A Literature Review and Analysis

F REEDOM FROM HUNGER

RESEARCH PAPER NO. 1

Are Credit and Savings Services Effective Against Hunger and Malnutrition?—A Literature Review and Analysis

Barbara MkNelly and Christopher Dunford

February 1996 Contents Executive Summary ...... 1 Introduction ...... 4 Part I...... 8 Linkage of Income to Food Security and Nutritional Status ...... 8 Linkage of Behavior Change to Nutritional Status ...... 16 Interactions of Women’s Empowerment with Income and Behavior Change ...... 19 Part II ...... 23 Freedom from Link Between Hunger’s Mission Poverty Lending and Income ...... 23 Founded in 1946, Freedom Link Between from Hunger promotes “Self- Poverty Lending Help for a Hungry World.” and Empowerment Freedom from Hunger brings of Women ...... 32 innovative and sustainable self-help solutions to the fight Linkage of Poverty Lending against chronic hunger and to Behavior Change poverty. Together with local and Nutrition Status ...... 35 partners, we equip families Conclusion ...... 41 with resources they need to Résumé Analytique ...... 42 build futures of health, hope and dignity. Resumen Executivo ...... 45 Works Cited...... 48 Annex ...... 54 Credits ©1996 Freedom from Hunger. Design No part of this document may be Michael Curry/ Donna Justice reproduced without the express written permission of Freedom from Hunger.

Credit with Education is a service mark of Freedom from Hunger.

1644 DAVINCI C OURT DAVIS, CA 95617 (530) 758-6200 FAX (530) 758-6241 [email protected] ARE CREDIT AND SAVINGS SERVICES EFFECTIVE AGAINST HUNGER AND MALNUTRITION? A LITERATURE REVIEW AND ANALYSIS

BARBARA MKNELLY AND CHRISTOPHER DUNFORD FREEDOM FROM HUNGER

EXECUTIVE SUMMARY lished program documents which are generally difficult to obtain. Poverty lending programs like the Grameen This paper aims to go beyond what Bank have captured the attention of an audi- Pinstrup-Andersen (1983) refers to as the ence that extends well beyond the traditional “black box approach” to program evaluation development community. Much of this en- to a more process-oriented approach. The thusiasm relates to the programmatic suc- “black box approach” focuses only on whether cesses— the repayment rates, the scale and/or the desired impact is achieved, while the lat- the potential for financial self-sufficiency— ter approach helps illuminate how the impact rather than the impact of the programs. Still, was achieved by tracing program impact the value of any development strategy ulti- through relevant processes. Part I of the pa- mately depends on its ability to achieve sus- per investigates evidence regarding the rela- tainable improvement in the quality of life. tionship of income, empowerment, and behav- We have examined the academic and ior change (hypothesized as the intermediate practitioner literature to determine what are benefits of poverty lending) to food security known, or strongly asserted, to be necessary and nutritional status—the ultimate outcome conditions for credit and savings programs to goals. Part II examines the evidence that pov- be effective against hunger and/or malnutri- erty lending programs have a positive impact tion. Knowing that no literature review can on the intermediate benefits necessary for be comprehensive, provide definitive answers, overcoming the underlying causes of hunger or be free of interpretive bias, we aim mainly and malnutrition. Each section begins with a to stimulate new thinking, research, and prac- hypothesized relationship, includes a review tice—all of which should be directed toward of the evidence we found pertaining to that building innovative, effective, sustainable, relationship, and ends with tentative conclu- large-scale efforts to drastically reduce chronic sions regarding the relationship. hunger and malnutrition throughout the world. The major conclusions are summarized The approach used is a review of second- below. ary sources of information—articles, reports, and, whenever possible, program evaluations. PART I: Relationship of the Intermediate In addition, interviews were conducted with a Benefits (Income, Behavior Change, and range of practitioners having expertise prima- Empowerment) to Food Security and rily in credit, gender issues, and nutrition (see Nutritional Status Annex for a list of individuals consulted). These interviews were invaluable in terms of 1. Certain conditions make more direct the the generous sharing of insight and experience; impact of increased income on household food they also afforded access to relevant unpub- security (access to food) and nutritional status. Interventions are more likely to have this

Research Paper No. 1!1 impact when they ensure that income increases and control seems likely, but we have yet to are 1) experienced by the poorest households, find documentation of such feedback. 2) controlled by women, 3) earned as steady 5. Both economic and social manifesta- rather than lump sum earnings, and 4) enhance tions of empowerment seem to be crucial for the households’ overall livelihood security. women to make nutritionally important behavior changes and to demand and use correctly 2. The link between household food se- health services and health technologies. In- curity and income is more direct than the rela- dependent sources of income are likely to af- tionship between income and nutritional sta- fect women’s status, autonomy, and self-con- tus, for a variety of reasons. First, nutritional fidence. Social dimensions, such as greater status is a function of an individual’s overall mobility, public interaction, and/or group iden- health and not simply a function of access to tification, are also important to women’s ex- food or even food intake. Second, posure to new ideas and potential openness to intrahousehold food allocation decisions and change. Again, positive feedback of behavior resources (such as a caretaker’s time) can change to empowerment was not documented greatly modify the effect of increased income. but seems likely. It also seems that empower- And third, key maternal and child health/feed- ment plays a pivotal role in creating a syner- ing practices and use of existing health ser- gistic effect between income and important vices also highly influence nutritional status. health/nutrition behaviors. 3. The nutritional impact of increased income will be disappointing if it is not also Part II. Relationship of Poverty Lending to coupled with improvement in the health of the Intermediate Benefits (Income, those most vulnerable to malnutrition, namely Behavior Change, and Empowerment) women and young children. Changes in nutrition and health care practices at the level of 1. Concrete evidence of the economic impact the household are likely to be the essential first of poverty lending programs is rare. The few line of prevention and treatment of malnutri- rigorous evaluations to date (primarily the tion. For example, each of the following has Grameen Bank and some ACCION affiliates) nutritional implications: the selection and dis- indicate that poverty lending programs do raise tribution of food within the household; prac- incomes, assets, and productivity of very poor tices related to breastfeeding, child feeding, borrowers, both men and women. and diarrhea treatment and prevention; diets 2. Poverty lending more often preserves during pregnancy, lactation, and/or during and an entrepreneur’s own self-employment rather after illness; use of existing health services; than creates new jobs. Incomes are most likely personal, food, and environmental hygiene. stabilized or moderately increased in the short Even without the benefit of increased house- term. However, with sequential loans and ac- hold income, these behaviors can dramatically cumulation of business experience, partici- improve household nutritional status. Con- pants may move into potentially more profit- versely, increased income may occur in the able activities. Labor productivity (hourly net absence of necessary behavior change and income) is an important variable to be included nutrition improvement. in any impact study of credit, especially for 4. Women’s ability to increase their in- women. comes or their control over income has a posi- 3. Poverty lending is designed to support tive effect on their empowerment (self-confi- primarily the existing economic activities of dence, status, and bargaining power within the poor. Because of the meager returns and their households). The possibility of positive structural constraints of women’s traditional feedback of empowerment to income earning activities, this minimalist approach probably

A Literature Review and Analysis!2 does not bring about major economic improve- have learned. But some kind of information ments for women. Because women constitute transfer and change promotion must occur the bulk of the participants in most programs, before women are likely to know what to poverty lending is unlikely to produce major change and why and how. economic gains for poor households. How- 6. With an education program, the poten- ever, in relative terms, these modest gains seem tial of poverty lending to counter malnutrition likely to make very important contributions to can be realized. Without education, poverty household survival, such as income smooth- lending may have only a weak positive effect ing and insurance against emergencies. And on household food security and little, if any, these are precisely the types of livelihood strat- impact on nutritional status. Education can egies that, if strengthened, are most closely be provided to poverty lending program par- associated with increased household food se- ticipants either by a separate program or as an curity and nutritional status. integrated component of the poverty lending program itself. 4. Poverty lending empowers women participants. By providing opportunities for self-employment, it increases women’s autonomy, self-confidence, and status within the household. Regular meetings and peer guarantee help foster group solidarity, which reduces women’s isolation and increases their exposure to new ideas and information as well as their skills for interacting in the public sphere. There is even some evidence in support of the hypothesis that solidarity groups create empowerment of their members independently of their economic impacts by creating new bonds and social identification that help women resist traditional restrictions and foster new cultural norms. A wider survey of literature on noneconomic self-help groups would likely reveal that intragroup solidarity has a strong, direct, and positive impact on measures of personal and group empowerment. 5. Women’s empowerment is unlikely to directly improve household food security and nutritional status without acting through behavior change that is either economically or nutritionally important. Likewise, poverty lending programs are unlikely to directly promote either economic or nutrition-related behavior changes without acting through some kind of educational process. Women’s empowerment is believed to make women “learning ready,” and women’s economic resources can enable them to take action on what they

Research Paper No. 1!3 INTRODUCTION The question we address in this paper is, “Are credit and savings programs designed for Despite dramatic gains in agricultural technol- the poorest of the productive poor appropriate ogy and food production, the number of indi- responses to the problems of hunger and mal- viduals suffering from hunger and malnutrition nutrition?” We have examined the academic grows. Global hunger and malnutrition is no- and practitioner literature to determine what are toriously difficult to quantify, but according to known, or strongly asserted, to be necessary one often cited source, the Bellagio Declara- conditions for credit and savings programs to tion: be effective against hunger and/or malnutrition. Knowing that no literature review can be com- ! One billion people live in households prehensive, provide definitive answers, or be too poor to obtain the food they need free of interpretive bias, we aim mainly to for work. stimulate new thinking, research, and practice. ! Half of those are too poor even to ob- All of which should be directed toward build- tain the food they need to maintain ing innovative, effective, sustainable, large- minimal activity. scale efforts to drastically reduce chronic hun- ! One child in six is born underweight ger and malnutrition throughout the world. and one in three is underweight by age 5. “Poverty Lending” ! Hundreds of millions of people suffer The Grameen Bank in Bangladesh has received anemia, goiter, and impaired sight from widespread acclaim as an innovation in credit diets with too little iron, iodine and/or and savings services that represents a genuine vitamin A.1 breakthrough in poverty alleviation. Several comparable “poverty lending” programs have A major challenge to the international de- developed in recent years to provide financial velopment community is to innovate solutions services to the poorest socioeconomic strata. to hunger and malnutrition that are both effec- They all employ innovative methodologies that tive and sustainable and have the potential to enable the poor to play a central role in their reach very large numbers of vulnerable people. own development.2 Poverty lending programs With the success of the Grameen Bank and have demonstrated that the poor are creditwor- other large-scale programs in providing access thy, that subsidized interest rates are not re- to credit for millions of poor households, credit quired to effectively serve this target group, and savings programs are increasingly cited as and that social collateral is better than physi- good ways to reduce hunger and malnutrition. cal collateral for securing loans. For example, responding to the 1993 Interna- The three circles in Figure 1 represent a tional Conference on Actions to Reduce Glo- hierarchical progression of borrower groups, bal Hunger, the World Bank and other lending each with different economic goals and finan- and donor institutions established The Consul- cial needs. According to Lassen (1990): tative Group to Assist the Poorest (CGAP), which will focus on supporting large-scale de- What distinguishes poverty velopment of credit and savings programs for lending from other microenterprise the very poor. support is the target group. Poverty

1 The Bellagio Declaration was produced and adopted by a group of development planners, practitioners, opinion leaders, and scientists for 14 countries meeting at the Rockefeller Foundation Center in Bellagio, Italy, in November 1989.

2 Some of the best known examples are Badan Kredit Kecamatan (BKK) in Indonesia, Working Women’s Forum and Self Employed Women’s Association (SEWA) in India, Production Credit for Rural Women (PCRW) in Nepal, and programs supported by ACCION and FINCA in Latin America.

A Literature Review and Analysis!4 lending assists directly the poorest around activities. Through savings (either of the poor. Its policies and proce- mandatory or voluntary) and successful repay- dures are designed to support the ment performance, loan sizes grow and opti- economic development of self- mally finance a progression of loan-funded ac- employed producers with no assets. tivities with increasingly higher return. With poverty lending, it is legiti- Modeled after the workings of the infor- mate to support sizes and types of mal financial sector rather than formal finan- activities (e.g., petty trading) and cial institutions, the loan application process uses of surplus (to feed one’s fam- for poverty lending programs tends to be in- ily) that are not promoted with formal and transparent, often taking place in producers and firms at higher levels the borrower’s community and requiring mini- on the economic ladder. . . . Poverty mal written documentation rather than requir- lending is dedicated to ing lengthy loan applica- reaching not only tions and review pro- those who would cesses. Peer guarantee

benefit from addi- Figure 1. Progression replaces physical collat- tional working capital, of Borrower Groups eral requirements of ei- but those who are ther land or assets. And struggling to eat. repayment is scheduled in periodic payments The potential of credit (often weekly) rather to alleviate poverty has long than as a lump sum at the been appreciated. Through- end of one year or an out the 1970s and early agricultural season. 1980s, millions of donor According to dollars and untold govern- Lassen (1990), the char- ment resources went toward acteristics of a poverty rural credit programs. The Adapted from USAID, 1989a. lending program’s suc- failure of these programs ei- cess in working with the ther to reach small farmers or recover loans is very poor include the following: “It makes capi- well documented. Studies show that the pro- tal available at appropriate levels of money portion of loans in arrears in traditional rural management experience—even $20 if appro- credit programs ranges from 30 percent to 90 priate; it develops the investment skills, confi- percent in Africa, the Middle East, and Latin dence, and experience of the severely poor; it America3 (Holt and Ribe, 1990). Traditional motivates financial discipline through required rural credit programs have been characterized savings and frequent repayment; it has no bar- by subsidized loans to “small farmers,” the size riers that impede participation of the very poor.” of which depends on the specific agricultural However, Lassen is quick to point out that in inputs to which they are tied. Poverty lending terms of financial principles (high repayment, programs typically extend a series of very small cost effectiveness) and methods (commercial (between $10 and $300), short-term loans (from interest rates), poverty lending and one to twelve months), generally for rapid turn- microenterprise credit programs are quite similar. 3 Unfortunately, these arrears do not represent income transfers to the poor because (intentionally or not) these programs exclude this group. Ironically, the subsidized interest rates justified on the grounds that the poor would be unable to pay commercial rates made it less likely that the programs reached the poor since the more powerful socioeconomic elite were able to usurp the cheap loans.

