Unequal Portions

UNEQUAL PORTIONS

Ending malnutrition for every last child Every child has the right to a future. Save the Children works in the UK and around the world to give children a healthy start in life, the chance to learn and be safe. We do whatever it takes to get children the things they need – every day and in times of crisis.

Acknowledgements This report is co-authored by Marie Rumsby and Katherine Richards. The new research has been developed by José Manuel Roche, Dimitri Gugushvili and Alexis Le Nestour. Considerable recognition must be given to the following people from across the Save the Children movement for their substantial contributions: Phoebe Corrigan, Róisín Hinds, Fran Roberts, Frances Mason, Sam Kennedy, Hugh Bagnall-Oakley, Joana Alfaiate, Amanda Lenhardt, Sylvia Szabo, Giorgiana Rosa, Andrew Wainer, Nicola Hypher, Davina Jeffery, Assumpta Ndumi, Lilly Schofield, Vanessa Self, Kjersti Koffeld, Cara Flowers, Mihir Mankad, Leah Finnegan, George Graham and Mark Buttle. We are delighted to include country examples, which are produced thanks to the inputs and collaboration of colleagues across the Save the Children movement, including: John Kabongo, Caroline Nenguke, Jorge Freyre, Michel Anglade, Angela Muriuki, Regina Mbochi, Hassan Abdille, Beatrice Otieno, Solomon Bahiru, Olayinka Adekugbe, Matthew Tasker, Andrea Menefee, Tatak Ujiyat, Pallavi Dhakal, Peter Oyloe, Bindu Gautam, Alice Atkins, Ramatu Jalloh, Tahrim Chaudhury, Taskin Rahman, Ngo Thi Ngoc Chau, Inna Sacci, Abigail Beeson, Mot Sana, Chamindri Katuwawala, Victoria Ward, Maritza Lily Lovo, Edith Rivera, Elizabeth Bocaletti, Beat Rohr, Rodríguez Solís, Blanca Xmucané and Jorge Rios. We are grateful to colleagues across the Save the Children movement for their comments and suggestions, including: Richard Morgan, Jonathan Glennie, Annabel Fenn, Stephanie Bellack, Julia Schilling, Smita Baruah, Karin Lapping, Catharina Bu and Alice Faye. We would also like to thank our external reviewers for their very helpful guidance: Robert Chambers, Institute of Development Studies; Tanya Khara, DFID; Margret Vidar, Right to Food Unit, FAO. We are grateful to Wenche Barth Eide and Asbjørn Eide for their valuable suggestions in the earlier stages of this report’s development, and to Manuel Silva Santos and Marcello Perez of Göttingen University and Anthrologica for their research contributions.

Some children’s names have been changed to protect identities.

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First published 2016

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Cover: Rebecca, 11, queues to receive food in South Sudan. Her family fled their home when conflict broke out in 2013. (Photo: Jonathan Hyams/Save the Children)

Typeset by Grasshopper Design Company Contents

Executive summary v

The story in numbers viii

Overview of the report x

Key terms xi

1 Introduction 1 Why does exclusion matter? 1 Why must we address malnutrition? 1 New findings and background research 2

2 Who are the malnourished children, where do they live, and why must we address exclusion to reach them? 3 The global picture of malnutrition: some progress but too slow and unequal 3 How are countries progressing in addressing malnutrition? 5 Which countries have done well in addressing malnutrition? 5 Which countries have struggled? 6 How do inequality and exclusion impact malnutrition? 7 The lottery of childhood: country regions and urban and rural areas 8 Unequal chances of malnutrition for the poor and rich 11 Children from excluded groups are at risk of being left behind 18 Projections are a cause for concern 19

3 Why are children malnourished? 24 Why are some people vulnerable to malnutrition? 26 Poverty and income 30 Regional disadvantage 31 Gender 33 Malnutrition from mother to child 34 Disability 36 Refugees, children on the move and children in conflict 37 Ethnicity 38 National and global drivers of malnutrition 39

4 How to address malnutrition inclusively 44 Nutrition commitments – are they inclusive? 44 How to take an inclusive approach 46 4.1 The child: addressing the immediate drivers of malnutrition 46 4.2 The household: addressing the underlying drivers of malnutrition 47 4.3 At national and global levels: basic structural and institutional drivers of malnutrition 55 4.4 Design principles for an inclusive approach 59

5 Conclusions and recommendations for world leaders 60 1. Overcome exclusion through appropriate laws, policies and investment 60 2. Break the intergenerational cycle of malnutrition – focus on mothers and adolescent girls 61

UNEQUAL PORTIONS 3. Address the large-scale drivers of malnutrition 62 4. Take a ‘leave no one behind’ approach – an appropriate policy and programme response based on the national context 63 Save the Children’s steps for a Decade of Action on nutrition – starting at the second Nutrition for Growth event 64

Appendices 65 Appendix 1: Methodological note 65 Appendix 2: Methodology to project SDG target 2.2 on ending all forms of malnutrition 67 Appendix 3: International human rights and the role of the state 69

Endnotes 70

iv Executive summary

Good nutrition – a healthy, balanced, MALNUTRITION – PROGRESS adequate diet – is a matter of life or death. AND PROSPECTS And the difference between surviving or thriving. The world has made progress in addressing undernutrition. The number of children with It is essential for a healthy immune system, stunted growth has fallen by more than a third to protect against disease throughout life. since 1990. And it’s crucial for a country’s inclusive and sustainable development. But progress has not been fast enough. Every year, 3.1 million children die because of undernutrition. But progress in tackling malnutrition is far too slow. Malnutrition is a daily global emergency. In the world Millions of children are missing out on adequate today, nearly a quarter of all children under five – nutrition because of who they are and where they 159 million children – are stunted.1 A lack of food, live. They are discriminated against because of their poor health or unsanitary environments mean these ethnicity or disability; they are excluded because of children are not benefiting from the nutrients they their parents’ lack of income or after being forced need to develop to their full potential. from their homes. Without a dramatically different approach This report tells the story of these forgotten the world won’t meet its nutrition goals. The children. And it sets out what is required to ensure world has pledged to reduce stunting by 40% by every last child gets the nutrition they need. If we 2025 and eliminate all forms of malnutrition by are serious about creating a world where no child 2030. But if we carry on as we are, that simply won’t is malnourished, we must tackle the discrimination happen. Unless the world dramatically changes and exclusion they face. course, malnutrition is here to stay. Save the Children has launched a new campaign to While a reduction of 30 million over 16 years in the help ensure that every last child survives and thrives. number of malnourished children2 signifies some We will work directly with excluded children, coming progress, it is unacceptably slow. By 2030 there up with innovative solutions and delivering world will still be 129 million stunted children. class programmes. We will advocate for increased Low-income countries will account for more than resources for nutrition. We will challenge the laws, a quarter of this global burden. norms and policies that have allowed malnutrition What’s more, even at the turn of the next century – and discrimination to persist. And we will campaign 70 years after the deadline to end malnutrition – with and for the world’s forgotten children. we are still likely to see 24 million children with The need for action has never been more pressing. stunted growth. Without a concerted change, the Our new research shows that, despite a global world is set to live through another century of commitment to eradicate malnutrition by 2030, wasted potential, damaging children’s education, on current trends there will be 129 million children life chances, income and productivity – and with under five with stunted growth worldwide by that serious consequences for the global economy. date. And even in 100 years from now, without a At the same time, the number of overweight dramatic change of course there will still be millions children is increasing. There are 41 million of malnourished children in the world. overweight under-fives in the world today – 10 million more than two decades ago.3 This is a

v vi UNEQUAL PORTIONS since 2000. 2000. since worse got actually has problem 13in the countries and are stunted, –over children of half Timor-Leste and Eritrea –Burundi, countries these of three In growth. fromstunted suffer children of more or 30% 115 of atotal of –out – countries data available with developing 44 In countries. between rates malnutrition in differences stark are There HOW BEEN? PROGRESS EQUAL HAS reversed. be should and Yet economy. global for could the it’s that atrend implications have will significant and mortality, and morbidity greater to lead will which trend, worrying since 1990. experienced world has the that progress unequal the of –acontinuation country the of rest the in or children of groups excluded in malnutrition eliminate to longer take much will it that predicted is it countries developing most Within nutrition levels. Our data shows that, on average, average, on that, shows data Our levels. nutrition their family’s their ultimately –and income practices, social and cultural their food, and education services, to access their determines largely lives achild Where inequalities. these create to helping are exclusion and Discrimination OTHERS? THAN TO MALNUTRITION VULNERABLE MORE PEOPLE SOME ARE WHY groups. ethnic between and areas urban and rural between regions, between rates stunting in particular, growing in inequalities Peru, has two. the between gap increasing an to leading ones, advantaged more the behind have lagged countries these in groups disadvantaged Ghana, in areas However, rural years. of recent exception the with in stunting in reduction asignificant have seen children. all include to failed often has nutrition on We progress But is possible. know progress than among the best-performing groups among best-performing the than Ghana, Peru and the Republic of Congo Congo of Republic the and Peru Ghana, 4 make problem pressing. increasingly the trends global –these 2030 by malnutrition of forms movement Nutrition Up Scaling the to up signing 57 countries –with malnutrition tackling to commitment worldwide greater never been has there while So survive. to need they essentials basic the get to them for difficult more it making world war, and homes fromtheir people forcing second the since crisis refugee worst the fuelled also have persecution and Violence people. 60 million than more affecting 15 and to drought countries bringing Niño, ever El recorded strongest the is malnutrition global of problem the Exacerbating require specialist care. care. specialist require they if –particularly need they services the get to able even be less may areas these in living children Disabled healthcare. have to not access may areas remote in living children example, For children. of groups certain of exclusion the exacerbating These drivers can intersect and overlap, climate change. as such factors environmental and context political the poverty, live, people which in environment health broader the care practices, security, food household health, and achild’s intake include dietary They are well known. malnutrition of drivers The TO MALNUTRITION? CONTRIBUTING HOW EXCLUSION IS the population. of fifth wealthiest the in fromfamilies children as birthday fifth their before die likely to as twice than are more families of 20% poorest the in children young regions, and countries developing Across fifth. richest the than rates wasting and stunting higher have children considerably of fifth poorest the that surprise no as comes it So child’s nutrition. a influence over asignificant has income Family areas. urban and rural between inequalities greater areas. urban in living children than stunted be likely to are 1.37more areas rural in times living children 5 In reality, these global averages mask even mask averages global these reality, In 7 and a global goal agreed to end all end to agreed goal aglobal and 6 EXECUTIVE SUMMARY vii The second Nutrition Growth for 11 ich policies and practices will best address ich groups of people most are marginalised e national drivers of and trends in rk with sectors relevant and stakeholders malnutrition and vulnerable to malnutrition and the barriers they face. th malnutrition wh wh dertake a multi-sectoral contextual analysis t in appropriate place policies and plans to sure appropriatesure finances in are place. Every t national nutrition targets, aligned to global

• Un to understand: • • Se Pu Wo En goals, which include specific targetsgroups all for of society, based on national contexts and trends. reach those targets,groups all for of society. This should form the basis no one of a ‘leave behind strategy’ – ensuring malnutrition is reduced groups across all of society. – including donors, academics, civil society and business throughout – the policy and planning process on tackling malnutrition, from contextual analysis, design of strategies and policies, to evaluation. implementation, and monitoring government should in invest the nutrition of their people. In addition, donors should prioritise nutrition as both a maker and a marker of development. sustainable

Policies that can contribute to inclusively addressing malnutrition through a multi-sectoral approach include child-sensitive social protection; universal sanitation and water, health improved coverage; hygiene; education and building resilience; and enhancing food security and livelihoods. A decade of action is required to end malnutrition. event marksevent the moment to prioritise and to invest end malnutrition last every for child. theSave Children recommends that governments: 1. 2. 3. 4. 5.

9 8 The values of empowerment, equity, 10 Commitments to address malnutrition should begin with the moral and legal imperative the for right to food and nutrition all. for Countries that have legally recognised the right to food tend to be more tolikely implement programmes tackling child nutrition. Economic growth can contribute to improved nutrition, and in low-income countries it is seen as an essential weapon in the fightagainst malnutrition. Governments signed have upto numerous global nutrition targets. While welcome, these goals are often the result of political negotiations rather than calculations based on trends in nutrition and the context in which countries operating. are It is therefore not surprising that the is not world on track to meet Health any of the six World Assembly nutrition targets. If want to see we real and equitable progress, these global goals must be translated into national targets, with adequate resources and plans that lay out eachhow country will reach its goals for all groups of society. States a binding have obligation, enshrined in international to respect, law, protect and realise right to survival.children’s The UN Convention on the Rights of the Child obliges states to do everything they can children toprevent from dying. meet this commitment,To states need to tackle malnutrition. many countries Yet, lack a legal framework that promotes child survival, and those that do often fail to implement it. HOW TO ACCELERATE PROGRESS ACCELERATE TO HOW FOR ALL universality and accountability should also be at the centre of efforts to reduce malnutrition. However, there is a complex relationship betweenHowever, economic growth and nutrition, and growth alone is not sufficient to tackle malnutrition.Policies that accounttake of the specificcountry context are also essential – necessitating a national contextual analysis to understand both the immediate and underlying causes of malnutrition to and how them.overcome The story in numbers

If we continue as we are…

there will be 129 million stunted children in the world in 2030

there will be 24 million stunted children in the world at the start of the next century

75 out of 114 countries will fail to reduce stunting by 40% by 2025

only three more countries will eradicate stunting between now and 2030

in most countries it is projected to take much longer for excluded groups to reach the targets than the countries as a whole or the best-performing groups.

Today there are…

159 million stunted children in the world – 24% of all children

50 million children too thin for their height (wasted)

more obese than underweight adults in the world – for the first time in human history

more than 1.9 billion adults – nearly 30% of the global population – overweight or obese. viii There has been some progress, but it has not been STORYTHE NUMBERS IN fast enough or equal enough…

100 out of the 115 countries for which we have data on the changes in stunting over time have reduced stunting

The prevalence of wasting has increased in far more countries than stunting. Of 113 countries, we found that in 38 it has worsened

No low-income countries feature on the list of the top 10 countries that have reduced stunting the fastest

Children living in rural areas are 1.37 times more likely to be stunted than children living in urban areas (across 56 countries with relevant data)

The poorest 20% of children are 2.26 times more likely to be stunted than the richest (across 56 countries with relevant data)

Ethnic groups with the worst wasting rates are six times more likely to be wasted than ethnic groups with the best rates.

ix Overview of the report

In this report we will look at how groups of children are excluded from progress on malnutrition based on their gender, ethnicity, regional differences within countries, disability, which economic group they fall into or because they are on the move. In part 1 we introduce the approach, methodology and new research. In part 2 we look at the problem – which countries and which groups of children are furthest behind in nutrition outcomes – and why this exclusion must be addressed. In part 3 we explore the drivers that make some people vulnerable to malnutrition, and we look at how international commitments have attempted to promote inclusive progress to date. In part 4 we suggest how governments can overcome the burden of malnutrition in an inclusive and sustainable way. We show that economic growth alone is not enough – the right policies need to be in place. In part 5 we make recommendations and calls for world leaders to address the drivers of malnutrition and exclusion.

This report is part of Save the Children’s Every Last Child campaign to tackle exclusion in a new era of development.

x Key terms

1,000-day window Overweight and obesity The 1,000-day period is the time between The terms overweight and obesity refer to when a conception and a child’s second birthday. The person is too heavy for his/her height. That person right nutrition during this critical period can have may be defined as having abnormal or excessive fat a profound impact on a child’s ability to develop accumulation that may impair health. Body mass mentally and physically, to learn and to rise out index (BMI) is a simple index of weight-for-height of poverty. It can also shape a society’s long-term that is commonly used to classify overweight health, stability and prosperity.1 and obesity in adults. A BMI greater than or equal to 25 is overweight. A BMI greater than Hunger or equal to 30 is obesity.5 This form of malnutrition Hunger is the body’s way of signalling that it is results from expending too few calories for the running short of food and needs to eat something. amount consumed, and increases the risk of 6 Sustained hunger can lead to undernutrition, non-communicable disease later in life. although it is only one of many causes; others include diarrhoea, malaria and HIV and AIDS.2 Stunting Stunting refers to a child who is too short for his Malnutrition or her age. Stunting is the failure to grow both Malnutrition is a broad term commonly used as physically and cognitively and is the result of chronic an alternative to undernutrition, but technically it or recurrent malnutrition. The effects of stunting 7 also refers to overweight and obesity. People are often last a lifetime. malnourished if their diet does not provide adequate calories and protein for growth and maintenance, Wasting or if they are unable to fully utilise the food they Wasting refers to a child who is too thin for his or eat due to illness (undernutrition). They are also her height. Wasting is the result of sudden or acute malnourished if they consume too many calories3 malnutrition, where the child is not getting enough compared to how many they expend. Good calories from food and faces an immediate risk nutrition is when the right balance of nutrients of death.8 enter, leave and are absorbed by the body.

Undernutrition Undernutrition is defined as the outcome of insufficient food intake and repeated infectious diseases. It includes being underweight for one’s age, too short for one’s age (stunted), dangerously thin for one’s height (wasted), and deficient in vitamins and minerals (micronutrient malnutrition).4

xi PHOTO: CJ CLARKE/SAVE THE CHILDREN

Selim, 12, left his home in Bangladesh when his brother beat him and now lives on the streets.

xii 1 Introduction

The world has made progress in addressing self-identify in another way; what their culture is; undernutrition. The number of children who whether they have a disability; or whether they are are stunted has fallen by more than a third rich or poor. No child should be treated unfairly or since 1990. But progress has not been fast discriminated against on any basis.6 enough or inclusive enough. The world is currently off track to meet its nutrition WHY MUST WE ADDRESS targets, including all six of those set at the 2012 MALNUTRITION? World Health Assembly1 (WHA) – which seek improvements in stunting, anaemia, wasting, Adequate nutrition is a case of life or death. It is a low birth weight, childhood overweight and case of surviving or thriving. Adequate nutrition is breastfeeding by 2025; and the recently agreed essential for a healthy immune system, to help protect Sustainable Development Goals (SDGs) – which against disease throughout life. A well-nourished strive to end all forms of malnutrition by 2030.2 and productive population is the difference between a country’s economy developing or stagnating. Discrimination – whether intentional or not – means Understanding the drivers of malnutrition and how that progress has not been spread equally among to ensure every child receives and is able to absorb all children. Some groups of children are being the nutrients they need is crucial for inclusive and excluded, leaving them particularly vulnerable to sustainable development everywhere. malnutrition and the impact this has on their lives. The moral imperative for addressing malnutrition is well recognised. In fact, the very existence of WHY DOES EXCLUSION MATTER? malnutrition can be presumed to be a violation of the human right to food.7 Nutrition is a precondition Exclusion is a clear violation of children’s rights. for sustainable, social, economic and human Discrimination – treating a person differently development, as set out in the United Nations because of who they are or where they are – stops Charter, the Universal Declaration of Human millions of children getting the food, healthcare Rights, and subsequent international human rights and education they need, leaving them vulnerable conventions including the CRC.8 to malnutrition and its impacts. The impact of exclusion on children can be severe, long-lasting and Malnutrition has severe, long-term human and wide-ranging, particularly so because of children’s economic consequences. Ensuring the right vulnerability and because childhood is such a critical nutrients are received and absorbed during those developmental period for nutrition.3 first 1,000 days of life – between conception and a child’s second birthday – can help shape a child’s – All of the major international human rights and wider society’s – long-term health, stability and 4 instruments explicitly protect rights of all groups. prosperity.9 Nutrients provide the biological building The principle of equality and non-discrimination is blocks for our organs, including the structural 5 at the heart of children’s rights. The Convention and functional development of the brain.10 45% of on the Rights of the Child (CRC), for example, deaths of children under the age of five are linked applies to all children, whatever their race, religion to malnutrition.11 The effects of malnutrition on or abilities; whatever they think or say; whatever physical stature, cognitive development, immune type of family they come from. It does not matter systems and the ability to do physical work can where children live; what language they speak; what lock children into poverty and entrench inequality. their parents do; whether they are boys or girls or

1 2 UNEQUAL PORTIONS of US$16of for every US$1. investment on return amedian –with investment global GDP.global lost in trillion US$2.1 to world up the costs and well nourished. are who children than adults as 20% less malnourished earn and are poor who Children Inequality Database on Education). World World the and UNICEF, (WHO), Bank World Organization Health Estimation, Mortality for Child Group Inter-agency (thesources UN public aggregated various and (MICS), Surveys Cluster Indicator Multiple and (DHS) Surveys Health Demographic of processing data direct on based is GRID Institute. Development Overseas the with collaboration in Children Save the by developed fromGRID, groups economic and areas urban/rural regions, sub-national ethnicity, on we availabledata use report this In (GRID) DATABASE INEQUALITY GROUPS-BASED THE 1for detail): more appendix see (please inputs research following the draw on this report in presented findings and evidence The groups. economic and social between chances life in inequalities analyse to and exclusion of diagnostic a global provide to order in data, additional produce and statistics existing compile to efforts substantial We have challenges. made data numerous presents children, of groups excluded on focus to intends and averages national beyond look to aims analysis that where malnutrition, eradicating in progress on analysis aglobal Conducting BACKGROUND RESEARCH AND FINDINGS NEW economy 10% of gross domestic product (GDP), product 10% gross domestic of economy the cost can undernutrition and hunger countries some in productivity, on impact along-term With 14 An investment in nutrition is a smart asmart is nutrition in investment An 12

Brazil, Guatemala and Honduras. and Guatemala Brazil, Sierra Lanka,Sri Vietnam, Leone, Bangladesh, Zambia, Myanmar, Cambodia, Indonesia, Nepal, Nigeria, fromKenya, studies fromcase detail includes report This communities. and groups excluded with countries of anumber in working highlight gained through They learnings experience. beneficiary and fromprogramme drawing by malnutrition address inclusively to ways practical highlight studies case These report. the of aspects various illustrate to Children the Save by developed from14 detail studies includes case also report This STUDIES CASE progress. by behind left being of risk are at groups which assess to country each inside groups economic and for social projections national beyond national averages. We disaggregate to move is projections our in innovation important One achieve to it. target the miss to are set that countries would it howtake for those long estimate to future the into further project and malnutrition; eliminating of target Goal Development Sustainable nutrition the reach to 2030, by 40%; by malnutrition reducing of target World Assembly the Health reach to 2025, by moments: landmark by usual’ as ‘business continue countries if be will rates stunting the what We country. estimate each inside groups level economic and for all and social national at projections of weaseries produced University, fromGöttingen researchers with collaboration In BEYOND AND BY 2030 PROJECTIONS 2025, 2 Who are the malnourished children, where do they live, and why must we address exclusion to reach them?

In this chapter we present the global picture The distribution of the stunting burden across the of malnutrition. We explore which countries world’s regions is highly uneven. Half of the world’s have done well in addressing malnutrition, children aged under five live in sub-Saharan Africa and which have struggled. We then look at and South Asia, but these children account for 80% 2 trends in inequalities of nutrition outcomes of all stunted children in the world. within groups of children, and present some With the exception of sub-Saharan Africa, each estimations projecting the current trends region of the world has seen a reduction in the into the future. absolute number of stunted children since 1990. The greatest reduction happened in East Asia where the number of stunted children decreased from THE GLOBAL PICTURE OF 80 million to 16 million (Figure 2). In sub-Saharan MALNUTRITION: SOME PROGRESS Africa the proportion of stunted children is reducing, but at a slower rate than population growth. As BUT TOO SLOW AND UNEQUAL a result, the total absolute number of stunted children in sub-Saharan Africa has increased from In 1990 there were 255 million children with stunted 43.5 million to 55 million (Figure 3). growth in the world – representing 40% of all children. The situation has improved since then, Progress shows it is possible to address malnutrition with an estimated 159 million stunted children in the successfully. In fact, a number of countries have world in 2014 – 24% of all children (see Figure 1).1 shown impressive progress towards their nutrition

FIGURE 1 CHANGE IN THE PREVALENCE AND NUMBER OF STUNTED CHILDREN GLOBALLY

350 50 300

45 250

40 Prevalence (%) 200

35 150

30 100

Number of affected children (millions) 25 50 Number of affected children

0 20 Prevalence 1990 1995 2000 2005 2010 2014

Source: UNICEF, WHO, World Bank Group, 2015. Levels and trends in child malnutrition.

3 4 UNEQUAL PORTIONS height (wasted) – 50 million children – of whom whom –of children million –50 (wasted) height 7.5% for their Globally, thin are too children of children behind. excluded left often too has and enough fast 1990 been since not has progress But society. of areas many in benefits the are and reaping goals, malnutrition child in trends and Levels 2015. Group, Bank World WHO, UNICEF, Source: Levels and trends in child malnutrition child in trends and Levels 2015. Group, Bank World WHO, UNICEF, Source: FIGURE 2 FIGURE FIGURE 3 FIGURE 37.6% Africa Sub-Saharan Stunted children (millions) 300 200 100 250 150 50 0

DI CH 1990 STRIBUTION OF STUNTED CHILDREN ACROSS THE WORLD REGIONS WORLD ACROSS THE CHILDREN STUNTED OF STRIBUTION ANGE IN THE NUMBER OF STUNTED CHILDREN ACROSS THE WORLD REGIONS WORLD ACROSS THE CHILDREN STUNTED OF NUMBER THE IN ANGE

19 95

20 00

20 05

at some point in their lives is considerably higher. considerably is lives their in point some at wasting have experienced who children of number the likely that highly is it therefore, changes; fast to subject condition ashort-term is wasting stunting, unlike every of 13 out But, one world. the in children approximately 16 million is This are severely wasted. 20 10

. . 20 14 42.5% Asia South 4.8% Africa North and East Middle 3.2% Caribbean and America Latin 10.6% Pacific and Asia East 1.4% Asia Central and Europe East Asia and Pacific and Asia East Asia Central and Europe Caribbean and America Latin Africa North and East Middle Asia South Africa Sub-Saharan

2 WHO ARE THE MALNOURISHED CHILDREN, WHERE DO THEY LIVE, AND WHY MUST WE ADDRESS EXCLUSION TO REACH THEM? 5

PHOTO: IVY LAHON/SAVE THE CHILDREN The greatest 4

5 children under of five whom 5.8 million are stunted), the million Democratic Republic of Congo (13.2 children under of five whom 5.6 million are stunted) and million Bangladesh children under five (15.4 of whom 5.5 million stunted). are WHICH COUNTRIES HAVE DONE WELL IN ADDRESSING MALNUTRITION? The vast majority of countries out of 115) (100 in our sample reduced have stunting since 2000. Some of these countries exceptional achieved have progress. South Africa reduced its stunting to between 24% from 33% prevalence 2004 and 2008. Afghanistan cut stunting from prevalence between 2004 Three outof to 41% 59% and 2013. prevalence of wastingprevalence is found in South Sudan (22.7%), Djibouti and Sri Lanka (21.4%), (21.5%) where fifth every wasted. child is In half of our the countries), wasting sample prevalence (57 exceeds the WHO threshold ‘public for of 5% health significance’. Sara, 3, eats a tortilla with herbs. Her family can’t afford enough food since a plague of coffee rust destroyed Guatemala. coffee across crops Some of the countries with the highest rates of stunting also are home to very large numbers of children aged under five,leading very to high absolute numbers of children being stunted as a whole. These countries include India (with 124.4 million children under five of whom 48.2 million stunted), are Nigeria (30.5 million children under10 five of million are whomstunted), Pakistan million (23.7 children under five of whom million stunted), are 10.7 Ethiopia million (14.4 Inequalities in nutrition outcomes more even are apparent as turn we to the country level. Only countries which data for have we nine out of 115 (Australia, Chile, Czech Republic, Germany, Republic of Korea, Saint Lucia, Singapore, Ukraine and the USA) stunting have rates and below 3% nearly of these all high-income are countries. In 44 countries, the of stunted prevalence growth in children is high – more than 30%. In three of these countries– Burundi, Eritrea and Timor-Leste – over half of the children stunted have growth. HOW ARE COUNTRIES PROGRESSING PROGRESSING COUNTRIES ARE HOW IN ADDRESSING MALNUTRITION? 6 UNEQUAL PORTIONS jointchildmalnutrition_2015_estimates/en/ http://www.who.int/nutrition/publications/ estimates, malnutrition child Joint 2015: Group Bank World WHO, UNICEF, Source: an experienced 13and have actually countries Korea) of Republic and change, no have seen (Romania countries two prevalence stunting, of the in reducing progress have significant made groups income and fromall regions countries While STRUGGLED? HAVE COUNTRIES WHICH for improvement. scope larger therefore and prevalence have wasting ahigher of to tend usually countries these that given surprising –not countries low- by income lower-middle and dominated is 21%of 11%. performers to best ten of list The prevalence 2012,even and froman higher 2003 between halved wasting nearly Faso Burkina 7%. to 16% of rate high fromavery 2014, and though 2006 prevalence halved between the than more which Togo, been has performer best the wasting, For Ghana. and Guinea Equatorial d’Ivoire, Côte Africa, –South Africa sub-Saharan in are four –and KoreaNepal and PDR Afghanistan, – countries are low-income performers best ten the

South Africa 2004–2008 4 FIGURE Initial rate Initial Afghanistan 2004–2013 Stunting rate, % 40 60 30 20 50 70 10 0

Korea PDR 2000–2012 BE

ST AND WORST PERFORMING COUNTRIES IN REDUCING STUNTING REDUCING IN COUNTRIES PERFORMING WORST AND ST Vietnam 2000–2013 La Albania 2000–2009 test rate test Côte d’Ivoire 2006–2012 Equatorial Guinea 2000–2010 Best performers

Bolivia 2003–2012

Ghana 2003–2014

Nepal 2001–2014 Papua New Guinea 2005–2010 economies. economies. are lower-middle-income performers worst ten of list the in all countries Thailand, income middle upper- and Mali low-income of exception the with Interestingly, from 4% 11% to 2008. to from2000 tripled prevalence nearly wasting the as increase alarge ToméSão experienced also Principe and 14.3%. to from4.4% prevalence tripled wasting 2010,to 2005 period five-year the within Guinea: New Papua in observed was increase greatest The 113. of out –38 countries of number larger much a in increased has wasting stunting, to Compared 20%. than more is rate stunting the Thailand) Montenegro, 13 (Kuwait, those of three allin but countries that given especially worrying, are highly trends 2012). and 2002 negative These 33.5%to between (from 26.5% Djibouti in and 2002–10) period the in (from to 50% 44% Eritrea in considerably increased prevalence also 2010. and Stunting 2005 between 49% to from44% prevalence increased stunting the where Guinea, New Papua in observed was The largest annual increase inincrease stunting. Eritrea 2002–2010

Djibouti 2002–2012

Vanuatu 2007–2013

Syria 2000–2009

Botswana 2000–2007 Worst performers

Pakistan 2001–2012

Armenia 2000–2010 Timor-Leste 2002–2009

Montenegro 2005–2013

2 WHO ARE THE MALNOURISHED CHILDREN, WHERE DO THEY LIVE, AND WHY MUST WE ADDRESS EXCLUSION TO REACH THEM? 7

Thailand 2006–2012 Thailand

Egypt 2003–2014 Egypt

Sri Lanka 2000–2012 Lanka Sri

Mali 2001–2006 Mali Bhutan 2008–2010 Bhutan

Worst performers Worst

Indonesia 2000–2013 Indonesia

Syria 2000–2009 Syria Timor-Leste 2002–2009 Timor-Leste

The relative ratio between Dodoma and Dar es Salam is 2.85, which means that children in Dodoma 2.85are times to more likely be stunted than children in Dar es Salam. Reduction in the ratio tells us more directly about equalisation in life chances, as the measures effectively more likely how show a child from one group is to be malnourished than a child from another group. There three are additional factors that support our decision to use ratio as the main metric in our analysis. Any differences in nutrition outcomes between groups can be ascribed to systematic differences in life chances, and fundamentally are unjust and a sign are of systematic discrimination. This means that the ratio between the top and bottom groups of is the revealing extent of inequity in life chances. Second, the gap between the most and least advantaged groups is easy both for politicians and citizens to understand, and should therefore motivate action. Third, examining the performance of the top-performing group in society shows what and pace of progress level is possible within a given country context.

