United Nations World Food Programme (WFP) - BVSDE
The Cost of Hunger in Bolivia
Social and economic impact of
child undernutrition
Series “Food Security Management Information System”
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
United Nations World Food Programme (WFP)
First Edition
February 2009
WFP Representative for Bolivia
Vitória Ginja
Country Report Authors
Adhemar Esquivel, UDAPE
Adalid Zamora, MSD
Rory Narváez, WFP
Study coordination in the Andean region and Paraguay
Rodrigo Martínez, ECLAC
Andrés Fernández, ECLAC
Amalia Palma, ECLAC
Lorena Flores, ECLAC
Technical review
Ana María Aguilar, CT-CONAN
Luis Rico, CT-CONAN
Ciro Koop, CT-CONAN
Ximena Loza, WFP
Oscar Antezana, WFP
Francisco Espejo WFP
Editing, style correction and editorial coordination
Claudia Dorado S.
Layout
Dalia Nogales A.
Cover design
Impresiones Quality s.r.l.
Pictures
WFP
Legal Deposit
4-2-204-09
The statements and opinions expressed in this document are exclusive responsibility
of the authors.
This publication was produced thanks to the financial support of the government
of Spain to the regional capacity development project 10411 of the WFP.
Any reproduction, in whole or in part, of the contents, by whatsoever means or
process, is forbidden without the express authorization of its authors.
Not for sale. Prepared and printed in Bolivia.
Table of contents
Introduction 7
Executive Summary 9
Analysis of the social and economic impact of child undernutrition in Bolivia 11
1. Background 13
2. Study methodology 15
2.1. Conceptual and methodological framework 15
2.2. Undernutrition effects 16
2.3. Analysis dimensions 17
2.3.1. Retrospective incidental analysis 17
2.3.2. Prospective analysis 18
3. Study Results 19
3.1. Results of the retrospective incidental analysis 19
3.1.1. Health-related effects and costs of undernutrition 19
Morbidity due to undernutrition 19
Mortality due to undernutrition 20
Health-related costs of undernutrition 20
3.1.2. Education-related effects and costs of undernutrition 21
Effects of undernutrition on schooling and repeated school years 21
Education-related costs of undernutrition 22
3.1.3. Productivity-related effects and costs of undernutrition 22
Effects of undernutrition on the productive capacity 22
Productivity-related costs of undernutrition 23
3.1.4. Synthesis of undernutrition costs 24
3.2. Results of the prospective analysis 24
3.2.1. Health-related effects and costs of undernutrition 24
3.2.2. Education-related effects and costs of undernutrition 26
3.2.3. Productivity-related effects and costs of undernutrition 26
3.2.4. Synthesis of undernutrition costs 27
3.2.5. Scenario analysis: costs and savings 28
4. Conclusions 29
Sources consulted 31
Page
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List of Tables
Table 1: Bolivia-Population and global undernutrition 13
Table 2: Effects of undernutrition on the life cycle 16
Table 3: Bolivia-Morbidity associated to global undernutrition in children under 5 year of age, 2005 19
Table 4: Bolivia-Mortality associated to global undernutrition, adjusted to the survival rate in children
under 5 year of age, 1941-2005 20
Table 5: Bolivia- Health-related costs of global undernutrition , 2005 21
Table 6: Bolivia-Costs resulting from the repeated school years differential, associated to global
undernutrition, 2005 22
Table 7: Bolivia - Productivity-related effects of global undernutrition due to mortality 23
Table 8: Bolivia-Summary of costs by area impacted by undernutrition, 2005 24
Table 9: Bolivia-Projection of the number of deaths associated to global undernutrition in children
under 5 years of age, 2005-2009 25
Table 10: Bolivia-Projection of morbidity associated to global undernutrition in children under 5 years
of age, 2005-2009 25
Table 11: Bolivia-Projection of morbidity costs associated to global undernutrition, 2005-2009
(in million U.S. dollars) 25
Table 12: Bolivia-Summary of global undernutrition costs by area of impact in the 0-59 months
of age cohort, 2005 27
Table 13: Bolivia-Total cost estimates for global undernutrition for the base year and the three scenarios
studied, 2005 and 2015 (in million U.S. dollars) 28
Table 14: Bolivia-Savings estimates according to scenarios, 2015 (in million U.S. dollars) 29
4
List of Charts
Chart 1: Bolivia-Evolution of global and chronic undernutrition in children under 5 years
of age, 1981-2003 14
Chart 2: Bolivia-Repeated school years associated to global undernutrition, 2005 22
Chart 3: Bolivia-Effects of global undernutrition on schooling distribution of the 25-64 years
of age population, 2005 23
Chart 4: Bolivia- Distribution of the global undernutrition cost according to analysis factors, 2005 24
Chart 5: Bolivia- Estimated distribution of schooling for the 0 to 59 months of age cohort of 2005
with and without global undernutrition 26
Chart 6: Bolivia-Distribution of the estimated cost of undernutrition by analysis factors, 2005 27
Chart 7: Bolivia-Trend of global undernutrition estimated costs in the three study scenarios,
2005-2015 (in million U.S. dollars) 29
List of Boxes
Box 1: Multi-Sector Zero Undernutrition Program (PMD-C) 15
Box 2: Child undernutrition in Bolivia 17
List of Figures
Figure 1: Undernutrition causes and consequences 16
Figure 2: Analysis dimensions according to age and the year of occurrence of undernutrition effects 18
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
Abbreviations
and acronyms
ADD
ARI
CELADE
CODAN
COMAN
CONAN
CT-CONAN
EAP
ECLAC
ENDSA
GNP
IMCI
INAN
INE
INTA
IUGR
M/H
MDG
MSD
NCHS
NGOs
NPV
Acute Diarrheal Diseases
Acute Respiratory Infections
Latin American and Caribbean Demographic Center - Centro Latinoamericano
y Caribeño de Demografía
Departmental Council for Food and Nutrition - Consejo Departamental de
Alimentación y Nutrición
Municipal Council for Food and Nutrition - Consejo Municipal de Alimentación
y Nutrición
National Council for Food and Nutrition - Consejo Nacional de Alimentación
y Nutrición
Multi-Sector Technical Committee of the CONAN
Economically Active Population
Economic Commission for Latin America and the Caribbean
National Demographic and Health Survey
Gross National Product
Integrated Management of Childhood Illnesses
National Institute for Food and Nutrition - Instituto Nacional de Alimentación
y Nutrición
National Statistics Institute - Instituto Nacional de Estadística
Food Technology and Nutrition Institute - Instituto de Nutrición y Tecnología
de Alimentos
Intrauterine Growth Retardation
Man/hours
Millennium Development Goals
Ministry of Health and Sports - Ministerio de Salud y Deportes de Bolivia
National Council Health Survey
Non-governmental organizations
Net present value
Food Security Management Information System
NTCD
PAN
PMD-C
PND
SEDES
SIE
SNIS
SUMI
TBC
UDAPE
WAP
WFP
WHO
Non-transmissible chronic disease
National Program for Assistance to Children under Six Years - Programa Nacional
de Atención a Niños y a Niñas Menores de Seis Años
Multi-Sector Zero Undernutrition Program - Programa Multisectorial de
Desnutrición Cero
National Development Plan - Plan Nacional de Desarrollo
Departmental Health Service - Servicio Departamental de Salud
Education Information System - Sistema de Información Educativa
National Health Information System - Sistema Nacional de Información en
Salud
Universal Maternal/Child Insurance - Seguro Universal Materno Infantil
Tuberculosis
Unit for the Analysis of Social and Economic Policies - Unidad de Análisis de
Políticas Sociales y Económicas
Working-Age Population
United Nations World Food Programme
World Health Organization
6
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
Introduction
Extensive evidence shows that undernutrition is one of the greatest determinants of child
mortality in Bolivia, thus becoming a serious threat for the compliance with the Millennium
Development Goals (MDGs). As a matter of fact, not only the first MDG -related to extreme
poverty and hunger eradication- runs the risk of not being met as a consequence of child
undernutrition, but so do others linked to human development, such as education and health.