Research Paper No. 1!5 The features that seem to be most closely ented approaches, it is necessary to know its associated with these high recovery rates are efficacy for improving household food secu- 1) peer guarantee and shared responsibility for rity and nutritional status. repayment; 2) short loan periods and periodic Pinstrup-Andersen (1983) characterizes (often weekly) repayment installments; and 3) many of the evaluations of nutrition programs terms and requirements that channel invest- as taking a “black box approach.” The impact ment away from agriculture to activities pro- of a particular program on the nutritional sta- viding a more steady stream of income, such tus of a specific population over a given pe- as trade, manufacturing, processing, or sales. riod is evaluated with little or no attention to At the same time, certain programmatic the intermediate steps or relationships lead- features common to most poverty lending pro- ing to that impact. According to Pinstrup- grams help to minimize administrative costs. Andersen (1983): Peer guarantee is not only effective, but it is much less expensive than time-consuming fea- If analyses of past and current sibility analyses of borrowers’ investment programmes are to be truly useful plans. The overhead of many small loans is for the choice and design of new also reduced by bundling them into a larger programmes and policies and single loan for solidarity groups (five to seven modifications or termination of people) or village banks (approximately 30 current ones, it is necessary to people) which is then disbursed to individual know not only by how much but borrowers. Finally, poverty lending programs also how nutritional status is tend to be “minimalist” with limited comple- influenced. . . . The job of evaluat- mentary services, such as training in business ing a given program then becomes skills, management or marketing services, one of tracing programme impact accompanying the loan. This combination of through the relevant processes program-generated revenue and cost-effective while estimating the impact on each delivery makes financial self-sufficiency an of the relevant components. obtainable goal. The “black box approach” has yielded Assessing the Nutritional Impacts of some evidence that programs providing small Poverty Lending loans at commercial interest rates to the poor Poverty lending programs have captured the and to women are associated with increased attention of an audience that extends well be- household food security and improved health yond the traditional development community. status of the participants. A comparison of Much of this enthusiasm relates to the pro- Grameen Bank members with equally poor grammatic successes—the repayment rates, households living in villages without the pro- the scale and/or the potential for financial self- gram found that 40 percent of the member sufficiency—rather than the impact of the pro- households were able to fulfill caloric require- grams. The value of any development strat- ments during the study period compared to egy ultimately depends on its ability to achieve only 27 percent of the nonmember households sustainable improvement in the quality of life. (Rahman, 1987). Also in Bangladesh, an in- The rapid expansion of poverty lending pro- dependent evaluation of a Save the Children grams and the sustained participation of bor- credit and savings program for women found rowers over multiple loan cycles indicate the that child mortality rates were lower and con- tremendous demand among the poor for these traceptive use higher among households where types of programs. However, before the value the mothers participated in the program of poverty lending can be assessed and com- (Barkat-e-Khuda, et al., 1990). Most striking pared to alternative hunger and nutrition-ori-

A Literature Review and Analysis!6 was that female children of program partici- We hypothesize that poverty lending can pants had a survival rate two times higher than benefit its participants and their households among the control group. by bringing about poverty alleviation, empow- While very encouraging, there are limits erment of women, and/or nutritionally impor- to the usefulness of these types of results. The tant behavior change. The program may be sole focus on the ultimate benefit (intermedi- effective against hunger and malnutrition by ate processes and benefits are in the “black producing one, two, or all three of these box”—Figure 2) prevents the study from docu- changes. menting how participation in the Grameen The relative impact on food security and Bank was nutritionally beneficial. It cannot nutritional status and the overall strength of provide insight into the relative contributions impact are expected to depend on the mix and of behavioral, attitudinal, or economic changes strength of the three intermediate benefits. stimulated by the program. If the expected Also, we anticipate that the intermediate ben- impact had not been evident, the evaluator efits can interact. This means that poverty could not know what steps to recommend to lending can directly cause one or two of the increase the intended benefit of the program. intermediate benefits and, through these direct In addition, “black box” studies are character- effects, indirectly stimulate change in other in- ized by methodological problems such as self- termediate benefits. And it is possible that it selection bias and/or nonequivalent compari- is one of these indirect intermediate benefits, son groups that confound attribution of cau- rather than one of the direct benefits of pov- sality. erty lending, that generates an intended outcome. The Poverty Lending Benefit Process Our inquiry of the literature is organized It is necessary to understand what mediates to examine what is known about each of the the program inputs of poverty lending on the linkages (arrows) hypothesized in the benefit intended impacts of food security and nutri- process diagram in Figure 2. In other words, tional status. Working backward from the we treat each linkage as a separate hypothesis most immediate causes of hunger and malnu- to be tested. In Part I, we start with the link- trition (as identified in Freedom from Hunger, ages between the intermediate benefits and the 1989 and UNICEF, 1990), we identify three intended outcomes. Then we look at the in- types of change among poverty-lending par- teractions among the intermediate benefits. In ticipants that are necessary to improve either Part II, we examine the evidence that poverty household food security or individual health/ lending directly generates one or more of the nutrition status or both (Figure 2). intermediate benefits. Finally, we draw some conclusions about the pathways by which poverty lending can bring about the intended outcomes.

Figure 2. Proposed Benefit Process of Poverty Lending

Research Paper No. 1!7 PART I: RELATIONSHIP OF THE INTERMEDIATE BENEFITS (INCOME, BEHAVIOR CHANGE, AND EMPOWERMENT) TO FOOD SECURITY AND NUTRITIONAL STATUS

LINKAGE OF INCOME TO FOOD A definition of food security recently pro- SECURITY AND NUTRITIONAL STATUS posed by UNICEF included both the household’s access to food and the proportion of total household resources committed to se- An increase of income is hypothesized to curing food. The latter is an important theo- increase household food security and/or retical contribution meant to capture house- improve nutritional status. holds’ vulnerability to hunger (Jonsson and Toole, 1991). The link between household food security (as Food insecurity, or “underconsumption,” it is most commonly conceptualized) and in- is experienced as hunger, a condition solely come is more direct than the relationship be- and directly related to the availability of food. tween income and nutritional status. Before Consequently, the food security literature has this statement can be examined, it is neces- concentrated on food availability, specifically sary to better define the terms being used. calories, as the marker for “adequate” food Recent work by UNICEF and IFAD, in con- consumption; e.g., less than 80 percent of the nection with the International Conference on recommended dietary allowance of calories Nutrition (ICN) sponsored by WHO and FAO, represents “underconsumption.” However, ac- have helped to clarify important distinctions tual consumption is quite difficult to measure between “food security” and “nutritional sta- objectively at the individual level. Nutritional tus” (FAO/WHO, 1992; Maxwell and status is easier to measure and often used as a Frankenberger, 1992; UNICEF, 1990, 1992). proxy for individual and even household food Although there has been considerable security. But this creates a problem for re- broadening and redefinition of the term in research and policymaking. cent years, household food security focuses on Nutritional status is the outcome of a the family’s capacity to produce or acquire “process whereby living organisms utilize food food (Maxwell and Frankenberger, 1992; (energy and nutrients) for maintenance of life, UNICEF, 1990). In the 1970s when the con- growth and normal functioning of organs and cept of food security was first made popular, tissues and the production of energy” the focus was on the adequacy of food supply (UNICEF, 1992). Food quality and illness play at the national and/or international level (Max- essential roles in determining an individual’s well and Frankenberger, 1992). Today, the fo- nutritional status, but they are not necessary cus is on households’ and individuals’ access for household food security.4 According to to food. At the household level, food security UNICEF: refers to “the ability of the household to se- cure, either from its own production or through For a long time nutrition has almost purchases, adequate food for meeting the di- been equated with food supply, etary needs of its members” (FAO/WHO, primarily because for a large 1992). number of people, food accessibil-

4 There is some disagreement on this point since reference to food for “meeting the dietary needs” implies food of good nutritional quality although, according to UNICEF, dietary intake is not an aspect of food security (UNICEF, 1992).

A Literature Review and Analysis!8 ity is not assured. Access to food appetite or nutrient absorption might be com- or household food security is a promised by illness. necessary but insufficient condition for adequate nutrition. . . . Another IFPRI study in Rwanda (von The underlying causes of malnutri- Braun, et al., 1991) found that doubling house- tion [poor nutritional status] are hold caloric consumption from 1,500 to 3,000 1) insufficient household food calories per adult equivalent—a very large security, 2) inadequate maternal change—would reduce stunting in children by and child health/nutrition practices, about a quarter of a standard deviation (17% and 3) insufficient health services of the z-score mean), whereas an intestinal and/or their use and unhealthy parasite eradication treatment would have the environment. same effect, and a clean latrine would have twice this impact. This comparison under- Depending on the particular circum- scores the importance of heath services and a stances, these factors determine, either alone healthy environment and not simply food for or in combination, the most direct causes of nutritional outcomes. Still, in the same study, malnutrition—inadequate dietary intake and the prevalence of malnutrition was greatest disease. among the poorest, most food insecure households. The prevalence of seriously under- Anthropometric measures (weight, weight children was 19 percent for households height, and arm or head circumferences) are with caloric deficiencies below 80 percent, and the commonly used, objective measures of nu- only 8 percent in other households (von Braun tritional status. They capture more than a et al., 1991). person’s dietary intake and actually reflect overall health performance (ACC-SCN, 1990). Focus on nutritional status requires more For this reason, there is increasing agreement of an intrahousehold perspective than a focus that nutritional status is not a valid indicator on food security, since not all members of a for food security. Anthropometric measures family are equally vulnerable. Due to the ad- capture much broader influences than access ditional nutritional requirements of pregnancy, to food. lactation, and rapid growth, women and chil- The fact that household food availability dren are most vulnerable to compromised nu- does not ensure adequate nutritional status tritional status or “malnutrition.” Yet it is not explains recent International Food Policy Re- only the greater nutritional requirements that search Institute (IFPRI) research findings of a make women and children more vulnerable. relatively weak link between the adequacy of Various sociocultural realities, such as food consumption at the household level and intrahousehold food distribution patterns, in- children’s nutritional status. Kennedy (1989) adequate feeding practices, or in the case of reviewed data from Sudan, Mexico, Malay- women, excessive labor obligations, exacer- sia, and Thailand to examine the relationship bate the situation. between income, household caloric intake, and According to Williams, et al. (1985), “re- preschooler caloric intake. Income was asso- peated cycles of reproduction, infection, hard ciated with higher household caloric availabil- physical work and nutrient drainage leave ity but not preschooler caloric intake. The re- women in a constant state of ‘maternal nutri- port concludes, “It now appears from this data tional depletion.’” This condition in turn leads that caloric availability within the household to low birthweight babies and a multigenera- may not be a precise indicator of a child’s nu- tional cycle of malnutrition. tritional status.” Even when food is available, It is essential that policymakers and de- it may not be offered to the child, or the child’s velopment efforts focus on alleviating malnu-

Research Paper No. 1!9 trition, not simply hunger. Malnutrition is even security for two reasons. First, they are the more insidious than hunger as a block to the group most likely to experience food insecu- development of human capacity because it di- rity. Second, marginal increases in their in- rectly affects and potentially permanently come are most likely to be used to purchase stunts physical and mental development food. One of the most fundamental principles (ACC-SCN, 1993; USAID, 1993). The scope of economics is Engel’s law stating that the of the problem is also immense. According lower the income, the higher the proportion to UNICEF (1990), “about 150 million chil- that will be spent on food (Blumberg, 1988). dren under five years old are underweight, and An IFPRI study conducted in The more than 20 million suffer from severe mal- Gambia provides a good example (von Braun, nutrition. . . . [Approximately] 350 million et al., 1989). Forty-nine percent of the poor- women have nutritional anemia. . . . Some 40 est households consumed less than 80 percent million children suffer from vitamin A defi- of caloric requirements, while this was the case ciency. . . . Iodine deficiency disorders afflict for only 2 percent of the highest income group. 200 million to 300 million people.” The threat Among the poorest quartiles, an income in- of malnutrition demands special attention to crease of 10 percent was associated with an the most critical periods in individual human increase in food expenditures of 9.4 percent, development—pregnancy, infancy, and child- indicating that virtually all of the income in- hood. Yet, unlike hunger, it often goes unno- crease was channeled toward food. ticed, even by its victims. The first step is a Food insecurity might be “acute,” the re- clear appreciation for the causes of malnutri- sult of a specific event, or experienced chroni- tion and the limitations of assuming a direct cally, either throughout the year or at certain association with household food security. times of the year. Particularly in rural areas, where seasonality is more pronounced and markets less developed, the prevalence of food Link Between Income and Household Food insecurity rises during the rainy season pre- Security ceding the harvest, a time of year commonly In examining the literature, it is clear that referred to as the “hungry season.” In either certain conditions make more direct the rela- case, the poorest households will more pro- tionship between income and household food foundly be affected. For example, an IFPRI security (access to food). Development inter- study in The Gambia found that seasonal fluc- ventions or policies that aim to increase in- tuations in caloric intake were a problem for comes as a means for improving household the poor, not the entire rural population (von food security should seek to maximize these Braun, et al., 1989). For the bottom income conditions, which relate to poverty level, quartiles, caloric intake decreased by 15 per- intrahousehold control, the type of the income cent during the wet season, while for the top increase, and the role income plays in the quartiles, it remained constant. household’s broader livelihood strategy. De Waal (1989) and others have ad- vanced a framework whereby food security is Household Poverty only one sub-objective of households’ greater Poor households commit a majority of their goal of livelihood security. Coping strategies, resources to securing food. Expenditure stud- risk management, and adaptive behaviors ies have shown that as much as 70 percent of might necessitate households’ enduring hun- the budget of the poorest income group is de- ger in the short-term to preserve productive voted to food purchases (World Bank, 1990). assets (seeds, animals, timely planting, etc.) It is well appreciated that increases in the and to avoid long-term impoverishment (Max- income of the poorest households will have well and Frankenberger, 1992). the most direct relationship to improved food

A Literature Review and Analysis!10 dence of gender differences and support the Households that are food insecure criticism that neoclassical household models in spite of using a large portion of underemphasize intrahousehold bargaining their resources are worse off. . . . and the essential differences in the two sexes’ However, many households achieve life experiences and cultural roles that lead to household food security at the significantly different expenditure preferences expense of [a] very large proportion (Blumberg, 1988; Bruce, 1989; Hoodfar, of their resources (time, money, 1988). land, etc.) . . . [These resources] are Many of these studies focus on the rela- at great risk and should be recog- tive proportion of women’s income spent on nized in programmes for household food (and other nutritionally important basic food security (UNICEF, 1992). needs, such as medicine) as compared to men’s expenditure pattern (Bruce, 1989). From this livelihood or resource perspective, the concern is not simply with short-term ! In Cameroon, Guyer (1980) found that food availability but “with wider issues of live- Beti women invested 74 percent of lihood, in particular with coping strategies and their income on food, while men spent long-term adaptation to food stress” (Maxwell only 22 percent. Of the total house- and Frankenberger, 1992). Increases in income hold food expenditures, 33 percent will improve food security most when it were made by men and 67 percent by strengthens the household’s resource base or women (Blumberg, 1988). Even at provides diversified income sources, either at higher income levels, women report- one point in time or over the year. For ex- edly spent the same proportion of their ample, savings schemes can be effective in incomes on food. In the lean period, providing a form of insurance against predict- they purchased less expensive proteins, able seasonal food deficits and unpredictable and when the profits were greater, they medical emergencies. Weekly cash income invested in higher quality food—spe- from trading activities can supplement much cifically more animal proteins. more substantial, but highly seasonal, income from agricultural activities. This type of ac- ! In the Tamil Nadu and Kerala states of tivity can help to smooth income over the year. South India, according to Mencher Income diversification, smoothing, and asset (1988), women allocated almost all of accumulation, such as cash savings, are likely their income to family needs, a con- to be very important to those living on the mar- sistently higher ratio than for men. gin of food insecurity. Clearly, increasing incomes of the poor- ! In Mexico City, Roldan (1988) found est households will have the most pronounced women contributed virtually all of their impact on household food security. earnings (primarily from the garment and textile industry) to the household, Women’s Control of Income while men kept a quarter or more for Intrahousehold control over income also seems their personal use. to affect the relationship between income increases and household food security. This per- ! In Kenya, Kennedy (1989) found that spective challenges the fundamental women’s income, as measured by the conceptualization by neoclassical economics percentage of total household income of the household as a single unit of analysis earned by women, had a positive ef- with a single utility function and expenditures. fect on household caloric intake, above Yet studies from around the world provide evi- that of household income.