São Tomé and Principe 2000–2008 Principe and Tomé São

Papua New Guinea 2005–2010 Guinea New Papua

India 2006–2014 India

South Africa 2004–2008 Africa South

Korea PDR 2000–2012 PDR Korea

Best performersBest 2000–2011 PDR Lao West Bank and Gaza 2002–2014 Gaza and Bank West

test rate Morocco 2003–2011 Morocco La ST AND WORST PERFORMING COUNTRIES IN REDUCING WASTING

BE 2002–2006 Uzbekistan

5 0

15 10 25 20

Wasting rate, % rate, Wasting

Burkina Faso 2003–2012 Faso Burkina Togo 2006–2014 Togo Democratic Republic of Congo 2001–2013 Congo of Republic Democratic Initial rate FIGURE 5 For instance, the stunting in in Tanzania, rate is 57% Dodoma, the most affected region in the country, and 20% in Dar es Salam, the least affected region. This means that the absolute gap between the two percentage regions is 37 points. If the gap in percentage points between Dodoma and Dar es Salam Dar for increases es Salam and to, say, 15% 60% Dodoma for – a gap of – then 45% the absolute gap has increased. This section considers two main metrics the for analysis of inequalities between groups: the absolute gap and the relative The ratio. absolute gap simply measures absolute difference in the given indicator between disadvantaged and reference groups. The relative ratio measures much how the more likely disadvantaged group is to experience the given condition compared to the reference group. How do we measureHow do we inequalities in nutrition between groups? HOW DO INEQUALITY DO HOW AND MALNUTRITION? IMPACT EXCLUSION Source: UNICEF, WHO, World Bank Group 2015: Joint child malnutrition estimates, http://www.who.int/nutrition/publications/jointchildmalnutrition_2015_estimates/en/ 8 UNEQUAL PORTIONS But there is huge variability between countries. between variability huge is there But areas, urban in living children with compared stunted be are likely 1.37more to areas rural in times living children sample, our In places. isolated and remote in living when experience children that exclusion the highlights further and countries, most in important also is areas rural and urban between gap The the world. in children of for millions issue are amajor stunting in inequalities geographical internal that means and Egypt, and Pakistan Congo, of Republic Democratic Nigeria, as such rates stunting high with countries large in case the is This region. best the in living those than malnourished be likely more to times three are than more for malnutrition region worst (19 available is data 56), of the in out living children for which countries the of athird about In country. each inside regions between disparities wide or gaps, largeurban/rural whether inequalities, geographical considerable shows analysis Our services. to access or infrastructure in differences to related are often inequalities geographical These 3% and respectively. 48% of rates stunting with Tacna, of region fromthe children than stunted be are 16 region likely more to Huancavelica times in children for example, Peru, In status. nutrition lower have considerably may regions remote or areas rural in Children avoidingmalnutrition. of child’s that of chances determinant ahigh remains country given any within lives achild Where AREAS RURAL AND URBAN COUNTRY AND REGIONS LOTTERYTHE CHILDHOOD: OF malnutrition rate. lowest have not the may groups these few cases, avery in that noting worth is it areas; urban and quintile richest we the use areas, urban/rural and groups economic of case the In rates. malnutrition lowest the with ethnicities and regions the example, –for all cases almost in point reference the as group performing best we the use analysis, our In of malnutrition. level the by affected are not ratios whereas rates, malnutrition high with countries in larger be to tends gap absolute the are correlated, ratio the and gap the although that noting worth also is It again interesting to consider Peru, where children in in children where Peru, consider to interesting again 6 It is is It data disaggregation. level we have of for this which countries the in inequality level geographical show of 7 below the 6and Figures minimal. is two the between difference the Liberia in whereas areas, prevalence urban as the twice have nearly areas rural Cameroon, in but (33%prevalence 32% stunting and of respectively), have similar also Liberia and Cameroon Niamey. capital the in those with comparison in malnourished be likely more to times are 2.4 region Diffa in living Niger, In children fromKinshasa. children than malnourished be likely more to are 3.7 times Congo of Republic Democratic the in region Sud-Kivu in Children Congo. of Republic Democratic the in larger are considerably inequalities geographical but 43%) (of prevalence have similar about stunting of countries Niger. and Congo of Republic Both Democratic Consider, inequalities. overcome to these possible is it that demonstrating inequality, geographical of levels different have remarkably may malnutrition levels of similar with Countries inevitable. are not inequalities geographical that newsis good The ARE NOT INEVITABLE BUT GEOGRAPHICAL INEQUALITIES avoiding malnutrition. child’s of that chances determining in lives child a where of lottery the by affected particularly are countries These indicators. malnutrition multiple in inequalities have geographical high Peru, Cameroon, Honduras Bolivia, and Guyana and wasting. stunting in both inequalities regional highest the with countries ten the among are ranked Guyana and Honduras Cameroon, Egypt, instance, For systematically. –almost wasting in inequalities have similar to also tend stunting in inequalities geographical high with Countries GEOGRAPHICAL INEQUALITIES? HAVE HIGHEST THE COUNTRIES WHICH reduce inequalities in nutrition outcomes. outcomes. nutrition in reduce inequalities to differences overcoming in these challenges face will conditions climate and geography in However, differences have vast that countries live possible. is they where of because experience children that exclusion overcoming the that shows This inequalities. geographical levels internal of lower sustain to able have been countries Many 33% 11% and respectively. of rates stunting with settings, urban in children than stunted be likely more to times are three areas rural 2 WHO ARE THE MALNOURISHED CHILDREN, WHERE DO THEY LIVE, AND WHY MUST WE ADDRESS EXCLUSION TO REACH THEM? 9 0 10

0 8

0 6

Stunting rate (%) 40

20 tional average

Na 10

Peru India Haiti Togo Niger Nepal rst region Kenya Bolivia Ghana Gabon Jordan Liberia Guinea Malawi Nigeria Albania Zambia Senegal Burundi Uganda Lesotho Rwanda Ethiopia Pakistan Namibia Moldova Armenia Maldives Tanzania Comoros Tajikistan Colombia Swaziland Honduras Wo Cambodia Zimbabwe Cameroon Azerbaijan Guatemala Bangladesh Timor-Leste Madagascar The Gambia The Mozambique Sierra Leone Sierra FFERENCES IN STUNTING BETWEEN REGIONS WITHIN COUNTRIES Burkina Faso Côte d’Ivoire DI Kyrgyz Republic Kyrgyz

Republic of Yemen Republic of Congo Dominican Republic Dominican São Tomé and Principe and Tomé São Arab Republic of Egypt Best region Democratic Republic of Congo of Republic Democratic FIGURE 6 Source: Save the Children UK, Group and Inequalities Database 10 UNEQUAL PORTIONS Source: Save the Children UK, Group and Inequalities Database Inequalities and Group UK, Children the Save Source: FIGURE 7 FIGURE Democratic Republic of Congo Urban Arab Republic of Egypt of Republic Arab São Tomé and Principe

Dominican Republic Republic of Congo of Republic Republic of Yemen of Republic

Kyrgyz Republic DI Ru Côte d’Ivoire Côte Burkina Faso Burkina ral FFERENCES IN STUNTING BETWEEN URBAN AND RURAL AREAS RURAL AND URBAN BETWEEN STUNTING IN FFERENCES Sierra Leone Mozambique The Gambia Madagascar Timor-Leste Bangladesh Guatemala Azerbaijan Cameroon Zimbabwe Cambodia Honduras Swaziland

Colombia Tajikistan Comoros Tanzania Maldives Armenia Moldova Namibia Pakistan Ethiopia Rwanda Lesotho Uganda Burundi Senegal Zambia Albania Nigeria Malawi Guinea Liberia Jordan Gabon Ghana Bolivia Kenya Nepal Niger Togo Haiti India Peru Na

tional average tional 0

Stunting rate (%) rate Stunting 30

70 2 WHO ARE THE MALNOURISHED CHILDREN, WHERE DO THEY LIVE, AND WHY MUST WE ADDRESS EXCLUSION TO REACH THEM? 11

PHOTO: COLIN CROWLEY/SAVE THE CHILDREN For example, Ghana and an Peru almost have identical national of stunting prevalence at 19% respectively.and 18% This is despite Peruhaving three times higher national gross income per disparities betweencapita. However, the richest and poorest children much are more pronounced in Peru, where 40% of the poorest children stunted; are the risk of stunting is the much for lower poorest children in Ghana – 26%. WHICH COUNTRIES ARE MOST UNEQUAL FOR THE POOREST AND THE RICHEST CHILDREN? In Peru, inequalities stunting in among economic groups exceptionally are high, with poor children times to more likely be stunted11 than those who rich.are This type of inequality is also very high in Jordan, Bolivia, Honduras and Gabon, where the ratio exceeds 5:1. Cameroon and Armenia topthe list of countries with the highest of inequalities levels in wasting, with poor children six times to more likely have weight height for low than rich children. They are by Kenya, Mozambiquefollowed and Swaziland, each with ratios exceeding 3:1. Equally, 17% of poor children wasted are Equally, 17% 7 But, again, the story is not quite simple. so Some inequalities, indicating much lower countries have it is possible to ease the economic constraints that poor households experience. in contrast to 9% of the richest children. The high rates of undernutritionexperienced by the even richest children in many of our sample countries clearly illustrate that being rich – relative to others in poor countries – does not necessarily guarantee nutrition. adequate Two-year-old Melvin is being treated for malnutrition in north-western Kenya, where successivehave made droughts it hard for many families to make a living. Family income is a strong determinant of a child’s nutrition status globally, it so comes as no surprise that in many countries the poorest fifth of children considerablyhave higher stunting and wasting rates than the richest fifth. Our analysis shows that across our sample countries, of 56 the poorest children 2.26 are times to more likely be stunted and to 1.89more likely be wasted than the richest children. UNEQUAL CHANCES OF MALNUTRITION FOR THE POOR AND RICH 12 UNEQUAL PORTIONS Source: Save the Children UK, Group and Inequalities Database Inequalities and Group UK, Children the Save Source: FIGURE 8 FIGURE Democratic Republic of Congo Bottom 20% Bottom Arab Republic of Egypt of Republic Arab São Tomé and Principe Dominican Republic Republic of Congo of Republic Republic of Yemen of Republic

Kyrgyz Republic DI

Côte d’Ivoire Côte Burkina Faso Burkina FFERENCES IN STUNTING BETWEEN THE RICH AND THE POOR THE AND RICH THE BETWEEN STUNTING IN FFERENCES Sierra Leone Mozambique The Gambia Madagascar Timor-Leste Bangladesh Guatemala Azerbaijan Cameroon Zimbabwe Cambodia Honduras Swaziland Colombia Tajikistan Comoros To Tanzania Maldives Armenia Moldova Namibia Pakistan Ethiopia Rwanda Lesotho Uganda Burundi Senegal Zambia Albania Nigeria Malawi Guinea Liberia Jordan Gabon Ghana Bolivia p 20% Kenya Nepal Niger Togo Haiti India Peru

Na tional average tional 10

Stunting rate (%) rate Stunting 40

6 0

8 0 2 WHO ARE THE MALNOURISHED CHILDREN, WHERE DO THEY LIVE, AND WHY MUST WE ADDRESS EXCLUSION TO REACH THEM? 13 8:1

6:1 continued overleaf

4:1

2:1 Ratio poorest quintile to richest quintile Inequalities in wasting Inequalities in

Haiti Kenya Ethiopia Namibia Armenia Colombia Swaziland Zimbabwe Cameroon Azerbaijan Mozambique managed to significant make progressreducing in these inequalities. In Kenya, example, for Inequalities in wasting more even are pronounced across ethnic groups. In Cameroon, of Biu-Mandara ethnicity11% children are wasted, while wasting of children occurs in 1% from the Bamilike ethnic In group. Ethiopia, of24% Nuwe ethnicity children wasted, are compared to of Kefficho 3% ethnicity children. In many cases, inequalitiesgeographical interlink with inequality between ethnic groups. Ethnic inequalities also appear tobe increasing countries outin of many 21 countries. in our Ten sample experienced have an increase in ethnic inequalities stunting 2000; in since the average ratio of inequality increased to 1.6:1. from 1.5:1 Ethnic inequalities in wasting increased in 14 out of 20 countries and the inequality average grew somefrom 2.2:1 countries to have 2.8:1. Yet :1 12

10:1

8:1

6:1

4:1

2:1 Ratio poorest quintile to richest quintile Inequalities in stuntingInequalities in

UNTRIES WITH THE HIGHEST INEQUALITIES IN STUNTING AND WASTING Peru Haiti Bolivia Gabon Jordan CO Namibia

Honduras Cameroon Republic of Congo Dominican Republic Dominican But in some countries, disparities are For example, in Nigeriaconsiderably higher. of Hausa ethnicity52% children stunted, are Igbo ethniccompared group children. to 14% In Ghana, of Gruma ethnic 33% group children stunted,are compared of children to 10% from Ga/Adangbe ethnic group. In nearly the all countries which data, for have we found considerablewe disparities in malnutrition betweenprevalence children in different ethnic groups. Our research shows that in our sample of 48 countries with available data on ethnicity, children in the ethnic groups with the worst nutrition outcomes, on average, 2.8 have times higher rates of stunting and six times higher rates of wasting than their more advantaged peers. Similar to geographical location and family’s economic chances status, of avoiding children’s malnutrition highly are determined by their ethnic background. ETHNICITY, RACE, RELIGION AND CASTE FIGURE 9 BETWEEN RICH AND POOR Source: Save the Children UK, Group and Inequalities Database 14 UNEQUAL PORTIONS Côte d’Ivoire, the relative difference in wasting in difference relative the d’Ivoire, Côte 1.7:1 of ratio 1998 1.6:1 In 2009. to and between froma decreased groups Swahili Kikuyu and Mijikenda/ the between in stunting inequality continued CASTE AND RELIGION RACE, ETHNICITY, FIGURE 10 FIGURE Source: Save the Children UK, Group and Inequalities Database Inequalities and Group UK, Children the Save Source: Democratic Republic of Congo Least affected ethnicity affected Least Republic of Congo of Republic

DI Côte d’Ivoire Côte Burkina Faso Burkina Sierra Leone Mozambique The Gambia Guatemala FFERENCES IN STUNTING BY ETHNICITY STUNTING IN FFERENCES Azerbaijan Cameroon Honduras Colombia Moldova Pakistan Ethiopia Uganda Senegal Zambia Nigeria Malawi Guinea Liberia Gabon Ghana Kenya Nepal Togo India Peru

Mo st affected ethnicity affected st 10

Na 1999 2012. and 2:1 of 1.2:1 fromaratio to dropped between groups best-performing and worst- the between tional average tional 40 Stunting rate (%) rate Stunting

10 0 2 WHO ARE THE MALNOURISHED CHILDREN, WHERE DO THEY LIVE, AND WHY MUST WE ADDRESS EXCLUSION TO REACH THEM? 15 continued overleaf Number of affectedchildren Prevalence Geographic inequalities 12 Prevalence (%) 10 8 6 4 2 0 . Joint child malnutrition estimates malnutrition child Joint . 14 6.1 40.7 20

10 inside countries can be in high: Pakistan, 40% of children in the most-affected regions are overweight, whereas in the least-affected regions the is 2.5%. prevalence In Egypt, in the region with the highest of children are prevalence, 32% overweight, overweight and are less in than 1% the region with the prevalence. lowest The vast majority of overweight or obese children in developinglive countries, where the rate of increase has been more than 30% higher than that countries. developed in THE LOTTERY OF CHILDHOODTHE LOTTERY OBESITYAND OVERWEIGHT Our analysis demonstrates that overweight and obesity related are to geography, economic status and ethnicity in various ways. Geography 37 5.7 20

11 05 5.3 33.1 20 9

00 5.1 30.6 20 at an estimated 8 More than 1.9 billion More than 1.9 10

95 4.9 30.7 19 ANGES IN OVERWEIGHT IN CHILDREN – GLOBALLY

4.8 31.2 1990

5 0

15 10 35 25 20 30 45 40 Number of children affected (millions) affected children of Number Source: UNICEF, WHO, World Bank Group, 2015. Levels and trends in child malnutrition FIGURE 11 Rates of overweight and obesity have theskyrocketed last over four decades and the for first now, time, there are more obese than adults. underweight Overweight and obesity also are forms of malnutrition. Indeed, these types of malnutrition increasinglyare recognised as one of today’s most visible yet – most neglected – public health problems because of the mortality, morbidity and extraordinary healthcare costs brought by their links to diet-related non-communicable diseases. For example,2.8 million people die each year as a result being overweight or obese deaths of all (5% worldwide), THE INCREASING AND PROBLEM OBESITY OF OVERWEIGHT economic cost of US$2 trillion a year. And overweight in infants and young children 0 to is becoming 5 years) (aged increasingly prevalent, increasing million in 1990 from 31.2 to 40.7 million this Worrying, upward in 2014. trend is apparent regions in all of the world, particularly in Africa and Asia. adults – nearly 30% of the global population – overweight,are and 600 million obese. are 16 UNEQUAL PORTIONS THE INCREASING PROBLEM OF OVERWEIGHT AND OBESITY continued OVERWEIGHT OF OBESITY PROBLEM AND INCREASING THE FIGURE 12 FIGURE Source: Save the Children UK, Group and Inequalities Database Inequalities and Group UK, Children the Save Source: Democratic Republic of Congo B est region est Arab Republic of Egypt of Republic Arab São Tomé and Principe Dominican Republic Republic of Congo of Republic Republic of Yemen of Republic

Kyrgyz Republic DI Côte d’Ivoire Côte Burkina Faso Burkina Sierra Leone Mozambique The Gambia Timor-Leste FFERENCES IN OVERWEIGHT BETWEEN REGIONS WITHIN COUNTRIES WITHIN REGIONS BETWEEN OVERWEIGHT IN FFERENCES Bangladesh Azerbaijan Cameroon Wo Zimbabwe Cambodia Honduras Swaziland Colombia Tajikistan Comoros Tanzania Maldives Armenia Moldova Namibia Pakistan Ethiopia Rwanda Lesotho Uganda Burundi Senegal Zambia Albania Nigeria Malawi Guinea Liberia Jordan Gabon Ghana Bolivia rst region rst Kenya Nepal Niger Togo Haiti India Peru

Na tional average tional 10

20 Overweight rate (%) rate Overweight

50 2 WHO ARE THE MALNOURISHED CHILDREN, WHERE DO THEY LIVE, AND WHY MUST WE ADDRESS EXCLUSION TO REACH THEM? 17 :1 16

:1 14

:1 12

10:1 Conversely, there eight were countries 13

8:1 in our dataset where the poorest children are tomore likely be overweight than the richest, including: Albania, Armenia, Benin, Democratic Republic of Congo, The Gambia, Haiti, Mali and Nigeria. Ethnicity, race, religion and caste Within countries, found ethnic we origin to be one determinant likelihood of of a child’s being overweight. In fact, out variables of all explored,we ethnicity yielded some of the most dramatic inequalities, with some children to more likely be15 times overweight than their peers of another ethnicity. most pronounced include Peru, Ghana, Côte d’Ivoire, Bangladesh and DominicanRepublic – in these countriesricher children three times are tomore likely be overweight than poorer children.

6:1

4:1 Ratio most affected ethnic group to least affected least affected to most group ethnic group ethnic Ratio

2:1 UNTRIES WITH THE HIGHEST ETHNIC INEQUALITIES IN OVERWEIGHT

Togo Nepal Ghana Liberia Senegal Pakistan Cameroon Mozambique Burkina Faso Republic of Congo Source: Save the Children UK, Group and Inequalities Database FIGURE 13 Inequality between rich and poor children countriesIn 47 found out that we of 55, the richest children the have highest chance of being overweight. The countries where this trendis Our analysis has not been able to identify why pronounced. the inequalities so geographic are Therefore, further research is necessary. Our initial results suggest that what seemingly is the most intuitive explanation this for inequality – ie,urban environments more obesogenic are than rural environments – may not be sufficient as explanation. a sole For example, urban children a significantly may have well higher risk of overweight in 43 out countries; of 55 countries this leaves where 12 they however, do not. Furthermore, globally the prevalence rate in urban areas is only one percentage point urban of all children overweight,higher are (4% compared to of rural children). 3% THE INCREASING AND PROBLEM OBESITY OF OVERWEIGHT continued 18 UNEQUAL PORTIONS than it increased in – 26 to 17. –26 in to increased it than wasting in Disparities countries more in reduced which difference, rural urban/ of exception the with wasting in are similar trends The countries. 44 of 23 out in widened has it areas rural and urban between and 35of countries; 21 in out widened has it children richest and poorest the between countries; 44 of out 30 in widened has acountry in regions prevalence between stunting in Weavailable. inequality that found is data for which group economic and social for each 2000s We the since progress analysed by progress. behind left being of risk are particular at groups fromexcluded Children targets. global by agreed date the beyond far remain to set is groups excluded among prevalence malnutrition of that indicate future the into trends historical projecting estimations New peers. fortunate more their behind further are falling children of groups excluded available, is data disaggregated which for countries most in reveals that progress past of analysis Our LEFT BEHIND AT ARE GROUPS BEING OF RISK FROM EXCLUDED CHILDREN Source: Save the Children UK, Group and Inequalities Database Inequalities and Group UK, Children the Save Source:

Number of countries 14 FIGURE -30 -35 -20 -25 -10 -15 30 20 25 10 15 -5 0 5

ineq in w Regional

17 SU ualities asting MMARY OF CHANGES IN INEQUALITIES BY NUMBER OF COUNTRIES OF BY NUMBER INEQUALITIES IN MMARY CHANGES OF -22

ine in w Ec 16 qualities onomic asting -18

Ur ine in w ban/rural 26 qualities asting -17

Sierra Leone. Ethiopia, Guinea, Liberia, Mozambique and of Congo, Republic Democratic Cameroon, in board the across increased Wasting disparities Peru. Madagascar, Niger, and Guinea, Nepal, Nigeria Gabon, Ethiopia, Congo, of Republic Democratic Congo, of Republic Cameroon, in available is data grew for which all in groups inequalities Stunting countries. more many in observed was inequality every in group increase an hand, other the On wasting. in Togo and disparities Pakistan decreased Namibia, Kyrgyz Republic, Honduras, while stunting, in inequalities group of all types reduced Zimbabwe and Senegal groups). Liberia, Kyrgyz Republic, economic regions, (urban/rural, sub-national analysed dimensions three the of each across well consistently have performed which countries are afew there inequalities, group reducing of have terms in mixed records countries most While 18 in 34 of countries. out widened children richest and poorest the between gap relative the and 39 of out countries; grew 22 in acountry in regions worst-performing and best- the between ine in s Regi 14 qualities tunting onal -30

ine in s Ec 14 qualities onomic tunting -21

Ur ine in s ban/rural 21 qualities tunting -23

2 WHO ARE THE MALNOURISHED CHILDREN, WHERE DO THEY LIVE, AND WHY MUST WE ADDRESS EXCLUSION TO REACH THEM? 19 . However, .However, The last places where BOTH INTERIMBOTH AND FINAL TARGETS WILL BE MISSED LARGE BY MARGINS The JME projections thatshow without step a countries action, out only in of 114 change 39 with available data willmeet the 2025 WHA target to reduce stuntingby 40% of those countries 39 income: only six low are Afghanistan, Cambodia, DemocraticPeople’s Republic of Korea, Liberia, Nepal and Sierra Leone. Our projections new show that in addition to the eight countries from our sample that already stunting have rates below 3%, only three more countries will manage to achieve the 2030 SDG target to eliminate stunting. Of those three, two upper-middle-income are countries – Belarus and Macedonia, and one is a high-income and Tobago. country – Trinidad countries will out of 137 53 tackle stunting the century. in next only stunting will be eliminated Malawi are year (the Timor-Leste Burundi (2146), Niger (2152), 2152), and Eritrea (2135). (2145) See further methodological details in appendix 1. In contrast to the JME model, our projections a sigmoid functionfollow based on the empirical Bayes method, which takes account of the fact that – similar to other child indicators – welfare progress in improving nutrition tends to decelerate longer periods over of time: the closer the countries come to the target, the more difficult it becomes to furthermake improvements. inside each country. For past national stunting rates, used we those reported by the JME. Data disaggregation by social and economic groups was estimated based on data from our (GRID), Database Based Inequality Group adjusting with national-level figures from JME. As a result, our research models future rates countries, of stunting including 1,694 137 for major socio-economic groups countries 56 (in with disaggregated based data) on trends in malnutrition since the 2000s. 14 National averages hide 15 In collaboration with researchers from Göttingen University, produced we projections at national social and all for and economiclevel groups inequalities within countries. While, on average, a country may be on track the to goals, achieve some social and economic groups within the country may be at risk of being left behind. The Joint Monitoring Estimates, developed by UNICEF, WHO Bank, and the World monitor country performance and assess whether countries on are track to achieving the 2025 targets. WHA SDG 2 sets two targets nutrition. for The ultimate target is to eliminate forms all of malnutrition by 2030, including stunting and wasting. SDG 2 also includes the interim target adopted Health by the Assembly World in 2012, which commits countries to reduce stunting by 40% between and 2025, and to reduce 2012 and maintain wasting by 2025. to 5% PROJECTING THE DEVELOPMENT SUSTAINABLE PROJECTING GOAL MALNUTRITION TARGETS Our projections build on the Joint Monitoring Estimates (JME) in a number of ways, including social for projections national disaggregating by and economic groups inside each country, by contemplating a series of timeframes, and by methodological innovations seriesintroducing of a below methodological for box (see details). Using available information on past progress, we ableare to estimate what the stunting rates will be if countries continue ‘business as usual’ by landmark moments: by 2025, to reach the WHA target of reducing stunting by 40%; by 2030, to reach the nutrition SDG target of eliminating malnutrition; and project further into the future to estimate how long countries for take it would that set are to miss the SDG target to actually it. achieve PROJECTIONS ARE A CAUSEPROJECTIONS CONCERN FOR 20 UNEQUAL PORTIONS Source: Save the Children and Göttingen University, based on Group and Inequalities Database and Joint Child Malnutrition Estimates Malnutrition Child Joint and Database Inequalities and Group on based University, Göttingen and Children the Save Source: FIGURE 15 FIGURE Bosnia andBosnia Herzegovina West Bank and Gaza and Bank West Dominican Republic Brunei Darussalam Kyrgyz Republic Saudi Arabia Montenegro Cabo Verde Kazakhstan Bangladesh El Salvador El Uzbekistan Costa Rica Costa Azerbaijan Nicaragua Seychelles Venezuela Argentina Honduras Colombia Barbados Paraguay Mauritius Mongolia Suriname Sri Lanka Sri Morocco Malaysia Romania Uruguay Thailand Maldives Armenia Moldova Lebanon Bulgaria Vietnam Georgia Jamaica Panama

Guyana Bahrain Senegal Kiribati Algeria Mexico Kuwait Tunisia Turkey Jordan Gabon Bolivia Ghana Tuvalu Nauru Tonga Serbia Oman Qatar WH China Belize Japan Brazil Libya Cuba Peru Iran

Fiji 2020 EN COUNTRIES WILL ELIMINATE STUNTING ELIMINATE WILL COUNTRIES EN

2040

206 0

208 0

21 00 Lao People’s Democratic Republic Democratic Republic of Congo Central African Republic African Central Arab Republic of Egypt São Tomé and Principe Papua New Guinea New Papua Republic of Congo Republic of Yemen Equatorial Guinea Solomon Islands Solomon Guinea-Bissau Turkmenistan Côte d’Ivoire Burkina Faso Burkina Sierra Leone Sierra Mozambique South Africa South South Sudan The Gambia Madagascar Timor-Leste Afghanistan Korea PRD Guatemala Mauritania Cameroon Zimbabwe Philippines Cambodia Botswana Swaziland Tajikistan Myanmar Indonesia Comoros Tanzania Namibia Pakistan Vanuatu Ecuador Ethiopia Djibouti Rwanda Lesotho Somalia Uganda Burundi Zambia Albania Nigeria Malawi Angola Guinea Bhutan Eritrea Liberia Kenya Nepal Sudan Niger Benin Chad Togo Syria Haiti India Mali Iraq

2 020

20 40

20 60

20 80

21 00

21 20

21 40

21 60 2

LOW-INCOME COUNTRIES, ESPECIALLY IN WHO ARE THE MALNOURISHED CHILDREN, WHERE DO THEY LIVE, AND WHY MUST WE ADDRESS EXCLUSION TO REACH THEM? TO REACH EXCLUSION ADDRESS WE MUST WHY AND LIVE, THEY DO WHERE CHILDREN, MALNOURISHED THE ARE WHO SUB-SAHARAN AFRICA, ARE THE FURTHEST FIGURE 16 NUMBER OF STUNTED AWAY FROM THE TARGETS CHILDREN BY COUNTRY INCOME CLASSIFICATION (IN MILLIONS) While the projections show that at the current pace most countries are decades away from reaching the 180 targets, it is low-income countries, many of 2.3 which are from sub-Saharan Africa, that will 160 struggle the most to eliminate stunting. This 18.1 is due to a combination of high rates of stunting and low rates of progress so far. In our sample, a median 140 1.5 low-income country is estimated to eliminate stunting 91 years later than agreed, in 2121, while 120 11.1 a median lower-middle income country will manage to do this by 2101. Similarly, a median sub-Saharan 100 African country is projected to reduce stunting by 40% only by 2110, whereas a typical country from 106.2 80 the rest of the world will do so by 2073. 80.4 Another worrying finding is that despite not being the worst performers, countries with the largest 60 under-five child populations are also many Number stunted of children (millions) decades away from eradicating stunting. Of 40 the five countries with the largest child populations, 0.2 Bangladesh is projected to be the fastest in reaching 20 1.6 the ultimate stunting target, but this will only 37.5 36.0 12.5 happen in 2082. In the other four countries – India, 10.2 Nigeria, Pakistan and the Democratic Republic 0 2015 2030 2100 of Congo – stunting will be eliminated only in the next century. Low income Upper middle income Lower middle income High income TENS OF MILLIONS OF CHILDREN WILL SUFFER FROM STUNTED GROWTH FOR Source: Save the Children and Göttingen University, based on Group DECADES TO COME and Inequalities Database and Joint Child Malnutrition Estimates If the current national-level trends continue unchanged, our projections show that there will still be 129 million stunted children by 2030, EXCLUDED GROUPS OF CHILDREN ARE and even by the turn of the next century AT RISK OF STUNTED GROWTH LONG AFTER 24 million children will have stunted growth. THE NATIONAL TARGETS ARE MET Of these children, a disproportionate share will be Given the existing large disparities and highly from disadvantaged and excluded groups. In our uneven past progress, excluded groups of children sample of countries, four out of five stunted children are at risk of being left behind by national progress. will live in rural areas and six out of ten stunted It will take 50 years longer to eliminate children will come from the poorest 40%. stunting among the poorest children as Countries that are presently categorised as compared to the richest children in our 16 Similarly, in about half of our sample, lower-middle income will account for most of the sample. stunting will be eliminated in the worst-performing reduction. The number of stunted children will region only a half century later than in the also decrease in presently low-income countries, best-performing region.17 but projected increases in child populations is anticipated to result in presently low-income Projected time lapses are considerable in nearly countries accounting for two-fifths of the all countries but are particularly striking in some. global burden of stunting by 2030. For example, in Bolivia and Nicaragua, the poorest children are projected to be almost a full century behind the richest children in terms of stunting

21 22 UNEQUAL PORTIONS Source: Save the Children and Göttingen University, based on Group and Inequalities Database and Joint Child Malnutrition Estimates Malnutrition Child Joint and Database Inequalities and Group on based University, Göttingen and Children the Save Source: available. is data which for year latest the indicate brackets in Dates Note: 3% below drop in will rate stunting the Pakistan, In 111 happen only will stunting of later, years 2121. in in 2010,stunting while in Huancavelica elimination the Tacna Peru, in And eradication. eliminated region Democratic Republic of Congo (2013) TO ELIMINATE STUNTING (= <3%)TO STUNTING ELIMINATE 17 FIGURE Richest Central African Republic (2010) Republic African Central São Tomé and Principe (2008) Principe Tomé and São Arab Republic of Egypt (2014) Egypt of Republic Arab Dominican Republic (2013)

Republic of Congo (2011) Republic of Yemen (2014) Yemen of Republic Kyrgyz Republic (2014)

Côte d’Ivoire (2012) Burkina Faso (2012) Faso Burkina Po Sierra Leone (2013) Leone Sierra Mozambique (2011)Mozambique Madagascar (2009) Madagascar Timor-Leste (2009) Timor-Leste PR The Gambia (2013) Gambia The Kazakhstan (2010) Bangladesh (2014) Uzbekistan (2006) Uzbekistan Azerbaijan (2013) Azerbaijan Nicaragua (2006) Nicaragua Cameroon (2011) Zimbabwe (2014) Zimbabwe Cambodia (2014)Cambodia Swaziland (2014) Honduras (2012) Honduras Colombia (2010) Tajikistan (2012) orest Tanzania (2014) Maldives (2009) Maldives Morocco (2011)Morocco Armenia (2010)Armenia Comoros (2012 Moldova (2012) Namibia (2013)Namibia Pakistan (2012) OJECTIONS FOR BEST AND WORST PERFORMING REGION IN EACH COUNTRY EACH IN REGION PERFORMING WORST AND BEST FOR OJECTIONS Ethiopia (2014)Ethiopia Rwanda (2015) Rwanda Lesotho (2014) Guyana (2014) Uganda (2012) Albania (2009) Burundi (2010) Burundi Senegal (2014) Zambia (2013) Nigeria (2014)Nigeria Malawi (2014) Guinea (2012) Turkey (2013) Liberia (2013) Jordan (2012) Gabon (2012) Gabon Ghana (2014) Bolivia (2012)Bolivia Kenya (2014) Kenya Nepal (2014) Nepal Brazil (2007) Brazil Niger (2012) Benin (2014)Benin Chad (2010) Togo (2014) Togo Haiti (2012) India (2014) Peru (2013) Peru Mali (2012) Mali

2000 tional average tional

20 30

20 50

2 c 2141, in stunting eradicate will region Suef Beni worst-performing the 2210. in point Egypt, In this o 1 00 in Islamabad, while Balochistan region will reach reach will region Balochistan while Islamabad, in 00 mpared with 2042 in New Valley 2042New in with region. mpared 21 00

21 50

22 00 2 WHO ARE THE MALNOURISHED CHILDREN, WHERE DO THEY LIVE, AND WHY MUST WE ADDRESS EXCLUSION TO REACH THEM? 23 00 22

50 21

00 21 tional average tional targets will be missed by margins large andthe promises made to end forms all of malnutrition will remain unfulfilledfor many decades come.to Na

50 20 rst-performing region

Wo 2000

Peru (2013) India (2014) India Haiti (2012) Haiti Togo (2014) Chad (2010) Chad Niger (2012) Niger Brazil(2007) Nepal (2014) Kenya (2014) Bolivia (2012) Ghana (2014) Ghana Gabon (2012) Jordan (2012) Jordan Liberia (2013) Liberia Turkey (2013) Turkey Tunisia (2012) Tunisia Guinea (2012) Guinea Malawi (2014) Malawi Nigeria (2014) Zambia (2013) Zambia Senegal (2014) Senegal Burundi (2010) Albania (2009)Albania Uganda (2012) Uganda Guyana (2014) Guyana Lesotho (2014) Lesotho Rwanda (2015) Ethiopia (2014) OJECTIONS FOR THE RICH ELIMINATE TO AND COUNTRY POOR BY Pakistan (2012) Pakistan Namibia (2013) Moldova (2012) Moldova Comoros (2012 Comoros Armenia (2010) Thailand (2012) Morocco (2011) Maldives (2009) Tanzania (2014) Tanzania Sri Lanka (2012) Tajikistan (2012) Tajikistan Colombia (2010) Colombia Honduras (2012) Swaziland (2014) Swaziland Cambodia (2014) Zimbabwe (2014) Cameroon (2011) Cameroon Nicaragua (2006) Azerbaijan (2013) Uzbekistan (2006) Guatemala (2009) Bangladesh (2014) Bangladesh Kazakhstan (2010) Kazakhstan PR The Gambia (2013) Timor-Leste (2009) Madagascar (2009) Mozambique (2011) Sierra Leone (2013) Burkina Faso (2012) Côte d’Ivoire (2012) d’Ivoire Côte

Kyrgyz Republic (2014) Republic Kyrgyz Republic of Yemen (2014) Republic of Congo (2011) Congo of Republic Dominican Republic (2013) Republic Dominican Trinidad and Tobago (2000) Arab Republic of Egypt (2014) São and Tomé Principe (2008) Central African Republic (2010) Best-performing region FIGURE 18 STUNTING <3%) (= Democratic Republic of Congo (2013) Congo of Republic Democratic Overall, these projections ring alarm bells:unless countries prioritise tackling malnutrition and take urgent steps toaccelerate theprogress with – a special focus on disadvantaged groups – the SDG Note: Dates in brackets indicate the latest year for which data is available. Source: Save the Children and Göttingen University, based on Group and Inequalities Database and Joint Child Malnutrition Estimates 3 Why are children malnourished?

