Patrick Webb

Nonfarm Income Diversification and Household Livelihood Strategies in Rural Africa: Concepts, Dynamics and Policy Implications

Asset, activity and income diversification lie at the heart of livelihood strategies in rural Africa. This paper introduces a special issue on the topic “Income Diversification and Livelihoods in Rural Africa: Cause and Consequence of Change.” We concentrate on core conceptual issues that bedevil the literature on rural income diversification and the policy implications of the empirical evidence presented in this special issue.

Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?

Maternal undernutrition contributes to 800,000 neonatal deaths annually through small for gestational age births; stunting, wasting, and micronutrient deficiencies are estimated to underlie nearly 3·1 million child deaths annually. Progress has been made with many interventions implemented at scale and the evidence for effectiveness of nutrition interventions and delivery strategies has grown since The Lancet Series on Maternal and Child Undernutrition in 2008. We did a comprehensive update of interventions to address undernutrition and micronutrient deficiencies in women and children and used standard methods to assess emerging new evidence for delivery platforms. We modelled the effect on lives saved and cost of these interventions in the 34 countries that have 90% of the worlds children with stunted growth. We also examined the effect of various delivery platforms and delivery options using community health workers to engage poor populations and promote behaviour change, access and uptake of interventions. Our analysis suggests the current total of deaths in children younger than 5 years can be reduced by 15% if populations can access ten evidence-based nutrition interventions at 90% coverage. Additionally, access to and uptake of iodised salt can alleviate iodine deficiency and improve health outcomes. Accelerated gains are possible and about a fifth of the existing burden of stunting can be averted using these approaches, if access is improved in this way. The estimated total additional annual cost involved for scaling up access to these ten direct nutrition interventions in the 34 focus countries is Int

The dynamics of livelihood diversification in post-famine Ethiopia

9·6 billion per year. Continued investments in nutrition-specific interventions to avert maternal and child undernutrition and micronutrient deficiencies through community engagement and delivery strategies that can reach poor segments of the population at greatest risk can make a great difference. If this improved access is linked to nutrition-sensitive approaches--ie, womens empowerment, agriculture, food systems, education, employment, social protection, and safety nets--they can greatly accelerate progress in countries with the highest burden of maternal and child undernutrition and mortality.

HIV/AIDS, Undernutrition, and Food Insecurity

Abstract Based on data for almost 300 households this paper explores associations among income diversification, household perceptions of livelihood risks, and changes in consumption outcomes across two points in time in post-famine Ethiopia. Four key questions are addressed: i) To what extent did households emerging from the famine period with relatively higher income and calorie consumption levels also have a more diversified income base?; ii) Was higher income diversification in 1989 associated with higher income and consumption levels by 1994?; iii) Which households increased their share of income from non-cropping activities most during the inter-survey years?; and iv) Did household heads perceive a lack of non-farm income activities to be an important risk factor in famine vulnerability? We find that wealthier households tended to have more diversified income streams; those initially more diversified subsequently experienced a relatively greater increase in both income and calorie intake; households with a greater concentration of assets were more likely to fall in their relative outcome ranking (as were female-headed households); and, initially less diversified households subsequently realized greater gains in income diversification. We also find suggestive evidence that personal perceptions of risk factors guided subsequent diversification decisions.

Famine in Africa: Causes, responses, and prevention

Despite tremendous advances in care for human immunodeficiency virus (HIV) infection and increased funding for treatment, morbidity and mortality due to HIV/AIDS in developing countries remains unacceptably high. A major contributing factor is that >800 million people remain chronically undernourished globally, and the HIV epidemic largely overlaps with populations already experiencing low diet quality and quantity. Here, we present an updated review of the relationship between HIV infection, nutritional deficiencies, and food insecurity and consider efforts to interrupt this cycle at a programmatic level. As HIV infection progresses, it causes a catabolic state and increased susceptibility to other infections, which are compounded by a lack of caloric and other nutrient intake, leading to progressive worsening of malnutrition. Despite calls from national and international organizations to integrate HIV and nutritional programs, data are lacking on how such programs can be effectively implemented in resource-poor settings, on the optimum content and duration of nutritional support, and on ideal target recipients.