Research Paper No. 1!11 such as Guyer (1980) and Mencher (1988), What is noteworthy in these comparisons women’s incomes were significantly smaller is not simply women’s proportionally greater than men’s. Even though women’s income is allocation to basic needs but a finding that men relatively small in comparison to total house- usually reserve part of their income for per- hold income, particularly when it is earned in sonal use even when overall income is quite small regular amounts, it leads to increased low (Bruce, 1989). In Mencher’s (1988) study food availability in the household (Buzzard, in South India, men continued to retain a rela- 1995). Even small amounts of income can tively constant amount of income for their per- have a significant effect, since women’s in- sonal use even when the household was expe- come is thought to influence spending in two riencing periods of economic stress. ways: directly, through women’s expenditures A number of economists have researched on food (and other nutritionally important ba- the impact of marginal income increase by ap- sic needs, such as medicine), and indirectly, plying a Nash bargaining model that allows since women’s cash contributions to the house- for intrahousehold differences in allocation be- hold budget lead to greater status and control havior (McElroy, 1990; Shultz, 1990; Thomas, over the intrahousehold distribution of food 1990). This approach was applied by Tho- and other resources (Bruce, 1989). Acharya mas (1990) to survey data on family income, and Bennett (1982) completed a detailed study health, and nutrition in Brazil. According to of household allocation decisions in Nepal and Thomas (1990), while both parents’ incomes concluded that the form and level of women’s were significantly and positively associated contributions to the family budget were related with household per capita caloric and protein to their intrahousehold bargaining power. Spe- intakes, “the effect of maternal income on nu- cifically, women earning cash incomes in the trient demand [was] between four and seven market economy had more influence over sub- times larger than income in the hands of fa- stantial household decisions than did women thers.” who worked as unpaid family laborers. The most common explanation for these Despite the diversity of settings in which gender differences refers to the particular cul- gender differences in spending have been dem- tural roles ascribed to the sexes and conse- onstrated, it is clear that contextual and cul- quently different spending obligations tural variables influence associations between (Blumberg, 1988). Women are expected to women’s income, expenditure patterns, and fulfill a nurturing role and, for this reason, may ultimate impacts on food expenditures and make less distinction between their own needs household nutrition. Certainly, there are ex- and the needs of their family—specifically amples of cultures where women’s income is their children. Moreover, men in many cul- not channeled toward food. For example, tures have been socialized to believe that cer- among the Berber of Morocco and the Serahuli tain types of nonproductive consumption— in The Gambia, men are responsible for all drinking, cigarettes, clothing—are “proper for family maintenance and food purchases; when men” (Bruce, 1989). There also may be cul- women received cash gifts, funds were spent tural expectations for men to spend their on jewelry or clothing (Blumberg, 1988). money to maintain the extended family “so- Carloni (1984) summarized the critical factors cially, economically, and politically” that might that color these relationships: women’s level be “important to the long-term well-being of of involvement in the market sector; the de- the family . . . [but that] do not affect immedi- gree of income pooling; and social and cul- ate food availability” (Buzzard, 1995). tural norms of gender spending obligations. In the majority of the case studies cited, According to Engle (1986), there are signifi-

A Literature Review and Analysis!12 cant differences in cultural practices, even referred to earlier, a 10 percent increase in in- within the same geographical area, pertaining come raised food expenditures by 9.4 percent, to the allocation of money, decisionmaking but caloric consumption by only 4.8 percent patterns, and gender obligations, that will in- (von Braun, et al., 1989). A study done in fluence the ultimate impact of increases in in- South India found that even when increased come. food expenditures practically matched higher incomes one-to-one, there was almost no Type of Income change in expenditures on nine major nutri- The form in which increased income is earned ents (Schiff and Valdes, 1991). Such find- may affect its relationship to food security. ings as these have led some observers to ques- Lump-sum income tends to be invested in mation the efficacy of attempting to improve nu- jor purchases, while steady earnings tend to trition by increasing incomes since incomes be channeled toward basic needs such as food would have to be greatly increased in order to (Alderman, 1986). If this is the case, this might have a significant impact on caloric or nutri- also, in part, explain the closer association of ent intake. women’s income to food purchases. At least In response, Ravillion (1990) and others in rural areas, men’s income is more often re- maintain that strategies for increasing income ceived in lump sums following the harvest, among the poorest income quartile can be im- which is more likely to be spent on “big ticket” mediately effective. They cite not only the items, while the nonfarm income-generating finding that increased income is most likely activities, such as petty trade commonly un- to increase caloric intake in the poorest house- dertaken by women, may be more likely to earn holds, which are the most vulnerable to mal- small but steady amounts of income. nutrition (e.g., The Gambian study mentioned above), but they also point to the impact of Link Between Income and Nutritional increased income on other nutrition-relevant Status investment areas, including potable water, As discussed in the introduction to this electricity, refrigerators, sewage systems, and section, even when increases in income lead medical services (Schiff and Valdes, 1989). to greater food availability at the level of the This broader perspective is important since household, this will not ensure improvement malnutrition is not simply a function of low in individual family members’ nutritional sta- incomes but of the broader socioeconomic tus because of issues pertaining to food qual- milieu that is associated with poverty. ity, intrahousehold dynamics, and the general health of the individuals and their environ- Women’s Income and Children’s Nutritional ment. However, maximizing the nutritional Status benefits of increased income again requires a As is true for food security, intrahousehold focus on the poor, on women, and on the control over income seems to have an impor- broader livelihood strategy within which this tant effect on the nutritional impact of in- increased income is earned. creases in income. Several studies have found Income and Nutritionally Important women’s income to have a more direct impact Expenditures Because households do not purchase foods on children’s nutritional status. Kumar (1978) based on nutritional considerations, increased in South India found “no uniform positive in- income has a weaker effect on the nutritional crease in child nutrition when paternal income quality (in terms of calories or nutrients) of rose, but increasing maternal income did ben- purchased foods than on more general access efit children.” Tripp’s (1982) research in to food. For example, in The Gambia study northern Ghana found that children’s nutri-

Research Paper No. 1!13 tional status was more closely related to the Tentative Conclusions or Programmatic mother’s than the father’s engagement in trad- Implications ing activities, despite the fact that men earned When incomes increase for the poorest quartile considerably higher income. Similarly, De of households, there usually are comparable Groote (1994) in Mali found that young increases in household food expenditures. women’s nonagricultural income, while quite However, although the effect is still greatest small relative to total household income, had for the poor (relative to higher income groups), a positive effect on children’s nutritional sta- increased income is much less likely to im- tus in the pre-harvest season, while no such prove the nutritional quality of diets (e.g., con- effect was found for household income. In sumption of calories, protein, and especially Kenya, the nutritional status of children in de micronutrients), particularly at the level of in- facto female-headed households was better dividual women and children in the household. than in male-headed households of comparable There is concern that only large increases income levels, implying that female-headed in household income can improve food secu- households used their resources in a more nu- rity and nutritional status. However, even tritionally efficient manner (Kennedy, 1992). small increases can improve food security for However, because of a woman’s dual role the poor by smoothing their income through as primary caretaker and economic actor, it is the year or by being saved for emergency use important that increased income is not earned during seasonal food deficits. Perhaps more at the expense of her nutritionally important important than the absolute amount of income domestic obligations (e.g., cooking, growing is whether the income helps poor households food for the family, caring for children). There reduce their vulnerability through greater di- is a large body of literature examining whether versification of income sources or asset accu- women’s labor force participation competes mulation. In addition, even small increases in with quality child care and, consequently, has income can be used for medical expenditures, a negative impact on children’s nutrition and investment in improved sanitation, reduction health status (Engle, 1986; Leslie, 1985; of women’s labor burdens, or other nonfood- Nieves, 1982; Popkin and Solon, 1976). For related changes that enhance nutritional sta- example, while increased income can mean a tus of household members. woman has additional disposable income to In many but not all societies, economic spend on her children, it might also mean that resources controlled by women are more she must work longer hours, have less time closely associated with household food secu- for rest, and leave her child with surrogate care rity and nutritional status than either men’s or providers (Engle, 1986). general households’ income. Women usually When improved nutritional status is the dedicate a larger proportion of their earnings goal, a broad perspective is required rather than to nutritionally beneficial items, such as food a narrow focus on increasing women’s cash and medicine. Even when the absolute earnings (Buzzard, 1995). Women need op- amounts of women’s earnings may be trivial tions that provide greater economic return but compared to the total household income, their that, at the same time, also help them to better impact may be more significant than their size balance their sometimes competing domestic might imply. Women’s cash contributions to and productive roles. Some examples would the household budget are believed to lead to be technologies that improve the productivity their greater status and influence over the of women’s work and income-generating ac- intrahousehold distribution of food and other tivities that are less arduous and/or more com- resources. There is also evidence that the nu- patible with child care. tritional benefit of women’s income is greatest when earned in small and steady amounts,

A Literature Review and Analysis!14 particularly during the hungry season. Al- though the absolute amount of women’s income is important, it is equally important to assess whether the income is earned in a manner that is compatible with women’s domestic and caretaking obligations. What is also clear from this review of the literature is that the nutritional impact of increased income will be disappointing if it is not also coupled with improvement in the health of those most vulnerable to malnutrition, namely women and young children. This issue is treated in more detail in the next section of the paper.

Research Paper No. 1!15 LINKAGE OF BEHAVIOR CHANGE TO faltering, and mortality (Kasongo Project NUTRITIONAL STATUS Team, 1982; Waterlow, et al. 1980). In fact, much of the malnutrition evident in older children is explained by growth faltering during Changes in adult diet, child care, and health the weaning period. management practices are hypothesized to improve household nutritional status. Important Nutrition-Related Behaviors The following is a brief description of specific As discussed in the previous section, ensur- household-level attitudes and practices that ing adequate nutritional status goes well be- make a tremendous difference in the nutritional yond simply ensuring access to food. It is status of household members. While still me- strongly related to behavior within the house- diated by a household’s economic resources, hold, specifically expenditure patterns that de- the adoption of many of these practices incurs termine the quality as well as the quantity of minimal or no economic costs. food brought into the household and the intrahousehold distribution of the good qual- Diet Quality During Pregnancy and Lactation ity food to the individual members most vul- Despite the additional nutritional demands of nerable to malnutrition. pregnancy and lactation, the quality of diets Moreover, the etiology of malnutrition often do not improve, and in some areas, cul- goes well beyond insufficient food or even tural taboos even restrict women’s intake at adult diets and child feeding practices inad- this time (Williams, et al., 1985). Women re- equate to nutritional needs. It includes poor quire three times more iron than men, which health management and hygiene practices explains in part why nearly two-thirds of preg- leading to frequent and prolonged infections. nant women and one-half of all other women Because health plays such an important role, are estimated to be anemic (Smyke, 1991). The the improvement of rural health delivery sys- detrimental effects of poor quality diets and tems, particularly maternal and child health iron deficiency on the health of the women care services (i.e., immunizations, prenatal and development of the fetus have been well care, growth monitoring, and family planning), documented (Norton, 1994; Viteri, 1994). as well as water and sanitation projects, has been a major element in nutrition improvement Breastfeeding strategies. Exclusive breastfeeding until an infant is about Yet, nutrition and health care practices at six months old is optimal (UNICEF/ WHO/ the household level are also essential because UNESCO/ UNFPA, 1993). Breastmilk is a they represent the first line of prevention and safe, affordable, and nutritionally complete treatment. Even if health services are avail- source of food that also helps protect infants able, their trial and sustained use depends upon against diarrhea, respiratory infections, and decisions and behaviors at the level of the other illnesses (ibid). Replacing breastfeeding household. Because of their particular vul- with bottlefeeding is a risky practice that un- nerability, pregnant and lactating women and necessarily exposes infants to contaminants preschool children are of particular concern. and potential illness. Breastfeeding also con- Therefore, the key practices pertain to the di- tributes to birth spacing, since it delays the ets and health of this group, especially chil- mother’s return to fertility (ACC-SCN, dren in the weaning period between six and 1991b). However, women may lack knowl- thirty-six months of age. The weaning period edge on the value of breastmilk, breast care, is the stage of a child’s life when he or she is or positioning of the baby for successful most susceptible to malnutrition, since it co- breastfeeding (Adhikari and Krantz, 1989). In incides with the highest rates of illness, growth addition, if women lack confidence that they

A Literature Review and Analysis!16 have enough breastmilk, they will give their babies other food and drink. When this hap- Health Management Practices and the Role of pens, the baby sucks less often and, conse- Feeding quently, less breastmilk is produced. Preschool children in the developing world are Weaning Practices ill approximately 20 percent of their lives, most Three of the most significant weaning prac- commonly with diarrhea and fevers (Brown, tices are 1) the ages when complementary feed- 1978). Breastfeeding of infants should con- ing begins and breastfeeding ends; 2) the types tinue and, if possible, increase in duration and of complementary foods given to babies; 3) frequency during episodes of diarrhea. With the feeding pattern and methods used (Mitzner, older children suffering from diarrhea, food et al., 1984). In general, infants do not require intake should be maintained and then increased foods complementary to breastmilk until they during the recovery period. The diminished are about six months old. However, depend- appetites associated with illness may require ing on the society, foods are often introduced special efforts on the part of the caretaker to much earlier or later than this optimal time. encourage children to eat. During persistent Traditional complementary foods are often episodes of diarrhea, oral rehydration therapy nutritionally inadequate. In fact, recent re- or home-prepared solutions should be given search has shown that in terms of child, and to children (ACC-SCN, 1991a). particularly weanling, malnutrition, there may have been “an over-emphasis on food energy Hygiene and Sanitization production and consumption, and a corre- Personal, food, and environmental hygiene sponding disregard for the contents and bio- practices are important for minimizing expo- availability of macro- and micro-nutrients in sure to infection and illness. Poor personal common food sources” (Brown, 1990). hygiene of food handlers is perhaps the most Using data from weanling studies in Peru common cause of food contamination leading and Nigeria, Brown (1990) demonstrates that to diarrhea and other diseases (Mitzner et al., with the typical feeding pattern of three times 1984). In addition, because microbial contami- a day and the limited gastric capacity of in- nants multiply quickly in a tropical climate, fants, weanlings require diets of significantly foods should be covered and eaten immedi- greater energy density than is the norm. Food ately after their preparation (Barrell and bulk can be reduced and digestibility increased Rowland, 1979). through processes like roasting, grinding, and fermenting (Adhikari and Krantz, 1989). Use of Existing Health Services Simple, nutrient-dense weaning mixtures can Maternal and primary health care services can be made from a protein-rich legume, a high- play an essential role in maintaining good nu- energy source (such as a fat, oil, or sugar), and trition and health. The most effective services a ground cereal (Mitzner, et al., 1984). Al- include: immunizations, pharmacies, birth at- though each of these components is readily tendants, pre- and postnatal care, and contra- available in virtually all parts of the develop- ceptives. Use of family planning is one of the ing world, this type of mixture is often not pre- most nutritionally beneficial health practices pared, primarily because caregivers are not because birth spacing greatly improves the aware of the particular nutritional requirements health of the mother and the newborn and re- of weaning-age children. During weaning, in- duces the overall demand on limited house- fants also require frequent feeding and the ac- hold resources. Often these types of health tive involvement of the caretaker in encour- services are not locally available, especially aging the child to eat (Adhikari and Krantz, to poorer households. However, even when 1989). they are available, due to a lack of knowledge or attitudinal barriers, the poor very often do

Research Paper No. 1!17 not make sustained and effective use of the services.

Micronutrient Deficiencies Specific nutrient deficiencies might be prevalent in certain areas or subgroups of the population depending upon local food availability and/or feeding practices. The most common micronutrient deficiencies are for vitamin A, iodine, and iron. A major finding of the last decade was the significant relationship of vitamin A deficiency to child morbidity and mortality (in addition to its better known association with blindness) (WHO/USAID/NEI, 1992). Even when sources of vitamin A are readily available and inexpensive, this deficiency may persist because of a lack of knowledge or because of the influence of traditional beliefs.

Tentative Conclusions Changes in nutrition and health care practices at the household level are likely to be the essential first line of prevention and treatment of malnutrition. Through their influence on dietary intake and health, a wide array of household behaviors affect the nutritional status of its members. For example, each of the following has nutritional implications: the selection and distribution of food within the household; practices related to breastfeeding, child feeding, and diarrhea treatment and prevention; diets during pregnancy, lactation, and/ or during and after illness; use of existing health services; personal, food, and environmental hygiene. Even without the benefit of increased household income, these behaviors can dramatically improve household nutritional status. Women have the sole, or at least primary, responsibility for all these nutrition-related practices in the vast majority of households worldwide. To make these changes often requires women to alter fundamental aspects of their most traditional roles. To do so requires not only health/nutrition information, but also a consciousness of the nature of malnutrition, social support, and attitudinal change.