The world has made progress in tackling Here in part 3 we explore the drivers of malnutrition. But the progress has been far malnutrition, using a human rights framework too slow, and, as shown in Part 2, some (see Figure 19) and looking specifically at children have been excluded, because of how group-based exclusion is further driving who they are or where they live. Inequalities malnutrition, and how malnutrition is passed between some groups are actually widening. from one generation to the next. We look at the large-scale (global and national) drivers of Unless we address this group-based malnutrition, and the response from policy-makers exclusion, children will still be malnourished so far. We cover a wide number of issues in this until at least the end of the century, 70 years section, but our analysis here is not intended after the SDG deadline for eliminating all to be all encompassing. forms of malnutrition. Human rights provides a powerful framework in We know that people are malnourished if their diet which to understand and address malnutrition. does not provide adequate energy, protein, fats Figure 19, which presents our analytical framework and micronutrients for growth and maintenance, or for this section, shows and implies a range of if they are unable to fully utilise the food they eat human rights – civil, cultural, economic, political, due to illness – leading to undernutrition.1 People and social – that must be realised in order to are also malnourished if they consume too many ensure that one’s right to food and good calories – leading to overweight and obesity.2, 3 But nutrition are achieved in an adequate, equitable to better understand how to accelerate progress in and sustainable manner.4 addressing malnutrition for all, we must understand the underlying drivers. PHOTO: ANDRE MALERBA/SAVE THE CHILDREN

Tum Lang, who lives in a small village in Myanmar, knows the importance of eating nutritious foods while pregnant. But food is scarce and people don’t have much choice about their diet.

24 3

FIGURE 19 A CONCEPTUAL FRAMEWORK FOR THE DRIVERS OF NUTRITION MALNOURISHED? CHILDREN ARE WHY

Level of intervention Nutritional status

Dietary intake Adequate dietary intake, for example through adequate nutrition for the first 1,000 days of life and adolescence, optimal breastfeeding and healthy diet THE CHILD Immediate drivers Health status/disease of nutrition Good health – the child is free from diseases such as malaria and diarrhoea

• availability, affordability and appeal of foods Household food • food safety security and healthy • physical access to food food environments • cash income Enjoyment of the right • transfers of food in-kind to adequate food of high • household assets nutritional quality • household knowledge and cultural beliefs around nutritious choices

• women’s empowerment Care practices • caregiver control of resources and autonomy for women • caregiver physical and mental status and for children • caregiver social status Enjoyment of the right • caregiver knowledge and cultural beliefs around nutritious to adequate care feeding practices HOUSEHOLDS • stimulation of child AND COMMUNITIES Underlying drivers Health environment • safe water supply of nutrition and services • adequate sanitation and hygiene Enjoyment of the right • healthcare availability to health; and prevention • environmental safety/shelter and control of disease. • knowledge and cultural beliefs around healthy lifestyle choices Enjoyment of rights to • public and community resource management and conservation water and sanitation

Poverty and inequality Fulfilment of the state’s obligations to control and manage the country’s available resources (environmental, human, financial, etc.), their progressively equitable use and the realisation of the population’s human rights

Economics and • financial capital income • human capital Potential resources of • physical capital the country environment, • socio-cultural knowledge and heritage technology, people • natural environment

• leadership on nutrition • human resource capacity • evidence collection, use and translation to policy NATIONAL Political context • law and order AND GLOBAL and governance • political stability Basic structural Prevailing political and • accountable, democratic governance systems with restraint and institutional economic ideology of corruption drivers in society • trade – stable, low food prices • agriculture and trade – stable, sustainable food production and supply

• climate change mitigation, adaptation and resilience Environmental • sustainable natural resource management • biodiversity, soil, water and air quality

Source: Modified by author with information from: Oshaug, A, Eide, W B and Eide, A ‘Human rights: a normative basis for food and nutrition-relevant policies’, Food Policy, 19, (6), 1994, 491–516; Smith, L and Haddad, L (2014) Reducing Child Undernutrition: Past drivers and priorities for the post-MDG era, IDS Working Paper 441, Institute of Development Studies; UNICEF (2013) Improving Child Nutrition: The achievable imperative for global progress; Black et al, 2013; Ruel and Alderman, 2013.

25 26 UNEQUAL PORTIONS to food cannot be reduced to calories or nutrients. or calories to reduced be cannot food to right the that indicates also this malnutrition; and consistent with existing cultural food norms. food cultural existing with consistent : acceptable culturally and contaminants; of free : safe be should food means also It texture. and taste of terms in well as as needs micronutrient and mineral vitamin, : meeting quality and requirements; quantity of the forms in sufficient be must food that means Adequacy for nutrition. implications important framework(see Figure 19).conceptual has This the in pathways drivers underlying the in reflected as adequate, is food accessible, and available being with along that, requires food to right The RIGHTS OTHER TO HEALTH FOOD, RIGHT AND THE TO MALNUTRITION? VULNERABLE PEOPLE SOME ARE WHY Cultural Rights, and Social Economic, on Committee Nations United 12 comment the general of in emphasised is This these. ensure to means the access to right their and has aperson needs nutritional the to refers quality needs; energy meet to intake calorific sufficient to refers Quantity quality. and quantity sufficient both of is that for food need the include to food nutrition good to invokes aright implicitly food to right The met. been not has food to right their these, of any to relation in face discrimination people if and above, listed requirements four the meet not does it if adequate considered be cannot development. Article 24(a) CRC explicitly the of Article development. and survival life, to rights the so to and health, children’s of to rights components are critical food safe and appropriate culturally adequate, nutritionally of accessibility and availability The adult. an as potential economic their fulfil to ability and alivelihood to right their and outcomes health their education, in potential full their to children’s participate and access to ability impacts it example, For development. child on hunger of impacts the to due term long the in and immediately both health, and development survival, to rights the as such rights, other access to children nutrition good and food to rights the of realisation the of A lack implications. health serious has obviously nourishment inadequate nourished; adequately be children that requires also health to right The : an meeting individual’s energy 6 as the right to be free from hunger fromhunger free be to right the as means a diminished ability for ability adiminished means , if we understand the right to to right the we, if understand 5 Food Food 7

fail to implement it. implement to fail frameworkoften have do alegal that states many and food; and health development, survival, child to rights the promotes frameworkthat alegal lack manner. countries equitable an in Many addressed above are discussed malnutrition of drivers the of all that ensure must states So, survival. to rights children’s realise to order in malnutrition tackle must children’s–states to development and health nutrition of centrality the –and survival child and malnutrition between correlation strong the Given food. and health development, survival, life, to rights children’s fulfil and protect respect, to CRC, the in enshrined obligation, legal have abinding States ability. decision-making autonomous or agency their recognise to and think, develop and to capacity advance their to essential is nutrition, and to food in relation specifically children, of rights cultural and social economic, the securing Furthermore, nourished. adequately are they that ensuring in critical are also hygiene water,Children’s adequate and to sanitation rights importance in early childhood. early in importance particular of as monitoring growth and nutrition citizens have access to the minimum essential food. essential minimum the haveto access citizens all their of that ensure to aminimum, at obligated, is state – every –specifically food to right the Under a long way to go. way Very were to a long found few countries still is there substitutes, breastmilk of marketing the regulate to laws develop endorse or to begun difficult. enforcement and implementation –making law national 2011,in in codified not was food to right the reviewed Save the Children by countries the of many Yet in institutions. relevant by national adopted is place and in is nutrition, including food, to right the on legislation comprehensive and appropriate that ensure to is to food, right the fulfil to obligation the meeting and food, to right the realising in step One of primary healthcare. of primary framework the within embedded be food nutritious provisionof the that mandate aspecific includes It would require. children’s health under to rights malnutrition combatting what part, in articulates, It development. and survival life, to rights the children’s of with along health, determinant underlying an as nutrition good of importance no. the 15 CRCcomment highlights the of General context. this in malnutrition addressing of 24(c) specifically speaks Article and mortality’ ‘diminish child to and infant governments requires 12 For example, while many countries have countries many while example, For 10 8 It also singles out adequate adequate out singles also It 9

3 WHY ARE CHILDREN MALNOURISHED? 27

PHOTO: JONATHAN HYAMS/SAVE THE CHILDREN

continued overleaf

(2015) identifies (2015) distinctfive types 13 These food systems very are different ocessed, and high in trans- or saturated fats, r examples include free school meal programmes in India and South Africa. Most countries, however, failed tohave address adequately the many causes of undernutrition, such as micronutrient deficiencies, poor infant and young child feeding practices, weak healthcare, hygiene and inadequate water, and sanitation. live in thelive world, their food local environments increasinglyare full of foods that highly are p but, interestingly, they increasingly all deliver packaged foods, snacks and other processed foodstuffs. This means that wherever children sugars – but in salt fibre low and and/or through which food becomes available to us transform, the mechanisms that produce, – transport and deliver our called food food – are systems, and they differ dramatically across the world. Differences in food systems explain why the price, quantity and quality of food varies much so from place-to-place. The Global Nutrition Report of food systems around the prevalent world: ‘emerging’, ‘transitioning’, ‘mixed’, ‘industrial’, and ‘rural’. LOCAL FOOD ENVIRONMENTS FOOD LOCAL Whether buy it, our we food or grow eat we the food that is available to us – ie, the food that is in our environment. local The processes When presented as a function of food consumed against calories spent, the causes of obesity can ostensibly appear individualised. the inequalities significant given However, demonstrated trends population-level and it is very clear thatin part 2, the page 17, increase in overweight among children is heavily influenced societies’by structures and norms. While the causes of obesity complex are and affect people differently, propose a simple we framework to the view dietary choices made by household every around the world. This framework might go some to way explaining the inequalities highlighted. DRIVERS OF CHILDHOOD AND OBESITY OVERWEIGHT to legislation have dealing specifically with child nutrition; some exceptions include food safety laws in Vietnam and China, and regulations on food support to vulnerable citizens in Mozambique. Significantly,countries thatlegally had recognised the right to found to food were be to more likely implement programmes tackling child nutrition; Nadia, aged one, is screened for malnutrition at her home in a refugee settlement in Lebanon, near the Syrian border. 28 UNEQUAL PORTIONS cheap a source of calories than healthy food. healthy than asource calories of cheap as times three to up be can food unhealthy UK the in that demonstrated Foundation Food The food. healthy of price the to relative cheap are becoming foods unhealthy countries, many In decisions. people’son consumption impact abig has and environment local food our of key feature another is food of price The of foodstuffs. profitability and delectability longevity, the increase to companies by excess in are used ingredients these consequences, health negative the despite But disease. diet-related and obesity overweight, to lead can and unhealthy salt is and sugars fats, of overconsumption The micronutrients. continued OVERWEIGHT OBESITY AND CHILDHOOD OF DRIVERS processed foods. energy-dense including foods, other for most than more rising been has vegetables and fruit of price the Mexico and China Brazil, as such economies emerging in that suggest to evidence found It economies. wealthiest the to limited just not is phenomenon this that found diet healthy a of cost rising the into ODI’sThe 2015 report Children and families everywhere are reached are reached everywhere families and Children advertisers. of abuses fromthe children protect to safeguards regulatory necessary the lack countries many Furthermore, products. healthy for exceedthose far drink and food unhealthy for budgets advertising The families. their and children at directed often is and channels multiple through occurs food unhealthy of Advertising decisions. sway consumption to companies by used is advertising via food of promotion The food preferences. our of key drivers the of some highlights section This comfort. and habit, convenience, wealth, age, morality, culture, region, as diffuse as issues of arange by ways different in and times different at are influenced preferences food our Indeed, factors. psychosocial of interplay acomplex by are determined Diets complicated. is we eat what eat to we choose Why FOOD PREFERENCES 15

healthy food preferences. preferences. food healthy their of development the encourage actively that for children environments safe create to efforts against works This salt. and sugar fat, in are high that foods promote that messages marketing by consumption of convenient but unhealthy food. food. unhealthy but convenient of consumption the in rise for the key reasons the of one is scarcity time that assume to wouldintuitive it be However, well-established. not convenience is of nutritional consequence of people’s prioritising The home. at grown prepared or previously was that food buy to money their use can income disposable with those example, For this. do to ability their in akey be factor may poverty families, many For food. on spends one time the reduce to sensible seem may it constraints, time these facing When practices. feeding childfor adequate time require parents and it; prepare and buy to time need we certainly afford it; workto to time need others of millions grow to it; time need people of Millions time. your on demands significant places food live, wherever you because diet on impact a negative have can This elderly. the and sick the children, care of unpaid the and employment remunerated of demands the between stretched duties their find often too will women where households poor, time unequal in themselves especially find often Families decisions. consumption food of adriver also is care responsibilities, of aresult as particularly scarcity, Time need. they knowledge the to access families giving by better for the shaped be can preferences children’s food campaigns, lifelong health public via or packaging food on labels the via communicated whether workplaces, and schools via formally or parents by provided informally Whether packaging. food on labelling clear including value food, our of nutritional the about information We transparent need also techniques. weight-management healthy and it, prepare to how is, diet ahealthy what know to need parents and Children preferences. food our of determinant important an is knowledge and Education 3 WHY ARE CHILDREN MALNOURISHED? 29 20 21 This means that businesses should take 19 a responsibility to respect and remedy human rights. Myanmar’s FoodMyanmar’s and Drug Board of Authority issued the Order of Marketing of Formulated Child. Myanmar’s Food Infant for and Young Order the follows international public health recommendation a Code for of Marketing of Breastmilk Substitutes. The Order ensures that mothers and families able are to make about decisions informed and appropriate infant feeding. Save the Children in Myanmar has developed a mobile application monitoring for the Order, which was adopted by the Department of Health and the National Nutrition Centre; and globally by the International Code Monitoring Centre. This application is being widely used across the country, including in rural and remote areas, to monitor and report Order violations. It is an easy-to-use application, the and it allows user to ‘spot’ a violation, a snapshot, take fill in some data, key and send the data directly to the International Baby Food Action Network’s Centre Documentation Code International and the National Nutrition Centre, where the violation is tracked and acted upon. So, companies need to step up and adhere to the Code. Governments must also the make financial and political investments necessary to implement the Code, monitor and company behaviour, ensure accountability in cases where the Code has been breached. CODE ADOPTION AND MONITORING MYANMAR IN active steps infringing to avoid rights and remedy Forviolationschildren in where they occur. Rights and the Business Children’s particular, Principles, co-created by Save the Children, the UN Global Compact and UNICEF, provide additional guidance businesses on how can ensure rights respected are children’s and promoted. 18

Where in the a world 16 17 is an important an is determinant Breastmilk the provides all energy and nutrients that infants need during the first six months of life. A woman might not breastfeed exclusively because of inadequate support her from partner or family, or because she lacks other forms of support, or because of labour burdens, or as a result of the aggressive promotion of formula as a breastmilk substitute. Inappropriate or aggressive marketing of BMS is a substantial global barrier to breastfeeding. The Code provides a set of standards to regulate the activities of the BMS industry, and to protect the public and healthcare providers despite However, marketing. inappropriate from many governments adopting the into Code eitherlaw, in part or in full, its implementation, levels national at enforcement and monitoring remains very weak. This goes against states’ individuals protect to rights obligations human from interference or violation of their rights by third parties, such as food and pharmaceutical highlights companies. evidence Recent substantial violations of the Code by BMS manufacturing companies. woman lives, her access to health services and support, and her exposure to the marketing of breastmilk substitutes (BMS) will, therefore, have an impact on her choice to breastfeed and the nutrients her child receives. The private sector, basedThe on the private sector, UN Guiding Principles on Business and Human Rights, bears Breastfeeding of adequatedietary intake young for children, with recent evidence showing that breastfeeding decreases the of undernutrition prevalence and overweight/obesity and diabetes later in life. Breastfeeding is a vital aspectof infantand young child feeding, and is affected by wider practicescare women for and children, for (see Universal page 25). breastfeedingFigure 19, could avert the deaths of 823,000 children and 20,000 deaths due to breast cancer each year – US$300and save billion. BREASTFEEDING OF CODE MARKETING AND THE INTERNATIONAL OF BREASTMILK SUBSTITUTES AND SUBSEQUENT RESOLUTIONS (THE CODE) 30 UNEQUAL PORTIONS and social shocks, economic environmental, to vulnerable particularly day but who still struggle to provide for their families. families. provide to for their struggle still who but day US$1.9 than more on a –ie, poverty relative in living be to are projected who people more are many there families on less than US$2 a day. Many have not Many aday. US$2 than less on families their feed live to and to are struggling farmers world’s the of Most smallholder shown. has year on small farms in developing countries. developing in farms small on live work and globally people 2billion estimated An poverty to linked closely is Malnutrition INCOME POVERTY AND the global population. global the of 2012, in 12.8% or people million 902 estimated an from down is This that’s 9.6% population. global the of US$1.9 than aday) less on 2015 in (living – poverty extreme in are living 702 people million projections, World Accordingto Bank families. for their essentials provide other and to food able be to them to available support or socialprotection opportunities poverty extreme in living are still households many Unfortunately, outcomes. achild’s to nutrition contributors major are family’s so the and income, family, household livelihood The opportunities nutrition. of driver akey is underlying inequality, alongside framework(Figure19,conceptual 25); page poverty, the in captured as and shown has chapter previous world 57.5. at the in income Ginicoefficients highest of the one in reflected as unequal, largely have been Zambia –COUNTRY INCOME POVERTY AND EXAMPLES wealth accounted for 52.6%. accounted wealth 9.1% 10% by top the while income, total the of wealth accordingto population be stunted as children from the wealthiest quintile. quintile. wealthiest fromthe children as stunted be likely to are 1.7 times as quintile poorest from the children 2002, since progress despite households; wealthiest the in children as underweight be to likely as twice are than more households poorest to 47% for the poorest quintile. poorest 47%to for the rising prevalence, stunting 40% than more with quintiles, poorest three for the high especially levels are Stunting –malnutrition. of experiences children’s and on– figures the in are reflected ’s economic growth is recognised to to recognised is ’s growth economic 32 In 2010, the bottom 50% of the the of 50% bottom 2010, In the 25 and donot have livelihood the as the impact of El Niño this this Niño El of impact the as 23 Of course, in addition to this, this, to addition in course, Of 33 These inequalities Theseinequalities 34 accounted for for accounted Children in the the in Children 24 for the for the They are They , 22 as the the as hygiene. insufficient or water,unsafe sanitation inadequate of aresult as infections, intestinal or diarrhoea repeated with associated be to considered is access to improved sanitation than the rest. the than improved to sanitation access 13 is have likely to less population times the of access to improved sanitation. improved to access have water,to safe likelyas times five nearly and haveto access to people poor likely as as twice are than more people rich Africa, sub-Saharan and slum-dwellers in urban areas. urban in slum-dwellers and areas rural remote in communities by experienced those as such countries, within exist also inequalities countries. income low- in children on falls burden disease this of most and poverty, linkedto closely is sanitation stunting rates of 38% or above. or 38% of rates stunting have Zambia in quintile wealth top the All but wealth. with quickly reduce not do rates stunted, be likely to are less Zambians wealthier Although wealth quintile. highest the in to 29% compared stunted, five under children of 48% with nutrition, in progress quintile Indonesia In malnutrition in Indonesia. in malnutrition of akey is driver poverty that indicates and aspects of malnutrition, except for except overweight, malnutrition, of aspects malnutrition. severe by acute affected is she or he if disease fromdiarrhoeal die likely more to 10 is child times A consequences. their and malnutrition, subsequent every year, deaths diarrhoea, child 1.4 million to due with are associated sanitation Poor and water policies. supportive of alack and agriculture in investment in decline the of because situation Two developments. aremarket this in people billion to quickly and respond to adapt them for difficult it makes which costs, transaction face higher they and capital, and assets to access lack they because for food demand increased to respond to able been order to address malnutrition in Zambia. malnutrition address to order in wealth of distribution unequal the addressing of importance the demonstrates This on. goes time as situation this reinforcing is growth economic of pattern the and income, in unequal very is 27 are being left behind from national fromnational behind left are being Poor access to clean water and adequate adequate and water clean Poor to access 26 lowest wealth wealth lowest the in , children Furthermore, 50% of malnutrition malnutrition of 50% Furthermore, 36 The trend is consistent for all consistent is trend The 28 In South Asia, the poorest fifth fifth poorest the Asia, South In 30 35 Significant spatial spatial Significant Zambiansociety 31

29 In In 37

3 WHY ARE CHILDREN MALNOURISHED? 31

PHOTO: TOM PILSTON/SAVE THE CHILDREN continued overleaf 38 , says Zahra, from a primary aged 14, gaps exist between regions within a country, systematic disadvantage may be at play. Such disadvantage indicates neglect on the part of decision-makers, whether intentional not. or The systems that exist the to nutrition improve of children, including health, nutrition and early development interventions, often are less accessible to those most in need, such as children with disabilities and particularly those living in poverty or in remote locations. There is also often a lack of nutritionists serviceunderstanding by providers and in these systems about to how support and treat children with disabilities, and about to how raise awareness among families and caregivers about interventions. appropriate school in Wajir town. school in Wajir Communities’ access to basic health and nutrition services County is limited in Wajir due to sparse facilities – they 50km are apart – on average coupled with nomadic lifestyle the people’s as they travel in search of pasture and water for reduced to – if zero join we hands, children young our survive” vary dramatically . While the percentage of Children in Wajir County recognise Children in Wajir 39 Malnutrition rates in Kenya geographically children who wasted are nationally stands at 4%, of children wasted are – County 17.8% in Wajir this puts the county into the WHO ‘emergency’ category. REGIONAL DISADVANTAGE – COUNTRY EXAMPLES – COUNTRY REGIONAL DISADVANTAGE the negative impact malnutrition and other illnesses on their have prospects survival. for children most young our of know, you “As die before celebrating their fifth birthday. I think this can be Delivering services in some regions can be challenging, whether due to remoteness, difficult terrain or regional conflict, and this may be expected to result in some variation in health, nutrition and education outcomes. Where major REGIONAL DISADVANTAGE REGIONAL As our research has part shown (see 2, regionalpage 8), disadvantage within countries significantly impacts nutrition. Group-based exclusion is often layered on top of regional disadvantage. It also driven by many of the aspects captured in the conceptual framework including page 25), poverty, and the Figure 19, (see services pathways. and environment health Yasmina, four, and her brother Mugisha, two, were forced to flee unrest and violence in Burundi and now live in a camp in Tanzania. 32 UNEQUAL PORTIONS vary from 28% in Khulna to 50% in Sylhet. in 50% to Khulna in from28% vary locations huge disparities across geographical Bangladesh In heard. often is never will talk’ they and talking, hasn’t who achild ‘Give started to liver saying, labour.‘grow big’, too The obstructed to leading to baby the causes this as pregnancy, of stages later the iron or in protein in rich foods eat not should women believe that Some malnutrition. aggravate also Traditional taboos and beliefs of 0.319,33. of coefficient Gini aregional with Bangladesh, in inequality of rates highest the has Division Sylhet average, national the with are line in rates overall the poverty Although are multifaceted. Division Sylhet in malnutrition of drivers The graveled, out of a 5,280km road network. a5,280km of out graveled, Wajir in roads of are County 440km Only food. nutritious of affordability and accessibility availability, the impacting infrastructure poor poor, extremely to also is due diversity Dietary of 1:1,000. ratio recommended 1:4,163, is ratio nurse/patient the to compared the and 1:5,000 recommended the to compared 1:132,000, is ratio doctor/patient –the workers health skilled of alack in result insecurity ongoing and climate Aharsh livestock. their DISADVANTAGEREGIONAL continued –COUNTRY EXAMPLES drought leads to poor diets.” poor to leads drought available…lack is due to food whatever of adequate milk…we child the with porridge give and milk animal our children give mostly said: “We A mother rate at 83 per 1,000 children. 83 at per rate at 12%; at prevalence ahigh wasting, of has also Sylhet 44 and the highest under-five mortality mortality under-five highest the and – rates across divisions [provinces] divisions across – rates 46 68% of the population live below population the of 68% , national stunting rates hide rates hide stunting , national 42

45 40

41 43

households (20.7%). households wealthiest the in living those (46.6%) as stunted be likely to as twice are than more households poorest the in living children Furthermore, respectively). 27%, and (38% areas urban than rural in higher significantly is five under children children and their families at risk. at families their and children put that conflicts political/ethnic and poverty; of out and up children lift to few opportunities etc); education, (health, services basic to access lack that areas hard-to-reach and remote in villages in living include: which factors, of variety Myanmar. in a to due is households rural This poor in living children affect disproportionately children receive care of variable quality. care receive variable of children –and (38%) symptom common most the be to –fever reported is illness frequent experience Children 32% to nationally. compared diet, Sylhet Division receive an adequately diverse in 23 months to six aged 18% children of Only reside in rural areas. rural in reside approximately of the poor three-quarters Myanmar In future through livelihoods, education orfuture education savings. throughlivelihoods, investtheir in to unable and shocks economic or climatic to vulnerable very people leaves This cultivate food. to which on land no or have and little day, a US$1.25 of line poverty international the inequality scores country. inequality in the gender highest the and girls, for adolescent rates attendance school worst the rates, literacy lowest female the through evidenced mothers, future and current of status nutrition the undermines in Sylhet inequality Gender , a predominantly rural , apredominantly 51 50 The drivers of malnutrition malnutrition of drivers The Stunting prevalence Stunting in 49 52 society, society, 48

47 47 3 WHY ARE CHILDREN MALNOURISHED? 33 56 59 continued overleaf There is evidence 55

54 and ongoing violations of the of violations ongoing and and those living in rural areas Although 50% of the women earn disproportionately experience experience disproportionately 58 meal portions. their income own – throughsmall-scale farming, fishing and petty trading – they are expected to theirhand over earnings to their husbands with no gains in decision-making in return. power that inadequate diet affects adolescents’ ability to learn and to work at maximum productivity. rights of girls and boys experienced are in relation to restricted access to nutritious food and other drivers of malnutrition, including education, child marriage pregnancy,and gender-based (including violence denialsexual of sexual violence), and reproductive health and rights, opportunities in public and political life and unpaid and unrecognised domestic work. These carry all the potential to impact an individual’s access to livelihood opportunities, income, food and nutrition, and healthcare. Adolescents in particular a neglected are and vulnerable While group. adolescents typically have been considered a low-risk group poor for health, this ignores the fact that many health problems later in life by or avoided can adopting be improved healthy adolescence. habits in lifestyle girls and Women of Cambodia contributing outcomes. nutritional The poor factors multi-dimensional are and complex. For social and family lower statusexample, women’s in the home and communityrelative to men’s directlyWomen diets. influences women’s commonly eat less in times of food insecurity. This can be explained by the expectation that The importance of gender the for underlying drivers of malnutrition is well-recognised, as captured in the practices care women for and children for pathway of the conceptual framework (see But page 25). the impact of genderFigure 19, cross-cuts the entire conceptual framework. Gender inequality For detail on the importance of adolescence for malnutrition, especially considering the effects that it has on childbearing andsubsequent child nutrition, please see the section following on parental factors.

