Undernutrition negatively affects the health, physical growth, and cognitive development of children, with consequences that last through adulthood and reduce their potential to learn and contribute to society, ultimately affecting human capital accumulation in countries.
Stunted growth of children under five, anemia, and low birthweight—all indicators of child undernutrition—still severely affect the Africa and South Asia regions. Globally, an estimated 150 million children (22 percent) had stunted growth in 2018, compared with 198 million (33 percent) in 2000.
Coordinated effort throughout the life cycle of the mother and child is required to improve nutrition determinants, including diet diversity, child feeding, the health of mother and child, and access to food, caregiving, health services, water, sanitation, and hygiene.
The evaluation assesses the contribution of the World Bank’s nutrition support in improving outcomes for reducing child undernutrition and in improving nutrition determinants through multidimensional and collaborative multisectoral interventions. The findings support lessons and recommendations to inform the design of future nutrition support.
Undernutrition negatively affects the health, physical growth, and cognitive development of children. It arises from the insufficient intake or absorption of nutrients, which starts with the nutrition and health of the future mother, affecting the growth and development of the child in utero and birth outcomes. Child undernutrition has irreversible effects in early childhood and beyond. The causes of child undernutrition are influenced by the mother and child’s access to and practice of behaviors related to nutrition determinants: caregiving practices, diet diversity, maternal and child health, and access to food, maternal resources, health services, and water, sanitation, and hygiene (WASH).
Reducing child undernutrition is essential for enhancing human capital accumulation, boosting economic growth, and reducing poverty. The consequences of undernutrition for young children last through adulthood and reduce their potential to learn and contribute to society. These consequences are also often intergenerational, extending to future children. Galasso and Wagstaff (2018) estimate the average per person income penalty from stunted growth is about 7 percent.
Global reports on indicators of undernutrition show mixed progress across regions in reducing the stunted growth of children under five, anemia, and low birthweight (LBW), with Africa and South Asia most severely affected. Moreover, although much of Latin America and the Caribbean and of East Asia and Pacific have low national prevalence of stunted growth of children, some countries and subnational areas have levels of stunted growth similar to Africa and South Asia. Stunted growth, wasting, and underweight are the most-used anthropometric measures of child undernutrition. Globally, more than 150 million children (22 percent) were estimated to have stunted growth as of 2018, compared with 198 million (33 percent) in 2000. In Africa, stunted growth rates have improved since 2000, yet total undernutrition is worsening as the population is growing; therefore, the total number of children with stunted growth is increasing. Reducing anemia and LBW have seen similarly mixed progress. The latest figures show that the prevalence of anemia in girls and women of reproductive age has stagnated at about 33 percent. Approximately 20 million babies are LBW globally, compared with 22.9 million in 2000 (Development Initiatives 2020; UNICEF, WHO, and World Bank 2019).
Improving child nutrition requires efforts at each stage of the life cycle of the mother and child. Malnourished pregnant women may deliver LBW newborns, and mothers with low body weight or micronutrient deficiencies may struggle to sustain exclusive breastfeeding or to feed and care for their babies (figure 1.1). Children with low or inadequate nutritional status are more prone to childhood infections, which further aggravate the child’s capacity to absorb nutrients, and have slower growth and impaired cognitive capacity (Maternal and Child Nutrition Study Group 2013).
Evaluation of child undernutrition requires the assessment of outcomes at different points in the life cycle of mother and child, with a focus on the early years of life. Within the life cycle, mother and child are most sensitive to the consequences of undernutrition from preconception through pregnancy, until the child is about two years old. For this reason, nutrition interventions often target mothers, children, and future mothers during this period, including girls, adolescents, and women before conception and during pregnancy, and households with mothers and young children. Given the many nutrition determinants that affect the life cycle of mother and child, the challenge of improving nutrition outcomes (anthropometric measurements, micronutrient status, and cognitive development) becomes multidimensional, requiring interventions in health, agriculture, WASH, social protection, education, and governance. Thus, improving outcomes in countries requires coordination to improve diet diversity, child feeding, the health of mother and child, and access to food, caregiving, health services, and WASH. It also involves engaging a range of actors, including government, communities, and households, to influence nutrition determinants.
