Positioning Nutrition as

Central for a Food

Secure Arab world

Clemens Breisinger, Olivier Ecker, Marc Nene and Perrihan

Al-Riffai, International Food Policy Research Institute (IFPRI)

Convener: The World Bank

Session - Food Security: Beyond Food Production

14 November, 14.30 – 16.00

1

Contents

Summary ................................................................................................................................................ 2

1. Introduction ...................................................................................................................................... 3

2. Nutrition in the Arab world ............................................................................................................ 5

3. Highlights of nutrition interventions ......................................................................................... 10

4. Summary .......................................................................................................................................... 12

References .......................................................................................................................................... 14

2

Summary

Food insecurity is a multi-dimensional challenge and nutrition is a central part of

achieving food security. Overcoming malnutrition, especially among children, is not

only important for achieving food security, but also important for realizing

successful future economic development. However, in the Arab world, on average

every fifth child younger than five is malnourished, while in Egypt and Sudan about

every third and in Yemen almost two thirds of children are stunted. To overcome

this unacceptable situation, this paper has raised a couple of important policy

questions and provided two initial suggestions for action that are based on global

experiences. Questions that need to be urgently addressed are: why is it that

economic growth (and rising incomes) does not seem to improve nutrition in Arab

countries? How can public resources be better targeted at improving food and

nutrition security? Global experiences show that the nutrition part of food security

tends to be underfunded in government budgets and in the budgets of the

international development assistance community relative to the size of the

problem, suggesting that investments in nutrition need to be scaled-up. The case

of Brazil shows the importance of integrating food and nutrition security into

national programs and demonstrates how well-crafted nutrition policies under

strong political leadership can engender a substantial reduction in chronic

malnutrition.

3

1. Introduction

Food and nutrition insecurity is a multi-dimensional challenge. The World Food

Summit in 1996 defined food security as a situation ‚when all people, at all times,

have physical, social and economic access to sufficient, safe and nutritious food to

meet their dietary needs and food preferences for an active and healthy life‛ (FAO

1996, par. 1). At the World Summit of Food Security in 2009, this definition was

reconfirmed, and the concept was extended and specified by adding that the ‚four

pillars of food security are availability, access, utilization, and stability‛ and stated

that ‚the nutritional dimension is integral to the concept‛ (FAO 2009b, p. 1, fn. 1).

To conceptualize the multiple dimensions of food and nutrition security, Ecker and

Breisinger (2012) have developed a framework that builds on the World Summit

definition and integrates the four pillars of food security into a system approach. It

links food security and nutrition acknowledging that food security at the household

(and individual) level is a necessary but not sufficient condition for adequate

nutrition and that food and nutrient intake interacts with the individual health

status (Figure 1).

Figure 1: Overview of the Food Security System

Source: Ecker O. and C. Breisinger. 2012.

4

Nutrition is an important part of food security. Nutrition of all members of a

household is subject to the household’s economic (and physical) access to food and

to basic household assets and (public) services that affect individuals’ health

conditions. A major factor of food access is household (real) income and the lack of

income does not only limit the access to food of sufficient quantity and quality but

also increases the vulnerability to food price shocks (Barrett 2002). Formal

education and nutritional knowledge of parents, especially mothers (Behrman and

Wolfe 1984; Glewwe 1999; Semba et al. 2008), and gender equality in decision

making on household resource allocation (Behrman and Deolalikar 1990; Kennedy

and Peters 1992; Thomas 1994) are also crucial factors of the nutritional status of

young children in particular. Children’s nutritional status is directly determined by

the mother’s nutritional and health status through the physiological and social

mother-child relationship. Finally, a person’s nutritional status is determined by her

individual health status (and vice versa), influencing physiological nutrient

requirements and interacting with the utilization of nutrients from food. For

example, parasitic and diarrheal diseases cause nutrient losses through blood and

stool and reduce nutrient absorption necessitating higher nutrient intake and thus

more food to cover the losses, if such compensation is possible at all (Katona and

Katona-Apte 2008; Stephenson et al. 2000). At the same time, poor nutrition

weakens the human immune system and therewith increases the risk of disease

and illness (Black et al. 2003). Thus, access to clean drinking water, hygienic

sanitation, proper shelter, basic health care for disease and illness treatment and

prevention including immunization, and related information and education

campaigns all determine people’s nutritional status indirectly through the link with

health (Fay et al. 2005; Frongillo et al. 1997; Smith et al. 2005).

