Nutrition Overview

Overview

Malnutrition is one of the world’s most serious but least-addressed development challenges. Its human and economic costs are enormous, falling hardest on the poor, women, and children. In 2020, 149 million children under five years old were stunted (low height-for-age), which indicates not only a failure to achieve one’s own genetic potential for height but is also a predictor of many other developmental constraints, including cognitive deficits and future economic opportunities, including impeding a country’s ability to accumulate human capital.

Over the last three decades, the worldwide prevalence of stunting declined from 40 percent in 1990, to 22 percent in 2020. However, the health and food systems disruptions caused by the COVID-19 Pandemic has rolled back years of progress on child undernutrition; it is estimated that, by 2022, an additional 9.3 million children will suffer from acute malnutrition and 2.6 million more children will be stunted. Additionally, stark regional differences in the current prevalence and numbers of stunted children persist, with South Asia and Sub-Saharan Africa remaining above the global averages. Almost 31 percent of all children under five were stunted in South Asia in 2020, decreasing from approximately 60 percent in 1990. Even though the prevalence of child stunting in Sub-Saharan Africa fell from 48 percent in 1990 to 32 percent in 2020, the total number of stunted children in Africa increased by 13.1 million during the same period as a result of high fertility rates and lower rates of decline in stunting.

Stunting early in a child’s life can cause irreversible damage to cognitive development and has educational, income, and productivity consequences that reach far into adulthood. The economic costs of undernutrition, in terms of lost national productivity and economic growth, are significant— our economy and society is paying US$3 trillion a year in the form of productivity loss, ranging from 3 to 16% (or more) of GDP in low-income settings. Moreover, the global expert consortium, including the World Bank, estimated economic productivity losses equivalent to US$29 billion globally by 2022 as a result of the additional malnutrition burdens attributable to the COVID-19 pandemic.

Fortunately, these losses are largely preventable if adequate investments in proven interventions are made, particularly those that focus on ensuring optimal nutrition in the critical 1000-day window between the start of a woman’s pregnancy and her child’s second birthday.

Globally, undernutrition is more common in poor households, but is also prevalent among wealthier households. Income is one—but not the only—determinant of stunting: food insecurity, diets lacking in diversity, high rates of infectious diseases and inappropriate infant feeding and care practices, and poor sanitation and hygiene practices also contribute to persistent stunting. Food and financial crises, as well as conflict, natural disasters and the COVID-19 Pandemic, have worsened undernutrition in many regions.

At the same time, a global nutrition transition is underway, leading to rapid changes in food systems, environments, and living conditions in many low- and middle-income countries (LMICs). These changes have stimulated a rapid increase in the burden of overweight and obesity, previously considered an ailment of wealthy countries. In fact, over the past 30 years, rates of overweight have risen faster in LMICs than in high income countries, and every region has seen some increase in the prevalence in overweight children under five years. In 2020, 38.9 million children under 5 were affected by overweight and obesity, which are now pervasive even in countries where children experience undernutrition. Overall, it is estimated that overweight and obesity cost US$2 trillion in economic and social expenses globally.

Countries are therefore starting to experience the double burden of overweight and stunting. Today, more of the world’s overweight individuals reside in low- and middle-income countries than in high income countries, and there is no evidence that the rise in obesity in LMICs will decline. As countries experience economic growth and achieve middle and upper-middle income status, their poor will experience a greater share of the burden of overweight and obesity, increasing their vulnerability to health and economic shocks. Both obesity and undernutrition are critical to improving human capital, a central driver of sustainable growth and poverty reduction, and can have a significant effect on the human capital index (HCI). There is an urgent need to ensure that the world’s poor have access to the knowledge, resources, and services needed to achieve optimum nutrition.