Given that the effects of child undernutrition compromise the human capital of future generations,
these should be viewed as problems generating present as well as future costs.
With the purpose of making evident the present and future costs of child undernutrition, the
Economic Commission for Latin America and the Caribbean (ECLAC) and the United Nations
World Food Programme Regional Office for Latin America and the Caribbean (WFP) started
a joint effort aimed at estimating the economic cost that countries such as Bolivia are paying
as a consequence of this scourge.
This study is part of the sub-regional initiative of the Andean countries that seeks to evaluate
the economic and social impact of child undernutrition. Its results provide sound evidence of
the unnecessary costs that Bolivia will be paying if concrete measures are not strengthened
in order to prevent and treat child undernutrition.
Beyond the ethical aspect of not addressing undernutrition, which limits the human and
economic potential of a country, there are negative economic consequences that may result
in high costs for the country vis-à-vis its Gross National Product (GNP).
Even though governments in the Andean sub-region signed declarations against hunger and
undernutrition, such problems persist, partly, due to the fact that there are no sustainable
budgetary allocations to make the fight against undernutrition effective.
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In this sense, the results of this study motivate the government authorities, the international
cooperation agencies and the private sector to join efforts to mobilize the funds needed to implement
concrete actions within the framework of the Multi-Sector Zero Undernutrition Program (PMD-C).
Ramiro Tapia
Minister of Health and Sports
Vitória Ginja
WFP Representative in
Bolivia
8
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
Executive Summary
Based on retrospective and prospective analyses, the present study reveals that undernutrition
is a problem that transcends the ethical sphere and has significant economic implications for
Bolivia.
Actually, the retrospective analysis on undernutrition costs for the year 2005 allowed verifying
that undernutrition has a direct incidence on the economically active population, due to the
fact that mortality rates derived from undernutrition reduce the proportion of active and
productive people in Bolivia. Likewise, it was verified that undernutrition has a direct impact
on school dropout rates, raising costs for the country. In fact, for the year 2005, the costs
generated by school dropouts -together with child mortality- accounted for 6% of the GNP.
The prospective analysis allowed estimating the future costs associated to undernutrition. It
was assessed that, in Bolivia, the highest costs are related to the loss of productivity as a
consequence of mortality and school dropouts resulting from undernutrition, generating 79%
of the undernutrition costs.
As part of the prospective analysis, three trend scenarios on undernutrition prevalence and
derived costs were examined. According to that analysis, if the present situation is maintained,
without introducing significant changes in the public policy related to the fight against
undernutrition, the future costs for Bolivia will increase. If interventions are carried out in
order to achieve the MDG related to decreasing global undernutrition to half of the prevalence
registered for 1990, important savings will be produced for the national economy. Furthermore,
realizing the international commitment for global undernutrition eradication or its reduction
to an acceptable level of 2.5% represents decreasing the cost of undernutrition by a third in
relation to the present scenario.
The main conclusions derived from this study stress the magnitude of the economic loss for
Bolivia if the present child undernutrition prevalence is maintained. Thus, among
recommendations submitted, the relevance of investing in nutrition is highlighted, given the
potential savings that cost-effective interventions would report if they prevent this scourge and
treat the population affected by it.
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Finally, beyond the potential economic savings that could be achieved thanks to the decrease
and/or eradication of undernutrition, investing on nutrition of the Bolivian population is a moral
obligation that will guarantee a fundamental human right: that of receiving appropriate
nourishment.
10
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
Social and economic impact of
child undernutrition in Bolivia
Food Security Management Information System
1. Background
Within the Andean sub-region, Bolivia is one of the countries with the greatest ratios of poverty
and indigence, as well as one with the highest undernutrition prevalence. The low weight for age
—weight deficit— affects almost eight out of every 100 children under five years old, while stunting
affects almost a third of this population group.
According to the latest available estimates, based on the 2003 Demographic and Health Survey
(known by its Spanish acronym ENDSA 2003) 1 , 7.5% of the Bolivian children from 1 to 59 months
of age had global undernutrition —weight/age— in the moderate and severe categories. 2 In spite
of significant progress made in relation to previous measurements, the country still exhibits a
persistent vulnerability in the undernutrition issue.
Table 1: Bolivia - Population and global undernutrition
Age groups
Size of population
(2005)
Affected population
(2005)
Undernutrition prevalence**
2003
Newborn (intrauterine 264 311 3 144 1.2%
growth retardation - RCIU)*
0-11 months 264 311 10 282 3.9%
12-23 months 259 007 35 743 13.8%
24-59 months 755 960 50 725 6.7%
Total 1 279 278 99 893
Source: Prepared in-house based on information from the Ministry of Health and Sports (MSD) of Bolivia, the
ENDSA surveys and estimates of the Latin American and Caribbean Demographic Center (CELADE).
* In a given year, the newborn population is the same as the 0-11 month's age group.
** Data estimated from the most recent undernutrition prevalence figure available.
Even though there is no official information that allows getting deeper into the analysis of the
nutritional condition of pregnant women, just as what happens in other countries in the region,
that group also suffers from serious undernutrition problems. In consequence, it can be said that
the undernutrition cycle starts at the intrauterine life.
Regarding the risk of suffering from undernutrition in the early years of life, as highlighted by
previous studies done in the region, in Bolivia the risk is greater over the first 24 months of life,
with a subsequent decline and stabilization on the pre-school stage.
13
It should be highlighted that the most vulnerable population is represented by indigenous children
living in rural areas. However, such problem does not appear only in those scattered areas, but in
peri-urban areas as well.
As it is shown in Chart 1 below, over a 14-year period, the global undernutrition rate in Bolivia
has followed a sustained decrease, with higher intensity as of 1994, and staying relatively stable
—above 7.5%— since 1998. In regard to chronic undernutrition, after decreasing considerably in
a first stage —1981 to 1994— it has not shown significant changes lately.
1. National Statistics Institute - Instituto Nacional de Estadísticas (INE), 2004
2. To allow comparisons with other countries participating in the ECLAC and WFP Regional Initiative, the use of the weight/age indicator
for child undernutrition was agreed upon.
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
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45
40
35
30
25
20
15
10
5
0
Chart 1: Bolivia- Evolution of global and chronic undernutrition in
children under 5 years of age, 1981-2003*
42.7
14.5
37.7
13.3
26.8 26.8
15.7
1981 1989 1994 1998 2003
Años
Global
Chronic
9.5
26.7
7.5
Source: Prepared in-house based on information from the MSD, National Institute of Food and Nutrition - INAN
(1982), and the 1989, 1994, 1998 and 2003 ENDSA surveys.