Malnutrition, especially among children, negatively affects productivity and

economic development. Good nutrition is fundamental for individuals to realize

both their physical and intellectual potential. It is the basis for individual and family

well-being and human capital formation and, as such, key to economic and social

development (Horton et al. 2010; Victoria et al. 2008). Malnutrition has serious

consequences at the micro and macro level in the current generation and, even

more so, for future generations. At the micro level, undernutrition reduces the

individuals’ income generation potential, lowers children’s schooling performance,

increases the risk of disability, morbidity, and mortality, and thus contributes to the

intergenerational transmission of poverty and illness (Black et al. 2008; Grantham-

McGregor et al. 2007). Even temporary malnutrition such as during food crises or

the (pre-harvest) rainy season (frequently referred to as ‘hunger season’) can cause

irreversible health impairments especially in children (Hadley et al. 2007). At the

macro level, malnutrition slows economic growth and deepens poverty through

three routes: (1) direct losses in productivity from poor physical and mental

performance (or death) of the work force, (2) indirect losses from reduced working

and cognitive capacity of the working population at present and in the future, and

(3) losses in resources due to increased health care costs (World Bank 2006). The

5

economic costs of malnutrition are substantial; only productivity losses to

individuals are conservatively estimated at more than 10 percent of lifetime

earnings and losses to gross domestic product (GDP) at 2 to 3 percent on average

(Horton 1999; World Bank 2006). Substantial losses in income and GDP are due to

impaired cognitive abilities, which are particularly relevant in more advanced

economies (Hoddinott et al. 2008; Horton and Ross 2003; Selowsky and Taylor

1973).

2. Nutrition in the Arab world

A key indicator for food insecurity at the household level is the prevalence of

child malnutrition. Young children’s nutritional status tends to be most responsive

to changes in living conditions and to be particularly vulnerable to food shortages

and diseases, due to their high physiological nutrient requirements for growth,

their special dietary needs, their often more direct exposure to adverse health

conditions, and their dependency on adults. Among the three common child

anthropometric measures (that is, height for age, weight for age, weight for

height), height-for-age scores (or, stunting), best reflect the cumulative effects of

chronic food deficits and illness and are therefore good overall, long-term nutrition

indicators. Focusing on young children, who are typically the weakest household

members, captures aspects of unequal intrahousehold resource distribution that

are ignored when using household-level indicators such as income poverty or

household food and nutrient consumption measures. Furthermore, at the country

level, high prevalence rates of stunted children are usually associated with poor

delivery of public services, especially in the health and education sector, and poor

development of water and sanitation infrastructure; rapidly growing populations;

low literacy rates and low educational attainment rates; and gender inequality.

6

Figure 2: Prevalence of malnutrition among children in Arab countries, Turkey and Iran

Source: Breisinger C., O. Ecker, P. Al-Riffai and B. Yu. 2012.

Note: In general, the latest estimate since 2006 is used. If no observations were

available after 2006, the prevalence of child undernutrition is projected using a

general nutrition–growth elasticity of 0.11, estimated from a global cross-country

regression model and country specific GDP per capita growth rates. High-income

countries have a low food insecurity risk. Low- and middle-income countries (LMICs)

are classified into five groups (quintiles) by level of food insecurity risk: low,

moderate, serious, alarming, and extremely alarming. The classification is carried

out for all LMICs with respective data. Thus, the nutrition situation in Arab-TI

countries is compared with the food-security situation in LMICs worldwide (130

countries in total).

In the Arab world, every fifth child younger than five is stunted, while in

Comoros, Djibouti, Egypt, Somalia, Sudan and Yemen about every third child or

more is stunted. The map in Figure 2 classifies Arab countries into five categories.

The countries with a low prevalence of child stunting are Bahrain, Oman, Saudi

Arabia, the United Arab Emirates, Tunisia, Qatar, Kuwait and the West Bank and

Gaza. In Algeria, Morocco and Libya between 15.6 and 21.6 percent of children are

stunted; in all other countries the situation is serious, alarming or even extremely

alarming.

7

Unlike in the rest of the world, overall growth does not improve child

malnutrition in the Arab world. One percent in overall growth in the rest of the

world leads to a reduction in the prevalence of child stunting by 0.12 percentage

points, but the relationship in the Arab region is statistically insignificant

(Breisinger et al. 2012). The plotted graph in Figure 3 suggests that the relationship

between the prevalence of child malnutrition and GDP per capita in the Arab-TI

region is somewhat similar to the global relationship until about the $5,000 level,

at which GDP continues to climb steadily while child malnutrition levels off. In

individual countries the relationship between child malnutrition and GDP per capita

is even more negative: for example, Egypt’s prevalence of child malnutrition spiked

significantly from 2003–08, though GDP per capita continued to rise. Taking the

child malnutrition levels as reference, this difference suggests that additional

factors play a role for determining malnutrition levels.

