Reference Document No
Addressing undernutrition in external assistance
An integrated approach through sectors and aid modalities
Prepared by France, Germany, Ireland, Poland, the United Kingdom and the European Commission
This document has been prepared by the Nutrition Advisory Service: Claire Chastre, Lola Gostelow, Dominique Blariaux, Yves Martin Prével, Carlos Navarro, Lawrence Haddad and Cristina Lopriore.
The preparation of the document has been coordinated by, and has benefited from, inputs made by representatives from France, Germany, Ireland, Poland and the United Kingdom as well as various services from the European Commission.
In light of the experience in drafting this Reference Document, modifications and adaptations will be made as and when necessary. To help with this work, comments, questions and suggestions are welcomed and should be sent to EuropeAid at the following email address: DEVCO-Nutrition-Support@ec.europa.eu
This and other related documents can be downloaded from: http://capacity4dev.eu/topic/fighting-hunger
Table of contents
executive summary iii
chapter 1: introduction 1
1.1 purpose and scope of the reference document 2
1.1.1 Using the reference document 3
1.1.2 Understanding malnutrition and undernutrition 3
1.2 UNDERNUTRITION AND ITS CONSEQUENCES 5
1.2.1 The consequences at individual level 5
1.2.2 Consequences at national level 6
1.2.3 Consequences at international level 6
1.3 THE SCALE OF THE PROBLEM 7
1.3.1 Fragile states 8
1.3.2 Trends 8
1.4 CAUSES OF UNDERNUTRITION 9
CHAPTER 2: IMPROVING NUTRITION THROUGH KEY THEMATIC AREAS 14
2.1 IMPROVING NUTRITION THROUGH HEALTH 16
2.2 IMPROVING NUTRITION THROUGH WATER/SANITATION/HYGIENE 17
2.3 IMPROVING NUTRITION THROUGH EDUCATION 18
2.4 IMPROVING NUTRITION THROUGH GENDER 19
2.5 IMPROVING NUTRITION THROUGH SOCIAL PROTECTION 19
2.6 IMPROVING NUTRITION THROUGH FOOD SECURITY 21
2.7 IMPROVING NUTRITION THROUGH AGRICULTURE 23
2.8 THE ENVIRONMENT AND SUSTAINABLE MANAGEMENT OF NATURAL RESOURCES 24
2.9 IMPROVING NUTRITION THROUGH GOVERNANCE 25
2.10 IMPROVING NUTRITION THROUGH HUMAN RIGHTS 27
CHAPTER 3: INTEGRATING NUTRITION IN THE PROGRAMMING PHASE 29
3.1 ANALYSING AND UNDERSTANDING UNDERNUTRITION IN A CONTEXT 30
3.1.1 Is there a problem of undernutrition? 30
3.1.2 Analysing and understanding governments’ response to undernutrition 31
3.1.3 Analysing and understanding other stakeholders’ responses to undernutrition 32
3.2 RAISING THE NATIONAL PROFILE OF NUTRITION 32
3.3 SHAPING A DONOR RESPONSE TO UNDERNUTRITION 33
3.3.1 Setting priorities 34
3.3.2 Specific approaches for humanitarian response, transition situations and fragile states 35
3.4 DESIGNING MONITORING, EVALUATION AND LEARNING 37
CHAPTER 4: NUTRITION IN AID DELIVERY METHODS 39
4.1 GUIDANCE FOR ADDRESSING NUTRITION THROUGH GENERAL AND SECTOR APPROACHES 41
4.2 GUIDANCE FOR ADDRESSING NUTRITION THROUGH PROJECTS 47
4.2.1 Guidance for addressing nutrition through development projects 47
4.2.2 Guidance for addresssing nutrition through humanitarian projects 48
ANNEX 1: GLOSSARY 53
ANNEX 2: COUNTRIES BEARING THE BURDEN OF UNDERNUTRITION 59
ANNEX 3: INDICATORS 61
ANNEX 4: TEN STEPS TO SUCCESSFUL BREASTFEEDING 69
ANNEX 5: HEALTH-RELATED INTERVENTIONS EFFECTIVE FOR NUTRITION 70
ANNEX 6: NUTRITION SITUATION ANALYSIS 71
ANNEX 7: TERMS OF REFERENCE FOR EVALUATING PROGRAMMES FOR NUTRITION OUTCOMES 76
list of figures
Figure 1: An overview of this reference document 3
Figure 2: An overview of undernutrition 4
Figure 3: 90% of the world’s stunted children live in 36 countries 8
Figure 4: Regional progress in addressing underweight in children 9