Medium- to Long-Run Implications of High Food Prices for Global Nutrition

Though famine has affected many parts of the world in the twentieth century, the conditions that produce famine—extreme poverty, armed conflict, economic and political turmoil, and climate shocks—are now most prevalent in Africa. Researchers differ on how to address this problem effectively, but their arguments are often not informed by empirical analysis from a famine context. Broadening current theories and models of development for conquering famine, Famine in Africa grounds its findings in long-term empirical research, especially on the impact of famine on households and markets. The authors present the results of field work and other research from numerous parts of Africa, with a particular focus on Botswana, Ethiopia, Niger, Rwanda, Sudan, and Zimbabwe. With these data, the authors explain the factors that cause famines and assess efforts to mitigate and prevent them. Famine in Africa is an important resource for international development specialists, students, and policymakers.

Treatment of severe and moderate acute malnutrition in low- and middle-income settings: a systematic review, meta-analysis and Delphi process

The combined food, fuel, and financial crises of 2007-2009 had severe and widespread negative impacts around the world. Two key questions challenging governments were: how long would the high prices last and with what effects on food security and nutrition over the longer run? This paper considers the drivers of the crisis and explores if, unlike past shocks, the recent price increases reflect structural changes in food price formation that will have lasting global implications. New cross-commodity relationships allowed prices to spike, although there was no shortage of food at the global level nor indeed a significant downturn in recent yields. Yet recent record levels of farm production were also mirrored by growing numbers of people chronically undernourished and/or micronutrient deficient. The gap between supply and need was underpinned by growing urban demand, consumption of processed and higher-value foods (including meat), biofuel policy, and purchasing power erosion, but also by short-term market-distorting policies implemented by governments responding to perceived shortages of food. Thus, the impact of future food price crises will depend largely on what policymakers chose to do in response to the peaks and what they do not do during the troughs. Appropriate investments are urgently needed not just in smallholder developing country agriculture, but in effective food policies and targeted programming that can reverse the recent negative trends in nutrition and that support access globally to improved diet quality as well as food quantity.

Nutrition Information and Formal Schooling as Inputs to Child Nutrition

BackgroundGlobally, moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) affect approximately 52 million children under five. This systematic review evaluates the effectiveness of interventions for SAM including the World Health Organization (WHO) protocol for inpatient management and community-based management with ready-to-use-therapeutic food (RUTF), as well as interventions for MAM in children under five years in low- and middle-income countries.MethodsWe systematically searched the literature and included 14 studies in the meta-analysis. Study quality was assessed using CHERG adaptation of GRADE criteria. A Delphi process was undertaken to complement the systematic review in estimating case fatality and recovery rates that were necessary for modelling in the Lives Saved Tool (LiST).ResultsCase fatality rates for inpatient treatment of SAM using the WHO protocol ranged from 3.4% to 35%. For community-based treatment of SAM, children given RUTF were 51% more likely to achieve nutritional recovery than the standard care group. For the treatment of MAM, children in the RUSF group were significantly more likely to recover and less likely to be non-responders than in the CSB group. In both meta-analyses, weight gain in the intervention group was higher, and although statistically significant, these differences were small. Overall limitations in our analysis include considerable heterogeneity in many outcomes and an inability to evaluate intervention effects separate from commodity effect. The Delphi process indicated that adherence to standardized protocols for the treatment of SAM and MAM should have a marked positive impact on mortality and recovery rates; yet, true consensus was not achieved.ConclusionsGaps in our ability to estimate effectiveness of overall treatment approaches for SAM and MAM persist. In addition to further impact studies conducted in a wider range of settings, more high quality program evaluations need to be conducted and the results disseminated.

