The Adams family has done the sums; they have checked and rechecked their assumptions. Over the short-, medium- and long-term they and their business are going to benefit from investing in an insurance policy. It is not exciting, it does not make the news headlines, but they know it is essential, a very good thing. They can afford to buy it now; they can even pay cash for it. They have more than enough information, they are aware of what could happen if they do not do it. Yet they get distracted, their attention wavers, they move on to something else, and spend the money on their rifle collection instead.
Sometimes I think the global community is like the Adams family when it comes to tackling issues of hunger and malnutrition.
Nutrition programs, many of which are evidently sound economic investments, and unquestionably are “good things,” are chronically underfunded. Behrman et al. (1) make this all-too-familiar observation at the conclusion of their paper on nutrition investment opportunities for the Copenhagen Consensus (2). (The Copenhagen Consensus aimed to set priorities among the many available mechanisms to address major global challenges. A panel of 8 eminent economists, including 3 Nobel Laureates, was asked to review commissioned papers on 10 identified global challenges and answer the question, “What would be the best ways of advancing global welfare, and particularly the welfare of developing countries, supposing that an additional $50 billion of resources were at governments' disposal?”) In fact, in their characteristically modest way they concede that their paper does not break new ground; it uses recent evidence to confirm what others have concluded before them, namely that the economic argument for investing in nutrition is solid. Why then does nutrition action remain underresourced?
Why does the gap between evidence and action persist? Do nutritionists simply need to work harder, communicate smarter, advocate more ardently? Or is it institutional arrangements and leadership that need refreshing? Or could it be that the guiding frameworks and approaches of the field are out of touch with the complexities of the nutrition problems of the 21st century?
The focus of this article is on the economic evidence for investing in nutrition. It first presents the economic argument and demonstrates that the question, how much? is being answered thoroughly and convincingly. It then argues that this evidence is not matched by action, and that equal rigor must now be applied to the question. There are encouraging signs that this is beginning to happen. An adequate response to the nutrition challenges of the 21st century requires nothing less.
INVESTING IN NUTRITION MAKES ECONOMIC SENSE
The nutrition community owes a debt of gratitude to Behrmann and coauthors for representing nutrition so effectively in the Copenhagen Consensus. Based on detailed analyses and using conservative estimates and discount rates, they lay out a carefully argued and convincing case that reducing the prevalence of low birth weight (LBW), addressing infant and child malnutrition and breast-feeding promotion, reducing micronutrient malnutrition, and investing in technology for agriculture in developing countries are sound development investment opportunities. The top economists who made up the Copenhagen Consensus panel concurred, and ranked the nutrition investments second, fifth, 11th and 12th among their recommendations for the best applications of a hypothetical $50 billion in additional development assistance (Table 1).
A person who is not an economist can hardly do justice to the intricacies of the economic theory underlying this work, and the detailed analysis used to arrive at the Copenhagen Consensus conclusions is beyond the scope of this article. Nevertheless, it is incumbent on nutritionists to speak the economists' language if they want a seat at the table when resource allocation decisions are made. This article, therefore, attempts a brief overview of the economics of child nutrition from a practitioner's perspective before turning to the pressing issue of turning evidence into action.
The following section explores 4 key economic questions related to child malnutrition. First, it explores the relationship between nutritional status and economic productivity. Then it asks what it costs to improve nutritional status, and whether the benefits from improving nutritional status outweigh the costs. Given the private benefits to investing in nutrition, it then asks whether public investment to improve nutritional status is justified on economic grounds. Finally, it weighs the aggregate cost to society of removing malnutrition as a public health problem.
WHAT IS THE RELATIONSHIP BETWEEN NUTRITIONAL STATUS AND ECONOMIC PRODUCTIVITY?
It is well known that the relationship between nutritional status and individual productivity is bidirectional, that the pathways are complex, and that different nutritional conditions have different effects. Figure 1 provides a framework for understanding these relationships (Behrmann et al. (2004) make the point that we can make more accurate estimates by tracing causal relationships rather than associations. This involves controlling for endogeneity, in other words, they attempt to isolate the impact of nutritional status per se on the outcome variable in question, rather than merely capturing associations between variables. [Nutritional status may be an indicator for some other condition, for example, unknown intrahousehold dynamics, rather than being the factor which itself has a direct impact on the outcome variable, such as cognitive development]).
