Opportunities

to Protect
and Enhance
Nutrition in
the East Asia
and Pacific
Region
 June 20, 2009

Judith S. McGuire
with assistance from Amber Willink and
Eko Pambudi
Opportunities to Protect and Enhance Nutrition
in the East Asia and Pacific Region

June 20, 2009

Judith S. McGuire
With assistance from Amber Willink and Eko Pambudi
EXECUTIVE SUMMARY

The East Asia and Pacific region shows dramatic contrasts in nutrition. Many of the Pacific
Islands have some of the highest obesity rates in the world (close to 80% among women in
Tonga) while Cambodia, Laos and Timor Leste have some of the highest rates of
underweight and stunting (close to or above 50%). Micronutrient deficiencies, especially
anemia, persist even among the successful East Asian countries like China and Thailand.
Women have high rates of anemia, excessive thinness, and short stature that are risk factors
for maternal mortality, low birth-weight, and poor health. Many of the countries in the
region are net food exporters and, on paper at least, have sufficient calories to feed their
populations and yet the poor, isolated populations and ethnic minorities are food insecure.
Major causes of child malnutrition include poverty and food insecurity, poor water and
sanitation, women’s status, and young child feeding practices.

The food and fuel price spikes of 2007-8 and the current financial crisis threaten food security
and nutrition in East Asia and Pacific region. Most of these economies, which grew at high
rates before the crisis, were particularly vulnerable because they were highly integrated into
world markets, many people lived close to the poverty line, their consumption basket and
diet were heavily dependent on one commodity (rice) which has a uniquely shallow market
structure, and because large numbers of people were already malnourished before the
crisis started. Food price inflation has been accompanied by rising unemployment in
certain sectors, particularly in urban areas, which has thrown some populations into a food
security crisis.

Most of the high burden countries have in place already national social and economic policies
that include nutrition as a key outcome. They also have national nutrition policies and
nutrition programs. The common problem appears to be reaching the community level,
management and quality control, consolidating services, and building and sustaining an
institutional framework that is multi-sectoral, operational, self-directed, and focused on
results at the community level. There are several policy, program, and institutional success
stories in the region serve as a knowledge base for other countries.

This paper concentrates on the countries of the region with the highest burden of under-
nutrition, examines their policy and programmatic context, and recommends Bank
engagement in nutrition through its strong portfolio on community-driven development
and conditional cash transfer programs. It proposes a three-pronged strategy with
opportunities for follow up engagements in several countries (Cambodia, Indonesia, Lao
PDR, Philippines, Vietnam and Timor Leste); sector work in those countries that lack
adequate data (Papua New Guinea and the Solomon Islands); and a regional research
program on preventing and mitigating obesity and diet-related chronic diseases. It also
recommends setting up a regional knowledge network which facilitates sharing knowledge,
procuring in bulk regional technical assistance, and creates a community of practice in
which participating countries, individuals, and institutions support each other.
Introduction

Improving nutrition is a key input to as well as outcome from development. In addition to being one
of a human being’s most basic needs (and, many feel, an inalienable right), good nutrition is
instrumental in building human capital: it affects survival, the immune system, cognitive
development and learning capacity, physical strength, capacity, and endurance, and successful
reproduction1. Malnourished and low birth-weight children have much higher risk of dying than
normally nourished children and the survivors have reduced life chances. Low weight-for-age
explains about one-third of total under-five mortality and over half of the post-neonatal portion of it.
Severely and acutely malnourished children – the tabloid image of “malnutrition” -- are extremely
frail and have very high mortality. But most of the nutrition-related mortality occurs in the mildly
and moderately malnourished children. Stunted, underweight and unhealthy women who get
pregnant are at greater risk of passing malnutrition on to the next generation especially if those
women continue their physically demanding work schedule and don’t eat a good diet or get needed
medical attention. Such women are also at greater risk of dying during childbirth. Data on women’s
nutritional status (aside from anemia) are sorely lacking but the high rates of maternal mortality, low
birth-weight, and anemia suggest that women’s malnutrition (both concurrent and vestiges of
childhood malnutrition, like stunting) adversely affects a large number of women in the region. Child
malnutrition adds up to 11% of the total global burden of disease. Stunting, severe wasting and low
birth-weight account for 21% of deaths in children under 5 and burden of disease in children under 5
and an additional 11% of the disease burden is due to micronutrient deficiencies 2. That does not
count the substantial effect of anemia and under-nutrition on learning.

The East Asia and Pacific region shows dramatic contrasts in nutrition. Many of the Pacific
Islands have some of the highest obesity rates in the world (close to 80% among women in Tonga)
while Cambodia, Laos and Timor Leste have some of the highest rates of underweight and stunting.
Micronutrient deficiencies, especially anemia, persist even among the successful East Asian
countries like China and Thailand. Most of the countries are net food exporters and, on paper at
least, have sufficient calories to feed their populations. The problem is that the poor and remote
families can’t buy the diet they need and many factors other than food availability affect nutrition.

The food and fuel price spikes of 2007-8 and the current financial crisis threaten food
security and nutrition in East Asia and Pacific region. Most of these economies, which grew at high
rates before the crisis, were particularly vulnerable because they are highly integrated into world
markets, many people live close to the poverty line, their consumption basket and diet are heavily
dependent on one commodity (rice) which has a uniquely shallow market structure, and because
large numbers of people were already malnourished or close to it before the crisis started. In
addition, the region suffered through multiple natural disasters (cyclones, flooding, earthquakes, and
epidemics) that further compromised food security.
1
World Bank. 2006. Repositioning Nutrition.
2
Black, R.E. et al. 2008. Maternal and Child Under-nutrition 1. Maternal and child under-nutrition: global and
regional exposures and health consequences. Lancet 317: 5-40. Lancet Nutrition Series

1
 While the developing countries of East Asia grew at 11.4% in 2007 they are projected to
grow at only 5.3% in 2009. China and Vietnam’s growth rates are projected to fall from 13.0 to 6.5%
and 8.5 to 5.5%, respectively. In Southeast Asia (Indonesia, Malaysia, Philippines and Thailand)
growth is predicted to fall from 6.2% to 0.7%, and the small economies from 6.7% to 1.6% 3. This
means that progress on reducing poverty will slow and poverty might increase in these countries. It
also means that nutrition at risk.

Food price inflation exacerbates economic distress for the poor, who spend a large
proportion of their income on food. As economic growth has stagnated, food prices have risen,
causing food insecurity.

Table 1. Food Consumer Price Inflation

2006 2007 Q1 2008
Cambodia 6.5 10 19.8 (1/2008)
China 2.3 12.3 21.0
Indonesia 14.7 11.4 12.4
Lao PDR 9.8 8.2 7.5
Malaysia 3.4 3.0 4.4
Mongolia 3.0 25.5 32.2
Philippines 5.5 3.3 7.0
Vietnam 8.7 11.2 26.0
Source: Brahmbhatt and Christiansen, 2008

Luckily, previous economic growth and sound fiscal policies enabled most of the affected
countries in the region to take decisive steps to protect the poor from the crisis. That is not enough,
however. Because nutrition is a fundamental input to human capital, these countries need to
protect and improve the nutrition of their populations during and after the crises. In particular, to
reduce their vulnerability to future economic shocks they need to address the long term “structural”
nutrition problem not just the transitory effects of the crisis. Now, while the governments and
donors are paying attention to the crisis, is the time to put in place or strengthen programs to
prevent malnutrition4.

This paper is funded by the Central Contingency Fund, which was set up to identify
opportunities for the World Bank to help countries improve nutrition in this time of crisis. The
purpose of this paper is to discuss the nutritional face of the East Asian economic crisis and present
opportunities to scale up action against malnutrition. General information and trends are presented

3
Appendix Table 4, Battling the Forces of Global Recession, 2009..
4
A word on terminology. Undernutrition is used here to describe the physical effects of not getting enough to
eat to cover needs. It includes growth failure in children (reflected in low weight-for-age, low height-for-age
(stunting) and low weight-for-height (wasting)) and it includes weight, height, and thinness of women. It also
includes micronutrient deficiencies as detected in physical, biochemical, and clinical signs. This is not the same
as “undernourishment” or “undernourished” as used by FAO to express food energy availability (corrected for
income distribution).

2
for the region as a whole and more detailed analysis is provided for the countries with the greatest
burden of undernutrition (Cambodia, Indonesia, Lao PDR, Philippines, and Vietnam).

3
I. The Nature of the Problem

Child malnutrition

The East Asia and Pacific region represents the global spectrum of nutritional well-being (see
Table 4). Underweight in children under five ranges from close to zero in Samoa up to 36% in
Cambodia, 40% in Lao PDR and 46% in Timor Leste (WHO, 2008). Similarly, stunting ranges from less
than 5% in Tonga, Singapore, Fiji and Samoa up to 45% in Cambodia, and 49% in Timor-Leste. Trend
data, where available, are highly variable and nutritional indicators do not always track national
income data. China has been able to reduce its malnutrition quickly as a result of rapid economic
growth but Vietnam, with rapid economic growth, has experienced slow improvement (from 59.7%
stunting in rural areas in 1985 to 34% in 2007 or about 1 percentage point a year, about the secular
rate worldwide. The Philippines, one of the wealthier countries in the region has the second highest
rate of low birth-weight (45.2%) (exceeded only by Cambodia at 64%). Anemia – a major cause of
cognitive deficit -- is widespread among women and preschool children. In Cambodia it affects close
to two-thirds of preschool children and 80% of children under two years of age. Even in Thailand,
anemia affects 25% of preschool children. Vitamin A deficiency ranges from less than 5% in Thailand
and Malaysia to 61% in the Marshall Islands, 45% in Lao PDR, and 40% in the Philippines. These
levels of vitamin A deficiency persist in spite of putative distribution of megadoses of vitamin A
ranging from 35% of children in Timor Leste to 100% of children in DPR Korea. Iodine deficiency
(measured in school children) ranges from 16% in China and Indonesia to 53% in Mongolia. Because
iodine deficiency is basically a geological issue (if there is no iodine in the local soils, foods grown on
those soils will not contain iodine), in the absence of mandatory iodization of salt, iodine deficiency
becomes widespread. Salt iodization ranges from 12% in Cambodia to 100% in Fiji. Malnutrition is
particularly severe in rural and remote areas and among ethnic minorities.

Table 2. Basic nutrition indicators for major low-middle income EAP countries

Underweight Severe acute

Stunting <5 <5 Wasting (<-3Z w-h)
Cambodia 48.2 32.9 8.9 0.5
China 21.8 6.8 3.0 0.8

Indonesia 28.6 24.4 14.4 0.9

Lao PDR 48.2 36.4 17.5 7.6

Malaysia 15.6 16.1 13.3 3.3

Mongolia 23.5 4.8 2.7 1.1

Myanmar 40.6 29.6 10.7 2.9

Papua N.G. 50.2 24.6 6.3 1.6

Philippines 33.8 20.7 6.0 1.6

4
 Korea DPR 44.7 17.8 8.7 3.5

Singapore 4.4 3.3 3.6 0.5

Solomon Islands 33.7 16.3 7.4 2.0

Thailand 15.7 7.0 4.7 1.4

Timor Leste 55.7 40.6 13.7 4.9

Vietnam 36.0 20.0 8.0 3.0
Source: WHO Global Database on Child Growth and Malnutrition (using WHO Child Growth Standards). Note
that anthropometry data are generally from the last five years except for PNG (1982-3) and Solomon Islands
(1989).

Where data are available, rural malnutrition is generally far worse than urban malnutrition
(See Figure 1).

This is undoubtedly due in part to the fact that poverty is considerably higher than rural
areas. Rural people also have far less efficient food and labor markets, less access to public services
(especially schools and health services), and often lack such amenities as improved water supply and
sanitation, modern floors in their homes, irrigation, and transportation. Ethnic minorities, who are
at higher risk of malnutrition, also tend to live in remote and rural areas in East Asia.

Fig. 1. Rural Urban Differences in Nutritional Status, selected EAP countries

60

Rural Stunting
50 Urban Stunting
Rural underweight
Urban Underweight
Percent m alnourished

40

30

20

10

0
Thailand (2005-6)
Cambodia (2005-6)

Indonesia (2004)
Philippines (1993)

Vietnam (2000/7)
Myanmar (2000)
Korea PDR (02)

Mongolia (2005)

Malaysia (1999)
Timor L. 2002

China (2002)
Lao (2000)

Source: DHS Cambodia, 2005

5
As can be seen from the following table, many countries have high levels of micronutrients
deficiencies although vitamin A capsule and iodized salt coverage are high (Source WHO, 2008).
Fig. 1 Cambodia, 2005 M alnutrition by Age

60

50
Underweight
Stunted

40 Was ted
Percent malnourished

30

20

10

0
0.49 0.99 1.99 2.99 3.99 4.99
Age (years)

Sources: WHO Global Database on Child Growth and Malnutrition and UNICEF ChildInfo.

6
 Underweight and stunting evolve rapidly between birth and the second birthday in countries
where malnutrition is a serious problem. This graph from Cambodia shows a typical pattern where
malnutrition balloons after six months of age:
Fig. 2. Cambodia, 2005 Malnutrition by Age

60

50

Underweight
Stunted
Wasted
40
Percent malnourished

30

20

10

0
0.49 0.99 1.99 2.99 3.99 4.99
Age (years)

Source: Cambodia DHS, 2005

As can be seen from the following table, many countries have high levels of micronutrient
deficiencies although vitamin A capsule and iodized salt coverage are high.

Table. 3 Micronutrient Indicators in Preschool Children

Anemia in Deficient Urinary
Children Vit. A Deficiency Vit. A capsules Iodine Iodized
under 5 (serum retinol) (full coverage) Schoolchildren salt
Cambodia 63 22.3 76 73
China 20 9.3 15.7 94
Indonesia 45 19.6 87 16.3 73
Korea DPR 32 27.5 69 20.4 58
Lao PDR 48 44.7 19.8 84
Malaysia 32 3.5 94
Mongolia 21 19.8 93 52.8 83
Myanmar 63 36.7 7 22.3 60
Papua N.G. 60 11.1 83 74.7 36
Philippines 36 40.1 95 23.8 45
Solomon Islands 52 13.1 12
Thailand 25 15.7 25
Timor Leste 32 45.8 50 57.4 92
Vietnam 34 12.0 95 60
Sources: WHO Global Database on Anemia; Global Database on Vitamin A Deficiency (VAD), UNICEF State of
the World’s Children 2009 (Table 2, vitamin A capsule coverage and iodized salt); WHO/SEAPRO, 2008 (Table
9.10) for iodine deficiency.

7
 Anemia is a particularly severe nutrition problem, both for women and for children. The
figures provided for children underestimate the problem. Children under the age of two have much
higher rates of anemia than children 2-5 years old. Data from Philippines show a typical pattern for
anemia by age:

Table 4. Evolution of Anemia over Age, Philippines 2003

Age Prevalence (%)

6-11 months 65.9
12-23 months 53.0
24-35 months 34.8
36-47 months 24.8
48-59 months 18.8
60-71 months 14.0
6-12 years 37.4
Source: 6th National Nutrition Surveys. Pedro, et al.

This is because they are growing fast and are born with low iron stores (due to maternal
anemia). Although breast-milk contains high quality iron, its contribution to the diet is small after
the first six months of life and infant’s dietary intake contains poor quality and quantity of iron.

Maternal Malnutrition

Maternal health and nutrition affects and is affected by reproduction and the physical labor
of farm work and off–farm employment as well as the high physical costs of hauling water and fuel-
wood, bearing and raising children, and household maintenance. Women’s health and nutrition, in
turn, affects the health and nutrition of their offspring. Low birth-weight reflects the cumulative
health and nutrition strains on women, reflecting as it does maternal stunting (a vestige of past
nutrition), thinness, and poor health in general. Anemia is quite high among pregnant women in the
region ranging from about 20% in Thailand to 66% in Cambodia. Maternal anemia reduces women’s
s ability to work and predisposes them to higher mortality risks during childbirth. Many women in
East Asia are so short (under 145 cm), thin (under 18.5 body mass index), and anemic that pregnancy
poses serious risks to their lives and those of their unborn children. Pregnant women also have
more night blindness (a symptom of vitamin A deficiency) and iodine deficiency disorders because of
the demands of pregnancy. To prevent maternal malnutrition and its consequences for their
offspring, interventions need to take place before and during pregnancy and include family planning,
delayed marriage and first conception, feeding girls well before and during their adolescent growth
spurt, and increased schooling (for better income options, to delay marriage, and to better manage
information within the household) as well as good care and feeding during pregnancy.

There are a number of indicators of maternal factors that affect nutrition. These include the
mother’s own nutrition and health status, high fertility and too closely spaced pregnancies, high
physical workload, domestic violence, and poor access to preventive care. Maternal disadvantage
expresses itself in high maternal mortality and low birth-weight as well as micronutrient status of
infants. If women are iodine or folate deficient at the time they become pregnant, they are at

8
greater risk of giving birth to mentally and physically handicapped infants. Anemic women are likely
to give birth to infants with lower iron stores, thus hastening the onset of anemia in infancy (which is
already quite high in all of these countries). Vitamin A deficient women have breast-milk that is
deficient in vitamin A as well so that WHO recommends that postpartum women be given
megadoses of vitamin A to protect the their health and that of their infants (megadoses of vitamin A
during pregnancy are known to be terato-genic).

Very few detailed data are available on women’s nutritional status in the region. Only
Cambodia has had comprehensive DHS surveys which explore women’s nutritional status. In
Cambodia in 2005, 7.7% of women were found to be so short (less than 145 cm.) and 20.3% were so
thin (BMI less than 19.5) that they are at elevated risk of obstructed labor and low birth-weight.
These indicators were worse in rural areas. Only 1.2% were obese (2.6% in urban areas). Women’s
nutrition showed the expected relationship with income (wealth). About half as many women in the
5th quintile (5.1%) were severely stunted (<145 cm) than in the lowest quintile (10.3%). Overweight
and obesity which ranged from 4% in the bottom quintile to 17.6% in the wealthiest quintile.
Overweight and obesity increased from 6% in 2000 to 10% in 2005. Anemia is high in all women
(46.6%) and shows a significant relationship to wealth (from 55.5% in the lowest quintile to 34.7% in
the highest quintile). Anemia improved between 2000 and 2005. Anemia also increases with high
parity (54.1% for women who have had six or more children compared to 44.5% for women who
have had no children). Pregnant women are more likely to be anemic (57.1%) than lactating women
(53.6%) and non-pregnant non-lactating women (44.3%). Rural women are more likely to be anemia
than urban women (48.4% vs. 37.7%), which is probably due to income but also to higher likelihood
of intestinal parasites in rural areas. Only 17.6% of women reported taking the recommended 90
iron-folate tablets during pregnancy and only 10.7% took deworming medication during pregnancy
to reduce blood loss to intestinal worms. Close to three-quarters of women reported using iodized
salt.

In addition to women’s health and nutrition, women’s education has been shown to have a
profound effect on child nutrition. To some extent this educational premium probably reflects
lifetime advantages but education also probably conveys concurrent advantages with respect to
income, self-confidence, and ability to manage complex information.

Table 5 shows the range of indicators for the main low and middle income EAP countries.

9
 Table 5. Maternal Factors that are Related to Malnutrition

Women who
feel domestic
Female
violence
Anemia in Contra- Low Adult Literacy (as
Total against
Pregnant ceptive MMR Birth female proportion
Fertility women
women prevalence weight obesity of male
justified under
literacy)
certain
circumstances
Cambodia 66.4 3.2 40.0 540 64.0 <10 79.0 55.2
China 28.9 1.7 85.0 45 2.4 <10 93.0
Indonesia 44.3 2.2 61.0 420 9.0 <10 93.0 24.8
Lao PDR 56.4 3.2 38.0 660 18.0 10 83.0 81.2
Malaysia 38.3 2.6 55.0 62 8.6 20 95.0
Mongolia 37.3 1.9 66.0 46 4.1 10 101.0 20.4
Myanmar 49.6 2.1 34.0 380 10.0 10 92.0
Papua N.G. 55.2 3.8 26.0 470 10.0 <10 86.0
Philippines 43.9 3.3 51.0 230 45.2 <10 101.0 24.1
Korea DPR 34.7 1.9 62.0 370 7.0 10 94.0
Singapore 51.1 1.3 62.0 14 13.0 15 50.9
Solomon
Islands 22.3 3.9 7.0 220 9.0 10 97.0
Thailand 22.9 1.8 77.0 110 10.0 20 85.4
Timor Leste 32.2 6.6 20.0 380 5.1 10 90.5
Vietnam 66.4 2.2 33.0 150 64.0 <10 femlit 63.8

Sources: WHO (National Estimates of Anemia), WHO-SEARO (2008) Obesity,

UNICEF State of the World’s Children 2009 and Child Info (the remainder)

10
In Cambodia, detailed data are available, one can see the impact of close child spacing on
nutrition.

Table 6. Relationship between child spacing and nutrition in Cambodia (2005)

Child Height- Weight- Weight-

Spacing for-age for- for-Age
Height
First 29.7 7.8 30.8
Birth
<24 46.5 7.1 44.5
months
24-47 40.7 6.2 38.5
months
48+ 33.9 8.8 32.0
months

Obesity

Much less is known about prevalence, causes of and solutions to obesity and diet-
related chronic diseases than is known about under-nutrition. Data are lacking in many
countries and trend data are sparse, except, perhaps, for China and the Philippines. The two
nutrition problems are not unrelated. Low birth-weight, for instance, is associated with higher
risk of diet-related chronic diseases in later life (the Barker hypothesis). Early under-nutrition
following by excess food intake also appears to be related to cardiovascular disease. Physical
activity is related to both problems as well with rural residents having very high levels of physical
energy expenditure relative to their energy intake while urban residents have very low physical
activity but high calorie intake. Even more problematic than the lack of data, however, is the lack
of successful national or large-scale programs from which to learn. The nutrition community is
divided over the importance of various dietary factors (calories, specific fats, specific
carbohydrates, protein, micro-nutrients), the relative importance of physical activity and diet,
the role of advertising, marketing, and modern food processing practices, and, most importantly,
how to effect sustainable long-term behavioral change. For the EAP region, piloting practical
programmatic approaches (rather than academic research) is urgently needed along with better
epidemiological data collection. Much more work needs to be done to identify the best policy
levers to use to prevent obesity and diet-related chronic disease from undermining health and
economic gains in these countries.

Reaching the Hunger MDG

The goal of the first MDG is to halve poverty and hunger between 1990 and 2015. It is
not surprising, given its impact on overall human development, infant, child and maternal
mortality, and education, that halving underweight is included as an indicator for the first
Millennium Development Goal. Improving nutrition is also intimately related to the rest of the
outcome MDGs (see Appendix 1).