Maternal and child nutrition: building momentum for impact

Few studies have explored whether or how nutrition knowledge interacts with education--do they act as substitutes or complements? Exceptions include research in Nicaragua (Lamontagne Engle and Zeitlin 1998) which found that maternal education and certain types of nutrition knowledge are significantly but independently associated with child outcomes. Another study in Brazil (Thomas Strauss and Henriques 1990) found that most of the correlation between maternal knowledge and child height could be explained by mothers’ access to media messages (on TV and radio) and that formal schooling and messages gained through community health services acted as substitutes. Similarly Glewwe (1999) found that maternal knowledge (rather than schooling) in Morocco strongly influences child height-for-age (a measure of longer-term child nutritional well-being) and that such knowledge is obtained mainly outside the classroom through the media from relatives and via public service messages. Variyam et al (1999 p. 381) also report that maternal schooling in the United States has a strong impact on children’s diets “wholly through its positive effect on maternal . . . nutrition knowledge.” Thus some of the contribution of schooling to child nutrition appears to come through its interaction with nutrition knowledge--possibly by enhancing women’s ability to acquire knowledge or by enabling them to put such knowledge into practice. However since nutrition knowledge has been shown to generate nutritional improvements even among illiterate populations and since formal education remains severely limited in most poor developing countries the potential for targeted transfers of nutrition information to assist in nutritional improvements may be large. This article offers preliminary support for such an argument. The article is organized as follows. Section II describes the survey data used in the analysis as well as the construction of our proxy for nutrition knowledge. Section III presents nonparametric evidence of the effects of nutrition knowledge maternal education and per capita expenditures on nutritional outcomes. Section IV presents supporting parametric results and Section V concludes with programmatic and research implications. (excerpt)

Support for agriculture during economic transformation: Impacts on poverty and undernutrition

372 www.thelancet.com Vol 382 August 3, 2013 In the 5 years since the Maternal and Child Undernutrition Series was published in The Lancet there has been a substantial increase in commitment to reduction of malnutrition at global and national levels. Most development agencies have developed or revised their strategies to address undernutrition focused on the fi rst 1000 days of life—the period from pregnancy to a child’s second birthday—as called for in the 2008 Series. One of the main drivers of this new international momentum is the Scaling Up Nutrition movement. National commit ment in low-income and middle-income countries (LMICs) is growing, donor funding is rising, and civil society and the private sector are increasingly engaged. Despite this progress, improvements in nutrition still represent a massive unfi nished agenda. The 165 million children with stunted growth in 2011 have compromised cognitive development and physical capa bilities, making yet another generation less productive than they would otherwise be. Countries will not be able to break out of poverty or sustain economic advances when so much of their population is unable Maternal and child nutrition: building momentum for impact support for the interventions that can be quickly scaled up or linked to nutrition programmes—such as early child development initiatives. It is equally important to take note of the message of Marie Ruel and colleagues— that in certain sectors, such as agriculture, the evidence of the eff ect of targeted programmes on maternal and child nutrition is largely inconclusive and requires new approaches to fi eld evaluation. Since 2008, there have been only limited increases in donor aid for nutrition. It is true that nutrition is not so readily attractive to politicians as an international development priority. Undernutrition has a complex set of political, social, and economic causes, none of which are amenable to easy solutions that fi t within the timeframe of a single political cycle. For this reason, the outlook today for nutrition is not wholly good. The target endorsed only a year ago at the World Health Assembly—to reduce by 40% the number of children stunted by 2025—is already on course to be missed. As the endpoint of the Millennium Development Goals approaches, countries and the international community may agree that nutrition was one of the great missed opportunities of the past 15 years. But this neglect can be turned around quickly. As sustainable development becomes the dominant idea post-2015, nutrition emerges as the quintessential example of a sustainable development objective. If maternal and child nutrition is optimised, the benefi ts will accrue and extend over several generations. This remarkable opportunity is why Stuart Gillespie and colleagues take a very diff erent approach to implementation than in any previous Lancet Series. Instead of exhorting politicians and policy makers to do something—or worse, simply hoping that political commitment will appear like a rabbit out of a hat—they set out a practical guide about how to seize the agenda for nutrition, how to create political momentum, and how to turn that momentum into results. This is the prize we have to grasp in the next 18 months.