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From Agriculture to Nutrition: Pathways, Synergies and Outcomes

THE WORLD BANK AGRICULTURE AND RURAL DEVELOPMENT DEPARTMENT O 2007 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433

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Cover photos by World Bank staff members: vegetable produce at a Guatemalan market by Curt Carnemark; Senegalese girl carrying cassava leaves by Lianqin Wang; mother in BangIadesh feeding her child a food supplement by Shehzad Noorani. ACRONYMS AND ABBREVIATIONS vii

ACKNOWLEDGMENTS ix

EXECUTIVE SUMMARY xi

World Food Security And Nutrition Situation 2 Structure of the Report 7

Determinants of Human Nutrition and the Pathways Linking Agriculture and Nutrition 9 Pathways Linking Agriculture to Nutrition 12

The Impact of Agriculture Interventions on Nutrition Outcomes 15 The Nutritional Impacts of Agricultural Interventions 16 Gender Outcomes of Agricultural Interventions 30 Lessons Learned 31

Orange-Fleshed Sweet Potato Production and Vitamin A Deficiency in Mozambique 33 Legume Systems and Child Nutrition in Malawi 36 Integrating Homestead Gardening and Primary Health Care Activities in South Africa 38 Homestead Gardening for Fruits, Vegetables, and Livestock in Asia 39 Lessons from the Four Case Studies 42 iv Contents

The Changing Context of Agriculture and Nutrition Linkages 43 Agricultural Policy 43 Agricultural Technology 47 Food Marketing Systems 50 Food Consumption Patterns 53 Conclusions 56

1 Institutional Frameworks for Action in the Agriculture Sector to Address Undernutrition 59 Institutional Barriers to Coordinated Action in Nutrition 60 Resource Allocation and Planning 61 Sector Mandates and Priorities 61 Unique Sectoral Worldviews 62 Constrained Capacity for Nutritional Analysis 63 Institutional Mechanisms to Enable Agriculturists to Address Undernutrition 63 Conclusions 67

0 Lessons Learned and Next Steps 69

APPENDIX 7 3

BIBLIOGRAPHY 75

Figures 1 Estimated Prevalence of Stunted Preschool Children 1980-2005 4 2 Estimated Prevalence of Underweight Preschool Children 1980-2005 5 3 Overweight and Obesity among Women 45-59 Years of Age, by WHO Region 6

4 Estimated Prevalence of Overweight Preschool Children (O/O) 7 5 Conceptual Framework of the Determinants of IUutritional Status 10 7 Changes in Food Production per Capita over Ttme 48 6 Potential Impact of Technological Changes on Food Production and Consumption 48 Contents v

Boxes 1 Messages from Publications on Agriculture and Nutrition, 1970s-2000s 11 2 lntroducing Orange-Fleshed Sweet Potato in Rural Mozambique 34 2 lntroducing Orange-Fleshed Sweet Potato in Rural Mozambique, Cont. 35 3 Legume Systems in Malawi: Building on Local Knowledge, lmprovi ng Nutrition 37 Trade Liberalization and Food Availability: Synthesis of Cases in South Asia 4 6 Trade Liberalization and Food Availability: Synthesis of Cases in South Asia, Cont. 47 Decline in Consumption of Pulses in India: The Effect of Technology and Domestic Policies 49 Situating Nutrition Administratively within the Public Sector 60 The Institutional Study under the Agriculture-Nutrition Advantage Project 6 1 Nutrition and Sectorwide Approaches to Planning 62 Home Economists as Agricultural Extension Agents 66

Tables 1 Prevalence and Number of Undernourished People in Developing Countries 1990-2003 3 2 Key Results from Selected Studies of Agricultural Commercialization 17 3 Summary of the Evaluation Findings of Horticultural and Nutrition Projects 2 1 4 Summary of Intervention Studies on Impacts of Animal Source Food Interventions on Nutrition-Related Outcomes 25 5 Potential Effects of the Changing Context on Pathways Linking Agriculture and Nutrition 44 6 Annual Average Growth in Retail Sales of Packaged Foods, 1996-2002 51 7 the Growth of Modern Retail in Developing Countries 52 8 Composition of Global Agricultural Food Exports (% of value) 53 9 Average Annual Growth in Global per Capita Consumption ofvarious Food Items (%) 54 10 Average Annual Share of Arable and Permanent Land Used for Harvest (%) 5 5 11 Worldwide Annual Average Growth in Food Production (%) 56

Acronyms and Abbreviations

AVRDC Asian Vegetable Research and Development Center BMI body mass index CDD community-driven development FA0 Food and Agriculture Organization (United Nations) FRT Farmer Research Team HACCP Hazard analysis critical control point HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HKI Helen Keller International TDRC International Development Research Center IFPRI International Food Policy Research Institute NGO nongovernmental organization OECD Organization for Economic Co-operation and Development OFSP orange-fleshed sweet potato SETSAN Technical Secretariat for Food Security and Nutrition (Mozambique) SFHC Soils, Food and Health Communities Study (Malawi) SWAP sectorwide approach TANA The Agriculture-Nutrition Advantage Project UNESCO United Nations Educational, Scientific and Cultural Organization UNICEF United Nations Children's Fund USAID United States Agency for International Development VITAA Vitamin A for Africa VITAL Vitamin A Field Support Project WFSP white-fleshed sweet potato WHO World Health Organization WTO World Trade Organization

This report was prepared by a multi-institutional and interdiscipli- nary team from the International Food Policy Research Institute (IFPRI)and the World Bank (WB). The key contributors were Corinna Hawkes, Marie Ruel, Mary Arimond, Zeina Sifri, Todd Benson, Devesh Roy, and Noora-Lisa Aberman (IFPRI), Peter Berti (HealthBridge, Canada), Jef Leroy (National Institute of Public Health, Mexico), Edward Frongillo (University of South Carolina), Nwanze Okidegbe, Lynn Brown, Gunnar Larson, and Chris Delgado (World Bank). The task team would like to extend their thanks to the project ad- visors Nicolas Minot (IFPRI) and Peter Berti (HealthBridge), as well as to Michelle Adato, Damiana Astudillo, Bonnie McClafferty,and Ginette Mignot. The report's content editor was Gumar Larson (World Bank, Agriculture and Rural Development). Peer reviewers included Meera Shekar, James Garrett, Harold Alderman (World Bank), Beatrice Rogers (Tufts University), and Bruce Cogill (UNICEF). The task team thanks Sushma Ganguly (retired), Mark Cackler (Sector Manager and Acting Director of World Bank Agriculture and Rural Development), and the ARD Management Committee for their support and guidance. The team acknowledges Lisa Li Xi Lau for her support in the logistics and production of the report.

Executive Summary

INTRODUCTION In a world of food abundance, millions of people suffer from poor nutrition. In some parts of the world, the poor have inadequate access to energy from food to meet their energy requirements. In these locations, food shortage is often a seasonal phenomenon and micronutrients are also generally lacking in the diet. Elsewhere, there is a stable supply of energy but the poor have monotonous diets lacking in essential micronutrients. In other places a "nutrition transition" is under way in which the poor and other consumers enjoy sufficient access to energy, and indeed often consume excessive amounts, but the quality of their diets is unhealthy owing to a combination of factors relating to nutrition and lifestyle. Excessive consumption combined with more sedentary lifestyles, often associated with urbanization, contributes to an increasing incidence of obesity and chronic disease such as diabetes in countries still plagued by undernutrition. A combination of these nutritional problems adversely affects about 2 billion people worldwide. The relationship between agriculture and human nutrition is far more complex than the relationship between food production and food consumption or the economic relationship between food supply and food demand. Increased food production raises the availability of food, but by itself does little to ensure that poor and vulnerable people have access to the food that is produced. Nor does the gross quantity produced say much about the quality or nutritional value of people's diets. The persistence of malnutrition as a global public health concern despite the successes in increasing agricultural production belies any notion that malnutrition and undernutrition can be solved entirely from the supply side. How then can agriculture, with its customary focus on productivity and yields, more effectively contribute to improved nutrition outcomes? Expanding agriculture's purview and capacity to embrace those contributing factors and determinants of nutrition that are tradition- ally the province of other disciplines or improving agriculture's interface with other, nonagricultural sectors, suggest themselves as possible ways forward. Those sectors that approach nutrition in relation to its essential role in building and maintaining human capital are particularly important prospective counterparts in this regard. Yet operationally integrating the necessary inputs of other sectors into agriculture interventions, or effectively coordinating the respective xii From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

contributions of sector ministries in larger develop- that shed light on how agricultural interventions ment programs and policies, is in practice fraught and investments may improve nutrition outcomes with difficulty. Historically, multisector efforts in- in low- and middle-income countries. tended to simultaneously address agriculture and nutrition have often been hindered by institutional barriers and insufficient resources. PATHWAYS LINKING The limitations of production-focused agricul- AGRICULTURE TO NUTRITION tural programs and interventions in delivering im- A widely used conceptual framework published by proved nutrition impacts have been recognized by UNICEF in 1990 identifies three main underlying some in the agricultural community for decades. In determinants of nutritional status: availability and the early 1980s a number of international develop- access to food, the quality of feeding and care giv- ment agencies undertook programs that sought to ing practices, and the health of the surrounding en- orient agricultural production to nutrition-related vironment and access to health care services. Each objectives, and over time a substantial body of lit- of these determinants is a necessary but not suffi- erature developed around the analysis of the pro- cient condition to good nutrition. The food supply grams' results. A review of this literature yields a chain linking food production with food consump- number of insights as to how agricultural invest- tion and human nutrition can be usefully consid- ments can be designed and targeted to improve nu- ered in terms of five pathruays. trition outcomes. Malnutrition remains an urgent global public health concern. Yet the question of Subsistence-oriented production for the how agriculture can most effectively contribute to household's own consumption improved nutrition outcomes remains essentially Income-oriented production for sale in markets unanswered. It is therefore time to revisit what is Reduction in real food prices associated with known and what can be done to improve the syn- increased agricultural production ergies between agriculture and nutrition. The po- Empowerment of women as agents instru- tential contribution of agriculture needs to be mental to household food security and health reexamined, especially in light of the changes the outcomes sector has undergone, by reviewing lessons from Indirect relationship between increasing agri- past experience and by analyzing current develop- cultural productivity and nutrition outcomes ments and what they mean for future change. That through the agriculture sector's contribution to is the purpose of this report. national income and macroeconomic growth Household production for the household's orun con- OBJECTIVE sumption is the most fundamental and direct pathway by which increased production translates into The report seeks to analyze what has been learned greater food availability and food security. The dif- about how agricultural interventions influence nu- ferent types of foods produced determine the im- trition outcomes in low- and middle-income coun- pact of the production increase on diet quality. The tries, focusing on the target populations of the production of staple foods leads mainly to greater Millennium Development Goals-people living on access to and consumption of energy. Increased less than a dollar a day. It also sets out to synthesize production of fruit, vegetables, and animal source lessons from past efforts to improve the synergies foods (dairy, eggs, fish, and meat) can likewise between agriculture and nutrition outcomes. The raise access to energy, protein, and fat, but can also report identifies a number of developments in agri- greatly improve the quality and micronutrient con- culture and nutrition that have transformed the tent of diets. Some proportion of the food produced context in which nutrition is affected by agricul- may also be intended for sale on local markets. ture. These developments have considerable prac- Some households may for instance meet their sta- tical significance for nutrition-related agricultural ples requirements themselves while depending on programs?including the design of those programs markets for other products such as fruits and veg- that aim to improve nutritional outcomes. Finally, etables. Others may rely mainly on home gardens the report draws a number of practical conclusions for fruits and vegetables. Whatever role produc- ... Executive Summarv XIII tion-for-income plays in this scenario is secondary from food to other expenditures, including produc- to the principal purpose of producing food to meet tive investments. the household's own food requirements. Finally, agricultural growth itself represents an in- Income-oriented production for sale in markets. AS direct pathway to better nutrition through its con- agricultural households become more market ori- tribution to macroeconomic growth and higher ented, production-for-own-consumption becomes levels of national income, which can support nutri- less significant relative to income from the sale of tional improvements by reducing poverty. what is produced. Technology becomes more im- Increases in agricultural productivity have been portant relative to the household's resource endow- vital factors in building sustained economic ment, and the selection of crops to be grown is growth in both developed and developing coun- based principally on their tradability and the price tries and have major impacts on poverty. One they are expected to command in local markets. cross-country analysis found that a 1 percent in- Extra income may be used to buy more food, crease in agricultural yields lowers the percentage higher-quality (more nutrient-dense) foods, or both; of a national population living on less than a dollar the balance between the two affects the final impact a day by between 0.64 and 0.91 percent-a poverty of this additional income on the household's con- effect that appears particularly great in African sumption of energy and micronutrients. The trans- countries (Thirtle et al. 2002). Overall, however, the lation of increased income into better child economic growth-to-malnutrition relationship is nutrition, in turn, depends on a series of intrahouse- modest. A doubling of gross national product hold factors and processes. These include women's (GNP) per capita in developing countries has been status, education, knowledge, health-related prac- associated with a much more modest reduction in tices, decision-making power, income, and access to childhood undemutrition-on the order of 23 to 32 and use of health and sanitation services. percent (Haddad et al. 2003). The empowerment of ~uomenis a pathway that carries special significance for household nutrition outcomes and in particular for children's health THE IMPACT OF AGRICULTURAL and nutrition outcomes. Women have consistently INTERVENTIONS ON NUTRITION been found to be more likely than men to invest in OUTCOMES their children's health and well-being, and the income and resources that women control wield dis- The literature reviewed in this report documents proportionately strong effects on health and the nutrition outcomes of agricultural programs nutrition outcomes generally. Women who are and can be usefully classified by the type of com- reached by agricultural programs that relay infor- modity the program involved: staples, fruits and mation on nutrition issues appear to be particularly vegetables, or animal source foods. Studies on the effective at delivering improved nutrition out- nutritional impacts of programs involving staple comes, and the effects appear to be most pro- crops such as maize and rice focused overwhelm- nounced among the lowest income groups. Taken ingly on aggregate production and food availabil- together, these characteristicsmake women natural ity rather than on individual- or household-level priorities for agricultural programs that aim at im- indicators and therefore yielded little evidence that proving nutrition. These programs, however, must is germane to this report. Moreover, the only agri- take women's time and resource constraints firmly cultural interventions involving staple foods that into account and, where and when possible, seek have been evaluated from a nutritional perspective means of relieving them. concern agricultural commercialization-the con- Lo~ueringfood retail prices by increasing food pro- version from staple subsistence food production to duction is another pathway linking agriculture to commercial food production. This type of interven- nutrition and is especially important in areas in tion aims to improve nutritional outcomes through which markets are less integrated. For net con- both the own-consumption and the income path- sumers, reduced food prices enable greater access ways, with potential indirect impacts through the to food and essential nutrients, resulting in better agricultural growth and price pathways. Evidence health and productivity for the general workforce from the review of studies on agricultural commer- while also freeing additional household resources cialization shows increases in household income, xiv From Agriculture to Nutrition: F'athways, Synergies, and Outcomes

including greater income controlled by women in nutrient-rich foods by target population groups, some cases and greater household food expendi- and the two studies that measured biochemical in- ture. These changes did not, however, translate into dicators showed reductions in vitamin A defi- substantial improvements in child nutrition. In ciency. Common elements that appear to have order to improve childhood nutrition, agricultural contributed to the success of these four programs commercialization interventions would most likely include a strong behavior change component, care- need to be complemented by components or paral- ful consideration of local contexts, partnership lel interventions that specifically target other deter- building with different community members to minants of child nutrition. These would include promote ownership, and a specific focus on improved health, care giving practices, and access women's empowerment. The studies also reaffirm to water and sanitation facilities to address the high that careful evaluation design is critical but re- rates of infections affecting young children in poor mains a challenge, as does the scaling up of suc- environments. cessful pilot programs. Agricultural interventions promoting increased Overall the review documents a wide range of production of fruit and vegetables-such as those successful agricultural interventions that have con- involving homestead gardens--carry considerable tributed to improved nutrition outcomes. In most potential to effectively address micronutrient defi- cases, however, the exact pathways by which im- ciencies. The review identified a significant body of pacts on nutrition have been achieved are difficult evidence documenting the success of homestead to track. Most studies document impacts on several gardens in raising production, income, household intermediary outcomes such as food security, in- consumption, and the intake of targeted fruit and come, or women's empowerment, but without di- vegetables by vulnerable population groups. rectly modeling these pathways of impact to Several programs also showed significant impacts nutrition outcomes. Because these outcomes are so on dietary and biochemical indicators of micronu- closely intertwined, it is impossible to determine trient deficiencies, and especially so when they in- from this literature the relative importance of the cluded components designed to change behavior different pathways that connect agriculture and through education and to empower women. nutrition. Programs and interventions involving animal The key lessons learned from this body of evi- source foods have even greater potential to tackle dence are that agricultural interventions are most micronutrient deficiencies, especially vitamin A, likely to affect nutrition outcomes when they in- iron, and zinc deficiencies. These micronutrients volve diverse and complementary processes and are more readily bioavailable in animal source strategies that redirect the focus beyond agriculture foods than in plant foods. Several interventions for food production and toward broader considera- showed gains in production, income, and house- tion of livelihoods, women's empowerment,and op- hold food security, and significantly greater nutri- timal intrahousehold uses of resources. Successful tion impacts when combined with interventions projects are those that invest broadly in improving involving women's empowerment, education, and human capital, sustain and increase the livelihood behavior change. assets of the poor, and focus on gender equality. Four case studies of agricultural interventions were reviewed because of their unique contribution to the body of knowledge on the linkages be- THE CHANGING CONTEXT OF tween agriculture and nutrition. They include an AGRICULTURE AND NUTRITION orange-fleshed sweet potato intervention to im- LINKAGES prove vitamin A intake in Mozambique, a legume systems and child nutrition program in Malawi, a Over time, changes in the global environment homestead gardening project integrated with pri- have been modifying how agriculture affects nu- mary health care activities in South Africa, and an trition and have made the need for integrating integrated homestead gardening and livestock pro- agriculture and nutrition interventions even more gram in Asia. All four programs achieved their ul- imperative. Four types of global changes are em- timate objective of improving the intake of focus phasized in the report: changes in agricultural pol- Executive Summary xv icy, agricultural technology, food marketing sys- availability, prices, demand, and consumption are tems, and food consumption patterns. These plant breeding and technologies related to food pre changes affect the broader context within which cessing and marketing, such as those that maintain nutrition-oriented agricultural interventions are a cold-chain from farm to plate. Technologies that implemented. They also affect each of the path- increase productivity, such as Green Revolution ways through which agriculture affects nutrition, crop breeding technologies, have significantly re- notably consumption of own-production, produced food prices of the targeted crops. This in turn ducer incomes, and food prices. has led to significant reductions in childhood malnutrition. Simulation models estimate that without the Green Revolution, the proportion of malnour- Agricultural Policy ished children in South Asia would now be 12 to 15 Agricultural policy in most developing countries points higher than it is. Improvements in posthar- has recently undergone a major paradigm shift as vest technology and marketing for fruit and vegeta- part of what is often termed "globalization." bles can also lead to sigruficantly reduced consumer Although the role of the government in food mar- food prices. Changes in technology affect the de- kets remains extensive, governments have disman- mand for agricultural labor and thus the income of tled state marketing mechanisms and liberalized farm and nonfarm households in rural areas. New trade and investment. The level of taxation or "dis- technologies can be labor saving or labor enhanc- protection" of agriculture has declined over time ing; some may have no effect at all on labor de- through trade liberalization in the nonagricultural mand. Studies published during the 1990s sectors and changes in exchange rate regimes. documented a variety of positive impacts of tech- Private markets have generally assumed greater im- nology change on labor demand, incomes, food portance relative to state intervention, and agricul- consumption, and diet quality-but failed to ex- ture's increased market orientation has changed hibit an impact on childhood nutrition. (This was in producers' incentives, with important effects on fact attributed to the failure of increased income and food availability and prices. food consumption to translate into better childcare, At the national level, the impact of liberalization feeding, and health-seeking behaviors-key ele- on commodity prices will vary across commodities ments of improved nutrition.) Biofortification, an depending on whether the country is a net-importer agricultural technology that can increase the mi- or a net-exporter of that commodity. The observed cronutrient content of staples, may confer large ben- pattern of trade in which developing countries are efits to poor rural populations who have little access net exporters of high-value, micronutrient-rich to expensive high-quality foods. These improved crops implies that consumer prices are higher for crops can benefit nutrition through the own-con- those products than the prices that would prevail in sumption pathway when they are consumed by a closed economy. The reverse would hold for the producers, through the income pathway when they supply of macronutrients since many developing are sold, or through the food price pathway when countries are net importers of grains. Agricultural they increase the availability of micronutrient-rich policy changes can also affect nutrition through the foods in the marketplace. producer income pathway. Again, the overall impact of trade liberalization on income is likely to dif- Food Marketing Systems fer depending on the initial status of the country (as a net importer or exporter), and across farmers The past two decades have seen a major transfor- within the country depending on whether they are mation and consolidation of food retail and an ex- net producers or net consumers. pansion of the food processing and food service industries, especially in middle-income countries and in urban areas of low-income countries. These Agricultural Technology trends are driven by rising household incomes, ur- The growth of agricultural technology has been banization, improvements in transportation, dramatic over the past 25 years. Developments that lifestyle changes, and liberalized foreign invest- carry particularly important implications for food ment regulations. The rapid growth of supermar- xvi From Agriculture to Nutrition: Pdthways, Synergies, and Outcomes

kets in developing countries in the past 10 to 20 sedentary lifestyles are dramatically reducing the years is increasingly important in shaping food level of physical activity and thus energy require- consumption patterns and will most likely affect ments. Negative outcomes like obesity, heart dis- nutrition through changes in food availability and ease, and diabetes quickly become endemic, which prices. With the rising availability and generally in turn prompt additional changes in the demand lower prices of processed foods in marketplaces for food. Functional foods that carry health benefits and food service establishments throughout much become the focus of advertising and the communi- of the developing world, a growing proportion of cation of health-related information, with dramatic food expenditures go to processed foods relative to effects on the types of foods that are demanded. fresh food sources. Changes in the composition of The trend offers a variety of important opportuni- agricultural exports also affect the types and price ties for producers who are able to respond to the of foods available and current trends show rapid changing demand. As consumers manifest greater growth in the share of agricultural products that willingness to pay more for healthier foods, re- are processed compared with fresh products. This sponsive producers find a very real prospect that changing pattern of exports has implications for the downward pressure on prices exerted by in- nutrition through the price pathway because it increased production may be reversed. However creases the availability of certain foods over others promising this prospect may be, the ability of poor in exporting and importing countries. Whereas producers to capitalize on the emerging opportuni- consumers in developing countries now consume ties is contingent on a number of factors, not the more processed foods and vegetable oils exported least of which is the risk of converting to the culti- from developed and other developing countries, vation of unfamiliar crops. In the final analysis, consumers in industrialized countries now con- much will depend on the success of arrangements sume more fruits, vegetables, and fish exported like contract farming, which enables poor farmers from developing countries. to link their production with large, often supermar- ket-led supply chains. Changing Consumption Patterns Conclusion The demand for higher-value, micronutrient-rich foods increases as incomes rise and livelihoods di- Changes in agricultural policy, technology, mar- versify around expanding markets, many of them kets, and associated changes in food consumption urban. Increasing incomes and urbanization drive patterns are changing the pathways through which changes in demand that provide food suppliers agriculture and nutrition are linked. Today, the with market signals that tend to reorient agricul- more market-oriented nature of agricultural poli- tural production away from the cultivation of sta- cies means that agricultural technology and mar- ples and toward higher-value products. For kets play a more important role in determining smallholders in particular, this reorientation is food prices and rural incomes, as more food is con- often in effect compulsory, because the viability of sumed from the marketplace and less from house- farming lower-value staple crops relies on much holds' own-production. The greater market larger scales of production than are possible on orientation of food production and consumption small farms. For food consumers, and especially has increased the bidirectional links between agri- net food consumers, the shift in consumption away culture and nutrition. Agricultural production re- from staples and toward higher-value food sources mains an important factor contributing to brings a phenomenon that is generically referred to nutritional outcomes, but changing food and nutri- as the "nutrition transition." The phenomenon is tional demands are exerting new effects on agricul- most pronounced in rapidly growing economies tural production. Agricultural programs with and in urban areas, in which the proportion of food nutritional objectives need to take this changing prepared at home declines in relation to the pro- context into account to ensure that the synergies portion of processed foods consumed in and out- between agriculture and nutrition are successfully side the home. Diets tend to become increasingly exploited and lead overall to better development energy-dense, and very often excessively so, at the outcomes. same time that automation, transportation, and Executive Summary xvii

