Positioning Nutrition as Central for a Food Secure Arab world Clemens Breisinger, Olivier Ecker, Marc Nene and Perrihan Al-Riffai, International Food Policy Research Institute (IFPRI) Convener: The World Bank Session - Food Security: Beyond Food Production 14 November, 14.30 – 16.00
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Positioning Nutrition as Central for a Food Secure Arab world
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Positioning Nutrition as
Central for a Food
Secure Arab world
Clemens Breisinger, Olivier Ecker, Marc Nene and Perrihan
Al-Riffai, International Food Policy Research Institute (IFPRI)
Source: Breisinger et al. 2012 based on SPEED database (2011).
Note: Averages of aggregates are weighted by population size.
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Some of the key messages are:
Arab countries allocate about the same amount of resources to agriculture
as all LMICs on average but significantly more than Latin America and the
Caribbean and Sub-Saharan Africa Yet, there are substantial differences
among Arab countries. The agricultural expenditure intensity is relatively
low in several FSC countries, including Yemen (3.9 percent), Lebanon (1.2
percent), and Morocco (4.4 percent), indicating potential underspending.
Arab countries devote 4.2 percent of GDP to education. This share is even
higher when excluding high-income countries from the average (Table 1),
thus no world region spends a greater share than the Arab region LMICs (4.3
percent). Countries that spent more than 5 percent of GDP on education
include Yemen, Jordan, Morocco, and Tunisia; Iran, Lebanon, Syria, and
Turkey spent less than 2 percent in 2007.
Arab countries spend about 2.0 percent of GDP on health, which is less than
in Latin America and the Caribbean region but more than in other regions.
There are large differences between countries: In 2007, Jordan and Bahrain
plus Egypt and Turkey spent more than 2 percent of their GDP on health,
and Lebanon and Morocco plus Syria and UAE spent less than 1 percent.
Spending on infrastructure, which refers here to transportation and
communication, in the Arab LMICs is high according to global standards;
however, the Arab-TI region is the only region where infrastructure budgets
have shrunk, where the decline in infrastructure spending is particularly
pronounced in oil-importing FSC countries, where spending has declined by
2.6 percent per capita and per year, while spending has sharply increased by
12.4 percent in (oil-exporting) FS countries (Breisinger et al. 2012).
Arab LMICs in particular have by far the highest spending on social
protection: more than double the size of Eastern Europe and Central Asia
and more than four times the size of Sub-Saharan Africa. In the Arab-TI
region, social protection expenditures are also by far the highest single
spending account, amounting to 4.7 percent of GDP on average, and 5.3
percent in Arab LMICs.
While there are no specific numbers available for Arab countries, in general the
nutrition subsector tends to be underfunded in government budgets and in the
budgets of the international development assistance community relative to
the size of the problem (Ecker and Nene, 2012). Although the amount of financial
resources allocated to nutrition is difficult to estimate precisely (especially given
the responsibilities scattered across government sectors), the poor progress in
reducing malnutrition in most developing countries demonstrates meaningful
evidence. For example, each stunted child in the 20 countries accounting for 80
percent of the global burden of child stunting received only $2 out of the $5-10
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Box 1: Cost-benefit ratios of large-scale
nutrition interventions (aggregates)
Micronutrient supplementation 17.3
Micronutrient fortification 9.5
Biofortification (plant breeding) 16.7
Deworming preschoolers 6.0
Community-based nutrition promotion 12.5
Source: Horton et al. (2008).
required to scale up community-based nutrition programs in 2006 (Horton et al.
2010, Morris et al. 2008).
It is not only the size but also the quality of public spending that matters for
food and nutrition security. At the country level, high prevalence rates of stunted
children are often associated with poor delivery of public services, especially in the
health and education sector, and poor development of water and sanitation
infrastructure; rapidly growing populations; low literacy rates and low educational
attainment rates; and gender inequality. For example, much like agricultural
spending, spending a large portion of GDP on education does not necessarily yield
results: youth literacy rates, for instance, show no clear relationship between
expenditures and educational achievements. Similar to the patterns for education
expenditure, comparisons of health expenditure and performance in terms of
MDGs 4 to 6 reveal no clear relationship, implying that there are also big
differences in the amounts spent per person and the quality of health services. One
reason may be that public spending is not well targeted to the food insecure. For
example, fuel and, in some countries, food subsidies are often higher than more
targeted social spending. In Egypt and Syria, for example, food and fuel subsidies
(accounting for about 20 percent of public spending) are more than two-fold higher
than spending on social protection programs and health combined.
3. Highlights of nutrition interventions
Nutrition interventions have very favorable cost-benefit ratios. Maybe the
most convincing argument for a stronger political commitment to nutrition, though,
is the high cost-effectiveness of direct nutrition interventions (Box 1). Asked to
rank 30 solutions to the ten great
global challenges primarily based
on economic costs and benefits,
the 2008 Copenhagen Consensus
listed five solutions addressing
the ‘malnutrition and hunger’
challenge directly and another
four indirectly through the link
with health and education in the
top ten solutions (CC 2008). The
proposed interventions include micronutrient supplementation and (bio)
fortification, nutrition and hygiene education programs, and immunization, of
which most of them are targeted toward women in reproductive age and young
children.