*Standards of the National Council Health Survey (NCHS).
Within the framework of institutionalization of the nutrition and food policy in Bolivia, it is possible
to highlight important advances made in the implementation of national actions to combat undernutrition
during the most recent years.
In this sense, the National Council for Food and Nutrition (Spanish acronym: CONAN) was created
on May 8th, 2003 by Supreme Decree 27029. Such body is in charge of promoting and coordinating
inter-institutional and inter-sector participation for the formulation and follows up of national policies
on food and nutrition.
14
Initially, CONAN was made up by representatives of several State ministries, under the coordination
of the First Lady Office. In spite of its commitment with nutritional issues, such structure was not
operational. For this reason, on the 5 th of April 2006, by Supreme Decree 28667, the CONAN was
repositioned with the following new objectives: to promote and coordinate the participation of public
sector institutions and civil society in the formulation, dissemination and follow up of national policies
on food and nutrition; and to promote the development of a national policy on food and nutritional
security, aimed at the promotion of the human right of receiving appropriate nourishment and the
eradication of undernutrition in the country.
CONAN is chaired by the President of the Republic of Bolivia and its members are the following
ministers: Presidency; Development Planning; Finances; Health and Sports; Rural and Agricultural
Development and Environment; Education and Culture; Production and Micro-businesses; Water; and
Justice. Representatives of civil society participate as well.
Structurally, CONAN has a Technical Secretariat under the responsibility of the MSD, and a Multi-
Sector Technical Committee (CT-CONAN), composed of delegates from the nine abovementioned
ministries, which are in charge of the elaboration and follow up of the policies defined by the CONAN.
At the departmental scale, the multi-sector instance for CONAN is the Departmental Council for Food
and Nutrition (CODAN). Such council is chaired by the department's Prefect and composed by
representatives of the different sector departmental services under the prefectures, representatives of
civil organizations, social organizations, private enterprise, churches and universities, among other
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
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institutions. Each CODAN has also a Technical Secretariat managed by the Departmental Health
Service (SEDES).
At the municipal context, the Municipal Council for Food and Nutrition (COMAN) is in charge of
managing actions among sectors. Each COMAN is chaired by the municipality mayor and composed
of representatives of social organizations, civil organizations, public and private institutions, private
enterprise and churches part of the municipality. One of the main attributions of the COMAN is to
promote and coordinate inter-sector, inter-institutional and civil society participation in the municipal
context, in order to execute actions and optimize the resources of the programs and projects being
developed at the municipalities. 3
Taking into consideration the different factors that determine undernutrition, Bolivia requires sound political decisions
made by the National Government to eradicate it. As part of this decision-making, the CT-CONAN devised the PMD-
C, which is executed at the municipal level with support from departmental and municipal governments, from
organizations of civil society, non-governmental organizations (NGOs) and international cooperation agencies.
The general objective of the PMD-C is to eliminate chronic and acute undernutrition in the population under 5 years
of age by year 2011, implementing comprehensive interventions, strengthening multi-sector structure and functionality
at the municipal and departmental levels, establishing transparent mechanisms for monitoring and evaluation of multisector
interventions, and consolidating community capacity and participation.
In order to make the inter-sector interventions operational in the 166 municipalities with greater vulnerability to food
insecurity, the structural base of the PMD-C is constituted by social networks, health networks, educational facilities
and centers where the National Program for Children Under Six years of age (PAN) is implemented.
Source: CT-CONAN (2008b)
Box 1: Multi-Sector Program Zero Undernutrition (PMD-C)
2. Study Methodology
2.1 Conceptual and methodological framework
The conceptual and methodological framework used in the present study is the same as the one used
by ECLAC and the WFP in the analysis of the socio economic impact of child undernutrition in Latin
America. 4 Such methodology had been previously applied in the analysis of child undernutrition costs
in Central America and the Dominican Republic, 5 and it was replicated in the sub-regional initiative
for the Andean Region and Paraguay.
15
This study considers that undernutrition is caused by multiple factors that act on a temporary or permanent
basis at the immediate, underlying or basic levels. Some of the immediate causes are the quantity and
quality of the food intake, as well as its absorption. Both types of causes are determined by productive
and biomedical variables that, in turn, are affected by environmental, socio cultural and political
institutional variables.
As it is known, undernutrition has a wide range of negative effects, among them, repercussions on health,
education and economy —public and private costs and expenditures, as well as diminished productivity.
Likewise, the impact of undernutrition results in greater problems of social inclusion and deepening of
poverty as well as of indigence, thus reproducing the vicious cycle of poverty and increasing, in turn,
vulnerability to undernutrition (Figure 1).
3. CT-CONAN, 2008a.
4. Martínez R. and Fernández A., 2006.
5. Martínez R. and Fernández A., 2006.
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
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Figure 1: Undernutrition causes and consequences
Productivity
Increased costs
(private-public)
Mortality
Labor desertion
Mortality:
acute/chronic
Neurological
development
Social inclusion
problems
Academic results
Undernutrition
Absorption of food
intake
Biomedical
Quantity and quality
of food intake
Productive
Environmental
Source: Martinez R and Fernandez A., 2006
Socio-culturaleconomic
Political-institutional
2.2. Effects of Undernutrition
In this study, the main negative effects associated with undernutrition are grouped in three areas of
analysis:
• Health-related: increase in the probability of mortality and morbidity.
• Education-related: deterioration of school performance and increase in school dropout.
• Productivity-related: costs derived from undernutrition in health treatments and inefficiency in the
educational process.
Such effects can be sorted out according to the stage in the life cycle of people affected by them (Table
2). This table offers a detailed view of the methodological approach used in this study.
Table 2: Effects of undernutrition on the life cycle
16
Stages of the Life
Cycle
Immediate Effects
Mediate Effects
Indirect Effects
Intrauterine Life
0-24 months
25-59 months
School Age
Adult age
Women in
Childbearing Age
Elderly
• Low weight at birth
• Perinatal mortality
• Morbidity
• Cognitive and psychomotor
deterioration
• Child mortality
• Poor pre-school performance
• Pre-school mortality
• Morbidity
• Child Mortality
• Poor concentration and school
performance
• Anemia
• Morbidity due to non- transmissible
chronic diseases (NTCD)
• Chronic transmissible diseases
(tuberculosis)
• Anemia
• Obesity
• Maternal mortality
• Morbidity due to NTCD
• Morbidity due to NTCD
• Child undernutrition
• Morbidity due to infections,
diarrhea, bronchopneumonia
• Stunting
• Cognitive deterioration
• Decrease in school performance
• Anemia
• Obesity
• Low schooling
• School dropouts
• Low birth weight
• Poverty
• Low birth weight
• Mortality
• Poverty
• Diminished productivity
• Higher public and private costs
• Diminished productivity
• Higher public and private costs
• Diminished productivity
• Higher public and private costs
• Diminished productivity
• Higher public and private costs
• Diminished productivity
• Higher public and private costs
• Diminished productivity
• Higher public and private costs
• Higher public and private costs
Fuente: Martínez R. y Fernández A., 2006.
