This is not good news for people's micro-nutrition. It may not be good for macro nutrition either, as high dependency on one staple does not spread risk (43). Furthermore, improvements in fundamentals such as public health and education need to continue--as also do campaigns to change unhelpful behaviours in feeding and care of infants, and the cycle of stunted mothers bearing stunted babies (44).

Political accountability for nutrition is a grey area in Bangladesh, owing to involvement of many government agencies, as well as strong involvement of large NGOs such as BRAC or HKI which step in to implement programmes the government might not otherwise implement. Particular problems arise when states are weak; NGOs take over public functions, thus leaving the state perhaps even weaker (Mason, 2002). NGOs might be less accountable to local people, though not necessarily. Furthermore, local accountability may not always be appropriate. For instance, the much-admired Grameen Bank makes a point of not adapting its programmes to local circumstances to avoid bias and corruption.

Nonetheless the political profile of Bangladesh's fight against hunger has been cited as a key factor underpinning its success to date (Sanchez-Montero et al., 2010.) Gender focussed non-farm employment opportunities and development of microcredit especially for women also contributed to Bangladesh's success to date (ibid).

What could agriculture do for better nutrition in this case? At the margin:

* Given the strong pressures on land in Bangladesh, the dangers of mono-cultivation, and the widespread micro-nutrient deficiencies, there is a strong case for Bangladesh to reduce rice production in favour of a more diversified production of crops and animals that are both more diverse ecologically as well as nutritionally. With extra earnings from this, the country can import rice, for example from Burma or Thailand (45).

* Home gardens, aquaculture, and small livestock are a part of this, particularly as they are a practice well established in Bangladesh with proven impacts on people's nutrition.

* Bio-fortification of staples--this appears to have potential, though largely unexplored.

* Diversify production to encourage better consumption of micronutrient rich food and diverse weaning diets. Home gardens are a good way to do this (46), with agricultural interventions particularly effective when combined with Mother & Child Health and Nutrition interventions.

Annex C. Tanzania: disappointing agricultural growth and not enough focus on health or education of girls means poor progress on child malnutrition

Observed changes in nutrition

Underweight and Stunting

* Tanzania has achieved good progress on underweight. It is possible the country could even achieve this indicator of MDG1, though not if the slow rate of improvement over the second half of the 2000s persists. A quarter of children under five were underweight in 1992. By 2010, underweight prevalence had fallen to 16.2%, a drop from high to medium severity by WHO's classification.

* It is worse among rural than urban children--though the gap has lessened since the mid-1990s.

* Progress on stunting rates has been discouraging. Nationally, 50% of under-fives were stunted in 1992. By 2010, the rate had fallen to only 43%. This is almost 20 years of 'very high' severity with disappointingly slow improvement. Though rates fell rapidly in urban areas from the early to late 1990s, this was not the case for rural preschoolers, and the decrease in urban areas reversed over the first half of the 2000s.

* As with underweight prevalence, stunting of children in rural areas is far worse than urban areas. In 2010 the margin was 13 percentage points: See Figure C.1.

Micronutrient deficiencies

Data on micronutrient status are not encouraging. The problem of iron-deficiency anaemia is severe in vulnerable populations. In 2004/05, 71.8% of pre-school age children had at least moderate anaemia (Haemoglobin below 110g/L) (WHO Global Database on Anaemia). At the same time, 58.2% of lactating women were at least moderately anaemic (47). By 2010, anaemia prevalence in under-fives had declined to 58.6% (NBS & ORC Macro 2011)--still a major public health problem, if 10 percentage points lower than the previous survey. Kinabo et al., (2008) wrote:

   Iron deficiency due to the low level of consumption of foods of
   animal origin is the main cause, but incidence of malaria and other
   parasitic diseases are contributing causes.

   ...


   'One of the factors contributing to the high prevalence of anaemia
   in the Southern zone is low consumption of fruit and animal foods,
   and low awareness about the relationship between food consumption
   and nutritional status.'


Vitamin A deficiency is thought to be widespread, mainly owing to low intake of animal products (48) high in absorbable retinol and not enough fruit and veg rich in vitamin A in diets. There are not however any surveys of national level vitamin A deficiency in children.

Growth of economy

Economic growth, while sluggish for most of the 1990s, with constant 2000 GDP per capita actually falling from 1990 to 1994, began to grow more rapidly after 2000, and by 2011 was about 55% higher than in 1990 (World Bank WDI).

Agriculture

Agricultural growth

Tanzania's economy is heavily dependent on agriculture, which accounted for about 45% of GDP and 2/3 of the country's export earnings in 2005. Furthermore, the agriculture sector is the main source of employment and livelihood for 76% of the population (Kinabo et al., 2008). Agricultural growth, however, has fallen short of its potential over the last 20 years, with per capita rates of growth discouragingly slow. While the net production index for agriculture has grown at a rate of 3.3% per year from 1990 to 2010, per capita it grew only half a percent per year over the same period, see Figure C.2.

Tanzania's agriculture is furthermore vulnerable to environmental shocks as the majority of production is rainfed and variable. Lean periods can last three or four months (FAO GIEWS), and in regions with one rainy season shortages are common. Inadequate storage also contributes (Kinabo et al., 2008).

Food availability--and its price

Overall calorie supply saw next to no change in per capita values over the 20 years from 1990 to 2009: see Figure C.3. The share coming from staples has fallen in favour of complementary foods.

Calories supplied from cereals per capita decreased at a rate of 0.3% a year from 1990 to 2009, while calories from starchy roots available per capita decreased at a rate of 2.9% per year over the same period. Other vegetable products supply grew at a rate of 2.9% per year and animal products (49) at 0.1%.

While diversity of average diets appears to have increased, diversity of children's weaning diets is still not good enough, with complementary foods comprising mainly cereal-based porridges with few or no vegetables and often lacking animal proteins (Muhimbula & Issa- Zacharia, 2010).

Staple food prices increased in real terms from 2006 to current levels. While longer term trends in staple food prices are difficult to track, wholesale maize prices in Dar es Salaam increased by over 50% in real terms from their average levels in 2006 to their average levels in 2011. They are also relatively volatile, which contributes to food insecurity (FAO GIEWS).

If food aid deliveries are an indication of trends in food security, they appear to have been getting worse. While it is difficult to pick out a trend in food aid deliveries, per capita deliveries from 1990 to 1999 were on average less than from 2000 to 2010, by more than half a kg per capita. Also, in 7 years of the most recent decade, food aid per capita was above 2 kg per capita, compared to being over 2 kg per capita in only 3 years of the earlier decade (WFP FAIS).

Poverty

Overall poverty

The proportion of poor people in Tanzania has reduced very slightly since the early 1990s. Poverty prevalence as measured at the national poverty line fell from 39% of the population in 1992 to 33% in 2007 (World Bank WDI).

Rural poverty

Rural poverty rates fell a little from 41% in 1992 to 37% in 2007 (World Bank WDI). The gap between urban and rural poverty rates is pronounced: 15 percentage points in 2007. Moreover, the absolute number of poor people has been rising, as reductions in poverty prevalence are not enough to lead to absolute reductions in the face of a relatively rapidly growing population (50).

In 2007 there were 2.6M more poor people in rural areas than in 1992, while the number of urban poor grew by 460,000 from 1992 to 2007: See Figure C.4

Health

Under-fives mortality rate

The mortality rate of under-fives has been declining in Tanzania at a dramatic rate since the mid-to late 1990s, especially when compared to the average rates of decline in LICs and LMICs. It fell from levels of about 157 per 1000 in 1990 to about 68 per 1000 in 2011. This is less than LICs as an aggregate and approaching the average for LMICs (World Bank WDI). A significant number of children continue to suffer malaria, acute respiratory infections, fever and diarrhoea and other diseases, the underlying causes of which are described (Kinabo et al., 2009) as: poor sanitation and care practices; low levels of education and awareness; and, low access to clean and safe drinking water and to adequate health services.

Water & Sanitation

Tanzania has seen a modest deterioration in prevalence of access to improved water sources over the last 20 years, with improvements failing to keep up with population growth, particularly in urban areas. While 55% of the total population had access to an improved water source in 1990, by 2010 the proportion had fallen to 53% (urban access levels dropped dramatically from 93% to 79%). Levels of access in general were above the LIC average until 1996, when they dropped below (World Bank WDI).