Over the last 15 years, the World Bank has been a major contributor to dialogue and action on scaling up actions to prevent stunting. The seminal report Repositioning Nutrition as Central to Development brought attention to the issue among key partners and governments. The follow-on 2010 World Bank publication Scaling Up Nutrition: What Will It Cost? and the Investment Framework for Nutrition 2017 provided the world with the first estimates of global nutrition costs, and the SUN movement launched in 2010 rallied partners around the cause.

Guided by the twin goals of ending extreme poverty and boosting shared prosperity, the World Bank’s commitment to investing in the early years of life (early nutrition, early learning and stimulation, and nurturing care and protection from stress) is necessary to build human capital. World Bank’s IDA and IBRD investments in nutrition have grown dramatically since FY10, from about 10m$ to about 1.2billion$ in FY18. In addition, new resources have been made available to support this agenda at both global and national levels—from partners such as the Bill & Melinda Gates Foundation, the Children’s Investment Fund Foundation, the Japan Trust Fund for Scaling Up Nutrition – which is focused on high-malnutrition burden country programs, the Dangote Foundation, Tata Trusts, the Power of Nutrition, and the Global Financing Facility. These and many other partners, including civil society organizations and Parliamentarians, have been working to catalyze further commitment in support of the Sustainable Development Goals.

The World Bank has led the effort to estimate the cost and cost-effectiveness of nutrition interventions to support advocacy and increase investment in nutrition at the global and country levels. At the global level, the World Bank, in partnership with R4D, 1000 Days, the Bill and Melinda Gates Foundation, and the Children’s Investment Fund Foundation published An Investment Framework for Nutrition which provides a roadmap, including estimates of resources required and possible financing scenarios to achieve the global nutrition targets set out by the World Health Assembly and enshrined in the Sustainable Development Goals.

At the country level, the Bank has conducted numerous studies to support governments in Sub-Saharan Africa and South Asia to plan for and scale up investments in nutrition. The studies provide estimates of the financing needs, impacts and benefits of scaling up a package of evidence-based nutrition interventions proven to improve nutrition outcomes during the first 1,000 days of a child’s life – starting from pregnancy to a child’s second birthday. They consider the current coverage of interventions, available delivery platforms, and unit costs for commodities, monitoring and evaluation, and capacity building. As of September 2021, scale-up studies have been completed for Cote d’Ivoire, Democratic Republic of Congo, Guinea-Bissau, Kenya, Madagascar, Mali, Nigeria, Togo, Uganda, Zambia, Bangladesh, and Afghanistan.

Additionally, the World Bank plays a role in supporting country-level program development and management. In 2017, the Bank partnered with the Government of Rwanda to develop the Stunting Prevention and Reduction (SPAR) Program, an ambitious multisectoral effort to eliminate chronic malnutrition in children under two, through the combined approach of the Stunting Prevention and Reduction Project (SPRP), the Strengthening Social Protection Project (SSPP) and the Sustainable Agricultural Intensification and Food Security Project (SAIP). The SPAR program leverages resources from the Power of Nutrition and the Global Financing Facility, respectively providing US$35 and US$18 million across the SPRP and the SSPP projects to co-finance the funding allocated through IDA. The program comprises a set of innovative supply- and demand-side health, social protection and agriculture intervention targeting 13 high-burden stunting districts and vulnerable children in the critical 1,000-day window. Impact evaluation efforts at the household, community health worker and facility-level are currently underway. These efforts are being supported by the Bill and Melinda Gates Foundation, The Power of Nutrition, and the Child Investment Fund Foundation.

The World Bank is further leading the global efforts to strengthen nutrition financing and accountability, including through the Tokyo Nutrition for Growth Summit hosted by the government of Japan in December 2021 which generated US$27 billion in commitments for nutrition actions.