11
 According to UNICEF’s calculations 5 Cambodia, China, Indonesia, Malaysia, Mongolia,
Singapore, Thailand, and Vietnam are all on track to meet the goal (or they were before the
economic crisis). Lao PDR, Myanmar and Philippines are making insufficient progress and Timor
Leste is making no progress. The remainders of the countries in the region have insufficient
data. The nutrition MDG, like the maternal mortality goal, is lagging behind the under 5 child
mortality goal, which has been or will be achieved in virtually all countries in the region (except
for Timor Leste, Myanmar, and Papua New Guinea).

What about severe acute malnutrition?

In the last few years there has been much publicity about “ready to use therapeutic
foods” (Plumpynut and plumpy paste are the two best known versions). Originally designed to
save the lives of acutely malnourished children without having to hospitalize them, the makers
of these foods are now promoting them as part of prevention. It is hard not to draw parallels
between Plumypnut and the infant formula industry, however. While the use of RUTF in
recuperation of severely acutely malnourished children has been shown to be effective such
interventions should only be used in emergency life-saving situations and as one tool in the
medical toolkit. To begin with RUTF are quite expensive (field personnel estimate $70 per case
of severe acute malnutrition). Second, it only addresses the immediate problem. Once the child
has recuperated, s/he returns to the environment that created the acute malnutrition in the first
place, whether that is a contaminated environment, parental neglect, improper management of
disease, or economic hardship. Decades ago it was found that recidivism from acute
malnutrition was high. The studies of RUTF so far have not studied recidivism.

Proponents of RUTF now want to move from therapeutic uses into what they call
“prevention”. This also includes a new disturbing trend in food aid to feed all children as a
“preventive” measure. By relying on exogenous, formulated foods, these programs are not just
creating demand for an unaffordable food; they are denigrating the traditional, readily available
and at the same time sending a clear message to parents that it is not in their power to
adequately feed their own children. In virtually every culture there is some combination of a
locally grown carbohydrate (corn, rice, wheat, potato, sweet potato), protein source (legumes,
milk, meat or fish) and vegetables (leafy greens, squash) that can be combined to make a
nutritionally adequate weaning food that honors cultural traditions, is within the means and
culinary powers of normal families, supports local food systems, and is resilient in the face of
inflation, world trade hiccups, and market disruptions. It is quite bizarre that the French, for
whom eating and culture is paramount, would be promoting a technological convenience food
for infants that sever the relationship between food and culture (Plumpynut is produced
exclusively by a French firm).

We now know that the technological “improvements” in the Western diet have had
profound negative influences on nutrition, including obesity and diet-related chronic diseases
like cardiovascular diseases, some cancers, hypertension, and diabetes 6 not to mention the
negative effects on small business, the environment and climate. Some would argue that
divorcing genetic evolution from culture and environment is a recipe for a new kind of
malnutrition (Nabhan). A series of studies have shown that Hawaiians reintroduced to

5
UNICEF ChildInfo http://www.childinfo.org/undernutrition_mdgprogress.php
6
Popkin, B. The World is Fat.

12
traditional foodstuffs and lifestyles (complemented with Western health services and a
traditional spiritual practice) were able to lose weight and lower risk factors for a variety of
chronic diseases. While certain donors and NGOs are heavily promoting these expensive
techno-foods as an alternative to affordable diets made in the home, the Bank should be
reluctant about getting on that bandwagon.

Focusing the effort.

As can be seen from the above data, underweight and stunting (collectively called
growth failure), low birth-weight, and anemia are the most prevalent unaddressed (or under-
addressed) nutrition problems in East Asia. Obesity and diet-related chronic diseases are
emerging problems particularly in China, Indonesia, the Philippines, Vietnam, and most of the
Pacific Islands. The “window of opportunity” 7 between conception and two years of age is the
most critical period in East Asia and the Pacific region for preventing growth failure and anemia.
Policies and programs which purport to address the problem need to reach these children and
their families and communities with effective preventive programs. For cost reasons, to prevent
damage to human potential, and to prevent suffering, prevention must take priority over
curative care. This priority has been proven time and again historically as well as in recent
reviews.

From the data presented above, it is clear that there are a small number of countries in
the EAP region which have markedly higher rates of under-nutrition and growth failure:
Cambodia, Indonesia, Lao PDR, Myanmar, Papua New Guinea, Philippines, Korea PDR, Solomon
Islands, Timor Leste and Vietnam. Two of those countries, Korea PDR and Myanmar, have very
limited engagement with the World Bank lending and will not be included in this document. Two
other countries – Papua New Guinea and the Solomon Islands – have data so old and unreliable
that much more work would need to be done on the ground to understand the problem
sufficiently to address it intelligently. Nonetheless, there is good reason to believe there is
severe under-nutrition in both countries. Timor Leste is without doubt one of the most severely
affected countries in the region and there is much that should be done there. The Pacific Islands
have some surprisingly severe micronutrient deficiencies, but their most obvious nutrition
problem is obesity, exacerbated by weakening of local agriculture, heavy dependence on
imported food shipped long distances, and undifferentiated local economies. While the food,
fuel, and financial crises might adversely affect the Pacific islands, the focus of the Central
Contingency Fund is on addressing under-nutrition. For the remainder of this paper, therefore,
the focus will be on the countries with severe nutrition problems where the World Bank can,
within a relatively short time frame, improve the targeting, content, quality and coverage of
national nutrition programs the address those nutrition problems that undermine national
development.

II. Why the region with the highest economic growth still has such high rates of
malnutrition
Malnutrition is an outcome of many different development processes. One might even
say it is the bottom line of development, since studies have shown it to be affected by water,
roads, education, agriculture, poverty, health, housing, physical activity, cooking smoke,
women’s status, culture, social dysfunction (alcohol and drug abuse, domestic violence), and

7
World Bank. 2006. Repositioning Nutrition as Central to Development.

13
psycho-social stimulation. The UNICEF Conceptual Framework (Fig. 1) has long been used to
convey this multi-causality. While the immediate causes of poor child growth and development
are food, feeding and caring behaviors and disease (especially diarrhea), many other factors play
important and sometimes even larger roles. Smith and Haddad found that women’s education
accounted for 43% of the reduction of malnutrition between 1970 and 1995, food availability
another 26%, safe water 19% and women’s status 12% 18. On a straight correlation basis, of all
the factors described here the highest correlation is between adult literacy and stunting
(R2=0.65).

F i g u r e 13: C a u s e s o f C h i l d M a l n u t r i t i o n

C h ild m a ln u t r it io n , O u tc o m e s
d e a th a n d d is a b ility

In a d e q u a te
D is e a s e Im m e d ia t e
d ie t a r y in t a k e causes

P o o r w a te r/ U n d e r ly in g
In a d e q u a te
In s u ffic ie n t a c c e s s s a n ita tio n a n d causes at
m a te r n a l a n d c h ild -
to fo o d in a d e q u a te h e a lth h o u s e h o ld /
c a r e p r a c tic e s
s e rv ic e s f a m ily le v e l

Q u a n tity a n d q u a lity o f a c tu a l
In a d e q u a te a n d /o r r e s o u rc e s - h u m a n , e c o n o m ic
in a p p r o p r ia te a n d o r g a n iz a t io n a l - a n d th e
k n o w le d g e a n d w a y th e y a r e c o n tr o lle d
d is c r im in a to r y B a s ic
a tt itu d e s lim it causes at
h o u s e h o ld a c c e s s t o s o c ie ta l
a c tu a l re s o u rc e s le v e l

P o te n tia l r e s o u r c e s : e n v ir o n m e n t, te c h n o lo g y , p e o p le

P o litic a l, c u ltu r a l, r e lig io u s ,

e c o n o m ic a n d s o c ia l s y s t e m s ,
in c lu d in g w o m e n ’s s t a tu s , lim it th e
u t iliz a t io n o f p o t e n t ia l r e s o u r c e s

S o u r c e : T h e S t a t e o f th e W o r ld ’s C h ild r e n 1 9 9 8

8
Smith, L.C. and L. Haddad. 2000. “Explaining child Malnutrition in Developing Countries: A Cross-
Country Analysis.” Research Report 111, International Food Policy Research Institute, Washington, DC.

14
Income and Poverty

Svedberg has recently shown that over half of the stunting in the world (1998-2002) can
be explained by income (log national per capita) 9. The problem is that aggregate income data
are associated with a large number of other factors that are also known to affect nutrition (not
the least of which are education, food supply, infrastructure, and quality of public services).
There is a vicious cycle between malnutrition and poverty. Poverty creates malnutrition
(through reduced access to food, poor health environment, and less access to services) and
malnutrition creates poverty (through reduced work productivity, educational failure, and poor
health). In DHS surveys, the lowest quintile always has more stunting and underweight than the
highest one or two quintiles10. While it is generally true that poor children are more likely to be
malnourished than rich children, it is also true that even among poor people a large proportion
of children are NOT malnourished and that the highest income groups still have malnourished
children. In Cambodia, a little more than twice as many children in the lowest quintile are
malnourished compared to those in the highest quintile (46.7% and 19.4%, respectively). It is
worthwhile noting that even in the poorest quintile more than half of the children are well
nourished. That is to say that the majority of the poorest parents are able to nourish their
children adequately. Something in addition to poverty is causing malnutrition. Particularly
important are such factors as water and sanitation, fertility and child spacing, many household
behaviors (including hygiene, breastfeeding, infant feeding, care of the sick child, and
psychosocial stimulation), maternal employment and childcare choices, parental (especially
mother’s) education, family dysfunction (particularly drug and alcohol abuse and domestic
violence), and access to information and services. Underweight prevalence is disaggregated
below by wealth quintile where available from MICS and DHS:

9
Svedberg, Peter. Has the Relationship between Undernutrition and Income Changed?” Copenhagen
Consensus, 2004; Commment on Hunger and Malnutritio at
http://www.copenhagenconsensus.com/Default.aspx?ID=223.
10
Ergo, A, M. Shekar and D.R. Gwatkin. Inequalities in malnutrition in Low and Middle-Income Countries.
Updated and Expanded Estimates. World Bank Country Reports on HNP and Poverty, Jan. 2008.

15
 Fig. 4 Nutrition Status by Weatlh Quintile EAP

50

45

40

35
Percent Underweight

30 Cambodia (2005)
Laos (2006)
Mongolia (2005)
25
Thailand (2005)
Vietnam (2006)
20 Indonesia (2000)

15

10

0
Q1 Q2 Q3 Q4 Q5
Quintile

Sources: Child Info, UNICEF (Laos, Mongolia, Thailand, Vietnam), DHS (Cambodia), Friedman (2006) citing
IFLS 2000 (Indonesia).

Clearly in some countries (Cambodia and Lao PDR), the wealth effect is large. It is interesting to
note that although the poorest are equally malnourished in Indonesia and Vietnam, the wealth
effect is much greater in Vietnam. It would appear that at low levels of malnutrition (Thailand
and Mongolia) there is little difference between the poorest and the wealthiest quintiles. Over
time the relationship between poverty reduction and nutrition improvement is non-linear (see
Appendix 2). In some countries (Cambodia, Indonesia and China), poverty has decreased more
slowly than malnutrition (in China poverty since 1990 has decreased faster than stunting but not
underweight). In other countries (Philippines, Thailand, and Lao PDR), however, poverty is
decreasing faster than malnutrition. At the very least this shows that poverty and malnutrition
have an indirect relationship with each other.

Food Supply

Table 4 presents FAO data of food availability during the 2003-2005 period. The average
calorie requirement is around 2100 calories per day (although actual needs could be
considerably different based on age, sex, and activity levels). When national calorie availability
and lack of access to adequate calories are plotted against stunting (not shown) there is a weak
correlation (r2=0.305 and 0.118, respectively). At any rate, the availability of food seems not to
explain malnutrition as well as per capita income (straight regression $PPP Atlas method)
(r2=0.65).

16
 Table 7. EAP Calorie Availability 2005

% not having
Calories access to Poverty Rate
available/capita adequate (date)
calories11
Brunei/Darussalam 3210 <5
China 2990 9 16.6 (00)
Cambodia 2160 26 34 (97)
Fiji 3010 <5
Fr. Polynesia 2900 <5
Indonesia 2440 17 7.5 (02)
Kiribati 2830 5
Korea PDR 2150 32
Korea Rep 3030 <5
Lao PDR 2300 19 26.3 (97-98)
Malaysia 2860 <5 <2 (97)
Mongolia 2190 29
Myanmar 2380 19
New Caledonia 2780 9
Philippines 2470 16 15.5 (00)
Samoa 2820 <5
Solomon Islands 2450 9
Thailand 2490 17
Timor Leste 2160 22
Vanuatu 2730 7
Vietnam 2650 14 <2 (00)

Source: Calories FAO (http://www.fao.org/faostat/foodsecurity/MDG_en.htm), Poverty WB

(http://devdata.worldbank.org/wdi2005/Table2_5.htm)Appendix 1. The MDGs and Nutrition

Food Prices

There are few reliable national data showing impact of the recent crises on nutrition.
One can only surmise from reduced economic growth and poverty reduction, and food price
inflation that food insecurity increased for those segments of society most dependent on
markets for income and food. Between 2005 and 2008 the price of rice rose from $286 to $650
a metric ton. In the first five months of 2009 it has fallen to $567. Because rice constitutes a
large proportion of the calorie intake and consumption basket of many East Asian countries (see
Table 5), this price spike probably resulted in a shift toward lower priced food stuffs and may
have resulted in dietary stress. The causes of the rice price spike included dollar depreciation,
uses of other grains for bio-fuels, agricultural factors, panic buying by large rice importers, export
restrictions by rice exporters, and speculation 12. The food price spike could have had both

This is termed “undernourished” by FAO

11

12
Milan Brahmbhatt and Luc Christiaensen. Rising Food Prices in East Asia: Challenges and Policy Options.
World Bank, May 2008 and Timmer, C.P., Rice Price Formation in the Short Run and the Long Run: The

17
positive and negative impacts on food security. Higher prices generally stimulate greater
production over time (and the 2008 harvest was 3.5% bigger than 2007’s) and they increase
income of farmers, many of whom are poor, but they also constrain consumption of the poor.

Table 8. Role of Rice in Diet and Food Basket in East Asia

Rice as a Rice as a proportion

Country proportion of of food consumption
calories basket
Cambodia 69
China 34
Indonesia 46 40
Korea DPR 30
Rep. Korea 30
Malaysia 31
Myanmar 68
Philippines 47 50
Thailand 32 36
Vietnam 65 43
Source: IRRI Table 16

Major rice importers (the Philippines is the world’s largest rice importer) suffered the
most from this price spike and they also exacerbated it by trying to make major purchases when
the market was most volatile, which drove the price up further (Brahnbatt and Christiansen,
2008). The major rice exporters (Thailand is the world’s largest exporter of rice) probably
benefited from the price spike. Vietnam, however, to protect its national consumers, put export
controls on rice to reduce its exportation, thus dampening income effects on farmers. This also
caused the price to rise on world markets.

Table 9. 2004 leading EA rice importers and exporters (tons)

Rice Importing Countries Rice Exporting countries

Philippines (1 M) Thailand (10 M)
China (928K) Vietnam (4.1 M)
Korea PDR (523K) China (901K)
Indonesia (390K) Myanmar (150K)
Hong Kong (326 K)
Korea (Rep) (206)
Also: Malaysia, Timor Leste Also: Cambodia, Lao,
Source:
http://internationaltradecommodities.suite101.com/article.cfm/rice_import_dependent_countries and
FAO.

Many countries in the region have instituted policies and programs to moderate the
price of rice. These include reducing import tariffs (China, Fiji, Indonesia, Solomons), export
reductions or taxes (Cambodia, China, Indonesia, Vietnam), reducing food grain taxes
(Cambodia, China, Fiji, Indonesia, Mongolia), price controls or consumer subsidies (China, Fiji,

Role of Market Structure in Explaining Volatility. Center for Global Development Working Paper 172, 2009.

18
Indonesia, Malaysia, Mongolia, Philippines, Solomons, Thailand, Timor Leste), and releasing
stocks to increase supplies (Cambodia, China, Indonesia, Malaysia, Mongolia, Philippines, Timor
Leste) 13. Only Laos took no action to control the price of rice but it suffered fairly low rice price
inflation.and it has recently inaugurated a Conditional Cash Transfer program. Most of the policy
interventions are expensive and can have perverse long-term impacts on food security. A
generalized rice subsidy, for instance, can incur an enormous fiscal cost (in the Philippines the
rice subsidy is estimated to consume 1.6% of GDP).

The nutritional impact of the ballooning price of rice would depend on what “inferior”
foodstuffs were available to substitute for rice and how well the poor gained access to and
utilized rice alternatives. Maize, tubers, and plantains are starchy substitutes in many East Asian
countries but little published work has examined the ways in which consumers changed their
eating patterns when rice prices were high. Usually those most dependent on the market for
their food (urban poor, landless, subsistence and semi-subsistence farmers) are the most
adversely affected by such price spikes. Rice substitutes may require more processing, more
time and fuel for preparation, or be less available in urban markets. But the nutritional effect
depends on more than carbohydrate substitutes. For infants and toddlers (indeed for everyone,
but young children are more vulnerable), rice is particularly deficient in protein and
micronutrients, even if is supplemented with breast-milk (which it should be until two years of
age). Families with children who grow well usually augment rice with vegetables, legumes, and
animal protein to make a more nutritious food. During economic hardship, however, these
additions to the rice may be sacrificed and the quantity and the quality of the diet deteriorate.
While adults can usually withstand long periods of moderate deprivation, young children,
especially those under the age of two, are more fragile. Thus, during economic crisis, it is critical
to protect the very young children. Pregnant women also need to be protected since they are
more likely to give birth to low birth-weight infants when they can’t get enough to eat.

The only nutrition data available on the crisis suggest that infants in urban areas are
particularly at risk. In Cambodia nutritional wasting of children under 5 in urban areas increased
from 9.6% to 15.9% between 2006 and 2008.

If the recent economic crises had a significant impact on nutrition, it is because of the
underlying vulnerability of the population. Those countries with the highest levels of
malnutrition before the crisis were the most vulnerable to nutritional impacts of the shocks.
This includes relatively well-to-do countries like Vietnam, Indonesia and Philippines (which have
inexplicably high rates of malnutrition) as well as the poorest countries of the region, Lao PDR
and Cambodia. Whether the populations of Myanmar and Korea PDR, which had high rates of
malnutrition beforehand, are affected or not is unknown due to the closed door policy of the
governments. Mongolia, which started with relatively low rates of malnutrition, seems to have
been buffeted back and forth by the various shocks and might well show some impacts on
nutrition. Malaysia and Thailand, which started with low rates of malnutrition, have been deeply
shaken by the economic strains but it is unlikely that malnutrition will rise significantly in part
due to high income (Malaysia) and to nutrition policy in Thailand.

Breastfeeding Practices

13
Bhrabhatt and Christiansen, Table 3.

19
 Although covered below under “Habits, Beliefs, and Practices”, breastfeeding should
rightfully be considered a food supply issue. The prevalence of exclusive breastfeeding during
the first six months of life is shockingly low throughout the region. Likewise, the proportion of
infants still being breastfed at 20-23 months is very low as well.

Table 10. Breastfeeding Practices in EAP

Exclusive Still
Breastfeeding Breastfeeding
(< 6 months) (20-23 months)
Cambodia 60 54
China 51 15
Indonesia 40 59
Korea DPR 65 37
Lao PDR 23 47
Malaysia 29 12
Mongolia 57 65
Myanmar 15 67
Papua N.G. 59 66
Philippines 34 32
Solomon Islands 65
Thailand 5 19
Timor Leste 31 35
Vietnam 17 23

Source: State of the World’s Children 2009, Table 2

Land Use

In Laos, Cambodia and Vietnam, rural people have long relied on hunted and foraged
wild food which are important dietary sources of protein and micronutrients. These foods
derive from the forests, lakes and waterways. In recent year’s privatization, deforestation, and
natural resource exploitation in general have eliminated or made inaccessible many of these
food sources. While efforts are underway in all three countries to preserve and sustainably
manage these wild lands and waters, their nutritional importance is not necessarily being taken
into account. Assuring the local people can continue to use traditional hunted and foraged foods
should be factored into land use decisions.

Water and Sanitation

Because diarrhea and intestinal worms are a major cause of growth failure and anemia,
the availability of improved water sources and sanitation are of great concern to those
interested in preventing malnutrition. On average, the lower and middle income countries of
EAP generally have good access to improved water and sanitation although rural and poor
populations are likely to have much less access. The best correlation between nutrition and
water and sanitation has an R 2 of 0.47 and 0.49 between underweight and improved water and
improved sanitation, respectively.
Table 11. Water and Sanitation in EAP High Burden countries

20
 Improved Improved
water sanitation
Cambodia 65 28
China 88 65
Indonesia 80 52
Lao PDR 60 48
Malaysia 99 94
Mongolia 72 50
Myanmar 80 82
Papua N.G. 40 45
Philippines 93 78
Korea DPR 100 36
Singapore 100 100
Solomon Islands 70 32
Thailand 98 96
Timor Leste 62 41
Tonga 100 96
Vietnam 92 65
Source: ChildInfo, UNICEF

Disease

Disease and malnutrition are often involved in a downward spiral. Disease causes
anorexia and heightens nutritional requirements which, in turn, result in nutrition’s deteriorating
over the course of malnutrition-prolonged disease. Malnutrition causes immune deficiency
which increases susceptibility to infection and duration of illness. Diarrhea is probably the most
important disease from a nutrition perspective. Water-borne and food-borne (including disease
spread by the hands that feed) diseases are usually the cause of diarrhea. Respiratory infections,
measles, and HIV are also important for nutrition. Parasitic diseases, particularly intestinal
worms and malaria, have an important role to play in under-nutrition and iron deficiency anemia
which is widespread in the region. As health care has improved in the region, vaccine
preventable and drug treatable diseases have waned. One presumes that diarrhea and intestinal
parasites have reduced as more people wear shoes 14 and water and sanitation have improved.
Many of the poor, especially the rural poor, still lack access to these advantages. The high
prevalence in anemia in most of these countries suggests that much more work needs to be
done on improving sanitation in tandem with improving the quality of the diet and feeding
behaviors for young children. There is a modest cross-country correlation (R 2 = 0.5) between
sanitation and weight for age (but not between other water, sanitation, and nutrition variables)
in EAP.

14
Hookworm, one of the major intestinal parasites, enters the body through bare feet.

21
Seasonality

In many countries in the EAP region seasonality is a major factor in malnutrition. There
is seasonality of food supply as well as of disease (diarrhea, respiratory infection, and malaria, in
particular). In Cambodia, for instance, temperature and rainfall peak in April, May and June. The
2000 and 2005 DHS surveys (as reported by UNICEF in 2008 MICS report) found that diarrhea,
fever and ARI are highest in February and lowest in July. Not surprisingly, underweight goes up
steadily from February to June wasting increases in April and May.