Progress with increasing access to improved sanitation has been a bit more encouraging, though absolute levels of access remain well below the LIC average. Nationally, percent of people with access to improved sanitation grew from 7% in 1990 to 10% in 2010. Access levels for urban Tanzania saw the most growth, while levels for rural Tanzanians have not grown since 1995 (World Bank WDI).

Female empowerment

Female empowerment has significant consequences for the nutrition of children. Infant feeding practices improved slightly from 1992 to 2005, for example with more exclusive breastfeeding of children up to three months old, although there are large numbers of children still receiving complementary foods too early--and a smaller number too late.

"Poor breastfeeding and child feeding practices augmented by very early introduction of nutritionally inadequate and contaminated complementary foods are major factors contributing to persistent child malnutrition in Tanzania." (Muhimbula & Issa-Zacharia, 2010)

Female schooling

While there have been increases in the proportion of girls achieving some primary education, this suffered recently. Only a very small percent of girls have some secondary education, and even fewer complete or go beyond secondary level. Only in the highest wealth quintile is there any completion of secondary school and the figures are very low. Ten percent of females in the highest wealth quintile in 2007/08 had no education, compared to 45% in the lowest wealth quintile.

Net enrolment ratio for girls in primary school was 97% in recent data (2007-2010), while the net attendance ratio over the same period was 82%. Net attendance ratio for female secondary school participation was 24% for 2005 to 2010.

Women's literacy levels have actually declined slightly from their levels in the late 1980s. They were above the LMIC country average until about 2005, after which they fell below. They remain above the LIC average, but may not longer if current trends continue; see Figure C.5.

The adolescent fertility rate for Tanzania fell only very slightly from 1997 to 2007, from 133 to 129 per 1000 teens 15-19. These rates are well above those for the LIC group, and the 11th highest in the world (51).

Specific nutrition interventions

National nutrition interventions have been undertaken, though success and coverage has been mixed, or undocumented. For instance, in 1995, a Salt Act was approved to ensure salt for human consumption was iodized. In 2005 as a result of this initiative, 84% of households used iodized salt (Kinabo et al., 2008, citing Tanzania Food and Nutrition Centre). Another survey found that about 74% of households used iodized salt, but that only 43% were using adequately iodized levels (>15ppm) (NBS and ORC Macro, 2005).

Some sub-national interventions show clearer improvements. World Vision's Micronutrient and Health (MICAH) programme in in Tanzania's Eastern zone for example resulted in a significant increase in rate of exclusive breastfeeding for the first six months (World Vision 2006), improved indicators for children's vitamin A and Iodine intake, as well as for their stunting and underweight (Berti et al., 2010). This programme involved vitamin A and iron supplementation, maize fortification; agricultural interventions such as home gardens, supply of fruit trees and small animals; water and sanitation; deworming and other health interventions, training of staff and volunteers, and education and media dissemination (World Vision, 2006).

While there is considerable overlap between specific agricultural nutrition interventions and other elements of nutrition programming, some examples are provided below.

Gender empowerment in food processing

Home gardens in Tanzania have a strong gender focus as women tend to be most heavily involved in this kind of agriculture. In Tanzania, women are usually responsible for food processing activities as well.

The Tanzania Food and Nutrition Centre (TFNC) implemented a project from 1995 to 1998 in a region where TFNC in collaboration with the Ministry of Agriculture had initiated a horticulture project to encourage vegetable gardens and fruit trees in 1992. The project aimed to encourage women who processed fruit and vegetables to use improved solar dryers which enhanced nutritional quality of the dried products as well as increasing women's income through dried food products. The intervention included education about nutrition and business training (Mulokozi et al., 2000). Results showed that while there was demand and good adoption of the improved solar drying technology, leading to more year-round availability of vitamin-A rich foods, most of the positive results on children's intake of such foods came from the nutrition education part of the intervention; highlighting the importance of nutrition education (ibid).

Home gardens and small livestock

Studies have associated home gardens in Tanzania with households eating statistically significant higher levels of vitamin A rich foods (Ecker et al., 2010).

One evaluation of a home gardening project in rural Tanzania in 1992-93 found five years later it had resulted in more gardens growing guava and pawpaw (Kidala et al., 2000). People were also eating more vitamin A rich food; 50% more than the control group. Though biochemical indicators were unchanged, behaviours related to vitamin A intake had changed, as helminth infections were lower than in the control areas, with 79% being infection free compared to 49% in control areas (Berti et al., 2004)

Small livestock systems have also been associated with better diets. For example, introduction of dairy goats from Norway in 1988 has led to improved diets and food security among smallholder farmers in the Mgeta area of Tanzania. The new technology is adapted and rapidly spreading to other parts of the country (Eik et al., 2008).

Bio-fortification

Projects promoting orange-fleshed sweet potato have been undertaken in Tanzania. For example, the Tanzanian National Sweetpotato Research Program has incorporated OFSP into its conventional breeding efforts (RAC, 2012). Though it is difficult to find evidence of impacts as yet, it appears to have considerable potential, as sweet potatoes are already part of the diet, and the orange-fleshed sweet potato has been accepted and enjoyed, particularly by children, in trials (RAC, 2012).

Quality Protein Maize (QPM) has also made some inroads in Tanzania. For instance it was promoted under CIDA's QPM Development project, which ran 2003 to 2010 in Ethiopia, Kenya, Tanzania, and Uganda, with 15% of funds for Tanzania. Results for Tanzania specifically are unavailable, but reportedly the project increased QPM production by an average of 31%. It increased consumption of QPM, especially by children and female members of farm families by 90% on average (CIDA, 2012). The extent to which it is cultivated in Tanzania and its impacts are not known, though its uptake is thought to be small scale to date. A key issue for adoption is availability of seed.

Interpretation

Restricted agricultural growth in Tanzania has likely contributed to disappointing improvements in child undernutrition though pathways including failure to reduce poverty. Poor care practices, low feeding frequency, low diversity of diet, and poor access to health care services also contribute. Neglect of attention to women's empowerment also stands out in the Tanzanian case.

What could agriculture do for better nutrition in this case?

* Improve production, particularly yield, of staple foods, particularly maize, where there is much scope to raise yields by, for example, raising fertilizer use from the very low levels seen in Tanzania, Figure C.6. Removing barriers to trade, particularly with neighbouring countries, would raise incentives to domestic producers.

* Focus on women farmers

* Bio-fortification of the staple, maize, particularly with vitamins like A and minerals like Iron could help.

* Diversify to encourage better consumption of micronutrient rich food and diverse weaning diets (combined with better education). Home gardens are a good way to do this, and if women in particular are involved, could help empower women.

Annex D. Zambia: faltering agriculture, slow progress on fundamentals, and high inequality means high levels of chronic child malnutrition

Observed changes in nutrition

Underweight and Stunting

In almost 20 years there has been almost no improvement in stunting of under-fives: it was 46% nationally in 1992 and still 46% in 2007. There has, however, been some progress in reducing underweight prevalence, reduced from 21% of under-fives in 1992 to 15% in 2007-- a drop from the WHO classification of high to medium severity.

Stunting of children in rural areas is far worse than urban areas. In 2010 the margin was about 8 percentage points; an improvement on the gap in 1992 which was more than 12, see Figure D.1.

As with stunting prevalence, underweight is worse among rural than urban children--though the gap has lessened since the early-1990s.

Micronutrient deficiencies

Micronutrient status is not good, though on some indicators it has improved owing to interventions. In the early 1990s, iodine deficiency was a severe public health problem, but since the enforcement of salt iodization in 1996, recent surveys of urinary iodine levels indicate sufficient iodine intake. Vitamin A deficiency has also decreased among women owing to supplementation. However, only about half of mothers receive these supplements during the post-partum period, and among children, vitamin A deficiency remains very high, in spite of supplementation covering almost two thirds of children.

Iron deficiency anaemia is found in more than half of pre-school age children, and almost one third of non-pregnant women. High malaria incidence and incidence of other parasitic infections contributes to high anaemia prevalence.

Growth of economy

Economic growth in Zambia has been patchy and poor. GDP per capita measured in constant 2000 USD fell from 1990 to 1999, following a decline nearly two decades long (Siamusantu, 2009), after which it began rising again. Overall, the change from 1990 to 2011 is an increase of only 14% in real GDP per capita terms (World Bank WDI).

