nutrition sensitivity



nutrition sensitivityHow agriculture can improve child nutrition

Save the Children works in more than 120 countries.We save children’s lives. We fight for their rights.We help them fulfil their potential.AcknowledgementsThis report was written by Hugh Bagnall-Oakeley, Marie Rumsby and DavidMcNair, all from Save the Children. Liam Crosby and Shawnee Hoover (alsofrom Save the Children) provided valuable inputs. Other colleagues fromacross Save the Children were involved in the development of the reportand provided guidance.We would also like to thank, without implication, David Hong (ONE), KebedeTefasse (ENGINE Project, Ethiopia), Peter Muhangi (Save the Children,Ethiopia), John Nyirenda (Save the Children, Malawi), James Lwanda (Save theChildren, Malawi) Professor Waage (LIDC), Laila Lokosang (CAADP Adviser,African Union), Modibo Traore (FAO), Bonnie McClafferty (GAIN), Liz Stuart(Save the Children) and Chris Penrose Buckley (DFID) for their commentsand insights on earlier versions of the report.Published bySave the Children1 St John’s LaneLondon EC1M 4ARUK+44 (0)20 7012 published 2014© The Save the Children Fund 2014The Save the Children Fund is a charity registered in England and Wales (213890)and Scotland (SC039570). Registered Company No. 178159This publication is copyright, but may be reproduced by any method withoutfee or prior permission for teaching purposes, but not for resale. For copying inany other circumstances, prior written permission must be obtained from thepublisher, and a fee may be payable.Cover photo: A kitchen garden in Ruhango district, Rwanda (Photo: SebastianRich/Save the Children)Typeset by Grasshopper Design Company

contentsExecutive summaryiv1 The relationship between nutrition and agriculture 1Malnutrition holds back economic and agricultural development 2The strong links between agriculture and nutrition 42 Policy frameworks for agriculture and nutrition 6A focus on increasing productivity 93 Governance of nutrition-sensitive agriculture 12Implementing nutrition-sensitive agriculture at the district level: a model 12Ensuring sustainability through profitability 16Putting nutrition-sensitive agriculture into practice 174 Shaping nutrition-sensitive agriculture throughglobal frameworks 19Global frameworks 19The way forward 215 Conclusions and recommendations 22Appendix 1Methodology for field case studies 24Appendix 2Stunting rates in CAADP and/or SUN Movement countries, and stated commitmentsto reducing malnutrition 25Endnotes 28Bibliography 30

Executive summaryIn 2011, 3.1 million children under the age offive died because they were malnourished –with malnutrition accounting for 45% of allchild deaths. 1 These children did not haveaccess to the correct balance of foods, ortheir bodies were not healthy enough toabsorb essential nutrients. Millions moremalnourished children are highly susceptibleto disease, have poor cognitive development,and stunted growth – all of which limit theirability to escape poverty during childhoodand in later life.Many African countries aspire to achieving middleincomestatus, with vibrant, dynamic and knowledgeledeconomies. But this aspiration is being hamperedby the damage done to today’s generation by a lackof proper nutrition; for example, adults who weremalnourished during childhood are likely to earn 20%less than their well-nourished counterparts.The impact of child malnutrition – on a country’sdevelopment, its children, and its economy – isunacceptably high. Food for Thought, a reportpublished by Save the Children in 2013, showed thatgood nutrition is a critical factor in the pursuit ofeconomic development; malnutrition represents asignificant barrier to economic development andgrowth, and means children are not able to livehealthy and productive lives.Until recently, malnutrition had neither the profilenor traction needed among policy-makers, plannersand decision-makers to get them to stand up andaddress this global challenge. However, a number ofrecent initiatives have been launched to address childmalnutrition and undernutrition, including the ScalingUp Nutrition (SUN) Movement, the Thousand DaysInitiative, The New Alliance for Food Security andNutrition, and the Nutrition for Growth event inLondon in June 2013, which agreed some bold targetsto improve nutrition among children and pregnantwomen by 2020, with funding commitments of$23.1bn.The African Union (AU) has declared 2014 as theYear of Agriculture and Food Security; this, togetherwith the joint annual reviews of CAADP (theComprehensive Africa Agriculture DevelopmentProgramme), presents an important opportunity tosecure significant policy and financial commitments toensure that agriculture supports and delivers thesechild nutrition goals.There is broad consensus on the need to scaleup nutrition-specific interventions– ie, directnutrition interventions such as promoting exclusivebreastfeeding, infant and young child feeding, orgreater coverage of vitamin A. But the limitedevidence base on nutrition-sensitive approachesmakes it difficult for agriculture, social protectionand other relevant policies to take account of theirpotential impact on nutrition. There is an urgentneed to strengthen the nutritional component ofmany agricultural policies and investment plans. 2A role of agricultural policy is to promote economicdevelopment and provide nutrition for a country’spopulation. CAADP plans should include a nutritionstrategic objective supported by clearly definedindicators. The indicators should be differentiatedby gender and age group (adult and child).Furthermore, throughout the policy and investmentplans, when discussing productivity or other issues,the strategic objectives and indicators must referto nutrition. Ensuring the country’s populationhas access to good-quality nutrition is agovernmental responsibility.The Lancet suggests that direct nutritioninterventions, even if implemented at 90% coveragein high-burden countries, would only reduce globalstunting by 20%. For that reason, in addition todirect nutrition interventions, Save the Children hasiv

long advocated for the need to take a multi-sectoralapproach that also employs nutrition-sensitiveinterventions in order to address the underlyingand inter-related determinants of malnutrition,through promoting exclusive breastfeeding, incomegeneration, women’s empowerment, good hygieneand social behaviour change. 3 Here, social behaviourchange is taken to be a process of transformingthe way society is organised in a way that leads tochanges in basic practices, such as the way food iscooked or consumed.This report examines the relationship betweenagriculture and nutrition in developing countries,focusing on how nutrition is currently prioritisedwithin agricultural policy frameworks, from theglobal to the district level. It suggests ways inwhich nutrition-sensitive interventions could beimplemented through existing government policiesand governance structures.The findings are based on an assessment ofagricultural policies in 15 African countries, alongsideCAADP plans from 18 African countries. Generallyspeaking, African agricultural plans are primarilyfocused on production and give limited emphasis tonutrition. This is not surprising on one level, giventhe importance of improving food production in thecontext of economic development and populationgrowth. But the findings also reveal notableexceptions to the rule, which offer some importantlessons for countries that want to improve childnutrition now, as well as helping their economiesgrow in the short and the longer term.Case studies in Malawi and Ethiopia show how, atthe district level, strong leadership is required toembed nutrition within agriculture programmes inorder to promote greater dietary diversity at thehousehold level. Two models are suggested, bothof which require strong collaboration betweenrelevant ministries.Discrete policy and programme-level changes canraise the profile of nutrition within the agriculturesector and ensure that agronomists and otherstakeholders prioritise (and are held to account for)improving dietary diversity and other actions thatwill lead to improved nutrition. It is not true thatincreased production of crops will automatically leadto improved nutrition and reductions in stunting.To ensure that nutrition-sensitive approaches areembedded in agricultural policies, we recommendthat the African Union:• commits to ensuring that agricultural investmentplans include nutrition objectives and appropriatemetrics to monitor progress on nutrition-relatedgoals• includes a stunting-specific indicator as part of theCAADP results framework. The indicator shouldbe adopted by national agriculture ministries andbe accompanied by actions to ensure impacts• establishes a common joint peer reviewmechanism that assesses the progress of CAADPimplementation. The joint annual review ofEthiopia’s Policy and Investment Framework(CAADP investment plan) provides a usefulquality standard• establishes a regional benchmarking process thatwould enable citizens to see how their country isperforming in relation to other countries• develops institutional links between thoseresponsible for national agriculture plans andScaling Up Nutrition (SUN) plans.We recommend that governments in high-burdencountries:• include improving nutrition as an explicit policyobjective in their agricultural policies andagricultural investment plans (CAADP plans),and more specifically:– establish multi-sectoral coordinationmechanisms to ensure that policy decisionsare owned by all relevant ministries– establish a cross-departmental working groupto oversee policy implementation and tomonitor progress against a set of commonlyagreed indicators– adapt district-level policy mechanisms toimprove coordination and integration ofnutrition concerns between agriculture andhealth ministries– where appropriate, explore the possibilityof utilising agricultural networks to delivernutrition interventions – for example, a moreunified extension service that delivers bothagricultural messages and nutrition messages.A number of government extension serviceshave adopted this paradigm– increase the level of agricultural biodiversity byinvesting in seed markets to generate a morediverse enterprise and cropping base, and thuspromote greater diversity of diet.Executive summaryv

nutrition sensitivityWe recommend that donors encouragegovernments to prioritise nutrition within agricultureplans by taking the following actions:• Strengthening the nutrition outcomes of initiativessuch as the New Alliance for Food Security andNutrition, by working with participating countriesto establish country-specific goals, outcomes,and actions on malnutrition – ensuring thatnutrition indicators in the results frameworkare implemented and integrated within nationalagriculture plans.• Developing a tool to enable agronomists andpolicy-makers to assess the nutrient constituentsof crops. Such a monitoring tool, if available inopen data format, could enable agriculturaliststo consider the implications of the crops andenterprises they promote from the perspectiveof their impact on child nutrition.• Ensuring that country-based donor technicalcommittees include civil society representativesto ensure accountability and reflect civil societyvoices in the planning colin crowley/save the childrrenMartha, pictured here with her daughter Juba, isa member of a group of 200 women farmers inPagak, South Sudan. They are part of a Save theChildren programme that aims to help womengrow more food.“Before, we never grew many vegetables,” saysMartha. “Now we’re growing beans, tomatoes,okra, kale and cabbage. After this harvest I willtry to use the knowledge to grow more cropsnext year.”Diversification of the agriculture base is animportant nutrition-sensitive principle, to improvedietary diversity. Rotation – planting differentcrops – breaks the build-up of pests and diseases,and improves soil fertility and