Lack of Childcare

Where women are actively engaged in wage labor or agricultural labor, it is often
necessary or desirable to leave an infant at home while the mother works. Usually the caretaker
is a sibling or other family member. Women’s work poses challenges to breastfeeding unless the
woman is encouraged to express milk and willing to feed the child on demand during the night
hours. Making sure that both mothers and caretakers know what to feed the infant, how often,
and how aggressively are critical to preventing inadequate nourishment. In many East Asian
countries, women’s employment has been critical to economic growth. This employment should
be complemented with increasing the availability of high quality crèches and daycare centers
that safeguard children’s nutrition and provide psycho social stimulation to enhance cognitive
development. Seasonal community crèches might also be encouraged when women’s work out
in the fields is demanding. Few data exist on the availability, quality, or impact on child growth
and development of daycare services in East Asia. The Philippines has made a special effort to
improve quality and availability but it is not clear how successful they have been. When
childcare is provided by children (older siblings), there is a real risk that both diet and hygiene
will be inadequate.

Habits, Beliefs, and Practices

In Cambodia, Lao PDR, Vietnam, Indonesia, and Philippines, a number of operational

research projects and program interventions have shown that beliefs and practices underlie the
poor nutrition of women and infants. Particularly important are beliefs and practices revolving
around giving infants colostrum (the antibody-rich first milk after delivery), the early
introduction of non-breastmilk liquids and foods to infants under six months, the bland, watery,
and starchy diet fed to weanlings, and the proscription of certain foods for infants and pregnant
women. Due to local customs, mothers routinely underestimate how many young children can
eat, how often they should eat, and how thick infant food should be. Habits, beliefs, and
customs (possibly in conjunction with poverty) often keep families from giving young children
vegetables, fruits, and animal products. The common perception (among foreign aid donors)
that habits and customs change only slowly is belied both by commercial marketing success and
by programmatic experience in these countries. In Cambodia, for instance, the country was able
to improve exclusive breastfeeding rates markedly through a behavior change program. In Laos,
Trials of Improved Practices showed that poor rural pregnant women were willing to eat more
food and to make and feed a multi-component improved weaning food to infants. In Vietnam, a
“positive deviance” program showed that some poor women helped their children grow well by
adding small crustaceans and leaves into the weaning foods. Their success strategies were
communicated to other local mothers and malnutrition improved markedly. In Indonesia, a
nutrition counseling program combined with growth monitoring, family planning, and home

22
gardening caused profound improvement in child growth. In Thailand, a similar multifaceted
community based growth promotion program enabled Thailand to show remarkable
improvement in child nutrition between 1980 and 2000. The bottom line is that people will
change behaviors, including intimate behaviors like breastfeeding and eating, if excellent social
marketing principles are applied.

Summary

To summarize, the East Asia and Pacific Region has serious nutrition problems, far more
serious than should be expected from their income levels. The causes are multiple:

 Suboptimal breastfeeding due to a combination of traditions and beliefs, women’s work,

misinformed health personnel, and marketing practices of manufacturers of breast-milk
substitutes. Initiation of breastfeeding within one hour of birth is very low (15% in Asia),
exclusive breastfeeding to six months is too low (only in DPR Cambodia, Korea, China,
Mongolia, and some Polynesian islands is it greater than 50%), and few mothers nurse
their child for the first two years of life.
 Inadequate complementary feeding. Young child feeding contributes to malnutrition
because weaning foods are of poor nutritional quality, watery, fed in inadequate
quantity and too infrequently and often contaminated.
 Women’s nutritional status – the high proportion of short, thin, and anemic women
coupled with heavy workloads and high fertility mean that women’s own health, quality
of life, and work capacity are impaired, they are at much greater risk of death and
disability during pregnancy, and they are likely to pass on malnutrition to their offspring
through low birth-weight and other nutritional handicaps.
 Low access to clean water and improved sanitation in rural and remote areas coupled
with poor hygiene leads to more diarrhea and intestinal parasites which leads to more
malnutrition
 Loss of access to forests and watercourses reduces access to high quality scavenged
foods that traditionally enriched the diet
 Poor outreach of government services to remote communities means that sick women
and children can’t get timely attention, schooling is inadequate, agricultural extension
fails and food production flounders, the social safety net isn’t in place to catch those
who need help, and people are distrustful of government. Lack of decent childcare
services means that women are torn between contributing to family income and
nurturing their children.
 Poverty, isolation, minority ethnicity all increases the likelihood of malnutrition.

III. Policy Framework

Most nutrition policies are a long laundry list of desiderata without any prioritization,
budgeting, or grounding in actual programs. They are usually over ambitious in both goals and
in number of programs. As a result, the institutional capacity is overwhelmed, no single program
is done well, and lack of results weakens political support. Heaver, in his review of Thailand’s
successful program credits their success with “using national nutrition investment plans (rather
than policy statements unlinked to resources commitments) as a way of generating a national

23
vision of what needs to be done, giving visibility to nutrition, and giving each implementing
agency clear responsibilities.” 15 Heaver also stresses the need for popular support for nutrition
as key to sustaining the long-term commitment required to make a program successful. The
politics of policy – including popular politics as well as party politics – was emphasized strongly
in a recent World Bank meeting on food policy 16. Little empirical work has been done in EAP (or
anywhere) to understand how technical issues, operational capacity, and policy processes
interact to produce broad-based sustainable improvements in nutrition.

Country studies in Thailand (still successful), Indonesia (once successful), and the
Philippines (unsuccessful) suggest that the following issues are important. First, nutrition should
be included explicitly in the national economic and/or planning policies and it must be framed as
a development investment. While Thailand has had an explicit nutrition policy in addition to
nutrition’s inclusion in national plans and economic policies. This was matched with multi-
sectoral institutional involvement in programs over the long term. Indonesia did not have an
explicit nutrition policy but had a strong voice in the planning ministry in Indonesia that assured
that nutrition was considered in national five-year plans and that it obtained budgetary
resources. Early on Indonesia had strong multi-sectoral support for a comprehensive national
program, but since the 1990s it has become a strictly health concern and, simultaneously, lost
political support and quality. The Philippines included nutrition in both national economic plans
and policies and separate nutrition policies. It had multi-sectoral programs and institutional
involvement but its programs have never quite managed to perform well. Perhaps this is due to
larger issues of governance. Contrast those experiences with China’s where nutrition was never
included in national policies and yet nutrition has improved dramatically, largely without large-
scale nutrition programs. The economic transformation appears to have been responsible for
improved nutrition, at least among the urban population. On the basis of these few examples,
one would have to conclude that incorporating nutrition into national economic policies and
plans is useful but methodical attention to program design and implementation must accompany
it.

Two areas in which a national policy appears to have made a marked impact is in food
fortification and breastfeeding. Policies that make the International Code on the Marketing of
Breastmilk Substitutes national policy lay down a line in the sand concerning what are ethical
and unethical practices for infant formula companies. Many of those companies try as hard as
they can to undermine the Code and they succeed, where enforcement is lax. If the country
takes the Code seriously though – particularly hospitals and public sector health personnel as
well as consumer watchdogs, breast-milk has a fighting chance against infant formula.
Prohibiting infant formula, however, while heartily embracing other seemingly magical
formulated foods (lipid based foods and ready to use therapeutic foods used outside the
therapeutic milieu, for instance) runs the risk of confusing the public about what constitutes a
nutritious infant food and undermining breastfeeding even more. With the Code embodied in
national legislation, strong breastfeeding promotion programs can make a major difference in
infant feeding. In Cambodia, for instance, a UNICEF sponsored campaign to increase exclusive
15
Heaver, R. Thailand’s National Nutrition Program: Lessons in Management and Capacity Development.
Heaver, R. and Y. Kachondam. HNP Discussion Paper. 2002.
16
Marcela Natalicchio Menno Mulder-Sibanda James Garrett Steve Ndegwa Doris Voorbraak, eds.. 2008.
Carrots and Sticks: The Political Economy of Nutrition Policy Reforms. HNP Discussion Paper. World Bank.

24
breastfeeding is credited with increasing exclusive breastfeeding in children under six months
from 11% to 60%. The Code has been fully incorporated into law in Philippines (34% EBF),
partially so in Cambodia (60% EBF), China (51% EBF), Indonesia (40% EBF), Lao PDR (23% EBF)
and PNG (59% EBF), and not at all incorporated in Myanmar (15% EBF).

National level fortification requires, at the very least standardization and verification to
work. Experience with iodized salt suggests that fortification legislation should be obligatory and
complemented with public education and an accurate, honest, and systematic process for
assuring that the food is fortified properly. The regulatory enforcement system is the most
difficult step in instituting food fortification. Universal Salt Iodization is mandated in Cambodia,
China, Korea DPR, Indonesia, Thailand, and Vietnam, although not always effectively enforced, as
evidenced by the figures in Table 3.

IV. What Works to Improve Nutrition

Recent publications17 have reiterated the long and established literature on what works
to improve nutrition. Table 4 in the Bank’s Repositioning Nutrition 18 lays out quite clearly the
most promising approaches. The “short route” interventions have been reiterated in the Lancet
nutrition series19. These can be summarized as follows:

 Behavior change: promoting breastfeeding and complementary feeding of infants,

hygiene, and adherence to micronutrient supplements
 Micronutrients: supplementation, fortification, and improving diet
 Other health interventions (deworming, treated bed-nets, intermittent preventive
malaria treatment, baby-friendly hospitals)
 Conditional cash transfer programs or microcredit with nutrition education
 Community based nutrition programs that include a range of the above
 Treatment of severe acute malnutrition

Nutrition interventions are among the best development bargains because for a modest
program cost (except for food or cash transfers are involved) they yield very high returns in the
form of better school outcomes, higher work productivity, and better health.

17
World Bank. Repositioning Nutrition, 2006; Bhutto, Z.A. et al. Maternal and Child Undernutrition 3.
What works? Interventions for maternal and child undernutrition and child survival. The Lancet 371, Feb.
2, 2008. pp. 417-40 and Web Appendix 17 to that chapter available at
http://download.thelancet.com/mmcs/journals/lancet/PIIS0140673607616936/mmc17.pdf?
id=0e96c9e6421f9512:50c74dbc:1224127705a:-34ed1246635589546 ; Behrman, J.R., H. Alderman and J.
Hoddinott. Hunger and Malnutrition. 2004. Copenhagen Consensus, 2004 available at
http://www.copenhagenconsensus.com/Default.aspx?ID=223 and Horton, S., H. Alderman and J.A. Rivera.
Copenhagen Consensus 2008 Challenge Paper Hunger and Malnutrition. 2008 at
http://www.copenhagenconsensus.com/Default.aspx?ID=1149
18
World Bank. 2006. Op. cit.
19
www.globalnutritionseries.org

25
 Table 12. Benefit-Cost of Nutrition Interventions

Benefit Cost 200420 Benefit Cost 200821

Breastfeeding promotion in 9–16
hospitals
Integrated child care programs 5–67
Iodine supplementation (women) 4–43
Vitamin A supplementation 15–520
(children < 6 years)
Iron fortification (per capita) 176–200
Iron supplementation (per 6–14
pregnant women)
Micronutrient supplement 17
(vitamin A and zinc in
diarrhea treatment)
Iodized salt and iron fortification 9.5
Biofortification 16
Deworming preschoolers 6
Community based nutrition 12.5
promotion

It should be noted that none of the reviews looked at program quality or operational
factors that contribute to success.

The constraint now, as always, is in designing and implementing high quality programs.
Appendix Table 17 to Chapter 3 in the Lancet nutrition series provides an excellent summary of
experiences with large-scale nutrition programs. To prevent growth failure (stunting and
underweight) in children under two almost always requires a community nutrition program
which helps mothers, caretakers, and families do a better job of caring for their children 22. This is
because feeding young children should happen several times a day, every day of the year. It is
not episodic, like immunizations or disease treatment, and therefore is not amenable for being
dealt with at a health clinic. The best solution, one which has been shown to work in many
countries (including Indonesia, Thailand, Honduras, Peru, Sri Lanka, Bangladesh, Uganda,
Zambia, Madagascar, Senegal, and elsewhere) is a comprehensive community based growth
promotion program which combines nutrition counseling, basic health services, and other
actions to address the underlying causes of malnutrition. In some countries, such programs
have included income generation, small scale food production, community water source
improvement, improved public sanitation, microcredit, family planning, daycare centers, and
local weaning food production. How all of these services are combined, managed, and phased in
is entirely dependent on local circumstances and the management skills of program staff. The
availability of community driven development projects and programs in a variety sectors offers
20
Behrman, Jere R., Harold Alderman, and John Hoddinott. 2004. “Nutrition and Hunger.” In Global Crises,
Global Solutions, ed. Bjorn Lomborg.Cambridge, UK: Cambridge University Press.

21
Horton, S., H. Alderman, J.A. Rivera. Copenhagen Consensus 2008 Challenge Paper. Hunger and
Malnutrition. 2008
22
Mason, J., D. Sanders, P. Musgrove, Soekirman, and R. Galloway. 2006. Community Health and Nutrition
Programs. Chapter 56 in Disease Control Priorities in Developing Countries 2 nd Edition, D. Jamison, et al.
eds.

26
an excellent platform from which to work, starting perhaps with using child growth as both an
motivating outcome and a measure of accountability. By the same token, many countries are
introducing conditional cash transfer programs which also offer a different opportunity to help
families and communities use additional income to improve child growth and development.

The most important characteristics of successful programs have been good

management: i.e. a systems approach to design and implementation (especially the
communications for behavior change component) and good quality supervision. As shown in
Indonesia, unfortunately, it is not enough to design and implement a good program. Its political
and institutional support needs continual care and feeding as well.

V. What’s on the ground now?

Indonesia, Thailand, Cambodia, and Vietnam all have national nutrition programs, at
least on paper. They are all ostensibly community based. Indonesia’s and Thailand’s appear to
truly have national coverage that extends to the community level while Cambodia’s and
Vietnam’s look good on paper but fail to reach the community. In the Philippines, many noble
programs have been rolled out, but few have had the longevity or the quality control to
effectively get to scale. The remainder of the countries have a mixed bag of national
breastfeeding promotion programs, micronutrient programs (mostly vitamin A supplements and
uninspiring iron supplementation programs for pregnant women), clinic based nutrition services,
and small scale community programs (mostly implemented by NGOs). Going to scale, getting to
the community, and improving quality of services (particularly communications for behavior
change) are challenges in all countries. In the Philippines one of the problems is the failure to
eliminate old programs when new ones are added so that the effort gets diluted.

Independent of the nutrition programs, many countries have instituted various kinds of
community driven development schemes in a variety of sectors. Community based growth
promotion, carried out as part of efforts to enhance community driven development across the
sectoral spectrum, offers the ideal vehicle to integrate services and engage communities, not just
households, in improving child nutrition. In addition several countries are considering
conditional cash transfer programs which also can be adapted to nutrition.

27
 Policy and Planning Documents that Include
Country
Nutrition
Cambodia National Strategic Development Plan 2006-2010
(and earlier Poverty Reduction
Strategy)
Strategic Framework for food Security and
Nutrition in Cambodia 2008-2012
Health Sector Strategic Plan (2008-2012)
National Policy on Infant and Young Child
FeedingNutrition Investment Plan
Salt Iodization
Code on Breastmilk Substitutes
Indonesia Five Year Plan
National Action Plan for the Prevention of
Malnutrition (2005-9), MOH
Salt Iodization
Code on Breastmilk Substitutes
Lao PDR National Socio-Economic Development Plan
2006-2010
National Growth and Poverty Eradication
Strategy 2004-2006
National Nutrition Policy (2008)
Health Strategic Plan 20008-2015, Accountability,
Efficiency, Quality, Equity. April 2008
Philippines Medium Term Philippine Development Plan
Medium-Term Philippine Plan of Action for
Institution(s) charged with nutrition Programs
Council on Agriculture and Rural Development National Nutrition Program
(coordinating body) (includes community
National Nutrition Council (Ministry of Planning) based programs and
Food Security and Nutrition Working Group (donors) micronutrients)
National Maternal and Child Health Center (MOH)
Provincial Nutrition Coordinating Committees
Village Health Support Groups
Directorate of Community Nutrition (MOH) Posyandu (community based
BAPPENAS (planning) growth promotion and
M. of Industry (salt) primary health care)
PKK (wives of civil servants, involved in Posyandu) Bidan di Desa (antenatal care,
Few NGOs childbirth assistance, and postnatal
attention)
Dept. of Hygiene and Prevention, MOH (current Disaggregated nutrition-related
focal point for nutrition) services provided
Nutrition center or institute to be created in MOH through several
National Science Council at Prime Minister’s Office different health
to establish National Nutrition Council departments and
Agriculture and Forestry Sector to develop strategies centers as well as other
for food security that encompass nutrition ministries.
National Commission for Mother and Child to Community Nutrition Project (WB,
establish a National Committee on Nutrition 2009)
Lao Women’s Union (involved in new Bank
community nutrition project)
Many NGOs
National Nutrition Council (rotating chair between Barangay Nutrition Scholars
ag, health, and social affairs) Accelerated Hunger Mitigation
28
 Policy and Planning Documents that Include
Country
Nutrition
Nutrition (includes rice subsidy, salt
iodization, food fortification, nutrition
education, supplemental feeding, and
food-for-school)
Responsible Parenthood and Natural Family
Planning Program
Early Childhood Care and Development Act
Code on Breastmilk Substitutes
Vietnam Strategy for Socio-Economic Development 2001-
2010
Comprehensive Poverty Reducation and Growth
Strategy (2002)
Poverty Alleviation Strategy, 2001-2010
National Nutrition Strategy 2001-2010
Institution(s) charged with nutrition Programs
Dept. of Health Program (includes increasing
Food and Nutrition Research Institute, Dept. of productivity in production,
Science and Technology backyard gardening, and
irrigation), improving ports and
farm to market roads, efficient
transport, and food for school and
daycare centers).
Dept. of Reproductive Health (main responsibility for National Targeted Program on
child malnutrition prevention program) in Child Malnutrition
collaboration with Dept. of Preventive Prevention (focused on
Care and HIV/AIDS Prevention and most difficult provinces)
Control in MOH (policy dialogue and Women and child nutrition
strategic planning) program
Dept. of Food Hygiene and Safety Vitamin A supplementation
National Institute of Nutrition (standing agency and Community based water and
coordinator of National Steering Committee; nutrition
technical and implementing with network down to Food Hygiene and Safety Program
grass root level)
29
VI. Institutional Issues

It is popular these days to blame all ills on institutional weakness and to prescribe academic
training as the solution. There is no evidence, however, that this has improved programs. To build
capacity to design and implement programs, it is more important to build capacity by providing action
learning, hands-on experience, and shared learning opportunities with other nutrition program
managers. In the East Asia and Pacific Region, country experiences (past and present) provide an
excellent training ground for learning and knowledge generation to create the institutional capacity
needed to develop and improve national nutrition programs. In addition to proposing specific country
initiatives, this paper proposes setting up a regional nutrition learning organization comprised of
operational staff from each county, to build national and regional institutional capacity as well as to
solicit and take advantage of external technical assistance as and when needed.

Heaver, in analyzing the successful Thai experience, found that they did not follow the standard
textbook advice about institutional strengthening. For one thing, he credits their success with
“managing implementation of the nutrition sector through a series of committees, rather than by fiat
through a single agency, which encouraged a wide variety of interest groups to feel that nutrition was
their business, rather than another agency’s.” 23 A similar approach was also used early on in Indonesia.
Thailand’s program was a multi-sectoral, community driven growth promotion program which “partially
empowered communities by involving them in needs assessment, planning, beneficiary selection and
program implementation, but keeping central government control over resource allocation, so as to
ensure a coherent national program.” 24 Most importantly, rather than sending staff to universities, the
Thais simply recruited two outstanding national universities to provide long-term support.

Some gross indicators of nutritional institutional capacity include the existence of a national
nutrition policy (including adoption of the Code on the Marketing of Breast-milk Substitutes), one or
more public organizational entities charged with implementation of the national policy, existence of
national nutrition programs (which may or may not be freestanding programs), inclusion of nutrition in
annual budgets, and coverage of needy and underserved populations (particularly children under two
and the rural poor). In the final analysis, though, the institutional capacity should be measured by the
quality and impact of the policies and programs. There are several different institutional homes for
nutrition in the EA Region. In China, nutrition rests in Chinese Center for Disease Prevention and
Control. In Cambodia and Timor Leste, nutrition is dealt with in a department within the health ministry.
In Thailand, nutrition is the responsibility of the Ministry of Health but it relies on technical assistance
from the Mahidol and Kasetsaert Universities. In the Philippines, nutrition is managed by the National
Nutritional Council, with revolving sectors taking the chairmanship, a Food and Nutrition Research
Institute within the Department of Science and Technology. The Department of Health manages many
components of the program, though (micronutrient supplements, nutrition within health services,
antenatal and postnatal care). In Indonesia, the Planning Ministry (BAPPENAS) and the Ministry of
Health share joint responsibility for nutrition. In Vietnam one Department has major responsibility for
nutrition but there is also a National Institute of Nutrition affiliated with the Ministry. Laos has not had
a special body responsible for nutrition but three new entities are proposed in the new nutrition policy.

In East Asia, as in the rest of the world, the Ministry of Health tends to give short shrift to
nutrition. So that even though many of the necessary nutrition services are provided by the health
ministry that may not be the strongest institutional home for nutrition. When Indonesia’s model
nutrition program was implemented, nutrition was particularly championed by the family planning
council (BKKBN), the planning ministry, and agriculture, the sum total of which kept nutrition high on the
agenda of the health personnel. In recent years, however, as nutrition has been brought into the health

23
Heaver, R and Y. Khachonddam, op. cit.
24
Ibid.
30
ministry, it has weakened considerably. For some reason, nutrition institutes throughout the world,
including in East Asia, tend to move more toward research and product development rather than toward
implementation. This is true in Vietnam as well.

VII. Bank Portfolio and Opportunities

The World Bank, until quite recently, had no active nutrition projects in the EAP region. The Lao
Community Nutrition Project was just approved as this report was being written. There are nutrition
components or services in health projects in Cambodia, Laos, Philippines, Vietnam, and Timor Leste. It is
worth noting that the World Bank has a long and respectable history in nutrition in East Asia and Pacific
region. Freestanding nutrition projects were critical to the expansion of the two most successful
nutrition programs in the region: Thailand’s national nutrition program and Indonesia UPGK program.
They were also among the Bank’s first nutrition loans. The importance of nutrition both to the client and
to the Bank in these projects was signaled by having freestanding nutrition projects, with dedicated staff
on client as well as the Bank sides. Subsequent projects in Indonesia, in which nutrition was subsumed
under a larger health context, led to inadequate attention being paid to the problems the nutrition
program encountered in its new institutional constraints. Interestingly enough, this same thing
happened in Tanzania when the Bank imbedded a successful national nutrition program within a health
framework. The Bank has also been involved, less successfully, in nutrition projects in the Philippines
and Vietnam. Bank involvement with salt iodization in China was deemed successful but the Bank has
not played a major role in nutrition in nutrition in China otherwise. In Laos and Cambodia and Timor
Leste, Bank health projects have provided some support to nutrition activities but mostly small-scale and
punctual efforts.