Agriculture

Agricultural growth

Net production indices for Zambian crops, agriculture in general, and livestock seem to have grown from about the mid-1990s. Cereals, which looked to be falling from 1990 to 2002-- though volatile--took off after that point, particularly after 2008, which meant overall they have a positive annual average growth rate of 3% in absolute terms, and 0.5% per capita, see Figure D.2. Livestock production declined in per capita terms.

Despite this weak growth, Zambia is the only country of the case study locations where agricultural contribution to GDP and employment in the agriculture sector have been rising since 1990: farming accounted for 50% of all employment in 1990, but 72% in 2005-- reflecting the low growth of other sectors in the economy.

Food availability--and its price

Diets in Zambia are mainly composed of cereals, predominantly maize, starchy roots and, to a lesser extent, fruit and vegetables. The heavy dependency on a single staple, maize, makes it especially vulnerable to droughts and floods, particularly for rural residents as urban farmers diversify staples increasingly towards other crops like rice and sweet potatoes (Siamusantu et al., 2009).

Per capita food supply, (production, including net trade and changes in stocks) in Zambia has declined from 1990 to 2009 overall, though there have been some increases in sub-groups. Most of the decline came from cereals, followed by sugar and sweeteners. Cereals and starchy roots, which made up over 70% of staples in 1990 fell to just under 60% in 2009. Proportion of calories supplied by oilcrops, pulses, fruits and vegetables, and sugar all increased slightly: See Figure D.3.

There is little evidence of either improved supply of food in terms of quantity, or even in terms of relative quantity changes that might indicate diets becoming more diverse: discouraging statistics.

Maize production's decline, particularly in per capita terms, contributes to food insecurity in Zambia (Siamusantu et al., 2009). Owing, however, to rising wages, staple foods in Zambia (and Kenya) have become more affordable over time:

Mason et al. (2009) show that average formal sector wages (in various public and private sector categories) in urban Kenya and Zambia rose at a faster rate than retail maize meal and bread prices between the mid-1990s and 2007. Although the recent food price crisis partially reversed this trend, the quantities of maize grain, and maize and wheat flour affordable per daily wage in urban Kenya and Zambia during 2008-09 marketing season were still roughly double their levels of the mid- 1990s. (Tschirley & Jayne 2009)

Seasonal price volatility does continue to be significant, however, particularly in years with smaller harvests. This volatility in prices contributes to food insecurity: See Figure D.4

Poverty

Overall poverty

Poverty rates in Zambia have shown slow improvement since the early 1990s. Poverty prevalence as measured at the national poverty line fell from about 70% of the population in 1991 to just under 60% in 2010 (World Bank WDI).

Rural poverty

Rural poverty, over 90% in 1993, fell to 77% in 2006, but the largest reductions were in urban poverty: already much lower than in rural areas, this fell from close to half of urbanites in 1991 to 27% in 2006 (World Bank WDI).

In absolute numbers, urban poor have shrunk slightly--from 1.5 to 1.1 million, but rural poor have increased, from 4.3 to 5.9M people: See Figure D.5. In addition, income inequality is very high in Zambia, among the highest in Africa.

Health

Under-fives mortality rate

On under five mortality, Zambia has the worst rates of all the case studies. Nonetheless, it has been declining rapidly, faster than the rates of decline in LICs and LMICs on average: in 1990 the rate was 193 deaths per 1000 live births; by 2011 this had become 83 deaths per 1000.

While malnutrition and micronutrient deficiencies are important contributing factors to overall morbidity and mortality among young children, major causes of under-five deaths were reportedly: neonatal (23% of deaths in 2000-2003), pneumonia (22%) malaria (19%), diarrhoeal diseases (17%) and HIV/AIDS (16%) (Siamusantu et al., 2009; citing WHO data).

Water & Sanitation

Zambia has seen only modest and disappointing progress in access to improved water and sanitation. While about half the population had access to improved water sources in 1990, by 2010 this had risen to only 61%; below the average for low income countries in general (WDI data). Access of the urban population in Zambia is reportedly good (according to World Bank WDI), and it is the rural population where the most progress needs to be made. Rate of improved access in rural Zambia appears to have stagnated from 2008.

Another source, Siamusantu et al., (2009), reported declining levels of access to good water supplies from the early 1990s, as reportedly commercialization of water begun in the early 1990s has made it unaffordable for 40 to 60% of urban dwellers in Lusaka and the Copperbelt, where most of Zambia's urban population lives. They cited estimates of access to safe water declining from 72% nationally in 1992 to 57% in 2002.

Progress with increasing access to improved sanitation has been less encouraging. Nationally, percent of people with access to improved sanitation changed little; from 46% in 1990 to only 48% in 2010.

Female empowerment

Female schooling

Zambia's progress on women's empowerment has been disappointing. Young female literacy levels increased only very slightly from 66% in 1990 to 67% in 2010. This rate dropped and remained below the LIC average levels from 2005.

In 2002, the government has declared free education for all for grades 1-7 (primary education) (CSO et al., 2003). This measure, coupled with expansion of school facilities, curriculum development, provision of education materials, provision of bursaries for vulnerable children and orphans (from primary up to tertiary level), and improvement of equity and gender balance, had a positive impact on school enrolment (OECD, 2006). The net primary enrolment ratio has increased for both male and female pupils from 68% in 1999 to 94% in 2007, but disparities remain between male and female rates of progression and completion of education (UNESCO, 2008). In 2005, 89% of boys but only 66% of girls completed a full course of primary education (UNESCO, UIS Statistics in brief, Zambia). (Siamusantu et al. 2009)

Net enrolment ratio for primary school girls (2007-2010) was 94%, and net attendance ratio 82%. For secondary school girls, net attendance ratio (2005-2010) was only 36%.

Teenage pregnancy rate

The adolescent fertility rate rose from 1997 to 2002, after which it fell, but only slightly, and from extremely high levels, well above those for the LIC group. At 142 per 1000 in 2010, they were the 7th highest in the world. (52)

Specific nutrition interventions

Zambia has had some success with iodine fortification. Serious shortfalls remain in iron and vitamin A status. Sugar fortification with vitamin A was reportedly begun in Zambia, in 1998, with only some success in urban areas. While fortification of sugar has worked successfully in Latin America, in Africa where sugar consumption is not as high, it is not very successful (World Bank, 2006).

Some success has also been seen in infant and young child feeding practices. Exclusive breastfeeding for instance has increased sharply since the

early 2000s (Siamusantu et al., 2009).

Agricultural interventions for nutrition

Nutrition sensitive gender empowerment, home gardens, aquaculture and small livestock

There is plenty of potential for improving women's status in Zambian agriculture. A recent gender assessment for Zambia (Rozel Farnworth et al., 2011) reported that women typically lack command over household assets which in turn inhibits their ability to take risks in production:

   Programmes aiming to integrate women into value chains generally
   pre-suppose a certain level of resources and capabilities that
   enable them to take on the risks inherent with engaging with value
   chains and entrepreneurship. Zambia's gender profile indicates that
   whilst women and men both face challenges to entrepreneurship due
   to poverty, men are much more able to engage in risk taking and
   grow their businesses due to their ability to build and command
   capital. This ability is critically linked to the superior position
   of men in relation to the ownership and deployment of household
   assets, and expenditure decisions. By way of contrast, women within
   male-headed households generally depend on their ability to
   maintain relations with male kin to secure access to productive
   assets. Their decision-making capacity over the use of those assets
   is demonstrably low in many cases. Female-headed households may
   well be able to take autonomous decisions, but they frequently lack
   sufficient assets for truly viable livelihoods. To engage women in
   value chain development will take several years of carefully staged
   engagement and withdrawal.


Women's disempowerment in Zambia is likely contributing to poor nutrition outcomes for under-fives.