structures within Women in Kambia, for Women 57 , women and children living in in the North (Port Kambia, Loko, But in Jordan, Gabon and the 53 example, may know about good practices in infant and young child feeding, but they may not be the ones who the make decisions in this area. women often are at theYoung bottom of the hierarchy when it comes to food distribution within the household; husbands and parents-in-law are commonly the first receiveto the largest and best households considered are to be drivers, key due to the impact on household decisions made nutrition. to relation in In Sierra Leone some districts Bombali) in and the a few East (Pujehun, Kenema) particularlyare vulnerable to malnutrition. Issues and complexities vary by district, but for Kambia, hierarchies and gender GENDER DISCRIMINATION – COUNTRY EXAMPLESGENDER – COUNTRY DISCRIMINATION .1% of boys and 39.5% of girls are stunted. Yet in of girls stunted. are of boys and 39.5% Yet .1% veloping/low-income the countries), stunting rate is e 2 In some countries disparities apparent are – and depending on the country, either boys or girls can be worse off. Girls left are behind in Bangladesh, of girlswhere underweight are 42% compared to 40% of boys. 51 countries out which data for of 56 have 51 we (mainly d higher girls for than boys. for For wasting, the figures girls, and boys boys for a have and 14.4% 13% for are higher wasting rate in 47 countries out of 55. Nutrition inequalities between boys and girls are very varied.the At and globalin some level countries, data no show major differences in nutrition outcomes between boys and girls. Globally, 4 GENDER Why is the picture Firstly, mixed? so global and national averages can mask actually what’s happening. Secondly, not enough is known about the biological differences between girls and boys, especially under the age of five. These biological differences an impact could have on nutrition outcomes. And thirdly, nutrition data is only measured up to the age of five, meaningwe only see part of the picture; the disparities between boys and girls thevery agecould over of five be different. Dominican Republic, boys being are left behind. In these three countries, there than fewer are girls 75 stunted 100 every for boys. 34 UNEQUAL PORTIONS women and girls with initiatives to improve their improve to their initiatives with girls and women before the child’s birthday. the second before stunting of for survivors, and, deaths newborn of risk the increases which are born, they before babies in growth restricted to contributes women in Undernutrition child. her of status nutrition and health the to contributor amajor is mother a of status nutrition and particular, health In the next. the to generation one from can pass malnutrition and exclusion Vulnerability, MOTHER TO CHILD MALNUTRITION FROM prepare food for children” food prepare should or grandmother mother it…so to the not used we [men] “because for children food preparing are in helpful would be not they that felt A few men mother” for the only are tasks believe “these they because housework do fathers see wantto not support the poor and weak. and poor the support and well, others treat attitude, have agood should they patient; and polite gentle, friendly, lovely” “look should they family; for the care and housework farming, do should women said that they behave, should women thought old were how asked 10–14 they years between aged girls of agroup When age. from ayoung are instilled roles gender prescribed These meal. nutritious most or portion better the with husband their provideand food their sacrifice will women ‘virtuous’, be to aim their In for women. Srey follow should Chbap women continued DISCRIMINATION –COUNTRYGENDER EXAMPLES the north-east. the 42% and in 55% north-west as high the in as rates stunting with average, national the exceed far Nigeria northern in levels malnutrition of The up. speak to try they if women ignore to members for community common is it that noted women Some provide ideas. who people as or decision-makers as public in participate to women power. for unusual considered is It decision-making have not do Yet often Cambodia in women their roles are considered to be undervalued. be to are considered roles their and children, the after look and home at stay to are expected They low status. social experience and caregivers, Women main are the implications. 63 Gender . 61 inequality has significant has inequality

60 The same girls did did girls same The 67 – a moral code –amoralcode Targeting Targeting , always be , alwaysbe 62 64

10% and 50% of male literacy rates. literacy male of 10% and 50% are between rates literacy female and boys, than In Pakistan In mothers or fathers. mothers stunted be to growing up of risk have a greater survive who infants The deficits. nutritional with born be or die likely more to are also babies Their pregnancy. by depleted nutritionally left be to or women, older than childbirth during die likely to year each birth giving are girls addition, 16 adolescent million window. day In 1,000 first crucial the misses often this because malnutrition, of cycle intergenerational the break to late too pregnancy) often is into several months often (which is professionals medical to themselves present they when only nutrition vulnerable group. aspecific as children street facedby risks huge the demonstrating globally, others to similar are considered study this in findings The study. fromthe arising issues important the of some are lives their in peers street of impact the and abuse, harassment, police exploitation, Parental years. ten under was began streets the on children’s these average which The at age life 60). =Rs. (US$1 day per 40–60 Rs. of income average an with aday, worked 8–12 hours them of majority the and income family supplement to street hadmoved the children to the of majority The occupations. unskilled in employed or unemployed levelswere and either education hadlow parents Their opportunities. economic of search in city moved the to hadrecently that fromlargefamilies came Most children. these in malnutrition of driver aclear is Poverty stunted. were girls than boys more sexes, between equal was wasting while and male (81%) female, than were more children, 12% these Of are wasted. children street service. health the with contact no with home the in happen deaths child of –80% assets and services low to levels access of extremely in resulting (through ‘kulle’ –seclusion), restricted is movement women’s and Nigeria, autonomy northern In 65 Girls are also less likely to attend school school attend likely to less are also Girls , astudy have stunted growth and and growth have stunted , and adolescent girls are more girls adolescent , and 66 found that 20% of of 20% that found 3 WHY ARE CHILDREN MALNOURISHED? 35

PHOTO: CJ CLARKE/SAVE THE CHILDREN 71

70 than geography of healthcare or level coverage in determining infant and child mortality rates. And in regions even of India where gender bias was common in intra-household food allocation, maternal education could erase the disparities in nutrition outcomes between sons and daughters. Although generally believed that it’s most of what matters adult for nutritional status is determined by middle adolescence, research new Lives suggests thatby Young not everything is settled years. by Even 15 after accounting a richfor set of factors, including the timing of the onset of puberty and nutritional status years,through to 15 a third of what determines nutritional years status is not explained. at 19 This indicates that it is it important to ensure good nutritional status an for adolescent in order to enable good nutritional outcomes her for children, and that at this even stage there may be potential to influence the nutritional status of an adult. height as(using a proxy)

confirms confirms 68 The degree to which a mother is 69 cording to the research, is generally greatest c in infancy, compared with being born to a non-stunted The risk of stunting mother. at birth, a early and into middle childhood. Additionally, Young Lives’ research findsAdditionally, other Young independent factors that increase the risk of a child being stunted: being a boy, later born child, poor household, less educated parents and rural location. where the mother is an adolescent. Children born to a stunted adolescent mother were points15 percentage to more likely be stunted than children born to a non-stunted older mother. These effects found to were persist through New Lives’ research by ‘Young THE IMPACT OF MATERNAL UNDERNUTRITION OF MATERNAL ANDTHE IMPACT CHILDBEARING ADOLESCENT that being born to a stunted mother increases the risk of the child being stunted and underweight Sharmin, pictured with two-year-old Lisam, works for a Save the Children Bangladesh, in project visiting families to advise them on good nutrition education. early and There is strong evidence that maternal evidence strong is There education and of female levels autonomy among are the strongest determinants of child health and nutrition outcomes. educated could mitigate the effects of other types of exclusion. For example, in India, research found maternal literacy was more significant 36 UNEQUAL PORTIONS of further complications. of further risk at children put can which nutrients, increased for aneed and loss, nutrient eat),to increased achild’s on have impact ability an that disabilities other or palate, or lip acleft to due (perhaps intake nutrient decreased to due malnutrition to lead also can Disability damage. neurological permanent to lead can which cassava, processed poorly in those as –such food in found toxins of concentrations high to exposure or macronutrients or micronutrients of lack through malnutrition, by caused be can disability of types Many malnutrition. of nutrition’,of aconsequence 25) and page Figure 19, ‘A drivers frameworkfor the conceptual (see adriver both is : disability interconnected Malnutrition and disability are closely DISABILITY the accuracy of this estimation is not known. not is estimation accuracy this of the data, of alack to due although, severeor disability, amoderate 14 aged children –live with younger or 20 in one 93–or children that million estimated is It municipality’s health services have limited have limited services municipality’s health The Yamarangüilain are multi-faceted. malnutrition of drivers The Intibucá. in located Yamarangüila, of municipality the of communities areforConcerns indigenous the heightened day. US$1 a than less on living people of 72% with Intibucá, in are high rates Poverty mothers. teenage to are born babies these of 20% and weight, birth 14% have low Intibucá, In babies of underweight. and malnourished 15%chronicallyare fives are under- of 48% where Intibucá, of department Honduran the in concern aparticular is This behind. left being to vulnerable particularly ateenage is sole carer mother whose – growth stunted with five under those Honduras In PARENTAL FACTORS –COUNTRY EXAMPLE , malnourished children – namely, –namely, children , malnourished 72 are considered considered are 73 15-year-olds who are not studying or in work. in or studying are not who 15-year-olds care 12- and of inclusion the to regarding vacuum’ ‘institutional an be to considered is there Furthermore, grade. ninth to make it do percentage asmall although grade, sixth than further no go children most and majority the for reach beyond is education Further children. Yamarangüila in five Families average, on have, planning. family of use of lack the in afactor is sway and great holds also Religion advanced. well is illness an when only services health out seek people Most high. relatively is centres treatment specialist to travelling of cost the and money Tegucigalpa. have little very Families capital, the to referred are mainly children severely and malnourished rehabilitation, for recovery and particularly capacity, the household. to contributing and surviving of chance a greater have who children devotedto be should resources limited that rationalising families with all, at fed not intentionally or food, liquid only given and infants as treated being food, of quantities smaller or nutritious less given being disabilities with children in result may disability surrounding Stigma starve. would quickly newborns These life. a productive would or lead anyway not die will child their that midwives and family by informed frombreastfeeding, discouraged be may disability a with newborns of mothers cultures, some In European Union had ratified the CRPD. the had ratified Union European CRC the and the and had ratified 127 countries 2013, February of 193 As kind. any of countries discrimination without rights their enjoy disability, or ability of irrespective all children, that ensuring of responsibility the world have accepted the around (CRPD), governments Disabilities with Persons of Rights the on Convention (CRC)Child UN the and the of Rights the on Convention UN the Under 74

3 WHY ARE CHILDREN MALNOURISHED? 37

80 – with A recent 83 77 Despite this, 81 The relevant legal provisions provisions legal relevant The 79 South Sudan and Syria 82 85 78 Moreover, using starvationMoreover, as a weapon in of war international conflictwar crime.is a In humanitariansituations, elements of the rights to food and good nutrition civilians, for while explicitlynot mentioned, protected are through and Conventions contained thein Geneva provisions Hague regulations. anaemia, treatable non-communicable diseases – which exacerbated are by lack of access to regular medication – and infectious diseases, including hepatitis A and B and parasitic diseases. their citizens living in conditions dire and suffering from a shortage of food and other essential items. many cities been have besieged in recent months – cities in Yemen, Tamil. This means communitiesTamil. often are unable to communicate with the district officials about the critical issues and daily challenges they face. High agriculture dependency has made communities vulnerable to climate change. The particularlyvillages receive no during rain water, the months of July The to distance September. to collect water exhausts farmers and dampens the outcome of their harvest. Children are also faced with extremely difficultconditions in order to continue their education. Most children 6kmwalk day every to school because of the infrequent public bus service. And the travelling distance exhausting is to clinics disinclines and families from obtaining necessary healthcare in a timely manner. study by Save the Children on infant and young Lesvos, on refugees among practices feeding child Greece, found a serious situation with breastfeeding andcomplementary feeding practices being far from optimal. aim to ensure that lack of food supply and denial of prevented. food are Food and the infrastructure required in order to maintain its production and supply must not be attacked, targeted, or removed rendered useless in order to starve a population.

75 , poor urban is home to 84 , the most vulnerable groups in Mullaitivu district has one of the highest severe acute malnutrition as as well rates at 6.1%, having a high rate of underweight children aged 6–59 months, wasting the for and 27.8% Oya Divisionsame Weli in group. the Mullaitivu District (Northern Province) CHILDREN ON THE MOVE – COUNTRY EXAMPLECHILDREN – COUNTRY ON THE MOVE In Sri Lanka areas and in the plantation sector. relation to malnutrition mainly are concentrated in post-conflictaffected areas many families that resettled were in 2013, following the end of the 30-year civil conflict. There a number are of causes of malnutrition in the area. Oya For example, residents Weli predominantly speak in Sinhalese, but the district’s administration process is conducted in In parts all of the world, the number of refugees, internally displaced people and asylum seekers is on the rise as a result of violenceand persecution, Refugees and IDPs protected are by the Convention on the Status of Refugees, and the Guiding Principles on Internally refugees Displaced Persons. Yet and IDPs a high burden have of malnutrition and More than half million of the59.5 world’s displaced people are under the age of 18. REFUGEES, CHILDREN ON THE MOVE AND CHILDREN IN CONFLICT Children who already are being discriminated against will often their have exclusion exacerbated during conflict and crisis situations. These children barriersface to accessing healthcare, education, food and shelter. and the total number higher is now than at any time This createssince the end of the second war. world a specificgroup of excluded childrenrefugees – and internally displacedpeople Children (IDPs). who remainin conflictwar and environments, or environments where extreme events such as drought taking are place, might also be excluded and vulnerable. 38 UNEQUAL PORTIONS and poor access to education, to access poor and distribution; income coverage; inequitable sanitation of lack include barriers reported Commonly especially among indigenous peoples. disadvantaged are groups common, ethnic among nutrition and health of Poor indicators ETHNICITY geographical region. geographical one for any that than worse are generally and Janajatis (an indigenous ethnic group) indigenous populations. Brazil’s among undernutrition to factors as contributory identified are also conditions sanitary poor and economy, market the in participation increased land, and resources best. the relatively, have, areas same the in living caste) (the highest Brahmins whereas scores, consumption food worst have the for example, areas, Hill the in (the lowest caste) living Dalits food. nutritious to access have limited more state fromthe and society in marginalisation and face discrimination that Groups malnutrition. and insecurity food with associated strongly are groups Excluded status. nutritional and security food with association a strong group NepalIn children for indigenous scenario nutritional unfavourable Brazil –COUNTRY EXAMPLES ETHNICITY before major health reforms were introduced. reforms health major before – ago decades four Brazilians non-indigenous of that approximates which are stunted, children conditions. and parasitic and disease, environmental infectious recurrent intake, nutrition and energy poor conditions, socio-economic unfavourable to exposure chronic with associated closely be to underweight and show stunting Studies 92 Food security indicator scores for Dalits for Dalits scores indicator security Food to which a household identifies has has identifies a household which to ’s malnutrition profile presents an presents profile ’s malnutrition in the country. in the caste, ethnic, or religious religious or ethnic, caste, , the 90 Reduced access to natural natural to access Reduced 93

91 88

25.7% of indigenous indigenous of 25.7% 86 as seen in the cases cases the in seen as

mountainous areas. mountainous in mothers expectant and care for children to relation in –particularly nutrition of awareness and knowledge limited and children; among diarrhoea and digestive-related diseases other frequent in result which systems, sanitation poor and practices and conditions unhygienic include drivers Other harvests. two the –between year a months three twoto for insufficiency food face families minority ethnic show many Surveys counterparts. 14% to compared Kinh their of are stunted, five to 12 aged children 52% minority ethnic of progress – nutrition to relation in behind left minority Ethnic coming into play in countries in the Sahel region. Sahel in playcoming the into in countries services health of use differential with inequalities, economic were linkedto closely differences mortality child ethnic that and birthday, fifth their before or infancy during were die likely more to groups fromethnic children that found countries 11 across Astudy Africa. African South and Brazil of two-thirds of the country’s poorest 10%. country’s the of poorest two-thirds for about accounted communities 2012, these In children. for their malnutrition of drivers the of one is families minority ethnic among Poverty done so. done 31% and Muslim Terai/Madhesi of had women hour, an within 34% only while of breastfeeding Newar, initiating women Janajati Hill and Brahman/Chhetri, the of half than more with groups, ethnic particular among breastfeeding of uptake the in variation some shows also Evidence between 21%–23%. is group majority Kinh the by dominated areas in children prevalence while among are stunted, Highlands) Central the and Areas, Mountainous and Midlands (the groups Northern minority ethnic by dominated in regions living five under children of 32%–37% regions. across 94

95 Further disparities are evident are evident disparities Further are are Vietnam in children 96 97

Nutrition is still woefully underfunded – both by NATIONAL AND GLOBAL DRIVERS MALNOURISHED? CHILDREN ARE WHY OF MALNUTRITION governments who are dealing with malnutrition in their own country (almost every country in the In addition to the drivers outlined above, there world) and by donors. are some drivers of malnutrition that occur across Of the world’s 29 biggest donors of official countries, or even at the global level. These are development assistance, seven spend nothing on the basic structural and institutional drivers measures to directly improve nutrition and a further of malnutrition, as captured in the conceptual six spend less than US$1m per year.99 The gap framework (see Figure 19, page 25). These require between what is required and what is currently special attention, given the scale of the impact they being spent is huge – around US$10 billion per year. have on malnutrition. In many countries, despite public commitments COORDINATION, FUNDING AND TRADE from governments to tackle malnutrition, For many years, nutrition lacked a coordinated and nutrition is not prioritised in government budgets. functional international system that donors, the UN, Furthermore, whether finances reach all areas and civil society and the private sector could contribute all groups of society within a country is not clear. to. There has been a lack of funds directed towards Save the Children has analysed the budgets of nutrition, and insufficient institutional capacity to several governments and found that they spend tackle malnutrition. And there have been weak links very little on nutrition, and in fact are not spending to country contexts and priorities.98 what they have publically committed to.

GOVERNMENT SPENDING – COUNTRY EXAMPLE

For example, the Government of Malawi at the Health, Agriculture, Irrigation and Water 2013 Nutrition for Growth event committed Development, Gender and Child Affairs, Local that the proportion of total annual government Government and Rural Development. It found expenditure allocated to nutrition would that the Government of Malawi is funding rise from 0.1% to 0.3% by 2020.100 Based on US$1.279 million for nutrition, some US$400,000 the 2014/15 Government of Malawi budget short of what was promised. There are of US$1.6 billion, the promised allocation to 6.8 million children in Malawi (Source: UNICEF nutrition works out at US$1.65 million. An 2016), of whom 46% are stunted. Thus, the spend assessment of nutrition interventions and budget on nutrition interventions per stunted child in the allocation was made across five ministries – 2014/15 budget was US$0.45.

FIGURE 20 GOVERNMENT SPENDING ON NUTRITION IN MALAWI

4.95 5

4.13 4 3.84

3.30 3.20 3 2.48 2.56

2 1.92 If 0.1% of total budget 1.65 rising to 0.3% of budget 1.28 is used 1 Already budgeted (from 2015) and based on Nutrition for Growth Government spending (US$ million) 0 commitments 2016 2017 2018 2019 2020

Source: Government of Malawi, Budget Estimates of Expenditure on Recurrent and Capital Budget for the financial year 2013/2014

39 40 UNEQUAL PORTIONS undernutrition globally. globally. undernutrition address to needed is what of estimates the than offshore financial centres. offshore through routed being inward to due investments revenues tax in annually billion US$100 lose about Trade countries developing Development, and on Conference Nations United the According to them. with associated avoidance schemes tax the flows and financial illicit of aresult as year revenue each tax potential in millions are losing world’s the of countries some poorest addition, In outcome. the by affected would be they that fact that despite concerns, their raise to didn’t table the at countries have aseat developing many that meaning OECD, the by convened was rules tax international modernise to find ways governments helping at – aimed Shifting) Profit and Erosion (Base –BEPS project A recent aren’t that representative. globally bodies by made are often system tax global the about Decisions people. their of nutrition the and services investpublic in to money have less countries by developing countries. This developing that means collected being money of pot asmaller to contribute all companies, multinational and countries rich favour that treaties tax and incentives, tax questionable standards, tax global Complex years. hundred of couple over last have occurred the that developments social the from benefit to struggling south global the in many with north, global the in Wealth remained has people. marginalised most or poorest favour the not does exists it as system financial the Globally, 56.4% to 59.3%. to 56.4% 2014, and from 2000 between 2.9% by increasing incidence its with poverty, of elimination its Guatemala –COUNTRYFUNDING EXAMPLE Hunger Pact interventions were carried out with with out were carried interventions Pact Hunger Zero planned nine the of four and two between were low 2015. in Education, average, On of Ministry the of exception Pact’, the with ‘Zero Hunger national the through malnutrition, Ministerial investments affecting 46.5% of children under five. under children of 46.5% affecting scourge, Guatemala’s be to greatest considered has taken a backwards step in in step abackwards taken has 107 Chronic child malnutrition is is malnutrition child Chronic 101 This is ten times more more times ten is This in efforts to address address to efforts in 108 each household. each embodied by agreements – to end poverty, end –to agreements by embodied and, indeed,international cooperation in trade trade – international of necessity the of argue many poverty is concentrated. is poverty where and productivity agricultural on depends mainly population rural the where especially most, the countries developing have affected changes These with 30%–40% in rich countries). rich in 30%–40% with GDP, of 10%–20% compared (generally ratios have low to tax tend also countries Developing 17 per 100,000 respectively. 17 100,000 per 113 at high, have remained rates and mortality neonatal and maternal aresult, As services. planning family and services, delivery services, care post-natal and neo- ante-, programmes; feeding and supplement micronutrient including vaccination, growth monitoring, resources, of lack this by were affected services ministry’s nutrition Welfare.the of Social Many and Health Public of Ministry the including cuts, budget haveexperienced ministries fivelargest accessibility, price and nutritional quality. availability, food impacting indirectly and directly by outcomes nutrition and system food the impact Trade often people. marginalised agreements most and poorest the benefit to fails that area is another system trade international The countries. high-income of skewed is needs towards that the infrastructure decision-making in lie funds tax of distribution unfair the of roots the level, international the at And population. their of nutrition investthe in to for available governments being fewer resources highlighted in this report. this in highlighted and registered obesity in increase for the part, in are responsible, advertising food global and this that argue Some expansion. market global their and corporations food transnational of entry subsequent the and investment, direct foreign and trade food towards international markets domestic of opening as such systems, food to changes important brought consumption, international the trade system power and purchasing influencing Besides behind. many left several has it ways 109 Furthermore, three of the the of three Furthermore, 106 105 While many people have people many While 110 102 All this leads to to leads Allthis 103 104 While While in in 3 WHY ARE CHILDREN MALNOURISHED? 41

PHOTO: CAROLINE TRUTMANN/SAVE THE CHILDREN and 118 The risks 116 115 Extreme events can also have but also because development 119 117 approaches do not routinely include drought cycles cycles drought approaches include routinely do not in planning scenarios, nor substantial investment in climate-proofing interventions. Climate change affects the frequency and severity of extreme events. Extreme events can affect people’s lives and nutrition status in a variety of ways. The most obvious immediate are impacts such as loss of life, injury, loss of livelihoods and assets, posed to livelihoods by extreme weather events such as floods, droughts, heatwaves and hurricanes increasing,are mainly because larger numbers of people and their assets being are exposed to weather; extreme destruction of crops, critical infrastructure and assets.community CLIMATE CHANGE,CLIMATE EXTREME WEATHER EVENTS AND NEGLECTED EMERGENCIES It is widely now accepted that the world will contend with more frequent and severe the to linked events extreme weather impact of climate change. change Climate exacerbates the risks of hunger and undernutrition in two main extreme ways: weather events and risks. climate gradual and long-term leadership and proactive intervention, the benefits of growth cannot be expected to translate into increased incomes or food budgets inthe most disadvantaged households, let alone dramatic malnutrition. in improvements 113 112 Subsidies can stimulate stimulate can Subsidies Without active government 111 114 At a globalAt level, the last years 23 seen have a huge increase in real GDP per head, and the number of people living on less than US$1.25 per day has the number of dramatically reduced. However, people eating too calories few to sustain an active life has fallen relatively – onlyslowly half as fast as thosefor in poverty. The Doha round of trade negotiations began in 2001 with a stronger developing country than voice previous negotiations countries up (developing make the developing two thirds of negotiators). However, countries having are very little influence over the discussions. This is due to the lack of negotiating manypower developing countries hold – because of their and size investment potential – and the lack of comparison in representatives country experienced with, say, the EU and the US. For example, the of subsidy levels to provided farmers in developed countries highly distorts the trade system, with many developing countries forced to sell their goods at reduced a price. This is the case many for west African cotton farmers because of the subsidies given to cotton farmers in the US, EU, China and India. been lifted out of poverty in the last decades, few the international trade system still lacks the means to address issues that affect the most disadvantaged. Ingrid and Nelson with their children in eastern One-year-oldGuatemala. Abner became severely a malnourished when severe drought destroyed crops and meant there was no work for his parents. excessive production,excessive resulting in cheap exports – or they can block imports. 42 UNEQUAL PORTIONS are having an impact on the food security of the the of security food the on impact an are having like Niño events El Ethiopia, as such countries, some –in people marginalised most and poor for the only issue an longer no is insecurity Food and unemployment. in inequality and increases and productivity, health and nutrition, attendance, school in declines as such economies, and lives on impacts indirect long-term, that arethat prevalent drought during cycles. diseases contracting of risk greater far at them children’s underdeveloped put immune systems as are extreme high temperatures. high are extreme as areas, vulnerable of anumber in are projected severe more droughts prolonged and Globally, deficiency. or micronutrient and wasting stunting, in result can This food. nutritious enough to access routine lack cycle, drought the of over course can, the production) agricultural small-scale and by-products animal of form (in the supplementation nutrition and income for both pastoralism and agriculture on primarily rely that live households in who Children diarrhoea. and dengue malaria, coli, E. like cholera, illnesses and diseases and heatstroke including threats of faceand arange impacts its to vulnerable are particularly children acountry, in unfolds cycle adrought When alone. Africa Southern in malnutrition for severe acute treatment require will children 1 million as many as UNICEF, According to pastoralism. and agriculture on reliant heavily are who families their and for children acute particularly is Niño El of impact The unfolds. year the as andlandslides flooding in usher to set looks major drought and cycles across continents three triggered has Niño El 12 past the months, Over lives. livelihoods and their to their to threats of arange to now exposed are people million 60 least at Consequently, scale. and strength event unprecedented of Niño El an world now is The experiencing MALNUTRITION FOR CONSEQUENCES THE AND NIÑO EL economic indicators. indicators. economic national and households, poorest the of many of livelihoods the production, agricultural on impact 120 123 122 Furthermore, Furthermore, 125 These will will These 124 meeting nutrition targets. in made been has that progress the undoing basis, aregular on compromised is status nutrition their and like this shocks to vulnerable world are routinely the around children of Millions targets. nutrition ambitious to up have signed which of world –many the around countries in indicators nutrition and livelihood on impacts visible and immediate having is Niño El urgent. more never been has change climate of frontline the on live countries in who children of for millions malnutrition chronic of cycle the break how of to question the to answer An Lancet (The rates breastfeeding on have impact an also can emergencies during substitutes breastmilk of donation or promotion The breastmilk. their on impact anegative all has –this are stressed or themselves, water and food nutritious enough water, clean getting are not fetch mothers or to walking busy are often conditions). Mothers crowded to living due infection of risk increased the and milk, animal and foods, nutritious water, clean of lack the of (because necessary most is it when time the exactly at decreases eventbreastfeeding or like Niño, El emergency an during often that us tells programmes Children’s fromSave the Experience malnutrition. and disease mortality, in preventto increases essential is like Niño events El and emergencies during practices feeding child young and infant Protecting prevent to it. measures on than rather emergencies, in malnutrition acute of treatment on focused has sector Traditionally, nutrition the social shocks. and environmental economic, to vulnerable more even and woulddisadvantaged be people These coupled with higher prices of major crops. major of prices higher with coupled lower income, therefore and output, agricultural lower means change climate world, the around people vulnerable For population. the of majority , 2016). continued overleaf continued 121

3 WHY ARE CHILDREN MALNOURISHED? 43 gaging male family members in activities ioritising home visits by field supervisors oviding support to mothers in and female community health volunteers, to goodreinforce health, sanitation and hygiene nutrition behaviours and disadvantaged group households poultry for keeping and vegetable growing, to increase their access to diversifiedfood. pr en to build their and roles valuing sharing in: the of women;workload raising and caring for accesschildren; to and facilitating women’s health and nutrition services and control over food and nutrition resources. pr

frameworks include the drought cycle; and they must prioritise greater investment in tackling malnutrition as part of a wider of package theinvestment in health system, including promoting measures malnutrition to prevent (such as breastfeeding) rather than treating it. Further, efforts development and governments national must ensure that early warning information triggers appropriate and timely early action by governments, donors and agencies. aid • • A Save the Children staff member observed the impact of the Suaahara project in educating people – and womenin particular – on the benefitsfor the of child breastfeeding during and after any adverse event. The staff member saw significantly levels thanlower expected of infections and malnutrition following last year’s devastating earthquake; donations of breastmilk substitutes did not appear to change practices. One woman local had been buried 24 for hours. She could not breastfeed to begin with, but she persevered, as she knew that this was the best thing her for child. •

This will mean that national mean that national will This 126 couraging behaviour change among its among change behaviour couraging (‘mother knows best’) drama radio serial and call-in programmes target population, through female community health volunteers, mothers’ groups, local community structures and its Bhanchhin Aama en

governments must ensure that development Following the 2011 faminein SomaliaFollowing and the 2011 successive rounds of major food and nutrition crises in the Horn of Africa and the Sahel, there isclear a consensus that development efforts need to focus more concertedly on tackling the structural vulnerabilities that expose some groups to climate shocks. And they need to focus more on strengthening the resilience of vulnerable to climate-induced shocks groups population stresses. and EL NIÑO AND THE CONSEQUENCES FOR MALNUTRITION continued Suaahara reaches disadvantaged groups in a number of ways, including: • Save the Children’s Suaahara projectSavethe is an Children’s integrated nutrition implementing programme out districts of 75 in 41 at scale in Nepal, with a particular emphasis on the most vulnerable areas and households. It supports the Government of Nepal in aiming household to improve of levels health and nutrition, targeting households with mothers and women lactating and pregnant of children under two (1,000-day The women). programme focuses on social and behavioural change at household through level the promotion of essential nutrition and actions and good maternal and infant and young child feeding practices. It also addresses other determinants of undernutrition, such as availability of and sanitationaccess and hygiene, to food, water, quality health care, and child spacing, and it considers socio-cultural factors gender like provides Suaahara marginalisation. and additional support to disadvantaged groups around nutrition. BUILDING RESILIENCE CHILD AND THROUGH INFANT FEEDING YOUNG IN NEPAL 4 How to address malnutrition inclusively

In previous chapters, we have explored goes to the poorest income quintile. It has been trends in malnutrition and how gaps are reported that this is also the measure that featured widening in nutrition outcomes between least frequently in MDG reports (ibid). different groups of children. We have looked The MDG framework did target certain groups – at the drivers of malnutrition, including for example (not exhaustive): how the exclusion of groups of children is Goal 3: “Promote gender equality and empower playing a role. In this chapter we explore women”, Target 3A: “Eliminate gender disparity how past and current commitments have in primary and secondary education, preferably taken an inclusive approach. We then look by 2005, and in all levels of education no later at appropriate policy responses, given what than 2015” was reported as achieved in primary, we have learned so far. secondary and tertiary education.2 Goal 7: “Ensure environmental sustainability”, NUTRITION COMMITMENTS – Target 7D: “Achieve, by 2020, a significant ARE THEY INCLUSIVE? improvement in the lives of at least 100 million slum dwellers.” Many political commitments towards nutrition exist, It was reported that between 2000 and 2014, more especially at the global level. The challenge for than 320 million people living in slums gained access many years has been lack of accountability for these to improved water sources, improved sanitation commitments, and the fact that global commitments facilities, or durable or less crowded housing, have not been translated into national targets and thereby exceeding the MDG target. However, more action. Here we consider how commitments at the than 880 million people are estimated to be living in global level have or have not worked to address slums today, compared to 792 million in 2000 and both malnutrition and exclusion. 689 million in 1990.3

MILLENNIUM DEVELOPMENT GOALS (MDGS) SUSTAINABLE DEVELOPMENT GOALS (SDGS) The Millennium Declaration was signed in 2000 In 2015, inequality was very much on the agenda by 189 of the world’s leaders on behalf of the and a new set of world leaders committed to “leave international community. It represented a promise no one behind”. The SDG Declaration states: “As we to coordinate and accelerate efforts to ‘spare no embark on this great collective journey, we pledge that effort to free our fellow men, women and children no one will be left behind. Recognizing that the dignity from the abject and dehumanising conditions of of the human person is fundamental, we wish to see the extreme poverty’ by 2015. At its core was a set of Goals and targets met for all nations and peoples and for fundamental values that included freedom, equality, all segments of society. And we will endeavour to reach tolerance and solidarity. However, concrete the furthest behind first.” measures on equality and social justice were not included and the measures that were used to Goal 10 of the SDGs is to “reduce inequality within monitor progress on the MDGs were couched in and between countries”. With target 10.2: “By 2030, terms of national averages and proportions.1 Only empower and promote the social, economic and political one indicator under MDG 1 touches on income inclusion of all, irrespective of age, sex, disability, race, inequality: the share of the national income that ethnicity, origin, religion or economic or other status”.