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
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As it is seen in the previous table, undernutrition effects can become apparent at birth or along the
life cycle of the person; in fact, intrauterine undernutrition generates consequences that extend
from birth to adulthood. It is important to highlight that undernutrition impact poses greater nutritional
risk and a higher incidence of other negative consequences for whoever had suffered this scourge
during the early stages of his/her life.
In order to have a comprehensive study of the undernutrition phenomenon, the methodology
proposed by ECLAC and the WFP takes into consideration the analysis of each of the consequences
of global undernutrition in health, education and productivity. Likewise, it includes the translation
of these effects into cost terms, from two analysis dimensions: retrospective and prospective.
2.3 Analyis Dimensions
2.3.1 Retrospective incidental analysis
This dimension allowed calculating, for a given year 6 , the costs generated by undernutrition that
affected the Bolivian population up to the year of analysis. In this sense, health-related costs were
estimated for preschool boys and girls —0 to 5 years of age— with undernutrition in the year of
analysis, the educational costs derived from the undernutrition suffered during the first five years
of life among school-age individuals —6 to 18 years of age—, and the economic costs due to loss
of productivity among working-age individuals —15 to 64 years of age— who were malnourished
when they were under 5 years of life.
Box 2: Child undernutrition in Bolivia
In lactating children, limited breastfeeding and inappropriate complementary feeding increase the risk of undernutrition.
In this regard, according to the 2003 ENDSA survey data, only 69.5% of infants of less than 2 months, 47.6% of
children from 2 to 3 months of age, and 30.7% of the children population from 4 to 5 months of age received exclusive
breastfeeding; in spite of the recommendation concerning breastfeeding up to 6 months of age. As a result, children
in these groups of age were deprived from essential nutrients for their growth and development -provided by breastfeedingand
had greater exposure to bacteria, increasing their risk of getting diseases and dying.
Inappropriate practice of breastfeeding and complementary feeding, both in frequency as well as in consistency and
caloric requirements, explain in part, the progressive increase of undernutrition levels in children under 2 years of age,
including those from 4 to 5 months.
On the other hand, Acute Diarrheal Diseases (ADD) and Acute Respiratory Infections (ARIs) are other factors that alter
absorption or utilization of food in the body. An analysis conducted by PROFILES (1998) demonstrates that 22% of
deaths in children younger than 1 year of age are attributable to diarrhea episodes due to the inappropriate use of the
nursing bottle.
17
With respect to the lack of access to health services, this is mainly due to geographical and cultural inaccessibility,
given that the economic accessibility problem for vulnerable groups was overcome thanks to the implementation of
the Universal Mother-Child Insurance (SUMI). Access to potable water and basic sanitation are also important in order
to improve women's nutrition, as well as that of children.
Among the underlying causes of undernutrition, we can mention the food insecurity at households, given the limited
availability and restricted physical and economic access to food. A factor that also influences undernutrition is the
low level of education and information in the population, especially in mothers.
All these causes result from structural factors that reproduce the vicious cycle of undernutrition/poverty. Such cycle
begins in the womb of poorly fed and malnourished pregnant mothers, who give birth to low weighted children with
high risk of death, and continues with the survivors of such pregnancies, who are exposed to higher risk of chronic
undernutrition, and who over time, do not reach their physical and intellectual potential, showing a limited work
performance and, as a consequence, receiving lower remunerations.
Source: MSD, 2005
6 2005 was selected as the reference parameter for this study due to its nearness to the 2003 ENDSA survey and the agreement
among countries to ensure the comparison of results in the Andean sub-region and Paraguay.
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
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2.3.2 Prospective Analysis
Taking into account the importance of this undernutrition analysis, the methodology applied in this
study also included the projection of present and future losses originated from health interventions,
school repetition and diminished productivity, related to undernutrition suffered by Bolivians younger
than 5 years old, in a given year. Using the scenario methodology, such analysis also allowed
estimating the potential savings in case of achieving different nutritional objectives.
Figure 2 below shows that the retrospective incidental dimension considers the social and economic
consequences of undernutrition in a given year (X) for several population cohorts that were affected
by undernutrition. Such cohorts are: from 0 to 4 years for health, 6 to 18 years for education, and
15 to 64 years for productivity. Likewise, the prospective dimension projects future effects and costs
resulting from undernutrition, in a given year (X), for the following age cohorts: X to X+4 for health,
X+2 to X+18 for education, and X+11 to X+64 for productivity.
Figure 2: Analysis dimensions according to age and year of occurrence
of undernutrition effects
18
Age in which Effects are Measured
15-64
6-18
Retrospective
incidental
dimension
Prospective
Dimension
0-4
x 2 4 11 18 64
Source: Martinez R. and Fernandez A., 2006
Años en que se miden los efectos
Health Education Productivity
Both for the incidental dimension and the prospective dimension, this study used global undernutrition
—weight/age— and its effects, rather than chronic undernutrition —height/age— in spite of the
significance of the latter in the region. Reasons that justify this selection are: 7
7. Further details on the justification for the use of this indicator are available in Martinez R. and Fernandez A, 2006.
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
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• Greater availability of empirical evidence on the weight deficit impact on morbidity, mortality
and educational performance;
• Greater possibility of comparing data among countries, due to the larger amount of information
available referred to global undernutrition; and
• The fact that low weight is the most visible undernutrition indicator during the first months of
life.
3. Study Results
3.1 Results of the retrospective incidental analysis
3.1.1 Health-related effects and costs of undernutrition
Undernutrition suffered at an early age determines greater morbidity and mortality risks in the
population. In this study, both effects were estimated through probability differentials based on data
coming from epidemiological surveillance and the country's official health statistics that were
complemented with information obtained from case studies and through interviews done to national
specialists.
Morbidity due to undernutrition
In Bolivia, the effects of undernutrition on the morbidity rates of different associated pathologies
—ADDs, ARIs and anemia, mainly— involved about 24 thousand cases out of the diseases registered
during 2005; almost 10 thousand cases of ADDs, 643 ARIs and a little more than 13 thousand cases
of iron deficiency anemia. 8 Such a situation is derived from the prevalence differences, 9 as shown
in the following table:
Table 3: Bolivia - Morbidity associated to global undernutrition in children under 5 year of age, 2005
Age groups
Pathologies
Differences in
Prevalence associated to
undernutrition
0-11 months Anemia 1.1% 111
EDDs 10.2% 1 044
ARIs 5.0% 512
12-23 months Anemia 10.1% 3 624
EDDs 11.4% 4 078
ARIs 0.4% 131
24-59 months Anemia 19.6% 9 922
EDDs 9.5% 4 831
ARIs 0.0% 0
Source: ECLAC based on data from the MSD and the ENDSA survey 2003.
Number of children with
illnesses associated to
undernutrition
19
Data referred to pathologies correspondent to critical nutritional deficiencies in calories and proteins,
such as severe emaciation or marasmus and edema undernutrition or Kwashiorkor, which in 2005
reached 4,630 cases, are added to the above data. 10 It should be noted that both severe clinical
expressions of undernutrition represent a high risk of death for those who suffer them and they
necessarily require hospital treatment. 11
8. In this study, estimates of effects and costs correspond to averages and are subject to the margins of error of the original data sources.
9. Probability differences are the higher probabilities the malnourished have of presenting a given pathology as a consequence of their
malnutrition.
