May 6 Lawrence Haddad

Child Growth=Sustainable Economic Growth: Why we should invest in Nutrition1

Sustainable and inclusive economic growth is the most powerful driver of development we know. In China, India and Brazil, economic growth has resulted in substantial improvements in wellbeing. We know that many things have to happen to accelerate inclusive and sustainable growth. Macro policies have to keep inflation and interest rates under control. Fiscal policies need to get the balance right between revenue generation and entrepreneurial incentives that generate jobs. Social policies need to maximise opportunity and address deprivation through investments in human capital. Institutions need to support governance that is participatory, responsive and accountable. But what does nutrition have to do with economic growth? A lot.

What do investments in malnutrition reduction have to do with economic growth?

A strong evidence base, mostly generated by economists, now exists to show that eliminating undernutrition in very young children can:
1. Boost GNP by 11% in Africa and Asia 2. Boost GNP even further by supercharging the demographic dividend 5. Increase school attainment by at least one year 3. Prevent more than 1/3 of child deaths per year

4. Reduce burden of disability for children under 4 by more than half 7. Make children 33% more likely to escape poverty as adults

6. Boost wage rates by 5% - 50%

8. Make women 10% more likely to own their own business when they become adults

9. Break the intergenerational cycle of poverty: stunted mothers are 3 times as likely to have malnourished infants

1. Boost GNP
Improved nutrition status leads to better economic growth. Better nourished kids, get sick less often, are in school longer, learn more in school, are more likely to be employed as adults, and are likely to earn higher wages. How does all this add up? Figure 1 shows the estimated GNP losses due to poor nutrition. It is based on the estimated relationship between wages and stature from dozens and dozens of rigorous micro and macro studies. With business as usual the study estimates it will take until 2050 for Africa to realise economic gains from improved nutrition (Asia is projected to reap the nutrition benefit from 2019). This long lag is partly because infants rescued from malnutrition take time to grow into productive adults in the labour force. But it is also because progress in reducing undernutrition has been so slow especially in Africa. Africans have a saying that the best time to plant a tree was 20 years ago and the next best time is today. We need to begin growing tall and strong children today. There is no time to waste.

See Background Paper by Lawrence Haddad, for further contextualisation of the evidence and full references for the studies drawn on. This paper was produced with the Childrens Investment Fund Foundation.

May 6 Lawrence Haddad

Figure 1: Estimated % of GNP lost due to poor nutrition, 1900-2010, and projections to 2050
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2. Supercharge the Demographic Dividend

The countries most affected by undernutrition are also undergoing rapid demographic changes. One key change is that the ratio of the working age to non-working age population is increasing (Figure 2). Figure 2: The Potential Demographic Dividend This increasing ratio has the potential to act as a spur to economic growth. More people are entering the labour force and the number of children they have to support is declining. This potential is called the demographic dividend. Most estimates suggest that a demographic dividend would add 1-3% to economic growth rates. Investments in nutrition can supercharge the potential demographic dividend in two ways: (1) the new labour force entrants will be better equipped to do well in the job market and (2) the number of children they have to support will decline fasterthe survival of healthy babies reduces the incentives to have larger families.

3. Prevent deaths and reduce the burden of disease

Undernutrition is about more than economics--it is a human tragedy. Undernutrition is responsible for at least 35% of all child deaths in the developing world. It is also the number one risk factor for 2

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May 6 Lawrence Haddad

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Figure 14: Global disability patterns by broad cause group and age, 2010

