Insufficient intake or absorption of nutrients results in undernutrition in children and negatively affects their health, physical growth, and cognitive development. These and other nutrition outcomes are affected by immediate determinants that include caregiving practices, dietary intake or diversity, and the health status of the mother and child. These immediate determinants are all difficult to realize when communities lack adequate underlying determinants of nutrition, such as access to nutrient-rich food, caregiving resources, health care, and water, sanitation, and hygiene (WASH) services. Successfully addressing both the immediate and underlying determinants of nutrition requires changing behaviors related to feeding, caregiving, health, and WASH practices throughout the life cycle of the mother and child and social norms related to early marriage, early pregnancy, birth spacing, and women’s empowerment.

This evaluation assesses the contributions of the World Bank to improving nutrition determinants and outcomes for children through its interventions during fiscal years (FY) 2008–19. The evaluation uses a variety of evidence at the global, country, and portfolio levels. Its findings are intended to inform the design of future nutrition support.

Main Findings

In line with the conceptual framework of child undernutrition, the World Bank’s approach to nutrition has evolved from a narrow focus on food security to a portfolio of multidimensional and multisectoral support. The multidimensional support combines nutrition-specific, nutrition-sensitive, social norms, behavior change, and institutional strengthening support. Institutional strengthening accounted for the largest share of the rapidly growing portfolio over FY08–19. Nutrition-sensitive interventions that aim to improve access to nutritious food, maternal resources, health care, and WASH services increased during the evaluation period. Meanwhile, nutrition-specific interventions that aim to address the immediate determinants of nutrition have not seen the same increase. Behavior change interventions are cross-cutting in the portfolio, especially in support to communities. Social norms interventions, which can support an understanding of gender roles in decision-making that may influence nutrition status among children and pregnant and lactating women, remain relatively limited in the nutrition portfolio.

The portfolio supports interventions known to be effective in improving nutrition determinants and thus contributing to the reduction of child undernutrition. The increasing focus on nutrition-sensitive interventions in recent years is consistent with growing global evidence of the need to support both nutrition-specific and nutrition-sensitive interventions in countries where there is a need. Nonetheless, there is an opportunity for World Bank projects to better emphasize nutrition-sensitive and nutrition-specific interventions that work. Nutrition-specific interventions that work to address immediate nutrition determinants in countries can be balanced with support to interventions that work across sectors to address underlying nutrition determinants; support to institutional strengthening of stakeholder, policy, and services; and knowledge work to facilitate evidence, learning, and leadership.

The evaluation confirms that the World Bank’s approach to nutrition—addressing dimensions of underlying and immediate nutrition determinants, social norms, behaviors, and institutional strengthening—provides a plausible pathway to improve nutrition outcomes. A combination of results across these dimensions is critical to support needs in countries. The associations among access to health services and social norms and a country’s nutrition outcomes are the strongest, followed by access to WASH and food and care.

Although World Bank interventions generally address country needs at the national level, significant gaps remain in addressing social norms and WASH. Gaps in country needs relate to areas where there are low levels of nutrition determinants and a lack of support for improvement. The alignment of the nutrition portfolio with country needs is particularly high in access to health care that has the strongest association with country nutrition outcomes, but synergistic support in social norms and WASH is often lacking in countries where these determinants are disadvantaged.

Case studies revealed that at the subnational level within-country alignment and targeting is challenging. Support to nutrition is led by various Global Practices (GPs), and in most countries, interventions are fragmented across projects and time, and coordination to ensure support to all relevant nutrition determinants is limited.

Country experiences also suggest a need for strengthening multisectoral arrangements for nutrition. The key for multisectoral response is having consistent support to develop leadership, services, systems, policies, and evidence to help countries sustain support to nutrition that involves multiple actors and sectors. Most institutional strengthening efforts in the case study countries are in one sector, with increasing examples of projects that contribute to strengthening multisectoral approaches for nutrition.

Moreover, case studies revealed that core nutrition projects are important because of their intentional design to address nutrition determinants. Noncore projects that integrate nutrition interventions do not have explicit nutrition objectives, are often not designed to improve nutrition determinants, and do not have a heavy nutrition focus. Health, Nutrition, and Population projects, for example, focus on health and family planning interventions, Water projects on WASH interventions, and Agriculture projects on agriculture and food approaches, and these interventions may integrate support to nutrition. Core projects, in contrast, are intentionally designed to support nutrition interventions that target immediate and underlying nutrition determinants.

The World Bank is also increasingly successful in achieving results related to underlying nutrition determinants and institutional strengthening, although the achievement of immediate nutrition determinants is more challenging given that they are higher on the results chain. The performance of World Bank projects in achieving underlying determinants improved over the evaluation period, with the most successful area being agriculture and food, although evidence also shows that the targeting of projects to address underlying nutrition determinants could be improved. In addition, 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. Project achievements in immediate determinants of nutrition resulting from nutrition-specific interventions have declined in recent years and require greater emphasis and more consistent longer-term support.

Although the overall measurement of results has improved, persistent measurement gaps highlight areas to strengthen the portfolio results. Measurement of expected results, especially those related to immediate nutrition determinants and to behavior change and social norms, must increase to foster learning and improve the results monitoring when these interventions are implemented in projects.

The evaluation highlights encouraging bright spots, including an increasing nutrition portfolio in countries burdened by undernutrition and improved nutrition outcomes in some countries. 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), with the number of projects tripling in recent years. This financing has supported interventions with broad positive evidence of effectiveness that can influence multiple nutrition outcomes and determinants. Some countries, Madagascar and Senegal among them, now have more than a decade of experience using a combination of financing and knowledge work to improve nutrition outcomes through multidimensional nutrition programs, from which other countries can learn. At the same time, the nutrition portfolio is young, with many countries recently developing their support, and there are opportunities to further improve the evidence base of interventions, knowledge work, the addressing of nutrition in the country programs, and results achievement and measurement.