10. This figure does not include direct effects of micronutrient deficiency but rather those associated to weighted undernutrition.
11. Unfortunately, up to 2007, the national health information system did not include a registry of cases hospitalized due to these two
severe undernutrition figures.
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Mortality due to undernutrition
Diarrhea, pneumonia, malaria and measles are the main pathologies associated with undernutrition
that, in turn, increase the country's mortality rate.
In order to limit errors derived from the inaccuracy and poor quality of the data obtained from
official records on causes of death in Bolivia, the estimation of undernutrition impact was done
considering the estimates from Fishman et al. (in World Health Organization - WHO, 2004) which
define differential relative risks for all death causes in children younger than 5 years of age, together
with mortality rates estimated by CELADE.
On the basis of such estimates, it was found that in Bolivia, in a 64-year period (1941-2005), close
to half million of children under 5 years of age died due to causes associated with undernutrition
(Table 4). Taking into account survival rates for the different cohorts under study, it was detected
that more than 82% of children of that age group of the population would still have been alive in
the year 2005 if they had not suffered from global undernutrition and, thus, they would have been
part of the current working age population (WAP). 12 Likewise, it was estimated that out of the total
of deaths occurred in population younger than 5 years old, in 2005, almost 16 thousand cases
(18%) were associated with global undernutrition.
Table 4: Bolivia-Mortality associated to global undernutrition, adjusted to the
survival rate in children under 5 year of age, 1941-2005
Period
Number of dead
children
20
1941-1950 69 268
1951-1960 79 973
1961-1970 90 611
1971-1980 94 763
1981-1990 66 441
1991-2000 45 614
2001-2005 15 855
Total 462 525
Source: ECLAC on the basis of CELADE`s population and
mortality statistics, and relative risks estimated by Fishman
et al.
Health-related undernutrition costs
Institutional —public system— and private health-related costs, 13 resulting from increased health
care related to the pathologies associated with undernutrition in children of less than 5 years of
age, in 2005,were higher for the age group of children from 12 to 23 months of age (Table 5): 35%
of the population affected by undernutrition and 50% of the total health cost for that cohort.
As shown in table 5, during 2005, the public and private health-related cost was 13.9 million U.S.
dollars, which accounted for 0.15% of the Bolivian GNP and to 4.3% of the national public spending
in health. The analysis of the origin of both costs shows that 95% corresponded to the public sector
and 5% to the private sector. 14
12. With the aim of comparing cost estimates, the working-age population is defined in this study as the population between 15 to 64
years of age.
13. In the case of public cost, indicators were estimated from information reported by the different branches of the MSD. For the private
cost estimate, the minimum official salary in Bolivia was taken, as well as the urban transportation rates and inputs not covered by
the public health system.
14. For the private sector, the greatest cost corresponds to the time and transportation required to get medical care.
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Table 5: Bolivia - Health-related cost of global undernutrition, 2005.
Age groups
Number of cases with
diseases associated to
undernutrition
Cost in millions of
Bolivian currency
Cost in millions of U.S. dollars
Newborns (IUGR) 3 144 0.4 0.1
0-11 months 13 274 18.5 2.3
12-23 months 45 095 55.4 6.9
24-59 months 67 264 37.2 4.6
Total 128 777* 111.5 13.9
Source: ECLAC, *Cases include 99 thousand direct treatments provided to affected children only due to the fact
of having low weight.
3.1.2 Education-related effects and costs of undernutrition
Effects of undernutrition in schooling and school years repeated
In 2005 in Bolivia, educational coverage registered in official statistics was high for primary education
(94%) and low for secondary education (59%).
According to information obtained from the 2005 Household Survey, that year, the average schooling
among adult population —19 and more years of age— was eight years, revealing a progressive increase
in schooling. Thus, among people from 55 to 64 years of age, the schooling average was five years less
than that of the population of 20 to 24 years of age, but maintained a high deficit in the coverage and
relatively low academic success: only 35% of the people had finished the secondary education level.
In the primary and secondary education levels, the Bolivian population suffering from undernutrition
showed an average schooling differential 2.8 years lower compared to that of non-malnourished students.
This can be explained, partly, because a good proportion of people that suffered from undernutrition
in their pre-school stage did not even attained first-grade primary education.
On the other hand, it has been found out that among the population with some degree of schooling,
91% of malnourished children only attended to the primary education level, while for those nonmalnourished
the figure was 55%. This relation is progressively inverted in secondary education, that
is why only 3.3% of malnourished children achieved 12 years of schooling, while 25.3% of those nonmalnourished
completed such education level. Such differences are very important indicators at the
moment of considering gaps in labor opportunities and income during working life in the country.
21
Another relevant result in this study is one referred to repeated school years related to undernutrition.
Certainly, during 2005, global undernutrition in the Bolivian school population generated 936 additional
repeated school years —44% of these cases corresponding to the primary level— 15 a figure that increased
costs in the education sector.
It should be noted that the group of children that suffered from undernutrition before 5 years of age,
showed a greater concentration of cases of repeating school years at the primary school level, compared
with those that did not have undernutrition. As can be seen in Chart 2, in both population groups, rates
of repetition were higher at the secondary school level, maintaining a gap with greater disadvantages
for students who were affected by undernutrition during their first years of life.
15 To estimate educational gaps generated by malnutrition, estimates of a longitudinal study undertaken in Chile between 1987 and
1998 (Ivanovic, 2005), were adapted. According to these estimates in populations similar in the socio economic aspect, persons
with malnutrition during preschool stage present higher risk of repeating any year at school, equivalent to 1.65 times more than nonmalnourished
students. In the absence of estimators and considering characteristics of the educational systems, in order to have
comparable estimates among Andean countries, such relative risk was applied to repetition and one differential of 1.4 for dropout
during the educational cycle.
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Chart 2. Bolivia - Repeated school years associated to global undernutrition, 2005
5.0
4.5
4.0
3.0
2.7
2.0
1.0
0.0
0.13
Primary
0.2
Secondary
Non-malnourished
Malnourished
Source: ECLAC based on data from the Ministry of Health and Sports (2005) and CELADE's population
estimates (2005)
Education-related costs of undernutrition
The additional cost due to a greater rate of school years repeated by those who have suffered from
undernutrition is one of the relevant costs of education in Bolivia. Consequently, in 2005, the 1,936
additional students originated by the differential repetition probability, meant more than 400
thousand U.S. dollars, an amount that corresponds to 0.06% of the public spending in education
and 0.004% of the GNP for that year.
Table 6: Bolivia - Costs resulting from the repeated school years differential
associated to global undernutrition
Costs
Primary Level
Secondary Level
Annual cost per student (in Bolivianos) 1 710 1 745
Annual additional cost (in Bolivianos) 1 459 495 1 889 985
Annual additional cost (in U.S. dollars) 180 943 234 313
415 256
Percentage of public spending in education 0.06%
Percentage of the GNP 0.004%
Source: ECLAC, based on official data from the Ministry of Education (2005)
22
3.1.3 Productivity-related effects and costs of undernutrition
Effects of undernutrition in the productive capacity
In general terms, undernutrition impacts negatively on the productive capacity of a country. This
is due to the higher prevalence of mortality among malnourished population of less than 5 years
old —caused by pathologies associated to undernutrition— as well as to the diminished educational
level that malnourished populations achieve.