A Literature Review and Analysis!18 INTERACTIONS OF WOMEN’S tonomy, self-confidence, openness EMPOWERMENT WITH INCOME AND to new ideas, belief in one’s own potential to act effectively), and BEHAVIOR CHANGE with a person’s status and efficacy in social interactions—in particular, It is hypothesized that earning and the ability to make and carry out controlling their own income increases women’s significant decisions affecting one’s empowerment (self-confidence, status, and own life and the lives of others bargaining power within the household), which (John Snow International, 1990). feeds back to enhance their earning and control of income and assets. It also This definition is more appropriate to is hypothesized that increasing women’s anti-hunger programming, because it involves empowerment predisposes them to learn and adopt new nutritionally beneficial practices a greater focus on behavioral and social mani- which feed back to enhance festations of empowerment which are more di- their empowerment. rectly linked to the ultimate goals of improved food security and nutritional status. Defining Empowerment The best measures for empowerment Empowerment is a term often used but rarely would be context-specific and would capture well-defined, despite its intuitive importance. the participants’ perception of the positive For some, “empowerment” has primarily po- changes in their lives caused by the program. litical connotations, such as in the following According to the Empowerment of Women definition: Program, the areas of inquiry appropriate for documenting empowerment would include the A spectrum of political activity following: ranging from an act of individual resistance to mass political mobili- relationships within the family, zations that challenge the basic bargaining power and control over power relations in our society allocation of resources within the (Antrobus, 1989). household, control over money, engagement in commercial transac- However, others conceptualize empow- tions, physical mobility, contacts erment in broader social terms that are outside the family, interactions with grounded in an individual’s actual and per- institutions in the public spheres, ceived (by themselves and others) capabilities ability to access health and other to take action. A description of empowerment services (ibid). analogous to this conceptualization is provided by the Empowerment of Women Program:5 The specific manifestations or examples of empowerment will depend on the cultural In our view, empowerment has setting, although it is likely to incorporate both various dimensions and manifesta- economic and social dimensions in virtually tions. It has to do with an inner all settings. While women everywhere face state (sense of self, of one’s au- sexism, change is likely to be most profound where restrictions on women’s personal and

5 This research group is interested in documenting the impact women’s empowerment can have on contraceptive use. Interest- ingly, they have chosen examples of poverty lending programs, such as the Grameen Bank, to research this relationship because they believe these types of programs most effectively lead to empowerment of women.

Research Paper No. 1!19 economic autonomy are greatest. others (Bruce, 1989).

Link Between Income and Empowerment Again, it is the increase in women’s “op- Both the inner manifestations (e.g., self-es- tions” rather than the absolute amount of in- teem) and the external expressions of empow- come that makes the difference. erment (e.g., status within the household) seem to be closely linked to increases in women’s Empowerment and Behavior Change incomes (Berger, 1989). An intensive study Women’s lack of self-confidence has been of household decision making in Nepal found identified as a major hinderance to the suc- that the greater a woman’s involvement in the cess of maternal-child health programs economic spheres outside of the household, (Griffiths, 1992; McGuire and Popkin, 1990). the greater her influence in household resource Women’s “silence” (lack of self-confidence to allocation and expenditure decisions (Acharya act or speak out) keeps them from obtaining and Bennett, 1982). This study indicates that attention for themselves and their children. it is not the “importance” of women’s work to Often, development interventions depend on the well-being or maintenance of the family local authority figures to engage women’s par- that affects her influence within the household ticipation in growth monitoring sessions, im- but rather her involvement in spheres beyond munization campaigns, or health services the household (such as the market economy) (McGuire and Popkin, 1990). This approach and her ability to earn cash. This effect on has limitations when the adoption and sus- status, bargaining power, and potentially self- tained use of health/nutrition behaviors, health confidence is associated with even small services, and health technologies depend upon amounts of income earnings. women’s self-confidence. McGuire and There is evidence suggesting that a Popkin (1990) cite several studies that under- woman’s status and bargaining power within score the importance of maternal confidence the household is also dependent on her self- to nutritionally important behaviors. Research confidence. According to Amartya Sen (qtd. done by Griffiths (1992) has found a positive in Bruce, 1989), women’s self-perception correlation between mothers’ self-image and strongly influences intrafamilial divisions and the health and nutrition of their children. inequalities: ! In Cameroon, mothers gave into the If a women undervalues herself, her self-destructive behavior of anorexic bargaining position will be weaker children by relinquishing power to the and she is likely to accept inferior child. However, in Swaziland, moth- conditions. ers’ “sufficient self-confidence” en- abled them to persist in feeding even Outside earnings can provide sick children refusing to eat. psychological and practical lever- age for women by offering them a ! In Turkey, a program intended to in- better fall back position should crease the early stimulation and cog- negotiations break down (e.g. nitive development of children found through divorce); an enhanced that it was first necessary to build the ability to deal with threats and self-confidence of mothers. While indeed to use threats (e.g. leaving some husbands and mothers-in-law the house); and a higher “per- objected to the program’s impact on ceived” contribution to the family women’s self-assurance, participation economic position by them and rates were high, and the program was

A Literature Review and Analysis!20 successful in fostering beneficial ma- programs in Bangladesh (the Grameen Bank ternal skills. and the Bangladesh Rural Advancement Com- mittee—BRAC) empowered women and if so ! In a nutrition and health education pro- whether this empowerment led to higher lev- gram in India, groups of women were els of contraceptive use. organized to listen and discuss a radio The Grameen Bank was found to have a program designed to motivate them to greater effect on contraceptive behavior, be- make nutritionally beneficial behavior cause it empowered women both economically changes. However, since mothers felt and socially. It put more emphasis on strength- too powerless for independent action, ening the economic role of women, because the fathers and grandmothers of nutri- enhancing their contribution to the family in- tionally at-risk children also required come was believed by program implementors education. to enable women to better make independent Griffiths’ (1992) experience in India un- decisions as well as to play a more decisive derscores the importance of women’s attitudes role in household joint decisions. But the and self-perception to their adoption of criti- Grameen Bank also “created an identity for cal health/nutrition practices. The women who women outside of their families [that gave] had limited power within their own family felt women socially legitimate reasons to move powerless to ensure the good care of their chil- about and to associate with one another in dren, were afraid that trying something new public spaces . . . expose[d] them to new would cause a problem, and refused to do ideas, and help[ed] them to become more con- something “special” or different because it fident and more skillful at interacting in the called attention to oneself. public sphere” (Schuler and Hashemi, 1994). These examples demonstrate how the The rituals of Grameen membership also empowerment (especially building self-con- helped to create a strong bond among the fidence) of women can make them more learn- women that was believed to make it easier for ing-ready and influence the adoption of nutri- them to resist the restrictions of the traditional tionally important behaviors. Empowerment family. Over time, participation in the pro- may also allow women greater mobility and gram has come to change family planning thereby increase their exposure to new con- norms, both among members and nonmem- tacts and information. bers in program communities. Using an ag- In terms of specific behaviors, self-con- gregate score for empowerment, 65 percent of fidence can be linked with greater success in “empowered” women were practicing contra- breastfeeding, introducing weaning foods, ception, as compared to only 45 percent of making changes in health practices, and per- those who were “not empowered.” sisting in recommended behaviors even when these mark a change in tradition or are resisted Tentative Conclusions by the child (McGuire and Popkin, 1990). Em- Women’s ability to increase their incomes or powerment is likely also to play a critical role their control over income has a positive effect in the adoption of contraceptive technologies. on their empowerment (self-confidence, sta- Recent work by Schuler and Hashemi tus, and bargaining power within their house- (1994) has made a significant contribution to holds). The possibility of positive feedback the understanding of how both the social and of empowerment to income earning and con- economic dimensions of empowerment can trol seems likely, but we have yet to find docu- lead to changes in important health behaviors, mentation of such feedback. such as the use of contraceptives. Through Both economic and social manifestations ethnographic and survey research, this study of empowerment seem to be crucial for women examined whether participation in two credit to make nutritionally important behavior

Research Paper No. 1!21 changes and to demand and use correctly health services and health technologies. In- dependent sources of income are likely to affect women’s status, autonomy, and self-confidence. Social dimensions, such as greater mobility, public interaction, and/or group identification, are also important to women’s exposure to new ideas and potential openness to change. Again, the possibility of positive feedback of behavior change to empowerment was not documented but seems likely. It also seems to be the case that empowerment plays a pivotal role in creating a synergistic effect between income and important health/nutrition behaviors. For example, the relationship between increased income and contraceptive use is synergistic (Buzzard, 1995). Women who have fewer or no young children are better able to earn additional income, and the capacity to earn greater income increases the demand for family planning. A similar interactive effect between income and better quality diets for women is possible and might also be mediated by empowerment. Empowerment cannot act directly on food security and nutritional status. However, it seems to act indirectly on household food availability by enhancing the income-earning performance of women, increasing their status and influence within the household, and strengthening their economic autonomy and self-reliance. It also seems very likely that women’s empowerment has greater impact on improving household nutritional status than women’s direct earnings might imply. Em- powerment has the potential to encourage the adoption of key health/nutrition behaviors by reducing women’s isolation, exposing them to new ideas and forms of public interaction, increasing their openness and self-confidence to try new behaviors or seek out health services, and possibly by fostering the creation of new health/nutrition norms.

A Literature Review and Analysis!22 PART II: RELATIONSHIP OF POVERTY LENDING TO THE INTERMEDIATE BENEFITS (INCOME, BEHAVIOR CHANGE, AND EMPOWERMENT)

LINK BETWEEN POVERTY LENDING AND ing systems and adapting program methodolo- INCOME gies. They also have little or no resources to carry out or commission impact evaluations. Second, there are major methodological chal- Poverty lending is hypothesized to increase lenges to rigorously and convincingly evalu- or stabilize the income of the poor. ating the impacts of poverty lending programs, Concrete evidence of economic impact at the most notably: the need to evaluate overall re- beneficiary level by credit programs, or even turn to participants’ various productive strat- by income-generating programs in general, is egies (or household income) rather than returns rare (USAID, 1989a; Buzzard, 1984). There from just one enterprise; the difficulty of elic- is considerable anecdotal evidence suggesting iting accurate self-reports of incomes, costs, significant benefits of poverty lending pro- or expenditures given the high degree of illit- grams, but few rigorous evaluations have been eracy and lack of financial records among the conducted to date. The majority of work has target clientele; the difficulty in quantifying focused more on the objectives, feasibility, and important social impacts, such as empower- utility of credit to the poor than on its impact ment; and issues of endogeneity and self-se- at the beneficiary level. Many practitioners lection, which make it difficult to attribute regard good financial monitoring data as ad- change or differences to the effect of the pro- equate evaluation information about a credit gram. program. A growing number of borrowers re- flects significant demand for credit among the General Economic Impact poor. High repayment rates indicate the loans A guiding philosophy behind “minimalist” are used productively. The ability of borrow- credit programs is that they provide loans for ers to pay substantial interest rates suggests existing or familiar income-earning activities, their loan activities are profitable (USAID, which seems to be associated with positive 1989a). Berger (1989) wrote “the preference impact (Tendler, 1987). In her review of 102 for direct credit programs has developed de- USAID-supported women-in-development spite little evidence of net impact of these pro- programs, Carloni (1987) found that credit programs on poverty.” grams were more successful than income-gen- Still, financial monitoring data cannot erating projects in having a genuine impact on substitute for beneficiary-level impact infor- women’s economic status. Specific income- mation. generating projects face the much more diffi- For example, an evaluation of a credit cult challenge of creating profitable employ- program for women in India found that women ment, whereas “untied” credit is a flexible in- were maintaining good repayment rates, but put that people can use in ways that they know the small profits they made were used to pay best to adopt any of several technologies avail- the interest due on the loans (Berger and able to them. Buvinic, 1989). Poverty lending (minimalist credit) pro- The lack of impact information is attrib- grams tend to preserve and diversify the self- utable to a number of legitimate factors. First, employment of entrepreneurs rather than cre- the poverty lending model is relatively new, ate additional employment opportunities for so program implementors, often indigenous or- others (Berger, 1989). The types of produc- ganizations, are typically too busy establish- tivity improvements that small working capital loans make possible—even to the smallest

Research Paper No. 1!23 microenterprises—include the following three steps and that they were halfway to the (Berger, 1989): ladder’s top. As expected, borrowers were able to im- ! Entrepreneur can buy larger quantities prove their economic returns by expanding of inputs at lower unit prices. their existing activities, diversifying their strat- ! Lack of working capital no longer egies, or by increasing their profit margin threatens to discontinue business op- through decreased costs. In several cases, the erations. reduced cost was for working capital, since ! Additional products can be added to the program replaced more expensive infor- the inventory to increase sales. mal sources of credit (Nelson, et al., 1995). ! Loans replace more costly sources of In Thailand, women participating in a Free- informal credit. dom from Hunger program had more diversified income sources, both in the short term (in- In the short term, program participants come from small business or animal raising generally experience more income stability and in the preceding month) and over the course moderate increases in income. However, one of the year (more likely to cultivate a dry sea- central question about poverty lending pro- son garden) (MkNelly and Watetip, 1993). grams is whether, through sequential loans and A methodological improvement for accumulation of business experience, partici- evaluating these programs would be to quan- pants “may over time with the succession of tify the degree of change in a borrower’s in- loans move into more complex and potentially come, assets, savings, or labor productivity more profitable activities” (McKee, 1989). rather than depend on participants’ self-reports. Some of the most extensive, good-qual- Self-Reported Impacts ity quantitative impact information comes The most common methods used by practitio- from the Grameen Bank. ners to evaluate the economic impact of their programs are participants’ self-reports of loan- Impacts of the Grameen Bank funded activity profitability and/or relative In a sample of over 900 borrowers, average changes in income or the quality of life since household income of Grameen Bank members joining the program (Nelson, et al., 1995; was 43 percent higher than for the target group Otero, 1987). While somewhat “crude,” this in villages without the program (Hossain, type of information provides important diag- 1988). The main reasons given for the im- nostic information to implementors as to provement in the living standard were accu- whether participants at least perceive the in- mulation of capital and additional employment tended program benefits. in productive work financed by Grameen Bank Program participants in diverse cultures loans—processing and manufacturing, trading, and settings (El Salvador, Honduras, Ghana, and transport operations. Livestock is an im- Senegal, Mali, and Thailand) felt that either portant asset for the rural poor; 63 percent of their business income or general household the members owned no cattle before joining welfare had improved because of the program the program, compared to 45 percent after two (Nelson, et al., 1995). An evaluation of years. For those who owned cattle, the aver- FINCA’s village bank program in El Salvador age number owned increased by 67 percent. attempted to qualitatively capture the broader After two years in the program, 80 percent of economic impact by asking respondents to rate the borrowers were found to have an increase their progress up a “ten step ladder of integral in working capital, which averaged from $30 development.” On average, respondents felt to $112—an increase of 64 percent per year that their families had been lifted more than when adjusted for inflation. The Hossain