1 The relationshipbetween nutritionand agricultureIn 2011, 3.1 million children under the age offive die because they were malnourished, withmalnutrition accounting for nearly half (45%)of all child deaths. 4 For millions of childrenwho survive, malnutrition makes their bodiesless capable of resisting disease, and harmstheir cognitive development. This condition,called stunting, locks millions of childreninto poverty by restricting their cognitiveand physical development and thus their lifechances – as children and later as adults.The first 1,000 days of a child’s life – countedfrom the start of a woman’s pregnancy until thechild’s second birthday – represents a ‘window ofopportunity’ for nutrition, because a child’s brainand body develop rapidly during this time. The first1,000 days are therefore crucial, because even if achild’s nutrition status improves after the age of two,any damage done during the first two years is largelyirreversible and has a devastating impact on the child’sfuture potential. 5, 6 When malnourished children reachadulthood, they are likely to earn 20% less than theirwell-nourished counterparts. 7 Malnutrition stuntsthe development of an estimated 165 million childrenaround the world each year; just 14 countries accountfor 80% of the world’s stunted children. 8For too long, malnutrition has been the Achilles’ heelof development – with insufficient attention paidto its impact on children’s health and development,as well as its consequences for national economicgrowth. This is, however, beginning to change, withhigh-profile initiatives such as the Scaling Up Nutrition(SUN) Movement, with 47 member countries (as ofMarch 2014), all of which have made commitmentsto integrate nutrition into their policy frameworks.Similarly, donors are starting to pay much greaterattention to nutrition through a variety of initiatives,such as the Thousand Days Initiative and the NewAlliance for Food Security and Nutrition. TheNutrition for Growth event in London in June 2013,moreover, resulted in pledges of more than $23bnfor interventions to improve nutrition among childrenand pregnant women by 2020.A large proportion of this investment was committedtowards nutrition-sensitive interventions, whichare defined by The Lancet as “interventions orprogrammes that address the underlying determinantsof foetal and child nutrition and development – foodsecurity, adequate care giving, resources at maternal,household and community levels and access to healthservices and a safe and hygienic environment – andincorporate specific goals and actions.” 9Despite this increasing attention by policy-makersand donors, the explicit policy links betweenmalnutrition and agriculture have received relativelylittle attention at the country level. Most Africanagricultural plans and investment frameworksprioritise increases in yield and productivity overimprovements in the nutrition status of children orother vulnerable groups.While it is right that national agricultural plansare focused on improving economic growth, it isimperative that they also give sufficient attentionto helping to address child malnutrition, givenits debilitating effects on national economicdevelopment and prosperity.Malnutrition holds backeconomic and agriculturaldevelopmentThe impacts of undernutrition on economicdevelopment have implications for the agriculturesector in three ways, each truly debilitating. First,with 45% of child deaths due to malnutrition, this hasa significant impact of the number of young peopleentering the agriculture sector.1

nutrition sensitivitySecond, stunting rates are, in most cases, higher inrural areas than urban areas. Figure 1 shows theratio of stunting in each. This is important becauseof the impacts of stunting on physical strength –critical to agricultural manual labour. Survey evidencefrom Guatemala suggests that physical strength isundermined, while susceptibility to disease is increasedby undernutrition. This particular study showedstatistically significant relationships between stuntingand hand strength (as much as 22%) at age 24.Third, malnutrition is both an outcome and a driverof inequality. In developing countries, children bornto the poorest 40% of families are nearly three timesmore likely to be malnourished than those born tothe richest 10% 10 – and are likely to go on to earn lessthan their better-off (and better-nourished) peers.The gap between the poorest 40% of families and thewealthiest 10% in terms of stunting actually increasedin many parts of the world between the 1990s and2000s (see Figure 2). 11 In Ethiopia, the economicimpact of poor nutrition appears in the working-agepopulation through the lower schooling achievements,which result in low productivity and lower incomeearning potential. 12 A significant percentage of thosewho suffered malnutrition at a young age will bemanual workers. In Uganda, stunted children have1.2 years less education, which will impact earningpotential. The estimated economic loss in nonmanualactivities is estimated to be UGX 241 billion(US $98 million), equivalent to 0.7% GDP in 2009.Looking to the future, many country agriculturalinvestment plans seek to increase production, with aview to increasing food supply within their country. Anincrease in food supply may increase the processingof agricultural produce. Increased agriculturalproduction or processing does not automaticallymean increased nutrition, as it is dependent on theagricultural products available. Furthermore, increasedproduction has human resource and labour marketimplications. Greater production and processing islikely to use more labour. It will also increase the levelof management required: the management of theseprocesses is complex, requiring significant managerialtime. The availability of management resources andtime will require attention.Save the Children’s 2013 Food for Thought report,which focused on unlocking children’s potential andboosting national prosperity through improvingnutrition, highlighted the cognitive developmentimpacts of under-nutrition in the first 1,000 days of achild’s life. For example, malnourished children score7% lower on maths tests, they are 19% less likely tobe able to read a simple sentence by the age of eight,and 13% less likely to be in the appropriate schoolgrade for their age. 13The lost earning potential from child malnutritioncould cost the global economy a staggering $125bnby 2030. 14 This evidence is corroborated by theCost of Hunger assessment conducted by the UnitedNations Economic Commission for Africa (UNECA),Figure 1 Stunting rate ratio (rural:urban) in selected high-burden countriesUgandaEthiopiaNigeriaTanzaniaKenyaDRCPakistanIndiaBangladeshEgypt0 0.5 1 1.5 2Source: Dobson R: 2007. BMJ V335 (7616): 367 – Urban children healthier than rural children in developing world.2

Figure 2 changes in Ratio of stunting between wealthiest 10% and poorest 40%‘Palma ratio’ of under-5 stunting prevalence in poorest 40%compared to richest 10% (population-weighted averages)76543210North Africa/Westand Central Asia/EuropeSub-SaharanAfricaSouth andSouth-east AsiaLatin Americaand CaribbeanSource: Comparative Health Systems: Global perspectives. Editors Johnson JA and Stoskopf CH Oct. 2010.World1990s2000s1 The relationship between nutrition and agriculturewhich demonstrates that child under-nutrition hasdebilitating impacts on national economies, reducinggross domestic product (GDP) by as much as 16%.The distribution and cost of productivity losses in fourAfrican countries have been estimated and are outlinedin productivity terms. They represent a significantdrain on GDP, of 3.9%, 16% and 2.9% respectively forUganda, Ethiopia and Swaziland (see Table 1). 15 Giventhat all three countries have a considerable proportionof their populations working in agriculture, the lossof productivity is significant. (For example, 88% ofUganda’s population is engaged in agriculture.) 16These production losses represent large numbersof people who would otherwise be part of thelabour force and contributing to national output (seeTable 2). Given that most smallholders are labourconstrained, an additional labour force (of potentially567,000, 175,000 and 3.2 million in Uganda,Swaziland and Ethiopia respectively) could make asubstantial difference to production and growth.Table 1 The cost of malnutrition to national economies (in local currency, US$,and as percentage of GDP)CountryLosses due to malnutrition(local currency)Losses due tomalnutrition (US$)Equivalent % of GDPEgypt EGP 20.3 billion $3.7 billion 1.9Ethiopia ETB 55.5 billion $4.7 billion 16.5Swaziland SZL 783 million $76 million 3.1Uganda UGX 1.8 trillion $899 million 5.6Source: Individual cost of hunger assessment reports for Egypt, Ethiopia, Swaziland and Uganda; published by the individual governments inconjunction with UNECA, ADB, AFC, WFP and others. Sept 20133

nutrition sensitivityTable 2 Cost of hunger statistics for three sub-Saharan African countriesCountryEconomic loss– non-manual(US$)Economic costof workinghours lost(US$)Lowerproductivityin manualactivities (US$)Total cost(US$)Uganda 94,055,459 256,185,869 163,453,861 513,695,189 3.9Ethiopia 33,066,125 2,120,041,218 680,209,871 2,833,317,213 16.0% of GDPSwaziland 25,894,415 12,998,790 35,076,100 73,969,305 2.9Sources: Cost of Hunger reports for Ethiopia, Swaziland and Uganda, Sept 2013None of these countries can afford to sustain thislevel of productivity losses. In Ethiopia and Uganda,there have been strong political statements aboutreducing these losses. In the Ethiopia Cost of Hungerreport, the foreword by the Ethiopia Minister ofHealth has hailed the report as “undoubtedly a callto action”. The release of the Cost of Hunger reportcoincided with the launch of the National NutritionPlan (NNP). The recent Joint Annual Review of thePolicy and Investment framework called for greaternutritional prominence. Taken together, these stepsdemonstrate that nutrition is high on the governmentof Ethiopia’s agenda. In Uganda and Swaziland, theCost of Hunger assessments have engendered similarlevels of priority and urgency.The strong links betweenagriculture and nutritionAgriculture and nutrition are closely inter-connected,providing people – irrespective of their age – withtheir daily nutrient intake. Agricultural productsprovide energy, protein, vitamins and minerals(calcium, phosphate and iron) – and are thereforecritical to addressing malnutrition, particularly amongchildren and vulnerable groups.In addition, a large proportion of children and adultswho are malnourished live in rural areas and dependon smallholder farming for their livelihoods. Ananalysis of Demographic and Health Survey (DHS) datashows that people living in rural areas are between1.3 and 3.3 times more likely to be stunted than theirurban counterparts (see Figure 1, page 2). 17 In somecountries, such as Malawi, agriculture provides up to80% of total employment and accounts for 29% ofGDP. 18 As such, the outputs from agriculture, alongsideinterventions to improve the nutritional status of thoseengaged in food production, could have a major impacton reducing the prevalence of stunting.The Lancet’s 2013 series of papers on maternal andchild nutrition helpfully outlines a range of channelsthrough which direct and proximate factors canimpact nutritional status. 19 Direct factors include(but are not limited to) adolescent health andpre-conception nutrition, dietary diversity, andnutrition interventions during emergencies.Nutrition-sensitive approaches include (but are notlimited to) social safety nets, early child development,water and sanitation, and agriculture and foodsecurity. Providing a policy environment thatprioritises and facilitates the implementation of thedirect factors mentioned earlier is equally important.A starting point for analysing nutrition-sensitiveagricultural approaches is to map the various pathwaysthrough which agriculture can impact on nutrition.While the literature on nutrition-sensitive agricultureinterventions is increasing, the focus tends to be ona very tightly defined kind of evidence, mainly fromcomprehensive literature reviews. Yet there hasbeen very limited investment in gathering this kindof evidence to date. One systematic review foundmore than 7,000 relevant research papers, but only23 qualified for inclusion in the study, due to criteriaabout the types of evidence that would apply. 20The key challenges in ensuring sustainability ofnutrition-sensitive approaches include creatinga viable, evidence-based business model thatsmallholder farmers can follow. It needs to generateenough income for smallholder farmers and theirfamilies to earn their livelihood. But such a modelalso needs to set appropriate nutrition-related goalsand targets to ensure that families have and pursue adiverse and nutrient-rich diet; accordingly, agricultureplans need to be designed with appropriate indicators4