INSTITUTIONS LESSONS LEARNED AND Improving nutritional outcomes is a decidedly NEXT STEPS multisectoral goal and requires the involvement of Policy makers and practitioners have long aimed to several players, including households and public influence nutritional outcomes through agricultural and private sector agents. It also requires the in- programs. Many of these programs supported com- volvement of government institutions that formu- mercialization and cash crop production or the pro- late public policy and that in so doing influence the duction of fruit and vegetables or animal source settings in which agriculture-nutrition pathways foods with overall objectives of raising agricultural are or are not operationalized. Jurisdiction over productivity and household income. The assump- food production and food supply is generally as- tion was that agriculture would tackle poverty and signed to a country's ministry of agriculture. malnutrition by increasing food production, lower- Nutrition, however, is not ordinarily considered a ing food prices, and increasing household income. sector but rather a policy issue or area that does not While food production and household food avail- fall cleanly within the jurisdiction of any particular ability, income, and in many cases food consump- ministry or agency. Health ministries generally as- tion and diet quality increased, childhood sume the most direct responsibility for nutrition, malnutrition persisted. This led to the conclusion but they have no administrative jurisdiction or in- that increasing agricultural production and income fluence over agriculture or trade-the most impor- were probably necessary but clearly not sufficient tant sector ministries addressing food supply and conditions to reducing malnutrition. Far more sub- availability. Common sense may suggest the estab- stantial impacts were achieved when agricultural lishment of a governmental multisector agency to interventions incorporated nonagricultural compo- coordinate joint action among these ministries, a nents or combined with complementary nonagri- course which has been pursued by a number of cultural interventions that addressed other countries. These coordinating bodies have how- determinants of child nutrition. These other deter- ever seen little if any success in achieving effective minants included maternal health-seeking and cooperation between sector ministries, leaving lit- caregiving practices. Arming women with knowl- tle empirical basis for assuming that such institu- edge about appropriate child feeding practices, the tional adaptations actually work. Concerted importance of different micronutrients, and the programmatic coordination between different min- food sources in which those micronutrients are isterial-level institutions tends to run headlong into available was a particularly effective way of im- the bureaucratic barriers that divide spheres of re- proving child health and nutrition outcomes. sponsibility between different line ministries. Incorporating nonagricultural criteria like Bureaucracies in general are organized to ration- health and nutrition into the design and conduct of ally divide responsibilities within institutions, not agricultural programs to improve nutrition sug- to orchestrate joint collaboration between them. gests developing an effective interface between Coordination between different government insti- agricultural and other institutions. Yet systematic tutions is therefore problematical, but cannot be high-level coordination between different sector dismissed altogether. Possibilities for such collabo- ministries is challenging given the bureaucratic ration are by no means limited to systematic high- barriers that typically divide them. The report level institutional frameworks. More limited, therefore examined alternative approaches to for- lower-level opportunities for collaboration to ad- mulating a more comprehensive approach for agri- dress specific and local issues contributing to mal- culture programs to embrace improved nutrition as nutrition appear to offer greater promise for a development objective. effectiveaction. This local collaboration offers the The empirical evidence presented in this report prospect of incrementally improving higher-level focuseson agricultural programs and interventions coordination of multisectoral action to address carried out at the level of local communities. food insecurity and malnutrition effectively on a Overall, the review found that the most successful national basis. projects were those that invested broadly in improving human capital and sustained and increased the livelihood assets of the poor. The four xviii From Agricullure to Nutrition: Pathways, Synergies, and Outcomes

key lessons learned about how these programs tion to the health and nutrition of their should be developed and implemented in order to children is an established axiom of develop- help achieve improved nutrition outcomes are ment planning. This education by no means summarized below. has to be limited to formal education. Develop and iinpleinent agriclrlttrral prograins Communication of information about health that take into account local contexts. The impor- issues such as appropriate child-feeding and tance of designing programs that accommo- childcare practices, water sanitation, and food date prevailing agricultural and nutritional safety issues carries great importance for nu- conditions has long been recognized and en- trition by addressing caregiving and health as tails developing a sound understanding of necessary conditions of good nutrition. Other producers' priorities, incentives, assets, vul- public information services, including those nerabilities, and livelihood strategies. For agricultural extension services that convey in- these programs to benefit nutrition, however, formation about issues like integrated pest there is also a need to understand and target management, likewise have important posi- the major nutritional problems experienced tive health impacts and many can also be tai- by the target communities an aspect that is lored to reach women. usually ignored in agricultural program de- Develop and impleineiit agrictrlttrral prograins sign and development. Understanding the that incorporate ntrtrition otrtreach and behavior motives and constraints that affect household change. Whether regarded as a resource or a consumption decisions is no less important service, the value of information that is di- than understanding those that affect produc- rected at behavior change among farmers and tion decisions. Cultural norms, for instance, consumers presents itself as a salient conclu- are often key factors determining which sion of this report. Agricultural interventions household members maintain control over that include a nutrition education component which household resources, and influence will increase the likelihood of positive nutri- such nutritionally vital decisions as the allo- tional outcomes. Those who are armed with cation of types and quantities of food among information and knowledge about the nutri- household members. Thus, successful agri- tional significance of the foods they produce culture programs aimed at improving nutri- and eat are able to make better production tion must first develop an understanding of and consumption decisions. Nutrition-related the economic, social, and cultural factors that education and communication strategies may determine household decisions concerning offer instruction on food preparation and livelihood, agriculture production, household safety and on child-care and feeding prac- consumption, and intrahousehold allocation tices, as well as on how to recognize and act of resources, as well as the context-specific upon signs of nutritional deficiencies. Here, health and nutrition problems that prevail. too, targeting women with health and nutri- Develop and iinpleinent agrictrlttrral programs tion information is likely to have a still greater that enable arid empozucr roomen. The essential catalytic effect, given their typically closer af- role of women in delivering health and nutri- filiation with the household and their crucial tion outcomes makes gender an inevitable role as child caretaker. priority area for agricultural programs and * Prozlide sinall prodticers rclith help and strpport to policies that seek to contribute to nutrition. respond to changes in the global environment and Targeting women in their roles as economic especially to the changing food demand. Anti- agents and stewards of household food secu- cipating and responding to changing demand rity and health generally entails increasing is a vital imperative for farmers in general, but their access to productive resources and serv- among poor farmers in developing countries ices-an ostensibly straightforward proposi- the stakes are particularly high. A significant tion that in reality must take into account and part of their production is intended for their purposefully navigate around a variety of households' own consumption, and therefore women's constraints, including cultural con- much of the demand they are satisfying is their straints. The significance of women's educa- own. With respect to the proportion of food Executive Summary xix

they produce for market, the changing agricul- learned sheds light on the dynamics and causal re- tural context has important implications for lations that agricultural practitioners should take the prices they are paid for their products, into account when planning programs or providing while increasing demand for high-value food policy advice that focuses the crosshairs of produc- sources represents an important opportunity tion goals onto a nutrition-related target or targets. to earn more income. Yet switching to new and There is by now good reason to anticipate that nutri- unfamiliar crops and producing for foreign tional aims will come to play more prominently in markets with stringent food quality and safety the calculus by which the value of agricultural pro- requirements is also fraught with risk, and grams is rated. Future agricultural programs irnple- both opportunities and risks need to be ad- mented with nutritional objectives will need to dressed by agricultural programs. address the real challenge of going to scale and This report consists mainly of a review of empir- should be carefully monitored and rigorously eval- ical evidence about past and ongoing cases of agri- uated to ensure that performance can be continually cultural interventions with nutrition-related tracked and improved. The expository account of- objectives and more broadly about connections be- fered in this report, it is hoped, lays the groundwork tween agricultural production and nutrition. Its for more practical work in which the details of ap- analysis of the practical implications of the lessons plying these lessons operationally can be prescribed.

Introduction

In a world abundant with food, millions of people suffer from poor nutrition. In some parts of the world, the poor have inadequate access to energy (measured in calories) from food. In these locations, food shortages are often seasonal phenomena, and the quantitative deficit of food energy is generally matched by deficits in food quality reflected in insufficient essential micronutrients including vitamin A, iron, zinc, folate, and many others. Elsewhere consumption among the poor is characterized by monotonous diets in which these micronutrient deficiencies are found despite stable and sufficient intakes of food energy. Still other places see a "nutrition transition" under way in which diets are characterized by excessive intakes of energy, largely from fat, added sugars, and energy-dense processed foods, and in which lifestyles are characterized by generally low levels of physical activity. This combination of excessive energy intake and low activity patterns is associated with overweight and obesity and a variety of chronic diseases including diabetes and heart disease. Together these adverse nutrition outcomes affect some 2 billion people worldwide. The factors that contribute to malnutrition and poor nutrition outcomes are complex and vary across production and consumption settings. Sector-specific strategies tend to approach nutrition issues along narrowly disciplinary lines and generally disregard contributing factors that fall outside the purview of that particular field. Agriculture's role as the source of food production makes its significance to nutrition unquestionable. Yet the persistence of malnutrition as a global public health concern despite increasing agricultural production belies any notion that the malnutrition and undernutrition problem can be solved entirely from the supply side by increasing production. Nutrition is intrinsically multisectoral, and strategies to improve nutrition outcomes should seek to purposefully integrate the contributions of relevant disciplines. How agriculture's necessary input into nutrition issues is to be operationally coordinated with the likewise necessary input of nonagricultural sectors is a more difficult matter. Historically, multisector efforts intended to simultaneously address agriculture and nutrition have often been hindered by institutional barriers and insufficient resources. Agricultural investments and interventions supported by the World Bank and other international development and donor agencies have seldom explicitly incorporated nutrition-related objectives. The From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

World Bank itself last examined this issue in 1981 in lessons from past experience and by analyzing cur- a study by Per Pinstrup-Andersen, which made a rent developments and what they mean for future number of recommendations for incorporating nu- change. This is the purpose of this report. tritional effects into the design and planning of agri- More specifically, the report seeks to analyze cultural policies and programs. A recent review of what has been learned about how agricultural inter- its agriculture and rural development portfolio re- ventions influence nutrition outcomes in low- and vealed little or no lending for nutrition issues to be middle-income countries, focusing on the target included in agricultural education or extension ser- populations of the Millennium Development vices. The only nutrition-focused agricultural inter- Goals-people living on less than a dollar a day. It ventions to receive significant support from also sets out to synthesize lessons from past institu- international development and donor agencies in tional and organizationalefforts to improve the syn- recent years involved the still-developing technol- ergies between agriculture and nutrition outcomes. ogy of biofortification. The report identifies a number of developments in The contexts in which agriculture and nutrition agriculture and nutrition that have transformed the are linked have, moreover, changed since the 1980s context in which nutrition is affectedby agriculture. (Hawkes and Rue1 2006b). The focus of nutrition as These developments have considerable practical a development issue, and a human development significance for nutrition-related agricultural pro- issue in particular, has expanded from an early em- gramsincluding the design of those programs that phasis on energy-protein deficiency to include mi- aim to improve nutritional outcomes. Finally, the re- cronutrient deficiencies, and more recently extends port sets out a number of practical conclusions that to the relationship between excess energy intake, shed light on how agricultural interventions and in- poor-quality diets, obesity, and chronic diseases. vestments may improve nutrition outcomes in low- The agricultural context itself is also changing. and middle-income countries. Although 75 percent of the world's poor still live in rural areas with poor access to markets and ser- WORLD FOOD SECURITY AND vices, fewer people are now dependent on agriculture for their livelihoods and more are connected to NUTRITION SITUATION markets. The percentage of poor people who live in The Food and Agricultural Organization (FAO) es- urban areas in developing countries is growing. timates that in 200043,854 million people world- Urbanization reflects a migration away from rural, wide were undernourished, as defined by food agriculture-based employment and into urban intakes that are continuously inadequate to meet livelihoods. People in cities are less likely to experi- dietary energy requirements (FA0 2006). The num- ence undernutrition and more likely to experience ber included 820 million people in developing the "nutrition transition" toward energy-dense countries, 25 million in transition countries, and 9 diets high in fats, sweeteners, and highly refined million in industrialized countries. In developing carbohydrates (Popkin 1999). Overall, the processes countries, this represents a decline of only 3 million of global market integration, or "globalization," people since 1990-92. And although significant have increased the market-orientation of the agri- progress has been achieved in Asia, the number of food system worldwide, unleashing dynamics undernourished people in Africa has been increas- throughout the food supply chain that affect food ing, as shown in table 1. producers and consumers. Food security, a broader concept than under- Malnutrition remains an urgent global public nourishment, necessarily goes beyond the satisfac- health concern. The question of how agriculture tion of people's energy requirements through can most effectively contribute to improved nutri- sufficient intakes to encompass access to "suffi- tion outcomes remains unanswered. It is therefore cient, safe and nutritious food to meet dietary time to revisit what is known and what can be done needs and food preferences for an active and to improve the synergies between agriculture and healthy life" (FA0 1996). A summary of the nutri- nutrition. The potential contribution of agriculture tional situation in the world is presented here in needs to be reexamined, especially in light of the three categories: childhood undernutrition, mi- changes the sector has undergone, by reviewing cronutrient deficiencies, and overweight and obe- Introduction 3

sity and related chronic diseases. More complete cronutrient deficiencies and disproportionately af- analyses of these trends are available in the 2006 fect women and young children. World Bank report Repositioning Nutrition for Childhood undernutrition dropped globally be- De7relopment and in the fourth and fifth reports on tween 1980 and 2005. Stunting now affects approx- the world nutrition situation issued by the United imately one-third of all children in the developing Nations Standing Committee on Nutrition in 2000 world, compared to one-half in 1980. The propor- and 2004. tion of underweight children fell from 38 percent to 25 percent during the same period. Yet there were an estimated 164.79 million stunted and 137.95 mil- Child Undernutrition lion underweight children in developing countries It is well recognized that the most nutritionally vul- in 2005. Figures 1 and 2 show that most of the re- nerable population groups are pregnant and lac- ductions in undernutrition since the 1980s have tating women, whose bodies must cope with the been achieved in Asia and Latin America. In Africa, additional nutritional stresses and demands of the number of stunted children decreased, while pregnancy and lactation, and infants and young the proportion and number of those who are un- children up to age two. The present report ad- derweight increased slightly dresses these vulnerable groups, but with a greater emphasis on children's nutrition because most of Micronutrient Deficiencies the work linking agriculture and nutrition to date has focused on this age group. Childhood under- Vitamin A, iron, zinc, and iodine are the most nutrition is typically reflected in anthropometric widespread nutritional deficiencies globally, and indicators such as stunting (low height-for-age), they affect women and young children dispropor- wasting (low weight-for-height), and underweight tionately. They may or may not overlap with pro- (low weight-for-age).Stunting reflects the cumula- tein and energy deficits. Vitamin A deficiency is tive effects of inadequate nutrition, whereas wast- widespread throughout the developing world, af- ing reflects more recent or acute weight loss. These fecting between 78 and 254 million people, includ- symptoms are nonspecific and reflect a combina- ing an estimated 127 million children (UN SCN tion of nutritional deficiencies including protein, 2004; West 2002). Shortage of the nutrient in the energy, and/or micronutrients. They may be sea- diet can limit growth, weaken immunity, cause xe- sonal or chronic. Dietary shortages of vitamin A, rophthalmia (an irreversible eye disorder leading iodine, iron, and zinc are the most widespread mi- to blindness), and increase mortality. Seventy per- 4 From Agriculture to Nutrition: Pa~hways,Synergies, and Outcomes

cent of preschool children in Benin and Kenya are immune function. In school-age children, it can af- subclinically vitamin A deficient, compared to just fect school performance, and in adults it may lower 5 percent in Venezuela, revealing the wide vari- work capacity. Iron deficiency anemia is responsi- ability in the condition's prevalence among devel- ble for tens of thousands of maternal deaths each oping countries (Somrner and West 1996). year (UN SCN 2004). Iron deficiency is estimated to be the most Iodine and zinc deficiency are also widespread prevalent nutritional deficiency, affecting 4 billion and account for a large share of the poor develop- to 5 billion people. The estimated prevalence of ment, health, and survival outcomes of children in iron deficiency among children under five years of developing countries (UN SCN 2004). Deficiencies age in 80 developing countries in 2004 was 54 per- of key vitamins and minerals continue to be perva- cent, as compared to an estimated 34 percent who sive, and they overlap considerably with problems are vitamin A deficient. Again, the range in preva- of general undernutrition (underweight, wasting, lence behveen countries is wide. An estimated 20 and stunting). percent to 35 percent of children under five years of age are iron deficiency anemic in Latin America Overweight, Obesity, and Diet-Related and Southeast Asia, compared to an estimated 75 Chronic Diseases percent to 85 percent in many African countries (Adarnson 2004). In young children, iron deficiency A set of very different nutrition-related outcomes may impair growth, cognitive development, and affect people whose nutrient intakes exceed their Introduction 5

energy expenditures, resulting in obesity and a va- but in Latin America, the Middle East, and South riety of chronic diseases associated with excess Africa, overweight is also higher than underweight weight, including heart disease and diabetes. in rural areas (Mendez and Popkin 2004). Overall, Among poorer populations in particular, energy- the World Health Organization predicts that by dense, low-quality diets are likely to remain defi- 2015, approximately 2.3 billion adults will be over- cient in essential micronutrients. Overweight and weight and more than 700 million will be obese obesity are now highly prevalent in every region of (WHO 2006). the world.' The prevalence of overweight children Overweight and obesity are strongly associated under five is also increasing throughout the devel- with the risk of several chronic diseases, including oping world. The prevalence of childhood obesity diabetes, cardiovascular diseases, and several in the developing world increased by 17 percent types of cancer. Figures 3 and 4 show trends in between 1995 and 2005, whereas in Africa it in- overweight by region since the 1980s among adult creased by 58 percent. The reason that Africa is ex- women and among preschool children. Chronic periencing such an exaggerated trend is not diseases are the largest cause of death in the world, entirely clear, owing to a lack of data, but the rise in prevalence of overweight among mothers is likely to be part of the explanation (World Bank 1 Overweight is defined as a body mass index (BMI) 2006b). The prevalence of overweight is consider- (weight/height square) greater than 25; obesity is defined as ably higher in urban areas in the developing world, BMI greater than 30. 6 From Agriculture to Nutrillon: Pathways, Synergies, and Outcomes

led by cardiovascular disease (17 million deaths in ease is the leading cause of mortality (WHO 2005). 2002, mainly from ischemic heart disease and The global prevalence of the leading chronic dis- \ stroke) followed by cancer (7 million deaths), eases is projected to increase substantially during chronic lung diseases (4 million), and diabetes mel- the next two decades. The number of individuals litus (almost 1 million) (Yach et al. 2004). Although with diabetes, for instance, is projected to rise from chronic diseases have been the leading cause of 171 million or 2.8 percent of the global population death in developed countries for decades, 80 per- in 2000 to 366 million, or 6.5 percent in 2030-298 cent of deaths from chronic diseases now occur in million of whom will live in developing countries developing countries, in which cardiovascular dis- (Wild et al. 2004). Introduction 7

STRUCTURE OF THE REPORT The background and description of types of adverse nutrition outcomes given in this introduction are followed in chapter 2 by an analysis of the determinants of human nutrition, setting out a number of pathways through which agriculture can potentially affect nutrition. Chapter 3 presents a review of available evidence of how agricultural interventions influence nutrition outcomes. Chapter 4 presents a series of four more detailed case studies of agricultural interventions that had explicit nutrition-related objectives. Chapter 5 examines the changes in agriculture and nutrition that are affecting the operational contexts in which nutrition- focused agricultural interventions are carried out. Chapter 6 focuses on the institutional issues related to the operationalizing agricultural development strategies that have nutritional objectives, primarily at the national level. It maps out the state-level institutions involved with agriculture and nutrition and analyzes the barriers that have posed Latin America and the C problems for closer coordination in the past. Chapter 7 draws a set of conclusions as to how agri- All Developing Countries cultural interventions and investments could ac- celerate improvements in nutrition in low- and Source: UN Standing Committee on Nutrition 2004. middle-income countries. Note: Preschool children defined as children under the age of 5.