Figure 3: Relationship between child malnutrition and GDP

Source: Breisinger C., O. Ecker, P. Al-Riffai and B. Yu. 2012.

Public spending in the Arab world needs to be reviewed in terms of its food

and nutrition security focus. Public spending is one of the key tools for

governments to improve food security, yet no comprehensive database exists on

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food security-related public spending in Arab countries. One of the most

informative databases to date is IFPRI’s Statistics of Public Expenditure for

Economic Development (SPEED), which disaggregates expenditure into agriculture,

education, health, infrastructure, and social protection. Table 1 shows a summary

of statistics from this database for the Arab world.

Table 1. Public spending (percent of GDP), 2007

Agriculture

Education

Health

Infrastructure

Social protection

Total

Ag. exp. / ag. VA

Food secure countries

0.7 2.9 2.5 0.9 4.7 26.6 6.9

Oil exporters 0.8 2.8 1.7 1.9 6.7 28.1 7.9 Algeria 0.7 4.4 1.2 3.8 4.7 30.2 8.4 Iran 0.8 2.1 1.8 1.3 7.8 26.6 8.0 Yemen 0.4 5.8 1.4 0.1 0.0 40.3 3.9

Oil importers 0.7 3.0 3.1 0.3 3.5 25.7 6.4 Djibouti 0.1 3.2 1.1 0.0 0.0 22.9 3.0 Egypt 0.8 3.7 3.7 0.5 7.3 26.9 5.8 Jordan 0.6 5.3 2.7 1.6 10.6 38.0 20.6 Lebanon 0.1 2.3 0.7 0.5 2.5 33.6 1.2 Morocco 0.6 5.6 0.8 0.2 4.5 30.1 4.4 Syria 1.6 2.9 0.2 1.6 0.4 29.1 8.9 Tunisia 1.5 6.4 1.5 0.8 7.5 24.9 14.6 Turkey 0.5 2.0 3.6 0.0 1.5 23.5 6.1

Food secure countries

0.2 3.7 1.7 0.7 6.1 35.6 29.2

Oil exporters 0.2 3.7 1.7 0.7 6.1 35.6 29.2 Bahrain 0.1 3.4 2.3 0.6 0.7 25.3 20.5 Kuwait 0.2 3.3 1.7 0.2 9.2 36.7 72.9 Oman 0.2 4.7 1.5 1.8 1.7 37.3 13.6

Arab countries (plus Iran and Turkey)

0.7 3.0 2.5 0.9 4.8 27.3 7.0

Arab countries (all)

0.7 4.2 2.0 1.3 5.5 30.4 7.1

LMICs 0.8 2.3 1.3 0.5 1.8 18.9 7.2 Arab-TI 0.7 2.9 2.5 0.9 4.7 26.6 6.9 Arab 0.8 4.3 2.1 1.4 5.3 29.3 6.9 A&P 1.1 2.0 0.6 0.3 1.4 17.8 7.9 EE&CA 0.4 1.2 0.9 1.1 1.9 21.3 7.6 LAC 0.3 3.6 2.7 0.3 1.3 15.7 4.7 SSA 0.8 2.8 1.2 0.6 0.8 17.5 2.6

Source: Breisinger et al. 2012 based on SPEED database (2011).

Note: Averages of aggregates are weighted by population size.

9

Some of the key messages are:

Arab countries allocate about the same amount of resources to agriculture

as all LMICs on average but significantly more than Latin America and the

Caribbean and Sub-Saharan Africa Yet, there are substantial differences

among Arab countries. The agricultural expenditure intensity is relatively

low in several FSC countries, including Yemen (3.9 percent), Lebanon (1.2

percent), and Morocco (4.4 percent), indicating potential underspending.

Arab countries devote 4.2 percent of GDP to education. This share is even

higher when excluding high-income countries from the average (Table 1),

thus no world region spends a greater share than the Arab region LMICs (4.3

percent). Countries that spent more than 5 percent of GDP on education

include Yemen, Jordan, Morocco, and Tunisia; Iran, Lebanon, Syria, and

Turkey spent less than 2 percent in 2007.