Figure 5: A model of the casual pathways leading to undernutrition 11
Figure 6: Nutrition framework for action 12
Figure 7: Aid delivery methods used by the European Commission 40
Figure 8: Making aid delivery methods nutrition sensitive 41
LIST OF TABLES
Table 1: The disease burden and deaths associated with undernutrition 5
Table 2: Nutrition in the Millennium Development Goals 6
Table 3: Nutrition in the donor country strategy paper 34
Table 4a: General/Global approach: Steps to incorporating nutrition 43
Table 4b: Sector Approach: Steps to incorporating nutrition 44
Table 5: Steps to incorporate nutrition aspects when preparing project support 47
Table 6: Steps to incorporate nutrition in emergency projects 49
LIST OF BOXES
Box 1: Impact indicators potentially relevant to all aspects of external assistance 15
Box 2: Key indicators of nutrition benefits through health 17
Box 3: Key indicators for nutrition benefits through water/sanitation/hygiene 18
Box 4: Key indicators for nutrition benefits through education 18
Box 5: Key indicators of nutrition benefits through gender 19
Box 6: Key indicators of nutrition benefits through social protection 21
Box 7: Key indicators of nutrition benefits through food security and agriculture 24
Box 8: Key indicators of nutrition benefits through environment and the sustainable management of natural resources 25
Box 9: Key indicators for nutrition benefits through governance 27
Box 10: Key indicators for nutrition benefits through human rights 28
Box 11: Introducing nutrition objectives into a national strategic framework 33
Box 12: Incorporating nutrition objectives in programming 33
Box 13: Principles of good international engagement in fragile states 36
Box 14: Sector Terminology 40
Box 15: Key nutrition indicators for general and sector approaches 45
Box 16: Key issues concerning nutrition in humanitarian response 48
Box 17: Key nutrition indicators in emergencies 51
AAP Annual Action Programme
BMI Body mass index (see glossary)
CSP Country Strategy Paper
DAC Development Assistance Committee (of OECD)
DALY Disability Adjusted Life Year (see glossary)
DHS Demographic and Health Surveys
DCI Development Cooperation Instrument
DG Directorate-General of the European Commission
DG DEVCO Directorate-General of EuropeAid Development Cooperation Office
DG ECHO Directorate-General for Humanitarian Aid and Civil Protection
EEAS European External Action Service
EC European Commission
EDF European Development Fund
EU European Union
FAO Food and Agriculture Organisation of the UN
GAM Global Acute Malnutrition (i.e. moderate + severe)
GBS General Budget Support
MAM Moderate Acute Malnutrition
MDG Millennium Development Goals
MICS Multiple Indicators Cluster Surveys
MS Member States of the EU
NIP National Indicative Programme
NSA Nutrition Situation Analysis
OECD Organisation for Economic Cooperation and Development
PAN Programa Articulado Nutricional, (National Programme in Peru)
PCM Project Cycle Management
PFM Public Finance/Financial Management
PROGRESA Programa De Educación, Salud y Alimentación, (National Programme in Mexico)
PRSP Poverty Reduction Strategy Paper
SAM Severe Acute Malnutrition
SBS Sector Budget Support
SPSP Sector Policy Support Programme
SWAp Sector-Wide Approach
TAP Technical and Administrative Provisions
UNDAF United Nations Development Assistance Framework
UNICEF United Nations Children’s Fund
WB World Bank
WHO World Health Organisation
Bachari and his friend, Maman, are both three, but
malnutrition when he was a baby has left Bachari
(right) severely stunted.