Determinants of Human Nutrition and the Pathways Linking I Agriculture and Nutrition

International development agencies have been designing approaches and programs linking agriculture and nutrition to address the problem of malnutrition since the 1960s. The conventional link has been from agriculture to food security. The lack of an explicit indicator of food security led to the use of anthropometric indicators to measure nutritional status. Yet these indicators capture far more than food security as illustrated in a conceptual framework of nutrition developed by UNICEF (UNICEF 1990), (Figure 5). Food security is just one underlying determinant of nutrition, along with the quality of maternal and child care, the adequacy and use of preventive and curative health services, and whether individuals are living in a healthy environment. The more immediate determinants of nutritional status are dietary intake and health status. The focus of this report is on the connection between agricultural production and dietary intake via food security. In the 1970s food price spikes prompted alarm and concerns about food availability and brought the term "food security" into the development arena. Programs operated under an assumption that agriculture's primary role in this equation was to address protein-energy deficiencies by increasing food production and lowering food prices. During the Green Revolution the availability of staple cereals increased globally and prices fell proportionately, yet protein-energy malnutrition persisted. Publications on agriculture-nutrition linkages became critical of what appeared to be an implicit assumption that improved nutrition would follow naturally from the gains achieved through production increases. Box 1 lists the key messages to emerge from these publications during this period and afterward. In 1981 the World Bank commissioned a report by Per Pinstrup- Andersen titled Nutritional Consequences of Agricultural Projects: Conceptual Relationships and Assessment Approaches, which argued that if agricultural development was to better contribute to improving nutrition, nutritional aims would have to be explicitly incorporated into agricultural production decisions. Amartya Sen's work on famines and the concept of entitlements, together with the failure to achieve real improvements in nutritional outcomes, led food security practitioners to shift their attention to improving poor households' income and their economic access to food. 10 From Agriculture to Nutrition: Palhways, Synergies, and Outcomes

The change was reflected by the messages in alleviating micronutrient malnutrition, includ- emerging from publications produced in the early ing through emerging technologies such as biofor- 1990s (box 1).In particular, the nutritional implica- tification (Bouis 2000). This reflected a shift in tions of agricultural commercialization (mainly the emphasis in nutrition programs in general. "Food- shift to cash cropping) were examined. Studies based" strategies were developed to promote mi- found that even when commercial agricultural cronutrient intake, such as through homestead schemes increased income, they did not substan- gardening. At the same time the food security def- tially improve child nutrition status, leading to the inition evolved from a focus on availability and conclusion that income alone could not solve mal- economic access to include food utilization, en- nutrition. In the nutrition community, meanwhile, compassing diet quality and care issues. This cul- there was a distinct shift in the late 1990s away minated in the 1996 World Food Summit definition from the concept of agriculture as an intervention of food security: to reduce energy deficiency and increase income and toward the importance of addressing mi- Food security exists when all people, at all cronutrient deficiencies through agriculture. A times, have physical and economic access to conference held in the Philippines in 1999, sufficient, safe and nutritious food to meet improving Human Nutrition through Agriculture: The their dietary needs and food preferences for Role oflnternational Agricultural Research, brought an active and healthy life. together nutritionists and agricultural scientists to assess the role that agricultural research could play World Food Summit Plan of Action Determinants of Human Nutrition and the Pathways Linking Agriculture and Nutrition 11 12 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Yet even today the conception of "food security" help improve nutrition by reducing diarrheal dis- employed by the agricultural community often ne- eases. These broader links between agriculture and glects the nutritional aspects of this more complete health are beyond the scope of this report but were definition and in so doing misses important op- discussed in a recent study by the International portunities to contribute to improved nutrition Food Policy Research Institute and a special jour- outcomes. This persistent neglect was a driver in nal issue on agriculture and health linkages undertaking the work leading to this report. The (Hawkes and Rue1 2006a; Hawkes et al. 2007). 1990s also marked a shift to greater focus on Five pathways linking agriculture with food women, including intrahousehold resource alloca- consumption and human nutrition along the tion issues in agriculture and income control and food supply chain are described below: caregiving. In the early 2000s efforts focused on the Increased consumption from increased food role of women and on the importance of combining production agriculture interventions with nutrition education Increased income from the sale of agricultural and behavior change to maximize their impact on commodities nutrition @ox 1). These complementary interven- Increased empowerment of women as agents tions and their focus on empowering women had instrumental to improved household food se- the objective of not only increasing food availabil- curity and health and nutrition outcomes ity and access, but also of ensuring appropriate Reductions in real food prices associated with child-feeding, childcare, and health-seeking prac- increased food supply tices to improve nutritional outcomes. Agricultural growth, leading to increased national income and macroeconomic growth PATHWAYS LINKING and to poverty reduction and improved nu- AGRICULTURE TO NUTRITION trition outcomes There are several pathways through which agri- The pathways are archetypal, representing culture can contribute to improved nutrition. The model forms that in reality are by no means self- agriculture-to-nutrition pathways can be charac- contained or mutually exclusive. Subsistence pro- terized along a continuum between the most direct duction, for instance, generally takes place and the least direct, the most direct being charac- alongside production for sale because few house- teristic of subsistence production, the least direct holds are self-sufficient in food and because food is reflecting the macroeconomic effects of agricultural not the only requirement that must be met. Income growth on national-and indeed global-popula- is therefore very important even among house- tions. Particularly in the case of households that holds that produce principally for their own con- produce principally for their own consumption, sumption. The income and price pathways are food and nutrient consumption is directly affected likewise overlapping in that the price reductions by the specific foods the households themselves resulting from increased food supply are given in produce. This relationship becomes more and real terms and as such serve to raise real income. more complex as production becomes more market Pathway 1: Increased consumption from increased oriented. food production (production-for-own-consumption). In Agriculture can also affect nutrition through af- cases in which the degree of market orientation is fecting health in general. Good nutrition is intu- low, food consumption is strongly influenced by itively a precondition for good health, but the the level and pattern of agricultural production. relationship runs both ways. Good health is also a The resource endowments of the households (such precondition for good nutrition, enabling people to as land and labor) along with the available tech- metabolize the nutrients they digest. Thus, if agri- nology determine the level of production of differ- cultural interventions support positive health out- ent crops, which, in turn, affects the consumption comes-by providing conditions conducive to the patterns of the households. This agriculture-con- reduction of infectious diseases, for instance-nu- sumption linkage is particularly relevant in the trition outcomes can be improved. Agricultural in- case of subsistence or semisubsistence households. terventions to improve food safety and reduce the Increases in production can lead to greater food incidence of food-borne diseases can, for example, availability and consumption at the household nts of Human Nutrition and the Pathways Linking Agriculture and Nutrition 13 level. This, in turn, can increase the food intake of improve the micronutrient content of their diet, young children, who are most at risk of malnutri- without necessarily increasing energy intakes. Of tion, assuming that intrahousehold allocation of course, the extent of the nutritional benefits relies food is equitable and takes into account their par- on the nutrient content of the higher-value substi- ticular needs. The type of food produced influences tute food; but it also relies on how well the substi- whether increases in production will affect mostly tutes offset existing nutritional deficits within the diet quantity (energy intakes) or diet quality (mi- household. The distribution of different types of cronutrient intakes). Staple foods can contribute food among different individuals in the household, significantly to alleviating energy (calorie) gaps, and among the more nutritionally vulnerable indi- whereas fruits and vegetables, dairy, eggs, fish, viduals in particular, is also a vital determinant of and meat products can make key contributions to nutrition outcomes. The distribution of nutrition alleviating gaps in essential micronutrients such as and other health-related benefits in the household iron, zinc, and vitamin A. Animal source foods and is a function of often complex decision-making fruits and vegetables make staple foods more processes strongly determined by culture and tra- palatable, thus leading to overall greater food in- ditions. The people with the greatest influence over take. Animal source foods themselves are also rich these decisions tend to be those who control house- sources of energy and protein. Some proportion of hold resources. In the production-for-own-con- the food produced may very well be intended for sumption scenario, these resources center on sale in local markets. Some households may, for in- control over the household's basic resource en- stance, meet their staples requirements themselves dowment of land, labor, and capital. In the pro- while depending on markets for other products duction-for-income scenario, the most important such as fruits and vegetables. Others may rely resource tends to be income, and the most impor- mainly on home gardens for fruits and vegetables. tant decision makers are those who control income Whatever role production-for-income plays in this flows. Thus who controls the income is critical- scenario is secondary to the principal purpose of and in part explains why women are so vital in in- producing food for the household's own food re- fluencing the pathway between agriculture and quirements. nutrition. Pathzuay 2: Increased incomefrom the sale of agri- Pathway 3: Empowerment of women agriculturists. cultural commodities (productionfor-income). As the Studies from Africa, Asia, and Latin America market orientation of agricultural households in- clearly show that women's income-and level of creases, the "production-for-own-consumption" control over income-has a significantly greater pathway just described declines in significance. positive effect on child nutrition and household Rather, income from the sale of surplus production food security than income controlled by men now assumes a primary role, while production for (Quisumbing et al. 1995; Katz 1994; Hoddinott and the household's own consumption becomes sup- Haddad 1994). Women have consistently been plemental. And, rather than desirability for con- shown to be more likely than men to invest in their sumption, ability to sell becomes a principal children's health, nutrition, and education. Thus, criterion influencing the foods produced. Increases agricultural interventions that increase women's in income can in turn translate into improvements income and their control over resources can dra- in household food security and food consumption matically increase the potential for positive child as well as individual food intakes. nutrition outcomes and health outcomes. The pos- However, additional income often has little or itive effects of increases in women's income on no effect on energy intakes because households childhood nutrition moreover appear most pro- tend to shift their consumption to purchase higher- nounced among the lowest income groups. quality, more expensive foods that do not neces- In their roles as agricultural producers and sarily provide more energy. Staple food producers, income earners, as well as in their roles as care- for instance, may use the income earned from the givers, women who are reached by communica- sale of their produce to buy fruits, vegetables, meat, tion and education services that relay information and fish, and their households may consume these on health and nutrition issues appear to be partic- as substitutes for some proportion of the staples ularly effective agents in delivering improved nu- they consume. This substitution may significantly trition outcomes. These roles include child and 14 From Agriculture lo Nutrition: Pathways, Synergies, and Outcomes

elder care, food production, food preparation, Pathzilay 5: Macroeconomic grozilth arising from water collection, and a variety of income-generat- agricultural growth. Agricultural growth can theo- ing activities, all of which have the potential to retically lead to broad improvements in nutrition contribute to improved nutrition. Thus, the incor- simply by virtue of its contributions to macroeco- poration of a gender equity dimension in agricul- nomic growth and national income. Increases in ture programs and the consideration of women's agricultural productivity have been and remain multiple roles and constraints must be addressed important drivers of sustained economic growth, for agricultural programs to achieve positive nu- particularly among countries in relatively early trition impacts. phases of economic development. Some evidence Pathway 4: Lower real food prices resulting fronr in- suggests that the growth in production results in creasedfood production. Increased food production lower food prices, higher real wages, and a related can reduce food prices, thereby raising the real in- reduction in poverty rates. In theory, as outlined in come of people who purchase this food in the the food price pathway described above, reduced marketplace. Food prices are also affected by na- food prices allow greater access to food, resulting tional food availability, which is a reflection of im- in better nutrition for the general workforce while ports and exports as well as production. Lower also freeing additional household resources from food prices, in turn, can increase household food food and other expenditures, to savings and pro- security and raise energy and micronutrient con- ductive investments. Recent evidence confirms sumption. that growth in agricultural productivity is impor- Changes in food prices are largely driven by tant for poverty reduction. A cross-country analy- changes in the technologies and marketing chan- sis published in 2002 found that a 1 percent nels employed by producers. Together, changes in increase in agricultural yields effectively decreases technologies and markets affect the cost of produc- the percentage of a country's population living on tion and, often (but not always), consumer prices. less than a dollar a day by 0.64 percent to 0.91 per- Lower retail prices are likely to benefit consumers cent, with a slightly higher reduction for African more than the agricultural households selling the countries (Thirtle et al. 2002). Overall, however, the food, but even so, the impact of lower prices on the economic growth-to-malnutrition relationship is net incomes of the agricultural households will de- modest. A doubling of gross national product pend on new costs of production and the elasticity (GNP) per capita in developing countries has been of demand. The most common example of this link associated with a much more modest reduction in is the effect of Green Revolution technologies on childhood undernutrition--on the order of only 23 the price of grains. to 32 percent (Haddad et al. 2003). The Impact of Agriculture Interventions

Outlined in the previous chapter are the potential pathways linking agriculture and nutrition. But what is the evidence documenting the actual contribution that agriculture has made to nutrition outcomes via these pathways? This chapter reviews this evidence, focusing on the first three pathways: increased consumption from increased food production, increased income from the sale of agricultural commodities, and empowerment of women agriculturists. Identifying evidence on the latter two pathways-the effect of lower food prices and agricultural growth-proved much more difficult, given that there is little documentation of the nutrition outcomes of these changes at the household or individual level. The review is based on a systematic search of recently published literature and a limited search of unpublished documents, as well as personal contacts with project officers and international agency staff. The search centered on studies of agriculture interventions that had evaluated individual-level nutrition outcomes, such as child nutritional status, individual food or nutrient intakes, and diet q~ality.~It drew on previous reviews (Peduzzi 1990; Soleri et al. 1991a, 1991b; Gillespie and Mason 1994; Rue1 2001; and Berti et al. 2004) with the purpose of updating and expanding on them. Much of the analysis related to animal source foods was taken from Leroy and Frongillo (forthcoming). A description of search methods and results is provided in the appendix. "Interventions" are defined broadly to mean changes purposefully introduced into an existing agriculture system to promote new technologies, management practices, production and marketing methods, and other aims that may or may not include components designed to improve nutrition. Those that do entail explicit nutrition objectives are emphasized in this report because these interventions are more likely to document nutrition outcomes. The nutrition outcomes themselves are treated in terms of the following. Household-level food consumption, which includes household- level consumption of foods and food groups, or energy (calories), and household expenditure on foods and food groups

2 Other types of agricultural interventions, such as ~~o~~foodcrops or oil seed crops or technology-based rather than crop-based interventions, were excluded from the review because they typically fail to examine nutrition impact. 16 From Agriculture to Nutrilion: Pathways, Synergies, and Outcomes

Individtlal food and nutrient intake, which in- prevailing idea that energy intakes were the pri- cludes intakes of macro- and micronutrients mary constraint in the diets of the poor (McClaren and of foods rich in specific micronutrients 1974; Waterlow and Payne 1975). Still, shifts to- that are the focus of interventions such as ward more diversified diets were documented in those addressing vitamin A and iron defi- instances in which they occurred. These studies ciencies also reported results disaggregated by income Nutrition status, which includes anthropomet- group and examined the role of control of income ric indicators, such as height, weight, and by women as opposed to men. body mass index, and micronutrient-specific Results from these and closely related studies indicators, such as serum retinol (indicator of were synthesized, yielding a series of conclusions vitamin A status) and hemoglobin (indicator that are summarized in table 2 (DeWalt 1993; of iron status) Kennedy et al. 1992; von Braun and Kennedy 1994). The principal results did not differ substantially between case studies of the commercialization of sta- THE NUTRITIONAL IMPACTS OF ple food crops versus other cash crops. In sum, the case studies documented fairly consistent positive AGRICULTURAL IN'TERVENTIONS impacts on focus crop production, household in- Interventions involving staple foods. The only agricul- come, and food expenditures, but no substantial tural interventions involving staple foods that have impacts on young child nutritional status (the main been evaluated from a nutritional perspective con- indicator assessed across studies). In one case in cern agricultural commercialization-the conver- which subsistence food production was not main- sion from staple subsistence food production to tained, outcomes were worse. DeWalt (1993) con- commercial food production. Although the evalua- cluded that a focus on commercialization per se tions had assessment of impacts on nutrition out- was misplaced and that impacts on food consump- comes as an objective, the interventions themselves tion and child nutrition were determined by con- were not designed to affect child nutritional status trol of production and income, allocation of per se; objectives were more general and aimed at household labor, maintenance of subsistence pro- increasing food production incomes for farm duction, land tenure, and pricing policies for both households, or both. The evaluations thus mea- food and nonfood crops. Kennedy et al. (1992) also sured the interventions' impact on nutrition out- attributed the lack of impact on child nutritional comes through the production-for-income pathway status to the generally high levels of morbidity ob- (indirectly, agricultural commercialization may served in project areas. also have had indirect effects through the agricul- Overall, the authors made the following nu- tural growth and price pathways). trition-related conclusions: Some early conceptual reviews of links between Generally, participation in cash-crop schemes agricultural commercialization and nutrition had resulted in increased household income. suggested the potential for negative impacts, al- Increases in income were accompanied by though some of these examples related to conver- increases in food expenditures, but impacts sion to nonfood crops (Fleuret and Fleuret 1980). on consumption were also dependent on One early review showed mixed effects on nutri- changes in relative prices. tion, some negative and some positive, but also Dietary energy intakes increased in most identified methodological issues that constrained cases but decreased in some, as food expendi- interpretation and comparison (von Braun and tures shifted to more expensive items such as Kennedy 1986). Given these uncertainties, the au- meat and fruits; potential improvements in thors designed and undertook a series of mi- diet quality were suggested but not quantita- crolevel case studies that included assessment of tively assessed. nutrition outcomes as an explicit objective (von Increases in women's income were docu- Braun and Kennedy 1994). The study's focus was mented in some studies and were generally on the impact of commercialization on energy in- linked to increases in household energy con- takes rather than on diet quality or micronutrient sumption; this effect was most pronounced intake and was therefore consistent with the then- among the lowest income groups. The Impact of Agriculture Interventions on Nutrition Outcomes 17 18 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes The Im~aclof Aariculture Interventions on Nutrition Outcomes 19 20 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Overall, participation in cash-cropping starting with the VITAL reviews and then reviews schemes did not have a significant impact- by Gillespie and Mason (1994), Ruel (2001), and negative or positive-n young child nutri- Berti et al. (2004). tional status. In 1990 and 1991 the USAID-funded Vitamin A Children's morbidity levels were generally Field Support Project (VITAL) carried out an as- high and not affected by the schemes and sessment of past and then-current household gar- were interpreted to be a major constraint to den interventions and their impacts on nutrition improving child nutritional status. outcomes. The aim was to inform the planning of Evidence from this set of studies suggests that future research and initiatives. Focusing on the ef- cash cropping was often associated with greater fects of homestead gardens on the intake of vitamin household income, including, in some cases, A-rich foods and improving vitamin A status, the greater income controlled by women, as well as review yielded a number of recommendations on greater food expenditures. This usually translated design, targeting, and evaluation of homestead into greater household-level energy intake, but gardens as a means of strengthening their nutri- sometimes households shifted to more expensive tional impact. The main recommendation was that sources of energy. When this shift occurred, it may interventions should focus on women (through the have resulted in greater dietary diversity, which is female empowerment pathway) and provide nu- generally a sign of improved overall diet quality, trition education services to promote appropriate but the studies did not specifically assess this as- processing, storage, and cooking techniques of vit- pect. Impacts on child nutritional status were lim- amin A-rich foods. They should also promote a di- ited and mixed. The studies therefore suggest that verse variety of vitamin A-rich foods to meet both although agricultural interventions that promote subsistence and marketing needs and take into ac- commercializationmay effectively increase income count cultural preferences when foods to be intro- and food expenditures, they are not sufficient to duced are selected. improve childhood nutrition if they are not com- A review by Gillespie and Mason published in plemented by interventions that specifically ad- 1994 considered 13 programs aimed at improving dress other determinants of child nutrition such as diet quality, seven of which included homestead improved health, diet quality, child feeding, and gardening. Four of these were combined with so- other caregiving practices. cial marketing activities, and all four exhibited a interventions involving fruits and vegetables. number of indirect benefits such as increasing Despite the existence of a wide variety of fruit and women's income and social status. Yet only one vegetable production systems, only homestead project, carried out in Bangladesh, showed a posi- garden production systems have been imple- tive effect on vitamin A status in addition to in- mented and evaluated with an explicit nutrition creased energy intakes and improvements in the objective. These primarily target the first pathway, economic status of women. A summary of the eval- increasing own production for consumption, with uation findings of horticultural and nutrition pro- a secondary pathway of income increases from jects is presented in table 3. sales of higher-value products. The results of more recent evaluations included Homestead gardens take a wide variety of in the reviews by Ruel (2001) and Berti et al. (2004) forms, in backyards, farmyards, kitchens, contain- are summarized in table 3. The Ruel review pub- ers, small patches of available land, vacant lots, on lished in 2001 found that the interventions that did rooftops and tabletops, and along roadsides and not include a nutrition education component (gen- the edges of fields. They are generally close to a erally those conducted before the mid-1990s) failed house and source of water and are managed by to achieve significant impacts on nutritional out- family members using low-cost inputs. Their prod- comes. Subsequent interventions that incorporated ucts include fruits, vegetables, herbs, condiments, education, social marketing, and mass media cam- and sometimes secondary staples like legumes and paigns together with homestead garden initiatives sweet potatoes, most of which are grown for did demonstrate impacts. The main conclusion of household consumption. The nutrition impacts of the review was that homestead gardening com- homestead gardens have been relatively well doc- bined with effective promotional and educational umented. This section draws on previous reviews, interventions have the potential to improve the nu- The Impact of Agriculrure Interventions on Nutrition Outcomes 2 1 2 2 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