Evolution of the Global Nutrition Agenda
Historically, the World Bank’s nutrition agenda has focused on access to food. In the 1970s, the World Bank approached nutrition by integrating it into poverty reduction through multisectoral rural development projects. Government commitments to implement these projects were often weak (MacNally 1983; World Bank 2014). Later projects shifted to focus mainly on the health sector (Berg 1987), where the challenge became how to meaningfully integrate nutrition interventions into one component of the project or to expand interventions in health services or interventions that had been confined to small geographical areas (figure 1.2).
Over the years, World Bank support to nutrition has evolved into a more multidimensional and collaborative multisectoral agenda. Countries and development partners have adopted the United Nations Children’s Fund (UNICEF) framework of child undernutrition (UNICEF 1990, 2015), which highlights the need to address multidimensional determinants, including access to food, caregiving, health services, and WASH throughout the life cycle of mother and child (figure 1.3). Among the milestones in the World Bank’s adoption of a multidimensional or collaborative multisectoral approach is a series of reports on combating nutrition (Gillespie, McLachlan, and Shrimpton 2003), strengthening country commitment (Heaver 2005), repositioning nutrition in the development agenda (World Bank 2006), scaling up nutrition (Horton et al. 2010), and improving nutrition through multisectoral approaches (World Bank 2013a).
The Scaling Up Nutrition Movement (2010) brought together countries, sectors, and development partners to act on nutrition and began to organize learning and operational efforts regarding the UNICEF framework of child undernutrition and addressing of nutrition determinants. In some countries, the movement initiated policy and institutional reforms to coordinate, plan, measure, and implement nutrition interventions and find solutions to overcome previous challenges relating to the countries’ ownership and delivery of the agenda; that is, nutrition does not fall within the mandate of any one sector (SUN Movement 2019). Within the World Bank, the commitment to the movement renewed the engagement of sectors (agriculture, social protection, health, water, and so on) to address nutrition in country programs (Alderman 2016; Hawkes and Ruel 2008; World Bank 2013a, 2014). The 2020 Independent Evaluation Group (IEG) Evaluation of the World Bank Group’s Global Convening cited the movement as an example of the Bank Group’s effective convening that transformed the execution of nutrition efforts by creating a multisectoral, multistakeholder platform and galvanized momentum in reducing malnutrition.
In 2008, the first of several Lancet series on nutrition began consolidating the knowledge and evidence on interventions that were effective in improving nutrition outcomes (Maternal and Child Undernutrition Study Group 2008). In 2010, the World Bank published the first estimates for financing nutrition interventions in countries; these estimates have led to more detailed country-level investment cases (Horton et al. 2010), work on the Optima Nutrition budget allocation decision tool (Pearson et al. 2018), and from 2013 became the basis for mobilizing financing for nutrition and political commitment through Nutrition for Growth, together with partners such as the Bill & Melinda Gates Foundation. Multisectoral knowledge sharing has also been supported through the SecureNutrition Knowledge Platform (World Bank 2017).
Since 2016, the Sustainable Development Goals (SDGs) have been adopted to improve nutrition outcomes, and the United Nations has declared the Decade of Action on Nutrition (2016–25). The Millennium Development Goals had focused on halving the prevalence of underweight children under five by 2015, which did not fully address the importance of nutrition to healthy growth and child development. The need for better nutrition is further recognized in SDG 2, which aims to end hunger, achieve food security and improved nutrition, and promote sustainable agriculture. SDG 2 emphasizes the transformational role nutrition can play in driving human capital development and the need to address multidimensional nutrition determinants and inequalities in the life cycle of mother and child. The SDG 2 focus on stunted growth was influenced by the World Bank’s strategy of reducing extreme poverty and promoting shared prosperity and by its emphasis on inequalities in early childhood development (ECD) and nutrition (Denboba et al. 2014; World Bank 2013b). Since the creation of the SDGs, the World Bank has supported nutrition investments in countries and analyses on the economic costs of child undernutrition (Galasso and Wagstaff 2018; Laviolette et al. 2016; Shekar et al. 2017; WHO 2014). Global nutrition targets set by the World Health Assembly for 2025 include a 40 percent reduction in stunted growth, a 50 percent reduction in anemia in women, a 30 percent reduction in LBW newborns, and an achievement of at least 50 percent for exclusive breastfeeding (WHO 2014).