The case of a Bajil District in Yemen shows how costs for nutrition
interventions can be estimated on a case-by case basis. Child health and
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nutrition programs are widely needed in Bajil District. The low use of birth control
methods (only 15 percent of non-pregnant woman) in spite of the widespread wish
of not having more children clearly indicates the need for implementing and
expanding birth control programs. There is also a pressing need for reproductive
health and child nutrition and health programs of various type (including mother
counseling). Table 2 shows the estimated annual costs of different health and
nutrition programs in order to increase coverage to 50 percent, 90 percent, and
100 percent of the population in need. In addition to that, information and
education campaigns targeted to the broader society can be an effective
mechanism for raising awareness and knowledge on diverse aspects related to
family health, nutrition, and social development. These campaigns should include
common issues such as qat consumption, healthy nutrition, child feeding practices,
hygiene, family planning, and women’s empowerment. Cost estimates for such
campaigns are reported in Table 2.
Table 2. Annual costs health and nutrition programs and information and
education campaigns in Bajil District
Proportion of individuals in need (%)
Annual costs (thousand US$)
50% coverage
90% coverage
Full coverage
Reproductive health Antenatal, delivery, and postpartum
care program (for pregnant women) 58
3.1 18.8 22.7
Birth control program for women in reproductive age wishing no additional children
46
20.4 36.7 40.8
Child nutrition
Mother counseling program for pregnant women (breastfeeding, child health and nutrition)
100
2.2 3.9 4.4
Feeding program for small-sized newborns
52
4.0 7.2 8.0
Child growth monitoring program for severely stunted children (aged 6-59 months)
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25.6 46.1 51.2
Information and education
General campaign (qat consumption, healthy nutrition, child feeding practices, hygiene, family planning, and women’s empowerment, etc.) for total population
100 85.1
Source: Own estimation based on CSO (2004), 2005-06 HBS data, and 2006 MICS data
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The case of Brazil shows how nutrition can be successfully integrated into
national programs and demonstrates that well-crafted nutrition policies under
strong political leadership can engender a substantial reduction in chronic
malnutrition. In one decade Brazil managed to almost halve the prevalence of
stunting among children under the age of five from an estimated 13.5 percent in
1996 to 6.8 percent in 2007 (Monteiro et al. 2010). Thanks to the poverty reduction
program and its health and nutrition components, the trend of declining child
stunting since the mid-1970s has been accelerated considerably. Trend analyses of
the determinants of child stunting suggest that nationwide two-thirds of the
reduction is attributable primarily to decline in poverty and increase in mothers’
education and secondarily to expansion of healthcare coverage and improvements
in sanitation (Monteiro et al. 2009, Monteiro et al. 2010). Food security had already
been part of Brazil’s policy agenda since the early 1990s, championed by a network
of civil society organizations. In 2003 the engagement culminated by a declaration
to combat hungers—a national priority by President Luiz Inácio Lula da Silva
(Kepple et al. 2012). Today, the resulting ‘Zero Hunger’ strategy coordinates
programs from 11 ministries and provides a framework for several initiatives
including the flagship conditional cash transfer program ‘Bolsa Família’, which is
considered the ‚cornerstone program for the promotion of food and nutrition
security‛ in the country (Ananias 2008, Chmielewska & Souza 2011). The success of
the ‘Zero Hunger’ strategy rests on its manifold integration in Brazil’s institutional
and legal framework. The National Council on Food and Nutrition Security
(CONSEA), which monitors the country’s food and nutrition situation, has broad
representation from the federal government and civil society and is institutionally
linked to the presidency. The food and nutrition security secretariat and social
protection secretariat—managing the ‘Bolsa Família’ program—are housed in the
Ministry of Social Development and Fight against Hunger, which has the mandate
to oversee the integration of food and nutrition security actions with the activities
of other relevant ministries. And third, the ‘Right to Food’—incorporated into
Brazil’s constitution in 2009—grants the status of public policy to food and
nutrition security and requires the federal states to enforce the universal right
guaranteeing regular and permanent access to food in sufficient quantity and
quality.
4. Summary
Food insecurity is a multi-dimensional challenge and nutrition is an integral part of
achieving food security. Overcoming malnutrition, especially among children, is not
only an issue of achieving food security, but also important for realizing successful
economic development. However, in the Arab world, on average every fifth child
younger than five is malnourished, while in Egypt and Sudan about every third and
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in Yemen almost two thirds of children are stunted. To overcome this unacceptable
situation, this paper has raised a couple of important policy questions and provided
two initial suggestions for action that are based on global experiences. Questions
that need to be urgently addressed are: why is it that economic growth (and rising
incomes) does not seem to improve nutrition in Arab countries? How can public
resources be better targeted at improving food and nutrition security? Global
experiences show that the nutrition part of food security tends to be underfunded
in government budgets and in the budgets of the international development
assistance community relative to the size of the problem, suggesting that
investments in nutrition need to be scaled-up. The case of Brazil shows the
importance of integrating food and nutrition security into national programs and
demonstrates how well-crafted nutrition policies under strong political leadership
can engender a substantial reduction in chronic malnutrition.
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