Source: Amadou Mbodj – Save the Children (Running on Empty)
Undernutrition is the biggest development challenge facing the world1. It is both a consequence and a cause of poverty; it affects child and maternal survival and is detrimental to the well being of populations. The knock-on economic costs of undernutrition have been estimated at 10 % of individuals’ lifetime earnings2 and at 2 % to 8 % of a nation’s GDP.3
Yet undernutrition can be prevented, so that individuals do not become underweight, too short for their age (stunted), dangerously thin (wasted) or deficient in vitamins and/or minerals. The current reality4, however, is that:
A third of children aged below five years in low/middle-income countries (around 195 million), are stunted.
A third of the world’s stunted children aged below 5 years live in fragile or conflict-affected countries.
About 75 million (13 %) children under five years of age in low/middle-income countries are wasted, 26 million severely so.
19 million babies a year start life with a low birth weight due to poor growth in the womb.
Only by tackling undernutrition might there be a realistic chance of achieving several of the Millennium Development Goals by 2015:
to eradicate extreme poverty and hunger (Goal 1)
to reduce child mortality (Goal 4)
to improve maternal health (Goal 5)
as well as
to achieve universal primary education (Goal 2)
to promote gender equality and empower women (Goal 3) and
to combat HIV/AIDS, malaria and other disease (Goal 6).
Improved nutrition can drive economic growth. Equitable economic growth, which benefits the poorest, can, in turn, significantly help improve nutrition. However, countries and development actors need to, first, create a policy environment geared to addressing undernutrition, and, second, invest in a coherent package of measures.
The EU’s Reference Document on Addressing Undernutrition in External Assistance seeks to help transform aid programmes so that they can achieve real progress in preventing undernutrition. A thoughtful approach is required, based on evidence and sound understanding of the context. Nutrition-specific objectives need to be incorporated in the design of assistance programmes – whatever the sector or aid modality – thereby seeking and measuring specific results on nutrition. Tackling undernutrition thus becomes the responsibility of all - not just left to technical experts.
There are numerous possible causes of undernutrition, as depicted in the conceptual framework below.
Mortality, morbidity, disability
Adult size, intellectual ability, economic productivity,
metabolic and cardiovascular disease
Maternal and child undernutrition
Source: Based on UNICEF, 1990: Strategy for Improved Nutrition of Children and Women in Developing Countries; and adapted in the Lancet Series (2008).
Immediate causes relate to the individual level and have two dimensions: dietary intake and health status. This distinction emphasises the limitation of ‘hunger’ to denote undernutrition, for hunger may or may not be a cause of undernutrition.
Underlying causes operate at household and community levels. They comprise three categories: household food security, care for children/women and health environment/ health services. Income poverty underpins all three.
Basic causes include a range of factors operating at sub-national, national and international levels, ranging from natural resources, to social and economic environments to political events.
The various determinants of undernutrition can act in synergy so that one cause influences others. Given this complex interplay, a multi-sectoral approach is required to act on multiple determinants and prevent/address long-term undernutrition. This is also true in humanitarian contexts, although assistance tends to prioritise life-saving interventions focused on immediate and underlying causes.
The Reference Document on Addressing Undernutrition in External Assistance provides a detailed description of how nutrition benefits can be realised by modifying the design of programmes in all relevant sectors and thematic areas – from health to governance, education to gender – and by choosing appropriate indicators to monitor progress.
Assistance through sectors that are not the traditional focus of nutrition action can bring about significant achievements in reducing undernutrition. For example, evidence from 63 countries shows that:
At the underlying level of causes:
43 % of the total reduction in undernutrition came from improvements in child care as represented by women’s education (female enrolment at school);
26 % came from increases in per capita food availability;
19 % came from improvements in the health environment (access to safe water); and
12 % came from improvements in women’s status (female to male life expectancy).