44 4 HOW TO ADDRESS MALNUTRITION INCLUSIVELY 45

5 However, challenges However, 6 progress global towards targets. Therefore, inequalities between regions or groups withina country not are visible. The is currently world off track to meet six all WHA nutrition targets. still remain in turning political commitment to implementation at scale. As SUN enters its second phase, the movement has agreed to greater give attention to the no one behind’ ‘leave agenda. SECOND INTERNATIONAL CONFERENCE CONFERENCE INTERNATIONAL SECOND ON NUTRITION (ICN2) The Scaling Up Nutrition Scaling The movement The issues highlighted around weak above coordination and leadership nutrition for in part led to the formation of the Scaling Up Nutrition (SUN) Themovement movement consists in 2010. now of countries56 and has seen success inputting nutrition on the global and national agendas and garnering political will to tackle the issue. Realising setting and future targets It is important to remember that global targets usuallyare the result of negotiation rather than being based on global trends, with countries and groups of countries negotiating based on their own situation. It is therefore vital to translate global goals into national targets, based on current trends and context. In November the 2014, Second International Conference on Nutrition (ICN2) took in place – jointlyRome organised by the United Nations Food and Agriculture Organization and the World Health Organization. Member states signed up to 60 priority recommendations – a comprehensive list of actions to address malnutrition. The accountability mechanism is not yet in place and, with many so voluntary commitments, it is difficult see to governments how will honour their commitments. The framework does not a ‘leave take no one behind’ approach – there is no mention of inequality in the framework, or of ways to ensure that progress is made social all for and economic groups in society. Of course, a number for of these recommendations – if implemented in the correct – theyway an could impact have in addressing malnutrition those for most marginalised. But at the moment, there is no guarantee that that will happen. (WHA) Resolution 65.6 4 crease in childhood overweight childhood crease in By 2030, end forms all of malnutrition, By 2030, end preventable deaths of By 2030, end hunger and ensureaccess by : : : % reduction in the number of children under % reduction birth in low weight % reduction of anaemia in women of duce and maintain childhood wasting to less crease the breastfeeding rate of exclusive in the first six months up to leastat 50% re than 5%. no in no in 50 reproductive age 30 40 five who are stunted 3.2 newborns and children under 5 years of age, with countries all aiming to reduce neonatal mortality to per at least 1,000 as as low 12 live births and under-5 mortality to at least as low as 25 per 1,000 births. live 2.2 including achieving,by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons. 2.1 all people,all in particular the poor and people in vulnerable situations, including infants, to safe, nutritious and sufficientfood all yearround.

These targets global are in nature, and while it is possible to apply global targets to national situations to set national targets, these targets will not be based on the context of the country and the current trends in the reduction of malnutrition. Reporting on these targets is done at the national level, with national used prevalences to assess • • • • • WORLD HEALTH ASSEMBLYWORLD HEALTH NUTRITION TARGETS Recognising that accelerated global action on malnutrition was needed, the World in 2012 AssemblyHealth WHA targets: • endorsed a comprehensive implementation plan on maternal, infant and young child nutrition, which specifiedset a of six global nutrition targets with a 2025.deadline of • The nutrition goal and target no also a ‘leave take one behind’ approach, with targets and 2.2, 2.1 and 3.2 particularly, of relevance: • • 46 UNEQUAL PORTIONS widely evidenced is it fact, In interventions. these role delivering in avital plays service health The breastfeeding. exclusive of promotion the and supplementation vitamin A include Examples malnutrition. of drivers immediate the address interventions nutrition Direct INTERVENTIONS HEALTH AND NUTRITION DIRECT 4.1 4.4). (section approach inclusive for an principles design We some explore then 4.1–4.3). level one sections –see to policies these assign to level possible is global it (asand as much national community, household, child, level the of move 25), do (page but fromthe malnutrition of drivers frameworkfor the conceptual the Weexclusion. have covered not of every area and malnutrition both address that responses policy of examples 4we explore part in Here take an to How inclusive approach vitamin supplementation. vitamin supplementation. growth feeding monitoring, supplementary and through –for example, programmes health child and newborn maternal, intake reproductive, into dietary impact directly that services nutrition (see Figure19, 25). page considered be then levels should global and national at and community, and household the in child, level the of the at malnutrition of drivers the addresses that response policy appropriate An country. the of analysis economy political and malnutrition of burden the malnutrition, of drivers the include should analysis contextual The groups. for different experiences the to given consideration careful with why, and are malnourished children which of analysis contextual a robust by informed be should all interventions groups, excluded for malnutrition address to order In CONTEXTUAL ANALYSIS

THE CHILD: 7, 8 7, that it is critical to integrate integrate to critical is it that A DDRESSING THE IMMEDIATE DRIVERS OF MALNUTRITION MALNUTRITION OF IMMEDIATE THE DRIVERS DDRESSING

where drought has caused an emergency. Malawi, southern in crops damaged and dry her with Agness section (4.2). section next the in explored is and need, they services health quality the have to access all people ensuring in Coverage approach one is Health Universal exclusive and breastfeeding. initiation early for support including care, postnatal and antenatal of part as advice and support nutrition receive also should women and girls These women. lactating and pregnant to and girls, adolescent to supplements onan providing emphasis multiple micronutrient be should there So, development. and growth for achild’s are critical life of days 1,000 first The PHOTO: JONAS GRATZER/SAVE THE CHILDREN THE GRATZER/SAVE JONAS PHOTO: 4 HOW TO ADDRESS MALNUTRITION INCLUSIVELY 47 Taking 13 Nutrition Nutrition 14 15

Development be can never 16 Addressing discrimination means discrimination Addressing 12 ve specialve attention to vulnerable and ffected communities, particularly those who data must also be transparent and available to the without public. impossible Empowerment is transparency in public affairs. all Without firstcollecting the right kinds of information, forms of discrimination and exclusion and which groups affected are cannot be accurately identified. For example,research has preferential treatmentof theshown significance resulting based in differing on gender, feeding practices and food intake. In Kenya, a strong gender bias in intra-household food distribution was found to lead to more girls with malnutrition, stunting, wasting and infectious diseases. security and nutrition programmes may envisage affirmative or positive discriminationfor the benefit groupsof – mainly marginalisedgroups andwomen – that historically have experienced discrimination. not only removing explicitly discriminatory policies, but also addressing and correcting the drivers of discrimination, such as inequitable resource allocation. a human rights-based approach to nutrition requires that information disaggregated by sex, income and ethnicity level is collected. truly sustainable unless the of affected voices communities heard are and included, and unless communities given are a stake in their own futures. The rights to food, health and other essential human resources require the active and Gi groupsmarginalised In order to address discrimination in of its all forms, human rights requires giving special attention – with a focus on solutions – to vulnerable and marginalised groups. What this means in effect is ensuring that any development policies and programmes target the worst-off first. Thisrequires a number of differentactions, but a firstconcrete step that governments must – alignedtake with the SDGs – is to ensure the collectionof disaggregated data. Empower and promote participation A beenhave excluded, must be included in any decision- and development programme policies, making that affect their rights, their children and their youth.

• •

DRESSING THE UNDERLYING DRIVERS DRIVERS DRESSING UNDERLYING THE

AD This means specifically that states 11 States that explicitly enable human 9 Please see appendix more detail 3 for on 10 ke theke right commitments THE HOUSEHOLD: THE

The most fundamental principle of human human of principle fundamental most The rights and human-rights based approaches is non-discrimination. Human rights prohibits discrimination, whether it is indesign or inimpact, and it is required that discrimination is addressed immediately.Discriminatory policies and practices serve to greatly limit the development outcomes of certain groups and must be addressed. Food Before anything else, governments must ensure that they agreed have to of the all commitments, human rights and otherwise, necessary to address malnutrition equitably. Human rights commitments, the on the including Convention Rights of the Child, establish moral and legal imperatives designed to ensure that no child is malnourished, and they specific provide guidance toon how do that in so a way is centred on human dignity, needs, and interests, and which also has efficiency improved instrumental regarding value and outcomes. should establish these rights in their constitutions and enact rights-based legislation designed to address nutrition where it does not already exist. Focus on non-discrimination equality on and Focus Ma

rights to be realised their for populations likely are to accelerate progress food and towards nutrition security. • APPLYING A RIGHTS-BASED A APPROACH APPLYING provide rights provisions human International a powerful framework within which to analyse, formulate and implement nutrition policies and programmes to reach everyone, including excluded groups. States an obligation have to ensure that the rights that affect nutrition – the children’s rights to adequate food, health, survival and development – are realised. OF MALNUTRITION Here, explore we policy solutions that address household food security, practices care women for and children, andhealth, environment and services. The rights-based approach is important here – enjoyment of the right to food, the right to adequate care, the right to health; prevention and control of disease and the right to water and sanitation. 4.2 HOW TO DEVELOP TO HOW A RIGHTS-BASED ADDRESSTO APPROACH MALNUTRITION • the of the role state in international human rights. 48 UNEQUAL PORTIONS is poor and often suffered from hunger. hunger. from suffered often and poor is family Their four. Berhanu, brother his and nine, Desalegn, CRC. the of articles specific by underpinned is investing in children of benefits developmental long-term the recognises it and children’s of vulnerability, and poverty patterns specific the addresses protection social Child-sensitive governments. by prioritised increasingly is and groups, for excluded malnutrition and poverty alleviating for aproven is intervention protection Social PROTECTION SOCIAL DEVELOPING CHILD-SENSITIVE growth and fair finance. finance. fair and growth inclusive to contribute can and redistribution,

allow them to be truly involved. truly involved. be to allow them that ways in processes these about information provide actively also should They implementation. regarding decisions necessary make the to and resolve them, to ways analyse to problems, their identify to designed processes in included be should marginalised and poor are who people Specifically, rights. their affect that processes all –in decision-making children – including informed communities of participation affected 17 It can be an effective tool for income for income tool effective an be can It

. Social protection for children for children protection . Social PHOTO: COLIN CROWLEY/SAVE THE CHILDREN THE CROWLEY/SAVE COLIN PHOTO: without apension. without households in those than taller five centimetres grow, apension average, receiving on households children; stunted of number the in have reductions all shown Colombia and Malawi Mexico, in Programmes malnutrition. and insecurity food poverty, child on impacts positive of evidence show strong countries of anumber across initiatives protection Social met. be can needs basic that ensuring and assets, and productive exclusion,discrimination protecting malnutrition, by reducing vulnerability, challenging of causes underlying the and immediate the both tackle help also can programmes protection Social • • • pathways: three through levels, community and household at malnutrition, of causes underlying the tackle can systems and policies protection social Child-sensitive and implementation. design programme in caregivers their and children voices and of views needs, the account into takes and children on impacts the monitors it children; on protection social of harm any minimises and impacts the maximises protection social Child-sensitive transfers programmes in Brazil in programmes transfers cash the with for groups, excluded dividends big have delivered programmes protection Social social development. for national benefits economic long-term and bring also interventions Such poorest. the on focus their of because children excluded benefited have disproportionately programmes these towardsexcluded groups, specifically targeted always not While celebrated. widely most perhaps by women. headed for families points 32 percentage of and for families, insecurity food perceived in points percentage 25 of reductions saw programme transfer cash Poverty Against Empowerment from 55% 46%; to scheme decreased stunting among child participants

and sanitation services. i promoting –by environment and services health approach days 1,000 the through populations vulnerable nutritionally targeting and feeding child young and infant improving ca fo income, improving –by security food household mprovement, access to and delivery of health health of delivery and to access mprovement, od access and increasing assets increasing and access od ring practices for women and children – children and for women practices ring 20, 21 20, 18 24 Malawi’s Mchinji Social Cash Transfer Cash Malawi’sSocial Mchinji 22 23 children in South African African South in children 27 Ghana’s Livelihood

25 and in Bolivia 19 26

4 HOW TO ADDRESS MALNUTRITION INCLUSIVELY 49 nutritious diet, with a focus on nutritionally vulnerable groups. In addition, programmes should be adaptive to be able to respond to shocks and crises, such asby scaling out to reach nutritionally vulnerable groups that affected are by the crisis or scaling up by adjusting the transfer amountor duration. The cash any minimise should mechanisms delivery transfer potentially negative impacts on pregnant women and childcare, especially in terms of burden of accessing cash transfers. The primary recipient of the cash transfers should be determined to maximise the potential cash for transfer spending to meet children’s needs; the primary recipient will often be the mother. Linkages and complementary activities to improve impact on nutrition Social protection – interventions or programmes can serve as delivery platforms larger-scale,for more comprehensive and more interventions. nutrition-specific effective However, social protection schemes nascent are However, in out and a roll of of universal coverage Myanmar, if adequately even funded,MCCTs, will time take to reach very remote rural communities – and especially conflict-affected or ethnically diverse areas. Further development and adaptation of complex accommodate mechanisms to delivery access socio-economic where environments, and open engagement highly are contested, will be required. who wield far more influence on the political decision-making apparatus. The MCCTprogrammes been have designed based on a robust understanding of malnutrition. The programmes target women and their infants during the critical window of the first1,000 days, with a cash transfer amount informed by the cost of a nutritious diet. The programmes also and encourageprovide beneficiaries to attend change behavioural and nutrition-focused social communication events, as as well mother-to- mother support group meetings, antenatal check-ups and immunisation. The programmes aim stunting to prevent in children and are expected to contribute to increased food security uptakeand of nutritious improved food. – Cash Under the framework broad 28 Inclusive approaches the have potential to build political support and generate high budget allocations because they universal. are MCCT benefitsSave the Children’s are made available across the wealth spectrum, reaching those living in poverty who often are politically weak, and those with middle to high incomes This is in contrast to poverty-based selection methodologies, such as means testing or proxy means testing, both of which include inherent inaccuracies in identification and of ‘poor’, the high exclusionhave rates. For example, Mexico’s Oportunidades excludes of the 70% poorest 20% of eligible households, due to exclusion MCCTerrors. programmes Save the Children’s also do not enforce conditions on recipients, to the most excluding of the likelihood minimise vulnerable women due to their inability to comply with strict conditions. APPLYING A UNIVERSAL SOCIAL PROTECTION APPROACH IN MYANMAR A UNIVERSAL APPROACH APPLYING SOCIAL PROTECTION Inclusive approaches, particularly when coupled with universal will coverage, drastically reduce the exclusion ratepoor for households. All three Maternalof Save the and Child Cash Children’s (MCCT) programmesTransfer in Myanmar a universaltake approach, where pregnant all mothers and their children under two years are eligible, independent of any othercharacteristic. transfers should be informed by affordability of a HOW TO HARNESS TO HOW SOCIAL PROTECTION ADDRESSTO MALNUTRITION FOR GROUPS EXCLUDED Universal social protection – Anyone who needs social protection should be able to access it. This is central to ending poverty and boosting shared prosperity. Universal social protection refers to the integrated set of policies designed to ensure income security and support to people all across the life cycle – paying particular attention to the poor and the vulnerable. Adequacy and effectiveness cash of transfers of universal social protection, nutrition-focused social protection should target the nutritionally vulnerable,to according age (with a focus on the first1,000 days adolescentand on well as girls) as disparities. income and regional 50 UNEQUAL PORTIONS change adaptation and resilience building. climate- warning, early reduction, disaster-risk in ofinvestment increased necessity the highlights security food on Niño El of impact negative current • • • through: shocks climate-related to resilience build also should Governments prevention. and mitigation, warning, early preparedness, include which actions, of range abroad through communities and individuals to risks disaster and vulnerability minimising to approach asystematic is Reduction Risk Disaster approach. necessary but acomplex is This contexts. geographic and cultural, livelihood, specific to adapted and targeted carefully be to would It need droughts. as such shocks during responses specific by reinforced and year, the throughout undertaken be to would need type this of programme Acountry-led changes. behavioural and livelihoods sanitation, hygiene, water, health, nutrition, addressing programme prevention and rehabilitation integrated term, along- require will This shocks. environmental and climate to resilience building mean will people for many malnutrition of cycle the Breaking risks. and events climate-related to vulnerability their linkedto closely be can status nutrition individual’s an we have household’s or seen, As BUILDING RESILIENCE

food shortages. shortages. food with deal quickly can country their ensure and volatility price food reduce to order in reserves, in approaches objectivesnutrition and nutrition-sensitive promotion of livelihoodsthe and include specific for provide opportunities households, poorest the protect that programmes protection broad social c as emergencies during needs nutritional with deal to built is capacity that ensure and for emergencies contingency include should plans nutrition growth; economic and production increased on focusing just than rather plans, livelihood and agriculture in approach take auniversal that objectives in vesting in and wisely managing emergency food food emergency managing wisely and in vesting cluding improved resilience and nutrition nutrition and improved resilience cluding overed earlier in this report, investing in in investing report, this in overed earlier 29 31 30 The The c) a) to: need we behind, one no leaves way that a child-sensitive in are delivered policies livelihood ensure to order In specifically. for children outcomes have positive increases income these that ensure and households, poorer of status improve economic the and level incomes raise household effectively on building livelihoods child-sensitive focusing workthrough livelihoods our of centre the at for children outcomes achieving put to aims Children the Save this, of recognition In assumed. be cannot nutrition child on initiatives livelihoods level improved of household impact positive the However, nutrition. child on outcomes have positive proven to been has incomes household Raising LIVELIHOODS of localof livelihoods nature the of understanding aprior requires This key. is objectives achieve to these adopt they that strategies livelihood the and objectives people’s livelihood their Understanding assets, f) e) d) b)

communities; for marginalised food nutritious of availability improve the that practices promotes actively In In En and to enhance evidence the base. practice best identify to consistently and openly shared be should generated Evidence impacts. positive maximise to order in groups different from children and boys and for girls outcomes Co etc; wage rates, conditions, working around –eg, measures child-sensitive promote to and groups, fromdifferent children and boys and girls on decisions workand livelihoods of s private actors (eg, other and partners Influence nutrition, WASH and care practices; WASH and nutrition, child –eg, boys and girls on positively impact to income invest additional best how to regarding have improved knowledge households that ensure phases;implementation and design the in consideration into taken and voices are heard their that ensure to evaluation, and monitoring well as as design, programme and assessments –in disabilities with those household resources for investing in their children; their in for investing resources household fromincomes use livelihoods promote of to the of use the on decision-making household in girls and role women of equal the promote to Seek ector, government) to be aware of the impact ector, impact aware be the of government) to volve girls, boys and their parents – including –including parents their and boys volve girls, corporate behaviour change elements to to elements change behaviour corporate sure that production-related programming programming production-related sure that nsistently monitor and review nutrition review and nutrition monitor nsistently – what types of livelihood livelihood of types –what 32 , which , which 4 HOW TO ADDRESS MALNUTRITION INCLUSIVELY 51 .

35 eater proportion of young children erall, nutritional status of children receiving e direct costs of the interventions were lk availability in intervention improved sites, milk stabilised the over dry season estimated to less be to 45% than 75% those estimated therapeutic for feeding management (community-based programmes of acute malnutrition). with production during the dry season higher than in sites without the intervention. Milk production was alsosustained longer. Ov Th Mi A gr consumed milk in the intervention sites, compared to the control sites.

Decisions about which healthcare services should be andprovided about resources how raised and are UNIVERSAL HEALTH COVERAGE COVERAGE UNIVERSAL HEALTH AND NUTRITION WHO defines Universal Health (UHC) Coverage as ensuring people that can use the ‘all promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship’. UHC is the aspiration that people all can obtain the quality health services they need without facing financial hardship. UHC promotes realisationthe of the human right to health, dissociating access to services from the ability to pay. • This was seen to be successful and further roll-outis planned in 2016. • • In 2014 and 2015, Milk Matters and 2015, In 2014 supported communities to rehabilitate areas of rangeland to be the usedfor only creation by of fodder, milking animalsthat stay to close the homestead during the dry season. FINDINGS Milk Matters found that in supporting the milking of animals that stay to close women and children during the dry season drought, and/or milk is children among consumption and production nutritionalimproved, and status children’s rises. • 34 This goes to the heart of 33 The second phase of the Milk Matters study was designed to assess the impact of community- defined livestock interventions on the nutritional status of young the children dry over season. Wherethe international response to malnutrition has typically been reactive in these areas, with the provision of a food basket and establishment of selective feeding as acute malnutrition rises, this study into looked the potential cost savings, both short- and long-term, economic and social, of a more preventative approach. Phase I of Save the Children’s Milk MattersPhase I of Save the Children’s study investigated the and use of milk value in these communities. It found that, when available, milk is prioritised consumption for by young children, and that the seasonal lack of access to animals and animal products, exacerbated during periods of drought, is widely perceived by pastoralists as malnutrition. child behind driver main the Children who in pastoralist live areas are increasingly referred to as some of the most nutritionally vulnerable in the world. In Somali Region,Ethiopia, of global levels acute malnutrition among young children regularly are reported to the defined level 15%, rise above as a nutritional emergency by WHO. MILK MATTERS: PREVENTINGMILK MATTERS: MALNUTRITION THROUGH LIVESTOCK INTERVENTIONS IN SOMALI REGION, ETHIOPIA Since traditional livelihoods such as such pastoralism livelihoods traditional Since or agriculture may long-term not provide food security, there is a need to greater place emphasis strategies livelihood alternative – promoting on especially youth. for Examples include vocational and technical education, life skills training, financial entrepreneurialliteracy, and training, encouraging youth to be competitive in their job local markets. the no one behind’ ‘leave approach, by ensuring that social all groups included are in the analysis and programmes. strategies employed are by people local and what factors constrain them from achieving their gained be Suchobjectives. understanding cannot without socio-economic and cultural analysis, so that particular social groups and their vulnerability can be understood. 52 UNEQUAL PORTIONS must be a priority. apriority. be must all in forms malnutrition addressing So, countries. within vulnerable most and poorest the affects often and countries, low-income and middle- high-, affects zero malnutrition. towards reaching step care –are acritical health child and newborn maternal, reproductive, quality delivering –ultimately course life the throughout malnutrition treats and prevents system a health way covered which in the and people of number the of terms in UHC, to pathway the on Choices absent. notably is nutrition where UHC, on discussions in and health, child and maternal promote to efforts of part as nutrition on for attention more aneed is there recognition, increased Despite linked. inextricably is children and women of status nutrition and health The for nutrition deliver must towards UHC efforts Why world. the around countries for many priority the be must nutrition addressing We funds. why below argue additional spend to how on priorities setting make when countries choices are the important equally UHC; delivering in countries for some step important an be could – fromtaxes revenue more Raising –for example, resources. human and systems surveillance information, of financing, improvements in health process acomprehensive require will malnutrition of treatment and prevention the for both delivers UHC Ensuring protections. rights human and security food education, employment, malnutrition: of determinants social the address that services and polices support also must efforts national malnutrition, treating and preventing in sector health the by made be can contributions While of interventions. cost-effectiveness the and need, health public on base evidence astrong as T and accountability. participation non-discrimination, of equity, principles fundamental guided by the be should setting priority in choices governments’ that believes Children the Save contexts, national accordingto differ towards UHC pathways While governments. with rest are spent how they h is is consistent with the right to health – as well –as health to right the with consistent is is 36 Malnutrition 37

country/region accountability specific governance effective Finally, growth. and development survival, child ensuring at aim that practices community and family promote and support demand side, national and local governments must the On nutrition. for financing equitable and adequate to and health, to barriers critical constitute often personnel health skilled of lack and infrastructure of lack or infrastructure poor where areas rural remote in particular in in and management, chain human resources on placed be should emphasis Specific delivery. service effective for aprerequisite is systems health of blocks building the strengthening side, supply the On considered. supply both that ensure to critical is it programmes, and policies designing When • • example: For outcomes. health and nutrition improving in sectors other with workhand-in-hand must sector health The broaderenvironment health the addressing in sector health the of role The • •

and informal working sectors. sectors. working informal and formal both leave in maternity as such policies enabling physical and social environment and and schedules working flexible of creation the exclusiveprotect breastfeeding Ma Co Be Go surgery. bariatric and mild obesity, with care for children primary in counselling schools, in education nutrition settings, community in campaigns diseases non-communicable nutrition-related and obesity, diets, unhealthy manage or prevent to settings various in individuals to for pregnancies adolescents. delayed and spacing birth contraception, of importance the address specifically should adolescents for education nutrition programmes should have provisions for providing and policies government growth, for human advertising, especially on television. on especially advertising, limit and labelling, food regulate schools, in food of advertising the control countries Some Peru. and Rica, Costa Colombia, Chile, Brazil, –for example, schools in generally for children, choices food healthy improving on focus that cause adolescence is such a critical period period acritical such is adolescence cause vernments should support, promote and and promote support, should vernments ny kinds of interventions can be delivered delivered be can interventions of kinds ny ntext-specific familyeducation planning ntext-specific 38 . These include social marketing marketing social include . These A number of countries passed laws laws passed countries of Anumber for health and supply supply and for health and demand and through through mechanisms 39 and and . are are

4 HOW TO ADDRESS MALNUTRITION INCLUSIVELY 53 44 42 46, 47 Schools can 43 45 posing individuals to new environments, environments, new to individuals posing women’s parting enhancing and self-confidence aching numeracyand literacy, thereby oviding women with the opportunity to form Im roles in decision making including – their interactions with healthcare professionals; Pr social networks, which can be of particular importance in isolated rural areas. Ex making them receptive to modern medicine; assisting caregivers in acquiring information and possibly nutrition knowledge; Te

5. 4. The links between schooling and nutrition provide us with another reason why it is encouraging so that global trends in education positive. are Data from developing countries an show average increase in years for of schooling from 2.60 to 7.62 boys and 1.50 from to 6.64 girls for between 1950 2010. and must not encourage This progress, however, complacency. Globally, of the 650 million children of primary school age, 250 million either are not in school in school or are but not learning the absolute basics of literacy and numeracy – while 40 million primary school-age children affected are by emergencies and protracted crises with possible negative impacts on their education. The children denied the beneficialconsequences of education must therefore be priority a key for policy makers. Children on and the forced move from their homes, children from indigenous and ethnic minorities, street children, and children with disabilities disproportionately all are missing from formal education. This has a negative impact on many other areas of their lives and driver is a key of their exclusion and, ultimately, the nutrition status of their children. own Furthermore, there is beneficial a feedback loop between education and nutrition. deliver lessons to enhance knowledge, attitudes enhance to lessons deliver and healthy food choices. the At same time, most countries in the school provide meals, world feeding at least 368 million children on a daily basis. If done well, school feeding programmes many can have beneficial effects, incentivisingschool including attendance amongst excluded groups example, – for sub-Saharanacross 32 African countries, girls’ school enrollmentincreased by of 28% an average shortly after school meals introduced. were 3. 2.

are among are the at both the The evidence sustains 40 Thus, programmes to ensure that children, 41 utrition directly; Transmitting informationTransmitting about health and n

1. The evidence as is mixed to what other school-based policies can be universally promoted as an evidence- based intervention tackling for undernutrition. there is considerable supportHowever, at for least overlapping five pathways. Schools shouldconsider: The potentialThe beneficialschoolingconsequence of on nutrition is immense. On the other side of the coin, better nutrition typically results in better school performance and learning outcomes, which in turn equates to increased individual earnings and national income – both pathways to improve nutrition in the long term. How is education having an impact on nutrition outcomes? female autonomy and of female levels strongest determinants of child health and nutrition outcomes. The evidence shows that the degree to which a mother is educated could mitigate the effects of other types of exclusion. The risk of stunting is significantly amonglower children with mothers with at least some primary schooling, and among lower motherseven with some secondary schooling. Paternal education primary and secondary also levels reduced the risk of stunting, although the effect is smaller than for schooling. maternal EDUCATION FOR BETTER FOR NUTRITION EDUCATION Our research has found that maternal education are notare to only key enabling progress in nutrition and the health status of populations, but critical are in terms of advancing the wider SDG agenda. Accountability mechanisms should include collection and data, data standardisation disaggregated of transparency, legal and regulatory frameworks and participation mechanisms. social especially girls, go to school, stay in school and succeed in school – including fee waivers, and cash transfers – can be expected to reduce the risk of undernutrition generations for to come. these premises. For example, UNESCO predicts that women all providing with primary education in low and middle income countries will reduce stunting by 4%, or stunting children. of 1.7 million Giving them a secondary education reduce would stunting by 26%. 54 UNEQUAL PORTIONS • • include: integration for WASHKey nutrition and areas stunting among months”; children aged 0–23 of risk reduced a16%–39% with associated is facility atoilet to access “household defecation, open with compared showed that, India in Research absorb nutrients. to ability their and children’sdamage intestines permanently can This ill. frequently children making environment, general the and water food, contaminates matter faecal because defecation, open of rates high with places in common more nutritional status of children. status nutritional improved the on WASH of interventions impact the of evidence growing international is There enteropathy. tropical or worms intestinal diarrhoea, as such diseases, communicable and intake dietary of are lack malnutrition of causes immediate two the that given for malnutrition, implications significant has practices (WASH) hygiene good and water, safe to access of Lack sanitation adequate SANITATION RESPONSE NUTRITION AND WATER, INTEGRATED AND HYGIENE studies to assess the impact of interventions. of impact the assess to studies long-term of alack noted also It quality. water of improvement and soap, provisionof via hygiene improved from conferred a(small)found benefit age of 18 under years children of growth physical the on WASH of interventions impact review the on worst conditions. the with children were 1.0than taller cm sanitation and storage, water sources, for water conditions best the with age of years two at children Peruvian

workers are within reach of every of child. reach areworkers within education and extension agricultural health, as such staff key sector that ensure will This marginalised. and vulnerable are most who those of needs the address that programmes integrated implement effectively to sectors, nutrition and St approach. integrated an support and endorse should implementers and governments, humanitarian and development Donors, contexts. in aligning and investments stakeholders and accessible equitable programming,integrated This provides a coordination framework to guide WASH nutrition. and integrating of importance the recognise that plans action nutrition and An rengthened capacity rengthened enabling environment enabling 48 Studies show that stunting is is stunting show that Studies 49 54

50, 51 50, of staff in WASH in staff of , with strong policies policies strong , with The 2013 The Cochrane 52 53

and and • • • • • •

by group. by disaggregated these of tracking and indicators nutrition interventions, development of shared and WASH of infrastructure functionality on data time real mapping, of use the feedback, accountability Co Jo integrated approach. integrated inclusive for an works’ ‘what of evidence the build to programmes, WASH nutrition and integrated hygiene management. menstrual including constraints, access in result that inequalities group-based and individual of impacts the to attending includes This approaches. rights human in embedded fully yet not therefore (2010) is and ratified recently only was water clean to right the that recognising WASH nutrition, and integrated soap at key times. key at times. soap with washing hand for nutrition);and important very is but neglected, (this often is faeces child for children); of areas play safe (ie, disposal safe hygiene environmental hygiene; food include: and everyone to accessible appropriate, culturally be change across communities. Messaging should behaviour encourage to leaders identifying behaviour, reinforce each to and behaviours multiple targeting platforms, delivery shared using resources, pooling skills, and experience sector’s each utilising by interventions change approach. days 1,000 the through children and women at targeted be should This children. affect mainly which schistosomiasis, and trachoma guinea-worm disease, helminthiasis, soil-transmitted as such diseases tropical neglected or diarrhoea, especially diseases, prevalence high water-related of with areas low and coverage improved of sanitation; prevalence high undernutrition; of with areas of investments Prioritisation Ado Ma affected communities first. first. communities affected most the prioritising practice, preparation food change communication, water and treatment messagingbreastfeeding into hygiene behaviour of integration as such messaging sectoral multi- deliver to workers for health resources and capacity sufficient ensure example, For should utilisedand be strengthened. interventions, platforms community and education health, Shared int monitoring, evaluation, reporting and evaluation,int monitoring, reporting regarding research operational ntinued ximisation of the benefits of behaviour behaviour of benefits the of ximisation ption of a rights-based approach of a rights-based ption , to deliver both WASH and nutrition WASH nutrition and both deliver , to , including through community community through , including 55

b y focusing on on y focusing to to 4 HOW TO ADDRESS MALNUTRITION INCLUSIVELY 55 58

accountable nder andpoverty – gender discrimination cess to land – existing land policies not are od quality – substantial amounts of food ghts holders – individuals – must have opportunities to claim their human rights in regard to adequate food the from relevant duty holders, whether state or non-state. For nutrition, the right to food, right to health, right to development and the right to survival should be constitution, referenced in a country’s and be justiciable and contained in a bill of rights or fundamental rights section. Brazil, and Kenya South Africa examples provide all of this. Only in this context can citizens hold governments to account through their courts. Be As stated, human rights laws are that nearly all countries agreed therefore,have to; governments canbe held accountable thefor harmful things they do, and the for good things they must do, don’t. but Ri instruments that individuals allow and groups to go to court to ensure that governments meet theirrequirements in terms of the rights to food, health, survival and development. This has been undertaken successfully in many cases. has a significant impact on household, community and national nutrition, and food security, perpetuating the cycle of poverty. Ge Ac tofavourable government plans to eradicate hunger and malnutrition. Small areas of land usedare subsistence for farming; large areas beingare acquired by multinationals with little advantage or benefit to Sierra Leoneans. Fo are beingare imported and of sub-standard are quality. Sierra Leone lacks the institutional capacity to test quality for and to regulate the foods. poor-quality of influx

• In February the 2016, government of Sierra Leone published the draft revised constitution. It includes the Right to Food under two sections: Human Rights and Freedoms of the Individual; and the Protection Socio-economic of Rights. • • •

they duty are 56 But human rights legal are 57 pact of malnutrition on maternal and child Im health – a vicious of malnutrition circle for women and children impacts on national outcomes. development gal obligationsgal and obligation an to act AT NATIONAL AND LEVELS: GLOBAL NATIONAL BASIC STRUCTURAL AT ven thatven most countries signed have and

