1.2. Formulación del problema
1.2.1. Problema General
2.2.1.6. Organización del sistema de control interno
Stuart Gillespie, Florence Egal, Martina Park1
Key messages
• Malnutrition tends to be most prevalent among poor rural communities who are also most dependent on agriculture for a livelihood.
• Globally, there is a struggle to get to grips with a double burden of coexisting undernutrition with overweight and obesity.
• Agriculture, nutrition and health are entwined in many ways – positively and negatively – but individual policies and programmes still operate largely out of sectoral silos.
• Sustainable improvement of nutrition requires an integrated approach combining agricultural and public health interventions.
• Gender-sensitive food and agricultural interventions aimed at sustaining livelihoods and increasing availability of, and access to, diverse and nutritious foods within poor rural communities need to be combined with preventive and clinical interventions provided by the health sector.
• Better governance at all institutional levels (in terms of fostering intersectoral collaboration and harmonized policy-making) needs to be matched by community-level convergence of agriculture, nutrition and health services and programmes that takes full account of local priorities and needs.
• Recent years have seen growing momentum for a more concerted, enlightened focus on tackling malnutrition that takes heed of its multiple
1 We would like to thank Purnima Menon, Ruth Butao and Andreas Groetschel for the case studies as well as Mara van den Bold (IFPRI) for her valuable contributions and support. Stuart Gillespie’s time was funded by the Transform Nutrition Research Programme Consortium with UK aid from the British Government. The views expressed in this chapter do not necessarily reflect the British Government’s official policies.
causes and seeks to incentivize various sectoral actors to come together. The Scaling Up Nutrition (SUN) and the 1,000 Days movements are leading examples.
9.1 Introduction
Nutrition is foundational to the development of both individuals and countries and to the achievement of all major social and economic goals, including the MDGs. Undernutrition in early life is responsible for 35% of deaths of children under five years; reduces cognitive attainment through various routes; substantially increases the likelihood of being poor throughout adulthood; and has a close link with illness or death during pregnancy and childbirth for both mothers and their babies. Increasingly, in poorer parts of the world, countries are facing what is referred to as the double burden of malnutrition – acute and chronic malnutrition, as well as micronutrient deficiencies, increasingly coexist with overconsumption of energy-rich foods in other population groups, all of which are signs of inappropriate diets (1)
.
NCDs – many of which are caused or aggravated by excessive body weight – are quickly gaining ground.Undernutrition shows an ongoing disturbing global situation: almost 200 million of the world’s children under five are stunted. India contains more than one third of all undernourished children and, at current rates of progress, will meet the MDG underweight target only in 2043, not 2015 (2). The latest data from the United Nations Standing Committee on Nutrition (UNSCN) indicate that only 18 of 42 African countries show improvement in underweight rates, while 14 show deterioration (3). This is unacceptable and puzzling – consideration of the drivers may explain the lack of progress.
The conceptual framework pioneered by UNICEF in the early 1990s (Fig. 9.1) clearly shows the determinants of malnutrition at different levels and the type of sectoral responses that may be appropriate for responding effectively. Since poor nutritional status is the final outcome of a combination of determinants clustered into food, health and care, it is generally agreed that alleviation of malnutrition will require the integration of food security, public health (including water, sanitation and hygiene) and social protection. This is a multifaceted problem requiring multisectoral solutions. Fig. 9.2 shows the interaction of four systems — agrifood, environmental, health/disease and, crucially, the system of individual and household decision-making.