At the basic level of causes:
50 % of the reduction in undernutrition came from increased per capita national income
Undernutrition needs to be understood as a multi-sectoral concern that requires a multi-sectoral response. Yet, responses have traditionally been single-sector and single-level, with inadequate emphasis on addressing the underlying and basic causes. Significant and sustained progress to improve nutrition cannot be achieved unless appropriate actions are put in place to address these determinants.
Such breadth of response can lead to a lack of clarity regarding how nutrition should be overseen and managed by government. In the absence of a consistent institutional ‘home’ for nutrition, coherence is built through strong and senior government leadership, which can oversee and coordinate the work of individual line ministries and departments. Donor support is undoubtedly critical to the success of such governance efforts.
Any cooperation strategy in the field of maternal and child undernutrition must take into account the nature of the problem, the commitment of the government, the strengths and weaknesses of the different sectoral or thematic interventions of the government and the strategies of other stakeholders. A basic starting point is nutrition-sensitive national policies that encourage a multi-sectoral approach to addressing chronic and acute undernutrition.
Having nutrition in a national plan or strategy provides legitimacy and enables donors to channel support. The type of support will depend on the outcomes of various analyses examining the extent of the undernutrition problem and the priorities and responses of key stakeholders. Typical investments are summarised below.
Aid Delivery Methods
Different aid delivery methods can be used to fund nutrition-sensitive assistance. The choice of method needs to be considered in light of context-specific institutional funding opportunities – whether project, sector or general approaches.
Each aid delivery method offers a fresh opportunity to introduce and embed nutrition-related concerns and factors. The process of working through each method tends to include several key steps that are common to all methods, as summarised below:
In contrast to most development situations, emergencies often have a very strong emphasis on undernutrition. The challenge therefore is not to integrate nutrition but to manage the responses, act on results and demonstrate the impact more consistently. Furthermore, nutrition concerns in emergencies are often superimposed on pre-existing undernutrition, in particular stunting, which is rarely prioritised. In this way emergencies offer an opportunity to start tackling underlying causes with a view to long-term outcomes.
The key challenges in addressing undernutrition in emergencies are:
Responding to early warning indicators;
Promoting quality management of undernutrition in emergencies through evidence-based decision-making and implementation;
Building an evidence base in research priorities, including field-appropriate methods to assess the impact of action;
Ensuring a holistic and meaningful impact on undernutrition;
Measuring impact in relation to nutrition and mortality in emergencies;
Strengthen national capacity;
Ensuring more sustained support from development actors for tackling undernutrition.
Experience has demonstrated the need to maximise sustainable, inter-sectoral support for undernutrition over the longer term, and not to simply isolate efforts within a humanitarian response.
A Call to Joined-Up Action
Such joined-up thinking is at the core of the EU Reference Document on Addressing Undernutrition in External Assistance − joining evidence to action; joining different levels of causes in order to sustain improvements; joining efforts across different sectors to build coherence; joining government aspirations and efforts to external support; and joining shorter-term investments to longer-term progress. In time, it is also hoped that this Reference Document will support on-going efforts to join up the approaches and priorities of the EU’s aid institutions across its Member States, thereby creating international momentum to combat undernutrition once and for all.
CHAPTER 1: Introduction
Undernutrition kills more than three million children every year. For those who survive, it can have irreversible consequences on their physical growth and mental development. This in turn undermines virtually every aspect of economic and human development. Up to 8 % of GDP can be lost as a result of undernutrition.
Yet undernutrition is wholly preventable, and there is sound evidence on the measures likely to have the greatest impact. International assistance needs to be planned comprehensively so as to use all possible avenues to prevent and mitigate the very serious consequences of undernutrition.
Current international concern and the increasing commitment shown means that its time to harness the potential to combat undernutrition. At the L’Aquila Summit in 2009, Heads of States called for increased support for food and nutrition security outcomes. The World Health Assembly adopted a specific resolution on infant and young child feeding5 calling for nutrition policies to be pro-poor, focus on people with specific nutritional requirements and be rooted in a multi-sectoral approach.