Table 6 shows an overview of the loss in productivity as a consequence of the deaths of more than
400 thousand children under 5 that occurred between 1941 and 1990 due to global undernutrition.
Considering occupation rates in the country by age cohorts, the estimated cost resulting from this
loss is equivalent to more than 583 million of hours worked; meaning 10.5% of hours worked by
the economically active population (EAP). If considering a potential workforce of 2,400 hours
worked per person per year, deaths associated to global undernutrition result in a loss estimated
to be 962.5 million hours, equivalent to 17.3% of the EAP.
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Table 7: Bolivia - Productivity-related effects of global undernutrition
due to mortality.
Age groups
Mortality due to undernutrition
(1941-1990)
Lost working hours
(2005)
15-24 years 66 441 46 130 939
25-34 years 94 763 151 470 561
35-44 years 90 611 156 839 994
45-54 years 79 973 129 909 973
55-64 years 69 268 99 114 734
Total 401 056 583 466 201
Hours lost in relation with the EAP 10.5%
Source: ECLAC based on CELADE's population and mortality statistics, relative risks
estimated by Fishman et al., and data from the Unit of Analysis of Social and Economic
Policies (UDAPE)
Regarding diminished productivity due to the schooling gap, this arises from differences in school
years at the primary and secondary levels of people that had global undernutrition compared to
those that did not. In this respect, Chart 3 below shows the educational level attained by the
population that could register at school.
Chart 3: Bolivia-Global undernutrition effects on schooling distribution
of 25 to 64 years of age population, 2005
Total
56% 7% 16% 20%
Malnourished
87% 4% 6% 3%
Non-malnourished
47% 8% 19% 25%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Primary, not completed
Primary, completed
Secondary, not completed Secondary, completed
23
Source: ECLAC based on the 2005 Household Survey data, ENDSA Survey
2003, and CELADE's population estimates (2005)
Productivity-related undernutrition costs
Costs in the productivity area respond to the economic value in which undernutrition effects are
translated. Thus, for 2005, it was found that the diminished school attendance in the population
generated a loss of 219 million U.S. dollars, equivalent to 12.6% of the social spending for that
year, 32.1% of the public spending in education and around 2.3% of the GNP observed in 2005.
On the other hand, it was estimated that for 2005 productivity loss was of 319 million U.S. dollars
—accounting to 3.4% of the GNP—, due to the effect of deaths caused by undernutrition experienced
by people that in that year could have been part of the working-age population group. Thus, if it
were not due to the levels of undernutrition registered in the country during the last decades,
productivity for the year 2005 would have been 5.7% higher.
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3.1.4 Synthesis of undernutrition costs
Global undernutrition to which population of the different cohorts living in 2005 was exposed to,
generated a cost of approximately 4,453 million Bolivianos, equivalent to 552 million U.S. dollars.
This cost corresponds to 5.8% of the GNP and 31.8% of the total social spending in the country
for that year. It is also important to note the considerable decrease in the country's productivity
due to the man/hours (M/H) lost as a consequence of mortality caused by undernutrition.
Tabla 8: Bolivia-Resumen de los costos por área de impacto de la desnutrición, 2005
Health-related
Increased cases of morbidity 128 777 111 14
Number of additional deaths 401 056
Education-related
Additional school repeated years 1 936 3 0.4
Dropout differential 343 853
Productivity-related
Loss of M/H due to mortality 583 466 200 2 573 319
Fewer years of schooling 2.8 1 765 219
Total 4 453 552
Social spending 31.8%
Percentage of the GNP 5.8%
Source: ECLAC
Units
Cost in million
Bolivianos
Cost in million
U.S. dollars
As shown in Chart 4 below, costs referred to loss of productivity due to mortality and schooling
factors —dropout and repetition— concentrate 97% of the total cost of undernutrition for 2005.
Chart 4: Bolivia - Distribution of the global undernutrition cost according
to analysis factors, 2005
Dropouts
39.63%
Morbidity Repeated
2.50% school years
0.08%
24
Source: ECLAC
Mortality
57.79%
3.2 Results of the prospective analysis
3.2.1 Health-related effects and costs of undernutrition
From projections based on census data, it was estimated that 69,426 deaths would occur among
the cohort of 0 to 59 months of age in 2005 before those children reach 5 years of age. Of these
deaths, more than 12 thousand (41%) are estimated to be associated to global undernutrition with
more than 5 thousand cases occurring in 2005 16 (table 9).
16. All estimates for the 0-4 years cohort of 2005 have a progressive diminishing process up to 2009. This is due to the passing of its
members to groups of older ages.
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Table 9: Bolivia. Projection of number of deaths associated to global
undernutrition in children under 5 years of age, 2005-2009
Age groups 2005 2006 2007 2008 2009 Total
0-11 months 2 558 --- --- --- --- 21.0%
12-59 months 2 806 2 838 2 122 1 411 702 79.0%
Total 5 365 2 838 2 122 1 411 702 12 438
Source: ECLAC based on CELADE's population and mortality statistics, on relative risks estimated by Fishman et
al. and the data of the 2003 ENDSA Survey.
Even if death incidence for the year 2005 was similar for the 0-11 months and 12-59 months groups
of age, according to projection done in this study, the number of deaths follows a diminishing trend
as children approach 5 years of age. It was estimated that almost 10 thousand children could die
between their first and fourth year of life, due to causes associated to global undernutrition.
Regarding morbidity projection up to the year 2009, it was estimated that among children of the
0 to 59 months cohort for 2005, more than 46 thousand additional cases would occur due to ADDs,
ARIs and anemia associated to global undernutrition. Of these cases, as shown in table 10 below,
57% correspond to the 24 to 59 months of age group.
Age groups
Table 10: Bolivia-Projection of morbidity associated to global
undernutrition in children under 5 years of age, 2005-2009
2005
Estimated total cases of diseases
2006 2007 2008 2009 Porcentaje
0-11 mos. 2 993 --- --- --- --- 6.0%
12-23 mos. 9 352 7 335 --- --- --- 36.0%
24-59 mos. 16 539 5 670 3 358 753 143 57.0%
Total 28 884 13 005 3 358 753 143 46 143
Source: ECLAC based on CELADE`s mortality and population statistics, relative risks estimated by Fishman et al.,
and data from the 2003 ENDSA Survey.
It should be added to the above morbidity cases the health care demand directly derived from
children suffering undernutrition; indeed, some 99 thousand treatments related to underweight per
se are estimated for 2005, and 58 thousand health care treatments are projected between 2006
and 2009. Of these cases, about three thousand cases correspond to children with low weight at
birth due to intrauterine growth retardation.
25
In 2005, the additional health care caseload derived from undernutrition, implied an additional
cost for the health sector of 14 million U.S. dollars, that means more than 21 million U.S. dollars
at present value, annual discount rate of 8% for the period 2005-2009 (table 11).
Table 11: Bolivia- Projection of morbidity costs associated to global
undernutrition, 2005-2009 (in million U.S. dollars)
Age groups
2005
2006 2007 2008 2009
Newborns 0.1 --- --- --- ---
1-11 months 2.3 --- --- --- ---
12-23 months 6.9 5.4 --- --- ---
24-59 months 4.6 1.6 0.9 0.2 0.0
Total 13.8 7.0 0.9 0.2 0.0
Net present value 21.3 --- --- --- ---
Source: ECLAC
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Values in the table above are translated into an annual cost equivalent to 6.4 million U.S. dollars
in the period, at an annual discount rate of 8%. That amount corresponds to 2% of the public
spending in health and to 0.07% of the 2005 GNP.