for measuring progress against these goals andtargets. Maintaining the political will to pursuenutrition-sensitive approaches may well be challengingin the face of competing issues and interests. But thepotential benefits demand no less. The maintenanceand enhancement of political momentum and clearpolitical leadership at the national, region, province,district and local government levels is vital. Thegains of improved nutrition are likely be realised andconsolidated at the lower administrative levels.Many factors affect household dietary diversity,including labour requirements, market conditions,agriculture policy, and other influences such as foodpreferences and consumption patterns. In orderto ensure consumption of the recommended dailyintake of vitamins and minerals, individuals needaccess to enough nutritious foods, social norms thatpromote good nutrition practices and increasedconsumption of nutritious foods, as well as adequateincome to purchase nutritious foods (if they are notgrowing or producing them). Ensuring nutritiousfoods are available at an affordable price at a locallevel is a first step for the agricultural sector.The remainder of this report looks at the policyframeworks and governance that guide nutrition andagriculture in 18 African countries (see Appendix 2).We focus on two countries (Ethiopia and Malawi)to review the management of agricultural systems atthe local and district levels, highlighting key lessonson the types of support needed to help ensure thatCAADP plans meet their objectives in jiro ose/save the children1 The relationship between nutrition and agricultureAwatash, a mother with three children from Tigray,Ethiopia, received five sheep from a Save the Childrenprogramme. She was also trained on how to growvegetables in her garden during the rainy season.“Before I got the sheep, I had difficulty feeding mychildren,” says Awatash. “We had two meals a dayonly of cereal. My children had health problems– skin diseases, diarrhoea, problems with theireyesight, and they were underweight.”“Now I give my children milk every day. Theirhealth is better and they are not too thin anymore,” she says.Access to livestock is an important source ofnutrition and revenue. But ensuring accessto communal grazing and providing animaldrinking water are likely have an impact on thedemands on women’s labour. Adverse impactneeds mitigation.5

2 Policy frameworksfor agricultureand nutritionMuch of the lack of progress on improvingchild nutrition to date has been the resultof a lack of political will and the absence ofstrong leadership. Progress is now beingmade, however, partly due to the efforts ofthe Scaling Up Nutrition (SUN) Movementand other high-profile initiatives to pushnutrition higher up the global agenda.Many countries are now developing national nutritionplans and are committing resources to implementthem. However, despite many of these plansbeing developed and ‘owned’ by multi-stakeholderplatforms, they are yet to be integrated into the plansof all relevant sectors.Agricultural policies and CAADP investment plansguide the prioritisation of agricultural production. Yetthe goal of improving child nutrition is notably absentin half of the plans and policies that Save the Childrenanalysed. In reviewing the national agriculture policiesof 15 African countries, Save the Children notes thatproduction or productivity is referred to 22 times inthe “strategic objective” outputs, while nutrition ornutrition security is mentioned only five times.Save the Children also noted how frequently certainkey words for nutrition were mentioned in thedifferent components of 18 national CAADP plans,to get a sense of their focus. The words ‘nutrition’or ‘nutrition security’ were included as part of the‘goal’ in just four of the 18 plans, and mentioned inthe ‘purpose’ of just three of the 18. The plans focusprimarily on crop production and prioritise a limitedrange of staple crops (maize, rice and wheat).Of course, it is not surprising that the plans focus onproductivity, and there is no question that individualcountries should set their own priorities. But tomake real progress in tackling child malnutrition, itis imperative that nutrition be made a more explicitpriority and be better integrated in these plans. Fromour analysis, nine 21 out of 18 of these plans includea nutrition component that can be built on (seeTable 3). However, there is a significant variation inthe per capita investment anticipated. Some countriesare spending more than US$200 per capita; incontrast, Burkina Faso is investing US$3.12 percapita and Nigeria is investing US$8.27 per capita.The purpose of the agricultural investment plans isto enhance agricultural and economic growth and toensure greater food security. Many countries havepredominantly agrarian economies and will requirehigh levels of investment to transform the agriculturaleconomy (or sector). More industrialised economies,such as Nigeria, can probably justify lower levels ofinvestment, but agriculture is still the basis of theindustrialisation process, and the need to reducestunting is a priority.Ghana’s CAADP Investment Plan (Medium TermAgriculture Sector Investment Plan (METASIP)2011–2015) identifies micronutrient malnutritionas the ‘silent killer’. 22 Its vision is for a modernisedagriculture base, leading to a structurally transformedeconomy, evident in improved food security andreduced poverty. The plan has an outcome indicatorto change food self-sufficiency levels, with a target(2015) “to achieve 100% food self-sufficiency”.The vision for the Ghana investment plan seeks a“modernized agriculture, a structurally transformedeconomy, evident food security, employmentopportunities and reduced poverty”. The plan’smission – “to promote sustainable agricultureand thriving agribusiness” – overlooks nutrition.However, the results framework, which is focusedon food security and disaster preparedness, doesinclude an outcome indicator on stunting in children,which is measured annually. Setting a specific childnutrition-related indicator within national agricultureplans is an important and positive first step toimproving nutrition outcomes.6

Yet in the METASIP results framework, specificsub-programme result areas have targets for a50% or 25% increase over baseline. The cowpeasub-programme has a 25% increase over baselineindicator. Specific results anticipated are listed bycrop (eg, for cowpea, a 25% production increaseover baseline). Separate results are also listedfor reduced levels of underweight and stunting inchildren (underweight and stunting reduced by50% by 2015). The result areas are individual anddiscrete. What is perhaps missing is linking theachieved agricultural targets with the achievedstunting and/or underweight targets. A moreintegrated results framework is required, whichlinks agriculture to nutrition results or outcomes.Kenya’s Agricultural Sector Development Strategy(ASDS), which implements the country’s CAADPplan priorities, 23 is centred on increasing productionTable 3 Proposed country CAADP budget (per capita) compared to stunting ratesCountryCAADP expenditureper capita (US$)Stunting rate (%)Benin 96.16 44.70 2006Burkina Faso 3.12 35.10 2010Burundi 119.00 57.50 2010/11Ethiopia 191.65 44.20 2010/11Ghana 28.66 28.60 2008Year of measurement2 Policy frameworks for agriculture and nutritionKenya 69.67 35.20 2008/09Liberia 220.70 39.40 2006/07Nigeria 8.27 36.00 2011Mali 47.39 38.50 2006Niger 64.57 54.80 2006Togo 185.76 29.80 2010Rwanda 55.86 44.30 2010/11Senegal 300.12 15.50 2012Sierra Leone 65.10 32.60 2010Tanzania 227.66 42.50 2009/10Malawi 81.32 47.80 2010The Gambia 160.47 27.60 2005/06Uganda 29.87 33.70 2011Seychelles 0.00 7.70 1987/88Côte d’Ivoire 0.00 39.00 2007Cape Verde 0.00 21.40 1994Guinea Bissau 0.00 27.70 2008Mozambique 0.00 43.10 2011Source: World Health Organization, Nutrition Landscape Information System7

nutrition sensitivityand greater commercialisation, with a subsidiarythematic area on food and nutrition security. It doesnot appear to include a results framework, so it isnot known what indicators are being monitored.The use of appropriate nutrition objectives is animportant factor in determining whether a policydelivers tangible change. Once the objectives havebeen set, supportive actions need to be integratedinto the plan (at every level) to ensure that theywill be achieved. Similarly, identifying appropriateindicators will enable the tracking of progresstowards achieving these objectives. At the districtand field levels, programme managers will beresponsible for delivering positive outcomes onindicators set at the purpose and output levels(“what gets measured gets managed”).Ethiopia (see box below) and Burundi bothrepresent examples of best practice, as their nationalagriculture plans include clear purpose- and outputlevelnutrition targets. Benin, The Gambia, Nigeriaand Uganda have a nutrition indicator at the goallevel. There is a full analysis of the CAADP logicalframeworks and the extent to which nutrition isintegrated into the 18 plans in Appendix 2. Nine ofEthiopia: coordinating growth and transformation,agriculture investments and nutritionEthiopia has what is considered a very highprevalence of stunting, affecting 44% of all Ethiopianchildren under five. As noted earlier, in Table 1, thisis costing the Ethiopian government an estimatedUS$4.7bn per year. 24 Agriculture is the main focusof Ethiopia’s economy, accounting for 46% of GDP,and providing 85% of total employment. Between2003 and 2009, Ethiopia spent 13.7% of its budget onagriculture; in 2011, the figure was higher, estimatedat 19.7%. Ethiopia is more than meeting its MaputoDeclaration targets – a drive to get African countriesto invest 10% of national budgets on agriculturaldevelopment. But despite this, malnutrition remainsa persistent challenge that affects the lives of millionsof people throughout the country and will continueto do so for a generation or more.Three policies in Ethiopia are critical to nutritionand agricultural development: the Growth andTransformation Policy (GTP); the Policy andInvestment Framework (PIF) (which is Ethiopia’sCAADP investment plan); and the NationalNutrition Programme (NNP). While these threeframeworks have a different focus and differentobjectives, there is strong coherence betweenthem. The GTP has a strong focus on povertyalleviation and food security, with a strategic pillaron “maintaining agriculture as a major source ofeconomic growth”. However, it makes no mentionof nutrition. The PIF has a development objectiveto “sustainably increase rural income and nationalfood and nutrition security”. The first strategicobjective of the NNP is to “improve the nutritionalstatus of women (15–59 years) and adolescents(10–19 years)”. The focus on nutrition evident inthese two plans is welcomed.The PIF includes reduced stunting as a developmentobjective and as an indicator (3% annual reductionin stunted and underweight children in ruralareas). Despite this, Save the Children’s analysisof the PIF found that its main focus on agriculturalproductivity affords little room for attention tonutrition. The PIF could provide an opportunity toutilise the investments made in agriculture so thatit makes a much greater contribution to reducingmalnutrition. The presence of an indicator tomeasure progress on reducing child stunting withinthe CAADP investment plan is very useful, andsomething that could easily be incorporated byother CAADP countries.Finally, the NNP aims to reduce the prevalenceof stunting from 44.4% to 30% by 2015, whichis broadly in line with the nutrition indicator ofthe PIF.As well as coherence across relevant policies,there is good coordination across ministries atthe national and district levels. Coordination isimportant because it helps to facilitate multisectoralprogramming and shared expertise, witha view to achieving the development objectivesidentified. For example, Ethiopia’s NationalNutrition Coordinating Body fulfils this purposeand has oversight of coordination structures atworeda and kebele levels.8

