A

strategy
to
reduce
malnutrition
Nutrition is a basic human need, one that continues, and will
continue, to remain unfilled for vast numbers of people in the
developing world. This article discusses the need for
nutrition-oriented food policies—a promising vehicle for a
major attack on the problem.

Alan Berg Accepting nutrition as a basic human need

has major implications for the way in which
the problem of malnutrition is perceived
and addressed. Such an approach empha-
sizes the importance of adequate nutrition,
both as an objective and as a means of eco-
nomic development. Moreover, it calls at-
tention to the nutritional needs of people
of all ages and both sexes—in contrast to
the tendency of most national nutrition
planning to focus almost exclusively on the
needs of children and pregnant and lactat-
ing women. This article addresses these
implications in the light of recent nutrition-
related research and experience.
Among all human needs, the need for
food is perhaps the most basic. Adequate

This article is based upon a longer paper, pro-

duced by the author for the World Bank.

Finance & Development I March 1980 23

©International Monetary Fund. Not for Redistribution
 nutrition is central to survival and is a crit- mistic (and perhaps least likely) set of as- ond, by adjusting consumer prices in ways
ical factor in an individual's growth and sumptions—high income growth and stable to assure that the poor have access to what
capacity to function in society. Even in food prices—the projections of the magni- they need.
normal, nonfamine conditions, inadequate tude of malnutrition in the five countries Every government now influences, in a
food consumption significantly affects the studied show a sharp reduction by 1995 in variety of ways, the quantities and kinds of
death rate. If adults fail to meet their food both the proportion of the population that foods being produced, traded, and con-
requirements, they lose weight. This can is undernourished and in the magnitude of sumed. Yet the nutritional effects of agri-
lead to diminished ability to cope with in- its deprivation. But even then, the absolute cultural and food policies generally are in-
fection and other environmental stresses, number of the undernourished remains adequately planned or anticipated. Few
to work, to enjoy the normal satisfactions over 150 million in these five countries. countries have systematically collected—or
of life, and to raise and educate healthy With high income growth and, as is more used in their planning—data on the nutri-
children. Maternal malnutrition during likely, slightly increased food prices, the tional consequences of changes in incomes
pregnancy results in low birth weight of number of malnourished would fall by only and in food prices. Fortunately, several
infants (the most important cause of infant about 1 per cent per annum from current countries (for instance, Brazil, India, Indo-
mortality), and malnutrition during lacta- levels. And with more pessimistic (and, nesia, and the Philippines) have begun
tion affects directly and indirectly the in- unfortunately, not implausible) assump- disaggregating food consumption data by
fant's health, as well as the mother's. tions, the number of malnourished would income group. These data, along with re-
Undernourished children are less active increase significantly. Projections based on cent analyses and project experience, sug-
than they should be. When a child's intake the actual recent experience of these coun- gest several key considerations for the de-
of food falls below 70 per cent of standard tries show that only Pakistan could expect sign of food policies aimed at improving
allowances, growth slows; if low levels of to have calorie adequacy within the next 30 nutrition.
feeding persist, adult stature is reduced. years. First, families with very low incomes
Whether small size per se is disadvanta- One key conclusion of this analysis is spend most of their incomes on food, but
geous is arguable. However, severe mal- that increases in income and in food pro- still often do not consume enough for nu-
nutrition associated with decreased growth duction are likely to fall far short of what is tritional adequacy. In many countries, more
also results in decreased brain size and cell required to meet basic needs in nutrition. than 40 per cent of the population have
numbers and altered brain chemistry. Even A specific strategy to improve nutrition is calorie-deficient diets, and upward of 15
when malnutrition is not severe, decreased thus required to complement what a policy per cent have gross deficiencies. Second,
growth is associated with low scores on focused only on growth would be too slow the foods they buy differ markedly from
tests of cognitive and sensory ability. Small to accomplish. those bought by the rest of the population.
stature caused by early malnutrition has In Indonesia, for instance, the lowest three
been directly related to poorer productiv- Policy considerations
income deciles obtain about 40 per cent of
ity. Recent studies of work performance of Emphasis here is on the relatively ne- their calories from cassava and corn; by
sugarcane cutters concluded that taller glected, deliberate use of public policy to contrast, the upper three deciles obtain
workers were more productive at all ages influence the character of production, pro- about 14 per cent of their calories from
than shorter workers. Work output in in- cessing, and distribution of food within a these foods. Third, and contrary to com-
dustry has also been linked to body size. country to increase the amount consumed mon assumptions, poor people tend to have
Improved nutrition, and the survival and by the poor. This can occur in two ways. an adequate balance between protein and
well-being it implies, is a sufficient justifi- First, by changing the strategy of agricul- calories in their diets, even when an im-
cation for a country to invest in better nu- tural production to put more emphasis on portant share of their calories comes from
trition for its population. In addition, re- the nutritional needs of the poor; and sec- low-protein starchy staples. Regrettably,
ducing or preventing malnutrition and its they are not always so rational when it
deleterious effect on work capacity and comes to the distribution of food to the
cognitive ability adds to human capital Alan Berg very young of their families.
and potentially increases output. Programs Fourth, while many of the malnourished
that improve the nutritional status of the are small farmers and their families, the
poor also help to achieve other social goals, majority are landless or near-landless ag-
including the distribution of income, and, ricultural laborers, those in other low-paid
through their impact on nutrition-related a U.S. citizen, joined the rural nonfarm or urban jobs, or the unem-
Juan Rossel for F&D