Arab countries spend about 2.0 percent of GDP on health, which is less than

in Latin America and the Caribbean region but more than in other regions.

There are large differences between countries: In 2007, Jordan and Bahrain

plus Egypt and Turkey spent more than 2 percent of their GDP on health,

and Lebanon and Morocco plus Syria and UAE spent less than 1 percent.

Spending on infrastructure, which refers here to transportation and

communication, in the Arab LMICs is high according to global standards;

however, the Arab-TI region is the only region where infrastructure budgets

have shrunk, where the decline in infrastructure spending is particularly

pronounced in oil-importing FSC countries, where spending has declined by

2.6 percent per capita and per year, while spending has sharply increased by

12.4 percent in (oil-exporting) FS countries (Breisinger et al. 2012).

Arab LMICs in particular have by far the highest spending on social

protection: more than double the size of Eastern Europe and Central Asia

and more than four times the size of Sub-Saharan Africa. In the Arab-TI

region, social protection expenditures are also by far the highest single

spending account, amounting to 4.7 percent of GDP on average, and 5.3

percent in Arab LMICs.

While there are no specific numbers available for Arab countries, in general the

nutrition subsector tends to be underfunded in government budgets and in the

budgets of the international development assistance community relative to

the size of the problem (Ecker and Nene, 2012). Although the amount of financial

resources allocated to nutrition is difficult to estimate precisely (especially given

the responsibilities scattered across government sectors), the poor progress in

reducing malnutrition in most developing countries demonstrates meaningful

evidence. For example, each stunted child in the 20 countries accounting for 80

percent of the global burden of child stunting received only $2 out of the $5-10

10

Box 1: Cost-benefit ratios of large-scale

nutrition interventions (aggregates)

Micronutrient supplementation 17.3

Micronutrient fortification 9.5

Biofortification (plant breeding) 16.7

Deworming preschoolers 6.0

Community-based nutrition promotion 12.5

Source: Horton et al. (2008).

required to scale up community-based nutrition programs in 2006 (Horton et al.

2010, Morris et al. 2008).

It is not only the size but also the quality of public spending that matters for

food and nutrition security. At the country level, high prevalence rates of stunted

children are often associated with poor delivery of public services, especially in the

health and education sector, and poor development of water and sanitation

infrastructure; rapidly growing populations; low literacy rates and low educational

attainment rates; and gender inequality. For example, much like agricultural

spending, spending a large portion of GDP on education does not necessarily yield

results: youth literacy rates, for instance, show no clear relationship between

expenditures and educational achievements. Similar to the patterns for education

expenditure, comparisons of health expenditure and performance in terms of

MDGs 4 to 6 reveal no clear relationship, implying that there are also big

differences in the amounts spent per person and the quality of health services. One

reason may be that public spending is not well targeted to the food insecure. For

example, fuel and, in some countries, food subsidies are often higher than more

targeted social spending. In Egypt and Syria, for example, food and fuel subsidies

(accounting for about 20 percent of public spending) are more than two-fold higher

than spending on social protection programs and health combined.

3. Highlights of nutrition interventions

Nutrition interventions have very favorable cost-benefit ratios. Maybe the

most convincing argument for a stronger political commitment to nutrition, though,

is the high cost-effectiveness of direct nutrition interventions (Box 1). Asked to

rank 30 solutions to the ten great

global challenges primarily based

on economic costs and benefits,

the 2008 Copenhagen Consensus

listed five solutions addressing

the ‘malnutrition and hunger’

challenge directly and another

four indirectly through the link

with health and education in the

top ten solutions (CC 2008). The

proposed interventions include micronutrient supplementation and (bio)

fortification, nutrition and hygiene education programs, and immunization, of

which most of them are targeted toward women in reproductive age and young

children.

The case of a Bajil District in Yemen shows how costs for nutrition

interventions can be estimated on a case-by case basis. Child health and

11

nutrition programs are widely needed in Bajil District. The low use of birth control

methods (only 15 percent of non-pregnant woman) in spite of the widespread wish

of not having more children clearly indicates the need for implementing and

expanding birth control programs. There is also a pressing need for reproductive

health and child nutrition and health programs of various type (including mother

counseling). Table 2 shows the estimated annual costs of different health and

nutrition programs in order to increase coverage to 50 percent, 90 percent, and

100 percent of the population in need. In addition to that, information and

education campaigns targeted to the broader society can be an effective

mechanism for raising awareness and knowledge on diverse aspects related to

family health, nutrition, and social development. These campaigns should include

common issues such as qat consumption, healthy nutrition, child feeding practices,

hygiene, family planning, and women’s empowerment. Cost estimates for such

campaigns are reported in Table 2.