An important alternative to the health sector approach is the community approach to

malnutrition. Rather than engage in straight nutrition projects or nutrition components in health
projects, there is a strong emphasis in several countries on community driven development, community
grants, local participation and accountability, and conditional cash transfers. Taken together, the Bank
portfolio particularly in Cambodia, Indonesia, Lao PDR, the Philippines, Vietnam and Timor Leste
provides the minimum structure upon which to build a community based, multi-sectoral nutrition
improvement program. These community programs include:

31
 Country Community based initiatives that could serve as foundation for community
nutrition program
Cambodia  Rural Investment and Local Governance Projects (2) (en extension of the Seila
Program)
 Land management and Administration Project
 Community Organization Project
 Empowerment for the Poor in Siem Reap Project
 Demand for Good Governance Project
 2nd Health Sector Support Project
 Civil Society Engagement and Small Grants project

Indonesia  National Program for Community Empowerment in Urban Areas,

 PNPM Rural II,
 Community Facilitators Development Program,
 National Program for Community Empowerment in Rural Areas,
 Farmer Empowerment through Agricultural Technology and Organizations,
 KDPs,
 Community Based Settlement Rehabilitation for Yogyakarta,
 Early Childhood Education and Development Project,
 Integrating Environment and Forest Protection into the Recovery and Future
Development of Aceh,
 Community based Settlement Reconstruction and Rehabilitation Project for NAD
and NIAS,
 Community Recovery in Earthquake Affected Areas through UPP,
 SPADAs,
 Third Urban Poverty Project,
 Second Water and Sanitation for Low Income Communities project.
Lao PDR  Health Services Improvement project
 Poverty Reduction Fund Project
 Lao Environment and Social Project
Philippines  Mindanao Rural Development Project (Phase 2), which promotions participation
in using a community fund for agricultural development,
 National Sector Support for Health Reform (which focuses only on supply of
health care services)
 emerging support for 4Ps
 Women’s Health and Safe Motherhood,
 ARMM Social Fund,
 Kalahi CIDSS,
 Support for Strategic Local Development and Investment projects.
Vietnam  Vietnam Rural Water, through an NGO, Red River Delta
 Rural Water Supply and Sanitation,
 Forest, Sector Development Project, and
 Community Based Rural Infrastructure).

32
VIII. Options and Recommendations

The Bank has the opportunity to make a major contribution to reducing regional malnutrition in
several high burden countries, including three of the 36 countries that contain 90% of the world’s
malnutrition. Some of these countries – Indonesia and Cambodia – are ripe for the picking. Others, like
Philippines and Vietnam, have political issues that could impede rapid effective action.

It is difficult in a desk review to know what is really happening on the ground. Each of the
country studies have attempted to consolidate existing information on nutrition and nutrition programs
in those countries. To the extent that the Bank wishes to engage in nutrition in the region, it is strongly
recommended that consultants working on the ground in those countries expand and validate the
country studies.

There are three tiers of countries with respect to malnutrition: 1) those that are ready to expand
and improve nutrition programs at scale (Cambodia, Indonesia, Lao, Philippines, Vietnam and Timor
Leste; 2) those the need further investigation to determine the need, the institutional capacity, and the
feasible programmatic options (PNG, Solomon Islands) and 3) those which don’t make sense to work in
now (Myanmar, Korea DPR, Pacific islands). In the first tier countries, local legwork needs to be done to
ascertain country interest and commitment and institutional capacity. In the second tier countries, the
Bank should engage in sector work to understand the nutrition problem better. The over-nourished
pacific islands have been excluded from this list. Because programming to prevent and reduce obesity is
in its infancy, further research will be needed to devise some promising strategies and test them out on
one or more islands. This should constitute its own separate regional research project.

Cambodia Indonesia Lao Philippines Vietnam

Severity of + + + + +
nutrition
problem
Institutional 2 5 1 5 3
capacity*
Ongoing + + + +
health
project

Ongoing + + +
social
protection
project or
program
Policy and + + + + weak
project
support for
participatory
community
projects

Prep work + + + +/- weak

done on
content for
nutrition
33
 Cambodia Indonesia Lao Philippines Vietnam
counselling
*1 = little capacity, 5=high capacity

If the Bank chooses not to opt for a major regional initiative on nutrition, the alternatives are to
work through social protection programs (particularly CCTs and community development funds) to
enhance the focus and impact on nutrition. The third alternative is business as usual, financing minor
efforts within health programs.

What Next

If the Bank wishes to make a substantial impact on malnutrition in the East Asia and Pacific
region, it should first make a very public commitment to doing so. As a first step is should invest staff
and contractor resources in fleshing out the opportunities proposed here for Cambodia, Indonesia, Lao
PDR, Philippines, Vietnam and Timor Leste. Based on that work, the region should develop a multiyear
plan of action which would first prepare projects for the focus countries. Part of preparation would
include creating a regional knowledge network (to include the five focus countries plus Thailand and
other countries with an interest in the topic). It would make sense to develop a regional technical
assistance project to work with the knowledge network and help all the countries prepare high quality
projects. Perhaps trust funds or a bilateral donor could be identified to fund the TA and the knowledge
network.

At the same time the Bank should undertake serious sector work in Papua New Guinea and the
Solomon Islands to determine whether the problem and the institutional capacity are appropriate for
Bank investment. A two-country piece of sector work might make sense given their relative proximity.

The Bank would also during this time frame launch a new regional research program to identify
effective policies and programs to prevent and mitigate obesity and diet-related chronic diseases with a
special focus on the China, Philippines, Vietnam, and the Pacific Islands with high rates of obesity. The
research would also be aimed toward developing a regional (or even wider) knowledge network to help
countries develop and implement programs.

34
Appendix Table 1. Nutrition and the MDGs
MDG
1: Halving poverty and hunger
2. Universal education
3. Promote gender equality
4. Reduce child mortality
5. Improve maternal health
How nutrition relates to it
In addition to the explicit goal of
halving underweight in children
under five, improving nutrition
contributes to reducing poverty
by enhancing physical capacity
and productivity, improving
education outcomes, and
reducing disease and death
through its effect on the immune
system.
Malnutrition in early live reduces
IQ and impairs learning ability. In
addition, parents often sent
malnourished children to school
at a later age.
Providing the opportunity for
girls and boys to grow and
develop properly gives them an
equal chance at excelling at
school, being productive workers,
and contributing to society
Undernutrition has been shown
to contribute to almost one-third
of under-5 mortality and to over
half of the post-neonatal portion
U5MR. Underweight,
micronutrient deficiencies, and
low birth-weight (evidence of
maternal malnutrition) all
contribute to elevated infant and
child mortality.
Malnutrition is sometimes
passed down through
generations through maternal
malnutrition. A short, thin,
anemic woman is more likely to
give birth to a small or preterm
baby whose life chances are
curtailed. Many women in high
risk environments “eat down”
Relevant development sectors
that affect or are affected by
nutrition
Child growth and development is
the outcome of many
development sectors including
health, water and sanitation,
agriculture, community
development, education,
infrastructure, and more. The
poverty line is usually based on a
least cost food basket designed to
meet nutritional needs.
Early childhood education
programs that extend childcare
and psychosocial stimulation to
children under two can provide
much needed nutrition and
compensatory help for at-risk
children. Parental education,
particularly that of women, has
more impact on nutrition of
children than income.
Good nutrition counseling
empowers women to become
knowledge workers in the home
and community. By helping
women successfully care for their
children, they gain confidence
and self-esteem in a non-
controversial endeavor.
Many health interventions that
will save child lives (treatment of
diarrhea and respiratory
infections, hygiene,
immunization, micronutrient
supplements, prenatal care,
treatment of parasites, and
prevention of malaria can and
should be integrated with growth
promotion.
Family planning programs,
especially child spacing, will not
only benefit the woman but it
will improve the nutritional
chances of her child. Good
reproductive health programs will
benefit both mother and child by
preventing unwanted and
unhealthy pregnancies and
35
 MDG How nutrition relates to it
during pregnancy to avoid having
a big baby. Maternal
malnutrition, especially iron
deficiency anemia, affects her
survival and health over the
course of pregnancy and
childbirth. Improving girls’
nutrition (in early childhood,
during the school years, and
particularly during adolescence)
will help girls grow up to be taller
and reduce their risk during
reproductive years. Early first
conception, high parity and
closely spaced pregnancies affect
both maternal nutrition and the
health and nutrition of her
offspring.
6. Combat HIV/AIDS, malaria and Certain nutritional deficiencies
TB (vitamin A and possibly zinc)
make HIV transmission more
likely and impair the
effectiveness of ARVs. PLWHA
often are anorexic and yet a good
diet helps them tolerate the
medications better.
Breastfeeding, if done exclusively,
has been found to be safer for
infants of HIV positive women
than bottle feeding in low
resource situations.
Environmental Sustainability Food security is an important
component of nutrition and risk
mediation. Food security is
intimately related to protection
of watersheds, forests, and the
general health of the local
ecosystem. In Cambodia and
Laos, forest foods and wild
caught fish are major sources of
proteins, micronutrients, and
general dietary diversity. In
addition, climate change
threatens to alter the food
system. Deforestation often
occurs for fuel-wood and
charcoal production for cooking.
Water resources Drinking water is as essential to
good health and nutrition as are
foods. But water can be a source
Relevant development sectors
that affect or are affected by
nutrition
promoting good maternal health
and nutrition. A strong healthy
woman is more than a better
mother, she is also a stronger
worker and will produce more on
the farm or in employment. She
will also get sick less often.
Pregnant women are far more
vulnerable to malaria and anemia
(which potentiate each other).
Preventing and treating them
together is safer and more
efficient.
When local peoples are
empowered to manage forest
and water resources upon which
they depend for foraged foods,
important protein and
micronutrient food sources, they
are more likely to be better
stewards of the land and water
than commercial exploiters.
Deforestion can be assisted
through introduction of higher
efficiency cooking technologies
and methods and access to non-
wood based fuel sources.
Improved water supply and
sanitation programs reduce both
the energy cost of water
36
MDG How nutrition relates to it Relevant development sectors
that affect or are affected by
nutrition
of infection and parasites which, procurement and, when
in turn, deplete the body of combined with hygiene
energy and nutrients and thus education, reduce the
contribute to malnutrition. The waterborne and water washed
human energy outlays for diseases that contribute to
carrying water for home use can malnutrition.
be high enough to threaten
nutritional status and usually it is
the girls and women who carry
water. Irrigation water can
contribute to greater food
security if it results in excessive
drawdowns that threaten the
water table and cause
deterioration in the home water
supply. Farming systems support
which takes into account both
nutritional needs and
hydrological limitations is
important for meeting economic,
health, and nutrition goals.

37
Appendix 2. Country Poverty and Nutrition Trends (where trend data available).

Pove rty and Malnutrition Trends Cam bodia

Philippines Poverty vs. Malnutrition Trend
70
60
60 Lao PDR Poverty vs. Malnutrition Trends
y = -1.3615x + 2773.1
50
R2 = 0.9905
50
60 y = -1.0127x + 2063
Malnutrition/Poverty Rates

R2 = 0.6091
40
40
50
Percent

Poverty
3030 y = -1.2654x + 2567.2
40 Stunting
R2 = 0.8713
wt-age
Underw eight
20
Percent

Linear (Poverty)
poverty
20
30 Linear (Underw Poverty
eight)
Linear (wt-age)
10 Linear (Stunting)Stunting
Linear (poverty)
10
20 Underweight
0 Linear (Poverty)
1992 1994 1996 (Stunting) 1998
Linear 2000 2002 2004 2006
100 Year
Linear (Underweight)
1965 1970 1975 1980 1985 1990 1995 2000 2005
0 Year
1992 1994 1996 1998 2000 2002 2004
Year

Thailand Poverty vs. Malnutrition

Indonesia Poverty vs. Nutrition

35

70 Indonesia Poverty
30 Indonesia Stunting
60 Indonesia Underweight

25 Linear (Indonesia Stunting)

50 Linear (Indonesia Poverty) Stunting
Linear (Indonesia Underweight) Underweight
20
Percent

40
P ercent

Thai pov
Linear (Thai pov)
30
15
Linear (Underweight)
20 Linear (Stunting)
10

10
5
0
1994 1996 1998 2000 2002 2004 2006 2008
0
Year
1985 1990 1995 2000 2005 2010
Year

China Poverty vs. Malnutritrion Trend

70

60
Poverty 65

50 Underweight
Stunting

40 Poverty
Percent

Linear (Underweight )
Linear (Stunting )
30

20

10

0
1989 1991 1993 1995 1997 1999 2001 2003 2005
Year

38
Appendix 3. How growth monitoring and promotion helps community development

1. A good summative indicator of human development with well documented correlations with
other outcomes like mortality, morbidity, educational achievement, work productivity.
2. Assessing the growth of children under two years of age focuses community and health care
personnel’s attention on preventing problems.
3. Child nutritional status is an MDG goal (#1) and instrumental to achieve other MDGs (child
mortality, education for all, gender equality, maternal health).
4. Child growth and nutritional status is quantitative, affects all children, can be expressed as a
continuous variable (for evaluating impact) or as a binary variable (for monitoring, reporting,
supervision, etc.).
5. Children under two are highly sensitive and responsive to changes in environment (food,
infection, family distress) both in terms of causality and solutions.
6. Focusing on child growth forces integration of services (nutrition, infection control,
immunization, maternal nutrition, family planning) and sectors (water and sanitation, poverty
and food security, health and social programs).
7. Growth is not event dependent (like illness or death or harvest); growth happens 24/7/365 for
children under 2. If there is inadequate growth, there’s a problem.
8. Solutions aren’t rocket science (often available in the home and community); with facilitation,
the community can discover most of its own solutions. Sometimes, solving the problem entails
creating a local enterprise (weaning foods production, childcare center) which can generate
income. Where exogenous solutions are needed, the community can use child growth data as
advocacy tool and documentation to demonstrate need (voice).
9. Children’s healthy growth and development is an outcome valued by local people as well as
national government and a useful predictor of future educational performance, work
productivity, and reproductive health. Nutritional status is normally distributed with accepted
international standards.
10. Child growth is affected by a number of developmental priorities: food availability and price,
poverty and income, water and sanitation, health, domestic violence and acute distress in the
family, maternal health and nutrition, gender, childcare, education, behavior (affected by
marketing and advertising).
11. Child growth is easy to measure (a weighing scales) and there are many ways of expressing
growth that are simple and communicative. The most difficult part of it is not getting an
accurate weight but getting an accurate age. As a program matures, age becomes precise
because of local surveillance system.
12. Child growth is also an effective means to target service and raise demand for underutilized
services, especially (but not restricted to) nutritional counseling and preventive and curative
health services.
13. Verifiable, replicable measurements. Which means it can be useful for accountability.
14. Means of reaching reproductive-aged women before they become pregnant (again) and thus do
preventive health care.
15. Where similar programs have been instituted (e.g. Honduras) the structure has provided well
organized mechanism for emergency assistance and reporting (e.g. after hurricane).
16. Enables systematic addition of services and sectors on an as needed basis.

An example of how community based growth monitoring and promotion has been used
(Indonesia, Honduras): All children under two weighed monthly. The adequacy of their growth is
checked against numerical standards for monthly weight gain (no more interpolating graphs). Note that
one does not classify children into “well nourished” and “malnourished” because growth is a dynamic
process. If a small child falls below the cutoff on the chart but is gaining adequate weight, he is growing
well. Counseling is given immediately after the growth is assessed and the message is tailored to specific

39
needs of each child (based on their growth performance). Every month, each village fills out a bar chart
to show the total number of children under 2, the total number of children attending growth monitoring
that month, the total number gaining adequate weight, the total number not gaining adequate weight
and the number of children failing to gain adequate weight two or more months in a row. By comparing
the first with the second bar, the village health worker can see her coverage and how many people failed
to show up. She then pursues those absentees through home visits. She also compares the second and
third bars to see how well she’s doing. Theoretically, she should try make the third bar equal the second
bar. She can easily compare last month’s performance to this month’s performance by pulling out the
bar graph from the previous month. From the discussion she had with the parent or babysitter for the
children in the third column, she can tell who needs extra attention (a home visit) and referral. The
fourth column children generally need supplementary services because their family has not been able to
reverse their decline on their own (this may be because of extreme poverty, extended illness, poor child
care, alcoholism, or domestic violence). In Indonesia, the bar graph was filled up and sent by mail to the
health center where the data were aggregated and sent further up the health system. These five
indicators can be used all the way up the health system to provide supportive supervision, to report
coverage, to monitor program quality, to assess the severity of the nutrition problem in an area, and to
identify operational problems that need attention. It is a simple but elegant system. Every three or four
months the competitive performance of the community’s children is presented at an open meeting.
Community members are encouraged to brainstorm about solutions and then act on the consensus
priority. In Sri Lanka, community brainstorming usually resulted in childcare centers and wells.

40
References

WHO Regional Offices for South-East Asia and the Pacific. 2008. Health in Asian and the Pacific. Chapter
9. Reproductive health, child and adolescent health, nutrition, and health for older persons.

Havemann, K. and P. Pridmore. Social Cohesion: The Missing Link to Better Health and Nutrition in a
Globalized World. Arusha Conference, “New Frontiers of Social Policy”. Dec. 12-15, 2005.

East Asia and Pacific Region, Regional Strategy Update. Draft. February 19, 2009 (PPT presentation)

UNICEF. 2008. State of Asia-Pacific’s Children.

World Bank. Rising Food and Fuel Prices: Addressing the Risks to Future Generations. October 12, 2008.

World Bank. East Asia: Navigating the Perfect Storm. Dec. 2008.

World Bank. Battling the Forces of Global Recession. April 2009.

Caulfield, L.E., S. E. Richard, J.A. Rivera, P. Musgrove, and R.E. Black. Stunting, Wasting, and
Micronutrient Deficiency Disorders. Chapter 28 in Disease Control Priorities, 2 nd Edition. Jamison, D. et
al. editors. World Bank, 2006.

UNICEF. State of the World’s Children 2009.

Brahmbhatt, M. and L. Christiaensen. 2008. Rising Food Prices in East Asia: Challenges and Policy
Options. May 2008.

Ravenga, A. Rising food prices: Policy options and World Bank response. 2008.

Alderman, Harold, Simon Appleton, Lawrence Haddad, Lina Song

and Yisehac Yohannes. Reducing Child Malnutrition: HowFar Does Income Growth Take Us? Centre for
Research in Economic Development and International Trade,
University of Nottingham. CREDIT Research Paper, 01/05.

41
 Cambodia

While Cambodia has some of the worst nutritional indicators in the EAP region, it is also one of
the most hopeful countries for effective action. Not only has its economy proved itself resilient in the
recent economic shocks, it has also laid the groundwork for forward motion. This is due in large part to
collaboration among donors, a focus on community based action, and significant dossier of programs
that can be adapted to the task of improving nutrition.

Nature of the nutrition problem

Malnutrition is a serious problem in Cambodia but improving slightly. UNICEF reports that
Cambodia is likely to achieve the first MDG goal25.

Table 1. Chronic Malnutrition in Children under 5 (NCHS standards)

Stunting Underweight Wasting Severe

Wasting
2000 (DHS) 45 45 15 4
2004 (CSES) 54 46
2005 (DHS) 37 36 7 1
2008 (MICS) 40 29 9

Malnutrition is worse in rural areas than in urban areas. Stunting is 30.5% in urban areas
compared to 38.3% in rural areas. Underweight is 34.7% in urban areas compared to 35.7% in urban
areas. This lack of difference between urban and rural is curious especially given the dramatic
differences among provinces and among wealth quintiles (see below). Perhaps the rural areas contain a
more heterogeneous mix of economic classes than usual.

Malnutrition starts at an early age. In fact most of the problem arises before the child’s second
birthday. The following table (from DHS 2005) shows average z-scores for height and weight of
Cambodian children. The average child is slightly malnourished even before six months implicating
maternal malnutrition and low birth-weight are part of the problem. Nutrition deteriorates precipitously
in the first two years of life.

25
UNICEF ChildInfo: http://www.childinfo.org/undernutrition_mdgprogress.php
42
 Fig. 1 Cambodia, 2005 Malnutrition by Age

60

50

Underweight
Stunted
Wasted
40
Percent malnourished

30

20

10

0
0.49 0.99 1.99 2.99 3.99 4.99
Age (years)

This suggests that breastfeeding and infant feeding are critical problems. Recent data from UNICEF
(MICS, 2008) suggest that underweight has continued to fall in children under 2 but increased slightly in
the 2-5 year olds since 2005.

Causes of malnutrition.

As with most countries, the causes of malnutrition range from inadequate quantity and quality
of food, poor feeding practices, including breastfeeding, for young children, high infection rates and
parasitic diseases, high fertility, lack of safe water supply, domestic violence, and time constraints
particularly of women. Suboptimal breastfeeding practices are a major cause of malnutrition in early
infancy. Although most infants are put to the breast within a day of their birth, over half are given some
“prelacteal feed” (water, a milk, or a traditional or symbolic liquid), which is not only inferior to
colostrums (the antibody rich first milk) but also potentially a source of infection. While virtually all
infants should be exclusively breastfeed until six months of age, in Cambodia only 45.6% of 4-5 month
olds are thus fed. Diarrhea is both a cause of malnutrition and an effect of poor nutritional practices
(bottle feeding, unhygienically prepared food, contaminated water). Diarrhea prevalence is highest in
the 6-24 month old age group – 32% of the 6-12 month olds and 28% of the 12-24 month olds had had
diarrhea in the past two weeks (DHS 2005). Access to “improved” water sources in Cambodia increased
from 38 to 65% and access to improved sanitation increased from 51-62% from 2000 to 2006 (WDI) but
it would seem that this did not translate directly into improved nutrition. The Food Security and
Nutrition Strategic Framework points out that this water is not reliably available year round.

The World Bank sent a nutrition consultant to investigate the problems with infant feeding in
2006 and USAID sent another team in 2007. In both cases, the consultants found that the underlying
causes of malnutrition were usually poor feeding practices. A rich and varied diet is available in rural
Cambodia (including foraged foods) that contains animal proteins, fruits and vegetables, and grains but
families often don’t want to feed them to young children. Another problem is that mothers do not
engage in “active feeding” – encouraging the fussy child to eat – nor in adequate dietary management of
disease (feeding the child during and after infection). Finally, some mothers are feeding young children
empty calorie junk foods. Nonetheless, the USAID team discovered one village that made an improved
43
“bobor” (baby food) with meat and vegetables added which had been taught to them a dozen years
before in a GTZ program. This suggests that even rural villagers are willing to adapt their young child
feeding practices when approached in a sensitive way.