the 18 plans analysed have a stated goal or purposeto improve nutrition. These range from Rwanda(which has a priority of “achieving food and nutritionsecurity for all Rwandans”) to Tanzania (whichhas a purpose-level indicator for “improving thenutritional status of the country, including childrenand other vulnerable groups”). Other countries, suchas Uganda, have an indicator for “household foodand nutrition security improved”. These strategicobjectives are a good first step, but could usefurther definition to ensure a pathway to success isadequately understood and monitored.Burundi’s CAADP plan states that child stunting isto be reduced by 3% per year, as does Ethiopia’sAgriculture Sector Policy and Investment Framework(PIF). The CAADP investment plan is thus linked toachieving a reduction in stunting. These are specific,quantifiable and time-bound indicators against whichprogress can be monitored. As a model for othercountries, these are positive steps, as their respectiveministries of agriculture will be obliged to reportprogress against these targets. Other countriesshould specify similar targets and monitor progressagainst them.These two examples stand out because of how theyprioritise nutrition and its linkages with agriculture.Other national agriculture plans do not provide thislevel of prioritisation, which is a critical shortcoming.A focus on increasingproductivityOften, the best indication of political commitmentto an issue is the budget allocated to it. Save theChildren analysed the CAADP budgets for fivecountries, which were selected based on theirstrategic importance for reducing malnutrition, andavailability of data. The analysis shows that 58% ofCAADP planned expenditure in these countries isallocated to agribusiness and market infrastructure,26% on further developing existing agriculturalextension services, 9.8% on agricultural research anddevelopment, and 5% on strengthening communityinstitutions through capacity building and training (seeTable 5). These budget allocations indicate that mostinvestment is going towards developing agricultureas a business. However, these investments couldprovide an opportunity to address malnutrition if thebusinesses are successful in generating income forworkers and smallholders to buy enough nutritiousfood for their families, through selling surplusproduction, generating revenue and enhancingpurchasing power.Most of the CAADP plans have been through apublic consultation process with local stakeholders,including civil society organisations, farmers’associations, and the private sector. However,2 Policy frameworks for agriculture and nutritionTable 4 Anticipated CAADP investment plan allocation (in US$)CountryExtensionsystemsAgricultureresearch anddevelopmentAgribusinessand marketinfrastructureStrengtheningcommunityinstitutionsUganda 282,136,000 132,319,000 23,658,000 24,652,000Ethiopia 0 0 152,000,000 0Kenya 10,102,179 0 605,085,254 0Malawi 101,778,500 6,519,850 85,806,500 35,912,000Rwanda 11,750,000 13,460,157 26,653,637 30,300,000Total 405,766,679 152,299,007 893,203,391 90,864,000% of total allocationto agriculture26.31% 9.88% 57.92% 5.89%Source: Analysis of CAADP agricultural investment plans for Uganda, Ethiopia, Malawi and Rwanda.9

nutrition sensitivitytheir development and implementation has beenled by the ministry of agriculture in the countryconcerned; as would be expected, most plans reflectthat ministry’s conventional priorities, principles andfunding allocations.CAADP plans were drafted around 2010 whennutrition was receiving relatively little attentionin the policy arena. However, the AU’s decisionto declare 2014 as the Year of Agriculture andFood Security reflects the growing momentum forintegrating nutrition into various sectoral plans inorder to achieve overall development outcomes.This presents a prime opportunity to review existingCAADP plans, ensure that they are on track todeliver on the “food supply and hunger” pillar of theCAADP framework, and take corrective actionswhere needed.Save the Children believes that hunger andfood security objectives cannot be fully realiseduntil adequate nutrition is secured, whichrequires agriculture plans to prioritise nutrition,and a shared, coherent vision across allrelevant sectors.Another opportunity to encourage nutrition-sensitiveagricultural development lies in the priorities setout in each country’s Poverty Reduction StrategyPaper (PRSP), as well as in economic recoveryor development policies that generally steer theoverarching government policy priorities. Integratingnutrition into the objectives of these policies andensuring that these are translated into specificpolicies and actions (whether within agriculture orother relevant sectors) is a critical step in improvingcoherence across government to achieve a reductionin nyani quarmyne/save the childrenA garden programme set up by Save the Children in Tessaoua, Niger.10

Biodiversity and nutritionOrange-fleshed Sweet Potato (OFSP) hasIncreased diversity of crops and farming systemsenhanced ß-Carotene, the pre-cursor to vitamin is known to support a range of income streams, 29A or Retinol. OFSP has been disseminated by which in turn can increase community resilience toHarvest Plus and through DFID’s Research into local or global economic shocks that have damagingUse programme in Uganda and elsewhere. There effects on food and nutrition security. 30 Similarly, bywas rapid uptake and vitamin A intake increased supporting the agro-ecological systems on whichsignificantly among women and children. 25people depend, biodiversity can improve people’sresilience to the harmful effects of climate changeFortification of foodstuffs is one mechanism that– contributing in turn to reduced negative impactshas received attention as an effective way toon nutrition.address nutrient deficiencies and other formsof malnutrition, and investments in this area are The concentration of industrial agriculture in thecritical. The people who are most food insecure hands of fewer businesses that are producing aoften rely on small-scale, local food production for relatively small variety of crops threatens thetheir livelihoods. Dietary diversity can also deliver biodiversity within food systems. Of the 10,000better nutrition and health, with benefits for crop varieties that have been used for humanlivelihoods, human development and productivity consumption, 31 only 150 are regularly cultivatedover the life course. 26by large-scale agriculture, and only three (maize,wheat, and rice) supply the bulk of global proteinBalanced nutrition requires not only diversity ofand energy needs.crops but also diversity within crops, as some32lesser-known crops are superior to staple crops in Smallholder producers are well situated to increaseterms of their micronutrient content. 27 Emerging biodiversity within agricultural production, andevidence shows how such systems contribute helping them do this could be beneficial in a widein practice to the reduction of micronutrient range of areas: encouraging greater communitydeficiency. A study shows that increasedresilience, strengthening livelihoods and incomebiodiversity in paddy fields allows aquaculture certainty, and reducing carbon emissions and otherto be practised alongside rice cultivation, with a harmful impacts of climate–rice system increasing net income by between7% and 65%, compared with paddy monoculture. 282 Policy frameworks for agriculture and nutrition11

3 Governance ofnutrition-sensitiveagricultureIt is important to have nutrition objectivesand strategies at the national level, particularlytargeted towards children, as these will guideimplementation at the district and communitylevels to deliver better nutrition outcomesfor children.The need for a clearly articulated agriculture policyis crucial, as is a clear understanding of how it will beimplemented at the district and community levels.The purpose of this chapter is to outline existinginstitutional structures at the district and communitylevels that can be helpful in implementing nutritionsensitiveagriculture approaches.Many countries are starting to put in place policyframeworks to coordinate nutrition across allrelevant government ministries and departments, andto integrate nutrition into various plans, strategiesand policies. With a multi-sectoral approach,collaboration between different governmentministries will be strengthened. Collaborationwithin and between ministries will also be furtherencouraged and developed through joint planningprocesses and reviews.Interviews with senior officials in Malawi and Ethiopiaabout the structure and nature of decision-making onagriculture and nutrition revealed certain challengesin ensuring that national plans on nutrition areinterpreted as intended, all the way down to thedistrict or local government level. One lesson that canbe drawn is that the different roles and responsibilitiesof officials involved in implementing joint agricultureand nutrition programmes must be clearly defined bythe principal secretary or other senior official whohas oversight of the convergence and implementationprocess. Another lesson is to develop sharedindicators on nutritional improvement across sectors,which different government departments are requiredto report on. Lastly, thematic working groupscomprised of representatives from different sectors(including civil society, the private sector, farmers’associations, and women’s groups) can be extremelyhelpful in developing the vision and pathways forwardto implementation.Implementing nutritionsensitiveagriculture at thedistrict level: a modelFigure 3 outlines a suggested institutionalconfiguration that is closely modelled on Malawi, butwhich also parallels other ministries of agriculturethroughout Africa.In this model, the District Commissioner (DC) hasoversight of all budgets within the district. The DC isthe secretariat for the District Executive Committee,which is advised and guided by the District Assembly.The DC is accountable to the Ministry of LocalGovernment for all expenditures.All the line ministries are answerable to andreport to the DC and the District Assembly. Lineministries also report to the Ministry headquarters.In a number of countries, depending on the extentof decentralisation, accountability is increasinglyundertaken by district staff, reporting to the DistrictAssembly and to the Ministry of Local Government.Districts have their own development plans, whichshould reflect local people’s needs and wishes. Itis therefore critical to provide the DCs with theknowledge and incentives to encourage their staff todrive forward nutrition-sensitive interventions.In this model, at the district or local governmentlevel, the government’s agricultural extension serviceprovides a ready-made network of individuals whocould ‘champion’ nutrition-sensitive agriculture.Most governments run agricultural extensionservices, which are expensive to maintain. It is vitalto maximise the benefits the extension service can12

