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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


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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


Food Security Management Information System

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).

The cost of hunger in Bolivia. Social and economic impact of child undernutrition


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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.

The cost of hunger in Bolivia. Social and economic impact of child undernutrition


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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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