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the burden of disease in Sub-Saharan Africa (Figure 3). Undernutrition is responsible, globally, for 5 5 M 10M one half of all years lived with disability for children under the age of 4 (the dark blue column in the Artic les 5 0 M left of Figure 4). Lives are lost, potential5M is wasted, talent is never realised.
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5 2 46 1 5 6 1 6 2 1 11 5 8 5 1 5 6 5 1 Another w ay to view the world s health challenges is by comparing how different 2 232 20 2 5 18 14 11 3 1 12 13 9 1 4 7 2 2 2 0 M 7 conditions rank. Figure 15 ranks the leading causes of disability by region, using 6 5 D 3 lowin 4 5 1 0 6 8 1 1 51 33 6fruits 7 5 6 7 4 5 10 6 8 5 9 8 8 11 13 6 5 8 5 5 7 9 7 87 iet 1 4 H 9 body-mas 2 9 4 3 2 6 2 81 7 3 2 1 32 color 1 4 1 8 5 9 to 3 sindex 1 41 2 9 5 4 3 high 2 2 condition 17 2 3 ranks 14 18in a 15 region. L ow back pain M 3 indicate coding how a igh 5 1 0 H 8 fas 3 glucos 5 6 4 0 1 3 10 1 18 5 plas 7 5 3 5 7 6 4 7 1 6 10 13 11 7 4 7 7 6 16 65 1 5 igh ting ma e 7 causes the m ost disability in man y4regions of the world. This condition can inhibit 38 38 C 38 23 1 3 25 1 8 21 8 1 4 39 438 8 1 38 1 38 1 0 .0 18 32underweight 37 9 39 38 38 32 23 13 25 21 14 4 8 9 1 1 1 hildhood Ins tute for Health Metrics and people s ability to perform different types of work both inside and outside the home 24 1 4 Ambient 4 1 9 matter 1 1pollution 1 0 24 7 91 9 9 6 11 32 6 24 1 4 14 7 4 27 27 26 25 14 1 12 19 11 10 24 7 19 6 32 25 16 14 7 particulate Evalua on. The Global Burden of Disease: Genera ng Evidence, Guiding 7 7 P 1 0 6 8 9 8 5 7 1 1 7 1 1 1 5 1 5 1 6 8 4 5 5 6 6 7 7 10 6 8 9 8 5 7 11 7 11 15 15 16 8 10 hys ical inactivityand lowphys ical activity and impair their mobility. In addition to low back pain,Age neck pain and other muscuPolicy. Sea le, WA: IHME, 2013. 1 1 9 D 7 high9 1 3 7 6 1 3 8 1 5 61 4 10 1 611 1 3 1 7 91 87 11 21 9 11 13 7 6 13 8 15 14 16 13 21 17 18 11 9 iet in s odium loskeletal disorders rank in the top 10 causes of disability in most regions. Another W ar & disaster Mental & behavioral disorders O ther com m unicable 8 8 D 1 2 low 8s 1 5 8 1 2 9 12 1 0 111 39 1 38 1 68 22 1 6 8 21 1 0nutsand 8 8 12 10 8 15 8 12 9 10 13 13 16 22 16 21 iet in eeds Intentional injuries Neurological disorders Nutritional deficiencies musculoskeletal disorder, osteoarthritis, appear s in the top 20 causes of disability in 1 7 21 Iron 1 9 deciency 1 2 1 2 1 7 4 1 2 13 6 20 9 32 1 1 0 4 174 21 4 1 4 21 1 35 22 19 14 12 12 17 4 Unintentional 12 6 9 11 10 4Digestive 4 diseases 4 injuries Neonatal disorders T ransport injuries C irrhosis Maternal disorders 27 Increasingly 24 1 5 1 4 1 6 9 1 5 1 3 1 0 1 0 4 3 3 3 22 27 24 15 14 16 9 15 13 10 10 4 3 3 3 14 22 S uboptimal breas tfeeding the first 1000 day window is being not justsub-Saharan as anmunicable opportunity to prevent every regionseen except central Africa. Chronic O ther non-com respiratory diseases NT D& m alaria 23 20 H 5 ehold 1 1 from 3 s 1 2 fuels 7 1 8air pollution ous olid 1 3