Figure 3 Suggested model for governance of nutrition and agricultureat the national levelMinistry ofAgricultureDept ofExtensionNutrition UnitDistrict LevelDistrict HealthOfficerMinistry ofHealthDistrict CommissionerMinistry ofEducationDistrictEducation OfficerDept of Nutrition(Office of thePresident andCabinet)DistrictAgricultural OfficerMinistry of LocalGovernmentand RuralDevelopmentDistrict AssemblyDistrict ExecutiveCommittee (DEC)Ministry ofGender andWomen’sAffairsDistrict NutritionOfficer3 Governance of nutrition-sensitive agricultureHealthSurveillanceAssistantSchoolGardensHome-GrownSchool Feeding(HGSF)AgriculturalExtension andDevelopmentOfficerDistrict SUNCivil SocietyPlatformFarm Home Assistant orHome Economics OfficerFood andNutrition Officer13 cost-effectiveinterventionsHousehold or Family and/or CommunityFigure 3 presents a district-level institutional configuration based on the governance structure in Malawi.The nutrition unit reports to the Director of Agricultural Extension. It is completely separate fromthe Department of Nutrition, which is a nationally based government department, located in theOffice of the President and Cabinet (OPC). There are strong links between these two institutions.The fundamental problem is that there is no institutional lead at district level.bring by broadening the spectrum of subject areasit covers to include not only training in agriculturalissues, but in nutrition. If government extensionworkers were equipped with the right tools – suchas Save the Children’s Cost of the Diet tool (whichcalculates the cost of the cheapest diet that meetsthe nutritional requirements of families using just thefoods available locally) – they could raise the profileof nutrition among smallholder farmers, includingencouraging greater crop diversity. (See box onpage 14 for more on the Cost of the Diet tool.).The nutrition messages require re-enforcementand triangulation – with the Ministry of Education,Agriculture and Health at the district level alldelivering the same message.13

nutrition sensitivityCost of the Diet: a tool to implement nutrition-sensitiveagriculture with smallholder farmersA key priority is for agriculture extensionists,nutritionists, and health and community workersto be able to determine the quantities ofmicronutrients delivered by a ration. A ration iscomprised of home-grown foods and purchasedfoods; the proportion of home-grown food andpurchased food varies throughout the year. In areasonable year home-grown foods may be availablefor three to four months after harvest, withpurchased foods playing an increasingly dominantrole in the lead-up to the succeeding harvest. It iscritical for the different household advisory staff toknow, recognise and understand the micronutrientsdelivered by a ration. Such information will bringnutrition into stark reality at a community level.In order to measure the nutritional value of cropsand help ensure that agriculture is nutritionsensitive,agriculture extension would benefitfrom encouragement to use some basic tools.Save the Children’s Cost of the Diet programmeuses a list of foods produced by the Food andAgriculture Organization of the United Nations(FAO) and generated from samples analysed in sixcountries (Senegal, Kenya, India, Egypt, Mexicoand Indonesia). It is a small spreadsheet that usesgeneric nutrient values for different crops andfoodstuffs. The tool will also generate informationon the cost of the diet to the consumer, enablingthe health extension agent to advise on thecheapest nutritious diet and on the diet with thebest nutrition available. Diets deficient in criticalmicronutrients can be modified with the additionof different foods available from home-grown orpurchased (market) sources.The regular use of such a tool, rolled out by districtnutrition officers and agricultural officers, inconjunction with other messages and interventions,and other relevant specialists (livestock officers,community development officers and districtofficers), would raise awareness and encourageagriculturalists and people with other unrelateddisciplines or from the private sector to considerthe impact and implications of the crops andenterprises they promote on household (andparticularly children’s) nutrition.In Malawi at present, in line with agriculture extensionpolicy, the government-funded agricultural extensionservice provides information to farmers on increasedcrop, livestock, tree and crop production. Theagricultural extension network covers the whole ofthe country; of all the different ministries, it is themost extensive network. Most extension workersdeliver agronomic and animal husbandry advice. Anumber of countries have a nutrition unit as part ofthe Department of Extension, within the Ministry ofAgriculture (as is the case in Malawi). The purposeof the nutrition unit – or home economics officers(as found in Kenya and Ethiopia) – is to includenutrition messages about the crops cultivated oranimals reared. The information will cover how tocook different agricultural products, the types ofnutritious food to target and other key nutritionrelatedmessages. The extension service, because ofits coverage and expertise, is well placed to providenutrition information to farmers and their families.The addition of a nutritional component into theextension messaging will provide a more extensiveextension package for very little additional trainingand costs. The inclusion of nutrition will providespecific nutrition information, permitting the recipienthouseholds to make more informed decisions on themix of crops, animal, tree and fish enterprises that willmaximise nutritional impact and micronutrient intake.Using the agricultural extension services to improvenutrition is a reasonable proposition. However, anumber of extension services suffer high vacancyrates. In Malawi, for example, some districts havevacancy rates of upwards of 40%. 33 Capacity andtraining remains a significant constraint. Much ofthe messaging delivered by extension agents tosmallholder farmers is unsupported by others withspecialist knowledge. Frequently, no nutritionistis available at the district level, nor are they fullybudgeted. Recruiting both specialists and generalistsat a district level is difficult due to remoteness andrestricted government staffing levels.Nevertheless, on a wider scale, there is a need todeliver more integrated and comprehensive advice onnutrition and the micronutrients required for healthygrowth and cognitive development. Information on14

how to reduce child malnutrition should also beincluded. District-level coordination committeescould be developed with the purpose of coordinatingthe different Ministry extension messages. Theseextension messages will come from the differentministries involved in the reduction of childnutrition, and should be coordinated and mutuallyreinforcing. Thus, the district’s population will receivecoordinated and mutually reinforcing messages onhow to reduce child malnutrition, including thebenefits of breastfeeding, nutritious foods, cooking,and good hygiene practices. These tasks are not theresponsibility of one ministry, but relate to the workof many ministries. Coordination is therefore vital.Agricultural extension workers are the mostextensive information network in many countries.As such, they offer a potentially powerful platformto deliver multiple messages to help each countryreach its goals on agricultural development,productivity, and overall food and nutrition security.It is important, however, to examine each contextseparately in order to avoid overburdening agricultureextension officers, or to give the impression thatagronomists should become nutritionists or viceversa. Rather, the goal is to effectively increase thecoordination of these complementary messages andhave them reinforced across ministries.In the governance model proposed in Figure 3,district officers manage the budget and implementpolicy, according to the guidelines. They areresponsible for staff working in specified disciplinesand designated geographic areas. Agriculturalextension workers are responsible for providingagricultural training within a given area, while healthextension workers cover the disease profile withintheir assigned geographic area.The district or local government level is the siteof implementation. In the case studies Save theChildren investigated for this report, district or localgovernment staff provided the platform for deliveryof nutrition-sensitive agricultural messages. However,that platform was constrained by a lack of resources(human and financial), and by a lack of districtlevelleadership. In some countries, nutrition unitsgoverned by the Ministry of Health are connectedwith the Ministry of Agriculture. The maximumbenefit from this arrangement could be achieved withstrong coordination, accountability and informationsharingbetween the different ministries.3 Governance of nutrition-sensitive agricultureHarvesting NutritionWhile there is much logic behind the argument thatmodifications to agricultural practices can improvenutrition, the evidence base remains limited. Theconcentration of agricultural innovation within a fewmultinational companies leaves many smallholderfarmers unable to improve yields or the nutritiousvalue of their crops. 34 It is essential that states andnon-state actors support innovative attempts toaddress this debilitating knowledge deficit.Save the Children has teamed up with the GlobalAlliance for Improved Nutrition (GAIN) and theSecureNutrition team at the World Bank to launcha competition intended to gather informationand results from projects that successfully bridgethe gap between agriculture and nutrition. Byinviting applications from agro-nutrition projectsfrom around the world, the Harvesting Nutritioncompetition 35 aims to gather examples from thefield, collect knowledge about how to integrateagriculture and nutrition programmes and policies,and identify the key challenges to bridging the gapbetween the two areas.The competition emphasises that new thinkingwill be needed in order to break down the silosbetween the agriculture and nutrition sectors.Submitted entries are marked not only on howthey tackle the links between the two areas, butalso on their scalability and impact, as well as thedegree to which they show innovative thinking intheir design.Nutrition is recognised as a problematic issue byagriculture ministries in many countries. In Nigeria,the federal Ministry of Agriculture has approved andis beginning to implement a nutrition value chain. InTanzania, the Ministry of Agriculture acknowledgesthat it has a key role to play in improving nutrition,and is formulating a national nutrition policy, whichover time will be further integrated into its mainagricultural policy. Such initiatives will take time tobecome fully embedded, and the necessary changesto agricultural extension policy and messages willalso take time to filter through.15

nutrition sensitivityThe appointment of a District Nutrition Officerto advise the district head is one option forstrengthening the link between nutrition andagriculture (and even water, sanitation and hygiene),and could help create effective, complementarymessaging that serves multiple purposes. TheENGINE project in Ethiopia (Empowering NewGenerations to Improve Nutrition and EconomicOpportunities) established a district-level (woredaand kebele) nutrition steering committee that hassucceeded in driving forward coherent nutritionand agriculture messages. The National NutritionCoordinating Council in Ethiopia has overall oversightof the kebele and woreda committees.Ensuring sustainabilitythrough profitabilityAny nutrition-sensitive agriculture policy mustacknowledge that agriculture is ultimately a business.Smallholder farmers manage their crop and/orlivestock enterprises, tree production and fishery,using their labour and management skills to producefoodstuffs or commodities to consume and/or sell.Evaluating the impact of the revenue generated isessential. Determining the return on investment madeand assessing the labour required and the return tofamily labour are essential assessments of profitability.The impact of nutrition-sensitive interventions on womenWhile there are a range of views about howtargeted agricultural programmes can improvenutrition, there is strong consensus that womenare a key part of the pathway to improved childnutrition, as they play a pivotal role in terms ofagricultural inputs, intra-household resourceallocation, child nutrition and providing labourfor agricultural management operations. 36 It isimportant to remember that the most successin improving child nutrition and thus in reducingstunting is achieved through dialogue with women.Thus, activities should be targeted at improvingwomen’s social status, empowerment, and accessto resources, and should culminate in theirinclusion in household decision-making.National agricultural policies should thereforeconsider the time and resources available towomen farmers, as well as the constraints theyface to their agency and empowerment. In manysocieties, women do much of the work involvedin agricultural production and provide significantinput into their own enterprises, but have alimited role in decision-making. Programmes andpolicies should include gender-disaggregated dataand indicators to assess the impact of nutritionsensitiveagriculture interventions on women andmen, as well as any unintended outcomes.Ways to empower women have long been identifiedas key to development, but few examples from thefield offer practical suggestions. In the HaryanaCommunity Forest Project, 37 women’s groupscreated a vehicle to provide literacy training(reading and writing), particularly in basic skillsand in business skills, through which the womencould run and manage their own businesses. Theformation of women’s groups is a useful vehiclethrough which to discuss a multitude of otherissues, such as nutrition, hygiene and health, aswell as discussing product quality, training in newtechniques, or village savings and loan schemes. Anypolicy work and planning must focus on improvingthe level of women’s education and must seek todevelop their status within any society, through aprocess of group formation, and improving theirability and capacity to manage a business. This willultimately lead to increased empowerment.Nutrition-sensitive interventions that wereanalysed in Ethiopia and Malawi for this researchshowed unintended impacts on women, principallythrough increasing their work burden (particularlyweeding, and carrying water). This reveals why itis so important for policies and programmes toconsider impact on women at the design stage,so that appropriate steps to mitigate any negativeimpacts (such as providing labour-saving devices)can be taken.16