Other articles in this supplement lay out the extent and causes of malnutrition, detail the impact of malnutrition on physical and cognitive development, and propose effective intervention strategies. The present article briefly reviews the pathways through which nutritional status influences economic productivity, and presents consolidated information on economic losses caused by malnutrition. The key pathways are increased morbidity and mortality, health care costs, and productivity losses resulting from learning and schooling deficits and reduced stature. Based on the available literature, this article provides evidence that the benefits of addressing malnutrition conditions outweigh the costs of nutrition programs and considers the implications of these findings.
The focus is on fetal and young child malnutrition, given that the earliest years of a child's life represent the period in which nutritional requirements per kilogram of body weight are highest, when the child is most susceptible to infection, and when insufficient food, care and health have the most debilitating effects on growth and cognitive development. Furthermore, growth faltering at that time is at best only partially overcome later in life (3).
Malnutrition, Morbidity and Mortality and Health Care Costs
The synergy between malnutrition and infectious diseases is well established (4). In a widely quoted study, Pelletier and coworkers (5) estimated that 56% of child deaths can be attributed to the potentiating effect of malnutrition (including LBW), with most of those deaths linked to mild or moderate malnutrition, rather than severe malnutrition. Although severely malnourished children are more likely to die, they are far fewer in number. Children with mild, moderate or severe malnutrition would be, respectively, 2.5, 4.6 and 8.4 times more likely to die than children whose weights are within the normal range for their ages. Not only can a significant proportion of child deaths from common infectious diseases be attributed to malnutrition (measles, 44.8%; malaria, 7.3%; diarrhea, 60.7%; and pneumonia, 52.3%) but malnutrition also increases the likelihood of having an attack of malaria, diarrhea or pneumonia (but not measles) (6). There is also increasing evidence that fetal malnutrition predisposes to the metabolic syndrome later in life (7).
Behrman and coworkers (1) review a number of studies, which identify low birth weight as a significant contributory factor in neonatal and infant deaths. In an analysis of 12 national data sets, including those from Guatemala and India, it was found that a full-term infant weighing 2000 to 2499 g was 4 times more likely to die in the neonatal period than an infant weighing 2500 to 2999 g and 10 times more likely than an infant weighing 3000 to 3499 g. In the postneonatal period, these ratios were 2 and 4, respectively. With LBW, genetic rather than nutritional factors may play a greater role in mortality. A study in the United States found that genetics played an important role in neonatal death rates, but was less significant after 28 d. The study observed a 14% decrease in mortality, with a 450-g increase in body weight at birth.
With regard to micronutrient malnutrition, eliminating vitamin A deficiency can reduce mortality from all causes in children 0 to 4 y old, by ≈13% (8). Experimental field research found that twice-yearly supplementation with vitamin A reduced overall child mortality by 25% to 35% (9).
The value placed on saving a life has a significant impact on the calculated benefit to the society of averting LBW, reducing stunting or improving micronutrient status. Estimating the monetary value of a human life lost is controversial, however, and researchers have used a number of different approaches, none of which are without problems. One option is to use actual resource costs applied by a society to avert a death through an alternative technology (eg, measles immunization) rather than using an assumed “absolute” value a society may wish to ascribe to a life (1). Using this measure, Behrman et al. arrive at an average estimate of $1250 for saving an infant's life in a developing country. The problem with this approach is that it would place a lower value on the life of a child in a country with a poorly developed health infrastructure than in a country with a sophisticated health care system. An alternative approach, proposed by the Copenhagen Consensus (2), is to assign an arbitrary value of $100,000 to a life. Such a valuation increases the benefits of averting a death from LBW by a factor of 80, but has the unrealistic implication that saving a child's life in a low-income country with an average adult wage of for example $500/y would be equivalent to 2000 adult-years of earnings, whereas in countries with higher wage rates of for example $5000/y, it would represent only 20 adult-years of earnings.
Malnutrition can directly contribute to increased health care costs through a number of mechanisms. A review of studies on the cost of LBW (1) conclude that LBW (not all caused by malnutrition) results in longer hospital stays where births occur in hospital settings and higher risk for future hospitalization and outpatient facility use at a cost in the US of ≈$263/case in 1995. Cross-country comparisons are made difficult by the differences among countries' medical systems, markets and policies. Health care costs will be substantially lower in countries in the south, but this comes at the expense of higher mortality and reduced productivity in adulthood.
Malnutrition, Schooling, Learning and Productivity
Malnourished children tend to start school later, progress less rapidly, have lower attainments, and perform less well on cognitive achievement tests, even into adulthood. These indirect effects of malnutrition on productivity are substantially more than the direct effects of height on schooling and hiring.