mortality, help reduce desired family size. Bank staff in 1972 and is ployed. They thus benefit only indirectly
now Senior Nutrition from programs designed to boost the pro-
Strategy needed Adviser. Before joining the duction of small farmers. Fifth, within any
The common official response to the Bank, he was a Senior country, the extent of deficiencies tends to
problem of food and nutrition has been to Fellow at The Brookings vary substantially between regions and be-
grow more food. More recent analysis, tak- Institution, Visiting Professor of Nutrition at the tween rural and urban areas. The varia-
Massachusetts Institute of Technology (M.I.T.), and
ing account of low demand or purchasing tions that occur partly reflect differences in
worked from 1966 to 1970 on nutrition problems in
power among the poor and malnourished, India. His publications include The Nutrition
incomes and tastes. They also reflect dif-
has also emphasized the need to increase Factor: Its Role in National Development ferences in prices resulting from differ-
their incomes. The relative importance of (Brookings, 1973), Nutrition, National ences in transport, production and storage
food production and income, and the effect Development, and Planning (M./.T. Press, 1973, costs, marketing margins, and government
that improvement in either would have on as senior editor), and was responsible for the pricing policies. Often nutritional ade-
the level of nutrition in a country, have nutrition section in The World Food and quacy of diets also varies a great deal by
been projected by Bank staff from data Nutrition Study (National Academy of Sciences, season and by year. Seasonal deficiencies
available on Bangladesh, Brazil, India, Mo- 1977). tend to be severe in countries with only
rocco, and Pakistan. With the most opti- one major harvest, where price rises gen-
24 Finance & Development I March 1980

©International Monetary Fund. Not for Redistribution

erally coincide with seasonally low earn- crease incomes of the poor, are the key ele- confirmed statistically. It was seen most
ings for agricultural laborers. Recent stud- ments in meeting nutritional needs in the dramatically in 1974, when ration supplies
ies confirm that the highest incidence of longer run. In the intervening (and often were sharply reduced and food prices on
malnutrition often occurs at this time. lengthy) period, measures are required to the open market sharply increased because
Introducing a concern with nutrition into reduce the prices the malnourished pay for the cost of imported food grains more than
food policy calls for a broad review of ag- their food. This generally involves the often doubled. In that year the death rate in-
ricultural production strategies. Most im- contentious issue of food ration and sub- creased significantly. The literacy rate had
portant is the need for more emphasis on sidy programs—or food demand pro- not changed, nor had the proximity to
the production of those low-cost foods grams. Such programs raise budgetary, health services or the quality of the water
consumed primarily by the poor. In Col- balance of payments, and agricultural pric- supply. There was no plausible reason for
ombia, a 10 per cent increase in the supply ing problems. Rationing programs are also the increased deaths other than the short-
of beef could add three times as many cal- difficult to administer, and they may build age of food. Programs to provide the poor-
ories to the daily diets of the already ade- up political constituencies that make them est with subsidized food grains in Kerala
quately nourished group as to the diets of difficult to cut back. It is not surprising that (India) and Pakistan also appear to have
the calorie-deficient group. In contrast, the many development analysts have believed had a positive impact on nutritional status.
In most developing and developed
countries, food is, politically, a special
commodity. There is ample evidence that
"Nutrition-oriented food production programs, redistributing incomes is politically diffi-
in conjunction with steps to increase incomes cult. However, many countries that are
of the poor, are the key elements in meeting unwilling to transfer income to the poor
nutritional needs in the longer run." are willing to transfer large sums to subsi-
dize staple foods.

