Nutritional Status & Agricultural Growth in Economic Development of Bangladesh
Introduction
Bangladesh faces an unfinished agenda with regard to nutrition. Child under nutrition rates remain among the highest in the world. Infant stunting and underweight rates in Bangladesh are above those in Sub-Saharan Africa (50% vs. 30% for underweight and 50% vs. 40% for stunting) despite the latter’s higher poverty rates. A key underlying factor, maternal malnutrition remains intractable despite efforts to improve the nutritional status of pregnant women. Iron deficiency anemia affects nearly 50% of all pregnant and lactating women. A direct consequence of this is low birth weight, which affects 30-50% of all newborns. It limits children’s growth potential and increases their vulnerability to infectious diseases and non-communicable diseases later in life. It also damages their ability to learn and develop useful skills, which exposes them to poverty and further under nutrition.

Bangladesh is thus characterized by a cycle of intergenerational poverty, ill-health and malnutrition. To-date, public sector investments to address this have had very little impact because they were limited in scale and scope. Malnutrition is a multi-dimensional problem requiring interventions that cut across sectorial boundaries. Sustained improvements in nutrition outcomes are achieved not only through improved food security, but also changes in behaviours and knowledge regarding dietary diversity, child care and health care. Such changes require broader interventions that cut across multiple sectors such as food and agriculture, water and sanitation, education and health. In Bangladesh, malnutrition has largely been viewed as a health issue, with interventions to address malnutrition channeled almost exclusively through the health sector. Such interventions have failed to deliver a coordinated solution to address the multidimensional causes of malnutrition.

The objective of this study is to demonstrate how the interaction between sectors can be improved to increase the effectiveness of sectorial interventions. It looks beyond the health sector to other sectors, which could have a large impact on nutrition, but whose potential has not been fully exploited yet in Bangladesh. In particular, it looks at how interventions in the agricultural sector and microfinance can be used to improve nutritional outcomes.

The study examines evidence from Bangladesh and elsewhere in the world to assess the impact of existing interventions and come up with recommendations for future action. The study will also pay special attention to the extent to which programmes and policies are successful at reaching poor and vulnerable groups in society and thus, reduce inequalities in nutrition.