There is evidence however that agricultural interventions including home gardening, for which women are often predominantly responsible, have positive outcomes for nutrition in Zambia. For instance, the Empowerment of Women in Irrigation and Water Resources Management for Improved Household Food Security Nutrition and Health (WIN) programme in Zambia, which involved vegetable gardens and aquaculture had positive results. Diversified vegetable production led to improved household incomes, better nutrition, and provided new links to local markets which enabled some participating households to move beyond subsistence level agricultural production. Fish production under the WIN programme increased available protein at a household level as well as providing participants with a high-value product for sale at local markets. The programme also involved food preservation and post-harvest value added processing, which contributed to improved nutrition (Eckman 2005)

A positive example of small livestock interventions for nutrition can be found in Heifer International's final report for its Miyoba Women's Draft Cattle Project which ran from 2001 to 2007. They found significant evidence of improved nutrition and income for participants, better employment, and more resilience in the face of natural disasters among other benefits (Heifer International, Accessed 2012). An evaluation was able to document substantial improvements in nutrition, income and assets, knowledge on basic care and management of animals, children's access to education, and gender equity (Thomaz, 2011).

Bio-fortification

Like Ghana, Zambia is one of the initial target countries for dissemination of HarvestPlus high vitamin-A maize.

Recent studies show orange maize is acceptable to consumers in Zambia, with potential to compete with white maize even without nutrition campaigns--and could fetch a premium over white maize where nutrition information is provided (Meenakshi et al., 2012).

As in other case studies, while potential for bio-fortified crops including OFSP and special types of maize appears high, there is little documentation of uptake: it is suspected that these types of intervention remain small scale.

Interpretation

Zambia is a case where not only agricultural but also overall economic growth has been poor. On indicators of women's empowerment it stands out as particularly disappointing.

Child care, health, schooling, all contribute as do highly risky and variable agricultural systems.

What could agriculture do for better nutrition in this case?

* Similar to the Tanzania case, Zambian producers and consumers would benefit from improved production, particularly yield, of staple foods, particularly (but not only maize). This will help contribute to a dietary energy supply that is currently insufficient to meet the population's energy requirements (Siamusantu et al., 2009).

* Diversifying more into other staples, such as cassava, ought to help overcome some of the risk associated with a single rainfed staple with poor drought tolerance in a country where droughts have such a high return period.

* Bio-fortification of staples, particularly maize could help.

* Quality and diversity of available food is not good enough, contributing to micronutrient deficiency (Siamusantu et al., 2009). As in the case of Bangladesh, diversify to encourage better consumption of micronutrient rich food and diverse weaning diets (combined with better education). Home gardens are a good way to do this, and if women in particular are involved, could help empower women.

Working on agricultural development at the same time as improving the general health environment, educating girls, and improving basic infrastructure, ought to pay dividends in nutrition rates of Zambian children.

Annex E. Kerala: focus on the fundamentals of health and education means Kerala is a leading Indian state for child nutrition.

A case study of India would be a task beyond the resources available. Although Kerala is only one state of India, with around 33M inhabitants, it is larger than Ghana and Zambia. Populations and growth rates for the cases are shown in the figure below.

Observed changes in nutrition

Underweight and Stunting

Stunting rates fell from 36% in 1993 to 25% in 2005. Surprisingly, then, rates of underweight have seen no progress in Kerala from 1990 to 2010, remaining at just under one in four. It appears the gains in reduced stunting are being offset by rising rates of wasting, from 13% to 16%. Relative to the national rate and rates in its neighbouring states however, figures for Kerala are better: indeed, Kerala has the lowest rate of stunting in all Indian states, and the fourth lowest rates for underweight amongst Indian states.

Micronutrient deficiencies

Anaemia rates in women in Kerala increased from 1998/99 to 2005/06, going from 23% in 1998/99 to 33% in 2005/06, although only 0.5% of women in either year had severe anaemia.

Children's anaemia prevalence in Kerala barely moved from 1998/99 to 2005/06, and is high at about 45%. Very few cases are severe in Kerala. Rates in Kerala are also better than the rest of India.

While there are few data assessing iodine deficiency in Kerala, in one district of Kerala in 1999 school children were considered to be in a transitional phase from iodine deficit to sufficiency, revealed by a total goiter rate in the children of 7.05 and a median urinary iodine level of 17.5 [micro]g/dL (Kapil et al., 2002). In 2005/06, surveys revealed some 70% of children under five were living in households with adequate salt iodization levels, while 74% of households were estimated to have adequate salt iodization in 2005/06 (IIPS, 2007).

Vitamin A deficiency levels in Kerala are not a public health problem for young children. A 2001-2003 survey of children 1 to 5 years old indicated no night blindness.

Although there are no up-to-date figures for women's vitamin A deficiency in the WHO database, in a 1998/99 survey, women aged 15 to 50 in urban Kerala had rates of 1.20% (slightly above the 1% WHO threshold), and women in rural Kerala had rates of 2.3%, indicating a public health problem.

Growth of economy

Economic growth in Kerala has been disappointing over the last 20 years, lagging compared to the rest of India and heavily dependent on remittances and tourism (Biswas, 2010). One feature of Kerala that makes its economy unusual is the high dependence on emigrants working overseas, particularly in the Middle East region, who send home remittances that annually contribute as much as a fifth of gross state product (GSP) (Kannan & Hari, 2002).

Agriculture

Agricultural growth

In 2004/05, agriculture contributed 17% of Kerala's Gross State Product (GSP), but by 2010/11 this is estimated to have fallen to 10.6% (Government of Kerala). Nonetheless, nearly half of Kerala's population is dependent on agriculture alone for income (Government of Kerala data from around the mid-2000s.). Over 70% of Kerala's agricultural land is reportedly used by small or marginal farmers.

Dev (2012) estimated the average annual growth rate of agricultural production in Kerala from 1999/2000 to 2008/09 at only 0.55%, India's second-worst performing state on this measure.

Kerala's key agricultural staple is rice. However rice production has been shrinking since the 1970s when it began to be more cost-effective to produce rice in other parts of India. Profitability of growing crops in general in Kerala is decreasing owing to a shortage of farm labour, high land prices, and small size of holdings (PCI, 2008). Agricultural production has consequently shifted towards perennial tree crops and home gardens which make up a significant proportion of Kerala's agricultural production (Mohan, 2004).

Food availability--and its price

Average calorie consumption in Kerala is lower than in India nationally, and appears barely changed from 1965 kcal per rural person a day in 1993/94 to 2014 kcal per rural person a day in 2004/05 (a 2.5% increase) and from 1966 kcal per urban person a day to 1996 kcal per urban person a day (1.5% increase) over the same period. These statistics describe consumption, and may not be comparable to the statistics in the other cases which show supply. This might explain why the Kerala levels seem low; quite close to being insufficient.

Average protein consumption in Kerala is close to national levels for urban areas, and just below national levels for rural areas. It has increased considerably from 1993/94 to 2005/06 in both rural and urban areas, by 9.1% and 8.2% respectively.

Average fat consumption in Kerala is above the national average for rural areas, and only slightly below the national average for urban areas. This has increased most strongly over the period in question, by 25% in rural areas and by 21% in urban areas.

Compared to neighbouring states of Karnataka and Tamil Nadu, consumption in Kerala was higher for average calories, protein, and fat. There was also less difference between urban and rural areas as well.

Diets in Kerala are about half cereal-based, with the fraction slightly higher in rural than urban areas. The contribution of cereals to the diet is lower in Kerala than in India nationally, and also than the neighbouring states. Of the non-cereal products, pulses, nuts, and oilseeds make up the next-largest share of calories. Fruits and vegetables share is low, though still above national proportions. Meat, eggs and fish make up a considerably larger share in Kerala than in the other regions to which it is compared, indicating potentially better consumption of micronutrient-rich livestock foods.

Kerala saw moderate improvements in average women's diversity of consumption from the late 1990s to the mid-2000s.While on average, more women in Kerala consume chicken meat or fish, eggs, and fruits in any given week than the national average, they lag behind the national average on prevalence of consumption of green leafy vegetables and pulses.

Real rice prices in Kerala were relatively stable from the early 2000s to early 2008, after which they became higher and more volatile. They have also tended to be a bit higher than in the neighbouring state of Tamil Nadu. Real wheat prices in Kerala rose from the early 2000s to the mid-2000s, and remained relatively flat across 2005 to early 2011, after which they dipped and rose (Retail price information system, GoI).

Poverty

Overall poverty

Kerala leads India on the Human Development Index. Poverty rates in Kerala have also declined dramatically over the last few decades, from 25% in 1994 to 12% in 2010.