Income and malnutrition

There are significant differences in nutrition across wealth groups (Table 2). In 2005 Stunting
was more than three times greater in the lowest quintile than in the highest one; underweight was
almost 50% higher in the fifth quintile compared to the first one. Although stunting has diminished
between 2000 and 2005, the trend across quintiles was almost identical. Similarly, the rate of
malnutrition is twice as high for children borne of mothers with no schooling (45.8%) compared to those
with secondary education or better (22.2%) (2005 DHS). Although malnutrition appears to be related to
income, the national income growth rate has not resulted in pari passu reduction in malnutrition. While
GNI/capita increased almost 60% from 2000 and 2005, good nutrition improved only a quarter as much.

Table 2. Malnutrition Rates by Wealth Quintile, Cambodia

Q1 Q2 Q3 Q4 Q5
Stunting 2000 52.6 48.4 42.6 41.5 27.5
Stunting 2005 46.7 42.5 36.5 35.5 19.4
Underweight 2000 52 47.9 42 43.1 33.5
Underweight 2005 42.9 39.8 33.5 34.3 23.1

Source: DHS Surveys 2000, 2005

Clearly, nutrition is not improving apace with economic growth. Cambodia is a rice exporter and expects
to increase its rice exports substantially in coming years. Yet the PRSP suggestions that “even within rice
producing provinces 30% of communes face chronic food shortages” (PRSP, 2002, pg. 27). A combination
of poor roads, lack of agricultural extension, poorly developed markets and insufficient irrigation
contribute to food insecurity. Landlessness contributes as well – 20% of farmers are landless and 40%
have access to less than 0.5 ha of land.

44
Geography of malnutrition

According to the 2005 DHS survey, stunting is worst in Pursat (61.6%), Siem Reap (53.3%), Mondor
Kiri/Rattanak Kiri (54.0%), Otdar Mean Chey (47.3%), Preah Vihear/Steung Treng (42%), and Kampong
Thom (41.1%) and best in Phnom Penh (22.3%). The 2004 World Bank poverty assessment found the
highest rates of poverty in many of these same regions as well as poorest access to roads and services.
Like poverty, malnutrition is most likely to be highest in remote and mountainous areas and among
ethnic minorities.

Micronutrient malnutrition

Young children are highly vulnerable to anemia, usually caused by iron deficiency, intestinal
worms, and malaria. As noted earlier, anemia has strong implications for cognitive development and
later school performance. Anemia among children under 18 months of age is well over 80% (DHS 2005)!
It decreases as children get older (in large part because they are growing less rapidly) but still 62% of all
children under five are anemic. The only anemia control program in place for preschool children is a
pilot program to promote micronutrient “sprinkles” to be added at home to the baby food. The
Micronutrient Initiative estimates that 17% of Cambodian school children have goiter due to iodine
deficiency and 22.3% of children under six vitamin A deficiency 26. Inexplicably, 76% of children
purportedly receive either vitamin A supplements or vitamin A rich foods and 72% of the households use
iodized salt27.

Women’s nutrition

Eight percent of women are so short (<145 cm.) and 20% are so thin (BMI <18.5) that pregnancy
poses an elevated survival risk for them and for the children they are carrying 28. Anemia poses
additional threats to women’s health and survival and that of their unborn children. Anemia in
reproductive-aged women fell from 58% in 2000 to 47% in 2005 3. This may be due in part to the
prenatal iron supplementation program. According to the DHS almost two-thirds of pregnant women
receive iron supplements but a recent report from the government states that many states experienced
stock outs in 2008. The MICS 2008 survey reports that 1.6% of pregnant women suffer from night
blindness, a sign of vitamin A deficiency but that 98.5% consume vitamin A rich foods and 27.3% of
postpartum women receive a megadose of vitamin A 3. Iodine deficiency is widespread and results in
increased rates of stillbirth and compromised mental capacity in children born to iodine deficient
women. Obesity in women was 1.5% in 2008, up from 0.9% in the 2005 DHS.

26
WHO Global Database on Vitamin A Deficiency
27
DHS Cambodia, 2005
28
DHS, 2005
45
Likely effects of recent shocks

The historically malnourished in Cambodia are most likely concentrated in rural remote and
mountainous areas in households are subsistence farmers, landless laborers or ethnic minorities. To
some extent the historically malnourished are sheltered from the global economic crisis by their lack of
integration into markets although 46% of their dietary value comes from purchased food (Strategic
Framework for FSN). These households would be most affected by reductions in remittances from newly
unemployed relatives, possibly by the return of newly unemployed household members, and by inflation
in prices of food and economic inputs. The rural poor have traditionally been able to forage or hunt for
food (and that food is especially rich in protein and micronutrients) from common property like lakes,
rivers, and forests, but these resources are increasingly being deforested , privatized or otherwise made
unavailable (ADB Participatory Poverty Appraisal, 2004).

The most recent nutrition data on the impacts of the recent shocks in Cambodia suggest a slight
deterioration in acute nutritional status overall but a serious impact in urban areas. Initial results from
the UNICEF (MICS) Cambodian Anthropometric Survey suggest that acute malnutrition increased from
8.4% (Sept. 2005-March 2006) to 8.9% in Nov. 2008 (not statistically significant though reversing the
trend in recent years. Acute malnutrition in urban areas, however, increased from 9.6% to 15.9% in that
same period, which is alarming. Food price inflation in mid 2008 followed by the more recent collapse in
tourism and exports might well have caused an uptick in acute malnutrition among urban children
especially those with parents suffering wage losses.

The newly malnourished are likely to be resident in Phnom Penh, be in households dependent
on employment in export-related industries, tourism, and construction, and entirely dependent upon the
market for their food. Infants of women working in the textile industry are particularly vulnerable
because they may not be receiving breast-milk (for which substitutes are either expensive or
nutritionally inadequate or both). Economic shocks can provide an incentive to breastfeeding because it
is “free”, but weaning is not necessarily reversible without tremendous commitment.

The FSN Forum is discussing (April 2009) the most appropriate response to the economic shocks,
which includes strengthening the health system’s ability to deal with severe acute malnutrition, scaling
up micronutrient programs, improving infant and young child feeding (at the community and facility
level, using behavior change tactics, and enforcing breastfeeding protection legislation), improving
maternal nutrition (micronutrients and nutrition education during pregnancy, family planning), targeted
“food-related interventions”, social safety nets, water, sanitation and hygiene improvement, food
fortification, and food production. This is a thoughtful and feasible list of actions. Attention to the
immediate problem, however, should not divert attention from the long-term underlying malnutrition
problem. If children had been well nourished at the beginning of the crisis, the impacts would have
been far less widespread and severe.

46
Policies and programs

Cambodia is fortunate to have a comprehensive development plan (National Strategic Development Plan
2006-2010) that establishes national priorities, steers ODA and NGO efforts into high priority areas, and
is geared toward achieving the millennium development goals. It reinforces Cambodia’s commitment to
addressing malnutrition through community-based programs. The 2002 PRSP cited evidence that
community based nutrition programs in Cambodia are cost-effective with a cost/benefit ration of 1:8. It
also stated that “[to] address the specific causes of malnutrition, it is necessary for the communities to
make their own assessment and analysis of the problems they face before appropriate actions can be
taken at all levels. Although the PRSP has been superseded by the National Development Strategy Paper,
the latter paper reinforces the commitment to addressing malnutrition and to community based
programs.

Cambodia is fortunate also to have strong donor coordination and partnership. Key strategies in
both health and agriculture, moreover, include nutrition in a central and high priority way. The country’s
Consultative Group of donors developed seventeen technical working groups among which is the Food
Security and Nutrition (FSN) Technical Working Group which is actively monitoring both historic and
transitory nutritional problems. The FSN working group is currently actively involved in developing a
nutrition-oriented social safety net. The Council for Agricultural and Rural Development is the
coordinating body for food security and nutrition issues in Cambodia and the National Nutrition Council,
at the Ministry of Planning, is the lead agency for the formulation of nutrition policy. In other words, the
key institutional and policy architecture is in place to address the problem. The national Nutrition
Investment Plan 2003-2007 was reviewed annually and a new Nutrition Investment Plan is in process
and an annual operational plan for 2009 is available. An excellent “Strategic Framework for Food
Security and Nutrition in Cambodia 2008-2012” lays out a comprehensive and sensible set of policies
and programs. The National Policy on Infant and Young Child feeding has just been released and it too is
first rate. The country appears to have devoted a considerable amount of attention to communications
and behavior change strategies. The World Bank and USAID have provided substantial technical
assistance to develop locally relevant nutrition counseling messages and materials for promoting infant
and young child feeding. Careful community-based research has gone into message development and
thus the basic platform upon which to build a strong program is already in place.

The country in 2006 put in place a Code on the Marketing of Breast-milk Substitutes and has
instituted (with UNICEF support) both a Baby Friendly Hospital Initiative and a Baby Friendly Community
Initiative to support breastfeeding. The country showed a dramatic rise in exclusive breastfeeding in
children under six months from 12% in 2000 to 60% in 2005 DHS surveys. Compliance enforcement with
the Code needs strengthening. Cambodia also has a law requiring iodization of salt although
enforcement is weak.

The National Nutrition Program (out of the National Maternal and Child Health Center of the
Ministry of Health) includes a large number of programs, studies, and pilots that include the full gamut
of nutrition options: community based nutrition promotion programs, upgrading quality of facility based
nutrition services, protection and promotion of breastfeeding, care of sick, acutely malnourished, and
HIV/AIDs affected children, micronutrient programs, women’s nutrition, capacity building, and
information systems. There appears to have been a fairly object assessment of the performance of the
National Nutrition Program (imbedded in the 2009 operational plan). This plan shows that coverage is
relatively low and there is need for improved management, greater attention to implementation at the
periphery, and insufficient attention to supervision, quality control, and helping the operational districts
do their jobs. Their diagnosis of the problem is insufficient manpower at the national level but one
wonders whether a higher priority might be to strengthen capacity (not formal nutrition training or
conferences) at the district level.

47
 In addition to the National Nutrition Program and operational plans (supported in part by the
Bank’s HSSP project), there is also a Strategic Framework for Food Security and Nutrition in Cambodia
2008-2012 which highlights programs that affect nutrition both within and outside of the health sector.
The Health Strategic Plan 2008-2015 also places high priority on improving maternal and child nutrition.
The Nutrition Operational Plan for 2009 is currently being discussed.

It almost appears that there are too many coordinating bodies and actors working in nutrition.
One wonders how, for instance, the National Nutrition Council and the Council for Agricultural and Rural
Development coordinate on nutrition and how the lower levels of government take care of cross sectoral
coordination and collaboration. Without an on the ground assessment, it is difficult to sort out the
institutional arrangements.

Although the rhetoric in the plans and strategies emphasizes decentralization, the reality
appears to be heavily weighted toward the central level (FSN Working Group, Nutrition Group within
National Maternal and Child Health Center, Ministry of Planning, and Council for Agricultural and Rural
Development) and toward studies, policies, reports, and pilots. Perhaps this is in keeping with the
normative role of the central Ministries however a complementary effort is needed at the province
(Provincial Nutritional Coordination Committees), district, commune and village level (Village Health
Support Groups). Capacity building, moreover, seems to be heavily weighted toward large meetings and
technical content and academic training and less on management and communications.

Beyond the narrow nutrition area, the priority within development programs is on
decentralization, giving voice and agency to communes, districts, and communities. The Seila and Seth
Koma programs which have been strengthening local decision making and implementation have been
operating in the country since 2000. The upcoming rural participation and infrastructure project
proposes to improve the quality of people’s participation

Donors and NGOs in Nutrition.

Cambodia has many partners in the nutrition field including major donors and U.N. agencies
(UNICEF, WHO, WFP, FAO), banks (ADB, WB), bilaterals (EU, GTZ, Japan, USAID) and NGOs (ADRA, Union
Aid Abroad – APHEDA, Reproductive and Child Health Alliance, Cambodian Health Education
Development, CARE, CARITAS, Church World Service, Clinton Foundation, Cooperation for Prosperity,
Development Partnership in Action, Groupe de Recherche et d’exchanges technologiques, Helen Keller
International, International Relief and Development, Lutheran World Federation, Partners for
Development, Save the Children, and World Vision). The NGOs appear to work well with each other and
the government to achieve national goals. According to the CAS 2008 there is weaker coordination
among donors, government agencies, and NGOs in the health sector than in other sectors. A common
theme for most donors, however, is the need for accountability and improved governance. WHO and
UNICEF have jointly sponsored a Nutrition Landscape analysis for the country (although a report could
not be found).

WB strategy in country

The World Bank focuses on four key themes in Cambodia: improving the climate for private
sector investment, strengthening public service delivery, increasing access of local communities to
natural resources and participation in their management, and supporting greater social accountability,
particularly through support to strengthened local government and civil society activity.

48
 The CAS notes that one of the governance issues impeding decentralization is the lack of
mechanisms for villages and citizens to participate in local planning, implementation, and to hold local
government to account. Also it notes an underdeveloped accountability framework limits capacity of
civil society to articulate demand for improved accountability. Under Objective 6 the CAS notes that
service delivery facilities are unavailable for poor communities and there is a lack of accountability
systems to monitor quality and performance. Of particular relevance to nutrition within the portfolio are
the Good Governance, Empowerment for the Poor in Siem Reap, Rural Investment and Local
Government, Community Forestry and the Second Health Sector Support projects.

The Bank’s first Health Sector Support Project provided considerable support for the national
nutrition program primarily to central functions and preparatory work (community based research
necessary to develop nutrition counseling materials, for instance). The second Health Sector Support
Project (co-financed with AusAID and DfID) does not specifically address nutrition but “calls for increased
community participation, multi-sectoral responses toward improving health, and empowering
communities to hold health systems more accountable.” (PID pg. 7) and notes that “program support will
be based on the Strategic Framework on community Participation of the MOH.” Just as the Health
Sector Support Project is improving the quality of services at clinics, so a community-nutrition program
could strengthen and rationalize demand for facility-based services and draw health personnel into the
community to deliver preventive care.

The Bank is engaged in strengthening community voice and management of development

programs. Community driven development projects and community nutrition projects could enhance
each other’s performance. The community development project benefit from the hard indicators
(growth of children) provided by the community nutrition program. These indicators are not only
objective, replicable, and meaningful; they are also emotive and capable of mobilizing the community to
ensure that young children are given their best possible chance in life. Child growth provides, in a word,
an easy and effective mechanism for holding communities and the state accountable for development
programs. The community nutrition program benefits from the Platform type projects by taking
advantage of the prior community organization efforts and drawing enabling the community to draw in
the sectoral investments (land use, water, roads) needed to address the causes of malnutrition. Both
types of project would benefit from the efficiency and synergies in management and supervision. The
following Bank-financed community development projects in Cambodia could be used as platforms for a
community nutrition project:

 Rural Investment and Local Governance Projects (2) (en extension of the Seila Program)
 Land management and Administration Project
 Community Organization Project
 Empowerment for the Poor in Siem Reap Project
 Demand for Good Governance Project
 2nd Health Sector Support Project
 Civil Society Engagement and Small Grants Project

Proposed nutrition options

All roads in development assistance in Cambodia lead to decentralization, de-concentration,

accountability, and good governance. In keeping with this goal and the FSN Strategic Plan and in light of
previous experience (in Cambodia (Seila), Thailand, and elsewhere), it is proposed that the Bank
concentrate on integrating the existing community-based nutrition program into on-going community
driven development efforts. A community nutrition approach would consolidate and piggyback on

49
existing but independent community based health and nutrition programs in Cambodia (breastfeeding
promotion through Baby Friendly Communities Initiative, identification, care and referral of the sick child
through Community based Integration Management of Childhood Infections (C-IMCI), micronutrients,
infant and young child feeding, community mobilization and oversight by village health support groups,
and promotion of malaria control by village health workers) and create demand for the strengthened
facilities based health services. In addition, by monitoring the growth of children and using it to mobilize
the community in a number of sections, a community nutrition program will enable communities to
integrate services across sectors (water, agriculture, health, social safety nets, infrastructure,
governance) and provide hard data which communities can use to demand services, show accountability,
and measure impact. A community based nutrition program is completely consistent with the existing
nutrition program portfolio of the government, donors, and NGOs and fits in seamlessly with the also
strengthens the new Health Sector Strategy of the government as well as the Strategic Framework for
food Security and Nutrition. The information generated by a community based nutrition program could
revitalize the Provincial Nutrition Coordinating Committees and commune councils and provide them
with an operational planning tool and an information system and enhance national nutrition capacity by
providing opportunity for learning by doing.

50
 References

National Policy on Infant and Young Child Feeding, October 2008

Cambodia Nutrition Investment Plan. Second Annual Progress Report, 2004

Collins, D., E. Lewis, K. Stenberg. Scaling Up Child Survival Interventions in Cambodia: The Cost of
National Programme Resource Needs. Final Report 19 june 2007. USAID/BASICS/WHO.

Poverty Reduction Strategy Paper, 2002.

National Nutrition Program (NNP). Annual Operational Plan (AOP) 2009

Trip Report, Kingdom of Cambodia, August 21-31, 2007. IYCN Project. USAID/IYCN.

Impact of Global Economic Crisis on Food Security and Nutrition. Food Security Forum. 10 April 2009
(PPT presentation)

Upcoming EC Food Security Assistance to Cambodia. 10 April 2009. Food Security Forum, 39 th Session
(PPT presentation)

Cambodia Anthropometrics Survey, 2008. Initial Findings of National Survey. (PPT presentation)

DHS, Cambodia 2000

DHS, Cambodia 2005

Strategic Framework for Food Security and Nutrition in Cambodia 2008-2012. May 2008

National Strategic Development Plan 2006-2010.

Health Sector Policy 2. 2008 Annual Progress Report on the Implementation of the National Nutrition
Program and Minimum Package of Activities (MPA) Module 10. January 2008.

Cambodia. Halving Poverty by 2015. World Bank, 2006.

Picado, J.I. 2006. Final Consultancy Report. Research on Infant and Young Child Feeding Practices in Five
Provinces of Cambodia.

ADB. Participatory Poverty Assessment. 2002.

World Bank. Country Assistance Strategy Progress Report for the Kingdom of Cambodia for the Period
FY05-08. April 17, 2008.

World Bank. 2009. Sustaining Rapid Growth in a Challenging Environment. Cambodia Country
Economic Memorandum. Draft, January 14, 2009

51
 Indonesia

Nature of the Nutrition Problem

Indonesia has made remarkable progress in reducing malnutrition since the 1970s due to a
combination of economic growth, agricultural development, improvement in water and sanitation, and a
community-based nutrition program. In fact, Indonesia’s old family nutrition program (UPGK) continues
to be a model for community nutrition programs.

A significant proportion of Indonesia infants are born at low birthweight (9%) and then a growing
number of children become malnourished between birth and their third birthday. Using the new WHO
standards for 2004 data, 28.6% of preshool Indonesian children are stunted, one 24.4% are underweight,
and about 14.4% are wasted (0.9% severely so).

UNICEF concludes that Indonesia is likely to reach the nutrition MDG 29. Since 2000, however,
there has been little improvement in malnutrition (Fig 1). The uptick in undernutrition in 2005, the
current global financial crisis, and poor nutrition program performance (Friedman et al, 2006; Sciortino,
2007, Soegianto, 2008; ADB, 2007) suggest that progress has stalled.

29
UNICEF ChildInfo: http://www.childinfo.org/undernutrition_mdgprogress.php
52
 Fig. 1 Indonesia Historic Trends in Nutrition (NCHS stds)

45

40

35

30
Percent Underweight

25

20

15 Underweight
Linear (Underweight)

10

0
1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006
Year

Source: WHO Global Database on Child Growth and Malnutrition

The causes of child malnutrition in Indonesia are well-documented and predictable: suboptimal
breastefeeding, poor complementary feeding practices in children under two, high levels of diarrhea and
other infectious diseases, maternal malnutrition, and poverty/food insecurity. Taken together, these
factors explain the deterioration the relationship between age and undernutrition.

Breastfeeding has been a particular focus of attention because breastmilk is the ideal food for
children under six months and because it provides an excellent uncontaminated easily digested food
source of protein and micronutrients for children over six months. Between 2002-3 and 2007 there has
been a deterioration in breastfeeding practices.

Table 1. Breastfeeding Practices in Indonesia

2002-3 2007
Immediate breastfeeding 38.7 43.9
(within one hour of birth)
Exclusive breastfeeding under 40% 32%
six months
Median duration of 22.3 20.7
breastfeeding
Ever breastfed 96 95

Source: DHS 2002-32007

Complementary feeding is often inadequate with respect to frequency, quantity, consistency,

and nutritional quality. The 2007 DHS survey found that only 41% of children under 5 were fed
“appropriately”. There are traditional high nutritional quality foods available in rural Indonesia for
infants (tempeh and tofu; leafy greens; oil) but such excellent local foods may be supplanted by

53
nutritionally inferior purchased foods or by public food supplementation commodities (DHS 2002-3;
ADB, 2007).

Maternal nutrition is also poor. The IFLS 2000 found that 14% of reproductive aged women were
chronically energy deficient (BMI under 18.5) 30 and the 2007 DHS survey found that 2.2% reported night
blindness. Nightblindness during pregnancy is alarmingly high in W. Sumatra (3.9%), Bangka Belitung
(4.7%), E. N.T. (5.9%) and S. Kalimantan (4.2%)31. IFLS (2000) found that 18.8% of women 15-49 years of
age were anemic32 (Friedman, et al 2006) whereas the 2008 Basic Health Survey (cited in “MDG 1 Target
2”) found that 24% of pregnant women were anemic even though 80% of pregnant women were said to
receive iron supplements (Friedman, 2006). In 2007 79% of women reported receiving iron supplements
during their previous pregnancy and 29% reported receiving the recommended 90 or more tablets.

As expected, malnutrition differs between rich and poor (Table 2). According Friedman et al.
anemia is 23% among poorest quintile women vs. 15% in the highest quintile. Night blindness during
pregnancy is 3.1% among poor women vs. 0.9% among the rich. Excessive thinness in women (BMI
<18.5) is 16% among the poor and 11% among rich women.

Table. 1 Differences in nutrition status by wealth quintile

Q1 Q2 Q3 Q4 Q5
Stunting 42.7 37.2 32.9 24.3 19.6
Underweight 29.4 28.5 28.0 25.5 20.6
Wasting 11.8 10.9 11.4 9.7 7.1
Anemia (<5s) 56.3 58.6 57.4 42.8 43.7
Anemia 22.8 19.4 18.8 17.2 15.3
(women 15-49)
BMI <18.5 16.2 17.5 13.8 13.1 10.7
women 15-49
BMI >=25 14.9 18.3 20.9 24.0 26.6
women 15-49
Source: Friedman, 2006 based on IFLS 2000.