The SUN CSP presented arguments the for Right to Food in Sierra Leone, including: • The SUN CSP the called for recognition of the right to food as a human right: “By including it in the constitution it will be legitimised and law-makers, as well as citizens, will have to abide by it.” DEVELOPING FOOD THE IN RIGHT SIERRA TO LEONE the ScalingIn 2015, Up Nutrition Civil Society Platform (SUN CSP) in Sierra Leone attempted to include the Right to Food into the National Constitution. The Right to Food agenda was recognised by the SUN CSP as an important tool the for development of equitable policies to address hunger and malnutrition all for vulnerable groups, with a particular emphasis on women and children. bound to respect, protect and fulfil these rights. Governments must not interfere with the realisation of these rights. They must ensure that third parties do not interfere, and they national through mustestablish environments, legislation, that these allow rights to be realised. Governments must measures take to provide thosefor who cannot themselves. for provide Many governments failing are to implement existing laws. Gi Le ratified international human rights treaties, such as the Convention on the Rights of the Child Economic, on Covenant the International and Social and Rights, Cultural In many cases, countries fail to translate law. national into obligations international ND INSTITUTIONAL DRIVERS OF MALNUTRITION OF DRIVERS INSTITUTIONAL ND

• NATIONAL LAWS AND LAWS NATIONAL POLICIES National laws and policies, polices and how are implemented and monitored, important are factors in states fulfilling their obligations to their citizens. 4.3 A 56 UNEQUAL PORTIONS for 25 years’.for 25 growth capita 5.9% per real requires 50% stunting with acountry in half to malnutrition Cutting countries. developing most of performance growth past the than higher much is This 25 years. over capita per growth real 3.7% would require alone growth economic through a level 30% of from stunting ‘halving that estimated been has It malnutrition. by affected are disproportionately who society, of segments excluded most the among shared be must of growth benefits the and step; intermediate essential an is growing economy froma key sectors in social investment sectors; other in growth than outcomes improved nutrition to relationship have direct amore to shown been has sector agricultural the in Growth outcomes. improved on nutrition deliver to growth economic of ability the of are key determinants distributed are benefits how and its growth of nature The tackle malnutrition. to sufficient not is growth own, its on and, nutrition and growth economic between exists relationship However, malnutrition. reducing in acomplex progress for any essential be to seen is it countries low-income in and outcomes, improved nutrition to contribute to shown been has growth Economic nutrition and inequality poverty, economic growth, between The relationship FOR NUTRITION? DELIVER GROWTH ECONOMIC HOW CAN be accessible for all people everywhere. for all people accessible be to need mechanisms These key. is nutrition and food adequate right to the noncompliance with about complaints or claims receive to and of accountability strengthening mechanisms and nutritional well-being. The development security food for their are essential that rights to appropriate institutions about violations of Pe government commitments. for accountability of forms generate to serve and countries many in exist institutions similar national human commissions rights and accountability For mechanisms. example, rights human of forms other numerous also l however, accountability, rights Human is not imited to decisions made by courts. There are There courts. by made decisions to imited ople must have the opportunity to complain complain to opportunity have the must ople 60

59 in China’,in would be for India cost same the and GDP annual of 0.4% to GDP, 0.2 represents which increased in annually billion US$5 and US$2.5 between be China would worth in alone deficiencies ‘preventingin physical productivity, micronutrient losses direct avoiding Besides economy. the benefit also nutrition in improvements outcomes, nutrition improved deliver can growth economic While outcomes. improved and nutrition growth economic between relationship atwo-way fact, in is, There budget transparency and participation. of measurement effective and analysis budget acomprehensive entails This comprehensible. and accessible budgets make outputs’, to and order in activities inputs, actual of distribution ‘the detailing and identifying by transparency budget promote effectively can others and society civil by led initiatives monitoring Budget region. Ceará the in 2005 in people young and children to US$760,000 of allocation additional an in resulted has budgeting in participation youth Brazil, initiatives. In led of community- funding in gaps of identification the to led This districts. from several different annually youths 1,000 around included that budget youth aparticipatory undertook amunicipality for example, Argentina, in participation, youth of case specific the In have proved successful. very budgeting participatory of Several experiences process. thebudgeting influence to achance and available, be not otherwise may that information budget to access first-hand gives process the of part authorities’. Being government of meetings scheduled of series annual an through budget apublic of part over least at decision-making to contribute regularly and voluntarily may associations, civic through or individuals as either citizens, ‘a is which by process budgeting Participatory processes. budgeting participatory or informed guarantee to is transparency budget way increasing of often-quoted An BUDGETING PARTICIPATORY 4 HOW TO ADDRESS MALNUTRITION INCLUSIVELY 57

67 66 rger-scale developments. rger-scale a a complex set of factors contributed to the sudden increase in food prices in 2008 – including longer- term factors population like growth and economic growth in developing countries leading to higher demand – it has been shown that rapid a diversion of agricultural production supplying towards demands biofuelfor played some in drivingrole up food prices. Agricultural growth must be inclusive and must target investments, research and developmentin vulnerable areas, access to land and secure land rights. This will create market opportunities marginalised for farmers – including value-added enterprise development – Policies that harness the benefits of growth nutrition improved for Income, spatial and gender inequalities play all a crucial part in mediating the effects of economic growth in nutrition. Economic growth can only reduce malnutrition if it increases incomes in an equitable if it way; boosts sectors and activities that nutrition; for relevant are and if both policies and the delivery of services inclusive are and pro-poor. Unequal provision of services has the potential to curb the positive effects of investments generated by growth, by excluding vulnerable groups. In Uganda, instance, for health funds allocated are according to population – although levels less populated remote regions often are high-need areas limiteddue to access to people’s services. Inclusive growth approaches to nutrition will, therefore, require targeted national approaches excludedfor groups as as well equitable of(re)distribution resources into nutrition-relevant areas, such as health, education and sanitation. And inclusive growth approaches will require social protection programmes in order to maintain food security. UN Food and According to a 2012 Agriculture Organization report on the state of food insecurity, order economic for “in growth to enhance the nutrition of the neediest Growth … (i) needs and reach the to the poor; involve poor (ii) need to use the additional income improving for the quantity and quality of their diets and improved for health services; governments and (iii) need to use additional public resources public for goods and services to benefit the poor and hungry”. andproductive employment opportunities from l

65 Agricultural growth 63

62 When agricultural production is targeted towards the export market, agricultural growth a can have negative effect on nutrition outcomes if it drives up the price of food. For example, the rapid increase in biofuel production in 2006/07 has been to linked the 2008 food price spike, which has been a huge setback in efforts to reduce malnutrition. Although But on its own, agricultural growth does not guarantee nutrition improved outcomes through either of these means. For improvements in nutrition outcomes, agricultural growth must be driven by nutritious and diverse food production. Growth driven by low-nutrient foods may increase incomes but it does the not improve supply of nutritious foods to the it must be noted market. that diversifying However, crops will often lead to an increase in labour burden, which often falls disproportionally on women. On the other hand, agricultural growth driven by animal foods, fat and sugar – the three most significant increases in food energy consumption globally – has been linked to increasing obesity worldwide. Agricultural growth and nutrition Agricultural growth has been shown to reduce malnutrition more than growth in other sectors, among those countries where agriculture plays a significantrole in the (whicheconomy includes countries). developing most Not only poverty are and inequalities factors by themselves, they also influence the provision of services that mediate the relationship between economic growth and nutrition. Policies related to agricultural development, girls’ and women’s education, and health systems vital – all mediating factors between economic growth and improvements in nutrition – can only harness the benefits from growth if these policies inclusive are and pro-poor. US$2.5 billion annually, 0.4% of its annual GDP. can contribute nutrition to improved outcomes in two main reduced ways: food prices and increased food security from more food being supplied to the market; and rising incomes of rural households – which up make the majority poorest of the world’s people. malnourished and ‘In Sierra Leone, lack of adequate policies and programmes to address anaemia among women will result in agricultural productivity losses among the female labourexceeding force US$94.5 million over the next five years.’ 58 UNEQUAL PORTIONS Mozambique. like nations lower-income of needs relevant the to more be may solutions policy nation developing Brazil’s commonalities, cultural and language the to policy solutions to hunger and nutrition. and hunger to solutions policy ownhomegrown its generated has that nation middle-income arising as expertise its of because Brazil with partnership froma benefit can USAID improve to nutrition. and family security, food and production agricultural increase to (ABC) Agency Cooperation Brazilian the with programme Future the Feed the worked through has –USAID Brazil like nation, –aPortuguese-speaking Mozambique In Mozambique. and Haiti, Honduras, in –specifically Africa and America Latin in programmes security food and nutrition emphasises agreement trilateral this rates, malnutrition and hunger reducing in Brazil’s success ownrecent trilateral aid was established in 2010. in established aid was trilateral on agreement Brazil–US general 2011 the after in Brazil with signed was partnership trilateral earliest the assistance, foreign US of terms In affinities. cultural and backgrounds similar with nations relationship”. towards equalitarian amore cooperation development reshape may know-how, of exchange which mutual and complementarity relationship, benefit cost- abetter “Promotes aid, trilateral Ideally, and projects”. programs cooperation development organization(s)multilateral implement to country(ies)/or adeveloped by supported countries developing more or two between partnerships driven “Southern- it as, defines UN the but cooperation, development trilateral of definition single no is There world’s nations. the of some in vulnerable most innovative development model to address malnutrition Trilateral development cooperation is one emerging by 2030. malnutrition end to models assistance traditionalthan bilateral and multilateral foreign likely take more will it decades, recent in survival child and nutrition on progress the with Even partnerships. develop innovative to is malnutrition Key ending to COOPERATION DEVELOPMENT TRILATERAL USA–BRAZILIAN MODELS: PARTNERSHIP NUTRITION EMERGING nutrition solutions and successes to other developing developing other to successes and solutions nutrition emerging donors disseminating their own homegrown add value can through cooperation development which also makes its agricultural development, development, agricultural its makes also which Mozambique, in those to similar soil conditions has and years power recent in agricultural global 69 72 In the nutrition context, trilateral trilateral context, nutrition the In Furthermore, Brazil has become a become has Brazil Furthermore, 68 70

Based on on Based 71 In addition addition In expertise in Brazil”. in expertise best the with US the in expertise best the combine we if job “We know effective weamore do can said, Florida of University fromthe expert one As equal. and effective more be to for it order in development international reshape to potential the have innovative partnerships these but agreements, onfor trilateral assessments impact development aneed is there model, emerging an is it Because developing nations like Mozambique. nations developing to building capacity security food and own agricultural 1970s, the providing its now is during and it funding strengthening institutional USAID –received Brazil in 1972 in crisis afood created was combat to which – Embrapa aid, trilateral of dynamics the of example and providing capacity and post-harvest training. production, local farmers’ strengthening research, socioeconomic through farmers small of capacity the increase to and production horticulture increase to are cooperating nations fromall three Institutions Mozambique. of Agriculture of Ministry the of behalf on (IIAM) Mozambique of Institute Research Agricultural the and ABC; of behalf on (Embrapa) Corporation Research Agricultural Brazilian the USAID; of behalf on University State Michigan and Florida of University are: The Mozambique in programme this through working institutions education higher the Among nutrition. and security food on training in countries fromall three education higher of institutions among cooperation the is Mozambique aid in trilateral of nature the of example An education programmes. nutrition and feeding school have piloted they where Honduras in and nutrition; child and maternal promoting on are working they where Haiti, on focused has assistance nutrition and security food trilateral USAID-ABC Mozambique, to addition In context. Mozambique the for fit a good as US partners by seen was and known internationally is agriculture tropical on Empraba’s expertise own researchers and technicians. own researchers its of time for the paid IIAM Mozambique; to travel to experts agricultural for Brazilian paid ABC while needed, equipment for the paid USAID institutions. all three among distributed was funding and support, technical were leveraged extend to partner education each of strengths varied and positioning The Mozambique context. workrelevant the to nutrition and security, food 74

80 73 79

77 In a further afurther In 75

4 HOW TO ADDRESS MALNUTRITION INCLUSIVELY 59 82 nsider the integration of behaviour change nsider utilisation of the complaint and derstand general and prevent negative omote, strengthen and adhere to legal and tegrate a well-designed complaint and response tegrate a robust monitoring and evaluation isability- and other group-sensitive, and services, with a specificfocus groups.on excluded side effects, particularly on the causes of obesity. and undernutrition communication and nutrition education in programmes tackling drivers of malnutrition or strengthened linkages with health and nutrition example, ensuring the programme lifespan is long enough change for to occur; and that it integrates to advocacy support change objectives to no leave one behind. Un Co mechanism that is accessible to all, particularly excluded groups. and monitoring and/or mechanism response systemevaluation to enable action to be taken when violations of the rights to food and nutrition occur. system a range covering of standard impact indicators that reflect the drivers of malnutrition, disaggregated by to group, assess success against malnutrition and to inform multi-sector plans. development Ensure programmes gender-, are ethnicity-, d consider the adoption ofactivities to promote economic empowerment,women’s improved decision-making within households, and tenure appropriate. where rights, Pr regulatory frameworks the for right to nutrition, including the rights to food, health, survival and development and the rights of the child In Co In

• experience, the case studies included in this report and global evidence been – have put together to help actors consider the design implications for such an approach. • • Monitoring • • • • OR AN INCLUSIVE APPROACH OR AN INCLUSIVE APPROACH F 81 nsider a universal approach to targeting in dertake a thorough contextual analysis, DESIGN PRINCIPLES ach the nutritionally vulnerable, with a sure thesure type of programme fits thelocal sure ansure integrated multi-sectoral approach arify the pathways through which the omote the participation of and involvement stainable change at the system by, level for clude the views and opinions of thoseaffected

Ensure the programme focuses on achieving su areas of malnutrition of high prevalence and/ or where people unable are to access what they need a healthy for life. focus on the 1,000 days (pregnant/lactating women and children under two years old) and girls. adolescent Co Re Pr those most affected by malnutrition, particularly excluded groups, as as well community leaders, caregivers and young people, in policy and monitoring. and design programme En context and takes into consideration what types of complementary services available, are making linkages to existing services. En that addresses malnutrition and its multiple drivers at different of society levels and facilitates cross-programmatic linkages. by malnutrition, particularly excluded groups, and also community leaders. In Cl programme is intended to an impact have on malnutrition the for most excluded groups, while considering progress all. for Un exploring the drivers of malnutrition-based on the looking conceptual page 25), framework (see at experiences and outcomes different for groups and the drivers any for exclusion.

• • • • Design and implementation • • • • Analysis • All nutrition interventions – policies and nutrition- and nutrition-sensitive programmes, specific – shouldadopt an inclusive approach to noleave one behind. The following principles – programmaticdrawing upon Save the Children’s INTERNATIONAL DESIGN PRINCIPLES FOR INCLUSIVE NUTRITION POLICIES AND PROGRAMMING 4.4 5 Conclusions and recommendations for world leaders

Our projections show that without a To speed up progress towards the globally agreed dramatically different approach, only nutrition targets, for all groups of society, 39 out of 114 countries with available data Save the Children is calling for action in the will meet the 2025 WHA target to reduce following areas: stunting by 40%. In addition to the eight 1. Overcome exclusion through appropriate laws, countries from our sample that already have policies and investment 2. Break the intergenerational cycle of malnutrition: stunting rates below 3%, only three more focus on mothers and adolescent girls countries will manage to achieve the 2030 3. Address the large-scale drivers of malnutrition SDG target to eliminate stunting. Fifty three 4. Take a ‘leave no one behind’ approach – an out of 137 countries will tackle stunting only appropriate policy and programme response in the next century. based on the national context. These projections do not have to be the reality. Below, we set out Save the Children’s Malnutrition and exclusion are both political recommendations for how to do this: problems that can be overcome. In fact, as we have shown, some governments have done just that. Peru, Honduras, the Dominican Republic and Liberia, 1. OVERCOME EXCLUSION for example, have all seen impressive progress in THROUGH APPROPRIATE LAWS, reducing national stunting rates in recent years. But in some of these countries, progress has not been POLICIES AND INVESTMENT equal. Peru and Honduras, in particular, have large Discrimination and exclusion may take many forms, inequalities in stunting rates between the best and ranging from investment, laws and policies that worst sub-national regions and between rural and explicitly or implicitly discriminate against particular urban areas. In addition, Peru and Honduras are groups, to social and cultural norms that result in both in the top ten countries for the greatest discrimination and the social exclusion of poor and inequalities in stunting rates between ethnic groups, marginalised children. and Honduras is in the top ten for worst countries in inequalities in wasting rates between ethnic groups. Taking a human-rights based approach and using These results show that while some countries have affirmative action or positive discrimination for achieved great progress overall, if you look at the the benefit of marginalised groups is required. picture below the national level, progress has not Addressing discrimination means not only removing been made for all and some groups of children are explicitly discriminatory policies, but also addressing being excluded and left behind. and correcting the drivers of discrimination, such as inequitable resource allocation. Commitments to address malnutrition for all should begin with the moral and legal imperative for the right to food and nutrition – drawing upon the right to food, health, development and survival. These commitments should centre on human dignity, needs, and interest, as well as the wider arguments regarding improved efficiency and outcomes.

60 5 CONCLUSIONS AND RECOMMENDATIONS FOR WORLD LEADERS 61

5 Providing all women Providing all 4 , through schools and working should boys provide and girls should raise, or sustain, the age should ensure adequate nutrition should in invest platforms (including but rnments rnments rnments vernments, donors, academics and l actors during the first1,000 days of life, including birthweight through adequate low preventing maternal nutrition, supporting, promoting and breastfeedingprotecting recommended and young child and feedingcare practices, treating and micronutrient deficiencies preventing and acute malnutrition, and promoting good sanitation practices. Go NGOs not limited to to reach schools) adolescent girls theirto improve nutrition. Gove Gove Gove Al with quality education beyond primary level, and put in appropriate place measures to encourage them their to in continue education including – fee waivers and cash transfers. of marriage girls for and enforce it in law. to 18 with partners such as youth organisations, should girls provide and boys with information toon how stay healthy during their reproductive years, them and provide with access to family and sexual fulfilling respecting and planning, reproductive health and rights. A particular focus on adolescence should be applied.

initiatives their to improve nutrition only when they pregnant are is often too late to break the because malnutrition, of cycle intergenerational this often missescrucial a part of the first1,000 In addition,day window. adolescent girls more are tolikely die during childbirth than older women, or to be left nutritionally depleted by pregnancy. Their babies also are to more likely die or be born with nutritional deficits. The infants who survive a have greater risk of upgrowing to be stunted mothers or fathers. Maternal education and of female levels autonomy the strongest determinants among child of are health and nutrition outcomes. with primary education and middle-income in low- countries could reduce stunting by 4%, or the stunting million children. of 1.7 Providing women with a secondary education reduce stunting would million children. by 26%, or the stunting of 11.9 Recommendations: • • • • • , 1 Maternal Maternal 2 16 million With 16 3 should incorporate incorporate should governments, civil societyand (governments, civil society society civil (governments, should ensure equal access boys for (governments, civil society and ( l actors l actors l actors l governments l BREAK THE INTERGENERATIONAL Al and donors in particular) should consider design principlesSavethe inclusive for Children’s nutrition interventions page 59). (see Al and girls, children on the children move, from different income groups and ethnic groups and children with disability, in skills-building opportunities and vocational training) (eg, to decent work/livelihoods.access Al donors in particular) should nutrition develop interventions that address societal norms and behaviours that drive inequalities based on ethnicity,gender, income group, disability or where a child lives. All actors donors in particular) should implement – rights provisions child and human international with principles equality of non-discrimination and at their heart – to a powerful provide framework within which to formulate and implement nutrition policies and programmes to reach everyone and addressdiscrimination levels. at all Al international obligations to relating the right to food, health, development and survival into This includesnational the law. Convention on the Rights of the Child and the Convention on Economic, Social and Rights. Cultural

YCLE OF MALNUTRITION – YCLE

Malnutrition is passed from one generation to the next. Undernutrition in women contributes to restricted growth of the baby before it is born, newborn deaths and, survivors, for to stunting before second the birthday. child’s C FOCUS ON MOTHERS AND ADOLESCENT GIRLS 2. • • • • Recommendations: • adolescent girls giving birth each year urgent attention is needed to keep girls in school, delay the age of marriage and increase access to women and girlsfamily planning. with Targeting overweight and obesity result in increased maternal mortality. infant and morbidity 62 UNEQUAL PORTIONS • • Recommendations: US$1 invested, the median return is US$16. is return median the invested, US$1 –for every investment asmart is nutrition in Yet assistance. investment an development overseas 1% of just receives it yet deaths, 45%child of cause underlying the is Undernutrition underfunded. and neglected been has nutrition years, for many this, to addition In years. hundred of couple last over have occurred the that developments social the from benefit to struggling south global the in many with north, global the in Wealth remained has people. marginalised most or poorest favour the not does exists, it as system, financial the Globally, FINANCE here. detail in explored are not but impact an having are also scale drivers large- below. are explored events Other weather and climate changecommitments, and extreme for nutrition accountability weak towards nutrition, directed levelThe funding of identified. have been malnutrition of drivers large-scale of A number D 3.

RIVERS OF MALNUTRITION moment to do this. this. do to moment right event the is Growth’ for ‘Nutrition second The factors. other and economy their size of malnutrition, of burden own national their on based share” commitment a“fair making by nutrition of drivers the and people their of nutrition investthe in should governments particular, In southern commitments. ICN2 and targets nutrition WHA SDG2, example, –for reach to have committed they targets and goals nutrition global the meet to other) required resources the place this. do to moment right event the is Growth’ for ‘Nutrition second The services. health basic and protection social child-sensitive through including reach, to hardest the reach they – ensuring approach a‘leave behind’ according to one no Fi Gove ADDRESS THE LARGE-SCALE LARGE-SCALE THE ADDRESS nances for nutrition rnments around the world should put in in put world should the around should be spent spent be should (financial and 6

• • Recommendations: hold account. to governments to them for difficult very it making budgets, about decisions or involvedare not design programme in Beneficiaries budgets. nutrition their from benefiting are groups which about or drivers, its and nutrition on spend they how much about transparent are not governments many malnutrition, with dealing In of children. groups economic and social different between outcomes nutrition in differences vast hidden has averages national with targets against Reporting budgets. and plans targets, national into goals those translating without of political negotiations, part as goals global to up have signed governments Many years. for many weak been has food to right the and nutrition around Accountability ACCOUNTABILITY •

capacity development to ensure its realisation. realisation. its ensure to development capacity with agenda, ‘leave behind’ one no the of part as accountability SDG of acore part be should This people. of safety and privacy the protecting while all, to accessible make results to and basis, systematic and aregular on collected outcomes, of monitoring effective enable to large enough be should groups for disaggregated sizes Sample location. geographic and disability status, migration ethnicity, race, age, sex, income, aminimum, at by, disaggregated data nutrition alike. poor and rich all countries, by delivered and are developed that reforms tax level through international an at tackled be avoidance must Tax compliance. tax increase to order in robust, are fair, they ensure to and progressive systems Go Al targets. nutrition national announce to place right the is summit Growth’ for ‘Nutrition second The commitments). ICN2 SDGs, targets, (such WHA as frameworks trends and context and harmonising relevant national account into taking developed be in targets place nutrition Fo governments without national national without governments r those l actors l vernments should reform their national tax tax national their reform should vernments should collect, analyse and share share and analyse collect, should , these should should , these 5 CONCLUSIONS AND RECOMMENDATIONS FOR WORLD LEADERS 63

, promote to eliminate that share policies that keep girls and boys versal health coverage versal ucation licies that build resilience novative partnerships novative tegrated water, sanitation and tegrated water, vernments should in invest and progress Universal child-sensitiveUniversal protection social and objectives nutrition specific with activities nutrition-focused with integration, and linkages to nutrition-relevant services. Uni malnutrition. tackle and inequalities Ed in school beyond primary education. In hygiene, and nutrition response. Po livelihoods and address malnutrition, especially in the most marginalised areas. In experience and knowledge to in how address malnutrition.

TAKE A ‘LEAVE NO ONE A ‘LEAVE BEHIND’ TAKE – – – – – Go policies that address malnutrition in an inclusive national on Depending way. sustainable and contexts, these policies may include: –

PPROACH – AN APPROPRIATE – AN APPROPRIATE PPROACH

As our analysis has shown,progress in addressing malnutrition has not been fast or equal enough. Certain groups do access not have to the services they need to ensure good nutritionoutcomes. Whether because they it’s from an are ethnic group, in remotelive areas, disabled, are children or are on thatthe not move been have reached by services, certain children missing are out. Economic growth, while vital in many countries, is on its own not enough to address malnutrition. The right policies also need to bein – and place they need to be pro-poor and include specific nutrition objectives. Part 4 of this report provides guidance thison how can be done. Recommendations: • 4. A POLICY AND PROGRAMMERESPONSE CONTEXT BASEDON THE NATIONAL , with the support of of countries vulnerable to ould transparently publish publish transparently ould should promote and strengthen the sh rnments tional governments tional l actors Gove Na the international community, should deal with priority long-term a as malnutrition chronic development and humanitarian within integrated action that strengthens the resilience of groups. population vulnerable Al participation of and beneficiaries, involvement particularly children and those most affected by malnutrition and food insecurity, in the development of nutrition budgeting, policy, programming and delivery and impact improve to children, among monitoring accountability. All actors their budgets and spend on nutrition-specific and nutrition-sensitive interventions, in an accessible way, onan annual basis as perthe SUN donor network methodology, with plans to disaggregated by it so group, is possible to see if resources being are allocated on an equitable basis. environmental shocks should in invest and manage emergency well food reserves, in order to reduce food price volatility and ensure their countries can quickly deal with food shortages.

• Recommendations: • CLIMATE CHANGECLIMATE AND EXTREME EVENTS The frequency and impact of extreme weather events set are to rise in the future, with increasing foodimpact and nutrition on people’s security. The current El Niño has event had – and will continue to – a devastating have impact on the lives of millions of people, with many citizens experiencing a violation of their right to food and nutrition. The response from the international community to events El Niño like has been too and slow inadequate. Some governments not put have in theplace right policies to deal with malnutrition in an inclusive and sustainable way, been and have to declareslow an emergency situation and seek the support they need to ensure the nutrition of their citizens. • • 64 UNEQUAL PORTIONS 2. facing extreme hunger. Thanks to skilled care from Save the Children staff, she made a full recovery. afull made she staff, Children the Save from care skilled to Thanks hunger. extreme facing people 13 million left prices food rising and drought 2011 in when malnutrition severe for treated was Kenya from Bishara 3. 1. STARTING AT GROWTH FOR EVENT NUTRITION SECOND THE – ACTION OF NUTRITION ON ADECADE FOR STEPS SAVE CHILDREN’S THE

malnutrition and the barriers they face. face. they barriers the and malnutrition to vulnerable and marginalised are most country a in people of groups which and malnutrition address will policies which malnutrition, in trends current malnutrition, of drivers and and trends. and contexts national on based society, of groups for all targets specific include that goals, global Se a assessment contextual astrong Undertake La society make progress in addressing malnutrition. addressing in make progress society of all groups ensuring strategy’ – behind one no society. for all of groups targets, to reach those to understand the patterns patterns the understand to analysis nd t national nutrition targets nutrition t national y down appropriate policies and plans plans and policies appropriate y down This could form the basis of a‘leave of basis the form could This , aligned to to , aligned 5. 4.

maker and a marker of sustainable development. sustainable of amarker and maker a as nutrition see should Donors people. its of nutrition investthe in should government Every En society). of all groups are reaching interventions if evaluation (including and monitoring and implementation policies, and strategies of process the throughout business) and society civil academics, donors, (including stakeholders Wo place. in are finances appropriate sure rk with relevant sectors and and relevant sectors with rk

, from contextual analysis, design design analysis, , fromcontextual PHOTO: ALLAN GICHIGI/ SAVE THE CHILDREN THE SAVE GICHIGI/ ALLAN PHOTO: Appendices

Appendix 1: Methodological note

GROUPS AND INEQUALITY NUTRITION DATA DATABASE (GRID) Stunting is defined as having a height-for-age The Groups and Inequality Database (GRID) was two standard deviations below the median of developed by Save the Children and is designed to the reference population produced by the World monitor group-based inequality across developing Health Organization. Wasting is defined as having countries in key dimensions of children’s rights and a weight-for-height two standard deviations below well-being, including: child mortality; malnutrition; the median of the reference population produced education; immunisation; child protection; and by the World Health Organization. water, sanitation and hygiene. As well as national The malnutrition rates for each social group estimates, data is disaggregated by the following were computed directly from household survey groups: boys/girls; urban/rural areas; subnational microdata for which data on child anthropometry regions; ethnolinguistic groups; and economic is available (211 in total). The WHO reference groups (quintiles based on the asset index). population provided by DHS was used to estimate Estimates are based on direct data processing of the undernourished population.1 The population of 280 Demographic and Health Surveys (DHSs) and reference corresponds to living children between Multiple Indicator Cluster Surveys (MICSs); on birth and five years old. The estimations at national official disaggregated figures for a few countries and group levels were cross-checked with those without survey data and on aggregated public provided by the DHS stat compiler when data was sources (the UN Inter-agency Group for Child available and no significant differences were noticed. Mortality Estimation; the Joint Child Malnutrition In order to make the DHS/MICS disaggregated Estimates from UNICEF, WHO and the World Bank; figures compatible with the Joint Child Malnutrition and aggregated data from various UN agencies). Estimates, we adjusted the figures in order that the national average in GRID is equal to the GRID has some advantages over data that can be national level for the given year from the Joint Child obtained from online stat compilers. GRID includes Malnutrition Estimates. Groups with a small sample data on sample sizes and standard errors in order size (fewer than 100 children) were not included in to assess whether comparisons are statistically the analysis. The standard errors were computed significant and to assess the reliability of estimates. for all groups. This is particularly important for analysis at the group level, as the sample size of some groups can be particularly small. Also, GRID is computed DATA COVERAGE systematically for all regions and ethnic groups available. It makes it possible to have figures for the GRID contains nutrition data at national level same ethnicity or region across all the outcomes for 150 countries covering 614 million children and across different periods. under five – or 91% of the world population of children under five. Disaggregated data across social and economic groups is provided for 69 countries covering, 381 million under-fives – or

65 66 UNEQUAL PORTIONS We used the following formula: We formula: following the used ethnicity. for regional outcome best the for ethnicity, and inequality, for regional outcome best the with region the analysis, gender for the boys we groups used reference As groups. countries/ across comparisons for making useful more is it group. We as ratio for the another opted from achild than die to is group fromone a child likely more show how much effectively measures the as chances, life in equalisation about directly more tells ratio the in Reduction mortality. child experiencing children of number absolute total the in conversion implies gap the in group. Reduction reference the with compared condition given the experience to is group disadvantaged likely the more how much measures latter the while groups, reference and disadvantaged between indicator given the in difference absolute measures former ratio. The relative the and gap absolute the analysis: for the metrics main We two using considered METRICS INEQUALITY GROUP-BASED points). data disaggregated (a 211 of 1,140 and total points data national level for 52 disaggregated points) at and countries level for 134 national at (covering countries 751 data are available projections, including data, series Time respectively. countries lower and middle-income low-income in living five covering 86% 75% and under children of countries, lower and middle-income low-income of is representative well data Disaggregated five. under children of world57% population the of Ratio =O O O outcome in Ratio =Inequality Where d a = estimated outcome in disadvantaged group group disadvantaged in outcome =estimated = estimated outcome in advantaged group group advantaged in outcome =estimated d /O a presented in the report. report. the in presented those to similar results yielded tests these cases, of majority vast the In inequality. of ameasure as gap absolute the using findings our checked have also We were groups compared. disadvantaged most of rates the which to point areference as averages national we used groups, advantaged most the of instead where, tests robustness we out have carried performer. Tobest findings our of validity the test the with up catching be may groups all other time same the at increase, may groups disadvantaged most/least the between ratio the while example, For distribution. entire the of account a full provide not We does ratio the are aware that context. country given a within arelevel possible progress paceof and what shows society in group top-performing the of performance the examining Third, action. motivate therefore should and understand, to citizens and politicians for both easy is groups advantaged least and most the between ratio the Second, chances. life in inequity of extent revealing the is of groups bottom and top the between ratio the that means This unjust. are and fundamentally chances life in differences systematic to ascribed be can groups between differences –any rights human basic are have education an to and nourished properly be to To protected, be analysis. our to survive, in metric main the as ratio use to decision our support that reasons additional are three There APPENDICES 67 uation 2 uation 1 4 , and Eq Eq . , estimated e > 0 implies a path 

ijt e

+ t

, and error term b

–1 +

) ij ·t) a 

+ a =

–( , region j )

, with weights given by the relative

ijt e

ijt + representsan outcome y in time t y t

1 – y (1 (

ln t – y < 0 implies progress – the zero towards case for For country i ESTIMATION: STRATEGY ESTIMATION: projectionsFollowing based are Lange (2014) on an empirical Bayes estimator that weights the mean between a uniform transition speed via weighted least squares (WLS), and the country- speed specific precision of those estimators, as measured by their variances. The uniform transition speed was estimated with WLS regression based on regional trends level data from GRID when disaggregated data was available and on national data level otherwise. The model is given by the equation: FUNCTIONAL FORM: THE SIGMOID FUNCTION Our model a sigmoid function: follows  stunting and wasting rates; and Where y towards onetowards – the case overweight for rates. main reasons justify usingTwo a sigmoid function instead of a linear function to model the transition path of nutritional outcomes time. over First, any projectedvalue from such a function falls within and upperlower bounds, typically and zero one, which applies rates to prevalence of nutrition. Second, the sigmoid incorporates the intuitive idea that absolute progress a target towards becomes increasingly difficult countriesas approach the target. For example, it is much easier a country for to reduce the percentage of stunted under-five (ie, a 0.5children percentage from 60 to 59.5% point reduction) than to reduce it from 0.5 to 0%.