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40a40 30 37 from 31 32 Brazil, 28 1 9 Guatemala, 1 8 1 8 9 8 India, 9 In set studies the South Africa 40of 38 loskeletal rank the top 10 causes of disability in m ost regions. An 38 Philippines 30 37 31 disorder 32 and 28 s 19 18 in 18 9 8 an 9 improvement 25 38 39 39 41 42 40 40 40 40 U nimproved s anitation 1 9 23 22 20 25 24 23 20 26 21 24 30 20 25 26 26 23 21 19 24 17 19 23 22 25 24 23 20 26 21 24 30 20 25 26 26 m usculoskeletal disorder, osteoarthritis, appear s inof the0.5 top 20 causes of disab 26 20 L ead expos ure of one standard deviation in the height of children under the age of 2 results in an increase 22 1 8 26 24 27 21 22 29 24 25 32 23 30 33 30 29 27 every 21 22 region 29 24 25 32 23 30 33 aharan 30 29 Africa. 27 19 19 17 20 21 22 18 26 24 D iet lowin polyuns aturated fattyacids except central sub-S highest grade attained. studies from Uganda, Tanzania, Zimbabwe and China find 28 the 1 9 28 21 school 33 26 27 1 7 38 28 34 35Other 37 36 37 21 29 23 24 15 23 28 19 28 21 21 33 26 27 17 38 28 34 35 37 36 37 28 D iet high in transfattyacids 41 42 43 41 37 32 34 34 37 33 30 31 1 7 1 1 7 8 40 40 38 40 41 41 42 43 37 32 34 34 37 33 30 31 17 11 7 8 29 grades in education attainment 41 V itaminA deciency similar losses of 0.5 to31 one due In and is one of the top t Depression is to a mnutrition ajor cause ofdisadvantages. disability across regions 33 31 23 29 32 28 29 33 34 26 33 29 29 29 31 34 33 32 28 32 33 31 23 29 32 28 29 33 31 34 26 33 29 29 29 31 O ccupational particulatematter, gas es , and fumes 30 causes of disability in every region except high-incom e Asia Paci c, w here it r 39 Guatemala, 39 39 39 29 children 29 28 25 not 35 stunted 27 31 28 at 21 36 1 3months 1 0 1 4 of age attained more than 3 extra grades in school. 37 37 36 37 39 39 39 39 39 29 29 28 25 35 27 31 28 21 13 10 14 31 Z incdeciency 26 27 37 26 1 7 25 32 30 28 20 27 26 26 32 32 34 fourth. This disorder can cause fatigue, decreased ability to w ork or at tend sch 28 31 31 that 19 33 26extra 27 37 year 17in25 32 30 leads 28 20 to 27 increases 26 26 32 32 32 studies 26 D iet high in s ugar-s weetened beverages We know from education an school in 34 lifetime earnings 25 26 30 28 30 37 30 26 29 30 29 35 31 26 31 27 suicide. Anxiety, m ental disorder , is one of the top 10 c 30 and 37 30 26 29 30 29 a different 35 31 26type 31 of 27 33 26 25 22 21 30 25 26 30 28 C hildhood s exual abus e 42 of 4120-30%. 42 42 40 Even 31 36at35 30lower 29 34bound 24 27 (because 1 2 9 1 2 there will be better stronger learning even if years in the 41 41 40 38 40 42 41 42 42 40 of 31disability 36 35 30 24 27 Additionally, 12 9 12 tw o other m ental disorder s, schizop in m29 ost 34 regions. 34 U nimproved water s ource 30 28 25 30 33 35 35 36 34 32 36 37 38 35 37 33 21 20 25 26 24 30 28 25 growth 33 and 35 35 36 first 34 32 36 appear 37 38 35ong 37 33boost 30 35 L ow bone mineral dens ity school do not increase) improvements in child in the 2 years of life will lifetime bipolar disorder, am the top 20 causes of disability in m an y re 35 35 33 33 31 34 31 32 36 35 37 36 34 30 33 32 33 35 34 36 35 35 35 33 33 31 34 31 32 36 35 37 36 34 30 33 32 36 O ccupational nois e 32 earnings 34 27 38 by 35 10% 38 33 through 40 38 40 39 education 41 37 41 route. 42 42 this 31 26 29 31 34 32 34 27 38 35 38 33 40 38 40 39 41 37 41 42 42 37 O ccupational carcinogens 29 43 36 34 37 31 30 37

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conditions rank. Figure 15 ranks the leading of at disability by region, usi fourth. disorder can cause fatigue, decreased ability to causes work or tend school, 20 22 This 7 26 16 25 1 20 19 22 23 21 21 31 12 22 22 20 17 color coding23 to indicate how high a22 condition ranks in a region. L ow back pain 1 7 20 21 24 1 9 and suicide. a 24 different of mental disorder, 18 14 Anxiety, 24 17 22 20 type 26 23 17 24 17 21 19 is one of the top 10 causes 15 causes the m ost disability in m an y regions of the w orld. This condition can inh 31 28 15 28 15 18 29 9 27 19 15 27 24 25 27 28 31 28 28 7 of disability in mostpeople regions. Additionally, othertypes mental disorder schizophrenia s ability to performtwo dif ferent of w ork both s, inside and outside the 1 8 21 20 22 23 25 21 23 26 22 27 19 25 23 21 25 14 18 20 23 and bipolar disorder, appear am ong the top 20 causes of disability in man y regions. 36 34 36 and im pair their m obility. In addition to low back pain, neck pain and other m u 19 15 16 16 25 28 20 18 28 22 22 33 21 33 36 34 36

5. Boost employment, wage rates and help to escape poverty

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0 F igure 5: R is k factors eas e, 2010 s a bility-a djus te dlife -ye a rswe re not qua nti e d. ranked by attributableburden of dis R e gionsa reorde re dbyme a n lifee xpe cta ncy. No da ta =a ttributa bledis a bility-a djus te dlife -ye a rswe renot qua ntie d.