There are wide disparities among districts and provinces. The least malnutrition (low weight for
age) is found in Bali (17.3%)DKI Jakarta (18,.8%), Jabar (18.9%) and Jogjakarta (12.5%) while the worst is
found in Gorontalo (37.4%), Kalsel (30.7%), Maluku (31.2%) and NTT (36.0%) (2005 data, source WHO).
That is to say there is a nearly threefold difference between the best and worst areas. Based on 2001
Susenas data, Friedman et al (2006) found that the districts with the highest proportion of both maternal
(thinness based on mid upper arm circumference) and child (low weight-for-age) malnutrition is
concentrated in NTT, NTB, South Sulawesi and East and Central Java. The rates of child malnutrition in
the 30 worst off districts range from 31.8% in Lombok Timur to 80.6% in Barito Selatan. Maternal
malnutrition in those districts ranges from 15.8% in Bekasi to 60% in TT Utara.

Overnutrition and obesity are apparently emerging health issues, especially among urban
women, and probably contribute to the rise of diet-related chronic diseases. The 2003 data (WHO) show
that 5.9% of children under five were overweight. At the same time that 14% of women were estimated

30
Friedman et al., 2006
31
Ibid.
32
Ibid.
54
to be underweight in 2000, about 21% of women were estimated to be overweight, including 27% in
Jakarta (Friedman et al, 2006).

Some micronutrient deficiencies have been largely eliminated while others persist. Iron
deficiency is clearly the most widespread nutritional problem. The IFLS found that nearly 70% of
children 1-2 years old were anemic and undoubtedly a higher proportion of younger children would be
anemic. Over half (53%) of preschoolers over one year of age were anemic. The 2007 DHS survey found
that 70% of preschoolers had consumed iron rich foods but there are no data on coverage of iron
supplementation programs for children although Friedman et al report that such programs exist in the
eastern part of the country. With very high rates (85%) of salt iodization, it is believed the iodine
deficiencies disorders are now limited to a small number of districts where artisanal salt is produced East
Java, Bali, and southern Sulawesi).

Effect of Recent Shocks

The impact of the recent food and fuel price spikes and the global financial crisis is difficult to
gauge. While food production increased in 2008, exports of petroleum rose then fell as prices dropped.
Unemployment is rising but inflation has dropped, especially food price inflation. Perhaps because of its
experience with financial crisis in the late 1990s, he government has taken early and aggressive steps to
protect the poor during the current crisis. The National Program for Community Empowerment program
(PNPM) and a conditional cash transfer program were rapidly launched on a wide scale to get resources
down to the community level and to protect the health and education of the poorest citizens. The
impact on food security and nutrition of nutritionally at-risk groups can only be surmised. To the extent
that urban unemployment increases among the poor, one would expect to see increases in food
insecurity and possibly acute malnutrition among poor children. There are media reports of such things
but it is difficult to ascertain the magnitude of the problem.

Policies and Programs

Nutrition has been included as an important element in the five year plans since the second
Repelita in 1974. In recent national plans, nutrition has become buried in health and not accorded high
level attention. The government instituted a national policy on the marketing of breastmilk substitutes
since 1985.

Indonesia has had community based nutrition programs for over forty years and it has included
nutrition in the national policy document for almost the same period of time. The Family Nutrition
Improvement Program (UPGK), started in 1974, is widely considered to be a model for community based
nutrition programs. It focused on monthly weighting of children under five, nutrition education, home
food production , promotion of birth spacing, nutritional “first aid” (vitamin A capsules, iron folate
tables, oral rehydration salts), referral of serious problems, provision of seeds for food production, and
rehabilitative supplementary feeding. One of the most useful innovations of UPGK was the SKDN
monitoring system (S is for the total target population, K is the number of the eligibles with a growth
card, D is the number attending the last growth monitoring session, and N is the number gaining weight).
Using a combination of SKDN indicators one can supervise the program, determine coverage, assess
quality of services, and assess impact. The program had high level political support. Some particular
strengths of the UPGK were that provincial and district level coordination boards were set up to oversee
the program and that a number of ministerial level entities (health, family planning, agriculture, and
religion) were involved in service delivery. UPGK was complemented with a similar community health
program (PKMD) in which communities self-surveyed, diagnosed problems, and devised interventions.
PKMD also included nutrition and food production. These programs were mutually reinforcing and built
on the tradition of community self-help (Soegianto, 2008).

55
 Since 1986, when UPGK was integrated with a number of health services into the posyandu, it
has lost status and effectiveness as (some say because) it became more formalized as a health program
and the family planning and food production components were dropped. In particular it is notable that
the goal of Posyandu is explicitly the reduction of infant and maternal mortality (not malnutrition). As
Indonesia was departing from UPGK, however, the model was being expanded and improved in other
countries (most notably Honduras, Nicaragua, and Peru).

In recent years there has been much criticism of the nutrition component of posyandu, the
successor to UPGK, because nutrition status has failed to improve, utilization of growth monitoring has
fallen, and performance measures suggest poor implementation even as the cost has increased. Many
have blamed the decentralization of the health system for posyandu’s weakness 33. The weaknesses were
apparent, however, long before decentralization took place ((Soegianto, 2008). In fact previous
evaluations pointed out exactly what was wrong with the program but apparently efforts were not taken
to remedy identified problems. Some problems can also be attributed to the capture of UPGK by the
formal health system and, in recent years, by the addition of virtually untargeted supplementary feeding
to the program mix.

Indonesia has had in place for decades a successful vitamin A supplementation program which
has virtually eliminated severe vitamin A deficiency. Currently it distributes through Posyandu two
megadoses of vitamin A per year to preschool children and a single megadose to postnatal women and it
promotes consumption of vitamin A rich foods. Coverage in 13 provinces in 2000 was estimated to be
68.5% for vitamin A supplementation of children and 42.5% supplement coverage for postnatal women
(Friedman et al). The 2007 DHS survey also found that 68.5% of preschoolers had received any vitamin A
supplement although 87% had consumer vitamin A rich foods within the previous 24 hours. The country
has also been successful in instituting salt iodization. In the 2000 survey, 84.8% of homes used iodized
salt but only 82% of the salt was deemed to be adequately fortified.

As early as 1985 Indonesia had begun to implement portions of what came to be known as the
International Code on the Marketing of Breastmilk substitutes. As of 2004, IBFAN found that Indonesia’s
regulation of the baby formula industry was incomplete and inadequately enforced. They found multiple
examples of formula companies providing inducements to health workers and mothers and engaging in
deceptive and persuasive marketing practices. Anecdotal evidence suggests that many problems with
enforcement remain. On the brighter side, UNICEF has recently introduced a new training program for
midwives on breastfeeding (“40 hour counselors”) which appears to be both popular and effective.

Public Investment in Nutrition

The World Bank states that public health investments have risen but are still inadequate (Rokx et
al, 2009). Likewise it states that nutrition spending has risen absolutely and as a proportion of health
spending. From 144 Billion IDR and 2.2% of the health budget in 2003 to 717 Billion IDR and 3.5% in
2007. Nutrition outcomes have not risen apace. Although some might argue for greater expenditure to
address malnutrition – for instance a recent paper prepared for the World Bank 34 suggests that for $483
million from 2009 to 2015, Indonesia could halve the prevalence of underweight preschool children. --
it is equally plausible that improving the composition and quality of expenditures would have greater
impact than across the board increases. In particular, Indonesia has embarked upon a virtually
untargeted food supplementation program through posyandu which appears to reach 70% of children

33
Friedman, ibid.
34
Anon. MDG 1 Target 2: Halving Malnutrition in Indonesia by 2015. What is needed and what it will cost.
Policy Note 17 April 2009.

56
under five –one document states that “complementary meals [were] a reward [for] visiting Posyandu”
(Friedman et al, pg. 21). Food supplements in 2000 reached 76% of the highest quintile children vs. 72%
of the poorest quintile children (Friedman et al). This is clearly not a pro-poor program and it
undoubtedly distracts posyandu workers from more important counseling activities. Improvements in
the quality of national nutrition program should be undertaken before any increment in spending takes
place. Those improvements are likely to increase unit costs and total budget only modestly and, if the
food handouts were eliminated, improvement could be cost neutral. As shown in the recent Lancet
series, supplementary feeding for preschool children is not considered efficacious (Lancet series chapter
4).

Institutional Strengths and Weaknesses

Indonesia has a two-part institutional structure for nutrition, having a dedicated group in
BAPPENAS (at national level), the planning commission, which does planning and budgeting, and
Directorate of Community Nutrition (within Dept. of Public Health within Ministry of Health), which is in
charge of technical guidance and support. Each of these entities has a provincial and district counterpart
which guides (provincial) and implements (district) programs. There are supposedly nutrition sections at
the central and provincial level but little budget to work with (Friedman, et al) and many districts lack the
appropriate staff complement. Some districts no longer have a dedicated nutrition section and one
(NTT) has two separate and overlapping sections. Nutrition is but one of many roles and responsibilities
of provincial health offices and not one of the priority areas that receives budget (Friedman et al). At the
district level nutrition is one of six major health programs but lacks staff and financial resources. In
addition a semi-governmental organization, PKK, comprised of the wives of civil servants, is involved in
posyandu nutrition and other nutrition activities.

In the 1970s, the family planning program was developed independently from the health system
because it was such a high priority issue. BKKBN provided family planning separately from health
services and was extremely successful, as demonstrated by the high rate of constraceptive usage in
Indonesia.. If nutrition is an important priority for the Indonesia government -- and it would appear that
malnutrition and maternal mortality are the MDGs Indonesia least likely to meet – then perhaps growth
promotion should be set up as a separate commission or initiative, still linked to health services, but
more closely allied with community development.

According to Friedman et al one of the problems with the shared responsibility for nutrition
between planning and health is that the planning is done without good data on the nutritional status
and program performance. While in the old days the SKDN system would have provided information on
program performance, this is apparently lacking today.

Apparently the quantity and quality of nutrition staff at the national level are adequate but
province and district nutrition staff may lack training in nutrition and post bacc education. Many
puskesmas (health centers) lack nutrition staff and some of those in place are not formal permanent
employees. Training has been weak since decentralization since lower levels apparently do not place
high priority on staff development.

Since decentralization the funds flow and budgeting processes have become more opaque,less
well-coordinated, and less evidence-based. No longer do earmarks guarantee funds for nutrition. Funds
for training, monitoring and evaluation have been cut as ell. Evidence based decision making is not the
rule.

At the district level the local parliament might take action on nutrition, but usually only when
severe acute malnutrition is detected (Friedman, et al).

57
Donor and NGO Programs

The Asian Development Bank has recently started a Nutrition Improvement through Community
Empowerment (NICE) program that proposes to strengthen posyandu growth promotion as a means of
social mobilization. It is not clear how NICE and PNPM will coordinate. ADB also support water services
and health. The UNICEF nutrition program concentrates on immunization, breastfeeding promotion,
micronutrient supplements, and treatment of severe acute malnutrition. Local NGOs are active in
fortification (KFI) and a number of local initiatives. International NGOs that have nutrition programs in
Indonesia including CARE, Helen Keller International, Catholic Relief Services, World Vision, Oxfam,
Mercy Corps, Islamic Relief, and Save the Children, some of which are devoted almost exclusively to
emergency and post-emergency relief. The presence of NGOs in Indonesia is somewhat lower than
other countries due to the special history and culture of the country.

58
The World Bank’s Program in Indonesia

The Behavior Change Communications project in Indonesia was one of the first ever nutrition
projects at the Bank. Until the 1990s, the Bank continued to support nutrition projects in Indonesia but
nutrition became part of health sector projects in the 1990s. In recent years the Bank has not invested
directly in nutrition except indirectly through health sector strengthening.

The CPS 2008-2012 lays out several key principles which provide an excellent framework for
improving nutrition sufficiently to meet MDG 1 based on community mobilization. All of the five
thematic areas (private sector development, infrastructure, community development and social
protection, education, and environmental sustainability/disaster mitigation) are relevant to improving
nutrition. The private sector is critical to improving the food supply, particularly with respect to food
fortification which will be increasingly important to prevent micronutrient deficiencies in the urbanizing
populations. Water supply and sanitation are critical to reduce women’s work as well as to reduce
diarrhea, one of the main causes of malnutrition in young children. Historically community development
and nutrition were intimately linked in Indonesia and, in the present environment, this link should be
strengthened for greater effectiveness and sustainability. Malnutrition compromises educability and
school readiness even as early childhood and childcare programs comprise an important route for
preventing malnutrition in children under two whose mothers are too busy to provide adequate
nutrition and stimulation. The over riding focus of the Bank’s program in Indonesia rests on community
driven development which is precisely what is needed to improve nutrition.

The current portfolio of the Bank has a number of projects which affect nutrition and might be
actively managed to improve nutrition more systematically. These include the water and sanitation
projects, community driven development projects (various KDP projects), early childhood education, and
the proposed new support for PNPM and a conditional cash transfer.

 National Program for Community Empowerment in Urban Areas,

 PNPM Rural II,
 Community Facilitators Development Program,
 National Program for Community Empowerment in Rural Areas,
 Farmer Empowerment through Agricutural Technology and Organizations,
 KDPs,
 Community Based Settlement Rehabilitation for Yogyajarta,
 Early Childhood Education and Development Project,
 Integrating Environment and Forest Protection into the Recovery and Future
Development of Aceh,
 Community based Settlement Reconstruction and Rehabilitation Project for NAD and
NIAS,
 Community Recovery in Earthquake Affected Areas through UPP,
 SPADAs,
 Third Urban Poverty Project,
 Second Water and Sanitation for Low Income Communities project.

Unfortunately, the KDP/PNPM community grants have been limited largely to building posyandu
structures rather than improving the quality of services provided within the structures 35. In part this
reflects poor program specifications and lack of outcome focus. Using SKDN to measure outcomes and
opening up the menu of eligible community improvements while holding communities accountable for
improvements in undernutrition could provide greater impact on MDG 1. The SKDN indicators have
broad applicability, including as a rapid alert system for detecting deterioration of human welfare during
35
Sciortino, Rosalia. Maximizing KDP for Health. Sept. 2007. Consultant report to World Bank.
59
downturns (as now). Enabling the communities to communicate rapidly (for example in text messages)
the data collected monthly in growth promotion sessions (SKDN) could be invaluable for emergency
readiness and early and rapid response to emerging problems.

Recommendations for Bank Action

The new initiatives of the government, particularly PNPM, offer an opportunity to update and
revitalize the community based nutrition program and simultaneously support community driven
development. This could be effected by updating the program to reflect what has been learned
elsewhere about community based nutrition programs and imbedding growth promotion in the
community rather than health services. In particular SKDN (or an upgraded version of it) could serve the
community’s need for a “bottom line” for diagnosis, planning, proposal justification, and evaluation.
Capturing as it does healthy child growth, it is an excellent proxy indicator for poverty and community
development. Better yet, because the growth promotion kaders are from the community, this provides a
unique indicator that the community itself can collect and analyze. In fact, if UPGK had continued,
communities would be using these data today for local planning.

Specifically, the following reforms should be considered for the community based growth promotion
program (nee UPGK and now imbedded in posyandu)::

1. Strengthen and support kaders with training, improved counseling materials, , supportive
supervision, and systematic incentives.
2. Revise SKDN system to enhance the counseling component and redefine S to be all children
under 3 and N to minimum adequate weight gain (using examples from Honduras and
elsewhere)
3. Convert the current supplementary food into a cash incentive which can be used by
communities, in conjunction with other cash grants, to improve nutrition
4. Return to the model of multisectoral participation and oversight of the community based growth
promotion program. Consider creating new institutional structure for it which actively involves
Village Community Empowerment, health, agriculture, education, infrastructure, and social
protection ministries as implementing partners. .

What Next:

Further work needs to be done with a broad range of political actors in Indonesia to generate
strong public support for self-reliant and community-driven approaches to preventing malnutrition.
Plenty of evaluations have been done and made very similar recommendations. It’s time to implement
the recommendations.

The SKDN data should be incorporated into an emergency alert system which will have the
added value of signaling to the underappreciated volunteers that their work matters. ICT could be
provided to kaders or communities as a means of rapidly transmitting data and to provide status (and
possibly an income source) to the kaders.

60
 References

Sciortino, R. Maximizing KDP for Health. Sept. 2007. Consultant report.

Setboonsarng, S. Child malnutrition as a Poverty Indicator: An Evaluation of the Context of Different
Development Interventions in Indonesia. ADB Institute Discussion Paper No. 21. Jan. 2005.

Anon. 17 April 2009. MDG 1 Target 2: Halving malnutrition in Indonesia by 2015. What is needed and
what it will cost. Policy Note. World Bank. DHS Survey, 2007.

Friedman, J., P.F. Heywood, G. Marks, F. Saadah, Y. Choi. Health Sector Decentralization and Indonesia’s
Nutrition Programs: Opportunities and Challenges. Consultant Report. Jan. 20, 2006. ADB. Proposed
Loan and Technical Assistance Grant. Republic of Indonesia: Nutrition Improvement through
Community Empowerment Project. August 2007.

World Bannk. 2009. COUNTRY PARTNERSHIP STRATEGY FOR INDONESIA FY2009-2012. Investing in
Indonesia’s Institutions for Inclusive and Sustainable Development.

61
 Lao Democratic People’s Republic
Nature of the Nutrition Problem

The most recent national survey data, from 2006, show that 36% of children under five were
underweight, 48% are stunted, and 18% are wasted (8% severely so). As with most countries, nutritional
status deteriorates precipitously in the first two years of life (Fig. 1). What is notable in Lao PDR,
however, is how many children are malnourished already in the first six months of life. The prevalence of
low birth weight (18%36) reinforces this. High early malnutrition suggests that maternal malnutrition and
poor health are a root cause of child malnutrition. Maternal mortality rate is extremely high in the
country (660 deaths per 100,00037) as well as anemia (56% of pregnant women), suggesting that
improving women’s health and nutrition is critical not only for their own well-being but that of their
children. Although infant mortality has fallen substantially over the last decade (from 77 in 2000 to 59 in
2006(WB)), it is unlikely to fall much further without attention to maternal and child malnutrition. Not
surprisingly, women’s literacy is fairly low also (83% of male literacy and adult literacy is only 69% to start
with).

Fig. 1. Lao PDR Nutrition and Age, 2000 (WHO stds)

70

61.3
59.5
60 Underweight 57.8
Stunted
Wasted

50 48.5

43.2
41.4
Percent of children

40
36.7
33.2

30
25.5 25.1 24.7

20.7 20.4 20.1

19.6
20
16.8
13.5
10.7
10

0
0-.49 0.5-0.99 1-1.99 2-2.99 3-3.99 4-4.99
Age (years)

Source: WHO Global Database on Child Growth and Malnutrition

Child feeding is undoubtedly a major cause of child malnutrition. Very few newborns are fed the
nutritious antibody-rich colostrums (first milk) and they are even starved for a few days until the mature
breast-milk comes in38. Fewer than one-fourth of infants under six months of age are exclusively
breastfed, which is the ideal diet, and less than half of children 6-11 months receive “appropriate”
complementary foods39. Young child feeding is also inadequate both in its late introduction (much later
than six months of age), its poor quality, low frequency, and passive style of feeding. Only 10% of

36
Unicef ChildInfo http://www.childinfo.org/low_birthweight_profiles.php.
37
UNICEF, State of the World’s Children, 2009.
38
Gillespie, A., H. Creed-kanashiro, D. Sirivongsa, D. Sayakoummane, and R. Galloway. Contulting with Caregivers.
Using Formative Research to Improve Maternal and Newborn Care and Infant and Young Child Feeding in the Lao
People’s Democratic Repaublic. Consultant Report. Oct. 2004.
39
UNICEF, op. cit..
62
children, however, are reached by nutrition education programs 40. Bank sector work in 2004 3 showed
that women are eating poorly during both pregnancy and lactation because of tradition. It also showed
that there are many food beliefs that negatively affect women and children. At the same time, the study
showed that mothers are willing to make changes in their own diets if they will increase breast-milk
production and to their children’s diets once they know what children should eat and how much they
can eat.

In addition to the purely nutritional causes, high fertility (3.2), poor water and sanitation access
(at best 60% and 48% respectively), intestinal parasites and malaria contribute to child malnutrition.

Nutrition indicators have improved slightly over time but they are still extremely high.

Fig. 2 Lao Trends in malnutrition

60

50 48

44 1993
42.4 2000
40.4 40.4
2006
40
37.2
Percent Malnourished

30

20
15.3

10
10
6.5

0
underweight stunting wasting
Type of Malnutrition

Source: WHO, Global Database on Child Growth and Malnutrition

Good and recent data are not available on micronutrient deficiencies. In 2000 12% of women
had had night blindness from vitamin A deficiency during pregnancy, 48% of children under six were
anemic (which means that a substantially higher proportion under two are anemic), and 20% of school
children were low in iodine41 (WHO).

Since Laos is a food exporter, it does not appear that food supply is the chief cause of
malnutrition. In addition to poverty, it is the heavy reliance on rice coupled with the loss of wild foods
which provide protein and micronutrients which make for diet of poor quality.

Lao PDR is seen to be making insufficient progress toward achieving the nutrition MDG. Indeed,
weight-for-age, the MDG indicator, is barely improving. An all out effort with high coverage and multi-
sectoral interventions would be required to break the inertia on improvement in underweight.

40
REACH. Overview of country documentation Lao PDR. April 2009.
41
WHO Global Databases on Vitamin A and Iodine, respectively
63
Income and malnutrition

Although the economy has been growing at a rapid clip, poverty reduction has not kept pace.
Up to date poverty data are not available but fairly recent (2005) analysis suggests that almost one-third
of the population still lives below the poverty line (WB). Poverty is neither a necessary nor sufficient
condition for malnutrition, but it is likely that rates of malnutrition are highest among the poor. Poverty
has fallen faster than malnutrition (Fig. 3).

Fig. 3 Lao PDR Poverty vs. Malnutrition Trends

60

50

40
Percent

30

Poverty
Stunting
20 Underweight
Linear (Poverty)
Linear (Stunting)
Linear (Underweight)
10

0
1992 1994 1996 1998 2000 2002 2004
Year

Source: World Bank Poverty Assessment and WHO Global Database on Child Growth and Malnutrition.

Lao PDR is rich in both natural and productive resources, including hydropower, which it is
exploiting to the fullest … in fact over exploiting in the case of forests. The forests are a valuable source
of high nutritional quality foods for the rural poor and the destruction of forests undoubtedly affects
nutrition as well as rural livelihoods and environmental degradation. Part of the problem with food
security relates to unexploded ordinance which affects 1/2 -2/3 of the potentially productive land and
has caused disability and death. Behavior is likely to be a major determinant of malnutrition.

Geography of malnutrition

The highest prevalence of chronic and acute malnutrition is in the South, where 46% of children
are stunted and best in the Central region where 35% of children are stunted but most of the
malnourished children live42. REACH analysis suggests that most of the nutrition programs are in the
Northern region while NGOs are concentrated in the Central region. Vitamin A capsules (69%) and
iodized salt coverage (75%) are the highest coverage nutrition interventions as well as deworming for
school children. Otherwise, except for the 20% of women who receive some iron supplements through
the health system, coverage by nutrition programs is very low.