A Literature Review and Analysis!24 (1988) study also supports the belief that, while on female than on male borrowers. For ex- moderate in the short-term, the economic ben- ample, after two years of participation in the efits of program participation increase after a program, women’s working capital increased series of small loans. For example, the bor- 88 percent, compared to the increase in men’s rowers’ share of equity in total investments working capital of 56 percent (Hossain, 1988). rose from 28 percent for first time borrowers This difference is explained by women’s more to 63 percent for members borrowing four limited economic involvement before the pro- times or more. gram. After joining the program, approxi- A more recent study of the household and mately 30 percent of the women borrowers intrahousehold impacts of the Grameen Bank moved from unemployment to self-employ- and similar credit programs in Bangladesh also ment, primarily in trading and processing. To found similar positive effects on the well-be- a lesser degree, men also used their loans to ing of poor households (Pitt and Khandker, change occupations, primarily from agricul- 1995). A methodological contribution of this tural wage labor to petty trade. study is that, through econometric methods and a quasi-experimental survey design that com- Impacts in Latin America pared target and nontarget households in pro- Quite different results were found in an evalu- gram and nonprogram communities, the po- ation of an ACCION-supported program in tential self-selection bias and endogeneity of Peru. The incomes of male participants were study variables were minimized. In a similar found to increase much more than the incomes way, the analysis was able to separate the esti- of female participants, and the gap between mates of the impact of borrowing by men and levels of informal sector earnings by men and by women. women were quite striking (Berger and The study concludes that program par- Buvinic, 1989). A survey of 560 female and ticipation had a significant effect on the well- 140 male market vendors found that women being of poor households. Program participa- earned on average $3.40 a day, while men tion had a positive effect on household expen- earned $5.00. Follow-up surveys found that ditures, asset accumulation, self employment, male vendors increased their incomes at a children’s schooling, food consumption, and much higher rate, 205 percent, as compared contraceptive use. Credit provided by the to women’s increase of 43 percent. Grameen Bank had the most significant im- The gender difference is typically ex- pact on variables associated with household plained by two factors. First, women are tra- wealth, women’s power, girls’ and boys’ ditionally relegated to the income-earning ac- schooling, women’s labor supply, women’s tivities with the lowest returns (e.g., commerce assets, and total household expenditure (Pitt and sewing). Even more so than poor men, and Khandker, 1995). The effect was greatest women have few productive assets that would when women were the program participants, enable them to earn a higher return (Berger even in terms of raising household expendi- and Buvinic, 1989). Second, a woman’s dual tures. A dollar loaned to women raised house- role as economic provider and caretaker un- hold expenditures by a greater absolute amount dermines her ability to earn greater returns. A than did a dollar loaned to men (Pitt, pers. study of market women in Lima, Peru found comm.). The authors conclude that “program that many had opted for lower incomes from participation benefits the poor, especially vending than higher incomes from factory women and children” (Pitt and Khandker, work, because marketing gave them greater 1995). flexibility to fulfill domestic obligations The Hossain (1988) study also found evi- (Bunster, 1983). The need to care for young dence of a somewhat more favorable impact and sick children was mentioned most often

Research Paper No. 1!25 as a motivating force behind choosing mar- strates that measurements of labor productiv- keting. Unlike men, women’s economic in- ity (hourly net income) is an important vari- volvement, options, and opportunities are very able to be included in any impact study of much influenced by their stage in life and the credit, especially for women. life cycle of the family. A study in three sub- Time allocation information is also avail- sistence communities in Guatemala docu- able for Grameen Bank participants. How- mented how women adjusted their economic ever, the data indicate that much of the increase activities to accommodate the demands of in women’s incomes was the result of the in- pregnancy, childbirth, lactation, and child rear- creased number of hours worked. ing (Cosminsky and Scrimshaw, 1982). Female members worked an aver- Impact on Women’s Time and age of 4.9 hours a day, of which 4.2 Productivity hours were spent in the loan- Given the excessive labor burdens of the poor, financed activity. In comparison, particularly poor women, time can be as im- housewives in the target-group portant an economic asset as income. It is pos- nonparticipant households spent sible that one of the primary benefits of a credit 0.64 hours a day in income-earning program for women would be that they could or expenditure-saving economic earn the same or slightly more income in less activities within the household time, freeing them to perform other duties or (Yunus, 1988). get much-needed rest. This possibility was documented in a study of the PRODEM pro- These numbers indicate that participation gram in Quito, Ecuador (Berger and Buvinic, in the program resulted in women working an 1989). additional 16 standard eight-hour days a Approximately 300 borrowers were in- month. However, since most of these women terviewed at the beginning of the PRODEM came from either landless or marginally land- program and then again 12 months later. A holding households, they had only limited ag- control group was selected from a population ricultural labor obligations and some surplus with similar characteristics. The study found labor. This would not be the case, however, that the monthly and hourly net incomes of in parts of Africa where women are actively the borrowers and the controls did not differ involved in farming for much of the year and much. However, the study did find increases would be unable to work an additional 16 days in the productivity of the borrowers, particu- per month on a loan activity. The possibility larly for women. “Women microproducer and of trade-offs between increased income and microvendor borrowers increased their hourly less time for child care or needed rest make net incomes (reducing total hours worked per the issue of productivity important. Women’s month) from 1984 to 1985 to a significantly time management skills, and the availability greater extent than did their male counterparts” of productivity-increasing technologies, will (Berger and Buvinic, 1989). PRODEM influence how beneficial the impact of credit women microentrepreneurs decreased the might be. number of hours they worked monthly by 14 to 17 percent, as compared with women Important Context Variables nonborrowers, who reduced their work hours The above examples demonstrate that poverty by only 4 to 7 percent. The authors concluded lending programs can help break the cycle of that women prefer efficiency because of their poverty and improve the lives of destitute bor- dual responsibilities. This finding demon- rowers. However, the likelihood that credit will help raise a given person’s productivity

A Literature Review and Analysis!26 or income will be influenced by numerous con- world by Michigan State University has drawn textual factors and the nature of the income- attention to the importance of this sector earning activity selected. The most important (USAID, 1989b). In the majority of countries contextual factors include the vibrancy of the studied, over 60 percent of total manufactur- local market economy, the strength of demand, ing is located in rural areas, with a high of 86 trends in the costs of inputs, and the availabil- percent in Sierra Leone.6 The overwhelming ity of technology. majority of these firms were very small, em- ploying fewer than five people. In many coun- Rural vs. Urban Settings tries a significant number of the small enter- Some observers feel that minimalist credit pro- prises were owned by women. Jiggins (1989), grams may be more suited to urban than rural in her review of the income-earning strategies areas: of poor women in sub-Saharan Africa, concluded that household-based agricultural ac- If urban markets are generally tivity remains the foundation of rural liveli- stronger and more easily identifi- hoods, but increasingly women are dependent able, the provision of relatively on self-employment (primarily in trading and “minimalist” credit itself might agroprocessing) or wage work for survival. enable low income individuals to According to the World Bank (1990), the respond quickly to new opportuni- importance of nonfarm income is increasing. ties. In rural areas, in contrast, In Kenya, among smallholder families, per livelihoods may be more likely capita income from nonfarm sources climbed constrained by a range of factors 14 percent a year between 1974/75 and 1981/ requiring a more comprehensive 82 while incomes from farm employment rose sectoral attack (McKee, 1989). only 3 percent per year. Also in Kenya, the rural nonfarm sector was found to be second Another challenge pertains to the fit be- in size only to small-scale agriculture, eight tween the terms of poverty lending and rural times as large as the urban informal sector, and people’s economic activities. Successful pro- larger than the combined modern private and grams demonstrate the importance of credit public sectors (Norcliffe and Freeman, 1980). terms (loan amount, its duration, and payment Other than farming, the rural nonfarm sector schedule) matching the productive and repay- had the largest proportion of women (one-third ment capacity of the beneficiary (Otero, 1987). of whom vended fruit and vegetables). Small amounts of capital, short loan periods, The demand for goods and services from and weekly repayment are not conducive to the rural nonfarm sector depends on the health agricultural investment, which is the primary of the local farm economy, so the two sectors work in most rural areas. may not be as discrete as some assume (World However, recent research has emphasized Bank, 1990). the significance of the nonfarm economic sec- One of the particular socioeconomic char- tor in rural areas and nonfarm income to rural acteristics of the survival economy is that household survival strategies. Large-scale households diversify income sources: “fam- field research conducted in the developing ily members engage in a wide range of income-

6 Research sites included Sierra Leone, Bangladesh, Jamaica, Honduras, Haiti, Egypt, and Thailand.

Research Paper No. 1!27 earning activities in different seasons to spread agers in the design and implementation of risk” (Carloni, 1987). Women play a particu- credit programs. larly important role in this pattern of livelihood diversification. They may have several Debates Pertaining to Poverty Lending seasonal income-earning activities in a single The success of programs like BKK, year or even simultaneously. The seasonality Grameen, and ACCION have greatly increased of rural life dominates the economic activity faith in the efficacy of credit to assist even the of rural people and must be taken into consid- very poor. However, a number of issues per- eration in credit program planning. It is pre- taining to the desirability of poverty lending cisely this type of livelihood strategy that, if programs continue to be debated. The follow- strengthened, can have the most direct effect ing are brief summaries of the most important on improving household food security. points of contention. First, not all observers are yet convinced Assured Supply and Demand of the creditworthiness of the poor. In a A review of the necessary characteristics of USAID review of credit programs, one sec- high-performance projects proposed that bor- tion focused on 32 programs targeted for the rowers must “undertake an economic activity poorest of the self-employed and unemployed for which they have assured supplies and an or for highly disadvantaged groups, like illit- established demand” (Berger, 1989). Unfor- erate women in economically remote areas or tunately, few, if any, of the survival strategies marginal urban areas. The review found the of the poor are characterized by such certainty. programs to be very expensive and found few A study of Ghana’s small enterprise sec- that had much positive impact on the borrow- tor concluded “that microenterprises are con- ers’ economic status. For example, the find- strained more by a lack of demand than a lack ings that 53 percent of borrowers experienced of credit (credit is more important for small serious difficulties and that fewer than 50 per- and medium-size firms)” (Holt and Ribe, cent improved their net worth were not con- 1990). However, other studies have reached sidered surprising by the reviewers. The re- the contrary conclusion that working capital port concluded, “This result is not unexpected, is a major constraint to the smallest entrepre- given the difficult business climate faced by a neurs. Credit needs will certainly differ among relatively inexperienced entrepreneurial group. poor groups and different settings. The precarious economic conditions of the cli- A GEMINI study of microenterprise ac- ents meant earnings were not reinvested in the tivity in Niger found that women were heavily enterprise but were used to meet consumption concentrated in the traditional income-earn- needs. . . . Entrepreneurship is not for every- ing activity of weaving mats (Mead, et al., one and good programs need to know when to 1990). However, the declining availability of quit” (USAID, 1989a). palm leaves resulted in higher raw material A very different perspective was offered prices and the reduction of women’s profits. by Stearns of ACCION: At the same time, plastic mats imported from China increased competition, particularly for Although there are legitimate urban markets, making it difficult to pass on causes of delinquency that lie the higher input costs to customers. The re- beyond the control of the credit port concluded that women must be helped to programs, experience from around diversify out of mat weaving. the world is showing that high The influence of the market on profitabil- delinquency is, more often than not, ity requires the close attention of project man- a function of a program’s objec-

A Literature Review and Analysis!28 tives, methodology and operations, cialization to adequately use credit that larger rather than target group and eco- enterprises would use to create employment nomic environment. In most cases, and generate demand. Women’s economic the microenterprise program itself strategies tend to be characterized more by eco- is the determining factor as to nomic diversity than by specialization. whether or not delinquency However, current trends indicate that emerges as a problem (Stearns, more and more very poor women, even in ru- 1990). ral areas, will enter the market economy as From this vantage point, the costliness operators of their own survival-level and high failure rate of the credit programs microbusinesses. Neglect of these very small reviewed by the USAID report might be more activities can have negative distributional con- related to their failure to follow the principles sequences and can frustrate poverty allevia- of what Lassen (1990) called “New Style” pov- tion and, most certainly, food security goals erty lending than to the inherent riskiness of (Berger, 1989). the clientele. A third area of debate concerns the de- A second point of contention relates to gree of help that minimalist credit can provide the objectives of credit programs. One view to women. Because of the meager returns and is that loans should be made to businesses most structural constraints to women’s traditional likely to generate employment and stimulate activities, some have questioned the efficacy links to other economic activities. This per- of the minimalist approach at bringing about spective is summarized in the following ex- significant economic improvement and em- cerpt: powerment (Marilyn Carr, UNIFEM, pers. com.; Downing, 1990; McKee, 1989). Ac- Most microenterprise assistance cording to Buvinic (1989): programs are a reaction to the failure of trickle-down economics Projects failed (to substantially and are based on the assumption assist women) because the objec- that assistance must be provided tive is to enable women to earn directly to the beneficiary. Every- extra income for the household one must be his or her own entre- instead of establish successful preneur. This perspective, how- women’s enterprise. Development ever, presumes an answer to a agencies view women’s economic question that is only beginning to role as earning extra pin money for be asked: trickle down from what the households, and it is easier to level? . . . the poorest target groups implement social welfare programs may best be reached by assisting than increase productivity and firms with the greatest potential for incomes of the poor. creating jobs accessible to the poor (USAID, 1989a). McKee (1989) proposed two alternative approaches: 1) to choose an existing subgroup From this economic growth-oriented per- of women workers (such as a trade group) and spective, the vast majority of the survival support a variety of program activities to im- economy (Figure 1, p. 2) is too marginal to prove the infrastructure and conditions of that merit program investment. Poor women, es- activity or 2) to choose economic activities pecially in rural areas, are viewed as lacking with the potential for high returns (e.g., mecha- the business skills, assets, and potentially even nized food processing, high-value handicrafts, the motivation for business expansion and spe- and so on) and attempt to move women into

Research Paper No. 1!29 those activities. Downing (1990) proposed Poverty lending more often preserves an that this second approach is a promising alter- entrepreneur’s own self-employment rather native to either the growth-oriented or pov- than creates new jobs. Incomes are most likely erty alleviation-focused approach to credit. stabilized or moderately increased in the short While both are provocative suggestions, term. However, with sequential loans and ac- the few existing examples of these approaches cumulation of business experience, partici- would be quite difficult to implement on a pants may move into potentially more profit- large scale, because of the substantial costs and able activities. specialized services involved. Moving women The gender-specific impacts of poverty into nontraditional areas is a risky and re- lending impacts on men’s, women’s and source-intensive task, and it would not be fea- household income and assets depend upon the sible for poor women alone to assume this risk program context. However, it seems likely that (Downing, 1990). Another important ques- women’s relegation to traditional income-gen- tion would be “is it more empowering to erating activities, balanced by their domestic achieve modest, tangible gains through an in- obligations, means that the absolute amount cremental strategy, or to pursue a potentially of income increases may not be as great for higher reward, risking failure?” (McKee, women. However, recent evaluations of the 1989). Grameen Bank found even greater improve- Buvinic (1989), in an evaluation of the ment in women’s income relative to men’s and characteristics of “better performing” credit a more positive association with increased gen- projects, concluded: “Better performing eral household expenditures when loans were projects are those run by specialized agencies made to women rather than men. that focus narrowly on a particular task and Measurements of labor productivity provide a single missing ingredient (usually (hourly net income) is an important variable credit) rather than integrated services.” Even to be included in any impact study of credit, programs like SEWA, that later provided their especially for women. It is possible that participants with a variety of services, began women themselves choose to earn less income as “minimalist programs” striving to provide so that they can better conduct both their do- poor women with credit. This relatively nar- mestic and economic obligations. One of the row focus expanded as the needs of the clien- primary benefits of a credit program for tele were better understood. Such a gradual women might be that they could earn the same process has two advantages: (1) it allowed or slightly more income in less time, freeing time for the organization to come to under- them to perform other duties or get much- stand the specific needs and obstacles facing needed rest. Or the credit program may pro- the poor and women in that context, and (2) vide a women with more options to undertake the program was not initially overcome by less arduous work and/or work that is more multiple institutional requirements (McKee, compatible with child care. 1989). Poverty lending may have more impact among the urban and periurban poor than in Tentative Conclusions rural areas. The small amounts of capital, short Concrete evidence of the economic impact of loan periods, and weekly repayment typical of poverty lending programs is rare. The few rig- poverty lending programs are not conducive orous evaluations to date (primarily the to agricultural investment, which is the pri- Grameen Bank and some ACCION affiliates) mary work in most rural areas. However, re- indicate that poverty lending programs do raise cent research has emphasized the significance incomes, assets, and productivity of very poor of the nonfarm economic sector in rural areas borrowers, both men and women. and nonfarm income to rural household sur-

A Literature Review and Analysis!30 vival strategies. One of the particular socioeconomic characteristics of the survival economy is that households diversify income sources. Women play a particularly important role in this pattern of livelihood diversification. They may have several different income-earning activities in a single year or even simultaneously. This may be an important reason poverty lending programs involve far more women than men. Poverty lending is designed to support primarily the existing economic activities of the poor. Because of the meager returns and structural constraints of women’s traditional activities, this minimalist approach probably does not bring about major economic improvements for women. Because women constitute the bulk of the participants in most programs, poverty lending is unlikely to produce major economic gains for poor households. How- ever, in relative terms, these modest gains seem likely to make very important contributions to household survival, such as income smoothing and insurance against emergencies discussed in the earlier section regarding income’s impact on household food security. And these are precisely the types of livelihood strategies that, if strengthened, are most closely associated with increased household food security and nutritional status. From the economic growth-oriented perspective, the vast majority of the survival economy is too marginal to merit program investment. However, current trends indicate that more and more very poor women, even in rural areas, will enter the market economy as operators of their own survival-level microbusinesses. Neglect of these very small activities can have negative distributional consequences and can frustrate poverty alleviation, food security, and nutrition improvement goals.