that ration and subsidy programs are much Target food programs
benefits of a 10 per cent increase in the pro-
duction of cassava would be received en- more a part of the development problem Food subsidies can be expensive, how-
tirely by the calorie-deficient group. Em- than a part of the solution. These programs ever. For example, in 1975 their share of
phasis on foods favored by the poor should are, however, one of the few ways to meet total budgetary expenditure was 21 per
extend to every aspect of agricultural strat- the basic nutritional needs of very large cent in Egypt, 19 per cent in Korea, 12 per
egy, including research, extension ser- groups of people. Experience in several cent in Morocco, and 16 per cent in Sri
vices, supply of inputs, credit facilities, countries shows that such programs can Lanka. To keep costs down, subsidies must
and marketing. effectively reach the poor and substantially be specifically aimed—or "targeted"—at
Effective programs aimed at improving reduce severe malnutrition and malnutri- the nutritionally needy. Otherwise, the
the production of small farms will gener- tion-related deaths. programs are likely to run short of funds
ally improve the diets of small-farm house- The nutritionally most successful (and fi- and supplies just when they are needed
holds, whether or not the programs di- nancially one of the most costly) food de- most, as Sri Lanka's program did in 1974.
rectly increase the production of the food mand program has been carried out in Sri Had the subsidies been directed more at
crops they consume. However, changes in Lanka. A 1970 survey shows that the rice the poor, as they are now, the increase in
agricultural cropping patterns or policies ration program (which then provided rice mortality could have been substantially re-
can sometimes have unexpected deleteri- to nearly the whole population) provided duced.
ous effects on nutrition. When a farm shifts about 20 per cent of total caloric intake and Target groups of malnourished can be
production from subsistence to cash crops, had a value equivalent to 14 per cent of in- identified in a number of ways—by in-
total income may increase but heads of come for the lowest income group. Only 5 come, by region, by season, by age, and by
households may not provide to their fami- per cent of the (adult-equivalent) popula- the staples in their diet. Income is probably
lies as much food as before, since it must tion consumed less than 1,900 calories per the best means of indicating where nutri-
now be bought at retail prices. This partic- day. In 1975, life expectancy was 66 years, tional problems on a large scale are con-
ularly affects young children and women, higher than in richer countries such as Bra- centrated. However, imposing a means test
who generally come at the end of the fam- zil, Korea, or Malaysia, and the highest in to define the target group is difficult, both
ily food line. Intensive nutrition education relation to income level of all countries for politically and administratively. Another
or plans to continue some subsistence pro- which data are available. It was 39 per cent way is by geographic area—a part of Col-
duction may be needed to avoid the dan- higher than would have been predicted for ombia's nutrition program, for instance,
gers inherent in such shifts. Similarly, when Sri Lanka's income level; infant mortality provides foods to specific age groups living
agricultural prices are increased as an in- was 67 per cent lower. in specified needy geographical regions,
centive to increase production, wages for How far is nutrition responsible for Sri regardless of income level. A promising
unskilled laborers, which are often at bare Lanka's long life expectancy and low in- but generally unexplored means of target-
subsistence levels, are generally slow to fant mortality? Sri Lanka also has a tradi- ing is by season. Countries with subsidy
rise in step, and the transitional effect on tion of assisting the poor in meeting other programs during the months when food
nutrition may be severe. It can be alle- basic needs—its literacy rate is 78 per cent, prices normally are highest will cover the
viated through wage policies, short-term health services are good, and the water periods of severest nutritional vulnerability
subsidies, or other food demand pro- supply is better than that of most other and of highest demand for expenditures of
grams. poor countries. Clearly such achievements human energy.
in meeting basic needs complement one Most target programs require rationing
Food demand programs another. But the direct relation between to avoid large-scale misuse. But when poor
Nutrition-oriented food production pro- food supply, nutritional adequacy, and the households constitute the target group, the
grams, in conjunction with steps to in- low death rate in Sri Lanka has also been need for rationing, with all the administra-
Finance & Development I March 1980 25