42
REACH, op. cit.
64
Likely effects of recent shocks

The impacts of the food, fuel and financial crisis on nutrition in Lao PDR is likely to be
concentrated among those employed in jobs related to exports (mining and agriculture) and tourism.
Because the Lao economy is relatively undeveloped, it is less affected by the world economic crisis than
economies more dependent upon trade. As a net food exporter, it may have been somewhat sheltered
from the food price spike. The underlying and long term nutrition problem continues to be the highest
priority.

Policies and Programs

Lao PDR passed a national nutrition policy in late 2008. This is an aspirational document that
describes the problem and establishes a number of excellent goals and processes but it lacks detail on
programs, timetables, and budgets. It lays out quite clearly the priority given to children under two and
women of reproductive age, it focuses on breastfeeding and young child feeding (especially dietary
diversity), and the need to give greater attention to ethnic minorities and remote populations. Some
notable aspects of the National Nutrition Policy are its mention of making nutrition programs culturally
sensitive, the emphasis on women’s playing an active role in planning and implementation, the principle
of other development sectors’ doing no harm to nutrition, the principle of participatory management,
monitoring and evaluation, and getting down to the village level. The document points out that the
country needs a nutritional focal point and it charges the Ministry of Health with establishing a Nutrition
Centre or Institute and the National Science Council in the Prime Minister’s Office with creating a
national nutrition council under. This suggests that institutional capacity in nutrition is weak. One hopes
that, starting from scratch, Lao PDR can avoid the problems encountered with nutrition institutes and
centers in other countries (excessive emphasis on research and new food technologies, too many
overseas meetings and graduate programs, being highly vulnerable to influence by donors, and
inadequate insertion into the operational activities in health and other sectors.)

In 1998 Lao PDR passed many provision of the International Code on the Marketing of Breast-
milk Substitutes. Also as recently as September 2008, however, researchers found that some Laotians
were giving their infants a coffee creamer in the mistaken belief that it was an infant food (based on
pictures on the label). Clear vigilance and enforcement of the Code are required.

Institutions

In the Ministry of Health the Department of Hygiene and Prevention and the MCH Center are the main
organizational entities responsible for nutrition. In addition the Center for Information and Education on
Health is involved in nutrition education. The Department of Hygiene and Prevention is currently the
focal point for nutrition. It provides technical support and normative guidance. The MCH Center in the
Ministry of Health delivers antenatal, delivery and postnatal care program in five provinces, provides
micronutrients, does nutrition and hygiene education and promotes breastfeeding. The Center for
Information and Education on Health designs, produces and disseminates IEC materials. The Ministry of
Agriculture promotes home gardens and food processing (in conjunction with the Lao Women’s Union),
livestock production, and nutrition education. The Ministry of education has a school health and
nutrition program. The Lao Women’s Union, a quasi governmental organization is involved in village
activities targeted to women in many different areas.

65
 From the REACH analysis, it would appear that the coverage of national programs is low and they
have some important building blocks of an effective behavior change communications strategy, much
work is needed to pull together the disparate nutrition programs into a coherent whole.

Donors and NGOs.

Four UN agencies (FAO, WFP, WHO, UNICEF and UNFPA), three bilateral donors, the World Bank and the
Asian Development Bank are involved in nutrition in Lao PDR. In addition, the REACH program (a joint
venture of the U.N. agencies) has recently been undertaking a stock taking exercise there as part of its
policy support and capacity building efforts. The ADB has a health sector development project in the
northern part of the country, the Primary Health Care Expansion Project, and is undertaking a pilot
project called “Developing Model Healthy Villages in Northern Lao PDR” which dedicates one “element”
(out of 8) to nutrition. But it is not clear how much attention is being paid to nutrition in that project.
Twenty-three NGOs are engaged in nutrition but apparently there is little coordination and, according to
the REACH analysis, their breadth and coverage is low. The REACH Project has not assessed the quality
of any of these programs.

World Bank Portfolio

The World Bank is focused on four key themes in Lao: sustaining growth, improving social outcomes,
capacity development, and completing the Nam Theun 2 dam. The Bank has just approved its first
nutrition project for Lao PDR, a Community Nutrition Project for $2 Million. This project will carry out a
small scale trial of combining conditional cash transfers with a community based health and nutrition
program. It will work with the Department of Hygiene and Prevention and the Lao Women’s Union on
implementation. The only thing missing from the community-based behavior change program is the use
of child growth monitoring to target counseling and supportive services. Child growth, a summary
measure of the gamut of improvements in the community (including health services but also water and
sanitation, agricultural gains, conservation of forests, and economic well-being), not only helps identify
children that need to be seen at the health facility, it also helps the community identify common
problems (e.g. water and sanitation; loss of forest foods) that can be acted upon by the community as a
whole.

In addition to the Community Nutrition Project there are many existing Bank projects which
work at the community level and could become platforms for a community nutrition program. The most
relevant projects currently under implementation are the following:

 Health Services Improvement project

 Poverty Reduction Fund Project
 Lao Environment and Social Project
 Sustainable Forestry for Rural Development Project

It would appear that the interest and will is there to support community driven development but
the public sector capacity to reach the community level is limited. The use of the Lao Women’s Union to
complement the normal public system is an excellent way to get to the local level fast. Care must be
taken to ensure their technical capability to handle the program.

Next Steps

66
The ink should be allowed to dry on the Community Nutrition Project but it will need considerable
technical assistance and oversight. It will provide valuable evidence for and experience in community
nutrition programs to fuel political support for future expansion. At the same time, it is possible to help
the GOL get ready to gear up by providing additional support for development of the program (a social
marketing strategy, communications materials, manuals, training materials, job descriptions, information
systems, etc.). In addition, it is possible that NGOs would be willing to pick up the CNP’s approach and
the LWU would be willing to take it to non-project areas (particularly those covered by participatory
community programs. Presumably, if the CNP is successful, the Bank will be amenable to financing a
national level scale up so some of the preparation could take place even as the project is getting off the
ground. Needless to say, the Laotians should also be involved in any regional learning community and
technical assistance program.

67
References

REACH. Overview of country documentation Lao PDR. April 2009.

National Nutrition Policy. December 2008

World Bank. Lao PDR Poverty Assessment Report. September 2006

Emergency Project Paper, Lao PDR Community Nutrition Project. 5 May 2009.

Gillespie, A, H. Creed-Kanashiro, D. Sirivongsa, D. Sayakoummane, and R. Galloway. Consulting with

Caregivers. Using Formative Research to Improve Maternal and Newborn Care and Infant and Young
Child Feeding in the Lao People’s Democratic Republic. October 2004.

Health Strategic Plan 20008-2015, Accountability, Efficiency, Quality, Equity. April 2008

68
 Philippines

Today, the level of malnutrition in Philippines is much higher than would be expected from its
level of income. The Philippines has probably had more and more varied nutrition programs than any
other country in the region as well as a large amount of excellent nutrition and food policy research and
technical assistance. Most of the programs proposed over time ere innovative concepts but they were
tried out only on a small scale or only for a short period of time. The hype of new programs seems not
to be matched by institutional endurance in implementation. Even today nutrition various programs
seemed to be competing with each other and may cause information overload among politicians. The
several nutrition institutions and organizations in Philippines were responsible for many of these ideas.
They appear not to have been sufficiently internalized into the mainstream government structure.

The Philippines does a far better job of measuring malnutrition than preventing it although even
measurement is a problem because the Philippines uses its own cutoffs and standards for defining
malnutrition (as it has done for poverty). The Philippines has been monitoring the national nutrition
series for many years. According to UNICEF, the Philippines is making insufficient progress to achieve the
poverty and hunger although the trend data suggest that they are not far off (Fig. 1).

Fig. 1 Philippines Poverty vs. Malnutrition Trend

60

50

40
Percent

30

wt-age
20 poverty
Linear (wt-age)
Linear (poverty)

10

0
1965 1970 1975 1980 1985 1990 1995 2000 2005
Year

Sources: World Bank Poverty Assessments and WHO Global Database on Child Growth and Malnutrition.

Although the most recent data (2003) are not disaggregated by rural/urban differences, an
earlier survey in 1993 showed that underweight rates were slightly higher in rural areas (31% vs. 28%
under weight and 35% vs. 31% in stunting). This slight difference between rural and urban malnutrition
seems odd given that poverty is much more severe in rural areas. According to the 2009 CPS, poverty
head count rates in 2006 were 19% in urban areas vs. 46% in rural areas.

Table 1. Nutrition Status (% malnourished) in the Philippines, 2003

WHO Philippine
standards Analysis
Weight-Age 20.7 26.9%
69
 Height-Age 33.8 30%
Weight-Height 6.0 5.5%

Source: WHO Global Database on Child Growth and Malnutrition and “6 th National Nutrition Surveys. Pedro MRA,
Cerdena, CM, Molano, WL, et al. 2006.

As can be seen from Fig. 2, malnutrition increases dramatically in the second and third years of
life. There is wide variation among regions with the national capital region having about 20%
underweight compared to close to 35% in the autonomous region of Muslim Mindanao (ARMM), which
generally has the worst indicators in the Philippines.

Fig. 2 Philippines 2003 Malnutrition X Age

50

45
W t-Age
Ht-Age
40 W t-Ht

35
Percent Malnourished

30

25

20

15

10

0
0.49 0.99 1.99 2.99 3.99 5
Age

Source: WHO Global Database on Child Growth and Malnutrition

In addition, the Philippines has a very high rate of low birth-weight – 45% -- which predisposes
infants to higher risks of disease, malnutrition, and death. One source in 2004 found the highest rate
(47%) being in the National Capital Region and one of the lowest in ARMM (7). 43 These data are difficult
to comprehend. As with other indicators, there are efforts to develop a national (lower) definition of
birth-weight rather than use international standards.

The crude fertility rate is high (3.4 in 2001) and conception by women before their 20 th birthday
is also high (one third of women), both factors contribute to malnutrition risk.

As is commonly the case, high rates of child malnutrition can be traced to suboptimal
breastfeeding and poor complementary feeding practices, poverty and food insecurity, infectious
disease, poor education, maternal malnutrition, and excessive fertility. In 2003 although 90% of infants
were ever breastfed, only 34% of infants under 6 months were exclusively breastfed and the mean
duration of breastfeeding was only 5.6 months. Survey data from 2003 3 found that half of all infants
were exclusively breastfeeding for less than 24 days, down from 1.4 months in 1998, and only 16% of 4-5
month old babies were exclusively breastfed. Reasons given by surveyed mothers were: not enough

43
Basics II. 2004. Newborn Health in the Philippines. A Situation Analysis.
70
breast-milk (30%), mother working (17%), and nipple/breast problems (17%) 44. Problems with
promoting and protection breastfeeding include aggressive marketing of breast-milk substitutes,
donations of formula after emergencies, insufficient enforcement of the Code, and insufficient
promotion of breastfeeding. “In the face of growing food insecurity, Maria-Bernadita-Flores (Executive
Director, National Nutrition Council) said the advocacy for breastfeeding as an anti-poverty measure
“should be strengthened and sustained.” 45

Even though 95% of preschool children supposedly receive two doses of vitamin A per year 46,
still 40% of that age group has had low or deficient levels of vitamin A in their blood 47. Most of pre-
schoolers diets don’t get enough energy, iron, and vitamin A in their diets … in fact on average they only
get about 70-80% of their needs 48. About 57% of household fail to consume enough energy to meet
their needs. Although salt is supposed to be iodized and 75% of households in a UNICEF survey in 2005
had some iodine in their salt, only 44.5% of the salt was adequately iodized.

Women’s nutritional status is not good. In 1998 13.4% of adult women suffered from wasting (BMI
<18.5) while 14.1% of females were overweight or obese 49. Close to a fifth (18% and 20% of pregnant
and lactating women, respectively) were deficient or low in serum vitamin A. Almost one quarter of
lactating mothers and 18% of pregnant women were iodine deficient in spite of a national salt iodization
program. In addition 12% of lactating women were considered chronically undernourished 50. In 2005,
28% of pregnant women were estimated to be nutritionally at-risk (up slightly from 27% in 2003)
because of excessive thinness or poor weight gain in pregnancy. . In 2006, about 40% of pregnant
women were anemic, with levels exceeding 50% in some provinces in Mindanao. An equal number of
lactating women were also anemic. Underweight pregnant women are more likely to deliver low birth
weight babies, who in turn become vulnerable to malnutrition, poor health, and delayed psychosocial
development. The prevalence of iron deficiency anemia is high among pregnant (51%) and lactating
(46%) women51.
Nearly half of pregnancies in the Philippines are unintended 52. Decentralization has
strengthened the hand of those who oppose public finance of contraception and so the rate of illegal
abortion has risen as a result. This in turn can contribute to heightened anemia in women due to
excessive blood-loss. Malaria is endemic in the Philippines and pregnant women are particularly
vulnerable. Malaria causes anemia and weekly chloroquine treatment for pregnant women has been
shown to reduce anemia in pregnant women.

Agricultural production and the population dependent on agriculture has fallen in the last
generation as the agricultural lands, which are located around the main urban areas, have been
converted to residential and commercial uses.

Recent food, fuel, and financial crisis

44
http://fex.ennonline.net/34/philippine.aspx
45
http://www.irinnews.org/PrintReport.aspx?ReportId-79274
46
State of the World’s Children, 2009
47
WHO Global Database on Vitamin A
48
Sixth Nutrition Survey, 2003.
49
FAO, 2001. Philippines Nutrition Country Profile.
50
MRA Pedro, C.M Cerdena, W.L. Molano, A. Constantino, L.A. Perlas, E.F. Palafox, L. Patalen, M. Chavez, J.
Madriaga, E. Castillo and C.V.C. Barba. 6th National Nutrition Suerveys. FNRI, DOST. PPT Presentation. 2004.
51
Sixth Nutrition Survey, 2003.
52
Paradox and Promise in the Philippines: Joint Country Gender Assessment, 2008. Asian Development Bank,
Canadian International Development Agency, European Union, United Nations Children’s Fund, United Nations
Development Fund for Women, United Nations Population Fund, and National Commission on the Role of Filipino
Women
71
 Just as the world was entering the food and fuel price spikes, Philippines was experiencing the
best economic growth it had had in decades (although this growth failed to reduce poverty which
increase slightly between 2003 and 2006). Nonetheless, the increase in the price of rice caused rioting
and panic in the Philippines. The government announced it was reducing its school feeding program to
target only the worst provinces and only the first three grades in schools in response. Being a net food
and energy importer, the price spikes were a double whammy for Philippines. Philippines clutch
purchase of rice in late 2007 is credited with causing speculation in rice which caused prices to soar.
Once self-sufficient in rice, the Philippines is now one of the world’s largest importers of rice.
Remittances constitute 10% of GDP (half from the US) in the Philippines and the global economic crisis
could reduce them substantially.

Institutions

The Philippines has one the richest and most chaotic institutional and human resources bases in
nutrition in the world. Nutrition appears to be a popular academic subject and nutritionists are
scattered throughout the public and private sectors. There are nutrition positions in the provinces and
municipalities and sometimes at lower levels but there is no obvious system for the structures. Nutrition
committees exist at the regional, provincial, municipal and barangay (village) levels although it is not
clear how well they are functioning.

The main interlocutor for nutrition is the National Nutrition Council (1974, highest policy level
nutrition body). The NNC is currently housed in the MOH, having been moved from the Department of
Agriculture in 2005, although the Departments of Agriculture and Local Government are vice chairs.
Previously the NNC was located in the Dept. of Social Welfare, which might be a better home for it now
that the 4Ps program as taken on nutritional goals. In addition to the NNC, other major nutrition actors
include the Food and Nutrition Research Institute, in the Department of Science and Technology, and the
private Nutrition Center of the Philippines, the Nutrition Foundation of the Philipplines, and the
Philippines Association of Nutrition complemented with the International Rice Research Institute (IRRI.
With decentralization since the mid 1990s, it is difficult to ascertain the chain of command in
implementing nutrition programs. For instance, it is not clear what role the Barangay Nutrition Scholars
play in the Accelerated Hunger Mitigation Program.

Implementation of nutrition interventions appears to be divided between the NNC (Barangay

Nutrition Scholars) and the Department of Health (vitamin A supplementation, food fortification,
enforcement of the Code, breastfeeding promotion and baby-friendly hospitals, and Garantisadong
Pembata a program to promote good child caring behaviors to prevent disease). The Department of
Health has recently instituted a food quality seal of approval (Sangkap Pinoy Seal Program) to identify
properly fortified foods and other nutritious foods. It is not clear to what extent this applies to foods in
general or just to those regulated by the Department/National Government.

As of 2004, there were more than 22,000 Barangay Nutrition Scholars, who are recruited,
trained, and remunerated by the NNC but the structure in which they work depends to a large extent
upon the Local Government Unit. Apparently there are provincial nutrition offices, Provincial nutrition
action officers, Municipal nutrition action officers, “regional nutrition Action Coordinators” 53, regional
nutrition program coordinators, regional nutrition committees, and LGU nutritionists (possibly but not
necessarily coordinated with or managed by the health bureaucracy) but it is difficult to obtain data on
nutrition manpower and their relationship to the health and agriculture systems. It seems that LGUs
have a great deal of discretion in whether and how they deal with nutrition. Annual awards are given to
53
http://www.pia.gov.ph/?m=12&fi=p081023.htm&no=72
72
LGUs and individual BNS for outstanding work but the criteria for selection are unclear. There are news
stories about food companies sponsoring nutrition meetings, including of nutritionists and BNS, which
raises questions about whether there are professional codes of conduct to guide activities and
recommendations of nutrition personnel.

Public Policies and Programs

In September 2004, the National Anti-Poverty Commission reviewed the social protection
programs in the Philippines. The commission recorded 111 different programs implemented by a wide
range of agencies. Of the programs, 11 were classified as safety nets, 11 as social insurance, 85 as social
welfare and assistance category, and 4 as labor market interventions. While the programs seemed to
address a wide range of risks, the Commission concluded there were major delivery and coverage
weaknesses, including program overlap resulting from poor coordination among providers and
government agencies. The commission also found targeting errors that resulted in under-coverage of the
poor and leakage of benefits to the non-poor source gender paper). Many of these programs are
nutrition programs.

In 2002 the government assed the ECCD (Early Childhood Care and Development) Act which
institutionalized an early childhood development programs for children under six. One goal was to
reduce by 40% the proportion of underweight children. An evaluation of the earlier ECD program, which
included food and micronutrient supplementation, growth monitoring, and parental education (inter
alia) low participation rates in child feeding, (although in intervention regions it increased)The
government implements food security, hunger, and malnutrition out of six departments (social welfare,
health, agriculture, education and DEPAR). While the major agencies responding to social risks of food
insecurity, hunger and malnutrition include local governments, NGOs, PCSO and NFA.

The decentralization program, instituted in 1991 through the Local Government Code, seems to
have resulted in a great deal of disorganization, featherbedding, and random motion with respect to
achieving national goals (like the MDGs). While some local governments perform well, others seem to
be devoted more to bread and circuses than to development. The solution is not to recentralize (which
wouldn’t be possible anyway) but to benchmarking performance and reform policy on devolution to
improve incentives for good governance (CAS 2009) and to educate and empower the citizenry to
become better overseers of local government. Social welfare programs in the Philippines suffer from
two problems: lack of control over local governments and failure to phase out and/or integrate
programs. The result is that there are a large number of uncoordinated nutrition-related programs in the
country and a lack of strategic follow-through on the local level. One would think that the “National Plan
of Action on Nutrition” (NPAN) would rationalize the national government’s approach and focus local
government activities on key interventions, but this appears not to be the case. According to a case
study done for the World Bank in 2003, nutrition programs have had low coverage (“typically two
percent of children) and intensity and there the government has tended to believe more in income
growth and food subsidies rather than direct nutrition programs to take care of malnutrition 54. The
current medium term development plan includes considerable attention to nutrition. The Medium-Term
Philippine Plan of Action for Nutrition (MTPPAN) strategies include: (a) prioritizing nutrition and related
services for infants and young children as well as pregnant women, especially those living in depressed
areas; (b) intensifying delivery of nutrition interventions that include micronutrient supplementation
such as vitamin A and zinc, food fortification, breastfeeding promotion, food assistance as well as food
production in homes, schools, and community; (c) improving service delivery to address nutrition

54
Gillespie, Stuart, M. McLachlan, R. Shrimpton. Combatting Malnutrition, Time to Act. 2003. World Bank.
73
deficiency; (d) stronger nutrition perspective in disaster management; (e) effective coordination among
those directly involved in nutrition interventions, among others. 55

Since 1986 (Milk Code) and 1992 (Rooming In and Breastfeeding Act) the Philippines has had in
place the full legislative suite to prevent unethical marketing of breast-milk substitutes and to protect
and promote breastfeeding but both the quantity and quality of breastfeeding and news reports of
violations of the Code suggest that enforcement is lax. Recently the Supreme Court turned nullified
several important sections of the Milk Code that prohibit promotion of breast-milk substitutes and
punish transgressors.

In 1995 Philippines past a salt iodization law which promoted iodized salt. Given the low
prevalence of adequately iodized salt, however, it would appear that enforcement is lax.

One of the Philippines early high visibility programs was the Barangay Nutrition Scholars
program, started in 1978, which trained and deployed villagers to promote healthy growth and
development in their own villages. There hasn’t been any large scale evaluation of effectiveness or
impact of this program but it continues notwithstanding. BNS volunteers (given a small monthly
honorarium) weigh village children (through Operation Timbang (not clear who is in charge)) and provide
nutrition education. Although on paper the program continues today, it has faltered due to lack of
financial, technical and moral support and the quality of the program is compromised by good
counseling messages and materials.

In 2006 the government launched the Accelerated Hunger Mitigation Program a cluster of
programs to cut hunger by half within a year (although it apparently extended beyond the year and,
obviously, did not cut hunger in half). “This program aims to answer the causes of hunger: poverty,
unavailability of food to eat, and a large family size” 56.. The program aims to improve both supply and
demand for food in the 40 (later 20) poorest districts. It includes a Food-for-School program (1 kg of iron
fortified rice for 120 days to families of children in preschools, daycare centers, and grade 1in school),
Gulayang Masa Program (an integrated backyard gardening program that provides seeds and planting
materials and livestock), increasing agricultural productivity, Tindahan Natin (providing subsidized rice
and noodles to 270,000 poor families through accredited stores in the national capital region). A
nutrition education and promoting “responsible parenthood” (small family size) are carried out in all
provinces. Port facilities and farm to market roads have also been improved as a mechanism to reduce
marketing costs. Allied programs include public works and food-for-work programs, and micro credit.