2 The projections a non-linear follow 3 .

The projections methodology the closely follows appliedapproachto project by Lange arrival (2014) years of universal primary and secondary school completion the for Education All For Global Monitoring Report 2015 In collaboration with researchersthe from University of Göttingen, projected we stunting rates note This level. disaggregated and national at summarises the methodology; further for details see and (2016). Silva Perez on ending forms all of malnutrition Appendix 2: Methodology to SDG target project 2.2 Our projections build on the Joint Child Malnutrition Estimates in a number of ways, including by social for projections national disaggregating and economic groups inside each country, by contemplating a series of timeframes, and by methodological innovations seriesintroducing of a as explained below. We project the rates prevalence of under-fiveWe stunting 2025 for and 2030, thereby assessing whether the Sustainable Development Goals (SDGs) childfor nutrition to likely are be met. Whenever that is not the case, project we the year in which the SDGs targets will be met. Projections computed are income world for groups, countries, regions within countries, genders, index quintiles, rural/urban areas, and ethnic groups. sigmoid function to model the transition speed of nutritional time, rates over taking into account that time progress crucially over depends on the starting level. The projections based are on an empirical Bayes estimator that incorporates both the uniform transition speed countries all for and a country-specific transition speed basedweighted on least squares regressions using disaggregated data from GRID. 68 UNEQUAL PORTIONS where where by: given is estimator Bayes empirical The country separately, and and separately, country for each regression aWLS running by estimated the weighted mean between the uniform transition transition uniform the between mean weighted the speed

b EB i . The empirical Bayes estimator is then simply simply then is estimator Bayes empirical . The

= b

i country-specific transition acountry-specific is s 2 i + s 2

s 2

b i

s 2 i b + s uniform transition uniform transition the is 2

s 2

parameter Equation 3 Equation out over time. out wear trajectories and events exceptional as mean, global converge will the to performances countries’ individual run long the in ie, reversion, mean of idea intuitive the incorporates estimator empirical Bayes the Theoretically, variances. their by measured as estimators, those of precision relative the by given weights with speed, country-specific the and speed APPENDICES 69 6

7 ovide enoughovide food that is safeand nutritious ke all necessary all ke steps to ensure that no one immediateke steps to end discrimination in progressive steps,ke to the maximum of its ta ta ta suffers malnutrition from hunger or severe pr to those who not are able to feed themselves, by either buying food surpluses from other parts of the country or seeking international aid access to food or resources food for production, such as land resources, ensuring towards that everyone can feed her or himself and his or her family in dignity.

FULFIL obligationA state’s to fulfil the rights foodto and good nutrition willinclude, where necessary, proactively engaging in activities intended to strengthen access to and utilisation people’s of food, facilitating efforts or household’s the individual’s to theirimprove resources, and opportunities to feed those for who unable are themselves to do so, or, directly. food adequate providing In order states for to a rights-based take approach to nutrition, they must: • • • • explicitly referencing the right to food, include provisions that affect the behaviour of businesses concerning food and nutrition outcomes for children. For example, the need to eliminate child destruction prevent labour, of the environment and use of marketingand advertising that protect and support child rights, particularly in relation to healthy lifestyles. 5

As per the UN Guiding Principles on Human Rights, the private sector has a responsibility to respect and remedy human rights violations, including those related to the right to nutrition. respecting and means responsibly behaving This legislation government and norms international in relation to food and nutrition. The Children’s Rights Business and Principles, not while PRIVATE SECTOR PRIVATE While states obligated are to ensure that all people adequately are nourished, everyone has a responsibility to respect the right to adequate nutrition. States’ obligation to protect the right to adequate nutrition means that governments must all take necessary steps to ensure that third parties, such as food companies, do not interfere with an individual’s right to adequate nutrition. PROTECT RESPECT In support or household’s own of the individual’s efforts, states must respect the freedom of undertaking from activity refrain and individuals that restrict would individuals or prevent from realising their right to access adequate nutrition. States also a binding have obligation, enshrined in international to respect, law, protect and realise right to survival.children’s The UN Convention on the Rights of the Child obliges states to do everything they can to many protect children from dying. Yet countries lack a legal framework that promotes child survival, andthose that one do often have fail to implement it. States three have discrete types of legal obligations under international human rights law – to respect rights, protect rights fulfil and rights.

Appendix 3: International human rights and the role of the role and thestate Endnotes

EXECUTIVE SUMMARY 7 UNICEF, WHO, World Bank Group, 2015. Levels and trends in child malnutrition. Joint child malnutrition estimates. Available online: 1 UNICEF, WHO, World Bank Group, 2015. Levels and trends in child http://www.who.int/nutgrowthdb/jme_brochure2015.pdf?ua=1 malnutrition. Joint child malnutrition estimates. http://www.who.int/ [Last accessed 040316] nutgrowthdb/jme_brochure2015.pdf?ua=1 8 UNICEF, WHO, World Bank Group, 2015. Levels and trends in child 2 From 159 million stunted children in 2014 to 129 million in 2030 malnutrition. Joint child malnutrition estimates. Available online: 3 UNICEF, WHO, World Bank. Levels and trends in child http://www.who.int/nutgrowthdb/jme_brochure2015.pdf?ua=1 malnutrition. UNICEF-WHO-World Bank joint child malnutrition estimates. UNICEF, New York; WHO, Geneva; World Bank, Washington DC: 2015. 1 INTRODUCTION 1 4 UNICEF, WHO, World Bank. Levels and trends in child The World Health Assembly nutrition targets were agreed in 2012. malnutrition. UNICEF-WHO-World Bank joint child malnutrition International Food Policy Research Institute. 2015. Global Nutrition estimates. UNICEF, New York; WHO, Geneva; World Bank, Report 2015: Actions and Accountability to Advance Nutrition and Sustainable Washington DC: 2015. Development. Washington, DC. 2 5 Save the Children’s own research GRID database, based on the DHS UN, 2015. Resolution A/70/L.1 Transforming our world: the 2030 agenda for sustainable development, United Nations. 6 Data in this paragraph are from UNICEF cross-country analyses of 3 household surveys, available at www.childinfo.org SCI, 2016. Every Last Children. Save the Children International. 4 7 The Scaling Up Nutrition, or SUN, movement unites governments, Including the Universal Declaration of Human Rights; the Convention civil society, donors, businesses and others in a collective effort to on the Rights of the Child; the Convention on the Elimination of improve nutrition. all Forms of Discrimination Against Women; the International Convention on the Elimination of All Forms of Racial Discrimination; 8 Save the Children, 2011. Why Law Matters? Save the Children the International Covenant on Economic, Social and Cultural Rights; International. Available online: https://www.savethechildren.org.uk/ the UN Declaration on the Rights of Indigenous Peoples; and the sites/default/files/docs/Why_Law_Matters_1.pdf Convention on the Rights of Persons with Disabilities. 9 Authors such as Vollmer, et al. (2014), Headey, D. and Chiu, A. 5 Non-discrimination is a fundamental principle laid down in the 1948 (2011), Heltberg (2009) and Wang, X. and Taniguchi, K. (2002) are Universal Declaration of Human Rights, adopted and proclaimed by among many who argue that economic growth is necessary for the United Nations General Assembly in 1948. reducing malnutrition, but is by itself insufficient. The same conclusion 6 has been reached by the FAO (2012). UNICEF, A summary of the rights under the Convention on the Rights of the Child. http://www.unicef.org/crc/files/Rights_overview.pdf 10 Save the Children, 2011. Why Law Matters? Save the Children 7 International. Available online: https://www.savethechildren.org.uk/ In line with the right to nutritious food as set out under Article 24 of sites/default/files/docs/Why_Law_Matters_1.pdf the Convention of the Rights of the Child. UNICEF, A summary of the rights under the Convention on the Rights of the Child. http://www.unicef. 11 On 1 April 2016 the United Nations General Assembly proclaimed a org/crc/files/Rights_overview.pdf; UN Committee on the Rights of UN Decade of Action on Nutrition that will run from 2016 to 2025. the Child, General comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24), 17 April; KEY TERMS Report of the UN Special Rapporteur on the Right to Food, May 2012; http://www.srfood.org/images/stories/pdf/officialreports/ 1 1000 Days Partnership, 2014. 1000 days. http://www.thousanddays. 20120306_nutrition_en.pdf 2013, CRC/C/GC/15, available at: org/about/ http://www.refworld.org/docid/51ef9e134.html 2 UNICEF, 2006. Progress for Children – Hunger definition. 8 Eide, W B, ‘Nutrition and Human Rights’ in Nutrition: A Foundation http://www.unicef.org/progressforchildren/2006n4/hungerdefinition.html for Development, Geneva: ACC/SCN, 2002. http://www.unscn.org/ 3 UNICEF, 2006. Progress for Children – Malnutrition definition. files/Publications/Briefs_on_Nutrition/Brief10_EN.pdf; UN General http://www.unicef.org/progressforchildren/2006n4/malnutrition Assembly, Convention on the Rights of the Child, 20 November 1989, definition.html United Nations, Treaty Series, vol. 1577, p. 3, http://www.refworld.org/ docid/3ae6b38f0.html, Arts. 24 and 27 4 UNICEF, 2006. Progress for Children – Undernutrition definition. 9 http://www.unicef.org/progressforchildren/2006n4/undernutrition 1000 Days Partnership, 2014, About 1000 days. http://www.thousand definition.html days.org/about/ 10 5 WHO, 2015. Overweight and obesity, act sheet No 311. World Health Save the Children, 2013. Food for Thought – Tackling child malnutrition Organization. Available online. http://www.who.int/mediacentre/ to unlock potential and boost prosperity: iv–v factsheets/fs311/en/ 11 WHO, 2016. Children: reducing mortality. World Health 6 UNICEF, WHO, World Bank Group, 2015. Levels and trends in child Organization. http://www.who.int/mediacentre/factsheets/fs178/en/ malnutrition. Joint child malnutrition estimates. Available online: 12 It has been estimated that stunted children earn 22% less than http://www.who.int/nutgrowthdb/jme_brochure2015.pdf?ua=1 their non-stunted counterparts, based on available longitudinal [Last accessed 040316] studies of the impact of malnutrition on education, and evidence from

70 ENDNOTES 71

. . , 19, (6), 1994, (6), , 19, , 17 April, 17 2013, CRC/C/GC/15, , 17 April, 17 2013, CRC/C/GC/15, http://www. . Committee on economic, social and cultural , Geneva: ACC/SCN, 2002. http://www.unscn.org/files/ . Joint child malnutrition estimates. Available online: , General Comment The 12: right to adequate food (art. 11) WHY ARE CHILDREN MALNOURISHED?

SCI, Why 2011. Law Matters? Save the Children International. This estimate is based on 23 countries out of 63 with available WHO, (2016). Global targets tracking tool. World Health SCI, Why 2011. Law Matters? Save the Children International. WHO, 2016. Global Nutrition Targets 20252025202: The Food Foundation (2016) Force-Fed: Does the food system constrict Wasting is an acute condition and can change rapidly – at times due SCI, Why 2011. Law Matters? Save the Children International. Based on the poorest 20% and richest 20% by economic asset index In out 27 of 56 countries with available data at regional level. General Comment to no the 12 International Covenant on Oshaug, A, Eide, W B and Eide, A ‘Human rights: a normative basis General Comment 1999. Council, Social – The and right Economic 12 to UN Committee on Economic, Social and Cultural Rights, Twentieth UN Committee on the Rights of the Child, General comment No. 15 UN Committee on the Rights of the Child, comment General UNICEF, 2006. Progress for Children – Undernutritiondefinition UNICEF, WHO, World Bank Group, 2015. Levels and trends in child UNICEF, 2006. Progress for Children – Malnutrition definition Eide, W B, ‘Nutrition and Human Rights’ in Nutrition: A Foundation for Publications/Briefs_on_Nutrition/Brief10_EN.pdf for food and nutrition-relevant policies’, Policy Food 491–516. adequate food (part. 11) rights. https://daccess-ods.un.org/TMP/7837179.30316925.html session Geneva, 1999 Agenda item 7 Substantive issues arising in the implementation of the international covenant on economic, social and cultural rights on the right(2013) of the child to the enjoyment of the highest attainable standard of health (art. 24) primary health- “Comprehensive refworld.org/docid/51ef9e134.html care programmes should be delivered alongside proven community- based efforts, including preventive care, treatment of specific diseases interventions.” nutritional and onthe right (2013) No. of the 15 child to the enjoyment of the highest attainable standard of health (art. 24) http://www.refworld.org/docid/51ef9e134.html definition.html malnutrition http://www.who.int/nutgrowthdb/jme_brochure2015.pdf?ua=1 Development http://www.unicef.org/progressforchildren/2006n4/undernutrition https://www.savethechildren.org.uk/sites/default/files/docs/Why_Law_ Matters_1.pdf Organization http://www.who.int/nutrition/trackingtool/en/ Organization healthy choices for typical British families? http://foodfoundation.org.uk/ food-foundation-launches-its-first-report-force-fed/ to unpredictable events – therefore, we do not include projections for wasting in this report. https://www.savethechildren.org.uk/sites/default/files/docs/Why_Law_ Matters_1.pdf Chilhood20252025: Childhood202: Childhood overweight policy policy overweight Childhood Childhood202: Chilhood20252025: http://www.who.int/nutrition/publications/globaltargets2025_ brief: policybrief_overweight/en/ https://www.savethechildren.org.uk/sites/default/files/docs/Why_Law_ Matters_1.pdf 13 14 5 6 7 8 9 10 11 12 13 14 15 16 17 3 1 2 3 4 12 disaggregated data for economic groups. Economic, Social and Cultural Rights http://www.unicef.org/progressforchildren/2006n4/malnutrition definition.html , Food and , 369(9555):60–70, , World Health Organization , 382(9890): 452–477. . Washington, DC. . http://www.who.int/nutgrowthdb/jme_brochure2015.. . http://www.who.int/nutgrowthdb/jme_brochure2015.. http://www.who.int/nutgrowthdb/jme_brochure2015.. HERE DO THEY LIVE, AND WHY MUST WE WHO ARE THE MALNOURISHED CHILDREN,

The Lancet (2016) Trends in adult body-mass index in 200 countries The benefit-cost ratio of scaling up nutrition-specific interventions FAO, 2013. The FAO, State of Food and Agriculture 2013 International Food Policy Research Institute. 2015. Global Nutrition WHO, 2015. McKinsey Global Institute (2014). Overcoming obesity: McKinsey Global Institute (2014). Overcoming obesity: An initial World Health OrganizationGlobal (2011): Status Report on These figures correspond to the 56 countries for which data is In out 52 of 56 countries stunting ratesare higher in rural areas. In WHO (2010) Country Profile Indicators Interpretation Guide, Nutrition WHO, Nutrition Landscape Information System Country Profile UNICEF, WHO, World Bank Group, 2015. Levels and trends in child UNICEF, WHO, World Bank Group, 2015. Levels and trends in child UNICEF, WHO, World Bank Group, 2015. Levels and trends in child economic analysis. Discussion Paper. http://www.mckinsey.com/ Paper. Discussion analysis. economic industries/healthcare-systems-and-services/our-insights/how-the- world-could-better-fight-obesity noncommunicable diseases 2010: Description of the global burden of NCDs, their risk factors and determinants. http://www.who.int/ p. 9. nmh/publications/ncd_report_chapter1.pdf?ua=1 available at this level of disaggregation. In each of the 56 countries (with the exception of Kyrgyzstan), stunting prevalence is higher for poor children. In Kyrgyzstan differences are not statistically significant. 52 In countries the prevalence of wasting is higher among poor children. a few countries (Egypt, Dominican Republic, São and Principe Tomé and Albania) children living in rural areas are slightly less likely to be stunted. Landscape Information System Indicators. World Health Organization: http://esa.un.org/unpd/wpp/ 12 DataQuery/ malnutrition pdf?ua=1 malnutrition malnutrition pdf?ua=1 pdf?ua=1 Report2015: Actions and Accountability to Advance Nutrition and Development Sustainable to 90% coverage in terms of its impact on stunting globally is 16 to 1. The analysis is based on an assumption, in line with the level of stunting reduction modelled by Bhutta et al. (2013), thatscaling up a core package of interventions will lead to a 20% decrease in the rate of stunting. Bhutta, Z. A., Das, J. K., Rizvi, A., Gaffey, M. Walker, N., F., Horton, S., & Black, R. E., 2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet The from to 1975 2014: a pooledanalysis of population-based 1698 measurement studies with million 19·2 participants. Issue: 387. Page: 1377–96 11 10 9 8 7 6 15 13 51 countries51 on the impact of education on earnings. Grantham- McGregor S, Development2007. potential in the first5 years for children in developing countries, Lancet The 5 4 3 2 1 2 W ADDRESS EXCLUSION REACH TO THEM? 14 An initial economic analysis. Discussion http://www.mckinsey. Paper. com/industries/healthcare-systems-and-services/our-insights/how- and Obesity 2015. the-world-could-better-fight-obesity; WHO, overweight. Factsheet number http://www.who.int/mediacentre/ 311. factsheets/fs311/en/ Agriculture Organization of the United the Nations. of Organization Agriculture 72 UNEQUAL PORTIONS Country-Main.cfm?ctry_id=47&c=Zambia&Country=Zambia&cn=&r=1 http://dhsprogram.com/Where-We-Work/ Survey. Health and who.int/publications/2008/9789241596435_eng.pdf promote health and protect to interventions of sustainability and benefits costs, health: sharing prosperity: progress and policies income-gini-coefficient levels between the richest and poorest 20% of the population. the of 20% poorest and richest the between levels 2010 update drinking-water, and sanitation http://childrenandbusiness.org/ who.int/publications/2008/9789241596435_eng.pdf promote health and protect to interventions of sustainability and benefits costs, health: to Nutrition Foundation. https://www.accesstonutrition.org/ lancet/PIIS0140-6736(16)00210-5.pdf lancet/PIIS0140-6736(16)00210-5.pdf needed action global coordinated formula: infant on Spotlight series. Breastfeeding 37 36 35 34 33 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 Lusaka: Government of Zambia: 148 Zambia: of Government Lusaka: 32 publication?id=b3067721-655e-4c0c-98e8-cabf54f2de58 what-we-do/our-approach/research-and-publications/view- 31 30 pubmed/18207566 doi: 10.1016/S0140-6736(07)61690-0. http://www.ncbi.nlm.nih.gov/ exposures and health consequences’, The Lancet regional and global undernutrition: child and ‘Maternal (2008) Group Study Undernutrition Child and Maternal Jand Rivera C, Mathers excluded groups. groups. excluded esaro/7310_gender_and_nutrition.html esaro/7310_gender_and_nutrition.html GuidingPrinciplesBusinessHR_EN.pdf Human 2012. Rights, http://www.ohchr.org/Documents/Publications/ un.org/unsd/mdg/data.aspx Sustainability Science in (forthcoming Delta” Sundarban Indian the from evidence development: sustainable and livelihoods hazards, “Natural (2016). files/odi-assets/publications-opinion-files/9580.pdf Overseas Development Institute. https://www.odi.org/sites/odi.org.uk/ economies emerging and high-income in foods of prices relative Changing operations/food/farmer.htm solution the of part be can farmers smallholder prices: for development sustainable implications context: Country-Main.cfm?ctry_id=47&c=Zambia&Country=Zambia&cn=&r=1 http://dhsprogram.com/Where-We-Work/ Survey. Health and UNICEF, 2016. Gender and nutrition. http://www.unicef.org/ nutrition. and Gender 2016. UNICEF, UN Human Rights Council, Guiding Principles on Business and and Business on Principles Guiding Council, Rights Human UN The rising cost of a healthy diet: diet: ahealthy of cost rising The S(2015) Keats, Sand Wiggins, The Lancet IDSS, 2012. WHO food and nutrition profile. nutrition and food WHO 2012. IDSS, Access to Nutrition, 2016. Global Access to Nutrition Index. Access Access Index. Nutrition to Access Global 2016. Nutrition, to Access Living Conditions and Monitoring Report 2006 and 2010 and 2006 Report Monitoring and Conditions Living 2012. CSO, WaterAid. Post-2015 toolkit Save the Children Myanmar, 2016, Case study on nutrition and and nutrition on study Case 2016, Myanmar, Children the Save UNDP, 2015. Income Coefficients GINI 2015. UNDP, Safer water, better better water, Safer J(2008) F, Gore Bartram R, Bos A, Prüss-Üstün goals the meet to gaps the Narrowing (2010) UNICEF example for See Save the Children’s own calculations, based on Zambia Demographic Demographic Zambia on based calculations, own Children’s the Save Save the Children’s own calculations, based on Zambia Demographic Demographic Zambia on based calculations, own Children’s the Save Black, RE, Allen, LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Ezzati M, Onis de LE, Caulfield ZA, Bhutta LH, Allen, RE, Black, United Nations. Millennium Development Goals Indicators Nations. United Ending extreme poverty and and poverty extreme Ending (2015) &Schellekens Quillin Foster, Cruz, Hajra, R., Szabo S., Ghosh, T., Matthews, Z., Foufoula-Georgiou, E. E. Foufoula-Georgiou, Z., T., Matthews, Ghosh, S., Szabo R., Hajra, Safer water, better better water, Safer J(2008) F, Gore Bartram R, Bos A, Prüss-Üstün Save the Children et. al, Children’s Rights and Business Principles, Principles, Business and Rights Children’s al, et. Children the Save Progress on on Progress (2010) Programme Monitoring Joint WHO/UNICEF International Fund for Agricultural Development, undated, Food Urbanisation and (2016) inequalities in a S. post-Malthusian Szabo, . McFadden, A. et al. http://www.thelancet.com/pdfs/journals/ al. et A. . McFadden, (2016) ‘Breastfeeding: achieving the new normal’, normal’, new the achieving ‘Breastfeeding: (2016) . World Health Organization, Geneva. http://whqlibdoc. Geneva. Organization, Health . World . World Health Organization, Geneva. http://whqlibdoc. Geneva. Organization, Health . World ) . http://www.wateraid.org/ . The World Bank Bank World . The . http://hdr.undp.org/en/content/ . Comparison of WASH access access WASH of . Comparison . Springer. 371 (9608) pp243–60. pp243–60. 371 (9608) . http://www.ifad.org/ . http://mdgs. , . indicators. http://dhsprogram.com/pubs/pdf/PR56/PR56.pdf Expenditure Survey data Survey Expenditure Planning and Economic Development & Ministry of Health, Myanmar. National of Ministry Taw, Pyi Nay Myanmar: Report. Final 2009–2010 Survey Cluster Indicator Multiple 2011. Myanmar Health. of Ministry https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf indicators. http://dhsprogram.com/pubs/pdf/PR56/PR56.pdf 216618~theSitePK:282575,00.html 0,,contentMDK:20206757~menuPK:483704~pagePK:148956~piPK: EXTHEALTHNUTRITIONANDPOPULATION/EXTNUTRITION/ Institute HouseholdIntegrated Survey 2011–2012 the from Results Bangladesh Index: Agriculture in Empowerment 38 Briefing paper 5 Sept 2014 Sept 5 paper Briefing 49 48 47 46 45 44 43 42 41 40 39 63 62 61 60 59 58 57 56 55 54 53 52 51 50 Government of the Republic of Kenya. Kenya. of Republic the of Government Nutrition_Disability_Groce_Challenger_Kerac.pdf Nutrition_Disability_Groce_Challenger_Kerac.pdf UNICEF. http://www.unicef.org/disabilities/files/Stronger-Together_ and Links Synergies Nutrition-Disability how-did-boys-and-girls-fare-last-decade how-did-boys-and-girls-fare-last-decade decade? the past diagnostic-ending-poverty-boosting-shared-prosperity-time-transition org/curated/en/2014/11/23025474/myanmar-systematic-country- transition of atime in prosperity shared Research and Training and Research Population of Institute National Indicators. Utilization Care Health Briefing paper 5 Sept 2014 Sept 5 paper Briefing Excluded Groups Excluded Groups, 2016. 2016. Groups, Excluded and Nutrition on Study Case Myanmar, Children the Save experience, Plan. The Government of the Republic of Kenya. of Republic the of Government The Plan. Behaviours survey report, 2014 report, survey Behaviours and Practices Attitude Knowledge nutrition child young and infant at what cost? The Lancet cost? what at and done be can what nutrition: child and maternal of improvement for interventions Evidence-based 2013. E., R. &Black, Horton, S., Briefing paper 5 Sept 2014 Sept 5 paper Briefing Ministry of National Planning and Economic Development & NOURISH Gender Analysis and Integration Strategy Integration and Analysis Gender NOURISH Government of Kenya, 2013. Wajir County Integrated Development Development Integrated County Wajir 2013. Kenya, of Government Sierra Leone: Getting beyond nutrition as “a women’s issue” “a women’s as nutrition beyond Getting Leone: Sierra 2014. SLRC Sierra Leone: Getting beyond nutrition as “a women’s issue” “a women’s as nutrition beyond Getting Leone: Sierra 2014. SLRC Save the Children Bangladesh, Case Study on Nutrition and and Nutrition on Study Case Bangladesh, Children the Save These observations are based on Save the Children’s programmatic programmatic Children’s the Save on based are observations These NOURISH Gender Analysis and Integration Strategy Integration and Analysis Gender NOURISH Child Malnutrition – How did boys and girls fare in in fare girls and boys did –How Malnutrition Child 2012. Bank. World The Women’s The A(2013). Ahmed, Aand Quisumbing, E, Sraboni, Focus group discussion in Wajir County, documented in Maternal, Maternal, in documented County, Wajir in discussion group Focus 2015, Kenya SMART survey, June 2015 June survey, SMART Kenya 2015, http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/ Bhutta, Z. A., Das, J. K., Rizvi, A., Gaffey, M. F., Walker, M. N., Gaffey, A., Rizvi, K., J. Das, A., Z. Bhutta, DHS, 2013. National Demographic Health Survey Report – Nigeria. –Nigeria. Report Survey Health Demographic National 2013. DHS, Sierra Leone: Getting beyond nutrition as “a women’s issue” “a women’s as nutrition beyond Getting Leone: Sierra 2014. SLRC Child Last Every 2016. SCI, Myanmar: Ending poverty and boosting boosting and poverty Ending Myanmar: (2014). Group. Bank World DHS, 2014, Demographic Health Survey Bangladesh – key –key Bangladesh Survey Health Demographic 2014, DHS, Stronger Together: Together: M(2013)Stronger Kerac, and E, Challenger, N, Groce, NOURISH Gender Analysis and Integration Strategy Integration and Analysis Gender NOURISH NIPORT. 2010. Bangladesh District Level Socio-demographic and and Socio-demographic Level District Bangladesh 2010. NIPORT. C.f recent poverty maps using 2010 Household Income and and Income Household 2010 using maps poverty recent C.f Government of Kenya, County Integrated Development Plans Kenya, of Government FSNSP, 2014. Food Security Nutritional Surveillance Project. Surveillance Nutritional Security Food 2014. FSNSP, DHS, 2014, Demographic Health Survey Bangladesh – key –key Bangladesh Survey Health Demographic 2014, DHS, http://data.worldbank.org/news/child-malnutrition- , 382(9890): 452–477. , 382(9890): , International Food Policy Research Research Policy Food , International , Save the Children International. International. Children the , Save . http://documents.worldbank. , Briefing Note. New York: New York: Note. , Briefing . The . The

. . . ENDNOTES 73

27 (2015): 27 921–942. , 371 (9612). pp. 608–21. (9612). , 371 . 11:3. http://www.ncbi.nlm.nih.gov/pmc/ 11:3. . 78.1 (2000): 78.1 30–41. . 12:23. http://www.equityhealthj.com/content/12/1/23 12:23. . . 12:23. http://www.equityhealthj.com/content/12/1/23 12:23. . . 12:23. http://www.equityhealthj.com/content/12/1/23 12:23. . . http://globalnutritionreport.org/the-report Save the Children’s own analysis. European Parliament Directorate-General for External Policies Save the Children (2015) Making a Killing: How tax scams are robbing Horta, B. L., Santos, R., Welch, J. R., Cardoso, A. M., Vieira dos Horta, B. L., Santos, R., Welch, J. R., Cardoso, A. M., Vieira dos Sri Lanka Civil Society Alliance for Scaling Up Nutrition, 2016. Case Gradin, Carlos. “Poverty and ethnicity among black South Africans.” Jayatissa, R., Gunathilaka, M. and Fernando, (n.d). D. National Morris, SS; Cogill, B; Uauy, R; for the Maternal and Child International Food Policy Research Institute (2015) Nutrition Global Horta, B. L., Santos, R., Welch, J. R., Cardoso, A. M., Vieira dos See http://www.wfp.org/news/news-release/wfp-food-convoy-enters- See Nepal further Analysis: Caste, Ethnic and Regional Identify in Nepal. Ferreira, A., Welch, J., Santos, R., Gugelmin, S. and Coimbra C. Jr, http://www.unicef.org.uk/Media-centre/Press-releases/Statement- Vietnam National Institute of Nutrition, 2012. Malnutrition figures . Young Lives, Young 2013. Nutrition and Health: Round 4 Preliminary Findings in Brockerhoff, Martin & Paul Hewett. “Inequality of child mortality World Bank, 2013. Vietnam: Achieving Success as a Middle as a Middle- Nepal further Analysis: Caste, Ethnic and Regional Identify in Nepal. Nepal further Analysis: Caste, Ethnic and Regional Identify in Nepal. Report European Journal of Development Research Development of European Journal besieged-areas-inside-city-taiz-yemen besieged-areas-inside-city-taiz-yemen Vietnam Santos, J., Assis, A. M., and Lira, Coimbra C. P. Jr, (2013). Nutritional status of indigenous children: findings from the Frist National Survey of Indigenous People’s health and nutrition in Brazil. of Journal International HealthEquity in (2012). Nutritional status and growth of indigenousXavante children, Central Brazil. Nutrition Journal articles/PMC3317817/ attributable-to-Hanaa-Singer-UNICEF-Representative-in-Syria-on- the-besieged-area-of-Madaya/ Further Analysis of the 2006 Nepal Demographic and Health Survey. 99 100 101 102 91 92 93 94 95 96 97 98 83 84 85 86 87 88 89 90 82 among ethnic groups in sub-Saharan Africa.” Bulletin sub-Saharan Africa.” in groups ethnic ofamong the World Organization Health Santos, J., Assis, A. M., and Lira, Coimbra C. P. Jr, (2013). Nutritional status of indigenous children: findings from the Frist National Survey of Indigenous People’s health and nutrition in Brazil. of Journal International HealthEquity in income Country income . Part Anaemia 1: nutrition micronutrient and survey 2012 among children aged 6–59 months and nutritional status of children and adults. Ministry of Health/UNICEF. http://www.unicef.org/srilanka/MNS_ Report-28.02.2013.pdf Further Analysis of the 2006 Nepal Demographic and Health Survey. poor countries of life-saving healthcare Santos, J., Assis, A. M., and Lira, Coimbra C. P. Jr, (2013). Nutritional status of indigenous children: findings from the Frist National Survey of Indigenous People’s health and nutrition in Brazil. of Journal International HealthEquity in it_proven_so_difficult_and_what_can_be_done_to_accelerate_ progress.pdf Revenue(2014) ‘Tax Mobilisation in Developing Countries: Issues and http://www.europarl.europa.eu/RegData/etudes/etudes/ Challenges’ join/2014/433849/EXPO-DEVE_ET(2014)433849_EN.pdf Undernutrition Study Group (2008) Group ‘Effective action Study Undernutrition international against undernutrition: why has it proven so difficult and what can be done to accelerate progress?’ Lancet http://www.iuns.org/wp-content/uploads/pdf/features/Article_ Effective_international_action_against_undernutrition_why_has_ Further Analysis of the 2006 Nepal Demographic and Health Survey. Study on Nutrition and Excluded Groups. Note: The case study draws on focus group discussions carried out by SUN PF in Weli Oya.