Research Paper No. 1!31 LINK BETWEEN POVERTY LENDING AND straight to the eyes of an unknown EMPOWERMENT OF WOMEN urban visitor (male or female). When one talks to a Grameen loanee woman the difference is Poverty lending programs are hypothesized striking and very obvious. They to directly increase women’s self-confidence will stand confidently and speak and other manifestations of their out as an equal partner in a conver- empowerment, perhaps even independently of any economic impact. sation. Though they have veils on the head and a baby on the lap, they do not bow down but reflect the Evidence of Impact on Empowerment spirit that now they are being Our personal observations indicate that the valued by the society. The spirit is earliest and most striking evidence of impact more apparent among those women by poverty lending programs is the increase in loanees who have been members women’s self-confidence. According to for a longer period. The new ones McKee (1989), there is significant evidence are proceeding step by step. that microlevel programs that improve women’s livelihoods also bring about “more Another observer of Grameen comments fundamental changes in their lives in terms of (Yunus, 1988): their self-esteem, confidence, participation in Poor women have been the greatest political and community life, and family deci- beneficiaries of the Grameen sion-making power and status.” efforts. Rural poor women are The following observations were made becoming income earners with the by an evaluator of the Production Credit for help of Grameen loans and subse- Rural Women Program in Nepal (UNICEF, quently are asserting their rights on 1989b): their male counterparts and the society at large. They have become Women reported that their hus- quite confident of their own ability bands consulted them more often, and can easily stand against social and neighbors and family members injustice. asked for advice more often. Min- istry of Health staff reported that Despite the importance of empowerment PCRW members used their services and the significant progress various poverty more and followed prescriptions lending programs have had in bringing it about, more carefully. Women said they this program benefit is often the least well ap- were more confident and less preciated and most casually documented. The dependent. principal reason is the methodological difficulty of defining and measuring empower- Reports from the Grameen Bank have all ment, particularly because the specific mani- been impressive, particularly since women in festations of empowerment depend on the so- Bangladesh traditionally have such a socially ciocultural setting. subordinate role. According to Yunus (1988): In most published accounts, it is not known or stated whether it is the increased The usual scene of a poor rural income gained by women in the poverty lend- woman is that under a long veil she ing programs that enhances empowerment or bows down and eyes are fixed on something about the structure or process of the ground and she talks in a shy the program itself. From our personal obser- and timid manner. She never looks

A Literature Review and Analysis!32 vations of the very early surge in self-confi- groups, it will only be in an atmo- dence among program participants, we suspect sphere of trust and support pro- the program design itself is empowering vided by these groups that women women. Since all poverty lending is done will be able to carry out analysis through self-help groups, generically called and courageously redefine the “solidarity groups,” we hypothesize that the structures of their oppression—that experience of participation in a solidarity is, to experience empowerment. group is empowering by itself, independent of the empowering effect of increased income- Ashe (1986) documented the functional earning performance. benefits of the solidarity group mechanism in a Women’s World Bank program in Cali, Co- Link Between Solidarity Groups and lombia (Ashe, 1986). Evidence of solidarity Empowerment was measured in terms of mutual assistance, In many parts of the developing world, par- social support, and collective action between ticularly in sub-Saharan Africa, women’s group members, and the tendency of the group groups have long been important for mutual to assume responsibility for carrying out the support and action. Women’s self-organized program functions of group formation, repay- savings societies are often an important ment, and program promotion. Of those in- mechanism whereby women can accumulate terviewed, Ashe found that 66 percent of the working capital for their income-generating ac- groups had at least one member who could not tivities or have access to funds for emergen- repay a loan; 88 percent of the groups had cov- cies or large expenses like school fees. These ered this outstanding loan to fulfill their re- savings societies engage in a wide variety of payment obligations; and 68 percent had community development activities. The use loaned money to one another. of solidarity groups by poverty lending pro- Ashe (1986) also found that evidence of grams builds on this tradition of self-help solidarity and the social impacts of the pro- groups of women. A study in Kenya con- gram increased with the length of program par- cluded that membership in these women’s ticipation, as the membership internalized the groups cuts across socioeconomic lines to in- solidarity aspects of the program. For exclude the very poor as well as better-off women ample, “of those who had been with the pro- (Muzaale and Leonard, 1985). gram more than five months, 80 percent ex- Observers note that empowerment and changed information about sources of financ- community development goals are achieved ing, and 92 percent shared information about in relation to the extent that solidarity groups where to purchase less expensive merchandise; are used and developed in poverty lending pro- this compared with 33 percent and 37 percent grams (McKee, 1989). From an economic per- for ’new’ groups.” spective, solidarity groups are noteworthy for Group savings schemes are another way their potential to reduce administrative costs of building solidarity and mutual cooperation. (e.g., bundling many small loans for easier The accumulated savings of the group can bookkeeping and replacing costly analysis of serve economic and welfare objectives, such loan and borrower creditworthiness with peer as when members use funds to assist those ex- group review). However, solidarity groups are periencing emergencies. According to Yunus also important for organizing individuals and (1988), the mutual and financial support that creating a spirit of greater mutual support. Ac- solidarity group members offer one another cording to Antrobus (1989): during difficult economic periods is an important element in the Grameen Bank’s success. Consistent with history and what is A highly innovative evaluation of a de- known about women’s solidarity velopment program in Kenya documented

Research Paper No. 1!33 both the outcome and the process by which ter group solidarity which reduces women’s individual and group empowerment was isolation, increases their exposure to new ideas achieved (Clark and Gakuru, 1982). The pro- and information, as well as their skills inter- gram under study shared many design features acting in the public sphere. There is even some with poverty lending. Utilizing a “before-and- evidence in support of the hypothesis that soli- after” research design, the evaluation found darity groups create empowerment of their that in addition to the economic benefits of members independent of their economic im- program participation, increased confidence pacts by creating new bonds and social identi- both at the individual and group level was also fication that help women resist traditional re- evident. According to Clark and Gakuru, “The strictions and foster new cultural norms. A most dramatic change was seen in interview wider survey of literature on noneconomic data related to confidence, which increased self-help groups would likely reveal that in- fourfold” at the individual level. Group con- tragroup solidarity has a strong, direct, and fidence was measured by staff log entries of positive impact on measures of personal and examples when groups exhibited either “a will- group empowerment. ingness or unwillingness to take a risk, con- front a problem, raise a question, or discuss a difficult issue” (Clark and Gakuru, 1982). Changes in the confidence indicators from before and after program participation closely mimicked a group’s successful completion of its collaborative activity. More recently, the Schuler and Hashemi (1994) study of empowerment and contraceptive use among Grameen Bank and BRAC participants in Bangladesh documents how participation in a group has an empowering effect beyond any direct economic impact. Women’s identification with the group gave them a socially legitimate reason to meet and interact in the public sphere which served to increase their exposure to new ideas, their self- confidence, and mobility. In particular, the more regimented and ritualistic approach of the Grameen program (compared to the BRAC program) was thought to develop a more in- tense identification and bond that made it easier for women to resist the restrictions of traditional family life and adopt new family planning norms.

Tentative Conclusions Poverty lending empowers women participants. By providing opportunities for self-employment it increases women’s autonomy, self- confidence, and status within the household. Regular meetings and peer guarantee help fos-

A Literature Review and Analysis!34 LINKAGE OF POVERTY LENDING TO and accumulated savings for emergencies BEHAVIOR CHANGE AND NUTRITIONAL seem to improve household food security. Poverty lending programs have the type of eco- STATUS nomic impact that is most directly linked to increased food security: income increases Poverty lending programs are hypothesized among the poorest households, income con- to be insufficient to significantly improve trolled by women, and income earned through household nutritional status without nonfarm income-generating activities which `linkage to education that specifically promotes generate the type of small steady earnings that nutritionally important behavior changes. are channeled directly toward food and other basic needs. While the productivity and profit Figure 3 summarizes the tentative conclusions gains tend to be modest, access to loan capital we have drawn to this point. The strongest plays an essential role in stabilizing and di- linkages, or causal connections, in the benefit versifying poor households income. Access pathway seem to be from poverty lending: to loan capital helps entrepreneurs weather periods of poor returns, when they might other- ! to modest increases in women’s in- wise have gone out of business, and provides come, savings, and assets, which lead the households with an alternative income ! to women’s empowerment, which lead source that helps augment and smooth incomes ! to changes in nutritionally important throughout the year. In addition, the opportu- practice, which lead nity to augment savings and build productive ! to improvements in household nutri- assets over multiple loan cycles provides ad- tional status, especially for women and ditional resources for emergencies or cyclical children in the household. periods of scarcity. Women’s experience with the credit, in- In addition, increased income, income creased capacity to economically contribute to smoothing and diversification through the year, the family’s well-being, and interaction with the solidarity Figure 3. Probable Pathway of Benefits from Poverty Lending group are also very likely making a direct and strong contribution to women’s empowerment. Empowerment enhances the effect of an increase in income on spending beyond women’s direct earnings, through their greater influence over household expenditures and/or resource allocation. There may be positive feedback from women’s empowerment to income generation and from successful behavior change to empowerment.

7 Village banking is a poverty lending methodology developed by John Hatch of FINCA. This methodology is similar to the Grameen Bank’s, in that borrower groups with approximately 30 members jointly guarantee each other’s loans and repayment and savings are typically made at regular weekly or bi-weekly meetings. However, loans are for a shorter period (four to six months), and groups are more self-mananged.

Research Paper No. 1!35 The Need for Education for participatory nonformal education and to Women’s empowerment is unlikely to directly use the same field staff to deliver both finan- improve household food security and nutri- cial and educational services, thereby minimiz- tional status without acting through behavior ing the extra investment in information trans- change that is either economically or nutrition- fer and change promotion. ally important. Likewise, poverty lending pro- Freedom from Hunger, together with its grams are unlikely to directly promote either local partners in Bolivia, Burkina Faso, Ghana, economic or nutrition-related behavior Honduras, Mali, and Thailand, is attempting changes without acting through some kind of to demonstrate the feasibility of this integrated educational process. Women’s empowerment approach, which they call Credit with Educa- is believed to make women “learning ready,” tion (Dunford, 1990, 1992, 1994; Lassen and and women’s economic resources can enable MkNelly, 1992; World Bank, 1993). They are them to take action on what they have learned. implementing a village banking7 methodology But some kind of information transfer and which directly incorporates nonformal educa- change promotion must occur before women tion at borrower group meetings to promote are likely to know what to change and why important health/nutrition and family planning and how. practices, microenterprise development, and If desirable behavior change is blocked credit group management. The education com- only by lack of money and/or self-confidence ponent is fully integrated into the poverty lend- (both are major blocks!), then more income ing methodology so that the delivery mecha- and empowerment could be sufficient to bring nism for both the financial and education ser- about desired changes. However, if lack of vices is the same, and participants simulta- information is a major block in itself, as it al- neously have access to greater information as most always is among the very poor women well as economic resources. This strategy aims served by poverty lending programs, then an to enhance the food security and nutritional educational program is required for the same impacts of poverty lending programs while solidarity groups of women taking loans. maintaining the financial sustainability nec- Without the extra investment in informa- essary for widespread expansion. tion transfer and change promotion, the ben- The health and nutrition education of efit pathway to improving household nutri- Credit with Education focuses on five topic tional status will probably be blocked by lack areas: diarrhea management and prevention, of change in nutritionally important practices breastfeeding, infant and child feeding, immu- of women and other household members. nizations, and family planning. The specific With an education program, the potential of topics, or ideal practices, addressed at the poverty lending to counter malnutrition can be meetings vary from country to country, reflect- realized. Without education, poverty lending ing local needs. All are within the scope of may have only a weak positive effect on house- resources and range of decision making nor- hold food security and little, if any, impact on mally available to women, and all relate to key nutritional status. causes of malnutrition in the program area. Preliminary impact research has shown that An Integrated Approach health and nutrition education through this in- Education can be provided to poverty lending tegrated approach can be effective for improv- program participants either by a separate pro- ing participant knowledge and probably be- gram or as an integrated component of the pov- havior. Further research is underway, and more erty lending program itself. The advantages will be needed to test whether the integrated of the second option are the opportunity to approach is more cost-effective for improv- use the solidarity group meetings as a forum ing nutritional status than delivery of poverty

A Literature Review and Analysis!36 lending and health/nutrition in parallel, but group. And, from a program design stand- independent, programs serving the same cli- point, these regular meetings also provide an entele. excellent forum and opportunity for education. The microenterprise education focuses on According to the founder of SEWA, a four topic areas: choosing an appropriate ac- poverty lending program in India, their pro- tivity, increasing profits, increasing sales, and gram “organizes borrowers to bring them to- managing a microenterprise. The field agent gether to think through their common prob- facilitates discussions that help the women use lems, agree on common issues, decide com- the local markets and their own activities for mon action, and forge common ideologies” case studies. They also help each other to find (Bhatt, 1989). This group capacity could be ways to make their loan-funded activities channeled toward behavior change essential complement rather than detract from their for improving the nutritional status of those other obligations so that increases in income most vulnerable to malnutrition and food in- can increase their families’ overall well-being. security. It is essential, however, that the edu- The need and efficacy of management cation be nonformal and participatory rather training has been questioned, particularly for than didactic if it is to be effective and build women’s very small and typically changing upon the potential of the group. mix of enterprises (McKee, 1989). One re- Nutrition education has great potential to view of several microenterprise credit pro- influence attitudes and behaviors critical to grams found that the minimalist programs pro- improve nutritional status, but evaluations of viding little training had as strong an impact nutrition education typically find this poten- on borrowers’ incomes as “credit-plus” pro- tial is rarely achieved (USAID, 1990). Les- grams (Berger, 1989). However, rather than sons or messages are commonly delivered in focus on inappropriate bookkeeping or ac- a lecture style with participation, if any, con- counting skills, microenterprise development fined to rote repetition of predetermined solu- education can and should focus on basic busi- tions. The manner in which messages are for- ness principles that can assist the borrowers mulated and delivered often hinders their ulti- to use the credit more strategically to earn a mate effectiveness. According to the Manoff greater return. According to one review of Group (1984), income-generation programs (Buzzard, 1984), “All too often, people make a product and hope The reason for many failed nutri- someone will buy it rather than searching out tion and health education programs what people want to buy and making that prod- is that the ideas for messages have uct.” This is an example of the type of eco- not come from investigations to nomic behavior change that can lead to higher identify the audience, its problems, incomes and consequently better food secu- and possible remedies, but from the rity and nutritional status. suppositions of those planning the programs and other experts. This Nonformal Education During Solidarity has culminated in projects advising Group Meetings villagers to boil drinking water One of the defining characteristics of poverty when fuel is scarce or designing lending programs is the regular meetings of posters with a written message solidarity groups either on a weekly, bi-weekly, when illiteracy is prevalent. Mes- or monthly basis. While it is true that these sages made of theories sometimes regular meetings facilitate the installment re- have impact, but more often than payment of the loan, they also play a crucial not they are rendered ineffective in role in forging the solidarity of the borrower the face of long-held customs and beliefs.