Government, the private sector and civil society canpromote different types of agricultural enterprisesthrough training extension workers, subsidisingcertain goods, providing markets, or land useplanning. For example, the private sector mayestablish a value chain to purchase sorghum andcassava of a given quality. Smallholders wouldrequire training on the accepted quality standards.All Purchase for Progress farmers (WFP) receivetraining in quality standards. Once many producersreach the required quality standards, there will bean increase in the quantity purchased by WFP. So, ifthe price and incentive structure is correct, supplywill increase.Putting nutrition-sensitiveagriculture into practiceThis section demonstrates how the Cost of theDiet tool (see page 14) can be used to monitor thenutritional value of a ration or meal.At the field level, there is a need to achieve abetter match between the crops cultivated and therecommended nutrient intake (RNI) of differentfamily members, based on their age, gender and levelof activity. Save the Children has assessed the diet ofa family in Ethiopia, using the Cost of the Diet tool(see Table 5).The family of four (a widow with three children)had received two interventions from the ENGINEproject – namely, five sheep (a ram and four ewes)and six chickens (a cockerel and five hens). Theseanimals produced milk and eggs. As a consequence ofthis diversified production, the family’s diet improved.Family members now consumed milk and eggs, andthere was enough produce left over to sell in thelocal market, which generated a small income thatwas used to buy other essentials such as iodised salt,oil and cooking oil. All these different products goto make up a meal or a ration. The family’s rationchanged from barley and a vegetable stew to a morediverse diet containing animal products.The breakdown of the different diets before and afterthe intervention is shown in Table 6. Before theintervention, the family diet was deficient in energy,protein and fat, with many vitamins not provided atall (vitamin A, C and B12). The absence of vitamins Aand C may be due to the absence of fresh vegetablesin the family diet, while the absence of vitamin B12reflects the vegetarian nature of the pre-interventiondiet. The calcium and zinc to phosphate ratio waslow, suggesting that the children’s bone formationmay be slow or compromised. Magnesium andvitamin B1 (Thiamine) are the only micronutrients insurplus, in what is otherwise a very poor diet.After the intervention, protein and energy haveattained a dietary surplus. Because animal productsare used, the vitamin B12 requirement is satisfied,ensuring cellular metabolism, which is essentialfor cellular production in the bone marrow, nervesheath, and for protein production. While thefamily’s diet has significantly improved, it is stilldeficient in energy, and low in five vitamins and twominerals (calcium and iron). To achieve a balanceddiet delivering all the necessary micronutrientsand minerals for children’s healthy growth, furtherfoods need to be added or substituted to the dietor ration. The diet is constrained by the spectrumof agricultural products produced, and by what ahousehold can purchase (revenue and availabilityof products).3 Governance of nutrition-sensitive agricultureTable 5 Dietary improvement of a household in Tigray (Ethiopia)Household Before intervention ration After intervention rationFamily of 4: 1 adult (widow) and3 children in Tigray, Ethiopia1.2 kg barley/day made into Njera1.0 kg (approx.) vegetable (pulse)stew2 eggs/day2 litres sheep milk/day1.2 kg wheat/day0.5 kg pulses (beans)17

nutrition sensitivityTable 6 Dietary breakdown of the diet consumed by different household members and the micronutrient constituents,before and after the interventionBefore interventionAgegroupEnergy Protein Fat Vit A Vit C Vit B1 Vit B2(Ribf)NiaEquivVit B6 FolicAcidVit B12 PantothAcidCalcium(abs)Mg Iron(abs)Zinc P:ZMolarRatio12–23-monthold849.60 30.00 5.52 0.00 0.00 1.25 0.62 20.32 0.72 31.20 0.00 0.58 19.80 319.20 0.52 6.72 3.18:0.1% 95.0% 275.2% 18.5% 0.0% 0.0% 249.6% 124.8% 338.7% 144.0% 20.8% 0.0% 28.8% 13.2% 532.0% 89.4% 163.9% LowRest offamily2336.4 82.5 15.2 0.00 0.00 3.43 1.72 55.88 1.98 85.80 0.00 1.58 54.45 877.80 1.43 18.48 8.75:0.28% 34.4% 73.3% 6.7% 0.0% 0.0% 100.9% 50.5% 121.5% 52.1% 7.2% 0.0% 10.6% 5.0% 131.0% 24.6% 89.3% LowAfter intervention12–23-monthold894.00 30.39 45.95 400.00 4.53 0.56 0.83 13.28 0.51 71.30 1.57 2.79 154.87 210.50 0.36 5.97 1.53:0.09% 100.0% 278.8% 154.2% 100.0% 15.1% 111.9% 166.6% 221.4% 102.0% 47.5% 174.4% 139.4% 103.2% 350.8% 61.7% 145.6% LowRest offamily4536.8 152.6 219.9 1,857.30 22.00 2.97 3.96 70.52 2.66 350.68 7.12 13.62 751.62 1,125.50 1.86 30.77 8.45:0.47% 73.9% 159.0% 107.5% 116.1% 18.3% 94.2% 125.9% 167.9% 75.1% 31.9% 107.9% 97.3% 83.5% 206.5% 35.4% 167.2% LowDeficiency18

4 Shaping nutritionsensitiveagriculturethrough globalframeworksIn this chapter we explore some (but not all)of the global and regional frameworks thathave been developed in recent years. Theseframeworks reflect the greater priorityaccorded to nutrition within internationalpolicy circles, suggesting how they canencourage national governments to developagriculture policies that are more nutritionsensitive.We then look at some case studiesof how to implement nutrition-sensitiveagriculture interventions at the district andcommunity levels, highlighting best practice.Global frameworksScaling Up NutritionPerhaps the single biggest step forward for thenutrition sector was the establishment of the ScalingUp Nutrition (SUN) Movement in 2010. This globalmovement is founded on the principle that all peoplehave a right to food and good nutrition. It workswith governments, civil society, UN agencies, donors,businesses and experts to improve nutrition inmember countries.As of March 2014, 47 countries have joined the SUNMovement and 17 38 have developed national costednutrition plans, aiming to secure the necessary financialresources for implementation nationwide. Many ofthe plans include an agricultural dimension that willbe jointly managed by the Ministry of Agricultureand other relevant ministries (covering, for example,water and irrigation, health, and gender and women’saffairs). However, it is not clear how these SUNcosted plans relate to the CAADP plans that havebeen developed in many of the same countries, orhow the two initiatives are working together. SUNmember countries are encouraged to have a SUN focalpoint to coordinate efforts across government; oneoption is for this role to engage with CAADP focalpoints – where they exist – to ensure that nutritioninterventions are integrated into agriculture planswhere appropriate.New Alliance for Food Securityand NutritionThe New Alliance for Food Security and Nutritionwas launched in 2012, under the United StatesPresidency of the G8. Its aim is to catalyse responsibleprivate sector investment in support of CAADP.Of the nine countries that have signed up sofar, seven are classified as having very high childstunting rates (40% or more), and at least two areexperiencing rising prevalence. While poverty is oneof the underlying causes of malnutrition, the evidenceshows that reductions in poverty or increases inincome do not automatically lead to reductions instunting. This means that the New Alliance goal tolift 50 million people out of poverty will not havea transformative effect on chronic malnutrition, orstunting, without a clearly stated nutrition goal andspecific accompanying actions.If the New Alliance were to set country-specificnutrition goals, it would change the conversationbetween governments, donors and businesses in apositive way towards ensuring real results on povertyand nutrition.The New Alliance’s draft accountability framework,released in May 2013, has the following indicators:• access to dietary diversity• food prices relative to income• prevalence of child stunting under the age of five• minimum acceptable diet for children aged0–24 months.19

nutrition sensitivityWhile the inclusion of these indicators is a welcomestep, the New Alliance’s recent progress report(2013) does not actually measure progress inrelation to the indicators. 39 This may be becauseactivities are still very much in the start-up phase;but going forward, reporting on these indicatorsshould be a priority. In addition, member countriesshould establish a distinct, country-specific goal andoutcomes aimed at reducing malnutrition (or childstunting rates), and outline the specific actions theywill take to achieve that goal.and agreed a global plan of action for nutrition.This conference brought the health and agriculturesectors together to address the goal of nutritionalsecurity for all and, as such, place nutrition in itsrightful place in development policy. The secondInternational Conference is due to take place inNovember 2014, and represents an importantopportunity to start to reshape the normativeframeworks that govern food security and nutrition,ensuring that nutrition is increasingly integrated intoother sectors, including agriculture.International Conferenceon NutritionThe first International Conference on Nutritiontook place in 1992 and was jointly organised by theWorld Health Organization (WHO) and the Foodand Agriculture Organization (FAO) of the UnitedNations. Delegates from 159 countries attendedNutrition for GrowthIn June 2013, the UK government, the government ofBrazil and the Children’s Investment Fund Foundation(CIFF) hosted the Nutrition for Growth summit inthe UK, with the aim of securing financial and politicalcommitments to tackle malnutrition globally. Theevent convened 21 heads of state from high-burdenphoto: sebastian rich/save the childrenA kitchen garden,Ruhango district, Rwanda.20

countries, alongside donors, multilateral agencies,businesses and NGOs, all of whom committed to anumber of ambitious targets. In total, $23.1bn wascommitted towards interventions between 2013and 2020. 40 This included $4.1bn for direct nutritioninterventions identified by The Lancet Series, and$19bn in proposed existing spending on agriculture,social protection and health – with the purpose ofmaking these sectors more ‘nutrition sensitive’. 41This presents a huge opportunity to showcase thebenefits of nutrition-sensitive agriculture, if investedin the right way, and for tackling malnutrition. Aneffective accountability mechanism will be essentialto ensure that the money spent does result in fewerchildren affected by malnutrition. Currently, data arenot available for many of the appropriate indicatorsof progress in this area, such as stunting. Investmentswill also be required to develop robust indicators.The ‘road to Rio’At the Nutrition for Growth summit, the Braziliangovernment made a commitment to hold another‘moment for nutrition’ during the Rio Olympics in2016. This event will be important for securing theresources required to develop the SUN costed planscurrently being formulated (more than 17 countriesout of 47 have developed plans that are in theprocess of being analysed). Rio will present anopportunity for a Southern government that hassuccessfully reduced malnutrition to share its modeland experience with high-burden countries.Brazil has succeeded in reducing levels ofmalnutrition dramatically, falling from 37% in 1976 to19% in 1990 and continuing to fall rapidly until 2011.However, this reduction has not been equitable, andmalnutrition rates remain high in the poorer northeastregion and among certain ethnic groups. Forexample, among the Quilombola (black communitieswhose land is in shared use), the rate of malnutritionis 76.1% higher than that of the average generalBrazilian population (nationally), and 44.6% higherthan that of the rural population. 42 At the same time,rates of obesity in Brazil are rising (the countryhas one of the highest rates of children who areoverweight anywhere in the world). 43The reductions in malnutrition that have occurredhave been a result of an integrated strategy toreduce poverty and inequality. Brazilian Public Healthexpert Carlos Montero suggests that reductions instunting between 1996 and 2007 can be attributed tointerventions in four areas: family income (22.5% 44 );maternal schooling (24.6%); maternal and childhealthcare (10.4%); and water supply and sanitation(5.8%). 45 However, Brazil must now focus on tacklingits growing overweight and obesity problem, as wellas the high rates of malnutrition that persist in someareas and among some groups.Analysing and identifying the nutrition-sensitiveprogramme interventions, policies and governancestructures that have achieved significant reductions inmalnutrition will provide lessons for others to learnfrom. This will provide Brazil with an opportunity tolead a global drive on reducing malnutrition.The way forwardFollowing the Nutrition for Growth event andthe momentum created by the SUN Movement,the opportunity to advance nutrition-sensitiveinterventions has never been greater. Country-levelownership, developed through the SUN Movement,has the potential to persuade policy-makers toprioritise nutrition and integrate it with other keysectors. However, once nutrition goals and targetshave been set, they must be integrated throughoutplans and programmes, with robust metrics andframeworks put in place to ensure that these highlevelcommitments are translated into real changesat the household level for children.4 Shaping nutrition-sensitive agriculture through global frameworks21