Pathways of influence between agriculture and nutrition
Interventions in the agriculture sector can potentially influence all of the three underlying determinants of malnutrition: food intake, caring practices and healthy environment. Agriculture affects food intake through the food production-consumption pathway, mediated by increases in incomes and reductions in price. Higher incomes also improve living conditions in general and increase access to health care. However, increased food consumption does not always translate into improvements in nutrition, and may simply lead to the consumption of more food, or more expensive food. Plus, intra-household resource allocation mechanisms may be such that the most nutritionally vulnerable members of the household do not gain from the greater availability of food. Increased empowerment of women resulting from efforts to give women more control over agricultural resources improves nutrition, especially because it helps improve the intra-household distribution of both food and care. Finally, agricultural growth can lead to broad improvements in nutrition outcomes through its impact on overall macroeconomic growth.
Impact of agricultural interventions on nutrition
While national food security has improved in recent years in Bangladesh, thanks to increases in the production of staple foods, household food security has not been achieved for a large proportion of the population. With limited land and labour entitlements to help improve access food, transitory food insecurity is a major problem for the poor, particularly in the aftermath of natural disasters. For households below the poverty line, chronic food insecurity is also a problem. Household survey data indicate that annual household expenditures per capita for these households are inadequate to purchase sufficient calories. Improvements in nutrition outcomes require not only food security, but also dietary diversity and better health and nutrition behaviours. Dietary diversity has decreased over the years for the poor in Bangladesh. The growth in cultivation of staple crops marginalized the land available for the production of key non-staples such as pulses and oilseeds. As a consequence, these protein-rich foods have become relatively scarce and their prices have risen. The production of fruit and vegetables has not increased either. Both these factors partly explain why dietary diversity has shown little improvement, particularly for the poor.
In Bangladesh and elsewhere, interventions to encourage the production of fruits, vegetables and animal source foods have proved to be effective in improving household food security and dietary diversity only when they are combined with efforts to empower women and nutrition education.
Technological interventions in agriculture around the world have had an important role to play in improving nutrition. The introduction of modern agricultural technological inputs and improved crop varieties for staple crops, plant breeding to improve the adaptability of fruit and vegetable crops, and improvements in storage and transportation of perishable foods have all contributed to better food security and greater access to a more diversified range of foods for a larger population at lower prices. Investments into the research and dissemination of agricultural technologies are critical for improving nutrition through the agriculture sector. Current research into improved crops, plant breeding and post-harvest technologies in Bangladesh is not sufficient and the resources and capacity for doing this type of research needs to be strengthened considerably. Integrating nutrition into community-driven development (CDD) programmes in the agriculture sector may hold potential for mobilising the agriculture sector to improve nutrition. A CDD approach to improving nutrition through the agriculture sector would take into account the community’s own assessment of its agroeconomic constraints, food security situation, and health and nutrition needs. A major risk in taking a CDD approach to designing nutrition programmes is that communities may not necessarily invest in nutrition interventions since malnutrition is not a very visible problem. It may be necessary to introduce some form of conditionality to invest in nutrition if a CDD approach is taken. There are no known examples of CDD approaches that have led to substantial investments in nutrition and consequently, to improvements in nutrition outcomes.
Two emerging trends pose new challenges for the relationship between agriculture and nutrition. Given the double burden of malnutrition associated with under- and over-nutrition in most developing countries today, the agriculture sector must not only ensure sufficient supplies of staples and micronutrient-rich foods to combat undernutrition, it also needs to discourage over8 consumption of nutrient-poor, energy dense foods to combat overnutrition. The view that agriculture’s role in Bangladesh is to ensure food security by providing as cheap a source of abundant calories as possible is not conducive to addressing the twin problems of malnutrition. Secondly, the high degree of market orientation of agriculture means that agricultural markets, in addition to production, play a crucial role in determining food availability and access today. To increase consumption of micronutrient-rich fruits and vegetables the market supply chain needs to be adapted and strengthened to make fresh produce more affordable to households, as well as increase producers’ access to markets.
Pathways of influence between microcredit and nutrition
Three potential pathways of influence between microcredit and nutrition exist: the direct income effect, where greater access to credit is associated with higher incomes and reduced economic vulnerability, which translates into greater household food security; the women’s empowerment effect, where greater access to credit for women is associated with a greater share of household resources being devoted to food and nutrition, and improved intra-household allocation of resources; and the direct effect of health and nutrition services provided in conjunction with microcredit.
Impact of microcredit programmes on nutrition
Both in Bangladesh and elsewhere, the evidence with regard to the impact of access to credit on incomes is ambiguous. It is clear, however, that access to microcredit has significantly reduced consumption vulnerability and potentially, food insecurity. This is a particularly important effect in the context of Bangladesh where transitory food insecurity during periods of scarcity is an important underlying cause of malnutrition.
Microcredit has had a positive impact on women’s empowerment in Bangladesh by improving their income generating potential and as a result, their status within the household and community. Women’s borrowing has been found to have a significantly greater positive impact on child nutrition than men’s borrowing. This is attributable in part to women being empowered enough to have a greater say over household resource allocation decisions with regard to food and care for children, and the fact that women are more likely than men to allocate more resources to children.