Malnourished children may receive less education than their well-nourished peers for a number of reasons. Caregivers may invest less in their education or schools may use physical size as a rough indicator of school readiness, and thus bar children of short stature from entering school at the appropriate age. Malnourished children are also sick more often and so absent more often, and learn less well when they are in school. Studies show that delayed entry to school leads to lower expected lifetime earnings because of fewer years in the workforce (1).
In addition to its impact on adult productivity through less schooling, severe malnutrition also affects learning capacity or cognitive development directly, with consequent impact on schooling productivity and labor productivity. Birth weight and breast-feeding both correlate with cognitive development; malnourished children perform poorly on cognitive tests, have poorer psychomotor development and fine motor skills, have lower activity levels, interact less frequently with their environments and fail to acquire skills at normal rates (10).
Malnutrition, Stature and Earnings
As indicated earlier, growth deficits in the first 2 to 3 y of life are only partially regained during childhood and adolescence, particularly when children remain in poor environments. Stature at age 3 is strongly correlated with attained body size in adulthood in several countries (11,12). In Zimbabwe, Alderman and coworkers (13) found that children exposed to drought at ages 12 to 24 mo were malnourished in later childhood, whereas children who were older during the drought were not, suggesting that early childhood malnutrition (during the 12- to 24-month window) is not easily reversed. Several studies (14–17) found associations between smaller stature in adulthood and reduced earnings. In a study in urban Brazil, for example, a 1% increase in height corresponded to a 2% to 2.4% increase in wages and earnings for women and men in the market sector (18).
Table 2 summarizes findings from several studies on productivity losses resulting from deficits in cognitive ability, schooling and stature in Asian countries (19).
Malnutrition and National Economic Productivity
Several studies have attempted to express the impact of nutritional factors on individual productivity in terms of national economic productivity. These estimates are useful to graphically demonstrate the impact of malnutrition and have been used effectively in advocacy campaigns. They are based on a series of assumptions about the linkages between individual productivity and national productivity, and often do not take account of other intervening variables, such as infrastructure development, including health and schooling, and are therefore more difficult to substantiate. Because of these limitations, authors are generally conservative in their estimates. Table 3 provides a summary of findings from a number of studies in India, Pakistan, Bangladesh and Vietnam (19).
WHAT DOES IT COST TO IMPROVE NUTRITION? DO THE BENEFITS OUTWEIGH THE COSTS?
Doing cost calculations as part of an impact evaluation of direct and indirect approaches to improving nutritional status is a difficult and costly undertaking. Unfortunately, gathering cost information is not considered theoretically interesting by most academics (J. Hoddinott, personal observation), and has tended to be neglected. More attention is now being given to program evaluations, and programs are being encouraged to collect more detailed costing information. To specify the economic gains from better nutrition more accurately, accurate information on the costs and effectiveness of programs is needed.
Evidence compiled from available studies (1) indicates that the benefits of effective interventions to address key nutrition conditions exceed the programmatic costs by a considerable margin, even when a high discount rate is used to put less weight on the long-term benefits of the investment, and when the upper limits of cost calculations are used. Table 4 provides a summary of the calculated monetary value of benefits to be derived from specific measures to address malnutrition conditions, and the programmatic costs, based on the best-available information.
IS PUBLIC INVESTMENT TO IMPROVE NUTRITIONAL STATUS JUSTIFIED?
The benefits of investing in nutrition outweigh the costs but are not sufficient for motivating the use of public money for such activities. At first glance, one would argue that nutrition is a private good; after all, most of the benefit accrues to the individual in better quality of life, better education, better job prospects, and ultimately better lifetime earnings. However, there is often insufficient private incentive for families to invest in nutrition. This may be due to a lack of information on the benefits of good nutrition. If capital and insurance markets do not work optimally, families may also not see benefits in investing in young children's nutrition. They may recognize that preventive action would not protect children from illnesses in the absence of proper affordable health care and sanitation. Furthermore, if unemployment is high and future employment prospects low, parents may not see the value of investing in their children's growth.
The social benefits of investing in nutrition may be considerable. Improved nutrition may decrease the likelihood that communicable diseases will spread in a community. A novel perspective proposed by Harold Alderman (personal observation) is that in communities where malnutrition rates are high, short and thin children may be the norm, and parents may not recognize the need to attend to their children's nutritional status. Under such circumstances, if some children in the community grow well, then the norm may indeed be challenged and begin to shift toward taller and sturdier children, with parents finding reasons to invest in their children's nutrition, in line with the new norm. It can also be argued that in cases in which governments are already investing substantially in education and health services, investment in nutrition can help to improve the efficiency of those investments and is therefore justifiable on efficiency grounds.