©International Monetary Fund. Not for Redistribution

tive work it entails, can be reduced, or transfer to the poor, it cannot be assumed are dependent on food production, as
even sometimes eliminated, by a careful that the funds not spent on food are farmers or farm laborers, for increases in
choice of the commodities to be subsi- wasted. People poor enough to have seri- their incomes.
dized. The best foods to subsidize are those ous nutritional problems in their families New attention is needed on developing
with a low cost per calorie or gram of pro- tend to spend more than half of their in- nutrition-oriented agricultural production
tein and with a positive income elasticity comes on food, and most of the rest is policies and programs. And to ensure that
for the poor and a low or negative income spent for other basic needs like shelter and • food reaches those in need, increased em-
elasticity for others. Coarse grains like sor- clothing. phasis is required on food demand pro-
ghum and millet, processed cassava flour, Target programs involving ration shops grams, including the strong possibility in
and certain food legumes favored by the or food stamps raise formidable institu- some cases of food subsidies aimed at spe-
poor (for example, macassar beans in Bra- tional problems. There is bound to be a cific target groups. Such programs should
zil, lentils in central India, black gram in good deal of bureaucratic inefficiency, and not be dismissed a priori because of past
south India) meet these criteria. They are the power of rationing officials to grant or fiscal and other problems associated with
generally consumed in lower quantities by withhold ration cards is an invitation to untargeted programs. (Nor should they be
middle-income and upper-income people, widespread corruption. But if administra- seen as a panacea for solving nutrition
so that a subsidy primarily would benefit tive costs do not wipe out food savings and problems; initial emphasis should be on
the poor. Such subsidies have rarely been if they appear to be proportionately lower experimentation and careful monitoring.)
tried. Most subsidies of staples have, in than those of other nutrition or poverty- These newer areas of policy emphasis
fact, been for high-status grains like wheat oriented efforts, such a program will be complement more commonly used, but
and rice (which have been widely available better than one that is not targeted at all. limited, ways of reducing the malnutri-
tion—nutrition education, the fortification
of staples with micronutrients, institu-
. . malnutrition is not just a poverty problem . . tional feeding programs, and the use of
health services to support nutrition pro-
countries committed to eliminating most overt grams. Different countries will have differ-
malnutrition appear capable of doing so. " ent program priorities, depending on the
distribution of malnutrition between rural
and urban areas, the extent to which the
in concessional foreign food aid programs) The potential disincentive to domestic rural malnourished are small farm families,
with the aim of reaching the urban lower- agricultural production that ration and the particular nutritional problems and their
middle and middle classes. subsidy programs pose is also a wide- causes, the likely cost-effectiveness of fea-
The malnourished can also be reached spread concern. Steps governments take to sible interventions, institutional and fund-
by subsidizing inferior qualities of a given reduce the balance of payments and fiscal ing capacity, and political constraints.
staple. For example, a subsidy on low- costs of the programs can lead to a net re- Children under three with problems of
quality rice (short-grain, with a high per- duction in the prices farmers receive for low birth weights (largely addressed
centage of broken grains) will have more their products and, hence, to a reduction through the mother) and those in the first
effect on the diets of the poor than a sub- in their output. The need to provide incen- year of life deserve priority attention, be-
sidy on higher quality rice. So-called com- tives for domestic agricultural production cause of the effect of early malnutrition on
posite flours (such as a mixture of cassava is increasingly accepted in developing subsequent life. But nutrition needs also
with wheat and soy flours) could have nu- countries, although the incentives are fre- exist among older children, the aged, and
tritional benefits as well. Subsidizing a quently inadequate and remain a serious working adults, who are able to produce
particular commodity—for instance, pro- problem. Food demand programs should more income and food for their families if
cessed weaning foods or special fortified be designed to take adequate account of they are better nourished. Even if planners
foods for pregnant women—can tend to disincentive risks. were concerned only about reaching chil-
limit beneficiaries of the subsidy to vulner- dren, it often would be more cost-effective
able groups. Priorities to reach them through programs affecting
Several high-priority areas for country malnourished households as a whole; in
Problems nutrition strategies emerge from this anal- many countries, a large percentage of mal-
Even food demand programs aimed at ysis. Accelerated growth in the incomes of nourished children at vulnerable ages can-
specific target groups will have substantial the poor and, with very few exceptions, in not be reached effectively in any other way.
leakages to people outside the groups and food production continue to play funda- The whole problem of the malnourished
through substitution when intended ben- mental roles in efforts to meet nutritional can be viewed as part of a complex tangle
eficiaries reduce their food expenditures or needs. While growth in income and in food of poverty; clearly, the fundamental causes
sell subsidized food. Such substitution may production is not a sufficient condition for of poverty loom large in any analysis of the
cause the program to become, at least meeting basic needs in nutrition, it is a problem. But malnutrition is not just a
partly, a disguised income transfer. There necessary condition. Without this growth, poverty problem. While virtually all people
is little empirical information on the exent the poor will afford less food and govern- suffering from calorie deficiencies are poor,
to which this happens. Only one study has ment revenues will not increase enough to not all poor people suffer from calorie or
rigorously compared the effect of a ration finance nutrition and other programs. other nutritional deficiencies. Some coun-
program on caloric intake with what would Similarly, there must be rapid increases in tries with high per capita incomes have
have occurred with an equivalent income food supply to meet increases in popula- considerable malnutrition, and certain low-
transfer; it found the nutritional impact of tion and in per capita incomes. Otherwise, income countries have little. In short,
the ration program in Kerala to be substan- the relative price of food will go up, at least countries committed to eliminating most
tially greater. But even if a program turns partly offsetting any increases in incomes overt malnutrition appear capable of doing
out to be primarily a disguised income of the poor. In addition, many of the poor so. HD
26 Finance & Development I March 1980

©International Monetary Fund. Not for Redistribution