24 From Agriculture to Nutrition: Pathways, Synergies, and outcomes

tritional status of populations-but that homestead creased income, including increased income gardening alone is much less likely to improve nu- among women agriculturists. Most of the studies trition. The review also emphasizes that using a showed a positive impact on production of animal gender-sensitiveapproach to agricultural interven- source foods, despite the large variability of pro- tions could strengthen their impact on nutrition. motional interventions. Similarly, most interven- The review published by Berti and colleagues in tions that measured income or expenditures also 2004 used a sustainable livelihoods framework to reported increases in these indicators. assess whether different agricultural interventions However, impacts on dietary intake and nutri- invest in different types of capital: human, physical, tional status showed mixed results. For aquacul- social, environmental, and financial. Interventions ture interventions, one intervention may have that invest more broadly invarious types of capital, actually decreased dietary quality because it led to as is usually the case with homestead gardening a switch from consumption of small fish (which are programs, tended to have a greater impact on nu- consumed whole and contain high levels of cal- trition than those that focus more narrowly on agri- cium and vitamin A) to greater consumption of culture. The authors concluded that the agricultural larger fish with poorer micronutrient density (Roos interventions most likely to be successful invest in et al. 2003; Bouis et al. 1998).In another, there were natural, physical, social (including gender consid- no differences in total fish consumption between erations), human (especially nutrition education), the fish-producing and non-fish-producing house- and financial capital. holds (Roos et al. 2003). In a third study, interven- The 2001 and 2004 reviews led to a common con- tion households appeared to have consumed more clusion that homestead gardeningprojects after the fish, but the analyses were not subject to statistical mid-1990s were successful if they incorporated testing (Thompson et al. 2000). human capital-related components, notably com- Similarly mixed results were found for dairy in- munication and nutrition education activities tar- terventions. In one intervention in India, house- geting behavior change among their audiences, holds in villages with milk cooperatives actually and the incorporation of gender considerations in consumed less milk than households in villages project design. The power of nutrition education without cooperatives. The overall nutrient con- has been identified in other studies. Block (2003), sumption of households with cows in intervention for example, demonstrated that nutrition knowl- villages did, however, rise, whereas nutrient con- edge is a key determinant in how household food sumption among nonproducing households fell budgets are allocated. Households with nutrition (Alderman 1987). In another intervention in India, knowledge allocate substantially larger shares of children in households that produced more than 5 their household food budgets to foods rich in mi- liters of milk per day had adequate dietary protein cronutrients and are unwilling to reduce con- intake, although none of the groups met their en- sumption when staple food prices increase. This ergy requirements (Begum 1994).A third interven- impact is not due to maternal schooling per se, tion in East Africa found that households with which has been independently demonstrated to crossbred cows consumed more energy, fat, pro- improve child nutrition outcomes. tein, retinol, and iron than nonadopters, and in Intervenfioru involving animal sourcefoods. Leroy Kenya, women participating in the intervention re- and Frongillo (forthcoming)reviewed 15 interven- ported increased milk consumption (Ahmed et al. tion studies on animal source foods, including 4 on 2000; Mullins et al. 1996). aquaculture, 5 on dairy production, 3 on poultry, Poultry interventions in Bangladesh and Egypt and 3 in which livestock production was one com- saw higher intakes of a range of nutrients among ponent of larger integrated projects. The findings participating households than among nonpartici- concerning the impacts of these studies on produc- pating households (Gala1et al. 1987; Nielsen 1996). tion, income and expenditure, women's status, and Another poultry intervention in Bangladesh did dietary intake and nutritional status are summa- not lead to increased egg or chicken consumption, rized in table 4, together with additional studies re- but participating households did eat more fish, viewed for this report. The studies cover several of suggesting that the intervention led to increased the pathways outlined in chapter 2, including in- income and subsequent dietary change (Nielsen et creased production of own consumption and inal. 2003). The Impact of Agriculture Interventions on Nulrition Outcomes 25 2 6 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

28 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes The lm~actof Agriculture Interventionson Nutrition Outcomes 29 30 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Three of the interventions focusing on animal women's status and their and control over income source foods incorporated nutrition education and are critical to improved nutrition outcomes. were combined with fruit and vegetable produc- Yet women farmers face a series of constraints tion (see "mixed interventions" in table 4). In that limit their potential as agricultural producers Ethiopia, children in participating households had and their control of the resources that flow from the slightly more diverse diets and were significantly adoption of new technologies. The constraints are more likely to drink milk four or more times a week well-documented and include weak land rights, (Ayalew et al. 1999a; Habtemariam et al. 2003). In limited access to common property resources, lack Vietnam the intervention group had higher intakes of equipment and appropriate technology, limited of vegetables, fruits, energy, protein, vitamin A, contact with agricultural extension, lack of access and iron and exhibited higher growth rates among to credit, and lower levels of education children (English et al. 1997).It is not clear whether (Quisumbing et al. 1995). All of these constraints the animal production caused the positive effects conspire to substantially lower the productivity of because the interventions were multifactorial. In women farmers, resulting in high opportunity Thailand, vitamin A intake increased in the inter- costs for households and communities (Alderman vention and the control groups, but the increase et al. 1995; Quisumbing- et al. 1998). was greater in the intervention group (Smitasiri Efforts to ensure that women benefit from agri- and Dhanamitta 1999). cultural development interventions can be broadly Leroy and Frongillo (forthcoming) concluded classified into three types of approaches: "women- that the interventions associated with marked im- only" projects, projects targeted to both women provement in dietary intake and nutritional status and men but with some resources allocated specif- had one of two key characteristics: either women ically for women, and projects in which gender is- played a critical role in the intervention or the in- sues are fully "mainstreamed." A review of the terventions included a nutrition education compo- evidence by Pena et al. (1996) found that the third nent. The conclusion was consistent with those of approach is the most likely to improve women's earlier reviews, such as Rue1 (2001). The only well- status in a sustainable way. conducted study to contradict these conclusions Interventions that seek to increase women's ac- was a study on the dairy cooperatives in India dur- cess to or ownership and control of resources are ing the 1980s (Alderman 1987). generally quite complex. Failure to understand cul- The authors note that an important question tural norms and the gender dynamics within the only partially answered in the reviewed studies household can result in unanticipated outcomes. In was whether the reported increases in consump- the Gambia, for example, a project geared to in- tion were a direct effect of increased production or creasing women's rice production was so success- an indirect effect of increased income. For exam- ful that the land it was grown on was reclassified ple, Alderman (1987) found that the increased nu- internally within the household. This resulted in trient consumption of milk-producing households output from that land being sold by men as op- was not due to an increase in milk consumption, posed to women. Women therefore lost their orig- inal income stream, but did retain an increased and so was likely to have come through the in- labor commitment (Dey 1981). Vegetables and come pathway. legumes are often regarded as women's crops. Recognizing this, a project in Togo was successful GENDER OUTCOMES OF because it promoted the introduction of soybeans AGRICULTURAL INTERVENTIONS as a legume rather than as a cash crop. Promotion as a cash crop would have resulted in the crop The role of women farmers has received much at- switching to male control. tention in the past few decades. In 1995 the UN The review in preparation by Leroy and Food and Agriculture Organization estimated that Frongillo (forthcoming) of interventions promot- women provide more than half the labor required ing the production of animal source foods also as- for food production in the developing world and sessed their impact on maternal income or that this proportion is even higher in Africa. This is women's control over income. The results were important from a nutritional perspective because quite mixed. For example, an intervention involv- The Impact of Agriculture Interventions on Nutrition Outcomes 3 1 ing intensified dairy farming in Kenya showed that increased production into increased household an important share of the additional income was consumption and individual intakes. controlled by women, whereas in Ethiopia men's Overall, the review documented a wide range incomes benefited significantly more from intensi- of agricultural interventions that have con- fied dairying than did women's (Mullins et al. tributed to improved nutrition outcomes. In most 1996; Tangka et al. 1999).Overall, the review found cases, however, the exact pathways by which im- that whether women's income is likely to increase pacts on nutrition have been achieved are difficult depends on the livestock or aquaculture produc- to track. The reason is that studies document im- tion system, the nature of the intervention, and cul- pacts on several intermediary outcomes such as tural beliefs and practices relating to gender. Even food security, income, or women's empower- if the intervention is targeted to women's livestock ment, but without directly modeling these path- and aquaculture activities, women may lose con- ways of impact to nutrition outcomes. Because trol over the income generated by those activities. these outcomes are so closely intertwined, it is im- The authors also noted that women's livestock possible to determine from this literature the rel- ownership rights may not be as stable as men's. In ative importance of the different pathways general, stress and constraints lead to an erosion of linking agriculture and nutrition. women's ownership rights because women's own- It is also clear that agricultural interventions ership of livestock is often considered a "secondary have not always been successful in improving nu- right." Evidence from around the world shows that trition outcomes. For instance, although all the an- the rights of pastoral women and their control over imal source food interventions reviewed were livestock management and marketing are being successful in increasing production of animal eroded (Niamir-Fuller 1994). source foods, many failed to improve nutrition out- The authors concluded that women's control comes. That is because production alone is insuffi- over income from livestock production activities cient to bring about improved nutrition if it does is very site- and production system-specific. not simultaneously address--or is complemented Livestock provides a real opportunity for women by other interventions that address-ther determinants of nutrition such as improved healthcare. to increase their income in some situations. In Agricultural interventions thus cannot be expected other situations, however, it merely leads to a sig- to achieve impacts on nutrition outcomes unless nificant increase in women's workload without a they are integrated with complementary efforts to considerable effect on their control over the addi- address other issues such as high levels of morbid- tional resources. This conclusion is most likely ity and inappropriate child-feeding practices. also applicable to other types of food production The review of evidence presented above sug- systems. gests a number of general lessons about how agricultural interventions can be designed to aclueve LESSONS LEARNED nutrition-related objectives. Most of these lessons pertain to processes and general approaches rather During the past 30 years development researchers than packages of specific components and should and practitioners have generated substantial new be considered by planners when devising more information and insights into the best strategies strategic approaches to nutritional goals: for ensuring that agricultural interventions reach Follow an integrative process of planning a~ldimple- the poor, improve welfare, and have a positive mentation. Successful interventions usually incorpo- impact on nutrition outcomes. Production is rate both agricultural and nutrition considerations clearly an essential component of these interven- at all phases of planning. Intervention activities tions. The nature of the intervention will deter- should be integrated with other health and devel- mine the effect on macro- or micronutrient opment services and should work in partnership supply: staple crops, for instance, can increase en- with different actors in the field. ergy, whereas animal source foods can increase Take local agricultural and nutrition contexts into protein and micronutrients such as iron and vita- account, and seek opportunities to build relation- min A. But the special challenge of integrated ships with local partners that are intimately famil- agricultural-nutrition interventions is to translate iar with these contexts. Successful interventions 32 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

often work with local groups and organizations- decision-making power directly affect the nutri- often nongovernmental organizations-that are tional status of their children. well placed to engage and consult with farmers as lncorporate communication and education compo- participants in designing interventions and devel- nents that target behavior change. Interventions that oping or adapting technologies. These local coun- successfully translate increased production into terparts can be especially valuable in identifying better nutrition outcomes, especially for children, opportunities to relate the intervention with exist- usually incorporate communication strategies that ing programs and to integrate intervention compo- relate the significance of positive or negative be- nents into those programs. These opportunities can haviors to health and nutrition effects. Information be important, and capitalizing on them can yield is a vital resource, and households that are positive effects on the intervention's sustainability. equipped with an understanding of nutrition- and Successful gardening interventions are an excellent health-related information display a tendency to- example. Those which have carefully considered ward more favorable allocation of food and health traditional gardening practices and the goals and budgets. Raising awareness of the health benefits preferences behind gardeners' production deci- of a newly available food commodity, one for in- sions have a distinct advantage. Highly relevant, stance that addresses a prevalent local micronutri- adaptive, and sustainable changes can be intro- ent deficiency, may be an important factor in its duced by identifying and making available im- adoption among producers, including those grow- provements that satisfy the gardeners, using the ing food for their own households' consumption. gardeners' own criteria and accounting for and ac- The importance of educational components is per- commodating the gardeners' own priorities, incen- haps most pronounced among mothers, whose tives, vulnerabilities, assets, constraints, and roles as caregivers extend to other, nonfood deter- livelihood strategies. This requires a trusting, col- minants of nutrition, such as hygiene and sanita- laborative relationship between the researcher or tion practices and preventive and curative health. project personnel and the participating commu- Armed with sufficient information, they are more- nity-a relationship in which the project personnel over more likely to know when it is necessary to are necessarily attentive and sensitive listeners and avail household members of health services. in which the community knows that its concerns Monitor and evaluate progress. Interventions with have been addressed. Local engagement is also im- sustainable impacts are generally characterized by portant in ensuring that the scope and causes of nu- effective monitoring and feedback loops that en- trition problems among targeted groups are able responsiveness to the shifting realities partici- accurately identified. The importance of local en- pants face. The nutrition-related objectives gagement suggests that a suitable approach in- pursued by the agricultural intervention will most cludes investing in pilot studies before large-scale likely remain unchanged, but the factors that act programs are initiated and then incorporating upon that objective may very well be in flux. what is learned about the existing conditions, cli- Changing livelihood strategies may be a particu- mate, and local culture. larly important set of developments to track, and Mainstream gender. Women play multiple roles here too, monitoring is likely to benefit consider- in both agricultural production and nutrition, and ably from good rapport between project personnel interventions that consider trade-offs between and participants. their respective roles and their time and labor con- Taken together, these lessons show that agricul- straints are more likely to lead to positive out- tural interventions are most likely to have an im- comes. Successful interventions are more likely to pact on nutrition outcomes when they involve take into account the range of factors that differ- diverse and complementary processes and strate- entially enable or constrain men and women in gies that redirect the focus beyond agriculture for terms of access to resources like land and services food production and toward broader consideration like credit. These influence and often determine of livelihoods and optimal intrahousehold use of their roles as decision makers in the household or resources. Successful projects are those that invest community. The significance of gender equity is broadly in improving human capital and that sus- particularly critical because women's status and tain and increase the livelihood assets of the poor. The four case studies of agricultural interventions presented in this chapter, none of which were included in previous reviews, provide insights into new approaches to the agriculture-nutrition nexus. All four interventions, explicitly aimed at integrating agriculture and nutrition during planning and implementation, took into account lessons learned in previous interventions and documented quantitative diet or nutrition outcomes at the individual level.

ORANGE-FLESHED SWEET POTATO PRODUCTION AND VITAMIN A DEFICIENCY IN MOZAMBIQUE Background. The first case study provides new insights into the use of a new technology, biofortification,as a nutrition-focused agricultural intervention. Staple foods interventions are generally not viewed as direct routes toward improving nutrition outcomes. This is particularly true in the case of primary staples like rice, maize, wheat, and cassava, which are good sources of energy but not of bioavailable micronutrients. Biofortification, the process of breeding food crops that are rich in bioavailable micronutrients, is attempting to overcome that limitation. One biofortified staple crop-orange-fleshed sweet potato (0FSP)-is already being widely disseminated,particularly in Sub-Saharan Africa. Unlike most staple crops, even unimproved OFSP is rich in vitamin A, and efforts to biofortify OFSP have included selection and breeding for still higher concentrations of the vitamin A precursors known as carotenoids. OFSP has been selected as a focus crop in a number of efforts to improve vitamin A intakes, including the Vitamin A for Africa (VITAA) partnership and the HarvestPlus biofortification program. OFSP is promising for a number of reasons. It contains very high levels of carotenoids; it is well accepted by the young children who are usually targeted; and it is easy to cultivate, is vegetatively propagated, and is fairly drought-resistantonce established. It is also a good source of energy for children and adults. Together these qualities make OFSP an excellent food security crop. It is also less labor-intensive than most other staple crops, and this is particularly helpful to labor-constrained households, such as those affected by HIV/AIDS. It can be planted over a broad range of time without considerable yield loss and can fill 34 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

some seasonal gaps in energy and vitamin A in- Assessing impact. Evaluation design and data col- takes. Finally, prices are generally low enough that lection. The evaluation employed a prospective, families will choose to keep some OFSP for home quasi-experimental design. The objective was to consumption, rather than selling all they produce. measure the impact of the intervention on chil- This case study reports on the results of the dren's vitamin A status (using serum retinol) and "Toward Sustainable Nutrition Improvement to document changes in the intermediate factors Project" in Mozambique (Low et al. 2007a; Low et leading to the nutritional impact, that is, changes in al. 2007b; Low et al. 2005). The project is purpose- knowledge, OFSP production and consumption, fully built on lessons learned from an earlier OFSP and vitamin A intake. Three districts were pur- intervention project in Kenya (Hagenimana et al. posefully selected. Within districts, villages were 2OOl).3 Box 2 presents a summary of the program characteristics and set of interventions and lessons learned. 3. Project website: http://aec.msu.edu/fs2/ts~~i/index.htm Case Studies 35

stratified by distance to services and other charac- design limitation was that participation in inter- teristics and randomly selected within strata. vention areas was restricted to those willing to join Within villages, all households with age-eligible farmers' groups, which precluded a full explo- children were invited to participate; in intervention ration of determinants of adoption. This also raised areas, study participation also entailed participa- the possibility of a self-selection bias, but this threat tion in local farmers' groups. A series of nine sur- to internal validity was addressed in the analysis. veys were undertaken. Information was gathered In addition, the time frame did not allow an as- on socioeconomic and demographic characteristics sessment of sustainability. Finally, this pilot project of households, agricultural production, child mor- was relatively small. Nevertheless, the study re- bidity, adult and child anthropometry, parental sults provide "proof of concept" and support the nutrition knowledge, food frequency, dietary in- relevance and the potential for impact of the larger takes, and biochemical indicators. In addition, VITAA, biofortification, and other efforts. sweet potato plots were measured annually, and Innovations. The project took several steps to en- market prices were monitored monthly. sure effectiveimplementation and to maximize the Impact results. The evaluation showed a marked potential for impact of this innovative agriculture decrease in vitamin A deficiency among interven- and nutrition intervention. Key features of the pro- tion households, from 60 to percent 38 percent. ject planning and implementation, which are be- That was accompanied by significant changes in lieved to have contributed to its success, include several of the intermediary factors along the im- the following: pact pathway, that is, large increases in production Integrated agriculture and nutrition compo- of OFSP as well as positive changes in knowledge nents at every stage of planning and imple- about vitamin A and child intake of vitamin A. mentation; Strengths and linzitations oftlze evaluation. The pri- Established links between researchers and mary strengths of the evaluation component lay in communities through implementing partners; the prospective design and in the comprehensive Identified and selected nutrient-dense vari- series of surveys, which documented a wide range eties that also addressed the needs of farmers of intermediate as well as final outcomes. The main and the preferences of consumers; 36 From Agriculture to Nutrition: Pathwavs, Svnewies. and Outcomes

Were grounded in thorough knowledge of dertaken were not necessarily designed to measure context; and attribute impacts. Nevertheless, some study el- Gave due consideration to the roles of women ements incorporated a quasi-experimental ap- and the constraints they face as farmers; proach, including the use of random sampling for Included strong nutrition education and de- quantitative surveys in intervention and compara- mand creation components, using multiple ble control villages over the life of the project. In channels and targeting multiple audiences; total, 24 research activities were undertaken be- Addressed sustainability through efforts to tween 2000 and 2004, including focus group dis- develop local markets for OFSP; cussions, semistructured interviews, participatory Employed quasi-experimental evaluation de- mapping, indicator development, yield collection sign and gathered detailed data on interme- exercises, soil and biomass sampling, and quantita- diate outcomes to enhance assessment of tive surveys covering dietary intakes, anthropome- impact. try, and hemoglobin measurement. The qualitative exercises covered a range of topics, including child care and feeding, legume expansion, and the nature LEGUME SYSTEMS AND CHILD of crop residue use and seed exchanges. NUTRITION IN MALAWI Evaluation results. Box 3 summarizes the results of the study so far. One notable success is reflected Background. The second case study highlights the by the expansion of farmer participation, which potential for a crop often overlooked as a nutrition- grew from 183 farmers in 7 villages in the first year focused intervention: legumes. Legumes do not to nearly 3,000 farmers in 77 villages in the fourth provide extremely high quantities of any individ- year. This included a relatively high participation ual micronutrient. But they are good sources of a by women (Bezner Kerr and Chirwa 2004). range of macro- and micronutrients, and they sub- Preliminary results also indicate that the project stantially improve the quality of grain/root/tuber- succeeded in nearly tripling the frequency of based diets, for both young children and other legume consumption by young children, relative to family members. The incorporation of legume controls (PATH Canada 2004). Further analyses of plant residues can improve soil fertility and poten- child nutrition outcomes, including anthropomet- tially increase future harvests. For these reasons, ric outcomes, are ongoing (P. Berti, personal com- interventions involving legume systems are being munica tion).6 implemented by a variety of organi~ations.~Within Strengths and limitations of the evaluation. the health sector, a number of nutrition education Available documentation did not allow an assess- interventions have aimed to increase young child ment of the evaluation design and sampling. The intake of legumes. Yet there are very few docu- evaluation's strengths lay in its use of rich qualita- mented examples of agricultural interventions that tive information, which provided insights into the focused on legumes and that also recorded impacts implementation, adoption, and demand for project on individual diets or nutrition outcomes. One activities. such study is the Soils, Food, and Health Commu- Innovations. Like the OFSP intervention study, nities Study (SFHC) in northern Malawi's Soils this project built on a range of lessons from the Food and Health Communities Project (Kerr and Chirwa 2004).5The SFHC study explored whether a legume system intervention could improve soil 4. See, for example, the Collaborative Crop Research Program fertility, food security, and child nutrition (Kerr at http://mcki~ight.ccrp.corneIl.edu/projects/i~~dex.html. 2006; Kerr and Chirwa 2004). This program supports several legume systems projects in Assessing impact. Design and data collection. The Africa (Tanzania, Malawi, and Mozambique) and Latin America (Bolivia and Ecuador) aimed at improving the use SFHC project was designed as a participatory re- of legumes, improving child nutrition, or both. search project introducing legume systems and 5 Web site: http://www.healthbridge.ca/food_soil~e.c€m. using an ecosystem framework to examine the sys- Accessed February 27,2007. 6 The project is also continuing in a second phase; see the tems' links with food security and health. Project HealthBridge (formerly PATH Canada) website at documents identify "monitoring change" as an ob- http://www.healthbridge.ca/food-soil-e.cfm for a project jective, and the wide range of research activities un- description. Case Studies 37

past. Agricultural and nutrition concerns were in- prising farmers selected by community members, tegrated from the outset. Gender issues and other carried out research along with external team social relations were carefully assessed and ad- members. The methods used to select farmer re- dressed, nutrition education was aimed at ensur- search team members were designed to ensure rep- ing impacts on child diets, and a number of resentation of less-advantaged community research elements did allow some monitoring and members, thus addressing an important shortcom- assessment of impacts. Strong participatory and ing experienced by several past efforts in which qualitative approaches were employed throughout teams were dominated by men and better-off the life of the project. Farmer research teams, com- household members. 38 From Agriculture to Nutrition: Pathways, Synergies, dnd Outcomes