Research Paper No. 1!37 Still, it is recognized that if nutrition edu- Second, solutions will be most appropri- cation can be made more effective by being ate and most likely to be adopted when they “more specific, more action-oriented, indi- are developed or modified locally. Immink vidualized and relevant” the benefits could be (1988) proposes, “The community collectively great (Lotfi, 1988). This is best achieved thinks about and discusses its food and nutri- through face-to-face communication and action problems, their immediate causes and tive participation by beneficiaries. This what priorities should be given to solving nonformal approach, together with the excel- them. In participatory sessions the commu- lent forum provided by the solidarity group nity decides on courses of actions and sets pri- meetings, exemplify the characteristics of the orities.” most effective approaches to nutrition/health A review of several nutrition education education. programs focusing on weaning practices con- First, the importance of beliefs and cus- cluded that the most successful examples were toms requires that nutrition education address based on negotiations with the target popula- social obstacles to behavior change and not tion regarding problem identification and so- simply impart information. The program field lution formation (Chauliac, et al., 1991). This agent “should listen to the community with a interactive process also strengthens people’s respectful attitude, learn from them, work with capacity at a local level to analyze their reality them and for them, and provide guidance rather and to take greater responsibility for imple- than simply teach them” (USAID, 1990). Soli- menting change (Immink, 1988). In addition, darity group members understand the kinds of there is some evidence that programs employ- constraints each woman is facing much better ing a learning approach to develop adult con- than even the most empathetic field agent. The fidence and collaborative skills also can re- advice and support they can offer one another sult in participants’ adoption of specific, nu- is more relevant, and the relationships within tritionally beneficial child feeding practices the group are much longer lasting and poten- (Clark and Gakuru, 1982). tially more influential over time. Synergy Between Increased Income and Even if the costs of change (in Nutrition Education terms of time or money) are per- A great opportunity exists to combine pro- ceived to be large, it may still take grams that increase incomes with education, place if a firm and trusting relation- that encourage allocation of quality foods for ship builds up between members of those must vulnerable to malnutrition, and that the target community and the agent support the adoption of key health and nutri- of change. . . . The relationship tion behaviors. Providing economic and infor- between extension worker and mation resources to the same participants can target families is an all-important have a synergistic impact that makes improve- factor in determining whether ments in food security and nutritional status change will occur. The extension more likely than would be the case if either worker must show the family that resource were provided alone. The possibil- he/she truly understands the kinds ity that the education component will posi- of economic and social constraints tively affect expenditure patterns and under which the family is living intrahousehold distribution of resources en- and support the family through its hances the likely nutritional impact of in- difficulties. Outsiders find this creased income from the credit program. difficult to do (Nabarro, 1984). Moreover, the nutritional impact of the education will also be strengthened by the simul- taneous improvement in economic status.

A Literature Review and Analysis!38 For example, a study of a food supple- The logic behind combining health and mentation program in the Philippines found nutrition education with a women’s income- that providing households with additional eco- earning project is quite clear to the women nomic resources (in the form of food) did not themselves. The Population Council con- affect critical intrahousehold behaviors that ducted a study of 21 women’s groups in Zim- would ultimately dictate whether this assis- babwe to better understand women’s percep- tance would have a positive impact on tions of the wisdom of combining income-gen- children’s nutritional status. Only the addi- erating, family planning, and literacy education of an education component had this ef- tion programs (Mutambirwa, et al., 1986). The fect. The authors concluded that: group members felt this approach was desirable because 1) children are better cared for When multivariate analysis is when the mother has ready cash to use in the employed, the nutrition education home, 2) adequate spacing of children provides component of the scheme shows no time for women to engage in income-generat- significant impact on household ing activities, and 3) when women engaged in food expenditures and acquisition, successful income-generating activities, their but food consumption and nutri- influence on the economic well-being of the tional status of preschoolers are family increased. The interest among women strongly affected, indicating that the for both types of assistance is also evident. A nutrition messages increased the survey examining training needs of women focus on children (Garcia and borrowers in an ACCION program in Peru Pinstrup-Andersen, 1987). found that while a third of the participants were interested in enterprise training, almost half Not only does the ultimate nutritional requested health-related courses in family benefit of increased economic resources de- planning, hygiene, and nutrition (Reichman, pend upon complementary nutrition educa- 1984). tion, but the reverse is also true. Greater nu- While many of the most nutritionally trition knowledge may only be effective if steps important behaviors are not costly, the eco- are taken to ensure a minimum socioeconomic nomic status of the household, and particularly status. This was the conclusion of a study of the role of women, will greatly influence the mediating effect of maternal nutrition whether they are adopted. For this reason, pro- knowledge on the association between mater- grams that combine credit with education are nal schooling and child nutritional status in increasingly recognized as important and nec- Lesotho (Ruel, et al., 1992): essary to “break the deadlock on women’s re- The effect of maternal schooling on sources for nutrition” (McGuire and Popkin, weight-for-age was mediated by the 1990). mother’s nutrition knowledge only Simultaneously, providing both economic among wealthier households. and information resources in a manner that These results imply that, in fosters the problem-solving capacity of the par- Lesotho, nutrition education for ticipant has the potential to overcome the ma- mothers could contribute to im- jor blocks to behavior change and conse- proving children’s growth, but only quently improved nutritional status. Accord- in households that have access to a ing to Nabarro (1984), even when a nutrition minimum level of resources. For or health message has been presented well and poorer households, nutrition educa- understood by the mother, change often still tion would not be sufficient. does not occur. This often happens because of a number of different kinds of “blocks.”

Research Paper No. 1!39 First, the “pragmatic” block refers to a With or without the 15- to 20-minute mother’s resistance to adopt a behavior education session held at each change, because it runs counter to her per- regular village bank meeting, the ception of the problem. field agent’s transportation costs, Second, the “ritual block” refers to tra- salary, and schedule for attendance at ditional practices and customs, like the be- the meetings remains the same. lief that pregnant women should not eat spe- Each agent is expected to handle a cific foods. Since adherence to these prac- portfolio of at least ten village banks, tices is associated with adherence to the sta- which is the same minimum ratio as tus quo, social support and empowerment are other village banking programs that necessary to overcome this block. Third, the lack an education component. perceived value of beneficial practices, together with the capacity of the household to 2. The education component employs a implement them, is necessary to address what nonformal and minimalist approach Nabarro (1984) calls the “economic capac- so that program operating costs that ity” block. Increased income from poverty solely pertain to the education lending can play an important role in over- component are quite small. Rather coming this type of block to key behaviors than depending on expensive flip that require added expense or time; for ex- charts or story boards, the education ample, additional protein in the diet or the sessions involve stories, skits, and preparation of weaning foods. the women’s own active discussions. The program has supervisory and training staff who are education Integration for Financial Sustainability specialists and whose benefits, While the nutritional benefits of incorporat- travel, and support costs do represent ing quality, nonformal education directly into additional expenses. However, these a poverty lending program are clear, this ad- additional costs for personnel and ditional service imposes additional delivery their support should constitute only costs. The added cost might seem to under- about 3 percent of total nonfinancial mine the program’s progress toward self-fi- costs of a large-scale program (Free- nancing sustainability in a timely manner. dom from Hunger, unpublished However, if tightly integrated and delivered data). in a cost-effective manner at large scale, the marginal cost of the education services can In brief, the impact of a poverty lending be negligible, as Freedom from Hunger is program is likely to be greatly amplified and demonstrating through the Credit with Edu- broadened by an education component, and cation version of village banking, for two these major benefits can be provided with reasons: modest additional investment. It is even likely that the program’s financial performance and 1. The education component of Credit long-term success will be enhanced by a with Education is so tightly woven healthier, better nourished, more informed, and into the credit service delivery more productive clientele. mechanism that it represents virtually no additional cost at the level of the village bank. The same field agent who organizes and trains village banks to manage loan capital also facilitates nonformal education.

A Literature Review and Analysis!40 CONCLUSION Incorporating nonformal health/nutrition and microenterprise education directly into the delivery system and organizational structure of a poverty lending program is a promising strategy for enhancing the food security and nutrition impact of these programs. Doing so builds upon the likely increases in women’s economic capacity and empowerment to promote the adoption of key nutrition and health behaviors that play such a critical role in re- dressing or preventing malnutrition. Through their cost-effective methods and remarkable repayment rates, poverty lending programs offer the possibility of reaching hundreds of thousands of poor households in a financially sustainable manner. Poverty lending combined with education could translate the likely modest increases in income and productive assets these households will enjoy into genuine improvement in household food security and nutritional status. It is interesting to note that this integrated strategy embodies many of the factors essential to successful nutrition programs identified at the 1989 International Conference of Inter- national Nutrition Planners in Korea (USAID, 1990):

! The need to address the problems of poverty and nutrition in an integrated, multisectoral manner. ! Active and genuine participation of the community, through decentralization of power, which promotes local searches for solutions. ! The targeting of the poorest and most marginalized. ! Greater attention to sustainability and cost-effectiveness and a central role for women’s groups.

Research Paper No. 1!41 RÉSUMÉ ANALYTIQUE comme étant l’approche de la “boite noire’ lors d’une évaluation de programme, en choisissant Les programmes de prêt à la pauvreté comme une approche plus orientée vers le processus. celui de la Banque Grameen ont capturé Cette approche de “boite noire” se concentre l’attention d’une audience qui s’étend seulement sur le fait de voir si l’impact désiré beaucoup plus loin que la communauté est atteint, tandis que la deuxième approche traditionnelle de développement. Beaucoup de aide à éclairer comment l’impact a été atteint cet enthousiasme est lié aux succès—les taux en suivant l’impact du programme à travers de remboursements, l’échelle et/ou le potentiel des processus adéquats. La première partie de pour une autosuffisance financière—plutôt ce document étudie l’évidence concernant les qu’aux impacts des programmes. Néanmoins, liens entre le revenu, la prise de pouvoir, le la valeur de toute stratégie de développement changement de comportement (hypo- dépend finalement de sa capacité à atteindre thétiquement en tant que bienfaits une amélioration pérennisée de la qualité de intermédiaires du prêt à la pauvreté) et la vie. sécurité alimentaire et le statut nutritionnel— Nous avons examiné la littérature les buts du résultat ultime. La deuxième partie académique et praticienne pour déterminer examine l’évidence que les programmes de quelles conditions nécessaires sont connues, prêt à la pauvreté ont un impact positif sur les ou solidement soutenues, pour que les bienfaits intermédiaires nécessaires pour programmes du crédit et de l’épargne puissent surmonter les causes sous-jacentes de la faim être efficaces contre la faim et/ou la malnutri- et de la malnutrition. Chaque section com- tion. En sachant qu’aucune revue littéraire ne mence avec un lien hypothétique, comprend peut être complète, ne peut fournir de réponses une revue de l’évidence que nous avons définitives, ou ne peut être sans préjudice trouvée pertinente à ce lien, puis finit avec des interprétatif, nous visons principalement la conclusions tentatives en ce qui concerne le stimulation d’une pensée, d’une recherche et lien. d’une pratique nouvelles. Toutes devraient être Les conclusions principales sont menées vers l’édification d’efforts innovants, résumées ci-dessous. efficaces, pérennisés et à grande échelle pour réduire radicalement la faim chronique et la 1ère PARTIE: Le lien entre les bienfaits malnutrition à travers le monde entier. intermédiaires (revenu, changement de L’approche utilisée est une revue des comportement, et prise de pouvoir) et la sources secondaires d’information—articles, sécurité alimentaire et le statut rapports et, chaque fois que possible, nutritionnel. évaluations de programme. De plus, des interviews ont été menées avec une variété de 1. Certaines conditions rendent plus direct praticiens qui sont principalement experts en l’impact du revenu augmenté sur la sécurité matière de crédit, des questions de sexe et de alimentaire du foyer (accès à la nourriture) et nutrition (voir ”annex” pour une liste des sur le statut nutritionnel. Il est plus probable individus consultés). Ces interviews se sont que des interventions auront cet impact quand révélées inestimables quant à leur part elles s’assurent que les augmentations de généreuse de perspicacité et d’expérience; revenus sont 1) vécues par les foyers les plus elles ont aussi permit un accès à des documents démunis, 2) contrôlées par les femmes, 3) de programmes non publiés qui sont gagnées de manière régulière plutôt que par généralement difficiles à obtenir. somme forfaitaire, et 4) qu’elles améliorent la Ce document vise à aller plus loin que ce sécurité générale de subsistance des foyers. que Pinstrup-Andersen (1983) mentionne 2. Le lien entre la sécurité alimentaire du

A Literature Review and Analysis!42 foyer et le revenu est plus direct que celui en- possibilité d’un feed-back positif de prise de tre le revenu et le statut nutritionnel pour une pouvoir concernant le gain et le contrôle des variété de raisons. Premièrement, le statut revenus semble probable, mais il nous faut nutritionnel est une fonction générale de encore trouver de la documentation sur un tel l’individu et non simplement une fonction de feed-back. l’accès à la nourriture ou même à la 5. Les manifestations économiques et consommation de celle-ci. Deuxièmement, les sociales de la prise de pouvoir semblent toutes décisions et les ressources concernant deux être cruciales pour que les femmes l’allocation de la nourriture à l’intérieur des effectuent des changements importants de foyers (tel que le temps du responsable) comportement nutritionnel et qu’elles peuvent considérablement modifier l’effet du demandent ainsi qu’utilisent correctement les revenu augmenté. Et troisièmement, les pra- services et les technologies sanitaires. Des tiques clés de l’alimentation de la mère et de sources indépendantes de revenus ont de fortes l’enfant et l’utilisation des services sanitaires chances de toucher le statut, l’autonomie et la existants influencent beaucoup aussi le statut confiance en soi des femmes. Des dimensions nutritionnel. sociales, telles qu’une mobilité plus 3. L’impact nutritionnel du revenu importante, une interaction publique, et/ou une augmenté sera contrecarré s’il n’est pas ajouté identification du groupe, sont aussi à l’amélioration de la santé des personnes les importantes pour la familiarisation des femmes plus vulnérables à la malnutrition, à savoir les aux idées nouvelles et à une découverte femmes et les jeunes enfants. Des potentielle du changement. En outre, un feed- changements dans les pratiques de soin back positif sur le changement de sanitaire et nutritionnel au niveau du foyer ont comportement envers la prise de pouvoir n’a plus de chance d’être la première direction de pas été documenté, mais parait probable. Il prévention et de traitement de la malnutrition. semble aussi que la prise de pouvoir joue un Par exemple, chacun des faits suivants a des rôle essentiel en créant un effet synergique implications nutritionnelles: la sélection et la entre le revenu et les comportements distribution de la nourriture dans le foyer; les importants sanitaires/nutritionnels. pratiques liées à l’allaitement maternel, à l’alimentation de l’enfant, et au traitement et 2ème PARTIE. Le lien entre le prêt à la à la prévention de la diarrhée; l’alimentation pauvreté et les bienfaits intermédiaires lors de la grossesse, l’allaitement , et/ou durant (revenu, changement de comportement, et et après une maladie; l’utilisation des services prise de pouvoir). sanitaires existants; l’hygiène personnelle, alimentaire et du milieu. Même sans le bienfait 1. Une évidence concrète de l’impact d’un revenu augmenté du foyer, ces économique des programmes de prêt à la comportements peuvent améliorer de manière pauvreté est rare. Les quelques évaluations dramatique le statut nutritionnel du foyer. rigoureuses à ce jour (principalement la Réciproquement, un revenu augmenté peut se Banque Grameen et certains affiliés produire en absence d’un changement de d’ACCION) indiquent que les programmes de comportement nécessaire et d’une prêt à la pauvreté augmentent en effet les amélioration nutritionnelle. revenus, les actifs et la productivité des 4. La capacité des femmes d’augmenter emprunteurs très démunis, à la fois hommes leurs revenus ou leurs contrôles sur le revenu et femmes. a un effet positif sur leur prise de pouvoir 2. Le prêt à la pauvreté préserve plus (confiance en soi, statut, et pouvoir de souvent le propre emploi de l’entrepreneur qui négociation à l’intérieur de leurs foyers). La travaille à son compte plutôt que de créer de