Table 2. Annual costs health and nutrition programs and information and

education campaigns in Bajil District

Proportion of individuals in need (%)

Annual costs (thousand US$)

50% coverage

90% coverage

Full coverage

Reproductive health Antenatal, delivery, and postpartum

care program (for pregnant women) 58

3.1 18.8 22.7

Birth control program for women in reproductive age wishing no additional children

46

20.4 36.7 40.8

Child nutrition

Mother counseling program for pregnant women (breastfeeding, child health and nutrition)

100

2.2 3.9 4.4

Feeding program for small-sized newborns

52

4.0 7.2 8.0

Child growth monitoring program for severely stunted children (aged 6-59 months)

39

25.6 46.1 51.2

Information and education

General campaign (qat consumption, healthy nutrition, child feeding practices, hygiene, family planning, and women’s empowerment, etc.) for total population

100 85.1

Source: Own estimation based on CSO (2004), 2005-06 HBS data, and 2006 MICS data

12

The case of Brazil shows how nutrition can be successfully integrated into

national programs and demonstrates that well-crafted nutrition policies under

strong political leadership can engender a substantial reduction in chronic

malnutrition. In one decade Brazil managed to almost halve the prevalence of

stunting among children under the age of five from an estimated 13.5 percent in

1996 to 6.8 percent in 2007 (Monteiro et al. 2010). Thanks to the poverty reduction

program and its health and nutrition components, the trend of declining child

stunting since the mid-1970s has been accelerated considerably. Trend analyses of

the determinants of child stunting suggest that nationwide two-thirds of the

reduction is attributable primarily to decline in poverty and increase in mothers’

education and secondarily to expansion of healthcare coverage and improvements

in sanitation (Monteiro et al. 2009, Monteiro et al. 2010). Food security had already

been part of Brazil’s policy agenda since the early 1990s, championed by a network

of civil society organizations. In 2003 the engagement culminated by a declaration

to combat hungers—a national priority by President Luiz Inácio Lula da Silva

(Kepple et al. 2012). Today, the resulting ‘Zero Hunger’ strategy coordinates

programs from 11 ministries and provides a framework for several initiatives

including the flagship conditional cash transfer program ‘Bolsa Família’, which is

considered the ‚cornerstone program for the promotion of food and nutrition

security‛ in the country (Ananias 2008, Chmielewska & Souza 2011). The success of

the ‘Zero Hunger’ strategy rests on its manifold integration in Brazil’s institutional

and legal framework. The National Council on Food and Nutrition Security

(CONSEA), which monitors the country’s food and nutrition situation, has broad

representation from the federal government and civil society and is institutionally

linked to the presidency. The food and nutrition security secretariat and social

protection secretariat—managing the ‘Bolsa Família’ program—are housed in the

Ministry of Social Development and Fight against Hunger, which has the mandate

to oversee the integration of food and nutrition security actions with the activities

of other relevant ministries. And third, the ‘Right to Food’—incorporated into

Brazil’s constitution in 2009—grants the status of public policy to food and

nutrition security and requires the federal states to enforce the universal right

guaranteeing regular and permanent access to food in sufficient quantity and

quality.

4. Summary

Food insecurity is a multi-dimensional challenge and nutrition is an integral part of

achieving food security. Overcoming malnutrition, especially among children, is not

only an issue of achieving food security, but also important for realizing successful

economic development. However, in the Arab world, on average every fifth child

younger than five is malnourished, while in Egypt and Sudan about every third and

13

in Yemen almost two thirds of children are stunted. To overcome this unacceptable

situation, this paper has raised a couple of important policy questions and provided

two initial suggestions for action that are based on global experiences. Questions

that need to be urgently addressed are: why is it that economic growth (and rising

incomes) does not seem to improve nutrition in Arab countries? How can public

resources be better targeted at improving food and nutrition security? Global

experiences show that the nutrition part of food security tends to be underfunded

in government budgets and in the budgets of the international development

assistance community relative to the size of the problem, suggesting that

investments in nutrition need to be scaled-up. The case of Brazil shows the

importance of integrating food and nutrition security into national programs and

demonstrates how well-crafted nutrition policies under strong political leadership

can engender a substantial reduction in chronic malnutrition.

14

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