If a policy objective is to achieve greater equality through the use of public funds, then a finance minister will be interested to know whether investing in nutrition would benefit the poor at least as much as or more than the wealthy. Given that malnutrition rates are higher among the poor than the rich, it may be argued that the benefits of malnutrition reduction initiatives are likely to be concentrated among the poor. Of course, although nutrition programs can have this impact, the design and implementation of the programs themselves will determine whether they are in fact pro-poor.
CAN SOCIETY AFFORD IT?
Having made the case that it makes economic sense to invest in improving children's nutrition and that cost-effective intervention approaches exist, the question remains whether countries and society at large can afford the outlay needed to address malnutrition. What will it cost?
A number of recent initiatives have included total cost estimates for selected interventions and countries. Given the uncertainties that surround these numbers, they are best used as indicative figures. What they suggest is that for most interventions, the costs are affordable to the global community. How they will be financed and specifically, how to deal with recurrent costs and building sufficient implementation capacity to absorb the additional development financing are hotly debated topics in the broader development community.
A study for the Millennium Project Task Force on Hunger (20) provides estimates for a 10-year global investment program. The study concluded that an annual investment of between $2.8 and $5.3 billion would provide broad coverage with vitamin A and iron supplements, fortification of commonly consumed foods, and community-based action in countries with the highest levels of childhood malnutrition (Table 5) (20).
Using different assumptions and cost estimates, the analysis for the Copenhagen Consensus (1,2) estimated that it will cost about US$ 2.8 billion annually to reach 25% of eligible mothers and children with interventions to improve LBW, improve infant and child nutrition and provide micronutrient supplementation and fortification to vulnerable groups. The authors estimate that it would become progressively more expensive and administratively more challenging to reach vulnerable groups, as malnutrition rates improve.
Can the world afford this? Affordability at a global level is not the primary reason for slow action to improve childhood malnutrition. The estimates given above, however imprecise they may be, are modest when compared to other expenditures. The upper estimate ($5.3 billion), which includes private spending, represents a small fraction (≈4%) of total estimated development assistance, which as is widely recognized, falls far short of the target of 0.7% of gross domestic product in developed countries. When these estimated costs are compared with annual expenditures on other “priorities,” as was done in the United Nations Development Program Human Development Report of 1998 (21) (Table 6), it is evident that money is not the limiting resource in achieving global nutrition goals.
HOW IS THE ECONOMIC EVIDENCE FOR NUTRITION INVESTMENT BEING USED?
How many more studies and reviews documenting nutrition as a sound investment are needed before investment in nutrition will increase substantially? There are a number of cases in which economic data were effectively used to increase investment in nutrition. For example, beginning in 1975, Berg skillfully used economic data to show that nutrition programs could be seen as investment rather than simply consumption and thus stimulated World Bank investment in nutrition (22). The use of the Modeling Program Profiles to estimate the economic cost of malnutrition, in Bangladesh for example (23), has also been credited with helping to convince policy makers of the need to invest in nutrition. However, as mentioned earlier, Behrman and coworkers (1) point out that in spite of the evident favorable cost–benefit ratios for nutrition programs, investment in nutrition remains stagnant.
Is more of the same needed? Should nutritionists try to convince ministers of finance and heads of development agencies of the economic merits of dealing with malnutrition and of investing in proven, cost-effective interventions? Yes, indeed, they should. Nutritionists need to be economically literate, able to speak with economists and finance ministers and understand enough of their language to speak with confidence in their forums. They need to make the arguments with country-specific data, offer solutions based on sound evidence, emphasize the short- and medium-term benefits, and not overstate the case. In particular, it is important to stress the need for complementary developments, including programs to improve women's status, address infectious diseases and improve water and sanitation as well as employment and income growth; otherwise families will not be able to take advantage of the benefits that accrue from improved nutrition. Furthermore, the figures seldom speak for themselves; skillful advocacy and careful timing helped to lead from evidence to action in the cases cited above.