Rural poverty

Poverty prevalence in urban and rural areas appear to have converged. Rural poverty fell from 26% of the rural population in 1994 to 12% of the rural population in 2010.

Poverty in absolute numbers has fallen overall from 1994 to 2010, however it has risen slightly in the fast growing urban population, see Figure E.3. While there were around 3.4 million rural poor and 1.3M urban poor in 1994, there were an estimated 2.2M rural poor and 1.8M urban poor in 2010.

Rural-urban gaps in Kerala are far less pronounced than in the other cases, where commonly urban poverty prevalence is 10 percentage points below rural ones.

Health

Under-fives mortality rate

The under-five mortality rate is one of Kerala's most impressive achievements. At 16.3 per 1000 live births in 2006, it was well below the rate for India, LMICs, and MICs on average.

Childhood vaccinations levels in Kerala slipped slightly for all basic vaccinations from 1998/99 to 2005/06. They remain however at relatively high levels, with three quarters of children in Kerala receiving all basic vaccinations, well above the average of less than half for Indian children in general. The administration surrounding immunization also appears stronger in Kerala, with a much higher percent using vaccination cards than do nationally and in neighbouring states; even Tamil Nadu where rates of vaccination are slightly higher.

On infant feeding and care practices, Kerala's statistics are also among the leading values for India. For example, initiation of breastfeeding within a day of birth is very high (96% in 2004/05).

Infant care during diarrhoea is significantly better in Kerala than other Indian states.

Water & Sanitation

Improvement in drinking water availability has increased dramatically in Kerala from the early 1990s to the mid-2000s. In 1992/93, 21% of households had access to improved sources of drinking water, but in 2004/05 this had risen to 69% of households (IIPS 1995, IIPS & ORC Macro 2000, & IIPS 2007).

Improvements in sanitation facilities have also been significant, despite coming from a relatively high base compared to the rest of India. In 1992/93, 71% of households had access to toilet or latrine facilities. By 2004/05 this figure had risen to 96%. For India, the comparable statistics were 30% rising to 31% (ibid).

Female empowerment

The ratio of female to male life expectancy at birth was used by Smith & Haddad (2000) as a measure of women's relative status. In Kerala, relative status by this measure is well above that of India and has improved from 2000 to 2009; in contrast the situation in India has deteriorated slightly over the period in question. For India in general, ratios are much lower with neglect of female health contributing to these low ratios (Sen, 1990).

Female schooling

Literacy rates in Kerala are high and improving, for both men and women, see Figure E.4. While in 2011 the gap between male and female literacy rates in India nationally was about 17 percentage points, it was only 4 percentage points for Kerala. The gap has also narrowed in Kerala since the early 1990s, when it was close to 8 percentage points.

Enrolment in education in Kerala is high, at more than 95% and much more equitable across income groups compared to neighbours and the rest of India, see Figure E.5. These data, almost two decades old, show education in Kerala has been equitable for some time.

Kerala is set apart from other states by its high literacy rate--much higher than in India, and also substantially higher than in China, especially for women (Sen, 1990).

Kerala's experience was one of state-funded expansion of basic education that begun two centuries ago by the rulers of the kingdoms of what was then Travancore and Cochin (53)-- and consolidated by a left-wing state government from about 1957 (Sen, 1990, Sen, 1991).

'The causal chain of Kerala's exceptional record goes back in history and includes among other things such steps as the public policy of "enlightenment" and "diffusion of education," clearly articulated by the reigning queen ... as early as 1817. The high level of education also contributed to the development and utilization of Kerala's extensive public health services, by making the population more informed, more articulate, more keen on demanding health services, and more able to make use of what is offered...

Literacy and basic education have also contributed, it can be argued, to Kerala's radicalism, by making it easier to depart from the traditional mold of Indian conservative politics.'Sen (1991)

Teenage pregnancy

The adolescent fertility rate is low in Kerala: in 2008 it was only 18.3 per 1000 women aged 15 to 19.

Specific nutrition interventions

Kerala has made great progress with salt iodization from the late 1990s to the mid-2000s. While in 1998/99, some 48% of households did not have iodized salt (worse than the national average of 28% of households), by 2005/06, 74% of Kerala's households had adequately iodized salt, and only 17% had no iodization of salt. In contrast, the national average levels of iodization barely moved over his period.

Iron and folic acid supplementation for pregnant and post-partum women is also high in Kerala, and has risen from already high levels in 1992/93 to 2005/06. The percent of women using (given or bought) IFA tablets or syrup who had given birth in years just before the survey went from 91% in 1992/93 to 96% in 2005/06, compared to national rates that rose from about 51% to 65% in the same period.

Agricultural interventions for nutrition

Home gardens and small livestock

Home gardens are the main form of agriculture in Kerala, where the average size of holdings is very small--in 1990/91, 84% of Kerala's land holdings were less than half a hectare (Mahesh, 2000)--and tending to reduce with further subdivision. Home gardens have emerged as a result of these small farm sizes in lowland areas and from growing lack of competitiveness for staple crops such as rice; the production of which has been shrinking in Kerala since the 1970s, as the state imports from other regions of India where rice is more economically viable.

Kerala's home gardens contain diverse species, tree crops as well as annual crops, pulses, vegetables, and in many cases animals--most commonly cattle and poultry. They are thought to be sustainable and efficient systems (Mohan, 2004; Salam et al, 1995). In the smaller gardens, households consume more than 50% of the produce, compared to about 20% for medium, large and commercial sized farms (Mohan, 2004), so home gardens clearly have an influence on food consumption in Kerala, with likely positive impacts for nutritional outcomes, particularly where food types cultivated are of high nutritional value. The role of home gardens in nutrition for Keralites however is not well documented and deserves more attention.

Bio-fortification

While sweet potato is produced widely in Kerala, how much is orange-fleshed is not clear. While there is clear potential for production and consumption of bio-fortified crops to have a positive impact on nutrition, as yet there is little evidence of programmes involving bio-fortification in Kerala.

Interpretation

Modern Kerala does deserve credit for consolidating and building on past achievements. But the background to these developments has to be traced, to a considerable extent, back to Kerala's remarkable past, and we have to take note, among other things, of its old policy of educational expansion. These issues are important since the role of education, and in particular of female education, may well be central to many problems of the contemporary world. Sen (1991)

Kerala has an unusual and enviable record on some of the basic determinants of nutrition, such as education, female status and health care: particularly when compared to the rest of India. Kerala shows how much can be done to improve child nutrition even where food availability and agricultural progress disappoint. There are connections between education, public activism, and the development and use of health facilities that are by no means unique to Kerala (Dreze & Sen, 1989).

What could agriculture do for better nutrition in this case?

* Smallholder farm development to improve incomes for Kerala's smallholder farmers would help as far as poverty alleviation is concerned, though there is no imperative to improve food production for the sake of availability in Kerala, where sufficiency can be met with supplies from other Indian states.

* Bio-fortification of staples and sweet potatoes

* Diversify to encourage better consumption of micronutrient rich food and diverse weaning diets. Home gardens and small livestock, already reportedly widespread in Kerala, are a good way to do this, perhaps through promotion of more nutritious products.

Annex G. WHO classifications of stunting, underweight, and wasting indicators.

Uses WHO Child Growth Standards adopted in 2006

                                              Severity of
                                              malnutrition
                                              prevalence
                                              (%)

                                              Low    Medium

Prevalence of       Children's skeletal       < 20   20 - 29
  low height-for-     (linear) growth
  age (stunting)      compromised due to
  in preschool        constraints to one
  children            or more of nutrition,
                      health, or mother-
                      infant interactions.
                    This is an indicator of
                      chronic nutritional
                      deprivation.
Prevalence of       This is a composite       < 10   10 - 19
  low weight-         measure of child
  for-age             nutritional status,
  (underweight)       reflecting both
  in preschool        chronic and
  in preschool        transitory
  children            nutritional
                      deprivation.

                    This is a Millennium
                      Development Goal
                      indicator.

Prevalence of       Children suffer           < 5    5 - 9
  low weight-         thinness resulting
  for-height          from energy deficit
  (wasting) in        and/or disease-
  preschool           induced poor
  children            appetite,
                      malabsorption, or
                      loss of nutrients.

                    This is an indicator
                      of transitory
                      nutritional
                      deprivation.