. , October 382, 9890, pp 427–51. , Briefing Note.York: New , Briefing Note.York: New , 18 June, 18 2015 http://www.unhcr. 24.4 (2012): 327–341. . (2016) Refugees: towards better access to health care Geneva Conventions Protocol I, Art. 54 (2); Protocol II, Art. 14. Langlois et al Langlois Observation based on programmatic experience, Save the Children Notes on method: Lives Young use data on childrenat ages 8, 12 Groce, N, Challenger, E, and Kerac, M (2013) Stronger Together: Ali, M. Shanhad, S. Ushijima, H. Muynck, A. 2004. Street children in DFID (2012) Working to improve nutrition in northern Nigeria. Business UNICEF State of the world’s child http://www.unicef.org/ 2013 Rome Statute of the International Criminal Court, 1998, Art. 8(b) 30 Fourth Geneva Convention, Article Hague 55(1). regulations, Secretary General, ‘Restoring Humanity: Global Voices calling Save the Child (2016) Assessment of infant and young child feeding Singh, Abhishek, et al. “Infant and child mortality in India in the last Ssewanyana, Sarah & Ibrahim Kasirye. “Causes of health inequalities Bose, Sunita. “The effect of women’s status and community on the UNHCR, ‘Worldwide displacement hits all-time high as war Black, RE, Victora, Bhutta, SP, CG, Walker, ZA, Christian, P, Groce, N, Challenger, E, and Kerac, M (2013) Stronger Together: Case and Summary 201874 practices among refugees on Lesvos Island, Greece Nigeria, Case study on Nutritionand Excluded Groups. 2015 https://interagencystandingcommittee.org/system/files/whs_ 2015 synthesis_report_executive_summary_final.pdf for Action. Synthesis of the Consultation Processfor the World United Nations Summary)’ (Executive Summit Humanitarian (xxv). and persecution increase’ UNHCR org/558193896.html 80 81 78 79 77 76 75 74 73 72 71 70 69 68 67 66 64 65 Nutrition-Disability Synergies Links and UNICEF. http://www.unicef.org/disabilities/files/Stronger-Together_ UNICEF. Nutrition_Disability_Groce_Challenger_Kerac.pdf Nutrition-Disability Synergies Links and http://www.unicef.org/disabilities/files/Stronger-Together_ UNICEF. Nutrition_Disability_Groce_Challenger_Kerac.pdf gender differential in children’s nutrition in India.” Biosoc Sci Journal 43.5 513–33 (2011): in Uganda: Evidence from the demographic and health surveys.” African Review Development services. The Lancet. No. 10016 387, Vol 1907 two decades: a geospatial analysis.” 26856. PLoS (2011): One 6.11 and from 15 Lives, Young a cohort study of 12,000 children across Ethiopia, India (Andhra Pradesh), Peruand Vietnam. This research uses data from the Lives Young cohort study to produce new evidence undernutrition, maternal of consequences intergenerational the on examining the consequences of maternal undernutrition and the age of motherhood on her child’s later development. do so, Lives Young To classify children into four groups, based on whether their mothers were stunted or not and on whether they were an adolescent when the child was born. Second, they examine the potential benefits of investments around adolescence for healthy growth in subsequent stages of development that may then be transmitted to the next generation. Stunting is used as a marker of chronic undernutrition and a recognised risk factor for child development that may be exacerbated by giving birth in adolescence, another risk to the offspring’s health and development throughout the offspring’s life course. doi: 10.1016/S0140- 6736(13)60937-X de Onis, M, Ezzati, M, Grantham-McGregor, S, Katz, J, Martorell, R, Uauy, R, and Maternal and Child Nutrition Study Group (2013) ‘Maternal and child undernutrition and overweight in low-income Lancet The middle-income countries’, and sowc2013/files/SWCR2013_ENG_Lo_res_24_Apr_2013.pdf Pakistan: A situational analysis of social conditions and nutritional status and conditions social of analysis situational A Pakistan: Social Science and Medicine. Issue Volume 59, 8. pp 11707–1717 http://www.sciencedirect.com/science/article/pii/S027795360400036x 74 UNEQUAL PORTIONS Food Policy Research Institute (IFPRI) Institute Research Policy Food in Bangladesh Undernutrition of Reduction Rapid the Explaining Enigma: Asian Other The 2014–2015 by Feenstra, R. C. and Taylor, E. and C. A. R. Feenstra, by 21st the in century cooperation economic Multilateral crisis: of age knowledge” 2012 existing of Areview nutrition: and security food on impacts “Climate 123 122 121 120 119 change/resilience-full-report.pdf https://royalsociety.org/~/media/policy/projects/resilience-climate- 118 117 116 115 114 113 112 111 110 109 108 107 106 105 104 103 impacts_on_food_security_and_nutrition.pdf impacts_on_food_security_and_nutrition.pdf knowledge” 2012 http://www.metoffice.gov.uk/media/pdf/k/5/Climate_ existing of Areview nutrition: and security food on impacts “Climate Development Goals. Guatemala: Segeplan. 2015 Segeplan. Guatemala: Goals. Development Millennium the of report compliance End –SEGEPLAN. Presidency http://onlinelibrary.wiley.com/doi/10.1111/obr.12081/pdf 14:S1, 120–134. Reviews: Obesity environments’ food on The0role0of0trade0in0ending0poverty.pdf WDSP/IB/2015/08/06/090224b083055c45/2_0/Rendered/PDF/ http://www-wds.worldbank.org/external/default/WDSContentServer/ Poverty Ending Trade in of change/resilience-full-report.pdf change/resilience-full-report.pdf https://royalsociety.org/~/media/policy/projects/resilience-climate- who_el_nino_and_health_global_report_21jan2016.pdf?ua=1 who_el_nino_and_health_global_report_21jan2016.pdf?ua=1 knowledge” 2012 existing of Areview nutrition: and security food on impacts “Climate International Food Policy Research Institute Research Policy Food International and AECI USAID, of support the with II Iand Volume municipalities. 166 priority in surveys Monitoring Plan. Hunger Zero Pact SEGEPLAN –2015 SEGEPLAN dis.7a2cee9e980f91ad7697b570bcc4b004 Disasters Currents PLoS evidence. the of review asystematic drought: of effects 2013 Health Virginia. Murray, Jolyon; change/resilience-full-report.pdf change/resilience-full-report.pdf https://royalsociety.org/~/media/policy/projects/resilience-climate- docrep/008/a0050e/a0050e05.htm#P0_0 docrep/008/a0050e/a0050e05.htm#P0_0 http://www.fao.org/ , FAO: Rome. 2005 Agriculture and Food of State http://onlinelibrary.wiley.com/doi/10.1111/obr.12081/pdf 14:S1, 120–134. Reviews: Obesity environments’ food on tw_app_ipad peoples-diets-may-be-changing-feast-and?frsc=dg%7Cc&fsrc=scn/ news/international/21635046-world-has-terrible-record-improving- world? the feed we Can Hungry: Billion One G(2012) Conway, The Royal Society: “Resilience to extreme weather” 2015 2015 weather” extreme to “Resilience Society: Royal The National Bureau for Economic Research (2014) Globalization (2014) in an Research Economic for Bureau National The Economist One Billion Hungry: Can we feed the world? the feed we Can Hungry: Billion One G(2012) Conway, Met Office and the United Nations World Food Programme: Programme: Food World Nations United the and Office Met Headey, D, Hoddinott, J, Ali, D, Tesfaye, R and Dereje, M, 2014. 2014. M, Dereje, Rand D, Tesfaye, Ali, J, D, Hoddinott, Headey, Met Office and the United Nations World Food Programme: Programme: Food World Nations United the and Office Met The Royal Society: “Resilience to extreme weather” 2015 2015 weather” extreme to “Resilience Society: Royal The Secretary of Planning and Programming of the Presidency – Presidency the of Programming and Planning of Secretary Met Office and the United Nations World Food Programme: Programme: Food World Nations United the and Office Met Stanke, Carla; Kerac, Marko; Prudhomme, Christel; Medlock, Medlock, Christel; Prudhomme, Marko; Kerac, Carla; Stanke, The Royal Society: “Resilience to extreme weather” 2015 2015 weather” extreme to “Resilience Society: Royal The Guatemala. Secretary of Planning and Programming of the the of Programming and Planning of Secretary Guatemala. As of January 2016. See http://www.who.int/hac/crises/el-nino/ See 2016. January of As Friel, S. et al. (2013). ‘Monitoring the impacts of trade agreements agreements trade of impacts the ‘Monitoring (2013). al. et S. Friel, The Role Role The (2015). Trade World Organization. and Bank World Government of Guatemala – SESAN and INE. Impact assessments assessments Impact INE. and –SESAN Guatemala of Government Friel, S. et al. (2013). ‘Monitoring the impacts of trade agreements agreements trade of impacts the ‘Monitoring (2013). al. et S. Friel, The The in reforms’ trade agricultural of impacts ‘Poverty FAO (2005). National Maternal and Child Health Survey Survey Health Child and Maternal National Health, of Ministry (ENSMI – in Spanish) –in (ENSMI , IFPRI Discussion Paper, Washington DC: International International DC: Paper, Washington Discussion , IFPRI (2014) Feast and famine, http://www.economist.com/ famine, and Feast (2014) . World Trade Organization: Geneva. Geneva. Trade. World Organization: . 38, pp. 10.1371/currents. pp. . 38, . Edited . Edited transfers in tackling child mortality child tackling in transfers Publications/Briefs_on_Nutrition/Brief10_EN.pdf for Development Emergency: Resilience and children in the Sahel the in children and Resilience Emergency: No 44, Transform Nutrition, Institute of Development Studies: 9 Studies: Development of Institute Nutrition, Transform 44, No era post-MDG the for priorities and i3154e/i3154e.pdf Programmes Security Nutrition and Food 10 9 8 7 6 5 4 3 2 1 I 4 126 125 124 22 21 20 19 18 17 16 15 14 13 12 11 Agriculture Organization evidence of Areview agriculture: and protection social Vulnerability and Adaptation Impacts, II: Group Paper. Save the Children International Children the Paper. Save second birthday Publications/Briefs_on_Nutrition/Brief10_EN.pdf for Development i3154e/i3154e.pdf Programmes Security Nutrition and Food Publications/Briefs_on_Nutrition/Brief10_EN.pdf for Development Publications/Briefs_on_Nutrition/Brief10_EN.pdf for Development assets/publications-opinion-files/8601.pdf Development Agency http://www.odi.org/sites/odi.org.uk/files/odi- journal of nutrition clinical European Kenya.” Eastern rural in old 5years under children of status 20 November 1989, United Nations, Treaty Series, vol. 1577, vol. p3 Series, Treaty Nations, 1989, United November 20 children, and adolescent girls. BMJ2015;351:h4173. girls. adolescent and children, topics/globaltargets_lowbirthweight_policybrief.pdf http://www.who.int/nutrition/ WHO. Geneva: Brief, Policy Weight wp-content/uploads/2015/05/SUN_ICE_FullReport-All(1-5-15).pdf Report Final Movement: Nutrition Report Studies Development of challenge of intersecting inequalities. Institute Convention on the Rights of the Child the of Rights the on Convention Assembly, General UN women, in health and Nutrition al. et E, Piwoz E, F, McLean Branca Birth Low 2025: Targets Nutrition Global WHA (2014). WHO Up Scaling the of Evaluation Comprehensive Independent 2015, Mokoro Global Nutrition (2015) Institute Research Policy Food International See See http://www.un.org/millenniumgoals/environ.shtml See http://www.un.org/millenniumgoals/gender.shtml The justice? social to apathway provide MDGs the Can N(2010) Kabeer, NCLUSIVELY Nutrition: A Foundation AFoundation Nutrition: in Rights’ Human and ‘Nutrition WB, Eide, Save the Children (2015) Child-Sensitive Social Protection Position Position Protection Social Child-Sensitive (2015) Children the Save Ndiku, Hellen, et al. “Gender inequality in food intake and nutritional nutritional and intake food in inequality “Gender al. et Hellen, Ndiku, Nutrition: A Foundation AFoundation Nutrition: in Rights’ Human and ‘Nutrition WB, Eide, Guidance Note: Integrating the Right to Adequate Good into into Good Adequate to Right the Integrating Note: Guidance FAO. 2012. The 1,000-day period between a woman conceiving and her child’s child’s her and conceiving awoman between period 1,000-day The Nutrition: A Foundation AFoundation Nutrition: in Rights’ Human and ‘Nutrition WB, Eide, Guidance Note: Integrating the Right to Adequate Good into into Good Adequate to Right the Integrating Note: Guidance FAO. 2012. Reducing Child Undernutrition: Past drivers drivers Past Undernutrition: Child Reducing 2014. L., &Haddad, L., Smith, Tirivayi, N., Knowles, M., Davis, B., 2013. The 2013. between interaction B., Davis, M., Knowles, N., Tirivayi, Nutrition: A Foundation AFoundation Nutrition: in Rights’ Human and ‘Nutrition WB, Eide, Lasting Benefits: The role of cash cash of role The Benefits: Lasting 2009. M., O’Donnell, J., Yablonski, ODI, 2013. Social protection and resilient food system, Overseas Overseas system, food resilient and protection Social 2013. ODI,

Ending the Everyday Everyday the Ending (2012) Vision World and Children the Save IPCC Fourth Assessment Report: Climate Change 2007: Working Working 2007: Change Climate Report: Assessment Fourth IPCC UNICEF (2011) Children and Climate Change Change Climate and (2011) Children UNICEF HOW TO ADDRESS MALNUTRITION MALNUTRITION HOW TO ADDRESS http://www.who.int/nutrition/topics/nutrition_globaltargets2025/en/ http://globalnutritionreport.org/the-report , Geneva: ACC/SCN, 2002. http://www.unscn.org/files/ 2002. ACC/SCN, , Geneva: , Geneva: ACC/SCN, 2002. http://www.unscn.org/files/ 2002. ACC/SCN, , Geneva: , Geneva: ACC/SCN, 2002. http://www.unscn.org/files/ 2002. ACC/SCN, , Geneva: http://www.unscn.org/files/ 2002. ACC/SCN, , Geneva: 65.1 (2011): 26–31. 65.1 (2011): 26–31. . http://scalingupnutrition.org/ , London, Save the Children the Save , London, , IDS Working Paper Volume 2014 Volume Paper Working , IDS . http://www.fao.org/docrep/017/ . http://www.fao.org/docrep/017/ , Food and and , Food ,

ENDNOTES 75 . , . Health . A report by the High Level , Geneva: ACC/SCN, 2002. http://www.unscn.org/files/ , Overseas Development Institute. https://www.odi.org/ Institute. Development Overseas , . http://siteresources.worldbank.org/NUTRITION/ . Water Aid, LSHTM, and SHARE (2013), Under-nutrition and water, Headey, D and Chiu Nutrition-sensitive (2011) growth economic Heltberg, R. (2009) Malnutrition, poverty and economic growth HLPE, security food 2013. Biofuels and Keats, S and Wiggins, S (2014) Future diets: Implications for agriculture Jovana Dodos et al. (2016) ‘ACF/UNICEF/ECHO WASH ‘Nutrition Hossain et al (2015) A Common Sense Approach to the Right to Food Checkley, R.H. W., Gilman, R.E. Black, et al (2004) “Effect of water Headey, Turning economic D (2011) growth into nutrition-sensitive Countries with a high burden of malnutrition that have not ratified JMP (2016), JMP equality checklist, WHO/ UNICEF Joint Monitoring WaterAid (2015), The State of the Toilets.World’s WaterAid. Rah J et al (2015) “Household Sanitation and Personal Hygiene Ibid. ibid ODI (2015) Education in emergencies and protracted crises: Toward SCI, Why 2011. Law Matters? Save the Children International. Eide, W B, ‘Nutrition and Human Rights’ In Nutrition: A Foundation World Bank. (2006). Chapter Why 1: Invest in Nutrition? In Water Aid, LSHTM, and SHARE. (2013), Under-nutrition and water, the treaty on economic, social and culture rights include Mozambique, Singapore, and South Sudan. and food prices sites/odi.org.uk/files/odi-assets/publications-opinion-files/8776.pdf Repositioning Nutrition as Central to Development: A Strategy for Large- ActionScale Resources/281846-1131636806329/NutritionStrategyCh1.pdf a strengthened response Pg. 14. http://www.odi.org/sites/odi.org.uk/ files/odi-assets/publications-opinion-files/9714.pdf International Food Policy Research Institute. http://www.csae.ox.ac.uk/ conferences/2011-edia/papers/633-Chiu.pdf for Developmentfor Publications/Briefs_on_Nutrition/Brief10_EN.pdf operational manual”; Dangour AD, Watson L, Cumming Boisson S, O, Velleman CavillChe Y, Y, S, Allen E, Uauy R. (2013) Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD009382. Practices are Associated with Child Stunting in Rural India: Cross- A Sectional Analysis of Surveys” Economics 66 56 57 https://www.savethechildren.org.uk/sites/default/files/docs/Why_Law_ Matters_1.pdf 58 59 60 61 62 63 64 65 48 49 50 51 52 53 54 55 47 sanitation and hygiene. Water Aid, London School of Hygiene and Tropical Medicine (LSHTM), sanitation and hygiene applied research equityfor (SHARE) http://www.wateraid.org/policy-practice-and- advocacy/health/resources programme (JMP) for Water Supply and Sanitation http://www.wssinfo. org/fileadmin/user_upload/resources/JMP-END-WG-Summary-2- pager.pdf growth, International Food Policy Research Institute. http://ebrary.ifpri. org/cdm/singleitem/collection/p15738coll2/id/124815/rec/2 IDS Working Volume Paper. 2015 No.458 and sanitation on childhood health in a poor Peruvian peri-urban community” sanitation and hygiene. Water Aid, London School of Hygiene and Tropical Medicine (LSHTM), sanitation and hygiene applied research equityfor (SHARE) http://www.wateraid.org/policy-practice-and- advocacy/health/resources Panel of Experts on Food Security and Nutrition of the Committee on http://www.fao.org/fileadmin/user_upload/hlpe/ Security. Food World hlpe_documents/HLPE_Reports/HLPE-Report-5_Biofuels_and_food_ security.pdf Volume 382, Volume 382, Volume 382, . Department for . Department for . http://www.ilo.org/global/topics/social-. . http://www.unicef.org/aids/files/CSSP_joint_ . , NBER – Working Paper No. 8495, Cambridge, MA, . Carolina Population Center, University of North Carolina: 14 http://globalnutritionreport.org/the-report Gelli, A., Espejo, U. and Meir, F. Does provision of food in school Ruel, M and H, Alderman ‘Nutrition-sensitive (2013) interventions EFA Global Monitoring Report (2014). Teaching and Learning: Handa, S., Park, M. J., Darko,R. O., Osei-Akoto, I. Davis, B. and Ruel, M and H, Alderman ‘Nutrition-sensitive (2013) interventions ibid. International Food Policy Research Institute (2015) Nutrition Global World Bank and ILO, 2016. The World Bank Group and ILO Universal The Global Panel on Agriculture and Food Systems for Nutrition DFID Cash (2011) Transfers Literature Review Case,A., 2001. Does Money Protect Health Status? Evidence from South SCI, 2016, A common cause. Save the Children UK. DFID, Help Age International, et al (2009) child-sensitive Advancing SCI, 2016. Non-Emergency Food Security and Livelihoods. See http://www.who.int/health_financing/universal_coverage_ See Save the Children and World Vision (2012) Ending theEveryday Coe, G. and de Beyer, J. The imperative for health promotion in DFID, Help Age International, et al (2009) Op. Cit. DfID, sheets guidance livelihoods Sustainable 1999. Ruel, M and H, Alderman ‘Nutrition-sensitive (2013) interventions ibid World Food Programme El Niño 2015–2016 Preparedness and See Generation Nutrition http://www.generation-nutrition.org/en/ Nutrition Generation See EFA Global Monitoring Report (2014). Teaching and Learning: Save the Children International. http://www.savethechildren.org/site/ c.8rKLIXMGIpI4E/b.9316579/k.9DA/NonEmergency_Food_Security_ and_Livelihoods.htm and programmes: how can they help to accelerate progress in improving maternal and child nutrition?’ Lancet The No. 9891, p536–551, August 10 2013 Achieving quality for all Pg. https://www.unesco.nl/sites/default/ 15. files/dossier/gmr_2013-4.pdf No. 9891, p536–551, August 10 2013 and programmes: how can they help to accelerate progress in improving maternal and child nutrition?’ Lancet The Report http://www.savethechildren.org.uk/resources/online-library/common- cause and programmes: how can they help to accelerate progress in improving maternal and child nutrition?’ Lancet The No. 9891, p536–551, August 10 2013 statement_10.16.09.pdf social protection 46 45 44 43 42 41 37 38 36 35 33 34 31 32 29 30 Response Situation Report #2. January 2016. 28 25 26 23 40 39 27 24 Diadone, S. 2013. Livelihood Empowerment against Poverty Impact Evaluation Emergency: Resilience and childrenin the Sahel universal health coverage (2014) Global Health: Science and Practice increase girls’ enrollment? Evidence from schools in sub-Saharan Africa. Food and Nutrition Bulletin, 28(2): 2007. p.149–155. blog/universal-health-coverage-scaling-nutrition-post-2015 International Development International National Bureau of Economic Research African pensions African definition/en/ Social Protection Initiative security/WCMS_378991/lang--en/index.htm Achieving quality for all https://www.unesco.nl/sites/default/ Pg. 191. files/dossier/gmr_2013-4.pdf (2016). Heathy Meals in Schools: Policy Innovations Linking http://glopan.org/sites/ Nutrition. and Systems Food Agriculture, default/files/HealthyMealsBrief.pdf International Development. http://r4d.dfid.gov.uk/PDF/Articles/cash- Development. International transfers-literature-review.pdf 76 UNEQUAL PORTIONS food-security-and-human-nutrition-in-mozambique/ food-security-and-human-nutrition-in-mozambique/ Inclusive_Growth_-_An_imperative_for_African_Agriculture.pdf http://www.afdb.org/fileadmin/uploads/afdb/Documents/Publications/ for Agriculture African imperative un-framework2012.pdf un-framework2012.pdf triangular cooperation’ https://www.cbd.int/financial/southsouth/ and South–South to support Nations United on guidelines operational of 2012 ‘Framework May Cooperation, South–South on prosavana-and-proalimentos/file trilateral-development-cooperation-in-mozambique-the-case-of- research-and-analysis/working-papers/1943-a-study-of-brazilian- Future Agricultures. http://www.future-agricultures.org/publications/ ProALIMENTOS and ProSAVANA of case The Mozambique: in Cooperation prosavana-and-proalimentos/file trilateral-development-cooperation-in-mozambique-the-case-of- research-and-analysis/working-papers/1943-a-study-of-brazilian- Future Agricultures. http://www.future-agricultures.org/publications/ ProALIMENTOS and ProSAVANA of case The Mozambique: in Cooperation prosavana-and-proalimentos/file trilateral-development-cooperation-in-mozambique-the-case-of- research-and-analysis/working-papers/1943-a-study-of-brazilian- Future Agricultures. http://www.future-agricultures.org/publications/ ProALIMENTOS and ProSAVANA of case The Mozambique: in Cooperation prosavana-and-proalimentos/file trilateral-development-cooperation-in-mozambique-the-case-of- research-and-analysis/working-papers/1943-a-study-of-brazilian- Future Agricultures. http://www.future-agricultures.org/publications/ ProALIMENTOS and ProSAVANA of case The Mozambique: in Cooperation prosavana-and-proalimentos/file trilateral-development-cooperation-in-mozambique-the-case-of- research-and-analysis/working-papers/1943-a-study-of-brazilian- Future Agricultures. http://www.future-agricultures.org/publications/ ProALIMENTOS and ProSAVANA of case The Mozambique: in Cooperation prosavana-and-proalimentos/file trilateral-development-cooperation-in-mozambique-the-case-of- research-and-analysis/working-papers/1943-a-study-of-brazilian- Future Agricultures. http://www.future-agricultures.org/publications/ ProALIMENTOS and ProSAVANA of case The Mozambique: in Cooperation 79 78 77 76 75 74 73 72 71 70 69 68 67 prosavana-and-proalimentos/file trilateral-development-cooperation-in-mozambique-the-case-of- research-and-analysis/working-papers/1943-a-study-of-brazilian- Future Agricultures. http://www.future-agricultures.org/publications/ ProALIMENTOS and ProSAVANA of case The Mozambique: in Cooperation prosavana-and-proalimentos/file trilateral-development-cooperation-in-mozambique-the-case-of- research-and-analysis/working-papers/1943-a-study-of-brazilian- Future Agricultures. http://www.future-agricultures.org/publications/ ProALIMENTOS and ProSAVANA of case The Mozambique: in Cooperation https://www.usaid.gov/brazil/history https://www.usaid.gov/brazil/history prosavana-and-proalimentos/file; trilateral-development-cooperation-in-mozambique-the-case-of- research-and-analysis/working-papers/1943-a-study-of-brazilian- Future Agricultures. http://www.future-agricultures.org/publications/ ProALIMENTOS and ProSAVANA of case The Mozambique: in Cooperation A study of Brazilian Trilateral Development Development Trilateral Brazilian of Astudy (2015) NN Fingermann, Inclusive Growth: An An Growth: Inclusive K(2014) Numasawa, AO and Salami, BS, Kanu, A study of Brazilian Trilateral Development Development Trilateral Brazilian of Astudy (2015) NN Fingermann, A study of Brazilian Trilateral Development Development Trilateral Brazilian of Astudy (2015) NN Fingermann, A study of Brazilian Trilateral Development Development Trilateral Brazilian of Astudy (2015) NN Fingermann, A study of Brazilian Trilateral Development Development Trilateral Brazilian of Astudy (2015) NN Fingermann, A study of Brazilian Trilateral Development Development Trilateral Brazilian of Astudy (2015) NN Fingermann, A study of Brazilian Trilateral Development Development Trilateral Brazilian of Astudy (2015) NN Fingermann, https://www.usaid.gov/brazil/our-work/trilateral-cooperation https://www.usaid.gov/brazil/our-work/trilateral-cooperation https://news.ifas.ufl.edu/2011/01/uf-receives-7-9-million-to-improve- A study of Brazilian Trilateral Development Development Trilateral Brazilian of Astudy (2015) NN Fingermann, Note by the UN Secretary General to the High-level Committee Committee High-level the to General Secretary UN the by Note A study of Brazilian Trilateral Development Development Trilateral Brazilian of Astudy (2015) NN Fingermann, , African Development Bank Group. Group. Bank Development , African

, , , , , , , , , number 87. University of Göttingen. 87. University number Papers, Discussion Countries’ Transition and Developing in Growth and Equity ‘Poverty, Centre Research Courant trends. historical against MDGs the towards progress Measuring Right: Progress Getting (2012). S Lange Sand 37; Klasen, and Paper Working Development Global for perspective historical in goals education International School: to Walk Long The MA(2004). Clemens, see: outcomes educational on progress food-security-and-human-nutrition-in-mozambique/ food-security-and-human-nutrition-in-mozambique/ 4 3 2 1 F 5 82 81 80 5 7 6 5 4 3 2 1 APPENDICES 6 capacity-building/ipc-chronic-scale/en/) capacity-building/ipc-chronic-scale/en/) detail0/en/c/162270) and chronic malnutrition (http://www.ipcinfo.org/ (http://www.ipcinfo.org/ipcinfo-detail-forms/ipcinfo-resource- malnutrition acute for differences the mind in bearing IFPRI and FAO, by WHO recommended as security food and malnutrition Development Review African surveys.” health and demographic the from Evidence Uganda: in 10.1016/S0140-6736(13)60937-X doi: and countries’, middle-income The Lancet low-income in overweight and undernutrition child and ‘Maternal (2013) Group Study Nutrition Child and Maternal and R, Uauy, Martorell, R, J, Katz, S, Grantham-McGregor, M, Ezzati, de Onis, M, Sudan. South and Singapore, Mozambique, include rights culture and social economic, on treaty the files/dossier/gmr_2013-4.pdf 15. https://www.unesco.nl/sites/default/ Pg. all for quality Achieving adequate_food_light_haki_zetu.pdf Netherlands: 15. http://www.hrbaportal.org/wpcontent/files/right_to_ Handbook Series (SPA) Africa on Programme Special food. adequate to right The practice: Publications/Briefs_on_Nutrition/Brief10_EN.pdf Development Matters_1.pdf https://www.savethechildren.org.uk/sites/default/files/docs/Why_Law_ Report. Monitoring Global All for Education 2013/2014 UNESCO Methodological Note pp.76–85. 95(S450), paediatrica, Acta age. and weight height, The Lancet cost? what at and done be can what nutrition: child and maternal of improvement for interventions Evidence-based 2013. E., R. &Black, S., Horton, F., Walker, N., M. Gaffey, A., Rizvi, K., J. Das, A., Z. Bhutta, stunting. of rate the in decrease a20% to lead will interventions of package core a up scaling that (2013), al. et Bhutta by modelled reduction stunting of level the with line in assumption, an on based is analysis The 16 to 1. is globally stunting on impact its of terms in coverage 90% to Ssewanyana, Sarah & Ibrahim Kasirye. “Causes of health inequalities inequalities health of “Causes Kasirye. &Ibrahim Sarah Ssewanyana, Ibid P, Christian, ZA, Walker, CG, SP, Bhutta, Victora, RE, Black, ratified not have that malnutrition of burden ahigh with Countries EFA Global Monitoring Report (2014). Teaching and Learning: Learning: and Teaching (2014). Report Monitoring Global EFA Haki Zetu ESC rights in in rights ESC Zetu Haki 2010. &FIAN. International Amnesty for AFoundation Nutrition: in Rights’ Human and ‘Nutrition WB, Eide, International. Children the Save Matters? Law 2011. Why SCI, the for paper Background Zero. to Projections S(2014). Lange, Outcomes: Nutritional Projecting MS(2016) Silva, Mand Perez, length/ on based Standards Growth Child WHO 2006. M., Onis, interventions nutrition-specific up scaling of ratio benefit-cost The For a discussion on the sigmoid as a functional form to model historical historical model to form afunctional as sigmoid the on adiscussion For Consider the IPC framework, http://www.ipcinfo.org/home/en/, http://www.ipcinfo.org/home/en/, framework, IPC the Consider For example, the household level and individual level indictors of of indictors level individual and level household the example, For https://news.ifas.ufl.edu/2011/01/uf-receives-7-9-million-to-improve- OR WORLD LEADERS

CONCLUSIONS AND RECOMMENDATIONS RECOMMENDATIONS AND CONCLUSIONS , Geneva: ACC/SCN, 2002. http://www.unscn.org/files/ 2002. ACC/SCN, , Geneva: . Amsterdam Netherlands, Amnesty International 24.4 (2012): 327–341. (2012): 24.4 , unpublished, paper available upon request , 382(9890): 452–477. , 382(9890):

382, 9890, pp 427–51. pp 9890, 382,

. Center . Center UNEQUAL PORTIONS

Ending malnutrition for every last child

Good nutrition: a matter of life or death.

The world has made progress in tackling malnutrition. But that progress has been far too slow.

Our research shows that the world is way off eradicating malnutrition. On current trends there will still be millions of malnourished children in the world 100 years from now.

What’s more, progress has been alarmingly unequal. While many children have benefited, particular groups of children are missing out on the nutrients that are so vital to their life chances.

Unequal Portions presents the findings of new research into what makes some children more vulnerable to malnutrition than others.

It analyses data from a range of sources to show how a deadly combination of poverty and discrimination is robbing certain groups of children – girls, children from ethnic minorities, those in disadvantaged regions of their country, disabled children, and children affected by war – of the healthy, balanced diet they need to survive and thrive.

Drawing on new findings and analysis, this report identifies a series of measures to ensure no child is left behind. And it calls on world leaders to address exclusion and ensure every last child gets the nutrition they need.

savethechildren.org.uk

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