Will more of the same be enough to address the evidence-action gap mentioned earlier? Unfortunately, there are several factors that make the task of increasing action on nutrition difficult and contribute to the intractability of the global nutrition problem. For example, the interests of policy makers and their constituencies may be remote from the interests of poor women and children. Even in families, children and women may have too little voice to be taken into consideration when families make decisions about allocation of resources. Nutrition must compete for attention with sectors that are better organized and institutionalized. It shares with other preventive approaches the characteristic that the problem, and its benefits when removed, is generally not immediately visible. “Slow, silent catastrophes” simply do not generate and maintain public interest the way crises do (24). The list goes on, and the literature is replete with conjecture about the causes of the gap between evidence and action and the need to close it. It is time to stop mentioning the evidence-action gap as the footnote to learned papers and talks and start doing something about it, and in the process, developing a deeper understanding of the problem. As Kurt Levin has said, “You cannot understand a system unless you change it” (25).
In 1992, Alan Berg noted the gap between evidence and action. He proposed that more attention needed to be given to implementation capacity, and he called for the development of a cadre of “nutrition engineers” who would help to resolve the implementation issues that hampered the successful realization of lofty nutrition policy goals (26). In a similar vein, Heaver (27) proposed systematic attention to building organizational capacity to address the evidence-action gap in nutrition. It is imperative that capacity development and organizational arrangements for nutrition be addressed in a more systematic manner. Organizational arrangements through which nutrition policy decisions are made and implemented at global, regional and national levels are changing. For example, civil society and nongovernmental organizations have become key actors, as has the private sector. The new reality is that the complex social challenges of the 21st century require that the 3 sectors of society (public, private and civil) find ways to work together toward solutions that would benefit all. Uncomfortable as it may be, given their different perspectives and ways of working, partnerships are the way forward for solving complex global problems (28).
In addition, there is a need to develop the nutrition policy process as a field of study. The same rigor should be applied to studying the policy process as is evident in epidemiological and economic studies of nutrition. A review of the current state of policy studies in nutrition shows limited activity and little coherence in this field. Most studies are of the case study variety and lack an explicit theoretical framework. In cases in which a theoretical framework is made explicit, the rationale for selecting 1 approach over another is seldom made clear (29). This rather haphazard approach means that studies are not building on one another, they are difficult to compare across studies, and progress in developing the field has been slow.
In contrast to other practice-oriented fields, such as rural development or social work, nutrition does not have a long history of theorizing about its policy and practice. Consequently, there is little vested interest in particular approaches and theories. There is therefore a great opportunity to find innovative solutions to the how question of the Introduction. By drawing on the most up-to-date literature and experience in other fields, as well as on practical experience of nutrition policy processes, robust and rigorous analytical approaches can be developed to understand how nutrition policy change processes work.
A number of recent initiatives suggest that nutrition is in fact on the cusp of a great leap forward on this front. For example, some are paying attention to the underlying assumptions informing nutrition science and suggesting that new paradigms are emerging. The New Nutrition Science Project, a joint undertaking of the International Union of Nutrition Sciences and the World Health Policy Forum, has set itself the task of “redefining nutrition science” (30,31). This initiative should provoke lively discussion and help to shape the conceptualization of nutrition theory and practice. Others are addressing the policy process directly. Thus, nutrition policy researchers (29,32) have proposed that the policy sciences approach (33,34) be adopted as a meta-framework for policy research programs. The policy sciences approach is comprehensive, covering such dimensions as social processes, decision processes, and problem orientation. It makes explicit the role of the policy analyst and promotes the use of multiple methods, acknowledging that there are multiple ways of knowing, and that moral goals are inherent in the policy process. Closer to the field, still others are applying new thinking on complex social problem solving to nutrition. For example, in India, UNICEF, in collaboration with Synergos and Hindustan Lever, are working with local stakeholders in the state of Maharashtra to test a social technology for solving complex social problems (35). The technology, known as the U-Process draws on phenomenology, dialogue and collaborative action research to develop a shared understanding of systems and the capacity to design innovative solutions together and implement them (36). Innovations like these in the areas of the field's basic assumptions, its policy processes and social change technologies are a rich resource for learning to answer not only the what, the why and the how much of nutrition, but also the all-important action question, how, to achieve the desired nutrition goals.
Economic evidence reviewed for this article indicates that it makes sound economic sense to invest in improving the nutritional status of young children. The question of how much is being answered thoroughly and the evidence is convincing. Not only are the returns on investment in terms of improved health, education, and productivity substantial but addressing malnutrition is also clearly cost effective and affordable. Because this evidence is not being matched by action, it is now necessary to focus on the how question, to ensure faster progress toward a malnutrition-free world. There are encouraging signs that this is beginning to happen in innovative programs and global initiatives. The nutrition challenges of the 21st century require nothing less.
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