                    Severity of
                    malnutrition
                    prevalence
                    (%)

                    High   Very
                           high

Prevalence of       30 -   > = 40
  low height-for-   39

  age (stunting)
  in preschool
  children

Prevalence of       20 -   > = 30
  low weight-       20 -
  for-age           29
  (underweight)
  in preschool
  in preschool
  children

Prevalence of       10 -   > = 15
  low weight-       14
  for-height
  (wasting) in
  preschool
  children

Source: Adapted from Table 7.1 in Alderman, Harold;
Jere R. Behrman, and John Hoddinott. 2005. Nutrition,
Malnutrition, and Economic Growth, in eds
Lopez-Casasnovas, Guillem; Berta Rivera & Luis Currais.
Health and Economic Growth: Findings and Policy

Implications. MIT & WHO website:
http://www.who.int/nutgrowthdb/about/introduction/en/index5.html


Annex H. Scaling up nutrition: the thirteen recommended direct interventions

Evidence Based Direct Interventions to Prevent and Treat Undernutrition

Promoting good nutritional practices ($2.9 billion):

* breastfeeding

* complementary feeding for infants after the age of six months

* improved hygiene practices including hand-washing

Increasing intake of vitamins and minerals ($1.5 billion)

Provision of micronutrients for young children and their mothers:

* periodic Vitamin A supplements

* therapeutic zinc supplements for diarrhoea management

* multiple micronutrient powders

* de-worming drugs for children (to reduce losses of nutrients)

* iron-folic acid supplements for pregnant women to prevent and treat anaemia

* iodized oil capsules where iodized salt is unavailable

Provision of micronutrients through food fortification for all:

* salt iodization

* iron fortification of staple food

Therapeutic feeding for malnourished children with special foods ($6.2 billion):

* prevention or treatment for moderate undernutrition

* treatment of severe undernutrition ("severe acute malnutrition") with ready-to-use therapeutic foods (RUTF).

Source: SUN 2010, with costs taken from Scaling Up Nutrition: What Will it Cost? Horton, et.al. 2009

Note: Figures in brackets are the estimated costs of these for the 36 countries where 90% of malnourished children live.

The Hunger Alliance is a joint DFID-NGO consortium which addresses food insecurity and undernutrition and promotes predictable long term responses to food insecurity. We bridge institutional differences between development and humanitarian responses to hunger (food insecurity and undernutrition) in contexts that have a particular vulnerability to crisis. We share information and generate learning around multi-faceted interventions to address food insecurity, including livelihood support to vulnerable groups (such as women, smallholder farmers, pastoralists and agro-pastoralists); safety nets and social protection and nutrition interventions. The Alliance provides a forum for formalising agreement on specific aspects of policy, enabling parties to join forces on policy influence and programming.

The following organisations within the Hunger Alliance
supported this project:

Action Against    Action Against Hunger is committed to
  Hunger UK         ending child hunger. We work to save
                    the lives of malnourished children
                    while providing communities with
                    sustainable access to safe water and
                    long-term solutions to hunger.
ActionAid         Founded as a British charity in 1972,
                    ActionAid is an international NGO
                    working in 45 countries worldwide, and
                    our positions and recommendations
                    reflect the experiences of our staff
                    and partners in Africa, Asia, the
                    Americas and Europe. Our vision is a
                    world without poverty and injustice in
                    which every person enjoys the right to
                    a life with dignity. We work with poor
                    and excluded people to eradicate
                    poverty and injustice.
British Red       The British Red Cross helps people in
  Cross             crisis, whoever and wherever they are.
                    We are part of a global voluntary
                    network, responding to conflicts,
                    natural disasters and individual
                    emergencies.
CARE              CARE International is a leading
  international     humanitarian organisation which fights
                    global poverty and provides lifesaving
                    assistance in emergencies. We place
                    special focus on working with poor
                    girls and women because, equipped with
                    the proper resources, they have the
                    power to help lift families and
                    communities out of poverty. Last year,
                    we worked in 84 countries assisting
                    more than 122 million people
Christian Aid     Christian Aid works in more than 40
                    countries across the world, in
                    partnership with local organisations,
                    the private sector, churches, and
                    governments, to tackle the effects of
                    poverty, as well as its root causes.
Concern           Concern Worldwide helps the poorest
  Worldwide         people in the poorest countries to
                    transform their lives. We seek out
                    those who most urgently need our
                    support, and work with them through
                    thick and thin to tackle poverty,
                    hunger and disaster.
Oxfam             Oxfam GB delivers emergency assistance
                    to people affected by disasters or
                    conflict, and helps to build
                    vulnerable people's resilience to
                    future crises. We also work with
                    others on long-term programmes to
                    eradicate poverty and combat
                    injustice.
Save the          Save the Children is the world's
  Children          independent children's rights
                    organisation. We're outraged that
                    millions of children are still denied
                    proper healthcare, food, education and
                    protection and we're determined to
                    change that.
Tearfund          Tearfund is a Christian relief and
                    development agency working with a
                    global network of churches to help
                    eradicate poverty. Tearfund supports
                    local partners in more than 50
                    developing countries and has
                    operational programmes in response to
                    disasters.
World Vision UK   World Vision is a Christian relief and
                    development organisation working with
                    children, their families and
                    communities to overcome poverty and
                    injustice in 100 countries around the
                    world.


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(1) Without the consumption safety nets, the extra spending is equal to around US$42 billion per year (constant 2009), the figure called for in the IF campaign launched in 2013.

(2) Undernourishment implies individuals not getting enough energy in their diet sufficient to lead a healthy and active life.

(3) Defined by height for age: children who are 2 standards deviations or more below the median for their age are considered stunted.

(4) Defined by weight for age: children who are 2 standards deviations or more below the median for their age are considered underweight.

(5) Although a precise definition of a smallholding may be elusive, FAO has adopted a two hectare threshold as a broad measure of a small farm. There are roughly 450 million farms in the world smaller than two hectares. Most of these in the developing world (Nagayets 2005).

(6) This draws partly on Gillespie et al. 2012 who set out seven ways that agriculture can affect nutrition in India.

(7) The selected countries are also all on the list of 36 countries identified in the Lancet (Black et al. 2008) that carry 90% of the stunting burden for which financing needs related to the Scaling up Nutrition (SUN) framework were estimated by Horton et al. 2009.

(8) Prices were deflated using the non-food Dhaka middle-income Cost of Living Index (and the national CPI after June 1998)

(9) Seeing trees concentrated around settlements, outsiders had assumed these were the remnants of extensive woodlands that had been cleared to leave the savannah grasses. Locals told researchers that no, the reason for the trees was they had been planted by villagers. Inspection of air photos from the past confirmed this: as the number of villages grew with population growth, so did the area under trees.

(10) An early draft of a 2012 review of subsequent studies on the relation of income to nutrition confirms these findings: that if anything the findings from Haddad et al. 2003 may be towards the higher end of income to nutrition effects.

(11) For the rest of this section, these are the sources, unless otherwise indicated.

(12) A second phase is now running

(13) The SHOUHARDO acronym stands for 'Strengthening Household Ability to Respond to Development Opportunities' and also means "friendship" or "amity

(14) Without the consumption safety nets, the extra spending is equal to around US$42 billion per year (constant 2009), the figure called for in the IF campaign launched in 2013.

(15) This is from a 2003 survey. Moderate anaemia means having haemoglobin levels in blood below 110g/L. WHO classifies anaemia prevalence of 40% and over an issue of severe public health significance (WHO, 2008).

(16) Malaria is hyper-endemic in Ghana, a leading cause of morbidity and mortality, especially among pregnant women and preschoolers [Estimates suggest malaria accounts for 22% of under-five mortality and 9% of maternal deaths (GSS & GHS 2009)]

(17) For instance, a recent study of two districts which had extremely severe rates of goitre in the 1994 survey shows there has been considerable improvement. One district in the Upper West Region saw total goitre rates (TGR) fall from 56% to 11%, and in another district in the Upper East Region rates fell from 57% to 18% between 1994 and 2007 (The Ghanaian Journal, 2009)

(18) WHO classifies TGR as public health problems as follows: <5 = no public health problem; 5-19.9 = mild; 20-29.9 = moderate; >30% = severe

(19) Recent revisions of FAO data put 1990 figures at 40% undernourishment, reportedly largely owing to larger estimates for food waste. By 1991 their estimates dropped to 30% and by 1992 to 25%.