Lessons

Five lessons follow from the findings:

1. More intentional planning of nutrition support (financing and advisory services and analytics) is needed in the country portfolio to improve nutrition determinants, social norms, behavior change, and institutional strengthening. The multidimensionality of the country portfolio matters for results.
   • Interventions can be supported by multidimensional projects that implement a range of interventions to address nutrition determinants or by trust funds and partnership, and better GP coordination. Interventions can also be integrated in noncore projects in GPs if they are accompanied by learning to design and target nutrition interventions and internal efforts to coordinate implementation. Trust funds and partnerships have been especially catalytic to designing new support in countries, which can be expanded with government ownership to develop comprehensive nutrition services.
   • Institutional strengthening can be done through support to stakeholder engagement, the development of nutrition services, and the coordination of plans, financing, and policies. At the national level, institutional strengthening can help develop multisectoral nutrition approaches and arrangements to coordinate, finance, plan, and communicate nutrition. At the local level, institutional strengthening has been important to engage stakeholders for the planning, monitoring, and delivery of nutrition programs. Links among these levels are also important for accountability and capacity building.
   • Addressing social norms is important to improve nutritional outcomes in countries. Only 6 percent of World Bank nutrition interventions address social norms. In particular, supporting the empowerment of key change agents can influence other behaviors and facilitate changes toward nutrition determinants.
2. The targeting and continuity of support in countries matter to successfully influence nutrition determinants. The evaluation finds that the targeting, continuity, and sustainability of nutrition interventions are important for achieving expected results from multisectoral nutrition approaches.
   • The quality and extent of subnational targeting of multisectoral interventions matter for the ability to address (disaggregated) needs within countries. Interventions must come together in the same community to synergistically address identified needs. Multidimensional projects are one option to coordinate interventions to meet needs in the same community, but they have not performed better or worse overall. An alternative is improved coordination across GPs and with other development partners in the implementation of multisectoral interventions.
   • Continuity of support, particularly at the community level, is important for successfully influencing nutrition determinants for results. Community interventions involve building the capacity of a wide range of actors and promoting behavior change, which need to be sustained. Strong community-based implementation is shown to be a success factor for improving project performance.
3. Improving the measurement of results for interventions addressing nutrition determinants and behavior change will support improvements in nutrition outcomes in countries.
   • Although the World Bank has improved its results measurement in the past 10 years, some areas still are not well measured. Projects measure only about 60 percent of the achievements of supported interventions toward nutrition determinants. The evaluation consistently identifies monitoring and evaluation of nutrition indicators as a pathway to improve project performance.
   • The World Bank’s nutrition-sensitive interventions increasingly have achieved results in underlying determinants of nutrition in countries. Yet, nutrition-specific interventions, mainly implemented by Health, Nutrition, and Population, have not seen the same improvements in immediate determinants of nutrition, and these results are more challenging to achieve and require consistent support in countries. Areas where projects had limited success include diet diversity, child feeding, and micronutrient outcomes in women and children.
   • Most projects do not track behavior change results along the results chain (engage-learn-apply-sustain). The World Bank’s contributions to behavior change focus mostly on lower-level indicators related to the engagement of actors. There is a need for learning in countries to better track behavior change, including on routine and periodic data sources to support results. Appendix C offers an example of a qualitative tool assessment used to track behavior change.
4. Refocusing the portfolio to have greater emphasis on a mix of nutrition-specific interventions balanced with nutrition-sensitive interventions across GPs can improve nutrition programs in countries. Although nutrition-sensitive interventions have increased in the portfolio, a similar proportional increase in nutrition-specific investments supported by health and other sectors is seen in only some countries (such as Rwanda), despite the critical importance of supporting these interventions in countries. The evaluation’s systematic review map shows that effective interventions can be delivered by health, social protection, agriculture, and WASH sectors. Investing in improvements to nutrition-specific interventions and nutrition-sensitive support in countries is needed.
5. Learning—the systematic generation and use of knowledge work—is important to help countries design and expand effective nutrition policy and programming. Some case study countries have used a combination of knowledge work to help develop nutrition interventions and policies. Key examples are Ethiopia, Indonesia, Madagascar, Rwanda, and Senegal.

• Country-level learning requires a stream of analytical work (evaluations, diagnostics, and so on) to improve interventions and expand their targeted delivery in national programs. For example, Madagascar had over a decade of advisory services and analytics to develop its community-based program, which is being expanded.
• Because nutrition is often not the objective of GP projects (such as those in Agriculture and Water), interventions do not target improving nutrition determinants and in some cases might even negatively affect child undernutrition (as in the example of cash cropping). Attention to this issue and learning has already started at the global level, for example, through research on nutrition-sensitive agriculture.
• Combining analytical work (such as evaluations and diagnostics) with knowledge sharing (within and across countries) and leadership-building activities in countries helps generate political commitment and the use of evidence to inform policies and programs and leverage resources.

Recommendations

The preceding lessons support two recommendations for the World Bank:

1. Adjust nutrition programming in country portfolios to (i) give more priority to institutional strengthening of stakeholder engagement, coordination, and services for nutrition and (ii) increase focus on subnational targeting of interventions to reflect areas of greatest disadvantage and persistency of need.
2. Strengthen nutrition support in GPs to (i) rebalance investments to have greater emphasis on nutrition-specific interventions and (ii) increase focus on social norms interventions and behavior changes, with more attention to tracking expected achievements to improve nutrition determinants.