Malnutrition was highly prevalent in Senegal at the start of the millennium when stunting affected as many as 30% of children under five. In response, the Government of Senegal, with support from IDA and other partners, shifted its approach on nutrition to a community-based holistic strategy. The effort was overseen by the Nutrition Policy Coordination Unit in the Prime Minister’s office, which worked with local governments, public service providers and NGOs to deliver to communities and households nutrition services, such as health education, breastfeeding promotion, infant and young child feeding counseling, monthly weighing sessions, essential micronutrient supplementation, conditional cash transfers, targeted food security support and more. The stunting prevalence in Senegal is now 19%, making it one of the lowest of Sub-Saharan Africa.
In Peru, strong government commitment and multisectoral approaches, results-based financing, in addition to Bank and partner efforts in advocacy, operations and non-lending technical assistance, led to a reduction in stunting from 28% in 2005 to 13% in 2016. This is among the fastest rates of reduction seen for stunting globally.
In Ethiopia, the Bank contributed to the development and scale up of the Government's National Nutrition Program (NNP) since 2008, which coincided with a reduction in stunting rates from 44 percent in 2011 to 38 percent in 2016. To further support the country's progress, the Bank is supporting the US$ 230 million Health Sustainable Development Goals Program for Results Additional Financing (Health SDG PforR AF) project (2017-2021). The project, which is co-financed by the Global Financing Facility for Every Woman and Every Child and the Power of Nutrition Trust Fund, supports the second phase of the Government NNP (NNP II), the National Food and Nutrition Strategy, and the National Health Transformation Plan. The program objective is to improve the delivery and use of maternal and child health and nutrition services, incentivize health system performance in maternal and child health and nutrition, and support critical technical assistance and capacity building activities. The midterm evaluation of the project highlighted significant progress in several indicators, including iron and folic acid supplementation for pregnant women, growth and monitoring and promotion for 0-23 months old children, vitamin A supplementation for children through routine systems, and transition of woredas in emerging regions from Enhanced Outreach Services (EOS) to Community Health Days (CHD).

The World Bank Group was a founding member of the Scaling Up Nutrition movement, and currently serves on the Executive Committee for Governance and in the SUN Lead Group. In April 2015, the World Bank Group joined the Power of Nutrition partnership of investors and implementers committed to helping children grow to their full potential, ending the cycle of undernutrition, and enabling countries to build strong and prosperous communities. Backed by leading organizations from private philanthropy and international development, the partnership aims to unlock US $1 billion dollars to tackle child undernutrition in some of the world’s poorest countries by 2022.

The Power of Nutrition’s $20 million investment in Tanzania, made through its partnership with the Bank, has multiplied investment in nutrition, enabling up to $44 million to be released for new nutrition-specific activities in Tanzania within a larger $306 million health and nutrition initiative in the country. This initiative is also financing additional nutrition-sensitive activities that will further improve the nutritional status of children and mothers, including iron and folic acid supplementation in pregnancy; bi-annual Vitamin A supplementation for children, and promotion of improved breastfeeding and complementary feeding practices.

The Bank also works in close alliance with key civil society organizations such as Results, Action, Save the Children, 1,000 Days, World Vision, FHI-360/Alive & Thrive, Action Against Hunger, and many others through SUN Civil Society Network and International Coalition for Advocacy for Nutrition.

The World Bank, in partnership with the Bill & Melinda Gates Foundation and the Burnet Institute, launched a new allocative efficiency modeling tool called Optima Nutrition in 2018. This quantitative tool helps facilitate country-level dialogue and decision-making toward allocating nutrition investments more efficiently. The model aligns with the World Health Assembly global targets on nutrition and, optimizing funding allocations to reduce child stunting, wasting, anemia and/or under-five mortality at both national and subnational levels. Global capacity building trainings have been conducted in Bucharest, Bangkok, Pretoria, and Kathmandu. Additional country-specific capacity building activities have been completed for several countries. Country applications and case studies have been completed in Democratic Republic of Congo, Pakistan, Sindh Province of Pakistan, Tajikistan, Burundi, Bangladesh, and Sierra Leone. Additional applications are under way in Benin, Burkina Faso, Chad, Togo, and Vietnam.