(20) While in the early 1990s about 1500 available average daily kilocalories came from cereals and starchy roots, by 2009, almost 2000 kcal/person/day was supplied from these sources.

(21) Non-staples, which supplied only a little over 500 kcal/capita/day in the early 1990s were supplying double the amount by 2009.

(22) This is close to the levels of access in lower middle income countries, and much higher than levels in low income countries.

(23) ENHANCE focused on full & timely immunisation, treated bednets, vitamin A supplements, hygiene practices, ORS to treat diarrhoea, antibiotics to treat pneumonia, health worker training and health education for caregivers.

(24) A CIMMYT initiative. Other initial target countries are Brazil, Ethiopia, Guatemala, and Zambia.

(25) Bean production took off in Kenya driven mainly as an export crop, but production increases have helped to boost domestic supply; from about 3kg per capita a year in 1990 to close to 10kg per capita a year in 2009. It is likely that this is partly supply-driven, though growing demand particularly from increasingly affluent urban markets has undoubtedly played a key role.

(26) While more educated people report knowing more about benefits of diverse diets rich in fruits and vegetables, this doesn't necessarily translate to higher consumption in these groups (See Nti et al., 2011), indicating other factors including potentially cost may be contributing

(27) Having haemoglobin levels below 110g/L

(28) WHO considers anaemia prevalence of 40% and over an issue of severe public health significance (WHO, 2008)

(29) Cravari et al. (2008) say insufficiency of dietary calcium is thought to be the underlying cause, while treatment with calcium (350-1,000 mg elemental calcium daily) is curative.

(30) This figure is still closer to that of LMIC economies rather than LICs as a whole (of which Bangladesh is one) that have an average undernourishment rate in 2011 of 30%

(31) Food aid (grain equivalent) which was around 10kg/capita in 1990 was only around 2kg per capita for the mid-2000s onward. To put it another way, while per capita annual food aid exceeded 4kg in 9 out of 10 years from 1990-1999, from 2000-2011 it exceeded 4kg/capita in only 1 year, and 2kg per capita in only 3 years.

(32) As measured by the food CPI deflated by the CPI in general

(33) Absolute numbers also fell in urban areas despite relatively fast population growth in urban areas, by about 800,000 people over the same period.

(34) Of the case study countries, Bangladesh is the only one to have a ratio of female to male life expectancy of less than 1 at any point in the last 20 years; although this improved to 1.02 by 2010, the low income country average was 1.04.

(35) LBW babies are more likely to fail to grow properly, which, combined with inadequate food intake and caring practices, leads to stunting and childhood and youth underweight. To break this cycle, it is important

not only to improve nutritional status of women, adolescent girls and children, but also to delay marriage and first pregnancy, while improving education and livelihood opportunities for women (Muiruri et al., 2012)

(36) Severe underweight rates in Bangladesh fell from 26% in 1991 to 12% in 2002, while moderate underweight rates fell from 62% to 43%, but attribution of these falls to the BINP is not possible.

(37) For example, Bangladesh's National Nutrition Programme (see for instance World Bank, 2006) only aimed to cover 105 of Bangladesh's 464 upazilas (less than 25% coverage).

(38) Consistency with this approach requires relying on both direct nutrition interventions and those that address underlying structural causes including poor sanitation, poverty, and deeply-entrenched inequalities in power between women and men (Smith et al., 2011).

(39) Worldview International Foundation's Nutritional Blindness Prevention Programme

(40) Since 2000 the interventions which were originally projects became official components of Bangladesh's Agriculture Sector Programme Support

(41) The Global Gender Gap Index (a composite measure of women's economic participation and opportunity; educational attainment; health and survival; and political empowerment) for Bangladesh ranked 86th in 2012, compared to Tanzania's rank of 46th and Ghana's of 71st. It was however still above India's rank of 105th, and Zambia, which had the worst rank at 114th (135 countries were measured, ranked from 1: Iceland, to 135: Yemen) (Hausmann et al., 2012)

(42) Agricultural policy in Bangladesh centres heavily on rice; perhaps not surprising as the famine of 1974 continues to influence politicians and citizens.

(43) Rice production in Bangladesh remains vulnerable to natural disasters which are relatively frequent.

(44) More than one in five (22%) of newborns have low birth weight and as many as 18% of mothers are acutely undernourished (Muiruri et al., 2012).

(45) Though high and volatile international prices for imported rice may complicate this strategy. In addition, while rice is the main calorie source in Bangladesh, staple supply is not high in absolute terms. Compared to Ghana for example, in 2009, when FAO estimates for Ghana's undernourishment reached <5%, it had about 260kg/capita more staple (staples for Ghana include cereals, starchy roots & plantain) supply than Bangladesh (some 13% more), while total calorie availability was some 15% higher.

(46) HKI reported studies have shown that children in households with developed gardens consume 1.6 times more vegetables and have a lower risk of night blindness than children in homes without homestead gardens.

(47) The WHO considers anaemia prevalence of 40% and over an issue of severe public health significance (WHO, 2008).

(48) Poverty limits consumption of animal products. Plant sources of vitamin A are more affordable, but bio-vailability of animal sources is higher (Kinabo et al., 2008).

(49) A recent survey in 2008 found very infrequent meat consumption, particularly in rural areas

(50) Tanzania's population has been the fastest growing of all the case studies, at a rate of 2.8% per year from 1990- 2012 (Data from FAOSTAT)

(51) Tanzania's population is quite young (43% below 15 years old), and the dependency ratio is high (85%), placing a heavy economic burden on the productive age groups (Kinabo et al., 2008).

(52) After Niger, DR Congo, Mali, Angola, Chad & Guinea.

(53) These were two native states not part of British India that joined with a small part of the old Madras presidency to form the new state of Kerala post-independence (Sen, 1990). In 1817, the queen of Travancore gave instructions for public support of education as follows: "The state should defray the entire cost of education of its people in order that there might be no backwardness in the spread of enlightenment among them, that by diffusion of education they might be better subjects and public servants and that the reputation of the State might be advanced thereby." (Sen, 1990)

Figure A.2 Complementary feeding of under-threes in
Ghana, comparing 2003 and 2008: focus on vitamin A
and selected animal products

       6 to 11 months,   12 to 23 months,   24 to 35 months,
       breastfeeding     breastfeeding      breastfeeding &
                                            non-breastfeeding

Meat/fish/eggs

2003   27.8              58.3               67.7
2008   43.9              79.8               88.5

Fruit and vegetables
rich in vitamin A

2003   31.3              50.2               59.2
2008   31.3              50.2               57.9

Source: Constructed with data in Table 15 of Agble et al.,
2009 & Table 11.5 in GSS & GHS 2009. Note: Meat, fish,
and eggs, includes poultry. Vitamin-A rich foods includes
fruits and vegetables such as pumpkin, red or yellow yams
or squash, carrots, red sweet potatoes, dark green leafy
vegetables, mangoes, papayas, and other locally grown fruits
and vegetables rich in vitamin A.

Note: Table made from bar graph.

Figure A.5 Absolute numbers of poor in
Ghana compared to population, rural and
urban: 1992-2006

       Rural        Urban        Rural poor   Urban poor
       population   population

1992   9.72         5.94         6.18         1.64
1998   10.53        7.76         5.22         1.50
2006   11.42        10.76        4.47         1.16

Source: With data from World Bank WDI for poverty
and FAOSTAT for population figures

Note: Table made from bar graph.

Figure A.6 Stunting and underweight of preschoolers
in Ghana in 2008 by wealth quintile

Wealth quintile   Stunting   Underweight

Lowest            35.1       19.2
Second            34.1       17.4
Middle            28.3       12.5
Fourth            14.4       8.6
Highest

Source: With data from Table 11.1 in GSS & GHS 2009.

Note: Table made from bar graph.

Figure B.4 Stunting and underweight rates in
Bangladeshi preschoolers by wealth quintile, 2011

Wealth quintile   Stunting   Underweight

Lowest            54         50
Second            45         42
Middle            41         36
Fourth            36         28
Highest           26         21

Source: with data from and BDHS 2011, Table 23

Note: Table made from bar graph.