There is also a national untargeted rice subsidy program that was estimated to absorb 1.6% of
GDP between 2000 and 200557. There is some evidence that the national rice subsidy has high leakage
(one report states that 40% of it reaches non-poor households 58). Then again, Philippines have a long
history of poorly targeted food subsidies (IFPRI studies and further back). Geographic targeting is
administratively simple and inexpensive to implement. However, with universal targeting at the school
level it is unsurprising that a substantial amount of the benefits leak to non-poor beneficiaries.130 Also,
some of the poorest families are missed, as distribution only occurs through DSWD accredited day care
centers, and many of the poorer barangays do not have one. The size of the transfer is also an issue and
it is unclear whether 1 kilogram is enough to improve the pupil’s nutrition. However, there is some
evidence (from a monitoring survey of 412 homes and 52 schools in 17 provinces) to show that there has
been a positive impact on school attendance. The program is thus achieving one part of its goal by
keeping children in school in the face of poverty and hunger. Source UNICEF Gender paper.

55
http://www.neda.gov.ph/devpulse/pdf_files/DevPulse-Malnutrition.pdf
56
http://www.neda.gov.ph/devpulse/pdf_files/hunger%20mitigation.pdf
57
http://www.manilatimes.net/national/2008/apr/02/yehey/top_stories/20080402top1.html
58
http://newsbreak.com.ph/index.php?option=com_content&task=view&id=5652&Itemid=88889053
74
 Kalahi-CIDSS, financed by the World Bank, is a community grant program that empowers
villagers to prioritize and implement activities with grants from the government. It currently covers over
one million households living in poor communities in 42 provinces. Although nutrition is not an explicit
part of the program, it could be if villagers wanted it. Most recently the “4Ps” program, a conditional
cash transfer targeted to the poorest provinces and cities, provides cash transfers targeted to the poor
when they utilize specific preventive health services (nutrition not specifically mentioned) and send their
children to school. Both of these programs are run out of the Department of Social Welfare and
Development.

One of the national nutrition priorities is for preschool children to drink a glass of milk a day.
This could have the unintended effect of discouraging breastfeeding and it is a difficult message to justify
given the high cost per calorie of milk, the land intensiveness of dairy production, the availability of good
non-dairy sources of protein, and the likely high prevalence of lactose intolerance in the population.

Other Donor and NGO Programs

The Philippines has a very strong and focused “Philipppine Development Forum” (donor
consultative group). The major issues are fighting corruption and improving public performance in a
decentralized state. The working group on MDGs and social progress covers nutrition and health. The
PDF helps donors and NGOs to coordinate and work together more effectively.

USAID has a number of integrated community health and nutrition programs going on, largely
thru international NGOs (SAVE, Christian Children’s Fund, ACDI, International Aid) and has for a long time
funded vitamin A supplementation programs, largely through Helen Keller International. UNICEF is quite
active in nutrition in the Philippines, especially in breastfeeding promotion, salt iodization and vitamin A
supplementation, and the special needs of children in ARMM.

Bank Strategy and Portfolio

With an eye to community based platforms that could benefit from and support community
nutrition programs, the following projects in the Bank’s portfolio are worth noting.

 Mindanao Rural Development Project (Phase 2), which promotions participation in using a
community fund for agricultural development,
 National Sector Support for Health Reform (which focuses only on supply of health care services)
 Plus emerging support for 4Ps and
 Women’s Health and Safe Motherhood,
 ARMM Social Fund,
 Kalahi CIDSS,
 Support for Strategic Local Development and Investment projects.

The single over arching theme of the new CAS (April 2009) is weak governance. National
elections will take place in mid 2010 and are likely to exacerbate matters. The Bank’s program will focus
on poverty alleviation, governance, and getting services to the poor. Centerpieces of the Bank’s program
are the community grants program (Kalalhi CIDSS) and a CCT program being piloted now (4 Ps). Sectoral
strengthening in health and education are also important. The current Bank portfolio in Philippines
provides a strong multi-sectoral framework within which some nutrition actions could be built or
improved. In particular, the portfolio in education and (previously) ECD, the engagement in women’s

75
health, and most importantly its support for a new CCT program (4Ps) and community grants (Kalahi
CIDSS). One problem is that the Philippines is good at starting new programs but it never seems to end
old ones. The trick will be to use new programmatic responses to consolidate programs.

What is needed (and next steps)

An on-the-ground assessment is needed on existing nutrition programs. Which are providing

high quality services, which are well targeted, what is their impact, what needs to be done to make them
more effective? To the extent that the Bank and the Philippines are going to put all of their poverty
reduction eggs into the Kalahi CIDSS and 4Ps basket, the existing nutrition programs should be stopped
and divided between:
 clinic based services, delivered through LGU health facilities (treatment of severe malnutrition,
some antenatal services) and strengthened as the supply side of 4Ps,
 community based services (growth promotion, micronutrient programs, some antenatal
services, preventive health services, ECD) which are strengthened and integrated with Kalahi
CIDSS,
 institute a system for early warning of nutritional deterioration from the financial crisis (or other
unexpected eventualities). This could be incorporated into the community based nutrition
program (as is done in Indonesia).

Any nutrition program will need to review, winnow, and revise existing program materials to meet
current needs.

Opportunities for the Bank

The nutrition situation in Philippines today is similar to that in Mexico during the crisis in the mid
1990s: serious nutrition problems among the poor (and over-nutrition among the rich) coupled with an
expensive and chaotic set of national nutrition related programs with many rent-seekers and bureaucrats
benefiting from the existing programs. Mexico ended up instituting the World’s first conditional cash
transfer (Progresa) as it phased out some (but, unfortunately, not all) of its food subsidy programs. What
Mexico did not do (and what the Philippines should do) is to improve the quality of community based
and health- facility-based nutrition services. But a prerequisite for any new investment in nutrition
programs should be phasing out old programs. The Bank can help advice and guide the Philippines
through this process.

References

Paradox and Promise in the Philippines: Joint Country Gender Assessment, 2008. Asian Development
Bank, Canadian International Development Agency, European Union, United Nations Children’s Fund,
United Nations Development Fund for Women, United Nations Population Fund, andNational
Commission on the Role of Filipino Women

MRA Pedro, C.M Cerdena, W.L. Molano, A. Constantino, L.A. Perlas, E.F. Palafox, L. Patalen, M. Chavez, J.
Madriaga, E. Castillo and C.V.C. Barba. 6th National Nutrition Suerveys. FNRI, DOST. PPT Presentation.
2004.

Basics II Project. Newborn Health in the Philippines. A situation analysis. 2004.

76
World Bank. Country Assistance Strategy Progress Report for the Republic of the Philippines. June 21,
2007.

Bert Hofman. Food and Energy Price Increases and Policy Options. N.d. PPT presentation.

Cabral, E.I. Social Protection Programs of the Government. PPT presentation 20 August 2008.

HabitoC.F. and R.M. Birones. Philippine Agriculture over the Years: Performance, Policies and Pitfalls.
Paper presented at conference entitled “Policies to Strengthen Productivity in the Philippines.” June 27,
2005.

World Bank. Country Assistance Strategy for the Republic of the Philippines for the period 2010-2012.
April 2009.

77
 Vietnam

Just under half (43%) of preschool children are stunted in Vietnam, over a quarter (27%) are
underweight and 6% are wasted. Malnutrition is almost twice as serious in rural areas (29.1%) as in
urban areas (16.2%). While the disparity between rural and urban has diminished only slightly over time
(Fig. 1). Not surprisingly, the wealthy have much less malnutrition than the poor. While 46.2% of rural
and 40.2% or urban poor under-fives are stunted, 24.2% of rural and 9.2% or urban wealthy are
malnourished. Malnutrition shows the all-too-familiar deterioration in nutrition status between birth
and the second birthday (Fig. 2). Although the levels of malnutrition are high, Vietnam has made better
than average progress on reducing malnutrition in the region. In the early 1980s 51.5% of preschoolers
were underweight. Vietnam has already achieved the nutrition MDG goal (Fig. 3).

There is a great deal of variation by region (between 18 and 45%). Malnutrition is most
prevalent in Tay Nguyen (Central Highlands), the northwestern area and the northern part of the central
area. Ethnic minorities, including Hmong, are at greater risk of malnutrition.

Micronutrient malnutrition is widespread. Over 10% of preschoolers have low vitamin A blood
levels (2003) and 31.3% of women have low vitamin A levels in breast-milk. While 28.6% of under-fives
were anemic in 2005, 56.9% of the 6-12 month olds were anemic. WHO reports that 60% of pregnant
women currently take iron during pregnancy. A program to sell iron folate supplements is credited with
the reduction in anemia. As of 2000, over three-quarters (78%) of households consumed effectively
iodized salt yet iodine deficiency affected 42.8% of those tested 59. NIN estimates that 30-40% of children
under one are deficient in zinc.

Even as the country is making great progress on reducing malnutrition, signs of diet related
chronic disease are emerging. Overweight is increasing especially in urban areas where, in 2004, 16% of
the population was overweight. Hypertension is also high in cities (23% in urban Hanoi in 2001)
(Phuong, 2006)

The causes of malnutrition are suboptimal breastfeeding, inadequate infant feeding practices,
infectious disease and parasites, food insecurity and poverty. WHO reports that only 17% of infants are
exclusively breastfed for the first six months of life and only 58% of mothers initiate breastfeeding within
the first hour after birth.

Food production in Vietnam has grown substantially since the 1990s as a result of economic
reforms and investments in agriculture. As income was rising, food prices were falling and many
Vietnamese benefited nutritionally. The diet appears to be changing away from very high carbohydrates
(particularly rice) to one with more meat and vegetables. Data from the Vietnam Living Standards
Survey suggest that while the poor and ethnic minorities benefited from the quantity and quality
improvements in food availability, it appears that rising inequity meant that certain population groups
did not benefit as much from the transformation 60.

As in Laos and Cambodia, it would appear the rural Vietnamese use forests as a source of highly
nutritious foods. Reversing the deforestation of Vietnam in recent years may strengthen the food
security of people dependent upon them for foraged foods as long as good forest stewardship and
access are allowed for local people.
59
Huynh Nam Phuong, and K. Lapping. Nutrition Situation in Viet Nam and Mainstreaming Opportunities. PPT
presentation, Oct. 11, 2006.
60
Thang, N.M. and B.M. Popkin. 2004. Patterns of food consumption in Vietnam: effects of socioeconomic groups
during an era of economic growth. Eur. J. Clin. Nutr 58: 145-153.
78
Impact of the food, fuel and financial crises

In 2007 and 2008, the prices of food, fuel, housing, land, education, and health all rose. Most
likely the hardest hits were those living in urban and peri-urban areas and those relying on the market
for a large proportion of their food. Complicating the global trends, were droughts and floods and a cold
winter in food producing areas, urbanization, increased cash cropping, and poor productivity gains in
agriculture61. The global financial crisis since late 2008 will undoubtedly reduce Vietnam’s rate of
economic growth, although it will continue to be relatively good (5.5%). Its exports, textiles, food and
footwear, had fallen in early 2009 but Vietnam has maintained or even grown its market share. In
addition to falling exports, Vietnam suffered retrenchment on construction and tourism. Remittances
are not expected to drop dramatically. Unemployment is likely to rise and those displaced might well be
put into a food insecure situation but it is unclear how broad this impact will be. Although Vietnam is an
agricultural exporter, there are still many food insecure households in rural and urban settings who are
adversely affected by food price inflation (recently creeping up again) and loss of remittances from urban
and overseas family members. The government announced a stimulus package including a cash transfer
to poor households (WB 2009), exoneration of health insurance and education fees, and subsidized
credit (Grosh, 2008) but it does not appear to be on the verge of implementing any massive social safety
net programs to cope with the crisis.

Institutional Situation

According to the Mainstreaming Nutrition Initiative, there are 16 ministries involved in nutrition
and overlapping programs (both national and international) Coordination is lacking at the provincial level
and below. In some localities, Vietnam appears to be in the early transition phase from old style
leadership educated in communist countries to younger more dynamic leaders educated in the West.
Although ostensibly an open society, there are few “watch dogs” keeping the government honest.
Within the Ministry of Health, two departments have main responsibility for nutrition: Dept. of
Reproductive Health in collaboration with Dept. of Preventive Care and HIV/AIDS Prevention and Control
(for Child Malnutrition Prevention) and Dept. of Food Hygiene and Safety. The National Institute of
Nutrition is the standing agency and coordinator of the National Nutrition Steering Committee but it is
more of a technical than policy institute. Officially NIN has a network down to the grassroots level but
anecdotal information suggests that this network is weak. NIN implements the four existing nutrition
programs (National Targeted Program for Child Malnutrition Prevention, a women and child nutrition
program in 10 high priority provinces, a small community based nutrition and safe water program, and a
vitamin A supplementation program for rural and mountainous areas (total budget about $11.7 Million).
Although there are provincial level planning processes and “people’s committees”, there appears to be
some disconnect with the Central level. The National Institute of Nutrition (NIN) is a semi-autonomous
entity within the Ministry of Health. In the mid-1990s NIN implemented programs but its focus in recent
years seems to be more in research and publications. The institute has a mandate to become self-
sustaining by 2012 and as a result it appears to be willing to shift its focus to attract funding. According
to anecdotal evidence, NIN is committed to behavior change communications and targeting and tailoring
counseling messages but they lack the capacity to actually develop and implement such programs. The
political entity, the Women’s Union, appears to be a strong link for non-sectoral community mobilization.
Although reducing stunting appears to be a national priority, some of the efforts (heavy emphasis on
micronutrients, free milk at schools and promoting milk drinking in children) are hardly the most cost-
effective ways of preventing stunting.

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www.ifap.org/en/about/documents/worldfarmerscongress/foodcrisis+Vietnam.pdf
79
 It would seem that Vietnam is following the Chinese model of improving nutrition: relying
primarily on economic growth to reduce malnutrition. As noted by one observer, “a national military-
style campaign, which Vietnam excels in,” doesn’t work so well for tackling malnutrition. 62

Public Policies and Programs

Vietnam has a National Nutrition Strategy 2001-2010 in which the goal is to reduce underweight
to less than 20%, stunting to less than 25%, obesity to less than 5%, and to assure that no province has
more than 30% stunting. It also stresses the need to reach ethnic minorities 63. It is interesting to note
that in the assessment of performance of the first national nutrition strategy, the government noted lack
of coordination among sectors, that implementation was too vertical, its failure to reach the household
level with behavior change messages, and insufficient social awareness and sense of responsibility for
nutrition improvement. It also noted that trained staffs were insufficient to work at the community
level, that efforts to mobilize community resources for nutrition was not well-developed and those local
authorities don’t take responsibility for implementing nutrition activities. Notwithstanding the assertion
that “nutrition activities must be supported firstly by the local authorities,” it does not appear that much
headway has been gained on mobilizing communities for the multi-sectoral approach the document put
forth. The remedy in the 2001-2010 nutrition strategy was to assign a broad range of sectoral ministries
and other entities to a nutrition steering committee chaired by the Ministry of Health. Now there is a
Plan of Action to Accelerate Stunting Reduction in Viet Nam 2008-2013 which includes the above goals
as well as a goal to reduce low birth-weight (currently at 9%) to less than 6%. They plan to target and
tailor the plan province by province based on stunting, poverty, and geography. Reproductive-aged
women will receive multi-nutrient weekly supplements and deworming in high priority areas and
deworming and social. Marketing of weekly iron-folate supplements in lower priority areas. Pregnant
women are to receive daily multi-nutrients in high priority areas whereas the will receive daily multi-
nutrition or iron folate supplements elsewhere. Children under 2 in high priority areas are to receive
breastfeeding promotion, vitamin A supplementation, promotion of complementary feeding,
deworming, zinc supplementation for diarrhea treatment, iodized salt, and fortified complementary
foods. Children in lower priority areas will receive the same but with “different funding mechanisms” 64.
Part of the program also includes promoting food production, disaster relief, nutrition education, health
care services, and promotion of hygiene and sanitation at the family level. While the Women’s Union,
private sector, and many ministries are mentioned as cooperating in the program, it is not clear how all
these entities will work together and at what level. There are currently three national programs:
National Program for Child Malnutrition Control, a national vitamin A deficiency program and an iron
deficiency program. Vietnam, with help from WHO, has passed regulations limiting the marketing of
breast-milk substitutes. There is an infant and young child feeding program at the central level managed
by NIN/MOH but it seems that there is little implementation at the provincial and commune levels.

One of the more promising public programs appears to be MOLISA (ministry of Labor, Invalids,
and Social Affairs) National Plan of Action for Hunger Eradication and Poverty Alleviation. A social safety
net program which has a budget of $1 Billion and is intended to have food security and nutrition
outcomes.

It would appear that commune leaders have an important role to play in promoting health and
nutrition programs because they allocate budget for commune health workers and prevention programs.
The study concluded that leaders’ lack of prioritization of anemia prevention combined with supply

62
http://www.irinnews.org/printreport.aspx?ReportId=84079.
63
Dr. N.C. Khan. Plan of Action to Accelerate Stunting Reduction in Viet Nam. Presentation at Standing Committee
for Nutrition, 2008.
64
Khan, op. cit.
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problems were major determinants of women’s taking iron supplements during pregnancy. 65 For
instance, a report on iron supplement consumption by pregnant women showed that women received
more information on anemia from commune health workers

Programs from donors and NGOs

After Vietnam opened up in the 1990s, many donors rushed in and started programs but many f
them are pulling back or pulling out over the next few years (Phuong, 2006). The country has been the
host of a number of multi-donor nutrition initiatives including the “Mainstreaming Nutrition Initiative” of
the World Bank, REACH (a collaborative program of UNICEF, WFP, the World Bank and a number of
NGOs), Alive and Thrive (a Gates foundation initiative), and the WHO/UNICEF “Landscape Analysis” have
taken place or have been proposed for Vietnam. Perhaps because of Vietnam’s remarkable success with
economic growth, many donors are phasing out so at present there are musical chairs around nutrition.
Plan, World Vision and Save the Children have been implementing area development projects that
include nutrition. Although SAVE piloted a community nutrition program based on positive deviance in
the early to mid 1990s, which documented impressive impacts on nutrition, they no longer support such
a program because the process is highly demanding of both time and specialized expertise (which is
lacking in Vietnam). UNICEF has a large. ADB has been the driving force behind a national fortification
program (particularly the innovative iron-fortified fish sauce) but anecdotal evidence suggests that the
fish sauce is not popular with consumers. ADB is also engaged in infrastructure and ECD. Vietnam is a
major recipient of PEPFAR (HIV-AIDs) funds from the US government which include feeding programs
(including ready-to-eat-foods) as part of clinical treatment and for orphans and vulnerable children.
USAID is apparently looking into NIN’s producing RUTF, which would divert its attention even further
from community based program implementation. GAIN, a global public private partnership promotes
food fortification, has an active program in Vietnam as well. At the best of the Mainstreaming Nutrition
Initiative, a Nutrition Partnership Group was formed in early 2007 to “galvanize the development
community and to coordinate the nutrition programs funded by international donors and INGOs.” MNI,
of which the goal is “to strengthen key health system capacities to enable effective delivery of IYCF-
related interventions”66, is currently working with one province to attempt to strengthen planning
processes.

Some notable successes in nutrition programs have included:

 Household Food Security for Nutrition Improvement Project which was a community growth
promotion, behavior change, small-scale agricultural technology, home gardens, and small
grants. It improved infant feeding knowledge and practices and reduced 12.8% in two years.
(FAO with Ministry of Agriculture and Rural Development plus NIN, 1997-2000),
 Integrated food security project improved infant feeding practices, ante natal and delivery care
utilization, growth promotion and vitamin A supplements. (GTZ),
 Positive deviance program identified what innovative behaviors poor mothers of better
nourished children had devised and disseminated those practices through education and
cooking demonstrations. Reduced severe under-nutrition (<-3Z weight-age) from 23% to 6% in
24 months and the benefits persisted for the subsequent child born after participation ended.
Save the Children (1991-1995)67,

65
Aikawa, R, M. Jimba, K.C. Nguen, Y. Zhao, C.W. Binns, and M.K. Lee. Why to adult women in Vietnam take iron
tablets. BMC Public Health 2006, 6:144.
66
http://mainstreamingnutrition.org/vietnam.aspx
67
U. Agnes Trinh Mackintosh, David R. Marsh, and Dirk G. Schroeder. Sustained positive deviant child care practices
and their effects on child growth in Viet Nam. Food and Nutrition Bulletin, vol. 23, no. 4 (supplement) . 2002
81
  Community based behavior change program promoting maternal and newborn care, nutrition
and micronutrients, and breastfeeding promotion. Its goal was to reduce maternal and neonatal
mortality. Impact: reduced underweight from 35.4% to 27.2%, increased antenatal care visits,
increased community capacity to respond to maternal or newborn emergency and ability to
recognize danger signs. Used existing organizational system based on prevalent political
administrative structure (Save the Children),
 Integrated Child Nutrition Project in community empowerment program. Project maintained
one year after funding ended. (JICA and Save the Children, Japan).

These successful experiences suggest that community based nutrition programs can be highly successful
if they work through the existing political structure at the local level rather than indirectly through the
health ministry.

World Bank in Vietnam

Surprisingly enough, given Vietnam’s Communist history and the World Bank’s emphasis
elsewhere in the region on participation and community driven development, there is precious little
“power to the people” in the Bank’s portfolio in Vietnam. Health sector projects revolve largely around
health financing, strengthening formal facilities and capacity building. The HIV/AIDs prevention project
discusses provincial planning but nowhere do participatory local processes appear. In only four projects
in Vietnam is there any discussion of participatory processes or engaging the community in planning or
implementation (Vietnam Rural Water, through an NGO, Red River Delta Rural Water Supply and
Sanitation, Forest, Sector Development Project, and Community Based Rural Infrastructure). This is
consistent with anecdotal information that suggests central control is still very much a reality in the
country. Although fighting corruption constitutes a major focus of the CPS, there is little mention of how
“more participatory approaches” will actually be affected. The government for its part appears to have
issued a “grassroots democracy decree” but it is not clear how long it will take to become a reality. The
CPS mentions “including an empowering ethnic minorities in the development processes and mentions
giving them “voice and participation in the development processes that affect them” through four
different investments. The CPS aspires to improve participatory planning and governance but this issue
plays a relatively minor role in the country strategy (compared to, for instance, those in Indonesia and
Cambodia).

Recommendation for Vietnam

Given the large number of major donor nutrition initiatives in Vietnam, the lack of a
knowledgeable and committed Bank staff member, and the weak platform for community based
nutrition; it would be difficult for the Bank to launch a rapid and large scale nutrition effort there. The
best option might be to engage in the Nutrition Partnership Group, provide punctual support through
ongoing health, education, and infrastructure projects for opportunistic nutrition initiatives, and to wait
until the decentralization process is more mature before embarking on a community nutrition program.
To the extent that Vietnam comes forth with a new social safety net program to mediate the negative
impact of the financial crisis on the poor, which might be the best vehicle for the Bank to use to prevent
nutritional deterioration.

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Fig. 1

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