The launch of the World Bank’s Human Capital Project in 2018 further reinforced the importance of reducing child undernutrition and of implementing a package of multidimensional interventions to achieve results. The percentage of children under five who do not have stunted growth is now used as a proxy for healthy child growth based on its emphasis in the Human Capital Index (World Bank 2018). The human capital agenda has led to (i) efforts to improve data on nutrition indicators and (ii) analysis to understand aspects of multidimensionality relating to how interventions from different sectors can be prioritized and integrated in a package to address disadvantaged nutrition determinants in a country context, that is, inadequate access to nutrient-rich food, caregiving resources, health services, and WASH (UNICEF, WHO, and World Bank 2019; Skoufias, Vinha, and Sato 2019).
Evaluation Objectives and Scope
The objectives of this evaluation are (i) to assess the contribution of the World Bank in improving outcomes related to reducing child undernutrition and improving nutrition determinants and (ii) to inform the design of future nutrition support. The evaluation provides evidence on results across sectors and lessons from operational experience to feed into country strategies, multidimensional and collaborative multisectoral approaches, and project design, particularly in those countries where child undernutrition is an important factor inhibiting the healthy growth of children and the accumulation of human capital.
The overarching evaluation question is, “What has been the contribution of World Bank support to improve outcomes and intermediate outcomes in reducing child undernutrition and improving nutrition determinants in countries burdened by undernutrition?” Underlying this question are three main lines of inquiry:
- To what extent is the World Bank supporting relevant interventions to improve outcomes and intermediate outcomes of child undernutrition and its determinants within the country context?
- How is the World Bank implementing multidimensional approaches to support outcomes and intermediate outcomes that reduce child undernutrition, improve its determinants, and strengthen countries’ institutional capacities?
- To what extent have World Bank interventions contributed to achieve outcomes and intermediate outcomes of reducing child undernutrition and improving its determinants, and what were the factors of success and failure?
To answer these questions, the evaluation focuses on World Bank engagements in nutrition (investment operations, development policy lending, and recipient-executed trust funds [RETFs]) that were active during fiscal year (FY) 2008–19 in countries that have reported high levels of stunted growth.
The evaluation design adopts a multilevel analysis at the global, portfolio, country, and intervention levels using quantitative and qualitative evaluative evidence and applying participatory, theory-based, and case-based principles.
The conceptual framework underpinning this evaluation is adapted from the UNICEF framework of determinants of child undernutrition (figure 1.3; Maternal and Child Nutrition Study Group 2013; UNCNC21 2000; UNICEF 1990, 2015). The framework models interlinked dimensions to sustainably address child undernutrition in a country context. In doing this, the evaluation takes a systems approach to look at the World Bank’s support and results across these dimensions. These dimensions are nutrition-specific and nutrition-sensitive interventions addressing the immediate and underlying determinants of nutrition, respectively, social norms interventions, and institutional strengthening support, considering factors within the country that are used to prioritize and target interventions (box 1.1). The evaluation methods look at each of these dimensions and confirm the interlinkages among the dimensions. This emphasizes the need for a mix support tailored to needs in countries to achieve results across these dimensions to contribute to nutrition outcomes (anthropometric measures and micronutrients deficiencies).
Box 1.1. Explaining the Logic of the Conceptual Framework of Child Undernutrition
The conceptual framework premises that nutrition outcomes for pregnant women and children (for example, anthropometric measures and micronutrient status) are better among women and children with adequate nutrition determinants. Immediate determinants of child nutrition relate to caregiving practices, dietary intake or diversity, and the health status of the mother and child. It is not possible to realize these factors when communities lack adequate access to underlying determinants of nutrition, including nutrient-rich food, caregiving resources, health services, and water, sanitation, and hygiene (WASH). Improvements in underlying determinants are interdependent; that is, access to food is not enough without adequate feeding, proper care, adequate and accessible health services, and clean water.
Successfully addressing both the immediate and the underlying determinants of nutrition requires transforming social norms relating to early marriage, early pregnancy, birth spacing, and women’s empowerment (decision-making regarding childcare, food production, health care seeking) and changing behaviors relating to feeding, caregiving, health, and WASH practices, including those related to gender relations and practices. Behavioral interventions are thus central to the framework and can target women, caregivers, children, and other agents of change (such as household members and community leaders) who can influence the prevailing social norms, and more broadly, behavior practices at the community and household levels.