Nutrition is increasingly perceived as a major development problem and it is generally agreed that agriculture and health are both prerequisites for good nutrition, yet both sectors tend to neglect this. Agriculture produces the food people eat and is the primary source of livelihood for the majority of the world’s
Breastfeeding & complementary feeding practices Micronutrient supplementation fortification Hygiene practices Immunization, use of preventive health care
Immediate causes Nutrition-specific Underlying causes at household/ community level Basic causes at societal level Basic causes at societal level Basic causes at societal level Child nutrition Interventions RESOURCES
ENVIRONMENT, TECHNOLOGY, PEOPLE Food/nutrient
intake Health
ECONOMIC STRUCTURE POLITICAL & IDEOLOGICAL FRAMEWORK
INSTITUTIONS Agriculture & food security
programmes
Poverty reduction & social protection/safety nets Income generation Education
Health systems strengthening Women’s empowerment Water & sanitation Policies (e.g. agriculture, trade, poverty reduction) Governance
Conflict resolution Climate change mitigation policies Health water/ sanitation Care resources Food security Nutrition-sensitive
Fig. 9.2 A systems framework for food and nutrition security
Source: Hammond & Dubé, 2012 (5).
Fig. 9.1 Conceptual framework of drivers and determinants of undernutrition
Source: modified from UNICEF, 1990 (4).
Pollution/Clean water availability DiseaseHealth/
system Environmental system Sustainability of food production Pollution/Soil degradation/ Climate Demand for food Incomes/ Prices/ Marketing Labour availability Food availability/ quality Susceptibility/ Immune response Nutrient absorption Priorities/ Opportunities Individual decision making Individual outcomes Agri-food system
poor who, in turn, are most vulnerable to ill-health and malnutrition. The interactions between agriculture and health are two-way: agriculture affects health, and vice versa. The process of agricultural production and the outputs it generates (including fibre and materials for shelter; bioenergy for cooking and heating; medicinal plants) can contribute to both good and poor health, among producers and the wider population.
Agriculture contributes to livelihoods and food security through direct production of food and by generating income that can be spent on food, education and health care that benefit nutrition. The TANDI (Tackling the Agriculture-Nutrition Disconnect in India) initiative of the International Food Policy Research Institute (IFPRI) has highlighted potential trade-offs, especially with regard to the role of women in agriculture. Women’s and children’s nutritional status may suffer if a rise in the demand for female agricultural labour is not matched by enhanced decision-making power and control of household resources, including time (6). Gender is closely intertwined with nutrition. And yet both agriculture and health sectors continue to view gender from narrow perspectives: the health sector focuses on the reproductive role of women; the agriculture sector looks mainly at their productive role (see Chapter 3).
As well as undernutrition, agriculture is associated with many other major health problems, including malaria, HIV/AIDS, foodborne diseases, diet- related chronic diseases and a range of occupational health hazards. Agriculture can contribute to both the spread and the alleviation of these health conditions. Conversely, undernutrition and poor health have tremendous implications for agriculture, influencing market demand for agricultural products, as well as their supply. Agricultural workers who are malnourished and/or in poor health are less able to work. This cuts productivity and income, perpetuating a downward spiral into ill-health and poverty and further jeopardizing food security and economic development for the wider population. Successful health policies benefit agriculture by protecting the labour force from days (and income) lost to illness, chronic disabilities or mortality (7).
Environmental changes such as global warming, desertification and loss of agrobiodiversity, and increasing use of food crops for non-food purposes in the face of energy crises, are further jeopardizing food security. Simultaneously, global economic and social changes are transforming food systems at an unprecedented rate; increasingly superimposed by marketing systems which demand food production to be intensified and standardized. While the landscape of agrifood business continues to be quite diverse, value chains tend to increase the power of retailers and supermarkets rather than producers. In consequence, retailers’ needs for high food-safety standards; traceability throughout the value
chain; standardization; and steady supply generally lead to a focus on a few large suppliers and make access to global markets more difficult for smallholders. Ultimately, these processes are accompanied by progressive marginalization of family agriculture, degradation and loss of (agro)biodiversity. This further jeopardizes the food and nutrition security of agricultural producers in developing countries. However, smallholders continue to play a crucial role in supplying local markets with fresh and affordable agricultural produce. National policies need to respond to the needs of these multiple and often conflicting governance structures (8), finding a balance between supporting agricultural producers’ connections with globalized value chains while meeting the needs for diverse and fresh foods in ‘traditional’ local markets.