3.2.2 Education-related effects and costs of undernutrition
The methodology allowed projecting the educational costs derived from malnourished children
under 5 years of age living during 2005 17 . It was possible to estimate the differential probability
of educational achievement, as well as additional costs that would be generated by the approximately
158 thousand future Bolivian students that were suffering from undernutrition in 2005.
Using the official education information, it was calculated that between years 2007 and 2022 there
would be 1,500 extra cases of school repetition. Of these cases, 44% correspond to the primary
level and 56% to the secondary level. As a result of additional repetitions, costs in the area of
education —expressed in present value at an annual discount rate of 8%— rise to 1.04 millions
of Bolivianos, equivalent to 0.13 million of U.S. dollars.
Indeed, during the period of 16 years in which the analyzed cohort would reach school age (2007-
2022), estimates of the total annual equivalent cost adds-up to 0.13 million U.S. dollars at the 2005
exchange rate, a figure that represents a very low percentage of the social spending in education
and that year's GNP. Of these costs, 17% shall be covered by the students' families and 83% shall
be covered by the national educational system.
Considering the higher dropout risk shown by malnourished children, the projection under this
study revealed that 22,732 students could abandon the educational process due to undernutrition.
Accordingly, a difference of two years of schooling was between among malnourished and nonmalnourished
students, with an average of about seven years of schooling for the first ones.
26
On the other hand, as shown in Chart 5 below, the projection implies that only 16 of every 100
malnourished children from the 0 to 59 months of age cohort of year 2005 will complete the 12
years of schooling in the formal system, while 39 out of every 100 of those non-malnourished will
complete their school education.
Chart 5: Bolivia- Estimated distribution of schooling for the 0-59 months of age cohort of year
2005, with and without global undernutrition
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
1 2 3 4 5 6 7 8 9 10 11 12
Grados
Non-malnourished Malnourished Total
Source: ECLAC on the based of the 2004 Household Survey, ENDSA Survey 2003, and CELADE's population
estimates.
17 This projection used data on education coverage of population in school age and on the education levels achieved by the 20-24
years of age cohort of the last Household Survey (2005).
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3.2.3 Productivity-related effects and costs of undernutrition
The schooling differential described above is translated into reduced cumulative human capital among
the malnourished population, with a direct negative effect on their productivity. Furthermore, 12,438
additional deaths are estimated as a result of undernutrition in the 0-59 months of age cohort, during
the 2005-2009 period, which represents an additional potential productivity loss of 1,047 million work
hours during their working life; that is between 2015 and 2069.
On the basis of these data, it was estimated that economic losses in the productivity area associated to
global undernutrition affecting Bolivian population of less than 5 years of age, reached 655 million
Bolivianos in 2005, equivalent to 81 million U.S. dollars of the same year, at an annual discount rate
of 8%. Of this amount, 53 millions are the result of a lower education level and 28 millions are due
to the mortality differential.
Indeed, during 2015-2069 the total annual equivalent cost amounts to 53 million Bolivianos, equivalent
to 6.6 million U.S. dollars. Of this amount, 2.3 million U.S. dollars correspond to mortality costs and
4.3 million of U.S. dollars represent losses as a consequence of less years of schooling.
It should be noted that the annual cost in terms of productivity is equal to 0.1% of the Bolivian GNP
and to 0.38% of the country's social spending.
3.2.4 Synthesis of undernutrition costs
In grouping all the sources of costs that are attributable to undernutrition for the cohort of malnourished
children of less than 5 years old living in 2005, the present value was about 827 million Bolivianos,
equivalent to 102.1 million U. S. dollars (table 12).
Table 12: Bolivia-Summary of global undernutrition costs by area of impact in
the 0-59 months of age cohort, 2005
Source: ECLAC
Units
Population affected
(2005)
Costs
(present value)
In million U.S. dollars
Health-related
Increased cases of morbidity 204 504 171.0 21.0
Number of additional deaths 12 438 --- ---
Education-related
Additional repeated years 1 482 1.0 0.1
Dropout differential 22 732 --- ---
Productivity-related
Loss of M/H due to mortality 1 047 249 164 224.0 28.0
Fewer years of schooling 2.1 431.0 53.0
Total 827.0 102.1
27
As shown in Chart 6 below, the loss of human resources due to lower educational achievement
(52.1%) and due to greater costs in health care (20.7%) as a consequence of morbidity, account
for most of the cost attributable to undernutrition.
Chart 6: Bolivia-Distribution of the estimated cost of undernutrition by analysis factors, 2005
52.1%
20.7%
0.1%
27.3%
Source: ECLAC
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3.2.5 Scenario analysis: costs and savings
From the costs estimated as a consequence of global undernutrition prevalence in the population
of less than 5 years of age in 2005, it was possible to simulate three future scenarios for Bolivia.
Such scenarios are:
• Scenario 1: As of 2015, the latest figures available on the prevalence of global undernutrition
used in this study remain stable (see table 1);
• Scenario 2: By 2015, the goal established in the MDG referring to decreasing global undernutrition
to half of the prevalence registered for 1990, is achieved. This would imply its progressive
reduction up to a rate of 6.35% in the population group of children of less than 5 years of age.
That is, it is a reduction of around 2.7 percentage points annually, in average;
• Scenario 3: In 2015 global undernutrition is virtually eradicated in Bolivia. This is equal to a
prevalence of 2.5% that represents the normal proportion of cases according to measurement
parameters set up by the NCHS. In order to make this possible, a decrease of 5.8 percentage
points annually is required.
The following are the results of the simulations corresponding to the three trend scenarios considered
for different undernutrition rates as well as for their impact on the country's costs in 2015:
• Scenario 1: By 2015 costs will have a slight variation —of approximately— 0.19% —given that
Bolivia shows a trend to slightly increase the size of the 0 to 4 years of age cohort— annual
0.3% in average, between 2005 and 2015;
• Scenario 2: By 2015 global undernutrition costs will decrease to 87.53 million U.S. dollars; 18
• Scenario 3: By 2015, costs will be further reduced, reaching a present value of 36.32 million
U. S. dollars. 19
Table 13 below shows a detailed comparison of costs estimated for 2005 with those projected to
2015 for each scenario. Data reveal that the greatest variation in costs is shown in the productivity
and health areas.