5 Conclusions andrecommendationsIn clinics and aid posts all across Africa andAsia, there will be a poster on the wallencouraging a nutritious diet as the basis forchildren’s healthy growth and development.At the same time, the agricultural policies andCAADP investment plans of many Africancountries prioritise agricultural productionand growth. While this is right, the potentialfor agriculture to be nutrition sensitive, andaddress the debilitating and long-lasting effectsof child malnutrition, also deserves attention.This report argues that including appropriate nutritionobjectives in agriculture policies and investment plans,which are then integrated throughout (and at everylevel of governance), is the best way to ensure thatthese plans succeed in promoting agricultural growthand nutrition. The use of appropriate indicators (suchas stunting rates) will enable all stakeholders to trackprogress and make any necessary changes.If agriculture is to provide the level of dietary diversityneeded to contribute to reducing child stunting,producers need access to research and innovationon a wider, more diverse range of crops, tree speciesand protein options that could also be economicallyviable. Companies with large supply chains can playa crucial role by including smallholder farmers in thevalue chain, and by shaping the market in ways thatpromote accessible and affordable nutritious foodsthroughout a country, particularly in countries thathave the highest stunting and malnutrition rates.Promoting nutrition-sensitive agriculture presentsan opportunity to review how agricultural extensionservices are functioning; as frontline extensionworkers could play an important role in deliveringcoordinated, complementary messages, not just onagricultural productivity, but on dietary diversity,food hygiene, and the benefits of different foods.Bearing in mind the increased level of politicaldecentralisation in many African countries, thereis a need to consider how the activities of differentministries are coordinated so that their extensionmessages are coherent. For example, agriculturalextension workers could provide information onthe nutritional and agronomic benefits of differentcrops and animal enterprises, and on how to cookfoods and preserve their nutritional value. Extensionworkers from other related ministries could delivermessages on the benefits of exclusive breastfeeding(at least for the first six months of life), optimal childfeeding practices (including cooking methods thatretain more nutrients), and good hygiene practices.At a district level, health, agriculture and educationministries will be delivering nutrition-relatedmessages. The challenge is how these differentmessages can be mutually reinforcing. Ethiopia’sexperience, highlighted earlier, saw the developmentof a local-level nutrition steering committee thatcoordinated the activities of these three principalministries in respect to nutrition. But how could thispositive experience be scaled up and rolled out indifferent countries?Many of the debates on nutrition-sensitive agriculturefocus on bio-fortification and on market gardens.Bio-fortification is an important element of thepolicy mix, but it is just one aspect of ensuring localavailability, access and utilisation of nutritious foods.The determinants of household nutrition arecomplex and cut across the responsibilities of variousgovernment ministries. Therefore, nutrition-sensitivegoals, outcomes and activities must be built intovarious sectoral strategies and coordinated at thenational and district levels. Given the key role ofwomen in the pathway to improved child nutrition,nutrition-sensitive approaches should be gendersensitiveand promote women’s empowerment.To ensure a countrywide approach, each country’sPoverty Reduction Strategy Paper (PRSP), economicrecovery plan or development policies shouldconsider including nutrition indicators. Strongercollaboration within and between ministries needs tobe encouraged and developed through joint planning22

processes and reviews. Without this multi-sectoralapproach, links between different governmentministries will remain weak, undermining whatnutrition-sensitive approaches can achieve.Many districts, irrespective of country, lack theadministrative structure to have good oversightof the nutritional effort, as well as capacity andknowledge of nutrition at all levels (senior districtofficials through to extension agent levels). However,the district level is frequently overlooked by policymakers,despite the fact that many African countrieshave decentralised their sector implementationprocesses. Strong leadership, collaboration betweensectors, and clearly defined roles and responsibilitiesare crucial to ensure that nutrition is embedded indistrict-level agricultural strategies.This should be underpinned by an approach thatmonitors the extent to which micronutrients areaccessible to households at the local level. Tools arereadily available for this, such as Save the Children’sCost of the Diet tool, which enables policy-makers,district officers and families themselves to calculatethe micronutrients provided by different crops.To promote the adoption of nutrition-sensitiveagriculture, through a multi-sectoral approach, asthe most effective way of meeting the joint goalsof delivering agricultural growth and reducing childmalnutrition, Save the Children makes the followingrecommendations.To ensure that nutrition-sensitive agriculture isembedded in agricultural policies and becomes areality on the ground, we recommend that theAfrican Union:• commits to ensuring that agricultural investmentplans include nutrition objectives, and appropriatemetrics to monitor progress on nutrition-relatedgoals• includes a stunting specific indicator as part of theCAADP results framework. The indicator shouldbe adopted by national agriculture ministries andbe accompanied by action to ensure impacts• establishes a common joint peer reviewmechanism that assesses the progress of CAADPimplementation. The joint annual review ofEthiopia’s Policy and Investment Framework(CAADP investment plan) provides a usefulquality standard• establishes a regional benchmarking process thatwould enable citizens to see how their country isperforming in relation to other countries• develops institutional links between thoseresponsible for national agriculture plans andScaling Up Nutrition (SUN) costed plans.We recommend that governments in high-burdencountries:• include improving nutrition as an explicit policyobjective in their agricultural policies andagricultural investment plans (CAADP plans), andmore specifically:– establish multi-sectoral coordinationmechanisms to ensure that policy decisionsare owned by all relevant ministries– establish a cross-departmental working groupto oversee policy implementation and tomonitor progress against a set of commonlyagreed indicators– adapt district-level policy approaches toimprove coordination and integration ofnutrition concerns between agriculture, healthand other key ministries– increase the level of agricultural biodiversityto generate a more diverse enterprise andcropping base, as the foundation for a morediverse diet.We recommend that donors encouragegovernments to prioritise nutrition within agricultureplans by taking the following actions:• Strengthening the nutrition outcomes of initiatives,such as the New Alliance for Food Security andNutrition, by working with participating countriesto establish country-specific goals, outcomes andspecific actions, ensuring that nutrition indicatorsin the results framework are implemented andintegrated within national agriculture plans.• Developing a tool to enable agronomists andpolicy-makers to assess the nutrient constituentsof crops. Such a monitoring tool, if available inopen data format, could enable agriculturaliststo consider the impact and implications of thecrops and enterprises they promote from theperspective of their impact on child nutrition.• Ensuring that country-based donor technicalcommittees include civil society representatives,to ensure accountability and to reflect the viewsof civil society in the planning process.5 Conclusions and recommendations23

Appendix 1Methodology for field case studiesA literature review was conducted using the usualmechanisms of searching for key words, of followingup papers cited in bibliographies, undertakingsearches using the web, and through contacts. Othermethods employed include interviewing field contacts,and finding out what reports they have used.Given the diverse interpretation of nutrition-sensitiveagriculture, the methodology for this research wasstrongly based around semi-structured interviews,using a wide-ranging checklist that was divided intofive components:• general questions• economic questions• agronomic questions, including on environmentalfactors and climate change impact• policy-level questions and nutrition• social questions.An assessment matrix was compiled, outlining thequestion, expected information source (or sources),and who (if anyone) would be best placed to answerthese questions.Given the time and budget available and theexperience of the authors, it was decided thata questionnaire survey would be inefficient andinappropriate. Notwithstanding, many governmentsand farmers have a negative attitude towardsquestionnaire surveys.The assessment matrix was an essential tool forrecording data from interviews with a wide range ofgovernment officials, civil society representatives,development partners, international organisations,and private sector respondents at the nationallevel. At the district level, a range of farmers wereinterviewed, including widows, widowers, femaleheadedhouseholds and other types of household,as well as households from different wealth groups.District officials were also interviewed to establishwhat they understood by nutrition-sensitiveagriculture.Fieldwork was undertaken in Ethiopia (Tigray,Oromia and SNNRP 46 regions) and in Malawi(Zomba and Chiradzulu districts).24