INTEGRATING HOMESTEAD Vegetables produced in the demonstration gardens GARDENING AND PRIMARY were cooked at the Isizinda on days when child growth was monitored (Faber et al. 2002b). HEALTH CARE ACTIVITIES IN Assessing impact: Evaluation design and data col- SOUTH AFRICA lection. Serum retinol concentrations of 165 chil- Background. The third case study focuses on yellow dren ages two-five were collected at baseline, and fruits and vegetables, including dark green leafy their food consumption was recorded during a vegetables in South Africa and is a useful example cross-sectional survey covering the intervention of an agricultural intervention that explicitly part- village. A neighboring village served as a control nered with the health sector. The pilot study was village. One year after implementation, the moth- implemented in 1999 in a rural village in Kwazulu- ers of a convenience sample of 100 two- to five- Natal, South Africa, to promote the production of year-old children (50 from households with a these crops at the household level. The project ef- project garden and 50 from households without a fectively linked an agriculture intervention with a project garden) were interviewed. Data collected set of health-sector activities to stimulate greater included food intake from 24-hour recalls. A cross- consumption of the products. The intervention sectional survey was also organized 20 months package included both an agriculture intervention after program implementation; serum retinol con- and a health-nutrition intervention. centrations of 221 children (110 from the experi- Agricultural intervention. The project provided a mental village and 111 from the control village) course on the theoretical and practical aspects of were measured, along with information on dietary vegetable production, such as soil preparation, fer- intake and growth of the children, and maternal tilizers, planting and sowing dates, plant spacing, knowledge on vitamin A. irrigation, crop rotation, cultivar choice, weeding, ResuIts of the one-year follow-up revealed that maintenance, pest and disease management, and dietary vitamin A intake increased significantly in harvesting (Faber and Benade 2003). Homestead children from households with a project garden, gardens were present prior to the intervention and and to a lesser extent in children from households included traditional garden crops such as cabbage, without a project garden. Twenty months into im- maize, vitamin A-rich pumpkin, and imifino (a col- plementation, results revealed that after the onset lection of dark-green leaves). A total of nine of the intervention, the number of project gardens demonstration gardens were established with the gradually increased to reach a total of 126 gardens following crops: butternut squash, carrots, orange- (including demonstration gardens). Only 8 per- fleshed sweet potatoes, and spinach, along with a cent of the households with project gardens sold papaya tree. These crops were new additions to the some proportion of the produce for cash. Between gardens but were already familiar to communities baseline and the 20-month follow-up, there was a in the area through their availability for purchase significant increase in maternal knowledge scores in local markets (Faber et al. 2002a). in the experimental village compared with the Health-nutrition intervention. In 1995 a commu- control village. nity-based growth-monitoring program was estab- At the same time, significantly more children in lished in partnership with the health sector. The the intervention village than in the control village program is a primary health care activity run by consumed carrots, pumpkin or butternut squash, nutrition monitors through home-based centers spinach, and imifino-all vitamin A-rich foods. known as Isizinda. The project was able to engage From baseline to follow-up, serum retinol concen- the Isizinda as a focal point to promote the local trations increased significantly in the experimental production and consumption of provitamin A-rich village and decreased significantly in the control foods. They also served as agricultural demonstra- village. At follow-up, children from the intervention and training centers and as nutrition education tion village had higher serum retinol concentra- centers providing instruction on the relation be- tions than children in the control village; the tween vitamin A and health, the identification of reverse was true at baseline. Among the children in vitamin A-rich foods, and cooking methods. the experimental village, those from households Case Studies 39 without a project garden had significantly lower HOMESTEAD GARDENING FOR serum retinol concentrations than did those from FRUITS, VEGETABLES, AND households with a project garden, and their concentrations were similar to those of children from LIVESTOCK IN ASIA the control village. Because all households in the Background. The fourth case study involved home- intervention village were exposed to the same nu- stead gardening for fruits, vegetables, and livestock tritional education and agricultural demonstration in Bangladesh and is notable not only for the range sessions regardless of whether they had a project of commodities it dealt with, but also because it is a garden, the finding above suggests that access to rare example of an intervention that was scaled up supply was critically more important than was ed- from the community to the national level and was ucation without ready access. ultimately replicated in other countries. Strengths and limitatiotls of the ez~aliiation.The Homestead gardening in Bangladesh is a mainly home-gardening program had a positive effect on seasonal activity, with about 70 percent of fruits serum retinol concentrations, habitual intake of tar- and vegetables being produced in winter. geted garden crops, and maternal knowledge Vegetable and fruit production satisfies less than 30 about nutrition. In addition, villagers appreciated percent of national demand. In an attempt to gain the fact that they no longer had to buy vegetables a better understanding of existing gardening prac- and recognized the health benefits apparent among tices, Helen Keller International (HKI) conducted a their children. The evaluation did, however, have small assessment in north-west Bangladesh in several weaknesses. The treatment and control 1988. On the basis of the findings, HKI developed groups were not randomized, and the effect of the a pilot program among 1,000 households between intervention was assessed using a cross-sectional 1990 and 1993. The aims of the program were to (1) survey comparing households with and without explore the feasibility of promoting low-cost veg- gardens. Self-selection of households (i.e., partici- etable gardens combined with nutrition education pating or not in the garden project) was not con- and (2) identify constraints that might prevent in- trolled for, and for logistical reasons, the evaluation creased production and consumption of vitamin A- survey was done at the beginning of the new grow- rich foods among poor households. ing season for many crops (20 months), when The pilot program provided a wealth of infor- mostly spinach and carrots are available. Had the mation on the successes and challenges of garden- evaluation been conducted at 24 months, then or- ing programs in Bangladesh and provided Helen ange-fleshed sweet potatoes and butternut squash Keller International with the information it needed would have been in abundance. It is likely that the to expand the program. Among the results were effects on consumption and nutritional status encouraging data suggesting that household pro- would have been even larger. duction of fruits and vegetables could be possible Itlnoz?atiz~efeaturesand successfactors. The success throughout the year with some technical assistance of this project appears to be attributable, at least in and support. A midterm evaluation in 1992 con- part, to successful coordination among multidisci- firmed that the combined homestead gardening, plinary groups of agriculturists, nutritionists, and nutrition education, and gender aspects of the pro- the community. The inclusion of complementary gram had a very positive impact on vegetable con- project components such as the primary health care sumption among women and young children. The activity (which monitored child growth) and nutri- monitoring and evaluation system of the pilot pro- tion education likewise also contributed to the program also identified challenges that needed to be ject's success. Nutrition and agriculture education overcome. For instance, households were unable to were found to be necessary but not sufficient con- sustain change without a regular supply of quality ditions to achieving marked improvements in nu- seeds and other inputs. Scaling up the pilot would trition. This finding suggests that, at least in this require greater understanding of a number of is- context, food insecurity was a significant constraint sues, including cultural beliefs about child feeding, to behavior change and that the collaboration be- maternal food intake during pregnancy, intra- tween agriculture and health allowed the synergies household food distribution, and the role women between the two sectors to improve nutrition. play in program activities. 40 From Aaricullure to Nulrilion: Pathwavs. Svne~ies,and Outcomes

The large quantity of data provided by the pilot which demonstrations and training on low-cost, program was then used to develop a larger-scale low-risk gardening practices were conducted and homestead gardening program, including the need seeds, seedlings, and saplings were produced and for adequate management and human resources to distributed. Most of the village nurseries in the pro- implement a large-scale community program. The gram operated as small enterprises. pilot study was expanded in collaboration with Each NGO was encouraged to form 45 village local NGOs and the government of Bangladesh nurseries per subdistrict, with a minimum of 800 into the "NGO Gardening and Nutrition Education square meters serving 5 to 10 villages. Five to 10 Surveillance Project" in 1993 (Talukder et al. 2000). working groups of the NGOs of approximately 20 Eventually, the program was scaled up to national- women each were linked to each nursery to partic- level coverage, supporting 900,000 households ipate in the gardening program. A group leader or supporting 4.5 million beneficiaries. selected individual was identified to develop and On the basis of the success of the experience in manage the nursery. The group leader also facili- Bangladesh, the project was replicated by Helen tated nutrition and health education through peer Keller International in Cambodia, Nepal, and the education among the women's groups. HKI pro- Philippines and adapted to Niger (HKI 2004,2006). vided training and technical assistance to the agri- Recognizing that micronutrients like vitamin A are culturists and extension agents of the partner less bioavailable from vegetable sources, HKI NGOs and, together with them, provided technical began a pilot extension of its home-gardening pro- assistance based on the needs of the households gram by integrating animal husbandry in and nursery owners. This technical assistance was Cambodia, Bangladesh, and Nepal. The incorpora- designed to reinforce and improve existing position of an animal-source food intervention bene- tive gardening and consumption practices. fited richly from collaboration with a long-running, Program monitoring was an essential part of well-established program with capacity for nutri- program implementation and was particularly im- tion education, production training, and monitor- portant in scaling up. Monitoring was used to iden- ing and evaluation. tify problems and priorities and develop solutions Intervention elements and scope. The objectives of based on sharing between the beneficiaries and the the Bangladesh homestead gardening program program staff. In addition to the monitoring of pro- were threefold: gram activities, HKI staff regularly supervised NGO field and management staff. By implement- To increase the number of households that ing the program in partnership with NGOs, house- sustainably produce different varieties of holds continue to receive technical support for vegetables and fruits throughout the year homestead gardening and the program continues To increase the number of households pro- to expand without input and resources from HKI. ducing more varieties of vegetables Gender was an important focus of project activ- To increase consumption of vitamin A-rich ities. Women in rural Bangladesh have tradition- foods and improve the nutritional status of ally managed seasonal homestead gardening, from the most vulnerable groups sowing to harvesting and storing seeds. Thus the The gardening and nutrition education activities program actively targeted women in an effort to were linked with the ongoing development pro- provide them with new opportunities to generate grams of local NGOs. Strong linkages were estab- income related to homestead gardening. Women lished with participating communities to ensure are also generally responsible for procuring and sustainability. The NGOs' work with women's preparing food for their children. It is estimated groups helped them to address the social and cul- that at least 90 percent of the targeted households tural constraints faced by women in Bangladesh. are represented by women. These NGOs were supported financially by HKI To incorporate animal source foods into the infor the first three years of the project. The estab- tervention, model farms were established with ex- lishment of village-level nurseries and homestead isting village nurseries. The animal source foods of gardens was conducted by the NGOs in conjunc- focus were poultry in Cambodia and Nepal and tion with community groups. The village nurseries poultry, milk, and fish in Bangladesh. Each model served as a community support service network in farm supported a number of households with Case Studies 41 training and support for household poultry rear- kg of fruits during the same period for control ing, including improved breeding stock and households (Bushamuka et al. 2005). chicken management services. Nutrition education Results also revealed that children in house- focused on dietary diversity, micronutrient con- holds with developed gardens consumed 1.6 times sumption, and maternal and child nutrition (HKI more vegetables. Among children ages 12-59 2003). In Cambodia, the village-level poultry farms months who had not received a vitamin A capsule were owned by village farmers and run as mi- in the six months prior to the survey, the risk of croenterprises. night blindness was lower when their house had a Assessing impact. The NGO Gardening and homestead garden. Thus, having a homestead gar- Nutrition Education Surveillance Project used an den appeared to reduce the need for vitamin A integrated monitoring system to provide regular supplementation. feedback on program progress. The data were col- Seventy-three percent of the gardens were man- lected on a regular basis using a simple question- aged by women, and women were the main deci- naire on seed production, vegetable and fruit sion makers concerning gardening practices and production and consumption, and income. In ad- the use of the income earned by selling garden pro- dition, a cross-sectional survey was conducted in duce (Talukder et al. 2000). February and March 2002 to evaluate the economic Households earned, on average, the equivalent and social impact of the program on its beneficia- of US$8 on a bimonthly basis by selling the fruits ries and the sustainability of the program. and vegetables. The main use of this income was This evaluation comprised three groups of 720 for food and also to invest in seeds, seedlings, households each, totaling 2,160 households, rep- saplings, poultry, or other income-generating ac- resenting active program participants, former tivities. Nearly 10 percent of households saved in- program participants, and control households. come generated from the garden. Results also Structured questionnaires were used, and data on revealed that households with improved or de- homestead garden production were estimated in veloped homestead gardens consumed micronu- kilograms by the homestead caretaker. Additional trient-rich, noncereal foods more frequently than information was collected on the adoption of did other households. These foods, such as lentils year-round production practices, consumption and animal products, are not actually produced in levels of garden produce, amounts of cash gener- the garden, but were purchased using income ated, changes in the ability of women to con- generated from the selling of garden produce tribute to household livelihoods, and other (HKI 2003). developments. Chicken liver is a particularly rich source of vit- Evaluation results. The program increased the amin A and other essential micronutrients. In production and consumption of fruits and vegeta- Cambodia and Nepal, the percentage of house- bles in the areas it covered and increased the num- holds consuming chicken liver increased from 21 ber of varieties consumed. Monitoring showed that percent to 35 percent and from 28 percent to 41 per- the percentage of households without a homestead cent, respectively, among those households con- garden decreased from 25 percent at baseline to suming it from their own production. less than 2 percent after one year (Talukder et al. In Bangladesh and Cambodia, egg production 2000). After one year of participation in the pro- and consumption increased. In Bangladesh, 94 gram, the percentage of households who practiced percent of the participant households consumed year-round (developed) gardening had increased eggs in the seven days before the survey-an in- significantly from 3 percent to 33 percent. The crease of 48 percentage points over the baseline. number of varieties and the volume of vegetables- More important, egg consumption increased dis- produced in developed gardens were three times proportionately among women and children, al- higher than those produced using traditional gar- most doubling. There were no changes in egg dens. The cross-sectional evaluation conducted in consumption in the control group. Nutrition edu- winter 2002 revealed that households participating cation emphasized both intrahousehold distribu- in the project produced a median of 135 kg of veg- tion issues and micronutrient consumption and etables and 24 kg of fruit in the preceding three focused on the special needs of women and young months, compared with 46 kg of vegetables and 14 children. 42 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

Strengtks, limitations, and conclusions. This pro- own production was the dominant one. The in- gram is a success story of the scaling up of a small- come pathway was not as consistently docu- scale gardening program. Limited experience mented, thereby preventing a firm conclusion exists of successful scaling up of gardening and nu- about its relative importance across the four case trition programs, and the Bangladesh model is one studies. The Bangladesh-Africa study, however, that has been well documented and has been suc- does document an impact on income, which trans- cessfully replicated in several countries in Asia. lated into purchasing and higher-quality foods and The program continues to expand in Bangladesh overall enhanced diet quality and nutrient intakes. into new areas and to additional households in the The case studies each made a unique contribution current working areas. The gardening model has to the current understanding of potential modalities been adopted by the Government of the People's linking agriculture and nutrition and key success Republic of Bangladesh and has become part of a factors. The biofortified orange fleshed sweet potato program of the Department of Agriculture intervention, which resulted in large increases in vi- Extension. In 1997, HKI started the phaseout of tamin A intakes and status, provides encouraging technical and financial support to NGOs that had signals for future interventions involving this newly already received three years of its support. bred crop. The focus on gender in the legume pro- Monitoring information from these areas one year ject was highly successful in achieving meaningful after the withdrawal shows that the households are increases in legume consumption in young children. maintaining their improved gardening practices In South Africa, the successful partnership between and continue to consume fruits and vegetables the agricultural and health sectors appears to be re- more regularly. sponsible for the impacts on maternal knowledge and vitamin A status. That study also underlines the LESSONS FROM THE FOUR importance of boosting food availability and access through agriculture in contexts in which food inse- CASE STUDIES curity is a major constraint to behavior change. In The case studies drew from the experience of many Bangladesh, both the production-consumption-in- previous interventions. All four employed a nutri- take pathway and the income pathway appeared to tion education component directed at behavior have played a role in improving vitamin A intake change in the participating communities. Each of and status. The Bangladesh case study is also a them also took local contexts into account, built unique example of the successful scaling up of a partnerships with different members of the com- homestead garden project and of the importance of munities to promote ownership, and purposefully focusing on women. involved women and targeted their empowerment. Earlier reviews had noted the importance of All four interventions achieved their ultimate properly designing and conducting evaluations of objective of improving the intake of focus nutrient- agriculture and nutrition interventions to better rich foods by target population groups, especially document impact and best practices. The case stud- women and young children. The two studies that ies reaffirm that careful evaluation design is critical measured biochemical indicators of vitamin A de- but remains a challenge because all the method- ficiencyalso documented a significant reduction in ologies employed had certain limitations. Scaling the prevalence of vitamin A deficiency in children. up also remains a challenge. With rare exceptions, The Bangladesh study documented reductions in the interventions remain small in scale and un- night blindness (a clinical sign of vitamin A defi- likely to achieve broad impacts. To scale up agri- ciency) among children of households with a cultural interventions to have a broad and homestead garden. Although none of the studies sustainable impact requires their integration into rigorously modeled the pathways of impact the the activities of institutions, both in the agriculture interventions followed, the marked increases sector and in other sectors whose activities can con- recorded in production, consumption, and intake tribute to improved nutrition outcomes. These in- suggest that the direct pathway of consumption of stitutional issues are dealt with in chapter 6. The Changing Context I of Agriculture and I

The economic and policy context surrounding agriculture-nutrition linkages has been changing rapidly during the past 25 years. This chapter examines four types of change that drive behaviors among producers and consumers and that together are transforming the agricultural landscape and its relationship to human nutrition. Agricultural policy Agricultural technology Food marketing systems Food consumption patterns These changes affect the broader context in which nutrition-oriented agricultural interventions are implemented. They also affect each of the pathways through which agriculture affects nutrition, notably consumption of own-production, producer incomes, and food prices. The effects on these three pathways, which are the subject of this chapter, are summarized in table 5.

AGRICULTURAL POLICY Until the 1970s and 1980s, domestic agricultural and food policies in many developing countries assumed an interventionist stance. The policies applied principally to staple crops, but extended outward to agricultural products generally, including fruits and vegetables. Government agencies often controlled trade in food products with laws that limited private trading, notably by restricting the purchase or movement of production output by private firms. These interventionist policy regimes tended to discriminate against agriculture and in favor of urban-industrial growth. Examples of such policies included import substitution, financial-sector controls, and overvalued exchange rates as well as taxing agriculture to subsidize urban and industrial development (Christensen and Witucki 1982; World Bank 1986; Krueger, Schiff, and Valdes 1991; Bhagwati 1993; Delgado 1995; Sanders et al. 1996; Sahn et al. 1997; Teranishi 1997; Badiane 2000; Thorbecke 2000). Agriculture was seen primarily as fuel for industrial growth rather than as a source of growth in itself. Since that time, agricultural policy in most developing countries has undergone a major paradigm shift as part of what is often termed "globalization." Although the role of the government in food markets continues to be extensive, governments have dismantled state marketing mechanisms and liberalized trade and investment. In addition, 44 From Agriculture lo Nutrition: Pathways, Synergies, and Outcomes