Figure B.5 Children aged 6 to 59 months in
receipt of a vitamin A capsule in the last
6 months, by characteristic

General

ALL                    60
Boys                   59
Girls                  60
Urban                  58
Rural                  60

District

Barisal                72
Chittagong             66
Dhaka                  49
Khulna                 56
Rajshahi               66
Rangpur                56
Sylhet                 69

Mother's education

No education           53
Primary incomplete     55
Primary complete       64
Secondary incomplete   62
Secondary complete     64
  or higher

Wealth quintile

Lowest                 55
second                 57
Middle                 61
Fourth                 64
Highest                62

Source: With data from BDHS 2011

Note: Table made from bar graph.

Figure C.4 Poverty numbers in absolute terms,
compared to urban and rural populations,
Tanzania, 1992-2007

       Rural        Urban        Rural poor   Urban poor
       population   population

1992   21.9         5.3          8.9          1.6
2002   26.4         7.6          10.2         1.8
2007   30.8         10.3         11.5         2.2

Source: With data from World Bank WDI and FAOSTAT for
population.

Note: Table made from bar graph.


Figure D.5 Poverty rates in absolute numbers, compared
to urban and rural populations: Zambia, 1991-2006

       Rural        Urban        Rural poor   Urban poor
       population   population

1991   4.9          3.2          4.3          1.5
1993   5.2          3.2          4.8          1.5
1996   5.8          3.3          4.8          1.4
1998   6.2          3.4          5.2          1.4
2003   7.1          3.8          5.3          1.4
2004   7.3          3.9          5.6          1.1
2006   7.6          4.1          5.9          1.1

Source: With data from World Bank WDI and population
statistics from FAOSTAT

Note: Table made from bar graph.

Figure E.3 Numbers of poor in Kerala compared to population,
rural and urban: 1994-2010 estimate

       Rural        Urban        Rural poor   Urban poor
       population   population

1994   14.4         5.1          3.7          1.3
2000   22.3         7.8          2.1          1.5
2005   21.1         11.3         4.3          2.1
2010   18.1         15.2         2.2          1.8

Source: With data from India's Planning Commssion,
GoK 2006, Ghoshal 2012, and Indian Census data

Note: Table made from bar graph.

Table 2.1 Food production and availability, northern Zambia, mid-1980s

Farmer Category:          'subsistent'   'emergent'   'commercial'

Average family size            6             6             6
Average number of              2             2             2
dependents
Farm area (ha.)               1.94          2.72          4.51
Farm area (ha.) devoted       1.57          1.66          1.80
  to food crops

Average quantities of food retained by households

Bags of maize                  4             7             11
Finger millet (kg)             13            17            18
Beans (kg)                    106           279           420

Source: IRDP (Serenje, Mpika, Chinsali), reproduced in Moore &
Vaughan 1987

Table 2.2 Under-five nutritional status by farmer category, northern
Zambia, mid 1980s

Farmer           No. of 90 kg      Proportion of     Proportion of
category         bags of maize    farm households   households where
                    sold to        with adequate    children showed
                  Provincial       nutrition of           mild
                Marketing Union      children         malnutrition

'subsistence'          0                70                 26
'emergent'           1-30               52                 41
'commercial'         30 +               50                 44

Source: IRDP (Serenje, Mpika, Chinsali), Reproduced in Moore &
Vaughan 1987.

Note: Sample consisted of 205 households containing 166 children
aged 6 to 60 months.

Figure 2.6 Changes in incomes, resurveyed villages,
North Arcot District, Tamil Nadu, 1973/74 and 1983/84

                    1973/74   1983/84

Small paddy farms   1,199     2,286
Large paddy farms   2,764     3,268
Non-paddy farms     1,732     2,032
Landless laborers     935     2,102
Non-agricultural    1,187     1,837
  households

Source: from Table 3.7, Hazell & Ramasamy 1991

Note: Table made from bar graph.

Table 3.1 Agricultural and economic growth,
food availability and poverty 1990-2012

             1990    2011

Agricultural net production indices per
capita; 1990-92 = 100

Ghana        78      158
Bangladesh   100     143
Tanzania     102     114
Zambia       105     126
Kerala       100     131

Food net production indices per capita;
1990-92 = 100

Ghana        78      159
Bangladesh   100     144
Tanzania     103     115
Zambia       106     117
Kerala       100     129

Food availability (kcal/cap/ day)

Ghana        2,080   2,930
Bangladesh   2,150   2,480
Tanzania     2,160   2,140
Zambia       2,060   1,880
Kerala       1,970   2,010

GDP per capita, real 2000 US$

Ghana        221     402
Bangladesh   280     588
Tanzania     305     473
Zambia       385     439
Kerala       743     1,209

Poverty (% national poverty line)

Ghana        52      29
Bangladesh   57      32
Tanzania     39      33
Zambia       70      59
Kerala       25      12

Rural poverty (% rural poverty line)

Ghana        64      39
Bangladesh   59      35
Tanzania     41      37
Zambia       88      77
Kerala       26      12

Sources: Various, see text. Note: Agricultural
net production indices are not available for
Kerala, so data displayed is for India. Kerala
is among the weaker agricultural states of India.

Table 3.2 Food security and nutrition 1990-2012

                       Ghana      Bangladesh     Tanzania

Under-nourishment   1990   2012   1990   2012   1990   2012
(% of population)

                     41     >5     35     17     29     39

Underweight (%      1994   2008   1990   2011   1992   2010
under-fives)

                     25     14     62     36     25     16

Stunting (%         1994   2008   1990   2011   1992   2010
under-fives)

                     34     29     63     41     50     43

Wasting (%          1994   2008   1990   2011   1992   2010
under-fives)

                     15     9      18     16     8      5

                       Zambia          Kerala

Under-nourishment   1990   2012   no data   2008
(% of population)

                     34     44               29

Underweight (%      1992   2007    1993     2006
under-fives)

                     21     15      24       24

Stunting (%         1992   2007    1993     2006
under-fives)

                     46     46      36       25

Wasting (%          1992   2007    1993     2006
under-fives)

                     6      6       13       16

Sources: Various, see text

Table 3.3 Health, water, sanitation, 1990-2012

                       Ghana      Bangladesh      Tanzania

Under-5 Mortality   1990   2011   1990   2011   1990   2011
rate (deaths/1000
live births)

                    121     78    139     46    158     68

Potable water (%)   1990   2010   1990   2010   1990   2010

                     53     86     77     81     55     53

Sanitation (%)      1990   2010   1990   2010   1990   2010

                     7      14     39     56     7      10

                      Zambia            Kerala

Under-5 Mortality   1990   2011   1992/93   2005/06
rate (deaths/1000
live births)

                    193     83      32        16

Potable water (%)   1990   2010   1992/93   2004/05

                     49     61      21        69

Sanitation (%)      1990   2010   1992/93   2004/05

                     46     48      71        96

Sources: Various, see text

Table 3.4 Female empowerment, 1990-2012

                           Ghana        Bangladesh      Tanzania

Adolescent fertility    1997   2010    1997     2010   1997   2010
rate (births/1000
females 15-19)

                         90     66      130      73    133    129

Youth female literacy   2000   2009    1994     2010   1988   2010
(% 15-24)

                         65     79      38       77     78     76

Female completion       1991   2008   no data   2009   1992   2009
of primary school *

                         58     69               71     59     87

                          Zambia          Kerala

Adolescent fertility    1997   2010   no data   2008
rate (births/1000
females 15-19)

                        143    142               18

Youth female literacy   1990   2010    1991     2011
(% 15-24)

                         66     67      90       94

Female completion       1998   2008    2001     2006
of primary school *

                         56     52      93       90

Source: Various, see text. Note: * Except in Kerala, where
comparable data is not available and the first data point refers to
enrollment of all children 6 to 10 years, the second to enrolment of
children 6-17 years. Data for enrollment of 5-14 year old children
in 2005 show slightly higher proportion of girls than boys enrolled
(UNICEF, May 2011)


Steve Wiggins & Sharada Keats

Overseas Development Institute

s.wiggins@odi.org.uk
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Title Annotation:p. S93-S137
Author:Wiggins, Steve; Keats, Sharada
Publication:African Journal of Food, Agriculture, Nutrition and Development
Article Type:Report
Geographic Code:60AFR
Date:Jun 1, 2013
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