The European Union has recently adopted several policies reflecting its increased commitment to fight undernutrition. Through different avenues, the Global Health, Food Security and Food Assistance Communications take the first steps towards a common framework for the EU and its Member States in combating malnutrition. More importantly, individual countries have launched their own programmes and strategies.6 This document is in line with these and highlights concrete steps to translate the political commitments into action and measurable impact.
The term undernutrition encompasses a range of conditions that are due to insufficient food intake and repeated infectious diseases. Individuals may be underweight, too short for their age (stunted), dangerously thin (wasted) or deficient in vitamins and/or minerals (micronutrient malnutrition).
Undernutrition is closely associated with food insecurity and hunger, but is distinct from them. Undernutrition is a physical outcome; food insecurity describes the socio-economic circumstances whereby individuals or households are unable to access enough quality food for an active healthy life. Hunger is a term used to describe estimates in the deficit of food intake for population groups – regardless of whether there is evidence of undernutrition.
The purpose of this reference document is to help transform aid programmes so that they achieve real progress in this area. The key is to incorporate nutrition-specific objectives into their design and to monitor progress with nutrition-specific indicators.
This reference document is intended as a resource to guide the practical incorporation of nutrition objectives into relevant sectors and different funding methods used by the European Union (EU) – whether in development cooperation or in humanitarian response.
The reference document is targeted primarily at aid administrators working within country teams - delegations of the EU and offices of Member States. It seeks to complement and extend existing efforts by Member States. In addition, it is anticipated that the discussions likely to emerge from the guidance here may prove of use to national counterparts and other stakeholders.
No nutrition expertise is assumed, or required, to apply the guidance.
Users are likely to focus on the specific sections that are most relevant to them. For this reason, the reference document has been structured and written in such a way that the chapters can be read independently. The only exception to this is humanitarian assistance, because there are no absolute divisions between emergency nutrition interventions and development interventions. To ensure sustainable progress on nutrition and save lives, there is a need for contiguity between nutrition emergency action and development. The critical requirement, always, is to ensure that the situation is analysed as fully as possible to determine the best course of action. Thus, all sections have been written with all types of operational context in mind. Occasionally, specific pointers are given regarding nutrition in emergencies.
Figure 1: An overview of this reference document
Throughout the document, the core text is accompanied by the following additional information:
case studies, highlighted in orange boxes or available on the web
practical tips and guidance
critical questions to consider
sources of further information. A list of references is available in a web link.
Text in italics denotes direct excerpts from references cited.
‘Malnutrition’ encompasses both undernutrition and over-nutrition (obesity). Although there are serious public health concerns about the increasing levels of obesity around the world, and the pressure this puts on health systems, the imperative to act on undernutrition remains even greater, hence the focus of this reference document.
Undernutrition is defined7 as the outcome of insufficient food intake and repeated infectious diseases. Undernutrition describes a range of conditions: it includes being underweight for one’s age, too short for one’s age (stunted), dangerously thin (wasted), and deficient in vitamins and/or minerals (micronutrient malnutrition). There are several ways of assessing undernutrition, typically with body measurements such as weight, height or arm circumference (anthropometry).
A full explanation of terms is given in the glossary in Annex 1. Figure 2 provides a simplified summary of the types of undernutrition.
Figure 2: An overview of undernutrition
While it is recognised that nutrition is important throughout a person’s life, the most vulnerable and critical period is during pregnancy and from birth to two years of age. This is when undernutrition can cause long-lasting health and developmental consequences (as described below), unless it is reversed at this stage. This period is therefore the priority. It offers a crucial window of opportunity to ensure that the right conditions are in place for optimal growth.
Making the period from pregnancy to two years of age a core priority implies seeking and measuring results of actions specifically for this group/period. However, this does not need to be at the exclusion of other groups of concern. It is not, necessarily, a targeting criterion because actions targeted at households, communities or nations can also result in improved nutrition for pregnant women and children under the age of two years (see Section 1.4). Along the same lines, interventions could be extended to children under the age of five when undernutrition is responsible for high mortality rates amongst these older children.
The period from pregnancy to 24 months of age is a crucial window of opportunity for reducing undernutrition and its adverse effects 8