through changes in exchange rate regimes and cantly altered the effective trade regime for agri- trade liberalization in the nonagricultural sector, cultural producers in many countries as well as the the levels of taxation or "disprotection" of the agri- availability of products for consumers. Two promi- cultural sector have declined over time. Overall, nent examples are the European "Everything but private markets have assumed greater importance Arms" initiative and the US "African Growth and relative to state intervention. Opportunity Act," both of which give expanded Trade liberalization has been a particularly im- access to selected low-income countries. Some portant policy change. Until the 1970s and 1980s, countries such as Bangladesh have also attempted developing-country governments favored restrict- unilateral liberalization. Regional trade agree- ing international food trade to limit import compe- ments have also been developed, increasing at a tition and to prevent export-driven increases in rate of 15 percent in the 1990s (FA0 2004). These food prices. This changed with the culmination of changes have resulted in a rising share of output the Uruguay Round and the Agreement on being traded, as well as changes in the composition Agriculture in 1994, which resulted in the develop- of trade. The average tariff on nonagricultural ment of a more open multilateral system for trade goods fell from about 40 percent in 1947 to 4.7 per- in agricultural products. Although the pace of recent by the end of the Uruguay Round in 1993. forms would later stall during the Doha Round of Since 1971, global agricultural exports have grown the World Trade Organization a decade later, a number of North-South preferential trading 7 These calculations are based on FA0 statistics for agricultural arrangements would still come into existence. exports and the World Development Indicators for agricul- Preferential trading arrangements have signifi- tural value added and the US dollar GDP deflators. The Changing Context of Agriculture and Nutrition Linkages 45 at 3 percent a year in real terms, while agricultural food availability was recorded in Kenya and production has grown at 0.7 percent a year. As a re- Malawi, whereas in China, per capita supplies of sult, the share of agricultural production that is ex- the principal nutrients improved dramatically. In ported has doubled, rising from 19 percent in 1971 Tanzania, per capita availability of the main nutri- to 40 percent in 2003.7 ents declined following reform. The effects of struc- This shift in agricultural policy has important tural policy reforms on household incomes tend to implications for nutrition. The increased market rely on the overall response of the economy to the orientation of agriculture has altered the incentives reforms. In countries in which postreform eco- for food producers to sell their products in the mar- nomic growth was inadequate, poverty was likely ketplace, thus altering availability for own-con- to deepen. Overall the study concluded that food sumption. There are also important implications availability, accessibility, and stability could be via the food price pathway and the income path- worsened in the short to medium term if trade lib- way, as discussed below. eralization is introduced without a policy package Agricultural policy changes and food prices. designed to offset its negative effects-specially Agricultural policy can affect food consumption for countries in earlier stages of economic develop- patterns by creating incentives, disincentives, or ment. The Economic Research Service of the U.S. both to the production of different foods, and there- Department of Agriculture has also examined fore their relative availability and prices (Nugent this question. The service used a computable 2004; Hawkes 2007a, 2007b). Liberalization of agri- model to assess the direct impact of agricultural culture and trade policy has particularly strong im- liberalization on the "nutritional gap" (i.e., per plications. In theory, liberalization can lead to capita food availability relative to minimum nutri- decreases or increases in consumer prices. At the tional requirements) in 67 low-income countries national level, the impact on commodity prices will (Trueblood and Shapouri 2001). According to the vary across commodities, depending on whether baseline forecast from the model, the nutritional the country is a net importer or a net exporter of that gap was projected to be 21.9 million tons in 2010. In commodity. The observed pattern of trade in which terms of the impact on prices, the study projected developing countries are net exporters of high- that long-run, real-world food prices would rise by value, micronutrient-rich crops implies that con- about 12 percent and that developing country ex- sumer prices are higher for those products than the ports would increase by about 30 percent following prices that would prevail in a closed economy. The global trade liberalization. When fed into the reverse would hold for the supply of macronutri- model, these price changes led to a reduction in nu- ents because the developing countries broadly are tritional gaps in the studied countries by 6.4 per- net importers of grains. cent. These gains are relatively modest because of Trade reforms affect food prices in part by af- the lack of producer response in developing coun- fecting the amount of food available. Thus, the tries, the declining share of agriculture in total ex- price of importable food products decreases with ports, and the small share of food imports in total trade liberalization (as supply increases with im- domestic food availability. ports) and the price of exportable food product in- Agricultural policy changes and producer incomes: creases with liberalization (as domestic supply In theory, the impact of trade liberalization on decreases). Box 4 presents a synthesis of cases in producer incomes depends on whether the sector South Asia that have undergone changes in their in question was protected or taxed initially. trade policies and have experienced different out- Sectors that were protected initially would face comes in food availability for consumption. The re- greater import competition and could lose out, lationship between trade reforms and food whereas those that were taxed initially could ben- availability, accessibility, and stability has been ex- efit from new opportunities from trade liberaliza- plored by FA0 in a series of 15 country case stud- tion. Theoretically, if resources (including labor) ies (Thomas 2006). Enormous differences in could be effortlessly transferred across sectors, outcomes were observed between the 15 countries, then the transition following trade liberalization some attributable to the nature and extent of the re- would be less detrimental to household income, forms themselves, others attributable to the het- with subsequent implications for food consump- erogeneity of initial conditions. Modest growth in tion. In reality, the structural features of the de- 46 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

veloping countries imply that resources are not tries, then trade liberalization can result in a rise freely mobile across sectors and those employed in poverty, at least in the short run. The impact of in the protected sectors would, in fact, suffer trade liberalization on income is therefore likely likely job and income losses due to trade liberal- to differ, depending on the initial status of the ization. When the group of losers from trade lib- country (as a net importer or net exporter) and eralization includes a large section of the poor, as then within the country across net producers and may well be the case in many developing coun- consumers. The Changing Context of Agriculture and Nutrition Linkages 47

AGRICULTURAL TECHNOLOGY technology has long focused on plant breeding and varietal improvements designed to raise produc- The growth of agricultural technology has been tivity and yields. In the past 50 years, technological dramatic during the past 25 years. Developments change has led to spectacular outcomes, such as the that carry particularly important implications for Green Revolution in wheat and rice and the broad food availability and patterns of food demand and acceptance of single-cross hybrids in maize consumption are plant breeding-focused mainly (Baenzinger 2006). on increasing yield and productivity, but more re- In 2003 a study published in the journal Science cently on increasing crop nutrient content-and presented an analysis of the contribution of Green technologies related to food processing and mar- Revolution crop breeding technologies to produc- keting, such as those that maintain a cold chain tivity by crop, region, and by decade between the from farm to plate. The effects of developments in 1960s and 1990s. Figure 7 shows the evolution of agricultural technology on food production and food production per capita. With the exception of consumption can be classified into three impacts Sub-Saharan Africa in the 1980s, the production of (shown in Figure 6). The first is the impact on rela- food per capita shows an increasing trend that can tive prices and on the relative profitability of dif- be largely attributed to new crop varieties ferent products for producers. The second is (Evenson and Gollin 2003). During the same time technology's impact on the labor and incomes of period, foods not subject to varietal improvements agricultural households. The third is the role of saw little or no productivity change and as a result technology in introducing new food products with have risen in price and been removed from many different nutritional properties. production portfolios. The case of pulses in India, Tec~zrzo~ogy'sinzpacts on relative prices arid relative which have seen little if any varietal improvement, profitability of dtfferent food products. Agricultural sharply rising relative prices, and declining aver- 48 From Agriculture to Nutrition: Pathways, Synergies, and Ourcomes

Technological change in agricultu~ Technological change outside agriculture In production Access to services In marketing Access to information The Changing Context of Agriculture and Nutrition Linkages 49

age consumption, provides a particularly useful il- for example, postharvest technology and market- lustration (box 5). ing are likely to play a more important role in re- In contrast, real food prices of the crops subject ducing prices. Estimates from the Rabobank (2006) to productivity gains declined during the 1980s conjecture that postharvest losses lead to the and 1990s, for the world as a whole and for most spoilage of up to 30 percent of the fruits and veg- developing countries. Using the IMPACT model etables produced in India. Postharvest losses in developed by the International Food Policy fruits and vegetables were as high as 50 percent in Research Institute (IFPRI), analysts simulated what Malawi in 2001 (Mwangwela 2001). In such a sce- food prices would have been in the absence of the nario, improved postharvest technology could sig- Green Revolution. The simulated prices were used nificantly affect marketing costs and consumer to calculate the economic availability of food and, food prices. in turn, the impacts on childhood malnutrition. Technology's impacts on labor and incomes ofagri- According to the study, had the Green Revolution cultural households. Technological change affects the not occurred, the proportion of malnourished chil- demand for agricultural labor and thus the income dren in developing countries would have been 6 to of farm and nonfarm households in rural areas. 8 percentage points higher than it is. In South Asia, There are a number of different impact scenarios. the percentage would have been 12 to 15 points As production expands there may be an increase in higher (Evenson and Gollin 2003). the demand for labor that has a positive effect on Many other agricultural technologies have im- the incomes of landless laborers. Alternatively, plications for food prices. For fruits and vegetables, technological change that leads to more mecha- 50 From Agriculture to Nutrition: Pathways, Synerg~es,and Outcomes

nization could reduce labor demand. It is possible they are consumed by producers, or through the that labor-augmenting and labor-saving technolo- income pathway if sold, or the food-price pathway gies could be introduced simultaneously, making if it makes micronutrient-rich foods more available the impact ambiguous. Technological change may in the marketplace. also depress prices and, under conditions of low Plant breeding technologies can also expand the demand elasticity, negatively affect the incomes of range of crops available for people to plant in some farmers, particularly those who do not adopt homestead gardens), thus again bringing potential the technology or those who adopt it late. nutritional benefits through the own-consumption A 1993 report (Kennedy and Bouis 1993) pub- and food price pathways. For example, a joint FA0 lished by the International Food Policy Research (Food and Agriculture Organization) and AVRDC- Institute provided a number of such examples in RCA (Asian Vegetable Research and Development which agriculture-nutrition linkages worked Center-Regional Center in Africa ) project to re- through changes in labor demand. An earlier study duce vitamin A and iron deficiencies sought to published in 1987 had examined households that stagger the production of different varieties of in- adopted modern rice varieties in the North Arcot digenous vegetables, many of which are seasonal, District of Tamil Nadu between 1973 and 1983. In to provide greater continuity throughout the year those households, the real value of consumption (Aphane et al. 2003). had doubled during that period, with a shift toward more varied diets as demand for labor increased during the early phases of the Green FOOD MARKETING SYSTEMS Revolution (Hazel11987). Subsequent phases of the The past 20 years have seen substantial change in Green Revolution, however, saw increasing trends the ways that food is marketed from farm-to-plate. toward mechanization and related declines in An important development has been the rise of labor demand (Binswanger and von Braun 1991). domestic and international marketing systems con- The studies examining the relationship between trolled by private actors rather than state market- agricultural commercialization and nutrition out- ing mechanisms. More open trade and investment comes summarized in chapter 3 included some have made buying companies, products, and ser- projects involving technology adoption. Overall, vices easier across national borders, so creating in- those studies found that although income and food centives for agri-food companies to grow and expenditures were affected, impacts on child nu- transnationalize through vertical integration and tritional status were limited and mixed. In a more global sourcing. The modernization of agricultural recent study, women with the most access to new marketing channels has had huge implications for rice varieties experienced less seasonal fluctuation agricultural producers via the income and own- in body weight, 1.1 kilograms compared with a 2.9- consumption pathway. The increasing importance kilogram fluctuation for women with the least ac- of private institutions has strong implications for cess (Kerr 2006). An earlier study of pregnant producers' incomes, and new marketing arrange- women in the Gambia indicated that less body ments have altered their incentives to sell food into weight fluctuation between the dry season and the the marketplace relative to producing for own-con- rainy season, combined with an additional 500 sumption. The process has also had important im- calories a day, would likely lead to improvements plications for food consumption patterns by in birth weights (Lawrence et a1.1987). These stud- altering the range and mix of products available in ies dealt with staple crops. For perishable crops like the marketplace, the price of the food, and the way fruits, vegetables, livestock, and fish, access to it is sold and promoted, all of which affect con- postharvest infrastructure and affordable technol- sumption decisions. Three changes in the market- ogy are also likely to affect farm incomes. ing chain are particularly important from a food Techrlology arzd the irltrodliction 01rle7oIood prod- consumption perspective: food processing, food ucts. Agricultural technologies can affect the nutri- retail, and food exports. tional properties of foods by increasing micro- Food processirlg. Food processors have emerged nutrient content, for example through biofortifica- as important actors in the agricultural marketing tion. Biofortified crops can benefit nutrition chain. Instead of selling crops direct for prepara- through the own-consumption pathway when tion in the home, agriculture increasingly supplies The Changing Context of Agriculture and Nutrition Linkages 5 1

raw materials to the food processing industry for developing countries, supermarkets' share of the the production of durable foods. This has implica- retail food market is highest in middle-income tions for nutrition through the food price pathway, countries such as Brazil, Argentina, and Thailand, because it has altered the availability and prices of and lowest in low-income Asian countries, such as processed foods in the marketplace. As food pro- Bangladesh and Vietnam. Supermarkets in devel- cessing has become a more important component oping countries are better able to handle both of the marketing chain, the share of processed food processed foods and fresh products, but in most in total consumption has risen. Global sales of developing countries, processed foods tend to have processed foods are US$3.2 trillion, of which about a smaller share of the market than fresh fruits and US$2.0 trillion is spent on packaged food and vegetables. US$1.2 trillion on beverages. These global figures These changes have implications for nutrition are strongly affected by demand in industrialized through the food-price pathway. Supermarkets countries, where consumers spend about half their have the potential to increase or lower food prices food budget on processed, packaged foods (Minot (Kuipers 2005; World Bank 2006). Because of and Roy 2006). Consumers in lower-middle-in- higher marketing efficiency, food prices in super- come countries spend less on processed foods- markets could be lower. At the same time, there about one-third, while in low-income countries like could be a premium on food prices as a result of the Kenya, India, and Vietnam, the proportion is less convenience and the standards that the supermar- than 15 percent (Gelhar and Regmi 2005). kets provide. Also, if the growth of supermarkets However, what is notable is that the rate of increase leads them to gain dominant market power, they of expenditure is far higher in developing relative could exploit the inelasticity of food demand to in- to developed countries, as shown on Table 6. In crease prices (Minot and Roy 2006). India, recent evidence points to a notable shift to- Two empirical facts are important to consider ward processed foods over time. A demand model when trying to assess the potential impact on food developed at the International Food Policy prices. First, supermarkets have not yet become the Research Institute (IFPRI) projects that Indian ex- supply source for all consumers in developing penditures on processed foods will rise faster than countries. There is ample evidence of supermarkets expenditures on both total food and nonfood and traditional retail existing side by side. In many goods (Ravi and Roy 2006). places, the emergence of supermarkets has created Food retail. Agricultural producers now sell more a segmented market, with the richer sections of the and more of their products directly to large-scale population sourcing their consumption from su- retail outlets (supermarkets, hypermarkets), rather permarkets and the low-income class sourcing than to local markets or to wholesalers. Supermar- from traditional retail. Second, in many developing kets have been growing rapidly in recent years in developing countries, driven largely by the growth 8 The data must be interpreted with caution because the defiii- of transnational enterprises (Table 7).s Among itions of supermarkets aiid retail sales differ across countries. 52 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

countries, including those like South Africa, in Food exports. As already noted, trade liberaliza- which the coverage of retail by supermarkets is tion has enabled a significant increase in the high, there is no evidence for any substantial in- amount of agricultural products that are exported crease in food prices. rather than consumed in domestic markets. The Two empirical studies provide some insights modernization of agricultural markets has also fa- into the impact of supermarkets on food prices. cilitated the expansion of the development and in- Neven et al. (2006) compared prices in Nairobi su- tegration of international food marketing systems, permarkets with the prices of similar products in including the extensive supply chains that serve traditional retail. The prices of nine fresh produce large food retail industries. Trade liberalization is items were, on average, 6 percent higher in super- also associated with a shift in the commodity com- markets, and the prices of processed food products position of international food trade toward higher- were, on average, about 3 percent lower. Consumer value products, accelerating a trend under way surveys revealed that the urban poor bought since the 1960s. Between the 1960s and the 1990s, processed foods in supermarkets and fresh pro- grain exports fell sharply from 15 percent to 8 per- duce in wet markets, as would be expected, given cent of the total value of agricultural trade (table 8). these price relationships. A similar analysis of hor- At the same time, exports of higher-value agricul- ticultural products in Argentina found that the tural products, such as fruits and vegetables, meat, prices for fruits and vegetables were, on average, 6 dairy products, eggs, and fish and seafood, grew percent and 14 percent higher in supermarkets, re- from 29 percent to 42 percent of total value. The spectively, relative to traditional retail outlets share of fish and seafood, in particular, increased (Ghezan et al. 2002). However, the average price from less than 5 percent to more than 13 percent of for all food and beverages was 5 percent lower in world agricultural trade. supermarkets. Despite the large market share of The composition of agricultural exports has also supermarkets in Argentina (70 percent in 2000), changed in terms of the share of processed versus small fruit and vegetable shops continued to dom- fresh products. It has been estimated that inate horticultural retail sales. The authors cite sur- processed food exports grew 4.2 percent per year vey results indicating that 71 percent of fresh fruits between 1980 and 1994--twice as fast as primary and vegetables were bought from traditional retail product exports (Athukorala and Sen 1998) and, outlets. according to FAO, the share of processed products The Changing Context of Agriculture and Nutrition Linkages 53

in agricultural exports increased from 41 percent in FOOD CONSUMPTION PATTERNS the 1980s to 51 percent in the 1990s (FA0 2004). The growth in the share of agricultural exports that are Economic growth, demographic change, urban- processed can be seen in almost all commodity cat- ization, and global media and mass marketing egories. The exceptions to this pattern are fruits have stimulated rapid changes and diversification and vegetables. The share among world agricul- in food consumption patterns. The shifting pattern tural exports of both primary and processed fruits is evident in increasing demand for high-value and vegetables has increased during this period, foods relative to cereals and pulses in most devel- but growth in fresh fruit and vegetable exports has oping countries (Popkin 2006). Per capita con- been greater. The proportion of processed foods sumption of cereals and pulses contracted during that are exported does, however, remain smaller the 1990s, while annual vegetable consumption than the proportion of agricultural commodities grew 3.7 percent; fish and seafood, 2.2 percent; and that are exported, probably, in part, arising from fruit and meat, between 1 percent and 2 percent the higher tariffs imposed on processed products (table 9). Less of this food is consumed from own- (Gelhar and Regrni 2005). production and more purchased from the market- This changing pattern of exports has implica- place. Regionally, between 1982 and 2002, East tions for nutrition through the food-price pathway and South Asian countries saw per capita con- because it increases the availability of certain foods sumption of vegetables and fruits rising quickly. over others in exporting and importing countries Meat, milk, eggs, fish, and seafood consumption (Hawkes 2006,2007a, 200%). Whereas consumers grew more slowly, but still increased more than in developing countries now consume more the consumption of staples. In 2002, East and processed foods and vegetable oils exported from Southeast Asia exhibited the highest per capita developed and other developing countries, con- consumption of vegetables in the developing sumers in developed countries now consume more world, at 64 kilograms per person per year, and fruits, vegetables, and fish exported from develop- the highest consumption of fish and seafood, at 26 ing countries. Another important trend is the in- kilograms per person per year.9 Increases in con- creased export of animal feed, which has enabled sumption of high-value food products were par- the rapid growth of livestock production around ticularly high in China, in which, between 1962 the world. Hawkes (2007a) cites an example from and 2002, per capita intake of vegetables grew 4.9 Colombia, in which trade liberalization in the 1990s percent; fruit, 8 percent; and meat, 8.7 percent. In led to increased imports of corn for animal feed from the United States4irectly stimulating the growth of the poultry industry. Subsequently,poul- 9 The FA0 definition of fruits and vegetables includes root crops such as potatoes and sweet potatoes. Because these try prices plummeted in Colombia and consump- items are almost staples in some countries, the definition tion soared, whereas beef consumption declined. overstates the share of the nonstaple food. 54 From Agriculture lo Nutrillon: Pathways, Synergtes, dnd Oulcom~s

2002, the Latin American and Caribbean region arable land used for vegetable and fruit cultivation had the highest annual per capita consumption of has remained stable in the developed countries, but fruits in the developing world, at 102 kilograms has increased markedly in most developing re- per person; the highest meat consumption, at 61 gions, as reflected in table 10. The share of land kilograms; and the highest milk and eggs con- used for cereals and pulses production declined in sumption, at 113 kilograms. Processed food con- developed countries and in Latin America, but re- sumption has risen in all regions. mained constant or slightly increased in Asia and As part of these trends, the consumption of Africa, implying that fruits and vegetables have re- high-calorie, nutrient-poor foods is also rising, no- placed other crops. The growth in grain production tably of vegetable oils, meat, processed foods, and declined from more than 4 percent annually in the food prepared away from home. These dietary 1960s to less than 1 percent in the 1990s (table 11). changes toward high-calorie, nutrient-poor The production of high-value agricultural com- processed and prepared foods are accompanied by modities in contrast has grown between 2 percent changing, generally lower, levels of physical activ- and 5 percent annually during the past 40 years, ity, as occupations shift to service-sector jobs, with the exception of milk, whch grew between 1 especially in urban areas. In these settings, con- percent and 2 percent.'" sumers in developing countries are now experi- These changes in production patterns are in encing what is termed the "nutrition transition" part a response to changes in consumer demand, toward some of the problems as well as the bene- in part a stimulator of consumer demand (Hawkes fits of populations in industrialized countries: the 2007a, 200%). They have implications for nutrition rise in overweight, obesity, and associated chronic through the food-price pathway and also through diseases like heart disease, hypertension, and dia- the income pathway because smallholder produc- betes (Popkin 1999,2002; Popkin and Du 2003). tion that answers the growing demand for high- As consumption patterns have changed, so have value food sources may have a positive effect on agricultural production patterns. Global production of oil crops, for example, increased by about 1.9 million tons annually between 1990 and 2005. 10 The shift in Chinese production has been particularly dramatic. China reduced the share of arable land in cereals by Production of vegetables has also increased half between 1975 and 2002, while grain productivity almost markedly, growing at 4.2 percent per year. An in- doubled. The share of land used for fruit productio~ihas increasing share of arable and permanent land is now creased from 2 percent in the late 1970s to 6 percent in 2002. used for vegetable and fruit production, and al- Similarly, for vegetables, land use has risen from 3 percent in the mid-1970s to 13 percent in 2002. In 2002 China accounted most all of this increase is occurring in developing for 47 percent of total world vegetable production (in volume countries (Minot and Roy 2006). The share of the terms) and 15 percent of fruit production. The Changing Context of Agriculrure and Nutrition Linkages 5 5

the producer's consumption by raising income. fish are labor-intensive, have low gestation peri- For example, in South and Southeast Asia, diver- ods, and generate quick returns. These qualities sification into high-value food commodities led to serve to make them highly suitable for smallhold- the development of innovative supply chains, ers, representing an often perfect opportunity to opening new prospects for augmenting income, utilize their surplus labor and augment their in- generating employment, and promoting exports comes (Barghouti et al. 2004; Weinberger and (Barghouti et al. 2004; Pingali 2004; Deshingkar et Lumpkin 2005). Whether a smallholder-dominated al. 2003; Pokharel 2003; Wickramasinghe et al. economy can actually diversify and whether small- 2003; Goletti 1999). Food security, moreover, im- holders participate substantially in the diversifica- proved in regions in which agricultural diversifi- tion of production toward high-value products is cation took place in favor of horticulture, animal context specific. A 2006 assessment of diversifica- husbandry, and aquaculture (Barghouti et al. 2005; tion toward high-value crops in India from the Dorjee et al. 2002). point of view of participating smallholders found From the perspective of poverty reduction, di- evidence that the probability of a household diver- versifying production toward high-value crops is sifying into vegetable cultivation is higher for particularly appealing. Most high-value food com- smaller farmers (Birthal et al. 2006). Vegetable cul- modities such as fruits, vegetables, poultry, and tivation was preferred over fruit cultivation, which 56 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

is generally less labor-intensive and more capital- of small farmers relative to large farmers is not intensive (with respect to start-up and working fixed and can change over time, usually as a result capital); both of these characteristics are to the dis- of changes in physical, human, or social capital. advantage of small farmers. Farmers may acquire new equipment or build The transition toward high-value agriculture is, physical capital, like irrigation works, that reduces however, not without constraints, especially for the cost of production. Farmer's skills and human smallholders. When the high-value commodities capital change over time as a result of leaming-by- are products the farmers have not grown before, doing, aided in some instances by technical assis- they will lack information on production methods, tance provided by buyers (Minot and Roy 2006). marketing opportunities, and the probable distribution of net returns. This problem can be particularly acute when producers have to satisfy highly CONCLUSIONS specific quality and food safety requirements Changes in agricultural policy, technology, mar- (Minot and Roy 2006). Larger farmers are also often kets, and associated changes in food consumption better able to bear the risks associated with pro- patterns are affecting the dynamics of the pathways ducing and marketing high-value commodities. between agriculture and nutrition. Today, the more Furthermore, for a small farmer to allocate land to market-oriented nature of agricultural policies a commercial crop may imply depending on mar- means that agricultural technology and markets ket purchases to meet food requirements, an addi- play a more important role in determining food tional source of risk. Some high-value agricultural prices and rural incomes, and more food is con- commodities also require significant investment, sumed from the marketplace rather than from own- including the use of specific inputs. Fruit produc- production. The greater market orientation of food tion involves planting trees and waiting 3-5 years production and consumption has increased the for them to begin producing. Farmers in develop- bidirectional links between agriculture and nutri- ing countries, particularly poor farmers, often lack tion: agriculture still affects nutrition, but food and the savings or access to credit needed to make these nutritional demands increasingly affect agriculture investments. In the case of highly perishable high- (Hawkes and Rue1 2006b). It is a twofold process. value commodities, production locations near mar- First, the increasing importance of the cash econ- kets and good marketing infrastructure are omy arising from changes in agricultural policy, particularly important (Torero and Gulati 2004). technology, and markets, and from rising incomes Small farmers are also less likely to enjoy access to and urbanization, is increasing the power of con- postharvest technologies. Yet the competitiveness sumers in the marketplace. Second, the rise of food The Changing Context of Agriculture and Nutrition Linkages 57 marketing institutions, such as food processors, re- more opportunities for nutrition-focused agricul- tailers, and exporters, is reducing the power of agri- tural interventions to improve the nutrition of net cultural producers in the agricultural supply chain. food consumers rather than just net producers. The rising role of the market has implications for There are also more opportunities for changing the relative importance of each of the pathways be- food consumption patterns among food consumers tween agriculture and nutrition: in general, the link to be exploited as a means of indirectly improving between agriculture and nutrition is becoming nutritional outcomes among producers (via in- more distant as income and food prices become come and price). Although not dealt with in this more important in determining food consumption chapter, it would also be important to take into ac- patterns relative to own-production. Agricultural count the impact of changing contexts on the em- programs with nutritional objectives need to take powerment of women agriculturists and the this changing context into account. With the rising development of human capital, given their critical role of the consumer in the marketplace, there are role in improving nutritional outcomes.