Research Paper No. 1!43 nouveaux emplois. Les revenus ont de fortes économiques en créant de nouveaux liens et chances d’être stabilisés ou plus ou moins une identification sociale. Ceci aide les augmentés durant une période de temps courte. femmes à résister aux restrictions Cependant, avec des prêts séquentiels et une traditionnelles et à encourager de nouvelles accumulation de l’expérience commerciale, les normes culturelles. Une étude littéraire plus participants peuvent passer à des activités étendue sur les groupes d’auto-assistance non potentiellement plus rentables. Une économique aurait de fortes chances de révéler productivité salariale (revenu net de l’heure) qu’une solidarité entre les groupes a un im- est un variable important qu’il faut inclure dans pact solide, direct et positif sur les mesures de toute étude de l’impact du crédit, surtout pour la prise de pouvoir de la personne et du groupe. les femmes. 5. La prise de pouvoir des femmes ris- 3. Le prêt à la pauvreté est mis au point que guère d’améliorer directement la sécurité pour soutenir principalement les activités alimentaire du foyer et le statut nutritionnel économiques existantes des démunis. A cause sans agir à travers un changement de des rendements pauvres et des contraintes comportement qui soit important soit structurelles des activités traditionnelles des économiquement soit nutritionnellement. De femmes, cette approche minimaliste n’amène même, les programmes de prêt à la pauvreté probablement pas d’amélioration économique risquent guère de promouvoir directement des importante chez les femmes. Parce que les changements de comportement qui sont liés femmes constituent la masse des participants soit à l’économie soit à la nutrition sans agir dans la plupart des programmes, le prêt à la grâce à une sorte de processus éducatif. La pauvreté risque guère de produire des gains prise de pouvoir des femmes est considérée économiques importants pour les foyers comme un fait qui rend les femmes “prêtes à démunis. Cependant, relativement parlant, ces l’apprentissage”, et les ressources gains modestes semblent faire des contribu- économiques des femmes peuvent leur tions importantes, telles qu’un revenu régulier permettre de mettre en pratique ce qu’elles ont et une assurance contre les urgences, à la survie appris. Mais un type de transfert d’information du foyer. Et ces dernières stratégies sont et de promotion du changement doit se précisément celles qui, si renforcées, sont produire avant que les femmes aient de fortes associées de manière la plus proche avec une chances de savoir pourquoi, comment et que augmentation de la sécurité alimentaire du changer. foyer et du statut nutritionnel. 6. Avec un programme éducatif, le 4. Le prêt à la pauvreté donne du pouvoir potentiel du prêt à la pauvreté pour riposter aux femmes participantes. En fournissant des contre la malnutrition peut se réaliser. Sans occasions pour un emploi indépendant, il l’éducation, le prêt à la pauvreté peut n’avoir augmente l’autonomie, la confiance en soi et qu’un seul effet possible et faible sur la sécurité le statut à l’intérieur du foyer des femmes. Des alimentaire du foyer et qu’un peu d’impact, réunions régulières et une garantie de leurs s’il existe, sur le statut nutritionnel. pairs aide à favoriser la solidarité de groupe, L’éducation peut être fournie aux participants ce qui réduit l’isolation des femmes et du programme de prêt à la pauvreté soit avec augmente leur familiarisation aux nouvelles un programme séparé soit en tant qu’élément idées et à l’information aussi bien que leurs intégré du programme même du prêt à la compétences pour dialoguer avec le secteur pauvreté. publique. Il y a même une preuve qui soutient l’hypothèse que les groupes de solidarité créent une prise de pouvoir de leurs membres indépendamment de leurs impacts

A Literature Review and Analysis!44 RESUMEN EXECUTIVO a un método más orientado al proceso. El método “black box” se enfoca solamente en Los programas de crédito para gente de el logro del impacto deseado, mientras que el recursos escasos como el Banco Grameen han último método ayuda iluminar como se logró captado la atención de una audiencia que al impacto por seguir el impacto del programa extende mucho más allá de la comunidad a través de procesos pertinentes. La Parte I tradicional de desarrollo. Mucho de ese del informe investiga la evidencia con respecto entusiasmo está relacionado con los éxitos a la relación entre los ingresos, el programáticos—el índice de devolución, la fortalecimiento de confianza en si misma, y el escala y/o la potencial para autosuficiencia— cambio de comportamiento (creido como los en vez del impacto de los programas. Sin em- beneficios intermediatos de crédito para gente bargo, el valor de cualquier estratégia de de recursos escasos) a la seguridad de desarrollo últimamente depende de la alimentos y el estado nutritivo—las últimas habilidad de alcanzar al mejoramiento metas. La Parte II examina la evidencia que sostenible de la calidad de vida. programas de crédito para gente con recursos Hemos examinado la literatura escasos tienen un impacto positivo en los académica y profesional para determinar qué beneficios intermediatos necesarios para está conocido, o fuertemente mantenido, como sobrepasar las causas fundamentales del condiciones necesarias para la eficacia de hambre y la desnutrición. Cada sección programas de crédito y ahorros contra el empieza con una relación hipotética, incluye hambre y/o la malnutrición. Por saber que un repaso de la evidencia que encontramos ninguna literatura puede ser comprensiva, no pertinente a la dicha relación, y termina con puede ofrecer respuestas definitivas, y no las conclusiones tentativas con respecto a la puede faltar el prejuicio interpretivo, queremos relación. actuar como estimulante para el pensamiento, Las conclusiones principales están la investigación, y las prácticas nuevas-- todos resumidas abajo. los cuales deben estar dirigidos hacia la construcción de esfuerzos innovadores, PARTE I: La relación de los beneficios efectivos, sostenibles, y de gran escala para intermediatos (Ingresos, Cambio de reducir drásticamente el hambre crónico y la comportamiento, y el fortalecimiento de malnutrición por todo el mundo. confianza en si misma) a la seguridad de El método implementado es un repaso de alimentos y el estado nutritivo. fuentes secundarios de información— artículos, informes, y cuando posible, 1. Ciertas condiciones hacen más directo el evaluaciones de programas. Además, hicieron impacto de ingresos aumentados en la entrevistas con varios profesionales expertos, seguridad de alimentos (el acceso a alimentos) principalmente en el crédito, los asuntos del y el estado nutritivo. Las intervenciones género, y la nutrición (vea el Annex para una probablemente tendrán este impacto cuando lista de individuos consultados). Estas aseguran que los aumentos de ingresos son entrevistas eran invalorables en cuanto al 1)experimentados por las familias más pobres, comparto generoso de ideas y experiencia; 2)controlados por mujeres, 3)ganados como también ofrecieron el acceso a documentos no ingresos continuos en vez de ingresos publicados de programas, los cuales por lo recibidos en suma global, y 4)buenos para la general no se puede obtener fácilmente. seguridad total de la familia. Este informe aspira ir más allá del método 2. La liga entre la seguridad de alimentos de la evaluación de programas llamado por de la familia y el ingreso es más directo que la Pinstrup-Andersen “black box” (caja negra), relación entre el ingreso y el estado nutritivo,

Research Paper No. 1!45 por varios razones. Primero, el estado nutritivo 5. Tanto la manifestacion económica es una función del salud total de un individuo como la social del fortalecimiento de confianza y no simplemente una función del acceso a en si misma parecen ser críticas para que las comida, ni siquiera el consumo de alimentos. mujeres hagan cambios importantes del Segundo, las decisiones y recursos del reparto comportamiento nutritivo y para que de alimentos entre familias (como el tiempo demanden y usen correctamente los servicios de la persona responsable del cuidado) pueden de salud y la tecnología de salud. Es probable modificar mucho el efecto de ingresos que los fuentes independientes de ingresos aumentados. Y tercero, las prácticas claves afecten al estado social de las mujeres, la de cuidado y alimentación de infantil y ma- autonomía, y la auto-confianza. Las terna y el uso de los servicios establecidos dimensiones independientes, como la también influyen al estado nutritivo. movilidad amplia, la interacción pública, y/o 3. El impacto nutritivo del ingreso la identificación con un grupo, también son aumentado será decepcionante si no está importantes para la exposición de la mujer a juntado al mejoramiento de la salud de los más nuevas ideas y la potencial para cambios. De vulnerables a la malnutrición, especialmente nuevo, la información positiva sobre los las mujeres y los niños. Cambios en la cambios de comportamiento a habilitarse tiene nutrición y las prácticas del mantenimiento de un papel principal en crear un efecto la salud al nivel de la familia estarán la primera sinergística entre los ingresos y los ruta de la prevención y el tratamiento de la comportamientos importantes de la salud y la malnutrición. Por ejemplo, cada de los nutrición. siguientes tiene implicaciones nutritivas: la selección y distribución de alimentos dentro PARTE II. La relación de crédito para gente de la familia; las prácticas relacionadas a la de recursos escasos a los beneficios lactancia materna, alimentacion de niños, y el inmediatos (Los ingresos, el cambio de tratamiento y la prevención de la diarrhea; las comportamientos, y el fortalecimiento de dietas durante el embarazo, la lactancia, y/o confianza en si misma). mientras de y después de una enfermedad; el uso de servicios establecidos de salud; la 1. La evidencia sólida del impacto económico higiene personal, ambiental, y de la comida. de programas de crédito para gente de recursos Aún sin el beneficio del ingreso aumentado escasos es rara. Las pocas evaluaciones de la familia, estos comportamientos pueden rigurosas hasta hoy (principalmente el Banco mejorar dramáticamente el estado nutritivo de Grameen y algunos asociados de ACCION) la familia. A la inversa, el ingreso aumentado indican que los programas de crédito para puede ocurrir en la ausencia de cambios gente de recursos escasos suben los ingresos, necesarios del comportamiento y el los bienes, y la productividad de los mejoramiento nutritivo. prestatarios más pobres, ambos mujeres y 4. La capacidad de las mujeres de hombres. aumentar sus ingresos o su control de los 2. El crédito para gente de recursos ingresos tiene un efecto positivo en su escasos a menudo preserva el auto-empleo del habilitación (la auto-confianza, el estado, y el empresario en vez de crear trabajos nuevos. poder de negociar dentro del hogar). La Es probable que los ingresos establezan o posibilidad de refuerzo entre el fortalecimiento aumenten en un corto plazo. Sin embargo, con de confianza en si misma y los niveles de préstamos consecutivos y la acumulación de ganancia y control parece posible, pero todavía experencia comercial, los participantes podrían falta la documentación de tal retro- cambiar hacia las actividades económicas más alimentación.

A Literature Review and Analysis!46 rentables. La productividad laboral (el ingreso las nuevas normas culturales. Una inspección total por hora) es una variable importante de más amplia de la literatura de grupos no incluir en cualquier estudio del impacto de económicos de auto-ayuda revelaría que la crédito, especialmente para las mujeres. solidaridad entre grupos tiene un impacto 3. El crédito para gente de recursos fuerte, directo, y positivo en los medidos de escasos está diseñado para apoyar fortalecimiento de confianza en si misma per- principalmente las actividades económicas sonal y de grupos. establecidas de los pobres. Por sus ingresos 5. Es improbable que el fortalecimiento bajos y los límites estructurales de las de confianza en si misma de mujeres mejore actividades tradicionales de mujeres, este directamente la seguridad de alimentos de la punto de vista minimalista probablemente no familia y el estado nutritivo sin actuar a través lleva a cabo mejoramientos económicos del cambio de comportamiento que es mayores para mujeres. Por el hecho que las importante economicamente o nutritivamente. mujeres constituyen la mayoría de los Del mismo modo, es improbable que los participantes en tales programas, es improb- programas de crédito para gente de recursos able que el crédito para gente de recursos escasos promuevan directamente los cambios escasos produzca ganancias económicas de comportamiento económicos o los significativas para los pobres. Sin embargo, relacionados a la nutrición sin actuar a través en terminos relativos, estas ganancias módicas de algún tipo de proceso educativo. Se cree pueden hacer una contribución importante a que el fortalecimiento de confianza en si la supervivencia de la familia, como la misma de mujeres las hace “lista para regularización de los ingresos y los seguros aprender”, y los recursos económicos de contra emergencias. Son precisamente los mujeres les permiten a realizar lo que han tipos de estratégias de ganarse la vida que, si aprendido. Sin embargo, debe pasar algún tipo reforzadas, son las más asociadas con la de transferencia de información y fomento de seguridad aumentada de alimentación famil- cambio antes que sabrían las mujeres qué iar y el estado nutritivo. cambiar y por qué y cómo. 4. El crédito para gente de recursos 6. Con un programa educativa, se puede escasos fortaleza la confianza en si misma de realizar la potencial de crédito para gente de las participantes mujeres. Por proveer recursos escasos de luchar contra la oportunidades de auto-empleo, sube la malnutrición. Sin educación, el crédito para autonomía de la mujer, su auto-confianza, y gente de recursos escasos solamente tendría su estado dentro de la familia. Las reuniones poco efecto positivo en la seguridad de regulares y la garantía de las otras ayudan a alimentación de la familia y poco, si lo hay, facilitar la solidaridad del grupo, que reduce impacto en el estado nutritivo. Se puede la aislación de la mujer y aumenta su proveer la educación a los participantes de exposición a nuevas ideas e información, tanto programas de crédito para gente de recursos como las habilidades de interactuar dentro del escasos por un programa separado o como un ambiente público. Existe la evidencia en componente integrado del programa de crédito apoyo de la hipótesis que los grupos de misma. solidaridad crean el fortalecimiento de confianza en si misma de sus participantes independientemente de los impactos económicos por crear nuevas ligas y la identificación social que ayudan a mujeres resistir las restricciones tradicionales y alentar

Research Paper No. 1!47 WORKS CITED

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Research Paper No. 1!53 ANNEX

Individuals consulted who contributed Noreen Clark—Professor and Chair, De- their advice, opinions, and guidance to the lit- partment of Health Behavior and Health Edu- erature review. (Titles reflect positions at time cation, School of Public Health, University of of consultation.) Michigan Marcia Griffiths—Manoff Group, Inc. Alan Berg—Nutrition Advisor, World Bank Nina Bowen—Africa Officer, Women and Development Office, United States As- Angela Van Rynbach—Country Director, sistance for International Development Save the Children (SAVE), Bangladesh (USAID)

Barry Sidman—Director, (IMPACT) Per Pinstrup-Andersen—Director, Cornell Food and Nutrition Policy Program Claudia Fishman—Deputy Director, Nu- trition Communication Project, Academy for Peter Gottert—Program Officer, Africa, Educational Development Academy for Educational Development

Dan Toole—Household Food Security, Reka Mehra—International Center for Project Officer, United Nations Children’s Research on Women Fund (UNICEF) Sidney Schuler—John Snow, Inc., Em- Eileen Kennedy—Senior Researcher, In- powerment of Women Program ternational Food Policy Research Institute Shelly Feldman—Faculty Member, Eugenia Eng—Department of Public Cornell Food and Nutrition Group and Em- Health, University of North Carolina, Chapel powerment Group, Department of Rural So- Hill ciology

Jeffrey Ashe—Independent Consultant Trudy Sharpe—Program Director Asia/ Pacific Region, Save the Children (SAVE) Julia Rosenbaum—Project Officer LAC/ Asia, Academy for Educational Development Urban Jonsson—Senior Advisor, (Nutri- tion), United Nations Children’s Fund Kenneth H. Brown—Department of Nu- (UNICEF) trition, University of California, Davis Valerie Uccellani—Program Officer Lynn Bennett—Women and Develop- Training, Academy for Educational Develop- ment Division, World Bank ment

Marilyn Carr—Senior Advisor, United Virginia Lambert—John Snow, Inc., Em- Nations Fund for Women (UNIFEM) powerment of Women Program

A Literature Review and Analysis!54