Are 28% more likely to undertake work classified as skilled or white collar For men, a one-standard deviation increase www .the la nc e t.c om Vol 380 D ec ember 15/22/29, 2012 in height- for-age at 36 months for boys raises 2248 www.the la nce t.com Vol 380 Dec ember 15/22/29, 2012 hourly earnings by 20 percent For women, a similar increase raises the likelihood that they operate their own business from which they derive an independent source of income by more than 10 percentage points. Are one third less likely to live in poor households as adults

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May 6 Lawrence Haddad

In addition, a one-standard-deviation increase in height-for-age of infants raises the per capita consumption level of the household that they live in as adults by nearly 20 percent. An earlier analysis of the same data finds male wage rates 46% increase for men who received the nutrition supplement as infants.

6. Break the poverty links between generations

Undernutrition reverberates through lifetimes, but also across generations. Short mothers are 3 times as likely to have children who are stunted by age 2. Short mothers were themselves more likely to be stunted, and so the negative legacy of malnutrition is unwittingly passed down the generations. Ending infant malnutrition breaks the cycle of malnutrition for life -- and for good.

Undernutrition can be Virtually Eliminated in the Next 20 Years

There has been progress in reducing undernutrition, but it has been too slow. Between 1990 and 2011, 21 years, the world cut stunting in children under 5 years old from 40% to 26% (UNICEF 2013). This is about 0.67 percentage points a year. If we can increase this rate of decline by 50% we can get global stunting to under 10%. Double the rate and global stunting is almost eliminated. However, something dramatic will have to happen in Sub Saharan Africa. Here the decline was very slow--from 47% to 40% over the same period0.33 percentage points a year. At a business as usual rate, sub-Saharan Africas stunting rate would only be reduced from 40% to 34% by 2030. If we can double the rate of decline for Africa we can get stunting rates down to 30%. Triple the rate of decline and we can halve stunting in sub Saharan by 2030.

Which Nutrition Investments Will Perform?

For the rates of decline in stunting to accelerate, we need to scale up investments in nutrition. These investments represent good economics. As Figure 5 illustrates, the benefit cost ratios (BCR) of investing in proven nutrition interventions are large, ranging from 4-54 with a median of approximately 20. These ratios compare favourably to BCRs from other investments2 in: large scale irrigation, with BCRs in the 10-50 range, water and sanitation with BCRs in the range of 2-3, and road infrastructure with BCRs of 11-61.
2

See background paper by Lawrence Haddad, IDS

May 6 Lawrence Haddad

What are the nutrition investment opportunities? There are three broad sets: those investments that have a nutrition as a prime objective, those that have nutrition as one of several objectives, and those that have the potential to accelerate nutrition even though nutrition is not an objective. Investments that have nutrition as a prime objective include (1) the introduction of key nutrients such as vitamin A, Iodine, Calcium, Zinc and Iron into the diet, either through the fortification of widely consumed foods or through supplements, (2) the promotion of breastfeeding as the best and only source of food for a child in the first 6 months of life and then the production of nutritious foods to complement breastfeeding between the ages of 7-24 months, (3) the treatment of the most extreme forms of undernutrition through therapeutic methods and (4) handwashing and other hygiene interventions. From independent rigorous evaluations these interventions have been proven to be effective. If scaled to 90% coverage they would eliminate one quarter of all undernutrition. Investments that have nutrition as one of several objectives include investments in the area of agriculture, safety nets and water and sanitation that have specific nutrition goals. When targeted to pregnant and lactating women and to children under the age of 2 who are most poorly nourished, these programmes deliver improved nutrition. More investments in these areas are good for nutrition as well as the other objectives such as producing more food and reducing poverty. Investments with potential to improve nutrition, but no specific nutrition objectives. These include many general agriculture and safety net investments. If they improve nutrition status, they do it inefficiently. Here, investment is not the key constraint to improved performance for nutrition, design is. With the right design features, these investments could complement the impacts of the first two set of interventions on nutrition status.

Improving Nutrition: the Ultimate Natural Resource Discovery

In recent years, many countries with high burdens of undernutrition have made significant natural resource discoveries. Often these natural resource discoveries do not easily get transformed into improved development. Without strong institutions, resources can be captured or invested in a short term way: the so called resource curse. Norway probably represents the best conversion of natural resources (oil) into GNP. Estimates suggest it took about 10 years after oil began to come online to increase its GNP by 11% over what it would have been without oil. For many other countries it would have taken longer. This 11% is the same as the economic losses due to current levels of undernutrition (Figure 1). In effect, stunting reductions would be the economic equivalent of a series of massive major natural resource discoveries. They would cost less to discover and would automatically be converted into durable life long investments. There would be no resource curse with stunting reductions--quite the opposite. Countries with high burdens of undernutrition need to speed up their stunting reduction if they want to accelerate economic growth, realise their demographic dividend and experience a massive human resource discovery. 5