Management of the World Bank thanks the Independent Evaluation Group (IEG) for the opportunity to respond to the report, World Bank Support to Reducing Child Undernutrition. The World Bank appreciates the close consultations IEG maintained with the operations teams during the evaluation.
Management welcomes this timely evaluation, given that the coronavirus pandemic (COVID-19) is undermining global progress toward Sustainable Development Goal 2.2. One projection is that over and above the current 149 million stunted children, an additional 9.3–13.6 million children will suffer from acute malnutrition, and 2.6–3.6 million more children will be stunted by 2022, rolling back years of progress. There is also a grave risk that these malnourished children will learn less in school and grow up to be less economically productive as adults. The Human Capital Index Update for 2020 warns that a decade of human capital gains could be reversed by COVID-19. The decision to elevate human capital as an special theme for the 20th Replenishment of the International Development Association reaffirms the World Bank’s commitment to enhancing the focus on the nutritional status of children as part of the World Bank’s COVID-19 response.
Management is pleased with the report’s conclusion that the World Bank’s approach to nutrition is sound and has evolved in a positive direction. The report states that “the World Bank’s approach to nutrition has evolved from a narrow focus on food security to a portfolio of multidimensional and multisectoral support” (viii) and it “provides a plausible pathway to improve nutrition outcomes” (ix). Further, management welcomes the finding that nutrition is being mainstreamed into sectors beyond Health, Nutrition, and Population and that non–Health, Nutrition, and Population projects accounted for 63 percent in FY14–19, with Agriculture being the largest at 29 percent. Management is also pleased to note the report’s finding that the World Bank is selective in its country engagements and has targeted its nutrition operations especially in those countries that had significant child undernutrition levels. The report notes that “in countries burdened by undernutrition, the World Bank invested an estimated $22 billion in nutrition across multiple sectors from FY08 to FY19 (including about $5.8 billion in [recipient executed trust funds] RETF), with the number of projects tripling in recent years” (63).
Management agrees with the report’s findings regarding the World Bank’s effective support to indirect pathways to high-level outcomes. The report highlights the strategic role that the World Bank has played in convening and influencing the global nutrition agenda, so the World Bank’s impact goes well beyond the projects that it finances. Scaling-Up Nutrition has been cited “as an example of the Bank Group’s effective convening” (6). The growth in the nutrition portfolio over the review period is also reflective of the World Bank’s efforts at the regional and country levels in advocating with governments to invest in nutrition. At the regional level, child nutrition interventions have been progressively integrated within the human capital regional plans and embedded in the human capital upstream support for policy and institutional reforms—including through development policy financing instruments, particularly in the South Asia and East Asia and Pacific regions. At the country level, many country programs have supported institutional reforms to support the nutrition agenda. The report also notes that “the World Bank is also increasingly successful in achieving results related to underlying nutrition determinants and institutional strengthening . . . Successful institutional strengthening of national and subnational systems is helping in some countries to institutionalize policies, effective services, and stakeholder engagement to enhance the achievement of nutrition determinants and outcomes, and to ensure sustained programs for continued outcomes improvement” (x). Management believes that the long-term support that convening, knowledge and operational engagement in institutional strengthening brings to countries—beyond the typical project implementation time frame—is fundamental to improving child nutritional outcomes.
Management supports the report’s quest for better measurement of child nutrition results in projects, yet it notes that high-level outcomes materialize long after project closing. First, the report notes that “most projects do not measure sustained behavior change results... The World Bank’s contributions to behavior change focus mostly on lower-level indicators related to the engagement of actors.” (xiii). Although management supports the increased focus on monitoring and evaluation, including interventions to change social norms and behaviors, it also cautions that sustained behavior change is a long-term development impact that is not easily measured or captured within a typical Bank project cycle. Project development objectives are grounded in the realism of what can be measured during the project lifetime, and projects are to be evaluated based on the impactful change that they can reasonably expect within the project and its lifetime. Also, the persistent gaps that exist when tracking achievements from nutrition-specific and social norms interventions requiring behavioral changes may be explained by the limited availability of information to differentiate adherence to social norms from the usual patterns of behavior reflecting food availability, affordability, convenience, and familiarity. It is important to note that very few studies in the global literature measure outcomes related to social norms; this reflects measurement challenges and the lack of globally validated indicators of social norms globally. As noted in the report, several projects are now pioneering more rigorous evaluation of nutrition programs, for example in Madagascar, Rwanda, and India, among other countries. In this context, it is worth noting that the Bank Group has recently issued guidance to strengthen measurement of high-level outcomes, such as improved child nutrition, at the country level and over multiple Country Partnership Frameworks, as part of a road map to strengthen its outcome orientation.
Management agrees to adjust nutrition programming in country portfolios (i) to give more priority to institutional strengthening of stakeholder engagement, coordination, and services for nutrition; and (ii) to increase the focus on subnational targeting of interventions to reflect areas of greatest disadvantage and persistence of need (recommendation 1). As mentioned above, the emphasis on institutional strengthening at the country level is a key aspect of World Bank engagement with clients, and the World Bank will continue to support institutional strengthening yet more decisively. As highlighted in the evaluation, the World Bank has been effective at targeting investments in countries with child undernutrition and will continue to emphasize subnational targeting to reduce child nutrition disparities within countries whenever needed.
Although management agrees with the spirit of recommendation 2 ([i] to rebalance investments to have greater emphasis on nutrition-specific interventions and [ii] to increase the focus on social norms interventions and behavior changes, with more attention to tracking expected achievements to improve nutrition determinants), management will continue to be guided by global evidence. Global evidence, compiled in The Lancet Series (2008, 2013, 2021), suggests that nutrition-specific interventions may be more effective when complemented with nutrition-sensitive interventions, and vice versa, and this is the approach that the World Bank plans to continue pursuing, depending on specific country contexts. Management therefore finds the word rebalancing somewhat ambiguous, as it suggests that greater emphasis on nutrition-specific interventions is required. Management also believes that in the case of social norms and behavioral change interventions, the World Bank should also follow global best practices. Management agrees with the report’s finding that greater focus on changing social norms is needed but also notes that inducing impactful behavioral change requires a long-term multifaceted engagement informed by evidence. Although there is consensus on the need to do more in relation to social norms, the evidence base to support country-level changes is still evolving. Best practice evidence suggests that increasing investments in evidence-based nutrition-specific interventions complemented with nutrition-sensitive sectors is paramount to improving nutrition outcomes, in addition to scaling-up interventions to address social norms. In addition, in many country contexts, other local or international partners that have a larger presence in the field may have a greater comparative advantage than the World Bank in changing social norms, and these changes may in fact be catalyzed by their complementary projects. Further, as stated above, it is important to note that social norms take a very long time to change and cannot realistically be measured within the time frame of World Bank projects, particularly considering the lack of globally validated indicators for measuring social norms. Several World Bank projects are now pioneering measurement of nutrition outcomes, and management will continue to support such efforts, in the quest for increased outcome orientation.
- 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).