The conceptual framework suggests that nutrition interventions within a country need to be multidimensional to address both the immediate and underlying nutrition determinants in their context; this may require synergizing interventions related to multiple sectors. Nutrition-specific interventions, such as adolescent nutrition, maternal nutrition, breastfeeding support, micronutrient supplementation, child disease prevention, and management and treatment of undernutrition, are expected to influence the immediate determinants of nutrition. Nutrition-sensitive interventions, such as cash transfers, WASH approaches, girls’ education, and food system improvements, are expected to address the underlying determinants. Whereas nutrition-specific interventions are often delivered by the health system and target women and children, nutrition-sensitive interventions may be delivered by various sectors and target households and communities or geographies with inadequate nutrition determinants (access to nutritious food, caregiving resources, health services, and WASH).
The country-specific situation, including the distribution of outcomes, frames the context in which to prioritize and target interventions, and the enabling environment frames interventions to strengthen institutional capacities at national and subnational levels over time in a country to support outcomes. Factors of fragility and distributional factors related to inequalities in nutritional outcomes, health and education status, and poverty can create different country scenarios in which to prioritize and target interventions to improve undernutrition. Moreover, the distribution of nutrition determinants in a population—that is, access to nutritious foods, caregiving resources, health services, and WASH—can provide information on investment needs. Institutional capacities in the enabling environment at the national and subnational levels can frame priorities for interventions to improve the delivery of services and programs, the engagement of communities, and the implementation of policies to address nutrition in countries.
Source: Independent Evaluation Group.
The evaluative findings and conclusions are a result of the triangulation of different evaluation components at the global, portfolio, and country levels. The evaluation adopted several innovative practices and broadened the methodological applications to ensure construct validity, internal validity, external validity, and reliability of findings through a transparent methodological design, with clear justification of choices made (see appendix A for the evaluation methodology).
At the global level, the evaluation methods included a systematic review map (SRM) that synthesizes the existing evidence from systematic reviews (SRs) of the literature on the effectiveness of nutrition interventions across sectors to support nutrition outcomes, immediate nutrition determinants, or underlying nutrition determinants (appendix B). The SRM provides a tool to visualize the existing evidence and benchmark it against the nutrition portfolio to review the alignment of World Bank support in Global Practices (GPs) to the evidence base. Additionally, a structured literature review identified and categorized behavior change concepts and evidence to develop a set of process maps describing a basic results chain for benchmarking behavior change in projects (appendix C). The process maps provide a qualitative tool to review behavior change support to nutrition determinants, which is often not tracked in projects.
At the portfolio level, the evaluation conducted a systematic identification, coding, extraction, and analysis of the World Bank’s nutrition lending portfolio based on its relevance, multidimensional approaches, and contributions to nutrition results in countries. The portfolio review and analysis combined a mapping of project indicators to measure nutrition achievements with artificial intelligence theory-based content analysis and unsupervised machine learning techniques to develop a taxonomy of common success and failure factors that influenced the results of nutrition projects (appendix D). In addition, portfolio data were contrasted against a heat map on nutrition outcomes and determinants in countries to assess the alignment of projects’ interventions to the country needs and to understand the empirical links of the conceptual framework (appendix F). Moreover, a qualitative stocktaking exercise of 12 countries was conducted to understand multisectoral approaches to nutrition in different country contexts and how the World Bank helped enhance multisectoral coordination through institutional capacity building (appendix H). Finally, a multivariate regression analysis was done to deepen learning on the portfolio data (appendix I).
At the country level, central to the evaluation are eight country case studies (Ethiopia, Indonesia, Madagascar, Malawi, Mozambique, Nicaragua, Niger, and Rwanda) that include a review of nutrition in the country program (including analytical work), semistructured interviews, and analysis of the World Bank’s contribution to results in each country (appendix G).
The report is structured as follows: chapter 2 focuses on the World Bank’s approaches to multidimensionality; chapter 3 looks at the World Bank’s contribution to results; and chapter 4 presents conclusions, lessons, and recommendations to inform the design of future multidimensional nutrition support by the World Bank.
- Through simulations, the 2020 Human Capital Index report shows that without any remediation, a decade of human capital gain could be reversed by the pandemic with a 0.44 percent drop in the index globally, and up to 0.73 percent loss in low income countries. (See World Bank. 2020. The Human Capital Index 2020 Update: Human Capital in the Time of Covid-19.)
- “Almost 40 percent of World Bank support is institutional strengthening, especially aimed at improved nutrition service delivery, such as quality assurance approaches, capacity building, and performance-based systems” (14).