Appendix 2Stunting rates in CAADP and/or SUN Movement countries,and stated commitments to reducing malnutritionCountryDoes it havea CAADPCompact?Joined SUNStunting rate(% underfive) (year)Nutrition indicators or targetstaken from CAADP planlogical frameworksBangladesh Yes 41.4 (2011)Benin Yes Yes 44.7 (2006) Poverty level mentioned at goallevel; in CAADP output 1 –indicator for the rate of coverageof food and nutrition needsBurkina Faso Yes Yes 35.1 (2010) Text about food security; nothingon nutritionBurundi Yes Yes 57.7 (2005) Yes, stunting annual reductionof 3% a yearCameroon Not yet signed Yes 32.6 (2011)Chad No Yes 44.8 (2004)Dem Rep ofCongo (DRC)Not yet signed Yes 45.8 (2007)Côte d’Ivoire Not yet signed Yes 39.0 (2007)El Salvador Yes 20.6 (2008)Ethiopia Yes Underdiscussion44.2 (2010/11) Yes, 3% annual reduction ofstuntingThe Gambia Yes Yes 27.6 (2005/06) Goal: increase in overall nationalfood and nutrition securitysustainable levels of self-sufficiencyin food production by 25%.Purpose level: improved nationaland household food security andadequate nutritional levelsGhana Yes Yes 28.6 (2009) Outcome indicator: increase infood self-sufficiency levels by 100%Guatemala Yes 48.0 (2008/09)Guinea No Yes 40.0 (2007/08)25

nutrition sensitivityCountryDoes it havea CAADPCompact?Joined SUNStunting rate(% underfive) (year)Haiti Yes 29.7 (2005/06)Indonesia Yes 39.2 (2010)Nutrition indicators or targetstaken from CAADP planlogical frameworksKenya Yes Yes 35.2 (2008/09) No nutrition targets set in CAADPplansKyrgyz Rep. Yes 18.1 (2005/06)Lao PDR Yes 47.6 (2006)Liberia Yes Yes 39.4 (2007) Dietary diversity scores andconsumption expenditure on foodMadagascar Yes 42.9 (2008/09)Malawi Yes Yes 47.8 (2010) Proportion of household consumingdiversified diet and micronutrientsmetMali Yes Yes 38.5 (2006) Global objective: improvenutritional state throughinformation dissemination andeducation. Output 1: poverty ratedecreasedMauritania Not yet signed Yes 23.0 (2008)Mozambique Not yet signed Yes 43.7 (2008)Myanmar(Burma)Yes 35.1 (2009/10)Namibia Not yet signed Yes 29.6 (2006/07)Nepal Yes 40.5 (2011)Niger Yes Yes 54.8 (2006) No outcome indicators citedNigeria Yes Yes 41.0 (2008) Goal level: secured food and feedneeds of the nation, but no othernutrition indicatorsPakistan Yes 43.0 (2011)Peru Yes 28.2 (2007/08)Rwanda Yes Yes 44.3 (2010/11) Absolute government priority– achieving food and nutritionsecurity for all Rwandans andhalving povertySenegal Yes Yes 28.7 (2010/11) No logical framework (cadrelogique)26

CountryDoes it havea CAADPCompact?Joined SUNStunting rate(% underfive) (year)Nutrition indicators or targetstaken from CAADP planlogical frameworksSierra Leone Yes Yes 44.9 (2010) No goal or specific objective(purpose) indicator on nutritionAppendix 2Sri Lanka Yes 19.2 (2009)South SudanTanzania Yes Yes 42.5 (2009/10) Purpose level indicator: improvingthe nutritional status of thecountry, including children andvulnerable groupsTogo Yes Yes 26.9 (2008) Goal-level indicator on rate ofprevalence of child malnutritionUganda Yes Yes 33.7 (2011) Goal-level indicator: householdfood and nutrition securityimprovedYemen Yes 57.7 (2003)Zambia Not yet signed Yes 45.8 (2007)Zimbabwe Not yet signed Yes 32.3 (2010/11)27

endnotes1R Black, CG Victora, S Walker, Z Bhutta, P Christian, M de Onis,M Ezzati, S Grantham-McGregor, J Katz, R Martorell, R Uauy, theMaternal and Child Nutrition Study Group (2013) ‘Maternal and childundernutrition and overweight in low-income and middle-incomecountries’, The Lancet, 382, 9890, pp 427–51 Maternal and ChildNutrition Series, Paper 12M A Ruel, H Alderman, the Maternal and Child Nutrition StudyGroup (2013) ‘Nutrition-sensitive interventions and programmes: howcan they help to accelerate progress in improving maternal and childnutrition?’ The Lancet, 382, 9891, pp 536–5513Save the Children (2012) A Life Free From Hunger: Tackling childmalnutrition, London, Save the Children4See note 15See 1,000 Days Partnership the Children (2013) Food for Thought: Tackling child malnutrition tounlock potential and boost prosperity, London, Save the Children7J Hoddinott, ‘Agriculture, Health, and Nutrition: TowardConceptualizing the Linkages’ in S Fan and R Pandya-Lorch (eds)Reshaping Agriculture for Nutrition and Health, International Food PolicyResearch Institute, 20128UNICEF (2013) Improving Child Nutrition: The achievable imperative forglobal progress, UNICEF9See note 110Pathela P (1995) Early childhood stunting and adult hand grip strengthin rural Guatemala, Emory University11See note 512The Cost of Hunger in Ethiopia: Implications for the growth andtransformation of Ethiopia, May 2013, African Development Bank,Agence Français, World Food Programme, UN Economic Commissionfor Africa.13See note 514See note 515The Cost of Hunger in Uganda: Implications on National Developmentand Prosperity, World Food Programme, UN Economic Commissionfor Africa, African Union Commission, May 2013; The Cost of Hunger inSwaziland: Implications of child under-nutrition for the implementation of theNational Poverty Reduction Strategy in Swaziland, African DevelopmentBank, World Food Programme, African Union Commission, UNEconomic Commission for Africa, May 2013; The Cost of Hunger inEthiopia: Implications for the growth and transformation of Ethiopia,African Development Bank, Agence Français, World Food Programme,UN Economic Commission for Africa16Uganda Bureau of Statistics: Uganda Census of Agriculture (UCA)2008/09 at a glance, May 201117P Menon, M Ruel, S Morris (2000) ‘Socio-economic differentials inchild stunting are consistently larger in urban than rural area: analysis of10 DHS data sets’, Food and Nutrition Bulletin, 21, 3, pp 282–89.18National Statistics Office of Malawi, 2013. Economics Indicators andSocio-demographic indices19See note 120E Masset, L Haddad, A Cornelius, J Isaza-Castro (2012) ‘Effectivenessof agricultural interventions that aim to improve nutritional status ofchildren: systematic review’, British Medical Journal, 344: d 822221Benin, Ethiopia, Gambia, Mali, Nigeria, Rwanda, Tanzania, Togo andUganda22Section 2.3.2; Nutrition trends, page 1323Kenya CAADP plan (Growth and Food Security Through IncreasedAgricultural Productivity and Trade; Medium Term Investment Plan)24The Cost of Hunger in Ethiopia: Implications for the growth andtransformation of Ethiopia, 201325Hotz C, Loechl C, Lubowa A, Tumwine K, Ndezi G, Masaur AN,Baingana R, Carriquiry A, de Brauw A, Meenakshi JV, and Gilligan DO(2012) Introduction of ß-carotene rich orange fleshed sweet potatoin Uganda resulted in increased Vitamin A intakes among childrenand women and improved Vitamin A status among children, Journal ofNutrition 142: 1871–188026EA Frison, J Cherfas, T Hodgkin (2011) ‘Agricultural biodiversity isessential for a sustainable improvement in food and nutrition security’,Sustainability, 3, 1, pp 238–5327J Fanzo, D Hunter, T Borelli, F Mattei (2013) Diversifying Food andDiets: Using agricultural biodiversity to improve nutrition and health,Routledge/Biodiversity International, p 4328M Halwart (2006) ‘Biodiversity and nutrition in rice-based aquaticecosystems’, Journal of Food Composition and Analysis, 19, 6–7, pp 747–5129Convention on Biological Diversity, ‘Biodiversity is key to sustainable,efficient, resilient and nutritious food production’, CBD – Get readyfor 2015. No. 5, July 2013, the Children, A Chance to Grow: How social protection can tacklechild malnutrition and promote economic opportunities, Save the Children,201231The State of Food Insecurity in the World 2010: Addressing food insecurityin protracted crises, FAO, 2010, EA, Smith IF, Johns T, Cherfas J Eyzaquine EB (2006)Agricultural biodiversity, nutrition and health: making a difference tohunger and nutrition in the developing world, Food and Nutrition Bulletin,Jun 27(2): 167–79.33Bagnall-Oakeley H, Sendall A and Melunga C, Farm IncomeDiversification project; End of Term review, phase I and mid-termreview phase II, Sept 201234De Schutter O, Special Rapporteur on the Right to Food, UNGeneral Assembly, 64th Session, Reference A/64/170, 23 July 2009,The right to food: Seed policies and the right to food – enhancingagro-biodiversity and encouraging innovations35For further information please see: Harvesting Nutrition, SecureNutrition note 137Haryana Community Forest Project, Empowerment of WomenMarch 2008, Haryana Forestry Department, Haryana State, India,

38See Scaling up Nutrition:;and see SUN Countries: Costed Plans Summaries: Alliance for Food Security and Nutrition, 2013 Progress ReportSummary, published by DFID with support of two convening Co-Chairsof the leadership Council: The African Union and the World EconomicForum40Nutrition for Growth Commitments, executive summary, Preventingat least 20 million children from being stunted and saving at least1.7 million lives by 2020, /uploads/system/uploads/attachment_data/file/207274/nutrition-for-growthcommitment.pdf41Ibid43R Black, CG Victora, S Walker, Z Bhutta, P Christian, M de Onis,M Ezzati, S Grantham-McGregor, J Katz, R Martorell, R Uauy, theMaternal and Child Nutrition Study Group (2013) ‘Maternal and childundernutrition and overweight in low-income and middle-incomecountries’, The Lancet, 382, 9890, pp 427–51 Maternal and ChildNutrition Series, Paper 144Percentage contribution to the reduction in stunting. The mosteffective intervention was maternal schooling, followed by familyincome increase.45C Monteiro, ‘The decline in child malnutrition in Brazil’, Cad. SaúdePública [editorial]. 25, 5, 2009, pp 950–51. – Southern Nations, Nationalities and People’s Regionendnotes42A de Freitas Barbosa, R Barbosa, V Callil, G de Freitas, M Dowbor,RLC Amorim, The Real Brazil: The inequality behind the statistics, CEBRAP,2012,

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nutrition sensitivityHow agriculture can improve child nutritionCOVER Photo: sebastian rich/save the childrenIn 2011 it is estimated 3.1 million children under theage of 5 years died because of malnutrition. Many morewere stunted and suffered poor cognitive development.The economic loss from malnutrition is enormous –around 16% of GDP in some countries.Agriculture provides food to a country’s population andcomprises a large proportion of the economy in manydeveloping countries. Yet for too long, agronomists haveneglected the critical role of diverse diets, adequateincome and education in supporting healthy populationsand improving nutrition. Instead, many countries’policies have focused on increasing the productivityof staple crops.The African Union has declared 2014 the year of familyfarming. The opportunity to seize this moment totransform the way agriculture is managed across thecontinent should not be missed.Nutrition Sensitivity examines and explores how nutritioncan be prioritised within agricultural policies, strategiesand investment plans, and demonstrates the power ofagricultural bio-diversity, social behavioural change,enterprise diversification, and women’s empowermentin improving nutrition in rural areas. It profiles districtlevelcoordination mechanisms, which could result inbetter communication and coordination – and betternutrition – at a household photo: hildren

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