4.1 The Relevance of Nutrition for Development
Three emerging bodies of work highlight the nature of the link between nutrition and human development: (1) nutrition, cognition, and school enrollment, (2) foetal nutrition and adult chronic disease, and (3) the importance of community-based approaches to development and the leadership of the nutrition community in this regard.
Nutrition, Cognition, and School Enrollment
Recent studies from the nutrition and economics literatures reaffirm the importance of nutrition for the cognitive achievement and school enrollment of children. In addition, study after study demonstrates that women’s educational attainment is a key factor in preventing infant undernutrition3 and that overall educational attainment is the key factor in escaping poverty.4
Recent nutrition studies confirm the strength of these relationships. Strong associations are found between the stunting of Filipino children under age 2 and their cognitive ability test scores between ages 8 and 11.5 There is a strong link between sub-optimal neonatal nutrition and cognitive function, particularly in males.6 In Jamaica stunting was strongly associated with developmental levels in 1- and 2-year-olds.7 Nutritional supplementation and stimulation of stunted children between 9 and 24 months of age have independent and additive effects on the development of the children at the age of 7 - 8 years.8
The economics literature offers compelling evidence of the importance of nutrition for development. At the mean of a nationally representative sample from Ghana, a 10% increase in stunting causes a 3.5% increase in age of first enrollment at school.9 For Pakistan, an improvement of 0.25 in Z-score height-for-age will lead, on average, to an increase in subsequent school enrollment rates of 2% for boys and 10% for girls. This increases to 5% and 16%, respectively, when diarrhoea rates are reduced by half.10 Another recent study yields smaller impacts on child schooling performance, but the link is still statistically significant.11
Given that these findings come from both experimental design and observational data and from both the nutrition and economics literatures, and that stringent statistical and econometric techniques have been used to generate them, they present a convincing and scientific basis for early childhood interventions.
Policy Implications of the Link between Foetal Undernutrition and Adult Chronic Disease
Evidence on the links between foetal undernutrition and chronic disease in adulthood has been discussed in Chapter 1. The implications of these links for formulating development policies are only now being thought through. Three points are noteworthy. First, an investment in avoiding foetal undernutrition becomes an even better investment because it not only improves maternal and infant nutrition but also slows down or prevents the onset of chronic diseases in later life. Of course, preventing these effects is intrinsically valuable, as emphasized by the human rights approach. In addition, prevention will have a significant impact on economic productivity - an impact that has not been captured in conventional estimates of the economic returns to improved nutrition.
Second, increasing health expenditures - whether private or public - to modify behaviour and prevent undernutrition throughout the life cycle may well diminish or at least postpone health expenditures to later in life. This postponement will better allow ageing populations to lead productive adult lives, thus enabling them to better insure themselves - formally or informally - against health shocks. Third, if the allocation of public health resources is to be guided by the global burden of disease metrics such as disability-adjusted life years lost (DALYs), then the new findings will lead to an enormous increase in the rationale for investing in adolescent, maternal, foetal, and infant nutrition, simply because foetal undernutrition is a leading cause of such major components of the global burden of disease as cardiovascular disease, hypertension, and obesity.
Decentralization and the Empowerment of Communities
Many institutions throughout the world are rapidly decentralizing the allocation of public resources - whether health and nutrition or otherwise. In principle, moving authority and accountability closer to the intended beneficiaries of an initiative - poor communities, for example - is likely to strengthen the incentives to use public funds more effectively and to facilitate the generation of complementary private funds. In practice, however, mechanisms to ensure sufficient local capacity and accountability have to be present as well. Communities also have embedded power structures, and in the absence of transparency and accountability mechanisms, local groups can misallocate funds. Moreover, if local communities are to compete for central funds, the better-equipped, more-cohesive, and less-excluded communities will capture them. Communities that are unable to organize proposals or are less likely to be noticed by central authorities will lose out.
The nutrition community has taken leadership in this area. Community-based nutrition programming has long been considered a vital component of the fight against malnutrition.12 Can these community-based efforts serve as a way of empowering communities to participate in other development activities? The body of quantitative empirical research on how community participation affects the performance of development projects is small but growing. The two studies that use data from a large number of projects and have paid most attention to the econometrics issues find that community participation leads to improved project performance.13, 14 Further, community-based lending schemes have higher repayment rates if their membership has higher indicators of social cohesion.15 In addition, there is a rapidly growing body of work linking membership in social and economic groups to accelerated upward income mobility.16
Ideally, data on a large number of nutrition projects will become available so that similar analyses can be undertaken. Can nutrition programs empower communities beyond their immediate concerns? And can community-based nutrition initiatives foster an increasing adherence to human rights by a wide range of actors? These questions remain to be answered, but the signs are promising. Several community nutrition projects have served to stimulate other decentralized development activities. In Sri Lanka, for example, the nutrition component of a World Bank - supported poverty alleviation project used participatory approaches to enhance nutrition awareness and improve feeding practices. The project used nutrition as an entry point to poverty alleviation, by combining it with community infrastructure development, savings, credit, and micro-enterprise development in a phased manner. In a setting characterized by top-down development planning, the project demonstrated that community ownership could accelerate positive change.17
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