Institutional Frameworks for Action in the Agriculture Sector to Address Undernutrition

The viability of using agricultural interventions to improve human nutrition outcomes has been empirically established by case studies and analyses like those presented in earlier chapters. These provide important precedents with valuable lessons for the planning and design of agricultural programs and interventions. While nutritional status itself is an individual-level attribute, the determinants of nutritional status extend far beyond the control of the household of which the individual is a member. Institutions are identified as "basic" determinants of nutritional status in the UNICEF conceptual framework presented in chapter 2. Government institutions establish policies and priorities and implement programs that affect nutritional outcomes at the aggregate national as well as at the household and individual levels. They can therefore be instrumental in ensuring that agricultural programs are effective in meeting national nutritional goals. Agriculture ministries clearly have a central role to play in scaling up pilot agricultural programs and interventions, but experience has demonstrated the insufficiency of approaching nutrition entirely from the production side. Nutrition is, of course, also a consumption- side issue. Health and education, in particular, pertain to nutrition in relation to their essential roles in human capital formation and in human development. Yet prescribing systematic coordination between different sector institutions as a means of achieving a more comprehensive approach to improved nutrition is problematic, given the bureaucratic barriers that characterize the administrative division of responsibilities and jurisdictions between them. This chapter examines the barriers that inhibit sectorally-defined institutions from organizing and carrying out joint cross-sectoral efforts to improve nutrition outcomes at a national level. It also identifies possible opportunities to work around these barriers to achieve greater impacts that no one sectoral institution is capable of. Its focus is on government institutions, based on the assumption that governments are chiefly responsible for providing infrastructure, resources, and services to promote and maintain the social and economic welfare of its citizens. The focus on government institutions is not to suggest that nongovernmental actors cannot make important contributions to improved nutrition. Nongovernmental organizations often provide many of the multisectoral goods and services that the undernourished require. Indeed, nongovernmental organizations were responsible for the success of a number of nutrition-oriented agricultural interventions reviewed in this report. Detailed analysis of the specific role of nongovernmental organizations in effectively 60 From Agriculture to Nutrition: Pathways, Synergies, and Outcomes

linking agricultural interventions to improved nu- health, education, agriculture, and trade. The exer- tritional outcomes is, however, beyond the scope of cise of political and administrative power follows this report. this framework, and resource allocations, incentives, and systems of accountability are managed accordingly. INSTITUTIONAL BARRIERS TO The underlying difficulties constraining agricul- COORDINATED ACTION IN ture and other sectoral institutions from effectively NUTRITION acting in concert to address the problem of undernutrition stem from the nature of the state bureau- The conceptual framework of the determinants of cracy. Most bureaucracies are not organized in a nutritional status is useful in identifying the sec- manner that facilitates broad, effective action toral institutions that are directly relevant to im- across sectors to address a problem. Even though proving nutrition and in mapping their roles in any undernutrition might be the responsibility of the coordinated efforts to address nutrition issues. public sector, the sectoral organization of the pub- However, in the details of undertaking these efforts lic bureaucracy clearly hinders undertaking the ac- within the bureaucracy of the state, the clarity of tion necessary. the framework is often lost, as barriers to mounting To identify the bureaucratic elements that were harmonized efforts across the various sectors of found to impede efforts by the state to address un- state are encountered. dernutrition in a comprehensive cross-sectoral man- "Bureaucracy" has long carried negative conno- ner, an institutional study of the linkages between tations of inflexible or convoluted procedures that agriculture and nutrition was carried out in Ghana, impede rather than facilitate effective collective ac- Mozambique, Nigeria, and Uganda as a component tion. Yet bureaucracies have emerged as a gener- of the Agriculture-Nutrition Advantage (TANA) ally successful solution to the problem of project described in box 7. The study identified four managing the activities of states and other large or- particularly important overlapping barriers that ganizations, being organized ideally on the basis of prevent the problem of undernutrition from being clear goals, a rational coordinated functional spe- addressed by the agricultural sector jointly with the cialization of subunits, formal operating proce- health, education, and other relevant sectors: the re- dures, and clear lines of authority. In virtually all source allocation and planning processes within the countries, the state is organized administratively bureaucracy, differing sector mandates and priori- within a bureaucratic framework of sector min- ties, differing sectoral worldviews, and capacity istries, which includes separate ministries for constraints for nutritional analysis within sectors. Institutional Frameworks for Action in the Aericulture Sector to Address Undernutrition 61

RESOURCE ALLOCA1-ION AND nated activities that would achieve a higher level of PLANNING impact. That being the case, the attainment of nutrition objectives will tend not to be advanced by Resource allocation processes of budgeting and per- routine sector planning mechanisms. In this re- sonnel management often make it difficult to mount gard, sectonvide approaches to planning are likely cross-sectoral action within a state bureaucracy. Like to make efforts to address undernutrition in a co- all economic entities, the state functions under con- ordinated, cross-sectoral way even more difficult to ditions of limited resources. Consequently,each sec- undertake, as discussed in box 8. tor, in seeking to carry out its mandates, will compete with other sectors for the resources it requires. Typically, the resource allocation process of SECTOR MANDATES AND government is judged a zero-sum game. For exam- PRIORITIES ple, a state-level nutritionist interviewed for the study in Nigeria noted that funding is at the core of Formally stated mandates and objectives are im- why there is little interaction between the agricul- portant organizing mechanisms for bureaucracies ture and health sectors: since they help to define courses of action and to distinguish areas of institutional specialization "Everyone wants to be in charge. If [the within the bureaucracy as a whole. They define the Health sector] writes proposals that include scope of action for a sector or institution and serve some agricultural components, [the Agricul- to identify the particular, unique competencies that ture sector] is unhappy with Health, as Agri- the institution should possess to meet those objec- culture feels that Health is on their turf, tives. These priorities also feed back into the plan- taking resources that should be theirs." ning system because they are the basis by which an (Benson, forthcoming) institution or sector can make substantive claims Moreover, if independent assessments are made on state resources. Moreover, for the individual of the way a sector made use of the resources it re- civil servant working in a sector ministry or ceived, sector-specific criteria are generally used as agency, personal incentives such as career ad- the criteria. The resource allocation mechanisms vancement tend to revolve around the contribution provide no incentives for carrying out joint coordi- that each makes to the attainment of these sector- 62 From Agricullure to Nutrition: Pathways, Synergies, and Outcomes

specific objectives, rather than broader, multisec- cannot be in dispute and any lack of success is more toral development goals. easily locked away in the ministry's cupboard." The problem for nutrition as a development pri- Attaining nutrition objectives clearly requires a ority is that addressing the problem of undernutri- range of action that is less neatly circumscribed tion may not be accepted by any one sector as a within a single sector. priority for which it is responsible and toward which it will allocate the resources it controls, including human resources. Particularly as doing so UNIQUE SECTORAL requires engagement with other sectors to address WORLDVIEWS the problem sustainably, there are compelling prag- The specialized training that sector specialists re- matic reasons for agricultural and other state insti- ceive tends to lead to discrete, nonoverlapping tutions to judge that it should not be among their areas of expertise and qualitatively different primary concerns. Improved nutrition can be de- worldviews. Knowledge and information that per- fined among a set of secondary objectives for a sec- tain directly to one's own discipline is selectively tor. However, with multiple objectives, the chances embraced, while other matters are discarded from of conflict emerging between the various objectives consideration as being irrelevant to the attainment of a sector are more likely. Some prioritization is re- of sector objectives. Agriculture-sector objectives quired. A senior agricultural researcher in Nigeria relate principally to increasing yields, profits, and noted that agriculturists have historically been most other benefits that farmers derive as producers. As concerned with raising yields and, second, with the such, the language and methods that agriculturists profitability of farming. Certainly, they may be will- will use, both in technical analyses and in imple- ing to take into account nutritional considerations, mentation of programs, will be quite different from but at the end of the day, he asserted, increasing what are used in other sectors, such as health and crop yields is the principal criterion used to judge education. Nutrition considerations will not fit the effectiveness of agriculturists in Nigeria neatly or completely into the worldview of agri- (Benson et al. 2004). Consequently, one generally culture or, for that matter, any of the core sectors of sees little evidence in the organization of the agri- government. cultural sector of any effective attention being paid The significance of this factor was observed in to what are seen as secondary concerns, such as nu- Mozambique, in which the Technical Secretariat trition. Thomson (1978) notes that most national- for Food Security and Nutrition (SETSAN), across- level ministries prefer mandates that are entirely sectoral food security and nutrition coordination within their own sectoral sphere of influence and body for which the Ministry of Agriculture pro- control. "Such circumscribed objectives are much vided secretariat services, was seen by most ob- less time-consuming and much more easily admin- servers to perform its functions with regard to food istered; rivalries, jealousies, and frustrations are security issues reasonably well. However, SETSAN lessened; and it is more satisfying to the personal had no nutrition experts among its staff and had ambition of the ministry staff; as credit for success not developed a conceptual approach to guide its Institutional Frdmeworks for Action in the Agriculture Sector to Address Undernutrition 63 work in addressing malnutrition in the country. perverse, but reflect, first, a rational organization of Consequently, despite its relative successes in ad- the state into sectors that enable it to fulfill many of dressing food security issues, because of difficul- its duties and, second, the fact that nutrition con- ties in defining how nutritional problems in the cerns fit poorly within this bureaucratic organiza- country should be addressed, SETSAN was felt to tion. Barriers also emerge because the areas of have generally failed to coordinate cross-sectoral expertise, the analytical methods, and the tools that efforts to address malnutrition (Benson et al. 2004). agriculturists bring to the tasks with which they are The observed lack of cross-sectoral exchange or un- charged are quite different from many of those that derstanding as a factor impairing action to address are needed to address undernutrition comprehen- undernutrition is not uncommon. The lack of sively. For a broad effort to reduce undernutrition, shared perspectives, concepts, and practices fre- agriculture will need to overcome the many diffi- quently results in the various sectors that could culties of communication and coordination of ac- work jointly to address undernutrition finding it tivities across its sectoral boundaries. In the next difficult to find common ground from which to section, several approaches by which agriculture launch such efforts (Maxwell and Conway 2000). could institutionally play a greater role in reducing undernutrition are assessed. CONSTRAINED CAPACITY FOR NUTRITIONAL ANALYSIS INSTITUTIONAL MECHANISMS TO ENABLE AGRICULTURISTS TO Identifying the cause of a nutritional problem is central to mounting effective action to address it. ADDRESS UNDERNUTRITION Ignorance of what are the determinants of poor nu- The various institutional barriers that hamper the tritional status and an inability to ascertain what re- agriculture sector from acting either alone or with sources and actions are needed to sustainably other sectors to effectively and sustainably reduce reduce undernutrition in a particular context are undernutrition are not easily overcome. Given part of the explanation for the inability of agricul- these constraints, it is unlikely that any single solu- turists or specialists in other sectors to address the tion to overcoming them can be found in most con- problem of undernutrition (Gillespie 2001). This texts. Rather, a more opportunistic, incremental was seen in all four countries in which the TANA approach will most likely yield more durable re- institutional study was conducted. In Mozambique, ductions in undernutrition. This section considers fewer than a dozen nutritionists have master's level several possible components of efforts that the or higher backgrounds. In Nigeria, on the other agricultural sector could be a part of or undertake hand, the skills of hundreds of professional nutri- on its own to address undernutrition: multisectoral tionists have not been applied effectively across sec- nutrition planning agencies; cross-sector issues as tors, and no positive trends in undernutrition are policy priorities; the inclusion of nutrition objec- in evidence. In the agricultural sector in all four tives in agricultural activities; community-driven countries, staff with expertise in nutrition was development; and including nutrition topics in either absent (Nigeria and Mozambique),withering agricultural training. (Uganda), or relatively isolated within the sector (Ghana) (Benson et al. 2004). Consequently, it is not Multisector Nutrition Planning Agencies necessarily surprising that the agriculture sector in each of these countries was seen to be contributing The cross-sectoral nature of the determinants of to improved nutrition only indirectly, if at all. nutritional status has long been recognized. A com- Building capacity for nutrition analysis among spe- mon approach in grappling with the problems of cialists across sectors increases the probability that mounting necessary action to address undernutri- they will recognize the synergies that can be at- tion across disparate sectors has been to establish tained by undertaking efforts in concert. national multisectoral nutrition planning agencies The barriers to the agricultural sector in most de- to ensure that coordinated efforts are undertaken. veloping countries accepting some of the responsi- However, of the many such agencies that were set bility for the problems of undernutrition in society up in the 1960s and 1970s, few catalyzed substan- are quite substantial. Many of these barriers are not tial reductions in malnutrition. Without any real 64 From Agriculture to Nutrition: Pathways, Synergies, and Ourcomes

authority over the range of sectors involved, they trition. With sufficient authority and resources, proved ineffective in coordinating efforts across cross-sectoral coordination bodies can ensure that these sectors. Moreover, as the political leaders proper incentives-both positive and negative- who championed their formation turned their at- are introduced to motivate sector institutions to tention to other issues, the material commitment of prioritize activities and allocate resources targeting government to address malnutrition dwindled, improved nutrition outcomes. Cross-sectoral and the agencies were starved of operational re- nutrition coordination bodies can operate the sources. Consequently, in the following decades, accountability mechanisms needed to ensure coordinated cross-sectoral programs to reduce that sector agencies carry out their mandated malnutrition in many countries were replaced by nutrition-related activities in alignment with sector-specific projects focused primarily on tech- broader government strategies to address malnu- nical nutrition interventions (Levinson 2000). trition. Moreover, such agencies should be ex- Such multisectoral coordination agencies re- pected to continually engage in relevant national main a common feature of national strategies to and sectoral policy processes, including in agricul- address undernutrition. Few of these agencies ture, to ensure that undernutrition continues to be established in recent years demonstrate any greater viewed by political leaders and sector managers as success than those created 30 to 40 years ago. a development priority (World Bank 2006a). Mozambique, Nigeria, and Uganda have established such agencies during the past 5 to 10 years, Cross-Sector Issues as Policy Priorities with no evidence of greater or more effective impacts on malnutrition than in Ghana, in which no In a normative sense, formal policies define in quite such agency is in place (Benson, forthcoming). The explicit terms what is considered the common challenges of cross-sectoralcoordination remain as good for the citizens of a nation and serve as state- daunting now as they were in the past, with agen- ments of how government intends to prioritize its cies generally lacking adequate authority or actions and its expenditures. Formal statements of resources to introduce incentives to compel cross- policy are arguably more important for defining sector coordination. priorities when related to issues, such as nutrition In reflecting on why many such attempts at co- issues, that fall outside of sector-specific interests. ordinating efforts to address undernutrition have Whereas sector-specific mandates and worldviews been unsuccessful, a clear problem relates to these serve to motivate action to address issues that fall agencies' scope of action. The agencies frequently within the competencies of a single sector, such in- have been too involved in implementation, partic- centives are absent for cross-sectoral issues. ularly when they have insufficient authority to di- Making it clear that the priorities of government in- rect how the sectors concerned actually go about clude mounting effective action to reduce under- their tasks. Heaver (2005) suggests that a better nutrition is one way in which sector priorities can arrangement would be to allow the sectors the lat- be swayed toward paying closer attention to the itude and resources to carry out their own pro- needs of the undernourished. Public resource allo- grams, with the nutrition coordination agency cations to the agriculture sector may be made con- being granted the necessary authority to define tingent on how much the sector has contributed overall policies and strategies and to guide the al- and plans to contribute to the attainment of location of resources. Government should make broader development objectives, such as those ar- use of the existing sectoral infrastructure to imple- ticulated in a master development plan or a ment programs, however imperfect it may be, and Poverty Reduction Strategy. This can put in place build on what is already in place (Kennedy 1994). stronger incentives for agriculturists to formulate A lesson that seems to have been widely recog- work plans that go beyond their traditional narrow nized, if not widely learned, is to "plan multi-sec- sectoral objectives. With that objective in mind, torally, but implement sectorally" (Maxwell and Ugandan nutritionists participated effectively in Conway 2000). 2004 in revising the Poverty Eradication Action As such, multisectoral coordination agencies Plan, the government's master development strat- have a place in the implementation of government egy, resulting in heightened attention to undernu- strategies to sustainably reduce levels of undernutrition within this broader policy (Benson et al. Frameworks for Action in the A~ricultureSector to Address Undernutrition 65

2004). However, follow-up research is needed to enhance nutritional knowledge within farming determine whether the increased emphasis on nu- households. Although their success in contribut- trition in this policy actually has led to increased at- ing to improved nutritional outcomes varies de- tention to the problem of undernutrition in the pending on the pathways by which the desired annual work plans of the various state sectors in nutritional effects are obtained, such activities do Uganda or in the allocation of resources to attain compel their implementers in the agricultural sec- improved nutrition objectives. tor to undertake nutritional analyses to identify For such high-level policy statements to influ- the nutritionally vulnerable in the population in ence sectoral efforts to address undernutrition, sus- which they work and to diagnose the causes of tained interest by political leaders in attaining that malnutrition. Such analyses, if conducted in broad improved nutritional outcomes is required. an informed manner, will highlight the important Political champions for the attainment of improved contribution that agricultural initiatives can make nutrition are needed: individuals who are politi- in assisting the undernourished, the need for com- cally well connected, are persistent in character, plementary action on the part of other sectors, and and have access to many of the multiple arenas and the importance of improved nutrition as an input institutional venues in which policy debates are to a more productive agricultural sector. With suf- undertaken. Such champions have been shown to ficient political support, initial efforts by agricul- be a key element in several instances in which sig- turists to contribute to improved nutrition should nificant changes were brought about in the priority increase in scope and complexity as the determi- given to state efforts to combat undernutrition nants of improved nutrition are increasingly made (Rokx 2000). Similarly, international donors can clear to those involved through practice. The nu- provide important incentives by providing fund- trition objectives of agricultural activities can fos- ing and capacity building opportunities to agencies ter a more holistic vision of what is needed across in the agricultural sector or other sectors so that the various public sectors to sustainably improve they can work toward reducing the numbers of the nutrition. However, progress in this regard is not undernourished in a country or area. However, if assured, as the example in box 9 shows. implemented in a one-off fashion, the sustainability of such changes is open to question (Winikoff Community-Driven Development 1978).If attention to undernutrition enjoyed a high profile in national policy process or in donor prior- Community-directed efforts also can provide im- ities, subsequent changes in leadership of govern- portant incentives for agriculturists to contribute to ment or of donor organizations often result in a efforts to reduce undernutrition, often working in diminished profile for nutrition as a development concert with other sectors. Community-driven de- objective. Continual strategic advocacy for nutri- velopment (CDD) gives control of many local de- tion action thus becomes an important element if velopment activities to those who will be most agriculture and other sectors are to undertake ac- affected by them, the local residents (Dongier et al. tions at a level and for a length of time sufficient to 2003). When governments support such efforts, bring about substantive reductions in the numbers they usually also commit to contributing state re- of undernourished in the population. sources and expertise to the community as its members work to realize their development ambi- tions. However, communities are unlikely to prior- Nutrition Objectives for Agricultural itize their development needs neatly according to Activities unique sectoral competencies (Mason 2000). That Activities with clear nutrition implications in the being the case, community expectations that state agricultural sector have been the focus of much agencies will help them address a problem requir- of the technical content of this report. These ining contributions from multiple sectors, such as un- clude the production and consumption of staple dernutrition, provide important incentives for food crops, fruits and vegetables, and animal cross-sectoral action to be undertaken. In instances products that are rich in micronutrients or other- in which governments are strongly committed to wise contribute to a high-quality diet and the supporting community-driven efforts, there may use of agricultural communication channels to be sufficient incentives from community demands 66 From Agriculture to Nutrition: Pdthwdys, Synerg~es,and Oulcomes