Table 13: Bolivia-Total cost estimates for global undernutrition for the base year and
the three scenarios studied, 2005 and 2015 (in million U.S. dollars)
28
Source: ECLAC
Costs to year 2005
(present value)
Scenario 1
Costs by year 2015
Scenario 2 Scenario 3
Health-related
Increase cases of morbidity 21 22 18 8
Education-related
Additional repeated school years 0.13 0.13 0.11 0.05
Productivity-related
Loss of M/H due to mortality 28 24 21 9
Fewer schooling years 53 57 48 19
Total 102.13 103.13 87.11 36.05
From the cost trends submitted, it is possible to estimate potential savings that could be generated
if achieving the goals proposed in the different scenarios. In this regard, Chart 7 below shows how
a progressive reduction in global undernutrition prevalence generates a progressive decrease in the
costs associated and, thus, savings. In such chart, the distances between the trend lines of scenario
2 in relation to scenario 1 and of scenario 3 in relation to scenario 1- illustrate the savings that
18. Value updated to 2015 at an annual discount rate of 8%.
19. Idem.
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would be generated year after year, accumulative up to 2015 as progress is made in reducing
undernutrition. Such savings, expressed in present value for the year 2005, 20 are equal to almost
50 and 254 million U.S. dollars for scenarios 2 and 3, respectively. Of these amounts, 35% and
40%, in each case, would be obtained thanks to the impact generated during the first half of the
process: 2006-2010.
Chart 7: Bolivia- Trend of global undernutrition estimated costs in the three study
scenarios, 2005-2015 (in million U. S. dollars)
Costos
120
100
80
60
40
20
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Años
Same prevalencencia Decrease to Eradication (2.5%)
Source: ECLAC
The above results imply that costs in 2015 could not only be significantly less, but also important
savings could be obtained along the process in scenarios 2 or 3 (table 14). At the same time, if
appropriate national policies are kept in operation, projected benefits would continue accumulating
after 2015.
Table 14: Bolivia- Savings estimates according to
scenarios, 2015 (in million U. S. dollars)
Decrease (5.6%) Eradication (2.5%)
Health-related 10.7 53.0
Education-related 0.1 0.3
Productivity-related
Loss due to mortality 10.7 58.5
Fewer schooling years 28.3 142.5
Total 49.8 254.3
Source: ECLAC
29
Economic benefits to be obtained in the process of eradication of undernutrition and the programs
leading to that, will generate positive impacts in the quality of life of people, as well as important
savings for society.
4. Conclusions
The study highlights the magnitude of the economic loss that Bolivia is experiencing by presenting
the current child undernutrition prevalence. Furthermore, the results support the need of investing
in nutrition, given the potential savings if cost-effective interventions are undertaken to prevent
undernutrition and to treat the children already affected by it.
20. Value updated to 2004 at an annual discount rate of 8%.
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
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Child undernutrition's greatest cost is expressed in a diminished productivity which, in turn, accounts
for 97% of the total costs estimated in the retrospective incidental dimension and 79% of those
from the prospective dimension. The results obtained, suggest that if effective interventions would
have been implemented to reduce child undernutrition in the past decades, Bolivia would not have
experienced a 6% GNP loss in 2005.
Costs in the areas of health, education and productivity might be avoided if eradication of child
undernutrition is assumed in an effective and efficient manner. This will allow to increase schooling
years, avoid additional expenses in terms of medical care and to gain in productivity, generating
a positive long term impact in the economic growth of the country.
A cost of 6% of the GNP in any given year, is a luxury that a country such as Bolivia cannot allow
to happen, loosing as well the opportunity of taking full advantage that the population base is still
young due to the current stage of the demographic transition, having an adult population —human
capital— with greater possibilities and capacities. Therefore, a national goal should be to achieve
scenario 3 —reduce at least to 2.5% global undernutrition— thus reducing undernutrition costs
by a third.
Even though the PMD-C is a program prioritized in the National Development Plan, it does not
have a sufficient budgetary allocation from the National General Treasury for its appropriate
implementation. Therefore, it is of the utmost importance that the ministries from economic area
internalize how the productive process is strongly affected by the nutritional issue, and the significant
returns that interventions in this area will provide.
With the objective of breaking the vicious cycle of poverty-undernutrition, the latter should be
addressed with preventive interventions, such as: strategies for behavior change, systems for
nutritional surveillance at the community, provision of fortified complementary foods, potable water
service and actions to improve productivity as well as economic income of Bolivian families.
Initially, those interventions should give priority to pregnant women as well as to children of less
than 2 years of age.
30
In the social area, interventions should contribute to make the PMD-C visible as an effective strategy
in the fight against undernutrition, instead of only focusing in conventional care models as the only
possibility for solution.
On its side, the CONAN should ensure a successful implementation of the PMD-C, through the
efficient performance of multi-sector alliances at the national, departmental and municipal levels,
with participation of the international cooperation, NGOs and, above all, of civil society organizations
and communities. This will allow compliance with the international commitment of achieving the
MDG 1 —eradicate extreme poverty and hunger— as well as the goals proposed in the PMD-C.
Finally, beyond the potential economic savings that can be obtained by eradicating undernutrition,
to invest in the nourishment of the Bolivian population is a moral obligation that, will guarantee
a basic human right: the right to receive appropriate nourishment.
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
Sources consulted
Publications
• Academy for Educational Development, PROFILES (1998). Process for the analysis of nutrition policies and
advocacy in favor of public nutrition. Linkages, Washington D.C.
• CT-CONAN (2008a). Activities Report 2007 for the Technical Committee of the National Council for Food and
Nutrition, La Paz.
• CT-CONAN (2008b). Multi Sector Program for Cero Undernutrition (first forecast), La Paz.
• Fishman, S. and others (2004). “Childhood and Maternal Underweight”, WHO (2004), Comparative Quantification
of Health Risks. Global and Regional Burden of Disease Attributable to Selected Mayor Risk factors, Geneva.
• INE (2004). Demographic and Health National Survey 2003, Macro Int., La Paz.
• Ivanovic, D. (2005). “Factors that bear on the permanence of the student in the educational system, within the
framework of a follow up study. Metropolitan Region, Chile, 1987-1998”, Instituto de Nutrición y Tecnología
de los Alimentos (INTA), Universidad de Chile.
• Martínez R. & Fernández A. (2006). Model for the analysis of social and economic impacts of child undernutrition
in Latin America, Series of Handbooks, No. 52, ECLAC, Santiago de Chile.
• Martínez R. & Fernández A. (2007). Cost of hunger. Social and Economic impact of child undernutrition in
Central America and the Dominican Republic, ECLAC and WFP, Santiago de Chile.
• MSD (2005). “Guidelines for the National Policy on Food and Nutrition Security” (mimeo), La Paz.
• World Bank (2006). Repositioning Nutrition as Central for Development, Washington D.C.
Sources for basic data
• For economic data:
• UDAPE (File of social and economic statistics, volume 16, 2006).
• INE (Household Survey 2005).
• Ministry of Finance, Bolivia.
• ECLAC
For population data:
• INE.
• CELADE.
For health data:
• INE (ENDSA 1989, ENDSA 1993, ENDSA 1998 and ENDSA 2003).
• INAN (National Survey on Nutritional Status 1981).
• Statistics Unit of the Children's Hospital "Dr. Ovidio Aliaga Uría" in La Paz, Bolivia.
• MSD (Integrated Strategy of Maternal/Child care for the attention of Childhood Diseases - IMCI/Bolivia, 2005).
• National Health Information System (SNIS) of the MSD.
• SUMI Unit at the MSD.
For education data:
• Information System for Education (SIE) of the Ministry of Education and Culture, Bolivia.
The cost of hunger in Bolivia. Social and economic impact of child undernutrition
Printing completed on February 2009, at the
Impresiones Quality s.r.l. facilities, calle Chichas 1292, La Paz, Bolivia.
Edition 500 copies
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