The consequences of increasing globalization of value chains reach well beyond the agricultural production system, however. The emergence of fast food outlets and supermarkets; intensification of advertising and marketing of comparably cheap industrialized products; foreign direct investment in developing countries; and acceleration of urbanization, often translate into changing dietary patterns. Specifically, an overall increase in consumption of energy-dense foods. Associated changes in lifestyles and occupational patterns lead to a shift from home-prepared and home-based meals to pre-prepared or ready-to-eat meals. These are often consumed away from home which, combined with decreased physical activity, leads to rises in obesity and diet-related chronic diseases (9). Against this backdrop, this chapter addresses the core question: How can the convergence between agriculture, health and other sectors be strengthened in order to reduce malnutrition more effectively and sustainably?
Recent efforts have promoted scaling-up of quick impact evidence-based interventions2 but limited efforts have been made to address institutional
challenges that beset convergence of nutrition-relevant sectors. Sectoral policies must incorporate consideration of nutrition (become nutrition sensitive) and be articulated so as to provide populations with the integrated support they require. Most countries have not tapped the agricultural sector’s potential to address undernutrition, as will be seen in the rest of this chapter. Moreover, if the agriculture and food sector works more closely with the health sector, the rising prevalence of diet-related NCDs and early deaths can be reduced through better nutrition and healthier lifestyles. The global food system has evolved over the past century to deliver a number of benefits: greater choice for consumers, greater food diversity and lower cost. But the food and agriculture sector must ensure that consumers can access an adequate mix of locally available, less- processed and culturally appropriate items for diverse and sustainable diets.
2 See The Lancet Series on Maternal and Child Undernutrition, 2008 (http://www.thelancet.com/series/maternal-and-
9.2 How ‘nutrition sensitive’ are agricultural policies and programmes in regions of high malnutrition?
The paucity of studies evaluating agriculture’s impact on nutrition outcomes further reflects the disconnect between food production and food consumption in the minds of agronomists and economists. Studies on the commercialization of agriculture tend to show that such interventions effectively increase income and food expenditures but usually do not show improvements in child nutrition. Yet, it is important to note that this can often be explained by the fact that project designers and evaluators often fail to look at the nutritional impact of their interventions, confining their analyses to impacts on food availability or household income. Like many previous studies, a recent comprehensive review by Masset et al. (10) concluded that agricultural interventions per se had been found to have little or no impact on child nutritional status. But importantly, and unlike previous reviews, the authors attribute this result to a lack of statistical power in the studies reviewed rather than the lack of efficacy of these interventions.
More and better evaluations that look beyond production increase, food availability and income generation are clearly needed. Policy-makers, donors and practitioners need to ensure that impact assessment of projects and programmes focuses on nutrition outcomes, or at least considers food consumption. The present rights-based movement (specifically, the right to food) should also seek to advance impact assessment of agricultural policies’ effect on people’s welfare and make food and agriculture stakeholders accountable for improving food consumption and avoiding negative impacts.
For many decades, the correlation between income and malnutrition has been viewed mainly from the perspective of how economic growth positively affects malnutrition rates (11). Many stakeholders, including the World Bank, have lately widely acknowledged that this mechanism works more robustly vice versa: better nutrition will boost economic development (12). The most recent cross-country evidence on the role of economic and agricultural growth in child nutritional status looks first at the productive sectors – agriculture and non-agriculture – as important mediating channels between overall economic growth and nutrition (13). Further examination considers social- sector channels such as health, education and family-planning outcomes. The study concludes that: (a) rapid economic growth is a necessary condition for sustainable reduction of malnutrition at lower levels of development; (b) with
the exception of India (see Case study 9.1), agricultural growth tends be more
nutrition sensitive than non-agricultural growth; and (c) nutrition sensitive development requires poverty reduction and social investments in health, education and family planning.