Progressive increased attention to nutrition within cultural production-oriented, most home economists agriculture is not assured. Agricultural extension ser- were eliminated from extension services. vices offer a case in point. Such services provide a Moreover, the service has also become more male channel for reaching rural smallholder households dominated as a result. That is due to gender sorting in with information on how they might provide better school, in which boys are more likely than girls to fol- care to their nutritionally vulnerable members. In the low the natural sciences-focused course of study neces- 1970s and f 98Qs, recognizing this, many extension sary to attain professional qualifications in agriculture. services in Sub-Saharan Africa, including Ghana and Several important determinants of nutritional status Uganda, inciuded among their fieldworkers home have strongly gendered characteristics, particularly economists, most of whom were women. Their func- breastfeeding, weaning, childcare, and meal preparation was primarily to work with women in farming tion. Consequently, although information on such nutri- households on both production and consumption is- tion concerns may still feature among information that sues, including nutrition. However, during the past 20 extension agents offer to farming households, male ex- years, most extension services have been reorganized, tension agents are a poor choice as messenger on these including through programs of "professionalization," topics. We should expect that the level and quality of whereby field extension agents had to meet minimum knowledge on nutrition obtained by farming house- professional qualifications to be retained in the ser- holds from extension agents certainly has not improved vice. Because these qualifications were primarily agri- with the restructuring of extension services.

for cross-sectoral activities to flourish despite the African countries, district-level agriculturists bureaucratic organization of the sectors. For exam- stated that local concerns were not necessarily ple, community nutrition programs that involve more important than sectoral concerns in guiding cross-sectoral teams from government agencies in their actions (Benson et al. 2004). These agricul- providing community facilitation services have led turists were still subordinate to sectoral superiors, to substantial reductions in undernutrition in sev- they operated with limited resources, and many eral Asian countries (Tontisirin and Gillespie 1999). of the incentives that motivated their individual Moreover, the local scale at which action will efforts hampered rather than fostered cross-sec- be taken by the agents of the various public sectoral action to assist communities. Consequently, tors concerned also may enable such action to be although community-driven development may performed more easily. The resource conflicts be- promote increased attention from agriculturists to tween sectors that were noted as constraining local nutrition problems, there is no guarantee cross-sectoral undertakings typically play out at that it will do so. the national level in most countries. At more local levels, civil servants may have more limited con- Nutrition in Agricultural Training trol over how resource allocations are made across the sectors. However, the ability of local- As was shown earlier in the review chapters, agri- level state agencies to work collaboratively in as- culture may provide important elements neces- sisting communities will vary on a case-by-case sary for sustained improvements to nutritional basis. In both Ghana and Uganda, countries in status in specific contexts, particularly among which the decentralization of state functions has farming populations. If improving nutrition is a progressed to a greater extent than in most other high priority development objective of govern- lnsritutional Frameworks for Action in the Acricullure Sector lo Address Undernutrition 67 ment, attaining that objective will require a more lems, demonstrates that there is considerable merit sophisticated understanding of the determinants in being task or problem oriented, starting small, of improved nutrition by professionals in the pub- achieving short-term goals, and building on these lic sectors concerned. Providing training in successes iteratively to address larger problems human nutrition to agriculturists is an important (Maxwell and Conway 2000). component of this objective. Whatever the sector Coordinated cross-sectoral efforts may be nec- or sectors, "the choice of the most appropriate in- essary to sustainably reduce undernutrition. tervention will depend on who is malnourished However, given the past failure of such efforts, and why" (Kennedy 1994). Providing training in new initiatives should first be piloted before being nutritional analysis will make it more likely that scaled up, particularly in those institutional envi- agricultural projects and programs that seek to ronments in which bureaucratic structures and improve the nutritional status of the target popu- processes are rigid. In such cases, "contrary to log- lation will be based on a clear conceptual and an- ical argument, the complex etiology of malnutri- alytical framework for the way the nutritional tion does not necessarily demand a complex goals will be attained. Similarly, it will also allow response" (Ross and Posanai, cited in Levinson for better identification and understanding of the 1995). Individual sectoral responses will often be needs of the undernourished that the agricultural the best that can be realistically expected. No nu- sector can assist in meeting and enable better trition program at the outset should depend on in- monitoring of project performance in meeting tersectoral coordination for its success. The risk those needs. However, few countries, if any, now that such coordination is not going to happen is require that their agricultural trainees acquire a too great (Levinson 1995). In instances in which basic understanding of the determinants of im- cross-sectoral action is required, alternative part- proved nutrition. ners to other sectors in the state bureaucracy, such as NGOs, may offer greater potential for success. However, simply ensuring that the agriculture CONCLUSIONS sector, or, for that matter, any other sector with a The institutional barriers that agriculturists, partic- role to play in improving nutrition, takes that role ularly those in the public sector, face in trying to seriously is an important first step. Coordinated mount effective action to assist the undernourished efforts should follow only once such commitments are durable and strong. The fact that the organiza- are clear. tion of these institutions is relatively ineffective for Moreover, the causes of undernutrition are addressing the problem of undernutrition in soci- context specific. Agriculturists need to be clear ety is unlikely to be sufficiently compelling to cause about what they can contribute in resolving mal- these institutional structures or the manner in nutrition in a particular context. Having this clear which they operate to change. Consequently, al- understanding not only guides program design, though strong action by the agricultural sector or but it also enables agriculturists to evaluate broad coordinated action by several sectors may whether means other than agriculture might logically appear to be required to reduce levels of be more efficient in attaining specific goals of undernutrition, in practice an opportunistic ap- nutritional improvement. There are likely to be proach may be more effective. Such a strategy significant opportunity costs associated with agri- would use existing individual activities in the agriculturists devoting their energies to nutrition cultural sector and in other sectors in an instru- objectives (Pinstrup-Andersen 1982). These costs mental way to address important context-specific need to be evaluated. Consequently, capacity for determinants of undernutrition. Working in this nutrition analysis is critical to any planning by incremental manner appears more likely to be suc- agriculturists to address aspects of the problem of cessful than mounting a large-scale cross-sectoral undernutrition. effort that is a poor match for the institutional The undernourished can improve their nutri- framework in which it would be implemented tional status through agricultural means. There are (Lynch 1979). Experience from many cross-sectoral many good reasons for providing incentives to efforts, focused on both nutrition and other prob- agriculturists to address problems of undernutri- 68 From Acriculfure to Nutrition: Pathwavs. Svnercies. and Oulcomes

tion in a dedicated manner. However, Levinson benefits to which agriculture can contribute forces (1995) suggests that the reverse relationship is also the sector to consider more rigorously who benefits important. "Increased agricultural production per from increased agricultural productivity and to se is insufficient if that production does not address change its priorities and activities where necessary hunger and malnutrition through its production or in light of these considerations. consumption effects." Attention to the nutrition Lessons Learned and Next Steps

This report analyzes what has been learned about the way agricultural interventions influence nutrition outcomes in low- and middle- income countries. It synthesizes lessons from past institutional and organizational efforts and identifies developments in agriculture and nutrition that have transformed the context in which nutrition outcomes are affected by agriculture. Emerging from this analysis is the fact that agriculture carries real potential to contribute to improved nutritional outcomes. Agricultural programs should thus include nutrition as a specific objective and a clear plan of how to implement nutrition-sensitive agricultural interventions and how to achieve impact. The experience of agricultural programs that have done so points to a number of general lessons. The very inclusion of nutritional objectives by these programs reflects an implicit recognition that investing in agricultural production and growth does not necessarily result in improved nutrition. Nor do improved nutrition outcomes flow automatically from increased agricultural production, lower food prices, or higher incomes. Although these pathways may be instrumental in satisfying a number of necessary conditions for improved nutrition, they are not in themselves sufficient. The persistence of malnutrition despite the generally overwhelming success of food production belies any notion that the solution to adverse nutrition outcomes is attainable through the production side alone. Nutritional criteria have to be explicitly incorporated into the design of agricultural programs if nutritional objectives are embraced and if food production is to effectively answer the demand for foods with particular nutritional qualities. That represents both a challenge and an opportunity for agriculture and its major actors. Incorporating nonagricultural criteria such as health and nutrition into the design and conduct of agricultural programs suggests developing an effective interface between agricultural and other institutions. Yet systematic hgh-level coordination between different sector rnin- istries is challenging, given the bureaucratic barriers that divide them. The report therefore examined alternative approaches to formulating a more comprehensive approach to improving nutrition as a development objective. The prominence of nutrition as a policy priority in national development plans and poverty reduction strategies may provide a useful starting point. At this level, nutritional objectives tran- scend the administrative divisions between different government-sector institutions whle still requiring their respective contributions. 70 From Acriculture to Nulrilion: Pathwavs. Svnercies. and Outcomes

Those institutions may find and capitalize on op- vested broadly in improving human capital and that portunities to work together, but their effective in- sustained and increased the livelihood assets of the puts should not be contingent on such active poor. Below we summarize the key lessons learned collaboration coming to pass. In this light, programs about how these programs should be developed and policies can be planned multisectorally, yet be and implemented to help achieve improved nutri- carried out sector by sector. Insofar as sector institutional outcomes. The recommendations should be tions are held accountable for their performance in implemented taking the changing context of agri- achieving improved nutritional outcomes this ac- culture and nutrition into account, and they should countability will provide them with incentives to be accompanied by the investments in human capi- explicitly address undernutrition within their re- tal and institutional changes needed for successful spective mandates and work programs. implementation. Sector ministries compete for limited govern- Trlke loci11 co~ltextsitlto uccourlt. Designing pro- ment resources. If their budgetary allocations are grams to accommodate prevailing agricultural and made contingent on their contribution to reducing nutritional conditions entails developing a sound malnutrition as a national policy priority, their ef- understanding of producers' priorities, incentives, fectiveness in that role is more likely to become an assets, vulnerabilities, and livelihood strategies. This institutional priority as well. Similarly, interna- is all too familiar to agricultural planners and can be tional donors can provide important incentives by said of virtually any agricultural intervention. The offering funding and capacity building opportuni- need to evaluate and target major nutritional prob- ties to agencies in the agricultural sector or other lems experienced by the community in program de- sectors so that they work toward reducing the sign is less familiar, but is an essential requirement numbers of undernourished in a country or area. for any agricultural intervention that has nutrition- To improve the chances of that happening, agricul- related objectives. Understanding the motives and tural institutions should develop the internal ca- constraints that affect household consumption deci- pacity to analyze the nutritional implications of the sions is in this sense no less important than under- programs they plan. standing those that affect production decisions. The context in which agricultural programs are Many of these factors relate to household eco- implemented is shifting as agricultural and trade nomics and to local perspectives of socioeconomic policies change, as new technologies are intro- realities. Some, however, are attributable to cultural duced, and as food marketing systems develop. norms that in and of themselves have little if any- These changes, which generally work to increase thing to do with economics-but that may bear the market orientation of agriculture, affect the heavily on the rationales behind households' eco- pathways linking agriculture to nutrition by alter- nomic decisions. They may determine outright ing the types and quality of the foods available in which household members maintain control over the marketplace, the price of food, the income of which household resources and may influence nu- food producers, and the amount of food consumed tritionally vital decisions such as the allocation of from own-production. They are also affecting non- different quantities and types of food among house- food factors that contribute to nutritional improve- hold members. From that angle, women emerge as ments, such as human capital. In addition, changing vitally important agents, both in their roles as pro- food consumption patterns affect the market de- ducers and as custodians of household welfare. mand that agricultural production seeks to satisfy. Their importance, moreover, generally increases in These changes present program planners with a the lowest-income settings and among households moving target in tailoring programs to fit local real- with high dependency ratios-in which a large ities. They also present practitioners and policy proportion of household members are nonearning makers with new factors to consider as they seek to and often nutritionally vulnerable dependents. replicate successful experiences across localities Beginning with pilot programs and conscientiously and scale them up to provincial and national levels. employing evaluation criteria before going to scale The empirical evidence presented in this report can be a particularly effective way to ensure that focused on agricultural programs and interventions local contexts are taken into account. carried out at the level of local communities. The Eiiublt.ui~d enlpori1er 7c~omerl.The resources and in- most successful such projects were those that income flows that women control wield dispropor- Lessons Learned and Nexr Steos 71 tionately positive impacts on household health and tionately afflict children and increase their risk of nutrition. In some parts of the world, women tend dying. Agricultural extension services and public to lack access to economic opportunities outside information campaigns such as those dealing with the domestic sphere to which traditional customs integrated pest management are also important ve- often confine them, especially in rural areas. They hicles for conveying health-related information. are also very often severely constrained by time Nutrition-related education and communication and the multiplmften simultaneous-roles they strategies may offer instruction on food preparation play as producers and caregivers. Agricultural pro- and safety, child care and feeding practices, and the grams and policies that empower and enable nutritional qualities of different foods. A woman women and that involve them in decisions and ac- armed with information that enables her to recog- tivities throughout the life of the program achieve nize the symptoms of a vitamin A deficiency and greater nutritional impacts. Such programs in- who has learned about key sources of this nutrient crease women's control over income and other pro- is better placed to make an appropriate dietary ad- ductive resources like credit by targeting them in justment--especially when she has participated in their roles as economic agents. an agricultural program involving a food source It~corporaterlntritio~~ orltreacl~ atzd belzauior chntzge. that can be applied to that nutrient deficiency. A Using information services to change the behavior woman equipped with knowledge that enables her of producers in order to make them more produc- to recognize a particular medical condition is like- tive or better able to respond to market signals is fa- wise by definition better placed to treat it or to miliar to agricultural practitioners. Similar know when the affected family member should be information services can be employed to change be- taken to a health service provider. havior among people in their roles as consumers Information is something that is required from and as decision makers within their households. households and communities as well as something Women's access to services can be as important to to be made available to them. The subjective eco- household nutrition as their access to income and nomic, social, and cultural reasons that underlie productive assets. Access to health services is a nat- household production and consumption decisions ural priority, but even this access presupposes that are largely inaccessible to program personnel from people know when to avail themselves of such ser- outside the participating community. Indigenous vices. Information services can educate women both knowledge and livelihood strategies are very often in their roles as economic agents and as typically the unspoken and may encompass local understand- principal stewards of household nutrition, food se- ing of opportunities and risks that carry important curity, and health. While women are by no means practical merit for nutrition programming-merit the sole intended audience of such knowledge, tar- that may very well not be obvious to the outside geting women with health and nutrition informa- observer. In areas in which community-based, tion is likely to have even greater catalytic effect, local civil society or nongovernmental organiza- given their typically closer affiliation with the tions are active, they may represent important household. sources of information on local perspectives and People who are armed with information and present agricultural programs with valuable part- knowledge about the nutritional significance of the nerships with which to engage local communities. foods they produce and eat are able to make better Community-based organizations represent impor- production and consumption decisions. Health in- tant reservoirs of social capital and are embedded formation services provide a potent means of in target communities in which community mem- changing behaviors to reduce the high levels of bers make collective decisions about how local re- childhood morbidity that are associated with inap- sources are to be used and how livelihoods are to propriate feeding practices, premature weaning, be advanced. Other organizations that have oper- and childcare generally. Providing households ated for years in local communities are likely to with health information about sanitary food prepa- have established relationships of intimate trust and ration and water use and the prevention of infec- rapport with families and individuals in local com- tious and food-borne diseases can dramatically munities and are able to listen to local concerns and improve nutrition outcomes-particularly with re- advise on possible resolutions. These can be con- spect to those diarrheal illnesses that dispropor- duits of two-way information flows between pro- 72 From Agriculture to Nutrilion: Pathways, Synergies, and Outcomes

gram administrators and community members Next Steps. There are a number of important is- and are often well-situated to serve as agents in sues not covered in this paper that deserve separate monitoring and evaluation. Local organizations, investigation and analysis. The effects of climate moreover, are often relatively free of the sectoral change and the implications of agricultural pro- divisions of higher-level bureaucracies and may duction shifting from food products to biofuels are employ agriculturists and health and nutrition ex- matters of serious concern for food security, health, perts from local government agencies who are well and nutrition. Analysis of their potential impacts aware of each other's activities, concerns, and pri- on food production and prices suggests itself as an orities and, as such, can operate in a more effective important object of future research. and coordinated manner. The experience of past and ongoing agricultural An additional lesson learned through the review interventions with nutrition-related objectives and is that poor prodrtcers shorlld be provideif ~oitlrlrelp arlif the connections between agricultural production srtpport to respotrd to clzatzgi?rgfoocl corrsrltriptiow pat- and nutrition more broadly, shed light on a num- terrrs. Anticipating and responding to changing de- ber of variables and causal dynamics that agricul- mand is a vital imperative for farmers in general, tural practitioners should take into account when but among poor farmers in developing countries planning programs or providing policy advice. the stakes are particularly high. A significant part Focusing the crosshairs of production goals onto of their production is intended for their house- nutrition-related targets is something that agricul- hold's own consumption and therefore much of the tural planners are likely to be called upon to do demand they are satisfying is their own. With re- more often, for there is good reason to anticipate spect to the proportion of food they produce for that nutritional aims will come to play more promi- market, the changing agricultural context has im- nently in the calculus by which the value of agri- portant implica tions for the prices they are paid for cultural programs are rated. Future agricultural their products, and increasing demand for high- programs implemented with nutrition objectives value food sources represents an important oppor- will need to address the real challenge of going to tunity to earn more income. Yet switching to new scale and should be carefully monitored and rigor- and unfamiliar crops and producing for foreign ously evaluated to ensure that performance can be markets with stringent food quality and safety re- continually tracked and improved. It is hoped that quirements are also fraught with risk, and both op- the expository account offered in this report lays portunities and risks need to be addressed by the groundwork for more practical work in which agricultural programs. the details of applying these lessons operationally can be prescribed. METHODOLOGY USED IN CHAPTER Third, we searched forward (Web of Science cited 3 (STAPLES) reference search) from three previous reviews (Kennedy et al. 1992; DeWalt 1993; Berti et al. 2004 The following searches were carried out for the purposes and evaluated resulting studies for relevance. of the literature review. In addition, in February 2007, a number of websites The most recently published review (Berti et al. were searched for project results papers, including 2004) employed a documented search strategy with the following: search date of November 2001. We repeated their - Bioversity International (formerly the search to cover the years 2001-2007, with slight International Plant Genetic Research modifications to their search terms (below). We Institute and the International Network searched in PubMed and in Science Citation Index for the Improvement of Banana and Expanded and Social Sciences Citation Index (latter Plantain): http:/ /www.bioversity two via Web of Science). This search was very interna tional.org / broad and yielded approximately 1,700 items in- - Collaborative Crop Research Program: dexed in Medline and approximately 1,800 items http:/ /mcknight.ccrp.cornell.edu/ indexed in Web of Science. projects/nutrition.html - (agricult* OR "sustainable development" OR - Food and Agriculture Organization: "rural development" OR "food production" OR http:/ /www.fao.org/documents/ farm*) AND (nutriti* OR anthropom* OR diet* - HarvestPlus Program: OK "child growth") http: / /www.harvestplus.org/ - Search limits also excluded studies with animals - Healthbridge Canada (formerly as subjects; search date March 2007. Programme for Appropriate Technology in Health, Canada): http://www. In addition, to ensure that no relevant studies were healthbridge.ca/foodandnutrition~e.cfm missed, we supplemented with Medline searches - International Center for Research on using the following terms: - nutriti* AND agriculture AND (trial OR interve* Women: http://www.icrw.org/ - International Food Policy Research OR effect* or effic' OR program OR policy) - "food security" AND agriculture AND (trial OR Institute: http://www.ifpri.org/ interve* OR effect* or effic* OR program OR - International Fund for Agricultural policy) Development: http: / /www.ifad.org/ - These latter two searches yielded 105 items and - Michigan State University, Towards overlapped with the broader searches. Sustainable Nutrition Improvement Project: http://www.aec.msu.edu/fs2/ tsni/index.htm From Aericulture lo Nutrition: Palhwavs. Svnercies. and Outcomes

METHODOLOGY USED IN Assessment"[MeSH] OR Dietary Guideline OR School-based intervention OR Program CHAPTER 4 (FRUITS AND OR Intervention OR Promotion OR Policy VEGETABLES) OR Nutrition Education OR Prevention OR "Education"[MeSH] OR "Behavior"[MeSH] Databases OR "Marketing"[MeSH] OR Mass-media OR "Schools"[MeSH] OR A structured electronic search of the PubMed data- "Communication"[MeSH] OR "Intervention base was conducted. It included publications from Studies" [MeSH] OR "Public Policy" [MeSH] 1980 to January 2007. Other limits included human OR "Randomized Controlled Trialsn[MeSH] studies in the following languages: English, OR "Health Education"[MeSH] OR French, Italian, and Spanish. Significant efforts "Government Programs"[MeSH] OR were also made to identify other studies through "National Health Programs"[MeSH] OR searches in the "gray literature" by accessing rele- "Health Promotion"[MeSH] OR "Nutrition vant Web sites. In addition, a number of experts Policy"[MeSH] OR "prevention and con- from various international organizations were control"[Subheading] OR "Guidelines"[MeSH] tacted through e-mail to ask for copies of reports OR Impact OR Efficacy OR Effectiv* documenting their experiences. The obtained reports were included in this review. Additional Inclusion/exclusion criteria: Only high-quality publications were obtained by going through the studies were included, that is, those that had an ex- references of the retained publications to identify perimental or quasi-experimental design for which those that were relevant for this topic. Finally, a the intervention was clearly described and that in- number of articles and reports were obtained from cluded tests of statistical significance in the impact colleagues who already had articles available that analysis. had been compiled for previous reviews.

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