Strong rationale exists for providing nutrition and health services in conjunction with credit because improvements in income alone, although sufficient for improving food security are not sufficient to improve nutrition itself. However, the evidence with regard to the effectiveness of these integrated programmes is not compelling. Since there are large interdependencies between the credit-led income effects and the health/nutrition education effects, it is possible that the two effects are mediated by one another. Given the lack of evidence, it would not be advisable to do away with the health/nutrition education components because of the potentially important role they play in communicating behaviour change messages to credit group members, who are poor, nutritionally vulnerable and important agents of change in the household and community.
Challenges to improving nutrition through interventions in agriculture and microcredit programmes
Given the potentially important role of nutrition education in agricultural interventions and microcredit programmes in improving nutrition outcomes, it is necessary to examine the most effective mechanism for delivering it. In the case of microcredit, existing programmes largely involve the microfinance institution (MFI) taking responsibility for the provision of both credit and health/nutrition programmes. While this may be feasible for large MFIs with a diversified portfolio, in most cases, the integrated provision may undermine the efficiency with which microcredit services are provided. In the case of agriculture, nutrition education often ends up being the responsibility of the agriculture sector, where staffs have neither the skills nor experience to design and implement this. MFI’s and agricultural agencies do not have much comparative advantage in providing nutrition services. A more efficient, but less well explored approach is for the MFI or agriculture agencies to establish strong linkages with existing health and nutrition service providers.
Similarly, efforts to empower women through agriculture or microcredit can enhance the impact on nutrition. However, it is equally important to consider women’s roles and constraints, and the cultural context when designing interventions. In general, women face unequal rights relative to men in terms of access to household resources, and greater institutional biases against them than men in access to training and new technological inputs. Failure to understand cultural norms and the gender dynamics in the household have generally resulted in less than optimal outcomes, both for women’s empowerment and nutrition.
The poorest of the poor gain little from interventions in the agriculture sector or microcredit programmes. The underlying determinants of malnutrition are highly correlated with poverty, making the poor the most vulnerable to malnutrition in Bangladesh and elsewhere. Their land and capital entitlements are virtually non-existent and labour entitlements not substantial enough to guarantee a regular source of income. This combined with a high perceived risk of failure in repaying the loans excludes these groups from most microcredit programmes. In Bangladesh in particular, the poorest of the poor include large numbers of landless households.
Numerous, small-scale interventions exist that provide agriculture or microcredit services in conjunction with nutrition components and are associated with improvements in nutrition outcomes; but attempts to scale up these programmes have met with limited success. The household food security programme in Bangladesh is a good example of a successful small-scale intervention that failed to have much impact when it was scaled up to the national level. Underlying causes for failure of scaling up in general include weak capacity for monitoring and evaluating (M&E) the interventions, not taking into account local needs and conditions, and larger institutional problems of cross-sectoral coordination.
Multisectoral response to malnutrition
Coordinated, multisectoral programmes to address malnutrition have proved largely unsuccessful. Policy responses to malnutrition should therefore not be held hostage to the success or failure of intersectoral coordination mechanisms. A more realistic response is to ‘plan multisectorally, implement sectorally’1. Operationally, this involves identifying interventions within sectors that have the potential to significantly improve nutrition and mobilising resources specific to that sector. Two factors are critical for this strategy to work. First, it is necessary to ensure that sector-specific stakeholders understand how their sector can contribute to alleviating malnutrition and to what extent the benefits outweigh any opportunity costs they face by committing sectorspecific resources to nutrition. Second, it is necessary to ensure that alleviating undernturtion remains a high level policy priority for the government.
Key recommendations
(1) Policy responses to malnutrition should not be dependent on intersectoral coordination.
(2) A more realistic response is to ‘plan multisectorally, implement sectorally’
(3) It is not feasible or cost-effective to incorporate nutrition components into all agricultural or microcredit programmes. Some agricultural and microcredit programmes are more suitable for integrating nutrition components than others.
(4) In agriculture, the greatest potential for improving outcomes by integrating nutrition lies in the production of fruit, vegetables, livestock and aquaculture, particularly small-scale production at the household level.
(5) In microcredit, the greatest potential for improving outcomes by integrating nutrition lies in targeting microcredit programmes that women are most likely to be involved in, and where there is a strong income effect.
(6) Financing and implementing the nutrition component should be the responsibility of the health and nutrition sector, which has comparative advantage in this; the design of agriculture and microcredit programmes should ensure the nutrition components are integrated effectively.
(7) Empowerment of women should be emphasised in the design of agriculture interventions and microcredit programmes
(8) Nutrition components of agriculture interventions and microcredit programmes should promote participatory learning to enhance women’s empowerment
(9) To scale up successful nutrition components in agriculture or microcredit interventions, M&E capacity needs to be strengthened and greater attention paid to local-level needs and conditions
(10) The institutional capacity of GOB agencies to establish and manage effective M&E systems needs to be strengthened considerably.
(11) Nutrition interventions should be integrated with combined microcredit and safety net programmes in order to ensure they reach the poorest of the poor.

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